rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
1,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2019-02-14,656,G,0,1,PXEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Care Planning - Interdisciplinary Team the facility failed to follow the care plan for one resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. Additionally, the facility failed to develop a care plan for one Resident (R#94) for the use of a travel pillow for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Care Planning - Interdisciplinary Team reviewed on 3/1/18 noted: 1. A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS (Minimum Date Set)); 2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team. The policy did not include additional information regarding the development and implementation of resident care plans. 1. Review of the clinical record for R#49 revealed that the resident had the following [DIAGNOSES REDACTED]., [MEDICAL CONDITION] (left eye) and depression. Review of the Annual MDS, for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing requiring two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of the Fall care plan for R#49 last reviewed on 1/24/19 revealed the resident was a fall risk and required extensive to total assistance for Activities of Daily Living (ADLs). Pertinent interventions in place at the time of the resident's fall on 12/15/18 included the following: to assist with all ADLs, total transfer assist with Hoyer lift, floor mat at bedside, assist rails x 2; Broda chair when out of bed for comfort and positioning; and to keep bed in low position. Review of the Behavior care plan for R#49 last reviewed on 1/24/19 revealed that R#49 had behaviors - at risk for complications/side effects r/t (related to) use of antipsychotic and other mood stabilizing medication use. The interventions documented that if resistive/combative behavior was noted, leave R#49 alone and return when safe to do so/provide additional assist as needed. Review of a handwritten statement dated 12/21/18 written by CNA FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse Charge Nurse AA on 12/15/18, revealed that CNA FF told Registered Nurse AA that R#49 was combative so she (CNA FF) went to the resident's door to ask for help and when she turned back around the resident was on the floor. CN AA said that even if CNA FF felt like she had to go get someone, she should have made sure the bed was lowered as indicated in R#49's plan of care. During an interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE, CNA EE revealed that it usually required two staff to care for R#49. When asked about steps to take when the resident became combative during care, CNA EE said staff were supposed to wait until she calms down and then try to give care later. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on 12/15/18 the CNA FF was providing care to R#49 when the resident became aggressive. CNA FF said the resident and she played tug of war with the face towel while CNA FF washed the resident's upper extremities. According CNA FF, R#49 was striking out at the CNA FF and also punched the side rail with her right fist. Continued interview with CNA FF revealed that she did not re-approach the resident as indicated in her care plan and did not use the call light to seek help from other staff. During a follow-up interview at the nurses' station on 1/31/19 at 9:58 a.m. with Registered Nurse Charge Nurse AA revealed that the she thinks the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Cross Reference F689 2. Review of the clinical record for R#94 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment for R#94 dated 1/8/19 revealed R#94 was severely cognitively impaired and required extensive to total assistance of one to two staff persons for all activities of daily living (ADLs). During this assessment period, R#94 received occupational therapy (OT), passive range of motion (PROM), and splint/brace assistance. Review of the Task tab printed from the electronic record for R#94 on 1/31/19 revealed Restorative staff was to provide R#94 with Passive Range of Motion (PROM) to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed that there was not a plan of care developed to address proper neck/head positioning. Review of the Occupational Therapy (OT) Discharge Summary for R#94 dated 1/11/19 revealed one of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation of R#94 in her room on 1/28/19 at 10:55 a.m. revealed that R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and Minimum Data Set (MDS) Coordinator revealed that R#94 had used the travel neck pillow for quite some time (over a year) at the daughter's request because she felt her mother was comfortable with its use. The MDS Coordinator confirmed that a care plan should have been developed to address the use of the resident's travel neck pillow. Cross Reference F688",2020-09-01
2,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2019-02-14,688,D,0,1,PXEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Resident Mobility and Range of Motion the facility failed to assess and provide treatment for one Resident (R), (R#94) for neck positioning. The sample size was 26 residents. Findings include: Review of the facility's policy titled Resident Mobility and Range of Motion reviewed on 2/1/18 revealed 3. Residents with limited range of motion will receive treatment and services to increase and/or prevent further decrease in range of motion; 4. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable .5. Therapy will evaluate/reevaluate the resident's mobility on a routine basis to determine the need for range of motion exercises. Review of the clinical record for R#94 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] with documented [DIAGNOSES REDACTED]. Continued review of the MDS revealed R#94 was severely cognitively impaired and exhibited no behaviors during the assessment period. The resident required extensive to total assistance of one to two staff persons for all Activities of Daily Living (ADLs). During this assessment period, R#94 received Occupational Therapy (OT), passive range of motion (ROM), and splint/brace assistance. Review of the Task tab for R#94 printed from the electronic record on 1/31/19 revealed the resident required total assistance for eating; required two-person total dependence for bathing, bed mobility, and dressing. These tasks were to be completed by the Certified Nursing Assistants (CNAs). Further review revealed Restorative staff was to provide the resident with passive ROM to the left hand six times per week for 15 minutes for each treatment and was to apply a splint/brace to her left hand for up to six hours - six times per week. The Task tab did not list the use of a travel neck pillow to be used for proper head positioning. Review of the comprehensive care plans for R#94 last reviewed on 1/12/19 revealed the plan did not list appropriate head positioning as a focus area requiring interventions. Review of Therapy Screening Forms for R#94 dated 4/26/18, 7/31/18, 9/25/18 and 12/17/18 revealed a section with instructions to Indicate all areas reflecting a change in condition or an area with a deficit that may warrant therapy. For each screening form, the items in this section were left blank and unaddressed. Some of the items included in this section were: Poor positioning/body alignment, swallowing difficulties, choking/coughing with meals/meds. The 12/17/18 screening form recommended an OT evaluation. Review of the OT Discharge Summary for R#94 dated 1/11/19 revealed R#94 received OT services from 12/18/18 through 1/11/19. R#94 received OT services for the following reasons: 1) increase trunk strength; 2) increase sitting balance during ADLs; 3) to achieve normal anatomical alignment of the right hand for three hours using a hand roll; 4) to exhibit a decrease in pain at rest in the left hand to improve functional use of upper extremities during ADLs; and 5) to safely wear finger extension splint on left fingers for up to five hours. R#94 was discharged from OT services on 1/11/19 due to achieving the highest practical level of functioning. One of the discharge recommendations was to continue to use cervical travel pillow when in bed and in Broda chair. Review of an Interdisciplinary Communication Memo for R#94 dated 1/11/19 completed by OT BB documented the following: to Continue to use cervical travel pillow when in bed and Broda chair to maintain appropriate head positioning. Observation in the resident's room on 1/28/19 at 10:55 a.m. revealed R#94 was lying in her bed with the head of the bed (HOB) elevated approximately 30 degrees. R#94 had a travel neck pillow around the back of her neck and the resident's head was bent forward and to the right near her shoulder with the resident's chin touching her chest as she slept. Observation in the resident's room on 1/30/19 at 11:35 a.m. revealed R#94 was lying in her bed and positioned slightly on her right side. The resident had the travel neck pillow around her neck, and her chin rested on her chest near her right shoulder. Interview at the nurses' station on 1/30/19 at 12:06 p.m. with Registered Nurse Charge Nurse (CN) AA revealed that R#94 used the travel neck pillow for positioning and for comfort. Registered Nurse CN AA confirmed, at this time, that the resident's head alignment was chin-to-chest, and stated that it had been that way for at least several months. Observation in the day room of the secured unit on 1/30/19 at 2:35 p.m. with OT BB present revealed R#94 was sitting in a padded Broda chair with her travel neck pillow behind her neck. The resident's chin was resting on her chest and leaning towards her right shoulder. During an interview at this time with OT BB in the day room of the secured unit, the therapist confirmed R#94 did not have appropriate neck positioning. OT BB revealed the travel neck pillow was something the family wanted the resident to have to address the resident's right lateral lean of her head towards her right shoulder that began over a year ago. OT BB stated that it was possible the travel neck pillow was contributing to the resident's chin sitting on her chest and therefore, OT BB felt she needed to screen the resident regarding neck flexion and the possible use of a neck collar. Interview on 1/30/19 at 3:50 p.m. with the Director of Nursing (DON) and MDS Coordinator revealed R#94's daughter encouraged and provided the use of the travel neck pillow. The DON said the pillow was brought in by the daughter over a year ago because the daughter felt her mother was comfortable with its use. Observation of R#94 in the day room of the secured unit with the DON present on 1/30/19 at 4:10 p.m. revealed the resident had the travel neck pillow around her neck and the resident's chin was resting on her chest. During an interview at this time in the day room of the secured unit with the DON, the DON stated she had not seen the resident's head/neck in that position before and felt that it (chin-to-chest position) was something that had recently happened. Interview on 1/31/19 at 8:55 a.m. with the DON revealed the DON had spoken with OT BB and that the therapist informed her that the intended purpose was for the travel neck pillow to be used as a preventative intervention for hyper-extension of the resident's neck (going backwards) but after looking again, the OT BB felt the travel neck pillow may be causing flexion of the neck muscle (going forward). Interview on 1/31/19 at 10:38 a.m. with the DON revealed OT BB assessed R#94 (on the morning of 1/31/19), and OT BB was going to call the residents daughter to discuss discontinuing the use of the travel neck pillow. Follow-up interview with the DON on 1/31/19 at 11:46 a.m. revealed that the DON spoke with the resident's daughter and that the daughter explained that the initial reason for getting the travel neck pillow was to keep the resident's head from leaning to the right side. She said the daughter realized that the resident's head was now moving forward in the chin-to-chest position and the daughter agreed with discontinuing the use of the travel neck pillow. Interview on 1/31/19 at 12:46 p.m. with OT BB revealed the therapist completed the resident's screening and the resident was going to be picked up for therapy to do some neck exercises and stretching and to determine if a soft collar should be utilized. OT BB said the daughter was in agreement of discontinuing the use of the travel neck pillow. Follow-up interview on 1/31/19 at 2:05 p.m. with OT BB revealed when asked about the resident's quarterly therapy screens not addressing the resident's neck posture, OT BB said that when she evaluated the resident earlier in (MONTH) 2019, she looked at her mostly for her hand splint. OT BB said she didn't realize until today (1/31/19) how thick and heavy the travel neck pillow was and said, gravity and the pillow are causing it (the resident's neck) to move forward and thrust her chin against her chest. The therapist stated the travel neck pillow needs to be discontinued.",2020-09-01
3,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2019-02-14,689,G,0,1,PXEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and review of the facility policy titled, Fall Policy the facility failed to provide supervision during a bed bath to prevent an avoidable fall for one Resident (R), #49. Actual harm was identified when R#49 suffered a midline laceration to the forehead and a [MEDICAL CONDITION] (Cervical) vertebral body requiring the use of a C-spine collar when she fell from her bed after being left unattended during a bed bath on 12/15/18. The sample size was 26 residents. Findings include: Review of the facility's policy titled, Fall Policy reviewed 3/1/18 revealed The facility will identify each resident who is at risk for falls and will plan appropriate care and implement interventions to assist in fall prevention. The facility will attempt to decrease falls with injury by providing an environment that is free from potential hazards. Review of the clinical record for R#49 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. and depression. Review of the Annual Minimum Data Set (MDS), for R#49, dated 9/5/18 and review of the Quarterly MDS dated [DATE] revealed that the resident was assessed to be severely cognitively impaired, had physical and verbal behaviors directed towards others for one to three days during the assessment period. Review of Section G of this MDS documented that during this assessment period the resident was assessed to be dependent on staff for bathing and required two plus person assist for bathing. R#49 had no impairment of the upper or lower extremities. Continued review revealed during this assessment period the resident had no falls and did not utilize any restraints or alarms. Review of a handwritten statement dated 12/21/18 written by Certified Nursing Assistant (CNA) FF documented the following: On 12/15/18 at 10:45 a.m., I (CNA FF) entered room [ROOM NUMBER]. I began washing R#49's upper body and during the process she was fighting. She was yanking on the face towel and shirt. She punch at me and hit the right bedrail. I let her head down and lifted the right bedrail up and begin peri care. I turned her (R#49) to her left side to clean her bottom. She continue swinging her right arm backward towards me and pushing back. I felt that I could not clean her well, so I place her on her back. I went to pull right bedrail back down (meaning put the siderail in place) and R#49 grabbed it and begin shaking and punching it. I left it up (meaning that the siderail was not in place) and walked to the doorway and called for help. While I was standing in the doorway I heard a bang and when I turned around R#49 was laying on her back on the floor. I went towards her and yelled for the nurse. Signed by CNA FF. (sic) Review of a Fall Report dated 12/15/18 completed by Registered Nurse Charge Nurse (CN) AA documented the following: CN AA (Registered Nurse Charge Nurse AA) was summoned to R#49's room and that the resident was noted lying on the floor on the right side of her bed .range of motion done, patient assessed and placed back on the bed. According to the report, the fall resulted in a laceration to the top of the resident's scalp. There were no other injuries noted. Predisposing Physiological Factors affecting the fall were noted as confused, drowsy, incontinent, recent change in condition, impaired memory and recent change in medications/New. Review of the section titled Witnesses revealed there were No Witnesses found. According to the report, the resident's Physician and family were notified of the fall. There was no other information included in the report. Record review of the Health Status Notes for R#49 dated 12/15/18 documented by Registered Nurse Charge Nurse AA revealed the following documentation in pertinent part: summoned to resident's room by caregiver, resident noted lying on the floor with a laceration to forehead extending to top of head with a small amount of bleeding. Patient assessed, and range of motion done and placed back to bed. Vital signs stable. Small amount of bleeding noted, able to control the bleeding. Neuro checks completed and intact .spoke to Nurse Practitioner who gave orders to send to ER (emergency room ). Spoke with patient's son and niece who agreed for her (R#49) to be sent out. Review of a History and Physical (H&P) Hospital Final Report from the acute care hospital dated 12/15/18 documented that R#49 was a [AGE] year old female with severe dementia, who presents from nursing home after ground level fall (do not know many details of how fall happened, attempting to contact nursing home and family) .Non-contrast head CT (computed tomography) scan revealed left parietal and occipital hemorrhage which appeared to be hemorrhagic conversion of ischemic stroke given fairly localized to PCA territory (neurosurgery in agreement). Patient also found to have a C1 fracture for which she was placed in a C-spine collar. Further review of this H&P revealed that the Assessment/Plan documents . found to have a left parietal and occipital ICH ([MEDICAL CONDITION]) which appears to stay fairly confined to the left PCA territory, suggesting hemorrhagic conversion of an ischemic stroke rather than traumatic ICH. She (R#49) was also found to have a C1 fracture which will require stabilization. On exam, she moves all extremities equally and spontaneously. Review of R#49's Task List Report (a list of tasks to be completed by the Certified Nursing Assistants (CNAs) printed on 1/31/19 revealed the tasks of completing personal hygiene, bathing, and bed mobility were initiated on 1/13/17 (the resident's date of admission). According to the report, R#49 required the total assistance of one-two persons for personal hygiene; she required the extensive assistance of one person for bathing; and she required the extensive assistance of one person for bed mobility. According to the Task Report, the resident's level of assistance during ADLs had not changed since the tasks were initiated on 1/13/17. Observation in the resident's room on 1/30/19 at 11:09 a.m. revealed the resident was in her bed sleeping and the head of bed (HOB) was elevated approximately 30-45 degrees. The bed was in a low position. R#49 wore a neck collar, and the floor mat was on the floor to the left side of the bed. Continued observations revealed a healed vertical scar down the middle of the resident's forehead spanning from the middle of her forehead and into her hairline. During an interview at the nurses' station on 1/30/19 at 11:55 a.m. with Registered Nurse CN AA revealed that on 12/15/18, when the nurse entered the resident's room after the fall, R#49 was on the floor and had a laceration to her forehead that was deep. R#49 was sent out to the emergency room for the laceration and once at the hospital, it was found that her injuries were more than that. Registered Nurse CN AA said she remembered CNA FF was in the resident's room providing care. CNA FF told Registered Nurse CN AA that R#49 was combative, so she came to the door to ask for help and when she turned back around the resident was on the floor. Registered Nurse CN AA said staff were trained to use the call light if a resident became combative. The nurse said staff should get help to come to the room because at that point they (residents) can't be left unsupervised. Registered Nurse CN AA continued that even if (CNA FF) felt like she had to go get someone, she should have made sure the bed was lowered. Interview at the nurses' station on 1/30/19 at 3:20 p.m. with CNA EE revealed that CNA EE did not usually work with R#49, but that she had assisted other CNA's who had were assigned to assist the resident. CNA EE said it usually required two staff to care for the resident because, she (R#49) fights. Continued interview with CNA EE revealed that when residents become combative staff were supposed to wait until she (the resident) calms down and then try to give care later. Go in with two people once she calms down. Telephone interview on 1/30/19 at 4:43 p.m. with CNA FF revealed on the day of the resident's fall, she entered the resident's room to provide care (bed bath). The resident was sitting in bed with the head of the bed (HOB) elevated approximately 60 degrees. CNA FF said she raised the bed in order to provide care and left the resident with the HOB elevated and in a sitting position in order to wash the resident's face and upper extremities. CNA FF said the bilateral side rails were lowered (meaning that they were in place). When CNA FF began to wash the resident's face, the resident became combative and was grabbing at the towel. CNA FF said they were playing tug of war with the towel. CNA FF said she was able to complete washing the resident's upper extremities and then began to put on the resident's shirt. At this point, CNA FF said the resident began to swing at her which prevented the CNA FF from being able to put the resident's arms in her shirt. CNA FF stated that at one point in an attempt to hit CNA FF, that R#49 punched the side rail. Once CNA FF completed the resident's upper body, she lowered the HOB and lifted the side rail towards the HOB (meaning that the side rails were not in place), so she could complete peri care for the resident. CNA FF stated she raised the side rail to complete peri care because it was easier to reach the resident with the side rail raised (meaning that the side rail was not in place). CNA FF turned the resident over on her left side while the resident was still being combative, and the resident was using her right hand to swing back at CNA FF and grabbing the towel. CNA FF said she continued to take the towel out of the resident's hand. Once on her left side, CNA FF realized that the resident had been incontinent of bowel. The resident continued to be combative and striking and CNA FF realized she needed help to complete the resident's care. At this point, CNA FF said she attempted to put the side rail back in place and attempted to lower the bed. Due to the resident's physical aggression, she was unable to do so, but CNA FF stated she believed the bed did lower some. CNA FF then went to the doorway of the resident's room to call for assistance from another staff member. CNA FF said she called for help three times and then heard a loud thump and turned around and saw the resident's feet on the floor. CNA FF went to the resident's side of the room and found the resident on the floor on her back with her head near the dividing wall between the resident's and her roommate's beds. R#49's legs were near the foot of her bed. CNA FF said she screamed out for help. Continued interview with CNA FF revealed that sometimes it required one and two staff members to provide care for R#49. When asked about methods of caring for residents who are exhibiting combative/resistive behaviors, CNA FF said options were: 1) re-approaching, 2) pushing call light, and 3) calling for help. CNA FF said she did not re-approach the resident and did not use the call light to seek help from other staff. CNA FF said the resident required a Hoyer lift for transfers and required staff assistance for bed mobility. According to CNA FF, R#49's level of assistance in bed mobility sometimes varied. Interview on 1/31/19 at 9:33 a.m. with CNA GG revealed R#49 usually required two person assist, but sometimes, it depends. CNA GG worked on 12/15/18, the day the resident fell from bed. CNA GG said she was on the other hall when the fall occurred but was told by CNA FF that the resident fell out of bed. CNA FF told CNA GG that she went to the resident's doorway to call her for assistance because the resident was being combative and fighting and while at the door CNA FF heard a thump and turned around and realized the resident fell out of bed. CNA GG said that when caring for combative residents, it was the staff's responsibility to make sure they (the residents) are safe before leaving their side to get help, or that staff should push call light to get assistance. During a follow-up interview on 1/31/19 at 9:58 a.m. with Registered Nurse CN AA, the nurse was asked what she saw when she walked into the resident's room. Registered Nurse CN AA said R#49 was face down on the floor and she could see a little blood on the floor. At that time, she turned the resident over and saw the laceration in the middle of her forehead. Registered Nurse CN AA said she thinks the bed was still in a high position and the side rail was up towards the HOB. Registered Nurse CN AA continued by stating she thinks that the resident's care plan called for one person for receiving care in bed and two people if resident is combative. Interview on 1/31/19 at 10:18 a.m. with Licensed Practical Nurse (LPN) HH revealed she was present along with Registered Nurse CN AA in R#49's room on 12/15/18, immediately after the fall. LPN HH said R#49's bed was in a high position and that the side rail was up towards the head of the bed (meaning the side rail was not in place). LPN HH revealed that she did not work on R#49's hall so she was not familiar with the kind of assistance the resident required; however, LPN HH said that when providing care for a combative resident that sometimes you need to get someone else or re-approach. Make sure the resident is safe and then ring call bell for assistance. An interview on 1/31/19 at 10:20 a.m. with the facility's Associate Medical Director (AMD) and the facility's Director of Nursing (DON) confirmed R#49's fall resulted in a C1 fracture. The AMD acknowledged that he was aware of the resident's combative behaviors and said the resident was very strong. During the interview, the DON said that when dealing with combative residents there should be two staff, and if a CNA realizes more assistance is needed, then they should get more help. The DON said it would have been a better choice for CNA FF to use the call light to ask for assistance, or to have lowered the bed and then seek help. She said that for R#49, one-two staff were required for care while in bed, it was at the CNA's discretion depending on the resident's behavior. Post survey telephone interview on 2/14/19 at 5:15 p.m., with the Administrator and Director of Nursing (DON) revealed that the Task List is a mini care plan that lists out Activities of Daily Living for CNA's for care planned individualized approaches. The DON revealed that if a resident has been assessed (such as for MDS) to require two plus person assist for baths then a two plus person assist bath should be provided. Further interview, at this same time, with the DON and Administrator revealed that during the facility's investigation of the fall they determined that CNA FF had left the bed in a high position and that the side rail was in the up position (meaning that the side rail was not in place at the time the resident fell out of bed). Continued interview with the DON revealed that what should have happened that did not happen was that CNA FF should have gotten additional assistance by using the call light or by yelling out, the CNA should have lowered the bed before leaving the resident, and that CNA FF should have ensured the safety of the resident. Post survey telephone interview on 2/14/19 at 6:25 p.m., with CNA FF clarified that that she was familiar with working with R#49, and that R#49 had exhibited behaviors like this before when she had provided care previously. CNA FF stated that previously she had been able to talk to the resident and redirect her but on 12/15/19 she was not able to re-direct the resident. CNA FF further revealed that she should have let the side rail down (put the side rail in place), and that she should have used the call button to call for help or even used her cell phone to call for help and that she should not have walked away from the resident.",2020-09-01
4,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2019-02-14,880,D,0,1,PXEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policy titled, Handwashing/Hand Hygiene the facility failed to ensure food was served in a sanitary manner for six of 41 residents (R), R#63 and five unsampled resident) residing on the secured unit. Findings include: Review of the facility's document entitled Handwashing/Hand Hygiene policy (undated) noted the following: 6. Wash hands with soap and water for the following situations: a. When hands are visibly soiled; b. After contact with a resident with infectious diarrhea .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: a. Before and after coming on duty; b. Before and after direct contact with residents; .i. After contact with a resident's intact skin; .l. After contact with objects in the immediate vicinity of the resident; .o. Before and after eating or handling food; p. Before and after assisting a resident with meals. Review of the clinical record for R#63 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly MDS dated [DATE] revealed the resident required the limited assistance of one staff person for eating and required the extensive assistance of one staff person for personal hygiene. During the lunch meal observation in the north dining room of the facility's secured unit on 1/28/19 at 1:07 p.m. an unsampled resident was seated at a dining table waiting to be served her lunch meal. The resident's left shoe was off of her foot and the resident was having difficulty putting her shoe back on. At this time, the Activity Director (AD) was passing out utensils wrapped in cloth napkins to all of the resident in the dining room and when the AD approached this unsampled resident, the AD set the tray of utensils down on the table and then assisted the resident by putting her shoe on for her. After the resident's shoe was on, the AD picked up the tray and passed out the remaining two cloth wrapped utensils that were on the tray. The AD did not perform hand hygiene before passing the utensils to the two other unsampled residents. Upon completion of passing out the utensils, still having performed no hand hygiene, the AD then served and provided meal set-up for three other unsampled residents. Continued observation of this meal service at 1:15 p.m., revealed the AD left the dining room area and went to R#63's room to escort the resident to the dining room for lunch. The AD was observed to brush R#63's hair as the resident was sitting on her bed. After brushing the resident's hair, the AD prompted the resident to stand up and then escorted R#63 to the dining room by using side by side assistance while holding the resident's hand. Once in the dining room, the AD assisted the resident in sitting down at the table. Without performing any hand hygiene, the AD served the resident her meal tray and then provided meal set-up. Interview with the AD in the north hallway of the secured unit on 1/28/19 at 1:25 p.m. revealed when the AD was asked what she should have done after assisting the unsampled resident with her shoe, the AD paused and then said, My hands! The AD continued and said that because she was multi-tasking, she over-looked the step of washing her hands or using hand sanitizer after assisting the resident with her shoe and after brushing R#63's hair. The AD said she missed that step. Interview at 1:30 p.m. at the nurses' station with Registered Nurse Charge Nurse (CN) AA revealed that the AD was also a CNA (Certified Nursing Assistant) and that she assisted the other CNA's with meal service on the unit at least once or twice each week. Registered Nurse CN AA confirmed that the AD should have performed hand hygiene after assisting the residents with their dressing and hygiene tasks. In addition, Registered Nurse CN AA said hand hygiene should be conducted between each resident's meal set-up.",2020-09-01
5,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2017-03-23,247,D,0,1,6QM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview with facility staff, review of the electronic records, and review of the policy titled Room Change/Roommate Assignment, revised (MONTH) 2006, the facility failed to ensure that written notification of room change was provided before moving a resident from the third floor to the fourth floor for one of 32 sampled residents (R) (R#194). Findings include: Review of a Social service assessment dated [DATE]; the resident is coded as independent for decision making skills and understanding the need for placement and participated in the placement decision. Review of the Room Change/Roommate assignment policy, revised in (MONTH) 2006 includes in part; Prior to changing a room or roommate assignment all parties involved in the change assignment (e.g.) Residents and their representatives (sponsors) will be given a 2-day advanced notice of such change. The notice of a change in room or roommate assignment may be oral or in writing, or both, and will include the reason(s) for such change. On 3/20/2017 at 1:00 p.m., R#194 was interviewed and he reported that he was very upset at the time that he was moved to this room from the third floor. He stated this happened about three months ago and no one prepared him for a room change. The resident said, they came to me after I finished my breakfast and moved me the same day. The resident stated, They told me I had to be moved because I no longer needed therapy and I became long term care. If they do it again I will speak up for myself because that really upset me. Review of the Shift Charting Notes dated 1/16/2017 at 9:49 a.m., the resident was transferred to (a room on the fourth floor) per staff. Medications and personally belongings transferred, report given as well. Review of a General Social Services Note dated 1/12/2017 at 3:18 p.m, documents the resident is to remain for long term care. MSW left a message on voice mail of his daughter to discuss room change to the 4th floor- traditional long term care unit. Advised bed is available a telephone service would need to be established if they desire a land line, needs a dresser and TV. Requested a return call to discuss this further. Planning for change to a fourth floor room, if agreeable. On 3/22/2017 at 11:03 a.m., during interview with the Social Service Associate he confirmed that he did not receive a return call from R#194's daughter and he did not call her back, nor did he document any conversation with the resident regarding any room changes. He stated that he was off for the weekend holiday and returned on 1/17/2017 and was then notified the resident had been moved from the fourth floor on 1/16/2016. He provided the surveyor with a room change notification form dated 1/17/2017 at 9:11 a.m., the form included new room number on the fourth floor and the residents' daughters' name as being notified a day after the move occurred.",2020-09-01
6,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2017-03-23,328,D,0,1,6QM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, facility policy review and staff interviews, the facility failed to ensure residents received proper [MEDICATION NAME] treatment and care by not capping the sterile end of an intravenous (IV) tubing nor removing air from syringes and intravenous tubing. This had the potential to affect one of two residents (R) (R#37) currently receiving IV medications in a universe of 32 sampled stage 2 residents. Failure to cap the sterile end on an IV could result in a resident infection and failing to remove air from syringes or intravenous lines could result in an air [MEDICAL CONDITION] (a blood vessel blockage caused by air bubbles in the circulatory system). Findings include: Observation in R#37's room on 3/23/17 from 9:30 a.m. - 10:00 a.m. revealed Licensed Practical Nurse (LPN) (LPN KK) verbalized intention to flush R#37's right hand intravenous (IV) catheter using a 10 cc syringe of sterile normal saline (NS), However, as she moved toward the IV with the syringe, she had not expelled the visualized air from the syringe. Surveyor stopped the procedure requesting she expel the air. She held the syringe horizontally expelling liquid while the air bubble remained. She turned to resume flushing and again was asked to remove the air from the syringe, requesting LPN KK hold it vertically, syringe tip up, to examine and expel the air bubble. LPN KK did remove the air, shaking her head, offering that she was nervous being watched but can do this as she flushed the IV extension tube with the NS. LPN KK then opened the sterile IV tubing package and connected a 100 cc bag NS with 1 gram of [MEDICATION NAME] (an Antibiotic) to the IV tubing. She ran the solution through the tubing without closing clamp or turning filter upside down. LPN KK then strung the tubing through the medication pump (used to regulate the time and amount of solution administered). The pump began beeping when it was turned on. It was noted there were multiple air bubbles still in the tubing. She had difficulty clearing them. She decided to switch tubing out to a dial flow rather than use a pump. She disconnected the medication bag from the pump tubing and ran the medication through the new dial a flow tubing then connected to the resident. The clamp to the R#37's extension tubing had not yet been opened. There was air still noted in the dial a flow tubing when surveyor asked to see it before proceeding. LPN KK then disconnected from R#37's and cleared the tubing of air and reconnected but the solution would not drip after she unclamped. She unhooked the IV tubing and draped it over the IV pole without capping the exposed connection tip. The tubing was noted to swing back and forth a few times when draped over pole. LPN KK cleaned tip with alcohol and covered with the cap after surveyor pointed her over sight out to her as she went to leave R#37's room. Examination of Facility Policy Administration of Infusion Therapy, Procedure for Continuous or Intermittent Infusion last reviewed 9/27/16 specified in step 7: Remove the tubing from the package and close the roller clamp. Step 10: Hang the bag (with the previously inserted tubing) on the pole, squeeze the drip chamber to establish the proper fluid level (1/2 - 2/3 full). Turn the filter upside down, open the roller clamp, and prime system of air. Step 12: Remove air from normal saline flush syringe (to flush the infusion access device.) Step 16: Disconnect administration set from injection valve and place sterile cap over leur-lock end of IV tubing. Interview of LPN KK at 10:00 a.m. revealed she was upset with myself and should have assured air was removed from syringe and tubing before proceeding. She acknowledged that capping the connection tip would protect from contamination. She further revealed she has had training in IV care but does so infrequently. During the 11:00 a.m. Interview on 3/23/17 of the Director of Nursing (DON), revealed LPN KK should have followed the IV procedures and My biggest concern is in regard to (LPN KK's) lack of air removal from the syringe and IV tubing. The DON revealed the facility does not perform competencies on nurses regarding IV medication administration but would see LPN KK is re-educated. However, at 12:30 p.m.,, the DON provided a copy of a 3/1/2016 Medication pass observation report performed by an RN Pharmacy Consultant of LPN KK performing a Normal Saline IV flush. The document did not include a check off of the expected steps of the observed IV push procedures nor was the use of intermittent IV med bag infusion or tubing care documented as part of the observations performed on 3/1/16.",2020-09-01
7,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2017-03-23,371,F,0,1,6QM511,"Based on observation, staff interview, anonymous interviews, review of dish washer temperature log, and review of the Dish Machine Temperatures policy, revised 1/2016, and the Uniform Dress Code policy dated 1/2016, the facility failed to ensure the high temperature dishwasher wash temperature was maintained at 160 degrees Fahrenheit (F) and final rinse temperature was maintained at 180 degrees (F), or higher, The facility failed to have test strips for the dishwasher and attach the test strips to the dishwasher log as required by facility policy, and failed to ensure that staff wore hair and beard restraints while in the kitchen. This failure had the potential to effect 128 residents that received food from the kitchen. Findings include: Observation on 3/21/17 at 10:37 a.m. of the electronic dishwasher monitor screen revealed that it was red and had a tringle with an exclamation point (!) in it. In an interview at this time Dietary Aide DD stated that the dishwasher monitor screen was red and had an exclamation point in the triangle, because the water temperature in the dishwasher was too low. Dietary Aide DD stated that the dishwasher was a hot water dishwasher, the wash water temperature is supposed to be 160 degrees F and the rinse is supposed to be 180 F, but the water temperature has been fluctuating. Continued observation on 3/21/17 from 10:37a.m. to 10:45 a.m. revealed that the Dietary Aide DD continued to wash the dishes and the monitor continued to be red with an exclamation point inside a triangle. The wash water temperatures on the electronic monitor fluctuated from 132 to 157 degrees F and the rinse temperature fluctuated from 177 degrees F to 192 degrees F. Further observation revealed Dietary Aide DD never verified the water temperature fluctuation with a test strip attached to a dish. In an interview at this time the Dietary Aide stated that he had washed about 10 racks of dishes and the other staff member put them on the storage rack. In further interview, Dietary Aide DD stated that his supervisor instructed him to continue to wash dishes, the repair person had been called and was on his way. In an interview on 3/21/17 at 11:05 AM the Dietary Manager CC stated that she had the staff re- wash all the dishes that were ran through the dishwasher using the three compartment sink and she in-serviced the staff on not using the dishwasher when the water temperatures were not correct. Duringan interview on 3/21/17 at 3:09 PM the Dishwasher repair person stated that the wash water temperature in the dishwasher was only getting up to 140 F degrees for wash temperature and the rinse water temperature was at 160 degrees F, but the wash should be at 160 degrees F, the rinse should be at 180 degree F, he would run his test strips through the dishwasher once he gets the water temperature corrected. In continued interview the Dishwasher repairman stated that the dishwasher booster heater was tripped by the cold water that had been sitting in the pipes and he would email this surveyor the invoice once the work was completed. Surveyor received an email from the dishwasher repair person on 3/21/17 at 4:07 p.m., requesting a call back. When called the repair person stated ESR booster heater not working, Temp was low on rinse and wash tank, reset booster heater, now reading 195 on the rinse, 160 on the wash. During an interview on 3/22/17 at 10:48 AM the Dietary Manager stated that the dishwasher's electric monitor was not working, she called the repair person to replace it and she did not have test strips to check the water temperature of the dishwasher. Review of the facility's Dish Machine Temperatures policy dated revised 1/16 revealed: Single-tank, conveyor, dual temperature machine: Wash temperature 160 degrees F, Final rinse temperature 180 F -194 F. High Temperature Dish machine- Record on Dish machine record form wash and final rinse temperatures during each period of use. Once a day, run a test strip through the dish machine to verify the surface temperature of a dish. Attach the used test strip to the temperature log. The test strip must verify that the surface temperature of the plate reached 160 degrees F. If documentation of the temperatures and test strips has been assigned to a Food and Nutrition Associate confirms that it is completed at each meal period. Director determines if reading is due to malfunctioning gauge or inappropriate temperature .If due to inappropriate water temperature (high temperature machine) or inappropriate concentration of sanitizer solution (low temperature), implements disposable service ware, contacts sources of repairs, documents action taken on back of form. Review of the facility's dishwasher log for the month of (MONTH) (YEAR) revealed that there were no test strips attached to the dishwasher log verify the surface temperature of a dish. In a confidential interview on 3/20/17 at 1:33 p.m. an employee stated that the staff are only wearing hair nets because surveyors were in the building. Observation on 3/21/17 at 12:05 p.m. revealed that Dietary Aide EE had facial hair and was in the kitchen without a beard restraint. In an interview at this time Dietary Aide EE stated that he is supposed to have on a beard restraint when he is in the kitchen. Observation 3/21/17 at 12:05 p.m. revealed that Licensed Practical Nurse (LPN) FF was in the main kitchen in the food prep area without a hair net. In an interview on 3/21/17 at 12:01 p.m. the Dietary Manager stated that staff are not supposed to be in the kitchen without hair nets or beard restraints. Review of the facility's Uniform Dress Code policy dated 1/16 revealed . Wear the approved hair restraint when on duty. The only exception is to remove hair restraints when delivering trays to patients/residents . Facial hair must be effectively restrained as per local and state regulations .",2020-09-01
8,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2019-01-25,584,D,0,1,4HRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of facility documents the facility failed to maintain a safe/clean/comfortable homelike environment for the residents in six rooms (out of 24 rooms) on one unit (out of five). Specifically, six rooms on Unit 300 had significant areas of bare walls where the paint had been scratched, scuffed or peeled off. The documents reviewed included the Daily Housekeeping Room Checklist, Housekeeping Review, Work Order Logs and the Call In Work Orders listing. Findings include: A tour of Unit 300 was conducted with the Maintenance Director (MD) beginning on 1/25/19 at 10:35 a.m. The following areas were confirmed with the MD including: room [ROOM NUMBER]: Multiple areas on one of four walls where paint is scuffed, scratched and peeling, missing; room [ROOM NUMBER]-A: Multiple areas on the wall behind the head of the bed where paint is missing; room [ROOM NUMBER]-A: Multiple areas on the wall behind the head of the bed where paint is missing; room [ROOM NUMBER]: A line of multiple scratched, scuffed areas where paint is missing approximately four feet from floor (waist high) on two of four walls; room [ROOM NUMBER]: Multiple areas on one of four walls where paint is scuffed, scratched and peeling, missing above the cove base; room [ROOM NUMBER]: An area on the entry wall five feet in length approximately three feet from floor (waist high) where paint is missing, scratched, scuffed. During an interview conducted on 1/25/19 at 9:57 a.m. with Maintenance Tech CC revealed that he receives work orders from the maintenance office to complete specific painting tasks. He could not confirm if there was any type of regular scheduled inspection of the rooms for routine maintenance. An interview with the Administrator was conducted on 1/25/19 at 10:15 a.m. revealed that the facility is currently undergoing a renovation by unit. She could not confirm when Unit 300 was scheduled for renovation but stated that even though they are under renovation in other areas, they are still addressing day to day maintenance issues including painting on Unit 300. An interview was conducted with the MD on 1/25/19 at 10:25 a.m. confirmed that staff call the Maintenance Department for any issues such as lights that need replacing and other repairs that may be needed. The maintenance staff create a work order, prioritize and then assign the task. He also confirmed there is no process for routinely auditing resident room conditions. He stated that the housekeeping department manager contacts the maintenance department for any repairs or issues noted during their daily cleaning of resident rooms and common areas. He was unsure if the housekeeping department utilized any type of checklists. He confirmed that there isn't any type of written communication process between housekeeping and maintenance. An interview was conducted on 1/25/19 at 10:30 a.m. with the Housekeeping Director (HD). She confirmed that the communication her department has with maintenance is mostly verbal. She provided a copy of a two page form entitled Housekeeping Review that addresses the cleanliness of the resident rooms and/or common areas but does not specifically reflect any required observations for maintenance issues or concerns. She stated that she uses the form several times a month basis but confirmed it is not completed on every resident room or on a routine scheduled basis. The form states: Directions: Members of the quality action team will review specific areas of the facility. A mark in the 'no' column may indicate a problem. The form contains a list of 17 areas to observe and check yes or no with a space for comments. The end of the form includes a place to document Problems identified; Probably reasons for problems; Goals; Action plan; Responsible staff. The HD also provided a copy of a Daily Housekeeping Room Checklist that includes space for daily checks of three rooms for the following areas: Bathroom; Resident's Room; Curtains; Bedside Table; Window Sill; Furniture; Floors; Pantry. It also has space to note what housekeeper is assigned to the room and any comments/date. Observed and reviewed a clipboard located on the wall of the nursing station for 300 Hall/Unit with forms entitled Work Order Log on 1/25/19 at 12:50 p.m. The form has a place for the month and year to be written in. One sheet was labeled Sept. (YEAR) and contained entries dated from 9/13/18 through 12/10/18. A second sheet was labeled Dec. (YEAR) and contained entries dated from 12/11/18 through 1/25/19. There are no entries on either sheet concerning paint issues in resident rooms. During an interview conducted on 1/25/19 at 1:13 p.m. with the Administrator, she confirmed that she does not have a policy on conducting any type of environmental rounds or the routine monitoring of the condition of resident rooms. She stated the MD performs preventative maintenance in the building.",2020-09-01
9,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2019-01-25,656,D,0,1,4HRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow the care plan related to administering medications as ordered for one Resident (R) (R#114). The sample size was 49 residents. Findings include: Review of the medical record revealed that R# 114 had the [DIAGNOSES REDACTED]. Record review revealed a care plan for the potential for medication side effects related to [MEDICAL CONDITION] medication. This care plan documented an intervention to administer medications as ordered. Further record review revealed a Physician order, with a start date of (MONTH) 1, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) to take one tablet twice daily as needed (prn) for 60 days for agitation. Review of the Medication Administration Record [REDACTED]. Interview on 1/24/19 at 9:40 a.m. with Licensed Practical Nurse (LPN) II confirmed that the PRN [MEDICATION NAME] 0.25 mg order was started in (MONTH) (YEAR) and should have ended (MONTH) 1, 2019. Interview with the Registered Nurse (RN) Unit Manager on 1/24/19 at 9:45 a.m. revealed that they typically get a report from the pharmacy when a medication needs to be stopped and the pharmacy consultant sends a monthly report. The Unit Manager revealed that a report had been received from the pharmacy consultant on 1/22/19, but she had not reviewed or followed up on the recommendations yet.",2020-09-01
10,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2019-01-25,657,D,0,1,4HRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled Comprehensive Person -Centered, the facility failed to update and revise a comprehensive care plan to reflect the vascular site and monitoring of the site for one resident out of five sampled residents (R#133) receiving [MEDICAL TREATMENT] services. Findings include: Record review of policy titled Care Plans Comprehensive Person-Centered stated It is the intent of Magnolia Manor facilities to develop and implement a person-centered plan of care for each resident that include goals for admission, discharge and desired outcomes. 3. (B) Incorporate risk factors (s) associated with the identified problems(s). (D) reflect treatment goals and objectives in measurable goals. B. Reflect the resident's specified goals for admission and desired outcomes. B. Reflect the resident's specified goals for admission and desired outcomes. F. Enhance the optimal functioning of the resident utilizing rehabilitative program as indicated. (5). Care plan are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. The resident has the right to participate in the process and to approve any changes to the plan of care. Record review revealed that R#133 had a Physician order dated 8/20/18 for an AV Fistula (ateriovenous fistula) shunt and attended [MEDICAL TREATMENT] two days a week on Monday and Friday. The Minimum Data Set ((MDS) dated [DATE] section C revealed a Brief Interview Mental Status (BIMS) score of 15 (a score of 15 out of 15 indicates cognitive intact) and a section O revealed a coding for [MEDICAL TREATMENT]. Review of [MEDICAL TREATMENT] care plan dated 10/16/18 (last reviewed on 1/2/19) revealed that there was not any interventions in place to monitor the vascular site or checking the site for bruit and thrill. Interview on 1/24/19 at 3:24 a.m., with the Director of Nursing (DON) revealed that staff should check every shift for bruit and thrill and observe for any infections at the site. She further stated the [MEDICAL TREATMENT] care plan should reflect how often to check and monitor the site. Interview on 1/25/19 at 1:09 p.m., Register Nurse (RN) DD revealed that she was not aware that the [MEDICAL TREATMENT] care plan did not provide interventions about monitoring of the AV shunt site. She further stated that the [MEDICAL TREATMENT] care plan was updated on today 1/25/19 (after the concern was identified during the survey). Interview on 1/25/19 at 1:15 p.m., with the Minimum Data Set (MDS) Coordinator revealed that the [MEDICAL TREATMENT] care plan should be specific to resident care needs. She confirmed that the [MEDICAL TREATMENT] care plan was not revised until 1/25/19 to address monitoring of the AV site.",2020-09-01
11,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2019-01-25,758,D,0,1,4HRK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure that PRN (as needed) medications were taken as ordered for one Resident (R) #114. The sample size was 49 residents. Findings include: Review of the medical record revealed that R#114 had the following [DIAGNOSES REDACTED]. Record review of the chart revealed an order, with a start date of (MONTH) 1, (YEAR), for [MEDICATION NAME] 0.25 milligrams (mg) with one tablet taken by mouth twice daily as needed for 60 days for agitation. Review of the Medication Administration Record [REDACTED]. Interview on 1/24/19 at 9:40 a.m. with Licensed Practical Nurse (LPN) II confirmed that the [MEDICATION NAME] PRN order started in (MONTH) and should have ended (MONTH) 1, 2019. It was reported that typically orders on the rehab unit are not written this way and that the pharmacy notifies when there is a hard stop on an order. Interview with the Registered Nurse (RN) Unit Manager JJ on 1/24/19 at 9:45 a.m. revealed that she had received a report from the pharmacy consultant on Tuesday but she had not reviewed or followed up on the recommendations yet.",2020-09-01
12,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2017-01-26,280,D,0,1,DVCB11,"Based on staff interview and record review, it was determined that the facility failed to revise a plan of care to include a pressure ulcer for one resident (#194) from a total sample of 22 residents. Findings include: A review of Resident (R) #194's clinical record revealed the resident had a stage two pressure ulcer to the left elbow since 10/31/16. During an interview on 1/24/17 at 10:12 a.m., Licensed Practical Nurse (LPN) AA confirmed the resident had a stage two pressure ulcer to the left elbow, identified on 10/31/16. There was a plan of care in place, dated 10/26/16, that R#194 was at risk for pressure areas related to incontinence and decreased mobility. Although interventions were implemented to address the pressure ulcer, the plan of care was not revised to include the presence of the pressure ulcer to the left elbow, until 1/25/17, after surveyor inquiry. During an interview on 1/26/17 at 1:49 p.m., Registered Nurse (RN) BB confirmed that the plan of care had not been revised and stated it was an oversight.",2020-09-01
13,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2018-02-01,761,D,0,1,0R9911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Medication Administration Procedural Guidelines and interviews the facility failed to ensure that the medication cart was locked during medication administration on one of four medication carts observed during medication administration. Findings include: Observation on 01/31/18 at 4:42 p.m. during Medication Administration with Licensed Practical Nurse (LPN) LPN AA on Unit 1 medication cart. revealed that LPN AA parked the medication cart outside along the opposite wall from room [ROOM NUMBER] on Unit 1 and at 4:21 p.m. and returned to the medication cart to remove medications to administer to the other resident in room, 125 A bed. At 4:24 p.m. LPN AA was observed to remov medications from the cart that was against the wall on the other side of the hall on Unit 1 that was not in direct view of the nurse in the residents room [ROOM NUMBER] [NAME] LPN AA then left the medication cart unlocked going into room [ROOM NUMBER] A leaving the door open however, the LPN's back was to the medication cart the entire time she was in the room. LPN AA then came out of the room and called for assistance to help reposition the resident in the bed, not realizing that the medication cart remained unlocked. LPN AA then went back into room [ROOM NUMBER] A continuing to leave the medication cart unlocked. After repositioning the resident with assistance and administering the residents medication the surveyor observed by standing right out side of residents door. LPN AA came out of the room at 4:35 p.m. Interview with the LPN AA, at this time revealed that she had not received any training here at the facility and did not have a preceptor here before starting on the floor, LPN AA also reported she was an agency nurse and started on the medication cart two months ago and comes two times a week. Interview on 2/1/18 at 11:00 a.m. with the Director of nursing reported that the licensed nursing staff do a skills check off list and Life safety packet annually and that on hire agency nurses only do the life safety packet but do not do a skills check off. The DON also reported that the facility receives a packet of the training and skills for agency nurse and what skills they have completed. The DON reported that the expectation is a safety expectation that the medication cart remains locked at all times. Interview on 2/1/18 2:00 at p.m. with RN Unit Manager on 200 Hall reported that all nurses and agency included know that the medication cart is to be locked when they are not in it or by it. Interview on 2/1/18 at 2:45 p.m. with the Administrator who reported that agency nurses receive training from the company they work with and that is noted in our contracts and that when they come to work in this facility the agency nurses receive the facility Life Safety Orientation packet on hire and in the packet they are to review it and it includes the facility Policies and Procedures and where they are located on each unit and in every department. The Administrator reported that any nurse would know that they are to lock their medication cart when not in it. Stated she is aware of the agency nurse that was observed during medication administration yesterday and stated of course her expectations would be that the LPN should have locked the medication cart. Review of the facility Medication Administration Procedural Guidelines dated (MONTH) (YEAR)- #18. During routine administration of medications, the medication cart is kept in the doorway of the patient's room, with open drawers facing inward and all other sides closed. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to patients or others passing by.",2020-09-01
14,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2018-02-01,812,E,0,1,0R9911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility's policy for food and nutrition the facility failed to maintain sanitary resident nourishment refrigerators in unit pantries, failed to store food items properly in resident nourishment refrigerator and failed to dispose of expired food items in a timely manner in resident nourishment pantry on three of five units. Findings include: Observation on [DATE] at 8:14 a.m. of resident nourishment pantry on Unit 3 revealed thickened sweet tea dated as expired on [DATE]. Confirmed as expired by Licensed Practical Nurse (LPN) A[NAME] Observation on [DATE] at 9:39 a.m. of resident nourishment pantry on Unit 1 revealed five cartons of Impact Advanced Reconstituted Nutritional Drink dated expired [DATE]. Confirmed by Registered Nurse (RN) BB as expired. Observation on [DATE] at 9:44 a.m. of resident nourishment refrigerator in the pantry on Unit 5 revealed two unlabeled/undated frozen food items in a take-out container in the freezer. Confirmed by LPN CC. LPN CC stated that the food items that were in the freezer had been brought in for a resident but she was unsure for which resident or when they were brought in. Observation on [DATE] at 9:55 a.m. of resident nourishment refrigerator in the pantry on Unit 4 revealed a large spill of brown liquid in the bottom of the refrigerator. Observation also revealed that the refrigerator contained the following an unlabeled/ undated open coke can, covered loosely by a paper towel, an open unlabeled/undated two- liter grape [MEDICATION NAME] beverage, an unlabeled/undated personal cup, a plate of food with staff signature of SH, LPN and dated [DATE]. The previously listed food items were intermingled with resident nourishment items. A separate employee refrigerator was provided for employee food and was labeled employee. LPN DD confirmed the previous findings. Interview with LPN DD revealed that all staff were responsible for upkeep of the resident nourishment pantries and refrigerators. Interview on [DATE] at 10:10 a.m. with the Administrator and RN, Infection Control Nurse EE revealed that they expect the Unit Manager to make sure that food items are not expired, dated and labeled. If the Unit Manager found that the pantry or refrigerator needed attention, then the expectation was that the Unit Manager would assign personnel to clean it or check food items as needed. They stated that their expectations regarding storage of food items was that staff food items would be stored separately from resident food items which was why staff refrigerators were provided. They stated that if staff and resident food items were stored in the same refrigerator that they would expect them to be stored on separate shelves as well as being dated and labeled. Review of policy for food and nutrition revealed that foods were to be stored, prepared, distributed and served under sanitary conditions. The policy also stated that perishable food items provided for residents must be in air tight containers and stored in the refrigerator in the pantry on the nursing unit and must have the date and the resident's name on it. The policy stated that perishable items left in the refrigerator for more than 48 forty-eight hours would be discarded.",2020-09-01
15,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2019-06-07,656,D,1,0,2RIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that medication for pain was administered for one of 12 residents(A) and failed to provide wound care for one of 12 residents (B) as care planned. Findings include: 1. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waits until her pain medication runs out to order more. Record review revealed that RA had a care plan since 2/819 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration. The care plan included an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed that there was a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. Record revealed that on 5/24/19 a physician's orders [REDACTED]. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. Therefore, the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. Cross refer to F697 2. Record review revealed that RB had a care plan problem, dated 4/2/19, for receiving treatment with an antibiotic for bilateral [MEDICAL CONDITION]. The care plan problem was updated on 4/29/19 to include the use of an intravenous antibiotic and an intervention for nursing staff to provide wound care as ordered. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. During interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes from 5/10/19 confirmed RB reporting the use of silver dressings to her lower extremity wounds. Cross refer to F684",2020-09-01
16,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2019-06-07,684,D,1,0,2RIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to ensure that wound treatments were provided as ordered by the physician for one of 12 residents (R B). Findings include: Record review revealed that Resident (R) B had [DIAGNOSES REDACTED]. During an interview on 6/5/19 at 3:45 p.m. R B stated that Treatment Nurse DD had applied a silver alginate dressing to her legs and she was not supposed to. A review of the clinical record revealed a physician's orders [REDACTED]. This treatment was ordered to treat venous wounds to the right and left lateral calves. During an interviews on 6/6/19 at 4:00 p.m. and 6/7/19 at 10:45 a.m., with Treatment Nurse DD confirmed that she had applied [MEDICATION NAME] Ag, which contains silver, to the open areas on the resident's lower extremities, one day prior to a visit to the wound clinic in (MONTH) 2019, to try something different to help the resident because she was upset about her legs. Treatment nurse DD confirmed that she did not obtain a physician's orders [REDACTED]. A review of wound clinic notes dared 5/10/19 confirmed that RB reported the use of silver dressings to her lower extremity wounds. During an interview on 6/7/19 at 12:55 a.m., with the Director of Nursing (DON) revealed that she expected licensed nursing staff to obtain a physician's orders [REDACTED].",2020-09-01
17,MAGNOLIA MANOR METHODIST NSG C,115004,2001 SOUTH LEE STREET,AMERICUS,GA,31709,2019-06-07,697,D,1,0,2RIR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, record review, and review of the facility policy titled, Obtaining and Receiving Medications from Pharmacy the facility failed to ensure the medication for pain was obtained timely for one of 12 residents (R A). Findings include: The facility had an Obtaining and Receiving Medications from Pharmacy policy. The policy documented that medications that must be reordered by the nurse included controlled substance medications. The policy further documented that Schedule II medications such as [MEDICATION NAME] and [MEDICATION NAME] products required a signed prescription by the physician and should be reordered at least seven days in advance. During interviews on 6/3/19 at 12:00 p.m. and 6/4/19 at 1:50 p.m. Resident (R) A stated that nursing staff waited until her pain medication ran out to order more. Record review revealed that RA had a care plan since 2/8/19 for being at risk for alteration in comfort related to [MEDICAL CONDITION] reflux disease, generalized pain and skin alteration with an intervention for licensed nursing staff to administer medication as ordered. Further record review revealed a Physician's order since 2/15/19 for [MEDICATION NAME] 10-325 milligrams (mg) to be administered every six hours for pain. There was also a physician's order since 2/13/19 for [MEDICATION NAME] 10-325 mg to be administered every six hours as needed for pain. However, a review of the clinical record revealed that the resident did not receive the scheduled [MEDICATION NAME] pain medication as ordered and as care planned on 4/23/19 at 12:00 p.m. and 6:00 p.m. On 4/23/19 a Physician's order was obtained to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when it was available. 2) Administer [MEDICATION NAME] 10-325 mg every six hours, scheduled and discontinue when the [MEDICATION NAME] became available. 3) Keep the order for [MEDICATION NAME] 10-325 mg every six hours as needed for pain. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. On 5/24/19 a Physician's order was again written to 1) Hold [MEDICATION NAME] 10-325 mg every six hours and resume when available 2) Administer [MEDICATION NAME] 10-325mg every six hours, scheduled, for pain and discontinue when [MEDICATION NAME] is available. The resident received [MEDICATION NAME] as scheduled through the 5/24/19 6:00 p.m. dose. The [MEDICATION NAME] 10-325mg was then administered routinely afterward until the supply on hand was exhausted on 5/29/19 at 6:00 p.m. When the on-hand supply of [MEDICATION NAME] 10-325 mg was exhausted, the [MEDICATION NAME] still had not been obtained from the pharmacy. During an interview on 6/3/19 at 12:40 p.m., Licensed Practical Nurse (LPN) AA stated that she phoned the pharmacy on the morning of 5/29/19 (a Wednesday) to check on the status of the [MEDICATION NAME] because she only had two doses of the [MEDICATION NAME] (for 12:00 p.m. and 6:00 p.m.) remaining. LPN AA stated that the pharmacy said they were waiting on a physician signature to fill the prescription. A new Physician's order was obtained on 5/30/19 to administer one Tylenol #4 every six hours as needed until the [MEDICATION NAME] arrived from the pharmacy. A review of the (MONTH) 2019 MAR's and narcotic logs revealed that the resident did not receive the Tylenol #4 until 12:30 a.m. on 5/31/19. Therefore, after the on-hand supply of [MEDICATION NAME] was exhausted and prior to obtaining and receiving the Tylenol #4 medication, the resident missed four scheduled [MEDICATION NAME] pain medication doses on 5/30/19 at 12:00 a.m., 6:00 a.m., 12:00 p.m. and 6:00 p.m. During an interview on 6/3/19 at 1:40 p.m. the Director of Nursing (DON) stated that the nurses should be checking and following up on medications that are low at the beginning of the week.",2020-09-01
18,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2018-07-19,656,G,0,1,9U3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility staff failed to follow the comprehensive care plan for Resident (R #40) on how to safely transfer the resident from one surface to another. On 7/5/18, R#40 was transferred improperly, without the use of a Hoyer lift, resulting in R#40 sustaining two fractured ribs on the left side. The sample size was 46 residents. Findings include: Record review revealed that R #40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#40's most recent comprehensive Minimum Data Set (MDS), a five-day scheduled assessment with an Assessment Reference Date (ARD) of 4/25/18 coded R#40 as cognitively moderately impaired, requiring cues/supervision with decision making and requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. A review of the facility document Nurse Aide's Information Sheet also referred to by the facility staff as the ADL sheet (a communication tool used by the Certified Nursing Assistants (CNA) to determine a resident's ADL needs, including transfers) documented that R#40 needed assistance of one staff member to place from bed into the wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Review of the facility investigation statement, written by CNA BB, revealed that the CNA had never worked with R#40 prior to this incident and had transferred R#40 from her bed to her recliner, at the request of the resident, and failed to obtain assistance from another staff member and did not use the Hoyer lift. CNA BB was on medical leave during the survey process and not available for interview. On 7/18/18 at 12:55 p.m. an interview was conducted with Licensed Practical Nurse (LPN) FF (who was assigned to the resident on 7/5/18) at the D hall nurse's station. LPN FF was asked how does staff know how to care for the residents they are assigned. LPN FF replied, The CNAs should look in the ADL book to determine the resident's transfer status. We also have meetings in the morning at the start of the shift. If they don't know they should ask. When the CNAs come in they should get their assignment and check the ADL book then meet with the nurse. There is no reason for them not to know how to transfer a resident. Further interview with LPN FF was asked to review the ADL sheet and acknowledged that it documented R#40 as an assist of one to transfer to the wheelchair. When asked who completed the ADL sheet, LPN FF stated that nursing was responsible for completing at the time of admission, We write it up in pencil, so it can be updated (with information from the care plan). On 7/18/18 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON) in her office. The DON was asked to explain the incident and investigation when R#40 was transferred on 7/5/18 resulting in rib fractures. The DON stated, We had never seen the resident get out of the bed, we want her to get up, but she refuses, and her family does not want her to get up. The DON stated that the aide had got R#40 out of bed on the morning of 7/5/18 using improper transfer techniques. The DON further stated that R#40 was normally bed bound and the aide should not have attempted to transfer the resident without assistance and should have used a Hoyer lift. The DON confirmed that CNA BB had worked at the facility for about a month and she had never worked with R#40 prior to the date of the incident. When asked how CNA BB would know what R#40's transfer status was the DON stated that it was on the ADL sheet (information from the resident's care plan). The DON was asked to review the information on the ADL sheet at the time of transfer. The DON verified that at the time of the transfer the ADL sheet documented R#40 as a one person assist for transfers to the chair and that this information was incorrect. When asked what the ADL sheet should have documented, the DON stated that it should have been updated to reflect the resident's actual transfer status at that time. The DON further stated that R#40 did not get out of bed and she was totally dependent, and the ADL sheet should have reflected that she needed, at minimum, a two person assist and / or a Hoyer lift for safe transfers. No further information was provided prior to the end of the survey process. Cross reference to F689",2020-09-01
19,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2018-07-19,689,G,0,1,9U3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family and staff interviews and records review, the facility staff failed to ensure that the correct information regarding safe transfer techniques for Resident (R#40) was accurate on the Certified Nursing Assistants (CNAs) care communication tool, the Activities of Daily Living (ADL) sheet. Between 4/18/18 and 7/5/18 R#40 was documented throughout the clinical record as being totally dependent for transfers and requiring a Hoyer lift for safe transfers. On 7/5/18 Certified Nursing Assistant (CNA) BB transferred R#40 without assistance of another staff member and without using a Hoyer lift. Following the transfer R#40 was documented as having increased pain on the left side and an X-Ray completed later that day documented that R#40 had acute fractures of two ribs on the left side resultling in the resident being transferred to the hospital for evaluation. The sample size was 46 residents. Findings include: Observation of R#40 on 7/16/18 at 9:30 a.m. revealed the resident was lying in her bed with her family at the bedside. An interview in R#40's room was conducted with a family member who stated that their mother was doing okay but that a couple of weeks ago she had been transferred from her bed to her recliner by an aide (CNA BB) and was found to have two fractured ribs following the transfer. When asked how the fractured ribs occurred the family of R#40 stated that the aide (CNA BB) had transferred the resident without assistance and did not use a Hoyer lift, which was how she was normally transferred. The family member further stated that the facility had reported the incident to the State and it was their understanding that the facility had investigated the incident. Review of R#40's clinical record revealed the resident's [DIAGNOSES REDACTED]. A review of R#40's most recent Comprehensive Minimum Data Set (MDS), a five-day assessment with an Assessment Reference Date (ARD) of 4/25/18, coded R#40 as being cognitively moderately impaired with poor decision making requiring cues/supervision. R#40's functional status was coded as requiring extensive assistance of two people for bed mobility and totally dependent of two people for transfers. Review of the Comprehensive care plan dated 12/13/17 with an Approach: Transfer with the help of one person and updated on 4/15/18 to 4/18/18 to reflect dependent Extensive, related to weakness, need total assist with Activities of Daily Living (ADL) and Hoyer lift by two persons under the Goal section. A hand written note at the bottom of the care plan dated 4/18/18: (MONTH) use Hoyer lift prn (as needed) during transfers related to weakness. The care plan was updated on 7/10/18 under Approach: Transfer-two person Hoyer lift. Located in a book at the nurse's station on the unit where R#40 resided there was an undated document titled Nurse Aide's Information Sheet (also referred to by the facility staff as the ADL sheet (a communication tool used by the CNAs to determine a resident's ADL needs, including transfers). Review of the sheet revealed R#40 was documented as requiring assistance of one staff member to place in wheelchair. An update was made on 7/9/18 for use of Hoyer lift by two persons for transfers. Further review of R#40's clinical record revealed that the resident was discharged from physical therapy on 4/18/18. The discharge summary documented the following; Patient progress and response to treatment: Per Medical Doctor, patient (pt.) is to discharge (D/C) from skilled physical therapy (PT) services. Transfers: Dependent. Review of the Nurse's Monthly Progress Note revealed the following: Dated: 4/24/18, Licensed Practical Nurse (LPN) AA documented R#40 as being totally dependent for bed mobility and transfers requiring a Hoyer lift. R#40's Activities of Daily Living are documented as deteriorated. Assistive Devices, Hoyer. Dated: 6/27/18, LPN AA documented R#40 as being totally dependent for bed mobility and transfers requiring a Hoyer lift. Assistive Devices, Hoyer. Review of R#40's Nursing notes revealed the following documentation: Dated: 7/5/18 at 3:12 p.m. notified by CNA that resident was complaint of (c/o) severe pain to left side, assessment done, noted resident c/o pain to left rib cage, [MEDICATION NAME] (a pain medication) 5/325 milligrams (mg) tablet (tab), 1 (one) given and Medical Director notified, X-ray of left rib cage and abdominal (ABD) area ordered, son notified. A review of R#40's Patient Report from the mobile imaging company revealed the following documentation: Dated: 7/5/18. Reason: Pain. In: 4:30 p.m. Examination: Left rib series. Findings: The visualized ribs demonstrate fractures of the left lateral 10th and 11th ribs. No underlying pneumothorax demonstrated. No overlying subcutaneous [MEDICAL CONDITION] noted. Patchy infiltrate in the left lung base. Impression: 1. Acute left lateral 10th and 11th rib fractures. 2. Left lower lobe pneumonia. Dated: 7/5/18 at 6:51 p.m. received x-ray report results of abdomen and left rib cage, revealed abdomen with nonobstructive bowel gas pattern and left lateral 10 and 11th rib fractures. Resident denies falling or bumping self into anything, c/o left rib pain [MEDICATION NAME] 5/325 mg by mouth (po) given for pain, spoke with son regarding resident c/o pain to left rib and abdomen area and of x-ray results. Will continue to monitor. Dated: 7/5/18 at 6:55 p.m. X- ray results for abdomen and chest showing fractured left 10th and 11th ribs and left lower lobe pneumonia. Called Medical Director and left message and also faxed results. Awaiting return call at this time. Dated: 7/5/18 at 8:56 p.m. No response from Medical Doctor. 911 called and hospital called and given report to nurse. Son notified that resident was going to be sent to emergency room (ER) for further evaluation. Awaiting transport at this time. A review of R#40's hospital admission record dated 7/5/18, revealed the following documentation: Disposition Summary: Preliminary [DIAGNOSES REDACTED]. Review of the facility investigative report conducted by the Director of Nursing (DON) regarding the incident with R#40 on 7/5/18, revealed the following written statements: Review of the written statement by CNA BB had never worked with R#40 prior to this incident and had transferred R#40 from her bed to her recliner, at the request of the resident, and failed to obtain assistance from another staff member and did not use the Hoyer lift. CNA BB was on medical leave during the survey process and not available for interview. Review of the written statement of dated 7/9/18 revealed a statement from an Occupational Therapist (OT) II who was in the room working with R#40's roommate at the time of R#40's transfer by CNA BB. The OT documented, in part, the following: I observed the CNA complete the transfer without a gait belt as she instructed R#40 to hold her neck as she proceeded to transfer her to the recliner as she held her by the side of her elastic waist pants. At the completion of the transfer I heard R#40 say, I don't want to do that again. The OT was not available for interview during the survey process. On 7/17/18 at 3:30 p.m., an interview was conducted with CNA CC at the D Hall nurse's station. CNA CC was asked what information she was provided regarding each resident's transfer status. CNA CC stated, I am familiar with the residents and know what they need. If I don't know then I will ask the nurse, or I can ask another aide. When asked if there was any type of communication tool, a care card or cheat sheet that directed the aides to the ADL needs of each resident, CNA CC stated I do not know of any. An interview on 7/17/18 at 4:00 p.m., with the Physical Therapy (PT) Supervisor in the therapy office. The PT Supervisor was asked if he was familiar with R#40 and he stated that he had worked with her in (MONTH) and (MONTH) of (YEAR) to get her back to her prior level of function. The PT Supervisor stated that at the request of her family and her physician her therapy was discontinued on 4/18/18. The PT Supervisor also stated at the time of discharge the resident was totally dependent, could not stand, walk or assist with her transfers. She needed a Hoyer lift for transfers. When asked how that information was communicated to nursing staff, the PT Supervisor stated that when therapy documented that someone was dependent nursing knew to initiate a Hoyer lift. An interveiw on 7/18/18 at 9:40 a.m., with CNA DD on the [NAME] hallway. CNA DD was asked how she knew the transfer status of each resident she worked with, especially if they were new to her. CNA DD stated, We have an ADL book that tells us what the resident care needs are. We can go to that book and see what to do. We also meet every day at three o'clock as a team to discuss the residents. On 7/18/18 at 12:55 p.m., an interview was conducted with LPN FF (who was assigned to the resident on 7/5/18 the day of the fall) at the D hall nurse's station. LPN FF was asked, how does staff know how to transfer a resident? LPN FF stated, The CNAs should look in the ADL book to determine the resident's transfer status. We also have meetings in the morning at the start of the shift. If they don't know they should ask. When the CNAs come in they should get their assignment and check the ADL book then meet with the nurse. There is no reason for them not to know how to transfer a resident. Further interview with LPN FF when asked what she could remember about R#40's functional ability leading up to the 7/5/18 incident, LPN FF stated R#40 could not walk and generally stayed in the bed. She had a recliner and from time to time I would see her in it. When asked how she was normally transferred into the recliner from the bed. LPN FF stated, I would say by a Hoyer lift. The resident had a lot of [MEDICAL CONDITION] and skin issues. I would question her being a one-person transfer, I wouldn't move her by myself and would call for help. LPN FF was asked to review the ADL sheet and the LPN acknowledged that it documented R#40 as an assist of one to transfer to the wheelchair. LPN FF commented the sheet was not correct at the time R#40 fell . We write it up in pencil so it can be updated. When asked what should have happened when R#40 was identified as being totally dependent by PT, LPN FF stated that the ADL sheet should have been updated. When asked how an update would be communicated to the aides working with the residents, LPN FF stated, They have to read the ADL book. Further interview with LPN FF revealed that on 7/5/18 the day of the fall, she had administered medications to R#40 at about 9:30 a.m.she was not sure of the time but the aide went in the resident's room to provide ADL care. LPN FF further stated that R #40 was put back into her bed by lunchtime and that she was unaware that R#40 was in pain until she went in to check on her at about 2:30 p.m. at which time she assessed the resident, provided pain medication and contacted the physician. The aide should never have transferred the resident without assistance. LPN FF stated that R#40 was very alert that day, unusually so, and asked to be put in the recliner. She revealed the aide should have asked for help. Before this incident the aides who worked with R#40 had been using the Hoyer lift. On 7/18/18 at 2:30 p.m. an interview was conducted with LPN AA, the Unit Supervisor, at the D Hall nurse's station. When asked about R#40, LPN AA stated that she was very familiar with the resident and that she hadn't been transferred in about two months leading up to the incident as she did not get out of the bed. If she was to be transferred then she was assessed for use of a Hoyer lift as she was not able to turn herself. When asked what it meant when therapy stated someone was total dependent, LPN AA stated that if the therapy department stated someone was total dependent that meant they could not bear weight and would need a Hoyer lift for transfers. When asked about the incident on 7/5/18 when R#40 was transferred, LPN AA stated She wasn't getting out of bed. I don't know what happened, the aide should have used the Hoyer lift. The ADL sheet was reviewed with LPN AA at this time. LPN AA was asked if the information regarding R#40's transfer ability was correct. LPN AA stated the ADL sheet used by the CNAs was incorrect, it documented that R#40 was a one person assist. When asked if this was the document used by the aides to determine a resident's transfer status LPN AA stated that it was. On 7/18/18 at 2:45 p.m. an interview was conducted with the Director of Nursing (DON) in her office. The DON was asked about the incident that occurred on 7/5/18, when an improper transfer occurred with R#40 that resulted in the residents rib fractures. The DON stated, We had never seen the resident get out of the bed. We wanted her to get up but she refuses and her family does not want her to get up. The DON stated that the aide had got R#40 out of bed on the morning of 7/5/18, using improper transfer techniques. The DON further stated that R#40 was normally bed bound and the aide should not have attempted to transfer the resident without assistance and should have used a Hoyer lift. The DON confirmed that CNA BB had worked at the facility for about a month and she had never worked with R#40 prior to the date of the incident. When asked how CNA BB would know how to transfer a resident that was new to her. DON stated that it was on the ADL sheet. The DON was asked to review the information on the ADL sheet at the time of transfer. The DON verified that at the time of the transfer the ADL sheet documented R#40 as a one person assist for transfers to the chair and that this information was incorrect. The DON further stated that R#40 did not get out of bed and she was totally dependent and the ADL sheet should have reflected that she needed, at minimum, a two person assist and/or a Hoyer lift for safe transfers. . On 7/18/18 at 4:30 p.m. an interview with the Administrator and Clinical Services Administrator was conducted in the Clinical Service Administrator's office regarding improper transfer of R#40 on 7/5/18. The Clinical Services Administrator stated that R#40 was transferred improperly and that the ADL sheet should have correctly reflected the resident's transfer status as that was the communication tool used by the CNAs. Observation and interview on 7/19/18 at 12:10 p.m. with CNA GG revealed that R#40 in her bed. During the repositioning observation by CNA GG revealed that she had worked with R#40 for a long time. When asked what R#40 transfer status was between the end of her therapy on 4/18/18 and the date of the incident on 7/5/18, CNA GG stated, When she came out of therapy in (MONTH) she did pretty well, she would stand and pivot but then in (MONTH) she stopped being able to assist with transfers and started requiring a Hoyer lift. CNA GG further stated, Starting then I always used a Hoyer lift on her, she cannot stand. When asked about the ADL book CNA GG stated that she did not realize that the ADL sheet was incorrect and further stated that R#40 had never really been a one person assist, she required extensive assistance regardless of what it says in the ADL sheet. An interview on 7/19/18 at 12:10 p.m., outside of R#40's room , with LPN HH, a nurse who has worked with R#40 consistently since was admitted . When asked about R#40's transfer status and what happened on 7/5/18, the day R#40 fell . LPN HH replied, She has required a Hoyer lift since May. She cannot stand and she cannot walk. Everyone was aware, but the aide was new and had never worked with this resident prior to the date of the incident. The aide should have asked for help or instructions, regardless of what it said on the ADL sheet. CNA BB did not know her. On 7/19/18 at 3:15 p.m. a telephone interview was conducted with R#40's Medical Doctor (MD). The MD was asked to describe R#40's functional status between 4/18/18 and 7/5/18. The MD stated, Zero, she cannot do anything independently, she has to be moved, she cannot do anything. When asked if one person would be able to safely transfer the resident, the MD stated, Absolutely not. That would be unsafe and the resident could not be safely transferred in that manner. She cannot do anything, she has been totally dependent for a long time. A review of the facility undated policy titled Facility Assessment documents, in part, the following: Staff Training Topics: Address areas of weakness as determined in nurse aides' performance reviews and facility assessment and may address the special needs of residents as determined by the facility staff. Staff Competencies: Activities of daily living - transfers, using gait belt, using mechanic (sic) lifts. On 7/10/18 the facility submitted a follow up report to the incident that occurred on 7/5/18 with R#40 that documented, Based on written statements and verbal reports, we believe that the left rib fracture happened during resident transfer. No further information was provided prior to the end of the survey process. A post survey telephone interview on 8/1/18 at 1:53 p.m., during Quality Assurance review, with the DON revealed the facility does have a process for what to do if the resident's physician does not return their phone calls. She revealed that the nurse would contact the Medical Director for direction but that the resident was also complaining of shortness of breath and the nurses felt the resident needed to be transferred to the emergency room (ER) for further evaluation. A post survey QA telephone call on 8/2/18 at 10:47 a.m. with the Clinical Services Administrator revealed that the resident had been a resident at the facility off and on for many years and the staff were familiar with her. She stated that the resident had experienced many fractures over the years due to osteopenia. She further revealed that this resident had been refusing to get out of bed for the last two months but that on 7/5/18 had asked to get up. The CNA was a new PRN (as needed) who did not know the resident. She confirmed that the resident was transferred improperly to get out of bed and that the CNA had also transferred her back to bed around lunchtime. It was at this time that the resident began complaining of pain in the rib area which progressed to also having shortness of breath. The Clinical Services Administrator revealed that the nurse did not document the resident's shortness of breath in the nurses notes, although it is documented in the five day report submitted to the state agency. After receiving the x-ray results, the nurse contacted the resident's physician and was awaiting a return call but due to the resident's shortness of breath, the nurse felt the resident should be transferred to the ER for immediate evaluation. The Clinical Services Administrator revealed that neither CNA BB or OT II had reported to nursing the improper transfer on 7/5/18. Review of the, undated, policy titled Physician Notification 5. The license nurse to notified Medical Director if no response from the attending Physician within 4 hours for any medical emergency. Review of an undated policy titled Hoyer Lift Policy: This is the policy to (name of) Facility to use a Hoyer lift as needed to assure a resident is moved safely and as comfortably as possible. Procedure: The procedure for using Hoyer lift includes, but is not limited to the following: There must be at least 2 people to assist with transfer. Review of policy titled Gait Belt Policy and acceptance form revealed that every CNA that works here wears a gait belt. It is your responsibility to wear your Gait Belt daily. The facility provided signed documentation the CNA BB had signed as agreed on 5/8/18, to wear a gait belt.",2020-09-01
20,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2019-11-15,585,D,0,1,O88D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interviews, record review and review of facility policies, the facility failed to make prompt effort to file a grievance for one resident (R) #25 who verbally reported to staff she was missing her lower denture. The sample size was fifty-seven residents. Findings include: Review of an undated policy titled Dental Policy revealed 3. Nursing staff to report missing dentures, notify social service, and fill out concern forms. Review of the policy titled Complaint (Grievance) Policy revised date of (MONTH) (YEAR) revealed Such complaints may include those related to his or her treatment, medical care, missing clothing or other complaints regarding their stay. Record review of the Minimum Data Set (MDS) significant change assessment dated [DATE] revealed R#25 had a Brief Interview for Mental Status of nine indicating moderate cognitive impairment. An interview and observation was conducted on 11/12/19 at 11:50 a.m. with R#25 who responded to interview questions appropriately. The resident was asked about dentures. The resident revealed she is missing her bottom denture. Observation of only top dentures in the resident's mouth. The resident also revealed she reported to the staff and the dentist that she was missing her lower denture. The resident revealed the lower denture has been missing for a couple of months. An interview was conducted on 11/15/19 at 3:25 p.m. with the Certified Nursing Assistant (CNA) CC. The CNA revealed R#25 had reported to the staff during mealtime in the dining room a month ago that she was missing her bottom denture. Record review of R#25's dental notes dated 9/10/19 revealed Patient states her lower denture has been lost. An interview was conducted on 11/15/19 at 9:44 a.m. with the Social Service Director (SSD). The SSD was asked how the facility handles residents missing items. The SSD revealed when a person reports (verbally or in writing) a missing item a grievance form is completed by the staff and the completed form is turned in to the social service department. The social service department will start the investigation to locate/replace the missing item. The SSD revealed there was no grievance filed for R#25's missing lower denture.",2020-09-01
21,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2019-11-15,732,C,0,1,O88D11,"Based on observation and staff interview the facility failed to categorize licensed and unlicensed nursing staff directly responsible for resident care per shift and failed to make certain staffing information was accurate and current. The facility census was 163. Findings include: An observation on 11/12/19 at 10:15 a.m., of the nurse staff information posted on the A/B hall near the treatment nurses office revealed a census of 161. The staffing posting consisted of 4 pages of staff names, staff assigned rooms, staff assigned breaks, staff assigned task, and total employee hours. The staff posting did not include the facility name or the number of licensed and unlicensed staff per unit. The posting appeared to be a facility schedule that listed all staff assigned to work for that day. The information included all licensed and unlicensed staff, as well as staff that do not provide direct care. Further review revealed that the nightshift CNA's assignment did not list the rooms assigned, but instead listed see book. It was difficult for a visitor or resident to know which staff (licensed or unlicensed) was assigned to provide care. An interview on 11/12/19 at 10:46 a.m., with the staffing coordinator, she revealed the A/B hall nursing station was the only place in the facility where the daily staffing is posted. An observation on 11/13/19 at 9:15 a.m,. of the nurse staff information posted on the A/B hall revealed a census of 161 which was not correct due to the actual census being 163.",2020-09-01
22,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2019-11-15,812,F,0,1,O88D11,"Based on observation, policy review and staff interviews, the facility failed to ensure opened food items in the dry storage area were securely covered, labeled and dated; failed to discard food items by expiration date; failed to maintain sanitary conditions in the kitchen by not stacking wet cookware and ensuring the cleanliness of kitchen equipment and not changing gloves during puree process. The facility also failed to maintain proper holding temperatures for cold food items at 41 degrees Fahrenheit (F) or below during meal service. There are 161 residents that receive an oral diet. Findings include: 1. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed in the dry storage area one opened/unsealed 12 ounce box of raisins with no open date; one 16 ounce opened/unsealed box of dry rice with no open date. In the walk in cooler, a large clear storage container with cooked chili with use by date of 11/3/19; one clear container with gravy with use by date of 11/5/19; one clear container of macaroni and cheese with use by date of 11/3/19; one clear storage container with red food substance, unlabeled with no use by date (identified by staff as stewed tomatoes); a large clear storage container of food substance, unlabeled with no use by date (identified by staff as green beans) and one stainless steel container of dinner rolls with use by date of 11/5/19. Interview on 11/12/19 at 11:15 a.m. with Certified Food Service Manager (CFSM) stated that the kitchen staff know that foods are to be dated and discarded after three days. She further stated that she has had many discussion with the dietary staff about not saving the leftover food, because they rarely use it. She verified the concerns identified during the initial tour. 2. Observation during initial tour on 11/12/19 from 10:05 a.m. to 10:31 a.m. with Certified Food Service Manager (CFSM), revealed food slicer on the back table with dried food debris on the blade and the slide tray; wet nesting of three stainless steel cake pans and two stainless steel medium sized holding pans, which were stacked with wet condensation between them; dust and crumbs/food particles on bottom shelving of stainless steel table with pots/pans and serving utensils stored on the shelf. Review of untitled and undated documentation provided by CFSM regarding cleaning and sanitizing stationary equipment, revealed to scrape or remove food from the equipment surfaces and to wash the equipment surfaces. Interview on 11/12/19 at 11:15 a.m. with Certified Food Service Manager (CFSM) stated staff have a cleaning list they are to do before leaving, and the shift supervisor checks the duties off before the staff leave for the day. During further interview, she stated there is not a scheduled list of cleaning tasks to be done. She stated she would talk with the supervisors about the dirtiness of the kitchen shelving and equipment and the wet nesting of the dishes. She verified the concerns identified during the initial tour. 3. During observation of steam table temperatures on 11/14/19 at 11:45 a.m., obtained by Dietary Cook DD with the facility's calibrated digital thermometer, observation of cold food item of jello, temperature was 47.9 degrees Farenheit (F) and milk temperature was 67 degrees F. Bowls of jello noted to be sitting on tray rack, with no ice bath. Milk cartons sitting in a shallow dish on the counter, with no ice bath. Review of untitled and undated documentation provided by CFSM regarding food temperatures, revealed cold foods should be held at 41 degrees or lower. Interview on 11/14/19 at 12:16 a.m. with Certified Food Service Manager (CFSM) stated that they check the temperature of the foods when they remove them from the oven, during mid service and post service. She stated that they don't obtain temperatures for the cold items, they just take them from the cooler when its time to serve. She verified the concerns identified during the initial tour. 4. During observation of puree food process on 11/15/19 at 10:29 a.m. with Dietary Cook DD, she measured out desired portion of fish filets and placed into food processor, along with bread slices and melted butter. During the blending process, she stopped the blender and placed her dirty gloved hand into the blender bowl to mix the partially blended food. Without changing her gloves, she continued the blending process, until food was blended smooth. She washed the blender bowl and lid in the three compartment sink, but did not allow the items to air dry before continuing the pureeing of squash. Interview on 11/15/19 at 10:55 a.m. with Dietary Cook DD, stated that she didn't think about changing her gloves before putting her hand into the food to mix the items in the blender to make it easier to puree. She further stated that she didn't know that she had to wait for the blender bowl and lid to air dry, before proceeding with the puree process. She stated she has always just rinsed them off and continued to puree until all items were pureed. Interview on 11/15/19 at 4:00 p.m. with CFSM, stated that they do not have policy and procedures for the kitchen, that she uses the servesafe manual for best practices. She stated that she did not have anything in reference to food storage and labeling/dating of opened food items or the process of pureeing foods.",2020-09-01
23,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2019-11-15,840,D,0,1,O88D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to provide documentation of a written agreement or contract with the company providing out patient [MEDICAL TREATMENT] services for one resident (R) (#44) of 3 residents receiving [MEDICAL TREATMENT] services. Findings include: A review of the clinical record revealed R#44 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of three, indicating severe cognitive impairment. Section: O revealed the resident was receiving [MEDICAL TREATMENT] while a resident in the facility. Review of the physician's orders [REDACTED]. Review of the Facility Resident Census and Conditions of Residents Form dated 11/12/19 revealed the facility had three residents receiving [MEDICAL TREATMENT] at an outside certified end-stage [MEDICAL TREATMENT] facility. Interview on 11/13/19 at 4:56 p.m., with the Assistant Administrator revealed the facility had been trying for months to obtain a [MEDICAL TREATMENT] agreement from the [MEDICAL TREATMENT] center but has not had any luck. She stated she would call again to speak with someone who understood the importance of having this information on file. During an interview on 11/14/19 at 12:05 p.m., the Administrator stated the facility had made several attempts to get a contract from the [MEDICAL TREATMENT] center. He reported and confirmed that when R# 44 was admitted , he was not made aware that there was not a [MEDICAL TREATMENT] contract. He further stated that he had made several attempts to get an agreement with the [MEDICAL TREATMENT] provider but had not been successful until today.",2020-09-01
24,PARK PLACE NURSING FACILITY,115005,1865 BOLD SPRINGS ROAD,MONROE,GA,30655,2019-11-15,908,F,0,1,O88D11,"Based on observations and interview, the facility failed to ensure that essential equipment in the kitchen was in working order as evidenced by, ice build up inside and around the door frame of the walk-in freezer observed on four of four days during the survey. There are 161 residents that receive an oral diet. Findings include: During the initial tour on 11/12/19 at 10:05 a.m. with the Certified Food Service Manager (CFSM) the surveyor inspected the walk-in freezer. During the inspection, the inside door frame, ceiling and floor inside door opening, had visible ice formation. Additional observations during follow-up visits to the kitchen, revealed continued ice buildup on the walk-in freezer door frame, ceiling and floor during all four days of the survey. Interview on 11/15/19 at 4:00 p.m. with the CFSM, stated that staff scrape off the ice in the walk-in cooler everyday. She stated that she has not reported the issue to the maintenance department. She further stated there were no policies related to maintenance of the walk-in freezer.",2020-09-01
25,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2017-02-09,278,D,0,1,OC5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to accurately assess pressure ulcers for one resident (R) (R#5) and failed to accurately asssess the oral/dental status for one resident (R#90) who had missing and broken teeth. The sample was 27 residents. Findings include: 1. R#5 was admitted to the facility on [DATE]. Further review of the record revealed the resident did not have pressure ulcers present on admission to the facility. A significant change MDS assessment was conducted on 3/23/16 and the resident was coded as having no pressure sores. On a quarterly MDS dated [DATE], the resident was coded as having an unstageable pressure sore to both heels which were present upon admission and present on the prior assessment. Review of the clinical record revealed the resident had unstageable pressure sores on her bilateral heels which developed in the facility. In addition, a quarterly MDS assessment was conducted on 9/9/16 and again the resident was coded as having the pressure sores present on admission. Review of a quarterly MDS dated [DATE] indicated the resident had a Stage 3 pressure sore upon admission and present on prior assessment. During an interview on 2/9/17 at 6:40 p.m., the MDS Coordinator confirmed she completed the assessments and further stated the resident's pressure sores her on bilateral heals were acquired in-house and both MDS assessments dated 6/23/16 and 12/2/16 were not coded correctly. 2. Review of records revealed R#90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Observation of R#90 on 2/07/17 at 10:43 a.m. revealed the resident had several teeth missing in the upper and lower gums and several teeth, broken with caries. Review of a Clinical Health Status assessment completed for R#90 on 4/26/16 revealed under the section, Oral/Respiratory, that the resident had broken, loose, or carious teeth. Review of the latest Clinical Health Status assessment last completed for the resident on 10/24/16 also revealed the resident was documented as having broken, loose, or carious teeth. Review of the most recent Quarterly Minimum Data Set (MDS) assessment completed for R#90 on 12/9/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates a moderate cognitive impairment. Further review of the last comprehensive assessment completed for R#90, the Annual MDS assessment with reference date of 5/3/16, revealed in Section L - Oral/Dental Status - the resident was documented as having no dental issues such as caries or broken teeth. Interview on 2/9/17 at 1:55 p.m. with the current MDS Coordinator revealed she was not employed at the facility when the last comprehensive MDS assessment was completed for R#90 and, therefore, could not explain why that assessment, completed by the previous MDS coordinator, documented that the resident had no dental issues while current observations indicate, and the comprehensive Clinical Health Status assessments documents the resident has broken and carious teeth.",2020-09-01
26,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2017-02-09,280,D,0,1,OC5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the comprehensive care plan to reflect the addition of [MEDICATION NAME] (an antipsychotic) to the medication regimen for one resident (R) (R#59) from a sample of 27 residents. Refer F329 Finding include: Review of the physician orders [REDACTED]. Review of section N of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed antipsychotic medications were documented as administered each day of the seven day look back period. Further review revealed the comprehensive care plan dated revised 12/1/16 indicated there was not a care plan developed to address the use of the antipsychotic medication. During an interview on 2/9/17 at 6:40 p.m., the MDS Coordinator confirmed the care plan was not revised to include [MEDICATION NAME] after the quarterly MDS was conducted in (MONTH) (YEAR).",2020-09-01
27,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2017-02-09,282,D,0,1,OC5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy and procedures, the facility failed to routinely implement care plan interventions related to behavior monitoring for one resident (R) (R#90) being treated with an antipsychotic medication from a sample of 27 residents. Refer F329 Findings include: Review of records revealed R#90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment for R#90 with reference date of 12/19/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates the resident has a moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Review of the resident's Annual MDS assessment with a reference date of 5/3/16 revealed that [MEDICAL CONDITION] drug use and behavioral symptoms triggered on Section V - Care Area Assessment (CAA) Summary - and the decision was made to complete a plan of care for these areas. Review of the policy titled Behavior Management Guideline dated 11/1/16 revealed that each resident's drug regiment will be free from unnecessary drugs, defined as a drug when used without adequate monitoring. A care plan is developed for residents exhibiting negative behaviors or those on an antipsychotic medication, and a monitoring system is established for targeted behaviors and medication side effects and effectiveness. Review of the Plan of Care for R#90, last revised 10/28/16 revealed a focus area related to the potential for drug-related complications associated with the use of antianxiety and antipsychotic medications, physical and verbal altercations with roommates and staff, and refusal of medications. The goal was for staff to monitor for psychiatric drug complications through the next review date. Interventions included: monitoring and reporting side effects to the attending physician; monitoring and documenting target behaviors such as symptoms of agitation, cursing, hitting at staff; and reporting behavioral changes to the physician. Review of the Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] HCL 50 mg, [MEDICATION NAME] 20 mg, and [MEDICATION NAME] 0.5 mg were administered as ordered. Review of the records for R#90 revealed Behavior Monthly Flow Sheets on which staff were instructed to monitor and document the presence of behaviors such as agitation, [MEDICAL CONDITION], and uncooperativeness for the resident related to her use of anti-psychotic, antidepressant, and antianxiety medications. These monthly monitoring sheets were included in the resident's records for (MONTH) through November, (YEAR), and February, (YEAR). However, no behavior monitoring sheets were found for the months of December, (YEAR) and January, (YEAR). Interview conducted on 2/9/17 at 4:50 p.m. with Medical Records Staff AA revealed that the administrative staff pulls behavior monitoring sheets each month from the monitoring book kept on the medicine carts and delivers these to the medical records department for filing in residents' records. However, he was never given a sheet for R#90 for (MONTH) (YEAR) or (MONTH) (YEAR). To his knowledge, behavior monitoring flow sheets were not completed for R#90 for these two months. Interview on 2/9/17 at 5:00 p.m. with Licensed Practical Nurse (LPN) BB revealed that the nurses are not required to routinely chart side effects unless side effects are noted. However, they are required to complete the behavior monitoring sheets for all residents receiving antipsychotic medications on every shift. Observation done at the time of the interview revealed Behavior Log on the medicine cart which contained Behavior Monthly Flow Sheets for R#90 and other residents being monitored for behaviors for the month of February, (YEAR). Behavior monitoring sheets for no other months were available in this log.",2020-09-01
28,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2017-02-09,329,D,0,1,OC5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to monitor two residents (R) for behaviors, that received antipsychotic medication (R#59 and R#90). The sample was 27 residents. Findings include: 1. Review of the physician orders [REDACTED]. Review of the Behavior Flow Sheet for (MONTH) (YEAR) revealed no evidence of behavior monitoring for hallucinations and wandering on the following dates and times: 2/3/17 on night shift 2/4/17 on night shift 2/5/17 on night shift 2/7/17 on night shift 2/8/17 on day, evening and night shift Further review of the medical record revealed no evidence of behavior monitoring for the months of October, November, and (MONTH) (YEAR) and (MONTH) (YEAR). An Interview on 2/9/17 at 7:55 p.m. with the Unit Coordinator DD confirmed there was no evidence of behavior monitoring for the dates noted in (MONTH) (YEAR). She further stated, in the past, the documentation of behaviors had been stored in a notebook, however, the notebook could not be located. 2. Review of the policy titled Behavior Management Guideline dated 11/1/16 revealed that each resident's drug regiment will be free from unnecessary drugs, defined as a drug when used without adequate monitoring. A care plan is developed for residents exhibiting negative behaviors or those on an antipsychotic medication, and a monitoring system is established for targeted behaviors and medication side effects and effectiveness. Review of records revealed Resident (R) #90 was admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Physician orders [REDACTED].; and an Abnormal Involuntary Movement Scale (AIMS) to be completed quarterly. Review of the most recent quarterly Minimum Data Set (MDS) assessment for R#90 with a reference date of 12/19/16 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 10 which indicates the resident has a moderate cognitive impairment. Section [NAME] - Behavior - of the same assessment documented the resident exhibited no evidence of [MEDICAL CONDITION], and no behaviors such as verbal/physical aggression nor rejection of care during the previous seven days. Section I - Active [DIAGNOSES REDACTED]. Review of the resident's Annual MDS assessment with a reference date of 5/3/16 revealed that [MEDICAL CONDITION] drug use and behavioral symptoms triggered on Section V - Care Area Assessment (CAA) Summary - and the decision was made to complete a plan of care for these areas. Review of the Plan-of-Care for R#90, last revised 10/28/16 revealed a focus area related to the potential for drug-related complications associated with the use of antianxiety and antipsychotic medications, physical and verbal altercations with roommates and staff, and refusal of medications. The goal was for staff to monitor for psychiatric drug complications through the next review date. Interventions included: monitoring and reporting side effects to the attending physician; monitoring and documenting target behaviors such as symptoms of agitation, cursing, hitting at staff; and reporting behavioral changes to the physician. Review of the Plan-of-Care for R#90, last revised 10/28/16 revealed a focus area related to behaviors such as yelling during care, shouting, and cursing. The accompanying goal was for the resident to calm down with staff interventions. Those interventions included: staff to attempt interventions before behaviors begin; give meds as ordered; and let attending physician know if behaviors interfere with daily life. Review of the Medication Administration Records (MARs) for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) revealed [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] HCL 50 mg, [MEDICATION NAME] 20 mg, and [MEDICATION NAME] 0.5 mg were administered as ordered. Review of nurses' progress notes and medication administration notes completed for R#90 from 2/1/16 through 2/7/17 revealed no documentation of adverse effects related to anti-psychotic use. Review of the records for R#90 revealed a quarterly Abnormal Involuntary Movement Scale (AIMS) was last completed on 1/12/17 with no symptoms of Tardive Dyskinesia related to the use of an anti-psychotic medication noted. Review of the records for R#90 revealed Behavior Monthly Flow Sheets on which staff were instructed to monitor and document the presence of behaviors such as agitation, [MEDICAL CONDITION], and uncooperativeness for the resident related to her use of anti-psychotic, antidepressant, and antianxiety medications. These monthly monitoring sheets were included in the resident's records for (MONTH) through November, (YEAR), and February, (YEAR). However, no behavior monitoring sheets were found for the months of December, (YEAR) and January, (YEAR). Interview conducted on 2/9/17 at 4:50 p.m. with AA, the staff member responsible for medical records, revealed that the administrative staff pulls behavior monitoring sheets each month from the monitoring book kept on the medicine carts and delivers these to the medical records department for filing in residents' records. However, he was never given a sheet for R#90 for (MONTH) (YEAR) or (MONTH) (YEAR). To his knowledge, behavior monitoring flow sheets were not completed for R#90 for these two months. Interview on 2/9/17 at 5:00 p.m. with Licensed Practical Nurse (LPN) BB revealed that the nurses are not required to routinely chart side effects unless side effects are noted. However, they are required to complete the behavior monitoring sheets for all residents receiving antipsychotic medications on every shift. Observation done at the time of the interview revealed Behavior Log on the medicine cart which contained Behavior Monthly Flow Sheets for R#90 and other residents being monitored for behaviors for the month of February, (YEAR). Behavior monitoring sheets for no other months were available in this log.",2020-09-01
29,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2017-02-09,514,D,0,1,OC5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of policy and procedure, the facility failed to maintain accurate clinical records for two residents (R), (R#77) related to [DIAGNOSES REDACTED].#59) related to inaccurate documentation of gastric tube feedings from a sample of 27 residents. Findings include: Review of facility policy titled Medication Review - Admission/ReAdmission revealed Medication review is intended to eliminate prescribing medication errors at care transitions by generating a complete and accurate list of resident medications. The second medication review will include review of admission orders [REDACTED]. 1. Review of the clinical record for R#77 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review revealed R#77 was a male. Review of the hospital clinical record for R#77 revealed he had been admitted on [DATE] and discharged to the facility on [DATE] and had not had surgery during his hospital admission. Transfer orders from the hospital for R#77, dated 12/27/16, included an order for [REDACTED]. Facility admission orders [REDACTED]. Review of the December, (YEAR) and January, (YEAR) MAR for R#77 revealed [MEDICATION NAME] 250 mg had been initialed as administered at 9:00 a.m. on 12/28/16, 1/2/17, 1/3/17 and 1/4/17. Interview 2/9/17 at 11:45 a.m. with the Director of Nurses (DON) revealed the [DIAGNOSES REDACTED]. The DON acknowledged the order for [MEDICATION NAME] had been transcribed incorrectly and recorded as administered incorrectly. The DON revealed the process for avoiding transcription errors for newly admitted residents is to review the MAR/TAR and compare with the admission orders [REDACTED]. The DON revealed she had compared the admission and transfer orders with the MAR for R#77 but had not noticed there was only one space to sign out [MEDICATION NAME] 250 mg on the MAR and that the spaces for 12/29/16, 12/30/16, and 12/31/16 had been crossed out. The DON revealed she also had not noted the error in the [DIAGNOSES REDACTED]. Interview 2/9/17 at 3:30 p.m. with the Administrator revealed she had checked pharmacy records and [MEDICATION NAME] 250 mg had been delivered for R#77. She indicated after checking medication disposition records for the [MEDICATION NAME] for R#77 had not been destroyed or returned to the pharmacy. The Administrator revealed the nurse who transcribed the admission orders [REDACTED]. Review of pharmacy disposition records for the month of (MONTH) indicated there had been no [MEDICATION NAME] destroyed or returned to the pharmacy. Review of Pharmacy dispensing records indicated six [MEDICATION NAME] 250 mg tablets were delivered to the facility on [DATE] for R#77. 2. Review of the Physician orders [REDACTED]. every shift and to administer [MEDICATION NAME] per the [DEVICE] as ordered Review of the MAR revealed the following missing documentation for the administration of the water flushes: 10/16/16 at 6:00 a.m. 10/28 at 6:00 a.m. 11/11/16 at 12:00 a.m. and 6:00 p.m. 11/12/16 at 6:00 a.m. 11/15/16 at 12:00 p.m. and 6:00 p.m. 11/16/16 at 12:00 p.m. and 6:00p.m. 12/17/16 at 7:00 a.m. Review of the MAR revealed the following missing documentation for the checking GT placement: 10/16/16 10/31/16 11/16/16 11/25/16 1/17/17 2/5/17 at 7:00 a.m. Review of the MAR revealed the following missing documentation for [DEVICE] feedings: 11/2/16 at 1:00 a.m. and 5:00a.m. 11/3/16 at 9:00a.m. 11/11/16 at 5:00 p.m. and 9:00 p.m. 11/15/16 at 5:00 p.m. 11/16/16 at 1:00 a.m. 12/14/16 at 1:00 p.m. 12/16/16 at 1:00 p.m. 12/20/16 at 1:00 p.m. 12/24/16 at 5:00 p.m. 1/17/17 at 1:00 p.m. 2/2/17 at 1:00 p.m. During an interview on 2/9/17 at 6:15 p.m., the Director of Nursing (DON), confirmed there were holes and missing documentation on the MARs and she further stated her expectation is for the nurses to document when they give the medication and/or treatments.",2020-09-01
30,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,584,E,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in nine resident rooms (rooms 3 B, 5 B, 11 B, 14 B, rooms 12, 20, 23, 30 and room [ROOM NUMBER]) on two of two halls. The facility census was 61. Findings include: Observation on 12/3/18 at 11:19 a.m., revealed in room [ROOM NUMBER] B, residents bedside tabletop fan, with dust build-up on the fan grill and blades. Observation on 12/3/18 at 11:48 a.m., revealed in room [ROOM NUMBER] B, scratched and peeling paint along the wall close to bathroom doorway. Observation on 12/3/18 at 2:47 p.m., revealed in room [ROOM NUMBER], electrical phone plate loosely hanging on wall, at the head of bed between bed A and bed B. Observation on 12/4/18 at 8:58 a.m., revealed in room [ROOM NUMBER], window curtain has circular stains in three different spots, approximately three by three inches. Window sill has dust build up with cob webs in low corner. Observation on 12/4/18 at 9:37 a.m., revealed in room [ROOM NUMBER] B, wall to the right of bed B, scuffed paint approximately four feet in length. Observation on 12/6/18 at 11:15 a.m., revealed in room [ROOM NUMBER] B, a large hole in the wall on the window side of the room, near the floor baseboard, window curtain noted with multiple brown stains, resembling liquid spill on curtain. Also, patch of peeling paint at head of bed B. Observation on 12/6/18 at 12:00 p.m., revealed in room [ROOM NUMBER], window curtain noted with multiple brown stains, resembling liquid spill on curtain. Observation on 12/6/18 at 2:31 p.m., revealed in room [ROOM NUMBER], window curtains with multiple red colored stains, appearing to be blood stains. Also, cob webs noted in left lower corner of window. Observation on 12/6/18 at 2:31 p.m., revealed in room [ROOM NUMBER], floor length window curtains stained with red and blue substance splattered on bottom of floor length curtains. Interview on 12/6/18 at 3:35 p.m., with Maintenance Supervisor, stated that he does routine room checks, checking side-rails, call lights, hot water temps and any other work orders that are submitted from the staff. He stated that he prioritizes the work orders based on need. He verified during walking rounds the concerns identified during the survey. He stated that he has a plan of painting the resident rooms when rooms become vacant, but will do before then, if the need is urgent. Interview on 12/6/18 at 3:44 p.m., with housekeeping aide, II, she stated that she works housekeeping on the weekends and her daily duties include sweeping, mopping, cleaning resident restroom, emptying trash, cleaning toilet and sink, restocking supplies in restroom, she dusts the rooms. She further stated that she dusts the residents personal belongings if they give her permission to dust. Interview on 12/6/18 at 3:52 p.m., with Housekeeping Supervisor, stated that the housekeeping staff go through a week of training with an experienced housekeeping staff on the floor. He further stated that they use the five & seven step cleaning process for training purposes. He stated that he does a Quality Control Inspection (QCI) of each deep clean room, which is done when the resident room becomes vacant. He verified during walking rounds the concerns identified during the survey. He further stated that he has tried washing the window curtains, but they get damaged during the wash cycle, so he will need to figure out how to clean the window curtains.",2020-09-01
31,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,636,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and policy titled Resident Assessment Instrument process, the facility failed to assess the resident (R) #24 on the Minimum Data Set (MDS) assessment for depression. Sample size was 37. Findings include; R#24 was admitted on [DATE]. [DIAGNOSES REDACTED]. During an unnecessary medication record review on 12/4/18 at 1:46 p.m. a review of R#24 medications include but not limited to [MEDICATION NAME] 10 mg 1 tab daily by mouth (po) for depression, [MEDICATION NAME] .5mg po for agitation at hour of sleep, (hs) and [MEDICATION NAME] 5mg daily for dementia. Further record review revealed Pharmacy Consultant reviewed R#24 record on 10/17/18 and made a recommendation to attempt a gradual dose reduction (GDR) for [MEDICATION NAME]. On 10/29/18 the Physician documented a GDR was contraindicated for this resident and declined the pharmaceutical recommendation. Continued review of R#24 record offers evidence resident was receiving psychiatric services and was last seen on 11/26/18. The review of records revealed a Nurse Practioner assessed resident on 11/12/18. The active problem list included a [DIAGNOSES REDACTED]. Review of several of R#24's most recent MDS did not assess the resident as having depression. MDS reviews included an annual dated 12/2/17 and quarterly's dated 2/7/18, 4/24/18, 7/10/18, and 9/19/18. Review of care plan revealed the resident is care planned for review of [MEDICAL CONDITION] medications. An interview with the Director of Nursing (DON) on 12/6/18 at 10:00 a.m. revealed the facility has been without a fulltime MDS Coordinator for more than 30 days. DON continued to state that corporate personnel and staff members from other facilities have been filling the positions. A telephone interview on 12/6/18 at 11:23 a.m. with, Regional Nurse Resident Assessment Consultant (RAC) revealed the MDS Coordinator is responsible for reviewing all MDS's in the facility. In clinical morning meetings what should take place is a review of orders to ensure there are corresponding [DIAGNOSES REDACTED]. There has been a lot of turnover. An interview with Corporate Area Resident Care Management Director (RCMD) on 12/6/18 at 12:00 p.m. stated she has been with the company since (MONTH) (YEAR). Stated she has identified care plan update issues. Her position is to come into the facility on and off to train the MDS Coordinator. The RCMDF Continued to state that now she comes to facility on a regular basis, especially since both staff members in MDS department resigned in (MONTH) and (MONTH) (YEAR). Continued interview indicated the process to ensuring the MDSs are accurate is to review the resident record, speak to staff and conduct resident interviews. Currently a new MDSs coordinator had been hired and is in orientation. An interview on 12/06/18 at 2:01 p.m. with Area RCMD confirmed R#24 had not been assessed for depression on the MDSs. Continued to state they just in put the [DIAGNOSES REDACTED]. Review of facility policy dated (MONTH) (YEAR) titled Resident Assessment Instrument (RAI) process states, on page 2 of 6, under procedure; the facility conducts a comprehensive assessment (MDS) to identify the resident's needs, strengths, goals, life history, and preferences within 14 days after admission (Initial admission assessment). This excludes readmissions where there is no significant change in the resident's physical or mental condition. The assessment must include at the following: j. Disease [DIAGNOSES REDACTED].",2020-09-01
32,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,655,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record review and policy title Baseline Care Plan, the facility failed to develop a baseline care plan for one resident (R) [NAME] Sample size was 37. Findings include; Resident A was admitted on [DATE]. [DIAGNOSES REDACTED]. Medications ordered included but not limited to; fleet oil enema (mineral oil),insert 133 milliliters (ml) rectally every 24 hours(hrs.) as needed(prn) for constipation may self-administer, senna tablet 8.6 milligrams (mg) (sennosides) give two tablets by mouth (po) at bedtime (hs) for laxatives, [MEDICATION NAME] powder (polyethylene [MEDICATION NAME] 3350) give 17 grams (gms) po at hs for constipation, [MEDICATION NAME] capsule 100 mg ([MEDICATION NAME] sodium) give one capsule po prn for constipation. An interview on 12/3/18 at 1:51 p.m. with R A stated hasn't had a BM in nine days. Continued to state has told the Certified Nursing Assistant (CNA) and the charge nurse. An interview with R A on 12/4/18 at 5:08 p.m. stated had bowel movement (BM) and is feeling much better. Stated they administered an enema and now is ready to go home. Record review on 12/5/18 on 8:19 a.m. evidenced a nurse's note dated 12/4/18 at 2:10 p.m. Medical Doctor (MD) at bedside this shift to assess and review medications; new orders to discontinue (d/c) [MEDICATION NAME], start [MEDICATION NAME] 50mg prn; Fleets Enema prn, and give senna and [MEDICATION NAME] every (q) hs; orders noted; Enema administered this shift with results; large loose stools noted. Resident states to writer, It's just what the doctor ordered. States, I feel much better. Further review of medical record on 12/5/18 at 9:32 a.m. revealed that two nursing skilled documentations dated 12/2/18 and 12/3/18 revealed the resident was assessed for being constipated. Review of resident record revealed there was no baseline care plan in place to address the resident's issue with constipation. An interview on 12/5/18 at 10:13 a.m. with Director of Nursing (DON) indicated the initial care plans should be under the tab in the electronic medical record (EMR), record which states baseline care plan. When DON attempted to retrieve R A's care plan, DON stated there was no care plan that had been initiated for this resident. The DON further stated that the person who regularly addresses and completes the MDS and care plans, is no longer with the facility. There have been staff members from other facilities coming in to assist with the MDS process, along with corporate personnel. A new person has filled the position on Monday 12/3/18 (day of survey entrance) and is being oriented to the facility and residents. An interview on 12/6/18 at 1:11 p.m. with Corporate Area Resident Care Management Director(RCMD) indicated the R A now had a baseline care plan which was developed 12/5/18, five days after admission. Per policy titled Baseline Care Plan dated (MONTH) (YEAR), on page two of four, states within 48 hours of admission to facility, the initial assessment information gathered will be used to initiate the baseline care plan (Electronic Health Record).",2020-09-01
33,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,656,E,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to develop a plan of care to address activities of daily living (ADL's) for one resident (R#38), Oxygen usage for two resident (R#3, R#29) and failure to implement care plan intervention for one resident (R #55) related to Restorative Nursing for Range of Motion (ROM) and one resident (R #214) for ADL care. The sample size was forty residents. Findings include : Review of the clinical record for R#3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had no known drug allergies and elected full code status. Review of the physician's orders [REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact; a Mood Total Severity Score of 0, indicating she was not depressed; and displayed no behaviors. Continued review of the same assessment documented R#3 as using oxygen while a resident. Review of the care plan, updated 11/28/18, did not include a care plan for oxygen to include goals and interventions. Observation and interview with R#3 on 12/03/18 at 12:25 p.m. revealed R#3 was wearing O2 via NC at 4.5 LPM. When asked if she knew what her O2 liter flow was supposed to be, she stated she believed her physician order [REDACTED]. She stated she was in no respiratory distress. Observation and interview with R#3 on 12/04/18 at 1:14 p.m., she was alert, oriented and pleasant sitting up in her wheelchair in her room. She was wearing O2 at 3 LPM via NC using a portable E-cylinder. She stated she was in no respiratory distress. Observation of R#3 on 12/04/18 at 4:49 p.m., noted she was asleep wearing O2 via NC at 3 LPM. She was in no apparent respiratory distress. Observation and interview of R#3 on 12/05/18 at 8:40 a.m., R#3 was seated upright in her bed wearing O2 via NC at 3 LPM. She stated she had just finished breakfast and was in no respiratory distress. Observation and interview with R#3 on 12/06/18 at 9:40 a.m., revealed she was wearing O2 via NC at 3 LPM. She stated she was in no apparent distress. Review of the vital signs for R#3 revealed an admission, 7/24/18 at 19:24 (7:24 p.m.), blood O2 saturation 99% on room air, which indicated her hemoglobin was adequately saturated with O2. Further review of O2 saturations for R#3 revealed an O2 saturation of 96% on 7/26/18 at 6:57 a.m. on O2 via NC. No O2 liter flow was documented. Continued review of O2 saturations for R#3 revealed an O2 saturation of 96% on O2 on 12/3/18 at 6:29 a.m.; 96% on O2 on 12/3/18 at 16:04 (4:04 p.m.); and 98% on O2 on 12/4/18 at 00:29 (12:29 a.m.). None of the O2 saturation readings reviewed indicated an O2 liter flow. In an interview with the Area Resident Care Manager (RCM) Director 12/6/18 at 11:34 a.m. regarding the contents of the care plan, she confirmed O2 was not included in the initial care plan or subsequent care plan updates. She identified facility issues such as the resignations of the MDS Director in (MONTH) (YEAR) and the MDS Coordinator in (MONTH) (YEAR) which delayed care plan and MDS updates and assessments. The Area RCM Director further explained the Sava (corporate) process for completion of the MDS assessment included reviewing the clinical record, speaking to the staff directly involved in resident care and resident interviews. 2. A review of the clinical record for R #38 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Review of updated care plan for R#38, dated 8/1/18, did not have evidence that R#38 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 12/3/18 at 1:49 p.m., 12/4/18 at 3:05 p.m., and 12/5/18 at 9:06 a.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. 3. A review of the clinical record for R #214 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #214 is a new admission and entry tracking Minimum Data Set ((MDS) dated [DATE] is only MDS available, therefore, no data available at this time. Review of care plan initiated 11/28/18 resident has activity of daily living self-care deficit related to left hip pain, difficulty walking and malaise. Interventions to care include encourage active participation in tasks, receives extensive to total care for baths, staff to do nail care, allow sufficient time to perform tasks and praise resident for all efforts at self-care. Observation on 12/3/18 at 12:48 p.m., 12/4/18 at 11:02 a.m., and 12/5/18 at 10:09 a.m., and 12/6/18 at 8:30 a.m. revealed that nails are untrimmed and dirty underneath on both hands. Resident stated he would like for them to be trimmed. 4. A review of the clinical record for R #29 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Section O revealed that the resident was assessed for Oxygen use while a resident. Interview on 12/6/18 at 1:11 p.m., with Registered Nurse (RN) CC stated that the Minimum Data Set (MDS) nurses do the initial care plan after the Admission Assessment is completed. She further stated that the interdisciplinary team (IDT) team can add to the care plan at any time and after the quarterly assessments are completed. During further interview, she verified that the facility has been without an MDS nurse for three weeks. She stated that she visits the facility daily and does MDS assessments when she visits. She further stated that other MDS nurses employed by corporate help out as well. Interview on 12/6/18 at 4:17 p.m., with RN BB stated that it is her expectation that the MDS nurses generate care plan for each area of concern that the resident will need to be addressed while a resident in the facility. Interview on 12/6/18 at 4:32 p.m., with RN BB verified that R#29 did not have a care plan to address his daily use of Oxygen therapy. 5. Review of resident (R#55's) medical record revealed the resident was admitted to the facility on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. Further review of R#55 medical record revealed his Minimum Data Set (MDS) quarterly assessment dated (MONTH) 3, (YEAR) indicated that R #55 has impairments to one side on the upper extremities and has impairments of both legs on the lower extremities. Additionally, according to resident Minimal Data Set he is receiving Restorative Services for 6 weeks with splinting devices. Review of R#55 care plans indicated that he was care plan for receiving Restorative Care for splint/brace assistance. The goal for R#55 was for him to achieve the highest level of optimal functioning with splinting over the next six weeks, the interventions included splinting to left elbow extremity with splint for first eight hours. Review of resident physician orders [REDACTED].#55 to have splinting brace on left elbow extremity and left resting hand splint with digit separator for first eight hours with skin checks. Program scheduled for six days a week for six weeks. Observation made on 12/04/18 at approximately 10:38 a.m revealed resident R#55 left hand contracted while in bed asleep without splinting device in place. At the time of the observation the splint was observed lying on his dresser beside him. Observation made on 12/05/18 at 1:34 p.m revealed resident R#55 in his bed asleep with the splinting device lying on top of the dresser beside him. Observation made on 12/05/18 at 2:44 p.m revealed resident R#55 in his bed awake with splinting device on his dresser. Review of resident restorative log for the month of (MONTH) (YEAR) through (MONTH) (YEAR) indicated there were no documented refusals of R#55 refusing to wear splinting devices. Additionally, there were no documented times to show when restorative aids place splinting devices on and off the R#55. On (MONTH) 5, (YEAR) at 02:15 p.m an interview was conducted with Certified Nursing Assistant (CNA) GG she stated that R#55 was supposed to have his splint brace on for eight hours a day and that she put his splint on earlier doing the shift but remove it after 2:30 p.m. She also stated that he cannot make his needs known and he rarely refuses care. On (MONTH) 5, (YEAR) at 3:30 p.m an interview was conducted with the Director of Clinical Services. She stated that R#55 should've had his splint on for the shift unless he refused care. She also stated that the Minimal Data Set Coordinator is responsible for making sure restorative is caring out their duties but at this time they currently do not have a MDS coordinator that oversees restorative nursing duties. Additionally, She did state that they are in the process of training an individual to take over for MDS at this time.",2020-09-01
34,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,677,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for two dependent residents (R) R#38 and R#214 related to nail care. The sample size was 40. Findings include: 1. A review of the clinical record for R #38 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Review of updated care plan for R #38, dated 8/1/18, did not have evidence that R #38 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 12/3/18 at 1:49 p.m., 12/4/18 at 3:05 p.m., and 12/5/18 at 9:06 a.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. 2. A review of the clinical record for R #214 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #214 is a new admission and entry tracking Minimum Data Set ((MDS) dated [DATE] is only MDS available, therefore, no data available at this time. Observation on 12/3/18 at 12:48 p.m., 12/4/18 at 11:02 a.m., and 12/5/18 at 10:09 a.m., and 12/6/18 at 8:30 a.m. revealed that nails are untrimmed and dirty underneath on both hands. Resident stated he would like for them to be trimmed. Interview on 12/6/18 at 8:34 a.m. with Certified Nursing Assistant (CNA) AA stated she is assigned 1-12 residents each day. She provides daily care consisting of bathing, shaving, brushing teeth, assisting with eating (meal set-up) and dressing, and feeding if they need help. If the residents are bed bound, she stated that she turns them every two hours. When asked about providing nail care, she stated that she checks nails about every two weeks, and cleans them if they are dirty. She further stated that she trims nails once per month. During further interview, she stated that she had not noticed that R#38 or R#214 needed their nails cleaned or trimmed. Interview on 12/6/18 at 8:55 a.m., with Registered Nurse (RN) BB, stated that when she has extra CNA staff, she will assign the extra person to do nail care and shaving residents. She stated if there are no extra staff members available assigned to nail care, it is her expectation that the CNA assigned to the resident check their nails daily and clean and trim them if needed. During further interview, she stated that she has a extra CNA assigned to take care of nails today. Interview on 12/6/18 at 5:22 p.m., with RN BB, verified that R#38 and R#214 had dirty and untrimmed fingernails.",2020-09-01
35,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,684,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, Interviews and record reviews, the facility failed to ensure quality care and services in accordance with professional standards for one resident (R#55) for the provision of Restorative Nursing for Range of Motion (ROM). The sample size was 40. The Findings: Review of resident (#55) medical record revealed the resident was admitted to the facility on (MONTH) 13, (YEAR) with [DIAGNOSES REDACTED]. Further review of resident (#55) medical record revealed his Minimum Data Set (MDS) quarterly assessment dated (MONTH) 3, (YEAR) indicated that resident (#55) has impairments to one side on the upper extremities and has impairments of both legs on the lower extremities. Additionally, according to resident MDS he is receiving Restorative Services for 6 weeks with splinting devices. Review of resident physician orders [REDACTED].#55) to have splinting brace on left elbow extremity and left resting hand splint with digit separator for first eight hours with skin checks. The program was scheduled for six days a week for six weeks. Observation made on 12/04/18 at approximately 10:38 a.m revealed resident R#55 left hand contracted while in bed asleep without splinting device in place. At the time of the observation the splint was observed lying on his dresser beside him. Observation made on 12/05/18 at approximately 01:34 p.m revealed resident R#55 in his bed asleep with the splinting device lying on top of the dresser beside him. Observation made on 12/05/18 at approximately 02:44 p.m revealed resident R#55) in his bed awake with splinting device on his dresser. Review of resident restorative log for the month of (MONTH) (YEAR) through (MONTH) (YEAR) indicated there were no documented refusals of resident (#55) refusing to wear splinting devices. Additionally, there were no documented times to show when restorative aids applied splinting devices on and off R(#55). On (MONTH) 5, (YEAR) at 02:15 PM an interview was conducted with Certified Nursing Assistant (CNA) GG she stated that R#55 was supposed to have his splint brace on for eight hours a day and that she put his splint on earlier doing the shift but remove it after 2:30 p.m. She also stated that he cannot make his needs known and he rarely refuses care. On (MONTH) 5, (YEAR) at 3:30 PM an interview was conducted with the Director of Clinical Services. She stated that R#55 should've had his splint on for the shift unless he refused care. She also stated that the Minimal Data Set Coordinator is responsible for making sure restorative is caring out their duties but at this time they currently do not have a MDS coordinator that",2020-09-01
36,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,695,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to maintain resident [MEDICAL CONDITION], medication nebulizer and oxygen equipment in a sanitary manner for three of seven sampled residents, Resident (R)#29, R# 38 and R#3. Findings include: 3. The facility failed to maintain resident [MEDICAL CONDITION], medication nebulizer and oxygen equipment in a sanitary manner for three of seven sampled residents, Resident (R)#29, R# 38 and R#3. Findings include: 3. Review of the clinical record for R#3 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She had no known drug allergies and elected full code status. Review of the physician's orders [REDACTED]. 1. Oxygen (O2) at two liters per minute (LPM) via nasal cannula (NC). 2. Change O2 tubing every Tuesday and when visibly soiled. 3. Pulse oximetry every shift 4. Check and clean (O2) concentrator filter every month and as needed. Observation of the O2 concentrator for R#3 on 12/03/18 at 12:25 p.m. revealed the equipment in good working order but the washable dust filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/04/18 at 1:14 p.m., revealed the washable filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/04/18 at 4:49 p.m., revealed the washable filter was covered with a thick, pale gray layer of dust. Observation of the O2 concentrator for R#3 on 12/05/18 at 8:40 a.m., revealed the washable filter was clean. Review of the most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 13, indicating she was cognitively intact; a Mood Total Severity Score of 0, indicating she was not depressed; and displayed no behaviors. Continued review of the same assessment documented R#3 as using oxygen while a resident. In an interview with R#3 on 12/5/18 at 8:40 a.m. regarding maintenance of the O2 concentrator, she stated she did not recall who or when the washable filter was cleaned. She was wearing O2 via NC at 3 LPM and neither displayed or expressed any signs/symptoms of respiratory distress. Review of facility policies related to O2 administration did not reveal any policy or procedure for cleaning O2 concentrator filters. DONE. 2. A review of the clinical record for R #38 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated mild cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Observation on 12/3/18 at 1:53 p.m. resident sitting in wheelchair in hallway outside his room. [MEDICAL CONDITION] speaking valve is dirty with brown debris on cap. There is not [MEDICAL CONDITION] around the tube and [MEDICAL CONDITION] are dirty with brown stained color. Observation on 12/4/18 at 7:54 a.m. resident in bed.[MEDICAL CONDITION] intact, but without a dressing [MEDICAL CONDITION] valve remains dirty. A review of the clinical record for R #29 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment. Section O revealed that the resident was assessed for Oxygen use while a resident. Observation on 12/3/18 at 10:14 a.m. Oxygen concentrator filter noted with thick layer of gray colored debris. Nebulizer mask un-bagged and undated, sitting on bedside nightstand. Observation on 12/4/18 at 8:25 a.m. Oxygen concentrator filter remains with thick layer of gray debris. Observation on 12/4/18 at 3:14 p.m. Oxygen concentrator filter remains dirty with thick layer of gray debris. Interview on 12/6/18 at 4:32 p.m. with Registered Nurse (RN) BB stated that the facility has an outside contract with Specialized Medical Services (SMS) that comes weekly to care for the residents [MEDICAL CONDITION]. She stated the nursing staff change the Oxygen tubing and nebulizer masks weekly. She further stated it is her expectation that the nurses change tubing weekly and clean the Oxygen filters weekly or as needed.",2020-09-01
37,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,757,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interview, the facility failed to ensure that one residents drug regimen was free from unnecessary medication with duplicated drug therapy for one resident (R) #17. The sample size was 40. Findings include: Review of facility policy titled Physician order [REDACTED]. Procedure receiving a written or faxed order number two: The licensed nurse receiving the order verifies the order to ensure it is complete and that it includes resident name, room/bed, date of order, time of order, Physician signature and date, Physician name, Medication name, accurate dosage, accurate frequency, duration of order, if applicable, accurate route if applicable and medical indication for medication or reason for use. Observation of medication administration on 12/4/18 at 8:25 a.m. with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#17. The following observations were made: Calcium + vitamin D3 (a medication given as a supplement) 600/400 milligram (mg) tablet one time a day, Duloxetine (a medication used to treat depression) 60 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 300 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat hypertension) 25 mg two times a day (bid), [MEDICATION NAME] (a medication used to treat fluid retention) 20 mg two times a day (bid), [MEDICATION NAME] (a medication used to treat acid reflux) 20 mg two times a day (bid) and [MEDICATION NAME] (a medication used to treat pain) 10 mg three times a day (TID), Aspirin (a medication used as a blood thinner) 81 mg one time a day, Senna (a medication used as stool softener) 8.6 mg two tablets one time a day, Isorbide (a medication used to treat hypertension) 30 mg one time a day and Polyethylene [MEDICATION NAME] (a medication used to treat constipation) 17 grams (gm) one time a day. During reconciliation with review of R#17 printed physician orders [REDACTED]. medication order was for [MEDICATION NAME] 20 mg two times a day (bid), administration times at 6:00 a.m. and 4:00 p.m. and [MEDICATION NAME] 20 mg three times a day (TID), with administration times at 9:00 a.m., 1:00 p.m. and 9:00 p.m. Interview on 12/4/18 at 10:36 a.m. with Registered Nurse (RN) BB stated the night shift nurses are responsible for verifying Physician order [REDACTED]. During further interview, she stated that she checks every MAR indicated [REDACTED]. Interview on 12/4/18 at 12:10 p.m. with RN BB stated she contacted R#17 Physician regarding clarification of the two duplicate medications and clarification orders were obtained from physician to discontinue one each of the duplicated orders.",2020-09-01
38,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,759,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure it was free of a medication error rate greater than five percent by not ensuring medications were given as ordered by physician for two residents (R) R#17 and R#54. A total of 29 medication opportunities were observed, and there were four errors for two of three residents (R) R#17 and R#54, by one of two nurses observed during medication pass, for a medication error rate of 13.79%. The census was 61 and the sample size was 40. Findings include: Review of the facility policy titled Medication Administration revised (MONTH) 2008 revealed under procedure number: 2: Verify the medication label against the medication sheet for accuracy of drug frequency, duration, strength and route. Section C: Report any discrepancies to the pharmacy. Do not administer the mediation until the discrepancy is resolved. Observation of medication administration on 12/4/18 at 8:04 a.m. on side one, cart one, with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#54. The following observations were made: [MEDICATION NAME] (a medication used to hypertension) 25 milligram (mg) tablet, [MEDICATION NAME] (a medication used to treat acid reflux) 150 mg tablet, [MEDICATION NAME] (a medication used to treat depression) 10 mg tablet, [MEDICATION NAME] (a medication used to treat hypertension) 5 mg tablet, Calcium + vitamin D3 (a medication given as a supplement) 600/400 mg tablet and vitamin D3 (a medication given as a supplement) 1000 units, two tablets. After all of the R #54's 9:00 a.m. medications had been prepared, LPN EE counted the number of medications to be given, and verified during interview that what she prepared was all of the medications R#54 received for that time of day. During reconciliation with review of R#54 printed physician orders for the month of (MONTH) (YEAR) revealed the following orders: [MEDICATION NAME] 25 mg two times a day; vitamin D tablet 2000 unit, give two tablets one time a day; [MEDICATION NAME] 150 mg two times a day; [MEDICATION NAME] 5 mg two times a day; [MEDICATION NAME] 10 mg one time a day; Calcium-D 600/400 mg-unit one time a day. Licensed Practical Nurse (LPN) EE failed to administer R#54 the correct dosage of vitamin D3 per physician orders of 2,000 units, two tablets a day. Observation of medication administration on 12/4/18 at 8:25 a.m. on side one, cart one, with Licensed Practical Nurse (LPN) EE revealed she administered multiple medications to R#17. The following observations were made: Calcium + vitamin D3 (a medication given as a supplement) 600/400 milligram (mg) tablet one time a day, Duloxetine (a medication used to treat depression) 60 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat [MEDICAL CONDITION]) 300 mg capsule one time a day, [MEDICATION NAME] (a medication used to treat hypertension) 25 mg two times a day, [MEDICATION NAME] (a medication used to treat fluid retention) 20 mg two times a day, [MEDICATION NAME] (a medication used to treat acid reflux) 20 mg two times a day and [MEDICATION NAME] (a medication used to treat pain) 10 mg three times a day, Aspirin (a medication used as a blood thinner) 81 mg one time a day, Senna (a medication used as stool softener) 8.6 mg two tablets one time a day, Isorbide (a medication used to treat hypertension) 30 mg one time a day and Polyethylene [MEDICATION NAME] (a medication used to treat constipation) 17 grams (gm) one time a day. During reconciliation with review of R#17 printed physician orders for the month of (MONTH) (YEAR) revealed the following orders: Duplicated orders for [MEDICATION NAME] 10 mg three times a day, with scheduled administration times at 6:00 a.m, 2:00 p.m. and 10:00 p.m. and the duplicated order of [MEDICATION NAME] 10 mg three times a day, with administration times at 9:00 a.m., 1:00 p.m. and 9:00 p.m. The second duplicated medication order for [MEDICATION NAME] 20 mg two times a day, administration times at 6:00 a.m. and 4:00 p.m. and [MEDICATION NAME] 20 mg three times a day, with administration times at 9:00 a.m, 1:00 p.m. and 9:00 p.m. Interview on 12/4/18 at 10:36 a.m. with Registered Nurse (RN) BB, stated that night shift staff are responsible for verifying physician orders against Medication Administration Records (MAR). She stated that she checks every one of the MAR's herself for accuracy. She verified the orders fort R#17 for [MEDICATION NAME] 10 milligrams (mg) three times a day (TID) and [MEDICATION NAME] 10 mg TID and [MEDICATION NAME] 20 mg TID and [MEDICATION NAME] 20 mg two times a day (bid), to be duplicated orders. Interview on 12/4/18 at 10:50 a.m. with Licensed Practical Nurse (LPN) EE, who read the physician orders for R#54 Vitamin D3 to read 2000 units, give two tabs every morning. She immediately stated to the surveyor I only gave two tablets this morning. She asked surveyor if she could go give the additional two tablets? Interview on 12/4/18 at 12:10 p.m. with RN BB, stated that she had contacted R#17 Physician regarding clarification of two duplicated medications and clarification orders were obtained from physician to discontinue one of each of the duplicated orders.",2020-09-01
39,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,761,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure that all drugs and biological's were discarded prior to expiration date. The facility census was 61. Findings include: Review of the facility policy titled Medication Storage in the facility dated ,[DATE], revealed the policy as medications and biological's are stored safely, securely and properly, following manufacturer's recommendations or those of the supplier. Procedure letter H revealed outdated, contaminated or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal. Observation on [DATE] at 2:53 p.m. of medication storage room/Central Supply room, with Administrator and Clinical Director of Health Services, revealed medications neatly arranged on multiple shelves. Observation of random bottles of medication revealed a 16 ounce bottle of Mineral Oil with expiration date of ,[DATE] and a 16 ounce bottle of [MEDICATION NAME] Cough syrup with expiration date of ,[DATE]. Interview on [DATE] at 2:53 p.m. with Administrator, stated that Central Supply Clerk is responsible for keeping the medications stocked and checked for expiration dates. She was not sure of how often she checks the medications/supplies. Interview on [DATE] at 9:10 a.m. with Central Supply Clerk, stated that she checks the medications in the supply room for expiration dates once per month. She stated that when she finds medications that are expired, she gives them to the Director of Nursing (DON). She stated she was not aware of the two bottles of expired liquids in the supply room.",2020-09-01
40,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,880,D,0,1,46UW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to utilize proper technique while providing [MEDICAL CONDITION] care for one resident (R) R#38. The facility census was 61 residents. Findings include: Observation on 12/3/18 at 11:16 a.m. revealed in room [ROOM NUMBER] B, un-bagged and unlabeled urinal on the floor behind the toilet and an unlabeled bar of soap on the sink ledge, in a bathroom shared by two male residents. Observation on 12/3/18 at 11:20 a.m. revealed in room [ROOM NUMBER] B, four unlabeled and unbagged bath basins, in a bathroom shared by two female residents. Observation on 12/3/18 at 11:27 a.m. revealed in room [ROOM NUMBER] A, un-bagged and unlabeled nebulizer mask sitting on bedside nightstand. Observation on 12/3/18 at 11:34 a.m. revealed in room [ROOM NUMBER] B, bar of hand soap sitting on sink ledge in bathroom shared by two male residents. Also, un-bagged nebulizer mask sitting on bedside nightstand. Observation on 12/3/18 at 11:46 a.m. revealed in room [ROOM NUMBER] B, labeled but un-bagged urinal in bathroom. Enteral feeding bottle hanging from pole at bedside to bed B, dated 12/1/18. No resident currently residing in bed B. Observation on 12/6/18 at 9:01 a.m. [MEDICAL CONDITION] care performed by Licensed Practical Nurse (LPN) EE for Resident (R) #38. Nurse EE gathered supplies and entered R #38 room. She washed her hands and donned clean gloves. Nurse EE removed soiled [MEDICAL CONDITION] dressing from stoma site. Moderate amount of brown drainage noted on dressing. No odor detected. Nurse removed gloves and applied clean gloves. She did not wash her hands or use hand sanitizer. She [MEDICAL CONDITION] kit and cleanse around [MEDICAL CONDITION] with normal saline. She placed drain sponge on residents chest and resident had a coughing spell and drain sponge was propelled off chest onto pillow on bed. Nurse picked the drain sponge from the pillow and placed it around [MEDICAL CONDITION]. She removed her gloves and put on clean gloves to [MEDICAL CONDITION]. She did not wash her hands or use any hand sanitizer. She removed gloves and applied clean gloves and then applied the [MEDICAL CONDITION]. Nurse cleaned up after procedure and discarded trash in soiled utility room. Nurse did not wash her hand or use hand sanitizer at any point during the procedure, or after it was completed. Interview on 12/6/18 at 9:30 a.m. with LPN EE, stated that she was nervous during the procedure and she forgot to wash her hands after changing gloves. She further stated that she normally washes her hands during the [MEDICAL CONDITION] care. Interview on 12/6/18 at 4:17 p.m. with Registered Nurse BB, verified on walking rounds the infection control concerns identified during the survey. She stated that it is her expectation that residents personal care equipment be labeled with their name and be stored in a clear bag. She further stated that there was not a policy on labeling and storing of resident personal care equipment.",2020-09-01
41,NORTH DECATUR HEALTH AND REHABILITATION CENTER,115012,2787 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-12-06,883,D,0,1,46UW11,"Based on resident interviews, staff interviews record review and policies titled Immunizations: Influenza (Flu) Vaccination of Residents and Staff and Standing Orders for Administering Pneumococcal Vaccines to Adults; the facility failed to document rationale of resident (R)#24 refusal of Flu and provide vaccine information statement (VIS) and offering of Pneumococcal vaccine and VIS to R# B. Sample was 2 of 5. Findings include; During review of facility's infection control processes on 12/6/18 at 11:41 a.m. unable to locate documentation for R#24 regarding refusal of flu vaccine. Also, unable to locate documentation that education via the VIS as recommended by the Center for Disease Control (CDC) was provided to resident and /or family member. Further review of R#24's minimum data set (MDS) which a is part of the United States federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes; assessed R#24 with a Brief Interview for Mental Status (BIMS) of two. BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A score of 00-07 indicates severe cognitive impairment. R#24 has family member who is the responsible party (RP). An interview with Director of Nursing (DON), with Corporate representative present, Director of Clinical Services, on 12/6/18 at 12:00 p.m. revealed that the electronic medical record (EMR) should show that the resident and /or RP was provided the VIS education. DON attempted to evidence the education had been given. Upon continued review of the R#24's record DON was unable to confirm the VIS education was provided; Nor was there evidence of a nurse's note indicating VIS education had been provided or discussed. On 12/6/18 at 12:55 p.m. Corporate representative, Director of Clinical Services provided a document dated 12/6/18 indicating the resident's RP had been contacted to discuss administration of the flu vaccine. The RP refused however; the reason for refusal not documented nor was it clear that the VIS was used to discuss the risks and benefits of the vaccine. An interview on 12/6/18 at 1:20 p.m. with DON and Director of Clinical Services present, revealed resident was offered the Pneumonia vaccine upon his admission in on 6/4/18. Four days after his admission. DON further stated no conversation about pneumonia took place this current flu season. An interview on 12/6/18 at 1:30 p.m. RB revealed does not remember when last received the pneumonia vaccine. Further stated that no one discussed administration on the pneumonia vaccine either upon his admission in (MONTH) (YEAR) or during this current flu season. R B has a BIMS of 10. A score of 08-12 indicates moderate cognitive impairment. RA was able to answer screening questions without difficulty; cohesively and coherently. Review of facility's policy titled Immunizations: Influenza Vaccination of Residents and Staff revised 2/2018 states on page 29 under Administration procedure bullet point B states; the VIS will be used to discuss the risks and benefits of the vaccine. In the case of residents this may be with their authorized representative when appropriate. Bullet point C states; Resident may refuse vaccination. Vaccination refusal and reason why should be documented. Review of facility's policy titled Standing Orders for Administering Pneumococcal Vaccines to Adults, no date, states on page two of four, bullet #3; provide all patients with a copy of the most current federal VIS.",2020-09-01
42,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,278,D,0,1,M6O611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to accurately assess the dental status for one (1) resident (R #30) who had missing and broken teeth and failed to accurately assess the swallowing/nutritional status for one (1) resident (R) (R #72) that exhibited signs and symptoms of possible swallowing disorder by coughing during meals. The sample was thirty six (36) residents. Findings include: 1. Record review for R#30 revealed a Nursing Admission Evaluation and Initial Plan of Care dated 9-8-14 and 10/03/2016, in the oral status section questions #79 and #81 was not checked to indicate the resident had missing and broken teeth. Review of the Minimum Data Set (MDS) assessment for R#30 dated 10/10/2016 did not indicate in Section L- Dental Status that the resident had missing and broken natural teeth. Observation conducted on 11/9/2016 at 12:23 p.m., revealed the R#30 sitting in the dining hall waiting for lunch. Missing and broken broken teeth noted during this observation. During an interview with the R#30 on 11/10/2016 at 9:29 a.m., it was observed that he was missing several teeth on the top and bottom of his gums. There were a few teeth on the left bottom gum that was visible when the resident opened his mouth. R#30 revealed he does not have any trouble eating and that he had not talked with anyone about receiving dental services. R#30 further stated that he had gingivitis in the past that resulted in some of his teeth coming out. Interview on 1/10/2016 at 11:54 a.m. with the MDS Coordinator DD confirmed that the MDS assessment for R#30 dated 10/10/2016 did not indicate the resident had broken or missing natural teeth. DD said R#30 would be re-assessed to verify if there are any missing or broken teeth. Subsequent interview with the MDS Coordinator DD conducted on 11/10/16 at 12:15 p.m. confirmed that after re-assessment, R#30 did have missing and broken teeth. DD further confirmed the dental status for R#30 was not properly coded in the MDS assessment. 2. R#72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment for R#72 dated 8/8/16 documented in Section K- Swallowing/Nutritional Status that the resident did not exhibit any signs and symptoms of possible swallowing disorder. Record review for R#72 revealed a Diet of NCS/NAS (No Concentrated Sweets/No Added Salt), regular texture, nectar thick liquids consistency. Dietary Supplement: Magic cup two times a day with lunch and supper. Review of admission orders [REDACTED]. Review of speech therapy notes dated 8/3/16, 8/4/16, 8/5/16 and 8/8/16 revealed R#72 had swallowing difficulties and was unable to tolerate regular foods well and exhibited coughing while drinking liquids. Interview on 11/10/2016 at 12:56 p.m. with the Dietary Supervisor (DS) revealed that she is responsible for the nutritional status of the MDS assessments. The DS stated she usually gets her information from the nursing assessment, nutritional assessments, [DIAGNOSES REDACTED]. The DS confirmed that she inaccurately assesses R#72's swallowing status as having no concerns and that she must have missed it.",2020-09-01
43,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,279,D,0,1,M6O611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to develop a care plan for one (1) resident (R) (#86) related to missing/broken teeth. The sample was thirty-six (36) residents. Findings included: On 11/07/2016 at 2:32 p.m., R#86 was observed to have missing, broken, and discolored teeth. A review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented in Section L- Dental Status that the resident had obvious or likely cavity or broken natural teeth. Section V- Care Area Assessment (CAA) triggered Dental Status with the decision to be care planned. A review of the medical record for R#86 revealed no evidence of a care plan related to the resident's dental status. During an interview with MDS Coordinator DD on 11/9/2016 at 3:53 p.m. she stated that she has been working at the facility since (MONTH) 2013. She confirmed that when a resident is assessed to have likely cavity or broken natural teeth, the MDS staff will create a care plan related to dental. She confirmed that there was no dental plan of care in place for R#86. DD stated that the reason the care plan was not created was pure human error'. She had addressed the impairments in the CAA and stated, At this point, it is just human error.",2020-09-01
44,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,323,D,0,1,M6O611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy and procedure, the facility failed to conduct neurological assessments (Neuro Checks) for one (1) resident (R) (R#134) after an unwitnessed fall. The sample was thirty six (36) residents. Findings Include: Review of the facility's Fall Prevention Protocol documented: Action (Step 4) After an incident of a fall, complete the Post Fall Risk Assessment, notify MD and Responsible Party, start Neuro check if there is a suspected head injury or for an unwitnessed fall as per facility Protocol: Record review for R#134 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 6, indicating severe cognitive impairment. R#134 was assessed for wandering 1 out of 3 days to a potentially dangerous place. Section G: Functional Status: Activities of Daily Living (ADL) resident requires supervised oversight encouragement or cueing with one person physical assist with bed mobility and transfer. Resident requires limited assistance with one person assist with walk-in room, walk-in corridor, locomotion on unit and locomotion off unit. A Nurse's progress note of 6/24/16 at 11:18 p.m., documented that the resident had a fall in her room resulting with injuries to include a skin tear to her right elbow, and a laceration to her right cheek,secondary to the resident attempting to turn off her light in her bedroom. R#134 confirmed to the staff she fell beside her bed while trying to turn off a light. Staff encouraged the resident to use her call light button when she needed something, staff placed non-skid socks on resident for added safety. Review of the Fall Assessment Note dated 6/25/16 at 02:55 revealed (unwitnessed fall) R#134 had intermittent confusion 1-2 falls in the last 3 months Ambulatory/Continent Adequate (with or without glasses). No noted drop between lying and standing. The care plan has been reviewed and updated per completion of this assessment, family, resident, and MD aware. IDT team to continue review for effectiveness of plan. Reassess per policy. Further record review for R#134 revealed no evidence or documentation of neurological assessments (Neuro checks). During interview with the Director of Nursing (DON) and the Nursing home Administrator on 11/10/16 at 1:45 p.m., both acknowledged there was no documentation of a Neuro checks for R#134 after her fall on 6/24/16. The facility failed to follow it's own Fall Prevention Protocol regarding Neuro checks for R#134 after an unwitnessed fall.",2020-09-01
45,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,363,E,0,1,M6O611,"Based on observation and staff interview the facility failed to follow recipes for the preparation of pureed stewed tomatoes and puree navy bean soup. This deficient practice had the potential to effect eleven (11) residents receiving pureed consistency from a total of ninety three (93) residents receiving an oral diet. Findings include: Review of the General Food Preparation and Handling policy revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of injurious organisms and substances. Review of the facilities menu for Wednesday, week five supper meal revealed puree diet was to receive pureed navy bean soup, stewed tomatoes with okra, cornbread, margarine, citrus gelatin, and milk. Observation on 11/09/16 at 1:40 p.m. of BB dietary aide preparing the food items for the puree supper meal. BB opened a one hundred two (102) ounce can of stewed tomatoes, placed contents inside a large blender bowl, added twelve (12) slices of white bread and turned blender machine on to pureed. Once the stewed tomatoes were pureed BB placed the contents in a stainless steel pan that was five (5) inches in length, 12 inches in width and six (6) inches in depth, covered with a lid then placed in refrigerator. Further observation revealed BB puree the navy bean soup for the supper meal. BB opened a 6 pound 6 ounce can of navy beans, placed the contents in the large blender bowl, turned blender machine on, stirred, and added water. Once the beans were pureed BB placed the contents in a stainless steel pan that was 5 inches in length, 12 inches in width, and 6 inches in depth. The dietary aid placed a lid on the top of the pan then placed in the refrigerator. Review of the recipe for Stewed [NAME]toes revealed the ingredients were to consist of chopped onions, melted margarine, crushed canned tomatoes, granulated sugar, and celery powder. The method for preparation 1) Saute onions in the margarine until golden brown. 2) Add remaining ingredients to onions. Mix well, bring to boil, simmer, covered ten (10) to twenty (20) minutes. 3) Portion with a four (4) ounce ladle. Continued review of the Stewed [NAME]to recipe revealed directions for diet preparations Puree: prepare as directed, Blenderize and strain. Review of the Bean Soup recipe revealed the ingredients included: dry beans, navy or northern, Boiling water, ham bones, chopped onions, diced carrots, and diced celery. The method of preparation 1) Wash beans thoroughly in cold water. 2) Cover beans with boiling water, cook two (2) minutes, turn off heat, let stand one hour or longer. 3) Simmer beans for one hour. 4) Add ham bones, onions, carrots, and celery to the water and beans. 5) Cook covered for one and one half hours or until beans are tender, mash beans. 6) Add water. 7) Remove ham bones. 8) Serve. Continued review of the Bean Soup recipe revealed directions for diet preparation: Puree, prepare as directed, Blenderize and strain. Interview on 11/09/16 at 1:40 p.m. with BB, dietary aide revealed she confirmed she did not follow the recipe for Stewed [NAME]toes. BB revealed there was no documentation indicating to add bread or how much bread to add when pureeing the Stewed [NAME]toes. BB revealed she had been told by the dietary Manager (DM) to add one slice of bread per serving for stewed tomatoes. Continued interview with BB revealed she did know there was a recipe for Bean soup. BB revealed the method she prepared the pureed navy bean soup is how she had been performing the task. BB revealed sometimes she would add pureed onion to the pureed beans. When asked if she tastes the pureed food items, B revealed no she does not taste. Interview on 11/09/16 at 1:42 p.m. with the DM revealed she confirmed BB, dietary aide, did not follow the recipes as printed in the recipe book for Stewed [NAME]toes or for Navy Bean soup. The DM revealed there is no documentation indicating how much bread for staff to add to some of the recipes. The DM revealed she did not realize there was even a recipe for the bean soup. The DM confirmed BB pureed navy bean straight from the can for the supper meal and did not add any of other ingredients listed on the recipe. When asked why the puree consistency diet was not prepared navy bean soup as the menu indicated, the DM could not explain. Continued interview with the DM revealed she sometimes will taste the pureed food items but not all the time. Interview on 11/09/16 at 1:44 p.m. with the Registered Dietitian (RD) revealed she expects the facility to follow the recipes as printed. Continued interview with the dietitian revealed she was not aware the facility was not following recipes.",2020-09-01
46,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,364,E,0,1,M6O611,"Based on observation and staff interview the facility failed to prepare puree food in a manner to conserve nutrient value by prolonged re-heating. This deficient practice had the potential to effect eleven (11) residents receiving pureed consistency from a total of ninety three (93) residents receiving an oral diet. Findings include: Review of the General Food Preparation and Handling policy revealed food items will be prepared to conserve maximum nutritive value, develop and enhance flavor and keep free of injurious organisms and substances. Review of the Meat and Vegetable Preparation policy revealed vegetables: Avoid overcooking and long holding times. Observation on 11/09/16 at 12:30 p.m. of the steam table revealed the pureed mixed vegetable had a dark orange brown color and the puree scalloped potatoes and puree chicken were light brown in color. Interview on 11/09/16 at 12:30 p.m. with the Dietary Manager (DM) revealed she knew the pureed food items were being held for a long period of time. When asked why the pureed foods were being held for a long period time the DM revealed that the ovens under the stove top are not working properly and if was difficult to get food items re-heated at the proper temperature in a timely manner. The DM revealed she had dietary staff puree food items early and put in oven in order to get up to the proper temperatures. Interview on 11/09/16 at 1:30 p.m. with BB, dietary aide revealed they wanted to clarify the process of the pureed food items prepared for the lunch meal today. BB revealed she began re-heating the pureed food items in the oven at 9:30 a. m. The dietary aide revealed the oven had not been working properly for the past two (2) weeks and in order to get the puree food items re-heated to the proper temperature she had start the process early. Interview on 11/09/16 at 1:35 p. m. with the registered dietitian (RD) revealed she expects the facility to re-heat the pureed food items no earlier than 1 hour before the meal is to be served. The dietitian was not aware that BB, dietary aide, was re-heating the puree food items as early as 9:30 a.m. .",2020-09-01
47,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,371,F,0,1,M6O611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and documentation review the facility failed to follow manufactures recommendations for sanitizing dishware in the three (3) compartment sink to prevent foodborne illness; failed securely wrap opened food items in the dry storage area as well in one (1) of 3 refrigerators for two (2) of four (4) days of the survey; failed to prevent wet nesting of stainless steel food pans to prevent bacterial growth; failed to ensure the stand-up mixer was cleaned after usage to prevent contamination; failed to ensure the inside ice slide to the ice machine was clean and free from debris. This deficient practice had the potential to effect all ninety three (93) residents receiving an oral diet. Findings include: Observation on 11/07/16 at 11:30 a.m. of AA, dietary aide, wash several cooking utensils in the 3 compartment sink revealed AA took the cooking utensils from the rinse sink compartment, then swished them all in the sanitizing solution compartment for a couple of seconds then placed on a shelf area to dry. Further observation revealed a poster was hung on the wall above the 3 compartment sink which indicated to submerge items for one to two (1-2) minutes. Observation on 11/07/16 at 11:35 a.m. of the first reach-in refrigerator revealed a stainless steel pan, five (5) inches in length, twelve (12) inches in width, and six (6) inches in depth containing a block of sliced American cheese that was eight (8) inches in length and four (4) inches in width and depth opened and not securely wrapped, the top of the cheese was exposed to the air. Observation on 11/07/16 at 11:40 a.m. of the stand-up mixer revealed under the mixing arm was an off white substance that was splattered around in several different areas. Observation on 11/07/16 at 11:45 a.m. of an inverted stack of three stainless steel pans ten (10) inches in length, 12 inches in width and 6 inches in depth, located under the food preparation table near the oven revealed when the top 2 pans were lifted and removed water was found underneath. Observation on 11/07/16 at 11:50 a.m. of the dry storage area revealed a clear re-sealable plastic bag containing shredded coconut. Continued observation revealed the clear plastic bag was not sealed and the shredded coconut did not have a date opened. Observation on 11/07/16 at 12:05 p.m. of the ice machine revealed eight (8) brown spots in center of the stainless steel ice slide located inside the machine the size of a pencil eraser. Interview on 11/07/16 at 11:30 a. m. with AA, Dietary Aide revealed she confirmed she did not submerge the utensils for 1 minute in the sanitizing solution of the 3 compartment sink and confirmed she swished the items in the sanitizing solution for only a few seconds. AA revealed there was a dietary in-service completed recently on using the 3 compartment sink and she did attend. When asked if she recalled how long to submerge dishware in the sanitizing solution AA revealed ten (10) seconds. Interview on 11/07/16 at 12:10 p.m. with the Dietary Manager (DM) revealed she confirmed the facility uses EcoLab Quaternary sanitizing solution for the 3 compartment sink. The DM confirmed dietary staff were in-serviced recently regarding the 3 compartment and were education that items need to be submerged for 1 minute and expects dietary staff to follow the in-service education. Continued interview with the DM revealed they confirmed the opened block of sliced American cheese was not wrapped before placing in the stainless steel pan in the reach-in refrigerator. The DM expects staff to wrap food items before storing in the refrigerator. The DM confirmed the stainless steel pans stacked under the food preparation table were stored wet. The Dietary Manager revealed she expects dietary staff to stack pans after they are dry. The DM confirmed the shredded coconut in the dry storage area was in a re-sealable plastic bag that was not sealed and did not have a date. She expects staff to close the re-sealable plastic bags and place date on opened food items before storing in dry storage. Observation on 11/09/16 at 2:25 p.m. of the stand-up mixer revealed the off white substance remained under the mixing arm. Continued observation revealed when the off white substance was touched it flaked off with finger. Observation on 11/09/16 at 2:30 p.m. of the first reach-in refrigerator revealed the same stainless steel pan containing the block of sliced American cheese. The American cheese was in a re-sealable clear plastic bag however the plastic was not sealed and the cheese was exposed to the air. Observation on 11/09/16 at 2:35 p.m. of the ice machine in the kitchen revealed the 8 brown spots the size of a pencil eraser on the stainless steel ice slide located inside the ice machine. Continued observation revealed when the spots were touched with a paper towel they were removable. Interview on 11/09/16 at 2:35 p.m. with the Dietitian revealed she confirmed there was an off white substance under the mixing arm. Interview on 11/09/16 at 2:35 p.m. with the DM revealed she confirmed the off white substance under the mixing arm. The DM revealed dietary staff uses the stand-up mixer about once a week and staff has not used the mixer this week. The DM expects dietary staff to clean the stand-up mixer after usage. Continued interview with the DM revealed she confirmed the clear re-sealable plastic bag containing sliced American cheese was not closed. The DM revealed she spoke with dietary staff on Monday regarding sealing food items while be stored in the refrigerator. The DM expects dietary staff to securely wrap or seal opened food items in plastic bags while being stored in the refrigerator. Further interview with the DM revealed she confirmed the brown spots on the ice slide inside the ice machine and confirmed when the surveyor touched them with a paper towel the spots were removable. The DM revealed dietary staff are expected to wipe the ice slide inside the ice machine daily as part of regular routine cleaning. Review of the Cleaning Dishes - Manual Dishwashing policy revealed to place the dishes in the sanitizing sink. Allow to stand according to the manufacturer's guidelines for sanitizer. Review of the EcoLab Product Specification Document for Multi-Quat Sanitizer revealed immerse all utensils for at least 1 minute. Review of the Food Storage policy revealed plastic containers with tight fitting covers must be used for storing cereal, cereal products, flour, sugar, dried vegetable, and broken lots of bulk foods. All containers must be legible and accurately labeled and dated. Continued review of the policy revealed leftover food is stored in covered containers or wrapped carefully and securely, each items is clearly labeled and dated before being refrigerated. Further review of the policy revealed all foods should be covered, labeled and dated. Review of the cleaning sheet revealed mixers are to be cleaned after each use. The DM revealed despite the title of the cleaning sheet stating Sample, the dietary staff are to use and follow. Review of the Food Preparation and Handling policy revealed Equipment: all food service equipment should be cleaned, sanitized, dried, and reassembled after each use. Review of the in-services completed in the dietary department for the past 12 months revealed dietary staff were educated on 03/29/16 regarding Food Safety, people who are elderly are receiving [MEDICAL CONDITION], or have chronic illnesses are more susceptible to foodborne illness than health people. Dietary staff also completed an in-service on 10/25/16 regarding Sanitizing Dishware, 3 compartment sink. Sanitizer in 3 compartment sink be aware of procedures, submerge at least 1 minute.",2020-09-01
48,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,431,D,0,1,M6O611,"Based on observation, record review and staff interviews, the facility failed to ensure that expired medications were disposed of properly in one (1) of two (2) medication storage rooms. (Unit A). Findings include: Review of the facility's policy titled Storage of Medications and Biologicals with revision date 10/20/2016 revealed on number five (5): The facility should ensure the Medications, Biologicals, Syringes and Needles are monitored for expiration dates, secured and stored appropriately. Observation on 11/09/2016 at 11:45 a.m. of the medication room on A hallway revealed one (1) bottle of ASA 325mg with expiration date 10/2016, one (1) bottle of Fiber Laxative with expiration date of 09/2016 and one (1) bottle of Zinc Sulfate with expiration date 09/2016. Interview on 11/09/2016 at 11:50 a.m. with the Licensed Practical Nurse (LPN)/Charge Nurse HH revealed the nurses check their medication carts daily and check the medications in the storage room especially when they have to get a medication from the storage room for the medication cart. LPN HH confirmed that the medications were expired. Interview on 11/09/2016 at 12:00 p.m. with the Director of Nursing (DON) confirmed that the medications: [REDACTED]. Stated the the medication rooms are checked every Sunday and the nurses check all of the medications daily and as needed. Stated her expectations are for there to be no expired medications on the medication carts or in the medication storage rooms.",2020-09-01
49,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,456,F,0,1,M6O611,"Based on observation and staff interviews, the facility failed to maintain two (2) of three (3) ovens in the kitchen in optimal working condition in order to prepare resident meals. This deficient practice had the potential to effect all ninety three (93) residents receiving an oral diet. Findings include: Observation and interview on 11/09/16 at 12:30 p.m. with the Dietary Manager (DM) revealed the 2 ovens under the stove top were not functional and had not be working correctly for the past four (4) months. The DM revealed that sometimes the oven works and sometimes it does not. When asked what it meant, work, the DM revealed sometimes the oven gets hot and sometimes it does not. Continued interview with the DM regarding the interview conducted on 11/07/16 at 12:15 p. m. when she told surveyor there was no kitchen equipment under repair or out of service, the DM revealed the convention was working probably but failed to report the 2 standard ovens did not work at times. Further interview with the DM revealed the free standing convention oven is working properly however there is not enough room to cook food items and re-heat the pureed foods. Interview on 11/09/16 at 1:30 p.m. with the facilities registered dietitian (RD) revealed she was not aware the standard ovens had not been functioning properly for the past 4 months. The RD revealed she visits the facility at least once a month and goes into the kitchen but was not aware of the malfunctioning ovens until today. Interview on 11/09/16 at 2:15 p.m. with CC, Maintenance Assistant revealed he was not aware the dietary department had problems with the ovens. He revealed 2 weeks ago the natural gas to the entire building was shut off to run a new gas line to the back-up generator and all kitchen equipment was turned off. CC revealed he was in the kitchen 2 weeks ago to re-light the pilot on the stove and ovens and the DM did not revealed any concerns with any kitchen equipment. Interview on 11/10/16 at 9:55 a.m. with CC, Maintenance Assistant revealed he expects the DM to submit a work order through the facilities computer system for any kitchen equipment issues. CC confirmed there was no work order submitted for the malfunctioning standard ovens and was only verbally told of the issue yesterday. Continued interview with CC revealed the DM was able to notify him verbally of kitchen equipment issues but expects the DM to follow up by submitting a work order. Interview on 11/10/16 at 10:15 a.m. with the DM revealed she verbally notified a maintenance worker 4 months ago that the ovens were not functioning properly. When which maintenance worker she spoke with the DM asked revealed they no longer are employed with the facility. The DM revealed she had never placed a work order in the computer to notify maintenance the issues with the oven. Interview on 11/10/16 at 11:00 a. m. with the Administrator revealed she was not aware of any issues with the ovens until it was brought to her attention yesterday. When asked if the DM revealed to her that the ovens had not been functioning correctly for the past 4 months, the Administrator was not aware. The Administrator revealed the DM can verbally notify maintenance of a kitchen issue but expects a work order to be completed as follow-up. Continued interview with the Administrator revealed the facility does not have a policy regarding completing work orders for equipment issues.",2020-09-01
50,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2016-11-10,514,D,0,1,M6O611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to ensure documentation for the use of a splint or refusal to use a splint for one (1) resident (R) (R#65) with a left hand contracture and failed to consistently document the urinary output for one (1) resident (R#93) with a urinary catheter. The sample was thirty six (36) residents. Findings include: 1. Record review for resident #65 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the [DIAGNOSES REDACTED]. Review of the care plan for R#65 dated 8/8/2016 indicated a left hand contracture [MEDICAL CONDITION] secondary to history of [MEDICAL CONDITION]. The goal of the facility is to minimize decline in left hand contracture. An intervention included to place splint as tolerated and maintain contracture and treatment prn as ordered. Review of restorative nursing care weekly notes dated 8/25/16 documented: range of motion active, transfer, dressing or grooming fair. The resident making fair progress towards goals. Continue with restorative nursing program. Observations of R#65 revealed a left hand contracture with no splint device in place on 11/09/2016 at 9:56 a.m. and 11/9/2016 at 12:00 p.m. An interview with R#65 on 11/9/2016 at 9:56 a.m. revealed the left hand contracture was the result of a past stroke. R#65 further stated she is unable to use her left hand to assist with any daily activity. Review of restorative CNA progress notes section dated 8/25/16 documented: range of motion active, training skill/practice: transfer/dressing or grooming progress is fair towards goals. Further review of the clinical record for R#65 revealed no evidence of documentation when the splint was placed or if the splint was tolerated by the resident. Further Record Review revealed no evidence of documentation related to (r/t) splint and/or refusal of splint wearing. Review of care plan revealed left hand contracture with intervention to splint as tolerated-no issues Interview with Charge Nurse OO on 11/10/2016 at 11:33 a.m. revealed the R#65 is not on restorative care services at this time and is able to eat without assistance, R#65 does not need restorative care services. This is documented in the Electronic Medical Record (EMR) and there are not any recommendations for restorative care for the resident. Interview with Certified Nursing Assistants (CNAs) MM and NN on 11/10/2016 at 1:55 p.m., revealed R#65 was on restorative care services previously for splint use as tolerated. CNA MM stated that R#65 refused to wear the hand splint. When asked if this information was documented, CNA's MM and NN were unaware if refusal of splint treatment was documented in the EMR. Interview with the Administrator on 11/10/2016 at 3:21 p.m., that the hand splint treatments, and restorative care services for R#65 was not documented for either the use of or refusal of wearing the hand splint as tolerated per the care plan. 2. Review of the policy for recording input and outputs documented that the facility will ensure that fluid intakes and outputs are calculated and recorded every twenty four (24) hours. R#93 was admitted to the facility on [DATE] with a urinary catheter for [MEDICAL CONDITION] and acute kidney injury. R#93 was discharged on [DATE] and re-admitted on [DATE] with continued urinary catheter. Review of the Physician orders [REDACTED]. Review of Medication Administration Record [REDACTED]. Interview on 11/10/2016 at 9:10 a.m. with the Certified Nursing Assistant (CNA) GG revealed that urinary outputs are recorded on the vital signs sheet which is provided by the nurse at the start of the shift. Outputs are recorded twice per shift (at the beginning and at end of the shift) and the vital signs sheet is handed back to the nurse for input into the computer. Interview on 11/10/2016 at 9:23 a.m. with the Licensed Practical Nurse (LPN) FF revealed that urinary output is recorded by the CNA on the vital signs sheet which she gives the CNA at the start of the shift. The CNA returns the form to the nurse at the end of the shift and at that time the nurse records the total output on the computer system. Interview on 11/10/2016 at 10:35 a.m. with the Director of Nursing (DON) revealed that the CNAs are expected to record urinary output on vital signs sheet and then hand the sheet over to the nurse at some point in their shift to enter it on the computer. The DON stated she expects the urinary output to be entered in the computer on each shift.",2020-09-01
51,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2018-12-06,580,D,0,1,Q9R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to notify the physician of a change in condition for one sampled Resident (R) #72 out of a total of 34 residents. Findings include: Resident #72 was admitted to the facility on [DATE] and re-admitted on [DATE] with current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#72 revealed the resident's cognition was intact, with the Brief Interview for Mental Status (BIMS) score of 15/15. The care plan dated 10/22/18 revealed the problem statement, I have an actual impairment to skin integrity r/t (related to) fistula which created an abdominal abscess to my LLQ (left lower quadrant). I have an ostomy bag in place for drainage. Interventions included: Staff will follow facility protocols for treatment of [REDACTED]. Treatment nurse and WC (wound care) will observe on rounds/document location, size and treatment of [REDACTED]. to MD. During resident observation and interview on 12/3/18 at 2:38 p.m., R#72 stated that a few weeks ago, she had a [MEDICAL CONDITION] done. I had a bump on my belly (pointed to her lower left abdomen), and had nurses look at it, but they never did anything about it until it turned into a bump, and I complained of that knot there, and they looked at it, but just said it will go away, or that I need to get 'cleaned out' (have a bowel movement). Then it formed a head, and then they had the doctor look at it, and he said it was a cyst, and opened it. It went down about 1-1/2 inches into my colon. So, they did this [MEDICAL CONDITION] . Review of the Nurses' Notes revealed: 8/21/2018 18:58 Nurses Note: C/O (complained of) stomach hurting all day. Said it hurt more than usual. Will continue to monitor. (No follow up documentation was noted by nursing for this change of condition until 8/25/18) 8/25/2018 16:55 Nurses Note: C/O stomach hurting. Resident stated she felt something on her left side of her abdomen. I felt her stomach and noted slight swelling on the left side of her abdomen. Resident stated it was tender to the touch. Will continue to monitor. 8/31/2018 13:50 Nurses Note: C/o stomach pain more than usual. Resident says the severity of the pain has increased. Says pain medication only helps a little. Will continue to monitor. Seven attempts were made to contact the nurse who wrote the above notes, but she was unavailable for interview. 10/13/2018 11:54 Nurses Note: Resident has a large abscess to L (left) hip. Area is red and inflamed. Resident states that area was tender yesterday, but (sic) did not notice the nodule until today. Tx (treatment) nurse aware. Warm compresses applied to area. 10/13/2018 14:15 Nurses Note. BP (blood pressure) 10/65 (sic) Temp (temperature) 98.1 axillary, Pulse 66, RR (respiratory rate) 17. Resident c/o of tenderness on L hip abscess. 10/14/2018 10:46 Nurses Note: Stool and pus drainage from abscess on L hip. 2 Tylenol 500mg given with minimal relief. ABD (abdominal) pad applied. 10/16/2018 20:35 Skin/Wound Note Text: Resident seen by NP (Nurse Practitioner) for abscess to left hip. Resident had very dark brown and white puss with very foul smell noted draining out of abscess opening. Resident abscess was sharp debrided and flushes with NSS (normal saline solution). resident had dankins (sic) (Dakin's solution) soaked gauze packing applied to wound and covered with ABD pad. 10/17/2018 13:27 Nurses Note: Transport picked resident up @ 1325. Resident left facility via stretcher on route to ER (emergency room ) for CT (computed tomography) scan of abscess in left quadrant. On 12/05/18 at 3:39 p.m., in the 100 hall during an interview with Registered Nurse (RN) DD, nursing notes for R #72 were reviewed and RN DD was queried as to what does Will continue to monitor mean as it relates to the residents' complaints. RN DD stated if she saw the note, Will continue to monitor, she would follow up with it, whatever the problem was. RN DD stated, I don't use that wording, because it doesn't specify the nurse's action. It's vague. On 12/5/18 at 3:43 p.m., in the 200 hall, Licensed Practical Nurse (LPN) CC was queried as to what does Will continue to monitor mean as it relates to the residents' complaints. Licensed Practical Nurse (LPN) CC stated if she saw the note Will continue to monitor, she would wonder how often it should be monitored, hourly, weekly? LPN CC stated, It's very vague, probably I would call the doctor, or go to my charge nurse for clarity. On 12/6/18 at 10:28 a.m., in the 100 hall, RN BB was queried as to what does Will continue to monitor mean as it relates to the residents' complaints. RN BB stated, Will continue to monitor? If I saw that note, I would expect another entry and the follow up where the nurse reassessed and documented the follow up that the nurse did with a reassessment. Interview on 12/6/18 at 10:21 a.m., in the Interim Director of Nurse's (DON) office, the DON agreed the note written by the nurse dated 8/25/18 indicated a change of condition for R#72. Maybe a hernia, doctor certainly needs to be aware of it. LLQ pain I would be thinking bowel impaction, diverticulitis, [MEDICAL CONDITION]. 'Will continue to monitor' to me would mean going back to the resident every 15-30 minutes to reassess. It's very vague to document 'continue to monitor.' I would prefer she said to return in 15-30 minutes to reassess, especially with complaints of pain, some tenderness upon palpation. (She should have) call(ed) the doctor with the change of condition, because it is pain related. R#72 is a very articulate lady, communicates well. She has frequently complained, not necessarily physical. In reference to the 8/31/18 note, the DON stated, But even with a history (of complaints), the nurse should have assessed and monitored, six days later, concerned about this because it has increased, pain should have been assessed more specifically for location, intensity, frequency, (and the nurse) should have notified the doctor. If she had called the doctor right away, maybe he would have ordered an abdominal xray then to see what was going on. Better to call the doctor and be told it's not a problem, then to not call and have something like this happen. Interview on 12/6/18 at 11:42 a.m., in her office, the RN Administrator stated regarding the 8/25/18 Nurse's Note she would expect some kind of follow up to resolve it or give a reason why it stopped being monitored. I would have expected her to notify the physician, and it was a change of condition. Interview on 12/6/18 at 11:53 a.m. with the Medical Director (MD) who stated R#72's condition was, One of those things that you could be brewing, and you don't know about it until you get imaging studies. The MD further stated he was made aware of the resident's tender abdomen and complaints on 9/19/18, and, If it came to my attention earlier, I would have come in to see her (R#72). I assume I would have examined her and asked her if she had any signs and symptoms .if I had been called sooner, I would have addressed her problems. The facility provided the policy titled, Notification of resident's change in condition dated (MONTH) 2014, and updated (MONTH) (YEAR). The policy directed, 2.3. except in medical emergencies, notifications will be made within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status.",2020-09-01
52,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2018-12-06,641,B,0,1,Q9R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately reflect the number of falls since admission/entry or prior assessment on the Minimum Data Set (MDS) at the time of the assessment of one Resident (R) (#35) out of thirty-four (34) sampled residents. Findings include: Interview with R #35 on 12/03/18 3:44 p.m. in his room revealed that he fell about three months ago and cracked a bone. Review of the Progress Notes dated 6/24/18 revealed that R #35 was heard yelling out I need help at 2:00 a.m. The aide arrived first in the room and alerted nurse that he was sitting on the floor. Nurse noted resident to be sitting on bottom with legs stretched out apart from each other. Resident stated that he rolled out of bed. Wheelchair noted to be rolled away from resident with brakes unlocked. Medical Doctor (MD) notified and family notified. Review of the Quarterly Minimum Data Set (MDS) for R #35 dated 7/10/18 revealed in Section: A- Re-entry from acute hospital on [DATE] C- Brief Interview Mental Status (BIMS)-14 cognitively intact J- No falls Review of the Quarterly MDS Assessment for R #35 dated 10/5/18 revealed in Section: A- Reentry 7/3/18 from an acute hospital. C-BIMS- 15 cognitively intact J- No falls Interview with the current MDS Coordinators (II and JJ) in the conference room on 12/06/18 at 4:00 p.m. revealed there was no reference to R #35's falls on the (MONTH) 10, (YEAR) or (MONTH) 5, (YEAR) MDS assessments. They stated that they were aware that R #35 had fallen as a Care Plan for his falls was written. They stated that a correction would be made to the MDS.",2020-09-01
53,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2018-12-06,657,D,0,1,Q9R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to revise care plans to address the current care needs of two sampled Residents (R#'s 72 and 55) out of 34 residents. Findings included: The facility provided the policy titled, Resident Assessments, dated 11/28/17 which directed, Resident assessments will be completed upon admission, quarterly, annually, and with a significant change in status. The resident's comprehensive assessment is not only for the purpose of understanding a resident's needs, but to understand their strengths, goals, like history and preferences . 1. R#72 was admitted to the facility on [DATE] and re-admitted on [DATE] with current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] R#72 revealed the resident's cognition was intact, with the Brief Interview for Mental Status (BIMS) score of 15/15. The care plan dated 10/22/18 revealed the problem statement, I have an actual impairment to skin integrity r/t (related to) fistula which created an abdominal abscess to my LLQ (left lower quadrant). I have an ostomy bag in place for drainage. Interventions included: Staff will follow facility protocols for treatment of [REDACTED]. Treatment nurse and WC (wound care) will observe on rounds/document location, size and treatment of [REDACTED]. to MD. During resident interview on 12/3/18 at 2:38 p.m., in the resident's room R#72 stated that a few weeks ago, she had a [MEDICAL CONDITION] done. R#72 further stated, Staff never comes in to check my [MEDICAL CONDITION] bag, I have not told them not to check it, they just don't. When I think it's full, I call them, and they empty it. Last Saturday, I misjudged, and the bag broke; it was such a mess. During an interview with R#72 on 12/4/18 at 9:35 a.m., in the resident's room, the resident stated, Nobody on last evening or night shifts checked my [MEDICAL CONDITION] bag. On 12/4/18 at 4:18 p.m. in the 100 hall nurse's station, the Certified Nursing Assistant (CNA) Kardex for R #72 was reviewed with Registered Nurse (RN) DD. RN DD, who stated there were no directions for the CNAs to check or care for the resident's [MEDICAL CONDITION] listed on the CNA care plan. On 12/5/18 at 2:09 p.m., in the resident's room, R #72 was asked how staff cares for her [MEDICAL CONDITION]. R #72 responded, Nobody had checked her bag the last day, and nobody checks it ever, unless I ask. On 12/6/18 at 4:44 p.m, the care plan for R #72 was reviewed with the Interim Director of Nursing (DON). The DON agreed there were no specific interventions in the care plan or the CNA Kardex care plan to direct the nursing staff to care for R#72's fistula/ostomy bag. The Interim DON acknowledged that nursing staff did not check the resident's ostomy bag. An interview on 12/6/18 at 3:28 p.m. concerning who is responsible for updating care plans was conducted with Minimum Data Set (MDS) Nurse JJ in her office. MDS Nurse JJ stated that floor nurses do not add to the care plan. Weekend and night shift nurses communicate with the MDS nurses via email with updates, information is also obtained from the communication board or morning report to update care plans. MDS Nurse JJ further stated we update the Kardex for the CNAs also. When asked if she knew why R#72's care plan was not updated to include ostomy care, MDS Nurse JJ responded R#72's care plan should include interventions like checking the amount and consistency of stool, monitoring of skin integrity. MDS Nurse JJ agreed specific interventions were not in place for R#72, because the Kardex, pulls the information from the care plan, and it wasn't there. 2. R#55 was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. R#55's Quarterly Minimum Data Set ((MDS) dated [DATE] recorded the resident was severely cognitively impaired. The MDS noted R#55 required extensive assistance of staff for bed mobility, transfers, dressing, eating and toilet use, and was totally dependent on staff for personal hygiene, locomotion and bathing. Review of the Activities of Daily Living (ADLs) care plan dated 11/6/18 directed staff: Anticipate my needs. BATHING: I require total staff participation with bathing. BED MOBILITY: I require total x2 staff participation to reposition and turn in bed. CODE STATUS: DNR (do not resuscitate). DRESSING: I require total x1 staff participation to dress. EATING: I require total assist x1 staff participation to eat. Heel boots as tolerated. PERSONAL HYGIENE/ORAL CARE: I require total staff participation with personal hygiene and oral care. Promote dignity by ensuring my privacy. SIDE RAILS: 3/4 Side rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN (as needed) to avoid injury. Staff to keep in mind that my level of assistance may fluctuate r/t (related to) my significant impairments in cognition and mobility. Document amount of assistance required. TOILET USE: I require total assist x2 staff participation to use toilet. TRANSFER: I require total assist x2 staff participation with transfers. SKIN INSPECTION: I require for staff to observe my skin for changes/alterations during ADL (Activities of Daily Living) care. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Review of the total care plan directed the intervention repositioning the resident, but R#55's care plan did not contain any information directing staff to position the resident during meals. Observation of R#55 on 12/3/18 at 1:18 p.m. in the dining room revealed the resident finished her lunch meal with one episode of coughing and was fed her meal by staff. The resident's broda chair was not reclined at 90 degrees and her head and neck were not supported during the meal. Observation further revealed the resident sat forward to take a bite from the offered spoon or straw, and periodically relaxed her head against the chair back. R#55's neck was mildly hyperextended. R#55's broda chair had a blue 3-sided strapped-on foam support behind the resident with wings laterally, which was placed behind her shoulder blades. This support acted as another layer of width behind her back, and with the chair back not upright, the resident rested the top of her head against the chair with more hyperextension of the neck than before, when she rested. On 12/4/18 at 4:18 p.m. R#55's Kardex was reviewed at the 100 nurse's station, with Registered Nurse (RN) DD, there were no positioning devices or instructions on positioning during meals listed on the CNA care plan (listed on Kardex). An interview on 12/6/18 at 3:28 p.m. in the Minimum Data Set (MDS) office concerning who is responsible for updating care plans was conducted with Minimum Data Set (MDS) Nurse J[NAME] MDS Nurse JJ stated that floor nurses do not add to the care plan. Weekend and night shift nurses communicate with the MDS nurses via email with updates, information is also obtained from the communication board or morning report to update care plans. MDS Nurse JJ further stated we update the Kardex for the CNAs also. MDS Nurse JJ further stated R#55's care plan should include the devices used for positioning and positioning during meals. MDS Nurse JJ agreed specific interventions were not in place for R#55, because the Kardex, pulls the information from the care plan, and no device interventions are listed. Interview on 12/6/18 at 4:44 p.m. with the Interim Director of Nurses (DON) in the Conference Room. The DON reviewed the resident's care plan and Kardex and agreed there were no specific interventions in the care plan or the CNA Kardex care plan to direct the nursing staff to place devices for R#55's positioning during meals. Cross reference F684 for R#55",2020-09-01
54,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2018-12-06,658,D,0,1,Q9R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy it was determined the facility failed to the ensure resident's electronic Medication Administration Record [REDACTED]. Findings include: Review of facility policy and procedures titled Medication Administration General Guidelines Section 7.1, Nursing Care Center Pharmacy Policy & Procedure Manual -dated 2007 indicated the following: - The person who prepares the dose for administration is the person who administers the dose - The individual who administers the medication dose, records the administration on the resident's MAR (medication administration record) immediately following the medication being given. - The resident's MAR/TAR is initialed by the person administering the medication, in the space provided under the date, and on the line for that for that specific medication dose administration and time. Initials on each MAR/TAR are verified with a full signature in the space provided or on the nursing care center's master employee signature log. Medication pass observation revealed on 12/3/18 at 10:27 a.m., Licensed Practical Nurse (LPN) KK administer the following medications to R#83: [MEDICATION NAME] 0.5 (anti-anxiety) milligrams (mg) one tablet PO (by mouth); Aspirin 81mg (blood thinner use to prevent [MEDICAL CONDITION] or stroke) one tablet PO; [MEDICATION NAME] 6.25 mg (medication for blood pressure and heart failure) one tablet PO; [MEDICATION NAME] 75mg (anti platelet) one tablet PO; [MEDICATION NAME] 40 mg (blood pressure) one tablet PO; [MEDICATION NAME] 150 mg (antidepressant) tablet PO [MEDICATION NAME] 5 mg (bladder spasms) one tablet PO; Duo Neb ([MEDICATION NAME]-[MEDICATION NAME]) 0.5 mg-3 mg(2.5 mg base)/3 mL nebulization solution used for nebulizer treatment ( a combination of [MEDICATION NAME][MEDICATION NAME] used to treat and prevent symptoms (wheezing and shortness of breath). A review of the eMAR during the medication reconciliation for R#83 revealed the medications that were administered by LPN KK were signed off (initialed) on the by Registered Nurse (RN) BB prior to the preparation and administration of medications by LPN KK. Initials were verified to identify nurse by reviewing the facility nurse Signature List. An interview conducted in the hallway on B Unit on 12/3/18 at 10:45 a.m. with LPN KK confirmed that medication administration for R#83 were initialed as prepared and administered by another nurse. When questioned why the medications were initialed as administered by another nurse, she stated she was training a new nurse. An interview with RN BB on 12/3/18 at 10:55 a.m. on B Unit revealed the RN was newly employed was being trained on medication administration by LPN KK and was directed by LPN to initial that the medication was given to reflect that it was given in a timely manner. Interview was conducted on 12/5/18 at 1:40 p.m. with LPN LL, unit nurse on B Hall. She stated that the time window for administering medications was one hours before and one hour after the prescribed time. She stated that she initialed a resident's medication after administering theprescribed medications Interview was conducted on 12/5/18 at 1:48 p.m. with LPN MM, Charge Nurse on B Hall. LPN MM stated that she initialed a resident's medication after administering the prescribed medications. She would never initial medications that she did not prepare and give to a resident herself. Interview was conducted on 12/6/18 at 4:15 p.m. with the Interim Director of Nursing (DON) in the DON's office. The DON stated the nurse who prepares and administers the medication to a resident is to initial the resident's medication administration record. A Nurse would never sign for another nurse, if prepared and given then sign after administered.",2020-09-01
55,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2018-12-06,684,D,0,1,Q9R911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to assess for positioning for Resident (R) #55 during meals. The sample included 34 residents. Findings included: R#55 admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. R#55's Quarterly Minimum Data Set ((MDS) dated [DATE] recorded staff evaluated R#55 as severely cognitively impaired. The MDS noted R#55 required extensive assistance of staff for bed mobility, transfers, dressing, eating and toilet use, and was totally dependent on staff for personal hygiene, locomotion and bathing. Review of the Activities of Daily Living (ADLs) care plan dated 11/6/18 directed staff: Anticipate my needs. BATHING: I require total staff participation with bathing. BED MOBILITY: I require total x (times) 2 staff participation to reposition and turn in bed. CODE STATUS: DNR (do not resuscitate). DRESSING: I require total x1 staff participation to dress. EATING: I require total assist x1 staff participation to eat. Heel boots as tolerated. PERSONAL HYGIENE/ORAL CARE: I require total staff participation with personal hygiene and oral care. Promote dignity by ensuring my privacy. SIDE RAILS: 3/4 Side rails up for safety during care provision, to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition PRN (as needed) to avoid injury. Staff to keep in mind that my level of assistance may fluctuate r/t (related to) my significant impairments in cognition and mobility. Document amount of assistance required. TOILET USE: I require total assist x2 staff participation to use toilet. TRANSFER: I require total assist x2 staff participation with transfers. SKIN INSPECTION: I require for staff to observe my skin for changes/alterations during ADL (Activities of Daily Living) care. Observe for redness, open areas, scratches, cuts, bruises and report changes to the Nurse. Observations of R#55 on 12/3/18 at 1:18 p.m., revealed the resident's Broda chair back was not at 90 degrees and her head and neck were not supported during the meal. Observation further revealed the resident sat forward to take a bite from the offered spoon or straw, and periodically relaxed her head against the chair back. R#55's neck was mildly hyperextended. R#55's Broda chair had a blue three-sided strapped-on foam support behind the resident with wings laterally, which was placed under her shoulder blades. This support acted as another layer of width behind the resident's back, and with the chair back not upright, the resident rested the top of her head against the chair with more hyperextension of the neck than before, when she rested. Interview on 12/4/18 at 4:16 p.m. with Certified Nursing Assistant (CNA) FF in the resident's room, who stated R#55 travels in a Broda chair or is in bed, and staff used a positioning support for her in the Broda chair. CNA FF stated, I never noticed her having position problems when she eats, and never reported it to the charge nurse. CNA FF further stated the CNAs use the Kardex as the CNA care plan. Interview 12/4/18 at 4:18 p.m. with Registered Nurse (RN) DD, who printed off R#55's Kardex and stated there were no positioning devices or instructions on positioning the resident during meals listed on the CNA care plan. Observation on 12/5/18 at 8:58 a.m. in the dining room revealed R#55 was fed breakfast by staff. R#55 was positioned in the same way as observed on 12/3/18, with no head and neck support to sit upright with her neck slightly hyperextended. At 9:23 a.m. the resident had a short episode of coughing. Staff did not reposition the resident during or after her coughing episode. Interview on 12/5/18 at 9:30 a.m. with the CNA in the dining room, who fed the resident breakfast, CNA NN stated she never noticed the resident sitting upright with no support and did not notice the resident sitting back in the chair periodically. CNA NN further stated she did not report positioning concerns to the nurse. Observation on 12/5/18 at 1:00 p.m. in the dining room revealed R#55 fed the lunch meal by staff. R#55 had the same positioning as previous observations, and ate lunch utilizing the same process of sitting forward to eat and drink and periodically resting the top of her head against the chair back causing her neck to be slightly hyperextended. Interview on 12/5/18 at 1:19 p.m. in the dining room with CNA EE who stated the blue lateral support was used to help keep the resident straight in the chair because the resident likes to lean left. CNA EE further stated that she has never seen anyone put a pillow behind the resident when she eats, but, I think a pillow would help her during eating her meals. I never reported the resident's positioning problems to the nurse. Interview on 12/5/18 at 1:40 p.m. at the nurse's station with RN AA who stated she has worked here six months, and That's the way she's always been, referring to the resident's positioning during meals and support devices. RN AA stated she never noticed any positioning problems but frequently monitors R#55's dining room during meals. Interview on 12/5/18 at 1:42 p.m. at the nurse's station with RN DD who stated therapy was working with the resident's positioning, and she has never made a referral to therapy for the resident's positioning. Interview on 12/5/18 at 1:53 p.m.in the Therapy Room with the Physical Therapy Assistant (PTA) and served as the department manager, who stated R#55 ended on Physical Therapy caseload on 12/29/16, almost two years ago. The PTA stated she placed the light blue covering on the resident's chair, a Cozy to offer support at that time, and later nursing added the blue support with lateral side stays for the trunk. The PTA stated, Nobody has made me aware of any concerns for positioning during meals. No referrals have come through nursing for her (R#72's) positioning. Interview on 12/5/18 at 2:01 p.m. with CNA GG who fed the resident lunch, stated she did not notice the resided having trouble with positioning during her meal. CNA GG further stated she never reported any positioning concerns to the nurse. During a follow up interview on 12/5/18 at 2:23 p.m. outside R#55's door, the PTA stated she just finished assessing the resident's chair and placed a pillow under the Cozy because the Broda chair would not come up to 90 degrees. The PTA stated she instructed the CNAs to add one more pillow if it appears the resident needed it during meals. The PTA then spoke to RN DD about this change, to which RN DD answered, OK, but as of 12/6/18 at 2:19 p.m., no Nurse's Note was documented, and no changes to the care plan or Kardex were made. Interview on 12/6/18 at 9:56 a.m., the PTA stated she planned to watch the resident at the lunch meal with the pillow placed. When asked if she would have expected nursing staff to refer the resident to therapy since 12/2016 for positioning during meals, the PTA expressed agreement by saying, I see what you mean. Interview on 12/6/18 at 11:20 with the Interim Director of Nursing (DON) who stated from a dietary standpoint it was certainly a concern for R#55's head to go back and rest on the chair, with the hyperextended neck, especially during eating to prevent choking. The DON stated, I would expect the staff to notice this, CNAs to report to the nurse and the nurses should have noticed over time and referred (her) to therapy for positioning evaluation. Interview on 12/6/18 at 2:44 p.m. with the Speech Language Pathologist (SLP) who stated she did not know R#55, however, generally the proper position for eating would be as upright as possible. The SLP further stated, A resident with dementia and some hyperextension would depend on staff to position her as upright as possible for eating. The facility provided the policy titled, Assistance with meals policy, dated 11/28/17 and updated 8/7/18, which directed staff, 1.c. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity . An additional policy was provided by the facility titled, Rehabilitative nursing care, dated 11/2016 which directed, 2. Nursing personnel are trained in rehabilitative nursing care. Our facility has an active program of rehabilitative nursing which is developed and coordinated through the resident's care plan .4. Rehabilitative nursing care is performed daily for those residents who require such service. Such program includes, but is not limited to: a. Maintaining good body alignment and proper positioning . The facility failed to observe, assess and refer the resident for proper positioning during meals.",2020-09-01
56,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2017-12-14,550,D,0,1,4OSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations record review, review of the facility policy titled Social Service- Dignity Policy, resident and staff interviews, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect. Specifically, three of 29 sampled residents (R B, R A and R C) stated that they are undressed and naked in the shower room while other residents are present. (Refer F583) Findings include: Review of the facility policy titled Social Service- Dignity Policy revised (MONTH) (YEAR) documented: According to federal regulations, the facility must promote care for residents in a manner, and in an environment, that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Dignity means that their interactions with the resident, staff carries out activities which assist the resident to maintain or enhance his/her self-esteem and self-worth. 1. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. The resident required extensive assistance with bathing and personal hygiene. Interview on 12/11/17 at 2:39 p.m. with R B revealed that staff undress and re-dress her in front of other resident's in the shower room. Resident B further stated that when she is finished with her shower, the staff transport her from the shower stall to the area where they dress everyone with only a small towel covering her. Resident B stated that this has been going on for so long that she has had to just turn it into a funny thing so that it's not an embarrassing thing and will tell herself Well, here comes (name!). R B further stated That's just the way it is! Interview on 12/14/17 at 10:29 a.m. with Certified Nursing Assistant (CNA A) who was actively providing care in the shower room revealed that they always have two residents in the shower room but not more than that unless one is leaving out and one is coming in. CNA A stated that the residents are in the tub area together being undressed and stated we try to have them back to back. CNA A further stated that once undressed, the resident is taken into the shower stall uncovered and naked. CNA A stated when they are finished with the resident's shower they put a towel over them and they are taken back to the tub area to be dried off and re-dressed. When CNA A was asked why the residents are not undressed and re-dressed separately or privately, she stated because they do two at a time with two CNAs and they usually finish their showers at the same time so they are dressed in the dressing area at the same time. She further stated there is only one curtain for that area CNA A stated that no residents have ever told her that they are embarrassed or humiliated. Interview on 12/14/17 at 11:19 a.m. with the Administrator revealed she was not aware that the staff were undressing and re-dressing residents in front of each other in the shower rooms. The Administrator stated she expects staff to maintain a resident's privacy and dignity at all times. The Administrator stated that the staff should not be dressing and undressing resident's in the open area where the bathtub is located. She stated that the two shower stalls in each shower room (Unit A and Unit B) are very large with privacy curtains. The staff should undress, shower and re-dress the residents in the shower stalls. 2. Review of the policy titled Resident Rights Policy, last revised 8/22/17, the resident has a right to a dignified existence and the right to personal privacy. Review of the Annual Minimum Data Set (MDS) Assessment for Resident (R) A dated 10/13/17 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident is cognitively intact. The resident was also assessed on the annual assessment as needing the support of one person with bathing and dressing. During interviews conducted on 12/11/17 at 3:26 p.m. and on 12/14/17 at 1:50 p.m., Resident A said she received showers on Mondays and Thursdays, and the staff takes as many as five or six residents in at a time into the shower area. Only two residents at a time can be showered in the two curtained shower stalls. However, the other residents wait right outside the curtained areas, sometimes wearing simply a towel. Afterwards, the two residents receiving a shower at any one time are taken into another curtained drying area to be toweled off and dressed in clean garments. She feels embarrassed at such times - while waiting outside the shower stall and while being dressed. She complained to the facility, at least once before, about having to sit undressed among several other residents. The facility addressed her concern, and the situation got better for a while, but it has deteriorated again to where staff are taking five or more residents in to the shower room at the same time. Observation of the vacant shower room on the resident's hall on 12/12/17 at 8:15 a.m. revealed the shower room consisted of two curtained shower stalls and an open area just in front of these stalls. To the right, when facing the shower stall, was a large area, also curtained with an old spa tub containing several discarded items. One wall of this tub area also had a curtain, and behind it was a toilet and sink. Review of facility care records revealed RA and several other residents are scheduled for showers on Mondays and Thursdays; other residents in the facility are scheduled for showers on Tuesdays and Fridays. Interview on 12/14/17 at 12:34 p.m. with Certified Nursing Assistant (CNA) AA revealed she sometimes provides showers for the residents if the shower team is not available. CNA AA said when she provides showers to residents, she usually does so on an individual basis. However, if another CNA is using the shower room at the same time to bathe another resident, they may take the two residents into the drying area at the same time. She takes care to protect the privacy of the residents and there are never more than two residents in for a shower when she assists residents with taking a shower. However, she has seen the shower teams take several residents into the shower area at the same time because of the volume of showers the team is required to complete on shower days. Interview on 12/14/17 at 2:00 p.m. with D, a family member of the roommate for Resident A revealed she has received complaints from Resident A and the roommate that several residents are taken into the shower area at the same time and must wait along with several other residents for their showers while sometimes dressed in only a towel. Family member D also said she reported to the state ombudsman, her concerns that several residents were being left in the hallway while awaiting their showers. This practice (residents waiting in the hallway outside the shower room prior to receiving a shower) occurred on a regular basis, but improved after it was addressed by the ombudsman earlier this year. 3. On 12/13/17 at 10:30 a.m. interview with Resident C revealed that, while crying, she states that she does not feel like she is treated with respect and dignity when she is taken to the shower and has to take her clothes off in front of other people who are also in the shower room waiting to take a shower. Review of R C Care Plan, dated 11/30/17, reveals planning for: a behavior problem related to (r/t) dietary preferences and inability to be satisfied with meals served even if an alternative meal choice is requested. Resident may manipulate family and staff at times. Resident C has negative feelings regarding staff and facility characterized by; anxiety, mistrust, conflict/anger, ineffective coping related to: unrealistic expectations regarding meals, ADL's, and activities after discharging from Hospice care. Family is aware of resident's inability to cope and persistent complaints. Interventions for the above behaviors include: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Other interventions include: Discuss feelings about placement with resident, offer activities of which resident has shown interest, talk with resident about setting realistic self-expectations and goals.",2020-09-01
57,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2017-12-14,561,D,0,1,4OSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the policy titled Resident Rights Policy, resident and staff interviews, the facility failed to ensure one of 29 sampled residents (R B) right to self-determination. Specifically, R B was told by staff that she was not allowed to have a peanut butter sandwich for a snack unless there was jelly on it. R B stated she told the staff she does not like jelly and she should be allowed to eat what she wants. Findings include: Review of the policy titled Resident Rights Policy revised 8/22/17 documented that the resident has the right to self-determination. The resident has the right to exercise his or her rights as a resident of the facility. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. Resident B was assessed as not having a swallowing disorder or dental conditions. Section F- Preferences for Customary Routine and Activity assessed that it is very important to R B to have snacks between meals. During an interview with R B on 12/11/17 at 3:10 p.m. she stated that she loves peanut butter sandwiches but the staff always put jelly on it. Resident B stated that when she asks the Certified Nursing Assistants (CNA), they tell her they cannot just make a peanut butter sandwich. Resident B stated they tell her they have to put jelly on it. Resident B stated she has told the staff she does not like jelly and they put way too much on it! Resident B stated that she should get to eat what she wants and what she likes. Interview on 12/13/17 at 1:50 p.m. with the Dietary Supervisor (DS) revealed the dietary staff deliver pre-made sandwiches to the resident pantry three times a day for snacks. She stated typically they always have peanut butter and jelly, pimento cheese, bologna, ham, and turkey sandwiches for snacks. The DS stated that if a resident asks for just a peanut butter sandwich they are not allowed to serve that. She stated the peanut butter sandwich has to have jelly on it. The DS stated this is not a written policy but it has been ordered by the Administrator because of choking hazard. The DS stated that they are supposed to honor the resident's preferences and choices. She stated this rule comes directly from the Administrator and was not a recommendation by the Registered Dietician. The DS stated this has been the rule for year and years. Interview on 12/13/17 at 2:18 p.m. with the Administrator revealed the Medical Director nor the Registered Dietician ever recommended to her that they should not be allowed to serve the residents a peanut butter sandwich without jelly on it, nor have they told her it was a choking hazard. The Administrator stated that [AGE] years ago, she had a personal experience in which a resident choked on a peanut butter sandwich and it just has scared her really bad. She stated it's just something she ordered for resident safety, not to restrict anyone from having what they want.",2020-09-01
58,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2017-12-14,583,D,0,1,4OSS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy titled Resident Rights Policy, and resident, family, and staff interview, the facility failed to provide privacy of their persons during showers to three residents (A, B, and C) from a sample of 29 residents. Findings include: 1. Review of the policy titled Resident Rights Policy, last revised 8/22/17, the resident has a right to a dignified existence and the right to personal privacy. Review of the Annual Minimum Data Set (MDS) Assessment for Resident (R) A dated 10/13/17 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident is cognitively intact. The resident was also assessed on the annual assessment as needing the support of one person with bathing and dressing. During interviews conducted on 12/11/17 3:26 p.m. and on 12/14/17 at 1:50 p.m., Resident A said she received showers on Mondays and Thursdays, and the staff takes as many as five or six residents in at a time into the shower area. Only two residents at a time can be showered in the two curtained shower stalls. However, the other residents wait right outside the curtained areas, sometimes wearing simply a towel. Afterwards, the two residents receiving a shower at any one time are taken into another curtained drying area to be toweled off and dressed in clean garments. She feels embarrassed at such times - while waiting outside the shower stall and while being dressed. She complained to the facility, at least once before, about having to sit undressed among several other residents. The facility addressed her concern, and the situation got better for a while, but it has deteriorated again to where staff are taking five or more residents in to the shower room at the same time. Observation of the vacant shower room on the resident's hall on 12/12/17 at 8:15 a.m. revealed the shower room consisted of two curtained shower stalls and an open area just in front of these stalls. To the right, when facing the shower stall, was a large area, also curtained with an old spa tub containing several discarded items. One wall of this tub area also had a curtain, behind which was a toilet and sink. Review of facility care records revealed RA and several other residents are scheduled for showers on Mondays and Thursdays; other residents in the facility are scheduled for showers on Tuesdays and Fridays. Interview on 12/14/17 at 12:34 p.m. with Certified Nursing Assistant (CNA) AA revealed she sometimes provides showers for the residents if the shower team is not available. CNA AA said when she provides showers to residents, she usually does so on an individual basis. However, if another CNA is using the shower room at the same time to bathe another resident, they may take the two residents into the drying area at the same time. She takes care to protect the privacy of the residents and there are never more than two residents in for a shower when she assists residents with taking a shower. However, she has seen the shower teams take several residents into the shower area at the same time because of the volume of showers the team is required to complete on shower days. Interview on 12/14/17 at 2:00 p.m. with D, a family member of the roommate for Resident A revealed she has received complaints from Resident A and the roommate that several residents are taken into the shower area at the same time and must wait along with several other residents for their showers while sometimes dressed in only a towel. Family member D also said she reported to the state ombudsman, her concerns that several residents were being left in the hallway while awaiting their showers. This practice (residents waiting in the hallway outside the shower room prior to receiving a shower) occurred on a regular basis, but improved after it was addressed by the ombudsman earlier this year. 2. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. R#62 resident required extensive assistance with bathing and personal hygiene. Interview on 12/11/17 at 2:39 p.m. with R Brevealed that staff pull curtains for privacy when they are in the shower stall but when she is finished with her shower, the staff transport her from the shower stall to the area where they dress everyone with only a small towel covering her. Resident B stated there are two or three residents in an open area where they are undressed and re-dressed. Resident B further stated that this has been going on for a long time. Observation on 12/13/17 at 9:12 a.m. of Unit A shower room revealed two shower stalls, both with privacy curtains. There was a large open room/common area with a bathtub in the corner. There was one large privacy curtain that could be pulled to close off this entire area. Observation on 12/13/17 at 9:14 a.m. of Unit B shower room revealed two shower stalls, both with privacy curtains. There was a large open room/common area with a bathtub in the corner. There was one large privacy curtain that could be pulled to close off this entire area. Interview on 12/14/17 at 10:29 a.m. with Certified Nursing Assistant A (CNA A) who was actively providing care in the shower room revealed that they (staff) always have two residents in the shower room but not more than that unless one is leaving out and one is coming in. CNA A stated that the residents are in the tub area together being undressed and stated we try to have them back to back. CNA A further stated that once undressed, the resident is taken into the shower stall uncovered and naked. CNA A stated when they are finished with the resident's shower they put a towel over them and they are taken back tub area to be dried off and re-dressed. CNA A confirmed that residents are typically in this area together at the same time and there is no privacy between them. When CNA A was asked why the residents are not undressed and dressed separately or privately, she stated because they do two at a time with two CNAs and they usually finish their showers at the same time so they are dressed in the dressing area at the same time. She further stated that if they did one resident at a time, they would never get all their showers completed because there is a lot of residents in this facility. CNA A stated that no residents have ever told her that they are embarrassed or humiliated. CNA A stated that she has worked here since (MONTH) (YEAR) and this has been the process for showers since she has been here. CNA A confirmed she received education related to privacy and dignity and was able to verbalize that curtains should always be pulled, doors should always remain closed and privacy for the residents should be maintained and stated but there is only one curtain in the dressing area of the shower room. Interview on 12/14/17 at 11:19 a.m. with the Administrator revealed she was not aware that the staff were undressing and re-dressing residents in front of each other in the shower rooms. The Administrator stated she expects staff to maintain a resident's privacy and dignity at all times. The Administrator stated that the staff should not be dressing and undressing resident's in the open area where the bathtub is located. She stated that the two shower stalls in each shower room (Unit A and Unit B) are very large with privacy curtains. The staff should undress, shower and re-dress the residents in the shower stalls. Review of the Relias Transcript for CNA A revealed she completed and Met requirements for the course titled Assist patient in and out of shower on 11/10/17. The course Description documented: Ensure privacy by closing the door and curtains, if available and the course Rationale documented: This maintains the individual's dignity and right to privacy. 3. On 12/13/17 at 10:30 a.m. interview with Resident C revealed that, while crying, she states that she does not feel like she is treated with respect and dignity when she is taken to the shower and has to take her clothes off in front of other people who are also in the shower room waiting to take a shower. Review of R C Care Plan, dated 11/30/17, reveals planning for: a behavior problem related to (r/t) dietary preferences and inability to be satisfied with meals served even if an alternative meal choice is requested. Resident may manipulate family and staff at times. Resident C has negative feelings regarding staff and facility characterized by; anxiety, mistrust, conflict/anger, ineffective coping related to: unrealistic expectations regarding meals, ADL's, and activities after discharging from Hospice care. Family is aware of resident's inability to cope and persistent complaints. Interventions for the above behaviors include: Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. Other interventions include: Discuss feelings about placement with resident, offer activities of which resident has shown interest, talk with resident about setting realistic self-expectations and goals.",2020-09-01
59,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2018-02-08,578,D,0,1,G4GK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an Advanced Directive, for five residents (R) observed. R# 11, R# 72, R#255, R# 84 and R#254. The sample size was 22 residents. Findings include: 1. Medical Record review revealed that Resident (R) #72 review of the medical record for R#72 revealed that there was not any evidence that an Advance Directive was completed. Further review of the admission file for R#72 revealed that the form, Responsible/Legal Guardian & Advanced Directive Checklist (no date) was incomplete. No response were checked for choice and there was not any evidence that an Advance Directive checklist was documented. 2. Medical Record review for R #255 reveals that there was not any evidence that the resident had an Advance Directive. Further review of the Acknowledgement of Receipt of Admission for Rehabilitation form reveals that there is not a check mark next to the Georgia Advance Directive for Healthcare. 3. Medical Record review for R #84 reveals that there was not any evidence that the resident had an Advance Directive. Further review revealed that R #84 does have a completed Acknowledgement of Receipt of Admission for Rehabilitation Information form in the resident's Admission Folder. 4. Medical Record review for R # 254 revealed that there was not any evidence that the resident had an Advance Directive on their medical record or in their admission folder. Further review of theAcknowledgement of Receipt of Admission for Rehabilitation information form revealed that R#254 does not have a check mark next to Georgia Advance Directive for Healthcare. 5. Medical record review for resident R#11 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated no cognitive impairment. Further review on clinical record on 2/6/18 lacked evidence that the resident had been offered options to formulate an advance Directive. Document titled Responsibility/Legal Guardian & Advanced Directive Information was provided by Social Services Director on 2/6/18. The form revealed that resident was responsible for self, but no other information was documented on the form as to her choice to formulate or not formulate Advanced Directives. Based on interview, record review and policy review, the facility failed to determine whether or not the resident wanted to formulate an advanced directive, for seven residents (R) observed. R# 11, R#76, R# 38, , R# 72, R#255, R# 84 and R#254; out of a sample of 22 Findings include: For all resident's in the sample, a form titled Responsibility/Legal Guardian and Advanced Directive Checklist were missing information regarding resident's response to an offer of formulating an advanced directive. On 2/6/18 11:31 a.m. an interview with Social Services Director (SSD) was able to provide a folder evidencing a form titled Responsibility/Legal Guardian and Advanced Directive Checklist. This document shows where the facility provided information to the resident and/or family member on legal guardianship, and Power of Attorney (POA) along with an advanced directives checklist. The checklist included a decision made by the resident to formulate an advance directive or not. This document did offer a decision. No decision was noted. Further interview by the SSD indicated the facility no longer uses the form as it was becoming confusing for the staff. When asked how does the facility know what the resident's decision was in the event of an emergency, SSD stated they use a form titled Acknowledgement of Receipt of Admission for Rehabilitation information. This document lists the Georgia Advanced Directive for Healthcare. A check by the document name indicates the resident and /or family member received the document. When asked what the time frame is for return of the document SSD stated we asked they return it within 24 hours. When the time frame runs out there is no follow up done. SSD was once again asked what is done if there is no documentation of resident's preference regarding advanced directives. SSD stated if there is no information on the record the resident the resident is considered to be a full code. On 2/7/18 11:23 a.m. an interview with Director of Health Services (DHS) and Administrator revealed that the form titled Responsibility/Legal Guardian & Advanced Directive Checklist is no longer used because their attorney stated it was not a legal document. When asked where is the resident's response to advance directives education documented, DHS stated that it should be in the admission noted or on the dashboard of the Electronic Medical Record (EMR). On 2/7/18 01:06 p.m. further interview with the DHS revealed the facility does not have any documentation as to resident's preference to execute an advance directive. A review of facility policy titled Advance Directives, no date, states information about whether or not the resident has executed an advanced directive, shall be displayed prominently in the medical record. Also, if the resident indicates that he or she has not established advance directive, the facility staff will offer assistance in establishing advance directives. The resident will be given the option to accept or decline the assistance, and care will not be contingent on either decision. Nursing staff will document in the medical record the offer to assist and the resident's decision to accept or decline.",2020-09-01
60,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2018-02-08,641,D,0,1,G4GK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one resident (R) #9 for the use of injectable's and insulin. The sample size was 22 residents. Findings Include: Record review revealed R#9 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as three, which indicates cognitive impairment. Section I-Active [DIAGNOSES REDACTED]. Review of MDS dated [DATE], section N-Medications, N0300 Injections: indicated that resident received 0 injections in last 7 days; NO350 Insulin was left blank. Review of a care plan initiated on 2/8/18, revealed that resident has potential for hyperglycemic or hypoglycemic episodes secondary to diabetes: resident uses insulin. Interview on 2/8/18 at 3:11 p.m., with MDS Coordinator, stated she gets information for the MDS assessments by having a face to face interview with the residents and information is obtained from the direct care staff caring for the residents. She stated information about medications is obtained from the electronic Medication Administration Record [REDACTED]. She verified that the 8/1/17 MDS did not reflect that the resident has received insulin injections 7 out of 7 days. She further stated that she would go ahead and modify the MDS assessment to indicate resident received insulin injections 7 out of 7 days.",2020-09-01
61,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2018-02-08,656,D,0,1,G4GK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to follow the care plan for one resident (R) #47 related to not placing a fall mat at the bedside post fall on 1/9/18. The sample size was 22 residents. Findings include: A review of the clinical record for R#47 revealed resident was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as two, which indicated cognitive impairment. Review of the care plan dated 1/9/18, revealed that R#47 had impaired physical mobility related to a fall from the bed. Interventions to be implemented included bed in low position and fall mat at bedside. Observation on 2/7/18 at 12:05 p.m., 2/8/18 at 9:19 a.m. and 2/8/18 at 4:11 p.m. revealed no fall mat at bedside, nor stored in the closet or under the bed. A review of facility policy titled Fall Management Program with effective date (MONTH) 25, 2010, revealed that the date and time of each fall and new intervention will be added to the care plan. Interview on 2/8/18 at 2:51 p.m., with Licensed Practical Nurse (LPN) AA, revealed that the procedure for when residents have a fall is to do a complete head to toe assessment, assessing for any injuries. She then notifies the Shift Supervisor, the residents Physician and family member. The residents nurse and the Supervisor discuss possible interventions and collaborate together what intervention is best suited for the situation. Supervisor inputs the intervention into electronic medical record (EMR) and the floor nurse is responsible for follow-up on implementation. She further stated the residents are observed for 72 hours post fall. She stated she did not know why R#47 didn't have a fall mat at the bedside. Interview on 2/8/18 at 4:06 p.m., with Assistant Director of Nursing, revealed that she and the floor Charge Nurse confer together discussing possible interventions to put in place after residents experience a fall. She further revealed that it is the facility's policy to implement interventions after each fall. She stated that when fall mats are ordered, the Certified Nursing Assistant (CNA) or the Charge Nurse are responsible for getting floor mats and placing them at bedside.",2020-09-01
62,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2018-02-08,758,D,0,1,G4GK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to indicate the need to extend orders for as needed (PRN) antianxiety medications for two residents (R#31 and R#25) beyond 14 days, and failed to document the reason for the extension or the period during which the extended order should be in effect. The sample size was 22 residents. Findings include: Review of the clinical records for Resident (R) #31 revealed she was admitted to the facility with [DIAGNOSES REDACTED]. Review of a Significant Change Minimum Data Set (MDS) assessment of 11/21/17 revealed the resident had evidence of mood symptoms, behaviors directed at others occurred 1-3 days during the assessment period, had active [DIAGNOSES REDACTED]. Review of the most recent physician order [REDACTED]. Further review of the clinical records for R#31 revealed no documentation that the PRN anxiolytic should continue beyond 14 days, the period during which it should be continued, or a rationale for its continued use. Interview with the Medical Director on 2/08/18 at 2:37 p.m. revealed the resident has had significant trauma in recent months and was placed on hospice soon after admission due to declining health. The resident has since been discharged from hospice, but continues to experience anxiety and needs the antianxiety medication on an as needed basis. He was not aware that he should have documented the ongoing need for this medication, but will do so going forward. 2. Review of clinical record for Resident (R) #25 revealed he was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicates no cognitive impairment. Review of (MONTH) (YEAR) Physician order [REDACTED].#25 was prescribed Klonopin 0.5 milligrams (mg) at bedtime as needed (PRN) for anxiety, with original order date of 8/8/17. Further review of the PO did not indicate that the use of the PRN medication had been re-evaluated by the physician, for continued use. Interview on 2/8/18 at 1:58 p.m., with Medical Director, stated that he has not been evaluating the continued need for PRN antipsychotic medications. He stated that if he wrote an order for [REDACTED]. He stated he has not been addressing orders for PRN antipsychotic's, but will start, because the government regulations have changed.",2020-09-01
63,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2018-02-08,761,D,0,1,G4GK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in one of two medication carts; and failed to discard expired biological's and medical supplies prior to expiration date in one of two medication storage rooms. The sample size was 22 residents. Findings include: 1. Observation on 2/6/18 at 4:25 p.m., third floor medication cart revealed one opened and used [MEDICATION NAME] respiratory inhaler. The inhaler had a sticker from the pharmacy that indicated the medication should be discarded 90 days after opening. The inhaler did not have a date when opened. Further observation, on the same medication cart, was [MEDICATION NAME] Propionate liquid, approximtely 1/2 of 16 ounce bottle, with expiration date of 12/17. 2. Observation on 2/6/18 at 4:25 p.m., in the third floor medication storage room revealed two catheter irrigation trays with expiration date of 1/18. 3. During medication pass on 2/7/18 at 12:28 p.m., with Licensed Practical Nurse (LPN) AA, revealed an opened multiple-dose vial of [MEDICATION NAME] Insulin with opened date of 1/2/18. A label on the vial read discard after 28 days. Review of the facility policy titled, Pharmacy Services and Procedures policy, revised (MONTH) 2013, indicated that the facility should ensure that medications and biological's have an expiration date on the label and have not been retained longer than recommended by the manufacturer or supplier. The policy further indicated the facility should record the date opened on the medication container when the medication has a shortened expiration date once opened. Review of the policy titled, Recommended Minimum Medication Storage Parameters, revised (MONTH) 29, (YEAR), indicated that multiple-dose vials for injection, are to be dated when opened and discard unused portion after 28 days or in accordance with manufacturer's recommendations. The parameters for [MEDICATION NAME] Inhalation Spray, indicated after initial priming, discard after 120 sprays or three months after first use. Interview on 2/6/18 at 4:25 p.m., Licensed Practical Nurse (LPN) AA stated that she doesn't know when the inhaler was opened. She stated that she puts open dates on all the medications that she opens. She stated that each of the med nurses are supposed to check the medication carts and storage rooms daily for expired medications and supplies. Interview on 2/7/18 at 12:40 p.m., LPN AA stated the policy for opened injectable medications is 30 days. She verified the opened bottle of [MEDICATION NAME]had 1/2/18 open date and the pharmacy sticker indicated to discard 28 days after opening.",2020-09-01
64,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2019-02-28,578,D,0,1,952S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately document the Advance Directive status for one Resident (R) R#18 from a sample of 17 residents reviewed for Advance Directives. Findings include: Review of the record for R#18 revealed the resident was admitted on [DATE] with the [DIAGNOSES REDACTED]. Review of the resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. A review was conducted of the physician orders [REDACTED]. Review of the facility form titled, Order Summary Report for R#18 documented Advanced Directive: CPR, order date [DATE]; order status active and documented active orders as of [DATE]. Review of the resident's care plan, provided by MDS Coordinator A for R#18, documented two Advance Directive (AD) code status determinations. The care plan focus area reflects a code status as Full Code with a date initiated of [DATE], revision on [DATE]. Another care plan focus area reflects a code status as Do not Resuscitate (DNR) with a date initiated of [DATE], revision on [DATE]. Further record review for R#18 revealed a form titled, Physician order [REDACTED]. The POLST was signed by the resident and dated [DATE]. The section for discussion and signatures was blank for the physician's name and signature. The POLST was found at the front of the record in a clear document sleeve with a bright orange DNR sticker positioned at the top of the clear plastic document sleeve. On [DATE] at 10:38 a.m. an interview was conducted with the Social Worker (SW), she explained that the process to obtain Advance Directive information for a resident begins in admission; they work with the long-term care and rehab residents. Those residents receive an admission packet that starts with an Advance Directive checklist where residents can choose options. If they can sign for themselves, they must have a good BIMS score, meaning no impairment cognitively. If they have a Power of Attorney or a Living Will, that will be requested. The SW stated that it is the Social Worker's responsibility to discuss those options on the form with the resident and family. The SW further stated that the Unit Secretary will scan and upload the forms into the electronic record and place a copy of the original in the hard copy medical record. On [DATE] at 9:30 a.m. an interview was conducted with MDS Coordinator A in the MDS office with MDS Coordinator B and the Director of Nursing (DON) present. A review and confirmation of the quarterly and annual MDS was conducted. A printed copy of the resident's quarterly care plan was provided, dated [DATE]. When MDS Coordinator A was asked where the nursing staff would look for the Advance Directive information and preference, she stated that in an emergency they run to the hard copy chart to find the code status located at the front of the chart. After review of the provided documents with the MDS Coordinators with the DON present, the MDS Coordinators stated that the POLST form signed by the resident on [DATE] is an error. They revealed that the POLST forms have not been officially initiated in the facility yet; they confirmed the POLST form located in the front of the resident's record that is signed by the resident, is not signed by the Physician, and should not have been in the record. They confirmed the care plan indicating a DNR code status is in error. The DON explained that the POLST has not been initiated yet, because another Social Worker that is planning to initiate the POLST form for all residents that choose a DNR determination has been on maternity leave. No documentation was found in the record from the Social Worker regarding a change in the resident's Advance Directive status. In addition, the MDS Coordinator A and the DON explained that once an order is received by the Physician, the nursing staff will have the Unit Secretary scan in the AD into the electronic system and the original copy is placed in the hard copy record. The DON stated the plan now was to get a hold of the Physician's Nurse Practitioner, the resident and family to sort out the wishes of the resident, then get an order if there is a change. On [DATE] at 4:00 p.m. the DON provided a copy of a monthly follow-up visit conducted by the Nurse Practitioner for R#18, dated [DATE]. The note documents: POLST is reviewed with resident on day of exam. No acute changes or concerns per staff. On the bottom of page 5 of the follow-up exam, there is a hand-written note dated [DATE] and signed by the Nurse Practitioner that documents: reviewed POLST election and resident continues to desire elections charted on POLST form ,[DATE]. The DON also provided a printed copy of the original POLST form with the Physician's signature added and dated [DATE]. The DON confirmed that the POLST form is the form the facility has decided to use but confirmed that it has not been initiated yet.",2020-09-01
65,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2019-02-28,604,D,0,1,952S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and record review the facility failed to ensure that one resident (R), # 296 out of 2 residents reviewed was free from restraints from a sample of 39 residents. Findings include: Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#296 with a Brief Interview for Mental Status (BIMS) score of 99, indicating that the resident was cognitively impaired. Further review of R#296 MDS provided evidence that R#296 required two-person extensive assistance with transfers and no documented evidence for use of restraint. Further review of resident R#296 clinical records shows that resident (R#296) was not assessed for the use of restraints. Additionally, there were no Physician order, plan of care or progress notes to show the needed use of restraints. Multiple observations were made of resident R#296 with a seatbelt around his torso area while sitting in his wheelchair. On 2/26/19 at 1:00 p.m., observed resident in the garden room involved in activities. Resident in wheelchair while seatbelt around his torso area. On 2/27/19 at 12:45 p.m., observed resident in dining room area eating his lunch, resident in a wheelchair with a seatbelt fasten around his torso currently. On 2/27/19 at 2:02 p.m. an interview was conducted with Registered Nurse FF, she stated that R#296 has a seat around him while he is in the wheelchair because he has problems with [MEDICAL CONDITION] activity and the seatbelt is being used to keep him for falling out wheelchair. On 2/28/19 at 3:05 p.m. an interview was conducted with the Director of Nursing (DON), she stated that R#296 should not have a seatbelt around his torso. The DON stated she believes that the daughter brought the wheelchair for R#296 to have but at this time the resident does not have a Physician order for [REDACTED].",2020-09-01
66,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2019-02-28,656,G,0,1,952S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and review of the facility documents the facility failed to follow the care plan/ Nursing Kardex related to two staff assistance for transfers for one resident (R) #67 of two residents reviewed. Actual harm was identified when R#67 sustained a left arm fracture from an improper transfer. Findings include: Record review revealed that R#67 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing Kardex dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could she stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up. The CNA revealed she felt pressure from the resident and eased her in the wheel chair. The CNA revealed she notified her charge nurse and called the supervisor. The CNA revealed she did not ask for assistance from another staff person. CNA revealed she is aware of the residents Kardex (guide on how to take care of the residents) and did not look at the resident's Kardex prior to the transfer. The CNA revealed she does not have a reason of why she did not look at the Kardex. An Interview was conducted on 02/27/19 at 11:46 a.m. the Assistant Director of Nursing (ADON) regarding R#67 transfers. The ADON revealed that R#67 is care plan transfer with two people or two people and a lifting device. The ADON revealed that each resident has a Kardex hanging at the end of the resident bed on a clip board that gives the CNA guidance on how to care for the residents. Refer to F689",2020-09-01
67,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2019-02-28,689,G,0,1,952S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and family interviews, and review of the facility documents the facility failed to ensure a safe and secure environment related to accidents, for one of two residents (R) reviewed for falls. Actual harm was identified on 1/11/19 when R#67 was transferred improperly by one Certified Nursing Assistants (CNA) when the resident required assistance of two staff resulting in a fracture to the left arm. Findings included: Record review revealed that R#67 was admitted to the facility on [DATE], current [DIAGNOSES REDACTED]. On 1/16/19 [DIAGNOSES REDACTED].#67 [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 4 indicating severe impaired cognition. Continued review of the MDS revealed the resident required extensive assistance with bed mobility and extensive assistance with transfers requiring two plus person physical assist. Review of the significant change MDS dated [DATE] revealed R#67 had a BIMS score of 10 which indicates the resident's cognition was moderately impaired. Section G revealed that the resident was assessed for total dependence assist by two plus persons for transfer and toilet use. The resident was assessed as total dependence for care. Review of the care plan, revision on, 2/6/19 with a problem onset dated 9/24/18 revealed impaired physical mobility related to fall. Interventions for R#67 requires two persons with all transfers and mechanical lift transfer as needed. Review of the MDS 3.0 Nursing Kardex dated 10/8/18 revealed under transfer that R#67 requires the assist of two plus person. Review of the progress note dated 1/11/19 at 10:40 a.m. revealed: Writer was notified by Certified Nursing Assistant (CNA) during transferring of resident from bed to wheel chair, resident knees gave out and was going down. CNA broke fall by supporting her arm under resident left armpit and ease her into wheel chair. ROM (range of motion) performed. Able to move RT (right) arm. HEX (history) old FX (fracture) to LT (left) shoulder and muscle weakness. C/O (complained of) discomfort to LT shoulder. NP (Nurse Practitioner) notified and ordered X - Ray LT shoulder. Review of the Physician orders [REDACTED]. Review of the x-ray of the left shoulder dated 1/11/19 revealed: no acute fracture or other acute abnormality Review of the progress note dated 1/13/19 at 05:08 it is documented in part c/o (complain of) pain in the left shoulder, medicated for pain x 1. There is no evidence that the nurse assessed the resident's left shoulder. Review of an Progress Note dated 1/15/19 at 02:24 it was documented in part by an Licensed Practical Nurse; Resident was assessed, to observe left upper arm and shoulder swollen and purple color discoloration. .An interview was conducted on 2/27/19 at 11:46 a.m. with the Assistant Director of Nursing (ADON) revealed the sister of R#67 called the ADON from the resident's eye appointment on 1/15/19 and requested that the ADON look at Resident # 67 arm because the resident was still complaining of pain and the resident had swelling and bruising. The ADON revealed on 1/16/19 she assessed R#67 and the left arm was swollen and bruising and called the Physician. The Physician gave an order to x-ray the left clavicle, left shoulder and left humerus. The x-ray was completed on 1/16/19 and the results of the x-ray revealed a [MEDICAL CONDITION] humerus. An Encounter note written by a Physician dated 1/22/19 documented R#67 was seen for a proximal humerus fracture that occurred while she was in care at the (Name) home. She was not using the lift but was being lowered to the floor and a pop was felt. She was initially told that her arm was not broken, but subsequently a fracture was determined to be present. The onset date of 1/11/19, lowered to the floor, CNA said she heard a snap. She is right-hand dominant. She also has limited hand functions and a moderate amount of pain. An interview was conducted on 2/27/19 12:01 p.m. with Registered Nurse Supervisor DD regarding the incident with R#67. Supervisor DD stated when she arrived at the floor, she assessed the resident. The resident verbalized pain and there was no swelling at the time of her assessment. The Supervisor asked the CNA why she was transferring the resident alone and the CNA responded she was helping another CNA, and this was not her assigned resident. Supervisor DD revealed the CNA should have had another staff person to assist her with the transfer. Supervisor DD revealed the CNA should have checked the resident's Kardex (guide on how to take care of the residents) prior to the transfer. Supervisor BB revealed that the Kardex was located at the end of each residents' bed on a clip board. The CNA's are in-serviced on using the Kardex as a resource. An interview was conducted on 2/27/19 at 12:30 p.m. with R#67 and her sister/Responsible Party (RP). Resident #67 family revealed on 1/16/19 she met R#67 at the eye doctor and when R#67 arrived she was crying. The resident expressed that she was in pain and her left arm hurt. The family member looked under R#67 clothes and seen that the arm was swollen and black and blue. The RP called the facility and spoke with the Assistant Director of Nursing (ADON) and asked her to assess the resident's arm. The next day when she arrived at the facility, she was informed by the ADON that R#67 had a [MEDICAL CONDITION]. The RP made an appointment for the resident to be seen by and orthopedic physician on 1/17/19. A phone interview was conducted on 2/27/19 at 12:45 p.m. with Certified Nursing Assistant (CNA) EE, regarding the incident with R#67. The CNA revealed the resident refused to use the lift to get up. She asked the resident if she could stand and pivot to the wheel chair and the resident said yes. The CNA revealed the resident was sitting on the side of the bed and had both her feet on the floor the CNA stood in front of the resident. The CNA revealed she placed her left arm under the resident's right armpit and her right arm went under the residents left arm pit. The resident was assisted to a standing position and pivot to the wheel chair and the resident's left arm went up the CNA revealed she felt pressure from the resident and eased her in the wheel chair. The CNA revealed she notified her charge nurse and called the supervisor. The CNA revealed she did not ask for assistant from another staff person. CNA revealed she is aware of the residents Kardex (guide on how to take care of the residents) and did not look at the resident's Kardex prior to the transfer. The CNA revealed she does not have a reason of why she did not look at the Kardex. Review of the Radiology report dated 1/16/19 revealed Impression: Acute displaced proximal humeral fracture. Review of the orthopedics History and Physical report dated 1/17/19 revealed the following, R#67 seen today for a left proximal humerus fracture. She has moderate amount of pain. An interview was conducted on 2/28/19 at 11:40 a.m. with the Director of Staff Development regarding if CNA EE received any in-service training for using the Kardex. The Staff Development Director revealed in-services are done but she has no documentation to support that CNA EE was in-service on using the Kardex.",2020-09-01
68,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2017-03-30,278,D,0,1,U5BR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) for one resident (R#109) taking a diuretic out of a total sample of 35 residents. Findings include: Resident #109 was admitted [DATE] with a [DIAGNOSES REDACTED]. Record review of the Admission MDS assessment dated [DATE] revealed in section N: medications that resident received two of the seven days of a diuretic in the last seven days. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Interview with the MDS Coordinator on 3/30/17 at 12:30 p.m. confirmed that the MDS was miscoded during that time",2020-09-01
69,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2017-03-30,282,D,0,1,U5BR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to follow the care plans related to the monitoring of blood glucose levels and the treatment of [REDACTED].#17) from a total sample of 35 residents. Findings include: Record review for resident (R) #17 revealed the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the care plan dated 1/9/17 stated R#17 has the potential for hypoglycemic and hyperglycemic episodes secondary to DM with the goal to provide relief of hypo/hyperglycemic episodes within 30 minutes of interventions. Continued review revealed to monitor blood sugar (glucose) levels per physician's orders [REDACTED]. Review of the Physician order [REDACTED].-300, give five (5) u, 301-350, give seven (7) u; greater than 351, give 10 u. Review of the Medication Record for (MONTH) (YEAR) revealed no evidence of blood glucose (bg) level documentation at bedtime for 1/6/17, 1/7/17, 1/8/17, and/or 1/24/17. Review of the The Medication Record for (MONTH) (YEAR) revealed no evidence of BG level documentation for 3/18/17. During interview with the Director of Nursing (DON) on 3/30/17 3:20 p.m., she confirmed that the care plan was not followed regarding blood sugars. 2.) During observation on 3/30/17 at 7:00 a.m. with Registered Nurse (RN) EE, she cleaned the pressure ulcer to the sacral wound with Dakins solution, then applied an oil [MEDICATION NAME] dressing to the wound bed and applied the calcium alginate to the tunneling area. Continued observation revealed that a sponge was applied to the site and a new canister applied to the wound. Review of the care plan for R#17 dated 1/9/17 revealed that resident has a pressure ulcer and the intervention included to treatment per current physician orders. Review of the (MONTH) (YEAR) Physician order [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 3/30/17 at 10:30 a.m., revealed that wound care for the resident's treatment is to apply the black sponge, which is the deriding agent and the application of the suction to the wound vac.",2020-09-01
70,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2017-03-30,309,D,0,1,U5BR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review, and staff interviews, the facility failed to follow physician's orders for the administration of insulin per sliding scale. Findings include: Record review for R#17 revealed that the resident was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the Physician Orders dated 1/20/17 revealed an order for [REDACTED]. Review of the Medication Record (MR) for (MONTH) (YEAR) revealed one incorrect dose of insulin administered at bedtime (HS) on 1/21/17, which was documented at 212. During further review, the MR revealed that four u of insulin were given; however, two u ordered. Review of the Physician Orders for (MONTH) (YEAR) revealed order for [MEDICATION NAME] 100 u/ml per sliding scale for BG greater than 160 mg/dl; give via subcutaneous injection before meals and at bedtime at 7:00 a.m., 12:00 p.m., 5:00 p.m. and 9:00 p.m. Continued review revealed that the sliding scale is as follows: 161-200, give one u, 201-250, give three u, 251-300, give five u, 301-350, give seven u; greater than 351, give 10 u. Review of the MR for (MONTH) (YEAR) revealed a total of seven (7) occasions when insulin coverage had no evidence of documentation for the following dates: 7:00 a.m. administration: 2/6/17 BG=174, 2/12/17 BG=162; bedtime administration: 2/4/17 BG=198, 2/5/17 BG=176, 2/11/17 BG=213, 2/12/17 BG=189, and 2/18/17 BG=187. Review of the (MONTH) (YEAR) MR revealed four (4) incorrect doses given, which includes the following: on 3/2/17 at 5:00 p.m. the BG was 232, and the resident was given two u instead of five units. Then on 3/8/17 BG=380, five u given, not 10 u as ordered; and on 3/13/17 BG=262-three (3) u given, instead of five (5) units. Review of the (MONTH) (YEAR) Physician Orders continued the same sliding scale insulin orders as (MONTH) (YEAR). Interview with Licensed Practical Nurse (LPN) DD on 3/29/17 at 11:15 a.m., she stated that inservices are held for all new medications, including how to draw up, if applicable, and administer. Continued interview revealed that annual inservices are held related to general medication administration. The procedure for self-reported medication errors is to contact the nursing supervisor, monitor the resident for any adverse reactions, complete the appropriate medication error paperwork and contact the physician and/or family. During an interview with the Director of Nursing (DON) on 3/30/17 3:20 p.m., she confirmed the discrepanceies on the Medication Records from (MONTH) (YEAR) through (MONTH) (YEAR). Continued interview revealed that she was unable to give an explanation for the medication discrepancies. Review of the Facility Policy and procedures titled, Administering Medications Version 2.0, Accucheck Blood Sugar Testing and Insulin Administration revealed that all detail the steps for correct documentation of the testing and administration processes: 1.) Date, time, blood glucose level. 2.) Type and amount of insulin administered and the injection site. 3.) If blood glucose level is above or below normal range, document the time the physician was notified. 4.) Any results achieved and when those results were observed. 5.) Signature and file.",2020-09-01
71,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2017-03-30,314,D,0,1,U5BR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy review, and staff interviews, the facility failed to ensure that one resident (R#64) pressure ulcer measurements were completed weekly from a total sample of 35 residents. Findings include: Review of the Documentation section of the facility's Pressure Ulcer Treatment policy and procedure revealed that following wound care, the wound appearance, including wound bed, edges, and presence of drainage should be documented. All assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound should be documented. Review of R #64's clinical record revealed that he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of his Admission Minimum Data Set ((MDS) dated [DATE] noted that he had one Stage 2 pressure ulcer which was present on admission. Review of an impaired skin integrity care plan developed on 2/24/17 revealed that R #64 had a Stage 2 abrasion to his left buttock. Review of his Braden Scale (a tool used to predict pressure ulcer development) dated 3/10/17 revealed a score of 14 (moderate risk for development of a pressure ulcer). Review of an [MEDICATION NAME] lab test dated 3/13/17 revealed a result of 1.5 (normal 3.5-5.0). Review of R #64's Wound Evaluation Form revealed that he had a Stage II pressure wound to the left buttock. On 2/24/17, the wound was measured as 1.5 cm (centimeters) long by 0.1 cm wide. On 3/3/17, the wound measurements were recorded as 1.0 cm long by 0.5 cm wide. On 3/10/17, the wound was measured as 0.5 cm long by 0 cm wide. Further review of all three of these wound assessments revealed that the depth was left blank in the Size sections of the form. During interview with the Assistant Director of Nursing (ADON) on 3/30/17 at 1:19 p.m., she stated that the nurse that measured and described the wound should have recorded the depth on the Wound Evaluation Form. During further interview, the ADON verified that this had not been done for R #64's left buttock pressure ulcer, and that the nurse should have recorded a 0 (zero) if the wound had no depth. Review of R #64's impaired skin integrity care plan dated 3/16/17 revealed that he had developed a Stage 2 darkish hue boggy blister to the left heel measuring 2.0 cm by 1.0 cm. Review of a Wound Evaluation Form for this left heel pressure ulcer revealed that the only assessment documented was on 3/16/17. Further review of this form revealed that the left heel had eschar in the wound bed. Review of computerized nurse's notes revealed no documentation of the left heel wound measurements and appearance. Review of physician's orders [REDACTED]. On 3/29/17 at 6:43 a.m., Licensed Practical Nurse (LPN) CC was observed performing R #64's left heel wound care. During this observation, no blister was seen, and the left heel appeared to have eschar in the wound bed surrounded by pink tissue. During interview with LPN DD on 3/30/17 at 10:18 a.m., she stated that the 11:00 p.m. to 7:00 a.m. shift nurse did the dressing changes, wound measurements and staging. During interview with the ADON on 3/30/17 at 1:19 p.m., she stated that there was an RN (Registered Nurse) on the night shift that measured and described wounds weekly. The ADON verified that there was no documentation on the Wound Evaluation Form after 3/16/17 for the left heel wound, and the only measurements she could find in the nurse's notes was on 3/18/17. Review of this note revealed the measurement was for the left buttock wound, not for the heel wound. The ADON further stated that if the heel wound contained eschar, that it would be unstageable, but the treatment would remain the same. During interview with the ADON on 3/30/17 at 3:27 p.m., she stated that she was not able to find a facility policy that specified how often wound assessments and measurements should be done. Review of the facility's Wound Evaluation Form revealed to COMPLETE SECTION BELOW (with date, size, stage, drainage, wound bed, undermining/tunneling, and periwound) WHEN AN ULCER IS FIRST DISCOVERED AND ON A WEEKLY BASIS THEREAFTER.",2020-09-01
72,"WILLIAM BREMAN JEWISH HOME, THE",115022,3150 HOWELL MILL ROAD N.W.,ATLANTA,GA,30327,2017-03-30,328,E,0,1,U5BR11,"Based on observations, record review, policy and procedure review, and staff interviews the facility failed to maintain clean inlet filters on oxygen concentrators for five residents (R) receiving oxygen therapy ( R#80, R#182, R#181, R#111, R#96). The sample size was 7 residents receiving oxygen therapy via oxygen concentrators. Findings include: 1. Observation on 3/28/17 at 2:47 p.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen at 3 liters by nasal cannula every shift. Observation on 3/29/17 at 9:47 a.m. revealed R # 182 lying in bed awake receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 2. Observation on 3/28/17 at 3:22 p.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen 2 - 5 liters as needed by nasal cannula to keep oxygen level above ninety (90) percent. Observation on 3/29/17 at 9:48 a.m. revealed R # 181 lying in bed with eyes closed receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 3. Observation on 3/28/17 at 3:35 p.m. revealed R # 111 seated in recliner chair at bedside receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 3 liters by by nasal cannula at night and 3 liters as needed during the day. Observation on 3/29/17 at 10:26 a.m. revealed R # 111 asleep in bed, private sitter at bedside. R # 111 is receiving oxygen by nasal cannula at 3 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. 4. Observation on 3/28/17 at 3:38 p.m. revealed R # 96 lying in recliner chair at bedside receiving oxygen by nasal cannula at 2 liters per minute (LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Physician order: oxygen continuously at 2 liters by nasal cannula or face mask to keep saturation above ninety (90) percent. Observation on 3/29/17 at 10:06 a.m. revealed R # 96 in bed, CNA at bedside providing morning care. R # 96 is receiving oxygen by nasal cannula at 2 liters per minute(LPM). The concentrator had one filter on the right side of the machine, coated in a thick layer of dust. Observation with the Director of Nursing (DON) on 3/29/17 from 4:35 p.m. to 4:58 p.m. confirmed the oxygen concentrators for R # 181, R # 182, R # 111, R # 207 had one filter on the right side of the machine coated with dust. Facility Policy on Departmental (Respiratory Therapy) - Prevention of Infection stated that filters from oxygen concentrators should be washed every 7 days with soap and water, rinse and squeeze dry, allow filter to dry prior to replacing back into machine. Telephone interview with LPN AA on 3/30/17 at 10:45 a.m. Stated that she works 3rd shift on the 3rd floor, and part of her duties include cleaning the oxygen concentrator filters on that floor weekly every Thursday, but she was off last week Thursday and Friday. Stated also that she did not follow up on 3/27/17 to ensure the oxygen concentrator filters were cleaned after resuming her normal work schedule. Telephone interview with LPN BB on 3/30/17 at 11:19 a.m. stated that she works 3rd shift on the 2nd floor and part of her duties include cleaning the oxygen concentrator filters on that floor with soap and water, air dry, and replace them every Thursday of every week, but forgot to clean them last week. Telephone interview with LPN CC on 3/30/17 at 3:00 p.m. stated that she started working on the 5th floor 3rd shift Wednesday last week, but did not clean the oxygen concentrator filters on that floor because she was not told during orientation that it was part of her duties to get the filters cleaned every week. Stated that she was only given that information yesterday by her supervisor. Interview with DON on 3/30/17 at 11:05 a.m. stated that there was no flow sheet or documentation to show when the oxygen concentrator filters were cleaned. However, she stated that as of yesterday she added a flow sheet to the Treatment Administration Record for all residents receiving oxygen. 5. On 3/27/17 at 12:53 p.m., the filter on the back of R #80's oxygen concentrator was observed to be covered with a thick coating of a white, dust-like material. Further observation at this time revealed that the tubing for the nasal cannula that delivered the oxygen to the resident was dated 3/21. During observation on 3/27/17 at 4:15 p.m. and 3/28/17 at 9:10 a.m., the nasal cannula tubing was dated 3/27/17, 7-3 (7:00 a.m. to 3:00 p.m. shift). Further observation revealed that there was still a thick coating of a white dust-like material on the oxygen concentrator filter.",2020-09-01
73,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,226,D,0,1,44GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure the abuse policy and procedure was followed to ensure 1 of 1 allegations of abuse was thoroughly investigated for 1 of 1 residents reviewed for abuse. (Resident #45) Findings include: On 7/25/16 at 3:30 PM, the Executive Director provided a policy titled Verification of Investigation of Alleged Mistreatment, Abuse, Neglect, Injuries of Unknown Source and Misappropriation of Resident Property Guideline, dated 3/2002 and revised 2013, and indicated the policy was the one currently used by the facility. The policy indicated .In the event of an alleged violation .involving mistreatment, neglect, abuse, injuries of unknown source or misappropriation of property, the center investigates the alleged violation thoroughly and reports the results of all investigation to the Executive Director as well as to state agencies as required by state and federal law. Investigation is conducted per the nursing policy Reporting Alleged Violations and documented on the Verification of Investigation form. Documentation reflects resident assessment; record reviews and sufficient employees/individuals were interviewed to derive at conclusion findings .Event Investigation: .The Executive Director, Director of Nursing or designee will initiate an event investigation immediately after the occurrence .2. Interview all people involved in the event. Discuss the event with associates involved, but DO NOT take written statements .8. Determine what recommendation or interventions have been or will be taken to prevent recurrence On 7/27/16 at 8:58 [NAME]M., record review indicated Resident # 45 was originally admitted to the facility on [DATE] with the most recent readmission on 7/15/16 with [DIAGNOSES REDACTED].diabetes mellitus type II, obesity, [MEDICAL CONDITION] and [MEDICAL CONDITION] A quarterly MDS (Minimum Data Set) assessment, completed on 5/11/16, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had normal cognition, the resident had no hallucinations or delusions, required extensive 2 person transfer assist and was independent for locomotion off of the unit. A sign out/in log for all appointment and leave of absence (LOA) form for Resident #45 indicated I, the responsible person named below, hereby accept complete responsibility for the above named resident, while away from (facility name). I will complete this form on departure from (facility name) and return to (facility name) . The sign in/out log indicated the resident signed himself out LOA on 7/7/16 at 11:51 [NAME]M. and returned to the facility on [DATE] at 2:30 P.M. A nurse note, dated 7/8/16 at 10:31 P.M., indicated received resident in bed sleeping, which was not the normal behavior. Writer could not wake the resident to take evening medications, vs (vital signs) blood pressure: 102/65, spo2 (oxygen saturation) 93%, blood sugar 165. Family members (mother and sister) visited because he did not answer their calls. Writer notified his NP (nurse practitioner), advised to hold BP (blood pressure) medications only for this evening. Will continue to monitor. A nurse note, dated 7/9/16 at 11:23 [NAME]M., indicated change of condition altered mental status. Resident received this morning in his bed, very difficult to wake up. Resident was unable to say any word but 'yes Mam', very slow to arouse, unable to swallow, very poor left hand grip tongue protruding from mouth which is not normal. Resident is on ABT (antibiotic)[MEDICATION NAME] mg (milligrams) for urinary tract infection [MEDICAL CONDITION] but was not given this morning because resident was unable to swallow, VS (vital signs) 97.6, 74, 18, 135/64, O2 (oxygen) saturation (sat) 93 at room air, O2 applied at 3 l (liters)/m (minute) and O2 sat went up to 97%. NP notified and she came and assessed resident, order received to send resident to emergency room (ER) on a 911. Resident sent to ER. Residents mother called and notified, resident left facility at 10:30 [NAME]M. A laboratory report, dated 7/9/16, indicated Resident #45 had a urine drug screen completed the test indicated the resident tested positive for cocaine and opiates. A consultation from the hospital dated 7/10/16, indicated history of present illness: a [AGE] year old male with a history of [MEDICAL CONDITION] secondary to a fall, hypertension, diabetes, recurrent UTI (urinary tract infection) and [MEDICAL CONDITION]. He presented to the emergency room via EMS due to altered mental status. It was reported that normally he is able to carry on conversation and feed himself and yesterday he was found to be very confused and unable to do any of the activities of daily living that he normally does. (Resident ' s name) was actually recently admitted to (hospital name) from (MONTH) 30th to (MONTH) 2nd due to a UTI. At that time, he also presented with altered mental status and [MEDICAL CONDITION]. Urine drug screen was done, interestingly was positive for cocaine and opiates. An Incident report, dated 7/11/16, was faxed to the Department of Health Regulation Division. The report indicated date and time of incident: 7/10/16. Details of incident: Resident was sent to (hospital name) due to altered mental status. Hospital called facility and stated that it was abuse on our part because (resident name) tested positive for cocaine. Physician notified: YES. Steps taken by facility to prevent further incidents: blank A 5 day follow up investigation, dated 7/15/16, was faxed to the Department of Health Regulation Division. The report indicated the resident was sent to (hospital name) due to altered mental status. Hospital called facility and stated that it was abuse on the facility's part because (resident name) tested positive for cocaine. Case Manager from the hospital contacted the facility and informed the facility that the hospital doctor believed this was abuse because the resident tested positive for cocaine. Because the potential allegation of abuse was present, the facility self-reported this incident. Details of the investigation: Executive Director, Admissions Director and hospital liaison met with the specific doctor that made the statement (allegation) at (hospital name). After speaking directly to the specific doctor making the statement, the doctor informed the Executive Director and all parties at the meeting that she was not aware that the resident in question was able to get around and/or sign themselves out to go into the community. The doctor initially believed that since the resident was paraplegic, that the resident was bed ridden. She also stated that she never suggested or agreed that the hospital case manager should document or contact the facility with an allegation of abuse as to it was merely her opinion. She was speaking from her opinion without fully understanding the resident's ability to leave the facility. It was explained to the doctor that this resident signs himself out, and leaves the facility for hours. The resident also catches transportation to move throughout the city and the resident is self-responsible. After receiving more information in regards to the resident's ability and resident rights, the doctor apologized for the allegation and stated that maybe I should ask questions first before using words like abuse or neglect. Conclusion: Facility concluded that this was a non-substantiated allegation. Facility will continue to monitor and respond to all allegations from residents, family members and all interested parties. Plan: Facility will continue to monitor for any allegations of abuse, neglect or any other incident involving its resident and staff. During an interview, on 7/27/16 at 2:30 P.M., Employee DD indicated she was the charge nurse on duty the morning of 7/9/16. She indicated she could not figure out what was causing the residents change in his mental status other than he was having increased pain from leg spasms and was on pain medication for this. She indicated the resident does not have many visitors other than his mother but she had a recent accident and has not been able to come to the facility. She indicated the resident is his own legal representative, he is alert and oriented and signs himself out for LOA's. She indicated she has never seen the resident come back from a leave of absence impaired. During an interview, on 7/27/16 at 2:50 P.M., Employee JJ indicated she was on duty the day of 7/9/16 and observed the change in mental status for the resident and reported it to the charge nurse and the charge nurse assessed the resident and sent him to the emergency room for an evaluation. She indicated the resident goes LOA and takes the Transport bus by himself and is not accompanied by anyone. She indicated he is usually gone just a couple of hours and has never seen him return from a LOA impaired. During an interview, on 7/27/16 at 3:30 P.M., the DON (Director of Nursing) indicated on the evening of 7/10/16 the evening supervisor contacted her and indicated a case worker from the hospital called the nursing facility and indicated the resident had a drug screen completed and tested positive for cocaine, and the doctor at the hospital feels the facility was negligent and it was abuse on the facilities part because the resident tested positive for cocaine. The DON indicated she did not interview any residents or staff as part of the investigation because of confidentiality, she indicated she notified the Executive Director and turned the investigation over to him. During an interview, on 7/27/16 at 3:35 PM, the Executive Director indicated the facility was made aware of the situation on 7/10/16 an incident report was completed and faxed to the state and an investigation was started. The ED (Executive Director) indicated the 5 day follow up investigation was completed and faxed to the state on 7/15/16. The ED indicated the investigation consisted of obtaining an appointment with the physician at the hospital where the resident was transferred to and discussed the allegation of abuse/neglect and that the resident was his own legal representative and did leave the facility on LOA's. The ED indicated he did interview staff verbally but there was no written documentation of this. On 7/27/16 at 5:15 P.M., the Executive Director presented 2 written statements from employees and indicated these were the 2 employees that were verbally interviewed regarding the situation but was never documented on paper until 7/27/16. Letter #1, dated 7/27/16, (resident name) was readmitted to the unit on 7/15/16. Prior to his arrival, a verbal report was called to the receiving nurse. This report stated that the resident was positive for cocaine abuse. I asked (resident name) if he was aware of the above and he stated emphatically that the hospital made a mistake and that if needed he was willing to have a repeat blood test. He stated that has never been my lifestyle. I informed (resident name) that I did not have an order to do a blood test but that it was ill advised for him to continue taking illegal drugs. Letter #2, dated 7/27/16, upon residents return from the hospital on [DATE] writer interviewed resident about dx (diagnosis) cocaine abuse per hospital report. Writer explained and educated the resident regarding cocaine especially since he's already on multiple pain medications. Resident denied any cocaine use and stated that I got wrong information. He stated that his mom already spoke to the hospital because they have misidentified somebody's blood as his. An Admission Agreement, undated, was received from the Director of Nursing on 7/28/16. The Admission Agreement indicated: .Drug and Medication: No medications (including non- prescription items such as aspirin or vitamins) are to be brought in for residents in this facility .Personal Choice: Entering and Leaving the Nursing Home: You have the right to enter and leave the nursing home as you choose, unless medically contraindicated as determined by your physician in accordance with state law. The facility may require you to inform it at the time you are leaving and re-entering the nursing home's grounds .",2020-09-01
74,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,253,E,0,1,44GN11,"Based on observation, interview, record, and facility vendor service agreement review, the facility failed to maintain dining areas and two (2) resident rooms on the Magnolia Wing in clean and sanitary condition. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. - - Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. 1. On 7/26/16 at 9:19 AM, Resident #117 room was observed standing near her bed. Residents ' bed control was lying on the bed spread. The bed control had exposed wires and there was some type of black sticky substance all over the back of it. 2. On 7/25/16 at 10:12 AM, Resident #143's bathroom was observed to have several dried splattered brown stains on the wall and on the outside of the toilet. Resident #143 stated We share with people in the other room also. 3. At 11:00 am during observation of the Magnolia Wing dining areas, there was a buildup of dirt in the corners and along the base boards of both dining areas. Residents were sitting in the dining area after participating in an activity. At 11:10 AM the Environmental Manager (EM) was queried about cleaning of the dining areas, particularly the floors. EM stated We have two people here on the 3 to 11 PM shift. One person is in laundry and the other person is doing the floors. On 7/27/16 at 9:25 AM, an interview was conducted with the Regional Environmental Manager (REM). REM was taken to the dining areas on the Magnolia Wing and shown the black dirty substance in the corners and along the base boards. REM stated Yes we need to do better with these areas. REM agreed the dirt on the floor, in the corners and along the base boards in the dining area should have been addressed by the housekeeping staff. On 7/27/16 at 9:40 AM an environmental tour was conducted with the Director of Nursing (DON) and Executive Director. Observed Resident #117 ' s bed control with wires exposed and sticky black substance. Dining area in which housekeeping staff had begun to clean and strip the floor. Resident #143 ' s bathroom wall and toilet with splattered brown stains were brought to their attention. They both agreed that these things needed to be addressed immediately. The facility failed to provide a clean and sanitary environment for the residents on the Magnolia wing.",2020-09-01
75,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,254,D,0,1,44GN11,"Based on observation, interview, and review of the Vendor's Master Service Agreement the facility failed to provide four (4) sampled residents (Residents #3, #117, #143 and #213) out of 31 residents sampled with clean bed linen, mattresses and pillows in good condition. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. -- - Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. 1. Observation and interview on 7/25/16 at 5:19 PM revealed Resident #3's pillow cover cracked and in disrepair. Resident #3 stated I don't like it. 2. During observation and interview with Resident #213 on 7/25/16 at 5:57 PM the resident stated that his bed pillow and mattress were filthy. Observed the resident's stained malodorous pillow and soiled malodorous mattress. Resident #213 stated the mattress was uncomfortable to him. 3. On 7/26/16 at 9:19 AM, entered Resident # 117's room. Resident #117 ' s bed was observed to be made up with a blanket that had a large tear in it. When asked to see the linen on the bed, the resident pulled back the blanket and there were multiple brown, yellow and green stains on the sheet. Resident removed the pillow case and the pillow had multiple brown stains all over it. CNA MM entered the resident ' s room and when asked how often the linen was changed. CNA MM replied CNA on night shift gets some of the people up. Linen should be changed every other day. The person that gets her up should change it because they see it. Needs to be changed. 4. On 7/26/16 at 10:12 AM, Resident # 143 ' s room was observed, resident had a dull, dingy colored pillow on the bed. When the resident pulled back the bed linen and exposed a flattened mattress with a faded blue cover on it. Resident #143 stated I have to fold it (pillow) in half to put my head on it and the mattress is not very comfortable but I guess that's all they have . On 7/27/16 at 9:40 AM, environmental tour was conducted with the Director of Nursing (DON) and Executive Director. Resident #117 who had brown stained pillow, torn bedspread. Resident #143 rooms who had flattened dingy colored pillow and mattress, bathroom wall and toilet with splattered brown stains were brought to management staff attention. They both agreed that these things needed to be addressed immediately and began to have staff remove the torn bedspread and bring new pillows to the resident ' s rooms. Interview and observation on 7/27/16 at 10:06 AM with the Director of Nursing Services (DNS) revealed Resident #3's pillow cover was cracked and flaking. Additionally, resident #213's pillow and mattress were observed heavily soiled. The DNS stated that she would replace both pillows and Resident #213's mattress. DNS stated will have the staff to audit all resident mattresses and pillows today",2020-09-01
76,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,279,D,0,1,44GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to develop a written comprehensive care plan for 1 of 5 residents reviewed for unnecessary medications. (Resident #12) Findings include: On 7/28/16 at 9:40 [NAME]M., record review indicated Resident #12's [DIAGNOSES REDACTED].diabetes type II, major [MEDICAL CONDITIONS], [MEDICAL CONDITIONS] and anxiety A significant change MDS (Minimum Data Set) assessment, completed on 6/20/16, documented Resident #12 had an active [DIAGNOSES REDACTED]. The current physician's orders [REDACTED]. The sliding scale orders were: 0-59 give 0 units, notify physician if blood sugar below 60 60-199 give 0 units 200-249 give 4 units 250-300 give 6 units, 301-349 give 8 units, 350-400 give 10 units, if blood sugar above 401 notify the physician. The [MEDICATION NAME]was originally ordered on [DATE] and the Humalog sliding scale insulin was ordered on [DATE]. On 7/28/16 at 11:00 [NAME]M., the care plans for Resident #12 was reviewed there was no care plan for the resident ' s [DIAGNOSES REDACTED]. During an interview, on 7/28/16 at 11:15 [NAME]M., Employee EE stated Resident #12 did not have a care plan in place for her [DIAGNOSES REDACTED]. During an interview, on 7/28/16 at 11:30 [NAME]M., the Director of Nursing stated the facility does not have a policy regarding the development of a care plan they go by the RAI (Resident Assessment Instrument) standards. During an interview, on 7/28/16 at 12:04 P.M., Employee FF stated Resident #12 was diagnosed with [REDACTED]. Employee FF indicated when the resident has a new [DIAGNOSES REDACTED]. The facility failed to develop comprehensive care plans for resident receiving insulin.",2020-09-01
77,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,323,D,0,1,44GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record, and facility policy review, the facility failed to provide adequate supervision for 1 sampled resident (Resident #61) from a sampled 31 residents. On 4/26/16 Resident #61 had expressed a desire to leave the facility, however the resident could not leave the facility unless accompanied by a family member. The facility was not aware the resident had left the facility unsupervised until 10 pm on 4/26/16. Findings include: Review of the facility's policy titled Elopement revised 2013 revealed the following information elopement is defined as that situation where a resident with impaired decision making ability , who is oblivious to his/her own safety, needs and therefore at risk for injury outside the confines of the living center, has left the living center without knowledge of staff. Review of Resident #61's active clinical record revealed the resident was readmitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Minimum Data Set (MDS), Medicare 30 day, indicated the resident was cognitively intact with a score of 13. -Quarterly MDS, dated [DATE] indicated the resident displayed no wandering behavior not exhibited and required supervision with all activities of daily living. Review of Care plans initiated on 3/11/16 revealed the following: Focus: - Resident #61 has impaired neurological status related to: Parkinson's disease, Dementia Focus: I forget things and can become anxious and it can create possible safety risks for me related to [DIAGNOSES REDACTED]. Review of the resident ' s progress notes revealed a late entry note dated 4/26/16 11:02Note Text: Resident noted to have left the faciity on this date without signing out. Resident's emergency contact person was called to determine if resident was picked up early for pending discharge. Family denies discharging resident early and stated that they were unaware of where resident may have gone. Resident was scheduled to be discharged to a PCH on 4-27-16 and was aware of this plan. Resident was present during discharge care plan meeting and was in agreement with discharge. Facility notified appropriate authorities and followed facility protocol for procedural variance. Resident is discharged from facility. The facility ' s investigation concerning this incident contained staff interviews and review of the facility monitoring tape. The investigation documents staff first identified the resident as missing around 10:45 PM, when it was noticed by the 3- 11 shift Charge Nurse who did not give the resident his medication because he was not in his room. Evening shift nurse stated medications were not administered to the resident during the shift since he was not present. CNA also reported to the charge nurse that she did not see the resident early in the shift. Documentation indicated on 4/26/16, before noon the resident was at the Dogwood unit and approached the nurse ' s station requesting to be signed out. Resident was told at that time that sister or niece needs to be with resident in order for him to sign out. Staff was aware that the resident wanted to leave the facility and the front desk was notified to keep an eye out for the resident. Review of facility ' s staff statements indicated housekeeping staff saw Resident #61 on the[NAME]bus at 3:30 pm and then the resident transferred to the[NAME]train between 4:00 - 4:15 pm. Afternoon Nurse PP stated I was assigned to Resident #61 around 5:00 pm when I was informed that the nurse who was supposed to come in for the GA/Dogwood cart (unit where resident ' s room was located) had not shown up . Between 7:30 - 8:00 pm I was asked by the CNA where Resident #61 was. I told her I wasn ' t ' sure and to ask the nurse assigned to him to see if she had seen him. Shortly thereafter when the primary nurse assigned to Resident #61 asked me had I seen him I stated that I had not seen him since around 2:30 pm in the front lobby looking out of the window On 7/25/16 at 4:39 PM. interview with Social Worker CC was conducted concerning residents who are assessed for elopement risk. SW CC stated the facility has a safety committee that meets concerning all residents who are risk for elopement. An assessment is completed and those who are risk for elopement have wander-guard bracelets placed on them. Social worker completes an elopement care plan for those residents at risk and the 3-11 PM nurses check all wander guards, to make sure the residents have them on. On 7/28/16 at 2:40 PM, the Director of Nursing (DON) and the Executive Director were interviewed concerning Resident # 61 who went missing from the facility on 4/26/16. The Executive Director stated the resident was not considered an elopement risk because he had never left the grounds before that day without anyone with him. Also, the resident was aware that he was being discharged to a personal care home the next day. When asked about the resident's [DIAGNOSES REDACTED]. We watched the tape and he planned to leave, He timed when the bus was coming and walked right out there and got on the bus. When asked why staff did not know the resident had left until 10:45 PM. the Executive Director and the DON both stated he was a very social guy and was rarely in his room. Executive Director and DON were asked why Resident #61 was being discharged to a personal care home, for what reason. Executive Director replied he was being discharged to a personal care home because that is where his family wanted him to go . When asked about the care plan that indicated the resident forgot things, became anxious and this was noted to create safety risks for the resident. DON stated he could make his needs known The facility was aware the resident wanted to leave but failed to provide closer monitoring of the resident ' s whereabouts. Several hours went by before the facility realized the resident was missing.",2020-09-01
78,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,328,D,0,1,44GN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and facility policy review the facility failed to ensure 1 resident (Resident #128) of 31 residents sampled, received the prescribed amount of enteral nutrition within a 24 hour timeframe. Findings include: Review of the facility's policy titled Administration of Enteral Feeding last reviewed 11/02/15 indicated Procedure: to ensure all residents who receive enteral feeding receive the appropriate care and services. - check physician orders-formula, amount, rate, flushes, and residual parameters. -document the amount of formula administered, the amount of free water administered and any exceptions noted with the administration of enteral feeding to the resident. On 7/26/16 at 9:17 a.m., Resident # 128 was observed in bed asleep with the head of the bed (HOB) at 45 degrees. A full bottle (1500 milliliters) of Osmolyte 1.0 (liquid nutrition) dated 7/26/16 at 4:30 AM was hanging on a pole connected to an infusion pump. The pump was turned off and the tubing was capped and draped over the pole. At 12:00 PM CNA JJ was observed with Resident #128 lying flat in the bed, providing incontinence care. The pump remained turned off On 7/26/16 at 2:20 PM, Resident #128 was observed in bed, HOB at 45 degrees, tube feeding (TF) was infusing at 75 ml/hr., no flush bag hanging. On 7/27/2016 9:15 AM , Resident #128 was observed in hospital gown in bed with 1500 ml (full bottle) of Osmolyte 1.0, dated 7/27 at 5:15 AM hanging on infusion pump pole capped and not connected to resident, not infusing. At 10:23 AM Resident #128 remained in bed and TF, remained off. Review of the Physician order [REDACTED].) for 22 hours to provide 1650 kilocalorie's in 1650 ml of volume. Every 2 hours flush peg tube with 200 ml of water. On 7/27/16 at 11:14 AM LPN KK was queried about the infusion times for Resident #128 ' s tube feeding and how often did the resident receives a flush. LPN KK responded it should be up for 12 hours and off for 8 hours. It was infusing when I came in but I turned it off to give medication. When asked why is the bottle still full. LPN KK offered no response. When asked how often he gives the resident flushes, LPN KK responded 200 ml every 4 hours. ON 7/27/16 at 11:20 AM, DON, & Executive Director were present on the unit and were asked if staff document daily how much TF was infused on Resident #128. DON responded staff does not document the amount of TF that is infused. DON was asked to check the pump in order to see the amount infused on the TF pump. Pump indicated 254 ml had been infused but a full bottle of TF was hanging. DON reviewed the physician order [REDACTED]. x 22 hours. When asked how the facility ensures the ordered amount is being infused daily when there is no documentation to indicate amount infused. DON and Executive Director stated We will began having staff document the amount of TF infused on each shift. The facility failed to ensure that Resident #128 received the prescribed enteral nutrition.",2020-09-01
79,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,431,D,0,1,44GN11,"Based on observation and interview, the facility failed to ensure expired medications were removed from 2 of 5 medication storage rooms, reviewed for medication storage. (Georgia and Dogwood) Findings include: On 7-27-2016 at 3:46 P.M., the policy entitled, Medication Storage in the Facility, Storage of Medications, was provided by the Assistant Administrative Director, and reviewed. The policy indicated, Procedures .H. Outdated, contaminated, or deteriorated medications .are immediately removed from inventory, disposed of according to procedures for medication disposal On 7-27-2016 at 10:02 [NAME]M., an observation of the medication storage room on Georgia Unit, was conducted with Employee G[NAME] A box labeled Heparin Lock Flush Solution, USP 10USP Heparin units/mL, was observed in the upper cabinet to the left of the locked medication storage refrigerator, and had an expiration date of (MONTH) 29, 2014. The box contained 13 preloaded and individually packaged Posi Flush Heparin Lock Flush Syringes. Each of the 13 individually packaged Heparin Flush syringes were labeled with the expiration date of (MONTH) 29, 2014. An interview at the time of the observation with Employee GG, indicated the out dated Heparin Lock Flush Solution, should have been removed from the medication storage room and discarded upon expiration. The employee indicated it was the responsibility of the nursing staff to look for and remove expired medications from the medication storage rooms. On 7-27-2016 at 10:28 [NAME]M., an observation of the medication storage room on Dogwood Unit, was conducted with Employee HH. 3 individual IV (intravenous) medications were observed in the locked medication storage refrigerator. Each of the 3 medications were labeled, Meropenem one gram (Merrem 1 GM) 100 ML IV infusion, and each had it's own stamped expiration date. The expiration dates were 6/08/2016, 6/13/2016, and 6/10/2016. An interview at the time of the observation with Employee HH, indicated the out dated Meropenem IV medication should have been removed from the medication storage refrigerator and discarded upon expiration. Employee HH indicated it was the responsibility of all nursing staff to check for expired medications and discard them per facility protocol.",2020-09-01
80,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,441,E,0,1,44GN11,"Based on observation, interview, and review of the facility vendor service agreement, it was determined the facility failed to handle and transport linens to prevent cross-contamination between dirty and clean linen in the laundry room. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. During a tour of the laundry on 7/27/16 at 9:19 AM interview with the housekeeping and laundry director (AA) and observation of the physical layout of the laundry's clean and dirty areas revealed the laundry from the Magnolia wing that is adjacent to the laundry in delivered into a corridor outside the laundry. There is no direct access into the dirty laundry room. The laundry must be transported through the clean laundry room in close proximity to the front door of the dryers. Interview with AA (the Environmental Services Director) during the observation of the laundry revealed a door was needed between the hallway and the dirty laundry room to prevent cross contamination of clean clothing from the dirty laundry transported through the clean room. Additionally, a barrel containing mop heads and towels was observed at the junction between the clean and dirty rooms. AA stated the items in the barrel were clean but then instructed the staff to re-wash the mop heads and towels that were in the barrel because they were contaminated and dirty. There were open bags of dirty laundry piled in large bins in the dirty laundry that had spilled out of the bins onto the floor of the laundry room. Observation of the clean laundry folding area during the same observation on 7/27/16 at 9:19 AM revealed towels, linen, and resident laundry draped on a desk and spilling out of barrels onto the floor. AA explained that the linen that was observed dragging on the floor was going to be discarded because it was stained and tattered. Interview with the Director of Nursing Service (DNS) 07/27/2016 10:37 AM regarding the laundry revealed that she would notify the Executive Director of the cross-contamination potential between the dirty and clean clothing as soon as possible. 07/27/2016 12:03:40 PM interview with the Regional Director for Environmental Services in the conference room revealed the concern of cross-contamination of dirty laundry going into the clean room before going into the washing area had been discussed in past years. The facility considered the cost of an additional door into the laundry through a support wall prohibitive and the discussion ceased because of the age of the building.",2020-09-01
81,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2016-07-28,456,E,0,1,44GN11,"Based on observation, interview and review of the vendor service agreement , the facility failed to keep the 3 (#1, #2, #3) of 4 laundry's washing machines in good working order. Findings include: Review of the current Vendor's Master Service Agreement revealed the following: -Services hereunder shall consist of housekeeping and laundry services provided on a scheduled and on call basis. - Areas to be serviced: Cafeteria and dining areas. Clean baseboards. Clean and sanitize lavatory and toilet bowls . - All laundry equipment is the property of GGNSC (Golden Living Center) Party, and all repairs and maintenance of such equipment are the GGNSC Party sole responsibility. Each GGNSC Party shall at all times keep and maintain all laundry equipment in good operating condition and repair in accordance with manufacturer's recommendations and applicable law and such equipment shall have sufficient capacity to permit laundry and linen items to be processed by Vendor in a timely and efficient manner. During tour of the laundry with AA (the Environmental Services Director) on 7/27/16 at 9:19 AM 2 (#1, #3) of 4 washing machines were observed leaking large pools of water onto the laundry room floor. The facility staff stemmed the flow of water with bedspreads. 07/27/2016 12:03 PM interview with the Regional Director for Environmental Services in the conference room revealed that AA had contacted the laundry washer manufacturer regarding the leaking washers and was waiting for documentation/call logs from the company. Follow-up interview with AA on 07/27/2016 4:25 PM in the day room revealed the technician from Laundry Equipment Sales responded to his call today and repaired the washers (#1 and #3). On 07/28/2016 at 12:52 PM observation and interview with AA revealed that the washing machines #1 was not leaking. However, new leaks were observed from washer #2 and washer #3.",2020-09-01
82,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2018-11-01,604,D,0,1,GW4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure that one (1) of 35 sampled residents (R) (R#44) was free from a physical restraint. While R#44 was seated in a high-back wheelchair, the resident's legs were strapped together for approximately three (3) hours, and the resident was unable to move her legs. The findings included: Review of R#44's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#44's Significant Change Minimum Data Set (MDS) assessment dated [DATE] and her Quarterly MDS dated [DATE] revealed the resident was severely cognitively impaired and had no physical behaviors. R#44 required extensive to total assistance for all activities of daily living (ADLs) and utilized a wheelchair for mobility. The resident had no falls during either assessment period. R#44 received no therapy services and no restraints or alarms were used during either assessment period. Review of R#44's ADL care plan dated 11/4/17 noted R#44 had an ADL self-care performance deficit related to (r/t) Alzheimer's and weakness. Goal for R#44 was to maintain current level of function in ADLs thru the review date. Interventions included: Dressing: receives total to extensive assist with one staff support; Bathing/hygiene - she receives shower 3 times per week with total assist from staff. Staff will trim her nails as needed (prn); encourage active participation in tasks; Bed mobility: requires total to extensive assistance by 1- to 2 (1-2) staff to reposition in bed and as necessary; Eating: requires extensive assistance with eating; Transfer: requires total assist by 1-2 staff to move between surfaces; Observe/document/report prn any changes any potential for improvement, reasons for self-care deficit, expected course, declines in function; Praise all efforts at self-care; physical therapy/occupational therapy (PT/OT) evaluation and treatment as per MD (doctors) orders. The care plan did not reference the use of a restraint. Review of R#44's fall care plan dated 11/4/17 revealed the resident was a moderate risk for falls r/t confusion and being unaware of safety needs. Interventions included: Anticipate and meet the resident's needs; Be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed; Ensure that the resident is wearing appropriate footwear rubber sole bottoms and describe correct client footwear; Review information on past falls and attempt to determine cause of falls. Record possible root causes. After remove any potential causes if possible. Educate resident/family/caregiver/IDT (Interdisciplinary Team) as to causes; and transfer with mechanical lift with the assistance of two staff. The care plan did not reference the use of a restraint. Review of R#44's OT Discharge Summary dated 6/21/18 noted Patient will demonstrate increase in upright sitting posture for 30 minutes in order to participate in social activities within the unit and for environmental orientation with use of appropriate seating device .wheelchair modification and adaptation including providing a high back recline chair, a saddle wedge cushion to improve posture for social interaction and comfort during meals. Staff education on positioning technique and application and care . Review of R#44's physician's orders [REDACTED].>Review of the Magnolia Assignment Sheet dated 10/31/18 revealed a Certified Nursing Assistant (CNA) was assigned to R#44. Review of the Magnolia Assignment Sheet dated 10/31/18 noted CNA FF was assigned to the resident for the 7:00 a.m. - 3:00 p.m. shift. Observations in R#44's room on 10/29/18 at 12:40 p.m. revealed the resident was in bed and appeared to be sleeping. A high-back wheelchair was sitting next to the resident's bed and a cushion had been placed in the seat of the wheelchair. Observations in the common area day room of Magnolia Hall on 10/31/18 at 10:00 a.m. revealed R#44 was sitting in a high-back wheelchair. R#44 was not seated correctly in the wheelchair and the resident's bottom was sliding forward in the seat of the chair. R#44's feet were positioned on the wheelchair's padded footrests, and the resident's legs were held together directly below the knees with a black strap that buckled in the front of the resident's legs. Interview at this time with R#44's Unit Manager (UM) CC confirmed the strap around the resident's legs was restricting the resident's movement, and R#44 was not able to unbuckle the strap without assistance. UM CC said the strap should not be in place and stated she would get with therapy to find out about the positioning/placement of the strap. When asked about the staff responsible for getting the resident up this morning, UM CC said she'd have to check with the 11 p.m. -7:00 a.m. shift staff because that's who got her up this morning. When asked if the resident had been checked and changed since that time, UM CC said the resident had been and she would determine who was responsible for taking care of the resident during the day shift (today). Observation on 10/31/18 at 10:10 a.m. in the therapy department revealed four (4) therapy staff re-positioned the resident in the wheelchair and discovered that the cushion in the seat of the wheelchair had been placed backwards in the seat. During this observation an interview with Certified Occupational Therapist Assistant (COTA) DD confirmed the strap should not have been buckled around the resident's knees/legs. COTA DD said the cushion in the wheelchair was an anti-thrust cushion used to prevent R#44 from sliding forward in the chair. COTA DD said, when the cushion is placed in the seat of the wheelchair correctly, the strap of the cushion should be buckled underneath the set of the wheelchair. During a follow-up interview at the nurses' station with UM CC on 10/31/18 at 11:35 a.m. UM CC again stated that the 11:00 p.m. - 7:00 a.m. staff assisted the resident in getting up this morning. UM CC stated the 7:00 a.m. - 3:00 p.m. staff who was assigned to R#44 this morning became ill and had to go home early from her shift. UM CC said the 7:00 a.m. - 3:00 p.m. staff did toilet the resident before she went home early due to illness. UM CC said there were no other staff working with the resident on the morning of 10/31/18. Interview on 10/31/18 at 12:45 p.m. in the hallway of Magnolia unit with Licensed Practical Nurse (LPN) EE revealed the nurse was not aware of the staff who was responsible for getting the resident up that morning. Interview on 11/1/18 at 12:00 p.m. with the facility's Director of Nursing (DON) revealed UM CC informed her on 10/31/18 that R#44's legs had been inappropriately and improperly restrained with the seat cushion's straps and buckle. Interview on 11/1/18 at 12:39 p.m. at the nurses' station with Certified Nursing Assistant (CNA) FF revealed she was assigned to R#44 on the morning of 10/31/18; however, the overnight staff had already dressed and gotten R#44 up that morning. CNA FF said she did see the overnight CNA wheel R#44 out to the common area around 7:10 a.m. on the morning of 10/31/18, but CNA FF did not notice that the resident's legs were restrained. CNA FF said she got sick about an hour into her shift and then left for home around 8:00 a.m. The aide said she did not toilet R#44 before leaving the facility on the morning of 10/31/18. CNA FF said she was aware that the strap to the cushion was to be buckled underneath the seat of the wheelchair. Review of the facility's Restraint Management policy revised (MONTH) (YEAR) noted: Restraints are implemented in accordance with State and Federal regulations. If indicated, the least restrictive restraint is used for the least amount of time. Restraints are not used as a disciplinary action or for the convenience of the facility to control behavior .Definitions - Physical Restraint is any manual method, physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body .Examples of Physical Restraints - Physical restraints include, but are not limited to, leg restraints, hand mitts, soft ties, lap cushions, and lap trays the resident cannot remove easily. The reason for the restraint must be documented in the resident's plan of care.",2020-09-01
83,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2018-11-01,880,D,0,1,GW4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to utilize proper hand hygiene prior to performing wound care for one of two residents, Resident (R) #15. Improper hand hygiene can promote the spread of infection in a facility. Findings include: R#15 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Wound Evaluation and Management Summary note dated 10/30/18 revealed the resident was admitted to the facility with the following wounds: Stage 4 pressure wound to the sacrum measuring 5.5 x 7.5 x 0.5 centimeters (cm). Stage 4 pressure wound of the right ischium measuring 1.8 x 3.5 x 1cm. Stage 4 pressure wound of the left ischium measuring 3 x 4.5 x 2.5 cm. The Wound Evaluation and Management Summary stated that the dressings were to be changed daily. Review of the facility policy titled Hand Hygiene dated 2012 stated Using an alcohol-based hand rub is appropriate after contact with inanimate objects in the patient's environment. Review of the facility policy titled Artificial Finger Nails stated the following: I. Length of nails: Fingernails should be kept clean, healthy, and short (1.4 inch or less beyond the tip of the finger.) II: Artificial nails: Artificial nails or nails enhancements should not be worn by any person whose responsibilities include handling of sterile supplies and/or direct hands-on resident contact. III. Nail polish: If used, nail polish should not be chipped. Studies have demonstrated that chipped nail polish may support the growth of organisms on the fingernails. If nail polish is worn, it should not be worn for more than 4 days. At the end of 4 days, nail polish should be removed and freshly reapplied. During an observation of wound care on 10/31/18 at 11:00 a.m. Licensed Practical Nurse (LPN) AA set up supplies to change R#15's dressing on the left ischium. She was observed to have long nails with chipped and worn polish and confirmed that they were artificial. LPN AA sanitized her hands with alcohol rub, then reached into her pocket, retrieved the keys to the treatment cart and opened it. She then opened several drawers on the cart and began to open dressings and dropped them onto a clean field. After touching the treatment cart and opening several drawers, she removed unsterile gauze from a packet without sanitizing her hands, put them into a cup, applied wound cleanser and then used them to clean R#15's wound. During an interview with LPN AA on 11/1/18 at 12:07 p.m., she revealed that she thought she could have artificial nails if she kept them short. An interview with Registered Nurse (RN) BB, Wound Care Coordinator revealed that she was unaware of a facility policy advising staff providing direct patient care should not wear artificial nails. During an interview with the Assistant Director of Nursing (ADON) Infection Control Nurse, on 11/1/18 at 12:24 p.m., she confirmed that the facility policy prohibited direct care staff from wearing artificial nails. She also confirmed that LPN AA should have sanitized her hands prior to removing the unsterile gauze for wound care, and that by not doing so she had contaminated her hands.",2020-09-01
84,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,272,D,0,1,FY6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to accurately assess dental status for one resident (#46). Sample size was 35 residents. Findings include: Resident #46 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) annual reassessment dated [DATE] was completed by staff. Review of this MDS assessment, including the accompanying Care Area Assessments (CAA's), revealed the facility staff failed to accurately assess this residents dental status. During interview on 11/3/2017 at 4:47 p.m., MDS nurse AA confirmed that R #46 was not accurately coded on the Annual Reassessment MDS or included in the CA[NAME] She stated that reassessments are done by face to face visits. She further stated that she may be confusing this resident with another. If she is made aware of a miscoding by staff or herself, then she will make a modification. She could not find a dental assessment on his record.",2020-09-01
85,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,281,D,1,1,FY6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the Georgia Practice Act for Registered Nurses (RN) and Licensed Practical Nurses (LPN), staff and family interviews the facility failed to ensure that resident vital signs were monitored per the Physician orders [REDACTED].#_), that Physician orders [REDACTED].#6) that received [MEDICATION NAME] injection, that nurses were conducting narcotic reconciliation per the facility's policy for one resident (R#201) reviewed for use of injectable [MEDICATION NAME] and that nurses were confirming that the pharmacy label for medications corresponded with the physician's orders [REDACTED].#201 and R#137). The resident sample was 35. Findings include: Review of the Georgia Practice Act for Registered Nurses 2.2.2: Standards Related to Registered Nurse Responsibility for Nursing Practice Implementation. [NAME] Implements treatments and therapy, including medication administration, delegated medicals and independent nursing functions. Review of the Georgia Practice Act for Licensed Practical Nurses 2.3.2: Responsibilities for Nursing Practice Implementation. [NAME] Implements appropriate aspects of client care in a timely manner. 1. Provides assigned and delegated aspects of client's health care plan. 2. Implements treatments and procedures. 2. Administers medications accurately. K. Documents care provided. 1. Review of the Controlled Substance Accountability Sheet for R#6 revealed a pharmacy medication label with an original date of 5/23/17 for [MEDICATION NAME] INJ 2MG/ML (2 milligrams per milliliter) [MEDICATION NAME]- Inject 0.5ML (0.25ML). Review of the Physician order [REDACTED]. Review of the MAR indicated [REDACTED]. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist (CP) confirmed that R#6 does not have an order for [REDACTED].#6, they should have notified the nursing supervisor and an order for [REDACTED]. 2. Review of the policy titled Controlled Drugs dated (MONTH) 2005 and revised (MONTH) 2011 documented: To ensure that controlled drugs are inventoried and administered as required by State and Federal agencies: 1. Maintain a declining inventory record by resident by drug on all controlled drugs. Records must be accurate and include: *Name of resident *Prescription number and name of issuing pharmacy *Drug name and strength *Medication form *Route of administration *Strength and dose administered *Date and time of administration *Signature of the person administering the drug 2. Reconcile the declining inventory record at the beginning and the end of each shift. Reconciliation is performed by a physical count of the remaining medication by two persons who are legally authorized to administer medications. Observation on 11/2/17 at 1:50 p.m. with LPN CC and Unit Manager LPN DD of the West Wing storage medication refrigerator on 11/2/17 at 1:50 p.m. revealed a plastic package with four vials of [MEDICATION NAME]. The label read; 2MG/ML, Inject 1MG (0.25ML) intramuscularly every four hours as needed, prescribed to R#201. Review of the Controlled Substance Accountability Sheet with LPN CC revealed the last dated entry of dispense was 10/31/17 with a remaining quantity of five vials. LPN CC and the Unit Manager, LPN DD looked in the refrigerator and were unable to locate the fifth vial of [MEDICATION NAME]. Interview on 11/2/17 at 1:58 p.m. with LPN CC revealed she had not conducted a count of the [MEDICATION NAME] in the West Wing medication storage refrigerator because the night shift nurse had to leave early due to an emergency. LPN CC confirmed that she signed the Change of Shift Controlled Substances Count Sheet but that she had only counted the narcotics in her assigned medication cart, but not the narcotics in the medication storage refrigerator. Interview with the Director of Nursing (DON) on 11/2/17 at 3:55 p.m. revealed that after an investigation it was discovered that on 10/28/17, R#201 was having [MEDICAL CONDITION] and LPN CC administered [MEDICATION NAME] on the dayshift. The DON stated that the LPN CC never signed out the [MEDICATION NAME] on the Controlled Substance Accountability Sheet on 10/28/17. The DON stated that if the nurses had been properly conducting narcotic counts as they are supposed to each shift, the discrepancy would have been discovered on 10/28/17 during the 3:00 p.m. count. The DON confirmed that the nursing staff had been signing off with their signatures on the Change of Shift Controlled Substances Count Sheet, that narcotic counts had been conducted. Review of the Change of Shift Controlled Substances Count Sheet revealed signed signatures from the Nurse Departing from Duty and the Nurse Arriving on Duty indicating that all narcotics had been accounted for on the following dates and time: 10/28/17 at 3:00 p.m., 11:00 p.m., 10/29/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/30/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/31/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 11/1/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m. and 11/2/17 at 7:00 a.m. A total of 15 shift narcotic counts were documented by nurses indicating that five vials of [MEDICATION NAME] prescribed to R#201 was remaining. Cross refer to F431 3. Record Review for R#201 revealed a Physician order [REDACTED]. Review of the pharmacy label for [MEDICATION NAME] indicated Inject 1 MG (.25ml) every four hours as needed for [MEDICAL CONDITION]. Review of the Medication Administration Record [REDACTED]. Review of the Controlled Substance Accountability Sheet indicated the amount administered 1 on 9/3/17 and 9/9/17. Record review for R#137 revealed a Physician order [REDACTED]. Review of the pharmacy label for [MEDICATION NAME] with original date of 10/27/17 indicated Inject Intramuscularly 1 vial every eight hours. [MEDICATION NAME] INJ 2MG/ML. Review of the Controlled Substance Accountability Sheet indicated [MEDICATION NAME] was dispensed on 10/28/17 at 3:00 a.m., 11:00 a.m. and 1:00 p.m. with amount administered 1. Interview on 11/3/17 at 12:30 p.m. with the DON and the Consulting Pharmacist (CP) confirmed that the pharmacy label for [MEDICATION NAME] and the order for [MEDICATION NAME] on the facility's Physician order [REDACTED].",2020-09-01
86,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,323,D,0,1,FY6A11,"Based on observation and interview, the facility failed to assure electrical safety in five rooms on two of five units where an electrical power strip was used to provide electricity to multiple medical devices. The sample size was 35 residents. Findings include: 1. Observation on 11/1/2017 at 11:04 a.m., on the Magnolia Unit, revealed room 117 a with a power strip sitting on the floor at the head of the bed. The power strip was not affixed to the wall but plugged into an electrical outlet to the right of the hospital bed. Connected to the power strip and supplying electrical current was a hospital bed. 2. Observation on 11/1/2017 at 11:14 a.m., on the East Unit, revealed three resident rooms (103 b, 106, and 121 c) with power strips affixed to the wall and plugged into an electrical outlet. Connected to the power strips and supplying electrical current were hospital beds, feeding pump and oxygen concentrators. 3. Observation on 11/1/2017 at 11:14 a.m., on the East Unit, revealed room 120 d with two power strips connected to each other and affixed to the wall. Connected to the power strips and supplying electrical current was a hospital bed and oxygen machine. 4. Observation on 11/1/2017 at 11:32 a.m., on the Georgia Unit, revealed a power strip in use in the dining room. The power strip was supplying electricity to the communal television and was noted to be hanging from the television and plugged into outlet in the wall. Interview on 11/3/2017 at 10:35 a.m., with Environmental Supervisor, stated he knows that powers trips can be used for residents personal equipment such as personal fans, phone chargers, radios, and televisions. He further stated he was not aware that power strips could not be used with Medical equipment.",2020-09-01
87,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,372,F,0,1,FY6A11,"Based on observation and interviews, the facility failed to ensure that the surrounding area of one of one dumpster was maintained free of garbage and debris; and failed to secure two of three grease barrel lids to prevent insect and rodent infestation. Findings include: A tour of the dumpster area was conducted on 11/01/2017 at 11:08 a.m. revealed the following concerns: there was a pile of weathered garbage, containing paper trash and vinyl gloves, approximately three feet behind dumpster in a grass area; there was broken and damaged chairs stored behind the dumpster. Furthermore, three grease barrels are located beside the dumpster, and two of the three barrels had lids that were unsealed and ajar. On 11/2/2017 at 12:25 p.m. during an interview with the Corporate Dietary Manager, he stated that he was not aware the grease barrels were not able to be sealed. He stated that he would contact the company,[NAME]Industries, to order the locking rings that seal the barrels and lids. He also stated that the trash and debris around the dumpster was not the responsibility of the kitchen staff. On 11/3/2017 at 10:35 a.m., with Environmental Supervisor, stated that he orders a roll-off dumpster monthly to haul off the damaged furniture and equipment stored outside the dietary department. On 11/3/2017 at 11:04 a.m. during an interview with the Assistant Administration, he stated that there was no written policy or process related to the maintenance of the dumpster area. He stated that the Maintenance Department is responsible for the upkeep of the exterior grounds, including trash and debris around the dumpster.",2020-09-01
88,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,425,D,1,1,FY6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility's Dispensing Pharmacy failed to ensure an accurate dosage on the pharmacy medication label for one resident (R#201) that received Ativan liquid injection and failed to ensure that Physician orders [REDACTED]. orders [REDACTED].#137 and R#201). The resident sample was 35. Findings include: 1. Record review for R#137 revealed a physician's orders [REDACTED]. Review of the medication pharmacy label on the plastic bag containing vials of Ativan 2MG/ML, prescribed to R#137 indicated Inject Intramuscularly 1 vial every eight hours. Interview with the Consulting Pharmacist (CP) on 11/3/17 at 1:55 p.m. revealed she does conduct random audits and selects random medication carts. She stated she checks the control sheet for narcotics and ensures that the medication count matches what is on the control sheet. The CP further stated she does check the narcotics in the medication storage refrigerators but only to check for expiration dates and the correct amount of medication. She stated she does not check for the accuracy of the pharmacy label to ensure that it matches the facility's Physician order. Interview on 11/3/17 at 5:00 p.m. with the Dispensing Pharmacist (DP) revealed that narcotic medications orders have to be reordered after six months. He stated the order for Ativan 1 MG injection previously prescribed for R#137 on 3/28/17 could no longer be filled. He stated the pharmacy received an order directly from the physician's office on 10/27/17 for Inject Intramuscularly 1 Vial every 8 hours quantity five and five remaining. The DP stated the facility would have to call for the remaining five vials. The DP stated the prescription does not read PRN (as needed). The DP stated there are several dispensing pharmacist and per the system notes, the pharmacist called the facility and documented that the prescription was reported to LPN KK and two other staff names. The DP stated that no last names were documented in the notes and he is unable to confirm if the actual prescription was faxed to the facility. Interview on 11/3/17 at 6:42 p.m. with Unit Manager LPN KK revealed that the prescription for IM Ativan for R#137 had expired so she called the Physician's office and asked them to send a new prescription. The Nurse at the Physician's office stated that she sent a prescription for IM Ativan directly to the pharmacy. LPN KK stated that the Pharmacy then called to clarify the order and she was telling them not to send multi dose vials and to send the 1ML vials. The Pharmacy asked her to call the physician's office back for a new prescription for a single dose vial. LPN KK called the Physician's office back and they stated that were faxing it to the pharmacy right then. LPN KK stated that she expected the order to be the same exact order for Ativan as he had been on for months and the only thing she wanted to make sure is that they send a single dose 1ML vials. LPN KK stated she did not request the new prescription from the pharmacy because it was a renewal. LPN KK stated they did not tell her that the prescription was a change from the previous prescription and they never faxed her the new prescription. LPN KK stated that the nurse should have compared the pharmacy label to the Medication Administration Record [REDACTED]. 2. Record review for R#201 revealed a physician's orders [REDACTED]. Review of the medication pharmacy label on the plastic bag containing vials of Ativan 2MG/ML, prescribed to R#201 indicated Inject 1 MG (0.25ML) IM every four hours as needed with original date of 8/29/17. Interview on 11/3/17 at 5:30 p.m. with the Dispensing Pharmacist (DP) revealed that the prescription order with an original date o 8/29/17 with the medication label that indicates Lorazepam INJ 2MG/ML, Inject 1MG (0.25ml) is a pharmacy error. The DP stated that the correct dosage for 1MG would be 0.5ML, not 0.25ML. The DP stated that the pharmacy technician receives an order and enters the order into the system. The Pharmacist is responsible for checking all orders for accuracy of dates, names, dosages etc. then the pharmacist checks a box indicating that he reviewed the medication. An electronic signature is captured when this box is checked. The DP stated that this check system is only conducted when an order first comes in, not with each refill. The DP further stated that the receiving Pharmacist called the physician's office and clarified that the order should be for 1MG (0.5ml). The DP stated that he could not find documentation in the system notes or fax documentation that the facility was notified when the prescription was changed from the original order. The Pharmacist stated when the currier delivers medications, the facility nurse will reconcile the medication from the manifest sheet to the medications actually in the tote.",2020-09-01
89,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,431,E,0,1,FY6A11,"Based on observation, record review, review of the policy titled Controlled Substance and staff interviews, the facility failed to ensure that a controlled substance, Lorazepam (Ativan) liquid injection, was accounted for in two of four medication storage refrigerators (West Wing Medication Storage Room and Dogwood/Georgia Medication Storage Room). The resident census was 35. Findings include: Review of the policy titled Controlled Drugs dated (MONTH) 2005 and revised (MONTH) 2011 documented: To ensure that controlled drugs are inventoried and administered as required by State and Federal agencies: Maintain a declining inventory record by resident by drug on all controlled drugs. Reconcile the declining inventory record at the beginning and the end of each shift. Reconciliation is performed by a physical count of the remaining medication by two persons who are legally authorized to administer medications. 1. Observation of the West Wing medication storage room on 11/2/17 at 1:50 p.m. revealed a locked refrigerator that when opened by staff contained commonly used medications and a controlled substance, Lorazepam (Ativan) liquid injectable. Observation with Licensed Practical Nurse (LPN) CC revealed a plastic package with four vials of Ativan. The label read; two milligrams per milliliter (2 MG/ML), Inject 1 MG (0.25 ML) intramuscularly every four hours as needed, prescribed to R#201. Review of the Controlled Substance Accountability Sheet with LPN CC revealed the last dated entry of dispense was 10/31/17 with a remaining quantity of five vials. LPN CC and the Unit Manager, LPN DD looked in the refrigerator and were unable to locate the fifth vial of Ativan. Interview on 11/2/17 at 1:58 p.m. with LPN CC revealed she had not conducted a count of the Ativan in the West Wing medication storage refrigerator because the night shift nurse had to leave early due to an emergency. LPN CC stated that the second night shift nurse, LPN EE told her that they had counted narcotics prior to the nurse leaving early. LPN CC confirmed that she signed the Change of Shift Controlled Substances Count Sheet but that she had only counted the narcotics in her assigned medication cart, but not the narcotics in the medication storage refrigerator. Interview on 11/2/17 at 2:24 p.m. with the Unit Manager, LPN DD revealed that if the night shift nurse left early, it would not negate a narcotic count and that LPN CC should have counted the Ativan in the refrigerator with another nurse at the beginning of her shift. Interview with the Director of Nursing (DON) on 11/2/17 at 3:55 p.m. revealed that after an investigation, it was discovered that on 10/28/17 R#201 was having seizures and LPN CC administered Ativan. The DON stated that LPN CC never signed out the Ativan on the Controlled Substance Accountability Sheet on 10/28/17 and did not record the administration of the Ativan on the Medication Administration Record [REDACTED]. The DON stated that if the nurses had been conducting narcotic counts as they are supposed to each shift, the discrepancy would have been discovered on 10/28/17 during the 3:00 p.m. count. The DON confirmed that the nursing staff had been signing off with their signatures on the Change of Shift Controlled Substances Count Sheet, that narcotic counts had been conducted. Review of the Progress Note dated 10/28/17 created by LPN CC at 2:50 p.m. documented: Writer called to resident bedroom at 1:17 p.m. and observe him having a seizure. Timed activity for a full minute. Ativan adm IM. Resident made comfortable. He seemed to quiet down but started seizing again. Shift Supervisor called to room to observe behavior. (Name) hospice nurse called, order to provide comfort measures or send him to their house facility. Resident finally calmed down after several episodes of seizures. VS 112/64, 66, 18, 97.5 (sic) Further review of the Change of Shift Controlled Substances Count Sheet revealed numerous signed signatures from the Nurse Departing from Duty and the Nurse Arriving on Duty indicating that all narcotics had been accounted for on the following dates and times: 10/28/17 at 3:00 p.m., 11:00 p.m., 10/29/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/30/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 10/31/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m., 11/1/17 at 7:00 a.m., 3:00 p.m., 11:00 p.m. and 11/2/17 at 7:00 a.m. A total of 15 shift narcotic counts were documented by nurses indicating that five vials of Ativan prescribed to R#201 was remaining, after a vial was dispensed without record on 10/28/17, leaving only four vials of Ativan. Interview with the Consulting Pharmacist (CP) on 11/3/17 at 1:55 p.m. revealed she does conduct random audits and selects random medication carts. She stated she checks the control sheet for narcotics and ensures that the medication count matches what is on the control sheet. The CP further stated she does check the narcotics in the medication storage refrigerators but only to check for expiration dates and the correct amount of medication. She stated she does not check for the accuracy of the pharmacy label to ensure that it matches the facility's Physician order. Interview on 11/3/17 at 3:45 p.m. with LPN GG confirmed that her signature was on the Change of Shift Controlled Substances Count Sheet between 10/28/17 and 11/2/17. LPN GG stated she counts the narcotics on the medication cart first, then counts the narcotics in the medication storage refrigerator. LPN GG stated that she cannot recall how many vials of Ativan was in the labeled bag prescribed for R#201. Interview on 11/3/17 at 3:55 p.m. with Registered Nurse (RN) HH revealed her signature is on the Change of Shift Controlled Substances Sheet between 10/28/17 and 11/2/17. RN HH revealed that on 10/28/17 (3:00 p.m. - 11:00 p.m.), she started narcotic count on the medication cart but then she received a new admission, then a call from hospice that needed information on a resident and she just got distracted and never made it to the refrigerator to count the Ativan. RN HH stated she should have conducted a narcotic count in the West Wing medication storage refrigerator and that is the protocol but she was just really busy that day at that particular time. Interview on 11/3/17 at 6:07 p.m. with LPN EE revealed she was working on the nightshift (11:00 p.m. - 7:00 a.m.) on 11/1/17 through 11/2/17. She stated that LPN FF was working that evening with her and had to leave early at 6:30 a.m. She stated that she and LPN FF conducted a count of the med cart narcotics, but they had not counted the narcotics in the West Wing medication storage refrigerator. LPN DD stated that the protocol does include counting the narcotics in the refrigerator and it was just overlooked. 2. Observation of the medication storage refrigerator on 11/2/17 at 3:20 p.m. in the Dogwood/Georgia medication storage room revealed a 20MG/10 ML (20 milligrams per 10 milliliters) vial of Ativan prescribed to R#138. The vial did not have graduation marks but appeared to have a 1/4 of liquid Ativan remaining. Review of the Controlled Substance Accountability Sheet indicated that 0.5 ML had been dispensed 10 times on 8/11/17 at 10:00 a.m. and 6:00 p.m., 9/19/17, 9/20/17, 9/21/17, 10/15/17, 10/16/17, 10/21/17, and 10/22/17 at 10:00 a.m. and 5:00 p.m., with 5 ML quantity remaining. Interview on 11/2/17 at 3:25 p.m. with the Unit Manager, LPN JJ revealed that there is no way to measure how much Ativan liquid remains in the 10 ML vial and stated It looks like 5 ML to me. LPN JJ further stated he's never had any problems in the past with the vials coming up short once all doses had been administered. He stated that he called pharmacy and told them that there was no way they could keep track of the Ativan amounts from the 10 ML multi use vial and they were supposed to fix it. Observation with LPN JJ of an unopened 20MG/10 ML Ativan vial was held next to the opened vial. The unopened vial liquid reached the top of the wrap around label and the opened bottle was clearly less than half of the vial. LPN JJ confirmed that if the resident received ten 0.5 ML doses of the Ativan, there should have been 1/2 the liquid left (5 ML) and that the amount of liquid left was only about 1/4 full. Interview with the DON on 11/2/17 at 3:55 p.m. confirmed that with 20MG/10 ML vials of Ativan, there is no way to accurately measure how much Ativan is in the bottle once opened. She confirmed that according to the Controlled Substance Accountability Sheet, R#138 was administered 0.5 ML of Ativan injection 10 times and that there should be 5 ML remaining in the vial. The DON observed an unopened vial of Ativan liquid injection compared to the opened 10 ML vial prescribed to R#138 and confirmed it did not look like it was 1/2 full. The DON immediately removed the 20MG/10 ML vial of Ativan and instructed the Unit Manager, LPN JJ to write up a report, discard the medication and call pharmacy to have it replaced with 1 ML bottles. Interview on 11/3/17 at 12:40 p.m. with the DON revealed she has no way of knowing how much Ativan was in the 20MG/10 ML prescribed to R#138 so she wanted to have the remaining contents drawn up so she could be sure there was 5 ML of liquid remaining. The DON had a nurse come into the room and draw up the remaining Ativan in the 20MG/10 ml vial. The nurse announced once extracted by syringe that there was only 3 ML of Ativan left in the vial. The DON again confirmed that there should have been 5 ML remaining in the vial and there was no way to account for the missing 2 ML of liquid Ativan.",2020-09-01
90,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,441,C,0,1,FY6A11,"Based on a review of facility records, policy review, and staff interview, the facility failed to maintain an infection control program designed to provide a sanitary environment for its residents for the period beginning (MONTH) (YEAR) to (MONTH) (YEAR). The facility census was 205. Finding include: Review of the undated Infection Prevention Manual revealed the facility's infection prevention program should include: surveillance of infections; investigation of outbreaks; regular review of the policies and procedures of the program with updates in response to changes; staff education related to infection prevention; incorporation of infection prevention into the quality assurance process; and the utilization of an Infection Preventionist to carry out the daily functions of the infection prevention program. Further review of the Infection Prevention Manual revealed the infection prevention program should also include reporting and documentation mechanisms. The Infection Preventionist is expected to monitor line listings of infections and complete monthly report forms which are reported to the Quality Assurance (QA) Committee and other staff for feedback. The infection preventionist is also expected to monitor and document compliance with infection prevention practices. Review of the facility's infection control program documents revealed documentation that the infection control program was maintained, accordingly, for the periods prior to (MONTH) (YEAR) and after (MONTH) (YEAR). However, the infection control program documents for the period (MONTH) (YEAR) through (MONTH) (YEAR) consisted only of line listings of infections maintained on the individual units of the facility, and facility wide CAI/HAI sheets for the months of (MONTH) (YEAR) and (MONTH) (YEAR) with calculated percentages of infections identified in the facility during those months. Interview on 11/2/17 at 2:15 p.m. with Registered Nurse (RN), BB revealed, she assumed the role of infection preventionist for the facility in (MONTH) (YEAR). Any previous records of the program would need to be obtained from the Director of Nursing (DON). 11/02/2017 2:41:41 PM - Interview with the DON revealed she functioned as the person in charge of the infection control program for the facility from (MONTH) through (MONTH) after the previous infection preventionist left. The DON further revealed that the facility's infection control program was not centralized; each of the five wings/units in the facility kept a line listing of infections on that unit for each month; the DON reviewed these listings at the end of the month, calculated the infection percentages, and took the findings to the QA Committee for month in question; she did not, during that time, maintain a centralized infection control program records nor did maintain copies after the findings after they were taken to the QA Committee.",2020-09-01
91,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,463,D,0,1,FY6A11,"Based on observations, resident and staff interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in five rooms (M123, W127, W130, W142, and D214) on three of five units. The facility census was 205 residents. Findings include: Observations on 10/30/17 at 11:27 a.m., during initial tour of resident rooms revealed the following: 1. On the Magnolia Unit, Room 123 bed A, did not have a call light for resident use and the call light casing in the bathroom was loose and partially hanging on wall. 2. On West Unit, Room 127 bed B, Room 130 bed A and Room 142 bed C, the call light was not functioning on initial tour. 3. On Dogwood Unit, Room 214, the call light casing in the bathroom was loose and partially hanging on wall. Interview on 10/30/17 at 12:36 p.m., with the Maintenance Supervisor revealed he had repaired the call lights in rooms M123 bed A bathroom and obtained a functioning call light for 123 bed A; repaired the call lights in W127 bed B, W130 bed A, and W142 bed C; repaired the bathroom call light in D214. He reported that they were now functioning properly.",2020-09-01
92,GLENWOOD HEALTH AND REHABILITATION CENTER,115025,4115 GLENWOOD RD,DECATUR,GA,30032,2017-11-08,514,E,1,1,FY6A11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure that the administration, justification, and effectiveness of PRN (as needed) antianxiety medication ([MEDICATION NAME] injection) was consistently documented on the Medication Administration Record (MAR) for five residents (R#6, R#137, R#138, R#201 and R#228) and vital signs were not recorded weekly, for one resident (#11), from (MONTH) (YEAR) until (MONTH) (YEAR). The resident sample was 35. Findings include: 1. Review of the Controlled Substance Accountability Sheet for R#6 revealed a pharmacy medication label with an original date of 5/23/17 for [MEDICATION NAME] INJ 2MG/ML (2 milligrams per milliliter) [MEDICATION NAME]- Inject 0.5 ML (0.25 ML). Review of the Physician order revealed no orders for [MEDICATION NAME] matching the pharmacy medication label. Review of the MAR revealed no order for [MEDICATION NAME] matching the pharmacy medication label, therefor, there was no documentation or evidence that [MEDICATION NAME] 0.25 ML injection had been administered to R#6. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist confirmed that R#6 does not have an order for [REDACTED]. The DON stated that the nurses should have noticed that there was no order for [MEDICATION NAME] and no order for [MEDICATION NAME] on the MAR. The DON further stated that the nurses should not have administered [MEDICATION NAME] to R#6, they should have notified the nursing supervisor and an order for [REDACTED]. The DON stated that the nurse receiving the telephone order is responsible for faxing the order to the pharmacy and entering the order into the electronic charting system, which in turn generates the order on the MAR. The DON stated she would have to find out who the nurse was that received the order. 2. Record review for R#137 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#137 revealed that [MEDICATION NAME] liquid injection was dispensed on 8/1/17 at 8:00 a.m. and 8:00 p.m., 8/2/17 at 4:00 a.m. and 7:35 p.m., 8/3/17 at 6:00 a.m., 9/23/17 at 5:00 a.m., 9/30/17 at 8:00 p.m., 10/1/17 at 4:30 p.m., 10/2/17 at 2:00 p.m., 10/4/17 at 6:00 a.m. and 7:35 p.m., 10/9/17 at 7:454 p.m., 10/11/17 at 6:00 a.m., 10/13/17 at 1:00 a.m., 10/19/17 at (no time), 10/22/17 at 6:00 p.m., and 10/28/17 at 3:00 a.m., 11:00 a.m., and 1:00 p.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on these dates. 3. Record review for R#138 revealed a Physician's order start date 11/30/16 for [MEDICATION NAME] Solution 2 MG/ML (two milligram per milliliter), Inject 1 MG subcutaneously as needed for unspecified [MEDICAL CONDITION] anxiety, give every six hours PRN (as needed) agitation. Review of the Controlled Substance Accountability Sheet for R#138 revealed 0.5 ML of [MEDICATION NAME] was dispensed on 8/11/17 at 10:00 a.m. and 6:00 p.m., 10/15/17 at 10:00 a.m., 10/16/17 at 2:00 a.m., 10/22/17 at 10:00 a.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] injection was administered on these dates. Interview on 11/3/17 at 1:50 p.m. with the DON and the Consulting Pharmacist confirmed that documentation on the MAR for R#138 was not consistently conducted by the nurses in correlation to the [MEDICATION NAME] dispensed on the Controlled Substance Accountability Sheet. The DON stated that all medications are to be documented on the MAR. 4. Record review for R#201 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#201 indicated that [MEDICATION NAME] liquid injection was dispensed on 9/10/17 at 6:00 p.m., 9/13/17 at 11:00 a.m., 9/14/17 at 2:00 p.m., 9/22/17 at 9:00 a.m. and 2:00 p.m., 9/29/17 at 11:00 p.m., 10/2/17 at 2:00 a.m. and 10/31/17 at 10:00 p.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on these dates. Interview on 11/3/17 at 3:45 p.m. with LPN GG revealed that she personally has never administered [MEDICATION NAME] injection for R#201 but it is expected to not only document on the substance control sheet but to execute it on the MAR at the time given, to select the code for justification and also document in the nurse's notes. 5. Record review for R#228 revealed a Physician order for [REDACTED]. Review of the Controlled Substance Accountability Sheet for R#228 revealed [MEDICATION NAME] liquid injection was dispensed on 8/17/17 at 4:00 a.m. Review of the MAR revealed no documentation or evidence that [MEDICATION NAME] was administered on this date. Interview on 11/3/17 at 6:07 p.m. with LPN EE revealed when she administers a narcotic medication, she is expected fill the out the substance control sheet with the date and time, dosage, number of single vials, wasted mount with another nurse/witness. LPN EE further stated she would document in the nurse progress notes and the MAR. On the MAR she must pick the justifying code for administration and it is supposed to be done right then when the narcotic was given not later. LPN EE stated the computer captures the time of entry and alerts the nurse to document the effectiveness. 6. Review of the facility Policy titled Physician Orders policy, dated (MONTH) 2011, indicated the licensed nurse receiving the order verifies the order to ensure it is complete and that it includes: accurate dosage, accurate frequency and duration as applicable. Further review of the Physician Orders policy indicated a physician's order is required prior to the discontinuation of any current order. R#11 was re-admitted to the facility on [DATE], after a hospitalization for an acute [MEDICAL CONDITION]. The resident had the following [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Record review of the hospital discharge Physician orders, dated 5/4/17, and handwritten orders with the same date signed by Registered Nurse (RN) KK and signed by the Nurse Practitioner (NP), revealed the resident had the following orders for treatment of [REDACTED]. Review of the electronic Physician Orders dated 5/4/17, signed by RN KK, revealed an order for [REDACTED].>[MEDICATION NAME] 0.1 milligrams (mg)-two tablets-three times per day-for three days only although the orders were signed by the NP. Review of the electronic Medication Administration Record (MAR) for May, June, (MONTH) and (MONTH) (YEAR) the resident's vital signs should be taken and recorded weekly. Further review revealed the resident's vital signs were taken although were not recorded in the record. An interview with RN KK and the Director of Nursing on 11/3/17 at 4:42 p.m. revealed that two nurses review the admission orders [REDACTED]. Review of the computer generated Physician's orders dated 5/4/17 are signed only by RN KK. The DON further revealed that this process, of having two nurses confirm the Physician orders, was not in place until after this error was identified by the surveyor. RN KK revealed that she made an entry error for the [MEDICATION NAME] which was not identified until the survey began on 10/18/17. Interview and review of the electronic Medication Administration Record (MAR), supplied by the DON on 11/8/17 at 6:00 p.m., for June, (MONTH) and (MONTH) (YEAR) revealed that the resident's blood pressure should be taken and recorded weekly since 5/4/17. Review of the MAR revealed a check that the blood pressure was taken although there is no evidence of the results for June, (MONTH) and (MONTH) (YEAR). The DON confirmed that staff did not document the resident blood pressure from (MONTH) 8, (YEAR) until the resident became symptomatic in (MONTH) (YEAR).",2020-09-01
93,MILLER NURSING HOME,115039,206 GRACE ST,COLQUITT,GA,39837,2018-06-28,640,E,1,1,KTS211,"> Based on record review and interview the facility failed to transmit resident Minimum Data Assessment (MDS) assessments timely for eight residents (R4, R2, R17, R20, R14, R7, R26 and R10). The facility census was 98. Findings include: Interview on 06/28/18 at 3:29 p.m. with Registered Nurse (RN) AA regarding the Minimum Data Assessments (MDS) revealed that a (MONTH) 10, (YEAR) batch of resident assessments were downloaded but was not uploaded and that it was that the facility's mistake. RN AA revealed that it is the responsibly of the facility to check to make sure that the assessments are uploaded and confirm that the assessments have been received. RN AA revealed that the 5/10/18 file was saved to Downloads, but was never exported, so there was not a receipt alerting her of the batch. Interview on 6/28/18 at 3:30 p.m. with the Director of Nursing (DON) and RN CC revealed that the MDS nurse in the facility is responsible for making sure the download of assessments is complete. The DON inquired with the MDS assessment nurses as to why the assessments were late. At this time, RN CC revealed that the QI data that is reported monthly is generated by reviewing the Resident Assessment Instrument (RAI) MDS schedule and reporting any assessments that haven't been completed by the RAI assessment due date. RN CC revealed that the 5/10/18 batch had been completed and sent to a zip file to be submitted to CMS, which caused the report to drop off the assessment due report however, it was never taken from the zip file and submitted and this caused the assessments to be sent in late. Interview on 6/28/18 at 3:32 p.m. with CC RN MDS revealed she made a file and uploaded the batch to the file and downloaded it to the site but apparently it did not go through. RN MDS CC revealed that when processing MDS assessments we save a zip file in the charting system and from there we must sign into the Quality Improvement and Evaluation System (QIES) submission website and attach the zip file to the state website; however, on 5/10/18, I failed to complete the second step of the process.",2020-09-01
94,MILLER NURSING HOME,115039,206 GRACE ST,COLQUITT,GA,39837,2017-07-13,167,D,0,1,TBPW11,"Based on observation and interview, it was determined that the facility failed to make the most recent survey results readily available to residents. Findings include: During an interview on 7/13/17 at 2 p.m., Resident (R) A stated she was unaware of the survey report. During an interview on 7/13/17 at 2:20 p.m., RB stated the he did not know where the survey results were kept. An observation on 7/13/17 at 2:40 p.m. revealed a sign posted on the large bulletin board, located across from the Unit 1 nurses station. The sign documented that the survey results were posted at the Nurses Station to be viewed at anytime. However, an observation of the nurses station revealed no visible survey results posted at that time. Registered Nurse (RN) AA was unable to locate the survey results. The Director of Nursing (DON) was able to locate the survey results in a folder in the drawer, behind the nurses station. She confirmed that the results were kept behind the nurses station.",2020-09-01
95,MILLER NURSING HOME,115039,206 GRACE ST,COLQUITT,GA,39837,2019-11-07,578,E,0,1,C7SX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, and review of the facility's policy titled, Advance Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED].#55, R#42 and R#117). This deficient practice affected 3 of 7 residents reviewed for Do Not Resuscitate. Findings include: Review of Advance Directives Policy revealed: 2. Prior to or upon admission of a resident, the Social Services Director or designee will inquire of the resident, and/or his/her family members, about the existence of any written advance directives. POLST Additional Guidance for Health Care Professionals III. When a POLST form is signed by an Authorized Person (other than the patient's Health Care Agent) and Attending Physician: I. If Section A indicates Allow Natural Death - Do Not Attempt Resuscitation, this order may be implemented when the patient is a candidate for non-resuscitation as defined in Georgia Code Section 31-39-2(4). A concurring physician signature is Required per Georgia Code Section 31-39-4(c). 1. Review of the medical record for R#55 revealed a POLST with a verbal signature noted for Allow Natural Death with one Physician signature on 9/13/17. There was not any evidence of any documentation that R#55 had a power of attorney for healthcare nor was there a healthcare agent identified. During an interview on 11/5/19 at 4:00 p.m. with the facility's Long-Term Care (LTC) Director revealed that if a resident has a legal next of kin to sign the POLST only one Physician's signature has been gotten and was signed by an authorized person who is not the health care agent. The LTC Director further reported that if there was no legal next of kin two Physician signatures would be needed. The LTC Director reviewed the POLST for R#55 and she confirmed that there was only one Physician signature for R#55. Upon reading the POLST LTC Director acknowledged that a concurring physician's signature was needed when residents do not sign the form and there is not a health care agent. 2. A review of the Quarterly Minimum Data Sets dated 8/20/19 for R#42 revealed that the resident had both long-term and short-term memory problems and was unable to answer the assessment questions. A review of the medical record for R#42 revealed a Physician order [REDACTED]. An interview on 11/6/19 at 10:35 a.m. with the Assistant Director of Nursing confirmed that the resident did not have a healthcare agent and that only one Physician had signed his POLST form. An interview on 11/6/19 at 10:54 a.m. with Social Service CC confirmed that R#42 did not have a healthcare agent on file. Social Service CC brought a POLST in that was signed on 11/6/19 after surveyor inquiry by a second physician. She confirmed that prior to surveyor inquiry that the lack of appropriate signatures for the POLST to be legal had not been identified. 3. A review of the Admission MDS assessment dated [DATE] for R#117 documented both long-term and short-term memory problems with the resident being unable to answer assessment questions. A review of the POLST form dated 4/18/19 for R#117 revealed it was signed by only one Physician, and the responsible party. The resident had no Power of Attorney (POA) or healthcare agent. A review of the Face Sheet identified that R#117 had an Advanced Directive of DNR. An interview on 11/5/19 at 4:06 p.m. with the facility's Long-Term Care (LTC) Director revealed if there was no responsible party or next of kin, we obtain two physician signatures, but if there was a responsible party or a next of kin that they had only been getting one physician signature and the signature of the responsible party. The LTC Director confirmed that based on what was written on the POLST form that there needed to be two concurring Physician signatures if there was no Power of Attorney with a legal healthcare agent. A review of the POLST with the LTC Director for R#117 confirmed that there was the signature of the next of kin and one physician signature and there was no legal healthcare agent for R#117. An interview on 11/6/19 at 11:29 a.m. with the LTC Director again confirmed that R#117 did not have a healthcare agent.",2020-09-01
96,MILLER NURSING HOME,115039,206 GRACE ST,COLQUITT,GA,39837,2019-11-07,584,D,0,1,C7SX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to ensure the resident fans on the vent unit were clean and free from dust build up for four of 15 rooms on Unit Two (Rooms: 20, 19, 22, 14). Findings include: The following observations were made: On 11/4/19 at 12:21 p.m. in room [ROOM NUMBER] there was a fan sitting on the table at the foot of Bed B that had a buildup of dust. On 11/4/19 at 1:13 p.m. in room [ROOM NUMBER] there was a fan at the end of Bed A with dust buildup. On 11/4/19 at 1:16 p.m. in room [ROOM NUMBER] at the end of bed A there was a fan with dust buildup On 11/5/19 at 8:09 a.m. in room [ROOM NUMBER] there was a fan with black dust buildup on the blades. On 11/5/19 at 3:10 p.m. in room [ROOM NUMBER] there was a fan with thick dust buildup. On 11/5/19 at 3:18 p.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/5/19 at 3:20 p.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/6/19 at 9:21 a.m. in room [ROOM NUMBER] there was dust noted on the fan by the sink. On 11/6/19 at 9:22 a.m. in room [ROOM NUMBER] there was dust noted on the fan. On 11/6/19 at 9:23 a.m. in room [ROOM NUMBER] there was dust build up on the fan. On 11/6/19 at 9:24 a.m. in room [ROOM NUMBER] there was dust noted on the fan. During a tour of Unit Two on 11/7/19 at 9:50 a.m. the Director of Nursing (DON) confirmed that in room [ROOM NUMBER] there was dust and buildup on the fan, in room [ROOM NUMBER] there was dust build up on the fan blade and the fan grille, in room [ROOM NUMBER] there was dust build up on the fan grille and, in room [ROOM NUMBER] there was dust build up on the fan and fan grille. During an interview with the DON on 11/7/19 at 9:58 a.m. revealed the Certified Nursing Assistants (CNAs) should clean fans when they are identified as having dust buildup. The DON further revealed that Maintenance should be notified when there is dust on the fan blades. The DON stated that CNAs should be wiping down the fans daily. There is no policy on personal fans and how often they should be cleaned.",2020-09-01
97,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2018-08-23,583,D,1,1,07R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to provide privacy of one resident's (R) body (R#25) during incontinence care and a shower. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); was extensive assistance for personal hygiene and toilet use; and needed physical help in part of bathing activity. On 8/20/18 at 4:13 p.m., Certified Nursing Assistant (CNA) BB was observed performing incontinence care for R#25 with her permission. CNA BB was observed to remove the resident's pants and incontinent brief, had the resident wipe herself with a washcloth, and then the CNA further cleaned the resident's perineal area and buttocks, before placing a clean brief back on her. Further observation revealed that R#25 was in a semi-private room in a bed closest to the window, and the bottom of the window blinds were raised approximately eight inches. Continued observation revealed that her room looked out to the front of the facility, and there was a car parked parallel to the building outside of her window. Further observation revealed that the door to the hallway had never been closed, and the privacy curtain between the two beds in the room had been not been pulled the entire length from wall to wall, leaving an opening of approximately 24 inches. On 8/22/18 at 7:25 a.m., R#25 was observed receiving a shower with her permission in the common shower room on the Mauve Hall by CNAs CC and DD. Continued observation revealed that R#25 pulled up on the grab bar just inside the shower room door, so that the CNA could remove her incontinent brief and pants, and then she sat back down on the shower chair (her shirt was still on). During further observation, another CNA was heard to knock on the shower room door, and CNAs CC and DD responded patient care. Continued observation revealed that this third CNA opened the hallway door into the shower room, and left it open with her head and upper body leaning inside the shower room with R#25 directly ahead, for approximately 15 seconds while she talked to CNAs CC and DD. Continued observation revealed that there was a privacy curtain available between the hallway door and the grab bar where R#25 was seated, but it had not been pulled. During interview with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) on 8/23/18 at 10:34 a.m., they stated that the blinds to a room should be completely lowered when incontinence care was being provided. The ADON stated during further interview that as long as the resident was covered enough from being seen that the privacy curtain did not necessarily have to be pulled the entire way, but that the hallway door should be closed during perineal care. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed to avoid unnecessary exposure of the resident's body.",2020-09-01
98,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2018-08-23,689,D,1,1,07R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to evaluate the risk of leaving one resident (R) (R#25) unattended while sitting on the side of the bed, resulting in a fall from the bed. The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 9 (a BIMS score of 8 to 12 indicates moderate cognitive impairment); she needed extensive assistance of two or more persons for transfers; was not steady, only able to stabilize with staff assistance for surface to surface transfer; had functional limitation in range of motion on one side of upper and lower extremities; and had one fall with no injury since prior MDS assessment. During interview with R#25 on 8/20/18 at 4:24 p.m., she stated that she had a fall today when staff was in the room with her. She further stated that she fell off the side of the bed onto the fall mat, and that the staff tried but were unable to catch her from falling. Observation at this time revealed that R#25 was in a bed lowered to the floor with an alarm, a bed rail up on both sides of the mattress, and she had a brace on her left leg. During interview with R#25 on 8/21/18 at 8:38 a.m., she stated that when she was receiving therapy in her room yesterday, the therapist sat her up on the side of the bed and then turned around, and she fell off the bed. During further interview, R#25 stated that she had left arm, back and right-sided facial pain after this fall. Review of incident reports revealed that R#25 had a fall from the wheelchair during a staff transfer on 11/25/17; unwitnessed falls from bed on 2/1/18, 3/30/18, and 6/26/18; and a fall from the bed during therapy on 8/20/18. During an observation of a transfer by Certified Nursing Assistants (CNA) CC and DD on 8/22/18 at 7:25 a.m., the tops of R#25's knees were both noted to be reddened and have skin tears. During interview with CNA CC at this time, she stated that R#25 had a fall on Monday (8/20/18), and she thought it was from that. R#25's left arm and leg were observed to be paralyzed, and she was not able to use them to assist with the transfer. Continued observation revealed that the CNAs placed a gait belt around R#25's waist after sitting her up on the side of the bed, and when CNA CC turned around to prepare the wheelchair and CNA DD did not have a firm grasp on the gait belt, the resident started to drift backwards on the bed before being caught supported by CNA DD. During interview with Physical Therapist Assistant (PT-A) EE on 8/22/18 at 12:43 p.m., she stated that she had heard that R#25 had a fall recently when a therapist was working with her, and that she was sitting on the side of the bed and was left unattended. During interview with Occupational Therapist-Registered (OT-R) FF on 8/22/18 at 1:03 p.m., she stated that on 8/20/18 she was working with R#25 on transfers, range of motion to her left arm and neck, and postural control. She further stated that she sat the resident up on the side of the bed, and that the resident's sitting balance on the side of the bed was fair. She stated during continued interview that she got up to move R#25's wheelchair closer to her, which was about two feet away, and had to go around the back of the wheelchair to unlock it. She further stated that she saw from her peripheral vision that the resident was falling, but was not able to get around the wheelchair and back to her before she fell . She stated during continued interview that the resident's whole body fell on to the fall mat at one time, as she had no protective reflexes from the stroke, and the only thing she complained of was that her head hurt just a little bit. During interview with the Physical Therapy (PT) Rehab Director on 8/22/18 at 1:16 p.m., he stated that R#25 had been assessed by PT and OT as Mod/3 for bed mobility supine to sitting, which meant one-person assist. He stated during further interview that one-person transfer assist would have been sufficient, but that he would have had the wheelchair positioned closer to R#25 and would have let go of the resident when she was sitting up. Review of an Occupational Therapy Treatment Encounter Note(s) for R#25 dated 8/20/18 revealed: This OT positioned this pt (patient) EOB (edge of bed) with pt demonstrating F- (fair minus) balance utilizing RUE (right upper extremity) to maintain balance, OT went to position w/c (wheelchair) to bed in preparation for t/f (transfer). Pt lost balance to left and fell from bed onto floor mat on floor beside bed.",2020-09-01
99,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2018-08-23,690,D,1,1,07R411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to perform perineal care in a manner to prevent potential urinary tract infections [MEDICAL CONDITION] to the extent possible for one resident (R) (R#25). The sample size was 34 residents. Findings include: Review of R#25's clinical record revealed that she had [MEDICAL CONDITION] (paralysis on one side of the body) following a stroke, urine retention, and a history of UTIs. Review of R#25's Modification of Annual Minimum Data Set ((MDS) dated [DATE] revealed that she was always incontinent of urine, and needed extensive assistance for toilet use. Review of R#25's urine cultures revealed infections with the following organisms: 11/14/17: Proteus mirabilis 3/20/18: Proteus mirabilis 5/10/18: [MEDICATION NAME] raffinosus During an observation of incontinence care with R#25's permission by Certified Nursing Assistant (CNA) BB on 8/20/18 at 4:13 p.m., the CNA was observed to obtain and place several wet washcloths on top of the resident's bed rail before removing her incontinent brief, which had a moderate amount of urine in it. Further observation revealed that the CNA asked R#25 if she wanted to wipe herself and she responded yes, and was given one of the wet washcloths. The resident was observed to wipe her right eye with the washcloth, and the CNA instructed her to wipe between her legs at which time she reached between her legs and wiped herself several times from the rectal area towards the urethra (back to front). Continued observation revealed that the CNA did not stop and instruct her the proper way to wipe. CNA BB was then observed to get another one of the wet washcloths on the bed rail, and cleaned the resident's perineal area properly from the front towards the back, and then turned her to her side and washed her buttocks with another wet washcloth from the bed rail. Further observation revealed that CNA BB did not dry the resident's skin before putting a clean incontinent brief on her. During interview with CNA BB on 8/20/18 at 4:35 p.m., he stated that he usually got a bath basin with water and peri-wash to perform incontinence care, but that R#25 liked to wipe herself, so he just used the wet washcloths. During an observation of a shower with R#25's permission on 8/22/18 at 7:25 a.m., she was observed in the common shower room in a shower chair with a large circular opening in the seat of the chair, and was placed in the shower stall by CNA CC. After washing the rest of her body, CNA CC obtained a clean soapy washcloth and first wiped R#25's inguinal areas, and then used the same washcloth to wipe the perineal and rectal area from underneath the opening in the chair in a circular and back and forth motion, and then rinsed her off. During interview with the Licensed Practical Nurse (LPN) Infection Control Nurse on 8/22/18 at 10:34 a.m., she stated that her expectations were that the staff wipe from the front to the back when doing perineal care, and that a separate section of the washcloth be used for each stroke. She stated during further interview that if a resident was allowed to wipe themselves and was doing it incorrectly, that the staff should educate them on why it was important to go from the front to the back due to the possible increase in urinary tract infection, and if they needed assistance to do so. The LPN Infection Control nurse further stated that a bath basin should be used for perineal care with warm water and soap and plenty of washcloths, and that it was not acceptable to place the washcloths on the bed rail, as there may be microbes on the rail. She further stated that the resident should be dried before a clean brief was applied. During continued interview, she stated that perineal care should be done in the same manner when a resident was in a shower chair and the staff reaching up from the opening in the chair, with a clean washcloth used and the resident cleaned from the front to the back with a different area of the washcloth for each stroke. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed: The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin . Steps in the Procedure: 1. Place the equipment on the bedside stand . 3. Fill the wash basin one-half full of warm water. Place the wash basin on the bedside stand within easy reach. 8. For a female resident: a. Wet washcloth and apply soap or skin cleansing agent. b. Wash perineal area, wiping from front to back. (4) Gently dry perineum.",2020-09-01
100,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2018-08-23,812,F,0,1,07R411,"Based on observation, record review and staff interview, the facility failed to ensure that two foods served from the steam table were held at 135 degrees or higher; that a fan mounted over a drink preparation area was free of dust; and that the amount of sanitizer used in the low temperature dish machine was 50 parts per million (PPM) to prevent potential chemical contamination of food on two of two observations. There were 123 residents that consumed an oral diet. Findings include: 1. During the initial tour of the kitchen on 8/20/18 beginning at 12:00 p.m., a light to moderate build-up of dust was observed on the wall-mounted fan over the drink preparation area. This same observation was made on 8/21/18 at 3:50 p.m. During interview with the Dietary Manager on 8/23/18 at 9:03 a.m., she stated that Maintenance was responsible for cleaning the fans in the kitchen, and that they did so weekly or every other week. She verified during further interview that the wall-mounted fan over the drink preparation area had a light to moderate dust build-up, would contact Maintenance to clean it, and thought they last cleaned it on Friday (six days ago). During interview with Maintenance Technician II on 8/23/18 at 12:36 p.m., he stated that he cleaned the fan over the drink machine today per the Dietary Manager's request, and that he had no documentation of the last time the fan had been cleaned. 2. During observation of the preparation of pureed foods on 8/21/18 at 3:33 p.m., the food processor parts were observed to be washed in the low-temperature dish machine between and after foods prepared, which was connected to a container of sodium hypochlorite sanitizer. Dietary Aide GG was observed to check the chemical concentration of the final rinse water after running the food processor equipment through using a chlorine test strip, and she stated she would interpret the result as 75 (PPM). She stated during further interview that she was trained that the result should not be less than 50 (PPM). On 8/23/18 at 8:56 a.m., the Dietary Manager was observed checking the sanitizer level in the low-temperature dish machine that was currently in use washing resident breakfast dishes. She stated during interview that she would record the chlorine level as 100 (PPM), and stated she thought the level should be 100. She verified during further interview that the Dish Machine Warewashing log specified a concentration of 50 PPM of the chlorine sanitizer, and stated that a level over 50 was OK as it just meant that more sanitizer was coming out. Review of a Dish Machine Warewashing log for (MONTH) (YEAR) revealed that the Chlorine Sanitizer PPM range was listed as 50 PPM, and the results obtained from 8/1/18 through 8/23/18 at noon revealed concentrations between 75 and 100 PPM recorded 65 of 68 times. Review of the facility policy Sanitization revised (MONTH) 2008 revealed: Low-Temperature Dishwasher (Chemical Sanitization): Final rinse with 50 parts per million hypochlorite (chlorine) for at least 10 seconds. Review of the facility policy Dishwashing Machine Use revised (MONTH) 2010 revealed: Dishwashing machine chemical sanitizer concentrations and contact times will be as follows: Chlorine: Minimum Concentration 50-100 ppm. 3. During observation of steam table temperatures taken at supper by Cook HH on 8/21/18 at 5:25 p.m. using the facility's calibrated thermometer, all of the foods were observed to be greater than 135 degrees Fahrenheit (F), except for the meatballs which did not register above 120 degrees F after several checks, and the Prince Edward blend vegetables temperature was 110 degrees F. This was verified during interview with the Dietary Manager at this time, who instructed staff to remove the two foods and place them back in the steamer to reheat. The Dietary Manager further stated that two residents had already received the meatballs. During interview with the Dietary Manager on 8/23/18 at 9:03 a.m., she verified that both the meatballs and the mixed vegetables were below the required holding temperature of 135 degrees at supper on 8/21/18. She further stated that about six residents had already been served the mixed vegetable. She stated during continued interview that food for supper was usually placed on the steam table around 5:00 p.m., and that most of the juices had gone out of the pan by the time the temperatures were checked on 8/21/18. The Dietary Manager further stated that the meatballs were usually held in a smaller pan than they were on 8/21/18. Review of the facility's Food Preparation and Service policy with a revised date of (MONTH) 2014 revealed: Food Preparation, Cooking and Holding Temperatures and Times: 1. The danger zone for food temperatures is between 41 degrees F and 135 degrees F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. 3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF (potentially hazardous foods) must be maintained below 41 degrees F or above 135 degrees F.",2020-09-01
101,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2018-08-23,880,D,0,1,07R411,"Based on observation, record review and staff interview, the facility failed to perform hand hygiene after performing incontinence care for one resident (R) (R#25). The sample size was 34 residents. Findings include: On 8/20/18 at 4:13 p.m., Certified Nursing Assistant (CNA) BB was observed performing perineal care, including the rectal area and buttocks, for R#25 after she had been incontinent of a moderate amount of urine. After the perineal care was completed, the CNA did not remove their gloves, and placed the resident's pants back on, and pulled the bed sheet and quilts back over her. CNA BB was then observed to place the call pad over the resident's abdomen, and used the motorized controls to lower the bed height, then repositioned the pillow under R#25's head before removing their gloves. During interview with the Licensed Practical Nurse (LPN) Infection Control Nurse on 8/22/18 at 10:34 a.m., she stated that staff should remove their gloves and wash their hands immediately after the soiled linen is placed in a bag following perineal care, before they touched the resident or did any other care. Review of the facility's Perineal Care policy revised (MONTH) (YEAR) revealed: 8b. Wash perineal area, wiping from front to back. 9. Discard disposable items into designated containers. 10. Remove gloves and discard into designated container. 11. Wash and dry your hands thoroughly. Review of the facility's Handwashing/Hand Hygiene policy revised (MONTH) (YEAR) revealed: 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents. j. After contact with blood or bodily fluids.",2020-09-01
102,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2017-09-21,431,D,1,1,KNJV11,"> Based on the facility's Storage of Medications policy, observations, staff interviews, and review of manufacturer's instructions the facility failed to ensure medications were: 1) dated appropriately when opened in 1 of 2 medication storage rooms, and 2) removed expired medication and biologicals from use in 1 of 2 medication storage rooms. The facility census at the time of the survey was 122 residents. Findings include: 1. Review of the policy titled Storage of Medications last revised on (MONTH) 2007, revealed in number 4, The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed. a. Failure to Appropriately Date Medications Once Opened. An audit of the Subacute Care (SAC) medication room refrigerator was conducted on 9/20/17 at 11:45 a.m. in the presence of Registered Nurse (RN) Unit Manager (UM). The audit revealed two opened and used multiuse vials of Tuberculin Purified Protein Derivative (PPD) solution (lot number 4). The containers and used vials of PPD solution were not dated when opened. The manufacturer's instructions on the side of the medication container revealed the medication should be discarded 30 days after being opened. During an interview with RN UM on 9/20/17 at 12:16 p.m. RN UM acknowledged the two used vials of PPD solution were not dated when opened. RN UM stated the medication should be dated when opened and the medication was only good for 30 days after being opened. RN UM removed the two opened and undated multiuse vials of PPD solution from use. b. Expired Medication and Biologicals An audit of the Subacute Care medication room cupboards were conducted on 9/20/17 at 11:50 a.m. in the presence of RN UM. The audit revealed: 1. Gericare Vitamin B-6, Dietary Supplement 100 tablets, 100 milligram (mg) unopened with an expiration date of 5/17. 2. Major Geravim liquid (lot number 0710B) 16 ounces unopened with an expiration date of 8/17. 3. Magnesium-oxide 400 mg tablets (lot number 39) 120 tablets unopened with an expiration date 3/31/17. 4. Magnesium-oxide 400 mg tablets (lot number 8042-6006) 60 tablets unopened with an expiration date of 3/31/17. 5. Magnesium-oxide 400 mg tablets (lot number 8042-6010) 60 tablets unopened with an expiration date of 8/31/17. 6. Benadryl 25 mg capsules of 30 capsules unopened with an expiration date of 2/2017. 7. Dextrose 5 in Lactated Ringer's injection (lot number J4N456) 1000 milliliter (ml) x 2 container unopened with an expiration date of 4/17 During an interview with RN UM on 9/20/17 at 12:16 P.M., RN UM acknowledged the expired drugs and intravenous liquids and she removed them from the cabinets. The UM stated she was responsibly to check for expired drugs but the unit was so busy with admissions she did not check. Interview on 9/21/17 at 5:03 p.m. with Assistant Director of Nursing (ADON) revealed the Unit Manager on SAC shoud be checking on all the medications for expiration dates every two weeks. She stated there is no signed sheet for documenting when the checks are done.",2020-09-01
103,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,159,E,0,1,6PVM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident trust fund accounts, and interviews, the facility failed to ensure that acceptable accounting principles were maintained for seven (7) residents (#137, # 31, #24, #35, #97, #75, #74 ) from twenty-five (25) fund accounts managed by the facility. Findings Include: An Interview with the Administrator, Director of Nurses and PP was conducted on [DATE] at 5:15 pm while reviewing the twenty-five (25) resident fund accounts managed by the facility. Discrepancies were identified in the following accounts. 1. Patient liability for Resident #137 was $406.00 in (MONTH) (YEAR). Resident liability was charged in (MONTH) 201.5 at $390.00, (MONTH) (YEAR) $235.00 and (MONTH) (YEAR) at $425.00. On [DATE] the resident was billed again $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 for [DATE] to [DATE]. $375.00 [DATE] to 5 /,[DATE] and [DATE] to [DATE] for $375.00 after liability was previously paid in those months. PP is not aware of why different amounts of liability was charged or why resident was charged twice for the months of January, February, March, April, (MONTH) and (MONTH) of (YEAR). 2. Resident #31's Patient liability for Jan (YEAR) was $1098.00. On [DATE] this resident was charged twice in the amount of $6045.00 for [DATE] to [DATE] room charge and [DATE] to [DATE] room charge. There is no evidence of past due liability. PP believes there was a time when the resident was charged private pay. There is no supporting evidence that the resident or responsible party was made aware of past due amounts or adjustments to the account. 3. Resident #24's patient liability on (MONTH) (YEAR) was $650.00. The residents account was charged on [DATE] $620.00 and $680.00 on [DATE]. PP was not aware of why differences in liability was charged. 4. Patient liability for Resident #35 on (MONTH) (YEAR) was $702.00. Liability was charged on [DATE] for $500.00, [DATE] for $485.00 and [DATE] for $475.00. PP indicated the resident also had other needs paid for and did not always have enough for liability and she did not want to leave him without a balance. 5. Resident #97's liability is $1616.00 in (MONTH) (YEAR). The resident was charged $1646.00, $1633.00 and $1635.00 for July, (MONTH) and (MONTH) of (YEAR). 6. Resident #75's liability was $1535.00 in (MONTH) (YEAR). PP revealed this resident did not always have enough funds to go to the beauty shop so she sometimes charged less liability. ,[DATE] liability was charged for $1530.53. ,[DATE] for $1501.90 and ,[DATE] for $1516.90. 7. PP was not able to determine Resident #74's liability for (YEAR). It was withdrawn as $1271.00 from 2014. After residents death on [DATE] her remaining balance of $59.15 was written as payment to the facility to be applied to her$ 32,718.00 balance due. PP revealed there are many accounts in which they do not receive payments correctly and have a balance upon death that is used towards the balance due. After completion of resident trust fund account review on [DATE] at 6:00 p.m. the Administrator revealed it is her expectation that the resident accounts be managed correctly with appropriate accounting techniques. No facility policy regarding resident trust funds was provided.",2020-09-01
104,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,221,E,0,1,6PVM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and interviews, the facility failed to ensure residents were free from the use of side rails to prevent mobility without assessment and/or physician's order reflecting the medical condition requiring use of side rails for six (6) residents (#39, #52, #122, #144, # 101 and #213) from a sample of fifty (50) residents. Findings include: 1. Observations conducted on 10/5/15 at 4:30 p.m. revealed resident #39 in bed with four (4) one-half (1/2) side rails in the up position. Interview conducted on 10/5/15 at 2:31 p.m. with the Licensed Practical Nurse (LPN) QQ responsible for providing direct care for the resident revealed that bilateral full side rails are used every now and then for safety when the resident tried to climb out of bed. Review of medical record reveals Physicians orders dated 2/1/2015 for side rails 1/2 x 2 aid with bed mobility and define parameters of bed. An order on 8/26/2015 Side rails x 2 to aid in bed mobility and define parameters of the bed. The care plan dated 5/24/2014 indicated the resident has a risk of falls and an intervention in place to assure side rails up x 2. 2. Observation conducted on 10/5/2015 at 1:05 PM and 4:20 p.m. revealed resident # 52 in bed with four (4) one-half (1/2) side rails in the up position. Interview conducted on 10/5/2015 at 2:28 PM with QQ revealed four (4) one-half (1/2) side rails are used to prevent falls because the resident climbs out of bed. The resident is capable of getting in and out of bed and the full rails do prevent her from voluntarily getting out of bed. Review of medical record revealed a Physicians order dated 9/28/2015 with NO side rail orders. Review of the residents most recent care plan did not include a plan of care for restraints or use of side rails. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview Minimum Status (BIMS) score of two (2). 3. Observations conducted on 10/5/15 at 1:40 PM and 10/6/15 at 2:25 PM revealed resident #122 in bed with four (4) 1/2 side rails in the up position. Interview conducted on 10/5/15 at 2:20 PM with LPN RR responsible for the direct care for resident #122 revealed four (4) 1/2 rails or full side rails are used for safety. RR further revealed the resident wiggles and the rails prevent her from falling out of the bed. Review of medical record revealed a physician ' s order for side rails 1/2 x 2 aid with bed mobility and define parameters dated 10/1/2015. Resident is care planned for use of two (2) side rails up to define parameters. 4. Observation conducted on 10/7/15 at 9:18 AM revealed resident #144 in bed with the bed in the lowered position. Three (3) one-half (1/2) rails were observed in the up position. One (1) on the left side and two (2) on the right side of the bed. Further observation revealed the resident had one (1) leg hanging over the right side of the bed between the two (2) raised rails on that side. Review of the medical record revealed resident #144 was re-admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The MDS assessment dated [DATE] assessed the resident with a BIMS of ten (10) and required limited assistance of one-person assist with bed mobility, transfers and locomotion and walking. Section P Coded the resident as not having Physical restraints. History of falls 2-6 months Review of the Care Plan dated 9/12/14 revealed no care plan for the use of restraints or side rails. Review of Physician's orders revealed an order for [REDACTED]. 5. Observation conducted on 10/08/2015 at 6:16 AM revealed resident #101 in bed asleep with two (2) full side rails in up position. Interview conducted on 10/8/15 at 7:18 AM with LPN FF revealed resident #101 has two rails at the head of the bed to help him/her get out of the bed. FF further acknowledged she was not aware of the doctor orders for side rails. Review of medical record revealed physicians orders for two (2) side rails to define parameters for this resident dated 10/7/2015. He was care planned for the use of two (2) side rails to define parameters. 6. On 10/7/2015 at 10:00 AM and interview was conducted with the Director of Nurses (DON) during chart reviews of residents with accidents. On 9/28/2015 at 0030 it was documented resident #213 was found in bedrails. Assisted resident in removing legs from rails. Bruising to Right Lower Extremity noted. Physicians and responsible party notified. This resident ' s admission and interim care plan dated 9/24/2015 revealed resident requires side rails. The updated care plan after 9/28/2015 accident requires and intervention of padded side rails x 2. No new physicians orders for side rails on 9/28. There is no evidence of admission orders [REDACTED]. An observation of resident #213 was made with the DON on 10/7/2015 at 1:30 PM. The resident was in bed with four (4) one-half (1/2) rails in the up position and padded with bed length blue pad on the right and left sides of bed secured with Velcro. Review of the facility policy Use of Physical restraints with the Director of Nurses and Administrator on 10/7/2015 at 4:15 PM reveals [NAME] Residents have the right to be free from any restraint imposed for the purposes of discipline or convenience and not required to treat the resident ' s medical symptoms. 1. Physical restraints are defined as any manual method or physical or mechanical device, material or equipment attached to or adjacent to the resident ' s body that the individual cannot remove easily which restricts freedom of movement or normal access to one ' s body. 2. Full side rails used on both sides of the resident ' s bed are considered restraints and are prohibited unless they are necessary to treat a resident ' s medical symptom or used as an enabler or to assist in mobility and transfer of a resident or by the resident ' s request. D. Before a resident is restrained the resident must have a specific medical symptom that would require the use of restraints and how the use of restraints would treat the cause of the symptom and assist the resident in reaching his or her highest level of physical and psychosocial well-being must be demonstrated. F. Prior to using restraints a systematic process of evaluation and care planning will be followed. 1. The presence of a specific medical symptom that would require a restraint. 2. A pre restraining assessment 3. Use of the least restrictive restraint. 4. Education of the restraint/representative. 6. Physicians written order for the use of [REDACTED]",2020-09-01
105,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,278,D,0,1,6PVM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to accurately assess the dental status of two (2) residents (#24 and #63) and Antianxiety medication use for one (1) resident (#167) from a sample of fifty (50) residents. Findings include: 1. Record review for resident #24 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented in Section L- Dental/Oral Status that the resident had no dental conditions present. Observation conducted on 10/7/15 at 9:35 AM of the dental status for resident #24 revealed no natural upper or lower teeth, the resident was edentulous. Interview conducted on 10/7/15 at 10:24 AM with the LPN/MDS Coordinator OO confirmed the Annual assessment dated [DATE] did not accurately assess the dental status for this resident and it should have identified resident #24 as edentulous. 2. Record review for resident #63 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented in Section L- Dental/Oral Status that no dental conditions were present. Observation conducted on 10/7/15 at 9:30 AM of the dental status for resident #63 revealed no natural upper teeth, missing lower teeth and fragmented lower teeth. Interview conducted on 10/7/15 at 10:28 AM with the LPN/MDS Coordinator OO confirmed the Annual assessment dated [DATE] did not accurately assess the dental status for this resident and it should have identified missing and/or fragmented teeth. 3. Record review for resident #167 revealed a Quarterly MDS assessment dated [DATE] which documented in Section N- Medications that the resident received antianxiety medication zero out of seven (0/7) days prior to the assessment. A review of the physician's orders [REDACTED]. Further record review of the Medication Administration Record [REDACTED].",2020-09-01
106,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,279,E,0,1,6PVM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview,the facility failed to develop a dental care plan for two (2) residents (#44, #138) A urinary incontinence care plan for one resident (# 84) and a [MEDICAL CONDITION] medication care plan for two(2) residents(#167 and #200) from a sample of fifty (50) residents. Findings include: 1. Record review for resident #68 revealed Minimum Data Set (MDS) assessment dated [DATE] which documented in Section L- Oral/Dental status that the resident's natural teeth were chipped. Section V-Care Area Assessment (CAA) triggered Oral/Dental status with the decision to be care planned. Medical record review of resident #68 revealed no evidence a Dental care plan had been developed. Interview conducted on 10/06/2015 at 3:30 pm with the Care Plan Coordinator NN confirmed the annual MDS assessment dated [DATE] triggered Oral/Dental with the decision to be care planned. Further, she confirmed a dental care plan was never developed and that a care plan for dental should have been developed. 2. Record review for resident #138 revealed a MDS assessment dated [DATE] which documented in Section L- Oral/Dental status that the resident's teeth were broken or chipped. Section V-Care Area Assessment (CAA) triggered Oral/dental with the decision to be care planned. A record view of resident #138 care plans revealed no evidence a dental care plan had been developed. Interview conducted on 10/7/2015 at 10:00 am with the Care Plan Coordinator OO confirmed the annual MDS assessment dated [DATE] triggered Oral/Dental with the decision to be care planned. She revealed the resident never asked for a dental exam so she did not developed a plan of care for resident #138 dental needs. 3. Record review for resident #177 revealed an admission MDS dated [DATE] which documented Urinary incontinence with the decision to be care planned. A review of resident #177 care plans revealed no evidence of a plan of care for resident #177 was developed to address urinary incontinence. Interview on 10/8/2015 at 11:00 AM with AA revealed resident #177 was assessed in the monthly nursing summary on 7/20/2015 as occasionally incontinent and started on a toileting program. Interview with NN on 10/8/2015 at 11:15 am indicated she was waiting to see if the toileting program worked for this resident before initiating a care plan for Incontinence. 4. Record review for resident #167 revealed a Quarterly MDS assessment dated [DATE] which documented in Section E- Behaviors that the resident had exhibited behaviors of delusions, hallucinations, verbal symptoms directed at others, other behavioral symptoms not directed at others and wandering. Review of the physician's orders [REDACTED]. Further record review of the Medication Administration Record [REDACTED]. Review of the care plans for resident # 167 revealed no evidence that a care plan was developed to address the use of antipsychotic medication. Interview conducted on 10/8/15 at 11:25 AM with the LPN/MDS Coordinator NN confirmed there was no care plan developed for the use of antipsychotic medication and that one should have been developed as soon as the resident began on the medication. She said the nursing staff is responsible for bringing it to her attention and they must not have told her that the resident began receiving an antipsychotic medication. 5. Record review for resident #200 revealed an Admission MDS assessment dated [DATE] which documented in Section D- Mood the resident exhibited moods of feeling down, depressed or hopeless, feeling tired or having little energy and having trouble concentrating on things. Section N- Medications documented that the resident received antidepressant medication seven (7) out of seven (7) days prior to the assessment. Further record review of the care plans for resident #200 revealed no evidence of a care plan for [MEDICAL CONDITION] drug use. Review of the physician's orders [REDACTED]. Interview conducted on 10/7 15 at 7:50 p.m. with the MDS Coordinator/LPN OO confirmed a care plan for [MEDICAL CONDITION] drug Use was not developed and should have been. She said she would develop one at this time.",2020-09-01
107,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,309,D,0,1,6PVM11,"Based on record review and interview, the facility failed to follow a physician's order to discontinue the use of antianxiety medication for one (1) resident (#167) from a sample of fifty (50) residents. Findings include: A review of the physician's orders for resident #167 revealed documentation on 8/24/15 via Physician Telephone Order Form to discontinue Klonopin 2 mg nightly. Further record review of the Medication Administration Record [REDACTED]. An interview conducted on 10/8/15 at 9:50 a.m. with the Director of Nursing (DON) confirmed the physician order on 8/24/15 to discontinue Klonopin 2 mg nightly and that the medication continued to be administered to the resident through 8/31/15.",2020-09-01
108,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,323,D,0,1,6PVM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview the facility failed maintain a safe environment for one (1) resident (#73) with history of wandering, from a sample of fifty (50) residents. Findings include: Record review of Resident #73 revealed an admitted [DATE] and [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment of this resident indicated a Brief Interview Mental Status (BIMS) of five (5) indicating she is cognitive impaired and in Section [NAME] assessed as a wanderer. A Nurses Summary note dated 10/6/2015 documented that resident #73 wandered into the unlocked laundry room and in attempt to sit on a tricycle slid backward and fell . The fall was witnessed and resident did not received any injury. Interview with Director of Nurses (DON) conducted on 10/7/2015 at 12:20 p.m. revealed there has not been any further investigation of this incident since the resident was not injured. Observations conducted on 10/07/2015 12:30 p.m. ,10/8/2015 at 6:00 a.m. and 7:15 a.m. revealed that the laundry room door was open and unattended. In the laundry room two (2) bottles of bleach visible and easily accessible along with laundry equipment and hangers. Interview with laundry technician II on 10/8/15 at 10:30 a.m. revealed the door to the laundry room was always closed in the past but she was told that it was not necessary to keep it closed. An interview with JJ Housekeeping supervisor on 10/08/2015 at 11:00 a.m. indicated it is her expectation that the laundry room door be locked in order to prevent residents from entering the laundry room. She also indicated that she only been on the job for one (1) week and does not know if this is the practice of the facility. No policy exists that she is aware of. An interview with the Administrator on 10/08/2015 at 8:00 a.m. revealed that her expectation that the laundry room door be locked when unattended. The facility Environmental Services Department Safety policy states cleaning agents shall never be left unattended in areas where patients or other person might come in contact with.",2020-09-01
109,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,329,D,0,1,6PVM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to monitor behavioral symptoms and side effects for one (1) resident (#167) that received and antipsychotic medication from a sample of fifty (5) residents. Findings include: A record review for resident #167 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented in Section E- Behaviors that the resident had exhibited behaviors of delusions, hallucinations, verbal symptoms directed at others, other behavioral symptoms not directed at others and wandering. A review of the physician's order [REDACTED]. A further record review of the Medication Administration Record [REDACTED]. There was no evidence of behavior monitoring or monitoring of medication side effects during the time frame in which the medication was administered. An interview conducted on 10/8/15 at 9:50 AM with the Director of Nursing (DON) CC revealed all antipsychotic medications are to be monitored for side effects and behaviors are to be monitored and documented in the MAR. She confirmed there is no evidence in the MAR from (MONTH) (YEAR) through (MONTH) (YEAR) of side effect of behavior monitoring had been conducted.",2020-09-01
110,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,441,F,0,1,6PVM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to establish and maintain an infection control program to help prevent transmission of disease and infection, failed to practice consistent infection control principles to prevent cross contamination in the laundry facility and failed to label and store personal care equipment in a sanitary manner on four (4) of four (4) halls (Blue, Brown, Green and Mauve). Findings include: 1. A review of the Infection Control Log for (YEAR) revealed listings of identified infections and antibiotic therapy only. There was no evidence of tracking, trending, follow up or infection control related in-services for staff. An interview conducted on 10/8/15 11:30 AM with the Infection Control Nurse AA confirmed there is no evidence of any in-services provided to the staff related to infection control and all she does is documents antibiotics. An interview conducted on 10/8/15 at 12:15 PM with the Infection Control Partner EE revealed she works mainly at the hospital but partners with the facility. The Nursing Home partner AA is responsible for providing in-services to the Nursing Home Staff. She confirmed at this time there is no evidence of in-service sign in sheets related to infection control practices. Further, she said there used to be an Infection Control Book which contained all the infection data, in-services and infection control audits but she does not know what happened to it. 2. An observation conducted of the laundry facility conducted on 10/8/15 at 11:00 AM revealed one very small room with one (1) washer and one (1) dryer. There was no separate entrance of area for soiled clothing. The dirty bin for the incoming soiled clothing was just inside the doorway to the left right next to the clean hanging clothes. The table for separating and folding the clean clothes is approximately three (3) to four (4) away from the dirty linen barrel. (See photo) An interview conducted on 10/8/15 at 11:05 AM with the laundry aide II revealed only the residents personal clothing is washed in this facility. All personal clothing is handles the same. Resident clothing that comes from an isolation room is kept in a yellow barrel in the resident's room but it is transported to laundry in a regular clear bag and washed with all the other clothing. She confirmed, once the clothing leaves the isolation room and enters the laundering room, there is no way to identify that it came from an isolation room. Interview conducted on 10/8/15 at 11:30 AM with the Infection Control nurse (Debbie Oliver/LPN) revealed she does not include the laundry services as part of her infection control monitoring but as the Infection Control Nurse the expected standard of practice for the handling of clothing coming from residents in isolation should be red bagged and washed separately from all other clothing. Interview conducted on 10/8/15 at 11:40 AM with the Director of Environmental Services JJ revealed she just took over this position about one week ago. She confirmed the laundry facility is very small, there is no separate entrance or area for the soiled linen and that the clean clothing is extremely close to the dirty/soiled laundry bin and should not be. 3. During a tour of the facility conducted on 10/5/15, improper storage and labeling of personal care equipment was found in the following bathrooms: Blue Hall: At 12:45 PM in the bathroom of room [ROOM NUMBER] revealed two (2) unlabeled urinals sitting on a hand rail behind the toilet, one (1) unlabeled denture cup on the sink, two (2) unlabeled wash basins stacked inside one another on the floor under the sink area and one (1) bagged but unlabeled bedpan, soiled with feces and a handful of toilet paper soiled with feces, hanging of the handrail to the left side of the toilet, for which two (2) residents share. At 1:05 PM in the bathroom of room of 105 revealed a bagged but unlabeled wash basin hanging on the handrail, for which two (2) residents share. Brown Hall: At 1:40 PM in the bathroom of room [ROOM NUMBER] revealed one (1) unlabeled, un-bagged wash basin in a geri- chair, one (1) unlabeled, un-bagged wash basin on the floor under the sink area and two (2) unlabeled oral basins one with a toothbrush and paste on the sink shelf, for which two (2) residents share. Green Hall: At 2:08 PM in the bathroom of room [ROOM NUMBER] revealed one (1) cup with an unlabeled tooth brush and paste in it and two (2) unlabeled wash basins stacked one inside the other on the bathroom floor, for which two (2) residents share. At 2:10 PM in the bathroom of room [ROOM NUMBER] revealed one (1) unlabeled denture cup sitting on the shelf above the sink and one un-bagged, unlabeled bedpan on the floor for which two (2) residents share. At 2:25 PM in the bathroom of room [ROOM NUMBER] revealed one (1) unlabeled wash basin with personal items in it on the floor and one un-bagged, unlabeled wash basin propped on the hand rail for which two (2) residents share. Mauve Hall: At 2:30 PM in the bathroom of room [ROOM NUMBER] revealed 2 un-bagged and unlabeled bed pans, for which two (2) residents share. At 2:32 PM in the bathroom of room [ROOM NUMBER] revealed 2 unlabeled wash basins with personal items in them on the floor for which two (2) residents share. Interview conducted on 10/8/15 at 3:21 PM with the Director of Nursing (DON) revealed there is no written policy for personal care equipment storage but the expectation and standard of practice is to label and bag all bed pans and urinals and hang them form the railing in the bathrooms. All wash basins are to be labeled and can hold personal items in them and stored in the resident ' s closet. All denture cups should be labeled and can be stores on the shelf above the bathroom sink. At no time should and personal care equipment be on the floor.",2020-09-01
111,"CENTER FOR ADVANCED REHAB AT PARKSIDE, THE",115040,110 PARK CITY ROAD,ROSSVILLE,GA,30741,2015-10-08,500,C,0,1,6PVM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide documentation of a written agreement or contract with two (2) companies (North Georgia [MEDICAL TREATMENT] Center and DCI) providing [MEDICAL TREATMENT] services for two (2) of two (2) residents that received these services (A and #200). The sample size was fifty (50) residents. Findings include: Review of the Entrance Conference Worksheet revealed that two (2) residents received [MEDICAL TREATMENT] services at an outside certified [MEDICAL CONDITION] unit. An interview conducted 10/8/15 at 11:20 AM with the Administrator revealed she was not able to provide evidence of a contract or agreement with either company providing these services and confirmed two (2) residents are receiving [MEDICAL TREATMENT] treatment, one from each company.",2020-09-01
112,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2018-09-20,578,D,1,1,UFSE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of medical records and staff interviews the facility failed to ensure an appropriate code status for one resident (R) (R#59). The sample size was 39 residents. Findings included: Review of the medical record revealed that R#59 was admitted with [DIAGNOSES REDACTED]. BIMS was 01 which indicated severe cognitive impairment. Review of history and physical revealed R#59 had mental [MEDICAL CONDITION], health care power of attorney (POA) revealed R#59 had the mind of an eight to nine years old. Further review revealed resident's care, and interaction with her, was difficult, and she refused care due to history of mental [MEDICAL CONDITION]. Preadmission Screening Resident Review (PASRR) level two revealed mental [MEDICAL CONDITION]. Review of the medical record revealed a form in the Advanced Directive (AD) section of the physical chart titled Five wishes. No other AD documentation was in the chart. Review of advanced directive checklist (ADC) revealed Do Not Resuscitate (DNR); Do Not Intubate (DNI). Review of the form Five Wishes revealed wishes for: 1. The person I want to make care decisions for me when I can't. 2. The kind of medical treatment I want or don't want. 3. How comfortable I want to be 4. How I want people to treat me 5. What I want my loved ones to know. The Five wishes form revealed Do Not Resuscitate (DNR) had been written on the first page, it had no name or date. On page six of the section titled What Life Support Treatment means to me, revealed it previously had I would want her to be resuscitated but not on life support. It had been scratched through and someone had written DNR but had no name or date. Review of Plan of Care initiated 11/18/16 revealed focus: Resident chooses to have death with dignity, advanced directive established. Individual wishes include DNR status. Review of a Social Services Progress note dated (MONTH) 26, (YEAR) revealed Advanced directive reviewed and she remains a DNR. Interview on 9/18/18 at 1:36 p. m. with the Social Services Director (SSD) revealed she had been working on the AD but was not able to provide additional AD information at this time, she would check into it further and get back with me. Interview on 9/19/18 at 12:46 p. m. with the SSD revealed a Physician order [REDACTED]. It was signed by the resident representative and the physician. The POLST was dated 9/19/18, after the missing AD was brought to the facility's attention by the surveyor. Review of Physician order [REDACTED]. Interview on 9/20/18 at 10:49 a. m. with the Administrator revealed he was aware of the Five Wishes form and did not feel it was an acceptable or legally binding Advanced Directive (AD). He felt it was a form that the prior owners used and accepted. He revealed they presently accept the Physician order [REDACTED]. Interview on 9/20/18 at 4:18 p. m. with Unit Three LPN BB revealed if he needed to know the code status of a resident he pulled the physical chart and looked under the advanced directive section. He wanted to see something on paper, he didn't look in the computer, electronic record. Follow up interview on 9/20/18 at 4:00 PM with the SSD revealed she had only been here since (MONTH) (YEAR) and had been going through all the charts to make sure all residents had acceptable Advanced Directives (AD). She had checked with medical records to see if any additional or relevant information from the admission paperwork in (YEAR), might reveal additional AD information. (The chart had been thinned a couple times.) R#59 had been listed Full code going back to (YEAR) with only the Five Wishes form filed on the chart. The chart had been thinned and the records had been stored at an offsite location therefore no additional information was available. The SSD revealed her experience with Five Wishes form, she did not feel it was an acceptable Advanced Directive or legally binding.",2020-09-01
113,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2018-09-20,656,D,1,1,UFSE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review and staff interview the facility failed to develop a person centered care plan for one dependent resident (R) #53 related to grooming: nail care. The sample size was 39. Findings include: Review of the facility policy titled Comprehensive Care Plan, revised (MONTH) (YEAR), indicated the facility will develop a comprehensive person-centered care (plan that identifies each residents medical, nursing, mental and psychosocial needs with seven days after completion of the comprehensive assessment. The care plan is developed with the resident or the resident's representative and reflects the resident's goals, wishes and preferences. The plan includes measurable objectives and timetables agreed to by t he resident to meet such objectives. The purpose is to provide effective and person-centered care for each resident. The minimum requirements of the comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. A review of the clinical record for R#53 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section G revealed that the resident was assessed for extensive assist for bed mobility, transfers, locomotion on/off the unit, dressing, toilet use and personal hygiene. Observation on 9/18/18 at 12:56 p.m., 9/19/18 at 12:18 p.m., 9/19/18 at 3:20 p.m. and 9/20/18 at 9:00 a.m., revealed that the resident's fingernails, on both hands, have dark brown material underneath and are untrimmed. Review of updated care plan for the resident, dated 8/1/18, revealed no evidence that R#53 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Interview on 9/20/18 at 9:30 a.m., with Certified Nursing Assistant (CNA) DD stated that ADL care consists of getting residents up, bathing/showering, feeding, dressing, grooming, including hair, oral care, brushing teeth/dentures, and shaving and making bed. She stated that nail care is done on Sundays during the day shift. She stated that nailcare can be done at any time when it is needed, but primarily nails are trimmed and cleaned on Sundays. Interview and observation on 9/20/18 at 10:16 a.m., with Director of Nursing (DON) verified that R#53 nails had dark brown material underneath them and they were untrimmed. She stated that it is her expectation that the CNA staff observe the residents nails when they are providing care. If nails need to be cleaned and/or trimmed, she expects the CNA staff to take care of it, not pass it on to the next staff member. She further stated that anyone can do nail care, and when it is recognized, it should be taken care Interview on 9/20/18 at 10:26 a.m., with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) FF stated that she gathers information for the assessments from staff interviews, medical records and observations of client. She verified that R#53 MDS CAA's triggered for ADL function. She stated that she did not do the assessment and she cannot give a reason why the resident did not have a care plan for ADL care. She She further stated that she would have care planned for ADL care because of the information that staff enter into the kiosk. Cross refer to F677",2020-09-01
114,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2018-09-20,677,D,1,1,UFSE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent resident (R) R#53 related to nail care. The sample size was 39. Findings include: A review of the clinical record for R#53 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section G revealed that the resident was assessed for extensive assist for bed mobility, transfers, locomotion on/off the unit, dressing, toilet use and personal hygiene. Review of updated care plan for R#53, dated 8/1/18, did not have evidence of a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 9/18/18 at 12:56 p.m., 9/19/18 at 12:18 p.m., 9/19/18 at 3:20 p.m. and 9/20/18 at 9:00 a.m., revealed that fingernails on both hands have dark brown material underneath and are untrimmed. Interview on 9/20/18 at 9:30 a.m., with Certified Nursing Assistant (CNA) DD stated that ADL care consists of getting residents up, bathing/showering, feeding, dressing, grooming, including hair, oral care, brushing teeth/dentures, and shaving and making bed. She stated that nail care is done on Sundays during the day shift. She stated that nailcare can be done at any time when it is needed, but primarily nails are trimmed and cleaned on Sundays. Interview on 9/20/18 at 10:16 a.m., with Director of Nursing (DON) verified that R#53 nails had dark brown material underneath them and they were untrimmed. She stated that it is her expectation that the CNA staff observe the residents nails when they are providing care. If nails need to be cleaned and/or trimmed, she expects the CNA staff to take care of it, not pass it on to the next staff member. She further stated that anyone can do nail care, and when it is recognized, it should be taken care.",2020-09-01
115,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2018-09-20,758,D,1,1,UFSE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews and review of Resident # 36's medical record, the facility failed to ensure that an anti-anxiety medication was not administered past 14 days, as needed (PRN) without a rationale and without an end date, for one resident (R#36). The sample size was 39 residents. Findings include: Review of R#36's medical clinical record revealed [DIAGNOSES REDACTED]. R#33 had a Brief Interview of Mental Status (BIMS) of 03 indicating severe cognitive impairment. Minimum Data Set (MDS) and Plan of Care (P[NAME]) revealed she had behavior problems. R#36 exhibited behaviors toward staff, hitting during care, shouting, kicking at staff, being verbally abusive to staff, pulling at tablecloth in dining room and pulling at other resident's food. Review of Physician order [REDACTED]. Review further revealed the initial order date was 7/14/17. Review of the clinical record revealed the consultant pharmacist made recommendations to the physician in April, May, July, and (MONTH) (YEAR): [MEDICATION NAME] had been ordered as needed (PRN) and had been ordered longer than 14 days without a rationale or stop date. Recommendation on 4/19/18: [MEDICATION NAME] 1 mg Q4h PRN, need rationale in medical record and indicate duration. Physician response to recommendation dated 7/13/18 was Will investigate. It was signed and dated on 8/20/18 but he did not make any change in the order and did not include a rationale or stop date. Response to the consultant pharmacist recommendation to physician dated 8/24/18, the physician response was Nurses report she still needs it. He signed and dated 9/4/18 but made no change to order and did not include a rationale or stop date for the medication. Review of the MAR for July, August, and (MONTH) (YEAR) revealed R#36 had been on [MEDICATION NAME] ([MEDICATION NAME]) PRN since (MONTH) 14, (YEAR). Further review revealed R#33 received [MEDICATION NAME] eight times in July, 12 times in August, and five times in September, thru 9/19/18. Interview on 9/20/18 at 4:50 p. m. with Registered nurse (RN) Unit Manager AA confirmed the order for [MEDICATION NAME] ([MEDICATION NAME]) 1mg by mouth every 4 hours as needed for agitation, the order was active and dated back to 7/14/17. Interview further verified the physician wrote will investigate on the Consultant Pharmacist Recommendation to Physician dated 7/13/18, signed and dated it on 8/20/18 but did not make any change in the order and did not include a rationale or stop date. Further verification with the RN Unit Manager revealed in the medical record on the Consultant Pharmacist Recommendation to Physician dated 8/24/18, the physician wrote Nurses report she still needs it, signed and dated 9/4/18 but made no change to order and did not include a rationale or stop date for the medication. Interview on 9/20/18 at 5:00 p. m. with the Director of Nursing (DON) revealed she was aware of the 14 day rule for PRN medications. She further verified R#36 had been ordered [MEDICATION NAME] ([MEDICATION NAME]), had been on it since 7/14/17 and it continued to be active. Interview also verified the Consultant Pharmacist Recommendation to Physician dated 7/13/18 and 8/24/18 regarding State & Federal guidelines for use of [MEDICATION NAME], limited to 14 days or provide a rationale in the medical record and indicate the duration for the PRN order, and the physician made no changes. Interview with the DON further revealed her expectation that the facility follows the regulation, and the medical director follows the regulation when writing medication orders. She was not able to provide me a policy.",2020-09-01
116,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,159,D,0,1,8OVO11,"Based on record review and staff interview, the facility failed to ensure four of four sampled residents' (R) (#17, #31, #76, #87) trust fund accounts remained under the $2,000 limit to maintain eligibility for Medicaid services. The facility handled a total of 65 resident accounts. Findings include: During interview with the Business Office Manager (BOM) on 10/26/17 at 8:51 a.m., she stated that if a Medicaid resident's trust account approached the eligibility limit, the facility sent out what she called a $200 letter to the family at the first of each month. Review of an example of this letter entitled Resident Fund Balance Notification revealed that the recipient was notified that their current resident fund balance was within $200 or exceeding what was allowable under Medical Assistance, and to contact the Social Worker within the next seven days to discuss ways to assure continuance of Medicaid benefits. During continued interview, she stated that she kept no documentation of when or who she sent these letters out to, nor any additional attempts to reach the responsible party (RP) if they did not respond to the letter. The BOM further stated that she was not afraid that the residents may lose their Medicaid eligibility if their balances were consistently over the $2,000 limit. During continued interview, she stated that if the RP did not respond to the $200 letter, that in weekly staff meetings they discussed ways to spend the residents' money down. Review of the following Medicaid residents' quarterly trust fund Resident Statement Landscape reports for one year revealed the following: 1. R #17: The account balance exceeded $2,000 since 11/1/16, with a balance of $2,570.65 as of 10/3/17. On 10/26/17 at 8:51 a.m., the BOM stated that the daughter had bought some clothing for the resident, but did not spend the account down enough to bring it below $2,000. 2. R #31: The account balance exceeded $2,000 from 5/3/17 through 7/13/17, and funds placed in a burial account on 7/25/17 to lower the balance. However, on 9/1/17 the balance again exceeded $2,000, with a balance of $3,356.56 on 10/12/17. During interview with the BOM on 10/26/17 at 5:49 p.m., she stated that the facility was the rep (representative) payee for this resident, which meant they did not have to ask the family to spend his money down. She further stated that the resident had received a large Social Security check of $4,341.00 on 3/3/17 and that he was in the hospital and on Medicare Part A in (MONTH) and July, and that they did not deduct the care cost liability during that time. She verified that his account balance had exceeded $2,000 since 9/1/17, and that they needed to transfer some of this money to a burial account. 3. R #76: The account balance as of 10/12/17 was $4,077.25, and had exceeded $2,000 since 6/12/17. During interview with the BOM on 10/26/17 at 5:49 p.m., she stated that he was in the hospital on Medicare Part A in (MONTH) and July, and his care cost was not deducted from his account. She verified that his balance exceeded $2,000 since 6/12/17, and nothing had been done to spend his account down. 4. R #87: The account balance had exceeded $2,000 since 3/31/17, with a balance of $3,400.02 on 10/11/17. During interview with the BOM on 10/26/17 at 8:51 a.m., she stated that she had sent a $200 letter to a family member of a resident, but had not heard back from him and had no documentation of any attempts she made to contact him. During interview with the BOM on 10/26/17 at 5:49 p.m., she stated that R #87 was able to make her needs known, and so the facility staff could ask her how she wanted to spend the money down. During telephone interview with a facility's corporate financial staff KK on 10/26/17 at 9:14 a.m., she stated that when a resident's trust fund account approached or exceeded the limit, they talked to the family to see how they wanted to spend down the account, such as setting up a burial account. She further stated that a letter was sent out to the families at the end of the month to notify them of the excessive account balance, and if there was no response the facility Social Worker would be asked to see if the resident needed something like clothing. She further stated that if the facility was the rep payee for the resident, that they would set up a burial account before the end of the month when the balance first exceeded $2,000. During further interview, she stated that the facility should be keeping a copy of the $200 letter they send out to the families, and they could document notes on the bottom of this letter of what else may have been attempted to spend the account down. During interview with the Administrator on 10/26/17 at 5:25 p.m., she stated the facility's process was to notify the resident and family when the resident's trust account approached $2,000, to see how they wanted to spend the account down. During further interview, she verified that the account balances for residents #17, #31, #76, and #87 exceeded the eligibility limit, and that she was worried that these residents could lose their Medicaid benefits. The Administrator further stated that their corporate financial consultant told her there could be some charges that had not come out of these residents' accounts yet.",2020-09-01
117,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,226,D,0,1,8OVO11,"The facility failed to obtain a criminal background check prior to hire for one of nine employees and failed to obtain reference checks for two of nine employees. Findings include: During an interview with Administrator on 10/26/17 at 10:30 p.m., stated she is the person responsible for checking references for new employees. She does not know how she missed an employee without references returned. She further stated that the therapy staff were contracted employees prior to changing ownership. All the personnel files are kept with the contract company, and therefore not in the employee file on site. She further stated that Corporate Office employed the Director of Nursing, and she was not accustomed to checking behind the Corporate Office hires. 1. Review of employee files on 10/26/17 revealed that Director of Nursing (DON) began employment with the facility on 4/3/17 without the return of reference checks. 2. Review of employee files on 10/26/17 revealed that Certified Nursing Assistant (CNA) FF began employment with the facility on 9/25/17 without the return of reference checks. 3. Review of employee files on 10/26/17 revealed that Physical Therapy Assistant (PTA) GG began employment with the facility on 6/5/17 without return of criminal background check until 8/8/17.",2020-09-01
118,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,247,D,0,1,8OVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to notify two residents (R) W and X that they would be receiving a new roommate. The sample size was 46 residents. Findings include: During interview with R W on 10/23/17 at 3:39 p.m., she stated that she had gotten a new roommate the previous week, but staff didn't tell her she would be getting a new roommate. Further interview, revealed that she had been out of her room, and when she returned to her room the new roommate was there. Review of R W's Brief Interview for Mental Status (BIMS) on her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a score of 14 (a score of 13-15 indicates a resident is cognitively intact). Review of her electronic interdisciplinary Progress Notes for three months revealed there was no mention that she was notified she would be getting a new roommate. During interview with R X on 10/24/17 at 10:04 a.m., revealed that she recently got a new roommate, but was not notified by staff. During further interview, she stated they just brought the new roommate in the room and there was no introduction, and felt that it was not a very nice thing to do. Review of R X's Quarterly MDS dated [DATE] revealed a BIMS score of 13. Review of her electronic interdisciplinary Progress Notes for three months revealed there was no mention that she was notified she would be getting a new roommate. Observation at this time revealed that residents W and X were both in the same four-bed room. During interview with the Administrator on 10/24/17 at 5:47 p.m., she stated that if there was a room-to-room transfer of an existing resident, the Social Services Director (SSD) notified the families and existing residents in the room, and documented this in the electronic medical record. During interview with the SSD on 10/25/17 at 3:23 p.m., she stated that when a resident was being moved to a different room, she would tell the resident(s) in that room to see if they wanted to meet the new roommate transferring to their room, do a meet and greet, and document this on a Notification of Room Change form. She further stated that she put a Social Services note in the interdisciplinary Progress Notes for both the resident that was getting a new roommate, as well as the resident being transferred to that room. The SSD further stated that a resident was transferred from a room on Unit 1 to R W and X's room on Unit 2 on 10/19/17, and verified that she did not put a note in the computer about it. During continued interview, she stated that she verbally told R W and R X, and they just asked who the new roommate was and when they were coming, but they did not say they wanted to meet her. Review of the facilty's Room & Roommate Assignment policy with a revision date of (MONTH) (YEAR) included: The facility will promptly notify the residents and the residents' representatives or interested family members (if known) when there is a change in room or roommate assignment. The notice of a change in roommate assignment must be made in writing, and documented in the Progress Notes section of the resident's electronic health record.",2020-09-01
119,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,253,E,0,1,8OVO11,"Based on observation and staff interview, the facility failed to ensure a clean and comfortable environment in 18 rooms on three of three nursing units as evidenced by patched but unpainted walls; cracked or broken flooring; dusty vent; stained walls and privacy curtain; improperly disposed incontinent briefs resulting in odors; and dirty light fixture. The facility census was 85 residents, and the sample size was 46. Findings include: During observations in resident rooms and bathrooms on Unit 2, the following environmental concerns were noted: Room 29 on 10/23/17 at 1:54 and 2:12 p.m.: The privacy curtain was unable to be pulled all the way across the A-bed as it was jammed in the ceiling track. There were several vertical scrapes on the wall behind and to the left side of the head of the A-bed that had been patched at one time, but not painted. Observation in the bathroom revealed that the vinyl flooring had been installed so that it came up approximately four inches on all four walls, and the flooring to the left of the commode had split where the wall met the floor, approximately two-thirds of the length of this wall. There was a long, thin, red streak below a wall vent located near the ceiling above the closet, and this vent had a moderate amount of dust on it. The laminate on one corner of D-bed's over bed table was missing, exposing the rough particle board underneath. [RM #] on 10/23/17 at 2:47 p.m.: There was an approximate two-inch vertical and a small circular brown stain on the privacy curtain for the B-bed. One corner of a floor tile close to the sink was broken off. A plastic bag was observed in the bathroom with what appeared to be a soiled incontinent brief tied to the grab bar next to the commode. There was an unpleasant odor in the bathroom, and one sock and a pair of pants were observed directly on the floor. Further observations in this bathroom on 10/24/17 at 10:33 a.m. revealed that the clothing was off the floor, but there was still a plastic bag with soiled incontinent briefs in it tied to the grab bar, and there was a urine odor in the bathroom. Room 28 on 10/24/17 at 10:27 a.m.: The flooring in the bathroom had long, vertical cracks where the floor surface was brought up along the wall on two of four sides. Room 16 on 10/23/17 at 2:41 p.m.: There were numerous black objects with the appearance of dead insects in the ceiling light fixture cover in the bathroom. Observation 10/25/2017 11:00 a.m. of facility environment. Room -14 bathroom base of wall on the left of the toilet has a hole 4 inches long and one and one half inches wide. Room - 8 bathroom wall behind commode has an area 12 inches wide and long of peeling paint. Baseboard where wall and floor meets is cracked open on three of four walls. Room - 12 bathroom overhead light fixture has several dead insects in it. Room-20 bathroom baseboard where floor and wall meet is cracked open on two of four walls. Room-21 bathroom baseboard cracked open on two of four walls. Room-23 inside resident's room underneath window are three feet long has scuffed peeling paint. Room-25 wall behind commode has area ten inches wide that had been patched over but not painted. Room -28 bathroom base board where floor meets wall cracked open on all four walls, dead insects noted in overhead light fixture. Room-42 overhead ceiling tiles with in resident's room around light fixture are cracked, bathroom flooring cracked at baseboard where flooring meets the wall. An interview 10/26/17 7:00 p.m. while rounding with Maintenance Director (MD) and Housekeeping supervisor, in rooms 8,12,14,20,21,23,25,28,29,30,36,39,41,42, revealed the issues found by this surveyor on environmental rounds, and other surveyors during initial tour. The MD revealed that he is aware of the flooring issues in the bathrooms that he has spoken with the Administrator about how they need to be repaired. Further interview with the MD, at this time, revealed that the facility had begun some general repairs throughout the facility although the repairs aren't completed as of yet. An interview 10/26/17 7:55 p.m. with the Administrator regarding the environmental issues found. Administrator stated that Cooperate has been informed of the bathroom flooring issues but they have not yet addressed the issue. During initial tour of the facility on 10/10/17 at 10:36 a.m., revealed the following cleanliness concerns: 1. Room 41 wall leading into bathroom was patched, but not painted. 2. Room 43 vinyl baseboard in bathroom was cracked and peeling away from the wall. 3. Room 39 bathroom light had dark debris in the globe and grab bar in bathroom was loose. 4. Room 40 wall in bathroom had patched sheet rock, but unpainted. Also, vinyl baseboard in bathroom was cracked and peeling away from wall. 5. Room 32 grab bar in the bathroom was loose and detached from bracket attached to wall. The losse grab bar was verified with Maintenance Supervisor on 10/23/17 at 12:38 p.m.",2020-09-01
120,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,278,D,0,1,8OVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the Resident Assessment Instrument Manual. The facility failed to properly assess and code the Minimal Data Set (MDS) for two (2) resident (R) #20 and R#82 for dental status, and one (1) resident R#75 for preadmission screening and resident review (PASARR) level two was not properly coded on assessment per Resident Assessment Instrument (RAI) guidelines. The resident sample was 46. Findings include: 1. Review of annual Minimum Data Set ((MDS) dated [DATE], for resident (R) #20, section C- cognitive patterns resident has a BIMS score of 2, the resident was unable to complete the interview. Further review of section L- oral/dental status revealed the resident's dental status is coded as the resident does not exhibit any obvious or likely cavity or broken natural teeth. Review of section V- Care Area Assistance (CAA) the resident's care area for dental status did not trigger for dental care. On 10/24/2017 at 2:17 p.m. the resident was observed sitting in his Brodie chair while in his room watching television, alert and pleasant when spoken to, the resident is noted to have missing or broken teeth. On 10/26/2017 8:48 a.m. the resident was observed sitting in his Brodie chair eating breakfast while in his room, the resident is very, pleasant responds when spoken too. No issues noted while eating, the resident is noted to have missing or broken teeth. Interview on 10/26/2017 at 6:13 p.m. with MDS Coordinator AA revealed the Point Click Care automated system automatically transfers information from the kiosk system into the MDS. The MDS coordinator AA stated if there is an issue or concern with the resident; the MDS coordinators will go into the MDS system and modify incorrect coding's, and enter a note in the progress notes. The MDS Coordinator confirmed at this time, that they are only doing paper reviews. During the interview, MDS coordinator BB, confirmed a correction should have been made to R 20s annual MDS dated [DATE] to reflect the correct coding of the resident's dental status. 2. Review of resident (R) #82's Admission Minimum Data Set ((MDS) dated [DATE] revealed that she had no oral or dental issues, and Dental Care did not trigger on the Care Area Assessment Summary. Review of her care plans revealed that one had not been developed for dental. Review of a Nursing Admission Data Collection assessment dated [DATE] revealed no natural teeth (edentulous), and no dentures. Review of a Nutrition Data Collection form dated 1/16/17 noted R #82 had her own teeth, with missing teeth and/or teeth in poor condition. Review of the facility's contracted mobile dentistry service's Dental Screening for R #82 dated 1/24/17 noted the resident had obvious or likely cavity or broken natural teeth, and inflamed or bleeding gums or loose natural teeth with no appliances. Dentition upper and lower with several missing teeth, broken teeth, and visible decay. Red, inflamed soft tissue, and the oral hygiene section noted heavy calculus/plaque/food debris. Observation of R#82's mouth on 10/23/17 at 2:21 p.m. revealed that she had several missing teeth. During interview with Registered Nurse MDS staff BB and Licensed Practical Nurse MDS staff AA on 10/26/17 at 2:05 p.m., revealed that the staff provide the information for the oral/dental section of the MDS and by talking to the staff and resident, and by looking in the resident's mouth. During interview with Licensed Practical Nurse MDS staff AA, at this time, she verified that R #82 was coded as having no dental issues on the 1/20/17 Admission MDS. She further stated that the 1/24/17 dental exam report may not have been available when they coded the dental section of R #82's Admission MDS, but they should have been able to observe the resident's missing and broken teeth themselves. 3. Record review of R#75's annual Minimal Data Set (MDS) assessment with reference date of 01/27/17 revealed preadmission screening and resident review (PASARR) level two was not coded on assessment per Resident Assessment Instrument (RAI) guidelines. Record review reveals R#75 was admitted to facility 03/20/15 with a PASARR level two due to [DIAGNOSES REDACTED]. Interview 10/24/17 4:45 p.m. Medical Social Worker (MSW) in regards to R#75 and PASARR level two MSW stated that resident did come with PASARR level two. Prior to resident's admission to facility resident's cousin stopped all psychiatric services. MSW further stated that resident is still considered PASARR level two. Interview 10/26/2017 6:46 p.m. with MDS staff Licensed Practical Nurse (LPN) AA regarding coding of the PASARR level two on assessments. MDS staff LPN AA revealed that R #75 was no longer PASSAR level two resident. MDS staff LPN stated a modification of the MDS will be done. Interview with DON. 10/26/17 7:05 p.m. stated that she expects the MDS staff to follow RAI guidelines when coding the MDS.",2020-09-01
121,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,279,D,0,1,8OVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of Resident Assessment Instrument (RAI) guidelines. Facility failed to provide a [MEDICAL CONDITION] care plan for one resident (R# 40) out of 46 sampled residents. Findings include: Record review of R #40 revealed resident takes [MEDICATION NAME] 0.25mg every morning and [MEDICATION NAME] 0.5 mg at bedtime for a [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) with assessment reference date 08/15/17 showed a care area assessment summary (CAAS) which triggered for [MEDICAL CONDITION] drug use and will be addressed in care plan. Further record review for R#40 revealed there was no care plan for [MEDICAL CONDITION] medication use. Interview 10/26/2017 6:46 p.m. with MDS staff Licensed Practical Nurse AA confirmed the resident was not care planned for [MEDICAL CONDITION] medications, although the resident should have been care planned. Interview 10/26/2017 7:05 p.m. with Director of Nursing (DON) she stated that she expects the MDS Coordinator to follow the RAI guidelines.",2020-09-01
122,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,280,D,0,1,8OVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to ensure one resident (R) W was notified of her care plan meeting dates, times, and location so that she could attend. The sample size was 46 residents. Findings include: During interview with R W on 10/23/17 at 3:26 p.m., she stated that she had been invited to attend her care plan meetings in the past and told the staff that she would like to go, but that nobody ever came to get her on the day of the meeting, and she didn't know where to go. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status score of 14, indicating that she was cognitively intact. During interview with the Social Services Director (SSD) on 10/25/17 at 3:23 p.m., she stated that she either called the families to set up a care plan meeting, or mailed the invitation if she was not able to reach them. She further stated that residents were invited to attend the care plan meeting if they were able to. During further interview, the SSD stated that if the family attended the meeting, they would walk to the resident's room together to see if they wanted to attend, and if the family did not come she would go to the resident's room by herself and verbally ask the resident if they wanted to attend. The SSD stated that she started working at the facility in April, and did not recall R W ever attending her care plan meetings. She stated that documentation of invitation to the meeting would be in a Care Plan Note in the interdisciplinary Progress Notes in the computer. The SSD reviewed R W's interdisciplinary Progress Notes from (MONTH) (YEAR) to the present date, and did not see a Care Plan Note, and stated it could possibly be documented in the paper chart. During interview with Licensed Practical Nurse MDS staff AA on 10/26/17 at 2:05 p.m., she stated that the SSD started scheduling and inviting residents and families to the care plan meetings for the last several months, and that R W had been invited but rarely attended. She further stated that there was no documentation of a resident's invitation to their care plan meeting, as it was done verbally. MDS staff AA further stated that she had personally verbally invited R W to her care plan meetings, but that the resident would refuse. Review of Interdisciplinary Meeting care plan meeting forms revealed that meetings were held for R W on 3/23/16, 6/6/16, 9/3/16, 12/2/16, 1/30/17, and 4/20/17. Further review of these forms revealed that R W did not attend any of them, and there was no notation of invitation and/or of any refusal to attend. During interview with Registered Nurse MDS staff BB on 10/26/17 at 2:05 p.m., she stated that she could not find a care plan meeting form for the 8/1/17 MDS, and verified that none of the other meeting sheets noted if R W was invited to attend.",2020-09-01
123,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,281,D,0,1,8OVO11,"Based on observation, staff interview, record review, review of the State of Georgia Rule 410-10-01 Standards of practice for Registered Professional Nurses and Rule 410-10-02 Standards of Practice for Licensed Practical Nurses and review of policy and procedure of Medication Administration-Preparation and general guidelines dated 05/2012,the facility failed to maintain professional nursing standards of quality and nursing standards of practice as evidence by performing finger stick blood sugars on two of two residents Findings include: 2. During observation on 10/25/17 at 5:32 p.m., Registered Nurse (RN) CC was noted to perform Finger Stick Blood Sugar (FSBS) check during routine afternoon med pass. The EvencareG3 Glucometer was lying on top of the medication cart when surveyor approached RN. Registered Nurse gathered the supplies, including glucometer, lancet, alcohol swabs and cotton balls. She failed to cleanse the glucometer before entering the residents room. Upon entering the residents room, she proceeded to lay all the supplies needed for the FSBS on the residents bed, without using a protective barrier. Registered nurse did not wash her hands before performing FSBS, nor did she wear any gloves during the procedure. Post procedure, RN gathered up the used supplies, including the lancet, and discarded them in the red trash bin on the med cart. She placed the glucometer on top of the medication cart, without cleansing the meter. She did not wash her hands after performing the procedure. Surveyor asked if she had any other FSBS to check at this time and she replied No. She proceeded down unit one hallway to administer medications to residents. Interview on 10/26/17 at 4:38 p.m., with DON, stated it is her expectation that staff clean the glucometer before and after each use for three minutes wetness, wearing gloves, disposing of sharps in sharps containers. She further stated that the nurses are to use a barrier between clean and dirty fields. She states that there has not been any inservice trainings for the nursing staff in the past year. Review of the Medline Operator's Manual revealed that the glucose meter should be cleaned and disinfected between each patient use using Clorox Healthcare Germicidal and Disinfecting wipes for one minute, and then allow to air dry. Cross refer to F441",2020-09-01
124,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,282,D,0,1,8OVO11,"Based on observation, record review, and staff interview, the facility failed to follow the care plan related to providing assistance as required for incontinent care for one resident (R) #101. The sample size was 46 residents. Findings include: Review of R #101's potential/actual elimination deficit related to bladder and bowel incontinence care plan, initiated on 3/28/17, revealed an intervention to provide assistance as required for toileting and incontinent care. Review of her ADL (activity of daily living) self-care performance deficit related to activity intolerance, confusion, fatigue, and limited mobility care plan initiated on 3/28/17 revealed an intervention that the resident was totally dependent on one to two staff for toilet use and incontinent care. Review of her risk for skin breakdown related to incontinence and poor self mobility care plan initiated on 3/28/17 revealed an intervention to provide incontinence care after each incontinence episode, or per established toileting plan. Observation on 10/23/17 at 2:09 p.m. revealed that R #101 was sitting in a wheelchair in her room, and a urine odor was noted. Further observation at this time revealed that her pants were wet in the perineal area. Observation on 10/26/17 at 3:00 p.m. revealed that R #101 was sitting in a wheelchair in the hall across from the nurse's station, and a urine odor was noted. Observation of incontinent care at 3:05 p.m., on the same day, revealed that her incontinent brief contained a moderate to large amount of urine and stool. Interview with Resident Care Specialist (RCS) II at this time revealed she last changed the resident around 11:00 a.m. that day. Cross-refer to F 315",2020-09-01
125,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,309,E,0,1,8OVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, Hospice contract and staff interview, the facility failed to integrate Hospice services and care planning according to the Hospice agreement for one Resident (R#95) of 46 sampled residents. Findings include: 1. Review of the clinical record for R 95, revealed current [DIAGNOSES REDACTED]. Further review revealed that R 95 was admitted for Hospice Respite on [DATE]. Review of care plan for R 95 revealed that resident chooses to have death with dignity, advanced directive established. Individual wishes include Hospice services and CPR, initiated on [DATE]. Interview on [DATE] at 4:51 p.m., with Director of Nursing (DON), revealed that each Hospice resident has a specific notebook for communications with Hospice provider and the facility staff. The notebook has the physician orders, service order for visit frequency's, Interdisciplinary Team (IDT) meeting notes and visit notes from each discipline. The Hospice notebook, nor any supporting documents for R 95, could be located within the facility. The DON could not locate the Hospice notebook on either unit. DON stated that it is her expectation is that Hosp(ice staff are to report to the floor nurses after each visit. Review of the Hospice agreement between the facility and the Hospice provider dated [DATE], indicated that the Hospice will be responsible for coordinating patient care, assessments and evaluations, discharge planning and bereavement. Further review revealed that the Hospice shall designate a member of the IDT to coordinate the implementation of the Plan of Care. The Hospice shall provide to the facility at the time of admission, copies of the Hospice Plan of Care, the Hospice election form and advance directive, names and contact information for Hospice personnel involved in the care of the patient, medication information and Hospice and attending physician orders [REDACTED]. Review of facility's Clinical Practice Standard for Hospice Care, revised (MONTH) 2008, revealed the facility staff is to be aware of their responsibilities in implementing the plan of care, as well as the responsibilities of the hospice staff. Interview on [DATE] at 9:30 a.m., with Administrator stated that Hospice staff took residents Hospice binder with them so that office staff could update the file with visit notes and paperwork. She had to go retrieve binder from Hospice office. She was not aware the binder had been removed from facility. Interview on [DATE] at 1:30 p.m., with Licensed Practical Nurse (LPN) DD stated the he saw the Hospice Nurse visit R 95 on [DATE]. He stated that she told him the resident was stable and no changes in orders at this time. He stated that he was not aware if he was to make notation about Hospice visits and/or reports from Hospice staff. He stated that he has not seen the Hospice Aide visiting resident this week and he has not been given any type of report from an Aide concerning R 95. Interview on [DATE] at 1:40 p.m., with Hospice RN EE stated that the Hospice provider are to leave visit notes at the facility after each visit. These notes are to be kept in the residents Hospice file. She stated that the office coordinator took R 95 Hospice binder to their office so it could be updated with paperwork and visit notes. She further stated that each Hospice employee is to give a verbal report to the charge nurse, before leaving after each visit. Hospice provider holds IDT/care plan meeting every other Wednesday. Facility staff and family are invited to the meetings, but they have not attended. She further stated that Hospice provider has never been invited to attend facility IDT/care plan meetings.",2020-09-01
126,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,315,D,0,1,8OVO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide incontinence care in a timely manner on two observations for one resident (R) #101. The sample size was 46 residents. Findings include: Review of R #101's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment). Further review of this MDS revealed that she needed extensive assistance for toilet use, was not on a toileting program, and was always incontinent of bowel and bladder. Review of R #101's potential/actual elimination deficit related to bladder and bowel incontinence care plan, initiated on 3/28/17, revealed an intervention to provide assistance as required for toileting and incontinent care. Review of her ADL (activity of daily living) self-care performance deficit related to activity intolerance, confusion, fatigue, and limited mobility care plan initiated on 3/28/17 revealed an intervention that the resident was totally dependent on one to two staff for toilet use and incontinent care. Review of her risk for skin breakdown related to incontinence and poor self mobility care plan initiated on 3/28/17 revealed an intervention to provide incontinence care after each incontinence episode, or per established toileting plan. Review of a Bowel and Bladder Evaluation dated 9/6/17 revealed that R #101 was incontinent of both bowel and bladder, and was not able to participate in a bowel and bladder program as she did not have cognitive skills for toileting retraining. Further review of this evaluation revealed that the resident would be kept clean and dry to prevent skin breakdown and UTIs (urinary tract infections). Observation on 10/23/17 at 2:09 p.m. revealed that R #101 was sitting in a wheelchair in her room, and a urine odor was noted. Further observation at this time revealed that her pants were wet in the perineal area. During interview with Resident Care Specialist (RCS) II on 10/26/17 at 2:48 p.m., she stated that she checked residents to see if they needed to be changed and/or if they needed to go to the bathroom every two hours. During further interview, she stated that R #101 did not know when she was wet nor ask to go to the bathroom, so staff just had to check her. She further stated that the last time R #101 was checked and placed on the bedpan was before lunch that day, around 11:00 a.m. Observation of R #101 on 10/26/17 at 3:00 p.m. revealed that she was sitting in her wheelchair in the hall across from the nurse's station, and a urine odor was noted. Observation on 10/26/17 at 3:05 p.m. of incontinence care by RCS II and assisted by RCS JJ revealed that the resident's incontinent brief contained a moderate to large amount of urine and stool. During interview with RCS II after the incontinent care was completed, she verified that she had last provided incontinence care for R #101 around 11:00 a.m. (what time did this occur? I know it wasn't done in the hall way! Please add a date and time. During interview with the Director of Nursing on 10/26/17 at 4:40 p.m., she stated that residents should be checked for incontinence at least every two hours. Review of the facility's Bowel and Bladder Management policy with a revision date of (MONTH) (YEAR) revealed to monitor wetness and dryness every two hours.",2020-09-01
127,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,323,D,0,1,8OVO11,"Based on observation, record review and staff interview the facility failed to maintain safe water temperatures below 120 degrees Fahrenheit in three resident rooms on one of three units. The census was 85. Findings include: Observation during the initial tour on 10/23/17 beginning at 11:04 a.m., the following unsafe hot water temperatures were obtained using the surveyor's digital thermometer: At 11:09 a.m., the hot water temperature in room 30 was 121 degrees Farenheit (F). At 11:17 a.m., the hot water temperature in room 34 was 122 degrees Farenheit (F). At 11:21 a.m., the hot water temperature in room 35 was 122 degrees Farenheit (F). On 10/23/17 at 12:30 p.m., the following unsafe water temperatures were confirmed by the Maintenance Supervisor, using the facility digital thermometer. [RM #] water temperature was 120.8 degrees F. Room 32 was 120.8 and Room 34 was 104.7. Interview on 10/23/17 at 12:30 p.m., with Maintenance Supervisor, stated that he checks the water temps every day. He has a scheduled list of which rooms to check each daily. He states that there are not specific times of day they check them, but he tries to do them early in the day. He starts on the beginning of the hall and ends on the opposite side of hall. He denies having any recordings of elevated water temps over 110 degrees Farenheit. He stated that if high temps are noticed, he would adjust the hot water control and retest the temps in 30 minutes. Interview on 10/23/2017 12:50 p.m., with Director of Nursing (DON), stated that she had not been informed by staff of hot water temps being hotter than normal temps. There have not been any complaints from residents about the water being too hot or too cold. She denies that there have been any burns reported. On 10/23/17 at 1:30 p.m., temperatures rechecked with Maintenance Supervisor. [RM #] water temperature was 119 degrees F and room 32 water temperature was 114.8. On 10/24/2017 at 9:59 a.m., Maintenance Supervisor and Administrator stated that they have shut off the hot water on Station three due to increased temp in rooms 30 and 32. They have placed a service work order to have mixing valve replaced in the hot water heater, servicing Station three. The Administrator stated that until the mixing value is replaced that staff will use hand sanitizer and disposable wipes for peri-cares. The Administrator further revealed that staff was being educated to use hand sanitizer and she has placed perineal wipes in each residents room for use for resident peri care. If residents need showers during the day, she instructed the staff on Station three to take residents to Station two for showering. On 10/24/2017 at 6:40 p.m., Maintenance Supervisor, reported that repairs have been made and he has rechecked the hotwater and water temps are back down under 110 degrees F. On 10/25/2017 at 7:39 a.m., observation on water temperature in [RM #] was 108 degrees F and room 32 was 109 degrees F.",2020-09-01
128,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,371,F,0,1,8OVO11,"Based on observation, interview, and review of facility policies and procedures, the facility failed to ensure the meat slicer was properly cleaned and sanitized to remove leftover dried food particles. This deficient practice has the potential to effect all residents who consume an oral diet. The resident Census was 85 resident with 77 residents who received an oral diet. Findings include: During a second tour of the kitchen with the Dietary Manager (DM) on 10/25/17 at 10:59 a.m. revealed a deli style meat slicer covered with a plastic bag indicating the equipment had been properly cleaned and sanitized after previous use. The DM removed the plastic covering at 11:00 a.m. to reveal the deli style meat slicer has dried food particles on the base of the meat slicer, and under the slicing blade. The DM confirmed the observation of dried up food particles on the base of the deli style meat slicer and under the slicing blade; the DM at this time stated that staff are to disassemble the meat slicer after each use, and clean away any food particles that have been left on the slicing blades and base. Review of Health Services Group Policy Statement titled Equipment revised (MONTH) 2014 revealed; It is the center policy that all foodservice equipment is clean, sanitary, and in proper working order.",2020-09-01
129,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,372,F,0,1,8OVO11,"Based on observations and staff interviews the facility failed to assure that garbage and refuse was properly disposed, and contained to prevent possible rodent infestation around two of two dumpsters. Findings include: During a brief initial tour of the kitchen and dumpster area on 10/23/17 at 11:15 a.m. with the Dietary Manager (DM), revealed the outside dumpster area where two (2) dumpsters were sitting side by side behind the facility in partially gated area. Observation of the ground area around both dumpsters revealed scattered needle cap coverings, food debris, and previously used gloves. Continued observation revealed that debris was located on the asphalt driveway near the back of both of the dumpsters. Observation of the trash dumpster area on 10/24/17 at 5:45 p.m. debris remains behind both dumpsters, continued observation on 10/25/17 at 1:05 p.m., and further observation of the trash dumpster area on 10/25/17 at 6:00 p.m. revealed the area remains dirty with debris. Interview with the Maintinence Supervisor (MS) on 10/26/17 at 2:59 p.m. revealed the maintinence department is responsible for cleaning around the dumpster area, and it should be checked daily. The MS confirms that the area has not been checked according to schedule in the past few days. The MS revealed he was notified on 10/25/17 that the area behind the trash dumpsters was dirty and needed cleaning. Review of facility policy titled Physical Plant Exterior Maintenance release/revision date: (MONTH) 2007 revealed the facility's procedure is to clean the building's exterior and grounds of all trash, rubbish, debris, unused equipment/furniture, in addition to periodic cleaning of problem areas. Interview with Dietary Manager (DM) on 10/26/17 at 1:30 p.m. confirmed that there was debris behind both of the dumpsters, and was not cleaned until 10/25/17 by the housekeeping and maintinence departments. He also confirmed he is not aware of cleaning schedule times.",2020-09-01
130,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2017-10-26,441,E,0,1,8OVO11,"Based on observation, record review, and staff interview, the facility failed to practice acceptable infection control practices to prevent possible cross-contamination as evidenced by not cleaning a glucometer (a device used to check blood sugars) before and after use; properly dispose of lancets used to obtain blood; provide a clean barrier between clean and contaminated objects or surfaces; perform hand hygiene when indicated; and wear gloves when contact with blood was possible. There was a total of eleven observations made of glucometer use and cleaning with concerns by one of seven nurses observed. The facility census was 85 residents, and the sample size was 46. Findings include: During interview with the Director of Nursing (DON) on 10/26/17 at 4:40 p.m., she stated her expectation was that staff clean the glucometer before and after use according to the manufacturer's instructions, and for the glucometer to maintain contact with the Clorox wipe for three minutes. She stated during further interview that the lancet used to obtain the fingerstick blood sugar (FSBS) should be disposed of in the sharps container, and that staff should wear gloves when doing the FSBS. During continued interview she stated that some sort of barrier should be used to place the glucometer on, such as a paper towel. During interview with the DON on 10/26/17 at 9:42 p.m., she stated that since she started working at the facility in (MONTH) no inservices had been done on how to clean the glucometer, and she could find no inservices on glucometer cleaning for the past year. She further stated that they were inservicing staff today on how to properly clean a glucometer, and return demonstrations were done by each nurse. During continued interview, the DON stated that Registered Nurse (RN) CC had been sent home for the day, and would not be allowed to independently work on a med cart until further training was provided. Review of the facility's Glucometer Decontamination Resident Care Policy revised 9/2015 revealed: The glucometer shall be decontaminated with the facility approved wipes following use on each resident. Gloves will be worn and the manufacturer's recommendations will be followed. The nurse will obtain the glucometer along with the wipes and place the glucometer on the overbed table on a clean surface, e.g., paper towel, wax paper. After performing the glucometer testing, the nurse shall perform hand hygiene, don gloves, and use the disinfectant wipe to clean all external parts of the glucometer. Gloves shall be removed, hand hygiene performed and clean gloves shall be donned. A second wipe shall be used to disinfect the glucometer, allowing the meter to remain wet for the contact time required by the disinfectant label. The clean glucometer will be placed on another paper towel. Gloves will be removed and hand hygiene performed. Review of the facility's Blood Glucose Monitoring policy revised 5/12/17 noted: The Centers for Disease Control and Prevention (CDC) recommends that, whenever possible, blood glucose meters should not be shared among patients. If a device must be shared, you should clean and disinfect it after every use following the manufacturer's instructions to prevent carryover of blood and infectious agents. After collecting the blood sample, discard the lancet in a puncture-resistant sharps container. Remove and discard your gloves and perform hand hygiene. Clean and disinfect the blood glucose meter using a disinfectant pad following the blood glucose meter manufacturer's instructions. Contaminated blood glucose monitoring equipment increases the risk of infection by such bloodborne pathogens as hepatitis B, hepatitis C, and human immunodeficiency virus. Perform hand hygiene. During observation on 10/25/17 at 5:32 p.m., Registered Nurse (RN) CC was noted to perform Finger Stick Blood Sugar (FSBS) check during routine afternoon med pass. The EvencareG3 Glucometer was lying on top of the medication cart when surveyor approached RN. Registered Nurse gathered the supplies, including glucometer, lancet, alcohol swabs and cotton balls. She failed to cleanse the glucometer before entering the residents room. Upon entering the residents room, she proceeded to lay all the supplies needed for the FSBS on the residents bed, without using a protective barrier. Registered nurse did not wash her hands before performing FSBS, nor did she wear any gloves during the procedure. Post procedure, RN gathered up the used supplies, including the lancet, and discarded them in the red trash bin on the med cart. She placed the glucometer on top of the med cart, without cleansing the meter. She did not wash her hands after performing the procedure. Surveyor asked the RN if she had any other FSBS to check at this time and she replied No. She proceeded down Unit one hallway to administer meds to residents. Interview on 10/26/17 at 4:38 p.m., with DON, stated it is her expectation that staff clean the glucometer before and after each use for three minutes wetness, wearing gloves, disposing of sharps in sharps containers. She further stated that the nurses are to use a barrier between clean and dirty fields. She states that there has not been any inservice trainings for the nursing staff in the past year. Review of the Medline Operator's Manual revealed that the glucose meter should be cleaned and disinfected between each patient use using Clorox Healthcare Germicidal and Disinfecting wipes for one minute, and then allow to air dry.",2020-09-01
131,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2016-12-08,309,D,0,1,ML9M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review it was determined the facility failed to follow physician orders [REDACTED].#147. R#147 was admitted to the facility on [DATE] at 6:13 p.m., and did not receive all prescribed medications the first night of the resident's stay at the facility. The facility's failure to ensure the resident received the necessary care and services to attain or maintain her highest practicable level of physical, mental and psychosocial well-being was due to staff's failure to obtain and administer physician ordered medications in a timely manner. Findings include: Review of facility policy titled Emergency Pharmacy Service and Emergency Kits with revision date [DATE] revealed the emergency pharmacy is available on 24 hour basis. Telephone/fax numbers are posted at each nursing station. Ordered medication are obtained either from the emergency box, from the provider pharmacy or back-up pharmacy. Record review for R#147 revealed the resident was admitted to the facility from an acute care hospital on Friday evening 01/8/16 at 6:13 p.m. The resident's admission [DIAGNOSES REDACTED]. On 1/9/16 at 3:30 p.m. the resident was transferred to another facility with medications. Admission Physician orders [REDACTED]. Sodium inject 100 mg subcutaneous every 12 hours related to presence of pacemaker, Atorvastatin Calcium 20 mg at bedtime for [MEDICAL CONDITION], , Artificial Tears one drop three times per day for dry eye syndrome, [MEDICATION NAME] HCL 25 mg at bedtime for depression, and Refresh pm ointment one application at bedtime for dry eye syndrome. Review of the Medication Administration Record [REDACTED] [MEDICATION NAME] sodium inject 100 mg subcutaneous every 12 hours related to presence of pacemaker [MEDICATION NAME] 32.4 mg for [MEDICAL CONDITION] [MEDICATION NAME] HCL 25 mg for depression Atorvastatin calcium 20 mg for [MEDICAL CONDITION] Refresh pm ointment one application at bedtime for dry eyes syndrome [MEDICATION NAME] sodium five mg for presence of cardiac pacemaker [MEDICATION NAME] 40 mg for [MEDICAL CONDITION] Artificial tears 0.4% sol one drop to both eyes for dry eye syndrome The Nursing Progress notes documented on 1/8/16 at 7:13 p.m. the resident's medications were ordered from the pharmacy. A notation on 1/8/16 at 10:51 p.m. was made the pharmacy will deliver medications tonight. An entry on 1/8/16 at 11:53 p.m. revealed the resident's left arm is in sling and pacemaker dressing to the middle of chest was intact without bleeding. The resident has been crying most of shift, states is unhappy about being in a nursing home. The resident was reassured will receive rehab services at facility. On 1/9/16 at 3:30 p.m. physician orders [REDACTED]. The resident is transferring to another facility with medications. The resident was given medications and exited facility in wheelchair. Observation on 12/8/16 at 9:10 a.m. on Station 1 ADU (Automatic Dispensing Unit) room revealed an Automatic Dispensing Unit was in place for obtaining emergency medications for residents. Licensed Practical Nurse (LPN) CC logged into the machine and entered a resident name and then checked the availability of physician ordered medications from the ADU. During an interview on 12/8/16 at 9:10 a.m. LPN CC stated if medications were not available from the ADU routine medications are usually delivered every night between 12 midnight and 1:00 a.m. A telephone interview with on 12/8/16 at 12:15 p.m. with LPN AA revealed she did not recall talking care of R#147. She said it was rare to admit residents after hours, but that it does happen at times. She also stated when a resident was admitted , physician orders [REDACTED]. LPN AA further said the pharmacy has to put the resident's profile information in the facility ADU system to enable the nurse's to get .the resident's medications out of system. Staff AA stated not all medications are available through the ADU system and staff have to wait until pharmacy delivers the medications later that evening. She said medications are usually delivered between 12 midnight and 1:00 a.m., and medications delivered at that time would not be appropriate to give for bedtime doses, because medications must be given an hour before or after scheduled time frames, bedtime medications need to be given by 9 p.m. When asked about the importance of R#147 receiving anticoagulants post-surgery and [MEDICAL CONDITION] medications LPN AA replied she did not recall taking care of the resident, but would have told the resident if she was unable to give her scheduled medications. LPN BB stated on 12/8/16 at 12:35 p.m. when a resident is admitted to facility physician orders [REDACTED]. The pharmacy makes medications available through the facility ADU system, not all medications are available through the ADU system and staff have to wait for the pharmacy to deliver the medications. Meds are obtained through the pharmacy and if staff need medications the pharmacy can be contacted and they will contact a local pharmacy. Staff can usually have any medications within an hour of contacting the pharmacy. The Clinical Nurse Consultant (CNC) said on 12/8/16 at 12:10 p.m. LPN AA did not use good nursing judgement in providing care to R#147. Staff should have ensured that all the resident's medications were available to administer to the resident at 8:00 p.m. that evening. He said it appears the facility staff need more education on ensuring essential medications are available and administered to residents as prescribed by the physician. The facility failed to ensure physician ordered medications were obtained and administered in a timely manner to meet the needs of R#147.",2020-09-01
132,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST,115045,2000 WARM SPRINGS RD,COLUMBUS,GA,31904,2018-07-12,641,D,0,1,1ZSP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility data, the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the respiratory status of one Resident (R) (R A). This failure to accurately assess the resident, resulted in a comprehensive care plan that did not reflect the respiratory status of R [NAME] The resident sample size was 24. Findings Include: A resident record review was conducted and reflected R A was readmitted from an acute hospital with a [DIAGNOSES REDACTED]. A review was conducted of the MDS annual assessment, dated 2/14/18 and the quarterly assessment, dated 5/15/18. The annual assessment reflected the following: hearing/vision= hearing impaired, unclear speech, impaired vision; mood=08 depression; behavior=00; the cognitive assessment reflects a Brief Interview for Mental Status (BIMS) was conducted with a cognitive score of 15 indicating no impairment; bowel and bladder= always incontinent of both; functional= 2 person assist with transfers and mobility needed, non-ambulatory/[MEDICAL CONDITION]; health conditions= shortness of breath (SOB)= none, tobacco use= yes; dental= cavities/broken natural teeth, inflamed gums; medications= antidepressant and opioids; skin= (Section M) application of a non-surgical dressing other than to feet; special treatments and programs= Respiratory Treatments (Section O-0100) indicates at letter Z none of the above while a resident. A review of the MDS with an Assessment Reference Date (ARD) of 5/15/18, reflected that in Section O-Special Treatments, Procedures and Programs O- -D-2 that Respiratory Therapy: number of days used was 0 days during the seven (7) day look back period. Review of the Physician orders [REDACTED]. Review of the facility form titled Treatment Record for the months of 5/18 and 6/18 reflected a documentation of treatment orders for: skin assessments (initially ordered 3/10/15) conducted every week by the treatment nurses; and a treatment order to apply daily dry dressing [MEDICAL CONDITION] (initially ordered 4/1/16). On 7/11/18 at 11:15 a.m. an observation was conducted of R A during the 11:00 a. m. smoke break for residents. The resident was observed smoking safely with a safety apron in place, and was observed using a provided ash tray appropriately. A neck dressing (band type soft collar) was observed in place; the dressing was clean and dry. On 7/11/18 at 11:45 a.m. an interview and observation was conducted with R A where she stated she was doing well, that she had [MEDICAL CONDITION] removed 2-3 years ago, but could not remember the details. At that time, the resident lifted the loose neck dressing and shared how the stoma looked; a clean and pink open stoma site was observed, without drainage, covered by a 4x4 inch gauze dressing that was secured by a soft neck band/collar. On 7/11/18 at 11:50 a. m. during a brief interview with staff nurse EE on the West-2 unit, She confirmed the resident does not require oxygen supplement and that the residents stoma site has been open but clean and healed for some time. On 7/11/18 at 1: 30 p. m. during a brief interview with Treatment Nurse BB she confirmed that one of the Treatment Nurses changes the [MEDICAL CONDITION]/stoma dressing daily. She stated the stoma site at one time was red and had issues, but has been pink and clean without issues for some time now. She confirmed that the Treatment Nurses are responsible for skin checks, and all skin treatments. During an interview on 7/12/18 at 8:00 a.m. with MDS Coordinator GG she reviewed the resident's comprehensive care plan with the surveyor and provided a paper copy. She stated she has worked for the facility since 2014. She confirmed that the resident was not assessed or care planned for having an [MEDICAL CONDITION] or for general respiratory care goals and interventions. A review was conducted of the provided facility policy entitled, Care Plans-Comprehensive Person-Centered reviewed and updated (MONTH) (YEAR). In the section under Procedural Guidelines the policy indicates: 1. An interdisciplinary team in co-ordination with other resident care services, develops and implements a care plan for each resident. 2. The care plan is developed from the resident assessment (MDS) and in coordination with the attending physician's regimen of care. The care plan will be reviewed and updated with participation of the resident and resident representative(s) and all personnel involved in the care of the resident as needed but no less than quarterly.",2020-09-01
133,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST,115045,2000 WARM SPRINGS RD,COLUMBUS,GA,31904,2018-07-12,686,D,0,1,1ZSP11,"Based on observations, interviews and record reviews, the facility failed to identify a pressure ulcer and failed to obtain a Physician's order for treatment for one Resident (R) (R#55) . The sample size was 24 residents. Findings Include: Observation on 7/10/18 at 2:24 p.m. with Certified Nursing Assistant (CNA) (CC), revealed thtat CNA CC was changing R#55 and a Opti- foam gentle silicone face foam and Broder dressing was observed on the right hip without a nurse's signature. CNA CC called the Unit Manager, Registered Nurse BB, Licensed Practical Nurse AA, Director of Nursing and Administrator the dressing was removed by RN BB wound nurse exudate and dry black blood and odor were observed. Measurements of the wound are 1.5 centimeters (cm) x 1.5 cm. No depth. Interview on 7/10/18 at 2:30 p.m. with R#55 revealed that staff put the dressing on her right hip one month ago. Interview on 7/10/18 at 3:00 p.m. with Certified Nursing Assistant CC related to R#55 right hip stage 4, pressure ulcer wound; CNA CC revealed the dressing was observed one week ago with no date, or signature. Interview on 7/10/18 at 3:10 p.m. with Wound Nurse BB, and Treatment Nurse AA in relation to the right pressure ulcer, both wound nurses revealed that they were unaware of the wound; and Wound Nurse BB said she completed a skin assessment for the resident on 7/6/18 and that there was not a pressure ulcer at that time the residents skin was intact. Interview on 7/10/18 at 3:20 p.m. An interview with Unit Manager, MDS Nurse, DON and Administrator revealed that they were all unaware of this pressure ulcer, however, they observed the old dressing not dated, without a nurse's signature and they observed exudate with dry black blood and odor. Interview on 7/11/18 at 10:40 a.m. with Medical Director reveraled that he was unaware of the pressure ulcer until the Unit Manager called him yesterday, 7/10/18, to obtain a treatment order. The Medical Director revealed that the resident previously had a Stage IV pressure ulcer on her right hip that had resolved on 5/26/18. The Medical Director revealed that he believed this wound was caused from the previous resolved pressure ulcer reopening.",2020-09-01
134,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST,115045,2000 WARM SPRINGS RD,COLUMBUS,GA,31904,2018-07-12,693,D,0,1,1ZSP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that one of one resident (R) (R27) who receives nutrition via a [DEVICE] ([DEVICE] a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) has a Physician order related to the amount of the bolus ( administration of a limited volume of enteral formula over brief periods of time) of [MEDICATION NAME] the resident should receive. The sample size was 24 residents. Findings include: Record review revealed that R#27 was admitted to the facility with [DIAGNOSES REDACTED]. Record review Minimum Data Set (MDS) annual assessment dated [DATE]. Section K-Swallowing/Nutritional Status: KO100. Swallowing Disorder signs and symptoms of possible swallowing disorders K- none. K0510 nutritional approach feeding tube. K0710 [NAME] Percent intake by artificial route 51% by artificial route during the entire seven days. B. Average fluid intake per day by IV or tube feeding 501 cc/day or more. Review of the care plan dated 5/10/18 identified the resident has a [DEVICE] for her tube feeding. At risk for complications. Has history of aspiration pneumonia. Requires meds crushed and given in tube. Goal resident will receive tube feeding as ordered without complications over the next 90 days. approaches include but not limited to: give tube feeding as ordered. Observation on 07/10/18 at 7:55 p.m. of the bolus feeding for R27 by Registered Nurse (RN) EE revealed that RN EE flushed the [DEVICE] with 175 cc of water and administered a bolus of [MEDICATION NAME] 1.5 250 milliliters (ml) by gravity. Review of the Physician orders for (MONTH) 1, (YEAR) through (MONTH) 1, (YEAR), revealed an order for [REDACTED]. Further review revealed that the Physician Orders did not contain the amount of [MEDICATION NAME] that the resident was to receive via bolus every four hours. Review of the Physician order dated (MONTH) 17, (YEAR) revealed [MEDICATION NAME] 1.5 1050 cc/day. Review of the physician progress notes [REDACTED]. An interview on 07/12/18 at 9:36 a.m. with Registered Nurse (RN) EE revealed that there was not a volume on the Medication Administration Record [REDACTED]. Further interview with RN EE revealed that a new employee would not have any idea of the volume of [MEDICATION NAME] that was to be administred to the resident based on the residents MAR. An interview on 07/12/18 at 9:44 a.m. with the Director of Nursing (DON) revealed that the enteral feeding order did not contain the volume of [MEDICATION NAME] that was to be bolused. The DON confirmed that this was an oversight and that the Physician orders should contain the amount of the bolus that was to be administered. An Interview on 07/12/18 at 11:52 a.m. via phone with the Registered Dietician for the facility regarding the volume of the bolus feeding for R27. The registered dietician revealed that the charts are reviewed for tube feeding orders and for accuracy and if there is any discrepancy she would talk to the nurse and obtain an order clarification. The Registered Dietician confirmed that the order for the residents [MEDICATION NAME] should include a volume.",2020-09-01
135,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST,115045,2000 WARM SPRINGS RD,COLUMBUS,GA,31904,2019-10-31,625,D,0,1,OMYR11,"Based on record review, staff interview and review of the facility policy titled Bed Holds the facility failed to ensure that two of four residents (R) (R#220, R#62) were provided a bed hold notice at the time of transfer to a hospital. Findings include: 1. Review of the medical record for R#220 revealed resident was transferred from the facility to the hospital on the following dates: 7/4/19, 7/8/19, 8/12/19, 9/11/19, 10/16/19. Review of the hospitalization s since (MONTH) 2019 did not reveal that a bed hold notice was provided to R#220. During interview on 10/31/19 at 3:39 p.m. with the Admissions Director who revealed that the bed hold policy is discussed upon admission but, nursing is responsible for sending out bed hold notices when residents transfer to the hospital. During interview on 10/31/19 at 3:43 p.m. with Unit Manager Licensed Practical Nurse (LPN) HH who reported that a packet is sent to the hospital with residents upon transfer. This packet included the face sheet, Physicians Order for Life-Sustaining Treatment (POLST), advance directives, transfer sheet, immunizations, current physicians' orders, last progress note, and the most current labs. Unit Manager further reported that bed hold notices are not a part of the packet that is sent to the hospital. Unit Manager LPN HH further reported that Admissions or someone in the financial department would be responsible for the bed hold notification. During interview on 10/31/19 at 4:00 p.m. with the Administrator, it was reported that Admissions and Reimbursements are responsible for notifying residents of bed hold upon transfer. Reimbursements would only do so as a secondary resource. It was further reported that bed hold notices should be sent with the other hospital documents at the time of transfer. The Administrator confirmed the Medicaid Status for R#220 for each date that resident was transferred to the hospital. During interview on 10/31/19 at 6:32 p.m. with the Administrator it was reported that bed hold notification was provided but there is no evidence to show that the bed hold notice was provided to R#220 at this time. Review of the facility's policy titled Bed Holds with a revision date of (MONTH) (YEAR), Procedural Guidelines for Medicaid residents: [NAME] Medicaid will pay for a resident's bed for a total of seven days. General Procedural Guidelines: [NAME] As part of the admission process, the Admission Director (or person responsible for admissions) should review the Policy on Bed Holds during Hospital Stays and Therapeutic Leave found in the Resident Handbook. B. In addition, at the time of transfer of a resident for hospitalization or therapeutic leave, written notice regarding the bed hold policy should be given to the resident or resident representative which specifies the duration of the bed hold policy. C. In cases of emergency transfer, notice at time of transfer means that the family or resident representative are provided with written notification within 24-hours of the transfer. This should be done by sending the resident's copy of the notice with the other paperwork sent with the resident to the hospital. 2. A review of patient transfer forms revealed that resident #62 was transferred on 2/8/19, 3/15/19 and 8/16/19 to an acute care hospital. There were transfers forms on the chart but no bed-hold forms found for any of the transfers.",2020-09-01
136,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - WEST,115045,2000 WARM SPRINGS RD,COLUMBUS,GA,31904,2019-10-31,641,B,0,1,OMYR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately code the Minimum Data Set (MDS) assessment for hospice for three resident's (R) R#75, R#43, and R#114 of 16 hospice residents. Findings include: 1. Record review revealed that R#75 was admitted to the facility on [DATE] on Hospice. Review of the Quarterly MDS assessment dated [DATE] for Section O: Special treatments and Programs revealed that Hospice was not triggered for R#75. Record review of the facility care plan for R#75 with an onset date of 3/29/19 with a problem area of hospice due to [MEDICAL CONDITIONS] and nutritional marasmus. Approaches: Coordinate care with hospice team, coordinate care with hospice to assure the resident has little pain as possible, provide resident and family with grief and spiritual counseling if desired, hospice to visit as ordered/indicated. Review of the hospice care plan from the hospice company dated 9/19/19 revealed R#75 had a current care plan with hospice. 2. Review of the medical record revealed that R#43 was admitted to the facility on [DATE] and was a hospice resident. Review of the Annual MDS dated [DATE] and the Quarterly MDS assessment dated [DATE] revealed that on Section O, the resident was not triggered for receiving hospice. Review of the facility care plan dated with a problem onset of 6/22/19 revealed R#43 was on hospice due to a terminal [DIAGNOSES REDACTED]. 3. Record review revealed that R#114 resident is a hospice resident. Review of the Re-Admission MDS assessment dated [DATE] revealed R#114 was readmitted to the facility and continued on hospice although hospice did not trigger on the re-admission MDS assessment. Review of the facility care plan with a problem onset of 10/18/19 revealed the resident was admitted to the facility on hospice. Coordination of care for the facility and hospice were in place on the care plan. An interview on 10/31/19 at 5:23 p.m. with Registered Nurse (RN/MDS) DD stated there is a process she follows to complete the MDS assessment. She revealed using the MDS tracking log to track all transmittals. RN/MDS DD verified R#75, R#43 and R#114 were not triggered for hospice although the residents were care planned for hospice. An interview on 10/31/19 at 5:26 p.m. with RN/MDS BB revealed that R#43 is hospice resident and when completing the Quarterly MDS assessment she clicked on the wrong area.",2020-09-01
137,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2020-01-24,812,E,1,1,1R0411,"> Based on observations, record review and staff interviews, the facility failed to ensure that all items on the kitchen tray line, specially ground pork, were held at the appropriate temperature to prevent food born illness which effected 20 residents who received ground meats. Findings include: Review of policies entitled, Food Preparation and Distribution, updated February 2019 revealed that a temperature monitoring log will be maintained throughout meal service hot foods will be held at greater or equal to 135 degrees Farenheit (F), cold foods will be held at less or equal to 41 degrees F, while frequently monitoring temperatures during meal service, if any temperature is determined to be out of ranger, corrective action will take place (hot items will be pulled from the tray line and re-heated until an internal temperature of 165 degree F for 15 seconds is reached; cold items will be pulled from the tray line and placed into an ice bath, cooler, freezer, or blast chiller until 41 degrees or lower is reached; and items will be re-checked and proper temperature verified before beginning to serve. Observation and interview of the main kitchen tray line temperature taken by Food Service Aide (FSA) AA with the facilities calibrated thermometer on 1/23/20 between 6:24 p.m. through 6:39 p.m., revealed that the ground pork had a temperature of 130 degrees F. Interview with FSA AA at this time revealed that he was unsure how many ground pork have been served so far. An interview with Dietary Manager on 1/24/20 at 12:51 p.m. revealed the facility has in-services monthly, and she expects that staff identify when temps are not correct and pull food and not serve any food at a temperature that is too low or too high.",2020-09-01
138,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,558,D,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to accommodate one resident's (R) environment (R#21) to enable him to easily access the bathroom, hallway, and closet. The sample size was 34 residents. Findings include: During interview with R#21 on 8/6/18 at 1:46 p.m., he stated that he was in the B-bed (by the window), and it was hard for him to get to the bathroom because of the way the beds in the room were arranged. He stated during further interview that he had scraped his knuckles before on the wall on one side and the footboard of the A-bed on the other side when he tried to go from his bed toward the hallway. R#21 stated during continued interview that he also could not get into his closet, if his roommate was up in his wheelchair between the A-bed and the closets. R#21 further stated that the beds in his room had been arranged this way since his current roommate was admitted to his room. Review of R#21's roommate's Minimum Data Set (MDS) revealed that he was admitted on [DATE]. Review of R#21's Quarterly MDS dated [DATE] revealed that he had a Brief Interview for Mental Status score of 15, indicating no cognitive impairment. Further review of this MDS revealed that R#21 was independent for locomotion in his room. Observation in R#21's room on 8/7/18 at 8:40 a.m. revealed that measurements taken with the surveyor's tape measure from the bed rail on the hallway side of the A-bed to the closets was 30 inches, and measurement from the footboard of the A-bed to the wall across from this bed was 32 inches. Continued observation revealed that the wall across from the A-bed had two continuous black scrapes, nine inches apart, from below the television set attached to the wall to the top of the nightlight, that extended all the way toward the hallway to the end of this wall. Observation on 8/7/18 at 9:38 a.m. revealed that the measurement taken with the surveyor's tape measure from the widest points of R#21's wheelchair (the extension brake handles) was 32 inches. R#21 demonstrated at this time that when he attempted to roll his wheelchair from his side of the room past the A-bed, he rammed into the footboard of the A-bed and had to back up and go forward several times until his wheelchair was sufficiently straight to maneuver past the A-bed. During interview with the Director of Nursing (DON) on 8/9/18 at 9:03 a.m., she stated that she was not aware of R#21 having any difficulty maneuvering his wheelchair in his room. She verified that the measurement from the end of the A-bed footboard to the wall across from the A-bed was 32 inches as measured with the surveyor's tape measure. She further verified the difficulty R#21 had maneuvering his wheelchair in his room during observation at this time when R#21 demonstrated that he had to back up and go forward several times to align himself sufficiently to go from his side of the room past the A-bed. During interview at this time, R#21 stated that maybe once or twice he was not able to get to the bathroom in time to keep from becoming incontinent, because of the difficulty maneuvering his wheelchair past the A-bed. R#21 further stated that he was not able to get to his closet when his roommate was in his wheelchair between the A-bed and the closets. Observation at this time revealed that R#21's roommate was in his wheelchair next to his bed, and it blocked access to get into either of the two closets in the room. During interview with the Maintenance Supervisor on 8/9/18 at 10:12 a.m., he verified the black scrapes on the wall across from the A-bed in R#21's room, and stated he was not aware of any difficulty with R#21 maneuvering his wheelchair in his room. During interview with R#21 on 8/9/18 at 11:17 a.m., he stated that he had told someone about the difficulty he was having getting around his room in his wheelchair a few weeks ago, and thought it was the head nurse. He further stated that he was told that it would be taken care of, but nobody had gotten back to him until the surveyor started talking to him about it.",2020-09-01
139,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,584,E,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in five resident rooms (rooms 136, 138, 303, 316, 317) on two of three halls and common dining areas in three of three dining rooms (dining rooms #1, #2, #3) and unit 100 hallways. The census was 95. Findings include: 1. Observation in room [ROOM NUMBER] on 8/7/18 at 8:44 a.m. revealed the following: -There were two continuous black scrapes on the wall 9-inches apart from below the television on the wall to the nightlight below it, all along the length of the wall going toward the hallway. -There was a triangular-shaped missing piece of laminate on the B-bed closet door at the bottom left side exposing the particle board underneath, and a 4-inch by 0.25-inch missing piece of laminate on the vertical aspect of the front of the dresser top in front of the mirror. Observation in room [ROOM NUMBER] on 8/7/18 at 8:56 a.m. revealed the following: -There was a 14-inch long by 7-1/2-inch wide section of sheet rock that had been plastered over but not painted across from the A-bed. -There were two holes in the wall, one above the other, 3/4-inch in circumference above the cork bulletin board across from the A-bed. -There was a 2-inch by 2-inch triangular-shaped hole in the wall to the left of the bathroom door above the baseboard. -There was a deep horizontal gouge in the wall 25 inches above the baseboard to the left of the bathroom door. These concerns were verified by the Maintenance Supervisor during a walk-through of the environment on 8/9/18 at 10:12 a.m. In addition to the above concerns, he verified that the laminate was missing off the third (bottom) drawer of the cabinet in the bathroom in room [ROOM NUMBER]. 2. Observation on 8/6/18 at 10:46 a.m., revealed room [ROOM NUMBER] had four patches of torn sheet rock above head of bed A, approximately two inches long; one ceiling tile above bed A with a one inch hole in corner; large circular patch of gouged, uneven sheet rock, approximately four inches in diameter, at head of bed B; four small holes, approximately size of nickels, on wall above television stand. Observation on 8/6/18 at 10:50 a.m., revealed room [ROOM NUMBER] had dusty window blinds and dusty air conditioner(AC) face grill/plate; Four small holes, approximately size of nickels, on wall above where television sitting on countertop. Observation on 8/6/18 at 1:44 p.m., revealed room [ROOM NUMBER] had dusty window blinds and dusty AC face grill/plate. Observation on 8/7/18 at 9:30 a.m., revealed room [ROOM NUMBER] had six small holes, approximately size of nickels, on the wall above where television is mounted on wall; cloth chair in bathroom with dark brown stains in chair cushion; night stand drawers broken from track; drawer in bathroom missing laminate covering from front drawer. Observation on 8/6/18 at 10:23 a.m., revealed dining room [ROOM NUMBER] had two patches of wallpaper strips missing on two separate walls, missing baseboards on three separate walls, one wall had approximately six inch cut/gouge in sheet rock and wallpaper and dusty blinds and window sills with cob webs and debris in corners of all windows in dining room. Observation on 8/6/18 at 11:04 a.m., revealed dining room [ROOM NUMBER] had dusty base boards and dusty blinds and window sills with cob webs and debris in corners of nine windows. Observation on 8/6/18 at 11:08 a.m., revealed dining room [ROOM NUMBER] had missing baseboards on two walls, missing strip of wall paper on one wall and peeling wallpaper beside break room, dusty blinds and window sills with cob webs and debris in corner of 19 windows. Observation on 8/6/18 at 10:37 a.m., revealed on 100 hall, two areas of patched sheet rock on walls above secured fire extinguisher cabinets. Interview on 8/8/18 at 10:36 a.m., with Laundry Aide LL stated that she and one other housekeeping aide split the rooms on the 100 hall. She stated that she sweeps, mops, damp dusts all the furniture and equipment in the residents rooms. She also wipes the blinds and air conditioner units daily. She further stated she also cleans the bathrooms, wipes down the walls, empties the trash and restocks supplies (soap and gloves). She further stated that she cleans the dining rooms after meals, wipes the tables down, changes the table clothes. She cleans the blinds and window sills every two weeks in the community dining areas. Interview on 8/9/18 at 10:10 a.m., with Maintenance Supervisor, stated that staff put work orders into computer system, and he sorts them according to priority and distributes assignments to the two maintenance staff. They work on work orders, plus perform general maintenance for facility, such a checking emergency exits, checking call lights and water temperatures, side rails, cleaning AC coils, changing AC filters and checking emergency doors. During walking rounds, Maintenance Supervisor verified environmental concerns identified during survey. Interview on 8/9/18 at 10:39 a.m., with Housekeeping Supervisor, stated that the housekeeping staff are trained and educated on their job responsibilities, including daily resident room cleaning of all furniture, hard surface areas, bathrooms, toilets, wipe down the walls, dust the window blinds and AC units and wipe the over bed table. She further stated they are also supposed to sweep and mop each room daily. She further stated that the staff are assigned to clean the offices, public restrooms and the dining rooms after meals. She stated that they are to be wiping the blinds and window sills in the dining rooms once per week, but could not give a specific day or shift it is done, just once per week. She stated that there is not a checklist of duties for staff to use for tasks needed to be done. She stated they just know they need to do it. She stated she does not perform spot checks to ensure tasks are being completed on a daily basis. She verified during a walk through the environmental concerns identified during the survey.",2020-09-01
140,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,656,D,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record reviews, and staff interviews, the facility failed to follow the care plan related to activities of daily living (ADLs), and activities for one resident (R#82), and failed to follow the care plan related to activities for one resident (R#74). The sample size was 34 residents. Finding include: Review of resident (R) #74's Annual Minimum Data Set ((MDS) dated [DATE] revealed staff assessment for activity preferences included listening to music, keeping up with the news, and participating in religious activities or practices. Review of R#74's psychosocial care plan with a revised date of 7/31/18 revealed behavior of being withdrawn and talking less, and she indicated activities that she enjoys are fresh air, religious services and her family. Review of the interventions to this care plan revealed to involve resident in activities or provide 1:1 (one-on-one) daily, and in room visits for social stimulation if resident cannot attend activities. Observation of R#74 on 8/6/18 at 11:36 a.m.; 8/7/18 at 9:52 a.m., 11:37 a.m., and 2:51 p.m.; 8/8/18 at 8:20 a.m., 11:57 a.m., and 2:09 p.m.; and on 8/9/18 at 8:00 a.m.; 9:10 a.m.; and 10:27 a.m. revealed that R#74 was in the bed with her television off. During interview with Certified Nursing Assistant (CNA) AA on 8/9/18 at 9:16 a.m., she stated that she had never seen R#74 with a radio or CD (compact disc) in her room, and that the resident's television worked. During interview with the Activity Director on 8/9/18 at 1:02 p.m., she stated that R#74 enjoyed television programs like game shows, and liked getting her hair brushed. She stated during further interview that she did not remember the last time that R#74's television was on. During interview with the Activity Assistant on 8/9/18 at 1:52 p.m., she stated that she did not know why R#74's television had not been on, could not remember the last time it was on, and that the resident liked to watch television. Review of R#74's activity participation records revealed the following: The only activities documented as given from 6/1/18 to 6/13/18 was one Move and Groove activity and nail care. From 6/15/18 to 6/30/18 there was documentation that the resident attended a total of seven activities. In July, there were only five activities documented for the entire month. From 8/1/18 to 8/7/18, only one one-on-one activity was documented 2. Observation on 8/07/18 at 11:10 a.m., R# 82 had fingernails on his right hand that were long and jagged with a dark substance underneath the cuticles. On 08/08/18 at 9:56 a.m., and 1:33 p.m., R# 82 observed in room sitting in a geriatric chair beside his bed. His fingernails on both hands remained jagged and long, with a dark substance underneath the fingernail cuticles. An interview on 8/8/18 at 1:52 p.m. with Certified Nursing Assistant(CNA) AA who gave R#82 a shower on 8/8/18. She stated that she washed the resident with soap and water, trims the resident's beard at their request, and she also trims the resident's fingernails. The CNA looked at R#82s fingernails on both of his hands and verified that R#82s fingernails were jagged and dirty with a bark substance underneath the cuticle areas. She stated that she filed the resident's nails today but did not clean underneath or trim his nails. She did not state why she did not trim or clean underneath R#82s fingernails. An interview with Registered Nurse (RN) OO on 8/8/18 at 2:09 p.m., verified the R#82s fingernails were dirty with a dark substance underneath them and that the fingernails needed to be cleaned and trimmed. 3. Review of R#82 care plan included one developed on 11/23/16 for psychosocial well-being with Interventions that included involving the resident in 1:1 activities or visits daily and in room visits for social stimulation if resident cannot attend activities. Observation on 8/7/18 at 11:00 a.m., the resident is observed in bed. He has not attended any scheduled activities in the facility. On 8/8/18 at 11:12 a.m., R#82 was observed lying in bed with the room lights on, awake with his eyes open looking at the ceiling. The resident does not have a television or radio on. R#82 observed lying in bed with his eyes open on 8/8/18 at 3:33 p.m. He is looking up at the ceiling. No visitors or 1:1 activities being performed. An interview with the Activity Director (AD) on 8/9/18 at 1:33 p.m. revealed that she performs an activity assessment on residents when they are first admitted to the facility and then each quarter. If residents are not able to communicate, she contacts their family and/or friends for information. If the resident has a change in condition, she finds out this information in the morning meeting. She stated that occasionally staff will bring R#82 out of his room for group activities. She stated that she performs 1:1 activities with the R#82 in his room. Activities she performs with the resident are applying lotion to R#82's hands and playing music tapes. The AD stated that the resident really doesn't respond to her working with him, but later said that sometimes the resident will look relaxed while she is interacting with him. The AD provided R#82 Activity Logs for June, July, and (MONTH) of (YEAR). The Activity Logs had documentation for R#82 1:1 music/video activity on 6/13/18 and 1:1 activity on 6/21/18 of soft touch/lotion and music/video. There was no other documentation of R#82 activities on the Activity Logs. The AD stated she was unsure why the Activity Logs were not completed for R#82. She was not sure how often the resident participated in Activities at the facility. Cross ref to F 679 and F677",2020-09-01
141,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,657,D,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to update the care plan for one resident (R) (R#54) to reflect exacerbations of [MEDICAL CONDITIONS] and new orders for nebulizer treatments. The sample was 34 residents. Findings include: Record review for R#54 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which assessed R#54 with shortness of breath (SOB) or trouble breathing on exertion. Review of the Chest x-ray dated 4/15/18 revealed an order for [REDACTED]. Review of the Physician order [REDACTED]. Review of the care plans in the Electronic Medical Record (EMR) for R#54 revealed no care related to [DIAGNOSES REDACTED]. Review of the paper clinical record for R#54 revealed Care Plan dated 7/5/17, through period 8/31/18 that identified the resident is at risk for shortness of breath, impaired breathing patterns secondary to [MEDICAL CONDITION]. An update on 4/14/18 added congestion and wheezing. Interventions included: *Provide reassurance and support to prevent anxiety during episodes of SOB *Provide rest periods as needed * In room visits for social stimulations if resident cannot attend activities * Observe for shortness of breath, noisy breathing, irregular breathing, increased coughing, temperature, cyanosis, early morning headache, unable to talk, [MEDICAL CONDITION], with follow up as indicated * Notify MD as needed. An update on 4/14/18 documented: [MEDICATION NAME] x 1, (4/15/18) CXR x 2 views. The care plan did not update for the order on 4/19/18 for [MEDICATION NAME] BID x 14 days. Further the care plan did not update in (MONTH) (YEAR) to reflect the order for [MEDICATION NAME] nebulizer treatments QID or exacerbations of [MEDICAL CONDITION]. Interview on 8/9/18 at 11:00 a.m. with the Director of Nursing (DON) revealed they are currently switching to the Electronic Medical Record (LG) which started in (MONTH) (YEAR). She stated that part of the care plans for R#54 had been entered into the EMR but some of them were still in the paper clinical chart. The DON confirmed the care plan did not include updates to reflect exacerbations of the resident's respiratory status in (MONTH) or (MONTH) (YEAR) or the need for nebulizer treatments. (Refer F684)",2020-09-01
142,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,677,D,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews, and record review, the facility failed to provide activities of daily living care, (ADL) related to finger nail care for one dependent Resident (R) # 82. The sample size was 34. Findings include: Record review revealed that R#82 had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R# 82 required extensive assistance from one to two staff members for most of his ADL care. Documentation specified that the resident required extensive one-person physical assistance from staff for his personal hygiene. Review of R#82's care plan related to activities of daily living (ADLs) updated on 5/16/18 revealed that the resident was totally dependent on staff for ADLs. Nursing were to assist R#82 with ADL care as needed. Observation on 8/7/18 at 11:10 a.m., revealed R#82 with long, jagged, dirty finger nails on the right hand with a dark substance observed under the nails and around the cuticles. The resident's left hand was unseen due to it being located underneath a bed sheets. R#82 was observed on 8/8/18 at 9:56 a.m., 11:12 a.m., and at 1:33 p.m. His fingernails on his right hand remained long, jagged, and dirty with a dark substance underneath and around the cuticle area. An interview on 8/8/18 at 1:52 p.m. with Certified Nursing Assistant (CNA) AA who gave R#82 a shower on 8/8/18. She stated that she washed the resident with soap and water, trims the resident's beard at their request, and she also trims the resident's fingernails. The CNA looked at R#82s fingernails on both of his hands and verified that R#82s fingernails were jagged and dirty with a bark substance underneath the cuticle areas. She stated that she filed the resident's nails today but did not clean underneath or trim his nails. She did not state why she did not trim or clean underneath R#82s fingernails. An interview with Registered Nurse (RN) OO on 8/8/18 at 2:09 p.m., verified the R#82s fingernails were dirty with a dark substance underneath them and that the fingernails needed to be cleaned and trimmed. Cross refer F656",2020-09-01
143,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,679,D,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews, the facility failed to provide an ongoing program of activities for three residents (R) (R #82, R#15, and R#74). The sample size was 34 residents. Findings include: 1. Review of R#82 care plan included one developed on 11/23/16 for psychosocial well-being with Interventions that included involving the resident in 1:1 activities or visits daily and in room visits for social stimulation if resident cannot attend activities. Observation on 8/7/18 at 11:00 a.m., the resident is observed in bed. He has not attended any scheduled activities in the facility. On 8/8/18 at 11:12 a.m., R#82 was observed lying in bed with the room lights on, awake with his eyes open looking at the ceiling. The resident does not have a television or radio on. R#82 observed lying in bed with his eyes open on 8/8/18 at 3:33 p.m. He is looking up at the ceiling. No visitors or 1:1 activities being performed. Record review revealed an Activity Quarterly assessment dated [DATE], that revealed that R#82 participates in two activities each week. The types of activities that the resident participates in are social/sensory activities. For participation level, the Assessment identified that R#82 requires assistance to attend activities. Per the Assessment, information for completion of the Activity Assessment was gathered from care plans, family interview, patient observation, and progress notes. An interview with the Activity Director (AD) on 8/9/18 at 1:33 p.m. revealed that she performs an activity assessment on residents when they are first admitted to the facility and then each quarter. If residents are not able to communicate, she contacts their family and/or friends for information. If the resident has a change in condition, she finds out this information in the morning meeting. She stated that occasionally staff will bring R#82 out of his room for group activities. She stated that she performs 1:1 activities with the R#82 in his room. Activities she performs with the resident are applying lotion to R#82's hands and playing music tapes. The AD stated that the resident really doesn't respond to her working with him, but later said that sometimes the resident will look relaxed while she is interacting with him. The AD provided R#82 Activity Logs for June, July, and (MONTH) of (YEAR). The Activity Logs had documentation for R#82 1:1 music/video activity on 6/13/18 and 1:1 activity on 6/21/18 of soft touch/lotion and music/video. There was no other documentation of R#82 activities on the Activity Logs. The AD stated she was unsure why the Activity Logs were not completed for R#82. She was not sure how often the resident participated in Activities at the facility. 2. Review of R (resident) #15's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#15's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had short- and long-term memory problems; severely impaired decision making; did not walk; and was dependent on staff for locomotion on and off the unit. Review of her Annual MDS dated [DATE] revealed the staff assessment for activity preferences included listening to music, doing things with groups of people, and participating in religious activities. Review of R#15's care plan for needs assistance to participate in activities due to cognitive impairment, with an onset date of 5/24/18, revealed interventions that included the following: -Provide one on one interventions to include: music, reading, spiritual support, reminiscence, sensory stimulation. -Provide reminiscing using retained long term memory during activities. -Provide sensory stimulation during activities. -Provide shortened activities to accommodate patient's attention span. Review of R#15's Activity Quarterly assessment dated [DATE] revealed the following: Activity environment preferences: Day room/activity room, indoor, inside center, one to one. Frequency of participation in activities: Participated in 2 activities/week. Types of activities patient participates in: (R#15) participates during devotional on Wednesdays and music relaxation, Activities Department provides 1:1 social visits/sensory. Participation level in activities: Behavior in activities is appropriate, is a passive participant, participates in activities with assistance, requires assistance to attend activities, responsive in one to one visits. Comments about participation level: During church services, (R#15) shows active participation by clapping her hands. During 1:1 and sensory, she will smile, talk, and reach out to hold your hand. Activity care plan considerations: Activities Department will continue to remind, invite and assist resident to church services. AD (Activity Director) will also continue to provide 1:1 social visits and sensory. Observation on 8/6/18 at 11:50 a.m. revealed that R#15 was in a reclining gerichair in her room. Further observation revealed that there was no television, radio, CD (compact disc) player, or any other form of stimulation in the room, and her roommate was not in the room. Observation of the resident's room revealed that it was located on a back hall at the end of the hall, with very little foot traffic outside her room. Continued observation of R#15 at this time revealed that her eyes were open and she was alert, but she had a dull, flat expression on her face. Review of the activity calendar revealed that there was a sing-a-long activity at 11:00 a.m. Observation on 8/6/18 at 12:40 p.m. revealed that R#15 remained in the gerichair in her room. Further observation revealed that the window curtains in her room were pulled and the lighting was very dim, and the roommate was not in the room. No music or other stimulation was observed to be provided. Observation on 8/6/18 at 2:19 p.m. revealed that R#15 was in a reclining gerichair in her room facing the hallway. Further observation revealed that there was no TV in the room and no music playing, and her roommate was not in the room. Observation on 8/7/18 at 9:21 a.m. revealed that a Certified Nursing Assistant (CNA) had just brought R#15 back to her room from the dining room in her gerichair after eating breakfast, and backed the resident into the space between her bed and the closets so that she could not see outside her room. Further observation revealed that her head was hyperextended and she looking either straight up at the ceiling, or at times to the right toward the window. Continued observation revealed that there was no TV in the room and there was no music playing, and the roommate was not in the room. Observation on 8/7/18 at 10:01 a.m. revealed that R#15 was in the gerichair in her room with her eyes open and head turned to the right. Review of the activity calendar revealed that there was a spiritual activity on 8/7/18 at 10:30 a.m. Observation on 8/7/18 at 11:36 a.m. revealed that R#15 had been brought out to dining room [ROOM NUMBER] in her gerichair. Further observation revealed there was only one other resident in the dining room at this time, and there was no activity in progress. Observation on 8/7/18 at 2:52 p.m. revealed that R#15 was in bed in her room with her eyes closed, no music or other stimulation noted. Review of the activity calendar revealed that there was a religious activity scheduled at 10:30 a.m. on 8/8/18. Observation on 8/8/18 at 2:55 p.m. revealed that R#15 was in a gerichair in her room which had been pulled between the dresser and bed so that she would not be able to see out in the hall. Further observation revealed that she was awake and her head was turned toward the window, but the privacy curtain was pulled between the A- and B-beds, so that she would not be able to see outside, the lights were off, and her roommate was not in the room. Observation on 8/9/18 at 9:08 a.m. revealed that R#15 was in a gerichair that had been backed into the space between her bed and the closets, so that she would not be able to see out in the hallway. Further observation revealed that the window curtains were partially open, and there was no TV and no music playing, and her roommate was not in the room. Observation on 8/9/18 at 10:13 a.m. revealed that R#15 remained in the gerichair in her room, was alert, and had pulled the water pitcher off her overbed table and spilled water on herself. Review of the activity calendar revealed that there was a religious activity offered at 10:30 a.m. During interview with the Activity Director on 8/9/18 at 1:02 p.m., she stated that one on one activities were done for residents not brought out of their rooms for socialization and sensory stimulation once a week and sometimes more. She stated during further interview that one on one activities included music, brushing hair, reading, reminiscing, and giving them a lollipop if they could have it. She stated during continued interview that R#15 liked to have her hair brushed, and would get disruptive in group activities at times and curse. During interview with the Activity Assistant on 8/9/18 at 1:52 p.m., she stated that she had done a social visit with R#15 at the beginning of the week, and verified R#15 had not been had not been out of her room for the church services or any other out-of-room activity this week. She further stated that R#15 would watch the activities and at times rub the staff's arm, and that she was not disruptive in activities. She stated during continued interview that the facility had a CD player to play music and a DVD player to display video that could be used for residents in their rooms. Review of R#15's activity participation records revealed the following: -In June, there was no documentation of activity participation from 6/1/18 to 6/10/18, and it was documented that she attended two out-of-room activities each week of the last three weeks. There was no documentation of any one-on-one activities done. -In July, there were no activities documented from 7/1/18 to 7/10/18. It was documented that R#15 attended two group and one one-on-one activity on 7/11/18 to 7/12/18; one group and one one-on-one activity on 7/18/18; four group and one one-on-one activity the week of 7/22/18; and two one-on-ones and one group activity the week of (MONTH) 29th to (MONTH) 5th. 3. Review of R#74's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#74's Quarterly MDS dated [DATE] revealed that she had short- and long-term memory problems, and moderately impaired decision making; walking did not occur; and she was dependent on staff for locomotion on and off the unit. Review of her Annual MDS dated [DATE] revealed staff assessment for activity preferences included listening to music, keeping up with the news, and participating in religious activities or practices. Review of R#74's psychosocial care plan with a revised date of 7/31/18 revealed behavior of being withdrawn and talking less, and she indicated activities that she enjoys are fresh air, religious services and her family. Review of the interventions to this care plan revealed to involve resident in activities or provide 1:1 daily, and in room visits for social stimulation if resident cannot attend activities. Review of R#74's Activity Quarterly assessment dated [DATE] revealed the following: Activity environment preferences: Day room/activity room, one to one, outdoor, own room, self-directed. Frequency of participation in activities: Participates in 3-5 activities/week. Types of activities patient participates in: Church services, 1:1 social/sensory, outside for fresh air, self directed such as tv in her room, napping, and visiting with family. Participation level in activities: Behavior in activities is appropriate; is an active participant; participates in activities with assistance; requires assistance to attend activities; responsive in one to one visits. Activity care plan considerations: Continue to provide activities of interest. Observation of R#74 on 8/6/18 at 11:36 a.m. revealed that she was in bed and alert. Further observation revealed that her television was off. Observation on 8/7/18 at 9:52 a.m. revealed that R#74 was alert and in the bed turned toward the window, the window blinds were closed, and her television was off. Review of the activity calendar for 8/7/18 at 10:30 a.m. revealed that there was a religious activity offered. Observation on 8/7/18 at 11:37 a.m. revealed that R#74 was in the bed with her eyes closed. Observation on 8/7/18 at 2:51 p.m. revealed that R#74 was in bed turned toward the door. R#74's television was off but her roommate's television was on and tuned to a football game, and the resident nodded yes when asked if she was watching the football game. Observation on 8/8/18 at 8:20 a.m. revealed that R#74 was in the bed with her eyes open, and her television was off. Further observation revealed that the roommate's radio was on at a low volume. Review of the activity calendar for 8/8/18 at 10:30 a.m. revealed that there was a religious activity offered. During a medication administration observation on 8/8/18 at 11:57 a.m., R#74 was in bed and was able to follow simple directions given her by the nurse. Further observation revealed that her television was off, and her roommate's television was tuned to a sports station. On 8/8/18 at 2:09 p.m., R#74 was observed in bed and alert, and smiled when spoken to. Further observation revealed that her television was off, and the privacy curtain was pulled between the two beds so that she would not have been able to see her roommate's television. Observation on 8/9/18 at 8:00 a.m. revealed that R#74 was in her bed with her eyes closed. Further observation revealed that the window blinds were closed, the privacy curtain between the beds was pulled, both televisions were off, and the roommate's radio was on but only static was heard. Observation on 8/9/18 at 9:10 a.m. revealed that R#74 was in bed and alert, one pair of blinds over the two windows was open, and her television was off. During interview with CNA AA on 8/9/18 at 9:16 a.m., she stated that R#74's television worked, and that she had never seen the resident with a radio or CD player in her room. CNA AA further stated that R#74 was totally dependent on staff for everything, and that the CNAs would assist the activity staff to get residents to activities. CNA AA stated during further interview that she had seen R#74 in a group activity maybe eight or nine times a month, and saw the Activity Director in the resident's room maybe once a week. Observation on 8/9/18 at 10:27 a.m. revealed that R#74 was in the bed with her eyes closed, and her television was off. Further observation revealed that the privacy curtain was pulled between the two beds, and R#74 would not be able to see any activity in the hallway outside her room. Continued observation revealed that there was a religious activity in progress at this time in dining room [ROOM NUMBER]. During interview with the Activity Director on 8/9/18 at 1:02 p.m., she stated that R#74 enjoyed television programs like game shows, and liked getting her hair brushed. She stated during further interview that she did not remember the last time that R#74's television was on. She further stated that R#74 would often refuse to come out of her room to an activity, and would nod her head yes or no when she was invited. Review of R#74's psychosocial/activity care plan revealed that there was no mention that she refused out of room activities. During interview with the Activity Assistant on 8/9/18 at 1:52 p.m., she stated that R#74 liked to have her nails painted, but refused when offered on 8/7/18. She further stated that she did not know why R#74's television had not been on, could not remember the last time it was on, and that the resident liked to watch television. Review of R#74's activity participation records revealed documentation that she attended the following activities: The only activities documented as given from 6/1/18 to 6/13/18 was a Move and Groove activity and nail care. From 6/15/18 to 6/30/18 there was documentation that the resident attended a total of seven activities. In July, there were only five activities documented for the entire month. From 8/1/18 to 8/7/18, only one one-on-one activity was documented. Review of the facility's Activities Comprehensive Program policy reviewed (MONTH) (YEAR) revealed: It is the intent of this center to provide an ongoing program of activities that is designed to meet the needs of each patient. The program should be periodically evaluated to promote that it still meets the needs and desires of the patient population. This center's activity program is designed to meet the interests and the physical, mental, and psychosocial well-being of each patient.",2020-09-01
144,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,684,D,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, review of the policy titled Medication Orders and staff interviews, the facility failed to transcribe the physician orders for nebulizer treatment in the Electronic Medical Record (EMR) and failed to administer nebulizer treatments per physician orders for one resident (R) (R#54). The sample was 34 residents. Findings include: Review of the facility policy titled Medication Orders reviewed and updated (MONTH) (YEAR) documented in section #3- Documentation of the Medication Order: [NAME] Each medication order is documented in the patient's medical record with the date, time, signature, and title of the person receiving the order. B. The following steps are initiated to complete documentation: 1) Clarify the order with the prescriber, if necessary. 2) Fax, call and/or submit electronically, the medication order to the provider pharmacy. 3) When necessary, transcribe newly prescribed medications immediately on the MAR indicated [REDACTED]. Enter the new order on the MAR. In an electronic record, the above steps are completed by the defined process. 4) After completion, document each medication order noted on the physician's order form with date, time, signature (fill name) and title. Section #4- Specific Procedures for the Four Types of Medication Orders. New Orders signed by the prescriber (handwritten or e-prescribed). 1) The nurse clarifies the order if necessary with the prescriber. 2) Notes the order and enters it on the Physician Order Sheet if not written there by prescriber or enters into the electronic health record. 3) Transcribes the order immediately to the MAR indicated [REDACTED]. R#54 was admitted with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted, the resident was rarely or never understood. Section J- Health Conditions assessed R#54 with shortness of breath (SOB) or trouble breathing on exertion. Observation on 8/6/18 at 1:06 p.m. revealed R#54 in bed with the blankets pulled up to her neck. R#54 was noted to have a loose, congested cough and loud, audible expiratory wheezing with mildly labored respirations and accessory muscle use that was obvious through the blanket. During the observation, R#54 stated she was wore out and I'm cold. Observed on the nightstand next to the head of the bed was an air compressor with a nebulizer and aerosol mask attached and stored in a clear plastic bag. Interview on 8/6/17 at 3:35 p.m. with Registered Nurse (RN) PP revealed the R#54 does have SOB with wheezing and stated that is pretty much a normal state for her. RN PP further stated the resident receives nebulizer treatments and they monitor her oxygen saturations. Observation on 8/7/18 at 2:27 p.m. revealed R#54 in her bed under the blanket. The resident was again observed with a loose, congested cough, audible expiratory wheezing and mildly labored respirations with accessory muscle use. The resident was pleasant but she was confused and it was difficult to interview her as she had difficulty understanding questions asked. The air compressor and nebulizer with aerosol mask remained on the nightstand at the resident's bedside. Observation on 8/8/18 at 8:25 a.m. revealed R#54 in the dining room in her wheel chair eating breakfast. The resident was alert and no signs or symptoms of respiratory distress were noted at this time. Interview on 8/9/18 at 1:35 a.m. with RN EE revealed R#54 has [MEDICAL CONDITION] and does cough and wheeze at times. She stated yesterday she was coughing so she checked her oxygen saturation which was 94% on room air. RN EE stated R#54 had [MEDICATION NAME] treatments at one time, months ago, but has not been on nebulizers for a while now. Observation on 8/9/18 at 2:40 p.m. revealed R#54 in her bed asleep. The resident was observed with audible congestion with slightly labored respirations. The air compressor and nebulizer with mask was no longer on the nightstand next to the resident's bed. Review of the Physician's orders on the Physician order for [REDACTED]. Review of the Medication Administration Records (MAR) in the electronic medical record (EMR) revealed the above order was not listed in May, June, (MONTH) or (MONTH) (YEAR). Review of the physician progress notes [REDACTED]. Review of the PAR Review for R#54 dated 4/19/18 documented the resident is noted with congestion and wheezing. Had fall on 4/17/18 with no injury. [DIAGNOSES REDACTED]. [MEDICATION NAME] BID x 7 days. X-ray of pelvis, bilateral hips, bilateral shoulders/arms. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Chest X-ray dated 4/15/18 documented Significant Findings- ASCVD. Linear bibasilar atelectasis is noted. These changes are new compared to the 9/20/17 study. No acute infiltrates demonstrated. No pleural effusions. Hand written on the report- Received 4/16/18 at 11:16, faxed to Dr. (name). The Scanned copy dated 4/16/18 documented in hand writing [MEDICATION NAME] treatments via nebulizer BID x 7 days. Interview on 8/9/18 at 11:00 a.m. with the Director of Nursing (DON) stated the [MEDICATION NAME] BID x 7 days was on the (MONTH) POF but not transcribed to the (MONTH) (YEAR) MAR. She stated the nurses' when giving the nebulizer treatment and seeing the order on the POF should have transcribed the order on the MAR indicated [REDACTED]. She stated that the Central Supplier (CSt) DD told her a nurse asked her to remove the nebulizer this week because the nebulizer treatments had been discontinued. The DON confirmed the order for [MEDICATION NAME] QID on the (MONTH) (YEAR) POF. The DON confirmed the order was never transcribed to the (MONTH) (YEAR) MAR indicated [REDACTED]. The DON further confirmed there was no record in the nurses notes related to the order for [MEDICATION NAME] QID or that the nebulizer treatments had been administered. She stated that the nurse that took the order should have flagged the POF by folding it over, the charge nurse then should note the order (verifying it was received, dated) and then fax the order to the pharmacy and transcribe to the MAR indicated [REDACTED] Interview on 8/9/18 at 11:26 a.m. with the Central Supplier (CS) DD revealed she spoke with RN RR regarding an order for [REDACTED]. She stated RN RR was going to check the order. She stated that the Infection Control Nurse took it out of the room this week on Tuesday. She stated that maybe she got another treatment over the weekend. Review of the Pharmacy Delivery Sheet dated 4/20/18 revealed Ipratroprium- [MEDICATION NAME] 0.5 - 3MG/ML QTY- 42 was delivered and signed by facility nurse on 4/20/18 at 9:51 p.m. The pharmacy had no record of the order in (MONTH) (YEAR) for [MEDICATION NAME] QID. Interview on 8/9/18 at 4:49 a.m. with the Nurse Practitioner (NP) QQ revealed R#54 has a long history of respiratory problems. She stated if the resident has a significant acute exacerbation, she would expect the nurse staff to call her. She stated the rattle and cough is probably never going to go away but the wheezing and use of accessory muscles could be managed and relieved by PRN nebulizer treatments. NP QQ stated that despite the Progress Notes, her thoughts were that if R#54 was wheezing, PRN (as needed) nebulizers were ordered. She stated that should be monitored by the nursing staff. NP QQ stated R#54 had been stable on her visits and she had not seen any labored respirations or wheezing on her visits but stated with her disease process, that could change at any time. NP QQ stated she visits the resident once a month.",2020-09-01
145,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,761,F,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to ensure that medications were stored at the proper temperature in two of two medication room refrigerators, and failed to ensure that needles used to deliver intramuscular injections were discarded after the manufacturer's expiration date in one of two medication rooms. The facility census was 95, and the sample size was 34 residents. Findings include: During observation in the Station 1 med room on 8/9/18 at 11:00 a.m., one box of 25-gauge 1-inch needles, and one box of 21-gauge 1-inch needles were observed with a manufacturer's expiration date of 12-2017 printed on the box. This was verified during interview with Licensed Practical Nurse (LPN) CC at this time, who stated that Central Supply staff stocked and checked the supplies in the medication rooms. During observation in the medication cart 2 with LPN BB on 8/9/18 at 11:10 a.m., she stated that there was a total of nine 25-gauge needles in the cart with an expiration date of 12-2017, but was not aware of any residents on her hall that received injections with this type of needle. During observation in medication cart 1 with Registered Nurse (RN) EE on 8/9/18 at 11:20 a.m. revealed that there was seven 25-gauge and six 21-gauge needles with an expiration date on the packaging of 12-2017. During interview with RN EE at this time, she stated that the night shift nurses gave vitamin B-12 injections to four residents, and that the nurses would use these needles for the injections. During interview with Central Supply staff DD on 8/9/18 at 11:29 a.m., she stated that she had not ordered any needles since the facility was bought by a different company in 2014, and had not checked the needle boxes for expiration dates. During observations in the Station 1 medication room on 8/9/18 at 2:20 p.m., the medication refrigerator temperature was 30 degrees (Fahrenheit) as measured by the facility's thermometer inside the refrigerator, and this was verified by LPN BB at this time. Review of the (MONTH) Med Room Refrigerator Temp Log for Hall 1 revealed that the temperature was recorded as 38 or 39 degrees each day. Further review of the log revealed that the refrigerator temperature should be maintained ranging between 36 and 46 degrees. Inside this refrigerator the following medications were observed: One vial of unopened [MEDICATION NAME] N insulin One vial of unopened Humalog insulin One vial of unopened [MEDICATION NAME] insulin One vial of unopened [MEDICATION NAME] R insulin Two Tresiba insulin pens 29 Dronabinol 2.5 mg (milligram) tablets in blister packs One [MEDICATION NAME][MEDICATION NAME] injection Two [MEDICATION NAME] 2 mg vials Five 1 ml single dose vials of [MEDICAL CONDITION] vaccine Two ten-dose vials of [MEDICATION NAME] PPD (purified protein derivative), one opened and one unopened Inside an e-box (emergency box) were four [MEDICATION NAME] 1-ml (milliliter) vials 12 [MEDICATION NAME] suppositories 1 Toujeo Solo Star 1.5 ml insulin pen Inside another e-box was one vial Humalog insulin; one vial of [MEDICATION NAME] insulin; one vial of [MEDICATION NAME] 70/30 insulin; 1 vial of [MEDICATION NAME] Solo Star insulin; one [MEDICATION NAME] flextouch insulin pen; and six [MEDICATION NAME] 25 mg suppositories. These observations were verified by LPN BB at this time. During observation in the Station 3 medication room on 8/9/18 at 2:33 p.m., the medication refrigerator temperature was observed to be 29 degrees (Fahrenheit) as measured with the facility's thermometer inside the refrigerator. This was verified during interview with RN GG at this time. Review of the Med Room Refrigerator Temp Log for Hall 3 for the month of (MONTH) revealed that the temperature ranged between 26 degrees and 30 degrees the entire month. Review of the (MONTH) Temperature Log revealed that the temperature was below 36 degrees five of the nine days recorded. Further review of this Log revealed the following notation: If temp is outside range please indicate what you did to correct it in comments section and recheck temperature in one hour and record results under comments. Continued review of the (MONTH) and (MONTH) Temp Logs revealed that no comments had been written in on either form. Inside this refrigerator the following medications were observed: One unopened vial of [MEDICATION NAME] R insulin Three 10-test vials of [MEDICATION NAME] PPD Two Trulicity insulin pens 22 [MEDICATION NAME] 25 mg suppositories Four [MEDICATION NAME] ([MEDICATION NAME] PPD) 10-test vials Four [MEDICATION NAME] 650 mg suppositories Four Tresiba insulin pens One Toujeo [MEDICATION NAME]pen Inside an e-box was one unopened vial each of Humalog, [MEDICATION NAME], and [MEDICATION NAME] 70/30; a [MEDICATION NAME]pen; a [MEDICATION NAME] Flextouch pen; and six [MEDICATION NAME] 25 mg suppositories. Inside another e-box were four [MEDICATION NAME] 1 ml vials These observations were verified by LPN FF at this time. During interview with the Administrator on 8/9/18 at 2:40 p.m., she stated that the medication room refrigerator temperatures should be whatever was directed on the Temp Log forms, so that it should be between 36 and 46 degrees. Review of the facility's Medication Storage in the Care Center policy with a reviewed and updated date of (MONTH) (YEAR) revealed: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Medications requiring refrigeration or temperatures between 2 degrees C (Centigrade) (36 degrees F) and 8 degrees C (46 degrees F) are kept in a refrigerator with a thermometer to allow temperature monitoring. The temperature of the med room refrigerators must be checked daily and documented on a Refrigerator Temperature Log. If vaccines are stored in the refrigerator, temperatures must be checked and documented twice daily. The temperature should be between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F). This log should be kept on or near the refrigerator in the med room. When the temperature of the refrigerator is not within the proper range (between 2 degrees C (36 degrees F) and 8 degrees C (46 degrees F), document the temperature and immediately notify the supervisor and/or Director of Nursing for further instruction and document the corrective action taken. Evaluation of handling of the medications in the refrigerator will be needed. Contact the pharmacy for instructions on handling.",2020-09-01
146,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,880,E,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to maintain cross contamination of clean linen during the folding process; and failed to maintain sanitary dining supplies. The facility census was 73 residents. Findings include: 1. Observation on 8/6/18 at 10:00 a.m., revealed in room [ROOM NUMBER], an unlabeled and unbagged urinal hanging on the grab bar in the bathroom that was shared by by two female residents. 2. Observation on 8/6/18 at 10:08 a.m., revealed in room [ROOM NUMBER], an unlabeled and unbagged urinal in the bathroom that was shared by two male residents. 3. Observation on 8/6/18 at 10:48 a.m., revealed in room [ROOM NUMBER], an unlabeled bedpan in a plastic bag, in the bathroom that is shared by four male residents. 4. Observation on 8/7/18 at 2:44 p.m., with Laundry Aide II, folding clean linen using a Helping Hand securing device to hold the end of a blanket. The blanket was touching the floor during the folding process. After the blanket was folded, she then proceeded to fan/slap the blanket against her legs, as if to remove wrinkles from blanket. Afterwards, she placed the blanket on top of already folded blankets stacked on the folding table. 5. Observation on 8/7/18 at 2:56 p.m., with Laundry Aide JJ, folding clean linen at the folding table, allowing the clean bed linen (sheet) to rest upon her abdomen while folding. Afterwards, she placed the sheet on top of a stack of already folded sheets stacked on the table. 6. Observation on 8/8/18 at 2:18 p.m., revealed that dining room three, had black metal condiment baskets that held clear plastic containers with sugar, salt and pepper packets for resident use. Six of the six baskets had yellow, black, crusted mold substance inside the basket bottom. Interview on 8/7/18 at 3:19 p.m., with Laundry Aide II, stated that she did not notice the blanket was on the floor or that she couldn't shake the linen on her legs. Interview on 8/7/18 at 3:29 p.m., with Laundry Aide JJ, stated that she was unaware that the linens were touching her abdomen during the folding process. Interview on 8/8/18 at 11:35 a.m., with Infection Control Nurse, stated that she does infection control rounds daily making sure gloves available in rooms, checks nebulizer masks/tubing are bagged, checks the Bilevel Positive Airway Pressure and Continuous Positive Airway Pressure machines(BPAP/[MEDICAL CONDITION]) machines, checks to make sure staff are not leaving trash in the resident rooms, makes sure bedpans, urinals, and bath basins are labeled and bagged and that foley bags are in privacy bags. Interview on 8/8/18 at 2:18 p.m., with Dietary Manager (DM) verified the substance on the black holders. He stated that the black holders were washed on Friday's in the kitchen in the dishwasher. The DM removed all holders from the tables and took them to the kitchen to be wash them. On 8/9/18 at 1:36 p.m., walking rounds with the Administrator, stated the that Infection Control nurse does random spot checks in resident rooms checking for unbagged personal care items, and she discards those items, if identified. She stated that she expects the staff to bag the personal care items and label them with room number or the residents name. Interview on 8/9/18 at 2:23 p.m., with Certified Nursing Assistant (CNA) KK stated that she always places urinals and bedpans in plastic bag and hangs them under the sink. She stated they should be labeled with residents names so you know which one to use for each resident. Interview on 8/9/18 at 5:30 p.m., with Regional Dietician stated that the facility does not have a policy on storage of personal care equipment (such as bedpans, urinals and bath basin.",2020-09-01
147,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,883,D,0,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews and review of the facility policy titled Immunizations: Pneumococcal Vaccination (PPV) of Residents, the facility failed to offer the pneumonia vaccine to two residents (R) R#15 and R#40 of five residents reviewed for the pneumonia vaccine. The sample size was 34 residents. Findings include: Review of the clinical record for R#15 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no indication that the pneumonia vaccine was offered or administered to the resident. Review of the clinical record for R#40 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no indication that the pneumonia vaccine was offered or administered to the resident. Review of the facility policy titled Immunizations: Pneumococcal Vaccination (PPV) of Residents reviewed and updated (MONTH) (YEAR), procedural guidelines state that all residents of our facility should receive the Pneumococcal vaccine if they are [AGE] years of age or older or younger than [AGE] years with underlying conditions that are associated with increase susceptibility to infection or increase risk for serious disease and its complications. Each residents Pneumococcal immunization status will be determined upon admission or soon afterwards, and will be documented in the resident's medical record. All residents with undocumented or unknown Pneumococcal vaccination status will be offered the vaccine. Informed consent in the form of a discussion regarding risk and benefits of vaccination will occur prior to vaccination. Interview on 8/8/18 at 11:35 a.m. with Infection Control nurse, stated she only works 16 hours per week. She stated that for the influenza/Pneumonia vaccinations, she gets consents for each residents. She was sending letters to the family and the family was to contact the facility for refusal. She stated that she was unable to find any documentation on the pneumonia vaccine for R#15 and R#40. She stated that she noticed that the facility was behind on the pneumonia vaccines; but that time last year was around the Scabies outbreak, and the facility focused on getting the residents treated for [REDACTED]. Interview on 8/9/18 at 7:40 p.m., with Administrator, stated she had done a facility audit in (MONTH) (YEAR) of residents in facility who had been given the pneumonia vaccine or refused the vaccine. She stated that approximately 50 residents were offered or administered the vaccine. She does not have a reason why the pneumonia vaccine wasn't offered or given to the other residents.",2020-09-01
148,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2018-08-09,924,D,1,1,ST5L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to ensure that two handrails were firmly and securely attached to the wall on 100 hall and in room [ROOM NUMBER] bathroom. The facility census was 95 and the sample size was 34. Findings include: Observation on 8/6/18 at 10:50 a.m., revealed a loose full length handrail in the bathroom. Observation on 8/6/18 at 2:41 p.m., revealed a loose handrail, on the left side of the hallway, at the beginning of 100 hall, between room [ROOM NUMBER] and 150. Walking tour on 8/9/18 at 10:10 a.m. with Maintenance Supervisor, confirmed the loose handrails on the 100 Hall and in room [ROOM NUMBER]. Interview on 8/9/18 at 10:10 a.m. with Maintenance Supervisor, stated staff put work orders into computer system, and he sorts them according to priority and distributes assignments to the staff. The staff work on work orders, plus perform general maintenance for facility, such a checking emergency exits, checking call lights and water temperatures, side rails, hand rails, cleaning Air Conditioner coils, changing AC filters, checking emergency doors. He further stated there is no formal checklist for routine maintenance items, but that the work orders are kept in the computer software system. He stated he was not aware of any loose handrails in the facility.",2020-09-01
149,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2019-02-05,725,F,1,0,6UET11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, review of the monthly schedule (needs list), daily assignments, grievances, staff and resident interviews the facility failed to provide adequate staffing to provide care for two out of two residents interviewed R A and R B. The facility census was 76. Findings include: Interview on 2/4/19 at 10:50 a.m. with resident (R) 'A' who stated that the longest she has had to wait for someone to change her brief has been 30 - 45 minutes. Further stated that she hasn't noticed it being on any particular shift or at a certain time of day. RR: Review of Quarterly MDS dated [DATE] revealed resident with BIMS of 13. Interview on 2/4/19 at 10:55 a.m. with the East Hall Unit Supervisor HH who stated that if they have a nurse to call in that they have an on-call schedule for the nurses. Further stated that she is on call this week and that she split a shift last night with another nurse to cover the shift. Further stated if a Certified Nursing Assistant (CNA) calls in they will ask someone from the previous shift to stay over or ask if someone from the on-coming shift can come in early. Stated that they have used CNA's from the hospital when the hospital census is low. HH further stated that they do use agency CNA's and currently have a contract nurse working nights for them. Interview on 2/4/29 at 12:30 with CNA BB stated that they work short staffed at times, but they ask her to work overtime a good bit, because they can't find anyone else to work. She further stated that they post a schedule with vacant positions on it, and staff are encouraged to sign up to work extra shifts, and she tries to work two to three extra shifts a week, because she needs the money. Interview on 2/4/19 at 2:00 p.m. with CNA EE stated that she works agency, but works three to four 12 hour shifts per week at this facility. Interview: 12/4/19 at 2:14 p.m. R 'B' stated that she has had to wait as long as 30 minutes for staff to answer call light to get help to go to bed. She stated she has a catheter, so she doesn't wet herself, but she has had a bowel movement and had to sit in it for 30 minutes, waiting for staff to come change her. Interview on 2/4/19 at 2:30 p.m. with CNA AA stated she works as needed (PRN), and she tries to work three shifts per week, because she is in school. Interview on 2/5/19 at 1:30 p.m. with the Director of Nursing (DON) who stated they currently have two licensed positions open and eight CNA positions open. Interview on 2/5/19 at 2:26 p.m. with the facility Administrator who stated that he feels the facility has adequate staffing to take care of the needs of the residents. He stated that he has been notified of grievances filed by residents pertaining to staffing concerns, and that the Nursing staff had taken care of those issues. He further stated that staffing has been in their Quality Assurance Performance Improvement (QAPI) for eight (8) months. He further stated that they are trying to work on recruiting staff and staff retention. He stated they use agency staff when needed to meet the resident's needs. Interview on 2/5/19 at 2:40 p.m. with CNA II who stated 'short staffed' to some means that 'they' don't think there is enough help but there is. Further stated that they try to schedule four CNA's on the floor but even if they have three it's okay. Stated that if they only have two CNA's on the floor that they always pull from the showers. Further stated that she knows they are hiring CNA's and have some in orientation. Further stated that even if they pull one CNA from the showers there is always one left to do showers. An interview on 2/5/19 at 2:45 p.m. with CNA JJ who stated that she works in the showers but will stay over or come in on weekends to help out. Further stated that she will sign up for extra shifts when the schedule comes out. Interview on 2/5/19 at 2:50 p.m. with CNA Scheduler CC, stated that she does the monthly scheduling of the staff, but the Charge Nurse on the floor makes the daily assignment. She stated that if staff call in, she tries to call other staff, PRN staff before calling the agency staff. She stated that as a last resort to fill the open positions, they pull from the shower team or restorative to work on the floor. Review of the facility grievances related to residents being left in soiled brief/bed and long wait times for assistance revealed: - 8/13/18: Family member found the R 'C' in bed with a soiled brief on and no pillow between her legs and staff reporting to the family that they don't have enough help. -8/15/18: Family member of R 'D' found the resident in bed with a soiled brief and a brown ring on the pad underneath the resident. -9/21/18: R 'E' reported that she sat in her chair in her room for four hours before someone came to change her brief. -11/16/18: R 'F' who stated that she stays wet all night due to staff not coming when she pushes her call light and staff telling her that they are 'short-staffed' and that they can't keep staff because they don't pay them enough. Review of the 'CNA Schedule [DATE] - (MONTH) 3, 3019' revealed that the facility posted staffing needs for everyday but three out of 28 days and that an agency CNA was scheduled to work 17 days out of 28 days.",2020-09-01
150,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2019-02-05,727,F,1,0,6UET11,"> Based on observation, record review, review of facility daily nurse staff posting and staff interview, the facility failed to provide the services of a Registered Nurse (RN) for at least eight (8) consecutive hours a day, for seven (7) days a week for three (3) days (1/2/19, 1/26/19 and 2/4/19) of a 30 day review. The census was 76. Findings include: Observation during initial tour on 2/4/19 at 10:22 a.m. revealed no Registered Nurse (RN) on duty, other than the Director of Nursing. Review of past 30 days of Daily Nurse Staffing posts, revealed there was no RN on duty for the minimum eight (8) consecutive hours per day on 1/2/19, 1/26/19 and 2/4/19. Review of the Daily Nurse Staffing posted for 1/2/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Review of the Daily Nurse Staffing posted for 1/26/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Patient per day (PPD) for 1/26/19 was below the State requirement. Review of the Daily Nurse Staffing posted for 2/4/19, revealed no RN worked in the building for eight (8) consecutive hours for that date. Interview on 2/5/19 at 1:30 p.m. with Director of Nursing (DON) stated that she looks at the Daily Nurse Staffing posting and hasn't noticed any days that an RN was not on duty, for eight consecutive hours. She stated that she does not make any revisions to the Daily Nurse Staffing posting once the unit clerk has it posted. She verified that on 1/2/19 and 1/26/19 there was not a RN coverage for eight (8) consecutive hours and on 2/4/19, there was not a RN for eight (8) consecutive hours. She further stated that the RN Supervisor was called in to cover the floor for staff call-outs on 2/19.",2020-09-01
151,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2018-04-18,609,D,1,0,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, staff interviews and family interview the facility failed to report and investigate an injury of unknown origin related to a burned area on the upper left chest of Resident #1 (R#1). The sample was four (4) residents. The facility census was seventy-seven (77). Findings include: Record review for R#1 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation conducted on 4/18/18 at 10:25 a.m. of R#1 an area of burned, discolored skin was noted on her left upper chest. She was sitting in the dining room for activities and her shirt was positioned slightly away from her left upper chest. The area was one inch long and three quarters inch wide with 2 small pink superficial open areas. The area was clean, dry, without drainage or redness. R#1 did not show any signs of discomfort. R#1 was confused and did not express herself clearly and could not explain anything about this burned area. Review of Nurse's Notes dated 4/14/18, time 20:35, revealed as follows: Resident noted to have an old burn mark in the shape of a curling iron on her left collar bone area. At least 3 days old it is beginning to peel off in areas. Resident is unable to say how it happened and expresses no c/o pain or (sic) from it. Resident's responsible party present and aware. Nurses notes revealed the Physician was notified of findings on 4/15/18 at 7:31. An Incident Report dated 4/15/28, time 8:14 revealed the same Nursing documentation as the above Nurse's Note. During an interview conducted on 4/18/18 at 1:30 p.m. Certified Nursing Assistant (CNA) CC revealed she had showered R#1 on 4/12/18 and she had no burn, blister or mark on her left upper chest. On 4/16/18 when she gave R#1 a shower she had recorded on the shower skin inspection sheet that R#1 had a blister on her upper left chest. Review of Body Audit Form, completed by the night shift working the night of 4/13/18 and the early morning of 4/14/18 revealed normal skin on R#1's chest. Review of Entity Reported Incidents sent by the facility to the State Complaint Intake and Referral Unit from 1/11/18 through 4/18/18 revealed there was no indication this was reported as an injury of unknown origin. On 4/18/18 at 2:40 p.m. an interview with the Quality Assurance and Compliance Nurse revealed the burn to R#1's left upper chest had not been reported or investigated. The Quality Assurance and Compliance Nurse had reviewed the Incident Report and Nurse's Note from 4/14/18 and 4/15/18 and thought the family had been using a curling iron on R#1's hair and dropped it on her chest. The Quality Assurance and Compliance Nurse confirmed that after reading these documents again, that is not what the documentation indicates. The Quality Assurance and Compliance Nurse verified she should have investigated this incident, and reported it within two (2) hours of it's discovery. A family member of R#1 was interviewed on 4/18/18 at 3:55 p.m. The family member revealed she had discovered the burn on the left upper chest of R#1 on 4/14/18 at approximately 7:30 p.m. and had no idea how she was burned. The family member indicated neither she or any other family or visitors that she knew of had been using a curling iron or anything else that would produce a burn on R#1. The family member had reported the burn to the Nurse on duty and the Nurse and CNA had not known anything about it either. An interview on 4/18/18 at 4:48 p.m. with the Director of Nurses (DON) revealed she had called the beautician on 4/18/18 at 4:30 pm and the beautician had not seen R#1. The DON revealed the Quality Assurance Committee and the Department Heads look at all incident reports in the morning meeting every week day. The Incident Report and Nursing documentation had been reviewed for the burn to R#1's chest and no one was questioned about the incident. No investigation occurred and the incident had not been reported to the State. The DON confirmed the Nursing documentation and incident report had been misinterpreted and everyone had thought the family had caused the burn with a curling iron. The DON verified that the documentation does not really indicate this and she had interviewed the family this afternoon and knows they did not burn the resident, and they do not know how the resident was burned. They DON acknowledged this was an injury of unknown origin and should have been reported within two (2) hours and then should have been investigated. Review of Abuse Prohibition Policy and Procedure effective date 12/20/17- Investigation of injuries of unknown source. Interviews will also be conducted when a resident has an injury from an unknown source. Signed statements will be gathered from : Staff who cared for resident just prior to and just after injury; Other reliable residents in the vicinity nearby area; Family or visitors who may have noticed anything. Once an injury of unknown source has been identified, staff will observe resident and watch behavior to see if the source of injury can be identified based on the resident's behavior (i.e. how they move their arms, walk, push a wheelchair, behave, etc.) The chart will be reviewed for any pertinent information that could help the investigation. If the abuse resulted in an injury, the facility will report to appropriate agencies no later than 2 hours after the allegation is made.",2020-09-01
152,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2018-04-18,610,D,1,0,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of facility policy, staff interviews and family interview the facility failed to investigate an injury of unknown origin related to a burned area on the upper left chest of Resident #1 (R#1). The sample was four (4) residents. The facility census was seventy-seven (77). Findings include: Review of Abuse Prohibition Policy and Procedure effective date 12/20/17- Investigation of injuries of unknown source. Interviews will also be conducted when a resident has an injury from an unknown source. Signed statements will be gathered from : Staff who cared for resident just prior to and just after injury; Other reliable residents in the vicinity nearby area; Family or visitors who may have noticed anything. Once an injury of unknown source has been identified, staff will observe resident and watch behavior to see if the source of injury can be identified based on the resident's behavior (i.e. how they move their arms, walk, push a wheelchair, behave, etc.) The chart will be reviewed for any pertinent information that could help the investigation. If the abuse resulted in an injury, the facility will report to appropriate agencies no later than 2 hours after the allegation is made. Record review for R#1 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. During an observation conducted on 4/18/18 at 10:25 a.m. of R#1 an area of burned, discolored skin was noted on her left upper chest. She was sitting in the dining room for activities and her shirt was positioned slightly away from her left upper chest. The area was one inch long and three quarters inch wide with 2 small pink superficial open areas. The area was clean, dry, without drainage or redness. R#1 did not show any signs of discomfort. R#1 was confused and did not express herself clearly and could not explain anything about this burned area. Review of Nurse's Notes dated 4/14/18, time 20:35, revealed as follows: Resident noted to have an old burn mark in the shape of a curling iron on her left collar bone area. At least 3 days old it is beginning to peel off in areas. Resident is unable to say how it happened and expresses no c/o pain or (sic) from it. Resident's responsible party present and aware. Nurses notes revealed the Physician was notified of findings on 4/15/18 at 7:31. An Incident Report dated 4/15/28, time 8:14 revealed the same Nursing documentation as the above Nurse's Note. On 4/18/18 at 2:40 p.m. an interview with the Quality Assurance and Compliance Nurse revealed the burn to R#1's left upper chest had not been reported or investigated. The Quality Assurance and Compliance Nurse had reviewed the Incident Report and Nurse's Note from 4/14/18 and 4/15/18 and thought the family had been using a curling iron on R#1's hair and dropped it on her chest. The Quality Assurance and Compliance Nurse confirmed that after reading these documents again, that is not what the documentation indicates. The Quality Assurance and Compliance Nurse verified she should have investigated this incident, and reported it within two (2) hours of it's discovery. A family member of R#1 was interviewed on 4/18/18 at 3:55 p.m. The family member revealed she had discovered the burn on the left upper chest of R#1 on 4/14/18 at approximately 7:30 p.m. and had no idea how she was burned. The family member indicated neither she or any other family or visitors that she knew of had been using a curling iron or anything else that would produce a burn on R#1. The family member had reported the burn to the Nurse on duty and the Nurse and CNA had not known anything about it either. An interview on 4/18/18 at 4:48 p.m. with the Director of Nurses (DON) revealed she had called the beautician on 4/18/18 at 4:30 pm and the beautician had not seen R#1. The DON revealed the Quality Assurance Committee and the Department Heads look at all incident reports in the morning meeting every week day. The Incident Report and Nursing documentation had been reviewed for the burn to R#1's chest and no one was questioned about the incident. No investigation occurred and the incident had not been reported to the State. The DON confirmed the Nursing documentation and incident report had been misinterpreted and everyone had thought the family had caused the burn with a curling iron. The DON verified that the documentation does not really indicate this and she had interviewed the family this afternoon and knows they did not burn the resident, and they do not know how the resident was burned. They DON acknowledged this was an injury of unknown origin and should have been reported within two (2) hours and then should have been investigated.",2020-09-01
153,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2018-05-02,584,E,0,1,04GG11,"Based on observations and staff interviews, the facility failed to ensure a clean, comfortable, homelike environment during meal service in one of two dining rooms (West Wing Dining Room). Specifically, the facility failed to clean up food, debris and utensils from the floor after first dining. This failure resulted in an unclean dining experience for residents that were scheduled for meal service during second dining. Findings include: Observation of the West Wing Dining Room on 4/30/18 at 12:24 p.m. revealed the first meal for lunch was served at 12:24 p.m. There were two tables on the left of the dining room with seated residents, a small half circular table to the back right with seated residents and one long table on the right side of the dining room with seated residents. There was one small table closer to the kitchen that was not occupied. At 1:08 p.m. a staff member began collecting clothing protectors left on the tables by residents that had finished their lunch. At 1:12 p.m. the Dietary Aide brought a large garbage bin and a cart with dish bins to the dining room. The staff began collecting plates, utensils and cups from the tables. The staff washed the tables with sanitizer wipes. Residents were noted outside the hall waiting for the second dining service. Observed on the left end of the long table was a large piece of dinner roll, food crumbs and pieces hash brown casserole under the table on the floor and the chair on the end had food crumbs on it. The back-left table towards the aisle side had a packet of saltine crackers and pieces if mixed vegetables (green beans and carrots) on the floor under the table. At 1:17 p.m. a resident with a walker came to sit on the left end of the long table. The resident was observed sweeping the crumbs off the chair with her clothing protector before she sat down. The resident then looked down at the floor and held her feet to the side so she would not put her feet on the dinner roll and hash brown casserole on the floor. The resident had to ask the staff to remove the food so she could put her feet down. At 1:20 p.m. a staff member picked up the dinner roll with a wipe, leaving the remaining food crumbs in place. At 1:27 p.m. another resident with a walker came into the dining room and pointed out the food under the back-left table. The resident stated there was food under the table and a staff member was heard saying It's crackers, I'll get it later. The resident then sat down at the long dining room table. No residents were seated at the back-left table during second dining. Observation after first dining on 5/1/18 at 1:17 p.m. of the West Wing Dining Room revealed several residents seated at tables. Observation of the back right half circular table revealed food debris and a butter knife on the floor. Observation of the back-left table revealed numerous large chunks of turkey and a fork on the floor under the table. Observation of right end of the long table revealed a straw on the floor under a resident's wheel chair and on the left end of the long table there was smashed peas on the floor near a resident's feet. Observation on 5/1/18 at 1:35 p.m. of the West Wing Dining room with the Director of Nursing (DON) confirmed the food debris, straw, fork and knife on the floor while residents were seated for second dining. The DON stated the dining room should be clean for second dining residents. She stated she is not sure of the policy for cleaning the dining room between first and second dining and that she would have to speak with housekeeping. On 5/1/18 at 1:40 p.m. an interview with the West Wing Housekeeper revealed she does not clean the dining room between first and second dining. She further stated she had been told not to go in the dining room and do any cleaning until both first and second dining had been completed and all residents were out of the dining room. The West Wing Housekeeper stated if there was a lot of food on the floor after first dining, the staff could call her to clean the food from the floor but staff have never called her to. Interview on 5/2/18 10:15 a.m. with the Dietary Manager revealed he works at the hospital kitchen and meals for the West Wing is delivered by a dietary aide between 12:00 and 12:10 p.m. He stated meal service for first dining should begin at 12:15 p.m. First dining is for residents that require assistance and second dining is for residents that eat independently. The Dietary Manager further stated there is no written policy or process for cleaning between first and second dining but he would expect that the dining room is equally clean and prepared for second dining as with first dining. He stated that if there is food on the floors or in the chairs, that should be cleaned before the second dining residents sit down for their meals by the staff and/or housekeeping. He further stated dropped utensils should not be left on the floor.",2020-09-01
154,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2018-05-02,600,D,0,1,04GG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, family, and staff interviews, review of the facility's Abuse Prohibition Policy and Procedure revised, 12/17, The facility failed to ensure that an allegation of verbal/mental abuse was reported to the State Agency (SA) and that a thorough investigation related to the allegation of verbal/mental abuse was done for one resident (R#74). Findings Include: Review of the Abuse Prohibition Policy and Procedure revealed that Abuse is also defined as any intentional or grossly negligent act or series of acts or intentional or grossly negligent omission to act which causes injury to a resident, including, but not limited to, assault or battery, failure to provide treatment or care, or sexual harassment of the resident. Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend d, or disability. Examples of verbal abuse include, but are not limited to: threats of harm; saying things to frighten a resident such as telling a resident that she will never be able to see her family again. Mental abuse includes but is not limited to humiliation, harassment, threats of punishment or deprivation. Investigation: Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, the following investigation and reporting procedures will be followed: 1. The description of the alleged complaint. 2. Information gathering. 3. Document the description of the injury. 4. Interviews will be conducted of all pertinent parties. 5. Past performances and/or previous incidents. 6. Describe actions taken by facility to protect resident. 7. All investigation information will be kept on file in a secured location. Record review for R#74 revealed the resident was admitted to the facility on [DATE], with diagnoses, including but not limited to cerebral infarction, localized [MEDICAL CONDITION], chronic pai[DIAGNOSES REDACTED], autonomic [MEDICAL CONDITION] in diseases classified elsewhere, [MEDICAL CONDITION] following cerebral infarction, flaccid [MEDICAL CONDITION] affecting right dominant side, other recurrent [MEDICAL CONDITION], anxiety, [MEDICAL CONDITIONS], diabetes mellitus. Review of the 4/14/18 Quarterly Minimum Data Set (MDS) assessment revealed a Brief Interview Mental Status (BIMS) score of 10 out of 15 which indicates that the resident was moderately cognitively impaired. Further review of Section G revealed total dependent for bed mobility with full staff performance at one time, two staff assist, bed transfer two person assist. During interview with R#74 on 4/30/18 at 12:00 p.m., in the resident's room, revealed that she had a nurse talk in an inappropriate manner to her. Resident stated her daughter would be there soon and ask that I speak with her because the stroke she had affects her ability to talk clearly. On 4/30/18 at 12:30 p.m. R #74's daughter requested the surveyor to speak with her with her Mom present. Upon entering the room R #74's roommate was not in the room and at the daughter request the door was shut to allow a private conversation. Daughter states that on Monday of the previous week her Mom was having a lot of pain and had refused her shower. She states a nurse told R #74 that if she didn't take a shower she would pick her up and throw her in the shower and this upset R #74 and she told the nurse she was not taking a shower because she was in a lot of pain and having a bad day. Daughter then stated that the nurse said, If you don't take a shower you will not get any more pain medication. Daughter states she called in a complaint to the Ombudsman who said she would get back with her but states she hasn't heard from her yet. Also states that she complained to the head nurse. During the interview R #74 would shake her head in agreeance to everything her daughter was telling me. R #74 stated that the nurse was joking but it was not funny. Interview with Social Services (SS) on 4/30/18 at 1:00 p.m. revealed that the Ombudsman had left her a message to return her call earlier in the week but did not actually speak with her until late in the day on 4/26/18. SS states that the Ombudsman told her that R #74's daughter called stating a nurse told her Mom if she didn't get a shower she would throw her in the shower and something else about not giving her any pain medicine. She stated that the Ombudsman said she was confused about the whole thing. States that the daughter of R #74 said she reported this to a person who has been gone from the facility since (MONTH) (YEAR). SS stated she went immediately and interviewed the resident and then spoke with the Director of Nursing ( DON) and the Administrator regarding the Ombudsman's call and the allegation that was made. Interview with DON and Administrator on 4/30/18 at 1:20 p.m. revealed that SS came to them on 4/26/18 and advised them that the Ombudsman had called her regarding a complaint but stated the Ombudsman was confused about what the daughter told her. The Administrator stated that a grievance/complaint is in process. The alleged abuse by the daughter and R #74 to the surveyor was reported to the Administrator and DON. During a telephone interview on 4/30/18 at 1:40 p.m. with R #74's daughter revealed that her Dad gave her the name of the head nurse and she didn't realize she had the wrong name but states her office is located just inside the rehab department, immediately to the left. She states there is a small hall and her office is at the end. Interview with DON, in her office on 4/30/18 at 2:00 p.m. revealed that she states she did not have a conversation with R #74's daughter. When asked if she had just had her hair done and highlighted recently she asked, How did you know that? I stated because when I called R #74's daughter to discuss the name of the person she had reported this incident to at the facility had not been there since (MONTH) of (YEAR) she stated that her Dad told her that was the name but then the daughter gave specific directions to the DON office and said she remembered specifically because she complimented her on her hair just being done and highlighted. The DON again stated that she had never spoken with R #74's daughter about this incident. During a telephone interview with Ombudsman on 5/1/18 at 11:45 a.m. revealed that she spoke with SS at the facility on 4/26/18 between 12:30 p.m. and 1:30 p.m. She stated she was under the impression the DON and Administrator had already worked their notice and left so she spoke with SS and informed her that R #74's daughter called her alleging that a nurse threated to throw her Mom in the shower after refusing to take one and that she would not get any more pain medication if she didn't take a shower. Ombudsman states SS told her that the person in the facility R #74's daughter said she spoke with has been gone since (MONTH) (YEAR). I explained to the Ombudsman the daughter stated to me that she had gotten her information from her Dad and the Ombudsman stated, Then that is where the confusion came in. I explained how the daughter described in detail how to get to the DON's office and the compliment the daughter states she made to the DON about her hair. Also explained how I interviewed with the DON after speaking on the phone with the daughter and that the DON states she never spoke with R #74's daughter. On 5/1/18 at 2:00 p.m. during an interview with DON, Administrator, and SS revealed that SS believes, if the allegation is true, that what took place between the nurse and R #74 is verbal abuse. Administrator was asked if this has been reported to the State Agency and he states it has not been reported because the Ombudsman was involved and SS spoke with the resident and she denied it, so he didn't see the need to report it to the State Agency. DON states she did not know anything about a nurse threatening to throw R# 74 in a shower until Monday when it was reported to her by the Surveyor. She also states that the only thing SS said to her was that the resident told her that a nurse threatened to withhold her pain medication because she didn't take her [MEDICATION NAME] that morning. SS states that she did inform both the Administrator and DON about the call from the Ombudsman. DON states, But you did not say anything about the nurse threatening to throw her in the shower. I went back to my notes and reminded SS of our conversation on 4/30/18 at 1:00 p.m. in her office and that she stated that the Ombudsman told her that R #74's daughter called stating a nurse told her Mom if she didn't get a shower she would throw her in the shower and not give her any pain medicine. SS then stated that the Ombudsman told her she herself was confused about the whole thing. On 5/1/18 at 5:40 p.m. during a telephone interview with alleged LPN (Nurse) revealed that she does sometimes cut up with the residents but she doesn't know for sure if she said she would throw R #74 in the shower. She states she did not tell the resident she would not give her pain medication if she didn't get in the shower. States the resident ask for a pain pill and she told her that she couldn't have a pain pill because she didn't take her [MEDICATION NAME]. When ask why she couldn't have a pain pill just because she refused her [MEDICATION NAME] the nurse stated it was because she was wheezing and having a hard time breathing and she needed the [MEDICATION NAME]. On 5/2/18 2:45 at p.m.during interview with the Administrator and DON revealed that the Administrator did not report the Allegation because the Ombudsman was involved already. Administrator was given a copy of the regulation regarding reporting allegations of abuse to the State Agency within 2 hours if there is injury, and within 24 hours if there is no injury. He states he understands and has a book where he has reported many things to the State Agency but he thought since the Ombudsman was involved there was no need to report it to the State Agency. States once he receives an allegation of abuse, the resident's safety is priority and maintained, it is reported to the State Agency, and an investigation is started. Complaint Form dated 4/26/18 revealed that SS, received a complaint from R #74 that a couple of days ago before lunch she asked for a pain pill from her nurse and the nurse told her no because she refused her [MEDICATION NAME] but then she returned an hour later with her pain pill.",2020-09-01
155,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2018-05-02,761,D,0,1,04GG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review, the facility failed to discard expired medication in one of four medication carts. The sample size is 24. Findings include: During medication pass on [DATE] at 8:45 a. m., with Licensed Practical Nurse (LPN) BB, revealed an opened multiple-dose vial of [MEDICATION NAME] R insulin with opened date of [DATE]. A label on the vial read discard after 28 days. Expired [DATE]. Review of the facility policy titled, Pharmacy Services and Procedure policy, revised (YEAR), indicated that the facility should ensure that medications and biological's have an expiration date on the label and have not been retained longer than recommended by the manufacturer or supplier. The policy further states facility should record the date opened on the medication container, if the medication has a shortened expiration date. Review of the policy titled, Recommend Minimum Medication Storage Parameters, revised (YEAR), indicated multiple-dose vials for injection, are to be dated when opened, and discard unused portions after 28 days or in accordance with manufacturer's recommendations. Interview on [DATE] at 8:45 a.m. LPN BB stated the policy for opened injectable medications is 28 days. She verified the opened bottle of [MEDICATION NAME] R insulin of [DATE] had an open date and pharmacy sticker indicated to discard after 28 days from opening date which is [DATE]. Interview on [DATE] at 9:15 a.m., Director of Nursing stated the policy for open injectable medications have a duration time, [MEDICATION NAME] 28 days. She verified the open bottle of [MEDICATION NAME] R insulin had [DATE] open date and the pharmacy sticker indicated to discard after 28 days from opening date which is [DATE]. Interview on [DATE] at 11:00 a.m., Pharmacy Consultant stated the policy for open injectable medications have a duration time, [MEDICATION NAME] 28 days. He verified the medication was refilled and sent to facility on [DATE], the open bottle of [MEDICATION NAME] R insulin had [DATE] open date and the pharmacy sticker indicated to discard after 28 days from opening which is [DATE].",2020-09-01
156,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2018-05-02,835,D,0,1,04GG11,"Based on record review, resident, family, and staff interviews, review of the facility's Abuse Prohibition Policy and Procedure revised, 12/17, The Adminstrator failed to ensure an allegations of verbal/mental abuse was reported to the State Agency (SA) and that a thorough investigation related to the allegation of verbal/mental abuse was done for one resident (R#74) Finding include: During interview with R#74 on 4/30/18 at 12:00 p.m., in the resident's room, revealed that she had a nurse talk in an inappropriate manner to her. Resident stated her daughter would be there soon and ask that I speak with her because the stroke she had affects her ability to talk clearly. On 4/30/18 at 12:30 p.m. R #74's daughter requested the surveyor to speak with her with her Mom present. Upon entering the room R #74's roommate was not in the room and at the daughter request the door was shut to allow a private conversation. Daughter states that on Monday of the previous week her Mom was having a lot of pain and had refused her shower. She states a nurse told R #74 that if she didn't take a shower she would pick her up and throw her in the shower and this upset R #74 and she told the nurse she was not taking a shower because she was in a lot of pain and having a bad day. Daughter then stated that the nurse said, If you don't take a shower you will not get any more pain medication. Daughter states she called in a complaint to the Ombudsman who said she would get back with her but states she hasn't heard from her yet. Also states that she complained to the head nurse. During the interview R #74 would shake her head in agreeance to everything her daughter was telling me. R #74 stated that the nurse was joking but it was not funny. On 5/2/18 2:45 at p.m.during interview with the Administrator and DON revealed that the Administrator did not report the Allegation because the Ombudsman was involved already. Administrator was given a copy of the regulation regarding reporting allegations of abuse to the State Agency within 2 hours if there is injury, and within 24 hours if there is no injury. He states he understands and has a book where he has reported many things to the State Agency but he thought since the Ombudsman was involved there was no need to report it to the State Agency. States once he receives an allegation of abuse, the resident's safety is priority and maintained, it is reported to the State Agency, and an investigation is started. Refer to F600",2020-09-01
157,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2017-05-18,257,E,1,1,KH1211,"> Based on observation, record review, review of the policy titled The Resident Environment, resident and staff interviews, the facility failed to ensure comfortable temperatures on one of two units (West Unit). The resident census on the West Unit was 46. The facility census was 83 residents. Findings include: Review of the facility policy titled The Resident Environment effective 5/2017 and expiring 5/2020 documented that Habersham Home long term and short stay resident accommodations meet all state rules/regulations to include: there is adequate temperature control. During tour of the facility on 5/15/17 that began at 10:08 a.m. on the West Unit it was noted to be extremely cold in the hallways. Some residents were noted to be wearing a [NAME]ets, sweaters and blanket across the lap. R A was walking through the hall and she was visibly shivering with her arms folded across her chest. Her lips were quivering. The resident was wearing a long sleeve shirt and when asked, she stated that she was cold. A CNA was alerted that R A was cold and she brought a [NAME]et to put on the resident. A West Unit dining observation, during the lunch meal on 5/15/17 at 12:30 p.m. revealed it was extremely cold. In addition to the cold temperature, there were four overhead fans blowing. There was no visible temperature gauge or thermometer in the dining room. Some residents were noted with their arms folded across their chest. Some residents were placing their arms underneath their clothing protector as if to keep them warm. While asking a random resident in the dining room if they were cold at 12:45 p.m., a family member of R B yelled out and stated It's always cold in here! We tell them but they don't do anything about it! At 12:56 p.m., another family member of a resident R C stated the residents are always cold in the dining room. She stated that her mother has a long sleeve shirt on and a sweater and she is still complaining of being cold. The family member stated that she is in the dining room at lunch almost every day and she always overhears the residents complaining that they are cold. She stated she will literally get up and shut the fans off herself. She stated that sometimes she even overhears the staff complaining that it is cold. During an interview with R [NAME] on 5/15/17 at 3:30 p.m., the resident stated it is very cold in the building and very cold in the dining room. She stated it is always cold. A family member of the resident came into the room and stated that it is so cold in the building. The family said she has seen residents have to get [NAME]ets and blankets for the dining room. She stated that she has made numerous complaints to the staff and the Administrator. The staff will turn the fans off in the dining room. She stated that the staff will come in the room and turn her mom's heat off. This is her mom's room and although she understands they are working, her mom is lying still in a bed and she gets cold. The family stated her Mother cannot get up and adjust the temperature when the staff come in her room, turn the air conditioning (A/C) on and leave. They had to have a sign put on her Mom's A/C unit that says please do not turn off heat Observation at the time of this interview confirmed the sign on the A/C unit. R [NAME] then stated it is freezing in here. During an Interview with Engineering staff AA on 5/15/17 at 6:48 p.m., he asked what the regulation was for temperatures in the building. He stated that the staff on the West Unit complain that they are hot and want the temperature turned down. He stated that the temperature should be comfortable for the residents, not the staff. Observation on 5/16/17 at 8:10 a.m. of dining room revealed the temperature was much more comfortable than the previous observation on 5/15/17 at 12:30 p.m. The overhead fans were turned off. No complaints by residents related to the temperature of the dining room were observed at this time. Interview with a family member of R B on 5/16/17 at 10:51 a.m. revealed he comes to the facility almost every day from around 10:00 a.m. and stays until after dinner around 6:30 p.m. He stated it is always cold in the dining room. His wife (R B) and several other residents complain that it is cold. He stated her can hear other residents say it's cold! He stated that the staff will go get blankets sometimes and put on the resident but they do not turn off the fans or fix the temperature. He stated the ceiling fans are always running and that makes it even colder in the dining room. The family stated that he has told staff right there in the dining room, but he is not good with names. He said they really don't do anything. He stated that he will get up and shut off the fan that is almost directly over his wife's table at times. The family of R B further stated his wife has to put a [NAME]et on everyday when she goes out of her room. In her room, he can adjust the temperature individually. Interview with R B at this time revealed it is difficult to enjoy her meal when she is so cold in the dining room. During an interview on 5/16/17 at 11:59 a.m. with R D, he stated It's cold in the eating room all the time. He stated he has to put on a heavier shirt over his clothes when he goes to the dining room. He stated that they keep it a certain temperature I guess. They won't make it warmer in the eating room. Sometimes if the residents are complaining they (staff) will turn off the fans and sometimes they won't. Observation at the time of the interview in the resident's room revealed a sign taped to the A/C unit that read Please do not turn heat off. The resident stated he can get up and control the temperature how he and his roommate needs it. He stated that sometimes if it is not the temperature the workers want, they will come in a turn it off. R D further stated that he does hear other residents complaining in the dining room that they are cold. Observation on 5/16/17 at 12:24 p.m. of the West Unit dining room revealed the fans were off and the temperature was comfortable. It was not too cold at this time. No residents observed with signs of being cold, no complaints heard of being cold. Observation on 5/16/17 at 4:15 p.m. revealed R F sitting in a wheelchair outside of her bedroom door in the hall of West Wing. The resident had a folded blanket on her from under her chin down to her feet. The resident stated I'm freezing to death! R F further stated the blanket does not do any good because it doesn't cover her back. The resident was observed wearing a long sleeve shirt and long pants. Although the resident was confused, she was able to understand some conversation and be understood in conversation. Observation on 5/16/17 at 4:22 p.m. in the hall of West Unit revealed R G was wearing three plaid flannel shirts and had a blanket across his lap. The resident is very hard of hearing so interview questions were conducted by writing notes. R G was asked in writing if he was cold. The resident stated that yes he was cold. The R G was asked if he ever gets cold in the dining room. The resident stated that most of the time, it is cold in the dining room. Interview with resident R [NAME] on 5/17/17 at 11:40 a.m. revealed the temperatures in the past couple of days have been much better. She stated that the dining room during meals has been much more comfortable the last couple of days but when she goes to the dining room for activities, it's freezing cold again. Interview with the 5/17/17 at 1:00 p.m. with the family of R C in the dining room revealed the dining room temperature is much better now. She stated she forgot to bring her [NAME]et for the dining room and was surprised that it was comfortable. She said she even asked her mother if she was cold and she said she was not. Observation of the dining room on 5/17/17 at 4:26 p.m. revealed several residents at table, the temperature was comfortable, the fans were on. Interview with Engineering staff BB on 5/18/15 at 8:25 a.m. revealed on Monday he received a work order to adjust the temperature in Day Room where the surveyors were working because it was too cold. He stated that the thermostat that controls the halls and the dining room is in the locked maintenance cabinet. The thermostat at the nurse's station no longer controls the temperature because it is actually locked out at the main thermostat in the locked maintenance closet. Only maintenance has access to the maintenance closet. Engineering BB stated that he has received work orders related to it being too cold on the West Unit by staff but he is not sure how to pull up past work orders from the computer. Interview with Engineering AA on 5/18/17 at 8:35 a.m. revealed that he did increase the temperature on Monday 5/15/17. He stated that he only had to change it one - two degrees, he could not remember exactly but thought it was set at 70 degrees at that time. He stated that the staff was constantly messing with the thermostat to suit their personal level of comfort. He stated that approximately one year ago, the A/C unit was replaced and the thermostat in the locked maintenance closet controls the temperature of the halls and dining room. Observation of the thermostat in the locked maintenance closet at 8:44 a.m. with the Engineering AA revealed a range set at 71-73 degrees with the current temperature of 73 degrees. Interview on 5/17/17 at 11:00 a.m. with Certified Nursing Assistant (CNA) DD revealed some residents will be fine with the temperature and some will say they are freezing. CNA DD stated this is mainly in the hallways and she will get them a sweater. Interview on 5/17/17 at 11:03 a.m. with CNA CC revealed some residents will be hot and some will be cold. She stated there are more cold residents than hot. She stated that residents have complained about being a cold and she will get them a [NAME]et or a blanket. CNA CC further stated that if a resident can't tell her they are cold, she can tell by touch or by signs of shivering. CNA CC stated that them (residents) being older, they do get colder more. During interview on 5/17/17 at 11:06 a.m. with CNA EE, she stated It's a mixture. Some residents are cold and some are not cold. CNA EE revealed that some of the families requested the signs to be placed in the room to keep the resident's heat on. Interview on 5/17/17 at 11: 12 a.m. with CNA HH revealed that she has heard some of the residents complain that it is cold in the dining room. CNA HH stated she will turn the fans off, get the residents [NAME]ets or a blanket and wrap them up. CNA HH further stated that the residents get colder because their skin is thin and they don't have good fatty tissue. Interview on 5/18/17 at 2:35 p.m. with the R H revealed that she has heard residents' complain about the cold temperatures in resident council meetings, including herself. She stated she has seen residents with [NAME]ets, sweaters and some with blankets in the dining room. She stated that it is cold in the hallways sometimes too. Interview on 5/18/17 at 2:42 p.m. with the Activities Director revealed that she attends the resident council meetings and she takes the minutes for the meetings. She stated there have been complaints about cold temperatures but it was related to the resident's rooms and staff turning the air conditioning (A/C) on and leaving it on. She has heard some residents and family members complain during activities in the dining room, that it was cold at time. The Activities Director stated would turn off the fans. She stated that the residents tend to get colder and they will wear [NAME]ets, sweaters or some like to have their blankets. She further stated that the offices in the building get hot. Review of the resident council minutes dated 5/10/17 documented a concern: Do not turn on air in rooms. Observation of the West Unit resident rooms on 5/18/17 beginning at 6:20 p.m. revealed the following rooms had a sign stating Please do not turn off heat posted to the A/C unit: 401, 402, 404, 309, 307, 303, 302 and 301. Interview on 5/18/17 at 6:35 p.m. with the Administrator revealed sometimes the residents complain about it being cold. They have a thermostat that is locked up so nobody can change it. If there is a problem, they will call engineering to come and adjust it. The West Unit has a new thermostat to try to regulate the temperatures throughout the unit better. Some of the air ducts were closed off and they have more even temperatures on the unit. It did not always cool throughout the unit the same. Some areas of the unit had different temperatures than others. Every once in a while, staff will turn down the residents A/C, not always but it has happened. She has talked to them and told them not to do that. The signs to leave the heat on were probably put on the A/C unit for a resident preference.",2020-09-01
158,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2017-05-18,280,D,1,1,KH1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to update the care plan to reflect the presence of an unstageable pressure ulcer, and failed to update the care plan related to pain assessment and management during wound care for one resident (R) #24. The sample size was 37 residents. Findings include: 1. Review of R #24's clinical record revealed that he was readmitted to the facility after a hospitalization on [DATE] with a Stage 3 pressure ulcer. Review of his 30-day Minimum Data Set ((MDS) dated [DATE] noted that he had one Stage 2 and one unstageable pressure ulcer. Review of Physician's Progress Notes dated 5/9/17 noted the resident continued to decline, and his Stage 3 sacral decubitus was not getting better. During observation of wound care done by the Director of Nursing (DON) on 5/17/17 at 9:07 a.m., the resident was noted to have a large sacral wound with grayish-black eschar in the wound bed. Review of R #24's care plans revealed a potential for pressure ulcer development last revised on 12/23/16, with no mention of the actual pressure ulcer. Review of a recurrent impairment to skin integrity of the right upper inner thigh care plan developed on 3/22/16 noted that the resident had blisters to the toes which resolved on 7/18/16, and was updated to reflect moisture [MEDICAL CONDITION] of the buttocks and coccyx on 7/9/16, 9/26/16, and 1/9/17. Further review of this care plan revealed that it did not include the actual pressure ulcer to the sacrum that the resident was readmitted with on 4/5/17. During interview with MDS Coordinator JJ on 5/18/17 at 3:49 p.m., she stated that at the time that R #24 came back from the hospital on [DATE], the wound nurse updated any care plans related to wounds, and did Section M (Skin Conditions) on the MDS. She further stated that for the past week the wound care nurse was assigned to the med cart, and that she (the MDS nurse) was responsible for doing the pressure ulcer care plan revisions and Section M of the MDS. MDS Coordinator JJ further stated that all nurses had the ability to update the care plan. She verified during further interview that the pressure ulcer care plan had not been updated to reflect the Stage 3 sacral wound R #24 was readmitted with, which was now unstageable. The MDS Coordinator added that the care plan should be updated at the time of the development of the pressure ulcer. Cross-refer to F 314. 2. Review of R #24's risk for pain and potential for pressure ulcer development care plans last revised on 12/23/16 revealed that they did not include any interventions for assessment of pain and/or pain management during wound care. During an observation of wound care performed by the DON on 5/17/17 at 9:07 a.m., R #24 said awwww in an uncomfortable tone when the sacral wound was cleansed, and again when the wound was packed with a dressing. Review of R #24's Medication Chart revealed that he did not receive anything for pain prior to the wound care on 5/17/17. During interview with the DON on 5/18/17 at 1:35 p.m., she verified that R #24 expressed discomfort when she cleaned and packed his wound, and verified she did not pre- medicate him with a pain medicine prior to the treatment. During interview with MDS Coordinator JJ on 5/18/17 at 3:49 p.m., she verified that the pain and the pressure ulcer care plans did not reflect pain management during wound care, and that it should have. Review of R #24's Pain Assessment done 5/15/17 noted that in the Care Planning and Documentation section, the response for Are factors that worsen pain or improve comfort addressed on the care plan? was answered Yes. Review of the facility's Resident Monitoring policy effective (MONTH) of 2008 noted: Sustained monitoring of resident issues and safety/preventative interventions will be accomplished through development of an individualized resident care plan which is designed to address a resident's specific health/care needs. Goals are established toward achieving their optimal level of functioning. Cross-refer to F 309.",2020-09-01
159,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2017-05-18,282,D,1,1,KH1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to follow the care plan related to following facility policies and protocols for the prevention of skin breakdown for one resident (R) #24. The sample size was 37 residents. Findings include: Review of R #24's 30-day Minimum Data Set ((MDS) dated [DATE] revealed that he had one Stage 3 and one unstageable pressure ulcer. Review of the Weekly Pressure Assessment Tool dated 5/4/17 revealed that the resident had an unstageable pressure ulcer to the sacrum. Review of R #24's potential for pressure ulcer development care plan last revised on 12/23/16 revealed an intervention to follow facility policies/protocols for the prevention/treatment of [REDACTED]. Review of the facility's Documentation of Treatments policy revised (MONTH) of 2009 noted: In order to assure proper monitoring and documentation of the condition of each resident's skin integrity, weekly assessments will be performed by a licensed nurse. Review of the facility's Resident Monitoring policy effective (MONTH) of 2008 noted: Licensed Nurses are to complete a weekly Skin Assessment form on every resident. Review of R #24's Body Audit Form skin assessments revealed that there were none found in the clinical record after 4/17/17. During interview with the Director of Nursing on 5/17/17 at 9:25 a.m., she stated that the wound care nurse did weekly skin assessments on all of the residents. During interview with Registered Nurse (RN) II on 5/18/17 at 1:35 p.m., she stated that she was the usual wound care nurse. During interview with RN II on 5/18/17 at 3:05 p.m., she stated that she could find no other weekly skin assessments after 4/17/17 for R #24. During further interview, she stated that she was responsible for completing the weekly skin assessments, but had not been able to do them lately because she was working as a medication nurse. Cross-refer to F 314.",2020-09-01
160,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2017-05-18,309,D,1,1,KH1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to evaluate one resident (R) #24 for pain during wound care. The sample size was 37 residents. Findings include: Review of R #24's clinical record revealed that he was admitted with [DIAGNOSES REDACTED]. Review of his 30-day Minimum Data Set ((MDS) dated [DATE] revealed that he had severe cognitive impairment, and had one Stage 3 and one unstageable pressure ulcer. Further review of this MDS revealed that he was not on a scheduled pain regimen, and had non-verbal sounds of pain or possible pain in the last five days for one to two days of the assessment period. Review of the risk for pain related to varied ability to make needs known care plan revealed interventions to monitor resident complaints of pain or signs and symptoms of non- verbal pain. Review of all of R #24's care plans revealed that no interventions included assessing for pain nor providing pain management during wound care. Review of a Pain assessment dated [DATE] revealed that R #24 received PRN (as needed) pain medications over the past five days, and was not on a scheduled pain medication regimen. Review of the Weekly Pressure Assessment Tool dated 5/4/17 revealed that R #24 had an unstageable sacral pressure ulcer measuring 4.6 cm (centimeters) long by 3.5 cm wide by 1.2 cm deep. Review of R #24's physician Telephone Orders dated 4/30/17 revealed an order for [REDACTED]. During observation of wound care by the Director of Nursing (DON) on 5/17/17 at 9:07 a.m., she was heard to tell R #24 that the treatment was going to be a little uncomfortable, and that she would be as gentle as I can. When the DON removed the old sacral dressing, a large, deep wound with a dry wound bed that contained grayish-black eschar was observed. When the DON cleaned the wound with wound cleanser that had been sprayed on gauze, R #24 was heard to say awwww in an uncomfortable tone. During further observation, the resident again said awwww when the wound was packed with the [MEDICATION NAME] dressing. At no point during the wound care observation did the DON stop and ask the resident if he was experiencing pain, nor if he wanted her to stop the treatment. R #24 did not express or exhibit any other signs of discomfort during continued observations of care after the treatment was completed. On 5/17/17 at 9:40 a.m., an interview was attempted with R #24 as he was asked if the wound care done today or the wound on his bottom hurt, but it could not be determined if the resident understood the question, and his verbalization could not be understood. Review of R #24's Medication Chart revealed that the last time that he received anything for pain prior to the wound care on 5/17/17 was on 5/16/17 at 8:00 a.m. This was verified during interview with Licensed Practical Nurse (LPN) NN on 5/17/17 at 9:33 a.m. During interview with Registered Nurse (RN) II on 5/18/17 at 1:35 p.m., she stated that she was the usual wound care nurse. She further stated that if a resident received a scheduled pain medication, she would do a dressing change around the time they received the pain medication. She also stated that if the resident only had a PRN pain medication scheduled, that she would ask the medication nurse to pre-medicate the resident prior to wound care if needed. During further interview, she stated that she had not been giving R #24 a pain medication prior to his wound care, as he denied pain during the treatment and was alert enough to let her know if he was hurting. During interview with the DON at this time, she verified that R #24 expressed discomfort when she cleaned and packed his wound, and did not know why she did not pre-medicate the resident prior to the dressing change. Review of the Pressure Ulcer Treatment Quick Reference Guide, developed by European Pressure Ulcer Advisory Panel (EPUAP) and National Pressure Ulcer Advisory Panel (NPUAP), 2009, related to management of pain from a pressure ulcer noted: Organize care delivery to ensure that it is coordinated with pain medication administration and that minimal interruptions follow. Encourage individuals to request a time-out during any procedure that causes pain.",2020-09-01
161,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2017-05-18,314,D,1,1,KH1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to use the correct wound care product as ordered, and failed to consistently do weekly skin assessments for one resident (R) #24, who was high risk for skin breakdown and currently had an unstageable pressure ulcer. The sample size was 37 residents. Findings include: 1. Review of R #24's clinical record revealed that he was admitted to the facility with [DIAGNOSES REDACTED]. Review of labs dated 4/7/17 revealed that he had an [MEDICATION NAME] level of 2.3 (normal 3.5-5.0). Review of a Braden Scale done on 5/15/17 revealed that he was assessed as high risk for skin breakdown. Review of a physician's orders [REDACTED]. Review of a Weekly Pressure Assessment Tool dated 4/5/17 revealed that the resident was readmitted to the facility that day with a Stage 3 sacral pressure ulcer. Review of his 30-Day Minimum Data Set ((MDS) dated [DATE] noted that he had severe cognitive impairment, was a pressure ulcer risk, and had one Stage 3 and one unstageable pressure ulcer. Review of physician's orders [REDACTED]. Review of Physician's Progress Notes dated 5/9/17 noted the resident continued to decline, and his Stage 3 sacral decubitus was not getting better. During observation of wound care to R #24's sacral wound performed by the Director of Nursing (DON) on 5/17/17 at 9:07 a.m., grayish-black eschar was noted in the wound bed, and the wound bed was dry. The DON was observed to clean the wound with wound cleanser, packed the wound bed with [MEDICATION NAME] Ag Extra, and covered the wound with a [MEDICATION NAME] dressing. During interview with the DON at this time, she stated that the [MEDICATION NAME] was used to help get rid of the slough, and to absorb moisture in the wound. Review of Weekly Pressure Assessment Tools dated 4/12/17 and 4/18/17 revealed that the wound had no drainage. Review of a Weekly Pressure Assessment Tool dated 5/4/17 revealed that the sacral pressure ulcer present on readmission as a Stage 3 was now unstageable and contained 100% slough. Further review of this Assessment noted that there was no drainage, and the wound progress was worse. During interview with the DON on 5/18/17 at 1:35 p.m., she verified that she used [MEDICATION NAME] Ag Extra instead of [MEDICATION NAME] Ag as ordered when she performed the wound care on 5/17/17, and stated that the Extra form of the product was all that was available on the treatment cart. During interview with Registered Nurse (RN) II at this time, who was the usual wound care nurse, she stated she thought that the Extra on the package labeling meant that the dressing was a larger size, not that it had any different properties than [MEDICATION NAME] Ag. During interview with RN II on 5/18/17, she stated that [MEDICATION NAME] Ag Extra was intended to be used for moderate to heavily-draining wounds, and was not the same product as [MEDICATION NAME] Ag, which was intended for light to moderately-draining wounds. Review of the facility's Dressing Changes policy revised (MONTH) 2007 noted that for a clean dressing change procedure, refer to treatment record and orders. Apply the appropriate dressing and secure. Review of the website of the manufacturer of [MEDICATION NAME] products revealed: [MEDICATION NAME] Ag Extra wound dressing is nine times stronger and has 50% greater absorbency as compared to the original [MEDICATION NAME] Ag wound dressing. 2. Review of R #24's Body Audit Forms since readmission to the facility on [DATE] revealed that skin assessments were done on 4/10/17 and 4/17/17, but none were found from 4/17/17 to 5/18/17. During interview with the DON on 5/17/17 at 9:25 a.m., she stated that the wound care nurse did the weekly skin assessments on all residents. During interview with RN II on 5/18/17 at 3:05 p.m., she stated that she was not able to find any other weekly skin assessments past 4/17/17 for R #24. She further stated that she was the one responsible for doing the skin assessments, but that she had not been able to do them lately because she was assigned to work on a med cart. During an observation of a skin assessment performed by RN II on R #24 on 5/18/17 at 3:21 p.m., the resident's feet were noted to be extremely dry and flaky, and a purplish area of skin was observed on his left lateral foot below the fifth toe. During interview with RN II at this time, she stated that she was not aware of this area, but the purplish area disappeared when the flaking skin in the area was removed. Review of the facility's Documentation of Treatments policy revised (MONTH) of 2009 noted: In order to assure proper monitoring and documentation of the condition of each resident's skin integrity, weekly assessments will be performed by a licensed nurse.",2020-09-01
162,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2017-05-18,322,D,1,1,KH1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to check for placement and residual prior to giving water flushes, medications, and enteral formula through a gastrostomy tube (GT) for one resident (R) #37. The sample size was 37 residents. Findings include: During a medication pass observation on 5/17/17 beginning at 12:54 p.m., Licensed Practical Nurse (LPN) KK was observed to prepare the medications for R #37 for administration via her GT. During further observation, the nurse connected the GT to a 60-mL (milliliter) syringe, and gave 80 mL of water flush, followed by the crushed medications dissolved in water, followed by a can of enteral formula, and followed with an additional 80 mL of water flush. The nurse was not observed to check the resident's GT for placement and/or residual enteral formula prior to the above observation. Review of R #37's physician's orders [REDACTED]. During interview with LPN KK on 5/17/17 at 1:25 p.m., she stated that she had forgotten to bring her stethoscope into R #37's room when she gave her medications, and verified that she did not check for placement of the GT or residual first. Review of the facility's Med Administration Enteral Feeding Tube policy revised (MONTH) of 2014 noted to check for correct placement of tube by injecting air and listening with stethoscope to abdomen or placing end of tube in glass of water and observing for air bubbles or aspiration of stomach contents. Review of the facility's Guidelines for Enteral Feeding policy last revised (MONTH) (YEAR) noted that open feeding systems bolus and/or gravity had the highest risk of side effects like abdominal distension, aspiration, reflux, diarrhea, vomiting and generation of high residual volumes.",2020-09-01
163,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2017-05-18,323,E,1,1,KH1211,"> Based on observation, record review and staff interview, the facility failed to keep potentially harmful chemicals in a secured area on two of four halls on two of two units (East and West units). There were 18 residents on the West unit and 17 residents on the East unit that were independently mobile and had severe cognitive impairment. The facility census in both buildings was 83 residents. Findings include: During initial tour of the facility in the East unit building on 5/15/17 at 9:45 a.m., the following observation was made in the unlocked Storage room across from room 123: On a shelf just inside the door were three 3-liter jugs with screw-on tops, low enough to be accessible by a resident in a wheelchair, with labeling that included: Cen-Kleen IV One-Step Disinfectant-Cleaner-Fungicide-Mildew Stat-Virucide. Danger. This observation was verified during interview with Licensed Practical Nurse (LPN) Supervisor LL on 5/15/17 at 9:53 a.m., who stated they normally kept chemicals locked up, and that these chemicals were used to clean the whirlpool tub. Observation at this time revealed that there were seven residents in the hall where this Storage closet was located, and LPN LL stated that six of them were independently mobile. During initial tour of the facility in the West unit building on 5/15/17 beginning at 10:11 a.m., an unlocked Custodian Closet was observed across from room 410. Further observation revealed the following chemicals inside that had TwistNFill caps unless noted otherwise: 1. One 1-gallon jug of DMQ Damp Mop Neutral Disinfectant Cleaner that had a measuring cup on the top and a screw-on lid on the floor in this closet. The jug was approximately 1/3 full, and the labeling included Danger. 2. Two 2-liter jugs of Heavy Duty Multi-Surface Cleaner Concentrate on a shelf; one jug was full and one jug was approximately 1/3 full. 3. Three 2-liter jugs of Non-Acid Disinfectant Bathroom Cleaner Concentrate on a shelf. One jug was approximately 1/2 full, and two jugs were full. The jug labeling included Danger. 4. One full 2-liter jug of Glass Cleaner Concentrate on a shelf. The above observation of unlocked chemicals was verified by the Administrator on 5/15/17 at 10:28 a.m., who stated that the closet was supposed to be kept locked. Review of a Resident Responses Analyzer report compiled by the East wing MDS (Minimum Data Set) Coordinator that listed residents with a Brief Interview for Mental Status (BIMS) score of less than 8 (a score of 0 to 7 indicates severe cognitive impairment) on their most recent MDS assessment, and who were independently mobile, revealed the following: West unit: 300-hall: 9 residents met this criteria 400-hall: 9 residents met this criteria East unit: First hall: 8 residents met this criteria Dining room hall: 9 residents met this criteria Review of Safety Data Sheets for the above chemicals revealed: Cen-Kleen IV: If on skin or hair, remove immediately all contaminated clothing, rinse skin with water. Wash contaminated clothes before reuse. If in eyes, rinse cautiously with water for several minutes. If swallowed, do NOT induce vomiting. Causes serious eye irritation. Causes skin irritation. DMQ Damp Mop Neutral Disinfectant Cleaner: Causes skin irritation and causes serious eye damage. Corrosive. Harmful if swallowed. Inhalation of vapors or mist may cause respiratory irritation. If in eyes, IMMEDIATELY CALL A POISON CENTER OR PHYSICIAN. 3M Glass Cleaner Concentrate: Serious eye damage/irritation. Non-Acid Disinfectant Bathroom Cleaner Concentrate: Acute toxicity (oral); serious eye damage/irritation; skin corrosion/irritation. Harmful if swallowed. Causes serious eye damage. Causes severe skin burns and eye damage. Heavy Duty Multi-Surface Cleaner Concentrate: Causes serious eye damage. Causes skin irritation. (MONTH) cause an allergic skin reaction. For skin contact, immediately wash with soap and water. Remove contaminated clothing and wash before reuse. For eye contact, immediately flush with large amounts of water for at least 15 minutes. Immediately get medical attention.",2020-09-01
164,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2019-06-27,550,D,1,1,3SRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, record review, and review of the policies Urinary Catheter Policy, (Insertion, Maintenance, Irrigation) and Resident's Federal and State Rights the facility failed to place a privacy bag over the indwelling Foley catheter of 3 out of 8 residents (R) (R#3, R#8, and R#127) on 1 of 2 units. Findings include: 1. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#3 revealed in section (C) a Basic Interview for Mental Status (BIMS) score of 11/15 indicating intact cognitive responses, (E) Behaviors - None. (G) Functional Status - 2+ person physical assist. (H) Bowel and Bladder - Indwelling Foley Catheter, and always incontinent of bowel. (I) Active Diagnosis (including but not limited to) - [MEDICAL CONDITION] bladder. (N) Medications - Antianxiety, antidepressant, diuretic, and opioid 7/7 days a week. Review of the medical record for R#3 revealed an order dated (MONTH) 2, 2019 for an 18 French Catheter with 20cc Balloon. Change monthly and as needed related to malfunction. During an observation on 6/24/19 at 1:30 p.m. of R#3 in her room revealed her catheter bag to be hanging, uncovered, on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 9:12 a.m. of R#3 in her room revealed her catheter bag to be hanging, with the upper portion of the bag covered, revealing the mid and lower portion of the bag. The catheter bag was noted to be on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 11:10 a.m. of R#3 during activities revealed her to be sitting in her wheelchair with the catheter bag hanging below the back of the chair and it was noted to be uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered completely and preferably hanging on the opposite side of the bed away from view of the hallway. She stated that if the resident is in a wheelchair she would expect the catheter bag to be hanging below the bladder underneath the back side of the wheelchair, off the floor, and covered. During an interview on 6/26/19 at 9:20 a.m. with Activities Coordinator/CNA AA she stated that she knows from working on the floor as a CNA that catheters should be hung below the bladder and should be covered to protect the privacy of the resident. She stated that she has had in-services regarding care of catheters related to Activities of Daily Living but nothing about privacy or where a catheter bag should be placed. During an interview on 6/26/19 at 9:25 a.m. with RN Supervisor CC she stated if a resident has a catheter she would expect nursing staff to ensure the catheter bag was placed below the bladder and that it was covered with a privacy bag. 2. Review of the Quarterly Minimum Data Set (MDS) for R#8, dated 3/23/19, section (C), revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. (E) Behaviors - None. (G) Functional Status - Extensive one-person physical assist. (H) Bowel and Bladder - Indwelling Urinary Catheter and is frequently incontinent of bowel. (I) Active Diagnosis - (Including but not limited to) [MEDICAL CONDITION]. (N) Medications - Antianxiety and Antidepressant 7/7 days a week. Review of the medical record for R#8 revealed an order dated (MONTH) 25, (YEAR) for an 18 French Catheter with 30cc Balloon. Change monthly and as needed related to [MEDICAL CONDITION]. During an observation of R#8 on 6/24/19 at 12:19 p.m., in his room, revealed his catheter bag uncovered and laying in his lap. During an observation of R#8 on 6/24/19 at 12:25 p.m. sitting in the dining room. Catheter bag noted in R#8's lap, uncovered. Catheter tubing noted to be looped up toward his left shirt pocket. During an observation on 6/24/19 at 12:40 p.m. in the dining room R#8 was served lunch. Catheter remained in his lab and the tubing remained looped up toward his left shirt pocket. During an observation on 6/24/19 at 1:00 p.m. in the dining room Activity Director/Certified Nursing Assistant (CNA) AA took R#8's tray, then R#8 propelled himself out of the dining room and down the hall. Catheter bag remained on R#8's lap, uncovered. During this time the catheter tubing was observed to be resting next to his left leg. During an observation on 6/24/19 at 1:10 p.m. in the hall revealed Registered Nurse (RN)/Supervisor CC stand in front of R#8 in the hall, speak to him momentarily, then walk away. During this time Activities Director/CNA AA escorted the resident into her office to complete section F of the MDS. With R#8's permission this surveyor observed the interview. The interview was completed at 1:25 p.m. and CNA AA took R#8 to his room. At no time did RN/Supervisor CC or CNA AA acknowledge the catheter bag in R#8's lap, that it did not have a cover, or place it below the bladder of R#8. During an observation on 6/25/19 of R#8 at 9:00 a.m. revealed him propelling wheelchair down hall with catheter bag noted hanging under chair uncovered. During an observation on 6/25/19 of R#8 at 11:15 a.m. in bed. Catheter bag noted hanging on left side of bed, uncovered, and exposed to hallway. During an observation on 6/25/19 of R#8 at 12:50 p.m. in dining room revealed his catheter bag hanging under his wheelchair uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered and preferably hanging on the opposite side of the bed away from view of the hallway. She stated that if the resident is in a wheelchair she would expect the catheter bag to be hanging below the bladder underneath the back side of the wheelchair, off the floor, and covered. LPN/Unit Manager BB stated that a privacy bag should cover the whole catheter bag to insure the resident privacy. She stated that R#8 was just put on antibiotics for a Urinary Tract Infection [MEDICAL CONDITION]. During an interview on 6/26/19 at 9:20 a.m. with Activities Coordinator/CNA AA she stated that she knows from working on the floor as a CNA that catheters should be hung below the bladder and should be covered to protect the privacy of the resident. She stated that she has had in-services regarding care of catheters related to Activities of Daily Living but nothing about privacy or where a catheter bag should be placed. Activity Director/CNA AA stated that she does remember seeing the catheter bag laying in R#8's lap but stated she was focused on what she was doing and just didn't think to place the bag in the correct place and stated she will definitely be more aware in the future. During an interview on 6/26/19 at 9:25 a.m. with RN Supervisor CC she stated if a resident has a catheter she would expect nursing staff to ensure the catheter bag was placed below the bladder and that it was covered with a privacy bag. She stated that if a catheter bag was observed not to be below the bladder she would expect staff to place the catheter bag below the bladder and ensure it was covered with a privacy bag. RN/Supervisor CC stated that R#8 moves his catheter around and sometimes puts it in his lap and staff remind him not to bother his bag. She stated that she remembers seeing the catheter bag in R#8's lap and stated that she had her mind on what she was doing at that time and just didn't think to place the catheter bag in the correct place but would be more mindful in the future. 3. Review of the clinical record for R#127 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no data available on Minimum Data Set (MDS) due to new admission status with entry tracking MDS dated [DATE]. Observation on 6/25/19 at 11:54 a.m. revealed resident (R) #127 sitting in his wheelchair in the hallway, across from the nurse's station on West Unit. Catheter bag was hanging from the arm of the wheelchair, above the level of the bladder. The tubing was looped over the arm rest of the chair. There was no evidence of a privacy bag covering the drainage bag. Observation on 6/26/19 at 9:06 a.m. revealed R#127 sitting in wheelchair in hallway, across from nurse's station. Catheter bag was hanging from back of wheelchair. There was no evidence of a privacy bag in use to cover drainage bag. Interview on 6/27/19 at 8:19 a.m. with Licensed Practical Nurse (LPN) LL, stated that residents with catheters, should have a privacy bag over the urine drainage collection bag. She stated that she did not notice that R#127 did not have a privacy bag over the drainage bag. Review of the Urinary Catheter Policy, (Insertion, Maintenance, Irrigation) policy revised (MONTH) (YEAR) revealed to maintain unobstructed urine flow by keeping the collection bag below the level of the bladder, and the tubing free of kinks. Urine flow must be downhill. Keep the collection bag off the floor. Review of the policy titled Resident's Federal and State Rights dated (MONTH) (YEAR) revealed the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Refer to F656",2020-09-01
165,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2019-06-27,584,D,1,1,3SRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in six resident rooms on one of four halls and one of two units (402 B, 403 B, 405, 406, 407 and 409) related to dirty air conditioner face grills and scratched paint on door frame. The sample size is 39. Findings include: Observation on 6/24/19 at 10:25 a.m. revealed in room [ROOM NUMBER] B, the call light was pulled out of the wall and laying on the floor. Resident stated it has not worked since he was admitted on [DATE]. Observation on 6/24/19 at 1:43 p.m. revealed in room [ROOM NUMBER] B, no privacy curtain hanging from ceiling. Observation on 6/24/19 at 1:49 p.m. revealed in room [ROOM NUMBER], bathroom door frame with multiples patches of chipped paint. Observation on 6/24/19 at 1:52 p.m. revealed in room [ROOM NUMBER], air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Observation on 6/24/19 at 1:55 p.m. revealed in room [ROOM NUMBER], air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Observation on 6/24/19 at 1:58 p.m., revealed in room [ROOM NUMBER] A, the call light switch plate on wall above bed was loose and missing two screws. Observation on 6/25/19 at 12:23 p.m., revealed in room [ROOM NUMBER] the air conditioner unit face grill dusty with small black spots, approximately two centimeters in diameter, on the slats. Interview on 6/25/19 at 9:00 a.m. with Maintenance Technician NN, stated that he has been having to change several call lights, because of the ten foot long cords. He stated they get tied around the side rails and when the rails go up and down, it puts tension on the cord, causing it to break at the point of connection. Interview on 6/27/19 at 10:28 a.m. with Housekeeper II, stated that she is the only housekeeping staff for the West Unit. She stated that she cleans each resident room daily. She stated that she sweeps, mops, wet dusts with a sanitizing cleaner. She wet dusts all surface items in resident rooms, including table tops, side rails on bed, window sills, blinds, bathroom toilets, sinks and mirrors. She also empties the trash and makes sure toiletries are stocked. She stated that she does not clean the air conditioners or wipe them down. Interview on 6/27/19 at 10:30 a.m. with Housekeeping Director, stated that the Housekeeping staff are to clean residents entire room, including inspecting privacy curtains. She further stated the housekeeping staff are supposed to be wiping down the air conditioner (AC) units. She verified on walking rounds the dirty AC face grills identified during the survey in rooms 406, 407, 409, and also that room [ROOM NUMBER] bed B did not have a privacy curtain.",2020-09-01
166,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2019-06-27,656,D,1,1,3SRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review, the facility failed to follow the person-centered comprehensive care plan related to privacy bags for 3 out of 8 residents (R) (R#3, R#8, and R#127) with indwelling Foley catheters on 1 of 2 units. Findings include: 1. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#3 revealed in section (C) a Basic Interview for Mental Status (BIMS) score of 11/15 indicates intact cognitive responses. (E) Behaviors - None. (G) Functional Status - 2+ person physical assist. (H) Bowel and Bladder - Indwelling Foley Catheter, and always incontinent of bowel. (I) Active Diagnosis (including but not limited to) - [MEDICAL CONDITION] bladder. (N) Medications - Antianxiety, antidepressant, diuretic, and opioid 7/7 days a week. Review of the care plan with an initiated date of 1/19/18 and revision date of 1/2/19 revealed R#3 has an indwelling Foley catheter. Interventions include: Position catheter bag and tubing below the level of the bladder with a privacy cover over the bag. Review of the medical record for R#3 revealed an order dated (MONTH) 2, 2019 for an 18 French Catheter with 20cc Balloon. Change monthly and as needed related to malfunction. During an observation on 6/24/19 at 1:30 p.m. of R#3 in her room revealed her catheter bag to be hanging, uncovered, on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 9:12 a.m. of R#3 in her room revealed her catheter bag to be hanging, with the upper portion of the bag covered, revealing the mid and lower portion of the bag. The catheter bag was noted to be on the left side of the frame of the bed and visible from the hallway. During an observation on 6/25/19 at 11:10 a.m. of R#3 during activities revealed her to be sitting in her wheelchair with the catheter bag hanging below the back of the chair and it was noted to be uncovered. During an interview on 6/26/19 at 9:16 a.m. with Licensed Practical Nurse (LPN)/Unit Supervisor BB she stated if a resident has a catheter, and is in the bed, she would expect the catheter bag to be covered completely and preferably hanging on the opposite side of the bed away from view of the hallway. She stated that if the resident is in a wheelchair she would expect the catheter bag to be hanging below the bladder underneath the back side of the wheelchair, off the floor, and covered and stated nursing staff know this because it is in the residents care plan. During an interview on 6/26/19 at 9:25 a.m. with RN Supervisor CC she stated if a resident has a catheter she would expect nursing staff to ensure the catheter bag was placed below the bladder and that it was covered with a privacy bag. She stated that all residents with a Foley catheter have a care plan related to privacy bags and ensuring the catheter is maintained below the bladder. 2. Review of the Quarterly Minimum Data Set (MDS) for R#8, dated 3/23/19, section (C), revealed a Brief Interview for Mental Status (BIMS) score of 6 indicating severely impaired cognition. (E) Behaviors - None. (G) Functional Status - Extensive one-person physical assist. (H) Bowel and Bladder - Indwelling Urinary Catheter and is frequently incontinent of bowel. (I) Active Diagnosis - (Including but not limited to) [MEDICAL CONDITION]. (N) Medications - Antianxiety and Antidepressant 7/7 days a week. Review of the care plan for R#8 revealed an Indwelling Catheter related to [MEDICAL CONDITION] and [MEDICAL CONDITION]. Interventions include: change every month and as needed (prn) for dysfunction using size of Foley catheter as ordered with 30cc balloon, position catheter bag and tubing below the level of the bladder and away from entrance room door, check tubing for kinks each shift and PRN, monitor and document intake and output, monitor for signs and symptoms of discomfort on urination and frequency, monitor/record/report to Medical Doctor (MD) for signs and symptoms of Urinary Tract Infection [MEDICAL CONDITION]: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns, [MEDICATION NAME] to secure urinary catheter, change weekly and as needed (prn). Review of the medical record for R#8 revealed an order dated (MONTH) 25, (YEAR) for an 18 French Catheter with 30cc Balloon. Change monthly and as needed related to [MEDICAL CONDITION]. During an observation of R#8 on 6/24/19 at 12:19 p.m., in his room, revealed his Foley catheter bag uncovered and laying in his lap. During an observation of R#8 on 6/24/19 at 12:25 p.m. sitting in the dining room. Catheter bag noted in R#8's lap, uncovered. Catheter tubing noted to be looped up toward his left shirt pocket. During an observation on 6/24/19 at 12:40 p.m. in the dining room R#8 was served lunch. Catheter remained in his lab and the tubing remained looped up toward his left shirt pocket. During an observation on 6/24/19 at 1:00 p.m. in the dining room Activity Director/Certified Nursing Assistant (CNA) AA took R#8's tray, then R#8 propelled himself out of the dining room and down the hall. Catheter bag remained on R#8's lap, uncovered. During this time the catheter tubing was observed to be resting next to his left leg. During an observation on 6/24/19 at 1:10 p.m. in the hall revealed Registered Nurse (RN)/Supervisor CC stand in front of R#8 in the hall, speak to him momentarily, then walk away. During this time Activities Director/CNA AA escorted the resident into her office to complete section F of the MDS. With R#8's permission this surveyor observed the interview. The interview was completed at 1:25 p.m. and CNA AA took R#8 to his room. At no time did RN/Supervisor CC or CNA AA acknowledge the catheter bag in R#8's lap, that it did not have a cover, or place it below the bladder of R#8. During an observation on 6/25/19 of R#8 at 9:00 a.m. revealed him propelling wheelchair down hall with catheter bag noted hanging under chair uncovered. During an observation on 6/25/19 of R#8 at 11:15 a.m. in bed. Catheter bag noted hanging on left side of bed, uncovered, and exposed to hallway. During an observation on 6/25/19 of R#8 at 12:50 p.m. in dining room revealed his catheter bag hanging under his wheelchair uncovered. 3. Review of the clinical record for R#127 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no data available on Minimum Data Set (MDS) due to new admission status with entry tracking MDS dated [DATE]. Review of R#127 care plan initiated on 6/18/19 revealed resident has indwelling catheter related to [MEDICAL CONDITION]. Interventions to care include change monthly and as needed (PRN) for dysfunction. Monitor each shift as per protocol. Position the catheter bag and tubing below the level of the bladder with a privacy cover over the bag. Observation on 6/25/19 at 11:54 a.m. revealed resident (R) #127 sitting in his wheelchair in the hallway, across from the nurse's station on West Unit. Catheter bag was hanging from the arm of the wheelchair, above the level of the bladder. The tubing was looped over the arm rest of the chair. There was no evidence of a privacy bag covering the drainage bag. Observation on 6/26/19 at 9:06 a.m. revealed R#127 sitting in wheelchair in hallway, across from nurse's station. Catheter bag was hanging from back of wheelchair. There was no evidence of a privacy bag in use to cover drainage bag. Interview on 6/27/19 at 8:19 a.m. with Licensed Practical Nurse (LPN) LL, stated that residents with catheters, should have a privacy bag over the urine drainage collection bag. She stated that she did not notice that R#127 did not have a privacy bag over the drainage bag.",2020-09-01
167,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2019-06-27,695,D,1,1,3SRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, staff interviews and review of the policy titled Oxygen Policy, the facility failed to ensure Oxygen concentrator filter was clean for one resident (R) (R#126). The sample size was 39. Findings include: Review of the facility policy titled Oxygen Policy revealed the policy states the facility shall provide oxygen therapy as ordered by the physician. Oxygen concentrator will be used for continuous therapy, with oxygen tanks available for emergency or temporary use. Concentrator filters are to be cleaned weekly in warm, soapy water, rinse and dried. Filters will be changed as needed. Review of the clinical record for R#126 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was no data available on Minimum Data Set (MDS) due to new admission status with entry tracking MDS dated [DATE]. Review of R#126 care plan initiated on 6/21/19 revealed resident has oxygen therapy related to shortness of breath. Interventions to care include oxygen settings at two Liters via nasal cannula continuous to keep sats above 90%. Observation on 6/24/19 at 1:25 p.m. revealed oxygen in use via concentrator at bedside. Concentrator has external filter on right side that is covered with thick gray layer of dust. Observation on 6/25/19 at 8:25 a.m. revealed oxygen in use via concentrator. External filter remains with thick gray layer of dust. Observation on 6/26/19 at 12:51 p.m. revealed oxygen in use via concentrator. External filter continues to have thick gray layer of dust. Observation on 6/27/19 at 8:09 a.m. revealed oxygen continues to be used, delivered by concentrator. External filter remains with thick gray layer of dust. Physician's order dated (MONTH) 27, 2019 revealed an order for [REDACTED]. Interview on 6/27/19 at 8:19 a.m. with Licensed Practical Nurse (LPN) LL stated the night shift is responsible for changing oxygen tubing, nebulizer masks and humidification bottles. She stated she is not sure whether or not it needs to be dated. She further stated that she is not sure about who is responsible for cleaning the filters on the concentrators. Interview on 6/27/19 at 8:30 a.m. with Licensed Practical Nurse (LPN) Unit Manager (UM) BB, stated that oxygen tubing, nebulizer masks and humidification bottles are changed out weekly by the night shift staff and it is done on Tuesday's, and as needed (PRN). She stated they should be dated as to when they were changed. She further stated that the filters should also be cleaned and/or changed on Tuesday by the night shift. She verified the filter on the oxygen concentrator for R#126 was dirty with gray dust.",2020-09-01
168,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2019-06-27,812,E,1,1,3SRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, observation, and review of policy titled Storage of Food and Supplies the facility failed to label and date opened food items in two of the walk-in coolers, walk-in freezer; and dry food storage area; failed to ensure cleanliness of food preparation stations; failed to ensure cleanliness and proper storage of ice machine scoop. The deficiency practice had the potential to affect 27 of 29 residents receiving an oral diet. The facility census was 76. Findings include: An initial tour of the kitchen was conducted on [DATE] from 11:08 a.m. to 11:50 a.m. with Dietary Service Director (DSD) CC, he confirmed that he wasn't a Certified Dietary Manager (CDM) at this time and his serv -safe is currently expired and was taking [DATE] off from work to renew his certification. He reported the serv-safe certified personnel Registered Dietitian (RD), and himself (currently expired). The DSD confirmed they had 20 food service staff that included the staff for the Bistro, Suite One Cafe and the two skilled nursing facility (SNF) called the Healthcare Kitchen. He explained the main kitchen provides meals to the hospital and the two skilled nursing facility. The Suite One Cafe serve staff, guest and any residents in the (SNF) and hospital that desire to go there on the second floor, which is a part of the Healthcare Kitchen services. During this initial observation and interview, DSD EE acknowledged that several food items were insecurely wrapped and unlabeled located in both walk-in refrigerators and deep freezer. The DSD EE confirmed that there should labels on each container containing the flour, sugar, breadcrumbs, with scooper removed from contents. He stated that due to the high turnover of staff, it's hard to keep track and remind them of the potential hazards. Continued observations on [DATE] of the Healthcare Kitchen with DSD EE present included: Walk-in refrigerators revealed the following unlabeled and no dated food items 1. One large bag of Spinach with no open date or expiration date. 2. A salami sandwich meat with no open date or expiration date. 3. Sliced yellow cheese with no open date or expiration date. 4. Extra heavy mayonnaise one-gallon container with no open date or expiration date. 5. Chopped garlic container five-ounce (oz.) container with no open date or expiration date. 6. Diced tomatoes container 32 (oz.) container with no open date or expiration date. 7. String beans 10 pounds (lbs.) bag Walk-in freezer revealed the following exposed unlabeled and no open date items 1. Three- five (oz.) deep skinned tilapia fish slices uncovered and no open date or expiration date. 2. Sweet green peas with no open date or expiration date. 3. A10-inch (in.) unbaked pie shells with no open date or expiration date. 4. Pound cake with no open date or expiration date. 5. Two (2)- 2 (oz.) frozen southern biscuits with no open date or expiration date. Tour of kitchen area with DSD EE revealed four containers of dry foods. The flour and sugar were observed inside a large white rubber 100 cup partially closed storage bin. Inside the container revealed two measuring scoopers left inside the contents with no open date. The white rubber container revealed several dried dark brown, yellowish stains three inches in diameter with no odor. The rice and breadcrumbs were observed in separate clear plastic containers with no open date and scooper left inside the contents. The food preparation areas with storage shelve underneath revealed dried old food stains and dust. The ice machine chute revealed that the white scooper was left inside the machine and stuck into the frozen mass of ice. Interview on [DATE] at 12:05 p.m. with DSD EE revealed that staffing issues is the cause of lack in knowledge related to safe food practices. He removed the ice scooper from the ice machine and delivered it to the dishwashing station. He also reported that all staff are responsible for checking food in the refrigerator and on the shelves in the pantry to assure food is covered, labeled and not expired. He further explained that when the items are placed in the plastic storage container a label should be added to the container identifying the use date that is listed on the original package. DSD EE revealed that all items should be labeled and dated. Interview on [DATE] at 12:08 p.m. with RD revealed that she works full-time at the facility. She states she helps in the kitchen when needed, which includes menus audits and correction. She reports seventy-four oral diets which include two tube feedings at the facility. Observation and tour on [DATE] at 12:10 p.m. with, Executive Chef (EC) FF of the food pantry revealed: 1. Five 20 oz. boxes of dried pinto beans, dried lentil beans, dried navy beans with pour spout left opened and uncovered. 2. One 8 oz. bag of pasta with no open date or expiration date. 3. One 16 oz. bag of marshmallow with no open date or expiration date. Interview on [DATE] at 10:00 a.m. with EC FF revealed he'd been employed for [AGE] years with the facility. He states when handling food storage; he makes sure he rotates first in and first out. He states that all storage containers should be six inches from the ground and not against the wall. He reports all open containers should be labeled with a date and that dented/damaged can goods are returned to the supplier. He states he's never received any training from the facility on the storage of food and supplies. Interview on [DATE] at 10:05 a.m. with (Dietary Aide) GG, revealed she'd been employed for four years with the facility. She states she never received any formal training from the facility on the storage of food and supplies. She states when she handles any storage of food, she makes sure it in a clear container with an label including the date opened. She states food must be thrown out within five days after opening. Interview on [DATE] at 3:10 p.m. with DSD revealed that although he has cleaning/closing checklist for employees to follow and ensure safe food storage and handling, he hasn't been using them due to the shortage of staff. Review of an undated policy titled Food Storage and Handling revealed that is the policy of the dining service department to cover, label, date and store foods in a safe appropriate manner. Review of an undated policy titled Food Storage and Handling revealed that it is the policy of the dining service department to cover, label, date, and store foods in a safe, appropriate manner. All cooked foods, pre-packaged open containers, protein-based salads, desserts, and canned fruits are labeled, dated, and securely covered. Cooked foods are stored above raw meats, poultry, and fish, at a temperature of 41 degrees for below. Frozen food storage is defined as 10 degrees or below. All products are rotated using first-in, first out (FIFO) inventory system. Dry bulk items, such as rice, sugar, and flour, are stored in seamless containers with tight-fitting lids and are clearly labeled. Scoops should not be left in food bins. Procedure: Dating system for open foods Follow the label P&P Always securely cover food item Using a label, complete the following: Write the expiration date on the product, using the guide below Clearly write the products name Return to designated storage (refrigeration, freezer, or storeroom) Check labels daily and discard outdated foods.",2020-09-01
169,HABERSHAM HOME,115099,"HIGHWAY 441 NORTH, BOX 37",DEMOREST,GA,30535,2019-06-27,880,D,1,1,3SRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to practice infection control policy for washing and/or sanitizing hands during wound care procedure. The facility census was 76 residents. Findings include: 1. Observation on 6/24/19 at 12:24 p.m. revealed in room [ROOM NUMBER] B, an un-bagged and unlabeled toothbrush sitting on sink counter and un-bagged and unlabeled urinal sitting on the floor beside the toilet. Observation on 6/21/19 at 1:28 p.m. revealed in room [ROOM NUMBER] A, two (2) un-bagged and unlabeled toothbrushes sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 1:50 p.m. revealed in room [ROOM NUMBER] B, one (1) un-bagged and unlabeled toothbrush sitting on sink counter and one un-bagged and unlabeled bath basin on floor under the sink. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 1:58 p.m. revealed in room [ROOM NUMBER] A, one (1) un-bagged and unlabeled toothbrush sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/24/19 at 2:07 p.m. revealed in room [ROOM NUMBER] B two (2) un-bagged and unlabeled toothbrushes sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/25/19 at 10:14 a.m. revealed in room [ROOM NUMBER], one (1) unbagged and unlabeled toothbrush sitting on sink counter. Bathroom is shared by two (2) female residents. Observation on 6/25/19 at 10:47 a.m. revealed an un-bagged and unlabeled urinal sitting on grab bar in bathroom. 2. Observation on 6/26/19 at 2:03 p.m., with Licensed Practical Nurse (LPN) wound care nurse JJ performed wound care for R#13. She gathered all materials needed for the procedure and placed them in plastic cups. She sanitized the residents over bed table and placed a barrier on the table and placed the plastic cups with supplies on the barrier. She washed her hands and donned on clean gloves and removed the old dressing. Dressing was discarded in trash can in residents room. Nurse changed her gloves, but did not wash or use hand sanitizer. She donned a clean pair of gloves and cleansed the wound on left lower leg with wound cleanser. She then laid the residents leg on a pillow that was used to prop the leg. The nurse did not place a barrier on the pillow, before laying the leg onto the pillow. She then removed her gloves, and donned a clean pair of gloves, but did not wash her hands or use hand sanitizer. After donning clean gloves, nurse placed a moistened 4X4 gauze pad over the wound surface and covered with dry 4X4 gauze pad and wrapped with roll gauze. She secured the dressing with tape, dated and initialed it. She removed her gloves, gathered the garbage bag from the residents rooms and discarded in soiled utility room. She then washed her hands after discarding the garbage. Interview on 6/26/19 with Licensed Practical Nurse (LPN) JJ stated that she uses hand sanitizer when changing her gloves multiple times during the procedure. She further stated that she was nervous during the observation and she forgot to use hand sanitizer. Interview on 6/27/19 at 8:30 a.m. with Licensed Practical Nurse Unit Manager BB, stated it is her expectation that all staff provide care to the residents as ordered. She stated that wound care should be done following Physician orders [REDACTED]. She further stated the nurses should be wearing gloves and washing hands or using hand sanitizer between glove changes. Interview on 6/27/19 at 10:10 a.m. with Infection Control Nurse KK, stated that she comes over to the West Unit once per week. She provides educational trainings on infection control for hand washing, using gloves, and best practices for Infection Control. While she is on the West Unit, she makes walking rounds and does random spot checks for staff following infection control practices. She stated that she will walk into residents rooms, looking for proper storage of personal care equipment. She stated that she would expect the equipment to be labeled with resident's name, but not sure about whether the items need to be bagged or not. She verified on walking rounds with Director of Nursing (DON), the concerns identified during the survey. She stated that for wound care, she would expect staff to change gloves often and wash hand or sanitize between glove changes.",2020-09-01
170,NHC HEALTHCARE ROSSVILLE,115104,1425 MCFARLAND AVE,ROSSVILLE,GA,30741,2018-04-19,758,D,0,1,IBN211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to discontinue orders for as needed (PRN) antianxiety medications for two residents (#80 and #239) after 14 days, failed to indicate the need to extend the order beyond that period, and failed to document the reason for the extension or the period during which the extended order should be in effect. The sample size was 21. Findings include: Review of the undated policy titled, Medication Utilization and Prescribing - Clinical Protocol, the physician and staff of the facility are to review the rationale for prescribed medications that lack a clear indication for use or are being used intermittently on a PRN basis, and the physician will provide/document a rationale when the dose, duration, or frequency of a prescribed medication exceeds the accepted practice or manufacturer's recommendation. 1. Review of the clinical records for Resident (R)#80 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the admission minimum data set (MDS) assessment of 1/8/18 revealed active [DIAGNOSES REDACTED]. The assessment also documented that the resident was receiving antianxiety medications 7 of 7 days. Review of the current order sheets for R#80 revealed an order for [REDACTED]. Review of the medication administration records (MARs) for R#80 revealed no administration of PRN [MEDICATION NAME] in February, (MONTH) or (MONTH) of (YEAR) 2. Review of the clinical record revealed R#239 was admitted on [DATE] with current and has current [DIAGNOSES REDACTED]. Review of R#239's quarterly MDS assessment of 2/8/18 revealed active [DIAGNOSES REDACTED]. The assessment also documented that the resident had was receiving antianxiety medications. Review of the current physician order [REDACTED]. Review of MARs revealed that PRN [MEDICATION NAME] 1 mg was last administered to R#239 on 3/2/18. Interview on 4/19/18 at 9:32 a.m. with the Assistant Director of Nursing (ADON) revealed residents on hospice such as R#80 and R#239 have their medication orders managed by the hospice physician. However, medications for all the residents are also managed and reviewed by the facility's pharmacist. When a resident receives a PRN order for a [MEDICAL CONDITION] medication such as [MEDICATION NAME], the pharmacy reviews the order and adds a 14-day stop order for that medication. She was not sure why such a stop order was not added to the resident's order for the [MEDICATION NAME] 1 mg every four hours as needed. Further review of the MARs for R#80 and R#239 on 4/19/18 at 2:00 p.m. revealed the orders for PRN [MEDICATION NAME] was discontinued as of 4/19/18.",2020-09-01
171,NHC HEALTHCARE ROSSVILLE,115104,1425 MCFARLAND AVE,ROSSVILLE,GA,30741,2018-04-19,761,D,0,1,IBN211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow the policy titled Storage of Medications and Biological ' s . The facility failed to ensure proper disposal of expired medication in one of three medication carts. Sampled size is 21. Findings Include: On 4/17/18 12:00 p.m. three medication carts were observed, with one expired medication in one cart: On 4/17/18 at 12:00 p.m. during an observation with Licensed Practical Nurse (LPN) EE found expired medication in cart number one of the three carts on the North Wing. One Humalog 100 Units milliliters of Kwik insulin [MEDICATION NAME] pen injection opened 3/16/18, expired 4/13/18. A record review of the facility ' s Storage of Biological Medications and Medication Administration policy with an issue date of (MONTH) 1st, 2007 and a review/revision date of (MONTH) 1st, 2010/ (MONTH) 1st, 2013, revealed the facility will ensure medications and biological's are stored, labeled, and disposed of properly by expiration date. An interview on 4/17/18 at 12:00 p.m. with the Licensed Practical Nurse (LPN) EE revealed staff are expected to date and label all medications when opened and check for expired medications in the medication carts on a daily basis before the administration of medication to all residents. An interview on 4/17/18 at 12:10 p.m. with the Director of Nursing (DON) revealed staff are in-serviced on medication storage, medication administration, and medication expiration date. An interview on 4/18/18 at 10:15 a.m. with the Pharmacy Consultant revealed staff are in-serviced on medication storage, medication administration, and medication expiration date on monthly basis.",2020-09-01
172,NHC HEALTHCARE ROSSVILLE,115104,1425 MCFARLAND AVE,ROSSVILLE,GA,30741,2019-06-27,585,D,0,1,7CZH11,"Based on record review, resident and staff interview, and review of the policy, Services Recovery/Grievance Procedure, the facility failed to document and promptly respond to a grievance filed by one resident (#48) from a sample of 30 residents. Findings include: During an interview on 6/24/19 at 2:14 p.m., R#48 revealed that the Certified Nursing Assistant (CNA) who assisted her with her shower on 6/17/19 had ignored her instructions on how to assist her from moving from a seated to a standing position. The resident said she did not believe the CNA was abusive, but by failing to follow her instructions about the best way to assist her, the CNA had inadvertently left a bruise on her right forearm. The resident said she had immediately called for the Director of Nursing (DON) to come to her room at which time she lodged a complaint about the CN[NAME] The DON told her she wrote it up, but no member of the facility staff had since communicated to her what was the outcome of her grievance/complaint. A review of the quarterly Minimum Data Set (MDS) assessment of 5/2/19 revealed that Resident (R) #48 had a Brief Interview for Mental Status (BIMS) score of 14. A score of 13-15 indicates that an individual is cognitively intact. Review of the undated policy, Services Recover/Grievance Procedure, revealed that staff are expected to address resident and family concerns as soon as they become aware of them. The center social worker was identified as center ombudsman responsible for following up in a timely manner, and documenting the summary, investigation, corrective action, resolution, and follow up of each concern reported. During an interview on 6/26/19 at 10:41 a.m. with the Admission Director (AD), it was revealed that residents are informed of the grievance process upon entrance and a copy of the process is provided in their admission packet. The AD also said that the Social worker (out on leave) was the facility's grievance officer), but that residents were informed that any member of staff was available to take their grievances. A review of the grievance procedure titled, Grievance Official provided by the admission director revealed that residents are encouraged to report grievances to staff, verbally or in writing and are assured that a response should be expected as quickly as possible, certainly within 5 working days. The grievance procedure advised residents to first report their concerns to the social worker, but also directed them to report further to other members of staff such as the director of nursing, even up to the administrator if needed. A review of the facility's grievances filed during the previous 6 months revealed no documented grievance related to the incident alluded to by R#48. During an interview on 6/26/19 at 2:35 p.m., the DON said she had spoken with R#48 the previous week (she believed the conversation occurred on 6/19/19, but was not sure) regarding a concern the resident expressed about one of the CNAs. The DON said the resident complained to her that the CNA helping her with her shower earlier in the day had not assisted her in rising from the shower seat to a standing position in a way in which the resident wanted/directed and that the CNAs decision to ignore her wishes had caused a bruise on the resident's right forearm. The DON said she had spoken with the resident's charge nurse and the charge nurse said the resident had the bruise on her arm prior to the day of the incident and that the prior weekly skin assessment documented this. The DON said she had also asked other residents if there were any concerns related to the CNA and no other resident had a concern. The DON further said the resident had complained about having new CNAs take care of her in the past, but said that the CNA, in question, was not new to the organization, but new to the facility. The DON had reassigned the CNA, in question, and had since assigned only CNAs that had worked at the facility for a long time and was familiar with the resident's preferences to provide care to her. The DON said she had not documented the investigation she completed related to this complaint, nor had she filed it as a grievance. She had not considered the resident's expressed concern to be a grievance at the time it was reported to her. During a follow-up interview on 6/26/19 at 3:18 p.m., the DON said that the facility Social worker normally acted in the role of the facility's grievance officer and, in this role, would normally be the person to document the residents' grievances, ensuring that their concerns were followed up with and resolved in a timely manner. The DON further said that the social worker had been away since the previous week and this contributed to the resident's grievance not being filed/documented in a timely manner. The DON said she would have another member of staff immediately document the resident's concern as a grievance and follow the grievance protocol.",2020-09-01
173,EFFINGHAM CARE & REHABILITATION CENTER,115106,459 HIGHWAY 119 SOUTH,SPRINGFIELD,GA,31329,2018-08-16,656,G,0,1,P8CL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the plan of care for Resident (R)#60 who had an intervention for staff to keep her bed in the lowest position. This failure to keep her bed in the lowest position resulted in harm for R#60 when she rolled off her high bed onto the floor and sustained a [MEDICAL CONDITION]. Additionally, the facility failed to follow the plan of care for one resident (R)(R#60) who had interventions for Certified Nursing Assistants (CNA) to check the skin during am/pm care and for Licensed nurses to monitor her skin weekly. The sample size was 26 residents. Findings include: 1. Review of a Nurses' Note dated 3/21/18 at 4:36 a.m. revealed that at approximately 12:00 a.m., R#60 was found kneeling on the floor with her torso on the bed. She told staff at that time that she did not know how she got on the floor but, that she must have rolled off the bed. The resident sustained [REDACTED]. Review of the revised care plan for R#60 dated 3/21/18 revealed that the resident was at risk for falls due to her history of falls prior to admission, impaired balance, dementia with forgetfulness and confusion with a new intervention to keep the bed in the lowest position. Review of the Nurses' Note dated 6/1/18 at 6:44 a.m. revealed that R#60 was found on the floor between the bed and her recliner. Review of the Nurses' Note dated 6/1/18 at 1:13 p.m. revealed that R#60 complained of pain. The physician was notified and ordered an x-ray and subsequent CT scan which showed that the resident had an acute subcapital left femoral neck (hip) fracture. Interview with the Director of Nursing (DON) on 8/15/18 at 12:32 p.m. revealed that during her investigation of the 6/1/18 fall, Certified Nursing Assistant (CNA) AA told her that she had left R#60 in the bed after providing care to check on a resident in another room. Continued interview revealed that CNA AA had left the resident's bed in a high position at that time because the resident did not move around much in the bed. The DON stated that the resident rolled out of the high bed and onto the floor sustaining a left [MEDICAL CONDITION]. Continued interview revealed that CNA AA was terminated for failure to follow safety policy and the resident's care plan to keep her bed in the lowest position. Continued interview revealed that she expected staff to maintain the resident's bed in a low position as care planned for safety. Cross refer to F689 2. R#60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 3/7/17 revealed that R#60 was at risk for pressure sores due to her decreased activity, chairfast status most of the time and admission with pressure sores with an intervention for Certified Nursing Assistants (CNAs) to monitor her skin with am/pm care and report any reddened, irritated or open areas. There was also an intervention for nursing to monitor her skin weekly. Although R#60 had a care plan intervention since 3/2/17 for nursing staff to provide weekly skin checks, review of the facility Skin Forms revealed that Licensed Nursing staff failed to check the resident's skin weekly in 7/2018. Review of the last Skin Form dated 6/29/18 revealed that Licensed Nursing Staff assessed the resident and noted that she had [DIAGNOSES REDACTED] on her feet but no pressure sore at that time. There was no indication that Licensed Nursing Staff assessed the resident's skin weekly after 6/29/18. Review of the 7/6/18 Skin Assessment completed by Certified Nursing Staff revealed that the resident had a sore on her foot and that A&D ointment (utilized to protect the skin from moisture) was applied. However, there was no indication that the CNA notified the nurse about the sore at that time. There was no indication that Certified Nursing staff assessed the resident's skin after 7/6/18. Review of the Nurses' Note dated 7/26/18 at 2:03 p.m. revealed that an unstageable pressure sore measuring 1 centimeter (cm.) by 1 cm. was identified on the resident's left medial foot. Continued review revealed that the wound bed was covered by tan slough. There was no drainage or odor. The Nurse Practitioner was notified and ordered staff to cleanse the pressure sore with normal saline, apply [MEDICATION NAME] and cover with a dry dressing every day and as needed. Interview with the Director of Nursing (DON) on 8/16/18 at 12:10 p.m. revealed that the CNAs were responsible for assessing a resident's skin daily during care for any skin changes and notifying the nurse about those changes as care planned. Continued interview revealed that Licensed Nursing staff were responsible for assessing a resident's skin weekly for any changes as care planned so that any breakdown could be identified early and treatment obtained timely. Cross refer to F686",2020-09-01
174,EFFINGHAM CARE & REHABILITATION CENTER,115106,459 HIGHWAY 119 SOUTH,SPRINGFIELD,GA,31329,2018-08-16,686,D,0,1,P8CL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Skin Care and staff interview, the facility failed to identify a pressure sore timely for one (1) resident (R) (R#60) of 26 sampled residents. Findings include: R#60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Date Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3 indicating that she was cognitively impaired. Continued review revealed that the resident required total assistance of staff for bed mobility and eating, was non-ambulatory, had a fall with major injury and was at risk for pressure sores. Review of the resident's care plan dated 3/7/17 revealed that R#60 was at risk for pressure sores due to her decreased activity, chairfast status most of the time and admission with pressure sores with an intervention for Certified Nursing Assistants (CNAs) to monitor her skin with am/pm care and report any reddened, irritated or open areas. There was also an intervention for nursing to monitor her skin weekly. review of the resident's medical record revealed [REDACTED]. Continued review revealed that staff placed interventions to prevent pressure sores and/or promote healing that included the initiation of soft heel boots, a pressure relieving mattress, Multivitamins, Vitamin C, Zinc and supplements. Review of the Quarterly Braden scale dated 7/11/18 revealed that the resident had a score of 12 indicating that she was at high risk for pressure sore development due to her very limited sensory perception responding only to painful stimuli; often moist skin; bedfast status; very limited mobility; and potential problem with friction/shearing. Although R#60 had a care plan intervention since 3/2/17 for nursing staff to provide weekly skin checks, review of the facility Skin Forms revealed that Licensed Nursing staff failed to check the resident's skin weekly in 7/2018. Review of the last Skin Form dated 6/29/18 revealed that Licensed Nursing Staff assessed the resident and noted that she had [DIAGNOSES REDACTED] on her feet but no pressure sore at that time. There was no indication that Licensed Nursing Staff assessed the resident's skin weekly after 6/29/18. Review of the 7/6/18 Skin Assessment completed by Certified Nursing Staff revealed that the resident had a sore on her foot and that A&D ointment (an ointment to protect the skin from moisture) was applied. However, there was no indication that the CNA notified the nurse about the sore at that time. There was no indication that Certified Nursing staff assessed the resident's skin after 7/6/18. Review of the Nurses' Note dated 7/26/18 at 2:03 p.m. revealed that an unstageable pressure sore measuring 1 centimeter (cm.) by 1 cm. was identified on the resident's left medial foot. Continued review revealed that the wound bed was covered by tan slough. There was no drainage or odor. The Nurse Practitioner was notified and ordered staff to cleanse the pressure sore with normal saline, apply [MEDICATION NAME] and cover with a dry dressing every day and as needed. Review of the resident's chart revealed that subsequent weekly assessments that included staging, measurements and descriptions were completed on the pressure sore. Observation on 8/13/18 at 3:44 p.m., 8/14/18 at 12:12 p.m., 8/15/18 at 1:17 p.m. and at 1:35 p.m. revealed R#60 was observed lying on a pressure relieving mattress and wearing soft boots with her feet elevated on pillows. Staff turned and repositioned the resident frequently. During observation of treatment on 8/15/18 at 12:12 p.m., the Registered Nurse (RN)/Treatment Nurse provided treatment to the pressure sore on the resident's left medial foot as ordered by the physician and using appropriate infection control. The pressure sore measured 0.5 cm by 0.5 cm by 0.2 cm. There was no odor or drainage. The RN/Treatment Nurse stated at that time that the pressure sore was unstageable with slough in the wound bed when it was first identified on 7/26/18. Continued interview revealed that Licensed Nursing staff was responsible for providing weekly skin assessments. Interview with CNA BB on 8/15/18 at 2:09 p.m. revealed that she ensured that residents at risk for pressure sores were turned and repositioned, that heel boots are applied and pillows used to elevate the resident's heels. Continued interview revealed that the CNAs were responsible for checking the residents' skin daily during care for any redness, discoloration or open areas and notifying the nurse right away. Interview with Licensed Piratical Nurse (LPN) CC on 8/16/18 at 8:18 a.m. revealed that she ensured that residents were turned and repositioned and that pressure relieving devices were in place during her rounds. Continued interview revealed that the nurses were responsible for completing skin assessments on the residents weekly. Interview with the resident's attending physician on 8/16/18 at 11:16 a.m. revealed that the resident's pressure sore was unavoidable due to her nutrition status (weight loss and protein-calorie malnutrition). Continued interview revealed that he expected staff to monitor her skin every day due to her high risk for breakdown and that the licensed to inspect her skin every week if care planned. Interview with the Director of Nursing (DON) on 8/16/18 at 12:10 p.m. revealed that the CNAs were responsible for assessing a resident's skin daily during care for any skin changes and notifying the nurse about those changes. Continued interview revealed that Licensed Nursing staff were responsible for assessing a resident's skin weekly for any changes so that any breakdown could be identified early and treatment obtained timely. The DON stated at that time that she had identified in 5/2018 that skin assessments were not being completed and did a 100% skin check on all the residents by 6/2018. However, as of 8/16/18, the DON was unable to provide documentation of the skin assessments. Review of the In-service Log revealed that inservices were provided to certified and licensed nursing staff on prevention of pressure sores, pressure reduction and wound care and/or documentation on 12/7/17, 1/23/18, 5/8/18, 5/29/18, 8/7/18 and 8/9/18. Review of the facility's Policy titled Skin Care last reviewed 4/10/18 revealed under Procedures: 2. A complete and systematic skin inspection is conducted on all residents upon admission and at least monthly. Nursing staff are instructed to pay particular attention to bony prominences. A post-survey telephone interview with the Administrator and the DON on 8/27/18 at 11:24 a.m. revealed that nurses are responsible for doing weekly skin checks for all residents in the facility and that the CNAs are to do a skin check during the resident's bath but may not be daily. The DON says the procedure was revised in (MONTH) (YEAR) and that the nurses had been educated on this process. When questioned as to why the skin policy had not been updated for the revised procedure when the policy was reviewed in (MONTH) (YEAR), neither the Administrator or the DON could explain why it was not updated.",2020-09-01
175,EFFINGHAM CARE & REHABILITATION CENTER,115106,459 HIGHWAY 119 SOUTH,SPRINGFIELD,GA,31329,2018-08-16,689,G,0,1,P8CL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's Falls Assessment and Prevention Policy and staff interview, the facility failed to ensure that Certified Nursing Staff lowered the bed to a low position for one (1) resident (R) (R#60) of three (3) residents reviewed for falls from a sample of 26 residents. This failure to lower the bed to a low position resulted in harm for R#60 when she rolled off the high bed onto the floor and sustained a left [MEDICAL CONDITION]. Findings include: Review of the facility's Falls Assessment and Prevention Policy revealed that residents at risk for falls will have interventions to minimize the occurrence of falls that include making sure that bed is at the safest and most functional height possible for each resident. Resident #60 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) score of 9 indicating that she had some cognitive impairment. Continued review revealed that she was non-ambulatory, required extensive assistance of two staff for bed mobility and had one fall with injury since her prior MDS on 1/18/18. Review of the resident's care plan dated 3/2/17 revealed that the resident was at risk for falls due to her history of falls prior to admission, impaired balance, dementia with forgetfulness and confusion. The care plan had appropriate interventions to prevent falls. Review of the Nurses' Note dated 11/11/17 at 3:29 p.m. revealed that at 2:00 p.m. R#60 was found on the floor in front of her wheelchair. She stated at that time that she was attempting to get up to go to the bathroom and fell face first onto the floor. The resident sustained [REDACTED]. The physician was notified and R#60 was sent to the emergency room (ER). An x-ray of her right arm showed that she had a right radial head (elbow) fracture. Review of the resident's care plan revealed that staff revised it to include a new intervention for a tab alarm. Review of the Nurses' Note dated 3/21/18 at 4:36 a.m. revealed that at approximately 12:00 a.m. R#60 was found kneeling on the floor with her torso on the bed. She told staff at that time that she did not know how she got on the floor but, that she must have rolled off the bed. The resident sustained [REDACTED]. Staff revised her care plan with a new intervention to keep the bed in a low position. Review of the Nurses' Note dated 6/1/18 at 6:44 a.m. revealed that R#60 was found on the floor between the bed and her recliner. Continued review of the Nurses' Note revealed that after returning the resident to bed, staff lowered the bed to the lowest position and placed the call light in reach of the resident. The nurse assessed the resident noting redness to the rim of her L (left) ear as well as the L-shoulder. No additional redness or bruising was noted to any other area of her body. The Nurse Practitioner was notified and ordered staff to monitor the resident. Review of the Nurses' Note dated 6/1/18 at 1:13 p.m. revealed that R#60 complained of pain. The physician was notified and ordered an x-ray and subsequent CT (Computer [NAME]ography) scan which showed that the resident had an acute subcapital left femoral neck (hip) fracture. Review of the care plan revealed that staff did not revise it to include a new intervention after this fall. Interview with the Director of Nursing (DON) on 8/15/18 at 12:32 p.m. revealed that during her investigation of the 6/1/18 fall, Certified Nursing Assistant (CNA) AA told her that she had left R#60 in the bed after providing care to check on a resident in another room. Continued interview revealed that CNA AA had left the resident's bed in a high position at that time because the resident did not move around much in the bed. The DON stated that the resident rolled out of the high bed and onto the floor sustaining a left [MEDICAL CONDITION]. Continued interview revealed that CNA AA was terminated for failure to follow safety policy and the resident's care plan to keep her bed in the lowest position. Continued interview revealed that she expected staff to maintain the resident's bed in a low position as care planned for safety. Review of the Statement of Events/Incident form dated 6/1/18 revealed that the nurse who assessed R#60 after her fall documented that the resident's bed was at waist or hip level at the time of the fall. Review of the In-service Log revealed that 18 staff attended an in-service on Fall Management and Risk on 2/6/18. However, review of the sign-in sheet revealed that CNA AA had not attended the in-service. There was no indication that staff were in-serviced on fall prevention after 2/6/18. Observation on 8/13/18 at 3:44 p.m., 8/14/18 at 12:12 p.m., 8/15/18 at 1:17 p.m. and at 1:35 p.m. revealed the resident in bed with the bed in the lowest position. The resident was not observed to attempt to get out of bed. Interview with CNA BB on 8/15/18 at 2:09 p.m. revealed that she was aware that R#60 was at risk for falls and that she ensured that the resident was positioned in the center of the bed so she did not roll off the bed. Continued interview revealed that she also ensured the bed was maintained in the lowest position. Interview with Licensed Practical Nurse (LPN) CC on 8/16/18 at 8:18 a.m. revealed that she ensured that interventions were in place to prevent falls during her two hour checks on the residents. Interview with the DON on 8/16/18 at 10:30 a.m. revealed that the resident's bed was not in a high position at the time of the 3/21/18 fall. Continued interview revealed that staff's review of the care plan after that fall revealed that the intervention keep bed in low position was not on the care plan at that time so it was added at that time. The facility failed to ensure that Certified Nursing staff maintained the resident's bed in the low position at all times which resulted in the resident rolling off the high bed onto the floor and sustaining a left [MEDICAL CONDITION].",2020-09-01
176,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2018-04-17,550,D,1,0,TFUK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, family interview and staff interview, the facility failed to ensure that dignity was maintained for one (1) resident (R) (R#A) from a sample of six (6) residents. The facility census was one hundred thirty-two. Cross refer to F 565 Findings include: An interview conducted on 4/11/18 at 2:01 p.m. with a family member of R#A revealed she had requested several times for her aunt to be dressed properly when in or out of the bed, during the day and night. The family member revealed she has found her aunt in bed, both at night and during the day for naps, with no pants or pajama bottoms on and has requested the Administrator, the Director of Nurses (DON), Social Service Director, Nurses and CNA's do something about this. Continued interview on 4/17/18 at 3:20 p.m. revealed she and the other family members do not want R#4 in bed or out without pants or pajamas bottoms on. Their aunt, when she was younger and alert, was modest and concerned about her appearance and would not go anywhere without the proper clothing and now that she is [AGE] years old gets cold easily. She would be embarrassed if she had to go to the hospital and knew she was only wearing a shirt and a brief, and she would be cold as well. The family would be very upset by this. Observations for R#A on 4/11/18 at 1:30 p.m. revealed she was in a wheelchair in the dining room wearing a T shirt, a pink over shirt, and matching pink pants. She was wearing non- skid footwear and had no signs of incontinence. On 4/11/18 at 4:45 p.m. an interview with Licensed Practical Nurse EE revealed the day shift Certified Nursing Assistants (CNA's) had put R#A to bed for an afternoon nap at 2:00 p.m. On 4/11/18 at 4:45 p.m. R#A was observed in bed wearing the same T shirt and pink over shirt she was wearing for earlier observations. The matching pink pants were folded twice and were on a chair in the corner of the room out of reach of the bed. The wheel chair was parked in front of the sink and was also out of reach from the bed. During observation of CNA FF checking for incontinence R#A was observed in bed with no pants on, only an incontinence brief and her shirts. An interview conducted on 4/11/18 at 4:55 p.m. with CNA FF verified R#A did not have any pants on. CNA FF revealed she was aware that R#A's family wanted her to have either pants or pajama bottoms on when she was in bed and this was recorded on the CNA Care Plan, and the family had told her this also. The CNA confirmed R#A was not independently mobile enough to take her pants off, get up from the bed, fold the pants and put them on the chair, and get safely back into the bed, without using the wheel chair that was far from her reach. CNA FF acknowledged the day shift CNA's had reported they put her to bed and they must have put her to bed without pants on. Review of care plan dated 11/4/15, for R#A revealed a care plan for ADL self-care deficit and is at risk for complications related to impaired cognition, dementia, [MEDICAL CONDITION], and lumbar sacral spondylosis. Resident requires max assistance from staff with bathing and extensive assistance with bed mobility transfer, locomotion on unit, dressing, eating, toileting, personal hygiene and ambulation in room. An update to this care plan dated 7/12/17 indicated resident does have the ability to take self to bathroom (br) - remove own clothing. Resident has been noted to line toilet seat with toilet paper when she has taken herself to the BR. Continued 2/3/18. Review of CNA care plan, no date, revealed R#A requires a wheel chair for mobility, is non- ambulatory, is incontinent and is dependent for one assist for dressing. On the reverse side of the care plan are interventions for the following: Use both items of PJ's top and bottom. If PJ's are wet change both items. Review of the Quarterly Minimum Data Set (MDS) for R#A dated 2/1/18 revealed a Brief Interview for Mental Status score of seven (7), indicating severe cognitive impairment. Section G: Functional Status, indicated R#4 requires extensive assistance of one person for bed mobility and dressing. For transfer R#4 required extensive assistance of two persons. Resident #4 required supervision with one person physical assistance for walking. For movement from sitting to standing, walking, turning while walking, and transfer between bed and chair or wheel chair, R#4 was not steady and only able to stabilize with human assistance. Review of CNA Activity of Daily Living (ADL) sheets indicated on 4/11/18 at 1:52 p.m. documentation revealed R#4 required one-person physical assistance for bed mobility, had been toileted, and a one person assisted transfer occurred. During an interview on 4/17/18 at 6:41 p.m. CNA HH and II revealed R#4 would not be able to safely get up from her bed now because her mobility is declining.",2020-09-01
177,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2018-04-17,565,D,1,0,TFUK11,"> Based on observation, record review and staff and family interview, the facility failed to resolve grievances filed for one resident (R), (R#4) from a sample of six residents. The facility census was one hundred thirty-two. Cross refer to F 355 Findings include: A family interview for R#A on 4/11/18 at 2:01 p.m. revealed she has discussed with the facility the family's wishes for R#A to wear proper clothing at all times. The family member revealed she had found R#A with out pants on when in bed, clothed only in a brief and shirt, or brief and pajama top at night, more than once. The family member revealed she has explained to the facility that the resident should wear pants when in bed during the day for naps and wear pajama bottoms at night when in bed. She revealed she brings home the resident's laundry and knows she has not been properly dressed when she finds 2 pajama tops and one or no pajama bottoms. She was unable to give dates and times when she has found the resident in bed with no pants on but it has happened more than once and she has found this recently. The family member confirmed she had expressed the family's wishes to the Administrator by email, at care plan meetings, in grievances and individually to Certified Nursing Assistants and Nurses over the last year, with improvement sometimes for a brief period, possibly a week then she will find her aunt without pants or pajama bottoms on in bed again. She revealed she has also repeatedly asked for lotion or oil to be applied to her aunt's skin every day and when laundering the clothing she is aware that this is not being done because the clothing sometimes has an excessive amount of dry skin on the inside. She revealed she intermittently also finds the residents pants and pajama bottoms soaked with an excessive amount of urine, like she had not received incontinence care at regular intervals and has included this in discussions, emails, and grievances without results. Record review of Care Plan Conference Summary, dated 6/20/17 revealed the family member of R#A expressed concerns regarding proper dress attire at bedtime, and regarding bedtime hygiene, dress and incontinence care. Review of a second Care Plan Conference Summary indicated on 12/14/17 the family member of R#A discussed proper dress at bedtime during a conference call. Review of Entity Reported Incident GA 476, reported on 1/23/18 revealed the Administrator received an email from the family member of R#A indicating the family had asked over and over to shower R#A and oil her skin, and that this matter had been addressed many times during care plan conversations, but they were still having this issue. The writer of the email indicated if the showers and oiling her skin had been consistent she would not find excessive amounts of dry skin in her clothes regularly. The facility Administrator replied the wound care nurse would assess R#A's skin and the facility would also look at her hydration and educate staff on skin care including the usage of lotion. Continued review of Entity Reports revealed on 3/30/18 the Administrator received an email from the family member of R#A indicating that there was dry skin on her aunt's clothes and her pants were wet, and she believed this was a form of abuse. The facility investigated by having the charge nurse conduct a skin assessment, and assess for dehydration. The CNA's were in-serviced regarding the frequency of incontinence care and change of clothing as needed. On 4/10/18 an email was received from the family member of R#A, which had been sent to the Administrator and the Director of Nurses regarding continuing to find wet pants in the laundry, and indicating if she were to find R#A without pants there would be a major problem. Review of CNA Care Report, no date, revealed R#A is to have ointment to skin every bedtime (HS) and with ADL care, the resident is non ambulatory, requires one assist for transfers and on the reverse side was an intervention to use pajama tops and bottoms and if they are wet change both items. During an interview conducted on 4/11/18 at 4:45 p.m. LPN EE revealed R#A had been put to bed by CNA's at 2:00 p.m. An observation on 4/11/18 at 4:55 p.m. revealed R#A was in bed with a T shirt, a pink over shirt and an incontinence brief on. The resident's wheel chair was parked in front of the sink. The pink pants matching the shirt R#A had been observed wearing when she was up in the common areas that day were folded in half twice and were on the seat of the chair out of reach beyond the foot of the bed. An interview was conducted with CNA FF on 4/11/18 at 4:56 p.m. in the room of R#[NAME] CNA FF revealed R#A had been put to bed by the day shift CNA's and was not mobile enough to get up, take off her pants, fold them and put them on the chair and return to the bed unassisted. CNA FF revealed she knew not to put the resident to bed without pants because the CNA Care Plan indicated she should have pants on and she had been told by the family to keep pants or pajama bottoms on R#[NAME] CNA FF revealed R#A must have been put to bed without her pants on. Review of CNA Activity of Daily Living (ADL) sheets revealed on 4/11/18 at 1:52 p.m. R#A had been toileted, and transferred and required one persons physical assist for bed mobility. Review of facility Policy titled Investigate Complaint/Grievance, no date, revealed the Social Service Director or designee will coordinate efforts to comply with this policy. The flowing procedures provide a prompt, thorough and equitable resolution of Resident voncerns and/or complaints.",2020-09-01
178,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2018-04-17,584,E,1,0,TFUK11,"> Based on observations, family interview and staff interview the facility failed to provide a clean, comfortable, homelike environment in two of three resident shower rooms. There were one hundred two (102) residents (R) potentially affected by the lack of shower room sanitation in the third and fourth floor showers. The facility census was one hundred thirty-two (132). Findings include: An observation of the third floor shower room was conducted on 4/11/18 at 5:45 pm. There were pieces of a brown substance on the floor, the room smelled of BM and there were 4 wet gloves and 3 wet towels on the floor. An interview on 4/11/18 at 3:20 p.m. was conducted with a family member of R#[NAME] The family member revealed she finds the showers dirty with trash on floor, wet towels and brown smears of bowel movement (BM) on the floor and smelling like BM whenever she has ever looked at them. An interview with the Unit Manager of the third floor on 4/11/18 at 5:50 p.m. revealed the housekeeper is expected to clean shower before they go home, and the Certified Nursing Assistants (CNA's) are expected to pick up the trash, wet linens and clean up any smears or stains of body substances before showering the next resident. An interview was conducted with R#D on 4/17/18 at 10:10 a.m. R#D revealed she has not made a formal complaint but she and others on her floor do not get to the shower room much because for the last 2 months the residents have been told intermittently that the shower drain was plugged and given bed baths instead. R#D revealed when she has had a shower the room was not clean and sanitary, with trash and dirty linen on floor first thing in the AM, so she knows it was probably from the day before and sometimes there are stains and smears on the floor. R#D revealed when she has been in the shower recently the drain was not plugged. An observation of the fourth floor shower room on 4/17/18 at 10:15 a.m. revealed pink and brown stains and standing water on a white plastic sheet suspended under the shower bed, and a red/brown substance on seat of shower chair. The water was turned on and allowed to run for five minutes and the drain was not plugged. An observation on 4/17/18 at 5:05 p.m. of the third floor shower room revealed the room smelled of BM and a brown liquid substance had been splashed on wall and floor under the shower head, splattered from 2 feet above floor tile, down to floor. An interview was conducted in the third floor shower room on 4/17/18 at 5:15 p.m. with the Director of Nurses (DON) confirmed the substance splashed on the wall and floor under the shower was probably BM and should have been cleaned by the CNA when the resident was taken to their room after showering. The housekeeper should also have cleaned the brown substance off the wall and floor before the end of their shift. An interview was conducted on 4/17/18 at 5:20 p.m. with the DON in the fourth floor shower room. The DON confirmed the thick dark brown substance on the back inner rim of the seat of the shower chair was probably BM. The DON acknowledged the standing water in plastic sheeting under shower bed, with pink stains and brown stains looked like mildew to her. The DON revealed the CNA's and the housekeepers should be cleaning the shower bed and shower chair, including the sheet under it used to catch water and fluids running through the drain holes, the CNA's after each shower and the housekeepers at the end of the day shift.",2020-09-01
179,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2018-04-17,606,E,1,0,TFUK11,"> Based on record review, review of facility policy and Administrator interview the facility failed to ensure Georgia Crime Information Center background checks were completed on seven (7) of eighteen (18) employees hired during the month of October, (YEAR). The facility census was one hundred thirty-two (132) residents. Findings include: During a record review of employee files for the dietary department a failure to provide a Georgia Crime Information Center (GCIC) background check was identified related to the Dietary Manager, hired on 10/19/17. The Dietary Manager had federal and county background screening. A review of facility policy titled Georgia Credentialing Checklist dated 12/27/17 revealed a Georgia Statewide Consent was required to be scanned and uploaded for each employee. An interview with the Administrator on 4/17/18 at 2:50 pm revealed a computer glitch with the outside vendor had caused the GCIC for the Dietary Manager's back ground screening to be missed. At this time all background check records for any new hires during the month of (MONTH) were requested. A review background checks for the eighteen employees hired by the facility during the month of (MONTH) (YEAR), revealed incomplete background checks, missing the GCIC screening, for seven of the eighteen employees. The seven incomplete files included county and federal back ground screening. Review of Grievances, Entity Reported Incidents and Resident Council Minutes for 10/1/2017 through 4/17/18 revealed the names of the seven employees without GCIC screening had not been mentioned. An interview on 4/17/18 at 4:30 p.m. with the Administrator revealed eighteen staff were hired in October. The company that is used to provide background checks had a computer glitch in October. The absence of a background GCIC had been discovered by the facility for the Dietary Manager and the background check company had been instructed to check for others. No one at the facility followed up on this and seven staff of the eighteen hired in (MONTH) did not have pre- employment GCIC screening, and still did not have GCIC screening. The Administrator acknowledged three Certified Nursing Assistants (CNA's), the Business Office Manager, the Dietary Manager, the Maintenance Manager, and the MDS Nurse did not have GCIC background check.",2020-09-01
180,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2017-05-14,252,D,1,0,S6LJ11,"> Based on observations and interviews, it was determined that the facility failed to provide a resident environment that was free from offensive odors in two of three floors. This failure resulted in no actual harm with the potential for minimal harm. Findings include: Observations conducted during the initial tour on 5/11/2017 between 3:15 p.m. and 4:30 p.m. on all three resident floors revealed strong urine odors around rooms 301 through 304 and fecal and urine odors around rooms 427 through 430. Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room 318 the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In room 328 soiled bed pads were noted in the trash can with a distinct urine odor coming from them. In the bathroom of room 418 odors were noted with a brown substance around the edges of the toilet. In the bathroom of room 417 a brown smelly substance was noted around the toilet seat. A brown residue was observed in the sink in the room. In the bathroom of room 430 a brown substance was noted around the toilet seat with a distinct odor of feces. Interview with family member of R#1 on 5/13/2017 at 11:30a.m. revealed that the bathroom of R#1 is smelly and rarely cleaned and there are odors all over the facility. She stated that she was very unhappy with the lack of cleaning in the room of R#1. Interview with R#3 on 5/13/2017 at 10:45a.m. revealed the staff don't clean the bathrooms the way they should or empty the trash cans as often as they should. Interview with R#4 on 5/14/2017 at 9:05 a.m. revealed that the staff don't clean the bathrooms very well and leave smelly items in the bathrooms and trash cans. Observation on 5/14/2017 at 9:00 a.m. revealed house keeping staff actively cleaning rooms and bathrooms that were reported to the Director of Nursing and Administrator on 5/12/2017.",2020-09-01
181,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2017-05-14,253,E,1,0,S6LJ11,"> Based on general observations of the facility and interviews, it was determined that the facility had failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior on two (2) of three (3) floors. Findings include: Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room 318 the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In the bathroom of room 321 an uncovered bed pan was noted on the floor. In the bathroom of room 322 a urine specimen collection pan was noted on the floor uncovered with a brown substance around the edges. In the bathroom of room 325 an uncovered urinal was noted on the toilet tank. The toilet was noted to be running with a broken handle noted. In the bathroom of room 324 an uncovered urinal was noted on the toilet tank. In room 328 soiled bed pads were noted in the trash can with a distinct urine odor coming from them. In the bathroom of room 418 odors were noted with a brown substance around the edges of the toilet. In the bathroom of room 417 a brown smelly substance was noted around the toilet seat. A brown residue was observed in the sink in the room. In the bathroom of room 422 an uncovered specimen collection device was noted on the floor. In the bathroom of room 421 a bedpan was noted on the floor next to the toilet with dirty tissue in it. In the bathroom of room 426 a bedpan was noted on the floor with a urinal in it and both were uncovered. Another uncovered urinal with a small amount of urine was noted on the other side of the toilet on the floor. Yet another urinal was noted uncovered on the toilet tank with a small amount of what appeared to be urine in the bottom. In the bathroom of room 427 an uncovered urinal was noted on the toilet tank with what appeared to be a small amount of urine in the bottom. In the bathroom of room 430 a brown substance was noted around the toilet seat with a distinct odor of feces. Interview with family member of R#1 on 5/13/2017 at 11:30a.m. revealed that the bathroom of R#1 is smelly and rarely cleaned and there are odors all over the facility. She stated that she was very unhappy with the lack of cleaning in the room of R#1. Interview with R#3 on 5/13/2017 at 10:45a.m. revealed that there is a problem with odors in the facility and the staff don't clean the bathrooms the way they should or empty the trash cans as often as they should. Interview with R#4 on 5/14/2017 at 9:05 a.m. revealed that the staff don't clean the bathrooms very well and leave smelly items in the bathrooms and trash cans. Observation on 5/14/2017 at 9:00 a.m. revealed house keeping staff actively cleaning rooms and bathrooms that were reported to the Director of Nursing and Administrator on 5/12/2017.",2020-09-01
182,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2017-05-14,441,D,1,0,S6LJ11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations the facility failed to store bed pans and urinals in a sanitary manner on two (2) of three (3) floors. The facility census was one hundred thirty six (136) residents. Findings include: Observations conducted of resident rooms and bathrooms on 5/12/2017 between 9:30 a.m. and 12:30 p.m. revealed the following: In the bathroom of room [ROOM NUMBER] the toilet was found to be off center on the floor and old chaulk subssstance was not around the base but in an area where the toilet base originally was located. Chaulk had been applied to the toilet base where it currently sits in an off center position and the old chaulk had never been removed. There were yellow stains around the base and a strong urine odor. In the bathroom of room [ROOM NUMBER] an uncovered bed pan was noted on the floor. In the bathroom of room [ROOM NUMBER] a urine specimen collection pan was noted on the floor uncovered with a brown substance around the edges. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank. In the bathroom of room [ROOM NUMBER] an uncovered specimen collection device was noted on the floor. In the bathroom of room [ROOM NUMBER] a bedpan was noted on the floor next to the toilet with dirty tissue in it. In the bathroom of room [ROOM NUMBER] a bedpan was noted on the floor with a urinal in it and both were uncovered. Another uncovered urinal with a small amount of urine was noted on the other side of the toilet on the floor. Yet another urinal was noted uncovered on the toilet tank with a small amount of what appeared to be urine in the bottom. In the bathroom of room [ROOM NUMBER] an uncovered urinal was noted on the toilet tank with what appeared to be a small amount of urine in the bottom. Observation on 5/14/2017 at 9:00 a.m. revealed house keeping staff actively cleaning rooms and bathrooms that were reported to the Director of Nursing and Administrator on 5/12/2017.,2020-09-01
183,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2018-05-17,641,D,0,1,PJ0M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, it was determined the facility failed to ensure Minimum Data Sheets (MDS) assessments correctly identified a resident with a urinary tract infection [MEDICAL CONDITION] for one resident (R) #80 of 32 sampled residents whose MDSs were reviewed. Findings include: Medical record review revealed R#80 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], documented the resident's cognition was moderately impaired, required extensive assistance with bed mobility, transferring between surfaces, dressing, eating and toilet use. The assessment also documented the resident was frequently incontinent of bowel and bladder. The MDS also assessed the resident had a UTI within the past 30 days. The resident's laboratory reports and medication administration records were reviewed and did not contain documentation that the resident was diagnosed and /or treated for [REDACTED]. Review of R#80's care plan, dated 4/25/18, documented: Problem: Resident has a potential for complications associated with incontinence of bowel and/or bladder. Approach: Monitor need for / schedule appropriate diagnostic procedures. Monitor and report any changes in bladder status to nurse such as low urine output, foul smelling urine, discolored urine, pain, bladder distention, frequency, urgency and fever. Report changes in bladder status to physician . On 5/14/18 at 8:30 a.m., during the initial tour the resident was observed sitting in her wheelchair at the nurses' station. On 5/14/18 at 3:20 p.m., the resident was observed sitting in her wheelchair at the nurses' station On 5/14/18 at 3:40 p.m., the resident was observed being toileted by the staff. The staff reported the resident would tell them when she need to go to the rest room. The resident's brief was dry at that time. On 5/15/18 at 12:10 p.m., the MDS Nurse #JJ was interviewed in the MDS office, regarding the UTI that had been identified on the resident's MDS assessment. MDS Nurse #JJ was asked for documentation of the resident having a UTI on the 4/6/18, quarterly MDS assessment. MDS Nurse JJ reviewed the resident's medical records and reported, it was an error, that the resident had not had an UTI within 30 days of the assessment. She then stated they would do a revision to the assessment and resubmit the assessment. On 5/17/18, at 2:00 p.m., the Administrator was interviewed in his office. The Administrator was informed of the error on the resident's MDS assessment. He reported he had been informed by his staff and it was being corrected.",2020-09-01
184,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2018-05-17,679,D,0,1,PJ0M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review interview and review of facility policy, the facility failed to provide activities to meet personal preferences for one Resident (R) #354. The sample size at the time of the survey process was 32. The findings include: R #354 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R #354's most recent Minimum Data Set (MDS), an admission assessment with an Assessment Reference Date of 5/9/18, documented R #354 as being cognitively severely impaired to make decisions regarding activities of daily living. In Section F, Preferences for Customary Routine and Activities, R #354 is coded as responding that activities such as having books, newspapers and magazines to read; listening to music; being around animals; doing things with groups of people; going outside for fresh air and participating in religious services were very important to him. A review of R #354's facility document titled Initial Quality of Life Lifestyle Review dated 5/8/18 and completed by the Activities Director, EE, documented the following activities enjoyed by R #354: Animals Art Children Crafts/[NAME]working Current Events/Politics Exercise Fishing/Hunting/Camping Games/Cards Happy Hour Inspirational/Religious Services Meditation Music Puzzles Reading Scrapbooking Shopping/Outings/Traveling Social Events Sports Tv News Theatre/Dance Writing Yoga R #354 was observed on the following dates and times: 5/14/18 at 9:15 a.m. - R #354 was observed seated in his wheelchair in his room. No reading materials observed in his room. No music playing and the TV was not on. There were no activities observed to be in progress at this time. 5/15/18 at 10:00 a.m. - R #354 was observed seated in his wheelchair in his room. The Resident was observed to be playing with his gastric tube and there was no music and the TV was not on. There were no activities observed to be in progress at this time. 5/16/18 at 12:30 p.m. - R #354 was observed receiving tube feeding while seated in his wheelchair in his room. No music or TV on and there were no reading materials in the resident's room. There were no activities observed to be in progress at this time. 5/16/18 at 3:45 p.m. R #354 was observed lying in his bed, eyes open and television turned on. An activity was taking place at this time on the fourth floor (R #354's room was on the second) that included music and bible study. There were no activities observed to be in progress at this time. Staff were not observed to engage with R #354 in any type of activities throughout the survey process. Observations throughout the days of the survey failed to reveal the staff engaging or encouraging the resident to participate in any of the scheduled or preferred activities. A review of R #354's care plan dated 5/2/18 documented, in part, the following: Problem: (1) 5/8/18 (201) Resident has previous recreational interests/patterns. Goal: (1) 5/8/18 Resident will participate as desire in self-directed activities of choice daily through next review date. Approach: (1) 5/8/18. Provide leisure supplies for self-directed pursuits. (2) 5/8/18 Invite to scheduled activities (3) 5/8/18 Explain importance of social interaction, leisure activity time. (4) 5/11/18 Obtain prior level of activity involvement and interests by talking with resident, staff, family. (5) Introduce to other residents with similar interests, disabilities, and/or limitations (6) 5/11/18 Consider impact of medical problems on activity level. (7) 5/11/18 Offer variety of activity types and locations. (8) 5/11/18 Offer to assist/escort resident to activity functions. (9) 5/11/18 Invite/encourage family/friends to attend activities with resident. (10) 5/11/18 Modify daily schedule, treat plan PRN (as needed) to accommodate activity participation. The care plan did not reflect any of the activities described in Section F of R #354's MDS Admission assessment dated [DATE] or R #354's facility document titled Initial Quality of Life Lifestyle Review dated 5/8/18. A review of the activity department's Quality of life daily log for the month of (MONTH) documented, in part, that R #354 attended the following activities; 5/4/18 - Cinco de Mayo celebration; 5/7/18 - Bingo at 2:30 p.m.; 5/9/18 - read Daily Chronicle (a facility newsletter) residents and reminiscing. No other activities were documented for R #354 for the month of May. A review of the facility Daily Participation Log for R #354 revealed three highlighted areas extending from 5/1/18 to 5/16/18 that indicated R #354 had participated in the following activities; Beauty/Grooming; Independent Activity; TV/ Radio. On 05/16/18 at 03:53 p.m. an interview was conducted with the Activities Director EE in the conference room. The Activities Director was asked to describe her training to provide an activities program to the residents. The Activities Director stated that she had received a certification to be an activities director a couple of years ago and she was also a Certified Nurse Assistant (CNA). The Activities Director was asked the purpose of the facility document Initial Quality of Life Lifestyle Review. The Activities Director stated that when the resident was interviewed for the MDS it provided more information about what the resident wants to do while here in the facility. R#354's MDS activities assessment was reviewed. When asked which of the activities identified by the resident had been provided during the month of (MONTH) to R #354. The Activities Director was unable to provide any documentation that the activities identified by Resident #354 were offered to him. During the interview a music / bible study activity was underway on the 4th floor and R #354 was not in attendance. When asked if R#354 was invited. The Activities Director stated that she thought so, but her assistant was responsible for bringing the residents to the activities. When asked if the nursing staff assisted with activities or getting the residents to activities the Activities Director stated that they did not, the activities staff (herself and the activities assistant) took care of all the activities. On 05/16/18 at 04:37 p.m. an interview was conducted with the activities assistant (FF). When asked her role at the facility the activities assistant stated that she helped get residents to the activities and helped with some of the activities. When asked what R #354 liked to do, the activities assistant stated that she didn't really know for sure, that she had not done his assessment. The activities assistant further stated, I invited him to bible study today but he said no. It's kind of hard sometimes to get the residents to go. When asked about the music taking place now, the activities assistant stated that she invited R#354 and he said no. We ask everyone daily. Some need a little more of a nudge then others. When asked what kind of activities she had encouraged R #354 to participate in the activities assistant was unable to say. The facility was unable to provide a policy regarding provision of activities for the residents.",2020-09-01
185,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2019-07-10,609,D,1,0,UF4211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure an injury of unknown origin was reported to the State Agency in a timely manner for one residents (R) (#14) of seven residents reviewed for reporting requirements. Findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIM's) score of 0 which indicates severe cognitive impairment. Section G0400 Functional Limitations in Range of Motion indicated no impairment of the upper extremities. The resident requires extensive assistance with bed mobility and transfers. Review of the Electronic Medical Record (EMR) dated 5/13/19 revealed the resident complained of pain in the right arm/shoulder x-ray revealed a right clavicle fracture with severe [MEDICAL CONDITION] changes and bony demineralization and [MEDICAL CONDITION]. The document titled SHC Medial Partners dated 5/13/19 by the Nurse Practitioner (NP) noted: Chief Complaint/History of Present Illness; shoulder pain, patient noted with acute onset right shoulder pain today. Unable to lift or move arm without pain. X-ray done showing overlapping acute distal clavicular fracture. Family notified, and request ER (emergency room ) transfer. Mechanism of injury- unknown. Plan: X-ray reviewed: Bony demineralization. Slightly angulated, slightly overlapping acute distal clavicular fracture. Severe [MEDICAL CONDITION] changes at the glenohumeral joint. Will transfer to ER for further evaluation. No reported hx (history) of recent fall or trauma to right arm. Follow up as needed upon return to the facility. Review of a mobile radiology report dated 5/13/19 at 3:04 p.m. revealed bony demineralization. Slightly angulated, slightly overlapping acute distal clavicular fracture. Severe [MEDICAL CONDITION] changes at the glenohumeral joint. Review of the SNF/NF to Hospital Transfer form the resident was transferred to the hospital on [DATE] at 9:50 p.m. the Emergency notes the Chief Complaint Clavicle Injury EMS (Emergency Medical Service) transported patient from (facility name) for a clavicula fracture x-rayed prior to arrival, unknown how the fracture occurred but R (right) shoulder is bruised. Patient is extremely hard of hearing and does not answer many questions posed to her but indicates her shoulder hurts. Review of the clinical record revealed R#14 returned to the facility on [DATE] at 4:36 a.m. During an interview on 7/9/19 at 10:50 a.m., Social Service Director (SSD) stated she was aware of the incident on 5/13/19 when the x-ray result came back but did not reported to DCH (Department of Community Health) until 5/15/19 because the doctor said it was most likely [MEDICAL CONDITION]. The staff then had a meeting on the 14th or 15th and decided to report it to the state and investigate. The SSD confirmed that the incident was not reported timely or investigated immediately because the doctor said that the resident has [MEDICAL CONDITION]. It was noted on a faxed Communication Result report that the facility notified the State Agency on 5/15/19 at 6:57 p.m.",2020-09-01
186,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2019-07-10,656,J,1,0,UF4211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of facility policy titled Comprehensive Care Plans and staff interviews, the facility failed to develop a person-centered comprehensive care plan with interventions that specified the need for monitoring for a resident with side rails, assessment of the need for side rails, alternatives to side rails that had been attempted, education of the family member requesting the side rails, and the increased risk of using an air mattress with side rails for one resident (R) (#23) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.25(n) Bedrails (F 700 Scope and Severity (S/S): J) C.F.R. 483.21(b) Comprehensive Care Plans (F 656 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(n) Bedrails (F 700 S/S: J). The facility had not provided a Removal Plan at the time of exit on 7/10/19 therefore the IJ is ongoing. Findings include: A review of the facility policy titled Comprehensive Care Plans revised on 7/19/18 revealed the following: A person-centered Comprehensive Care Plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident. The care plan will include how the facility will assist the resident to meet their needs . Each resident's Comprehensive Care Plan is designed to: a. Incorporate identified problem areas. b. Incorporate risk factors associated with identified problems. j. Reflect currently recognized standards of practice for problem areas and conditions. The interventions will reflect action, treatment or procedure to meet the objectives toward achieving the resident goals. The care plan should reflect the current status of the resident and be updated with changes in resident status. The attempts to find alternative means to address the identified need/risk shall be documented in the care plan. Review of the clinical record revealed R#23 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Event Manager revealed the above incident occurred on 4/1/19 for R#23 as follows: R#23 was observed on floor on buttocks with neck lodge (sic) between bed and railing. Fall mats were documented in place next to the bed and the bed was in low position. The attending Physician for R#23 was notified on 4/1/19 at 6:23 a.m. and the Responsible Party (RP) was notified on 4/1/19 at 6:40 a.m. R#23 was transported to the hospital. A description of precipitating factors included the air mattress on bed was inflated high. Continued review of the Event Manager revealed a staff member, Certified Nursing Assistant (CNA) DD, documented that the air mattress sometimes inflates too high and moves the patient. The room mate of R#23 had notified LPN GG that R#23 was on the floor. LPN GG documented that there was no injury. Review of R#23's comprehensive care plans revealed side rails had not been included in any problem areas on the electronic medical record or on the care plan in the paper clinical record. A comprehensive care plan for Activities of Daily Living (ADL), dated 11/4/15, included an intervention, dated 3/23/17, for side rails to be used as an enabler. Review of an interdisciplinary care plan for falls revealed on 5/28/19 R#23 fell without injury. Interventions on this care plan included half (1/2) side rails to define bed boundaries. There was no further mention of side rails on this care plan. Review of the undated Certified Nursing Assistant (CNA) Care Card, found in a binder at the Nurses Station for R#23, revealed under the heading of Safety/Positioning Devices, Side rails were to be kept down. Interviews conducted with CNA XX on 6/26/19 at 9:32 a.m., CNA YY on 6/26/19 at 9:35 a.m., and CNA ZZ on 6/26/19 at 9:35 a.m. revealed they keep the side rails up when R#23 is in bed. The CNA's revealed that the resident has always had half side rails since they started working with her, except for a few weeks after she fell and was caught in them. The CNA's also revealed the CNA care plans are not kept up to date and they do not check them because they get their information from other CNA's and the nurses. The CNA's revealed they had never seen R#23 move and did not know how she fell out of bed twice. During an interview on 7/2/19 at 9:00 a.m., Licensed Practical Nurse (LPN) BBB revealed she has worked with R#23 intermittently for nine years. LPN BBB stated R#23 has always had two top half side rails, for as long as she can remember, and half rails are all she has seen in the facility. LPN BBB revealed she will sometimes update the CNA care plans, but the Unit Manager and the DON usually take care of that. LPN BBB revealed she does not see the CNA's checking their care plans very often. An interview was conducted on 7/2/19 at 3:30 p.m. with the former Director of Nurses (DON). The former DON reviewed the CNA care plan for R#23 and revealed she had updated the CNA care plan when R#23 fell and was entrapped in the rail on 4/1/19. She revealed they had fastened R#23's rails so they could not be raised, then a few days later when the family gave permission the Maintenance Director removed the rails. The former DON revealed she had not updated the CNA care plan when the resident fell again on 5/28/19 and the family requested the side rails be reinstalled. The former DON reviewed the paper care plan for R#23 and stated this was the current updated care plan and acknowledged there was no problem listing for side rails. The former DON then reviewed the policies for bed safety and comprehensive side rails. She stated since the policies did not specifically state that side rails were to be care planned as a problem with interventions to keep the resident safe from injury or entrapment, she thought the care plans were adequate and did not need to include the side rails as a problem with potential risks. The former DON revealed she was aware that side rails do present a risk to some residents. A resident with side rails should be monitored more frequently and positioned away from the edges of the bed. The rails should be checked for gaps, wear and loosening periodically. If an air mattress is used concurrently there is additional risk because the edges of air mattresses compress and can cause a resident with no independent movement to be rolled off the bed. The former DON refused to answer if any of this missing information should have been included in a person-centered care plan, or if the care plans for R#23 were person centered. The former DON revealed she expected the Unit Managers to provide the interdisciplinary team with care planning needs for all residents, to review and identify both comprehensive and CNA care plans that needed updating, and to identify residents that have potential problems and immediate risks that should be care planned. Cross refer to F700",2020-09-01
187,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2019-07-10,700,J,1,0,UF4211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, facility and hospital clinical record review, review of the facility policy titled Bed Safety, and review of the Food and Drug Administration (FDA) guidelines titled Recommendations for Health Care Providers about Bed Rails, the facility failed to provide an environment free from the risk of entrapment within the side rail or between the side rail and air mattress for two residents (R) (#23 and #24) of three residents reviewed for the use of side rails with air mattresses. On 7/8/19 a determination was made that the facility's noncompliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Administrator and Social Service Director were informed of the Immediate Jeopardy (IJ) on 7/8/19 at 12:45 p.m. The noncompliance related to the IJ identified to have existed on 4/1/19 when R#23 was found with her head and neck entrapped between a side rail and air mattress. The IJ is outlined as follows: 1. R#23 had an order for [REDACTED]. The manufacture's recommendation per the facility was not to use side rails with an air mattress. The side rails were not removed until 4/8/19 after the family agreed to have them removed. The resident remained in the facility with side rails in place after sustaining another fall on 5/28/19. The air mattress was removed instead of removing the side rails. 2. Record review revealed that on 2/3/19, R#24's leg was caught in the side rail. X-rays were completed at the time of the incident and revealed no injuries. The Physician discontinued the side rails as an enabler on 4/11/19. An assessment was completed on 4/16/19 and revealed the residents side rails were not indicated and gave no reason for use. However, R#24 was observed to still have half side rails in use and an air mattress in place on 6/25/19 and 6/27/19. The IJ was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.25(n) Bedrails (F 700 Scope and Severity (S/S): J) C.F.R. 483.21(b) Comprehensive Care Plans (F 656 S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25(n) Bedrails (F 700 S/S: J). The facility had not provided a Removal Plan at the time of exit on 7/10/19 therefore the IJ is ongoing. Findings include: Review of the facility policy titled Bed Safety revised 1/2/19 revealed the interdisciplinary team shall assess the residents sleeping environment, with input from the resident and family. If side rails are used their use must be reevaluated quarterly and as needed (prn). If a bed rail is to be used it will be installed when the attempt to use an appropriate alternative has not been effective and did not meet the resident's needs. Review of Guidance for Industry and FDA Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment issued 3/10/06 revealed reassessment of bed safety programs may be appropriate when accessories such as mattress overlays are added. Powered air mattress replacements are easily compressed by the weight of a patient and may pose additional risk of entrapment when used with conventional hospital bed systems. When these types of mattresses compress, the space between the mattress and the bed rail may increase and pose an additional risk of entrapment. When rail entrapment occurred the most commonly injured body parts were the head and neck and 143 out of 145 events resulted in fatalities. Use of bedrails should be based on patient's assessed medical needs and should be documented clearly and approved by the interdisciplinary team. Bedrail effectiveness should be reviewed on a regular basis. The patient's chart should include a risk-benefit assessment that identifies why other care interventions are not appropriate or not effective if they were previously attempted and determined not to be the treatment of [REDACTED]. Monitoring of the bed, mattress and accessories should be ongoing. Review of the undated FDA document titled Recommendations for Health Care Providers about Bed Rails revealed the facility should inspect and regularly check the mattress and bedrails to make sure they are still installed correctly and for areas of possible entrapment and falls. Regardless of mattress width, length, and/or depth, the bed frame, bed side rail, and mattress should leave no gap wide enough to entrap a patient's head or body . Inspect, evaluate, maintain and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards. Be aware that gaps can be created by movement or compression of the mattress which may be caused by patient weight, patient movement, or bed position, or by using a specialty mattress, such as an air mattress, mattress pad or water bed. 1. A review of the clinical record revealed R#23 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of Quarterly and Annual Minimum Data Sets ((MDS) dated [DATE], 2/5/19 and 5/7/19 revealed R#23 had a Brief Interview for Mental Status Score of 00, indicating severe cognitive impairment. R#23 was also assessed to require extensive two person assist for bed mobility, was totally dependent for transfers and had impaired movement of both upper and lower extremities on both sides. A review of Physician's Orders for R#23 revealed an order dated 1/15/19 for quarter side rails bilateral/enabler. On 4/16/19 the Physician ordered to discontinue (dc) side rails, continue air mattress with bolsters. On 6/4/19 the Physician ordered may have bilateral half ( 1/2) side rails to define bed boundaries, per family request. There were no orders prior to 1/15/19 for side rails. Review of the Evaluation for Use of Side Rails dated 10/31/18 and 11/8/18 revealed side rails were being considered to allow resident increased bed mobility. No was checked indicating the side rails would not assist the resident with bed mobility, transfer, avoiding rolling out of bed, or provide a sense of security. Recommendation was that side rails were not indicated at this time. One-fourth partial rails and one-half partial rails were checked on the 11/8/18 assessment but not addressed on 10/31/18. Side rails precautions and alternatives to side rails was not checked as being discussed with the resident or family/resident representative. Review of the Evaluation for Use of Side Rails dated on 4/10/19 (five months from the previous assessment and nine days after the entrapment of R#23) continued to reveal that side rails were not assisting the resident, that side rails were not indicated, and documented no reason for the side rails. The evaluation dated 4/10/19 indicated bilateral bolsters were added to the overlay and precautions and alternatives to side rails had been discussed with the resident and family/representative. There were no documented alternatives. The size of the rails was not addressed. Review of the Evaluation for Use of Side Rails dated 4/16/19 revealed the family agreed to the use of bolsters for the air mattress and continued to include that alternatives had been discussed with the family. The Physician discontinued the side rails on this date. A Social Service Progress Note dated 4/17/19 at 8:29 p.m. revealed on 4/8/19 a care plan meeting had been conducted with R#23's son and the Social Service Director (SSD), Director of Nurses (DON), Unit Manager, Wound Care Nurse, and a Certified Nursing Assistant (CNA). The fall risk, interventions in place due to the fall risk, and the risk of the side rails were discussed with the son and he agreed to allow the rails to be removed. There were no previous Social Service progress notes in the clinical record that referred to informing R#23's family of risks of side rails. A review of the care plan for R#23 revealed on 11/4/15, Activity of Daily Living (ADL) was identified as a problem. Interventions for this problem included assist with all transfers, turn and reposition, shifting weight to enhance circulation, range of motion (ROM) provided during ADL care, and on 3/23/17 side rail(s) as an enabler. A fall care plan developed on 11/4/15 revealed R#23 was at risk for fall related injury. On 4/1/19, the fall care plan problem was updated with a fall on 4/1/19 related to poor bed mobility and cognitive deficits. Interventions for fall risk updated on 4/1/19 included side bolsters to mattress and landing mat. Additionally, on 4/1/19, keep side rails down had been crossed through and updated with removed, indicating there were no side rails, dated 4/9/19. There was no other mention of side rails in any other care plans. Review of Event Manager revealed an incident occurred on 4/1/19 for R#23 as follows: R#23 was observed on floor on buttocks with neck lodge (sic) between bed and railing. Vital signs were as follows: blood pressure 146/87, temperature 97.5, pulse 68 and oxygen saturation 96%. R#23 had no falls in the last 90 days. Fall mats were documented in place next to the bed and the bed was in low position. The attending Physician for R#23 was notified on 4/1/19 at 6:23 a.m. and the Responsible Party (RP) was notified on 4/1/19 at 6:40 a.m. R#23 was transported to the hospital. No time was provided for this transfer. A description of precipitating factors included the air mattress on bed was inflated high. Continued review of the Event Manager revealed a staff member, Certified Nursing Assistant (CNA) DD, documented that the air mattress sometimes inflates too high and moves the patient. The roommate of R#23 had notified LPN GG that R#23 was on the floor. LPN GG documented that there was no injury. A review of the hospital clinical record revealed R#23 arrived in the ED on 4/1/19 at 7:40 a.m. and was seen by the ED Physician at 8:03 a.m. R#23 was transported by Emergency Medical Services (EMS). The ED Physician's History revealed the patient was found on the ground that morning with her neck between the bed rails. The ED Physicians Physical examination revealed R#23 had a contusion on the left parietal region (bruise on the left side of the top of her head). The radiologist's interpretation of a Computerized [NAME]ography (CT) scan for R#23 revealed she had a left frontoparietal scalp hematoma, otherwise no acute intracranial abnormality. The ED Physician also ordered a cervical spine CT scan. The radiologist's interpretation revealed R#23 had a history of [REDACTED]. R#23 was stable for discharge at 9:23 a.m. A list of active rentals of air mattresses as of 6/27/19 was reviewed and R#23 had been provided with her current air mattress on 8/19/18. The manufacturers recommendations for the brand of air mattress that was indicated on the above list of active rentals for R#23 were requested on 6/26/19 at 1:35 p.m.; however, were not received until 7/1/19 at 2:09 p.m. and included the following: * When using side rails and/or assist devices, use a mattress thick enough and wide enough so that the gap between the top of the mattress and the bottom of the side rails and the gap between the side of the mattress and the side rails is small enough to prevent a patient from getting his or her head or neck between the mattress and the side rail. Failure to do so could result in serious patient injury or death. * Failure to use bed rails in raised position could lead to accidental falls. Air mattresses have soft edges that may collapse when patients roll to that edge. A review of air mattress audits by the former wound care nurse for R#23 revealed the following: On 8/20/18 the air mattress of R#23 was documented on the audit sheet. Her documented weight was 119.5 pounds (lbs.) with a question mark and the bed setting was not documented. On 9/25/18 the air mattress of R#23 was listed on the audit sheet with a weight of 116.8 and a mattress setting of 150 lbs. On 10/5/18, R#23's air mattress audit was documented with a weight of 113.3 lbs. and no mattress setting. On 10/3/18, 10/15/18, 10/22/18, and 10/29/18, there were no initials to indicate who performed the audit. R#23's weight was documented as 113.3 lbs. and her low air loss mattress was set at 150 lbs. On 11/6/18, 11/12/18, 11/19/18 and 11/22/18, there were no initials on the audit sheet to indicate who performed the audit. R#23's weight was documented as 115.8 lbs. and the air mattress setting documented was 150 lbs. On 1/14/19, 1/20/19, and 2/5/19, the documentation of the audits of the air mattress had no mattress setting. There were no other audits of air mattress settings for R#23. A review of Quality Performance/Peer Review, Facility Plan of Action/ Continuous Quality Improvement dated 4/1/19 revealed the facility documented on 4/4/19 R#23's incident. Side rails on beds with air mattresses were reviewed and removed if possible. Manufacturers guidelines for all models of air mattresses being used in the building will be obtained and placed at the Nurse's Station. Licensed Nurses and CNA's will be educated on the location of manufacturer guidelines for air mattress use. Licensed Nurse will be educated on checking air mattress setting every shift, checking setting upon notification of problem and checking setting as patients weight changes .Licensed Nurse will be educated . not to use side rails with air mattress unless approved by the Chief Executive Officer (CEO) after entrapment zone review. Licensed Nurses will be educated on side rails: use, assessment, consents, Physician (MD) orders, and care plans. This education was documented initiated on 4/12/19. CNA's, Housekeeping, and Maintenance will be educated to only allow settings to be adjusted by Licensed Nurse or Equipment technician, and to notify Nurse if setting is bumped or changed. This education was documented initiated on 4/10/19. Review of educational records related to side rail entrapment, eliminating side rails, side rail use update, and air overlay with bolsters and positioning in bed properly for R#23 and a town hall meeting on 4/23/19 revealed 57 of 204 staff were educated. This equals 27.94% of all staff educated on side rail safety from 4/1/19 through 5/15/19. Review of the Evaluation for Use of Side Rails dated 6/14/19 revealed side rails for R#23 were evaluated again and included that her son preferred R#23 to have side rails to define the bed edge. The size of the rails indicated upper half rails were to be used. Alternatives to side rails were documented as addressed with the resident and family, but no alternatives were documented. The side rails were evaluated again on 6/20/19 for R#23 and were considered to allow resident increased bed mobility as an enabler/safety. The side rails were to assist the resident to avoid rolling out of bed and provide a sense of security. Observations were conducted as follows: On 6/26/19 at 9:40 a.m., R#23 was up in chair in room. There were half side rails on both sides of the upper half of her bed. A foam pressure relief mattress was on the bed. On 6/26/19 at 2:30 p.m., R#23 was centered in bed on left side with two top half side rails raised. On 6/27/19 at 7:45 a.m., R#23 was turned to the left and was in the center of the bed with two top half side rails raised. On 7/2/19 at 10:35 a.m., R#23 was turned to the right and was in the center of the bed with two top half rails raised. During an interview on 6/26/19 at 7:50 a.m., the former DON revealed R#23 has a history of traumatic brain and cervical spine injury from a motor vehicle accident eleven years ago and has been in this facility since her discharge from the hospital. R#23 has very little movement and requires total care. On 4/1/19, R#23 somehow rolled out of her bed and became entrapped with her head and neck between the side rail and the mattress. R#23 was sent to the hospital and had no injury. The RP received education related to the corporate policy to not have side rails on the beds of residents with air mattresses and he allowed the facility to remove the side rails. Then on 5/28/19, R#23 rolled out of bed again and had no injury, but the son requested the side rails be returned to the bed. The former DON revealed he consented to the air mattress being removed and a pressure relief mattress was put on the bed. The former DON revealed the air mattress on R#23's bed, and the other air mattresses in the facility, had no settings for variable air pressure that were accessible from the outside of the control panel, and there was no bed in the facility that was set on intermittent air pressure. The former DON revealed there was no possibility the air mattress had been set to maximum inflation. During an interview on 6/26/19 at 9:32 a.m., CNA XX revealed she received education related to the proper positioning of residents on air mattresses and watching for gaps between resident's side rails and mattresses that they could become trapped in and injured. CNA XX confirmed the education also included not changing any settings on the control panel and to notify the nurse immediately of the settings were accidentally changed or the mattress seemed to be over inflated. CNA XX revealed she has worked with R#23 for years and she has always had half side rails except for a few weeks after she was caught in the side rails, and also that she has never seen R#23 move her body or extremities independently. During an interview on 6/26/19 at 9:35 a.m., CNA YY revealed she has worked with R#23 many times and she was aware R#23 slid from her bed and her head and neck were caught in her side rail. CNA YY revealed she did not know how this happened because R#23 does not move at all. CNA YY revealed she has never seen R#23 use her side rails for any bed mobility. CNA YY revealed she did not remember attending education related to side rails and the danger of entrapment, and the increased risk of entrapment with air mattresses. CNA YY revealed she was aware that she should always observe for gaps that any resident could become entrapped in between the mattress and side rails, to not touch the control panel settings and to observe for air mattress over inflation and report to the nurse immediately if an air mattress seemed to be malfunctioning. CNA YY revealed R#23 has always had two top half side rails except for a few weeks after she fell the first time. Interview with the new Wound Care Nurse, LPN BB on 6/26/19 at 10:42 a.m. revealed she has been employed by the facility for three weeks and there were no user manuals or factory recommendations attached to the mattress, control panel, or in her office. The Wound Care Nurse revealed she had received education in orientation related to the risks of side rail entrapment and the risks of using air mattresses. Interview on 6/27/19 at 4:55 p.m. with the former DON revealed after reviewing the current and overflow clinical records for R#23, there was no consent for side rails or any indication the RP for R#23 had been informed that the side rails posed a risk for entrapment and that the addition of an air mattress increased the risk for entrapment. The former DON revealed that R#23 had probably had side rails for the [AGE] years she had been a resident in this facility. The former DON acknowledged that there were no side rail assessments found for R#23 prior to (MONTH) (YEAR), and that there is no documentation related to the alternatives to side rails that were attempted or discussed with the RP. The former DON revealed the resident representative had requested side rails after R#23 fell out of bed on 5/28/19. The former DON revealed she expected the Wound Care Nurses to explain the increased risk of using side rails with an air mattress to the resident/resident representative, and to monitor the settings on the air mattress control panels weekly. She revealed she had not reviewed the monitoring of the settings but was aware the former Wound Care Nurse kept them in her office. The former DON revealed she had not in-serviced the new Wound Care Nurse, here for three weeks, related to the weekly monitoring of the air mattress control panel settings. During a telephone interview on 6/27/19 at 5:39 p.m., the former Wound Care Nurse, LPN AAA revealed she remembers R#23 and remembers discussing the air mattress with the RP when it was applied to the bed last summer. LPN AAA revealed she had not provided any information to the resident/resident representative related to the increased risk of entrapment in side rails when used in conjunction with an air mattress. She did not consider that R#23 would have any increased risk because she had contractures of all four extremities and she could not move. LPN AAA revealed she monitored air mattress settings every Monday on every resident with an air mattress and filled out check lists that are located in the Wound Care office. LPN AA revealed she was Wound Care Nurse here for three and a half years and had never seen R#23 move and she had always had bilateral top half rails. She revealed she had never found any of the air mattress settings changed. She had never been told that R#23's air mattress could have been over inflated, and she had not received any education related to the increased risk of entrapment when air mattresses are used for residents with side rails before or after R#23 had been entrapped in her side rail. An interview was conducted on 6/28/19 at 7:16 a.m. with CNA DD. CNA DD was assigned to the care of R#23 on the morning of 4/1/19. CNA DD revealed the roommate of R#23 had called for help when R#23 was found on the floor with her head and neck entrapped in her side rail. LPN GG went to the room first and called for help. The resident was in a praying position on the floor with her head between the air mattress and the side rail which was up. CNA DD stated R#23 could not get up and the air mattress was inflated a lot. LPN GG adjusted the setting to what it should be. CNA DD revealed the resident was last seen by LPN GG at approximately 6:00 a.m. when she administered medications and the roommate called for help between 6:30 a.m. and 6:45 a.m. During an interview on 7/2/19 at 9:00 a.m., LPN BBB revealed she has worked with R#23 intermittently for nine years and she does not move on her own and she has always had two top half rails. LPN BBB revealed she was on duty when R#23 returned from the hospital after entrapment in her side rail and had not noted any bruising or swelling on her head. She revealed she had attended education a few days after the incident related to checking the settings on the air mattress control panel every shift or more often and checking for gaps between the side rails and the mattress and bed frame. An interview with the Staff Development Coordinator (SDC) on 7/2/19 at 9:50 a.m. revealed she had not included information related to the risks of side rails and air mattresses in CNA orientation prior to 4/1/19. The SDC revealed most of the CNA orientation is clinical and the orienting CNA's are provided with mentors and she did not know if any of the mentors mentioned side rail or air mattress risks. The SDC revealed since R#23 was entrapped she has started including information related to risks of side rails and air mattresses in the licensed nurse's orientation and does include their role in monitoring and adjusting settings on the air mattresses as well as monitoring the side rails for gaps and secure placement. An interview was conducted with the Customer Service Representative for the air mattress supplier on 7/3/19 at 11:33 a.m. The Representative revealed he does not recommend any specific setting for air mattresses and leaves this up to the facility and they should adjust according to the resident's comfort and body shape. The Representative revealed the weight settings are just a guide and he has seen them set as much as fifty pounds over what the resident weighs with no issues with the resident's safety. The Representative revealed the weight settings, maximum inflation and alternating pressure are all accessed from the control panel and can be easily changed. The Representative revealed there was always a chance of the resident rolling off the air mattress with the firmer settings and the resident should ideally sink into the mattress about four inches. Further interview with the former DON on 7/2/19 at 3:30 p.m. revealed she expected the Unit Managers, Charge Managers and the Interdisciplinary Team (IDT) to review all new orders and if the order is not appropriate such as ordering quarter rails as an enabler for R#23, this should be brought to the attention of the Physician and corrected. The former DON acknowledged that there are no quarter rails in the facility, only half rails and that R#23 is not capable of using side rails as an enabler. An interview was conducted on 7/2/19 at 4:20 p.m. with the third floor Unit Manager LPN FF. LPN FF was unable to locate any manufacturers guidelines or operators' manuals for the air mattresses for the residents on the third floor. An interview on 7/3/19 at 9:00 a.m. with the Therapy Manager revealed the therapy department has no part in side rail assessments. The Therapy Manager revealed she is very familiar with R#23 and is aware that R#23 does not have the capability to move due to cervical spine and traumatic brain injuries eleven years ago. The Therapy Manager stated she does not know how it would be possible for R#23 to independently move enough to fall off her bed twice. During an interview on 7/3/19 at 1:59 p.m., the Interim DON reviewed the air mattress setting audits conducted by the former Wound Care Nurse for R#23 and confirmed there were many blanks where the weight setting should be filled in, and there were many dates when the weekly monitoring was not completed. When monitoring was completed it did not always include R#23. The Interim DON revealed that education related to air mattresses and side rail risks, documentation and management that was initiated on 4/5/19 was still ongoing. The Interim DON revealed during her review of the audits of documentation she had found many residents without orders, with incomplete and incorrect assessments, and without informed consents for side rails. The Interim DON revealed that she is not sure all the documentation concerns have been corrected. During a telephone interview on 7/5/19 at 12:09 p.m., LPN GG confirmed she was on duty on 4/1/19 at 6:30 a.m. and had been passing medications on the fourth floor. LPN GG revealed she had given a medication in the room of R#23 at approximately 6:15 a.m. and then continued administering medications to other residents on the same hall when approximately 15 minutes later, R#23's roommate came out of the room and said loudly that R#23 was on the floor. LPN GG revealed she immediately went into the room and found R#23 sitting on her bottom on the landing mat beside her bed with her body facing the door and her head caught between the side rail and the mattress with her face turned to face the head of the bed. Her chin was resting on the bottom horizontal rail of the side rail and the bed was in the lowest position. R#23 was not making a sound, her eyes were open, and she was breathing without effort. LPN GG stated she shouted for CNA DD who came right away. They were able to slide the mattress over, put down the rail and get R#23 back into bed. LPN GG revealed the air mattress had felt tight like it was too full. LPN GG checked the settings on the air mattress control panel and the settings were the same as always. Maximum inflation and alternating pressure had not been activated. LPN GG revealed she remembered the weight setting was also where it always was whenever she checked it, on 120 lbs. She had not touched the settings but had reported she and CNA DD had both thought the mattress was over inflated and may have malfunctioned. She had worked with R#23 intermittently for over a year and had never seen R#23 move and could not think of how she could fall. LPN GG revealed she had performed a head to toe assessment and checked vital signs and there was no indication R#23 was injured. An interview with the Medical Director on 7/10/19 at 9:07 a.m. revealed she remembers discussing side rails at Quality Assurance meetings and agreed with the recommendations the committee made to reduce the use of side rails. The Medical Director was not able to remember discussing R#23 being entrapped in her side rail on 4/1/19. The Medical Director revealed she is involved in care planning for all aspects of resident care and expects care plans to reflect any risk to the resident's wellbeing, with side rails as a risk, and the additional risk of an air mattress. These risks should be considered problems for the care plans and require interventions for the resident's safety. The Medical Director confirmed this should be explained to all residents and families that are consenting to side rails. An interview on 7/10/19 at 10:10 a.m. with the Administrator revealed her first day in facility was 6/4/19 and she was not given any information that a resident had been entrapped in side rails until the surveyors arrived. Meetings take place daily related to preventing falls, assessing individual needs, care planning and accuracy of orders. The Administrator revealed she attends at least three clinical meetings a week. The Unit Managers are expected to provide accurate updates and provide the Interdisciplinary team with new problems and risks for any resident whose care plan does not represent accurate information related to risks such as side rails and air mattresses. 2. Resident #24 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The baseline care plan dated 12/22/18 noted R#24 was at risk for falls related to weakness. Interventions included side rails bilateral (enabler). Review of the Evaluation for Use of Side Rails for R#24 dated 1/20/19 revealed the use of side rails were being considered for R#24 to allow resident increased bed mobility. However, the same document indicated the resident's mobility is very limited: makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently. In addition, the Quarterly MDS assessment dated [DATE] Section G0110A Bed mobility revealed that R#24 requires total assistance to move in bed. Section C0500 Brief Interview for Mental Status is coded 00 which indicates R#24 was severely cognitively impaired and unable to be interviewed. Review of a document dated 1/30/19 titled Daily Skilled Nursing Note revealed R#24 is alert and responsive, non-verbal. Requires total dependence on staff for all ADL's and transfers. Review of the Progress Note for R#24 dated 2/3/19 at 11:19 p.m. revealed residents right leg caught in bed rail. No bruising noted. Right leg and ankle [MEDICAL CONDITION]. No obvious signs of injury. Review of the Physician's telephone order dated 2/4/19 revealed Right Knee x-ray 2 views and Right ankle x-ray 2 views, indication: pain and swelling. Review of document titled SHC NP (Nurse Practitioner) Medical Partners dated 2/4/19 revealed, Chief Complaint/History of Present Illness, lower leg pain, Patient noted with right leg caught in side rail of bed, onset of symptom -1 day ago. Mechanism of injury-direct trauma. Severity -mild, Pertinent Findings- swelling, denies bruising, denies decreased range of motion, denies pain with movement and denies warmth. Review of page 3 of 3 included the NP's Plan; right leg pain, X-ray right knee and ankle continue to monitor for changes/worsening and symptoms, Nursing to continue assistance with ADL's and care, Tylenol as needed for pain, Elevate extremity and rest. Will",2020-09-01
188,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2019-07-10,842,D,1,0,UF4211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Neurological Evaluation/Monitoring, and staff interviews, the facility failed to document neurological assessments related to an unwitnessed fall for two residents (R) (#27 and #31) of four residents reviewed for falls. Findings include: Review of the facility policy titled Neurological Evaluation/Monitoring revised 11/12/18 revealed neuro (neurological) checks will be performed using the Neurological Evaluation Flow Sheet for a full 72 hours and placed in the medical record. The neuro checks will be performed every 15 minutes x 4 check, every 30 minutes x 4 check and every 1-hour time x 4 followed by 72 hours q (every) shift assessment and documentation. 1. Review of the face sheet revealed R#27 was admitted to the facility on [DATE] for rehabilitation following a stroke. Her admitting [DIAGNOSES REDACTED]. Review of the SBAR (Situation Background Assessment and Response) Communication Form dated 6/25/19 at 12:05 a.m. revealed R#27 had a fall on 6/24/19 at 5:00 p.m. when attempting to transfer unassisted. The resident was experiencing slurred speech and left facial drooping. The resident was sent to the emergency room (ER) for evaluation. There was no documented evidence of post fall neurological assessments. Review of the hospital records dated 6/25/19 revealed resident arrived at the ER with clear speech. Resident stated she requested pain medication along with her night time medications and she thinks that is why she had slurred speech. CT and X-ray reports of left side of body were negative. Physician requested MRI for further evaluation, but resident refused. 2. Review of the clinical record revealed R#31 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed R#31 had an unwitnessed fall without injury on 6/23/19 at 7:35 p.m. There was no evidence of documentation of post fall neurological assessments. Interview with the former Director of Nursing (DON) on 6/26/19 at 2:45 p.m. revealed that all unwitnessed falls must be followed by neurological checks according to facility policy. Former DON stated R#27 and R#31 met the criteria for unwitnessed fall and neuro checks should have been performed and documented. During an interview on 7/9/19 at 4:50 p.m., the Corporate Clinical Nurse revealed that following an extensive search, she was unable to locate any documentation of neuro checks for R#27 and R#31.",2020-09-01
189,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2017-07-20,371,F,0,1,XEII11,"Based on observation, staff interviews, and review of facility policy, it was determined the facility failed to ensure one of three resident refrigerators was maintained at a temperature of 41 degrees Fahrenheit (F) or below. In addition, the facility failed to ensure that resident food and drink items were labeled with a resident's name and dated on two of three resident nourishment refrigerators. There was a total of 113 residents receiving oral feedings. The census was 132 residents on the first day of the survey. Findings include: A review of the policy titled Record of Refrigeration Temperatures revised 7/1/14 revealed the following under the sub-section titled PR[NAME]EDURE: 4: The refrigerator must be clean and temperatures must be 41 degrees F or less. 5. Temperatures greater than these areas are to be reported to the Dietary Manager (DM) immediately. 8. Nursing unit refrigerators and freezers and any other refrigerator/freezers having resident food stored in it must be clean, have Use By Dates on food product. 1. On 7/19/17 at 9:38 a.m. an observation was conducted of the fourth-floor resident nourishment refrigerator. The Unit Manager, Registered Nurse (RN) AA was present. There were two thermometers in the refrigerator and both read 50 degrees F. RN AA confirmed the temperatures of 50 degrees F. On 7/19/17 at 9:54 a.m. an observation was conducted of the third-floor resident nourishment refrigerator with the Unit Manager Licensed Practical Nurse (LPN) BB present. There was a sign on the outside of the refrigerator door that read: Pantry Refrigerators are for resident food only. Please be sure that any items placed inside of fridge are labeled with a name, room number, and a date. (Any unlabeled items will be discarded.) The observation revealed the following - An opened 32-ounce container of thickened liquids. There was no date to indicate when the item was opened. LPN BB confirmed that the container contained thickened liquids for residents, and that it was not dated. - A Kentucky Fried Chicken box dated 7/15/17 was partially opened and contained two pieces of fried chicken. There was no resident name or room number on the box. - A plastic bag labeled[NAME]nd dated 6/11/17. LPN BB identified the item in the bag as a biscuit. - A squeeze container of Hershey's sundae dream syrup and a squeeze container of Hershey's chocolate syrup was opened but not dated. LPN BB said they were used for residents during ice cream socials, but could not state when the containers had been opened. - A soft sided cooler was in the refrigerator and contained an almost empty quart-sized container of what appeared to be coleslaw with a whitish dressing, and an open package of what appeared to be a chocolate cookie. The items were not dated or labeled with a resident's name or room number. During the observation, an interview with LPN BB revealed that items are typically discarded every few days. She stated the Dietary Department was responsible for cleaning the refrigerator and discarding the items. The Dietary Manager (DM) was interviewed on the first-floor dietary hallway on 7/19/17 at 10:11 a.m. He revealed the night shift nursing staff were responsible for checking the refrigerators and discarding out dated food items. The Director of Nursing (DON) was interviewed in her office on 7/19/17 at 10:22 a.m. and stated the nursing staff were responsible for checking the temperatures in the refrigerator and the Dietary Department was responsible for discarding outdated food. 2. A second observation was conducted of the fourth-floor residents' nourishment refrigerator on 7/19/17 at 11:22 a.m. The Dietary Manager and the Maintenance Manager (MM) were present during the observation. The DM confirmed that both thermometers in the refrigerator read 50 degrees F and stated that he had not been notified of any issue with the temperature in the refrigerator. The MM stated that he had not been notified of issues with the refrigerator temperatures; but the (MONTH) temperature flow sheet document did not indicate any temperatures had been greater than 40 degrees F. A thermometer inserted into a carton of milk by the DM read 43 degrees F. The DM confirmed the refrigerator temperature should be 41 degrees F or lower and stated he could not say how long the milk had been above that temperature. The MM checked the refrigerator temperature with a hand-held beam type thermometer and stated the temperature inside the refrigerator was 43 degrees F. The pantry was noted to be very warm, and the Maintenance manager stated this was because of the ice machine in the room. The room temperature checked with a hand-held thermometer was 94 degrees F. 3. On 7/19/17 at 3:41 p.m., a third observation of the fourth-floor refrigerator with LPN CC revealed both refrigerator thermometers registered 50 degrees F. The refrigerator contained two cartons of milk in the door of the refrigerator and a closed Kentucky Fried Chicken box labeled with a resident's name and a date of 7/18/17. The box contained chicken pieces, a portion of fried potatoes and a biscuit. 4. On 7/19/17 at 3:55 p.m., an observation of the second-floor pantry refrigerator was conducted with LPN DD. The observation revealed the following: - A red soft sided cooler bag containing an unlabeled/undated jar full of a white moldy substance. LPN DD could not identify the substance or state when it had been placed in the refrigerator. - An additional black and white polka dot soft sided cooler which contained an unlabeled/undated clear container that held corn on the cob. - A clear plastic container that contained strawberries and blueberries and was labeled with a resident's room and bed number. There was no date on the container to indicate the age of the fruit or when it was placed in the refrigerator. - A clear container holding melon chunks was labeled with a resident's name and room number, but there was no date on the container to indicate the age of the food item or when it was placed in the refrigerator. - A plastic bag contained an unopened sleeve of crackers and what appeared to be potato salad. There was a resident's name and room number on the container; however, there was no date on the container to indicate when it had been placed in the refrigerator. An interview was conducted with the facility Administrator on 7/19/17 at 3:50 p.m. The Administrator was informed that the refrigerator on the fourth floor still registered a temperature of 50 degrees F and there was milk and chicken labeled with a resident's name in the refrigerator. He revealed the Maintenance Manager had just checked the refrigerator temperature and it remained at 50 degrees F and the refrigerator was being taken out of service. The Administrator was also informed that there were unlabeled and undated food items in the second and third floor resident refrigerators that could potentially cause a resident to develop a food borne illness; and there was a concern a resident could be given an expired food item. The Administrator stated the issue would be addressed immediately.",2020-09-01
190,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2019-08-01,636,D,0,1,FRPF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a Minimum Data Set (MDS) comprehensive assessment for one resident (R) (#2) of 44 sampled residents. Findings include: Resident was admitted to the facility on [DATE]. Record review for R#6 revealed an MDS Annual assessment dated [DATE] and a Quarterly assessment dated [DATE]. No other comprehensive assessments were documented for R#6. The Annual Assessment was scheduled on 5/30/19 but was not completed. Review of an alphabetical resident census revealed R#6 was currently a resident in the facility. During an interview on 8/1/19 at 1:45 p.m. MDS Coordinator Licensed Practical Nurse JJ revealed that she left in (MONTH) of (YEAR) and assessments were current. She stated when she returned in (MONTH) of 2019, the assessments were behind. An assessment was initiated on 8/1/19 and was in progress.",2020-09-01
191,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2019-08-01,640,B,0,1,FRPF11,"Based on record review and staff interview, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for four of seven discharged residents (R) reviewed (#1, #3, #4, and #6). Findings include: 1. Review of the discharge record revealed R#1 was discharged from the facility on 3/22/19. Review of R#1's MDS list revealed there was an Admission assessment completed on 2/15/19, and the MDS discharge assessment was not completed until 6/12/19. 2. Review of the discharge record revealed R#3 was discharged from the facility on 2/20/19. Review of R#3's MDS list revealed there was an Admission assessment completed on 2/13/19, but there was no MDS discharge assessment listed. 3. Review of the discharge record revealed R#4 was discharged from the facility on 4/15/19. Review of R#4's MDS list revealed there was an Admission assessment completed on 2/7/19, but there was no MDS discharge assessment listed. 4. Review of the discharge record revealed R#6 was discharged from the facility on 4/26/19. Review of R#6's MDS list revealed there was an Admission assessment completed on 3/23/19, but there was no MDS discharge assessment listed. During an interview on 8/1/19 at 1:45 p.m. MDS Coordinator Licensed Practical Nurse JJ revealed that she left in (MONTH) of (YEAR) and assessments were current. She stated when she returned in (MONTH) of 2019, the assessments were behind. The four late discharge assessments were completed on 8/1/19.",2020-09-01
192,SIGNATURE HEALTHCARE OF BUCKHEAD,115110,54 PEACHTREE PARK DRIVE N.E.,ATLANTA,GA,30309,2019-08-01,803,D,0,1,FRPF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, residents and staff interviews, the facility failed to follow their menu of choice for two residents (R) (#113 and R#322) of 44 sampled residents. Findings include: 1. Review of the clinical record revealed R#113 was admitted to the facility on [DATE]. The Admission Minimum Data Set ((MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) was coded as 13, which indicated no cognitive impairment on Section C. 2.Review of the clinical record revealed R#322 was admitted to the facility on [DATE]. MDS was not complete but baseline care plan was done and noted R#322 was alert and oriented to person, place and things. During a dining observation during lunch on 7/29/19 at 1:00 p.m., R#113 and R#322 were served baby lima beans, rice, tilapia and bread rolls. Both residents requested green beans as printed on the meal ticket. Dietary Aide FF stated they did not have any green beans. R#113 and R#322 left and went to their rooms. During an interview on 7/29/19 at 1:38 p.m., R#322 also stated the facility has limited items. She stated the facility always changes the menu and does not change the meal ticket or inform the residents. Interview on 7/29/19 at 1:45 p.m., with Dietary Aide FF revealed the menu was changed and she did not know why the meal tickets were not updated. Dietary staff were supposed to notify the residents, but she had no idea why it was not done. During an interview on 7/29/19 at 2:00 p.m., Dietary Manager stated she did change the menu, but forgot to change the meals tickets and notify the residents.",2020-09-01
193,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2019-01-31,561,D,0,1,TKWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one resident (R#11) out of 44 sampled residents was provided with a choice regarding showers/baths. R#11 preferred showers; she received bed baths. Findings include: R#11 was admitted to the facility on [DATE]. Review of a Physician's Note dated 11/9/18 revealed the resident was [AGE] years old. The resident's medical history and [DIAGNOSES REDACTED]. Surgical history included a [MEDICAL CONDITION] (surgically created hole in the windpipe that provided an alternative airway for breathing). The Physician's Note indicated, The patient is oriented to person, place, and time. Speech is fluent and words are clear. Thought processes are coherent, insight is good. There are no obsessive, compulsive, phobic or delusional thoughts; there are no illusions or hallucinations .recent and remote memory intact. The patient's fund of knowledge: awareness of current events and past history is appropriate for age. The patient's higher cognitive functions are intact . Review of the Annual Minimum Data Set ((MDS) dated [DATE] under the section for Customary Routines and Activities revealed it was very important for the resident to be able to choose between a bed bath, sponge bath, tub bath or shower. Review of the Quarterly MDS dated [DATE] Cognitive Patterns section revealed R#11 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 15 out of a total of 15. The Behavior and Mood sections revealed no behavioral or mood concerns. The Hearing, Speech, and Vision section revealed the resident was unable to speak. The Functional Status section revealed the resident was totally dependent on staff for transfers, locomotion on and off the unit, dressing, toilet use, hygiene, and baths. The resident was impaired in range of motion on one side in both her upper and lower extremities. The care plan dated 8/21/18 to address the resident's impairment in activities of daily living (ADLs) related to history of a stroke, left sided weakness, [MEDICAL CONDITION], and debility revealed staff were to provide total care with a goal of the resident being clean, groomed and dressed. Approaches included in pertinent part, using the Hoyer lift for transfers, providing care, dressing the resident, provision of personal hygiene, and bathing the resident. Review of the Shower Schedule -West Wing Effective 12/9/17 revealed R#11 was to receive showers on Wednesdays and Saturdays during the 7:00 a.m. - 3:00 p.m. shift. R#11's schedule was based on her room and bed number. The Shower Schedules for the East and West wings were both reviewed and revealed every resident on these units was scheduled for two showers a week with the day and shift for baths being based on their room number. No individualized shower schedules were documented (i.e. more frequent baths or preferences such as shower versus tub bath being noted). Review of the Bathing Report from 11/1/18 - 1/31/19 revealed no showers were given to R#11. The Bathing Report indicated the resident received baths only. The documentation did not indicate whether the bath was a tub bath or a bed bath; however, staff and the resident confirmed in interviews, R#11 received bed baths only (see interviews below). Review of the C.N.[NAME] Skin Care Alerts (documentation completed by Certified Nurse Assistants of the resident's skin, whether he/she was shaved, hair shampooed, and whether nails were trimmed when showers/baths were provided) completed from 11/1/18 - 1/31/19 did not indicate the resident received any showers during this time frame. Twenty six C.N.[NAME] Skin Care Alerts were completed during this three-month period, which staff indicated were bed baths and not tub baths (see interviews below). On 1/28/19 at 10:52 a.m. in R#11's room, R#11 was interviewed using an alphabet on a piece of paper the resident kept within reach while lying in bed. R#11 pointed to the corresponding letters of the alphabet to spell out words. R#11 stated she did not take showers or tub baths. R#11 stated she received bed baths only. R#11 stated she wanted to be showered and this was very important to her. R#11 stated the facility did not have a shower bed which was needed for her to be able to take a shower. R#11 stated there was a shower chair, but it was difficult and painful to her leg when sitting in the shower chair. The resident was observed lying in bed during the interview with use of her right hand only (left hand paralyzed), which she had used to spell words. The resident had [MEDICAL CONDITION] place with oxygen being administered. In an interview on 1/30/19 at 10:08 a.m. in the dining room, Certified Nurse Assistant (CNA) YY stated the CNAs provided tub baths or showers to the residents to whom they were assigned on the designated bath days. CNA YY stated residents received two tub baths/showers a week. CNA YY stated there was a shower list which documented when residents were to be showered/bathed. CNA YY stated, She (R#11) gets a bed bath. We tried to take her to the shower, but she refused. It was because of her leg pain. CNA YY stated there was only one shower chair and there was no shower bed available. CNA YY stated R#11 remained in bed most of the time; however, staff got her up occasionally and she sat in a Geri chair in a semi-reclined position. CNA YY stated the shower chair did not recline; residents had to be able to sit upright to use the shower chair. CNA YY stated there was no shower bed available, which could be used as an alternative to the shower chair. CNA YY stated R#11 got bed baths at least twice a week. CNA YY stated R#11 was totally dependent on staff for ADLs; however, could operate her cell phone with her good hand and communicated using the alphabet. CNA YY stated R#11's left leg was painful when moved/touched and she had to be careful with repositioning and providing care to R#11. Restorative Aide (RA) CC and RA DD were interviewed together on 1/30/19 at 10:35 a.m. in the dining room. The RAs stated R#11 received restorative services such as the provision of range of motion exercises and application of a brace to the resident's affected leg and splint to her affected hand. The RAs stated R#11 could not sit upright in a chair independently, and when she was up, she sat in a semi-reclined position in a Geri chair. An interview on 1/31/19 at 10:22 a.m. with the Assistant Director of Nursing (ADON) stated R#11 stayed in bed most of the time per her preference. The ADON stated the resident had a stroke which impacted her left side, she had a trach, used oxygen and stated when the resident got out of bed, she sat in a reclined position in a Geri chair. The ADON stated, She (R#11) leans back . She does not sit erect. The ADON stated R#11 would have to sit in an erect position to use the shower chair, to receive a shower versus a bed bath. The ADON stated the facility did not have a shower bed which would enable the staff to shower R#11. The ADON stated she had mentioned this to the Director of Nursing (DON) about a week ago. The ADON stated, There are people who need it (shower bed) . Other residents could benefit. The ADON stated R#11 got bed baths and not showers or tub baths. The ADON stated baths/showers were scheduled according to a resident's room number and verified the schedule did not deviate from two showers/baths per week based on room number for any of the residents on the West unit. The ADON stated, We tell them (new residents) the bath schedule upon admission. On 1/31/19 at 3:30 p.m. the DON and Unit Manager East Wing were interviewed together. The DON stated the ADON said something last week about needing a shower bed. The DON stated the facility used to have a shower bed available in the building, but it was not being used. The DON stated the shower bed was moved into a storage shed due to storage problems in the building. The DON stated the shower bed took up a lot of space in the shower room. The DON stated the facility retrieved the shower bed from storage and it was now available for use. The DON stated R#11 had not voiced a concern about not receiving showers. The DON stated the staff asked residents on admission about bathing preferences; she verified there was no documentation of this and the shower schedule for the East and West wings did not reflect any individualized bathing/shower schedules (all residents were scheduled for two baths per week based on their room number). The DON stated R#11 could be showered now using the shower bed. In a follow up interview with R#11 in her room on 1/31/19 at 4:14 p.m., she stated the staff had never asked her what her preference was for showers/baths. R#11 stated the facility had a shower chair in which she had been showered previously, but it was painful to her leg. R#11 stated she had not requested a shower after her previous experience in the shower chair, knowing use of the shower chair was her only option. R#11 stated she had been told there was no shower bed available. The resident stated it was very important to her to take a shower and stated she was excited at the prospect of taking a shower in the future using the shower bed.",2020-09-01
194,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2019-01-31,578,D,0,1,TKWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review and staff and family interviews the facility failed to properly execute the advance directive wishes for one Resident (R), #18 of three residents reviewed for advance directives. Findings include: On [DATE] review of the medical record for R#18 revealed the front page had a large red sticker with the letters DNR (do not resuscitate). In the medical record behind the tab labeled Advance Directives were documents related to the code status and wishes of R#18. The first page was a document titled Specialty Care of[NAME]Advance Directive Checklist. This document was signed by R#18 on [DATE] indicating he wished to have the code status of Do Not Resuscitate. The second page is a facility document titled, DNR Face Sheet. This document is checked for R#18 to have the code status of DNR. Additional documents in this section of the medical record are the POLST (Physician order [REDACTED]. In Section A of the POLST the code status is marked to Allow Natural Death (AND)-Do Not Attempt Resuscitation. The POLST is signed by the physician on [DATE] at 1:00 p.m. A fourth document titled Official Code of Georgia Annotated Title 31. Health Chapter 39, Cardiopulmonary Resuscitation Section A states DO NOT RESUSCITATE and is signed by the attending physician. Section B of the same document also states, DO NOT RESUSCITATE (name of R#18) and is dated [DATE]. Review of the care plan for R#18 revealed there is a care plan in place with the identified concern as being a code status of DNR with Advanced Directives on record. The goal is listed as if the resident's heart stops, or if they stop breathing, CPR (cardiopulmonary resuscitation) will not be initiated in honor with their DNR wishes ongoing through next review date. Identified interventions include: 1. Discuss Advanced Directives with the resident and/or appointed health care representative. 2. Staff to follow Advance Directive for DO NOT RESUSCITATE. 3. Refer to Social Services as needed. This care plan was formulated [DATE] and updated on [DATE], [DATE] and [DATE], each time to continue the current plan of care. Review of the monthly POS (physician's orders [REDACTED]. Review of the monthly POS for the past 6 months revealed the same order each month, from the physician regarding the code status of R#18. On [DATE] an interview with the ADON (Assistant Director of Nursing), at 1:13 p.m., confirmed information in the medical record indicated R#18 had Advanced Directives to be a DNR. She also confirmed the physician's orders [REDACTED].#18 contained an order for [REDACTED]. On [DATE] at 3:42 p.m. during an interview with the DON (Director of Nursing) in her office, she stated R#18 was here previously and was a DNR at that time. In (MONTH) (YEAR), he was hospitalized and when he returned from the hospital the order became a full code and his Advanced Directive was not confirmed with the physician. On [DATE] at 4:02 p.m. during an interview with the Administrator and SS (Social Services), the Administrator reported SS had completed an audit of the Advanced Directives. SS stated she did complete an audit, but the audit was only to ensure the Advanced Directive wishes for each resident were in the medical record and it did not include making sure the Advanced Directive wishes were confirmed by a physician order. On [DATE] at 4:15 p.m. during an interview with the DON, she stated the facility procedure is for admissions or social services to obtain signature of resident or family on the appropriate Advanced Directive documents. Once the documents are signed, SS will place them in the physician mailbox for him to review and sign. The physician will then place the signed document in the chart and flag it for new orders. The nurse will then send the order to pharmacy who will then include it on each monthly POS. The DON confirmed this process had not been followed when R#18 was readmitted to the facility on [DATE]. She stated she would confirm the code status of R#18 with the physician. The DON confirmed the monthly POS for full code, do not match R#18's Advanced Directive for DNR. During the care plan meeting on [DATE], the daughter was present during the meeting. During this meeting, documentation noted, she confirmed her father's wishes were to be a DNR. A phone call to the daughter on [DATE], had no answer with no return phone call as of [DATE]. Review of an undated facility policy titled, Advance Directive Procedure revealed it does not address how to make the physician aware of resident wishes, nor does it address how advanced directive/code status orders will be transcribed to be maintained in the medical record of any resident. By failing to ensure physician's orders [REDACTED].#18, this could have resulted in R#18 being resuscitated against his wishes if he had experienced cardiac or respiratory arrest.",2020-09-01
195,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2019-01-31,656,G,0,1,TKWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to implement a comprehensive person-centered care plan for falls for one resident (R#4). Failure to follow the care plan contributed to the resident sustaining harm. The sample size was 44 residents. Findings include: Record review of the policy and procedure titled Comprehensive Care Plans dated 9/21/16 revealed a person-centered comprehensive care plan meets the resident's medical, nursing, mental needs. The care plan will include how the facility will assist the resident to meet their needs, goals, and preferences. Review of the Fall Risk Evaluation dated 8/24/18 revealed the facility had assessed the resident as a 13 which indicated the resident was at risk for falls. Review of the Significant Change in Status Minimum Data Set (MDS) signed and dated 8/7/18 revealed the facility admitted R#4 with [DIAGNOSES REDACTED]. Continued review of the MDS revealed the resident to sometimes make self-understood and usually understands others, moderately impaired vision, short-term and long-term memory problems. The facility assessed the resident not to have displayed behaviors. Continued review of the MDS revealed R#4 required extensive assistance of two staff with bed mobility and personal hygiene, extensive assistance of one staff for dressing, toilet use, and was totally dependent on one staff for bathing. The resident was always incontinent of bowel and bladder. Review of the Care Area Assessment (CAA) Summary revealed the resident had triggered for falls. Review of R#4's care plan dated 8/7/18 revealed, Problem- resident is at risk for fall as he is dependent on staff for all are related to impaired mobility, [MEDICAL CONDITION], feeding tube and dementia. Goal- Resident will not sustain a fall or fall related injury through next review date. Approach- Staff to provide assistance to meet resident's needs for all activities of daily living. Review of the Fall-Fall with Injury-Major Investigation dated 9/24/18 at 10:50 a.m. stated, Certified Nursing Assistant OO (CNA) was giving R#4 a bed bath, turned away to the closet to retrieve clothes and towels from the chair when the CNA heard the resident scream, patient noted lying on his right side on the floor beside the resident's bed. Small amount of bright red blood noted draining from the resident's right forehead, hematoma noted. Continued review of the fall investigation revealed the resident was not able to state what had happened and continued to moan out in pain. Interview on 1/31/18 8:45 a.m. with CNA MM on the 100 Hallway revealed she was R#4's caregiver for the day. She stated she was familiar with the resident's care needs. She stated the correct way to give the resident, or any resident a bed bath would be to first gather all needed supplies then raise the bed to waist level. She stated she was aware R#4 was a fall risk and could roll out of the bed an injure himself/herself if he was not supervised during bath time. She stated she learned how to give a bed bath and prevent falls in CNA school and various in-services presented at the facility. She stated she received report from the nurses and the off going CNA on how to care for each resident during shift report and did walking rounds with the off going CN[NAME] Interview on 1/31/18 at 2:40 p.m. with MDS Director revealed it was common sense for a staff member not to turn away from a resident while the bed is elevated. A care plan is individualized to provide specific care to each resident. He stated following the care plan is an expectation not an option.",2020-09-01
196,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2019-01-31,684,D,0,1,TKWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, one resident (R), #R156 out of 44 sampled residents failed to be positioned appropriately in bed. This created the potential for discomfort and impaired breathing. Findings include: R#156 was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. Review of the 11/14/18 Quarterly Minimum Data Set (MDS) revealed the resident was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of zero out of 15. The MDS indicated R#156 had no mood or behavior indicators. The MDS indicated the resident required extensive assistance with activities of daily living (ADLs) including bed mobility, transfers, dressing, toilet use and hygiene. The resident was impaired in range of motion (ROM) on one side of the upper extremities and both sides of the lower extremities. The Nurse' Note 1/12/19 revealed the resident was transferred to the hospital on this date for possible feeding tube placement due to the resident not eating or drinking. A feeding tube was not placed in the hospital and the resident was readmitted back to the facility on the same day Review of a Physicians Note dated 1/12/19 revealed the resident was a [AGE] year old female who went to the hospital due to increased fatigue, dysphasia and poor intake. The note indicated the resident had a urinary tract infection, was unable to express her needs, was incontinent of bowel and bladder, and needed total care with ADLs. The Physician recommended hospice/comfort care. Review of a Nurse's Note dated 1/17/19 revealed the resident was admitted to hospice on this date. The note indicated the resident required maximum to total assistance with activities of daily living that had to be attended to and met by staff. The head of the resident's bed was to be kept elevated 30 to 45 degrees as tolerated and the resident was to be repositioned frequently. Review of the care plan dated 1/23/19 revealed the resident was at risk for falls related to decreased weakness, decreased balance and decreased safety awareness. The resident required assistance with transfers; she had a history of [REDACTED]. Approaches to address fall risk included transferring the resident with a Hoyer lift. Review of the care plan dated 1/23/19 to address pain to the lower extremities, history of an ankle fracture and stroke included a goal for the resident to experience pain relief. Approaches included providing comfort measures such as repositioning as needed. Review of the care plan dated 1/23/19 to address the residents need for assistance with ADLs included a goal for the resident to be clean, groomed, bathed and dressed. Approaches included staff assistance with dressing, toileting, personal hygiene, feeding, bathing, and assisting with turning and positioning on rounds and as needed. Observations revealed the resident was not positioned appropriately in the bed as follows: -On 1/28/19 at 11:15 a.m. the resident was lying in bed on her back with her eyes closed with part of her left shoulder and the left side of her head off the side of the mattress. The resident's torso was positioned in an awkward angle leaning to the left while her legs lay straight on the middle of the bed. The head of the bed was elevated at 45 degrees. The resident's pillow was on top of her head. The resident's head and shoulders were on the elevated part of the bed; the rest of her body was on the flat portion of the bed. -On 1/28/19 at 12:14 p.m. the resident had been positioned so her head and shoulder were fully on the mattress; however, the head of the bed continued to be at approximately 45 degrees and her torso, shoulders and head continued to lean to the left side with her legs straight down the middle of the bed. The resident's head and shoulders were on the elevated part of the bed; the rest of her body was on the flat portion of the bed. -On 1/28/19 at 1:02 p.m. the resident was in the same position as previously noted at 12:14 p.m. -On 01/29/19 at 2:09 p.m. the resident was lying in bed on her back with her eyes closed with her torso, shoulders and had positioned in an awkward angle leaning to the left while her legs lay straight on the middle of the bed. The head of the bed was elevated approximately 45 degrees. The resident's head and shoulders were on the elevated part of the bed; the rest of her body was on the flat portion of the bed. -On 01/30/19 at 8:35 a.m. the resident was lying on her back in bed with the head of the bed elevated at approximately 30 degrees. The resident's torso, shoulders and head were leaning to the left side. -On 1/30/19 at 9:45 a.m. the resident was lying in bed on her back with the head of the bed elevated at approximately 45 degrees. The resident's torso, shoulders and head were leaning to the left. The resident's head was off the pillow with her head near the edge of the mattress. The resident's head and shoulders were on the elevated part of the bed; the rest of her body was on the flat portion of the bed. -On 1/30/19 at 11:04 a.m. the resident was in the same position as at 9:45 a.m. except her head was cocked further to the left at the edge of the mattress. The resident's head was next to the pillow. The resident's head and shoulders were on the elevated part of the bed; the rest of her body was on the flat portion of the bed. In an interview on 1/30/19 at 11:30 a.m. Certified Nurse Assistant (CNA) VV stated R#156 required total care and she did everything for the resident. CNA VV stated the resident was hospitalized a couple weeks ago and her condition had been declining, resulting in her sleeping most of the time. She stated the resident's positioning in the bed had been problematic because R#156 tended to lean or slide down in the bed to the left side with her torso and head. CNA VV stated R#156 slid down in the bed and verified the head of the bed was elevated significantly. CNA VV stated she kept the head of the bed elevated because the resident made a noise as if there was something in her throat. CNA VV stated she tried to reposition the resident every 45 minutes or so. An interview on 1/31/19 at 10:17 a.m. with the Assistant Director of Nursing (ADON) revealed R#156 had a stroke and multiple hospitalization s. The ADON stated the resident was dependent on staff for all care and was now on hospice care. The ADON stated the resident was not able to reposition herself. The ADON stated the head of the bed should be elevated when the resident was being fed at around 45 degrees, but otherwise it should be lowered so the resident would not slide down in the bed. The resident's posture in the bed was conveyed to the ADON; she stated she was not aware of the resident's positioning. In an interview on 1/31/19 at 3:10 p.m., the Director of Nursing (DON) stated the staff tried to keep the bed slightly elevated due to swallowing issues, but it should not be elevated too much. The Restorative Nursing Policy and Procedure Manual, dated (MONTH) 2010, under the heading of Positioning revealed, Positioning is probably the most important element to ensure the prevention of pressure ulcers and is invaluable and preventing hypostatic pneumonia as well as preventing the development of contractures. The purpose was to instruct restorative nursing staff in the general principles and techniques of positioning residents in the bed, chair, and wheelchair to prevent decubitus, contractures, and pneumonia. The policy stated the restorative nursing staff would provide positioning in accordance with the restorative plan of care utilizing proper body mechanics and general principles of positioning. the policy was dated (MONTH) 2010",2020-09-01
197,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2019-01-31,689,G,0,1,TKWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and policy review, the facility failed to ensure each resident received adequate supervision to prevent accidents. Harm was identified when one Resident (R), #4, sustained a [MEDICAL CONDITION] which required sutures after they fell out of the bed during a bath, unsupervised by staff. The sample size was 44 residents. Review of the policy titled, Fall Prevention dated 6/1/15 revealed it was the intent of the facility to provide residents with assistance and supervision to minimize the risk of falls and fall related injuries. Review of the Fall Risk Evaluation dated 8/24/18 revealed the facility had assessed the resident as a 13 which indicated the resident was at risk for falls. Review of the Significant Change in Status Minimum Data Set (MDS) signed and dated 8/7/18 revealed the facility admitted R#4 with [DIAGNOSES REDACTED]. Continued review of the MDS revealed the resident to sometimes make self-understood and usually understands others, moderately impaired vision, short-term and long-term memory problems. The facility assessed the resident not to have displayed behaviors. Continued review of the MDS revealed R#4 required extensive assistance of two staff with bed mobility and personal hygiene, extensive assistance of one staff for dressing, toilet use, and was totally dependent on one staff for bathing. The resident was always incontinent of bowel and bladder. Review of the Care Area Assessment (CAA) Summary revealed the resident had triggered for falls. Review of the Fall-Fall with Injury-Major Investigation dated 9/24/18 at 10:50 a.m. stated, Certified Nursing Assistant (CNA) OO was giving R#4 a bed bath, turned away to the closet to retrieve clothes and towels from the chair when the CNA heard the resident scream, patient noted lying on his right side on the floor beside the resident's bed. Small amount of bright red blood noted draining from the resident's right forehead, hematoma noted. Continued review of the fall investigation revealed the resident was not able to state what had happened and continued to moan out in pain. Review of CNA OO statement dated 9/24/18 stated, As I turned around to retrieve resident's clothes from the closet, I heard him/her scream. R#4 was lying on the floor on his/her right side. Right forehead was bleeding and a hematoma was noted. Review of the Infection Control Nurse LL statement dated and signed 9/24/18 at 11:45 a.m. revealed .Hematoma to right temporal frontal aspect of skull measuring approximately three inches across with serosanguinous drainage .Emergency Medical Services to bedside at 12:00 p.m. Review of the Emergency Department Notes signed and dated 9/24/18 at 1:08 p.m. by a Registered Nurse (RN) revealed the resident arrived from the facility after staff reported he/she was found on the floor at 11:25 a.m. Patient presented with a laceration and a hematoma to the right anterior forehead. Review of the Emergency Department Provider Notes signed and dated 9/24/18 at 2:36 p.m. by a Physician Assistant (PA) revealed R#4 required six sutures to close a three-centimeter laceration on the forehead. Review of R#4's care plan dated 8/7/18 revealed, Problem- resident is at risk for fall as he is dependent on staff for all are related to impaired mobility, [MEDICAL CONDITION], feeding tube and dementia. Goal- Resident will not sustain a fall or fall related injury through next review date. Approach- Staff to provide assistance to meet resident's needs for all activities of daily living. Telephone interview on 1/31/18 at 10:30 a.m. with CNA OO revealed she was with R#4 to provide direct care on 9/24/18. She stated she did not feel she did anything wrong when she turned her back on the resident or left the bed elevated to waist level. She stated she did not see R#4 fall out of the bed, however, when she turned around from the closet and faced the resident, the resident was on the floor. She stated she did have the bed raised to her waist, and it might have been a good idea to put the bed in the lowest position prior to turning her back on him. She stated she did not see an injury to the resident at that time. Interview on 1/30/19 at 12:40 p.m. with CNA JJ revealed anytime care was provided to a resident in the bed you should first gather all needed supplies, then raise the bed to your waist level. She stated if you had to leave the resident unattended the bed should be put back down to the lowest position. She stated you should never turn your back on a resident when providing care as the resident could fall out of the bed and sustain an injury. The CNA stated she had learned this in CNA school, and it was important to know. Interview on 1/31/18 8:45 a.m. with CNA MM revealed she was R#4's caregiver for the day. She stated she was familiar with the resident's care needs. She stated the correct way to give the resident, or any resident a bed bath would be to first gather all needed supplies then raise the bed to waist level. She stated she was aware R#4 was a fall risk and could roll out of the bed an injure himself/herself if he was not supervised during bath time. She stated she learned how to give a bed bath and prevent falls in CNA school and various in-services presented at the facility. Interview with Licensed Practical Nurse (LPN) HH on 1/30/19 at 12:35 p.m. revealed to give safe care during a bed bath you should gather all your supplies first, raise the resident's bed up to waist level, and never turn your back on the resident. She stated your eyes should remain on the resident throughout the delivered care or else the resident could roll out of the bed and sustain an injury. Interview on 1/31/19 at 8:35 a.m. with the Infection Control Nurse revealed as he was doing his infection control rounds on 9/24/18 he saw the nurses putting R#4 back into the bed from the floor. He stated the resident had a large hematoma on the forehead. He revealed in the monthly clinical meetings, the facility required the clinical staff to attend because it was an opportunity to discuss clinical expectations. He went onto state it was an expectation staff have all their supplies prior to starting a resident bath and focus only on the resident during the task. He revealed R#4's fall with contusion could have been avoided. Interview with the Unit Manager of the 200 Hallway on 1/30/19 at 11:14 a.m. in the Administrator's Office revealed during the investigation it was determined CNA OO raised R#4's bed up to give a bed bath. The CNA then turned away from the resident and did not reposition the bed to the lowest level and the resident fell out of the bed onto the floor. She stated the CNA should not have turned away from the resident. Interview with the Director of Nursing Services (DNS) on 1/31/19 at 4:00 p.m. revealed it was everyone's job and a facility goal to keep the resident's safe. She stated prior to this incident, the facility had offered education on safe care and how to prevent falls. The DNS stated the CNA should not have turned away from the resident to gather supplies. Interview with the Administrator on 1/31/19 at 3:00 p.m. revealed she expected staff to do all they can do to protect the residents. She revealed the CNA had made an error when she delivered care to R#4. She stated she was ultimately in charge of the facility and maintaining resident safety was the responsibility of the entire staff. Record review revealed the facility had provided staff education regarding activities of daily living care (ADL) as well as fall prevention monthly.",2020-09-01
198,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2019-01-31,880,D,0,1,TKWX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of Infection Control Reports and the policy titled [MEDICAL CONDITION] it was determined that the facility failed to ensure infection control procedures were followed to prevent the spread of infection for one Resident (R#106) with a [DIAGNOSES REDACTED]. Findings include: Review of the facility policy titled [MEDICAL CONDITION] revised in 2014 indicated preventive measures would be taken to prevent the occurrence of [MEDICAL CONDITION] infections among residents and precautions would be taken while caring for residents with [MEDICAL CONDITION] to prevent transmission. The policy documented in pertinent part, reservoirs for [MEDICAL CONDITION] included infected people and surfaces. The policy indicated spores could persist on resident care items and surfaces for several months and were resistant to common cleaning and disinfection methods. Steps towards prevention and early intervention included increasing awareness of risk factors, frequent hand washing with soap and water, wearing gloves, disinfectant of items with a disinfecting agent recommended for [MEDICAL CONDITIONS], household bleach or an EPA (Environmental Protection Agency) registered germicidal agent effective against [MEDICAL CONDITION]. The policy directed staff to wear gloves when caring for residents, washing hands with soap and water upon exiting the room of a resident and strict adherence to hand hygiene. The policy indicated contact isolation gloves and a gown must be worn by staff. Personal protective equipment (PPE) was to be utilized by all staff and visitors. The policy indicated for disposing of used PPE, staff where to place the dirty PPE in the red biohazard bags in the resident's room. PPE should be removed right away if it got soaked with blood or other body fluids and staff were to make sure the bags were not overfilled. The monthly Quality Assurance Performance Improvement (QAPI) infection Control Reports were reviewed for the period from (MONTH) (YEAR) - (MONTH) 2019 and revealed the following: -The (MONTH) (YEAR) Infection Control QAPI Report revealed four [MEDICAL CONDITION] infections for the month; two were acquired in the facility. -The (MONTH) (YEAR) Infection Control QAPI Report revealed two [MEDICAL CONDITION] infections; neither were acquired in the facility. -The (MONTH) (YEAR) Infection Control QAPI Report revealed one [MEDICAL CONDITION] infection; it was acquired in the facility. -The (MONTH) (YEAR) Infection Control QAPI Report revealed five [MEDICAL CONDITION] infections; none were acquired in the facility. -The (MONTH) 2019 Infection Control QAPI Report revealed two [MEDICAL CONDITION] infections; neither were acquired in the facility. R#106 was admitted to the facility on [DATE]. A Minimum Data Set (MDS) had not yet been completed. Review of the facility document titled Infection Preventionist Form dated 1/24/19 revealed the resident was admitted to the facility from the hospital with a [DIAGNOSES REDACTED].#106 to be on contact isolation precautions. According to the Center for Disease Control website, under Healthcare Associated Infections, (https://www.cdc.gov/hai/organisms/cdiff/cdiff_infect.html) [MEDICAL CONDITION] is bacteria that causes life-threatening diarrhea. It is usually a side-effect of taking antibiotics. Symptoms include: diarrhea: loose, watery stools for several days, fever, stomach tenderness, loss of appetite, and nausea. [MEDICAL CONDITION] can easily spread from person to person. Review of R#106's baseline care plan dated 1/25/19 revealed R#106 had a [MEDICAL CONDITION] infection and was prescribed [MEDICATION NAME] (an antibiotic) for eight days which ended on 2/1/19. According to the care plan, nursing staff were to administer medications per physician's orders; observe for signs and symptoms of adverse reaction to medications; and to report signs and symptoms of worsening infection to resident's physician. The care plan indicated the resident had [DIAGNOSES REDACTED]. Observations revealed the following: -On 1/28/19 at 1:03 p.m. a Certified Nurse Assistant (CNA) member entered R#106's room without donning a gown or gloves in response to the call light that had been activated. The staff member spoke with the resident, turned off the call light, left the room and applied hand sanitizer in the hallway right after leaving the room. There was a sign on the door indicating contact isolation procedures were in effect. The sign on the door for contact precautions indicated everyone had to clean their hands when entering and leaving the room. The sign also directed doctors and the staff to gown and glove at the door. There were supplies such as gloves and gowns hanging on the door into the room (in a fabric dispenser). -On 1/29/19 at 2:51 p.m. the door to the resident's room was open. A garbage can with a red bag was visible from the hallway. The garbage can was overflowing with used yellow gowns; the gowns were not all contained in the garbage can. In an interview on 1/30/19 at 10:01 a.m., Housekeeper XX stated her regular assignment of rooms to clean included R#106's room. Housekeeper XX verified R#126 was on contact precautions which was posted on the door into the room. Housekeeper XX also stated she was responsible for cleaning the surfaces within the room as well as the floor. Housekeeper XX reported she used a disinfectant to clean the surfaces in the room, bathroom and the floor. Housekeeper XX produced a spray bottle of Virex 11 256 from the housekeeping cart, indicating this was the product she used. The label of Virex 11 256 indicated the chemical was ammonia chloride. The label did not indicate the product included bleach or was appropriate to use for [MEDICAL CONDITION] infection. Housekeeper XX further stated, I use it (Virex 11 256) for everything in the room including the bathroom, especially for isolation. An interview on 1/30/19 11:14 a.m. with CNA VV revealed R#106 was part of her resident care assignment. CNA VV stated when she entered the resident's room, she would put on a yellow gown and gloves from the supply located on the door into the resident's room. CNA VV stated the resident did a lot of her own care; however, needed help with personal hygiene and dressing. CNA VV stated R#106 walked in the room and transferred herself. CNA VV stated she encouraged the resident not to go to the toilet by herself, stating the resident wore a brief and had some incontinent episodes. CNA VV stated there were red bags in the resident's room for disposing of gowns, gloves, and any soiled items such as briefs. CNA VV stated if a soiled brief was placed into a red bag, the appropriate protocol was to tie it up, take it to the laundry and dispose of it immediately. CNA VV further stated there was an incident this morning in which she discovered stuff everywhere in the resident's room. CNA VV stated there was a soiled brief in the garbage can, a wet towel in bathroom, a basin full of soapy water and a gown on the floor when she entered the room. CNA VV stated she used a baby wipe or rag with hot water to clean the room, I don't use chemicals. CNA VV stated the appropriate protocol for hand washing was to wash her hands before entering the room and after she left the room. CNA VV stated she removed the gown and gloves and placed them into the trash can prior to exiting the room and then proceeded to the pantry near the nursing station to wash her hands (rather than washing before leaving the room as directed in the facility policy). In an interview on 1/31/19 at 10:10 a.m. the Assistant Director of Nursing (ADON) stated R#106 was on contact isolation for [MEDICAL CONDITION]. The ADON stated staff should put on gloves and a gown when entering the resident's room. The ADON stated red bags were used for garbage that was handled separately from regular trash due to it being a bio hazard. The ADON stated the CNAs should use a bleach product when cleaning in the resident's room. The ADON also stated, Bleach will kill [MEDICAL CONDITION]. It ([MEDICAL CONDITION]) can live a long time on surfaces. Licensed Practical Nurse (LPN) ZZ was the resident's nurse and was at the nurse's station during the interview with the ADON. LPN ZZ stated the resident was no longer having diarrhea; however, she was still receiving antibiotics. LPN ZZ stated she washed her hands before providing care and again before she left the room. LPN ZZ also stated she disposed of the gown and gloves in the red bag prior to leaving the resident's room. An interview on 1/31/19 10:29 a.m. with the Infection Control Nurse LL revealed contact isolation required staff to wear gloves and a gown when entering the resident's room. Infection Control Nurse LL stated staff could use hand sanitizer in addition to washing hands, but washing hands was mandatory. Infection Control Nurse LL stated gloves should be worn for handling any items such as picking up a tray or turning off call light. Infection Control Nurse LL stated staff should wash their hands before and after providing care and staff should not walk out of the room to wash their hands elsewhere as in the case of CNA VV according to her interview. Infection Control Nurse LL stated staff should use a bleach-based wipe for cleaning in the room and stated housekeeping staff should also use a bleach solution. In an interview on 1/31/19 at 11:03 a.m., the Housekeeping Manager stated housekeeping staff should use a product called Virasept or use bleach-based wipes for cleaning in the room. The Housekeeping Manager stated the Virex disinfectant solution used by Housekeeper XX for cleaning in rooms was not the right product for [MEDICAL CONDITION]. The Housekeeping Manager stated he was not aware of Housekeeper XX using the incorrect product Virex to clean in the resident's room. In an interview on 1/31/19 at 3:23 p.m., the Director of Nursing (DON) stated a gown should be worn when contact isolation precautions were in place, when going in the room and touching things. The DON stated if answering a call light, gloves should be worn for turning off the call light. The DON stated staff should follow the contact precaution parameters that were posted on the door. The DON stated bleach wipes should be used for cleaning things up, or for cleaning equipment. Review of the facility's training record for infecction control dated 12/27/18 revealed the purpose of the in-service was to review the process of cleaning, isolation procedures and preventing the spread of [MEDICAL CONDITION]. The in-service record indicated when staff went into the room, they were to dress in isolation clothing provided by the nursing staff outside of the isolation room including gloves and gown. Approved solutions for cleaning in the room were Clorox bleach germicidal wipes, disinfectant cleaner with bleach and Microdot bleach wipes. The in-service record revealed Virex solution was not to be used for cleaning [MEDICAL CONDITION]. Inservice records revealed Housekeeper XX attended this in-service.",2020-09-01
199,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2017-02-03,164,D,0,1,4LIP11,"Based on observation, record review, interview, and review of facility documents it was determined the facility failed to ensure privacy for two sampled residents while providing incontinent care and administering medications from a total of 24 sampled residents. (Residents #233 and #276) resulting in potential for visitors and staff to observe care being provide to the residents. The findings include: A review of the facility's undated document titled Georgia Resident Handbook and Admissions section 290-5-35-.18 Residents' Rights (page #29) documents . (f) Each resident shall be treated with respect and be given privacy in the provision of personal care. Each resident shall be accorded privacy and freedom for the use of the bathroom at all hours. 1. During an observation on 2/1/17 at 8:45a.m. R #233 informed the surveyor that she was incontinent twice since 7:00 a.m. and still had not been changed. At 9:30a.m., a request was made for the assigned Certified Nursing Assistant (CNA) to check the resident. CNA OO entered the private room and closed the door however failed to close the room's window blinds. The resident's room window faces the side parking (utilized by staff and visitors). From the resident's window you can observe people and cars passing on the street. To the right of the resident's window outside was a table with bench seats. CNA OO proceeded to undress the resident without informing the resident of what she was doing, R#233 was incontinent of urine and stool. R #233's genital area was exposed and the window blinds in the room remained opened An additional observation 15 minutes later revealed the CNA had completed incontinence care for R#233 and was redressing the resident with the windows blinds still open. A review of the resident's incontinence care plan dated 2/13/16, revealed as an intervention the facility staff would maintain privacy and dignity when providing incontinence care after each episode. An interview with CNA OO on 2/1/17 at 9:53 a.m. concerning providing privacy for R#233 during incontinence care, revealed the staff member was not aware that she needed to close the window blinds to ensure the resident's privacy and did not know if the resident could be seen from the street. Additional observation of R#233's room on 2/1/17 at 2:00p.m., revealed the surveyor could stand outside the resident's window and look directly into the room and see the resident in bed. An interview with the Director of Nursing (DON) on 2/1/17 at 12:15p.m., in her office revealed the staff receive training on respecting and maintaining resident's dignity and privacy. Staff should be pulling privacy curtains and closing room doors when providing continent care. When asked about closing window blinds the DON first stated the staff member should have closed the blinds but perhaps the resident did not want the blinds closed. The surveyor asked if the CNA should have asked the resident about closing the blinds and the DON stated yes. 2. Medication administration for R #276 was observed with Licensed Practice Nurse (LPN) KK on 2/3/17 at 1:05 p.m. LPN KK was administering a crushed medication thru the resident's gastrostomy tube. The nurse had closed the resident's room door but failed to close the window blinds. The window faced the parking lot and people could be seen walking by on the street. The resident's abdominal area with the gastrostomy tube was exposed for approximately five minutes. During an interview at 1:15 p.m., with LPN KK she revealed that in orientation, ensuring the resident's privacy was discussed. When providing care and giving medications in the resident's room she had been instructed to pull the privacy curtains and closed the room door. But nothing was ever mentioned about closing the window blinds. LPN KK acknowledged the resident window did face the street and if the resident could be seen from the street then the resident's privacy was not maintained.",2020-09-01
200,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2017-02-03,280,D,0,1,4LIP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to revise the care plan to reflect the appropriate use of hand orthotic splint for one resident (R#110) and notification of changes in resident care for one resident (R#72) from a sampled 24 residents. The findings include: 1. Record review for R #110 revealed according to the quarterly Minimum Data Set ((MDS) dated [DATE]the resident was assessed as being cognitively impaired and was totally dependent on staff for activities of daily and the resident had limited range of motion of upper and lower extremities. A review of the Occupational Therapy Discharge Summary dated 11/28/16, indicated the caregiver and restorative staff instructed and educated on in the wear and care of right elbow hand wrist orthotic device. Resident to wear orthotic device to improve alignment of right elbow and right hand it is recommend to wear the device two hours on and two hours off. A review of R #110's Restorative Range of Motion (passive) interdisciplinary care plan dated 8/20/16 with a revision date of 11/20/16 revealed it was documented the resident had actual contractures to the hand; the only intervention added on 11/20/16 was a splint to the left hand. The intervention identified the wrong hand but also failed to identify the frequency and the duration of time the splint was to be in place. Interview with Assistant Director of Nursing (ADON) DD on 2/2/17 at 9:10 a.m. revealed R # 110 is supposed to wear a splint during the dayshift for two hours at a time. Reviewed the restorative care plan and was not aware the care plan was not revised to reflect the splint on the resident's right hand and the frequency/duration of the orthotic splint device. The care plan should have been revised in the care plan meeting but all the nurses have ability to revise the resident's care plans as needed and agreed this resident care plan should have been revised. Cross refer to F318 [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, no cognitive impairment. Interview with R#72 on 1/30/17 at 3:16 p.m. revealed the facility did not notify her of new physician orders. Review of the physician's orders [REDACTED]. Further review of the clinical record revealed the facility did not notify the resident of the new orders five times. Interview with Licensed Practical Nurse (LPN) JJ on 2/1/17 at 12:15 p.m. revealed if a resident was alert then the staff should notify them of any new orders. The staff should document it on the bottom of the telephone order sheet who they contacted. Interview with the Director of Nursing on 2/2/17 at 6:06 p.m. revealed the nurse who took the new order should notify the resident, if alert, or the responsible party. The staff should document who they notified on the bottom of the order sheet or in the nurses' notes. No one checked to see if the resident or responsible party was notified. Further interview with the Director of Nursing revealed the facility did not have a policy regarding resident notification of changes in treatment. The facility failed to notify the alert resident of changes in her care.",2020-09-01
201,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2017-02-03,318,D,0,1,4LIP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview it was determined that the facility fail to consistently provide passive range of motion exercises to upper extremities and place an orthotic splint device to maintain range of motion of right shoulder and wrist for one sampled R#110 out of 24 sampled residents reviewed for range of motion, resulting in the potential for decrease in range of motion. The findings include: Record review for R #110 revealed the resident was admitted in to the facility on [DATE] status [REDACTED]. The resident required one to two person physical assistance with transfers, bed mobility, dressing, toileting and personal hygiene. The resident had limited range of motion of upper and lower extremities; the resident had bilateral contractures of the upper extremities. A review of the Occupational Therapy Discharge Summary dated 11/28/16, revealed the R#110 is to wear an orthotic splint on right hand and fore arm. The resident's care plan with a revision date of 11/20/16, documents the resident has hand contractures and is to wear a hand splint. The care plan does not identify the duration or the frequency of the splint. Review of the facility document titled Restorative Service Delivery Record for the month of (MONTH) documents the resident wearing the splint on 11/29/16 and 11/30/16. The facility was unable to provide the records for the months of (MONTH) and January. Review of the facility document titled Restorative Nursing Report dated from 12/10/16 thru 1/27/17 revealed no documentation of the orthotic splint device being placed on R#110 on the following days 12/10, 12/11/ 12/12, 12/16/16, 1/1/17, 1/2, 1/6, 1/7, 1/8, 1/9, 1/13, 1/14, 1/15, 1/21, 1/22, and 1/27/17. The facility was unable to provide the requested information documenting that the staff had applied the orthotic splint device as recommended by occupational therapy. Multiple observations of R#110 on 1/30/17 at 3:23 p.m. 1/31/17 at 8:35 a.m. and 11:15 a.m., revealed the resident in bed with bilateral contractures of the upper extremities. R#110 was not wearing right hand/elbow orthotic splint. Resident's orthotic splint device was observed in the resident's wheelchair. An additional observation at 2:10 p.m. revealed R#110 with the orthotic splint on right hand/elbow. Observation on 2/2/16 at 9:05 a.m. revealed the resident in bed wearing the orthotic splint device on right hand. An interview with the Restorative CNA on 2/2/17 at 9:15 a.m. revealed she was responsible for ensuring the resident wears the splint and conduct passive range of motion (PROM) exercises for this resident. Restorative CNA stated R #110 is to have the device applied to his right hand to prevent increasing contractures to the resident's arm and shoulder. The resident is to wear the splint on the right hand for two hours on and two hours off during the dayshift. The restorative aide documents the splint and PROM exercises in the kiosk. The days the restorative aide is off the regular assigned CNA is responsible for ensuring the resident wears the splint and receives the PROM exercises. During an interview with the Director of Nursing (DON) on 2/2/17 at 9:40 a.m. the surveyor requested the documentation done by the restorative aide showing the resident was receiving the orthotic splint and PROM exercises as recommended by occupational therapy. The DON stated the facility has recently started electronic documentation but she should be able to pull up the restorative aides' documentation. By the end of the survey the facility still had not provided the requested documentation. Cross refer to F280 and F514",2020-09-01
202,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2017-02-03,323,E,0,1,4LIP11,"Based on observation and interview, the facility failed to maintain a safe environment by ensuring public restrooms, without call light systems, were not accessible to residents, maintenance and laundry areas that contained hazardous chemicals and dangerous tools were not left unsecured . Finding includes: On 1/31/17 at 9:25 a.m., a facility tour was conducted. Two public lobby restrooms were observed to be unlocked and not have an emergency call system. At the end of East hall there were two unlocked public restrooms without an emergency call system. In that same hall, there were two opened doors that lead to the laundry area, The laundry area had harmful chemicals stored there and no staff was in attendance. An opened maintenance room had tools and chemicals inside and a cart with multiple tools was observed to be sitting outside the maintenance room, in the hall, no staff in attendance. The halls are accessible to all residents. On 2/1/17 at 10 a.m., the Administrator had stated doors should be closed when staff is not in attendance and instructed the Maintenance Assistant to change locks on restrooms for safety. The maintenance door was observed to be open and no staff was in the area. The two public restrooms were observed to have a coded door knob installed but were unlocked and had no emergency call system in place. The two public restrooms off the lobby were observed to be the same, unlocked and without an emergency call system. On 2/2/17 at 8:45 a.m., the following was observed, the maintenance door remained opened and no staff was in the area. The two public restrooms with coded door knobs, remained unlocked with no emergency call system in place. The two public restrooms off the lobby were also observed to be the same, unlocked and without an emergency call system.",2020-09-01
203,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2017-02-03,371,F,0,1,4LIP11,"Based on observation, interview and facility policy, it was determined the facility failed to ensure the kitchen equipment was the thoroughly cleaned after each use. The facility failed to ensure that proper procedures for cleaning the food thermometer used for checking food temperatures and that proper handwashing was utilized while plating foods for residents in the Transitional Care Unit. The findings included: 1. The following concerns were identified during the kitchen inspection tour on 1/30/17 at 10:40a.m: - ceiling air vent positioned over rack with clean dishes had dust debris on grill portion of the vent. The surveyor took an ink pen to scrape along the vent grill to confirm the dust debris and showed to the Dietary Manager (DM) - large metal top with smeared greasy film and pan with dried debris on it was stacked with clean pots and pans . - observed the meat slicer, with grease stains 10:44a.m. - observed the large mixer and roto coup blender both with dried debris and grease stains. Interview on 1/30/16 at 11:00 a.m., with the Dietary Manager (DM) revealed the DM confirmed the dust debris on vent grill and was unsure the last time maintenance cleaned vent. The DM also confirmed the condition of the meat slicer, large mixer, and robo blender and stated that the equipment should be cleaned after each use. 2. Observation of the meal service on 1/30/17 at 12:40 p.m. on the Transitional Care Unit revealed Dietary Aide FF temping chicken with the food thermometer, wiping the food thermometer off with a dry paper towel, and then tempting the seasoned spinach. Interview with Dietary Aide FF at this time revealed she should have cleaned the food thermometer in between temping foods with alcohol wipes instead of a paper towel, however the dietary department was out of alcohol wipes, and she was more concerned with keeping the food warm and at the correct temperature. She stated, I could've got some alcohol wipes from the nurse's station but I did not. She stated, temping foods without proper sanitation of the thermometer between temps can cause cross contamination of the food and make people sick. Interview with the Dietary Manager on 1/30/17 at 12:50 p.m. in her office revealed the dietary department does have alcohol wipes and the staff have all been trained to use them to sanitize the thermometer in between each food temperature taken in order to prevent cross contamination of food. Review of the policy and procedure titled, Service Temperature of Food dated 2/14 states, 1. Wash, rinse and sanitize a dial face, metal probe-type thermometer with alcohol wipe. Re-sanitize the thermometer after each use. Review of the document titled, Competency Checklist-Diet Aide/Wait Staff/Hostess dated 9/28/15 reveals Dietary Aide FF has been trained on food sanitation and food temperatures on 7/23/15. 3. Observation of the meal service on 1/30/17 at 12:40 p.m. on the Transitional Care Unit, Dietary Aide FF with gloved hands touched food ladles, her clothes, the food service table while also picking up bread and placing it on residents' food plates, all with the same gloves. She was not observed to change her gloves or sanitize her hands. Dietary Aide FF was asked about touching inanimate objects with gloved hands and without washing hands and changing gloves, serving bread to the residents. Dietary Aide FF replied she should have used bread tongs to serve the bread and she might have caused cross contamination by not using tongs, or not changing her gloves. Interview with the Dietary Manager on 1/30/17 at 12:50 p.m. in her office revealed Dietary Aide FF has been trained on cross contamination and not to pick up foods with contaminated gloves. Review of the document titled, Competency Checklist-Diet Aide/Wait Staff/Hostess dated 9/28/15 reveals Dietary Aide FF has received facility training on hand washing, personal hygiene, food handling and plastic gloves on 7/23/15.",2020-09-01
204,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2017-02-03,514,D,0,1,4LIP11,"Based on observation, record review, and interview it was determined the facility failed to maintain accurate documentation on the placement of an orthotic splint device for one resident (R#110) from a sampled 24 resident. The findings include Record review of the occupational therapy recommendations dated 11/28/16, revealed R#110 wear to an orthotic splint device to the right hand to maintain good alignment to the right shoulder and prevent further contractures. A review of R#110 restorative care plan dated 11/28/16 documents the resident to wear a splint on the left hand. A review of the nurses' notes dated 11/23/16, 12/1/16 and 12/8/16 documents the splint is in place on the resident's left hand. Observation on 2/2/16 at 9:05 a.m. revealed the resident in bed wearing the orthotic splint device on right hand. During an interview with the Restorative Aide (RA) on 2/2/17 at 9:15 a.m., she confirmed the resident is to wear the orthotic splint on the right hand. The RA reviewed the documentation and stated it was incorrect. During an interview with the Director of Nursing (DON) on 2/2/17 at 9:40 a.m. it was confirmed that documentation of splint in the care plan and in the nursing notes was inaccurate.",2020-09-01
205,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2018-02-22,582,B,0,1,HW6Q11,"[NAME] Tracy Based on record review and staff interview the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to two (2) residents (R) #20 and (R) [NAME] of three (3) residents or their responsible party's for two of three residents (R) reviewed (#34 and #46), who were discharged off Medicare Part A services and remained in the facility. Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form provided by the facility revealed in the clinical record for R#20 the resident started to receive physical therapy and occupational therapy services on 12/6/17 and these services ended on 12/26/17 with benefit days remaining. Review of the clinical records for (R) [NAME] revealed the resident started to receive physical therapy and occupational therapy services on 12/15/17 and these services ended on 1/8/18 with benefit days remaining. During an interview with Social Worker, AA on 2/21/18 at 2:56 p.m she stated she did not issue a SNFABN to (R)E or R#20. She also stated she did not know that a SNFABN had to be issued to residents who did not exhaust their coverage days of skilled services and who remained in the facility.",2020-09-01
206,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2018-02-22,804,E,0,1,HW6Q11,"Based on observation, staff interview, and record review the facility failed to serve the proper serving size of Braised sliced turkey per the cycle menu for one meal. This deficient practice had the potential to effect 15 of 30 residents observed to receive a regular oral diet in the main dining room at the time of the meal observation. Findings include: Review of the daily spreadsheet (Menus) week 4 day 2 for lunch on 2/19/18 revealed resident's receiving a regular diet were to receive 3 ounces of Braised Turkey Breast with 1/2 cup of potatoes and 1/2 cup of Brussels sprouts and bread. Observation on 2/19/18 at 12:45 p.m. during the lunch meal in the main dining room revealed dietary staff assembling resident meals. The Dietary Manager (DM) was asked to weigh the braised turkey that dietary staff had placed on the plates. The DM used the calibrated facility scale and weighed the serving of braised turkey which was 2 ounces. The DM confirmed that 3 ounces was to be served to residents and 15 of 30 residents observed at the time of the observation had already been served lunch with the 2-ounce portion. Interview on 2/19/18 at 12:50 p.m. with Assistant Dietary Manager BB revealed the meat is always weighed prior to cooking. He stated he weighs the meat before cooking to ensure it weighs according to the menu. When asked what is done after the food is cooked, Assistant Dietary Manager BB was unable to provide a response.",2020-09-01
207,SIGNATURE HEALTHCARE AT TOWER ROAD,115115,26 TOWER RD,MARIETTA,GA,30060,2018-02-22,812,D,0,1,HW6Q11,"Based on observation and review of facility's in-service education documents titled Guidelines for Proper Food Temperatures and Holding and Serving and interview with dietary workers, the facility failed to hold food items above 135 degrees Fahrenheit in the rehabilitation dining room to prevent food borne illness. This deficient practice had the potential to effect 7 of 7 residents observed in the rehabilitation dining room who receive an oral diet. Findings include: Steam table temperatures in the rehabilitation dining room were obtained on 2/21/18 at 12:50 p.m. The temperatures were taken by a dietary worker using the facility's calibrated thermometer. The following food items were not being held above 135 degrees Fahrenheit which were confirmed by dietary worker: Pureed mechanical soft stew 125 degrees Fahrenheit Green beans 127 degrees Fahrenheit Baked chicken 132 degrees Fahrenheit Review of the in-service education titled Guidelines for Proper Food Temperature, question #1. Danger Zone temperatures are between 41 and 135 T/F . The answer key indicates the answer is True. Question #9 Residents can become sick and possibly die if food was not kept within the proper temperatures during any part of preparation, storage, reheating or serving T/F. The answer key indicates the answer is True. Further review of a form titled Holding and Serving, item #9 states Minimum holding temperatures on the tray line for potentially hazardous food is 41-degree Fahrenheit or less for cold foods and 135 degrees Fahrenheit or greater for hot foods. Interview on 2/21/18 at 1:30 p.m. with the Dietary Manger (DM) revealed that she felt the food temperatures were adequate at 127 degrees Fahrenheit. Continued interview revealed that the steam table was not plugged in and should have been.",2020-09-01
208,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,567,B,0,1,3B0P11,"Based on observation, record review, resident (R) and staff interviews, the facility failed to have petty cash available for resident withdrawal after posted banking hours from 9:00 a.m. to 8:00 p.m. on weekdays, and 9:00 a.m. to 7:00 p.m. on weekends. The facility handled a total of 73 resident trust fund accounts. Findings include: 1. During interview with the Business Office Manager (BOM) on 6/7/18 at 8:31 a.m., she stated that if a resident wanted to withdraw $50.00 or less from their trust fund account, they obtained this from the receptionist. She further stated that the receptionist was there from 8:00 a.m. to 8:00 p.m. seven days a week. The BOM stated during further interview that if a resident let her know in advance that they wanted to withdraw money outside of these times that she would arrange to leave it with the nurse, but that the facility did not routinely keep petty cash with the nurses at night. During interview with receptionist KK on 6/7/18 at 8:36 a.m., she stated that she worked 8:00 a.m. to 4:00 p.m., and another receptionist came in to work from 4:00 p.m. until 8:00 p.m. She further stated that there was a receptionist during these times seven days a week. Receptionist KK stated during continued interview that if a resident wanted their money after 8:00 p.m., that the receptionist was gone for the day, and the resident would not have access to their money. Observation at this time revealed a laminated sign taped to the ledge of the receptionist window that noted: BANKING HOURS MONDAY-FRIDAY 9AM-8PM SATURDAY-SUNDAY 9AM-7PM During interview with R P on 6/7/18 at 8:52 a.m., he stated that he had not tried, but was told in the Resident Council meeting that it was impossible to get money out of his account after the receptionist left at night. During interview with R R on 6/7/18, she stated that she had not needed to, but knew that she could not get money out of her account at night. During interview with R Q on 6/7/18 at 9:04 a.m., he stated that he attempted once on a weekend after the receptionist was gone to get money out of his account, but was not able to. Review of the resident trust account Trial Balance report revealed that residents P, R, and Q had active trust fund accounts. Review of residents P, R, and Q's most recent Minimum Data Set (MDS) assessments revealed that they had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment). Record review of the resident council minutes on 6/4/18 at 12:30p.m. revealed personal funds availability included in the meeting minutes from resident council for (MONTH) (YEAR). Interviews during resident council meeting on 6/4/18 at 2:00pm, attendance 15 residents, revealed Resident (R) P and Resident (R) Q voiced concerns of not being able to get their money after business office hours during the week and on not at all on weekends. Interview with the Activity Director during the resident council meeting on 6/4/18 at 2:00p.m. revealed that the residents can only get their money during business hours on weekdays and on the weekends only if the business office staff are working.",2020-09-01
209,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,582,B,0,1,3B0P11,"Based on record review and staff interview, the facility failed to issue the Notice of Medicare Non-Coverage (NOMNC) to two residents (R) discharged off Medicare Part A services (R #35 and R #101), and failed to mail a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) to the responsible party for completion for one resident (R #35). Three residents were reviewed for provision of the proper notices. Findings include: Review of the Beneficiary Notice-Residents discharged Within the Last Six Months form completed by the facility revealed that R #101's last covered day of Part A Services was 5/21/18, she remained in the facility, and did not use all of her benefit days. Review of the beneficiary notices revealed the only notice completed was the SNFABN. Review of the Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that R #35's last covered day was 4/7/18, she did not exhaust all of her benefit days, and she remained in the facility. Review of the beneficiary notices revealed that the only notice provided was the SNFABN, and the section on the form to indicate whether or not the resident or responsible party wanted to continue skilled services was blank. During interview with the Social Services Director (SSD) on 6/6/18 at 3:09 p.m., she stated that when she took over issuing the beneficiary notices a few months ago, that she was told to discard all notice forms except the SNFABN, and the CMS (Centers for Medicare and Medicaid Services)-R-131 form for residents on Part B services. She stated during further interview that one of the forms she was told not to use anymore was the NOMNC, so she had not been issuing one for any resident coming off skilled services. She further stated that when she was not able to contact a responsible party in person or by phone to explain the resident's right to appeal and continue skilled services, that she did not mail the form to them, nor request the form be completed and returned to her.",2020-09-01
210,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,584,D,0,1,3B0P11,"Based on observation, staff interviews , and the facility policy titled Cleaning Spills or Splashes of Blood or Body Fluids, the faciity failed to provide a sanitary homelike dining experience for residents by not removing a urine spill from the floor that was visible to a large group of approximate 50 residents seated in the main dining room. The facility census was 112 and the sample size 112. Findings include: Observation on 6/14/18 at 12:39 p.m revealed Resident (R#32) sitting in his wheelchair at the table eating lunch in the dining room. R#12 later became incontinent of urine, urinated on himself resulting in a large puddle of urine on the floor underneath his wheelchair. R#32 was observed wheeling himself to Restorative Nusing Assistant (RNA) FF to inform her of his accident. RNA FF and R#32 was observed speaking with Administrative Staff GG (who was assisting in the dining room with lunch) about his incontinent accident and the urine spill. Further observations revealed, Staff GG wheeling R#32 out of the dining room. Later observed the Chaplain placing a wet sign cone by the urine spill. RNA FF and RNA DD stated that Housekeeping Staff Supervisor (HKS) HH refused to clean up the urine spill because residents were still dining. RNA DD then left the dining room.The urine spill was left uncovered for approximate four (4) minutes until Restorative Nursing Assistant (RNA) DD returned to the dining room and placed a towel over the spill. The urine spot remained on the floor throughout the entire dining . The last resident to leave the dining room was at 1:20 p.m. and this was R#98. Further observation revealed other residents seated either across or in the rear of R#32 table, all had a visual view of the urine spilled. The white towel that was placed over the urine spill was soiled and had a yellowish color. During an interview on 6/4/18 at 12:40 p.m., with RNA DD verified that the urine spill resulted when R#32 had an incontinent accident and that the spill remained on the floor until after lunch dining was over. She stated that she was always informed that housekeepers should clean bodily fluids spills on the dining room floor and not nursing staff. She stated that RNA FF informed her that housekeeping refused to clean the spill. During an interview on 6/4/18 at 2:30 p.m. RNA FF verified that R#32 had an incontinent episode in the dining room during lunch. She further stated that R#32 asked her do you see water on the floor, I urinated on the floor. I think there's urine on the floor. She stated that she informed Administrative Staff GG who assisted R#32 out the dining room. When asked who should had clean the spilled. She stated that she felt that it was the housekeeper position to get up the urine spills because the residents was eating dinner. During an interview on 6/7/18 at 10:07 a.m. , RNA FF reported that after the Administrative Staff GG had requested for housekeeping to be paged to the dining room, she also spoke with the (HK) HH. The Housekeeper Supervisor stated that she could not use chemical to clean up the spill during dining. She further stated that she placed a towel over the urine spill. When asked how she will feel if she had to sit through lunch with urine on the floor? She answered with No, I will not like that. During an interview on 6/7/18 at 10:09 a.m., Administrative Staff GG reported that resident R#32 infomed her about his incontinent urine accident. She asked the Chaplain to put a wet floor cone sign near the urine. She was the one who wheeled R#32 out of the dinning room. Administrative staff GG stated that she would not like it if she had to sit through lunch with urine on the floor and stated that she had received infection control training. During an interview on 6/7/18 at 10:23 p.m., the Chaplain stated verifed putting the wet sign cone next to the urine spill after Administrative Staff GG asked him too. He further stated that RNA DD later informed him that she was going to clean the area with a towel. He stated that he left the dining room and did not witness anything else. He confirmed receiving infection control training. He was informed a nursing staff will remove bodily fluid and housekeeper would then mop up the spill. Further interview revealed that he would feel embarrassed if he had to sit through lunch with urine on the floor. During an Interview on 6/7/18 on 10:29 p.m., the (HKS) HH (employed with the facility as a supervisor for approximate 5 years) verifying being paged into the dining room and not cleaning the dining room due to her training and policy 'not to use chemical cleanser to clean up spills during resident's dining. (HKS) HH further stated that she did inform the staff that she would clean the area after lunch was over. She does remember the exact time that she and her staff cleaned the urine. She reported staff receives infection control and environment every month. HKS HH stated that she would feel bad if she had to sit through lunch with urine on the floor. During an interview on 6/7/18 at 12:03 p.m., the Housekeeping Aide (HA) II (worked for facility for approximate 5 months) reported that she was informed about the urine spill after entering the dining room. She confirmed that all the residents had exited the dinining room and trays were removed from the table. HA II verified that a soiled towel was on the floor next to a wet cone floor sign. She further stated that the process is to wait until residents exit the dining room and dietary staff remove all the trays off the tables before housekeeping can proceed to clean any spills and bodily fluids with chemicals. HA II further revealed that no one should have to eat a meal when there was urine on the floor. During an interview on 6/7/18 at 4:48 p.m., the Director of Nursing (DON) revealed that his expectations are for staff to cover up any urine/bodily fluids spills, or cover up the spills with a towel, or perhaps wipe up the spills with a towel. He further stated that maybe staff should had wipe it up with the towel but have second thoughts about staff disrupting the dining experience. DON reported that his main concern was to make sure urine spill was covered. He stated safety precautions/purposes for the residents in the dining room. Since the incident occurred and was identified , it has been discussed (staff) and he was trying to determine how far you should go into the disinfectant things during resident dining,whether to use a disinfectant spray in the area, or just dried urine up with towels. The DON stated that he reviewed clinical policy and policy talks about using chemical products. Not sure if this as to what is the correct approach at this time . DON reported that someone came to him to tell the urine on the floor, cannot remember the staff name, He said just put a towel over it and mark it with the wet sign. When asked him how it would make him feel if asked if he was a resident and had to eat lunch in dining room with a urine spill? He expected someone to do something about it; if, he knew about it. Policy Review of policy dated 1/2012 and titled Cleaning Spills or Splashes of Blood or Body Fluids revealed Spills or splashes of blood or other body fluids must be cleaned and the spill or splash area decontaminated as soon as practical. 1. Whoever spills or splashes blood or body fluid, or witnessed splattered or spilled blood anywhere in the facility , shall notify environmental services that a spill or splash of blood or body fluids has occurred and shall provide pertinent information , including the amount and area in which the incident occurred. 2. An appropriately trained and authorized individual shall clean and disinfect any surfaces or equipment contaminated with spills or splashes of blood or body fluids as soon as practical to prevent exposure.",2020-09-01
211,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,677,D,0,1,3B0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family and staff interview, the facility failed to ensure that the activities of daily living (ADL) of nail and denture care were consistently provided for one resident (R)(R S) who was totally dependent on staff for ADL care. The sample size was 51 residents. Findings include: Review of R S's Admission Minimum Data Set ((MDS) dated [DATE] revealed that she had short- and long-term memory problems, and was unable to complete the interview for mental status determination. Further review of this MDS revealed that she was totally dependent on staff for ADLs, including personal hygiene. Review of R S's comprehensive care plan for ADL self care deficit revealed that she was dependent on staff with all of her ADLs. Review of a physician progress notes [REDACTED]. On 6/4/18 at 1:00 p.m., a family member of R S stated that the resident's fingernails were longer than she kept them when she lived at home. Observation at this time revealed that the resident's fingernails were long, and had a small amount of dark debris underneath them. On 6/6/18 at 8:51 a.m., a family member of R S showed the surveyor the resident's top denture, which he stated had been left in her mouth all night. Observation at this time revealed that the denture had several areas of dark and tan debris adhered to the surface. Further observation revealed the resident had not yet been fed breakfast. During interview with the family member at this time, he stated that the dentures should have been removed from her mouth last night, and soaked in the denture cup. Observation on 6/7/18 at 2:40 p.m. revealed that R S's fingernails remained long with a small amount of dark debris underneath. During interview with a family member of the resident at this time revealed that the resident usually kept her fingernails shorter than this. During interview with Registered Nurse (RN) CC on 6/7/18 at 4:33 p.m., she stated that nail care was done daily during the bath by the CNAs (Certified Nursing Assistants), and that dentures should be removed at night and cleaned. During observation of R S's fingernails at this time, RN CC verified that they could be clipped down, and stated that they appeared as though the resident had been scratching. During interview with the Director of Nursing (DON) on 6/7/18 at 6:03 p.m., he stated that his expectation was that nail care be done every shift, and oral care given at night and as needed. Review of a facility document Giving a Bed Bath Competency reviewed on 6/1/15 noted that during the bath to check the resident's fingernails, nail beds, and between the fingers. Review of the facility's procedure on Nail Grooming (undated) revealed that regular fingernail care will promote cleanliness and prevent infection. The nursing staff will provide observation and care of nails for all residents daily and as necessary.",2020-09-01
212,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,756,D,0,1,3B0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the consultant pharmacist failed to make a recommendation to address the continued use, after 14 days, of a PRN (as needed) antianxiety medication, [MEDICATION NAME], for one resident (R) (R #4). The sample size was 51 residents. Findings include: Review of R #4's physician's orders [REDACTED]. Review of R #4's Controlled Drug Record revealed that she had received 16 doses of the [MEDICATION NAME] between 4/27/18 and 5/26/18. Review of the consultant pharmacist monthly recommendations revealed that the last one made for R #4 was dated 5/16/18 to evaluate for a dose reduction for the antidepressant medication, [MEDICATION NAME]. No pharmacist recommendations were seen to address the continued use of the PRN [MEDICATION NAME]. During interview with the Director of Nursing (DON) on 6/7/18 at 3:35 p.m., he verified that R #4 had received PRN doses of the [MEDICATION NAME] since 4/26/18, and that the pharmacist should be making a recommendation for evaluation of continued use after 14 days. During interview with the DON on 6/7/18 at 6:11 p.m., he stated that he was not able to find any pharmacy recommendations for addressing the continued use of the PRN [MEDICATION NAME] for R #4. Review of the facility's [MEDICAL CONDITION] Medication Policy and Procedure policy (undated) revealed that orders for PRN [MEDICAL CONDITION] medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances. The pharmacist and/or consulting pharmacist: 1. Monitors [MEDICAL CONDITION] drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration. 2. Performs a monthly drug regimen review including a review of the resident's medical chart. This review includes but is not limited to the use of [MEDICAL CONDITION] medications. The pharmacist will document a separate report of any irregularities and notify the attending physician, the medical director, and the DON. Cross-refer to F 758.",2020-09-01
213,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,758,D,0,1,3B0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to address the use of a PRN (as needed) [MEDICAL CONDITION] medication ([MEDICATION NAME]) over 14 days for one resident (R) (R #4). The sample size was 51 residents. Findings include: Review of R #4's physician's orders [REDACTED]. Review of R #4's Controlled Drug Record for [MEDICATION NAME] ([MEDICATION NAME]) 0.25 mg tablet revealed that 16 doses had been administered since 4/27/18. During interview with the Director of Nursing (DON) on 6/7/18 at 3:35 p.m., he stated that he kept a list in his office of residents that were on PRN [MEDICAL CONDITION] medications, and put it in the attending physician's box so that he could address them if they were ordered over 14 days ago. During continued interview, he stated that the consultant pharmacist should also be alerting the staff during the monthly Medication Regimen Review (MRR) if a PRN [MEDICAL CONDITION] medication was ordered over 14 days ago. Review of a [MEDICAL CONDITION] Primary Care Physician Audit Tools form provided by the DON revealed that R #4 was listed on the form as receiving the antianxiety drug [MEDICATION NAME]. Further review of the directions on top of this form revealed: As of (MONTH) 1, (YEAR) the Primary Care Provider will monitor and document if any PRN [MEDICAL CONDITION] medication should be continued or discontinued if not used. The documentation will be done every other week and included in the Primary Care Providers progress notes. 14 day supply maximum. Document 1st week and 3rd week of each month. Need rationale, duration of the medication in the medical record. During interview with the DON on 6/7/18 at 6:11 p.m., he stated that he was not able to find any pharmacy recommendations for the continued use of the PRN [MEDICATION NAME] past 14 days for R #4. Review of the facility's [MEDICAL CONDITION] Medication Policy and Procedure policy (undated) revealed that orders for PRN [MEDICAL CONDITION] medications will be time limited (i.e., times 2 weeks) and only for specific clearly documented circumstances.",2020-09-01
214,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,761,E,0,1,3B0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to secure all drugs and biologicals in a locked storage area and permit only authorized personnel to have access to the area in one of two medication storage rooms. Findings include: Observation on 6/7/18 at 8:57 a.m. revealed that Licensed Practical Nurse (LPN), BB was observed entering the locked medication room that is located behind the nursing station/desk on Unit 100 leaving her keys in the lock on the exterior of the door, at this time there were residents walking about and propelling themselves in wheelchairs around the nursing station. LPN BB returned to the nursing station on 6/7/18 at 9:03 a.m., opened the medication room door and retrieved her keys from the lock. During an interview with LPN BB at 9:07 a.m. on 6/7/18, she confirmed the keys that were hanging in the lock were her responsibility. She also confirmed that the door to the medication room is to be locked at all times and that only licensed nurses are to have access. Further interview with LPN BB revealed that she forgets the keys and leaves them in the lock frequently. An observation of the locked medication room was made on 6/7/18 at 10:30 a.m. with LPN BB. The room contained a supply of over the counter medications including but not limited to aspirin, [MEDICATION NAME], various vitamin preparations, stool softeners, laxatives and antacids. There was a medication refrigerator that contained a locked box. LPN BB reported that this box contained narcotics. During an interview with LPN CC, revealed that the medication room is to be locked at all times and only the nurses on the carts, the charge nurse and the unit manager have keys to access the medication room. During an interview with the Director of Nursing (DON) on 6/7/18 at 10:40 a.m., revealed that he expects the medication rooms to be locked at all times and that only licensed nurses are to have access to the medication rooms.",2020-09-01
215,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,806,D,0,1,3B0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to honor food consistency preferences, and failed to follow the physician order [REDACTED]. Findings include: Review of R R's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment). On 6/4/18 at 1:37 p.m., R R was observed to be served a CCHO (consistent carbohydrate) mechanical soft lunch, and stated during interview that she did not like ground meat. During interview on 6/5/18 at 11:01 a.m., R R stated that recently she had gotten new dentures and could chew her food without difficulty, and told staff that she no longer wanted the ground meat they served but they kept bringing it. She stated during further interview that she had told one of the aides (Certified Nursing Assistant/CNA) that she did not want the ground meat, and was told she'd have to talk to someone in the kitchen, but said that she was unable to bring herself down there. She further stated that she told a nurse, and the nurse stated that she told the kitchen staff three times not to grind her food. During interview with R R on 6/6/18 at 8:01 a.m., she stated that she had recently been served fried fish that was chopped up, and that she could not eat it prepared that way. Review of a Dietary Communication-For Long Term Care Menu dated 5/18/18 in R R's clinical record revealed the section Diets/Modifications noted a Regular CCHO-NAS (no added salt) diet. Further review of this form revealed that the options for mechanical modification were not checked. Review of her physician's orders [REDACTED].>Observation on 6/6/18 at 1:57 p.m. revealed that R R was served a mechanical soft diet at lunch, and refused to eat it because she could not tell what the food on her plate was. During interview with the Certified Dietary Manager (CDM) on 6/7/18 at 1:58 p.m., she stated that R R lost her dentures earlier this year and was having difficulty chewing the food and was losing weight, so she was placed on a mechanical soft diet. Review of the Resident Diet Information report dated 6/7/18 revealed that the resident was listed as being on a CCHO Mechanical Soft (Level 3) diet. Interview with the CDM at this time revealed that the level indicated how much the food was ground, and that a Level 3 diet was ground more than a Level 1 diet. During review of R R's physician's orders [REDACTED]. She further verified that there was two copies of the Dietary Communication form in R R's clinical record dated 5/18/18 for a regular-consistency diet, and stated during interview that the nurse filled out this Communication form and should have given one of the copies to dietary. DONE",2020-09-01
216,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,842,D,0,1,3B0P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review the facility failed to maintain a complete and accurately documented medical record for one resident, R#362. The sample size was 51 residents and the facility census was 112 residents. Findings include: Observation on 6/6/18 at 8:04 a.m. with Licensed Practical Nurse AA of medication administration for [MEDICATION NAME] 650 mg for R#362 revealed that LPN AA failed to check the Medication Administration Record [REDACTED]. Record review of the order revealed that [MEDICATION NAME] 325 mg tablets - give two tablets (650 mg) by mouth every 6 hours as needed for pain (prn) is ordered. The order states the resident is not to exceed three (3) grams of [MEDICATION NAME] in 24 hours. Review of the Federal Drug Administration website revealed that the danger of excessive amounts of [MEDICATION NAME] such as taking more than the recommended amount can cause liver damage, ranging from abnormalities in liver function blood tests, to acute liver failure, and even death. (FD[NAME]gov Consumer Information - [MEDICATION NAME]) The electronic (EZ) MAR indicated [REDACTED]. Also, the Daily Skilled Nursing Note for 6/6/18 was reviewed and there was no documentation that the [MEDICATION NAME] was administered. During an interview with LPN CC on 6/7/18 at 10:40 a.m. revealed that she expects nurses to document on the electronic MAR indicated [REDACTED]. The nurses are to open the EZMAR computer system and review the resident's PRN orders; they are to remove the correct medication from the cart and give it to the resident; they are then supposed to document the administration of the medication in the EZMAR system. Interview on 6/7/18 at 5:42 p.m. with the Director of Nursing (DON) revealed that he expects the nurses to sign out any narcotics or other PRN medications given to a resident and to document the administration of the PRN medications in the EZMAR system. Review of a facility policy entitled: Medication Administration General Guidelines and dated (MONTH) (YEAR). Page 6 of 6 states: 5. When PRN medications are administered, the following documentation is provided: a. Date and time of administration, dose, route of administration (if other than oral), and if applicable, the injection site. b. Complaints of symptoms for which the medication was given. c. Results achieved from giving the dose and the time results were noted. d. Signature or initials of person recording administration and signature or initials of person recording effects.",2020-09-01
217,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2018-06-07,880,E,0,1,3B0P11,"Based on observations and staff interviews the facility failed to follow infection control procedures by staff failing to sanitize hands during the passing of meal trays on one of four (1/4) halls and touching the rims of 24 glasses on a tray while filling each glass with ice and beverages during dining for approximately 50 residents. This had the potential to effect 111 residents. Findings include: Observation on 6/4/18 at 12:15 p.m. revealed that the Chaplain was touching the rim of the glasses with his fingers while filling the glasses with ice and beverages. This observation revealed 24 glasses on the tray (tray one (1) positioned on a small rolling cart. Interview with the Chaplain on 6/7/18 at 5:10 p.m. revealed that he really didn't have any training on how to pour ice and beverages in a glass, that he had observed other staff members . He revealed that he assisted with dinner meals on Mondays and Thursdays. Interview on 6/7/18 at 5:20 p.m., with RNP FF, reported that that the proper technique of filling the glasses with beverages is to avoid touching the rims of each glass. She verified that there are usually 24 glasses per a tray. She verified receiving training and that some of the staff who were assisting in the dining room on 6/4/18 was only assisting for that day because the state was in the building. She further stated that she was the staff who assisted with the second set of glasses to ensure the process was done correctly. 2. During observation of lunch service on Unit 2 on 6/4/18 at 1:23 p.m., Certified Nursing Assistant (CNA) LL was observed to serve resident (R) (R #34) lunch in her room. After putting the lunch tray on the resident's overbed table, CNA LL was observed to position R #34's overbed table in front of her, move the wheelchair and swing back the footrests of the wheelchair, and remove the trash can liner out of the trash can in the room. CNA LL was then observed to leave the room, obtain another lunch tray out of the food delivery cart, and took the tray in R #52's room. Continued observation revealed that the CNA set up the foods on R #52's plate, and began feeding the resident including picking up a roll with her bare hand, which the resident took a bite of. CNA LL was not observed to wash or sanitize her hands after touching the objects in R #34's room, before serving and feeding R #52. During interview with the Registered Nurse Staff Development/Infection Control Coordinator on 6/7/18 at 1:55 p.m., she stated that if staff touched contaminated objects she would expect them to wash their hands with soap and water between residents if there was visible soiling, or else use hand sanitizer. She stated during further interview that it was never good practice to touch the rims of drinking glasses when preparing drinks for residents.",2020-09-01
218,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-07-18,656,E,1,0,LBOB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to follow the care plan for weekly skin checks for three of five residents (R#2, R#4 and R#5) and failed to develop a care plan for behaviors for two of five residents (R#4, R#5) with known behaviors. Findings include: 1.) R#2 was initially admitted with [DIAGNOSES REDACTED]. Review of R#2's care plan revealed planning for weekly skin checks on admission beginning 5/10/19. Review the of 'Weekly Skin Integrity Evaluation's' revealed that R#2 has received two 'Weekly Skin Integrity Evaluation's ' one on 6/24/19 and one on 7/15/19. Review of the 'Weekly Skin Integrity' Evaluation' completed on 6/24/2019 thirteen days after her re-admission. The next 'Weekly Skin Integrity Evaluation' was completed on 7/15/19, three weeks after the last skin evaluation. 2 [NAME]) Resident #4 admitted [DATE] with [DIAGNOSES REDACTED]. Review of a Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Section E: Behaviors revealed no behaviors have been recorded for this resident. Review of Section G: Functional Status revealed R#5 requires extensive or total assistance for all ADL's except walking, which did not occur, and locomotion on the unit. Resident is able to use a wheelchair with supervision. Review of R#4's Care Area Summary reveals care planning for Cognition, Communication, ADL's, Falls, Nutrition, and pressure Ulcer Prevention. Review of R#4's care plan also revealed planning dated 5/9/19 for Head to toe skin checks weekly. Special Instructions: complete non-pressure observation or wound management form if appropriate. Review of Progress Notes revealed there was not any evidence of documentation entered from 6/5/19 through 7/17/19 for weekly skin checks. 2 B.) Observation on 7/17/19 at 12:40 p.m. of R#4 in her wheelchair in the dining room. Resident appeared to have streaks of dried blood smeared on the lower half of her shirt and on the left leg of her capri style pants. R#4 is rubbing and picking at her skin. Interview on 7/17/19 at 5:30 p.m. with CNA DD who revealed the R#4 picks at her skin all the time. She is reminded to stop and redirected. Telephone interview with Licensed Practical Nurse (LPN) HH on 7/19/19 at 2:57 p.m. who stated that the R#4 picks at her skin all the time and she probably caused the wounds herself. She stated the resident has had this behavior for a long time and is reminded and redirected frequently to stop. LPN HH was asked why this behavior was not recorded in the Progress Notes or on the Medication Administration Record under Behaviors, she stated that she thought one of the week day nurses had already reported it. LPN HH agreed that this behavior was not care planned but should be. 3 [NAME]) Record Review revealed that R#5 was admitted from the hospital with [DIAGNOSES REDACTED]. Review of R#5 care plan also revealed planning dated 5/9/19 for Head to toe skin checks weekly. Review of R#5's 'Weekly Skin Integrity' Evaluation' revealed no weekly skin checks were performed from 6/10/19 through 7/1/19, a period of 27 days. 3 B.) Observation and interview on 7/16/19 at 12:30 p.m. with the resident in the dining room in her wheelchair. Resident able to feed self, has a regular meal. She appears to be non-verbal but makes her needs known. She gestures, makes signs, points etc. and staff seem to understand her. Very animated, appears pleasant, engaged. Resident indicates her tummy hurts, denies it is because she is hungry. R#5 indicates that her tummy hurts frequently, and she gets medicine for it. Interview on 7/18/19 at 12:15 p.m. with the LPN Unit Manager (UM) II who revealed that R#5 displays attention-seeking behaviors. She has a [DIAGNOSES REDACTED]. She enjoys being hugged, just likes you to spend time with her. Staff work with her a lot, take her where she wants to be or put her in a spot where she can people watch. She enjoys activities and likes to be busy, but she is a late sleeper. She will agree with everything you say so you have to make sure she understands what you are asking her. She uses pain as an attention seeking device. When asked, UM II states she does not think resident is care planned for any behaviors or her repeat claims of pain. Interview on 7/18/2109 with the DON who states that he runs a 24-hour report of 'Progress Notes' from the EMR that shows him all documentation entered in the EMR. Everything should be reported by the CNA and then documented by the nurse in the Progress Notes. He states pain should be monitored and recorded on the Medication Administration Record (MAR) and entered in the Progress Notes and changes in behavior should be recorded in the 'Progress Notes'. He stated that some of what the nurses call behaviors related to R#5 are just how she communicates. Since she can't speak, she gestures and mimics to demonstrate what she wants. When asked about resident's frequent complaints of pain and crying when she wants attention, the DON agreed that those should be investigated and care-planned. He also agreed that care planning her methods of communication should be done since it could be misunderstood as a behavior.",2020-09-01
219,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-07-18,740,D,1,0,LBOB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews, and clinical record reviews, it was determined that the facility failed to ensure that two (2) of five sampled residents (R) #4 and R#5 received necessary behavioral health services to address known behaviors. The findings included: 1. Review of the medical record for R#4 revealed that the resident was admitted with [DIAGNOSES REDACTED]. Review of R #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#4 was assessed under Section E: Behaviors as having exhibited no behavioral symptoms during that review period. R#4 had a Brief Interview of Mental Status (BIMS) score of 05 indicating significant cognitive impairment. Review of R#4's Care Area Assessment (CAA) conducted during her Annual MDS Assessment on 4/10/19 revealed the resident did not trigger for Behavioral Symptoms and was not care planned for them. Review of Section N: Medications revealed the resident received no antianxiety, antidepressant or antipsychotic medications during the seven day look back periods of both assessments and received no psychological therapy. Review of all MDS Assessments for this resident beginning with the admission assessment dated [DATE] revealed no behavioral symptoms were noted. Review of Section N: Medications revealed that the resident had received no antianxiety, antidepressant or antipsychotic medications since admission and she has received no psychological therapy. Review of R#4's Medication Administration Record 6/16/19 through 7/16/19 revealed no behaviors or behavioral symptoms recorded. Review of R #4's clinical Progress Notes revealed no documentation of behaviors or behavioral symptoms. Review of R#4's clinical 'Weekly Skin Integrity' Evaluation' dated 7/12/19 and the 'Weekly/Monthly Summary' for all shifts, dated 7/14/19 revealed no notations of any injuries or bruises and no behaviors or behavioral symptoms. Review of the most recent 'C.N.[NAME] Skin Care Alert' dated 7/16/19 revealed no bruises or injuries. Interview with the Director of Nursing (DON) on 7/16/19 at 4:20 p.m. who revealed all observations are supposed to be recorded in the Progress Notes, reported to the physician and the resident's responsible party (RP) and an 'Event form completed for anything new. Continuing interview with the DON revealed that these reports in conjunction with 'Progress Notes' report is used as the basis for the 'At Risk' meetings held each Friday to evaluate residents for changes in condition such as behaviors, pain, infectious processes affecting mentation, etc. Observation on 7/17/19 at 12:40 p.m. of R#4 in her wheelchair in the dining room. Resident appeared to have streaks of dried blood smeared on the lower half of her shirt and on the left leg of her capri style pants. R#4 is rubbing and picking at her skin. Observation on 7/17/2019 at 2:50 p.m. of resident in dining room playing Bingo. Resident observed rubbing legs and arms while engaged in activity. Interview on 7/16/19 at 12:40 p.m. of R#4 in the dining room. Resident states her skin is very dry. Resident is picking at her arms and rubbing her left leg during the conversation. She smears blood on her shirt and pants. Resident complains of leg pain and raised her pant leg which exposed an oval area about 2.5 inches below her left knee and to right of the shin. The area measured about 0.3 x 2.5 inches with a thin yellow circular scab in the center measuring about an inch across. Below that wound and further right was another, smaller scabbed area about and an inch in size and behind that, almost in the calf, was a very thick, circular, raised dark brown scab about 1.5 inches in circumference. None of the wounds had any bleeding or discharge. Continued observation of R#4's arms revealed multiple small scabbed areas Interview on 7/17/2019 at 2:50 p.m. Resident stated that she rubs her arms and legs frequently but doesn't know why because 'they don't bother me now'. Interview on 7/17/19 at 5:30 p.m. with CNA DD revealed that R#4 picks at her skin all the time. She is reminded to stop and redirected. CNA DD observed a wound on the resident's left lower leg on 7/12/19 and reported it to LPN HH. CNA DD applied an adhesive bandage to the wound to keep resident from continuing to pick at it. Interview on 7/18/19 at 12:05 p.m. with LPN LL stated she was aware of wounds on R#4's right leg, they have been there for a while. She had been putting skin prep on them. Believes they are caused by the resident's constant picking and scratching at her skin. When asked, LPN LL agrees that she has not documented this behavior because she thought everyone already knew that resident did this. Interview on 7/18/19 at 2:55 p.m. with the Director of Nursing (DON) who stated he spoke with R#4 who told him that her skin is dry and that staff put lotion on her occasionally and that makes it feel a lot better. The DON stated that he had assessed the resident and she has multiple scabbed areas on her left arm. He noted some bruising on R#4's lower left leg, and three areas on her lower left leg that are scabbed over. Interview on 7/18/19 at 2:10 p.m. with LPN LL who states that R#4 is doing fine. She is being treated for [REDACTED]. She agrees that she had not completed any 'Progress Notes' related to the care of resident's skin or her behaviors. Telephone interview with Licensed Practical Nurse (LPN) HH on 7/19/19 at 2:57 p.m. who stated that R#4 picks at her skin all the time and she probably caused the wounds herself. She stated the resident has had this behavior for a long time and is reminded and redirected frequently to stop. LPN HH was asked why this behavior was not recorded in the Progress Notes or on the Medication Administration Record under Behaviors, she stated that she thought one of the week day nurses had already reported it. LPN HH was then asked if she had reviewed the Progress Notes or documented the wound or the treatment she had provided and she agreed that she had not. 2. Record Review for R#5 revealed she was admitted [DATE] from the hospital. Her [DIAGNOSES REDACTED]. defect, unspecified, [MEDICAL CONDITION] without current pathological fracture, vitamin B12 deficiency [MEDICAL CONDITION], unspecified, [MEDICAL CONDITION], unspecified, chronic rhinitis, fever, unspecified, other specified nutritional deficiencies, overactive bladder, allergic rhinitis, unspecified dysphagia, oropharyngeal phase. Review of most recent MDS quarterly review dated 5/15/19 revealed a BIMS score of 5, indicating significant cognitive impairment. Resident exhibits no behaviors or moods and requires limited, one-person assistance for all activities of daily living (ADL's) except walking and personal hygiene which require extensive assistance. R#5 receives anti-depressant and anti-coagulant medications daily and . Review of Section O: Special Treatments and Programs revealed resident has never received psychological therapy is not receiving any therapy or involved in any special programs. Review of the CAA dated 9/19/19 reveal recommendations the following areas were care planned for; cognition, communication, incontinence, falls, nutrition, and pressure ulcer risk. Review of physician's orders [REDACTED]. Observation and interview on 7/16/19 at 12:30 p.m. with the resident in the dining room in her wheelchair. Resident able to feed self, has a regular meal. She appears to be non-verbal but makes her needs known. She gestures, makes signs, points etc. and staff seem to understand her. Very animated, appears pleasant, engaged. Resident indicates her tummy hurts, denies it is because she is hungry. R#5 indicates that her tummy hurts frequently and she gets medicine for it. Interview on 7/17/19 at 3:05 p.m. with resident in the dining room playing Bingo. She indicates that her left arm and both lower legs are painful from a fall she had yesterday. Resident is tearful, holds up her left forefinger that has a bandage on it and [MEDICAL CONDITION] it, indicating it hurts. LPN LL confirms that resident had a fall but states she has not complained of any pain. LPN LL further states that resident complains of pain frequently in different places, believes it is an attention seeking mechanism. You can tell if the resident really isn't feeling well because she will go to bed and stay there. Otherwise, resident is always up and busy. Interview with resident in her room on 7/17/19 at 12:15 p.m. Resident remains in bed, dressed in a nightgown. She complains of right arm pain by holding her arm and making a sad face. Resident is tearful, asks for pain medication. LPN alerted, states she will order an x-ray and medicate resident for pain. Phone interview on 7/17/19 at 9:45 p.m. with Administrator who revealed R#5's X-ray report was negative for acute injury. Interview on 7/18/19 at 12:15 p.m. with the LPN Unit Manager (UM) II who revealed that R#5 displays attention-seeking behaviors. She has a [DIAGNOSES REDACTED]. She enjoys being hugged, just likes you to spend time with her. Staff work with her a lot, take her where she wants to be or put her in a spot where she can people watch. She enjoys activities and likes to be busy, but she is a late sleeper. She will agree with everything you say so you have to make sure she understands what you are asking her. She uses pain as an attention seeking device. When asked, UM II states she does not think resident is care planned for any behaviors or her repeat claims of pain. Interview on 7/18/2109 with the DON who states that he runs a 24-hour report of 'Progress Notes' from the EMR that shows him all documentation entered in the EMR. Everything should be reported by the CNA and then documented by the nurse in the Progress Notes. He states pain should be monitored and recorded on the Medication Administration Record (MAR) and also entered in the Progress Notes and changes in behavior should be recorded in the 'Progress Notes'. He stated that some of what the nurses call behaviors related to R#5 are just how she communicates. Since she can't speak, she gestures and mimics to demonstrate what she wants. When asked about resident's frequent complaints of pain and crying when she wants attention, the DON agreed that those should be investigated and care-planned. He also agreed that care planning her methods of communication should be done since it could be misunderstood as a behavior.",2020-09-01
220,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-07-18,842,E,1,0,LBOB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to ensure that documentation was complete and accurate for three of five residents (R#2, R#4, R#5) by failing to document weekly skin checks, wounds, and skin tear, and reddened area. Findings include: 1. R#2 was initially admitted [DATE] with [DIAGNOSES REDACTED]. Review of R#2's care plan revealed planning for weekly skin checks on admission beginning 5/10/19. Review the of 'Weekly Skin Integrity Evaluation's' revealed that R#2 has received two 'Weekly Skin Integrity Evaluation's ' one on 6/24/19 and one on 7/15/19. Review of the 'Weekly Skin Integrity' Evaluation' completed on 6/24/2019 revealed no concerns but was completed on 6/24/19, thirteen days after her re-admission. The next 'Weekly Skin Integrity Evaluation' was completed on 7/15/19, twenty one days after the last skin evaluation and revealed no concerns. 3. R#3 admitted with [DIAGNOSES REDACTED]. Observation on 7/16/19 at 1:42 p.m. of resident in her room revealed R#3 is up in her wheelchair, looked confused. Resident has significant purple, blue-black and red bruising on both the left and right forearms and purple bruising in the of the right antecubital fossa. Review of R#3's Admission assessment dated [DATE] and completed by LPN GG revealed no documentation of bruising on forearms and antecubital fossa or other concerns with skin integrity. Review of the 'Facility Event Summary' dated 6/16/19 through 7/17/19 revealed R#3 had a skin tear to her chest documented on 7/10/19. No additional 'Event' documented for observed additional existing skin tear or new skin tear, both observed by surveyor on 7/16/19. Interview on 7/16/19 with LPN GG at 4:24 p.m. When asked why she did not document the R#3's skin tears and bruising on the Admission Assessment, LPN GG revealed that she thought those issues were documented by the CNA's when they did their skin assessments. The 'Admission Assessment' was to document things like catheters, PICC lines, etc. Interview with on 7/18/19 at 1:05 p.m. with LPN AA who stated she knows she is supposed to document skin tears, bruising and other injuries on residents, but there is no real system in place for doing it. If there is, she hasn't been trained. All the nurses do the same thing - they document only if it is an event or something big. No one has been trained on a new system for reporting. When the 'Weekly Skin Integrity' Evaluation' is completed, only new injuries are documented. Phone interview on 7/18/19 at 1:30 p.m. with RN FF who stated that she thought you only documented new injuries when you completed a Weekly Skin Check. There's really no way to tell in the new system if it is old or new, so a lot of things probably aren't documented. Interview on 7/18/19 at 1:45 p.m. with CNA MM who explained that she doesn't document old injuries when she completes the C.N.[NAME] Skin Care Alert, especially if it is new admission because everything should have been documented on the Admission Assessment already. She reports new observations to the nurse and most nurses respond when she reports something. She revealed that she has been asking how this new injury reporting system is supposed to work and no one understands it. All the CNA's that she has talked on document new injuries on the C.N.[NAME] Skin Care Alert form. No one really received training on the new system (EMR), they're still waiting for the company to train them. The old system really was better for the CNA's. Interview on 7/18/19 at 3:35 p.m. with the Unit Manager (UM) JJ who states a lot of the issues staff are having now are related to the lack of training they received when the new EMR went live. There isn't a good reporting system for wounds or a good order system in place for regular wound care and bruising. If you need to document for a pressure ulcer, the EMR is set up for that. We knew that skin tears and bruises weren't being recorded because they didn't show up on any of our reports. She stated reporting of skin issues the new EMR was difficult for all staff, especially the CNAs because they were very good at it before. They had a human figure they could select for each resident and then mark the areas of concerns. That forwarded to the nurses for follow up. Now, they use a piece of paper and have to write and describe everything, then give it to the nurse. The nurse can't stop what she is doing to review it, so it gets set aside. There's no reminder system to go back and look at it. Now the CNA's will tell the nurses if they have a wound that needs care. The nurse is supposed to assess it, create an event form, then get orders and treat it and enter it in Progress Notes. Even the ordering system is set-up for pressure ulcers. When you are trying to enter an order and select bruising, there is nothing. If you have to pick wound, it's all about pressure ulcers. You have to start a brand new order and manually enter what you need. The whole process is very time consuming just to treat a bruise. 2. Resident #4 admitted with [DIAGNOSES REDACTED]. Her most recent Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7, indicating severe cognitive impairment. Review of Section E: Behaviors revealed no behaviors have been recorded for this resident. Review of Section G: Functional Status revealed R#5 requires extensive or total assistance for all ADL's except walking, which did not occur, and locomotion on the unit. Resident is able to use a wheelchair with supervision. Review of R#4's Care Area Summary reveals care planning for Cognition, Communication, ADL's, Falls, Nutrition, and pressure Ulcer Prevention. Review of 'physician's orders [REDACTED]. Special Instructions: complete non-pressure observation or wound management form if appropriate. Once A Day on Fri 01:00 - 01:00 ordered on [DATE]. Order for skin prep. Special Instructions: sin (sic) prep to right low leg twice daily. Once A Day entered 5/23/19. Review of R#4's care plan also revealed planning dated 5/9/19 for Head to toe skin checks weekly. Special Instructions: complete non-pressure observation or wound management form if appropriate. Review of Progress Notes revealed no documentation entered from 6/5/19 through 7/17/19. Review of Progress Notes revealed no documentation related to the resident's current wounds on the left leg and no documentation related to the need for or application of skin prep on the right lower leg ordered on [DATE]. Review of 'C.N.[NAME] Skin Care Alert' forms dated 7/2/19, 7/5/19 and 7/9/19 revealed no bruising, wounds or open areas documented. Reddened area on her left buttock was noted on 7/5/19. Review of the 'Weekly Skin Integrity Evaluation's' dated 7/12/19 reveals no skin integrity concerns. Review of the 'Weekly/Monthly Summary' dated 7/14/19 reveals no skin integrity concerns. Review of the 'C.N.[NAME] Skin Care Alert's' dated 7/5/19, revealed a red area noted under the left buttock. Review of 'Progress Note's' revealed no follow up documentation for redness noted on the 'C.N.[NAME] Skin Care Alert's' dated 7/5/19, although alert is signed by an LPN. Review of the 'C.N.[NAME] Skin Care Alert's dated 7/2/19, 7/9/19 and 7/16/19 reveal no skin integrity issues. Review of the 'Facility Event Summary' dated 6/16/19 through 7/17/19 revealed no entries for this resident. Interview on 7/16/19 at 12:40 p.m. of R#4 in the dining room. Resident states her skin is very dry. She has complained about, but nobody listens to her. She agrees that nurses put lotion on her skin sometimes, and it helps, but it doesn't fix the problem. Resident is picking at her arms and rubbing her left leg during the conversation. She requests assistance to go to her room and staff is notified. Surveyor accompanies resident to her where two CNA's are attending another resident but are visible to resident and surveyor. Surveyor tells CNA's that resident has blood on her clothing and requests that resident's clothing be changed. CNA's state that resident scratched and rubs her skin all the time and she may have scratched herself. R#4 complains of pain to her left leg. Redness is visible at the hem line of resident's capri style pants. Resident is asked to raise her pant leg which exposed an oval area about 2.5 inches below her left knee and to right of the shin. The area was swollen and inflamed, measuring about 0.3 x 2.5 inches with a thin yellow circular scab in the center measuring about an inch across. Below that wound and further right was another, smaller scabbed area about and an inch in size and behind that, almost in the calf, was a very thick, circular, raised dark brown scab about 1.5 inches in circumference. None of the wounds had any bleeding or discharge. Observation of R#4's arms revealed multiple small scabbed areas. The source of the blood on the resident's clothing was undetermined. The CNA's began to assist the resident, surveyor excused self from the room. Interview on 7/18/19 at 4:30 p.m. with the DON and the Administrator who states that he runs a 24-hour report of 'Progress Notes' from the EMR that shows him all documentation entered in the EMR. Everything should be reported by the CNA and then documented by the nurse in the Progress Notes. He was unaware of any skin issues or behaviors with this resident. Nothing had been reported in the morning meetings or the Interdepartmental Team (IDT) meeting and the reports from 'Progress Notes' didn't record anything. He agrees resident should be care planned behavior's. He is currently working with staff on injury and wound reporting. Right now, the only way to report an injury is to create an 'Event' in the EMR and then enter a 'Progress Note' with details about it. If the nurse doesn't do an 'Event', she should still document the wound in the 'Progress Notes' so it can be caught on the report, otherwise it's not visible. The CNAs' and the nurses are supposed to document all injuries including bruises on the skin reports, every shower day by CNA and every week by the nurse. The nurse signs off on the CNA skin observation, they are supposed to be looking at it and following up on any injuries noted on it then compare that information with what they see on the weekly skin observation. 3. Record Review revealed that R#5 was admitted with [DIAGNOSES REDACTED]. Review of R#5 care plan also revealed planning dated 5/9/19 for Head to toe skin checks weekly. Special Instructions: complete non-pressure observation or wound management form if appropriate. Once A Day on Mon - 15:00 - 23:00. Review of R#5's 'Weekly Skin Integrity' Evaluation' revealed no weekly skin checks were performed from 6/10/19 through 7/1/19, a period of 27 days. Interview on 7/18/19 at 4:30 p.m. with the DON and the Administrator who states that he runs a 24-hour report of 'Progress Notes' from the EMR that shows him all documentation entered in the EMR. Everything should be reported by the CNA and then documented by the nurse in the Progress Notes. He was unaware of any skin issues or behaviors with this resident. Nothing had been reported in the morning meetings or the Interdepartmental Team (IDT) meeting and the reports from 'Progress Notes' didn't record anything. If the nurse doesn't do an 'Event', she should still document the wound in the 'Progress Notes' so it can be caught on the report, otherwise it's not visible. The CNAs' and the nurses are supposed to document all injuries on the skin reports, every shower day by CNA and every week by the nurse. The nurse signs off on the CNA skin observation, they are supposed to be looking at it and following up on any injuries noted on it then compare that information with what they see on the weekly skin observation",2020-09-01
221,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-08-08,550,D,0,1,FZQ711,"Based on observations, staff interviews, record review, and review of the facility policy titled, Assistance with Meals and Resident's Rights the facility failed to ensure the dignity for two of 20 residents (R#113, R#22) assessed for total dependency for feeding. Specifically, staff were observed standing while feeding R#113 and R#22 and eating while feeding R#22. Findings include: Review of the facility policy titled, Assistance with Meals dated 6/27/18 documents the following: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. 1. Residents will be encouraged to eat in the dining space of their choice. (a). Facility staff will serve resident meals and will help residents who require assistance with eating. b. Employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of food borne illness, including personal hygiene practices and safe food handling. c. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: i. Not standing over residents while assisting them with meals. ii Keeping interactions with other staff to a minimum while assisting residents with meals. Record review of the facility policy titled, Resident Rights revised 6/30/17 documents: All residents have the right to be treated with respect and dignity. These rights will be promoted and protected by the facility. 1. An observation on 8/5/19 at 12:14 p.m. revealed Certified Nursing Assistant (CNA) II was in R#113 room and was observed standing while assisting the resident to eat. There was no chair observed in the room 2. An observation on 8/5/19 at 12:16 p.m. revealed CNA GG in R#22's room and CNA GG was observed standing while assisting R#22 to eat. There was no chair observed in the room. 3. An observation on 8/6/19 at 12:42 p.m. revealed resident R#22's door closed. When the door was opened CNA FF was observed sitting on the resident's bed in a sideways position with a cell phone in one hand and using her other hand to scroll through her phone. Further observation revealed a resident's pureed meal on the over the bed table and a napkin with two pieces of pork chop half eaten beside the meal. On the floor was a 16-ounce (oz) orange soda half filled. Later in the observation, CNA FF was observed picking up the spoon to feed R#22. A later observation was made with Licensed Practical Nurse LPN HH to identify the above concern on 8/6/19 at 12:42 p.m. LPN HH knocked on the door and was invited into R#22 's room by CNA FF. CNA FF was observed sitting in the same position, sitting sideways on the bed, and CNA FF was observed to be eating porkchops using her hands. After being observed doing this CNA FF picked up the spoon and started to feed R#22. LPN HH informed the CNA that she could not eat while feeding the residents nor use her phone. LPN HH asked CNA FF to wash her hands. Interview with the CNA FF on 8/6/19 at 12:43 p.m. revealed that she had received in-service training on infection control about not eating while feeding residents and not using her phone. When asked how this will make her feel as a resident if she observed a staff eating her food first before feeding her. She provided no comment and refused to answer the question. Interview on 8/7/19 at 2:10 p.m. with CNA GG revealed her reason for standing was due to no available chair in the room. She reported that she was in-serviced on not standing and instructed to sit in a chair when assisting/feeding residents with meals during orientation and also on yesterday on 8/6/19. She revealed as a resident that she would feel bad if staff stood while feeding her. She revealed her preference is for staff to sit at eye level. Interview on 8/7/19 at 11:52 a.m. with the Administrator and the Director of Nursing revealed that the Administrator's expectations are that CNAs should never have food in the room. The Administrator stated that the nursing staff are supposed to monitor for Resident Rights and Dignity during resident dining. Further interview revealed that the Director of Nursing (DON) stated that CNAs shouldn't stand while eating, per policy, and that his expectations are that CNAs and nursing staff were not to eat while feeding residents, also per the facility policy. The DON stated he wanted the CNAs to focus on feeding the residents. Interview on 8/8/19 at 12:41 p.m. with CNA II revealed there was not a chair in the room. She revealed she had received training about sitting when feeding residents. CNA II revealed that she knew to get a chair but just did not take the time to do this. When asked how she would feel if someone stood to feed her? CNA II revealed that she would prefer for someone to sit while feeding.",2020-09-01
222,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-08-08,638,D,0,1,FZQ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that a Quarterly Minimum Data Set (MDS) Assessment was completed in a timely manner for one of 35 residents (RA) reviewed for MDS assessments. Findings include: Resident A was re-admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of RA 's MDS Assessments in the facility's computer system (Matrix) revealed that a Quarterly Assessment was completed on 4/18/19, and that a Quarterly Assessment was in progress dated 7/18/19. However, there was no evidence that the Quarterly assessment dated [DATE] was completed. Interview with the MDS Coordinator on 8/8/19 at 6:38 p.m., revealed that the Quarterly Assessment should have been completed by the end of (MONTH) 2019.",2020-09-01
223,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-08-08,641,D,0,1,FZQ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to accurately assess one of 35 residents (R#82) reviewed for accurate Minimum Data Set Assessments. Findings include: Review of R#82 Quarterly Minimum Data Set Assessment (MDS) with an assessment reference date of 7/4/19 revealed in Section P that restraint were used during the seven (7) day look back period. Record review of R#82 's Physician Orders (POF) for the month of (MONTH) 2019 and the last previous months since her admission revealed no physician order for [REDACTED].> Interview on 8/7/19 at 2:00 p. m., the MDS Coordinator revealed that a weekend nurse, Registered Nurse (RN) JJ completed the Quarterly MDS and made the data entry error. She was not aware of the error until it was brought to her attention during the survey.",2020-09-01
224,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-08-08,689,G,0,1,FZQ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and review of facility policy titled, Resident Lift the facility failed to ensure that one of three residents (R A) was transferred appropriately using a Hoyer lift with two-person assist. Actual harm was identified on 11/25/18 when CNA EE transferred R A by herself without the assistance of any other staff or mechanical lift, as care planed, and the resident fell and suffered a fractured tibia and fibula which required open reduction internal fixation surgery. Findings include: Review of the facility policy titled, Resident Lift dated 6/1/15 with revision date of 5/30/18 documented the following: #2 - At least two trained staff are needed to transfer a resident when using a lift. Record review revealed that RA was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C: Cognitive Pattern, that RA was assessed as 13 on her Brief Interview for Mental Status (BIMS) score, which means that she was cognitively intact. Also, review of Section E: Behaviors, revealed no behaviors during the look back period. Further review of Section G: Functional Status, revealed that RA was totally dependent and required two plus person physical assist. Section G0400, of this same assessment, documents that R A had impairment to her bilateral upper and lower extremities. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed in Section C: Cognitive Pattern, that RA was assessed as 15 on her Brief Interview for Mental Status (BIMS), which means that she was cognitively intact. Also, review of Section E: Behaviors, revealed no behaviors during the look back period. Further review of Section G: Functional Status, revealed that RA was totally dependent with two-person assist. Review of the care plan for R A revised 12/27/18, revealed that resident required assistance with transfers, bed mobility, bathing, grooming related to her left AKA and [MEDICAL CONDITIONS] with interventions of using a mechanical lift (5/13/16) and two-person lift required during transfers (5/13/16). Review of the Fall Risk Evaluation dated 11/25/18 revealed that the resident was assessed for falls and the assessment revealed that the resident scored 16 indicating that the resident was at risk for falls (A resident who scores a 10 or higher is at risk). Review of a Situation, Background, Assessment, and Recommendation (SBAR) dated 11/25/18 revealed the following documentation: Situation: The change in condition, symptoms, or signs observed and evaluated are fracture of tibia and fibula, this started on 11/25/19. The Functional Status Evaluation revealed: An X-ray obtained yielding results of fractured tibia and fibula. Further review of the SBAR revealed the following documented under Appearance: Resident appears to be in excoriating pain related to fall acquiring (sic) a fracture, transferred to an acute care hospital. Record review of a Physician order dated 11/25/18 revealed an order to send RA to hospital ER (emergency room ) for TX (treatment) and evaluation of Fx (fracture) of tibia and fibula. Review of the Radiology Report dated 11/25/18 revealed an acute tibia/fibula fracture. Review of a radiology report from an acute care hospital dated 11/26/18 for the right tibia revealed diffuse osteopenia and fracture, proximal tibia and fibula. Review of an acute care hospital X-Ray Report dated 11/26/18 for the right femur revealed severe osteopenia. Review of an acute care hospital report (page 2 of 2) dated 11/26/18 revealed that RA had a right intra-articular proximal tibia fracture, and options were discussed including operative and non-operative options. Further review revealed that the physician recommended open reduction internal fixation surgery and RA elected to have this surgery. Review of a typed statement documented the following: Statement from RA of event on 11/25/18 dated 12/3/18: Certified Nursing Assistant (CNA) EE tried to transfer her (the resident) from the wheelchair to the bed by herself. She usually don't have me and this was her first time putting me to bed. She (CNA EE) went to put me in bed but I felt like she didn't have a good grip on me. When she transferred me, I got to the tip (edge of the bed), then my leg went to buckle and gave away. I heard my knee cracked and I yelled out and clear my lungs. I know that this was an accident. (sic) The typed statement was witnessed by the CEO (Chief Executive Officer) and Unit Manager but was not signed by the resident. Review of a handwritten statement from CNA EE dated 11/26/18 documented the following: I lowered the bed, pulled the covers back. I put the locks on the chair. I secured her (RA) by grabbing around the waist, and lifting her out the wheelchair. She (RA) held onto the chair and her and the chair was going up at the same time. I tried to put her back in the chair, but she got heavy, so I lowered her to the floor. When I seen that her foot was under her, I slowly moved her foot out from under her. I called for help and two co-workers came to help me get her in bed. I am very sorry this happened. The statement was signed by CNA EE. Review of a typed statement dated 12/3/18 documented the following, in pertinent part: CNA EE and the Administrator visited with RA in the hospital on [DATE] . RA said, when the CNA (CNA EE) placed me on the bed, my knee buckled or gave way, I slid off the bed with the CNA helping me down to the floor. That is when my knee started hurting. This statement was signed by the CEO and CNA EE. Review of a typed statement dated 12/4/18 documented the following, in pertinent part: that the Unit Manager and the Administrator visited with the resident and discussed the incident and RA explained, she wanted to be put in bed, the CNA pulled the chair next to the bed, placed me on the bed and then my knee gave way or buckled. That's when me and the CNA went to the floor, and somewhere in that situation my knee was hurt. This statement is signed by the CEO and the Unit Manager. Interview with RA on 8/7/19 at 2:20 p.m., revealed that she felt that staff did not do their job because she was a two person assist for a Hoyer lift, and a Hoyer lift wasn't used on the day that she fell . RA said that the Certified Nursing Assistant (CNA) did the transfer by herself even after she mentioned to her that she was a two person assist. RA stated that the CNA said she could do it by herself. The resident stated that the fall resulted in a fracture of her right knee, which she had to be hospitalized for [REDACTED].>Interview with CNA CC, on 8/8/19 at 10:30 a.m., revealed that the resident was a two person assist at the time of the fall, as well as now. Interview with CNA EE on 8/8/19 at 1:53 p.m., revealed that she has not worked with the resident since the incident. She stated that, at the time of the incident, she was trying to transfer RA from her wheelchair to the bed when the resident's leg got stuck in the wheelchair, which CNA EE stated that she was unaware of at the time, so she (CNA EE) lowered RA to the floor. CNA EE stated that she had worked with the resident four to five times prior to this incident. CNA EE confirmed that she knew that the resident was a two-person assist.",2020-09-01
225,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-08-08,758,D,0,1,FZQ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and pharmacy interviews, and review of the facility policy titled, Medication Administration General Guidelines the facility failed to ensure that one of five residents (R#52) reviewed for unnecessary medications had a proper [DIAGNOSES REDACTED]. Findings Include: Review of the policy titled, Medication Administration General Guidelines, Procedures, under, Medication Administration, Number 1. Medications are administered in accordance with written orders of the prescriber. If a dose seems excessive considering the resident's age and condition, or a medication order seems to be unrelated to the resident's current [DIAGNOSES REDACTED]. If necessary, the nurse contacts the prescriber for clarification. This interaction with the pharmacy and the resulting order clarification are documented in the nursing notes and elsewhere in the medical record as appropriate. Record review revealed that R#52 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED] 1. [MEDICATION NAME] tablet; 0.5 milligrams (mg); and the [DIAGNOSES REDACTED]. ([MEDICATION NAME] is classified as a benzodiazepine, which is a psychoactive drug primarily used to treat anxiety. 2. [MEDICATION NAME] tablet; 10 mg; the [DIAGNOSES REDACTED]. ([MEDICATION NAME] is classified as a benzodiazepine, a psychoactive drug primarily used to treat anxiety). 3. [MEDICATION NAME] tablet 20 mg; the [DIAGNOSES REDACTED]. ([MEDICATION NAME] is classified as an antidepressant used to treat depression). 4. [MEDICATION NAME] tablet 0.5 mg; [DIAGNOSES REDACTED]. ([MEDICATION NAME] is classified as an antipsychotic primarily used to treat [MEDICAL CONDITIONS] disorder and irritability caused by autism). Interview with the Director of Nursing (DON) on 8/8/19 at 7:54 a.m., revealed that he expects the nursing staff to ensure the orders are brought over to the next month's MAR indicated [REDACTED]. Interview with Pharmacist AA on 8/8/19 at 10:23 a.m., revealed that every month when he comes in to check the medications, he is also checking that medications have a proper diagnosis. He also stated that these medicines and their erroneous [DIAGNOSES REDACTED].",2020-09-01
226,SIGNATURE HEALTHCARE OF SAVANNAH,115120,815 EAST 63 STREET,SAVANNAH,GA,31405,2019-08-08,880,D,0,1,FZQ711,"Based on record review, observations, and staff interviews the facility failed to ensure infection control preventive measures were being maintain for one of 20 residents (R#22) who were assessed to require assistance for feeding. Findings include: An observation on 8/6/19 at 12:42 p.m. revealed Certified Nursing Assistant (CNA) FF sitting on R#22's bed scrolling through her cell phone, and eating her lunch, which was porkchops, with her hands. In addition, CNA FF was observed feeding R#22 her lunch (which was a pureed meal). A later observation was made with Licensed Practical Nurse (LPN) HH to identify and confirm the observation on 8/6/19 at 12:42 p.m. During this observation, CNA FF was observed sitting in the same position, sideways on the bed eating her lunch, which was pork chops, using her hands. After being observed doing this CNA FF picked up the spoon and started to feed R#22. LPN HH informed the CNA that she could not eat while feeding the residents nor use her phone. Interview with the CNA FF on 8/6/19 at 12:43 p.m. revealed that she received in-service training on infection control about not eating while feeding residents and not using her phone. Interview on 8/7/19 at 11: 52 a.m., with the Administrator and the DON revealed that the Administrator stated that his expectations are that CNAs should never have personal food in the resident's rooms. The Administrator stated that nursing staff are to monitor for cross contamination and for infection control concerns. Further interview with the Director of Nursing (DON) revealed that his expectations are that the CNAs and nursing staff should not eat while feeding their residents, per the facility policy. The DON stated that he wanted the CNAs to focus on feeding the residents. Further interview with the DON revealed that he considers staff sitting on the bed, while he or she is eating, an infection control issue. During a later interview on 8/8/19 at 11:10 a.m., the DON revealed that staff are in-serviced on infection control including using their telephone, and washing hands when they are assisting residents with meals during orientation. The DON revealed that his expectations are that staff do not use the phone during any form of patient care. Interview on 8/8/19 at 4:21 p. m., with the Infection Control Preventionist (ICP) revealed that she was not aware of a CNA sitting on the bed and eating while feeding a resident. The ICP revealed that she considered a person hands as the dirtiest part of the body due to microorganism growth. A staff member eating with her hands and then touching resident's foods, and utensils increase the risk for infection. Touching cell phones and sitting on resident 's bed can contribute to spreading microbes.",2020-09-01
227,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2020-02-27,578,E,0,1,WB3D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the policy titled, Advance Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED]. (R) (R#67, R#120, R#118). Findings include: Review of the facility's policy titled, Advanced Directives documented the following: C. Procedures for periodically reviewing resident choices and preferences related to health care decisions after admission: 7. During Advanced Care Planning (ACP) conversations, education may be provided to residents on the Georgia Physician order [REDACTED]. The POLST is a physician's orders [REDACTED]. a. A POLST that has been appropriately completed will be accepted and followed by the facility. Review of the Advanced Directives policy related to residents without any advance directive revealed the following: B. The physician will have his/her medical decision concurred with by another physician when possible. 1. Review of medical record for R#67 revealed a POLST with a choice to allow natural death/DNR. The form was signed by one Physician and a family member that was not the residents Power of Attorney, but there was no concurring Physician's signature nor was the form dated. Further review of the Medical Record for R#67 revealed that there was not a Health Care Agent for R#67. 2. Review of medical record for R#120 revealed a POLST with a choice to allow natural death/DNR. The form was signed by a family member on 1/22/2020 but the form was not signed by a Physician. Further review of the medical record revealed that R#120 did not have a health care agent. During an interview with the Director of Nursing (DON) on 2/26/2020 at 2:18 p.m. revealed that on admission the nurse asks resident and family member regarding code status. It was further reported that Social Services was responsible for following up with the resident and family member regarding code status and Advanced directives. The DON also revealed that the Admissions Director discusses the healthcare agent information during the Admissions process. The DON revealed that if a resident wants to change code status after being in the facility that this information was discussed with the nurse and by social services. Further interview with the DON revealed that if a resident is cognitively intact, he/she can sign the POLST for self, otherwise a family member or health care agent signs the form. The DON revealed that if a non-health care agent signs the form that two physician's signatures would be needed, and Social Services would have been responsible for assuring that the POLST form is completed and had the appropriate signatures. Review of the POLST for R#67 with the DON revealed that the DON confirmed the missing concurring Physician signature and dates. Review of the POLST for R#120 the DON confirmed that it did not have a Physician signature. 2. Review of a Physician's Do Not Resuscitate (DNR) Order Form for Adult Hospice Patient/Resident Without Decision-Making Capacity With Authorized Person Other Than Durable Power of Attorney for Healthcare Georgia for R#118 revealed that an authorized person signed the DNR form on 7/3/19, and the attending physician only signed the form on 7/6/19. No concurring physician signature was noted. The instructions at the bottom of order form documents the signature of a concurring physician is not required if the authorized person completing Parts 1 and 2 is an agent appointed by the Patient under Durable Power of Attorney for Health Care or Advance Directives for Health Care executed by the Patient. No Durable Power of Attorney for Health Care or Advance Directives for Health Care executed by the Patient noted in medical records. Review of Minimum Data Set (MDS) Admission assessment dated [DATE] revealed received hospice and Brief Interview of Mental Status (BIMS) score of nine indicating moderate cognitive impairment. Review of R#118's Physician order [REDACTED]. Review of Social Service assessment dated [DATE] revealed Resident #118 was under hospice care with a code status of DNR. Interview with the DON on 2/26/2020 at 4:46 p.m. confirmed that Resident # 118 only had one physician signature. The DON stated there should have been a concurring physician signature included.",2020-09-01
228,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2020-02-27,684,D,0,1,WB3D11,"Based on observation, record review and staff interview, the facility failed to follow Physician's order for a splinting device and for a pureed renal diet for one resident (R) A) of 50 residents reviewed. Findings include: Review of R#A's medical record revealed a Physician's dietary order for a renal pureed diet. There was also a restorative order for splint to bilateral lower extremities for three hours a day as tolerated and splint to right knee for 6 to 8 hours daily. Restorative Supervisor provided a copy of daily restorative care for R# [NAME] Review of the restorative form revealed restorative services 21 days in (MONTH) and 15 days in (MONTH) 2020. Further review of the documentation did not reveal that splint devices were applied or refused for R# [NAME] During observations of R#A on 2/25/2020 at 8:53 a.m. and 2:40 p.m., 2/26/2020 at 8:42 a.m. and 1:05 p.m. there was no splinting device observed. During lunch observations on 2/24/2020 at 12:10 p.m. and 2/26/2020 at 12:13 p.m. there were no lunch trays delivered to room for R# [NAME] During an interview with R# A family member 2/26/2020 at 1:05 p.m. revealed that R# A had not received a meal tray since returning from the hospital in (MONTH) 2019. During an interview with Unit Manager MM on 2/26/2020 at 2:04 p.m. revealed that R# A had not received a pleasure tray since (MONTH) 2019 when he/she returned from the hospital. Unit Manager then confirmed current dietary order for pureed renal diet for R# [NAME] During an interview with the Director of Nursing on 2/26/2020 at 4:34 p.m. revealed that the nurse should have checked the orders. The DON also reported that the registered dietitian should have followed up on admission once it was determined that the order changed for dietary. The DON further revealed that there should have been clarification orders for the splints since the resident no longer was using those. During an interview with the DON on 2/26/202 at 5:18 p.m. revealed that when residents returned from hospital there was no order for the pureed diet, and the order was overlooked during the changeover. DON further reported that the Unit Manager should have checked orders and checked against Physician's orders for January. Once the discrepancy was found a clarification order should have been written and faxed to the pharmacy. Interview with Certified Nursing Assistant (CNA) LL on 2/27/2020 at 2:22 p.m. revealed that she had never seen R# A with splint devices. CNA LL further reported that R# A had not received a pleasure tray since he/she returned from the hospital in (MONTH) 2019.",2020-09-01
229,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2020-02-27,695,D,0,1,WB3D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the facility policy titled, Medication Administration the facility failed to obtain a Physician's Order for one of 26 Residents (R) (R#55) receiving oxygen. Findings include: Review of Medication Administration Policy updated on (MONTH) 2019 indicated, Medications are administered as prescribed, in accordance with good nursing principles. Guidelines are as follow but not limited to 1) Medications are administered in accordance with a valid prescriber order. 2) All current medications and dosage schedules, except topical medications used for treatments, are listed on the patient's Medication Administration Record [REDACTED] Review of Most current comprehensive Minimum Data Set (MDS) assessment dated [DATE] in Section O revealed R#55 received oxygen while a resident at the facility. Observations on 2/24/2020 at 11:34 a.m. revealed R#55 receiving oxygen therapy via nasal cannula at 2 LPM (liters per minute). Observations on 2/25/2020 at 9:21 a.m. and 2/25/2020 at 4:57 p.m. revealed R#55 receiving oxygen therapy via nasal cannula at 1.5 LPM. Review of the Medication Administration Record [REDACTED]. Review of Nursing notes during the time period of 12/24/19 through 2/25/2020 revealed R#55 received oxygen administration while at the facility. Review of care plan updated on 12/24/19 revealed R#55 was readmitted back to facility after a five-night hospital stay for [DIAGNOSES REDACTED]. Review of Medication Reconciliation form dated 12/24/19 upon return from hospital stay revealed no oxygen listed under active medication orders. Interview on 2/26/2020 at 3:20 p.m. with Registered Nurse (RN) KK revealed R#55 received oxygen at 2LPM continuously, but she has a history of taking it off on occasions. RN KK confirmed that oxygen should not have been given without an order and that it should have been documented on MAR for R#55. RN KK stated the admitting nurse should have clarified the need for oxygen and written the order upon the resident's return from the hospital. RN KK was unable to locate an order in the resident's records. Interview on 2/26/2020 at 5:19 p.m. with the Director of Nursing (DON) revealed he expects nurses to have an order for [REDACTED].",2020-09-01
230,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2020-02-27,760,D,0,1,WB3D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and review of the facility's form titled, Control Drug Record, the facility failed to accurately reconcile a medication count with the off going shift for one of four medication carts that was reviewed for correct narcotic count/medication reconciliation. Findings include: On [DATE] at 10:04 a.m. observations were conducted for four of the eight medication carts to check for expired, unlabeled or undated medications. A narcotic count/dose check and review of the medication reconciliation form was also conducted on the four (4) medication carts: on Unit N1 (low side), Unit S2 (low side), Unit N2 (high side) and Unit S2 (high side). During the medication cart check on Unit S2 (low side) on [DATE] at 2:00 p.m. with LPN FF, a narcotic count/dose check was conducted. The narcotic medications were double locked. The medication cart was organized and clean. A review of the facility form titled, Controlled Drug Shift Audit Report revealed that the most recent narcotic reconciliation was documented as conducted on [DATE] from 6:45 a.m. to 7:15 a.m. with two nurse signatures documented; LPN OO, the off going shift nurse and LPN GG, the oncoming shift nurse. This form had documentation on the bottom that indicated that if any error cannot be reconciled, an incident report MUST be completed before reporting off shift and signed by both nurses. Review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] During the narcotic count and observation with LPN FF of the 15-medication dose packet ordered by the Physician on [DATE], this revealed two (2) [MEDICATION NAME] 150 mg capsules left in the bubble pack. The facility form titled, Control Drug Record for [MEDICATION NAME] 150 mg capsule documented on [DATE] at 7a.m. that one (1) capsule was left in the packet, signed by LPN OO, indicating a discrepancy. During the narcotic count and observation with LPN FF of a another 15-medication packet ordered by the Physician on [DATE], this revealed 14 [MEDICATION NAME] 150 capsules left in the bubble pack. This second facility form titled, Control Drug Record for [MEDICATION NAME] 150 mg revealed 15 capsules present (none signed out). At this time, LPN FF confirmed that the LPN OO had made a mistake, and confirmed the reconciliation done that morning was incorrect, stating that both Control Drug Records were signed out wrong. An interview was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on [DATE] at 8:35 a.m. the DON revealed that he was not aware of any reported medication discrepancy. The DON confirmed that any medication that is not reconciled is to be reported by the nurse to him. The DON stated that the process for a medication error is that he will investigate, a medication error form is completed, and the pharmacy and/or Physician is contacted. The DON stated that for a transcription/documentation error after investigating it, they will have re-education of the staff. The medication reconciliation procedure/policy was requested but was not provided.",2020-09-01
231,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2020-02-27,761,E,0,1,WB3D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of the facility policy's titled, Pharmacy Services- Medication Storage in the Care Center and the facility policy titled, Pharmacy Services- Medication Administration-General, the facility failed to maintain temperature logs for 4 of 4 medication refrigerators, and failed to ensure food was not stored with medications in 2 of 4 medication refrigerators. In addition, the facility failed to ensure food was not stored in 1 of 8 medication carts and failed to ensure multi-dose medications were labeled with an open date to assist in determining a discard date in 4 of 8 medication carts. Findings include: A review of the facility policy titled, Pharmacy Services- Medication Storage in the Care Center, updated 10/2019, documented that medications and biologicals are stored safely, and properly following manufacturer's recommendation or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. At section No. 16, policy documented that refrigerated medications are kept in closed and labeled containers with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications. Other foods are not stored in this refrigerator. A review of the facility policy titled, Pharmacy Services- Medication Administration-General, documented that the intent is that medications are administered as prescribed, in accordance with good nursing principles. At section No. 5, policy documented that medications dispensed for multi-use, e.g. blister/punch cards, large volume liquids, multidose vials, shall be labeled by the nurse as to the date of first use or first administration. Check expiration date of the medication. Under no circumstances should an expired medication be administered to a patient. Observations and medication storage checks were conducted with nursing staff for four of four medication storage rooms and in four of eight rolling medication carts as follows: Medication Rooms An observation was conducted on 2/26/2020 at 10:22 a.m. with Licensed Practical Nurse (LPN) GG of the Unit S2 medication room where a small package of cheese was found in the medication refrigerator, in the freezer section. The freezer had a large amount of frost. The LPN confirmed she had never noticed it before and stated she did not know who it belonged to. LPN GG stated that the Maintenance Department was responsible for defrosting the refrigerator. A review was conducted of the requested forms titled, Refrigerator Temperature Log for (MONTH) 2020 and (MONTH) 2020. The review revealed that two temperature logs provided by the LPN for the month of 1/2020 documented discrepancies in temperature documentation (varying temperatures) for the dates from 1/1/2020 through 1/15/2020, and discrepancies in the nurse staff initials (varying initials) documenting the temperatures for those days. Review of the (MONTH) 2020 Refrigerator Temperature Log revealed a missing temperature recording for the 2/25/2020 morning shift and the 2/26/2020 morning shift. An observation was conducted on 2/26/2020 at 10:50 a.m. with LPN KK of the Unit S1 medication room where a review was conducted of the provided Refrigerator Temperature Logs for (MONTH) 2020 and (MONTH) 2020 which revealed missing temperature recordings as follows: no recordings were found for the period 1/1/2020 to 1/6/2020; duplicate documentation was found for 1/13/2020, with a temperature discrepancy; for 1/14/2020 no evening shift recording; for 1/18/2020 no morning or evening recording found; for period 1/23/2020 to 1/31/2020 no temperature is documented for the morning shift. For review of the month of (MONTH) 2020, no morning shift temperature recordings are documented for dates from 2/1/2020 to 2/3/2020, for 2/15/2020, 2/16/2020 and 2/26/2020. No temperatures were documented for the evening shift for the dates of 2/4/2020, 2/5/2020, 2/7/2020, 2/11/2020, and 2/23/2020. An observation was conducted on 2/26/2020 at 11:07 a.m. of the Unit N1 medication room with Registered Nurse (RN) NN. A review was conducted of the provided temperature logs for (MONTH) 2020 and (MONTH) 2020 that revealed missing temperature recordings on the Refrigerator Temperature Log. Missing temperature recordings were as follows: no temperature recording for the morning shift for 1/13/20 and 1/27/20; no temperature recording for the evening shift for 1/16/2020, 1/17/2020, 1/26/2020, and 1/29/2020. An observation was conducted on 2/26/2020 at 11:17 a.m. of the Unit N2 medication room with LPN HH. Observation of the medication refrigerator revealed no expired or unlabeled medications or biologicals/vaccines, however, in the freezer compartment a frozen 16.9 ounce of Aloe [NAME] Juice with Honey was found lying in a large amount of frost. In the medication room, on a storage shelf containing IV supplies, two BD Vacutainers used for specimen blood tests was found; one 8.0 ml BD Vacutainer had an expiration date of 11/30/2019. LPN HH confirmed she did not know who the juice belonged to; she then asked another nurse to put it in the pantry refrigerator. LPN HH stated she did not know who was responsible for defrosting the refrigerator. LPN HH stated that they rarely draw blood and didn't know where the specimen tubes came from. A review was conducted of the provided Unit N2 Refrigerator Temperature Log for 2/2020 that revealed missing temperature recordings on the log for the morning shifts for 2/25/2020 and 2/26/2020. The LPN confirmed she could not locate the log for 1/2020. A brief interview as conducted on 2/26/2020 at 11:28 a.m. with LPN FF from Unit S1 where she explained that a new Refrigerator Temperature Log was initiated two months ago that now reflects temperature recordings twice daily, for each twelve-hour shift. She confirmed prior to that they were only recording temperatures once daily. Review of the Refrigerator Temperature Log that was revised 1/13/2020, documented that refrigerator temperature must be between 36 degrees Fahrenheit (F) - 46 degrees F. Documentation areas for recordings were as follows: date, time AM temp, initials, time PM temp, initials and comments. General guidelines located at the bottom of the form instruct that associates will monitor temperature of the medication refrigerator at least twice per day to keep temperature between 36 degrees F-46 degrees F. No food items will be stored in medication refrigerators. Refrigerators and freezers will be kept clean and neat, free from spills. Medications will be dated when opened. Expired medications will be removed from the refrigerator for destruction per policy. Medication Carts An observation with a medication check was conducted on 2/26/2020 at 1:50 p.m. of the Unit N1 (low side) medication cart with LPN II that revealed an opened stock multi-dose medication as follows: 1. [MEDICATION NAME] Powder (for constipation)- the 17.9 ounce/30 dose multi-use container was not dated when opened for use and did not name a resident; the container had 2/3 of the contents remaining. A faded room number (109) was on the container written with a Sharpie type pen. LPN II was unable to determine if the medication belonged to a resident currently in that room. An observation with a medication check was conducted on 2/26/2020 at 2:00 p.m. of the Unit S2 (low side) medication cart with LPN FF that revealed opened stock multi-dose medications as follows: 1. Certa-Vite (vitamin with minerals)- the 300 tablet multi-dose container was not dated when opened for use; the container had 9 tablets remaining. 2. [MEDICATION NAME] (mild pain reliever) 500 mg tablets- the 100 tablet multi-dose container was not dated when opened for use; the container had 1/8 of the contents remaining. 3. Senna (for constipation) 8.6 mg tablets- the 100 tablet multi-dose container was not dated when opened for use; the container had 1/2 of the contents remaining. 4. Antacid (no trade name) 500 mg tablets- the 150 tablet multi-dose container was not dated when opened for use; the container had 1/2 of the contents remaining. An observation with a medication check was conducted on 2/26/2020 at 2:20 p.m. of the Unit S2 (high side) medication cart with LPN GG that revealed opened medications as follows: 1. [MEDICATION NAME] (mild pain reliver) 325 mg tablets- the 100-tablet container was not dated when opened for use; the container had 1/2 of contents remaining. 2. [MEDICATION NAME] (for chest pain) 0.4 mg sub lingual tablets- two open containers (of 25 tablets each) had a resident label for Resident (R) #73- both opened containers had a small orange label attached documenting to discard after 180 days once opened; however, no open date was recorded, unable to determine the use by date. 3. Nicotine [MEDICATION NAME] (to reduce nicotine cravings) 4mg [MEDICATION NAME]- the 27 [MEDICATION NAME] container was not dated when opened for use and did not have a resident's name label attached- 5 [MEDICATION NAME] remained in the box. The LPN was unable to determine which resident was taking this medication. An observation with a medication check was conducted on 2/26/2020 at 3:00 p.m. of the Unit N2 (high side) medication cart was conducted with LPN HH that revealed an opened multi-dose stock medication and a food product as follows: 1. [MEDICATION NAME] (treatment of [REDACTED]. 2. A pre-packaged bowl of Raisin Brand breakfast cereal was found- the food container was not labeled for resident use; was removed and taken to the food pantry by the LPN who confirmed she had kept it there in case any of her residents got hungry. During an interview on 2/27/2020 at 8:35 a.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON), the DON revealed they had their Nurse Consultant assist them in revising their Refrigerator Temperature Log for temperatures to be checked twice daily to maintain required temperature for medications, vaccines and biologicals. The DON stated they had a new policy initiated. The DON confirmed that they have a protocol for medication room refrigerators, that night shift nurses are responsible for defrosting the medication freezers as needed. The DON confirmed that nurses were responsible for maintaining their medication carts.",2020-09-01
232,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2020-02-27,812,E,0,1,WB3D11,"Based on observation, staff interview, and review of the facility policy titled, Ice Machines Policy & Procedure the facility failed to maintain the cleanliness and sanitation of the ice machine in the resident pantry. This had the potential to effect 123 residents receiving an oral diet. Findings include: Review of the facility policy titled Ice Machine Policy & Procedure revealed Policy: The following procedure will be followed check water filter, check air filter, clean coils, sanitize interior, and clean interior. Observation on 2/24/2020 at 11:20 a.m. of the ice machine of the south two pantry revealed yellow and brown stain on the outside door. Inside of the ice machine had a same yellow and brown debris. The metal joints (hinges that holds the door on) were brown in color. The side of the ice machine had grayish color debris going down the side. Inside the ice machine noted the metal joints brown in color was running into the ice. Inside the ice machine the upper inner splash panel has small specks of black debris Observation and interview on 2/26/2020 at 10:30 a.m. with the Maintenance Supervisor (MS) revealed a leaky brown rusty substance dripping into the ice machine. Interview at the time of the observation with the MS revealed that his expectations are for the ice machine to be cleaned thoroughly and free from grime and debris. He states it's his responsibility to check the ice machine on a monthly basis and that the ice filter is to be changed every ten years. He reported he didn't feel the residents could get sick from the leaky substance. Interview on 2/26/2020 at 1:44 p.m., the Maintenance Director (MD) revealed that it's his expectation is for the ice machine to be put on a preventative maintenance work log that is reviewed and checked off every six months. The MD described the filmy and flaky substances as a product of corrosion which resulted from water residue and calcium deposit built up, The MD further stated that he has since contacted the equipment service company to come out and clean/replace the water filter for the ice machine. Interview and observation on 2/26/2020 at 2:45 p.m. with the MD regarding the schedule of cleaning the ice machine. The MD revealed the ice machines are cleaned every six months by a reputable company. The ice is dumped the machine is taken apart cleaned with a food grade sanitizer and the filter is changed. After the ice is made after cleaning, the ice is dumped again. Every four months the ice machine is cleaned with a nickel bath. The ice is dumped, the ice machine is placed on a cleaning cycle and the inside box is sanitized. After the machine makes ice, it is dumped again before use. The MD revealed he is aware of the yellow stain on the outside of the ice maker but has not been able to remove the stain. Interview and observation on 2/27/19 at 1:00 p.m. with the Administrator regarding the ice machine in the pantry. The Administrator revealed she was not aware of the condition of the ice machine. The Administrator stated that her expectation is for all ice machines to be cleaned under scheduled equipment, including the internal components of ice machines that are not drained, cleaned, and sanitized as needed and according to manufacturer's specifications.",2020-09-01
233,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2018-08-16,561,D,0,1,YI7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, facility policy and procedure review, the facility failed to provide one resident (R) R#110 with showers when it was the resident's stated bathing preference. The sample size was 56. The findings include: Review of the medical record for R#110 revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 13 which indicated intact cognition. R#110 was assessed as requiring one-person physical assist with part of bathing activity. The interview for daily preferences revealed it was very important tothe resident to be able to choose between a bath or a shower. During an interview with R#110 on 8/13/18 at 10:50 a.m., in his room, he stated My only complaint is I haven't had a shower since I have been on this floor. I've only had sponge baths. I have asked for a shower, but I never get one. I asked the evening staff and they tell me I'm on the night schedule, and I ask the night staff and they tell me I'm on the day schedule. They are very short handed around here. Review of the baseline care plan dated 7/5/18 revealed R#110 was listed as requiring total dependence for bathing with an assist of one. Review of the comprehensive care plan dated 7/25/18 revealed a problem identified with resident needing assistance with activities of daily living. An intervention was listed for the staff to assist with shower/bath per schedule. Review of the facility's shower lists for all shifts on the North Two Unit revealed R#110 was not included on any of the lists. Review of the Comprehensive Certified Nursing Assistant (CNA) Skin Monitoring Sheets that were located in the Shower Team Book for North Two Unit for 8/1/18 - 8/14/18 revealed there was no documented evidence that R#110 had received any bath or shower for the period in review. Review of the yellow binder titled North Two Shower Book revealed no documentation of a bath or shower for R#110 from 8/1/18 through 8/14/18. Interview with Registered Nurse (RN) AA on 8/14/18 at 3:30 p.m. at the nurses' desk revealed We ask the resident for their preference of a bath or shower and the times of day on admission or transfer. If the resident can't speak, we will try to determine what is best for him. The Treatment Nurse or the Unit Manager will assign the resident to a shower day. The CNAs have a Kardex for care for each resident, but we don't put bath information on there because it changes. This resident just came from another unit on 8/3/18. After reviewing the shower books for both the shower teams and the floor CNAs, RN AA confirmed there was no evidence of showers or baths for R#110 since arrival on the North Two Unit. Interview with CNA BB on 8/14/18 at 3:35 p.m. revealed the shower team works Monday - Friday from 5:00 a.m. 1:00 p.m. The shower team completes assigned showers and then the floor CNAs perform showers assigned on the other shifts. CNA BB stated, I just added this resident to our schedule for Monday, Wednesday, Friday. An interview with the Director of Nursing (DON) was conducted on 8/15/18 at 11:45 a.m., at the South Two Unit nurses' station and the DON stated We don't have a written policy or procedure for getting bath or shower preferences for residents. We use the residents right to choose but it is done orally, and the preferences are then put on the shower schedule. A second interview was conducted with the DON on 8/15/18 at 3:20 p.m., in the conference room. The DON revealed he knew R#110 had a shower on Saturday 8/11/18 because it was on the CNA computer documentation. After reviewing the computer documentation, he referenced, the DON was unable to see anything, but bed baths documented. The DON stated, I saw a shower sheet in the book today that the CNA gave him a shower. When asked if he was aware that the resident stated he hadn't had a shower since admission to the unit, the DON stated, So he says, he also says his wheelchair doesn't roll but he just isn't pushing it. Review of the shower sheet that the DON produced revealed a date of 8/11/18 with R#110's first name and room number. Shower was circled and signed by CNA CC. An interview was conducted with CNA CC on 8/15/18 at 3:30 p.m., in the conference room. CNA CC stated Resident names are in the book for their shower shift. We have to ask the resident twice if they want their shower. If they refuse, then we can offer a bed bath. If they refuse the bed bath, then we report it to the nurse. They started a new shower team the end of (MONTH) or the first of (MONTH) and that has helped so much. We don't give showers on Sundays, but residents are scheduled Monday, Wednesday, Friday, or Tuesday, Thursday, Saturday. They are supposed to get a bed bath on the non-shower days so they get washed daily. I worked Saturday and the resident asked me for a shower. He said he hadn't had a shower since he came to our unit. I went to check, and he wasn't on the shower schedule, so I told the nurse. The nurse said he would put him on the schedule, but I should give him a shower since he hadn't had one. I didn't actually take him to the shower room, but I used the bedside thing with the bag. We keep it in the shower room. Observation of the North Two shower room with CNA CC was conducted during the interview. The shower room contained a device labeled EZ Shower that was a bag with an attached hose and nozzle hanging on a rolling metal pole. CNA CC stated You fill the bag with warm water and then you rinse the resident off while they are in bed. I have to change the sheets on shower day anyway, so I don't mind if everything gets wet. The facility was asked to provide a policy and procedure for the use of the EZ Shower in the facility. The only document provided was the manufacturer's instructions for setting up the device. Review of the facility provided policy titled Bathing (Shower/Tub) reviewed and updated (MONTH) 2014 revealed the following: Intent It is the intent of Magnolia Manor facilities to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin through the provision of a shower or tub bath. Procedural Guidelines General guidelines for providing a Shower/Tub Bath can be found in the Lippincott Manual of Nursing Practice and AHCA's How to be a Nurse Assistant. Procedure 16-3. SHOWER 1. Help the resident to the shower room with all necessary supplies. 2. Help the resident sit on the chair, using safety straps if needed and available. 3. Turn on the shower with warm water. Test the water on the inside of your wrist and have the resident feel it with their hand or foot. Adjust the temperature as needed. 4. Help the resident remove their clothing. 5. Help the resident into the shower. Encourage them to use the safety rails. There were no instructions included on when or how to use the EZ Shower.",2020-09-01
234,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2018-08-16,677,D,0,1,YI7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and observations, the facility failed to ensure two of a of 56 sampled residents (R) R#37 and R#124, who were dependent upon staff for care, received sufficient assistance from staff to complete all of their Activities of Daily Living (ADLs). Specifically, R#37 was not receiving scheduled showers or routine nail care, and her glasses were observed to be dirty throughout the survey period, and R#124 was not receiving scheduled showers or routine nail care. Findings include: 1. R#37 was admitted to the facility on [DATE] with diagnoses, according to the Face Sheet, undated, including type II diabetes, history of stroke with [MEDICAL CONDITION] and obesity. Review of the resident's Minimum Data Set (MDS), a quarterly assessment of overall health status, dated 6/11/18, indicated R#37 was cognitively intact (BIMS score of 15/15), required glasses to see clearly, required the assistance of two staff members to complete all of her Activities of Daily Living (ADLs), including bathing and grooming, and had limited range of motion to her upper and lower extremities. The resident was not coded as being resistive to care. Review of the resident's Vision Care Plan, dated 6/13/18 read, in pertinent part, (R#37) at risk for decline in vision. Has [DIAGNOSES REDACTED]. Approaches included, Staff to ensure that resident's glasses are clean and within reach of resident. Review of the ADL Care Plan, dated 6/13/18 read, in pertinent part, (R#37) has an ADL deficit related to left side [MEDICAL CONDITION] from [MEDICAL CONDITION](stroke). Goals included, (R#37) will be clean, dry, and appropriately dressed through next review period. The Facility Shower Schedule was reviewed and indicated all facility residents were to receive showers at least three times per week. Residents were scheduled for bathing based on their room number. R#37 was scheduled to receive showers on Tuesday, Thursday, and Saturday. Review of R#37's Bath Day Roster, dated 7/1/18 through 8/15/18 revealed that, although R#37 was to receive showers at least three times weekly per the facility shower schedule, she was only documented as receiving showers on 7/3/18, 7/10/18, 7/19/18, 7/21/18, 7/26/18, 7/28/18, 8/7/18, and 8/12/18. During this time frame, the resident received only eight of her 20 scheduled showers. Bed baths were documented as being given on all other scheduled shower days during the referenced period. The facility was unable to provide documentation that the resident received nail care during this timeframe. On 8/13/18 at 2:48 p.m., R#37 was observed lying in bed in her room. Her glasses were observed to be very dirty with smudging on the lenses and brown debris caked to the rims; and her hair had pieces of food debris throughout it. In addition, the resident's finger nails were long and had brown debris under the nail beds. R#37 stated, I'm scheduled for a bath three times per week, but they just don't do it. They don't have enough staff. My glasses are as dirty as I am. They don't clean them. R#37 was observed, lying in bed, on 8/15/18 at 9:37 a.m. She was wearing her glasses and they were observed to be in the same condition as the day before, with smudging on the lenses and brown debris on the rims. The resident's fingernails were still dirty. During this observation R#37 stated, Oh my fingers are dirty. They don't trim my fingernails. I'm a diabetic, so the nurses are supposed to trim them. They don't. R#37 indicated her glasses had not been cleaned since the day before. R#37 was observed, laying in her bed, on 8/16/18 at 9:11 a.m. The resident's glasses remained dirty and her nails remained long and unclean. R#37 stated, It makes it hard to see through them when my glasses are dirty. Today's my shower day. It depends on who's here. If there are not enough people (here today) I'll have a bed bath. I have psoriasis and I need an actual shower. I'm scheduled for a shower three times a week and they tell me we don't have enough people, so I get a bed bath instead. I've got a big beef about that, and I've told them this. R#37 indicated she had reported her concerns to UM MM but was unable to recall the date or time of the reports. During an interview with Certified Nursing Assistant (CNA) KK on 8/15/18 at 10:00 a.m. in the unit nurse's station, she confirmed she worked on the unit with R#37 on a full-time basis, and stated, Residents are given showers based on their room numbers. They should get them three times per week. Some residents get bed baths .maybe because there isn't enough staff to do showers. During an interview with CNA LL on 8/15/18 at 10:31 a.m. at the unit nurses' station, she confirmed she worked full time on the unit with R#37 and stated, We try to get to most of the showers. Showers get done when we have enough staff. We often don't have enough staff and so we give (residents) a bed bath. (R#37) is not getting her showers because there is not enough staff. (Even though) she wants a shower, she gets a bed bath a lot. Nursing is supposed to do her finger nails. They say they do them, but they are long and dirty. Quite a few people have nails that are long dirty. (R#37) lets us clean her glasses. She likes to be clean. She says that. She complains to me that she wants showers and not bed baths, and that she is getting bed baths. She just complained (about that) last week. During an interview with Registered Nurse (RN) JJ on 8/15/18 at 5:07 p.m. at the unit nurse's station, she confirmed she worked full time on the unit with R#37 and stated, We don't do finger nails here. I don't clip them. The Podiatrist has to clip both toes and fingers. Activities will paint them sometimes. I have seen the wound nurses clip nails a couple of times. I won't touch a diabetic's nails. I'm too scared of that. On 8/16/18 at 10:33 a.m., Unit Manager (UM) MM observed R#37 with the surveyor in the resident's room. UM MM agreed R#37's glasses were very dirty, and her fingernails were long and dirty, and stated, I know she can't see through these (glasses). I have to clean my own glasses every morning. UM MM cleaned R#37's glasses in the sink. UM MM indicated it was her expectation that Activities of Daily Living (ADL) care, including the cleaning of glasses and care of fingernails was to be done routinely by staff. Interview with the Administrator on 8/16/18 at 2:00 p.m. revealed the facility did not have any specific policies related to bathing and grooming. The Administrator stated it was her expectation that all ADL care was to be provided routinely per facility schedule and/or according to each individual residents' preference. 2. R#24 was admitted to the facility on [DATE] with diagnoses, according to the Face Sheet, undated, including type II diabetes and severe dementia. Review of the resident's Minimum Data Set (MDS), a quarterly assessment of overall health status, dated 7/25/18, indicated R#24 was severely cognitively impaired and was totally dependent upon two or more staff members to complete all of her ADLs, including bathing ad grooming. The resident was not coded as resisting cares. Review of the resident's ADL Care Plan, dated 7/25/18 read, in pertinent part, (R#24) has a functional deficit related to advanced dementia. Goals included, (R#24) will be clean, dry, odor free, and appropriately dressed and groomed Q (every) day x 90 days. Review of R#24's Bath Day Roster, dated 7/1/18 through 8/15/18 revealed that, although R#24 was to receive showers at least three times weekly per the facility shower schedule, she was not documented as receiving any showers. Bed baths were documented as being given on all scheduled shower days during the referenced period. The facility was unable to provide documentation of the resident receiving nail care. R#24 was observed, laying in her bed on 8/13/18 at 11:46 a.m. Her finger nails were observed to be very long and dirty, with brown debris under the nail beds. R#24 was observed, laying in her bed on 8/15/18 at 9:36 a.m. Her nails remained long with brown debris observed in her nail beds. R#24 was observed, again laying in her bed on 8/16/18 at 9:57 a.m. Her nails remained long and were observed to be dirty. During an interview with CNA LL on 8/15/18 at 10:31 a.m., she stated, We have a bath bed (boat) on the unit, and showers can be done in there. For (R#24) .she can have a shower in the bath boat. She has a tube (gastrostomy tube in her stomach for feeding), but the nurses can unhook it. She is supposed to be getting a shower, not a bed bath. We just don't have enough staff to give her a shower, so she gets a bed bath, instead. During an interview with UM MM on 8/15/18 at 5:08 p.m., she confirmed showers were expected to be given per schedule (three times per week) and stated, nail care for residents with diabetes was expected to be done by nursing staff. She stated no records of nail care were kept by the facility.",2020-09-01
235,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2018-08-16,761,D,0,1,YI7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, record review, observations, and interviews, the facility failed to ensure all medication was stored appropriately to ensure optimal effectiveness. Specifically, one insulin pen on one of four medication carts reviewed for appropriate medication storage was observed to be expired. The insulin was in use for one Resident (R) R#106 15 days after the indicated expiration date of the medication. Findings include: Review of the facility document titled Insulin Administration Policy, dated ,[DATE], read, in pertinent part, Date ALL insulin bottles with date of first puncture. Depending on manufacturer's recommendations, insulin MUST be replaced 28 to 42 days after first use. During an inspection of the facility's medication carts on [DATE] at 9:04 a.m., the medication cart on the 200 North Low-End Unit was inspected. A [MEDICATION NAME] R Insulin Pen was observed to have an open date of [DATE], and an expired date of [DATE] indicated on a sticker on the side of the pen. The [MEDICATION NAME] R Insulin Pen was assigned to R#106. Licensed Practical Nurse (LPN)II was interviewed during the observation and stated the insulin pen was currently in use for R#106 as sliding scale insulin. She confirmed the insulin pen was out of date and should not have been in use for the resident since the indicated expiration date of [DATE]. She also stated she would order a new pen. LPNII further stated medication carts were supposed to be audited every Wednesday to ensure no expired medication was on the carts. She stated she did not know how R#106's insulin pen had been missed. Record review revealed R#106 was admitted with [DIAGNOSES REDACTED]. Review of the resident's monthly physician's orders [REDACTED]. Review of the facility's Finger Stick Blood Glucose Log, dated ,[DATE], revealed R#106 received the insulin per sliding scale 31 times between [DATE] and the morning of [DATE]. During an interview with the Director of Nursing (DON) on [DATE] at 11:56 a.m. in the DON office, he stated, Insulin should be dated when opened and discarded on or before the expired date. He indicated the facility's Nurse Consultant had identified that some insulin pens were out of date on the medication carts in (MONTH) of (YEAR), and education had been done on how to properly date and time pens when opened and how to discard when expired. He stated [MEDICATION NAME] R expired 28 days after being opened.",2020-09-01
236,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2018-08-16,814,D,0,1,YI7C11,"Based on observations, interviews and review of the contract, the facility failed to properly dispose of refuse/oil waste. This practice created the potential for harboring pests, insects and organisms. Findings include: 1. The initial kitchen tour was conducted on 8/13/18 from 8:30 a.m. through 9:15 a.m., Dietary Supervisor (DD) accompanied the surveyor. The outdoor grease trap located just outside and to the left, behind the outside door, from the back hallway by the kitchen. Observed black balls of grease over the area with the grease trap covered greater than 80% with dark brown to black greasy coating. Further observation revealed the cement tray the grease trap was sitting on had pooled black greasy substance with black balls of grease in the tray. Strong stench noted immediately walking outside. Supervisor DD stated it is emptied monthly and is maintained by the Maintenance Department. 2. The second observation of the grease trap and surrounding area was made on 8/16/18 at 8:45 a.m. The area remained in the same condition it had been on 8/13/18. The strong stench remained with 80% of the grease trap covered with dark brown to black greasy coating and black balls of grease remained. 3. The Maintenance Director (EE) was interviewed on 8/13/18 at 4:00 p.m. at the grease trap area and stated he has called and left a message with the disposal company that empties the grease. He is waiting for a call back. 4.Maintenace Director EE was interviewed on 8/14/18 at 10:00 a.m. in the hallway by the kitchen, stated cleaning and maintaining the grease trap is not on maintenance schedule. EE stated the kitchen dumps the used grease into the trap and they are not careful. EE also stated he has a guy that works part time and he will have him pressure wash it when he works. He further stated states the disposal company will come the first of the week and evaluate the grease trap, empty it, clean it up and replace the trap. EE presented to the surveyor the plan for the meeting with disposal company. 5. The Maintenance Director was interviewed in the kitchen, on 8/15/18 at 10:15 a.m. and presented to the surveyor a plan of cleaning kitchen. 6. Cook (FF) was interviewed in the kitchen, on 8/16/18 at 2:40 p.m. states she has nothing to do with emptying the fryers, the dietary aide does that. 7. Dietary Aide (GG) was interviewed 8/16/18 at 2:45 p.m. at the grease trap area. Dietary Aide GG stated he empties the fryers and puts the grease in the grease trap on Tuesday and Thursday. Wednesday is fried chicken day and Friday is fish day. They always use fresh oil when these items are cooked. When he puts oil in, if it is full, he lets the supervisor know. It is empty when he puts oil in it the next time. Dietary Adie GG also stated it has always looked like that. He doesn't remember it ever being cleaned. It is not on the kitchens cleaning schedule. Dietary GG added he thought that maintenance staff maintained the grease trap. 8. Dietary General Manager (HH) was interviewed on 8/16/18 at 2:50 p.m. in the hallway by the kitchen, states maintenance was monitoring and maintaining the grease trap. It is not on the kitchen's cleaning schedule. There is not a kitchen policy for the grease trap. The dietician has no input to the working of the kitchen, equipment or maintenance. The dieticians' role is working with Dietary General Manager for the diets. States the Administrator is aware of the dirty grease trap. 9. Administrator was interviewed in the administrative office, 8/16/18 at 3:15 p.m. states she is aware of the dirty grease trap. States prior to the survey there was a discussion about moving the grease trap. She had spoken to the Dietary General Manager and the Maintenance Director. 10. The agreement with the disposal company, Used Cooking Oil Removal Service was dated 1/16/14. In section 2. Read Customer shall immediately communicate with DPS in the event of any problems with service or Equipment. Customer shall provide a suitable site at each Service Location for the Equipment and shall be responsible for placing all of its Rendering Material inside the Equipment. Customer shall be responsible for any Rendering Material not placed inside the Equipment. The facility failed to dispose of refuse/oil waste properly creating the potential for harboring pests, insects and organisms.",2020-09-01
237,MAGNOLIA MANOR OF COLUMBUS NURSING CENTER - EAST,115124,2010 WARM SPRINGS RD,COLUMBUS,GA,31904,2018-08-16,880,D,0,1,YI7C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, clinical record review, observations, and staff and resident interviews, the facility failed to ensure proper infection control measures were followed for two residents (R) R#20 and R#59 of 56 total sampled residents. Specifically, R#20 received antibiotic treatment for [REDACTED]. And a blood glucose monitor was not properly sanitized prior to use for R#59. Findings include: Review of the facility's Antibiotic Mission Statement, dated 10/17 read, in pertinent part, Our center embraces the importance of an infection prevention and control program that includes an antimicrobial stewardship program, providing antibiotic use protocols and monitoring to prevent antibiotic resistance. We are committed to the prudent use of antibiotics on behalf of all patients we serve through a sustainable antimicrobial stewardship program. The McGee's Criteria dated 10/12 and utilized by the facility as the guide for antibiotic use for UTIs read, in pertinent part, For urinary tract infections without a catheter the new definitions differ substantially from the original guidelines. The definitions take into account the low probability of UTI in residents without catheters if symptoms are not present as well as they now take into account the need for a urine culture for microbiologic confirmation; and Criteria 1: At least one of the following signs or symptoms: Acute costovertebral angle pain or tenderness, suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency. In the absence of fever or leukocytosis, then two or more of the following sub-criteria: suprapubic pain, gross hematuria, new or marked increase in incontinence, new or marked increase in urgency, new or marked increase in frequency; and Criteria 2: At least 105 cfu(colony forming unit)/ml (milliliter) of no more than two species of microorganisms in a voided urine sample, or at least 102 cfu/ml of any number of organisms in a specimen collected by in-and-out-catheter. Record review revealed R#20 was admitted to the facility on [DATE] with diagnoses, according to the Face Sheet, dated 8/16/18, including [MEDICAL CONDITION], [DIAGNOSES REDACTED], and dementia. The resident was receiving hospice care related to her [DIAGNOSES REDACTED] diagnosis. Review of teh resident's Minimum Data Set (MDS), an admission assessment of overall health status dated 5/26/18, indicated the resident was moderately cognitively impaired, required extensive assistance to complete all Activities of Daily Living (ADLs); had received antibiotics one day during the assessment reference period of seven days prior to the assessment; and did not have a catheter inserted in her bladder. Review of the resident's Acute Urinary Tract Infection Care Plan, most recently dated 6/10/18 revealed the resident had experienced repeated UTIs (urinary tract infections) while in the facility. The care plan interventions included medications as ordered. A review of the physician's orders [REDACTED]. - Physician's Telephone Order, dated 6/10/18 indicated an order for [REDACTED]. - Physician's Telephone Order dated 6/22/18, indicated an order for [REDACTED]. - Physician's Telephone Order, dated 6/27/18, indicated an order for [REDACTED]. A review of resident's clinical record revealed a Hospice Orders, dated 8/4/18, indicated an order for [REDACTED]. Medication Administration Records, dated 6/2018, 7/2018, and 8/2018 were reviewed and revealed the above antibiotics were administered to the resident as ordered. R#20's laboratory reports were reviewed and revealed one urinalysis (UA) was completed on 6/11/18. The results of the UA were negative. No culture and sensitivity related to this report was found in the resident's record. A second urinalysis was completed for the resident on 6/22/18. The results of this test were positive, and the culture and sensitivity indicated [DIAGNOSES REDACTED] (a bacterium commonly found in urinary tract infections). During an interview with Unit Manager (UM) MM on 8/13/18 at 3:44 p.m., she stated, Hospice has been putting her (R#20) on lots of antibiotics. They don't do any tests or anything. They just put her on the antibiotics. UM MM indicated that even when a urinalysis was done, the hospice nurse did not wait for results before starting R#20 on antibiotic therapy. During an interview with Hospice Registered Nurse (RN) OO on 08/15/18 at 11:30 a.m. at the nurse's station, she stated she had been treating R#20 for UTIs since her admission. She stated the resident was given a broad-spectrum antibiotic, and it was started before a urinalysis or culture and sensitivity results came back based on the resident's symptoms. RN OO also stated she was aware the urinalysis done on 6/10/18 had been negative, but since the antibiotic treatment had been started before the urinalysis came back, the course of medication was completed as ordered. RN OO further stated that the above ordered antibiotics had been prescribed for R#20 based on complaints of burning with urination along with some confusion, stating, We use those symptoms to diagnose a UTI and we order an antibiotic based on that. RN OO stated she had not received training for, and was not familiar with the concept of, Antibiotic stewardship, or the criteria to be used for antibiotic prescribing. During an interview with UM MM on 8/15/18 at 11:40 a.m. at the nurse's station, she acknowledged she reviewed all medication orders daily, but stated she did not recall receiving training related to antibiotic stewardship and was not familiar with the criteria for ordering antibiotics. UM MM also stated, In the past we did hold off on ordering antibiotics until a urinalysis and culture and sensitivity came back positive, but we haven't been doing that lately. I don't know why. UM MM added, Hospice orders antibiotics for everything. During an interview with the Director of Nursing (DON) on 8/16/18 at 11:34 a.m. in the DON office, he stated, We use McGeers Criteria here. It's probably been five or six months since we did any in-servicing. Hospice should be following our diagnostic criteria (McGeers). Moving forward I will give them copies of in-services (related to antibiotic stewardship). They should have learned about antibiotic stewardship on their own, or the floor nurses could have educated them on antibiotic stewardship. The orders for (the antibiotics prescribed for R#20) would be in direct contradiction to our protocols on antibiotic stewardship. The DON stated that he reviewed all orders each morning in the facility stand-up meeting. He acknowledged he reviewed the orders for R#20's antibiotics but missed the fact that no urinalysis or culture and sensitivity had been completed prior to the antibiotic administration. The facility provided documentation of in-service training on antibiotic stewardship, including use of the McGeers' Criteria for antibiotic usage and dated 12/13/17. The review revealed the UM MM was signed off as having attended the training on that date. The facility was unable to provide any documentation to show that the hospice nurses had been trained on antibiotic stewardship or the use of any type of antibiotic prescribing criteria. 2. Blood Sugar Monitors Review of the facility's document titled Cleaning and Disinfecting Glucometers Procedure, dated 3/15 read, in pertinent part, Cleaning: 1. Wear appropriate protective gear such as disposable gloves; 2. Open the cap of Clorox Germicidal Wipes container, pull out towelette and close the cap; 3. Wipe the entire surface of the jmet3er 3 times horizontally and 3 times vertically using one towelette to clean blood and other body fluids; 4. Dispose of used towelette in trash can; and Disinfection: (The meter should be cleaned prior to disinfection). 5. Pull out one new toilette and wipe the entire surface of the meter 3 times horizontally and 3 times vertically to remove blood-borne pathogens; 6. Dispose of the used towelette in the trash; 7. Allow exteriors to remain wet for 1 minute, then wipe the meter using a dry cloth; 8. After disinfection, the user's gloves should be removed and thrown away. Wash hands before proceeding to the next patient. Record review revealed R#59 was admitted to the facility on [DATE] with diagnoses, according to the Face Sheet, dated 8/16/18, including type II diabetes. A review of the monthly physician orders, dated 8/18, indicated an order for [REDACTED]. A review of the facility's Finger Stick Blood Glucose Log, dated 8/18, indicated the blood sugars were being monitored as ordered. Observation on 8/15/18 at 11:16 a.m. revealed Licensed Practical Nurse (LPN) JJ obtaining the R#59's blood sugar, immediately after that another resident's blood sugar had been obtained using the same blood sugar monitor. The monitor was not cleaned or disinfected in any way prior to LPN JJ using the monitor to obtain Resident #59's blood sugar. During an interview with LPN JJ on 8/15/18 at 4:55 p.m. at the nurses' station, she stated, The blood sugar monitors are to be cleaned with Sani-wipes. I didn't clean the monitor between residents today. I was probably nervous, and I'll be honest, I don't do it all the time because a lot of times I am the only nurse down here to 38 residents. During an interview with the Director of Nursing (DON) on 8/16/18 at 11:34 a.m.in the DON's office, he stated blood glucose monitors were to be cleaned and disinfected between each resident per facility policy.",2020-09-01
238,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2017-05-21,241,E,1,0,WJQH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews the facility failed to serve residents their meal trays at the same table at the same time, failed to assist the residents to eat leaving their food in front of them, and failed to assist residents to consume their food in a dignified manner for one resident (R#5) and three randomly observed residents from a total of 16 residents in the dining area on the 5th floor. Findings include: 1. Review of the medical record for R#5 revealed a [DIAGNOSES REDACTED]. The resident was also assessed as requiring one person assist for eating. Observation on 5/20/17 at 12:28 p.m. of the 5th floor dining area revealed resident lunch trays were being delivered. The lunch trays were first distributed to the dining room on the unit, then Certified Nursing Assistants (CNAs) passed lunch trays to the three halls on the unit. The 5th floor dining room was located behind the nursing station with two doorways into the room. The dining room was long in shape with windows facing the outside, on one end of the room was a television (TV), and at the other end of the room was a half-moon table with the circle part against the wall. Other tables in the dining room were square in shape, allowing four settings at each table. The dining room had two rows of tables. Most of the tables were along the wall of windows, against the wall allowing only three residents to a table. The side of the room next to the nursing station allows room for four residents to a table, however there is only three tables on that wall due to the doors and the wall space. There were 16 residents in the dining room and three staff assisting the residents (leaving staff to serve and assist the other 36 residents on the halls of the 5th floor). Observation on 5/20/17 at 12:28 p.m. of R#5 revealed that he was sitting at a table in the dining area on the 5th floor in a high back wheelchair. Sitting next to R#5 was female resident who was calling out in the room for someone help him (R#5) eat, stating that he cannot eat himself. Continued observation revealed R#5 lunch meal consisted of carrots, tomato soup, small glass of water, small glass of ice tea, a piece of cake, mashed potatoes, and a cut up chicken patty. The resident was not trying to feed himself and the female resident continued to be concerned about him eating. Staff were observed not addressing her concerns or the fact that R#5 was not eating. Further observation revealed R#5 picked up his fork with his left hand and stuck the fork in the slice of cake, picking up the entire slice and placing it in his mouth. Staff were observed not assisting R#5 with his lunch meal, staff did not cut his cake up for him, and no staff encouraged him to eat except for the female resident sitting at the table with him. Shortly thereafter a male visitor dressed in casual attire, later identified as a family member (FM) of R#5, entered the dining room and spoke to the female resident and R#5. The man wiped the cake crumbs off of the lap of R#5 and removed him from the dining room. Interview on 5/20/17 at 1:15 p.m. with two FMs of R#5, revealed they visited often and they felt like the staff just didn't care about the residents and where there just to get a check. They felt like there was not enough staff to care for the residents. They stated the lady sitting next to R#5 in the dining room was always concerned about his eating, and that many times staff did not assist R#5 to eat. Interview on 5/20/17 at 12:00 p.m. with Licensed Practical Nurse (LPN) AA revealed the normal staffing pattern on 500 hall (5th floor) included two LPNs and five CNAs however today there are two LPN, four CNA and one Activity Staff. The unit has approximately 52 residents. Observation on 5/21/17 at 8:45 a.m. revealed R#5 in his room laying in the bed. On the over bed table was the breakfast tray, however the resident was not sitting up in bed, the head of the bed (HOB) was not elevated and he could reach the tray. The resident's breakfast tray contained eggs, oatmeal, muffin, juice, coffee and water. Continued observation revealed CNAs DD and EE entered R#5 room, they pulled him up in bed and then raised the head of his bed. The resident stated he wasn't feeling well and became agitated and stated to the CNAs if they couldn't do it right leave it alone, in a raised angry tone of voice as they were placing the top sheet over him. Interview on 5/21/17 at 8:45 a.m. with the CNAs DD and EE revealed that at times R#5 would eat by himself but he needed encouragement. Observation on 5/21/17 at 9:05 a.m. of R#5 revealed he was sitting up in bed and feeding himself oatmeal, a muffin and eggs. 2. Observation on 5/20/17 at 12:35 p.m. revealed a male resident sitting at a table across from the table of R#5. This resident was short in stature with his chin about one inch above the table top, he was bent over with his chin and face almost touching his plate, scooping his food into his mouth. 3. Observation on 5/20/17 at 12:45 p.m., of the 5th floor dining area revealed LPN AA had come into the dining room, walked through the aisle and stated, did a named resident get a tray, as he continued to walk through the aisle entering one doorway, exiting through the other he stated I will call and get him a tray. The tray for this resident was present during the whole observation. Continued observation revealed a CNA who had been passing trays to the residents in their rooms entered the dining room and began to assist the resident. The CNA, however, made no effort to reheat the food which had been delivered to the unit at 12:28 p.m. In addition, this resident had been sitting in the dining room with his lunch tray in front of him across the table out of his reach, while other residents were eating. 4. Observation on 5/20/17 at 12:48 p.m. revealed on the other end of the dining room on the 5th floor revealed a male resident sitting against the wall looking down the room toward the TV, however he is not at a table, nor participating in the meal. Next to him was the half-moon table against the wall which had his lunch on it, however it has not been served to a resident. Next to the half-moon table was another male resident sitting looking toward the doorway with his back to the window, however he was not engaged in dining and has no lunch tray. Neither of these residents were observed to be engaged in the dining experience as they watched other residents be served and assisted in eating lunch.",2020-09-01
239,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2017-05-21,252,D,1,0,WJQH11,"> Based on observations and interview the facility failed to ensure resident furniture was maintained properly to provide home like environment on one floor (5th floor) of four resident floors. Findings include: Observation on 5/20/17 at 12:28 p.m. of the 5th floor dining room chairs revealed that they had wooden legs and arms. The dining chairs were worn without the finish on the legs and arms. Observation on 5/20/17 at 12:40 p.m. of room 525 (room of R#5) revealed a built-in cabinet to the right of the doorway. The cabinet was topped with Formica with approximately a one inch edge, the edge nearest to the doorway revealed the Formica was broken and removed exposing a long narrow opening, with jagged edges. Interview with the family member of R#5 on 5/20/17 at 1:15 p.m. revealed that one time they came to see R#5 and they found a scraper that maintenance had used and left at the beside. The family also stated that the patches in the ceiling had not painted for a long time, and that the cabinet in the room (525) needed repairs. Observation on 5/20/17 of room 510 revealed the night stand in the room was marred, with the furniture finishing worn off.",2020-09-01
240,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2017-05-21,314,D,1,0,WJQH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews the facility failed to ensure that pressure ulcer dressings were changed as physician ordered to promote healing for one resident (R#6) from a sample of 12 resident with a pressure ulcers. Findings include: Observation on 5/21/17 at 2:45 p.m. of R#6 with the Licensed Practical Nurse (LPN) CC and wound treatment nurse present in the room revealed that the pressure ulcer dressing on the resident's left foot had a date of 5/18/17. Continued observation of the pressure ulcer revealed a dark color area on the inner aspect of the bottom of the foot/heel about the size of a half dollar. The skin was dry and intact. Review of the physician order [REDACTED]. Cleanse wound with normal saline. Pat dry. Apply [MEDICATION NAME] to wound bed cover with 4x4 gauze then dry dressing. Review of the Treatment Administration Record (TAR) revealed no evidence by signature that the pressure ulcer treatment was completed on 5/16/17, 5/19/17 and 5/20/17, therefore validation that the dressing dated 5/18/17, was the last dressing change completed. Interview on 5/21/17 at 2:45 p.m. with LPN CC revealed that there are two treatment nurses and they were alternating weekends of work. LPN CC could not explain why the dressing was dated on 5/18/17, as she did not do that dressing change and she did not know what happened. Interview on 5/21/17 at 2:45 p.m. with LPN AA revealed that the skin had never broke open and the wound was stable.",2020-09-01
241,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2017-05-21,441,E,1,0,WJQH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations and interviews the facility failed to prevent the likelihood of cross contamination for eight residents (R#4, R#5, R#6, aa, bb, cc, dd', and ee) including failure to wear isolation Personal Protective Equipment, wash hands, sanitize a blood sugar machine and failed to cap feeding tubes from a sample of 12 residents. Findings include: 1. Observation on 5/20/17 at 12:00 p.m. of R#6 revealed the resident was lying in bed, the resident had a tracheostomy (trach-stoma in the trachea to breathe through) collar, receiving continuous oxygen (O2) via the trach collar, and a gastrostomy ([DEVICE], a tube inserted into the stomach to provide nutrition ) feeding of [MEDICATION NAME] 1.5 tube feeding formula. Observation of the label on the bottle of [MEDICATION NAME] 1.5 tube feeding revealed it was hung on 5/19/17 at 6:00 a.m., and the bottle had 650 cubic centimeters (cc) still inside. Attached to the [MEDICATION NAME] was a Kangaroo bag with a clear liquid fluid in it, which appears to be water however there is no label to indicate what the fluid is, when it was hung, or who hung it, with 400 cc of fluid in the bag. Continued observation revealed the tubing used to administer the tube feeding was not labeled with date it was hung. In addition, the tubing for the [MEDICATION NAME] tube feeding and the fluid in the Kangaroo bag was draped over the pump pole, uncapped and open. A 60 cc syringe was hanging on the pole in a plastic bag, undated, the used syringe was not opened and pulled apart, there was no evidence of moisture or water in the bag, the cap of the syringe was inside the bag but not on the end of the syringe and the syringe had tube feeding colored substance on the end of the tip, as if the syringe had not been cleaned after the last use. Further observation of R#6 revealed the O2 concentrator had a humidifier water bottle on the back of the machine, without a label indicating when it was opened. Observation of the resident's O2 trach collar revealed no evidence of when it was applied or had been changed. During the observation of R#6, Licensed Practical Nurse (LPN) AA came into the room to obtain a Finger Stick Blood Sugar (FSBS) reading. He placed the machine on the bedspread of the resident, told her what he was going to do, removed her left hand from under the bed spread, pricked her finger, obtained the blood sample, and then placed the machine back on her bedspread. After the reading, LPN AA covered her hand up with the bed spread, as he pulled the cover up over her hand, the machine fell into the floor, he picked the machine up off the floor, threw the sample strip in the trash at bedside, put the machine on top of the medication cart prior to cleaning it from falling on the floor. LPN AA then picked the machine up and wiped it with a disposable cloth, then laid it back on the medication cart, however LPN AA never wiped the medication cart after placing the machine on the top of it after it was removed from the floor. Then, LPN AA proceeded to re-enter the room and go to B bed (R#4) and obtain her FSBS reading. Interview on 5/21/17 at 2:00 p.m. with LPN AA revealed that he did fail to sanitize the blood sugar machine after he dropped it on the floor, he said he looked in the cart and did not have the disposable sanitizing wipes, and he didn't know what to do, he got nervous and just wiped the machine with alcohol, he stated he knew better. 2. Observation on 5/21/17 at 9:25 a.m. of LPN HH going in room [ROOM NUMBER] of Raa and Rbb, both residents were on isolation precautions. LPN HH failed to put on Personal Protective Equipment (PPE) before entering the room. LPN HH was observed exiting this room, went to the medication cart and failed to sanitized/wash her hands. LPN HH was observed then going into room [ROOM NUMBER] of Rcc and Rdd, exited the room, went to the medication cart again, left the cart went to the nursing station, came back to the medication cart, gave medication to resident in 215B, Raa, and did not sanitize her hands. Interview on 5/21/17 at 9:25 a.m. with LPN HH confirmed the findings, including she failed to wear PPE, and failed to wash or sanitize hands. 3. Observation and interview on 5/21/17 at 9:30 a.m. with a family member of the resident in room [ROOM NUMBER], Ree, revealed they were informed that the resident was on isolation due to Methicillin-resistant Staphylococcus aureus (MRSA), however they did not use PPE, despite the sign posted on door, and supplies available at door.",2020-09-01
242,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,241,D,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to ensure 2 of 42 stage 2 sampled residents (R301 and R126) were provided care and treatment in a manner that maintained or enhanced their dignity and respect. R301 was dressed in a hospital gown for ten days following admission. R126 was spoken to in a demeaning manner by staff. Findings include: 1. Observation of R301 on 9/20/16 at 1:49 p.m. showed he was asleep in his bed, wearing a hospital gown. Additional observations on 9/20/16 showed at 2:30 p.m. R301 remained asleep in bed wearing a hospital gown and at 4:00 p.m. R301 remained in bed, was awake and continued to wear the hospital gown. A review of R301's Admission Record revealed R301 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. On 9/20/16 at 2:35 p.m., when questioned about R301 wearing a hospital gown, Licensed Practical Nurse (LPN) 18, also the Unit Manager, stated the resident, did not have any clothes. LPN18 then contacted R301's social worker about his lack of regular clothing. Review of R301's Progress Notes revealed the social worker wrote a note on 9/20/16 at 2:56 p.m. DRS (Director Resident Services, the title for R301's Social Worker) left messages for both contacts to advise of DOS (delivery of service meeting) and resident's need for clothing. On 9/21/16 at 9:08 a.m. R301 was in observed in bed wearing a hospital gown. On 9/21/16 at 11:07 a.m. the DRS wrote a progress note DRS spoke with RP (responsible party) who advised that she would need to reschedule the DOS until 9/28 @10 am. RP advised that she would make arrangements to have clothes brought to facility. In an interview on 9/21/16 at 2:05 p.m. the DRS stated it did not normally take a week to get a resident clothes after they were admitted . We have the DOS (delivery of service) meeting normally in the first week. The daughter moved it off today to the 28th. The DOS (the first meeting when a resident comes into the facility) is where we would address the teeth and clothing. When asked what the process was, the DRS stated When I find out, I contact the family because sometimes they don't want them to have clothes others left (in the facility). Then I communicate with the laundry department. Any time nursing or staff lets me know, I do make the effort. I wasn't notified until yesterday. In an interview on 9/22/16 at 3:00 p.m. the Administrator stated it was the Concierge who was responsible for labeling clothes when a resident arrived. The Concierge was supposed to notify her supervisor (the DRS) if a resident didn't have clothes. When asked if there was a policy, the Administrator stated only the Resident Rights policy would apply. Review of the Resident Rights policy indicated residents had the right to retain and use personal possessions, including some furnishings and appropriate clothing, as space permitted, unless to do so would infringe upon the rights or health and safety of other residents. In an interview 9/22/16 at 3:35 p.m. the Administrator stated Certified Nurse Aides (CNA) and Nurses should notify the Social Worker about a resident's need for clothes. Following the Surveyor's bringing the lack of clothing for R301 to the attention of staff, clothing was obtained for the resident. Observation on 9/23/16 at 9:45 a.m. showed R301 sitting on the bed, dressed in clothes. 2. The Admission Record indicated R126 was admitted to the facility in (MONTH) 2011 and her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (a comprehensive assessment that drives the care planning process), dated 11/17/15, indicated R126 was alert and oriented, had no cognitive impairment, no delusions or hallucinations, and no verbal, physical, behavioral, or rejection of care issues. The MDS indicated R126 was incontinent of bowel and bladder and required the assistance of two staff for incontinence care. The 12/3/15 facility Investigation Report indicated that on 11/25/15, R126 told the assigned evening shift CNA (CNA19) her right arm hurt from a recent procedure and reported CNA19 did not care. The facility Investigation Report report indicated the CNA fussed at her (R126) for having repeated bowel movements. During an interview with R126 on 9/22/16 at 10:25 a.m., R126 recalled the incident. R126 said she had a few bowel movements that evening, and CNA19 was not happy she had to assist her with personal care. R126 said CNA19 was not nice and made comments that upset her. R126 said she reported the incident to the staff the following day. During an interview with the Administrator on 9/22/16 at 8:00 a.m., the Administrator said she discussed the incident with CNA19. The Administrator said the CNA told her she told R126, I see you are back digging again. The Administrator said CNA19 acknowledged the comment was not appropriate. The Administrator said CNA19 spoke inappropriately to R126 and did not treat the resident with dignity and respect.",2020-09-01
243,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,253,E,0,1,DI4L11,"Based on observation and interview, the facility failed to provide housekeeping services maintain a clean and sanitary environment in the Pantries on 3 of 4 resident units (units 2, 3, and 5). Specifically, the cabinets, drawers and base board were observed with an accumulation of dust, food crumbs, and black particles. Findings include: During the facility tour on 9/19/16 at 10:30 a.m., the room labeled Pantry Room on the 2nd Floor was observed. The cabinet drawers contained dust and a moderate amount of food crumbs and the cabinets under the sink contained a large amount of dust and black particles. The drawers and cabinets contained no stored food items or utensils. The baseboard had a large amount of accumulated dust adhered to it. During the facility tour on 9/19/16 at 10:45 a.m., the Pantry Room on the 3rd Floor was observed. The inside of the cabinet drawers was dusty with a moderate amount of food crumbs and the inside of the cabinets located under the sink contained a large amount of dust and black particles. The drawers and cabinets contained no stored food items or utensils. The baseboard had a large amount of accumulated dust adhered to it. During observation of the Pantry Room on the 5th Floor on 9/19/16 at approximately 2:00 p.m., the inside of the cabinet drawers contained a small amount of food crumbs and the inside of the cabinets located under the sink contained a moderate amount of dust and black particles. The drawers and cabinets contained no stored food items or utensils. The baseboard had a large amount of accumulated dust adhered to it. During a subsequent tour and interview with the Maintenance Director on 9/22/16 at 2:30 p.m., the Maintenance Director confirmed the cabinet drawers and cabinet area under the sinks in the Pantry Rooms on the 2nd, 3rd, and 5th floors needed to be cleaned and stated Housekeeping was responsible for cleaning inside the cabinets and drawers. In addition, the Maintenance Director stated the black particles were shed from the old pipes and confirmed that the black particles under the sink were not rodent droppings.",2020-09-01
244,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,279,D,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop comprehensive care plans for 2 of 42 stage 2 sampled residents (R153 and R43). Specifically, the facility failed to develop a care plan to address the care, monitoring, and potential complications following a medical procedure for R153. The facility failed to develop a care plan to address hygiene and personal care for R43. Findings include: 1. R153 was admitted to the facility with the [DIAGNOSES REDACTED]. The resident had been discharged from the facility and R153's closed record was reviewed during the survey. The Minimum Data Set (MDS), dated [DATE], indicated the resident was moderately cognitively impaired and required assistance of 2 persons for toileting and moderate assistance of 1 person for personal hygiene and dressing. The MDS also indicated that the resident was frequently incontinent of urine. A Physician's note dated 8/15/16 at 2:00 p.m. revealed the following a core prostate needle biopsy was performed. Normal -basic blood in urine, BMs (bowel movements) and ejaculate x (times) 7-10 days. Return to clinic in 2 wks (weeks). Needs [MEDICATION NAME] (an antibiotic) 300 mg (milligrams) po (by mouth) daily x 2 days. A review of R153's record revealed no care plan was developed to address the care and necessary monitoring following the prostate biopsy procedure. The resident had a [DIAGNOSES REDACTED]. During an interview on 9/22/16 at 11:55 am, the Assistant Director of Nursing (ADON) who was assigned to the unit the resident had resided on, stated that she would have to review R153's computerized discharge medical records. Later that day, at 1:00 pm, the ADON stated a care plan had not been developed to direct the necessary care related to a prostate biopsy and confirmed that there should have been a care plan. The ADON stated that she already started to in-servicing the staff regarding developing and documenting care plans. 2. The Admission Record indicated R43 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of the 5/5/16 quarterly MDS assessment indicated R43 was totally dependent on staff for hygiene/personal care. On 9/21/16 at 11:00 a.m., 9/22/16 at 9:30 a.m., and 9/23/16 at 9:45 a.m., R43 was observed with thick hair on her upper lip. On 9/23/16 at 9:55 a.m., the Surveyor and RN5 observed R43. RN5 acknowledged the hair on R43's upper lip was in need of removal. The 8/6/15 Plan of Care did not address R43's requirement for assistance with removal of excess hair on her upper lip.",2020-09-01
245,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,280,D,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise the Plan of Care for 2 of 42 stage 2 sampled residents (R72 and R37). Specifically, the facility failed to: -Revise R72's Plan of Care to include occasional refusals of showers and accusations that staff did not give her a shower. -Revise R37's Plan of Care to include frequency of monitoring the Wander Guard related to elopement. Findings include: 1. The Admission Record indicated R72 was admitted to the facility in (MONTH) of 2014 and her [DIAGNOSES REDACTED]. The (MONTH) (YEAR) Plan of Care indicated R72 required assistance with personal care and there was no indication R72 refused personal care. During an interview with R72 on 9/21/16 at 1:00 p.m., R72 said the staff were to give her 2 showers per week. R72 said sometimes the staff gave her 1 shower a week. During an interview with Certified Nurse Aide (CNA) 13 on 9/21/16 at 1:26 p.m., CNA13 said the staff gave R72 2 showers per week. CNA13 said although R72 was alert and oriented, sometimes she was confused and said the staff did not give her a shower. CNA13 said R72 occasionally refused her shower; however, would usually take a shower later in the day. During an interview with Registered Nurse (RN) 7 on 9/21/16 at 1:15 p.m., RN7 said R72 was alert and oriented and able to make her needs known. RN7 said the staff gave R72 2 showers per week. RN7 said R72 occasionally reported the staff did not give her a shower. RN7 said when she investigated R72's allegation of not getting a shower, she determined R72 received the shower. RN7 acknowledged the Plan of Care did not address R72's occasional refusals of showers and did not address the accusation that showers were not given. 2. Resident (R) 37 was admitted to the facility on [DATE]. Review of the medical record revealed the resident used a wheelchair to move about the facility. Review of the medical record revealed R37 had dementia with confusion. Review of the medical record revealed an Elopement Risk assessment dated [DATE] which found the resident to be at risk for elopement (leaving the building without supervision) due to his behaviors of wandering, impaired safety awareness, and trying to get out of the building. Review of the medical record revealed an elopement care plan was initiated on 4/24/16 after R37 attempted to leave the building. The interventions included applying a Wander Guard for safety. A Wander Guard system includes the use of a device the size of a watch that is applied to an individual's arm or leg that sounds an alarm when the resident approaches a specific exit door or doors. The care plan directed staff to check the Wander Guard for placement (on the resident) every shift and to check the function of the Wander Guard every week. Review of the medical record revealed a 5/16/16 10:54 a.m. late entry nurse's note: Resident was observed moving up the hill outside the facility. When asked where he was going, he stated he was going home. Resident stated he lives four blocks away and he was getting out of here. He was escorted back into the building by staff. During an interview on 9/22/16 at 11:20 a.m., Registered Nurse (RN) 5 stated, The resident would remove the Wander Guard and I would replace it. He did not have the Wander Guard on when he got out of the building. I put one back on when he was returned to the building. During an interview on 9/22/16 at 11:20 a.m. RN5 was asked if a resident who was known to remove the Wander Guard and had attempted to leave the building should be monitored more frequently than once a week; RN5 answered, Yes. Although the resident was known to remove the Wander Guard and had eloped a second time on 5/16/16, the resident's elopement care plan had not been revised.",2020-09-01
246,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,282,D,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to implement care plan interventions for 4 of 42 stage 2 sampled residents (R37, R73, R126, R115). Specifically, the facility failed follow care plans by: -Monitoring the placement and function of a Wander Guard for R37. -Implementing hand hygiene for R73. -Providing 2-person staff assistance to R126 during incontinence care. -Providing assistance with personal hygiene, the removal of facial hair, for R115. Findings include: 1. Resident (R) 37 was admitted to the facility on [DATE]. Review of the medical record revealed the resident used a wheelchair to move about the facility and had [DIAGNOSES REDACTED]. Review of the medical record revealed an elopement care plan was initiated on 4/24/16 after R37 attempted to leave the building. The interventions listed included applying a Wander Guard for safety. A Wander Guard system includes the use of a device the size of a watch that is applied to an individual's arm or leg that sounds an alarm when the resident approaches a specific exit door or doors. The care plan directed staff to check the Wander Guard for placement (on the resident) every shift and to check the function of the Wander Guard every week. During an interview on 9/22/16 at 11:20 a.m. with RN5 and Restorative Aide (RA) 6 it was revealed the RA was responsible for checking the Wander Guard placement and function every Friday. Although staff was to check placement of the Wander Guard every shift, documentation indicated it was checked weekly. Review of the medical record revealed a 5/16/16 10:54 a.m. late entry nurse's note demonstrating the resident was found outside the facility on the street, stating he was going home. Review of the Wanderguard Audit Sheet for R37 revealed an audit sheet was filled out for the month of (MONTH) (YEAR). The Wanderguard Audit Sheet was not completed in accordance with the care plan for the month of (MONTH) (YEAR), the month in which he was found on the street (5/16/16 nurse's note). 2. Resident (R) 73 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (an assessment tool used to plan care), dated 6/2/16, revealed R73 had a Brief Interview for Mental Status (BIMS) score of 3, demonstrating severe cognitive impairment. Further review of the MDS dated [DATE] revealed R73 was completely dependent on staff for all activities of daily living (ADLs). Review of the care plan for contractures (muscle or tendon that has shortened causing a deformity and rigidity of a joint) of both hands and elbows dated 4/12/16 included the intervention to wash the resident's hands with soap and water, and to rinse and dry her hands thoroughly. Observation of R73 at 3:10 p.m. on 9/19/16 revealed a strong sour, yeast-like odor emanating from her hands. This observation was confirmed with Licensed Practical Nurse (LPN) 9 and Registered Nurse (RN) 10. On 9/19/16 at 3:10 p.m., LPN 9 gently opened R73's hands and fingers to find a buildup of moist debris in her palms and between her fingers. Based on the accumulated and foul smelling debris in R73's hands, the resident's care plan for handwashing had not been implemented.",2020-09-01
247,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,312,D,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure 3 of 42 stage 2 sampled residents (R43, R115 and R73), who required staff assistance with activities of daily living, were provided adequate assistance to maintain personal hygiene. R115 and R43 were not shaved; R73 was not provided with handwashing and nail care. Findings include: 1. The Admission Record indicated R115 was admitted to the facility in (MONTH) 2010 and his [DIAGNOSES REDACTED]. The annual Minimum Data Set (comprehensive assessment driving the care planning process), completed on 8/5/16, documented R115 had severely impaired cognition and was dependent on staff for bathing and personal hygiene. On 9/20/16 at 2:00 p.m., 9/21/16 at 11:00 a.m. and 4:00 p.m., 9/22/16 at 9:30 a.m., and 9/23/16 at 9:45 a.m., the Surveyor observed R115 had hair on his face and was in need of a shave. During an interview with Certified Nurse Aide (CNA) 12 on 9/23/16 at 10:00 a.m., CNA12 said R115 was dependent on staff for shaving. CNA12 said the staff shaved R115 after his shower and as needed (prn) and reported R115 was not resistive when shaved. CNA12 said when the unit was short staffed, the staff were not always able to complete everything needed for a resident. CNA12 said R115 needed to be shaved and she did not know when R115 was last shaved. During an interview with Registered Nurse (RN) 5 on 9/23/16 at 9:21 a.m., RN5 said R115 needed to be shaved. 2. The Admission Record indicated R43 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. The quarterly Minimum Data Set (MDS), completed on 8/5/16, documented R43 had severely impaired cognition and was dependent on staff for bathing and personal hygiene. The 8/6/15 Plan of Care indicated R115 required assistance with bathing. On 9/21/16 at 11:00 a.m., 9/22/16 at 9:30 a.m., and 9/23/16 at 9:45 a.m., R43 was observed with thick hair on her upper lip. During an interview with CNA11 on 9/23/16 at 11:55 a.m., CNA11 said there was not always enough time to complete all the necessary care a resident required such as shaving and nail care. CNA11 said R43 had facial hair on her upper lip that had not been shaved. On 9/23/16 at 9:55 a.m., the Surveyor and RN5 observed R43. RN5 verified that R43 had hair growth on her upper lip and agreed the resident was in need of shaving. 3. Resident (R) 73 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (an assessment tool used to plan care), dated 6/2/16, revealed R73 had a Brief Interview for Mental Status (BIMS) score of 3, demonstrating severe cognitive impairment. Further review of the MDS dated [DATE] revealed R73 was completely dependent on staff for all activities of daily living (ADLs). Review of the care plan for contractures (muscle or tendon that has shortened causing a deformity and rigidity of a joint) of both hands and elbows dated 4/12/16 included the intervention to wash the resident's hands with soap and water, and to rinse and dry her hands thoroughly. Observation of R73 at 3:10 p.m. on 9/19/16 revealed a strong sour, yeast-like odor emanating from her hands. This observation was confirmed with Licensed Practical Nurse (LPN) 9 and Registered Nurse (RN) 10. On 9/19/16 at 3:10 p.m., LPN 9 gently opened R73's hands and fingers to find a buildup of moist debris in her palms and between her fingers. R73's fingernails were long and pressing into the palms of her hands. After the Surveyor brought R73's lack of hand hygiene to the attention of staff on 9/19/16, care was provided and the resident's hand no longer smelled or contained debris. Observation at 11:40 a.m. on 9/20/16 revealed that R73's fingernails to be trimmed and her hands clean and dry with no odor.",2020-09-01
248,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,323,D,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the nursing staff failed to supervise and implement preventive interventions for 1 of 42 stage 2 sampled residents (R37) who was at risk for accidents from elopement (leaving the building without supervision). These failures resulted in R37 leaving the building; he was found propelling himself in a wheelchair on the street. Findings include: Resident (R) 37 was admitted to the facility on [DATE]. Review of the medical record revealed the resident used a wheelchair to move about the facility. Review of the medical record revealed R37 had dementia with confusion. Review of the medical record revealed an Elopement Risk assessment dated [DATE] which found the resident to be at risk for elopement due to his behaviors of wandering, impaired safety awareness, and trying to get out of the building. Review of the medical record revealed an elopement care plan was initiated on 4/24/16 after R37 attempted to leave the building. The interventions included applying a Wander Guard for safety. A Wander Guard system includes the use of a device the size of a watch that is applied to an individual's arm or leg that sounds an alarm when the resident approaches a specific exit door or doors. The care plan directed staff to check the Wander Guard for placement (on the resident) every shift and to check the function of the Wander Guard every week. Review of the Nurses' Notes revealed: 4/23/16 at 1:06 a.m., in pertinent part: Resident is a f/u (follow up) new admission, he is very confused, he is in and out of other's rooms. He goes down stairs, outside, he cannot find his room. 4/25/16 at 12:02 a.m., in pertinent part: Resident is confused and urinate in his room on the floor, get out of his hall and go down stairs and try to get out of the building .Foot alarm (Wander Guard) is placed on the resident's right foot to enable staff to know when the resident is trying to get out. 5/16/16 at 10:54 a.m., a late entry: Resident was observed moving up the hill outside the facility. When asked where he was going, he stated he was going home. Resident stated he lives four blocks away and he was getting out of here. He was escorted back into the building by staff. During an interview on 9/22/16 at 11:20 a.m. with RN5 and Restorative Aide (RA) 6 it was revealed that a Wander Guard Audit Sheet was initiated monthly for each resident who had a Wander Guard. The RA was responsible for checking the Wander Guard placement and function every Friday. Review of the Wanderguard Audit Sheet for R37 revealed an audit sheet was filled out for the month of (MONTH) (YEAR), but not for the month of (MONTH) (YEAR). Review of the (MONTH) Wanderguard Audit Sheet revealed that R37's Wander Guard was last checked on (MONTH) 29, (YEAR). Subsequent months of (MONTH) through the survey showed the audits were completed. During an interview on 9/22/16 at 11:20 a.m., Registered Nurse (RN) 5 stated, The resident would remove the Wander Guard and I would replace it. He did not have the Wander Guard on when he got out of the building. I put one back on when he was returned to the building. When asked who found R37 wheeling himself up the hill, RN5 stated, A staff member who was coming to work on the 3-11 shift. The nursing staff's failure to adequately supervise R37 and check the function and placement of the Wander Guard resulted in R37 leaving the facility without detection and being later found in the street.",2020-09-01
249,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,327,D,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure 1 of 42 stage 2 sampled residents (R300) was provided with sufficient fluids. R300's diet order was not followed which resulted in R300 not having water or other fluids available at the bedside. R300 complained of having dry lips and a swollen tongue. Findings include: A review of the Admission Record revealed R300 was admitted to the facility on [DATE] with medical [DIAGNOSES REDACTED]. In an interview on 9/19/16 at 3:35 p.m. R300 complained the facility staff, keep giving me thickened water and baby food and that his lips were chapped and his tongue was swollen. In a second interview on 9/20/16 at 2:05 p.m., R300 stated the night nurse had given him two glasses of regular water the previous night, but he didn ' t have water at the bedside and he did not receive the fluids he wanted between meals. Observation of R300's room on 9/19/16 at 3:35 p.m. and on 9/20/16 at 2:05 p.m. revealed no water or other fluids available for the resident to drink; the resident was observed with dry lips and mucous membranes at these times. A review of R300's electronic health records (EHR) revealed a physician's orders [REDACTED]. Further review of the EHR revealed a Diet Slip with the handwritten diet of honey thick liquids with puree food signed by Licensed Practical Nurse (LPN) 19 on 9/16/16. In an interview on 9/21/16 at 10:00 a.m. regarding the Diet Slip for thickened liquids and the pureed diet for R300, the Director of Nursing (DON) stated she did not know; however, she looked at the computer and stated R300 should be on a regular texture diet with thin liquids. In an interview on 9/21/16 at 2:45 p.m. R300 stated he was happy with the thin water now available. Observation of R300 at this time revealed his lips and mucous membranes were moister than they were on 9/19/16 and 9/20/16 and there was ice water at the bedside. In a subsequent interview on 9/22/16 at 9:50 a.m., R300 stated he was getting regular water and no longer receiving baby food. In an interview on 9/22/16 at 9:55 a.m. LPN19 stated she might have talked to a Certified Nurse Aide (CNA) and made the diet order change to thickened liquids and a pureed diet in error. LPN19 stated s/he would not have made a diet change without observing the resident. A review of the undated facility provided Policy 87: Hydration revealed the Procedure: . 2. Each resident will be provided a drinking glass and water pitchers in their room. 3. Water pitchers are filled with ice/water at least, but not limited to, twice a day. In an interview on 9/23/16 at 11:35 a.m. the Administrator stated all residents should have water at the bedside, even if on thickened liquids; however, there was no specific policy regarding thickened water. Regarding the Diet Slip on 9/16/16 calling for a pureed diet and thickened liquids, the Administrator stated the nurse was probably confused because another resident admitted at the same time was on a pureed diet with thickened liquids.",2020-09-01
250,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,329,D,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff and resident interview, the facility failed to ensure the root cause of depression was assessed and signs and symptoms were present and monitored to ensure adequate indication for use of an anti-depressant medication for 1 of 42 stage 2 sampled residents (R61). Findings include: The Admission Record indicated R61 was admitted to the facility in (MONTH) 2012 and her [DIAGNOSES REDACTED]. During an interview with the Director of Nurses (DNS) on 9/23/16 at 12:42 p.m., she said R61 currently received the anti-depressant medication [MEDICATION NAME]. The DNS said she was not aware of the specific symptoms or causes of R61's depression. The 9/1/13 Pharmacy Consultation Report indicated R61 received [MEDICATION NAME] 20 milligrams (mg) since (MONTH) 2011. The Consultation Report recommendation included decreasing the [MEDICATION NAME] to 10 mg daily; the Physician initiated the recommendation. The 3/5/14 Pharmacy Consultation Report indicated R61 had received [MEDICATION NAME] 10 mg since 9/20/13; a recommendation was made to decrease the [MEDICATION NAME] to 5 mg daily. The Consultation Report indicated the Physician initiated the recommendation. The 12/29/15 computerized physician Order Listing included discontinuing the [MEDICATION NAME], prescribed at 5 mg daily, which was implemented. The 2/12/16 computerized Physician order [REDACTED]. The Nurses' Notes, Social Service Notes, and physician progress notes [REDACTED]. The Psychopharmacological Medication Use Policy, revised on 1/1/13, indicated when a Physician/Prescriber orders a psychopharmacologic medication for a resident, Facility should ensure that Physician/Prescriber has conducted a comprehensive assessment of the resident and has documented in the clinical record that the psychopharmacologic medication is necessary. During an interview with R61's Physician on 9/23/16 at 2:03 p.m., the Physician said after he discontinued the [MEDICATION NAME], if R61 had signs of depression or an exacerbation of depressive symptoms, he expected the staff to notify him. The Physician said he probably started R61 on [MEDICATION NAME] in (MONTH) (YEAR) related to information given to him by the nurses. The Physician said he did not know the specific cause or symptoms of R61's depression that warranted the initiation of [MEDICATION NAME]. The Physician said he was not aware there was no documentation in the clinical record that indicated R61's depression returned after the [MEDICATION NAME] was discontinued, and therefore, on 2/12/16, he started R61 on [MEDICATION NAME]. During an interview with the Administrator on 9/23/16 at 1:47 p.m., the Administrator said there was no documentation that indicated R61 had a decline in her mental status and/or an exacerbation of depression after the [MEDICATION NAME] was discontinued in (MONTH) (YEAR). The Administrator said the Psychopharmacological Medication Use Policy was not followed; a comprehensive assessment was not completed demonstrating the anti-depressant medication was necessary. The 2/12/16 Plan of Care (P[NAME]) related to R61's use of anti-depressant medication, included monitoring for signs of depression that included sad, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, [MEDICAL CONDITION], negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety, and/or constant reassurance, and notification of the Physician. The DNS, interviewed on 9/23/16 at 12:42 p.m., said she was not aware of the specific symptoms of R61's depression and said the staff monitored R61 for the symptoms mentioned in the P[NAME]. The 6/1/16 Pharmacy Consultation Report (in error) indicated R61 received [MEDICATION NAME] 5 mg since 3/20/14 and the recommendation included a trial of discontinuing the [MEDICATION NAME]. The Pharmacy Consultation Report indicated the Physician documented R61's target symptoms returned or worsened after the most recent gradual dose reduction (GDR) within the facility and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. The Consultation Report did not include any additional information as mentioned in the above sentence. The Psychopharmacological Medication Use Policy, revised on 1/1/13, indicated the Physician/Prescriber should document the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior. The Physician, interviewed on 9/23/16 at 2:03 p.m., said he was not aware he was required to document specific information as to why he was not initiating a GDR of [MEDICATION NAME] for R61 and believed documenting a past decline in symptoms was sufficient. The Physician said he was not aware of a specific decline in R61 when the [MEDICATION NAME] was discontinued. The quarterly Minimum Data Set (comprehensive assessment driving the care planning process), with an assessment reference date (ARD) of 8/19/16, documented R61 made herself understood, understood others, and had some cognitive impairment. The MDS indicated R61 had no mood or behavior symptoms, and received an anti-depressant medication 7 days of the lookback period. The Nurses' Notes, Social Service Notes, and physician progress notes [REDACTED]. The Surveyor observed R61 on 9/20/16 at 2:47 p.m., on 9/21/16 at 2:00 p.m., on 9/23/16 at 10:30 a.m. and 1:55 p.m. R61 had no signs of depression, was pleasant, and was observed conversing with staff and residents. During an interview with R61 on 9/23/16 at 1:55 pm, R61 said she felt okay and was not depressed. R61 stated the Physician had not discussed her medications, including prescription of [MEDICATION NAME], with her. The 9/23/16 physician progress notes [REDACTED]. The physician progress notes [REDACTED].",2020-09-01
251,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2016-09-23,431,E,0,1,DI4L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure medications for 28 out of 201 total residents (those residing in rooms 310-327) were stored securely when not in the direct sight of a licensed nurse. Findings include: Observation of the medication cart at 12:34 p.m. on 9/22/16 for the third floor, north assignment showed the cart parked at a 90o angle to room [ROOM NUMBER] on the north hall. No staff was observed in sight of the cart; the keys were on top of the cart and the lock was in the open position. A male resident in a wheelchair was in the hall approximately 10 feet away from the cart; the unlocked drawers were facing him. Licensed Practical Nurse (LPN) 8 appeared from behind a privacy curtain in room [ROOM NUMBER] and was surprised to find the surveyor standing at the cart. When questioned if it was the facility policy to leave the medication cart unlocked, LPN8 stated It's policy if I can see it. When asked if she saw the surveyor approach and stand at the cart, LPN8 responded she was not able to see the cart from behind the curtain. LPN8 explained this was her first day of orientation, but that she had been a nurse for [AGE] years and knew better (than to leave the cart unlocked and unattended.) LPN9 (the nurse orienting LPN8) then walked up to the cart and when questioned, stated the cart contained medications for 28 residents. The top left drawer had stock medications and the top right drawer had eye drops and insulins. The second left drawer had medications for rooms 310 to 318, third left drawer contained the medications for rooms 319 - 327 (medications that included anti-emetics, anti-hypertensives and vitamins). The second small drawer on the right contained locked controlled substances; the third right drawer contained liquid medications that included liquid potassium. The bottom drawers contained inhalant medications and topical medications. A review of the facility Medication Cart Procedure, included direction to keep the cart clean and addressed hand sanitation; however, the procedure did not address medication security. In an interview on 9/23/16 at 2:10 p.m. the Director of Nursing stated If the cart is out of line of sight of the nurse, then yes, the cart should be locked.",2020-09-01
252,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2018-10-18,656,D,0,1,U7QI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record review and review of facility policy it was determined that the facility failed to ensure the comprehensive care plan was implemented to maintain the nutritional status for one Resident (R) R#192 out of 35 sampled residents. The findings included: Review of the medical records for R#192 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date of 9/21/18 revealed R#192 had a Brief Interview Mental Status (BIMS) with a score of 15, which indicates cognitively intact for decision making. The assessment identified the resident's functional status for bed mobility and transfers - requires extensive assistance with resident involved in activity and staff provide weight bearing support with one - person physical assist. Eating- needs supervision with set up help only. Nutrition - coded as Therapeutic Diet. The Care Area Assessment (CAA) Summary triggered for nutritional status and a care plan was developed to maintain R#192 nutritional status. Review of R#192 care plan (9/7/18) revealed the Focus- Resident at potential for altered nutrition and or fluctuations in weight related to receiving therapeutic diet related to [DIAGNOSES REDACTED]. BMI (body mass index) indicates normal weight. Labs show depleted protein, will recommend nutritional protein will recommend nutritional supplements to provide additional kcals (units of calories) and pro (protein). Will continue to monitor resident until stable and make adjustment as needed. Interventions include: Administer medication as ordered. Monitor/ Document for side effects and effectiveness. Monitor/ record/ report to medical doctor (MD) as needed, signs and symptoms of malnutrition: Emaciation (Cachexia) muscle wasting, significant weight loss: 3 pounds (lbs). in 1 week, greater than 5% in 1 month, greater than 7.5 % in 3 months. Registered Dietician (RD) to evaluate and make diet change recommendations as needed. In an interview with R#192 on 10/15/18 at 12:15 p.m. in the resident room, the resident revealed he was not eating the food and he was losing weight. He revealed his dislike of the food. R#192 said he did not have to tell the kitchen he was not eating they could see on his tray that he was not eating the food. A review of the weight record for resident #192 revealed: 9/18/18 138.9 lbs. 10/11/18 120.4 lbs. An 18.5 lbs./ 13.32% weight difference. No reweigh was noted.C The RD was not notified. The MD was not notified. An interview was conducted on 10/17/18 at 3:01 p.m. with RD KK in her office. RD KK revealed the restorative aide who had weighed R#192 had not notified her of the weight discrepancy. There was a miscommunication over when and how to notify her of a weight discrepancy. The MD had not been notified of the weight loss. A phone interview was conducted with MD RR on 10/18/18 at 3:46 p.m., revealed he had not been informed of the weight loss. MD RR said he had expectations for the facility to inform him of weight loss. Review of the facility policy titled Weight Assessment and Intervention Policy dated (MONTH) 28, (YEAR), revised on (MONTH) 2, (YEAR) revealed policy statement- The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. The nursing staff will measure resident weights on admission, the next day and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the dietitian.",2020-09-01
253,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2018-10-18,692,D,0,1,U7QI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record reviews and policy reviews, it was determined that the facility failed to provide care and services to maintain an acceptable parameter for the nutritional status for one Resident (R) R#192 of the 35 sampled residents. The findings include: R#192 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set (MDS), with an Assessment Reference Date of 9/21/18, revealed R#192 had a Brief Interview Mental Status (BIMS) with a score of 15, which indicates cognitively intact for decision making. The assessment identified the resident's functional status for bed mobility and transfers to require extensive assistance with resident involved in activity and staff provide weight bearing support- one-person physical assist. Eating - coded as needing supervision with set up help. Nutrition - Therapeutic Diet. The Care Area Assessment (CAA) Summary revealed the resident trigger in the care area for Nutritional Status. In an interview on 10/15/18 at 12:15 p.m. in the resident room, R#192 revealed he was not eating the food. R#192 said he does not eat pork and sausages, but the kitchen keeps sending him the same thing over and over. R#192 said he had spoken with the dietitian but it had not changed anything. R#192 revealed that he was losing weight and his pants were not fitting. R#192 said he did not have to tell the kitchen he was not eating, they could see on his tray that he was not eating the food. A review of the R#192 medical records for weights revealed: 9/18/18 138.9 lbs. 10/11/18 120.4 lbs. An 18.5 pounds (lbs). / 13.32% difference. No reweigh was noted on the next day. No notification to the dietitian No notification to the physician. An interview was conducted on 10/17/18 at 3:01 p.m. with Registered Dietitian (RD) KK in her office. RD KK revealed the restorative aide gets the resident's weights for their assigned units. The restorative aide puts the weight into the facility system. The restorative aide compares the weights of the resident from one week to the next and is supposed to inform the dietitian of any weight discrepancy. RD KK said there was a miscommunication on how and when to inform the dietitian of a weight discrepancy. RD KK revealed any weight discrepancy would have been discussed at the weight meeting for Patients at Risk Meetings and the physician would be notified. RD KK said she had not been notified and the physician had not been notified of the weight discrepancy for R#192. An interview was conducted on 10/17/18 at 3:01 p.m. in the dietitian office with Restorative Aide (RA) OO. RA OO said she does take the weight of the residents assigned to her on the unit. RA OO said she enters the weights into the facility computer system, but she had not been told to do a comparison of the weights. RA OO stated she was told to just enter the weights and the dietitian would see the problem and tell her to weigh the resident again. An interview was conducted on the phone with medical doctor (MD) RR on 10/18/18 at 3:46 p.m. MD RR said he had not been informed of the weight loss for R#192, and no action had been taken. He said, his expectations were for the facility to follow the policy and that they usually left a note in the book or they would call the office or speak with his assistants. An interview was conducted on the phone with physician assistant (PA) SS on 10/18/18 at 5:01 p.m. PA SS revealed he would expect the facility to call when they see a weight loss. He said weight loss is a big issue. Review of the facility policy titled Weight Assessment and Intervention Policy dated (MONTH) 28th, (YEAR), revised on (MONTH) 2, (YEAR) revealed policy statement - The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. 1. The nursing staff will measure resident's weights on admission, the next day and weekly to two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing we notify the Dietitian.",2020-09-01
254,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2018-10-18,698,D,0,1,U7QI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record reviews and facility policy reviews, it was determined that the facility failed to provide professional services for [MEDICAL TREATMENT] care to one Resident (R) R#312 out of 35 sample residents. The findings include: Review of the medical records for R#312 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. . Review of R#312's Nursing Admission Evaluation and 48 Hour Initial Care Plan dated 10/12/18 revealed the resident needs [MEDICAL TREATMENT] ([MEDICAL TREATMENT]) related to [MEDICAL CONDITION]. The outcome - the resident will have no signs or symptoms of complications from [MEDICAL TREATMENT] through the next review date. Interventions included; Check bruit and thrill every shift and as needed. Monitor labs and report to doctor as needed. Monitor/document/ report to MD (medical doctor) as needed for signs and symptoms of [MEDICAL CONDITION]: changes in level of consciousness, changes in skin turgor, oral mucosa, changes in heart and lung. No lab or blood pressure in arm with [MEDICAL TREATMENT] shunt or [MEDICAL CONDITION] dominant arm. In an interview on 10/15/18 at 4:17p.m. in the resident's room, R#312 said she had not had [MEDICAL TREATMENT] for four days. She stated she came in late on Friday and was told she would receive her scheduled [MEDICAL TREATMENT] on Saturday at 11: 00 a.m. by the staff. R#312 said the [MEDICAL TREATMENT] did not happen on Saturday. R#312 said she was told later, she would go on Tuesday, her next scheduled date. The resident said she was having body urges she usually did not have and was very concerned about her fluid retention. R#312 said she was already a scheduled client with the [MEDICAL TREATMENT] center the facility used and had scheduled chair times to be dialyzed on Tuesday, Thursday and Saturday. R#312 said, the facility should have let her stay at her prior location until they got the arrangement straight for her appointment. An interview was conducted on 10/15/18 at 10:40 a.m. with License Practical Nurse (LPN) BB at the nursing station. LPN BB revealed that if a resident comes into the facility and needs [MEDICAL TREATMENT], the admissions coordinator will let the charge nurse know to inform the staff of their needs. LPN BB said the transportation person is informed by admissions. The information comes by e-mail and they give a copy to the resident. LPN BB said that R#312 was listed as going to the same [MEDICAL TREATMENT] center she was already scheduled for prior to coming to the facility. In an interview conducted on 10/17/18 at 10:15 a.m. with Unit Manager (UM) AA at the nursing station, it was revealed that R#312 was admitted late to the facility on Friday 10/12/18. The UM AA said she received an e-mail (communication sheet) from admission with the resident location and chair time for [MEDICAL TREATMENT]. An interview was conducted on 10/17/18 at 11:35 a.m. with the Admission Coordinator (AC) PP in the employee breakroom. AC PP indicated that she did all the coordination and had put all the clinical paperwork together for R#312. AC PP said an e-mail was sent to the transportation company the facility uses for [MEDICAL TREATMENT] transport with the resident's information, location and chair times. The required information was e-mailed to the transporting agency when the referral for admission was confirmed. The communication sheet emailed by admissions to the transportation agency had R#312 schedule for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday at 11:00 a.m. The correct information was sent timely. AC PP said she was informed on Monday (10/15/18) that R#312 did not make her scheduled [MEDICAL TREATMENT] appointment on Saturday 10/13/18. An interview was conducted on 10/17/18 at 2:01p.m. with the Administrator in her office. The Administrator said that Admissions sets up the transportation for the residents admitted to the facility needing [MEDICAL TREATMENT]. The Administrator said that the Admission Director had informed her that the transportation for R#312 to go to [MEDICAL TREATMENT] had not occurred. The Administrator and Admission Director had contacted the transporting agency to inquire why the transportation did not occur. The transport agency Director response was the agency was not aware of the resident needing transportation to [MEDICAL TREATMENT]. The Administrator said, the facility dropped the ball. A phone interview was conduct on 10/17/18 at 4:49 p.m. with MD CC. MD CC said when he came to the facility on Monday, he assessed R#312 and she was stable. The facility had informed him that a problem had occurred with transportation and that R#312 did not go to [MEDICAL TREATMENT] on Saturday . The communication sheet emailed by admissions to the transportation agency had R#312 schedule for [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday at 11:00 a.m. Review of Policy titled [MEDICAL TREATMENT], Care of the Resident Receiving [MEDICAL TREATMENT] Treatment date of issue (MONTH) (YEAR), revised (MONTH) 2, (YEAR) - Policy Statement - To prevent complications such as fluid overload, infection or clotting of the access area, or hemorrhage in residents receiving [MEDICAL TREATMENT]. #8. Arrange for [MEDICAL TREATMENT] as ordered. #9. Resident that is diagnosed with [REDACTED].",2020-09-01
255,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2017-12-21,642,D,0,1,2MCC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to accurately assess the status of one resident, Resident #89 (R#89) on return from a hospital stay related to the presence of a feeding tube which resulted in inaccurate information recorded in the Minimum Data Set (MDS) Assessment. The sample size was 35 residents. Findings include: Resident #89 was re-admitted to the facility on [DATE]. The MDS was coded in Section K, Swallowing/Nutrition Status, subsection K0510B as R#89 having a feeding tube on the 9/24/17 Prospective Payment System (PPS) five-day Scheduled Assessment. R#89 was also coded as having a feeding tube on the 9/30/17 PPS 14-day Scheduled Assessment and again on the 10/17/17 PPS 30-day Scheduled Assessment. Resident observation and interview on 12/21/17 09:16 a.m. revealed R#89 seated in her wheelchair, dressed and groomed. She greeted this surveyor with smiles and hello and stated she was doing well today and ate some of her breakfast which she could not recall what that was. No feeding tube was visible. Observation of R#89's room revealed no feeding pump at the bedside. The Assistant Director of Nursing (ADON) for the 5th floor was interviewed on 12/21/17 at 10:00 a.m. and stated the feeding was removed some time ago but she could not recall or locate the exact date in the medical record and believed she returned from the hospital without the feeding tube on 9/18/17 but could not be sure. The Administrator stated in an interview on 12/21/17 at 2:00 p.m., the feeding tube was removed on 10/2/17 at the doctor's office. She located this information in the physician's report from the office. On 12/21/17 at 4:55 p.m. interview with the Registered Dietician (RD) she stated she was not present in the facility when she completed the 10/17/17 PPS 30-day assessment which inaccurately documented the presence of a feeding tube for R#89. She relied on the accuracy of the documentation in the medical record to complete her assessment. She did not see in the chart where or when the feeding tube was removed and, thus, concluded the feeding tube still present. The Minimum Data Set assessment (MDS) Director stated on 12/21/17 at 5:10 p.m. that she expected accuracy with all assessments from all assessors. She did not know the RD had not seen R#89 before completing the 10/17/17 PPS 30-day Scheduled Assessment but she did expect all assessors to confirm what was documented in the medical record for accuracy and timeliness. The Director of Nursing (DON) stated in an interview on 12/21/17 at 5:20 p.m. she expected each team member who participated in the assessment process to provide complete and accurate information always.",2020-09-01
256,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2017-12-21,761,F,0,1,2MCC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of facility data, the facility failed to ensure that expired medications and /or biological's, were not available for resident use in four of four medication storage rooms and one of three medication carts reviewed. Sample size was 42. Facility census was 217. Findings include: 1. On 12/20/17 at 8:45 a.m. an observation of the 2nd floor medication room with the medication nurse NN was conducted. Expired were six Hemorrhoid Suppositories- dated as expired 9/17. 2. On 12/20/17 at 8:20 a.m. an observation of the 3rd floor medication room with medication nurse MM was conducted. The room was cluttered with various new and old supplies. Expired medications were found as follows: 1. One vial [MEDICATION NAME] Tromethamene Ophthalmic Solution 0.4%- expired 8/08 2. One vial [MEDICATION NAME] Purified Protein 5Tu/0.1 ml, label written opened 11/1/17- manufacture instructions on the box recommends to not use 30 days past opening. 3. Two vials of [MEDICATION NAME] HCL 25 mg injection- expired 10/15/17 4. Two vials Pneumococcal Vaccine 0.5 ml vials- expired 11/12/17 5. Six Promethagan HCL Suppositories 25 mg each- expired 4/17 3. On 12/20/17 at 9:50 a.m. an observation of the 4th floor medication room with medication nurse OO was conducted. Expired medications were found as follows: 1. One Glucerna 1.2 (a dietary supplement) 237 ml can- expired 5/1/17 2. Twenty-eight NaCl 0.9% 5 ml (used for inhalation) expired- 5/09 4. On 12/20/17 at 10:10 a.m. an observation of the 5th floor medication room with medication nurse PP was conducted. Expired medications were found as follows: 1. One Artificial Tears Ointment 1.5% 3.5 grams- expired 11/17 2. Twenty-five vials [MEDICATION NAME] HCL injection 25mg/ml- expired 11/17 5. On 12/21/17 at 10:29 a.m. an observation and review of the 3rd floor medication carts with medication nurse RR reflected two floor stock medications (on cart #2) were expired as follows: 1. One opened bottle of [MEDICATION NAME] 80mg tabs- expired 11/17 2. One opened bottle of Aspirin 325 mg tabs- expired 11/17 During an interview on 12/20/17 at 8:45 a.m. with medication nurse MM on 3rd floor he explained that there is a medical supply vendor and that the pharmacy has monthly pickup for discarded/unused medications. Delivery of medications comes from the vendor pharmacy up to three times daily. He confirmed they have had no problems getting ordered medications. He confirmed it was the floor nurse's responsibility to take care of the medication storage room. During an interview on 12/20/17 at 9:15 a.m. with nurse NN she confirmed the process is that expired/or unused medications are destroyed on the weekend, where she will box them up and place in the Assistant Director of Nurse's (ADON) office which is locked. During a phone interview on 12/2/17 at 5:17 p.m. with one of the facilities Pharmacist Consultants SS the pharmacist stated he does monthly visits to the units. He confirmed that it was the floor nurse's responsibility to pull unused and expired medications and write them up on a facility form called Certificate Inventory & Destruction. The pharmacist stated that the Director of Nursing (DON) will then sign off and help reconcile the medications which are boxed up and picked up by the pharmacy vendor. He further stated he does monthly audits on all the medication carts; and had not seen any significant issues of expired medications. During an interview on 12/21/17 at 8:15 a.m. with the DON in her office, she stated that it was a combination expectation of both the medication Licensed Practical Nurses (LPN's) and the specific unit managers to maintain the medication storage rooms including supplies and medications. She confirmed they were responsible for removing unused and expired medications and medical/equipment supplies. She also stated that once yearly the facility has a nurse consultant look at medication storage and she thought they might be needed more often and have a look again. Review of facility policy 1.2 Provider Pharmacy Requirements dated 5/16, confirms it is the pharmacy's responsibility to provide regular and reliable pharmaceutical services to residents with prescription and non-prescription medications, services and related equipment and supplies. Review of facility policy 1.3 Consultant Pharmacist Services Provider Requirements dated 11/16, reflects at Procedures Section (4f) that quality assurance (random) inspections of medication storage areas, carts and rooms at appropriate intervals to check for proper storage, cleanliness and dating of medications. This is a random check for oversight of systems in place for medication storage, not a three-way audit, nor a complete check of all medications at the nursing care center. This includes checking of the emergency medication supplies (kits) to ascertain that they are properly maintained and that the contents are not outdated. Recommendations from these inspections are included in the consultant's reports. A review of facility policy 4.1 Medication Storage/Storage of Medication, dated 5/16 was conducted. In Section #14, the documentation reflects that outdated, contaminated, discontinued or deteriorated medication and those in containers that are cracked, soiled or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exits. In Section #16 in the above policy, documentation also reflects that medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken.",2020-09-01
257,NURSE CARE OF BUCKHEAD,115129,2920 PHARR COURT SOUTH NW,ATLANTA,GA,30305,2017-12-21,880,F,0,1,2MCC11,"Based on observation, interviews and record review, the facility failed to maintain an effective infection prevention and control program that demonstrated ongoing surveillance, recognition, investigation and control of infection to prevent the onset and spread of infection. The sample size was 42. Findings include: Review of the Infection Control Monthly/Yearly Report from 1/17 to 11/17 revealed the facility did not have collected surveillance data for five out of 10 months (June through October). During interview with Director of Nursing (DON), the Infection Control Preventionist (ICP) on 12/21/2017 at 7:41 a.m., reported the facility's Infection Control Nurse had taken another position in the facility and the facility had been without a nurse in that position for several months. The DON stated I just started the infection control duties in September. Further interview with the DON stated, she did not know where the infection control tracking data for the five missing months (June through October) was. She stated she checked with the previous employee, and she doesn't have any data for those months. Review of facility's undated policy titled Infection Prevention and Control Program Overview indicated the major activity of the program is surveillance of infections with implementation of control measures and prevention of infections. The policy further explained that the Infection Preventionist (IP) monitored the resident infection cases and completed the line listing of infections and monthly report forms. The IP would then report to the Infection Prevention Committee, reports to the DON, and provided feedback to staff as needed. Compliance with the infection prevention practice is monitored and documented by staff evaluation and observation of practices. The DON was interviewed on 12/21/17 at 7:41 a.m., about the infection rates being between 2.33% and 7.6%, and she stated she does not know why, and re-stated that she assumed the responsibility of Infection Control in (MONTH) (YEAR).",2020-09-01
258,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2017-01-19,371,E,0,1,URZZ11,"Based on observation and staff interview and record review of the facility' policy, Food Storage Principles, the facility failed to properly label food in one walk in cooler and maintain two ceiling vents over a kitchen prep table to prevent contamination of foods. This deficient practice had the potential to affect 92 residents receiving an oral diet. The census size was 94 ninety-four. Observation on 1/17/2017 at 10:10 a.m., of the walk-in cooler revealed the following food items to have the following descriptive label and expiration dates: Blue berries date 12/16 Buttermilk dated 2/16 Interview with the Dietary Manager (DM), at this same time, verified the dates of both items. Interview on 1/19/17 at 3:10 p.m., with the DM revealed that dietary staff had mislabeled the food items. She revealed that dietary staff had omitted adding the year on the label of both items and stated that the year on the buttermilk should have been labeled as 2/16/2017 and the blue berries should have been labeled as 12/16/2017. The Dietary Manager revealed that both food items had Used by Dates that was prior to being opened and her dietary staff had forgotten to write the word Used by per her recommendation for labeling food items. The DM further revealed that her expectation is for all food items to be labeled correctly in the cooler after being opened and stored. Interview on 1/19/17 at 8:10 p.m. with the Administrator revealed that her expectations are that all food items are to have proper dates at all times. Review of the Facility Policy Food Storage Principles revealed a statement that documents: Label each package, box, can, etc. with the expiration date, date of receipt, or when the item was stored after preparation . Observation on 1/19/17 at 1:10 p.m., of the kitchen observed two (2) ceiling vents containing moss and leaves and under the vents was one prep table. Further observation of the vents revealed an absence of a screen between the metal openings that would had prevented the moss and leaves from escaping. Below the vents, on the prep table, was a mixer that had been washed but was observed to be uncovered mixer and six (6) sandwiches wrapped. Interview with the Dietary Manager, at this time of the observation, revealed that sandwiches were prepared earlier on the prep tab by dietary staff and the mixer should not have been left uncovered. She verified that the substances in the vents were leaves and moist. She further revealed that she was unaware of the leaves and moss present in the ceiling vents. She revealed that the maintenance supervisor was responsible for cleaning the vents and not the kitchen staff. Interview on 1/19/17 at 2:40 p.m. with the Maintenance Supervisor revealed that the vents are cleaned monthly by the maintenance dept. He reported that this was the first time he had observed any leaves or moss was observed in the vents. He reported cleaning the vents on 12/27/16. He later revealed that the leaves and moss entered the kitchen vents from a large opening from a vacuum air vent located on the roof of the kitchen. Interview and observation on 1/19/17 at 2:40 p.m., with the Administrator revealed that her expectations were for the vents to be free of debris. The Administrator verified that the substances were leaves and moss.",2020-09-01
259,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2018-11-08,574,D,0,1,LI3X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to post, in a manner accessible to all residents, a list that included names, mailing address, and email address of all pertinent State agencies and advocacy groups. The facility census was 82 residents. Findings include: During the initial tour on 11/5/18 at 10:39 a.m. an interview was conducted with the Family Member of R#18. R#18 has a Brief Interview Mental Status Score (BIMS) of 3 (three), a score of 3 out of 15 indicates cognitive impaired. The interview revealed that the Family Member of R#18 has had a history of [REDACTED]. This family members verified being provided with the facility business card that listed a complaint call line at the time of R#18 's admission to the facility. The business card was later identified during the survey as a complaint line for the facility Corporate Hotline Number for complaints. When asked if he was familiar with the location of posting of the State Agency contact informaiton He answered No, and requested assistance. During a group interview 11/7/18 at 9:54 a.m., with the facility Resident Council Members five of the seven residents revealed they were unaware of the identifty of the Ombudsman and their right to contact the Ombudsman's Agency. All five (5) residents revealed they wanted to know about the Ombudsman's Role as an Advocacy for the Residents. Residents also verified being unaware of the location of the Ombudsman and State Agency contact information. Observation on three of four (3/4) days during the time frame of 11/5/18 at 11:00 am. 2:00 p.m., and 4:00 p.m., and 11/6/18 at 8:00 a.m., 2:00 p,m., and 4:00 p.m. and 11/7/18 at 8:00 a.m., 3:00 p.m. and 5:00 pm. revealed that there was no posting of the State Agency or the the Ombudsman contact information in a location that was visible to residents and families. On 11-7-18 at 11:05 a.m. during tour of facility (walk through of the halls and common area) with the Administrator (ADM) and the Activity Director (AD), they both confirmed there was no State Office Information Poster, or any information for reporting abuse or grievance at or near the front entrance of the facility. The ADM and AD also confirmed that the Ombudsman poster was not by the front entrance but posted by the entrance door on TCU Hall (which was the rehab unit) and indicated it was an entrance that visitors and ambulance people enter thru. When asked If this was an entrance, then why staff failed to post the Medicare/Medicaid notice of survey sign on the door? The ADM did not provide an answer. They acknowledged the fact that there was not a survey notice sign on the door but had no explanation why it was not posted. During tour (a walk-through of the halls) of LTC Hall, Rear facility Hall and TCU Hall on 11/7/18 at 11:09 a.m. with the Administrator and the Activity's Director (AD) revealed that there was not any State Agency Contact information found, this was confirmed by the Administrator. The AD revealed they were not aware of the poster we were talking about, but the information was available for residents, family, visitors. They said it was posted/located by the nurses station on TCU Hall on the Family bulletin board, and on LTC Hall. Tour of TCU and LTC halls revealed a typed sheet titled Grievance and Abuse Contact Information which had names and phones numbers listed. It was located and posted above the eye level of this surveyor standing up, approximately 5 and 1/2 feet. Observation on 11/7/18 at 11:51a.m. revealed that State Agency Contact number was posted but not clearly defined as to what the contact number is to call for complaints for the State Office or that it the number identified as the complaint line for the State Office Reporting Agency. The number was listed on the bottom page of eight inches by ten inches (8 x10) sheet/form titled Grievance & Abuse Contact Information. Further review of the form revealed a complied list of various advocacy numbers. The font size was observed to be small. The form failed to provided all contact information for each Survey agency including email and mailing addresses. A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal nursing facility regulation, including but not limited to resident abuse, neglect, exploitation, misappropriation of resident property in the facility, and non-compliance with the advanced directives requirements and requests for information regarding returning to the community Observation and Interview on 11/7/18 at 11:30a.m., revealed that R#333 came by in her wheelchair, said its fuzzy to me and could not read it. During an interview on 11/7/18 at 11:48 a.m. the Maintenance Technician was asked to measure the height of the contact numbers located on a cork bulletin board on TCU Hall, and in a frame on the wall located by the nurse's station on LTC Hall. The Maintenance Technician verified the posted sheet measurements on LTC hall were 59 3/4 (three and a fourth inches) from the floor to bottom of frame and 71 1/2 (one half inches from floor to top of frame. On the TCU hall the measurements were 61 1/2 inches from floor to bottom of page and 72 1/4 (one and a fourth inches) from floor to top of page. During an interview on 11/7/18 11:53 a.m. R#53, who has a (BIMS) Score of 13 indicating that the resident is cognitively intact, said I can ' t see that (referring to the Grievance & Abuse info sheet). I can ' t see that and said he had never seen that sign before. During an interview on 11/7/18 at 12;09 p.m., of the 8 inch x10 inch posting in the frame on Hall LTC with R#8, with the Administrator and the Social Service Director present revealed that R#8 stated that the print size was blurry Interview on 11/8/18 at 1:30pm with R#77 (BIMS-15) stated that he did not know where the State Agency contact information was located and was only in the building for rehab. R#77 also verified receiving noneducational information both verbally and nonverbal about the Ombudsman and was unfamiliar with the location of the Ombudsman Posting. However R#77 was able to provide a business card from his wallet that listed the Corporate Office Hotline number. He reported that he was given this number at admission and advised to call about any problems. He further stated that this was the only contact number provided by the facility staff., he was given as a contact if he had any problems or complaints Interview on 11/8/18 at 1:34 p.m. with the Family of R#17 stated that did not have contact number for the state agency and that he was unaware where the State number is located. He reported that he was unaware that the State had a contact number to call and that he was not familiar with the Ombudsman contact sign and what is an Ombudsman 's job duties and how they assist residents. R#17 provided a card of the contact number provided by the facility company showing a contact number. R#17 revealed that he was given this number to contact for any concerns. The business card was identified as the Corporate Hotline Number) which was provided by the facility staff. Interview with the Wound Nurse on11/8/18 at 1:37pm revealed that she was informed to contact the State Office to file a complaint by calling [PHONE NUMBER] (Corporate Hotline Number) which is in the break room on a bulletin board. and that a number is posted on the bulletin by the time card machine. During observation at the time of the interview with the Wound Nurse on 11/8/18 at 1:40 p.m., the Wound Nurse confirmed the absence of the State Agency contact information was not the State Agency contact information. Interview on 11/8/18 at 2:00 p.m. with a group of staff 4 (four) Certified Nursing Assistants, , (1)one Housekeeper, and (1) Licensed Nurse(LPN) in the break room revealed that they had been informed that the State Agency contact number was located on the board of the staff break room. Further review revealed that the break room revealed that the number was observed to be [PHONE NUMBER]. and was identified as the Corporates Compliance Hotline.",2020-09-01
260,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2018-11-08,636,D,0,1,LI3X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete a Minimum Data Set (MDS) Discharge Assessment for one resident (R#1) out of 30 sampled residents. Findings include: Resident admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Record review for R#1 revealed a completed MDS Admission assessment dated [DATE], MDS Discharge assessment dated [DATE] with return anticipated, and a MDS Admission assessment dated [DATE]. No other comprehensive assessments were documented for R#1. Resident was discharged home from the facility on 6/20/2018. An interview on 11/08/2018 at 8:14 a.m (AA) LPN MDS Case Manager revealed the resident was readmitted on [DATE] and was discharged home on[DATE]. She verified that a discharge MDS was not completed on the resident after he was discharged . She stated her process consists of pulling the MDS schedule off of the computer, prints it and puts the residents names and type of assessment due on a paper calendar. She does this monthly. She looks in the computer daily for new admissions, discharges or any change in payer types and opens up the assessments in the system. She adds or removes assessments on paper calendar as needed. She stated when a resident goes from a skilled type assessment to a non skilled assessment (ie: Medicaid) the dates change. She stated she did receive a call from the State informing her of the late/missing assessment.",2020-09-01
261,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2018-11-08,656,D,0,1,LI3X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, the facility failed to follow the care plan for one resident R#60 who received an intravenous (IV) medication. The sample size was 30 residents. Findings include: Record review revealed R#60 was an [AGE] year old female re-admitted to the facility on [DATE] with a diagnosis' that include [MEDICAL CONDITION], hypertension, pneumonia, and urinary tract infection. The Admission Minimum Data Set ((MDS) dated [DATE] revealed section C-Cognition with a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impaired cognition. An observation of R#60 made on 11/05/2018 at 12:44 p.m. revealed a peripheral Intravenous (IV) catheter located in the residents left arm. The dressing covering the IV site was not dated and had blood in the catheter tubing. Review of R#60's care plan revealed resident receiving IV therapy for [MEDICAL CONDITION] to sacral region, with a goal indicating resident will remain free of complications of IV therapy throughout course of treatment. The Care Plan Interventions include dressing changes and IV site changes as ordered (per facility protocol), IV therapy per MD order, monitor IV site for potency, flush as ordered, and observe for signs and symptoms of infection/infiltration and notify MD if needed. Interview on 11/06/2018 at 7:50 a.m. with LPN MM who verified R#60 is no longer on IV medications. Interview on 11/07/2018 at 8:55 a.m. with LPN BB revealed R#60 was no longer on IV medications and was not aware resident has a IV in her arm. She verified according the the residents current orders that there are no orders to flush the IV, change the IV, or to change the IV dressing. She stated she has not had any inservices on medication administration and/or IV administration. She stated she is unsure of the policy and if the IV was a PICC line or a peripheral line. Interview on 11/07/2018 at 10:41 a.m. with R#60 revealed the nurse came in and removed the IV. She also stated the IV had not previously been changed or the dressing changed since she has been here. She stated they have not been doing anything to the IV. She stated they had troubles with it and the antibiotic would go in very slow. Interview on 11/08/2018 at 11:05 a.m. with the Director of Nursing (DON) revealed when a resident has an order for [REDACTED].#60 did not have any flush order, order to check IV site or order to change the dressing during treatment or currently. He also stated the IV should have been pulled after the resident finished the antibiotics, he stated the nurse should have called the MD for an order to remove the IV. Cross reference Tag F694",2020-09-01
262,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2018-11-08,694,D,0,1,LI3X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation,staff and resident interview, record review, and review of policy titled Guidelines for preventing Intravenous Catheter-Related Infections the facility failed to get a physicians order for peripheral intravenous (IV) dressing changes, IV catheter flushes, IV site observation or IV catheter needle changes since re-admission to the facility on [DATE] with IV antibiotic orders for one resident (R) (R#60). The sample size was 30 residents. Findings include: Record review revealed R#60 was an [AGE] year old female re-admitted to the facility on [DATE] with a diagnosis' that include [MEDICAL CONDITION], hypertension, pneumonia, and urinary tract infection. The Admission Minimum Data Set ((MDS) dated [DATE] revealed section C-Cognition with a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate impaired cognition. An observation of R#60 made on 11/05/2018 at 12:44 p.m. revealed a peripheral IV located in residents left arm. The dressing covering the IV site was not dated and had blood in the catheter tubing. An observation of R#60 made on 11/06/2018 at 7:50 a.m. revealed resident sitting up in bed, noted the dressing for the peripheral IV in left arm was not dated. Blood was noted in the catheter tubing. An IV pole and pump was noted beside bed. An observation of R#60 made on 11/06/2018 at 4:12 p.m. revealed resident up in a wheelchair in her room, noted the dressing for the peripheral IV in left arm was not dated. Blood was noted in the catheter tubing. Review of R#60 Medication Administration Record [REDACTED]. No order for a peripheral IV flush, IV site monitoring for infection/infiltration/potency, or IV dressing changes noted on MAR for (MONTH) or November's MAR. MAR for (MONTH) (YEAR) indicated resident did not receive the IV antibiotic on 10/28/2018 and 10/29/2018 due to code 9 which indicates other: see nurses notes. The administration box for 10/27/2018 was blank. The MAR for (MONTH) (YEAR) indicated the administration box for 11/1/2018 was blank. The medication was given on 11/2/2018 and 11/3/2018. Review of R#60's Progress Notes revealed a note dated 10/28/2018 at 7:34 a.m., 11/1/2018 at 11:31 a.m., and 11/1/2018 at 11:53 a.m. indicating an alert for a possible drug allergy to the [MEDICATION NAME]. There was no indication the alert was called to the physician or the medication was changed. Further review of the Progress Notes revealed a note dated 10/28/2018 at 12:44 p.m. that the Cefpine Solution was not available and was ordered from the pharmacy. A Progress Note dated 10/29/2018 at 9:03 a.m. revealed the pharmacy sent the wrong medication. A Progress Note dated 10/28/2018 at 21:14 p.m. indicated IV to left AC intact. A Progress Note dated 10/30/2018 at 4:56 a.m. indicated left arm IV site dressing remains dry and intact, IV flushed with 10 cubic centimeter (cc) normal saline (NS). A Progress Note dated 11/2/2018 at 22:06 p.m. indicated resident receiving IV Cefpine for [MEDICAL CONDITION] to sacral region via peripheral line in her left arm. IV patent and flushed with NS before and after medication administration. No adverse reactions noted. A Progress Note dated 11/3/2018 at 15:29 p.m. indicated IV site in right arm is flushed and patent without signs and symptoms of infiltration noted. A Progress Note dated 11/6/2018 at 4:05 a.m. indicated IV site to left arm patent with dressing dry and intact. Review of R#60's care plan revealed resident receiving IV therapy for [MEDICAL CONDITION] to sacral region, with a goal indicating resident will remain free of complications of IV therapy throughout course of treatment. The Care Plan Interventions include dressing changes and IV site changes as ordered (per facility protocol), IV therapy per MD order, monitor IV site for potency, flush as ordered, and observe for signs and symptoms of infection/infiltration and notify MD if needed. Interview on 11/06/2018 at 7:50 a.m. with MM LPN who verified R#60 is no longer on IV medications. Interview on 11/07/2018 at 8:55 a.m. with BB LPN revealed R#60 was no longer on IV medications and was not aware resident has a IV in her arm. She verified according the the residents current orders that there are no orders to flush the IV, change the IV, or to change the IV dressing. She stated she has not had any inservices on medication administration and/or IV administration. She stated she is unsure of the policy and if the IV was a PICC line or a peripheral line. Interview on 11/07/2018 at 10:41 a.m. with R#60 revealed the nurse came in and removed the IV. Resident stated someone came in and removed the IV. She also stated the IV has not been changed or the dressing changed since she has been here. She stated they have not been doing anything to the IV. She stated they had troubles with it and the antibiotic would go in very slow. Interview on 11/08/2018 at 11:05 a.m. with the Director of Nursing (DON) revealed when a resident has an order for [REDACTED].#60 did not have any flush order, order to check IV site or order to change the dressing during treatment or currently. He also stated the IV should have been pulled after the resident finished the antibiotics, he stated the nurse should have called the MD for an order to remove the IV. Review of the facility Policy titled guidelines for preventing Intravenous Catheter-Related Infections without a reference date revealed under the heading of General Guidelines b. proper procedures for the insertion and maintenance of IV catheters. Under the heading of Surveillance indicated observe the insertion site every shift, on admission, and with dressing changes. Observe visually or by palpation through the intact dressing. Under the heading of Catheter Site Dressing Regimens indicated to change initial dressing after placement within 24 hours, monitor the catheter site visually during dressing changes. Under the heading of Replacement of IV Catheters indicated a peripheral short catheter can stay in place no longer than 96 hours, if left in place longer than 96 hours, an facility must obtain a physicians order to keep catheter in place. Remove catheters at the end of treatment if there are no further plans for use of the catheter. Under the heading of Documentation indicated to record the appearance of the insertion site, catheter and dressing in the residents medical record.",2020-09-01
263,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2018-11-08,759,D,0,1,LI3X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and review of the policy titled Medication Pass Guidelines the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 31 medication opportunities were observed, and there were six errors for three of three residents (R) (R#71) and (R#76) and (R#60) by one nurse (LPN BB), that was observed administering medications. The error rate was 19.35%. The facility census was 82 residents, and the sample size was 30 residents. Findings include: Review of Policy titled Medication Pass Guidelines revised 4/25/17 reviewed Physicians Orders- Medications are administered in accordance with written orders of the attending physician. The Purpose of the policy is to ensure the most complete and accurate implementation of physicians medication orders and to optimize drug therapyfor each resident by providing for administration of drugs in an accurate, safe, timely, and sanitary manner. Administer medications within 60 minutes of the acheduled time. Observations made during medication pass to R#71 on 11/07/2018 at 8:13 a.m. with Licenced Practical Nurse (LPN) BB revealed an order for [REDACTED]. an order for [REDACTED]. an order for [REDACTED]. Observations made during medication pass to R#76 on 11/07/2018 at 8:30 a.m. with LPN BB revealed an order for [REDACTED]. The nurse varified she had a [MEDICATION NAME] 500mg tablet available but stated is was not scorable. Observations made during medication pass to R#60 on 11/07/2018 at 8:50 a.m. with LPN BB revealed an order for [REDACTED]. The medication was unavailable as a floor stock medication or on a medication punch cart for the resident and was not given to the resident. Review of the Physician order [REDACTED].>Review of the Physicians Orders for R#76 for (MONTH) (YEAR) revealed an order for [REDACTED].>Review of the Physician order [REDACTED]. Interview held on 11/07/2018 at 8:27 a.m. with LPN BB revealed she stated when medications are not available she reorders them in the computer, pulls the label and faxes it to the pharmacy and looks in the Omnicell medication dispencer, if not available in the machine she calls the pharmacy. She stated she did not understand how the back up pharmacy works. She usually is in Medical Records and not on the medication cart. Interview on 11/08/2018 at 11:05 a.m. with the Director of Nursing (DON) revealed his expectations are when a resident is down to approximately seven pills left on a medication card the nurse is to re-order the medications in the computer. They can also pull the re-order labels and fax them to the pharmacy. When a resident is admitted to the facility the orders are checked and if a medication is not on the formulary the physician is contacted and a new order is received.",2020-09-01
264,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2018-11-08,773,D,0,1,LI3X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure prompt notification to the physician of laboratory results that fall outside of the clinical reference range for two residents, Resident (R#25) and (R#80) out of a sample of 30 residents. Findings include: 1. Review of the laboratory results for R#25 revealed that a [MEDICAL CONDITION]-stimulating hormone (TSH) was drawn and results reported back to the facility on [DATE]. There was no documentation revealing that the attending Physician was notified of the results. There was no documentation in the clinical record to indicate that these labs were received on 9/26/18 or reviewed or that the attending Physician was aware of the results, thereby giving him the opportunity to evaluate and treat the resident. The following result were flagged by the laboratory as being out of the clinical reference range: TSH (a test done to find out if your [MEDICAL CONDITION] is working the way is should) Reference range: 0.35-5.50 ulU/mL test result: 0.02 (L) indicating that it was low. Review of the Progress Note section of the medical record did not contain any information about the above-mentioned lab results or notification to the attending physician. On 11/7/18 after identification of the lab concerns the facility notified the Physician and received an order to send the resident to the hospital. During an interview on 11/07/18 at 1:02 p.m. with the Director of Nursing (DON) revealed that when a lab is received, the nurse should document that the Physician had been notified of results. Continued interview revealed that facility Medical Director only wants to be notified of critical lab results. Further interview revealed that DON confirmed that there was no documentation supporting that the Physician had been notified of the abnormal lab results. During an interview on 11/08/18 at 10:30 a.m. with the DON revealed that the facility does not have a policy specific to reporting abnormal labs to the physician. During the interview the DON provided a document titled Changes in Condition Guideline with no date noted on the guideline. Review of document #2. A significant change in the resident's physical, mental, or psychosocial status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications. The following has been generated as part of the facilities quality assessment and assurance process and constitutes confidential quality assurance committee record. Ref.42 CFR 483.75(o). This is not a policy and used as a guideline only. Further interview with the DON, at this time, revealed that it depends on the severity of the lab results if the physician is notified. 2. Resident (R) R#80 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the laboratory results for R#80 revealed that a [MEDICAL CONDITION]-stimulating hormone (TSH) was drawn and results reported back to the facility on [DATE]. There was no documentation revealing that the attending Physician was notified of the results. There was no documentation in the clinical record to indicate these labs were received on 7/24/2018 or reviewed or that the attending physician was aware of the results, thereby giving him the opportunity to evaluate and treat the resident. The following result were flagged by the laboratory as being out of the clinical reference range: TSH (a test done to find out if your [MEDICAL CONDITION] is working the way is should) Reference range: 0.35-5.50 ulU/mL test result: 49.98 (H) indicating that it was high. Review of the Progress Notes dated 7/26/2018 and 8/2/2018 did not contain any information about the above-mentioned lab results or notification to the attending physician. The Physician indicated a [DIAGNOSES REDACTED]. Review of the residents Medication Administration Record [REDACTED]. Resident was discharged home on[DATE]. Interview with the Director of Nursing (DON) on 11/8/2018 at 11:31 p.m. revealed his expectations are that the nurses are instructed to check the labs daily. The nurses are expected to review the labs, call the Physician with any abnormal labs, receive orders if indicated and write any new orders. He also expects the nurses to make a note in the progress notes that the physician was notified. Further interview revealed that DON confirmed that there was no documentation supporting that the physician had been notified of the abnormal lab results. He also revealed the facility does not have a policy specific to reporting abnormal lab tests to the physician.",2020-09-01
265,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2018-11-08,880,E,0,1,LI3X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy Preventing Spread of Infection 2001 MED-PASS, Inc. (Revised (MONTH) 2012), and staff interview, the facility failed to ensure that a Certified Nursing Assistant (CNA) properly disposed of contaminated water and wash her hands with soap and water after providing care for one (1) resident (R) (R#70) of two (2) residents reviewed for transmission-based precautions (TBP) and the facility failed to serve food to the residents in a sanitary manner, for three meals observed over two days Findings include: 1. Review of policy provided by the facility revealed that In addition to Standard Precautions, implement Contact Precautions for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the resident's environment. Under section titled Gloves and Handwashing Sections B. While caring for a resident, change gloves after having contact with infection material (for example, fecal material and wound drainage. C. Remove gloves before leaving the room and perform hand hygiene. R#70 was admitted on [DATE] with a [DIAGNOSES REDACTED]. diff), a bacterium that can cause symptoms ranging from diarrhea to inflammation of the colon. Review of his medical record revealed that he was being treated with [MEDICATION NAME] (an antibiotic) for sixteen (16) days and had been placed on isolation/contact precautions. On 11/6/18 at 12:05 p.m., Certified Nursing Assistant (CNA) HH was observed providing incontinent care for a dependent resident. A kit with Personal Protection Equipment (PPE), i.e., gowns, gloves and masks, was observed hanging on the resident's room door. CNA HH donned a gown, and gloves before providing care. CNA HH performed care with three washcloths soaked in a basin of soap and water. CNA HH put all washcloths with fecal matter on them in the basin of soap and water and disposed of the dirty water in the sink in the bathroom in the resident's room. Continued observation revealed CNA HH wiped the basin with a paper towel, put the basin in a plastic garbage bag and placed the basin on the shelf in the bathroom. CNA HH put the dirty paper towel in a trash can, removed her gloves, tie the garbage bag closed, removed the garbage bag from the garbage can and walk out of the room with it in her hands. CNA HH walked down the hallway and placed the garbage bag in a bin in the soiled utility room. CNA HH did not wash her hands with soap and water before leaving the resident's room. During an interview on 11/06/18 at 1:30p.m. with CAN HH revealed that she did provide incontinent care on dependent R#70. Continued interview with CAN HH revealed that she cleaned stool from R#70 with washcloths soaked in soap and water, placed the dirty washcloths in the basin of soap and water after each use and then placed them in a plastic garbage bag. Further interview revealed that CAN HH revealed that she stated that she emptied the dirty water in the sink, wiped the basin with a paper towel and then placed the basin in a trash bag for storage in the resident's bathroom. CNA stated that she took the garbage and dirty linen bags to the soiled utility room and placed the garbage in the trash can and the linen in the regular dirty linen container. CNA stated that she's not sure if the linen or garbage needed to be placed in a bio hazard bag. CNA HH verified that she didn't perform hand hygiene before leaving the resident's room. During an interview on 11/06/18 at 1:45 p.m. with the Housekeeping Supervisor revealed that when a resident is on contact precautions their laundry should be placed in a sugar bag and then sent to the laundry department to be washed. Continued interview revealed that the facility hasn't had sugar bags for a long time. During an interview on 11/06/18 at 1:50 p.m. during interview with the Infection Control Nurse revealed that it her expectation for staff providing care for a resident on TBP to gown and glove up before entering the resident's room. Stated that all linen is considered contaminated and is not required to be placed in a special bag. Continued interview revealed that she stated that it would be accepted practice for staff to throw water that has been used to clean stool from a TBP resident down the sink in the resident's bathroom. Further interview revealed that she stated that she would have to double check on the correct way to clean a sink after pouring contaminated water down the sink. Infection Control Nurse stated that she would expect the staff to wash their hands with soap and water before leaving the resident's room. During an interview on 11/06/18 at 2:00 p.m. with the Director of Nursing (DON) revealed that it is his expectation for staff to wear proper PPE (gowns, gloves and masks) when providing care to a resident on TBP. Stated that linen may be placed in a regular trash bag and sent with regular dirty linen because all linen is treated as contaminated in this facility. Continued interview revealed that garbage and dirty linen from [DIAGNOSES REDACTED] doesn't have to be placed in bio hazard bags for disposal. Further interview with DON revealed that it his expectation for dirty water to be disposed of down the toilet and not in a sink in a resident's room. Stated that if dirty water from [DIAGNOSES REDACTED] was put down the sink, the sink would have to be cleaned with a product that it known to kill the [DIAGNOSES REDACTED] spores. Review of the facility in-service with content: Providing care to residents on contact based precautions, Disposal of dirty water after incontinent episode in room with contact precautions, Hand hygiene for transmission based precautions rooms, Disposal/Handling laundry for contact precautions room, ADL care when residents on contact precautions dated 11-6-18 revealed that CNA HH attended the in-service. Further review of in-services dated 9-4-18 and 9-26-18 with the content: Isolation Precautions when suspecting contagious conditions/Contact precautions, Infection Control and Prevention, Contact Isolation Rooms, Providing Care in Rooms, and Hand Hygiene revealed that CNA HH attended both of the in-services. 2. Observation on 11/5/18 in the main Dining Room between 11:55 a.m. to 12:40 p.m., 16 residents sitting at ten tables and being served by four staff. Three residents were assisted in eating by two CNA's and one resident was observed and assisted by another staff. Staff used hand sanitizer mounted on the wall in the dining room. The CNA assisting were talking to the residents and prompting them to eat. It was a homelike environment with table cloths, small arraignment on table, regular plates, utensils, glasses & napkins. Observations on 11/6/18 between 8:00 a.m. and 8:45 a.m. in the dining room revealed 14 residents were seated at ten tables, being served breakfast by four certified nursing assistants (CNA ' s) and one licensed practical nurse (LPN). Hand sanitizer was mounted on the wall in the dining room. Observation on 11/5/18 at 8:15 a.m. revealed LPN DD handled the side of the open food cart, removed the tray from the cart and served the resident by placing the plate, napkin with utensils, and fluids on the table. Observation on 11/5/18 at 8:20 a.m. revealed that LPN DD touched the resident ' s wheelchair, and repositioned the chair she was sitting in, then started feeding Resident (R) # 38. LPN DD did not sanitize her hands after touching the chairs or cart, and before starting to feed the resident. Observation on 11/5/18 at 8:23 a.m. revealed that LPN DD touched the table while feeding R # 38, she got up from the table and touched the chair when getting up. LPN DD went to the kitchen door and requested something from dietary staff. LPN DD came back to the table, sat down, touched the arm of the chair pulling it closer to the table and did not sanitize. The Dietary manager brought an extra bowl of grits and juice from the kitchen. LPN DD picked up the meal slip and look at it, added butter to the bowl of grits, and started mixing it up, she had not sanitized her hands since getting up from the table. Observation on 11/5/18 at 8:30 a.m. LPN DD got up to check on Resident # 68, at the same table and had started coughing, she said something to CNA EE who was feeding R # 68 and CNA EE took over feeding R # 38. CNA EE picked 68 ' s (the one who was coughing and taken out of the dining room) plate lid/cover, placed it over his plate and started back feeding R # 38, she did not sanitize hands. Observation on 11/6/18 at 12:22 p.m. revealed CNA EE feeding a resident in the dining room during the lunch meal with hands that had touched items and did not sanitize hands. CNA EE touched her shirt, put her hands in her lap, touched the straw and rim of the glass while feeding the resident. Observation on 11/6/18 at 12:28 p.m. revealed CNA GG fed a resident in the dining room during the lunch meal with hands that had not been sanitized after touching items. CNA GG touched the resident ' s hand and placed her hands in her lap while feeding the resident and did not sanitize hands. Interview on 11/8/18 at 10:45 a.m. with the Director of Nursing (DON) revealed his expectation that staff follow policy and sanitize hands before handling food, the policy was requested. Review of the policy provided by the DON, titled Food Handling Practice with a reviewed date of 8/29/17, revealed policy indicated food service employees comply with strict time and temperature requirements and use proper food handling techniques to prevent the occurrence of foodborne illness. Under Fundamental Information the objective of good food preparation included receive, store, prepare, cook, hold, serve, and cool foods under sanitary conditions. Under procedure the policy indicated staff wash and sanitize hands regularly.",2020-09-01
266,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2017-11-16,225,D,0,1,MGYB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and policy Abuse & Neglect Prohibition, the facility failed to thoroughly investigate bruise of known origin noted on arm for one Resident ( R) #102 out of a sample of 29 residents. Findings include: Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed R#102 was coded total care for bath and required extensive assistance with transfer two person. The Brief Interview for Mental Status (BIMS) revealed a score of 15 out of 15 which indicates the resident is cognitively intact. Review of Quarterly Review MDS dated [DATE] reveal the resident BIMS was coded -14. Interview on 11/14/17 12:30 p.m. and 2:30 p.m., R#102 stated that when Certified Nursing Assistant (CNA) DD and another CNA GG was assisting her to transfer to the shower chair on 8/14/17, she suffered a bruise to her upper right arm. and that her responsible party took a picture of the bruise and the incident was reported to facility staff, CNA BB, the Administrator and Licensed Practical Nurse (LPN) EE who assisted with taking a picture of the bruise. She continued to state that her responsible party reported the incident and showed the photo of the bruise to the Administrator. During several interviews with the Administrator on 11/14/17 at 2:49 p.m. 11/15/17 at 10:00 a.m. and 11/16/17 at 2:10 p.m. the Administration stated she was not aware of any allegations of abuse or incident of bruises involving R#102. She also said that she was not aware of any photos or speaking with R#102 or her responsible party about the incident, nor did any facility staff tell her of an incident resulting in R#102 sustaining any injury or bruises. The Administrator stated the facility policy is to start an investigation immediately when a complaint is made from a resident. On 11/14/17 12:30 p.m. an interview was done with R#102 in her room When the resident was asked about the incident that she reported, she stated that around the time of the hurricane, two CNA's were in her room transferring her to the shower chair. She said that at the time this occurred, she was not yet able to move her legs very well and had a sore on the bottom of her foot. She stated that when she was standing up she could not move her legs and the CNA was rushing her, so she panicked and could not move at all. She said that the CNA told her rudely to sit down. She then stated that she noticed later that she had a bruise on her upper right arm. I asked her how the bruise happened and if it was associated with this same incident and the resident answered that she thought so. Interview with R#102's responsible party on 11/14/17 at 5:50 p.m. and 11/15/17 at 6:00 p.m. revealed that she had spoken with the Administrator on 8/14/17 and shared photo of the bruises on R#102 's arm. she continued to say that LPN EE assisted with the photo by holding R#102 's arm and LPN EE's hand is shown in the photo and the Administrator 's response to the photo was CNA DD will no longer provide care to R#102. Interview on 11/15/17 at 9:40 a.m. with the Administrator in regard to responsible party 's disclosing photo to her of R#102 's bruises per R#102's and her responsible party's statements. The Administrator continue to report not being aware of R#102 's incident. The Administrator stated an investigation started on yesterday. She continue to state that per her interview none of her staff were knowledgeable about R#102's incident. She said CNA DD, the alleged perpetrator was place on suspension on yesterday. She continue to state R#102 was interviewed on yesterday and she unable as to recall speaking to surveyors about the incident. Interview on 11/15/17 at 11:16 a.m. during an interview with CNA BB revealed that R#102's responsible party summoned her to R#102 's room to observe bruises on R#102's arm. CNA BB confirmed witnessing bruise on R#102's right arm and reporting this incident to a former unidentified LPN who was on duty that evening. She reported this LPN is no longer employed with the facility. She continue to report that R#102's responsible party reported to her that she has photo of the bruises. Interview on 11/15/17 at 12:53 p. m. with LPN CC revealed that she recall speaking with CNA DD sometimes during the time frame of 8/14/17. She stated that CNA DD reported being suspended and re-assignment from working with R#102. LPN CC stated that CNA DD attribute the re-assignment due to R102 allegations and complaining about her CNA DD reported the bruise occur from using a stand up lift instead of Hoyer lift. LPN CC continue to report that in (MONTH) (YEAR) , R#102 was total care and required a Hoyer lift with two person assist for transfer. LPN CC stated she was aware that a photo was taken of R#102's bruises but does not recall actually witnessing any bruises on R#102. Interview on 11/15/17 at 1:23 p.m., LPN EE verified that she was the staff holding R#102 arm in the photo. She stated that she reported the incident to the Unit Manager and the Social Worker, who also later accompanied her in R#102 room. When she exited the room R#102 's, the Unit Manager and the Social Worker was in the room conversing with R#102 and her Responsible party. Interview on 11/16/17 at 10:00 a.m. CNA DD reported being re-assigned from working with R#102 due to R#102 alleged complaint of getting a bruise during transfer. She continue saying the re-assignment is still in effect as of today and has not worked with R#102 since this incident. CNA DD stated that she and another certified nursing assistant, CNA GG was assisting R#102 with transferring using a stand up lift instead of the Hoyer. She stated that later CNA GG informed her that she R#102 was claiming that she hurt her arm. CNA GG informed her that R#102 did not want her to work with her anymore. CNA DD stated that the Administrator summoned CNA GG and her into the office to inquire about the incident. CNA DD stated that she and CNA GG was reprimand with suspension for 1 day in (MONTH) (YEAR) by Administrator. She and CNA GG was asked to write a written statement about the incident. Interview with Administrator on 11/16/17 at 2:15 p.m. she reported that she was not aware of CNA DD and CNA GG providing statements or being suspended due to any incidents or concern with R#102 or any other residents. She continue to report having no documentation in either CNAs' files in regard to issues about R#102 complaint of a incident on 8/14/17. The Administrator verified CNA GG as being currently employed. Employment files for CNA DD and CNA GG were requested for review. The Administrator did not provide employment files to show any suspension for both CNA's. She stated that only time CNA DD was sent home on suspension regarding R#102 complaint was on 11/14/17 during the investigation. The Administrator started she is actively continuing to investigate the complaint and submitted a Self-Reportable to State on 11/14/17. Review of facility policy title Abuse & Neglect Prohibition dated 8/23/16 revealed the facility will conduct an investigation of any alleged abuse/neglect etc .in accordance with state or federal law. The facility will protect residents from harm during the investigation. Review of facility Incident Report and Grievance Log, and Resident Council Minutes for the month of (MONTH) (YEAR) revealed no documentation of reports of accidents/complaints/grievances for R#102. Record review for R#102 ' s skin assessment during period of month of (MONTH) (YEAR) revealed no documentation of bruises or any skin discoloration noted to her upper right arm. Further review of weekly skin assessments for the month of (MONTH) (YEAR) revealed no documentation of any bruises or skin conditions.",2020-09-01
267,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2017-11-16,282,D,0,1,MGYB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and policy title Comprehensive Person-Centered Care Plans, the facility failed to follow the care plan to provide skin assessment and use of the Hoyer lift for transfers for one Resident R (#102). The sample size was 29 residents. Findings include: Refer to F 226 Review of clinical record revealed a Care Plan dated 7/6/17 coding for impaired skin integrity with the following interventions 1) observe skin during ADL (Activity of Daily Living) /incontinence care for any red or open areas and report to nurse 2) skin checks weekly by licensed nurse, report any skin problems to MD (Medical Doctor). Further review of Care Plan dated 7/6/17 revealed a coding for ADL Self Care performance deficit related to [MEDICAL CONDITION] immobility, debility with following interventions 1) observe for redness, open areas, scratches, cuts, bruises and report changes to the nurse 2) requires a Hoyer lift for transfers times (x 2) assist. Interview on 11/14/17 at 2:20 p.m. with R#102 revealed that Certified Nursing Assistant, CNA GG and CNA DD used a two-stand lift instead of the Hoyer lift when assisting with her transfer while in the shower room. She stated that she suffered a bruise to her upper right arm in (MONTH) (YEAR). She further stated that she has photo of the bruises which was shared with the Administrator by her Responsible party. She stated that Licensed Practical Nurse (LPN) EE was also made aware of the bruise and assisted her daughter with the photo. Interview on 11/15/17 at 12:53 p. m. with LPN DD verified being informed by CNADD that she no longer is assigned to R#102 because of injury caused resulting from using a two-stand lift instead of Hoyer lift. Reported that R#102 was assessed as total care during month of (MONTH) (YEAR) and required a Hoyer lift. Reported R#102 had a fear of falling. Interview on 11/15/17 at 1:23 p.m. with LPN EE verified observing the bruise on R#102 right upper arm and assisting R#102 with taking a photo, She further verified and identified her hand as being in the photo. She also identified the Nurse Manager, Register Nurse (RN) II as witnessing the bruise along with the Social Worker HH. She reported that R#102 was assessed for a Hoyer lift with two-person assist and was considered total care at that time. She was also informed that CNA DD and another CNA used a two stand lift instead of the Hoyer lift. Interview with Administrator on 11/15/17 at 1:30 p.m., revealed that her expectations are that her staff follow the care plan if a resident requires a Hoyer lift for transfer. She reported that she was not aware of R#102 obtaining a bruise from staff assisting her with transfers. She further stated that she expects her staff to perform weekly skin assessment per the care plan. Review of the facility policy title Comprehensive Person-Centered Care Plans dated 3/28/17 revealed the services provided or arranged by the facility as outlined by the comprehensive care plan must be provided by qualified persons in accordance with each resident 's written plan of care.",2020-09-01
268,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2017-11-16,460,E,0,1,MGYB11,"Based on observations and staff interviews, the facility failed to ensure bedrooms were equipped to afford full visual privacy for each resident during personal care, treatment or as necessary for the residents. This deficient practice was noted for sample residents on Hall 1, Hall 2, and Hall 3. Individual ceiling track for privacy curtains and the actual curtains for semi private rooms were not in place during the initial tour. The sample size was 29 . The facility census was 84 . Findings include: 1. Observation on 11/13/17 at 10:30 a.m. , 2:00 p.m. and on 11/14/17 at 9:00 a.m., 11:00 a. m., 2:00 p.m., and on 11/15/17 at 1:00 p.m. 3:00 p.m. and 5:10 p.m. revealed the privacy curtains in the semi -private rooms on hall 1, hall 2, and hall 3 did not provide full privacy. An interview with a Certified Nursing Assistant (CNA) AA, on 11/16/17 at 9:30 a.m., revealed she was unaware that semi private rooms should be equipped with full privacy curtains for both residents. She stated that resident care is alternate at various times throughout the shift due to lack of privacy curtains. 2. On 11/16/17 at 9:55 a.m. the following observations were made; in room 32 A and B - there is one curtain between the beds which when pulled it's full length is approximately one foot too short to provide total privacy between the beds. There is also one curtain which is on a track that reaches from the wall by the door to the wall beside the window around the ends of both beds. However, the curtain, when pulled to it's full length is not long enough to provide privacy for both beds at the same time. When pulled out it's full length, and touching either of the walls with one end, there is an open area where the curtain ends which is about four feet in length, leaving the other resident without full privacy. The two residents in this room require assistance from staff with Activities of Daily Living ( ADL ) care. During an interview with the Administrator at time of observation on 11/16/17 at 5:20 p.m. the Administrator verified missing tracks for privacy curtain and that actual privacy curtains were not in place for semi private rooms on hall 1, hall 2, and hall 3. She further stated that she was unaware that the semi-rooms did not provide full privacy curtains for each resident Review of facility policy title, Resident Dignity and Personal Privacy revealed the following use a closed door, a drawn curtain or both , to shield the resident during all personal care and treatment procedures.",2020-09-01
269,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2017-06-02,224,L,1,1,YO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of facility, hospital and police records and staff, resident and family interviews, staffing agencies interviews, the facility failed to ensure that staffing agency employees, utilized by the facility, complied with the facility's Abuse policy and the contract between the facility and the staffing agencies, specifically: This failure resulted in actual harm and death for one resident (R) B of 12 sampled residents. Review of the CMS Form-672, Resident Census and Condition of Residents, dated [DATE], the census was eighty five (85) 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. Immediate Jeopardy was identified to exist on [DATE], the date of the injury to R B and subsequent death, and was removed on [DATE] which was verified by the surveyor through observation, review of policies and interviews with staff. On [DATE] around 7:30 a.m., during morning care, CNA AA, held R B legs down tightly due to combative behavior of the resident then heard a crack. CNA AA alerted the nurse telling her that he found the resident in this condition. CNA AA did tell the facility what had occurred before lunchtime. R B was transferred to the hospital and it was determined that the resident had a fractured femur requiring surgical repair. During surgery the R B began to bleed excessively and did not respond to interventions. The resident was transferred to the Intensive Care Unit (ICU) and died on [DATE] at 2:12 a.m. The facility was notified on [DATE], by the hospital, that the R B had died as a result of the fracture. The facility then contacted the local police department on [DATE] who contacted the Georgia Bureau of Investigation (GBI) and CNA AA was arrested by the GBI. Review of the local police department's Incident/Investigation Report dated [DATE] at 14:57 (2:57 p.m.) arrived at the facility to begin the investigation of CNA AA and R B. The facility Administrator, Director of Nursing (DON) and the Nurse Consultant were informed on [DATE] at 9:51 a.m. that Immediate Jeopardy exists. The non-compliance related to the immediate jeopardy was identified to exist on [DATE]. The immediate jeopardy continued through [DATE]. The facility implemented a Credible Allegation of Compliance related to the immediate jeopardy on [DATE]. The facility implemented a Credible Allegation of Compliance alleging the immediate jeopardy was removed as of [DATE]. Based on observation, record reviews, review of the revised policy for background checks for agency staff and agency contracts, staff, residents and family interviews related to the abuse protocol, it was validated in the corrective actions plans that the immediacy of the deficient practice was removed. However, the facility remains out of compliance as they continue to implement systematic changes related to abuse training, screening of employees and agency staff prior to working directly with residents while management level staff continues to oversee and Quality Assurance monitors the effectiveness of the systematic changes. The Scope and Severity (S/S) was lowered as follows: F224: S/S-F, F282: S/S-F, F490: S/S-F. Findings include: Review of the facility's Policy titled Grievances-Abuse Prohibition Screening and Hiring Practices, updated (MONTH) (YEAR): 1. Screening and Hiring Practices: [NAME] The center will conduct a thorough investigation of the histories of individuals being considered for hire, in addition to the inquiry of the State Nurse Aide Registry or licensing authorities. All reasonable efforts will be made to check references and information from previous and/or current employers to uncover information about any past criminal prosecutions. B. The screening of all applicants will involve the following: 1. Background investigations 2. Criminal Records Check for Pre-employment Screening 3. Substance Abuse C. Prior to hiring an employment applicant, the center shall request a criminal record check from Georgia Crime Information Center (GCIC) to determine whether the applicant has a criminal record. A nursing home shall make a written determination for each applicant for whom a criminal record check is performed. A nursing home shall not employ a person with an unsatisfactory determination. Review of the facility [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R B revealed the resident was admitted to the facility [DATE], was cognitively impaired and unable complete interview questions, was assessed for behaviors of hitting, kicking, verbal behaviors and rejection of care on a daily basis. The resident was assessed for extensive assist by one or two persons for Activity of Daily Living (ADL) and was assessed for extensive assist, by one person, for dressing. Review of the care plan for R B revealed a Problems/strengths: Resident resist Activities of Daily Living (ADL) at times evidenced by cursing and hitting at staff with potential to cause harm to self. Intervention dated [DATE]: Two person assist when resident is combative and an intervention dated [DATE]: Allow resident time to calm down and approach again at a later time. Record review of the Physician order [REDACTED]. 1/2 tablet at bedtime for GAD, [MEDICATION NAME] 10 mg at bedtime for dementia, [MEDICATION NAME] ,[DATE] mg one tablet twice daily as needed for pain, not to exceed two per day, [MEDICATION NAME] 0.5 mg one tablet daily as needed (prn) for agitation but no blood thinners. Review of the Situation, Background, and Appearance and Review (SBAR) report dated [DATE] at 8:00 a.m. revealed that R B's right thigh was swollen and right foot is turn inward. The resident's vital signs were recorded as follows: Blood Pressure-,[DATE], pulse-112, respirations-20 and temperature-96.0. Resident is shouting more than normal Oh my leg. The resident's Physician was notified with a new order to send to the hospital. Nursing notes: called into the room by the CN[NAME] Patient's right thigh swollen and right foot turned inward. Family notified. Signed by Licensed Practical Nurse (LPN) BB. Review of the facility's Follow-up Entity Report dated [DATE] revealed that during their investigation, staff and the resident's roommate were interviewed. CNA AA provided two written and verbal statements dated [DATE] without times; 1. He was providing care to the resident and observed swelling to the resident's right thigh and immediately called for a charge nurse. 2. The CNA AA, at approximately 11:30 a.m. and 12:00 p.m., provided a verbal and written statement to the Administrator and the Director of Nursing (DON), where he stated that he held the resident's legs down tightly and heard a crack, then immediately notified the nurse but did not tell the nurse what had happened. CNA AA was immediately sent home and staffing agency was notified of the incident and informed that CNA AA could not return to the facility due to the incident. Education of staff has been implemented regarding Abuse, Neglect and Resident Rights. Record review of the Interdisciplinary Progress Notes dated [DATE] at 8:00 a.m. revealed a note by LPN BB that she had been called into R B's room by the CN[NAME] Patient lying in bed, yelling out. Patient's right thigh swollen, tender to touch, right leg turned inward. Patient sent to hospital for evaluation via ambulance. Family member notified. Patient was offered pain medication several times, resident refused and attempted to hit medication out of LPN's hand. Review of the hospital emergency room records dated [DATE] beginning at 9:05 a.m. Registered Nurse (RN) entry: Patient presents to the Emergency Department (ED) via Emergency Management Services (EMS) from facility with complaint (c/o) pain and swelling. Per EMS, patient was found this morning to have obvious deformity to upper right leg. Per facility nobody knows what happened as nothing was reported from night shift. Patient has advanced dementia and is a poor historian. Patient confused but complaining pain to the right leg. Leg noted to be swollen, pedal pulses not found. Will get Doppler for pulses. Physical exam: Blood Pressure (BP) ,[DATE] (low blood pressure), pulse: 85, Temperature 97.7 degrees Fahrenheit (F), respirations: 18. Medical Doctors notes dated [DATE] at 9:36 a.m. revealed the resident is oriented to person, place and time. The resident appears well-developed and well-nourished. Non-toxic appearance. The resident does not have a sickly appearance. She does not appear ill. No distress. Screaming in pain. Systolic BP: 70. Hematoma over right mid-thigh. Complete Blood Count (CBC): Red blood count: 3.43 (low), Hemoglobin 10.2 (low), Hematocrit: 31.8 (low). [MEDICATION NAME] Time (PT): 19 (high), International Normalized Ratio (INR): 1.62 (high). Nursing note dated [DATE] at 9:45 a.m. Patient BP low. Physician ordered bolus of fluids. X-ray of right femur: Confirmed right femur fracture. Consult with Orthopedic Surgeon for surgical repair of fracture. Admit in-patient. An interview with the Director of Nursing (DON) and the Administrator on [DATE] at 6:00 p.m. revealed that CNA AA was an agency employee. The DON explained that when she came into the facility on [DATE] the resident had just left to go to the hospital (after 8:51 a.m.) and therefore did not see the resident that morning herself. The Administrator revealed that she had been alerted by nursing and did see the resident before she left for the hospital. They further revealed that an investigation was started immediately and the State Survey Agency was notified within two hours of an injury of unknown origin for R B. Review of the facility staffing for the last month revealed that the facility used a number of agency staff daily. On [DATE] of 12 Licensed Practical Nurses (LPN's), one agency LPN (Agency #3) worked two shifts and of 26 CNAs, 12 were agency CNAs (11 CNAs from Agency #2 and one CNA from Agency #1) which were consistent with the days reviewed from [DATE] through [DATE]. An interview with the DON on [DATE] at 6:42 p.m. revealed that CNA CC, the staffing coordinator, is responsible for the daily staffing schedule. She is responsible for reviewing the background checks and [MEDICAL CONDITION] test for all agency staff before they work. It is unclear who does this when CNA CC isn't working. Continued interview with the DON revealed that neither she nor the Administrator were aware that the staffing coordinator was not receiving a background check which met the facility's Abuse policy or the contract between the facility and the staffing agencies. Continued interview with the DON revealed that when the DON first interviewed CNA AA, on [DATE] shortly after the DON arrived at the facility and had him write a statement, he stated that the resident was found with a swollen thigh when he was doing care after coming on duty that morning. She contacted the staffing agency in an attempt to speak to the agency CNA who had taken care of the resident on the 11:00 p.m. to 7:00 a.m. shift but was unable to get in touch with the night CN[NAME] She then asked to speak to CNA AA again for more detail but this time CNA AA changed the story somewhat. At this time, the DON became suspicious and asked CNA AA to speak to her and the Administrator around 11:30 a.m. to 12:00 p.m. It was at this time the CNA confessed to holding R B's legs down tightly due to the resident kicking and resisting care, until he heard a crack. The DON revealed at that time the CNA was sent home after this interview. The Administrator was then asked for copies of the contract with the staffing agencies and the background check for CNA AA and all agency staff which were in the building today. An interview with the DON and Administrator on [DATE] at 7:42 p.m. they supplied the background check of CNA AA plus his CNA and CPR certificate and a recent skills check list. The DON stated that when the facility was notified that the resident had died at the hospital on [DATE], at which time, the facility then notified the local police department. They explained that the local police department notified the Georgia Bureau of Investigation (GBI) who immediately began an investigation. She revealed that the GBI agent had been to the facility multiple times and questioned employees, including earlier today. She revealed that the GBI agent had made her aware of a forthcoming press release from the GBI related to the incident. A telephone interview on [DATE] at 1:08 p.m. with the family member of R B revealed that the facility notified the family member timely. The family member reported that R B could be combative at times. The family member reported that on [DATE] the resident was sent to the hospital and found to have a fractured femur which would require surgery to repair. The surgeon had said it would take about one hour but after two hours the surgeon came out and said they were having trouble stopping the bleeding. The resident was sent to ICU and died about 2:00 a.m. on [DATE]. Record review of the agency contracts for the three agencies used by the facility revealed for all agencies: 4. Screening of Employees: The Agency warrant that Temporary Personnel providing services under this agreement have been thoroughly screened by Agency. This screening will include but is not limited to: Verification of current State of Georgia professional license or certification, if applicable, the Office of Inspector General's (OIG) participation exclusion listing, National and Georgia criminal background reports (to include Georgia Crime Information Center (GCIC); and any other screening requirements as set forth under the Georgia Medicaid Provider Manual. The provision to meet Georgia Medicaid Provider screening requirements is required even if Agency is not actively enrolled as a Medicaid provider. Temporary Personnel with a felony conviction within the last ten years and/or listed on the OIG exclusion listing will not provide services to the Nursing Center. Review of the Background checks for 16 agency staff CNAs (CNA II, JJ, KK, LL, MM, NN, OO, PP, QQ, RR, SS, TT, UU, VV and WW), including CNA AA, with the DON, from all three agencies revealed that the background checks did not meet the facility's Abuse policy or the facility's contract with the agencies. An interview with the DON and Administrator on [DATE] at 5:30 p.m. revealed that they could not get an answer regarding whether the agency staff screening complied with the facility's Abuse policy or with the contract between the staffing agencies and the facility until after the holiday weekend. The Administrator and DON were asked if there had ever been a problem with CNA AA or anything that might have indicated there was a concern. They both answered there had not been any problems with CNA AA and that he had been a good employee. The Administrator and the DON did not mention that CNA AA had been part of a facility investigation, at their facility, for an injury of unknown origin, which was not substantiated by the facility, on [DATE]. A news story on the evening of [DATE] indicated that CNA AA had been previously arrested for elder abuse in (YEAR) which was confirmed by the GBI agent, via telephone, on [DATE] at 9:39 a.m. A second telephone interview with the GBI agent on [DATE] revealed that copies of the police reports would be supplied and were obtained on [DATE] at 3:07 p.m. Review of the police reports revealed that CNA AA had been arrested in (YEAR) for resident abuse at another facility. A review of reports which named CNA AA revealed seven reports to the State of Georgia, beginning with GA 587 dated [DATE], due to allegation of neglect by CNA AA, which was not substantiated. Review of GA 505 dated [DATE], due to allegation of sexual abuse by CNA AA, resulted in a police report but was unsubstantiated. Review of GA 743 dated [DATE], GA 744 dated [DATE] and GA 746 dated [DATE] by the same facility for three different resident who had reported CNA AA of abusive behavior revealed that CNA AA was terminated and the police notified. Review of GA 495 dated [DATE] due to allegation of abuse by CNA AA, the allegation was unsubstantiated. Review of GA 753 dated [DATE], due to an allegation of sexual abuse by CNA AA, with the CNA being terminated and escorted off the property. Review of GA 610 dated [DATE], at the current facility, due to bruising of unknown origin, was not substantiated which was not disclosed to the surveyor. Review of GA 590 dated [DATE] due to an allegation of abuse by CNA A[NAME] The CNA AA was terminated immediately, the police were called and investigated the incident which resulted in CNA AA being arrested in (MONTH) (YEAR). Review of the police report and investigation, related to GA 590 at another facility, dated [DATE] and the Incident Narrative dated [DATE] with details regarding the incident. A warrant was issued for CNA AA's arrest on [DATE]. CNA AA was arrested on [DATE]. The disposition of this case is unknown. On [DATE] at 9:30 a.m. and an interview with the Administrator, DON and Corporate Regional Nurse BBB on the same day at 9:51 a.m. to inform them that an immediate jeopardy existed due to abuse and improper screening of agency staff that did not comply with the facility's Abuse policy or the contract between the facility and the staffing agencies. The Administrator revealed that she was not aware that the agencies screening did not meet the facility's policy or the contract between the facility and the staffing agencies until the surveyor brought this to her attention and they had not looked closely enough at the background checks. She further revealed that the staffing agency contracts are standard corporate contracts but are entered into by the individual facilities. She agreed that it was assumed the staffing agencies were doing screenings that met the facility's Abuse policy and the contract between them. She had no explanation for this failure. She did confirm that staffing issues had been placed in Quality Assurance (QA) earlier in the year as there is so much competition in this area for staff, it is difficult to get staff. An interview with R F, R B's roommate on [DATE], on [DATE] at 11:30 a.m. revealed the resident in bed and appeared to be alert and oriented at this time. Review of the resident's Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 15. The resident could not remember any specifics of [DATE] when R B was sent to the hospital. She stated that there had been no problems for her with CNA AA or other staff. On [DATE] at 1:30 p.m. the local police report, dated [DATE] at 14:57 (2:57 p.m.) was obtained from the local police department which provided the same information as the entity five day investigation report. An interview with the DON on [DATE] at 4:00 p.m. revealed that staffing was placed into QA in ,[DATE] and in ,[DATE]. The facility began incentives for referrals from current staff. They increased salaries in (MONTH) (YEAR) which brought staff in but once they were trained they left for higher pay at other healthcare facilities in the area. Staffing continues to be a major problem for them. An interview with CNA CC, scheduler, on [DATE] at 10:28 a.m. revealed that she is responsible for ensuring the agency staff have background checks although she was not aware that the agency employee's screening and background checks did not meet the facility's Abuse policy or the contract with the facility. She was not aware until after the surveyor brought this to the Administrator's and DON's attention. An interview with LPN CCC on [DATE] at 11:24 a.m. revealed that she usually works as a charge nurse but is working in a CNA position today. The facility is no longer using agency staff until the screening issue is resolved. She revealed that CNA AA has worked under her several times. She is not aware of any other facilities that he may have worked nor has received any complaints from residents about CNA A[NAME] An interview with LPN BB on [DATE] at 12:52 p.m. revealed that she has been employed at the facility for nine years. She revealed that she gave a written statement about the incident on [DATE]. She revealed that on the morning of [DATE], around 8:00 a.m., that she was passing medications on the 200 hall and heard R B yelling out, which was not usual for the resident during care. She then stated that CNA AA was standing at the resident's door and motioned for her to come. She saw the resident's leg and ask CNA AA what happened to which he replied I found her this way. She states that the resident pants were around her ankles. She revealed that R B's leg was swollen and bruised with her foot turned inward. She called the ambulance service, the doctor and the family member. The resident was transported to the hospital. She stated that when the resident was on the stretcher CNA AA said I'm so nervous and she said why? LPN BB further revealed that she went back to passing medications and CNA AA went to take care of another resident. She states that CNA AA called her to that room and found R I on the floor with a skin tear. She says that CNA AA said the resident just rolled out of bed and onto the floor. LPN BB further revealed that CNA AA was pulled off the floor, by the DON, around lunch time on [DATE]. An interview with the DON on [DATE] at 1:34 p.m. revealed that she arrived at the facility about 8:00 a.m. on [DATE] and was told about the incident with R B although the resident had already gone to the hospital when she arrived. She says that CNA AA was doing care for R F at that time and she called him out to find out what had occurred with R B. She states that LPN BB had made her aware that R I had fallen out of bed during care. The DON revealed that LPN DDD may be able to give more information regarding this incident. An interview with LPN DDD on [DATE] at 1:41 p.m. revealed that she did not work closely with CNA AA but thought that CNA EEE did work with CNA AA frequently and she was working on [DATE]. She only knew that R I had fallen out of bed but did not know the details. An interview with CNA EEE on [DATE] at 1:52 p.m. revealed that she assisted CNA AA to get R I up from the floor and back to bed, after the nurse assessed the resident. She stated the bed was at a high position, the resident was sitting on the floor with towels due to his arms bleeding, when she entered the room. She revealed that the R I had made the statement to her about CNA AA picking the resident up by himself and she asked if the resident remembered me helping, which he did. Continued interview with CNA EEE, at this time, revealed that CNA AA would sometimes tell her that he had just come from another job, working nights at another facility. She revealed that she and CNA AA were providing care to a cognitively impaired resident and that CNA AA stated that he was afraid of what some of the confused residents might say he did to them. She thought this was an odd statement but did not report the comment. An interview on [DATE] at 2:00 p.m. with the Administrator revealed that the facility had stopped using agency staff as of [DATE] until Corporate worked out the screening issues. A telephone interview, post survey Quality Assurance review, on [DATE] at 10:01 a.m. with the Administrator revealed that the previous DON had trained the current DON and CNA CC about the agency book. The Administrator further revealed that she would ask CNA CC if she was keeping up with the agency book but that no one realized the background checks from the agencies did not met the facility's Abuse policy nor the contract between the agencies and the facility. She confirmed that CNA CC, the previous or current DON, had ever seen the contract between the agencies and the facility. The Administrator assumed that the agencies were following the contract but she did not confirm that they were. The Administrator was asked why the facility did not report to the police the day the incident occurred and the Administrator revealed she was in touch with the Corporate Consultants and they did not feel that CNA AA had intended to harm the resident. After hearing that R B had died , it was decided that the police should be called. The Administrator revealed that the responding police officer didn't think it was a criminal act at that point. Post survey review of the Emergency Medical Services (EMS) records and the hospital records for R B, received on [DATE] revealed that the call came in to EMS on [DATE] at 8:10 a.m., they arrived at the facility at 8:25 a.m. and left the facility at 8:51 a.m. then arrived at the hospital emergency room (ER) at 9:01 a.m. The records revealed a Physician's note dated [DATE] at 12:33 p.m. The resident has angular deformity, difficulty moving the leg and was brought to the ER and found to have a mid-shaft oblique femur fracture shortened and angulated. Orthopedic service was called to consult. Review of the Surgeon's Postoperative [DIAGNOSES REDACTED]. Laboratory test were ordered during surgery revealing the resident's INR was at 8 (normal 0XXX,[DATE].12) with a hematocrit of 5.5 (normal 36XXX,[DATE].0). We continued with our resuscitation attempts transfusing two units of packed red cells and two units of Fresh Frozen Plasma (FFP). The resident was transferred to the Intensive Care Unit (ICU) and the Physician notified the family of the events and that it is unlikely the resident will recover from this event. Review of the hospital Demographic Information dated [DATE] revealed that R B died on [DATE] at 2:12 a.m. Review of hospital Final [DIAGNOSES REDACTED]. The autopsy report for R B is pending. A telephone interview with staffing agency #1, on [DATE] at 4:16 p.m. revealed that she employed CNA AA who had worked for her since beginning the business years ago. She stated that she had not received any complaints about CNA AA and was shocked by the news. She confirmed that a background check had been run on CNA AA [DATE] but that she has Public Record Reports run as background checks. She was unaware that Criminal Background checks were needed and was not aware these background checks did not meet the facility's policy or the contract with the facility. She then asked for a copy of the contract as she did not have one. She had never heard of a Georgia Criminal Information Center (GCIC) background check. She revealed that reference checks were not conducted on potential employees. The surveyor requested a list of assignments for CNA AA to include dates and names of facilities which were supplied via email on [DATE]. A telephone interview on [DATE] at 1:19 p.m. with staffing agency #3 Administrator revealed that CNA AA had never worked for their agency. The Administrator revealed that a nationwide background check is done but does not include a GCIC background check. The agency does reference checks and is Joint Commission accredited. A telephone interview on [DATE] at 1:34 p.m. staffing agency #2 revealed that CNA AA had never worked for their agency. They do a background check but it is not the GCIC background check. They are not always able to conduct reference checks as some employees, who are currently employed, do not want their employer to know that are working extra. They do conduct personal references. A telephone interview, during post-survey Quality Assurance review, on [DATE] at 9:35 a.m. revealed that CNA CC had started in this position around (MONTH) (YEAR). She revealed that before she took over keeping up with the Agency book, (which included: background checks, license/certification, TB testing and CPR certification) the previous DON was responsible. The previous DON had worked with her and the current DON as to what was kept in the book although neither the previous or current DON, was aware the background checks did not met the agency/facility contract. CNA CC revealed that she has never seen the contract between the agencies and the facility. CNA CC further revealed that since the agencies basically sent the same people over and over again, who already had a folder in the agency book (including CNA AA), she did not need to recheck the background checks which had already been done and were contained the agency book. The facility implemented the following actions to remove the immediate jeopardy: 1. Beginning on [DATE] 11:45 [NAME]M. the agency CNA that was involved in the incident is no longer providing care in our center. On [DATE] all agency employees utilized from agencies will receive Georgia Criminal Information Center (GCIC) background checks prior to returning to work. 2. All Residents have the potential to be affected. 3. To prevent reoccurrence, the decision was made by management and operations support team to not use agency until agency personnel have abuse training and a GCIC background completed and submitted to the center for review by the Administrator, Director of Nursing or Overhouse Supervisor . The administrator contacted the agencies by telephone on [DATE] to request that backgrounds be rerun on the agency employees that they send to center. A certified return receipt letter was mailed that day requesting same. On [DATE] the administrator emailed the agencies to inform them that the background checks had to include the GCIC as part of the background. The Agency contracts have been revised to include providing the center with a copy of GCIC background check, PPD (TB test), and reference check information for any agency staff used by the center. These requirements also apply to direct hires. In addition the center will provide abuse training for agency and direct hires prior to patient contact. The Administrator, Director of Nursing or Overhouse Supervisor will review the information provided from the nursing agency prior to them working to ensure it meets guidelines. If information provided does not meet the standard or reveals information that prohibits their eligibility to provide service, the individual will not be permitted to work at the center, and the agency will be notified. 4. The policy for background checks for agency staff has been revised to reflect current practice. The agency contract has been revised [DATE] to ensure background checks include GCIC requirements. Our parent company notified the agencies by letter on [DATE] that we are conducting a review of their process and a copy of their screening process was requested. An attestation of compliance will be required of the agencies. 4 of 4 hiring associates and 10 of 10 directors received training on [DATE] on the Agency Personnel Hiring Guidelines. Training for center associates began on [DATE]. As of [DATE] 80 of 90 center associates have received education on abuse. Those that have not been educated are either on FMLA or are temporary associates. Those associates will receive training prior to working. 4 of 4 agency associates",2020-09-01
270,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2017-06-02,282,L,1,1,YO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews the facility failed to ensure that the care plan was followed for one resident (R) B relating to combative behaviors. This failure resulted in actual harm and death for one resident (R) B of twelve sampled residents whose right femur was fractured by CNA AA and the resident died , at the hospital, within 24 hours. Review of the CMS Form-672, Resident Census and Condition of Residents, dated [DATE], the census was eighty five (85) residents. On [DATE] around 7:30 a.m., during morning care, CNA AA, held R B legs down tightly due to combative behavior of the resident then heard a crack. CNA AA alerted the nurse telling her that he found the resident in this condition. CNA AA did eventually confess what had occurred with R B. R B was transferred to the hospital and it was determined that the resident had a fractured femur requiring surgical repair. During surgery R B began to bleed excessively which did not respond to interventions. The resident was transferred to the Intensive Care Unit (ICU) and died on [DATE] at 2:12 a.m. The facility notified the local police on [DATE] who turned the investigation over to the Georgia Bureau of Investigation (GBI). CNA AA was arrested by the GBI. 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. Immediate Jeopardy was identified to exist on [DATE], the date of the injury to R B and subsequent death. The facility Administrator, Director of Nursing and the Nurse Consultant were informed on [DATE] at 9:51 a.m. that Immediate Jeopardy was determined to exist. The non-compliance related to the immediate jeopardy was identified to exist on [DATE]. The facility implemented a Credible Allegation of Compliance alleging the immediate jeopardy was removed as of [DATE]. Based on observation, record reviews, review of the revised policy for background checks for agency staff and agency contracts, staff, residents and family interviews related to the abuse protocol, it was validated in the corrective actions plans that the immediacy of the deficient practice was removed. However, the facility remains out of compliance as they continue to implement systematic changes related to abuse training, screening of employees and agency staff prior to working directly with residents while management level staff continues to oversee and Quality Assurance monitors the effectiveness of the systematic changes. The Scope and Severity (S/S) was lowered as follows: F224: S/S-F, F282: S/S-F, F490: S/S-F. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] for R B revealed the resident was admitted to the facility [DATE], was cognitively impaired and unable to complete interview questions, was assessed for behaviors of hitting, kicking, verbal behaviors and rejection of care on a daily basis. The resident was assessed for extensive assist by one or two persons for Activity of Daily Living (ADL) and was assessed for extensive assist, by one person, for dressing. Review of the care plan for R B revealed a Problems/strengths: Resident resists Activities of Daily Living (ADL) at times evidenced by cursing and hitting at staff with potential to cause harm to self. An intervention date [DATE]: Two person assist when resident is combative. Intervention dated [DATE]: Allow resident time to calm down and approach again at a later time. An interview with the DON on [DATE] at 6:42 p.m. revealed that when the DON first interviewed CNA AA, on [DATE] and had him write a statement, he stated that the resident was found with a swollen thigh when he was doing care after coming on duty. She then asked to speak to CNA AA again for more detail but this time CNA AA changed the story somewhat. At this time, the DON became suspicious and asked the CNA AA to speak to her and the Administrator together. It was at this time the CNA confessed to holding R B's legs down tightly due to the resident kicking and resisting care, until he heard a crack. At that time he called for the nurse although he did not share what had occurred, only that he found the resident in this condition. CNA AA made a second written statement to this fact which is dated [DATE] but does not include a time. The DON revealed that the facility policy and the resident's care plan for a resident who is resisting care, is to walk away and approach the resident later. She agrees that CNA AA did not do this which resulted in the fracture of R B's leg. Cross refer to F224 The facility implemented the following actions to remove the immediate jeopardy: 1. Beginning on [DATE] 11:45 [NAME]M. the agency CNA that was involved in the incident is no longer providing care in our center. On [DATE] all agency employees utilized from agencies will receive Georgia Criminal Information Center (GCIC) background checks prior to returning to work. 2. All Residents have the potential to be affected. 3. To prevent reoccurrence, the decision was made by management and operations support team to not use agency until agency personnel have abuse training and a GCIC background completed and submitted to the center for review by the Administrator, Director of Nursing or Overhouse Supervisor . The administrator contacted the agencies by telephone on [DATE] to request that backgrounds be rerun on the agency employees that they send to center. A certified return receipt letter was mailed that day requesting same. On [DATE] the administrator emailed the agencies to inform them that the background checks had to include the GCIC as part of the background. The Agency contracts have been revised to include providing the center with a copy of GCIC background check, PPD (TB test), and reference check information for any agency staff used by the center. These requirements also apply to direct hires. In addition the center will provide abuse training for agency and direct hires prior to patient contact. The Administrator, Director of Nursing or Overhouse Supervisor will review the information provided from the nursing agency prior to them working to ensure it meets guidelines. If information provided does not meet the standard or reveals information that prohibits their eligibility to provide service, the individual will not be permitted to work at the center, and the agency will be notified. 4. The policy for background checks for agency staff has been revised to reflect current practice. The agency contract has been revised [DATE] to ensure background checks include GCIC requirements. Our parent company notified the agencies by letter on [DATE] that we are conducting a review of their process and a copy of their screening process was requested. An attestation of compliance will be required of the agencies. 4 of 4 hiring associates and 10 of 10 directors received training on [DATE] on the Agency Personnel Hiring Guidelines. Training for center associates began on [DATE]. As of [DATE] 80 of 90 center associates have received education on abuse. Those that have not been educated are either on FMLA or are temporary associates. Those associates will receive training prior to working. 4 of 4 agency associates that meet the requirements have been trained on abuse and have the appropriate background checks to include GCIC. 5. Center QAPI meeting was held on [DATE] to conduct a post event review that included abuse and resident rights. Another Center QAPI meeting was held [DATE] to review the revised guidelines for background screening for agency personnel and details entered into the QAPI meeting minutes. Our Operations Support representatives and Chief Compliance Officer reviewed and approved the updated guidelines on [DATE]. Medical Director notified of incident and the opportunities identified to correct in the future. Administrator or Director of Nursing will monitor for compliance. 6. Human Resources associate audited 100% of current associate files for abuse training and back ground checks to include GCIC on [DATE]. The administrator or Human Resources associate will audit twelve agency or direct hire associates files per week for four weeks to ensure abuse training has been completed prior to patient care and background checks are correct to Include GCIC background. Random audit of six associate files will be completed per month for accuracy for three months. A Quality Improvement Data Collection Grid, titled Associate Abuse Training and Background Checks to include GCIC, will be used to document compliance. All audit reviews will be reviewed in the QAPI meeting to ensure ongoing compliance. We are alleging compliance as of [DATE]. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Removal as follows: 1. Review of the facility's five day investigation and review of the staff schedule from [DATE] through [DATE] revealed that CNA AA was crossed off the schedule and replaced with another CN[NAME] 2. The Administrator has confirmed that interviews with some residents regarding CNA AA were done and have spoken to any residents or family members that have expressed concern regarding the incident and news stories. 3. Review of the staffing schedule from [DATE] through [DATE] revealed that only direct staff were on the schedule and in the building. All staff in the building for [DATE] and [DATE] were verified per the facility schedule for the day and evening shifts. There were no agency staff in the building during the review. 4. The facility policy titled Agency Personnel-Background Screening revealed the policy was update in (MONTH) (YEAR) and was reviewed. An in-service conducted on [DATE] on Overview of Meeting Agency personnel hiring requirements revealed that 13 facility employees, and one Corporate Regional Nurse, who are responsible for decisions to call in agency staff participated in the in-service. A form titled Quality Improvement Data Collection Grid to be utilized by the hiring associates and managers to track that all information is available from the agencies before allowing the agency employee to work with residents. An interview with CNA CC, scheduler, on [DATE] at 10:28 a.m. revealed that when she is not working, or on the weekends, the Overhouse nurse would make the decision if staffing agency personnel is needed. She revealed that she had participated in an in-service on [DATE] regarding the new procedure for agency staff. The nurse would be responsible for checking background checks and [MEDICATION NAME] (TB) skin test were completed and negative before agency staff can work with residents. She reveals that now GCIC background checks are required of agency staff before they can work in the facility. 5. The facility and corporate office have reviewed the agency contracts. After further review, it was determined that the contract did not need revision although a process to ensure the contract was followed was put into place. A review of the new attestation form titled Affirmation of Compliance Provisions Background Screening of Agency Personnel revealed that these are signed, in addition to the contract, by the Staffing Agency owner or manager. The Staffing Agency that employed CNA AA is in process of contracting with a background screening service to offer GCIC services but in the meantime the employees will go to the local police department to have the needed background check completed before working. The facility policy titled Agency Personnel-Background Screening revealed the policy was updated in (MONTH) (YEAR) and was reviewed. An in-service conducted on [DATE] on Overview of Meeting Agency personnel hiring requirements revealed that 13 facility employees, and one Corporate Regional Nurse, who are responsible for decisions to call in agency staff participated in the in-service. A form titled Quality Improvement Data Collection Grid to be utilized by the hiring associates and managers to track that all information is available from the agencies before allowing the agency employee to work with residents. Review of the facility in-services on Abuse from [DATE] through [DATE] revealed that 80 of the 90 employees had completed the in-service which also included an understanding quiz. Interviews on [DATE] with CNA DD at 11:36 a.m., CNA GG on [DATE] at 2:56 p.m., interviews on [DATE] CNA CC, scheduler, at 10:28 a.m., CNA FFF on [DATE] at 11:00 a.m., CNA EEE on [DATE] at 1:52 p.m. revealed that they had recently participated in in-services on abuse, recognizing abuse and to who they should report any allegation of abuse to at the facility. An interview with the Assistant Director of Nursing (ADON) R.N., on [DATE] at 2:45 p.m. revealed that she had recently had in-services on multiple items including recognizing abuse, what to do if it is reported to her and how to report to the State. Interviews on [DATE] at 11:41 p.m. with Housekeeper EE and on [DATE] with Housekeeper GGG at 11:16 a.m. revealed that they had recently had an in-service on abuse, were aware of what abuse involved. They would report any allegation of abuse to their supervisor or the nurse on the floor. They were aware of the Ombudsman program and the abuse hotline and where the posters were located in the facility. Interviews on [DATE] with LPN HH at 3:01 p.m., on [DATE] with Registered Nurse (RN) FF at 3:23 p.m., LPN CCC at 11:24 a.m., LPN BB at 12:52 p.m., LPN DDD at 1:41 p.m. who revealed they had recently participated in multiple in-services relating to abuse, identifying abuse, who to report abuse to in the facility or how to report abuse to the State. 6. Review of the Quality Assurance Improvement Plan (QAIP) sign in sheets reveal that on [DATE] and [DATE] QAIP meetings were held to discuss the immediate jeopardy issue. A telephone interview with the Medical Director on [DATE] revealed that she is aware that staffing issues are a problem at the facility and has been discussed in the QA meetings that she has attended. She also revealed that the facility made her aware of the incident with R B and CNA AA the day after the incident. She discussed the situation with the DON on the next visit. Review of the facility audit sheet revealed that 100% of direct facility employees have been confirmed as having had abuse training and a background check that includes a GCIC background check.",2020-09-01
271,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2017-06-02,371,E,1,1,YO2T11,"> Based on observations, interviews and record review, the facility failed to ensure that the kitchen was maintained in a clean and sanitary manner related to (1) three staff observed not wearing hairnets while in the food preparation (prep) area on two separate days ; (2) one staff not using proper hand hygiene and not washing the soiled prep table during a pureed prep observation; (3) one of one walk-in refrigerator cooler leaking water onto fresh vegetables; and (4) staff serving food that was not at the appropriate holding temperature during one of two tray line observations. Findings include: (1) On 5/30/2017 at 11:24 a.m. an initial tour of the kitchen was conducted with the Dietary Manager. She stated that for the past three weeks, the kitchen has been shared by the staff at a sister facility (which is a temporary situation which was approved by the State Survey Agency). She stated that they come and cook the other facility's food and transport it back to the facility. Dietary Aide EE was observed in the food prep area without a hair net and the Kitchen Manager stated that Dietary Aide EE was staff member from the sister facility. Dietary Aide EE confirmed that she did not have on a hair net. On 5/31/2017 at 11:35 a.m. Maintenance Assistant GG and Regional Maintenance Director HH was observed to enter the kitchen. Regional Maintenance Director HH had a full beard with no beard net and Maintenance Assistant GG had no hair net on. They were standing in the food prep area inspecting the stove hood. There were uncovered baked rolls in a pan directly where they were standing and behind them was the tray line stream table with the food items ready for serving and uncovered. Regional Maintenance Director HH stated that he forgot to put on a beard net. Maintenance Assistant GG stated that he usually puts on a hair net when he comes into the kitchen but that he just didn't today. At this time the Kitchen Manager stated that it is the expectation that everyone who enters the kitchen wear a beard guard and/or hair net. A review of the Departmental Policies Dietary Services (not dated) revealed that the policy intent to prevent contamination of food products and therefore prevent foodborne illness. Procedural guidelines included: It is the Food Service Manager responsibility to provide safe food service for patients and associates; Proper attire for food handlers should include a hair covering (hairnets or caps) and beards should be covered; (2) On 5/31/2017 at 10:12 a.m. the puree prep was observed. Cook FF was observed to prepare the puree meal. During this observation, she was observed to take a pan to the garbage can. Then she used her gloved hands to open the lid, dumped the contents of the pan into the garbage touching the side of the garbage can to the pan. She then took the pan and placed the pan on the prep table. She then moved the pan to another area of the prep table. She continued to prep the chopped meat, removing items from the oven, and removing items from the steamer without changing her gloves and without cleaning the prep table. During an interview with the Kitchen Manager on 5/31/2017 at 10:35 a.m. she stated that it is the expectation that the staff change gloves after touching the garbage but stated that it is hard due to the garbage can having a lid that you have to remove by hand. She stated that they really should have a garbage can that you can use your feet to open. A review of the Departmental Policies Dietary Services (not dated) revealed that the policy intent to prevent contamination of food products and therefore prevent foodborne illness. Procedural guidelines included: It is the Food Service Manager responsibility to provide safe food service for patients and associates; Wash hands carefully with soap and water whenever they become soiled; All work surfaces should be cleaned and sanitized after each use. (3) On 5/30/2017 at 11:24 a.m. an initial tour of the kitchen was conducted with the Dietary Manager. The walk-in refrigerator was observed at this time. Fresh vegetables were observed in boxes stored on the shelves. Water from the top of the refrigerator was observed dripping on the vegetables (cabbage heads) from the ceiling. There was a large puddle on the floor. The Kitchen Manager stated that maintenance had fixed this once before but it has been a problem. During an interview with the Maintenance Director on 6/1/2017 at 1:54 a.m. he stated that he was aware of the leak in the walk-in refrigerator and that he worked on it about a week ago. He stated that he believes that the water is coming from the roof when it rains. The Maintenance Assistance stated that it has been doing this for a little over a year. The Maintenance Director stated that there were sprinklers installed over the walk in refrigerator a little over a year ago and that is when the leaking started. He stated that the most recent leaking started last week and he that that he had repaired it. He confirmed that he had not recorded this repair on a log. During an interview with the Maintenance Assistant on 6/1/2017 at 2:29 p.m. he stated that the leaking had occurred at least three times in the past years. Policy related to hair nets, damage to the refrigerator, temperature of food, food prep area cleanliness: A review of the Departmental Policies Dietary Services (not dated) revealed that the policy intent to prevent contamination of food products and therefore prevent foodborne illness. Procedural guidelines included: During an interview with the Maintenance Director on 6/1/2017 at 3:04 p.m. he stated that the roof is a canvas top roof with no shingles. He stated that he does a treatment on the canvas that will sometimes dry out by the sun and crack. He stated that when it rains, the water drips through the cracks and makes the walk-in refrigerator cooler leak. During an interview with the Nursing Home Administrator on 6/1/2017 at 3:20 p.m. she there was no policy related to maintenance of the kitchen equipment. A review of the Equipment (Kitchen) Service Instructions & Log with revised date of (MONTH) 2011 noted that the facility will record all repairs on log. (4) On 5/31/2017 at 11:40 a.m. the first tray line holding temperatures observation was observed. The Kitchen Manager was observed to measure the temperatures with a dial thermometer calibrated with ice water. The pureed potatoes were observed on the steam table at 130 degrees Fahrenheit (F). The Kitchen Manager reheated to the pureed potatoes to 165 degrees F. The chopped meat was observed to measure at 110 degrees F. The Kitchen Manger reheated the chopped meat to 165 degrees F. On 6/1/2017 at 7:15 a.m. a second tray line holding temperature observation was observed. The Cook II was observed to calibrate the thermometer and measured the food items: Bacon measured at 100 degrees F; Sausage [NAME]es measured at 90 degrees F. At that time, the cook let the line continue to serve the bacon and the sausage. When asked if there was anything she would do with the bacon and the sausage, she stated that they will discard what is left over after serving all the residents. The Kitchen Manager was informed of the temperature of the bacon and the sausage and stopped the tray line and reheated the sausage 142 degrees F and bacon to 136 degrees F.",2020-09-01
272,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2017-06-02,441,D,1,1,YO2T11,"> Based on observation, interviews, and record review, the facility failed to ensure that staff used a barrier when handling food during two (Lunch on 5/30/17 and Breakfast on 6/1/17) of two meal observations. Findings included: During dining observation on 5/30/17 at 12:00 p.m. staff was observed touching the bread while assisting residents with meals. Certified Nursing Assistant AA was observed assisting R#42 with her meal and was observed to grab the residents roll with her bare hands without using a barrier and place the roll in the resident's hand. Certified Nursing Assistant BB was observed assisting R#33 with her meal and was observed to pinch off pieces of the roll with her bare hands without using a barrier and place the pieces into R#33's month. A review of the Departmental Policies for Dietary Services (not dated) revealed that the policy intent to prevent contamination of food products and therefore prevent foodborne illness. Procedural guidelines included: Foods are prepares and served with clean tongs, scoops, forks, spoons, spatulas, or gloved hands as manual contact of food is prohibited; Fingers are to be kept out of food. During an interview with the Dietary Manager on 6/1/17 at 3:20 p.m. she stated that no one should be touching food without gloves or without using some type of barrier. During an interview with the Director of Nursing on 6/1/17 at 3:46 p.m. she stated that if the nursing staff touches any prepare foods, they should be using gloves. She stated that she does continuous education with the staff and they should not be using their bare hands to touch any food. During observation of the breakfast meal on Unit II on 6/1/17 between 8:40a.m. and 9:25 a.m., the following was observed: Licensed Practical Nurse (LPN) DD used (ungloved) bare hands to open the biscuit belonging to Resident (R) #101, empty a jelly packet unto the surface, and place both halves of the biscuit together again before replacing it on the resident's plate. Certified Nursing Assistant (CNA) CC, took one piece of toast from the plate of R#28 with her bare hand, plastered jelly on the toast using a knife, took several pieces of bacon from the resident's plate (also with her bare hand) and placed these on the slice of jellied toast. CNA CC then folded the toast in two and replaced it on one side of the resident's plate. CNA CC repeated the same process with a second piece of toast on the plate; using her bare hand to grasp the toast, she used the resident's knife to smear it with jelly. She then replace the knife on the resident's plate, used her bare hand to place the remaining bacon on the jellied toast before folding said toast and placing it on the resident's plate. While assisting R#51 with breakfast, the communication device of CNA CC fell to the floor. CNA CC retrieved the device from the floor and, without washing or sanitizing her hands, returned to assisting the resident with eating. A few minutes later, CNA CC used her bare hands to open the resident's biscuit, add jelly to said biscuit, and then offered the biscuit to the resident. After the resident held the biscuit and took a bite, CNA CC removed the biscuit from the resident with her bare hand and placed it on the plate. A few minutes later, the CNA removed the biscuit from the resident's plate using her bare hand again and offered it once more to the resident. LPN, DD opened the biscuit of R#42 with bare hands, emptied a jelly packet on the surface of one half, covered this with the other half before replacing it on the resident's plate. During an interview with CNA CC on 6/1/17 at 9:30 a.m., she stated that it was ok to touch a resident's food with her bare hands if she sanitized her hands before doing so. During an interview with LPN DD on 6/1/17 at 11:50 a.m., she revealed that she routinely touches residents' food items such as bread and rolls with bare hands if the resident needs assistance, but only after sanitizing her hands. She uses a barrier such as gloves to touch a resident's food only if that resident specifically asks her not to touch his/her food with bare hands.",2020-09-01
273,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2017-06-02,456,E,1,1,YO2T11,"> Based on observation, record review, and interviews, the facility failed to ensure that the walk-in refrigerator was maintained in a sanitary operational manner related to one of one walk in refrigerator leaking water onto the floor and fresh vegetables. Findings included: On 5/30/2017 at 11:24 a.m. an initial tour of the kitchen was conducted with the Kitchen Manager and the walk-in refrigerator was observed at this time. Fresh vegetables were observed in boxes stored on the shelves. Water from the top of the refrigerator was observed dripping on the vegetables (cabbage heads) from the ceiling. There was a large puddle on the floor. The Kitchen Manager stated that maintenance had fixed this once before but it has been a problem. During an interview with the Maintenance Director on 6/1/2017 at 1:54 a.m. he stated that he was aware of the leak in the walk-in refrigerator and that he worked on it about a week ago. He stated that he believes that the water is coming from the roof when it rains. The Maintenance Assistance stated that it has been doing this for a little over a year. The Maintenance Director stated that there were sprinklers installed over the walk in refrigerator a little over a year ago and that is when the leaking started. He stated that the most recent leaking started last week and he that that he had repaired it. He confirmed that he had not recorded this repair on a log. During an interview with the Maintenance Assistant on 6/1/2017 at 2:29 p.m. he stated that the leaking had occurred at least three times in the past years. Policy related to hair nets, damage to the refrigerator, temperature of food, food prep area cleanliness: A review of the Departmental Policies Dietary Services (not dated) revealed that the policy intent to prevent contamination of food products and therefore prevent foodborne illness. Procedural guidelines included: During an interview with the Maintenance Director on 6/1/2017 at 3:04 p.m. he stated that the roof is a canvas top roof with no shingles. He stated that he does a treatment on the canvas that will sometimes dry out by the sun and crack. He stated that when it rains, the water drips through the cracks and makes the walk-in refrigerator cooler leak. During an interview with the Nursing Home Administrator on 6/1/2017 at 3:20 p.m. she there was no policy related to maintenance of the kitchen equipment. A review of the Equipment (Kitchen) Service Instructions & Log with revised date of (MONTH) 2011 noted that the facility will record all repairs on log.",2020-09-01
274,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2017-06-02,490,L,1,1,YO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Administrator job description and interviews including staffing agencies interviews, the facility failed to ensure that staffing agency employees, utilized by the facility, complied with the facility's Abuse policy and the contract between the facility and the staffing agencies, specifically: On [DATE] at approximately 7:30 a.m. Certified Nursing Assistant (CNA) AA (a staff agency CNA) was getting resident (R) B dressed. CNA AA notified Licensed Practical Nurse (LPN) BB that R B had a swollen right thigh and was complaining of pain. LPN BB assessed the resident and it was determined that R B had a swollen right thigh and the right foot was turned inward. LPN BB contacted the Physician and family at 8:00 a.m. and the resident was transported to the hospital for evaluation. Record review of the hospital emergency room notes revealed that R B had a fractured right femur which required surgical intervention to repair. Post-survey review of the Emergency Medical Services (EMS) report, dated [DATE], revealed the call came into EMS at 8:10 a.m., EMS at the scene at 8:25 a.m. and left the facility at 8:51 a.m. arriving at the hospital at 9:01 a.m. The facility was notified on [DATE], by the hospital, that the R B had died as a result of the fracture. The facility then contacted the local police department on [DATE] who contacted the Georgia Bureau of Investigation (GBI) and CNA AA was arrested by the GBI. Review of the local police department's Incident/Investigation Report dated [DATE] at 14:57 (2:57 p.m.) arrived at the facility to begin the investigation of CNA AA and R B. 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. Immediate Jeopardy was identified to exist on [DATE], the date of the injury to R B and subsequent death. The facility Administrator, Director of Nursing and the Nurse Consultant were informed on [DATE] at 9:51 a.m. that immediate jeopardy was determined to exist. The non-compliance related to the immediate jeopardy was identified to exist on [DATE]. The facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on [DATE]. Based on the validation of the Credible Allegation of Compliance, the State Survey Agency (SSA) determined the immediate jeopardy was removed. The Scope and Severity were lowered as follows: F224:F, F282:F, F490: F while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance monitors the effectiveness of the systematic changes related to abuse and screening of agency staff prior to working with residents. Review of the CMS Form-672, Resident Census and Condition of Residents, dated [DATE], the census was eighty five (85) residents. Cross refer to F224 Findings include: Review of the Administrator job description revealed: Directs the day to day functions of the Nursing Center in accordance with current federal, state and local regulations that govern long-term care centers, and as may be directed by the Regional Vice President, to provide appropriate care for our patients. Review of the Administrators State license revealed that it is current. An interview with the Administrator on [DATE] at 5:30 p.m. revealed she had been at the facility since 2005. She has never experienced a situation like what happened on [DATE] with R B and CNA A[NAME] She revealed that the incident was first thought to be an injury of unknown origin that was reported to the State within two hours. She revealed that the Director of Nursing (DON) had interviewed CNA AA and had him write a statement which described that he found the resident with a swollen thigh and yelling in pain which was reported to the nurse. After asking additional information from CNA AA, by the DON, the story changed somewhat at which time it was decided to interview him together. CNA AA confessed that he had held the resident's legs down tightly, due to the resident being combative and kicking at him, then heard a crack. The resident immediately started yelling that her leg hurt and was swollen. CNA AA provided another statement, which is dated but does not have a time, to these facts. At that time the CNA was sent home and the staffing agency was notified and that CNA AA could not come back to the facility. An interview with the Administrator and the DON on [DATE] at 7:42 p.m. revealed that the facility was notified on [DATE] that the resident had died , at which time, they contacted the local police who came to the facility to take the report on [DATE] at 2:57 p.m. (14:57). The case was turned over to the Georgia Bureau of Investigation (GBI) who began an investigation immediately. The GBI agent interviewed the Administrator and staff at the facility and CNA AA was arrested by the GBI for elderly abuse. The Administrator supplied a copy of the background report for CNA AA and the facility contracts with three staffing agencies utilized by the facility. All background checks were requested for agency staff in the building today. Review of the facility's Policy titled Grievances-Abuse Prohibition Screening and Hiring Practices, updated (MONTH) (YEAR): 1. Screening and Hiring Practices: [NAME] The center will conduct a thorough investigation of the histories of individuals being considered for hire, in addition to the inquiry of the State Nurse Aide Registery or licensing authorities. All reasonable efforts will be made to check references and information from previous and/or current employers to uncover information about any past criminal prosecutions. B. The screening of all applicants will involve the following: 1. Background investigations 2. Criminal Records Check for Pre-employment Screening 3. Substance Abuse C. Prior to hiring an employment applicant, the center shall request a criminal record check from GCIC to determine whether the applicant has a criminal record. A nursing home shall make a written determination for each applicant for whom a criminal record check is performed. A nursing home shall not employ a person with an unsatisfactory determination. Record review of the agency contracts for the three agencies used by the facility revealed for all agencies: 4. Screening of Employees: The Agency warrant that Temporary Personnel providing services under this agreement have been thoroughly screened by Agency. This screening will include but is not limited to: Verification of current State of Georgia professional license or certification, if applicable, the Office of Inspector General's (OIG) participation exclusion listing, National and Georgia criminal background reports (to include Georgia Crime Information Center (GCIC); and any other screening requirements as set forth under the Georgia Medicaid Provider Manual. The provision to meet Georgia Medicaid Provider screening requirements is required even if Agency is not actively enrolled as a Medicaid provider. Temporary Personnel with a felony conviction within the last ten years and/or listed on the OIG exclusion listing will not provide services to the Nursing Center. Review of the facility staffing for the last month revealed that the facility used a number of agency staff daily. On [DATE] of 12 Licensed Practical Nurses (LPN's), one agency LPN (Agency #3) worked two shifts and of 26 CNAs, 12 were agency CNAs (11 CNAs from Agency #2 and one CNA from Agency #1) which were consistent with the days reviewed from [DATE] through [DATE]. An interview with the DON and Administrator on [DATE] at 5:30 p.m. revealed that they could not get an answer regarding whether the agency staff screening complied with the facility's Abuse policy or with the contract between the staffing agencies and the facility until after the holiday weekend. The Administrator and DON were asked if there had ever been a problem with CNA AA or anything that might have indicated there was a concern. They both answered there had not been any problems with CNA AA and that he had been a good employee. The Administrator and the DON did not mention that CNA AA had been part of a facility investigation for an injury of unknown origin, which was not substantiated by the facility, on [DATE]. A news story on the evening of [DATE] indicated that CNA AA had been previously arrested for elder abuse in (YEAR) which was confirmed by the GBI agent, via telephone, on [DATE] at 9:39 a.m. A second telephone interview with the GBI agent on [DATE] revealed that copies of the police reports would be supplied and were obtained on [DATE]. A review of reports which named CNA AA revealed seven reports to the State of Georgia, beginning with GA 587 dated [DATE], due to allegation of neglect by CNA AA, which was not substantiated. Review of GA 505 dated [DATE], due to allegation of sexual abuse by CNA AA, resulted in a police report but was unsubstantiated. Review of GA 743 dated [DATE], GA 744 dated [DATE] and GA 746 dated [DATE] by the same facility for three different resident who had reported CNA AA of abusive behavior revealed that CNA AA was terminated and the police notified. Review of GA 495 dated [DATE] due to allegation of abuse by CNA AA, the allegation was unsubstantiated. Review of GA 753 dated [DATE], due to an allegation of sexual abuse by CNA AA, with the CNA being terminated and escorted off the property. Review of GA 610 dated [DATE], at the current facility, due to bruising of unknown origin, was not substantiated which was not disclosed to the surveyor. Review of GA 590 dated [DATE] due to an allegation of abuse by CNA A[NAME] The CNA AA was terminated immediately, the police were called and investigated the incident which resulted in CNA AA being arrested in (MONTH) (YEAR). Review of the police report and investigation, related to another facility, dated [DATE] and the Incident Narrative dated [DATE] with details regarding the incident. A warrant was issued for CNA AA's arrest on [DATE]. CNA AA was arrested on [DATE]. The disposition of this case is unknown. A telephone interview with staffing agency #1, on [DATE] at 4:16 p.m. revealed that she employed CNA AA who had worked for her since beginning the business years ago. She stated that she had not received any complaints about the CNA and was shocked by the news. She confirmed that a background check had been run on CNA AA on [DATE] but that she has Public Record Reports run as background checks. She was unaware that Criminal Background checks were needed and thought that the background checks she does covers everything needed. She had never heard of a GCIC background check. She revealed that reference checks were not conducted on employees. The surveyor requested a list of assignments for CNA AA to include dates and names of facilities which were supplied via email on [DATE]. An interview with the Administrator on [DATE] at 9:51 a.m. revealed that she had no idea the background checks did not meet facility's Abuse policy requirements or the contract requirement with the staffing agencies until the surveyor brought it to her attention. She revealed that the contracts are standard corporate contracts but are entered into by the individual facilities. She agreed that it was assumed the staffing agencies were meeting the facility's Abuse policy for screening their employees and per the contract between the staffing agencies and the facility. She had no explanation for this failure. A telephone interview, post survey Quality Assurance review, on [DATE] at 10:01 a.m. with the Administrator revealed that she had been in this position since 2005. She revealed that CNA AA had been sent to this facility around the first of (YEAR). She further stated that the previous DON had trained the current DON and CNA CC about what to keep in the agency book although they were unaware of the background check requirements. The Administrator further revealed that she would ask CNA CC if she was keeping up with the agency book but that no one realized the background checks from the agencies did not meet the facility's Abuse policy nor the contract between the agencies and the facility. She confirmed that CNA CC, the previous or current DON, had ever seen the contract between the agencies and the facility. The Administrator assumed that the background checks the agencies were sending met the contract although the facility was accepting what the agencies sent to the facility without checking them. The facility implemented the following actions to remove the immediate jeopardy: 1. Beginning on [DATE] 11:45 [NAME]M. the agency CNA that was involved in the incident is no longer providing care in our center. On [DATE] all agency employees utilized from agencies will receive Georgia Criminal Information Center (GCIC} background checks prior to returning to work. 2. All Residents have the potential to be affected. 3. To prevent reoccurrence, the decision was made by management and operations support team to not use agency until agency personnel have abuse training and a GCIC background completed and submitted to the center for review by the Administrator, Director of Nursing or Overhouse Supervisor . The administrator contacted the agencies by telephone on [DATE] to request that backgrounds be rerun on the agency employees that they send to center. A certified return receipt letter was mailed that day requesting same. On [DATE] the administrator emailed the agencies to inform them that the background checks had to include the GCIC as part of the background. The Agency contracts have been revised to include providing the center with a copy of GCIC background check, PPD (TB test), and reference check information for any agency staff used by the center. These requirements also apply to direct hires. In addition the center will provide abuse training for agency and direct hires prior to patient contact. The Administrator, Director of Nursing or Overhouse Supervisor will review the information provided from the nursing agency prior to them working to ensure it meets guidelines. If information provided does not meet the standard or reveals information that prohibits their eligibility to provide service, the individual will not be permitted to work at the center, and the agency will be notified. 4. The policy for background checks for agency staff has been revised to reflect current practice. The agency contract has been revised [DATE] to ensure background checks include GCIC requirements. Our parent company notified the agencies by letter on [DATE] that we are conducting a review of their process and a copy of their screening process was requested. An attestation of compliance will be required of the agencies. 4 of 4 hiring associates and 10 of 10 directors received training on [DATE] on the Agency Personnel Hiring Guidelines. Training for center associates began on [DATE]. As of [DATE] 80 of 90 center associates have received education on abuse. Those that have not been educated are either on FMLA or are temporary associates. Those associates will receive training prior to working. 4 of 4 agency associates that meet the requirements have been trained on abuse and have the appropriate background checks to include GCIC. 5. Center QAPI meeting was held on [DATE] to conduct a post event review that included abuse and resident rights. Another Center QAPI meeting was held [DATE] to review the revised guidelines for background screening for agency personnel and details entered into the QAPI meeting minutes. Our Operations Support representatives and Chief Compliance Officer reviewed and approved the updated guidelines on [DATE]. Medical Director notified of incident and the opportunities identified to correct in the future. Administrator or Director of Nursing will monitor for compliance. 6. Human Resources associate audited 100% of current associate files for abuse training and back ground checks to include GCIC on [DATE]. The administrator or Human Resources associate will audit twelve agency or direct hire associates files per week for four weeks to ensure abuse training has been completed prior to patient care and background checks are correct to Include GCIC background. Random audit of six associate files will be completed per month for accuracy for three months. A Quality Improvement Data Collection Grid, titled Associate Abuse Training and Background Checks to include GCIC, will be used to document compliance. All audit reviews will be reviewed in the QAPI meeting to ensure ongoing compliance. We are alleging compliance as of [DATE]. The State Survey Agency (SSA) validated the facility's Credible Allegation of Immediate Removal as follows: 1. Review of the facility's five day investigation and review of the staff schedule from [DATE] through [DATE] revealed that CNA AA was crossed off the schedule and replaced with another CN[NAME] 2. The Administrator has confirmed that interviews with some residents regarding CNA AA were done and have spoken to any residents or family members that have expressed concern regarding the incident and news stories. 3. Review of the staffing schedule from [DATE] through [DATE] revealed that only direct staff were on the schedule and in the building. All staff in the building for [DATE] and [DATE] were verified per the facility schedule for the day and evening shifts. There were no agency staff in the building during the review. 4. The facility policy titled Agency Personnel-Background Screening revealed the policy was update in (MONTH) (YEAR) and was reviewed. An in-service conducted on [DATE] on Overview of Meeting Agency personnel hiring requirements revealed that 13 facility employees, and one Corporate Regional Nurse, who are responsible for decisions to call in agency staff participated in the in-service. A form titled Quality Improvement Data Collection Grid to be utilized by the hiring associates and managers to track that all information is available from the agencies before allowing the agency employee to work with residents. 5. The facility and corporate office have reviewed the agency contracts. After further review, it was determined that the contract did not need revision although a process to ensure the contract was followed was put into place. A review of the new attestation form titled Affirmation of Compliance Provisions Background Screening of Agency Personnel revealed that these are signed, in addition to the contract, by the Staffing Agency owner or manager. The Staffing Agency that employed CNA AA is in process of contracting with a background screening service to offer compliant screenings but in the meantime the employees will go to the local police department to have the needed background check completed before working. An interview with CNA CC, scheduler, on [DATE] at 10:28 a.m. revealed that when she is not working, or on the weekends, the Overhouse nurse would make the decision if staffing agency personnel is needed. She revealed that she had participated in an in-service on [DATE] regarding the new procedure for agency staff. The nurse would be responsible for checking background checks and [MEDICATION NAME] (TB) skin test were completed and negative before agency staff can work with residents. She reveals that now GCIC background checks are required of agency staff before they can work in the facility. Review of the facility in-services on Abuse from [DATE] through [DATE] revealed that 80 of the 90 employees had completed the in-service which also included an understanding quiz. Interviews on [DATE] with CNA DD at 11:36 a.m., CNA GG on [DATE] at 2:56 p.m., interviews on [DATE] CNA CC, scheduler, at 10:28 a.m., CNA FFF on [DATE] at 11:00 a.m., CNA EEE on [DATE] at 1:52 p.m. revealed that they had recently participated in in-services on abuse, recognizing abuse and to who they should report any allegation of abuse to at the facility. An interview with the Assistant Director of Nursing (ADON) R.N., on [DATE] at 2:45 p.m. revealed that she had recently had in-services on multiple items including recognizing abuse, what to do if it is reported to her and how to report to the State. She further revealed that she had been in-serviced on what was needed prior to agency staff being allow to work in the facility. Interviews on [DATE] at 11:41 p.m. with Housekeeper EE and on [DATE] with Housekeeper GGG at 11:16 a.m. revealed that they had recently had an in-service on abuse, were aware of what abuse involved. They would report any allegation of abuse to their supervisor or the nurse on the floor. They were aware of the Ombudsman program and the abuse hotline and where the posters were located in the facility. Interviews on [DATE] with LPN HH at 3:01 p.m., on [DATE] with Registered Nurse (RN) FF at 3:23 p.m., LPN CCC at 11:24 a.m., LPN BB at 12:52 p.m., LPN DDD at 1:41 p.m. who revealed they had recently participated in multiple in-services relating to abuse, identifying abuse, who to report abuse to in the facility or how to report abuse to the State. 6. Review of the Quality Assurance Improvement Plan (QAIP) sign in sheets reveal that on [DATE] and [DATE] QAIP meetings were held to discuss the immediate jeopardy issue. A telephone interview with the Medical Director on [DATE] revealed that she is aware that staffing issues are a problem at the facility and has been discussed in the QA meetings that she has attended. She also revealed that the facility made her aware of the incident with R B and CNA AA the day after the incident. She discussed the situation with the DON on the next visit. Review of the facility audit sheet revealed that 100% of direct facility employees have been confirmed as having had abuse training and a background check that includes a GCIC background check.",2020-09-01
275,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,550,D,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and review of training information titled Resident Rights- Dignity, Respect, [MEDICATION NAME] and Communication, the facility failed to ensure resident's dignity was maintained by referring to dependent residents as feeders during meal service on Unit One. This affected one of three Units during hall meal service delivery. Findings include: Observation on 7/8/19 at 1:10 p.m. revealed Certified Nursing Assistant (CNA) AA referred to meal trays for a dependent resident as a feeder. During interview on 7/10/19 at 2:28 p.m. CNA AA referred to dependent residents as feeders when discussing meal tray delivery. During further interview CNA AA acknowledged that she should not have referred to residents as being feeders but should have instead said residents that need assistance. During interview on 7/11/19 at 3:25 p.m. with the Assistant Director of Nursing (ADON) it was reported that staff have been in-serviced related to the dignity of residents. ADON reported that residents should not be referred to as feeders. ADON further reported that this is covered in orientation of new staff. On 7/11/19 at 4:07 p.m. the ADON provided a copy of in-service for dignity and resident's rights. ADON reported that this document is used during orientation. Review of the document Resident rights- dignity, respect, [MEDICATION NAME] and communication revealed residents have the right to: be treated with dignity, respect and consideration at all times. The in-service information also stated to not use the term Feeders. An interview on 7/11/19 at 4:43 p.m. with the Director of Nursing (DON) who reported that patients are to be referred to by their given name or name of choice. She further reported that staff should not refer to patients as feeders but should instead refer to residents as needing assistance with meals.",2020-09-01
276,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,578,D,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy titled Skilled Inpatient Services- Advance directives, the facility also failed to ensure an accurate code status determination was documented in the record for R#77 and failed to inform and provide written Advance Directive information to one Resident (R) (R#484) or his representative, and ensure a code status was ordered by the Physician upon admission. The sample size was 32 residents. The findings include: 1. Review of the medical record for R#77 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE], documents in Section C- a Brief Interview for Mental Status (BIMS) was not conducted, that resident is rarely or never understood. Review of the resident's care plan documents a care area/problem of Advanced Directive (AD) updated 6/27/19, with a goal that patient and/or responsible party will participate in Advance Directive/Advance Care planning discussion during the review period, dated 6/6/19 onset. Interventions included: ensure AD documents are complete/noted in the medical record dated 6/24/19, Full Code status dated 6/24/19, maintain a copy of AD documents on the chart, dated 6/24/19. Evidence by: Social Worker (SW) has discussed advanced directives and code status with resident and/or resident representative 6/24/19 onset. Review of the Physician's Orders in the electronic medical record for R#77 revealed an order for [REDACTED]. A Physician Orders for Life Sustaining Treatment (POLST) form signed on 6/11/19 by a Physician, and signed but undated by the resident's authorized signature and Power of Attorney (POA), was found in the electronic recorder under scanned documents. The POLST documents to allow natural death and do not attempt resuscitation. Another copy of the original POLST form was provided by the Social Worker (SW) on 7/11/19 that had an additional signature by a concurring Physician, dated 6/28/19. No evidence was found in the record of a care plan update or an order change reflecting the DNR code status to allow natural death-do not attempt resuscitation. An interview was conducted on 7/11/19 at 9:15 a.m. with the SW when she explained that once the POLST form is signed, the nurse can change the care plan. The POLST form then goes to medical records to be scanned in the electronic record. She stated they were initially waiting for the resident's family member to bring in evidence of having POA for the resident. The SW stated that the nurses should have changed the care plan and Physician's Order from a Full Code status to a DNR, saying the Full Code status order should have been lined out. She further explained the 6/11/19 POLST was the first one, then then the 6/28/19 POLST has the two physician signatures for DNR status. The SW explained they have been very busy without an Admission Coordinator (AC), that she is filling in for the Admission Coordinator. She explained their AD process is twofold, in that the AC starts the process and gives AD information to the resident and their representative, then will ask a few questions about their wishes, ask if they know their wishes and have signed an Advance Directive, have a POA, Living Will or evidence of a POLST. If they have any of these, she will obtain it or ask the family/or representative to bring in a copy. She stated this AD information is brought to the initial care plan meeting held with the resident and their representative. The SW stated the second line is for her to review the AD wishes in detail with the resident or their representative to make sure they understand it. If the resident has a POLST, to make sure it is properly signed and given to medical records to scan in the electronic record. The nurses are informed at the care plan meeting the resident's wishes, and are responsible that the Physician's Order and the care plan reflect their wishes. The SW then confirmed that this one slipped though and wasn't changed. 2. Review of the electronic record for R#484 revealed that the resident was admitted [DATE] from an acute hospital with a [DIAGNOSES REDACTED]. Record review revealed there was no AD Physician Order; and there was no AD information or checklist was found. An initial review of the resident's Physician Orders revealed there was no code status order. Review of the resident's current care plan dated 6/26/19, revealed a care area/problem- Advanced Directive, updated 7/9/19. Interventions- full code status 7/9/19 onset. Provide education on Advance Directives and Advance Care Planning, dated 6/26/19. An interview with the SW on 7/11/19 at 9:15 a.m. revealed that she is also the Admission Coordinator as they are in the process of hiring one. She confirmed that there was no code order prior to 7/9/19, explaining that the code status is started in admissions and then goes to her to finish getting information if no decision is made. The admission nurse reviews orders and to put in an order, then Medical Record scans any documents in the electronic record, such as the AD checklist, POLST, POA, or a Living Will. She confirmed they are behind and missed that there was no code status order. She further revealed that the code status information is gotten from several sources and information is brought to the care plan conference and then is put into the care plan. Review of the facility policy titled Skilled Inpatient Services- Advance directives updated (MONTH) 2019. Section 1. Informing Patient and or Representative of Rights/Options: [NAME] (3) Written information will be provided to the patient and a verbal explanation of advanced directives will be given. [NAME] (4) The Advance Directive Check List will be completed and filed on the patient's chart, this form documents that written information was provided. C. (5) Results of advance care planning decisions will be documented in the patient's medical record. This documentation will include identification of new care instructions, clarification or changes in care instructions or whether care instructions remain the same. Based on interview and record review, the resident did not have evidence of Advance Directive planning and/or information in the record and did not have a Physician's code status order until 7/9/19, the resident was admitted [DATE].",2020-09-01
277,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,623,D,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the Ombudsman with notification of hospital transfer for one resident (R#23) out of three residents reviewed. Findings include: An interview with R#23 on 7/8/19 at 12:38 p.m. revealed he had a history of [REDACTED]. A review of the Minimum Data Sets revealed a discharge assessment for 4/2/19 and an entry assessment for 4/6/19. The discharge assessment revealed that the resident was discharged to an acute hospital on [DATE]. A review of the Physician order [REDACTED]. A review of the care plan revealed that the resident had [MEDICAL CONDITION] disease related to [MEDICAL CONDITION]. A review of the Nurse's Note dated 4/2/19 revealed that the resident's oxygen saturation was 93% (percent) and oxygen was applied. The resident was requesting to go to the hospital and the facility obtained an order to send him to the hospital. A Nurse's Note dated 4/3/19 revealed that the resident was admitted to the hospital with [REDACTED]. An interview on 7/11/19 at 10:55 a.m. with the Social Service Director MM revealed that she had not been notifying the Ombudsman of residents who were discharged to the hospital. An interview on 7/11/19 at 11:43 a.m. with the Administrator revealed that she expected the Ombudsman to be notified of emergency transfers once a month. An interview on 7/11/19 at 11:54 a.m. with Vice President of Social Activities/Consultant NN stated that she didn't know why the Ombudsman was not been being notified because she had sent out an email notifying the facilities that they needed to be doing this.",2020-09-01
278,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,690,D,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that the catheter tubing and urine drainage bag for two of four Residents (R) (R#484 and R#46) with indwelling catheters, were positioned to ensure that these items did not meet contact with the floor. The sample size was 32 residents. Findings include: 1. Record review for R#484 revealed that the resident was admitted to the facility on [DATE] from an acute hospital with a [DIAGNOSES REDACTED]. Record review of the physician's orders [REDACTED]. Review of the resident's current care plan dated 6/26/19, revealed that the resident has a urinary catheter, and will be free of complications of an indwelling catheter through the review period. Interventions include: care/changing of urinary catheter as ordered, encourage adequate fluid intake, offer at frequent interviews, keep catheter tubing placed below level of bladder, maintain a closed, sterile system with tubing free of kinks, monitor urine output, appearance, amount, odor, and clarity, and observe and report any signs and symptoms of urinary tract infection. Observations were conducted of R#484's catheter tubing and urine drainage bag from 7/8/19 to 7/11/19 as follows: Observation on 7/08/19 at 11:12 a.m., at 1:10 p.m. and at 6:00 p.m. revealed that R#484 was observed in bed, with. the bed in a low position, the catheter bag secured to the bed, however, the urine bag half full of dark yellow urine was sitting on the floor, with urine, in the bag, visible from the door. Observation on 7/9/19 at 10:26 a.m. revealed that R#484 was observed in bed, the catheter bag is covered in a privacy pouch, however bag and tubing are both touching the floor. Observation on 7/9/19 at 3:34 p.m. revealed that R#484 was observed sitting in his wheelchair, the urine bag in a privacy pouch cover; however, the bag in the privacy pouch and tubing are lying on the floor under his wheelchair. Observation on 7/10/19 at 7:45 a.m. revealed that R#484 was in bed, and the urine bag was in a privacy pouch type cover, however, the tubing and urine bag in the pouch were lying on the floor. Observation on 7/10/19 at 9:30 a.m. during medication pass with Licensed Practical Nurse/Charge Nurse (LPN) CC revealed the resident's urine bag was lying on the floor, the catheter tubing touching the floor. The LPN CC stated the urine looks good; Certified Nurse Assistant (CNA) CNA DD was present in the room, removing the breakfast tray and both did not remove the urine bag from the floor. An interview on 7/10/19 at 3:30 p.m. with LPN CC revealed that a resident with a Foley catheter should have a privacy bag and the bag and/or tubing should not be on the floor. Review of the provided facility policy titled, Skilled Inpatient Services-Foley Catheter Care, updated (MONTH) 2019, documents the intent is to promote hygiene, comfort and decrease the risk of infection for patients with an indwelling catheter and is performed daily and as needed for soiling. The Guideline Section No. 8 documents- secure the catheter to drainage bag, Section No. 9- secure the catheter with a securement device, and Section No. 10- position the catheter drainage bag below the bladder. 2. Record review revealed that Resident (R)#46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Quarterly Minimum Data Set (MDS), Section O-Special Treatments and Programs, dated 5/9/19 revealed the presence of an indwelling (urine) catheter. Review of the care plan, updated 5/21/19, revealed a care plan for the urinary catheter with appropriate goals and interventions. An observation of R#46 in his bed on 7/8/19 at 2:36 p.m. revealed a urine catheter and bag placed in a privacy pouch with the pouch lying on the floor alongside the bed. An observation of R#46 in his bed on 7/9/19 at 9:45 a.m. and at 4:37 p.m. revealed the urine catheter/bag was inside the privacy pouch but the pouch was lying on the floor. An observation of R#46 in his bed on 7/10/19 at 3:45 p.m. revealed the resident's urine bag inside a privacy pouch, the pouch and catheter tubing were attached to his bed, the bed was in a low position; however, the catheter bag and tubing were lying on the floor. An interview with the Assistant Director of Nursing (ADON), who is also the Infection Control Nurse, on 7/11/19 at 3:33 PM, revealed that her expectation was that the catheter bag must be inside a privacy pouch which should not rest on the floor surface.",2020-09-01
279,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,698,D,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to maintain completed documentation of the [MEDICAL TREATMENT] Pre/Post Communication Report following eight of 16 [MEDICAL TREATMENT] sessions from 6/1/19 through 7/8/19 for one Resident (R)#71 of 32 sampled residents. Findings include: Review of the policy titled, Skilled Inpatient Services: [MEDICAL TREATMENT] Patient, revealed the intent was to assure safe care for the [MEDICAL TREATMENT] Patient. Procedural guidelines included: 1. Weights are obtained according to Physician Order. 2. Observe vascular access site. 3. Coordination with [MEDICAL TREATMENT] Plan of Care. Review of the clinical record revealed that R#71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 6/7/19, documented a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact, in Section C - Cognitive Patterns and [MEDICAL TREATMENT] while a resident, under Section O-Special Treatments and Programs. Review of the care plan, updated 6/27/19, revealed care plans for [MEDICAL TREATMENT]; risk for abnormal bleeding; potential for abnormal bleeding/bruising; potential for shortness of breath, chest pain, [MEDICAL CONDITION], and hypertension. Review of the physician's orders [REDACTED]. check for Thrill/bruit (vibration/sound which is felt/heard over a blood vessel) every eight hours, and check the [MEDICAL TREATMENT] site every eight hours. Review of the [MEDICAL TREATMENT] Communication Book revealed missing Pre/Post [MEDICAL TREATMENT] Communication Reports for the following dates: 6/7/19, 6/10/19, 6/19/19, 6/26/18, 6/28/19, 7/1/19, 7/3/19, and 7/5/19. An interview with R#71 on 7/10/19 at 11:49 a.m., revealed that he takes the Communication Form with him to [MEDICAL TREATMENT] clinic then the clinic writes something on it when his session is done and gives it back to him to return to the facility. He stated he doesn't know what happens to the forms after that. An interview with the Director of Nursing (DON) on 7/9/19 at 1:10 p.m. she confirmed there were communication reports missing from the [MEDICAL TREATMENT] Communication Book. An interview with the DON on 7/10/19 at 3:15 p.m. revealed that she was unable to explain what happened to the missing Communication Forms although she would expect the staff nurses to complete their portion of the form prior to [MEDICAL TREATMENT] and would ensure the post-[MEDICAL TREATMENT] forms were completed upon the resident's return to the facility. She further revealed that the nursing staff should contact the [MEDICAL TREATMENT] center, if the post form was not complete, and once completed they would put the form in the [MEDICAL TREATMENT] Communication Book.",2020-09-01
280,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,732,B,0,1,8NL611,"Based on observation and staff interviews, the facility failed to assure the nurse staffing information form was fully completed for four of four days during the survey. Findings include: During observation on 7/9/19 at 8:13 a.m. the daily staffing was posted but missing the facility name. During an interview with the Director of Nursing (DON) on 7/11/19 at 8:49 a.m. it was reported that night supervisor is responsible for completing daily staffing form and a copy is left for her to post each day. During an interview with the Administrator on 7/11/19 at 10:26 a.m. who confirmed that the posted staffing information did not have the facility name on it. The Administrator reported that it had not been noticed that the facility name was not on the form.",2020-09-01
281,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,757,D,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and policy review titled [MEDICAL CONDITION] Medications the facility failed to consistently document monitoring of side effects for behaviors for two of five residents (R# 60 and R# 68), who were receiving [MEDICAL CONDITION] medications. Findings include: Review of the policy title [MEDICAL CONDITION] Medications documented that when [MEDICAL CONDITION] therapy is initiated, the patient is monitored quantitatively and qualitatively to determine the effectiveness of the medication and the presence of side effects. The policy further indicated that behaviors should be noted using 0, 1, 2,3, or C if continuous episodes per shift per day. It further indicated that side effects should be indicated with a Y for yes and N for no related to side effects noted per shift per day. 1. Review of the clinical record for R#60 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician order [REDACTED]. Review of MAR for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 revealed medications given as ordered except when refused by resident. Review of behavior monitoring for R#60 revealed there was no behavior monitoring each shift for twelve days in (MONTH) 2019. There was no behavior monitoring each shift for twenty-eight days in (MONTH) 2019. There was no behavior monitoring each shift for ten days in (MONTH) 2019. An interview on 7/11/19 at 4:30 p.m. with the Director of Nursing (DON) who reported that when the electronic medical record program only allowed the behavior monitoring tool documenting for day or night. She further reported that with the behavior monitoring tool staff should be completing twice a day. It was also reported that side effects of the medication are documented only if there are behaviors note. The DON confirmed that there were missing days on the tool and reported that she had not previously identified this as a problem. 2. Review of the clinical record for R#68 revealed resident was admitted to the facility on [DATE] with a primary [DIAGNOSES REDACTED]. The resident's Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, indicating some cognitive impairment. Section D revealed no down depressed mood, sleeps much of the day and easily annoyed. Section [NAME] revealed no rejection of care or wandering exhibited. Review of resident's care plan initiated 4/12/19 revealed resident was at risk for [MEDICAL CONDITION] drug use. Interventions to care include administer medications as ordered, assess for fall risk, assess for non-drug interventions, document episodes of refusing requested care, monitor behavior as indicated, notify physician as indicated, and observe for possible side effects. Review of Physician order [REDACTED]. Review of Behavioral Monitoring log dated 5/1/19 - 7/11/19 reveals two episodes of abnormal behavior. The Behavioral Monitoring log fails to consistently monitor the behaviors and side effects of medications taken by Resident # 68. In (MONTH) 2019 there were 37 missed monitoring opportunities during the day and seven missed opportunities during the night. In (MONTH) 2019 there were 48 missed opportunities during the day and 25 missed opportunities during the night. In (MONTH) 2019 there were 22 missed opportunities during the day and seven missed opportunities during the night. The behavior monitoring log only showed monitoring of side effects on 5/2/19, 5/15/19, 5/18/19, 5/19/19, and 6/14/19.",2020-09-01
282,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,761,E,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews, and review of the policy titled, Pharmacy Services Medication Storage in the Care Center the facility failed to properly label and discard expired biological's by the expiration date printed on the medications in three of four medication carts inspected. Findings include: Review of the facility policy titled Pharmacy Services Medication Storage in the Care Center (12/17) revealed: #18. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, reordered from the pharmacy, if current order exists. Observation on 7/10/19 at 8:24 a.m., of the Unit 3 Medication Cart, Short Hall, was completed with, Licensed Practical Nurse (LPN) FF which revealed the following non-labeled and expired medications: [REDACTED] [MEDICATION NAME] Ophthalmic 3.5 grams (g) (ointment) expired on 6/2019, [MEDICATION NAME] and [MEDICATION NAME] 30 g (cream) expired on 6/2019, Fast Acting Mi-Acid (12 ounces) 355 milliliter (mL) (liquid) was open with no open date. An interview with Licensed Practical Nurse (LPN) on 7/10/19 at 8:33 a.m. confirmed that the medications (meds) listed above were not properly labeled/or expired. LPN FF further revealed that when meds are opened then a label showing the date they were opened should be placed on that medications and when meds are expired, they are removed from supply and put in the medication disposal box located on Unit One. Observation on 7/10/19 at 9:25 a.m. of the Unit 1- Medication Cart, Side A, with LPN CC revealed the following non-labeled and expired medications: [REDACTED] [MEDICATION NAME] 80 g (ointment) open with no open date, [MEDICATION NAME] and [MEDICATION NAME] B sulfates and [MEDICATION NAME] Ophthalmic 3.5 g (1/8 oz.) (ointment) open with no open date, [MEDICATION NAME] 40 extended release tablets open with no open date, [MEDICATION NAME] cream 1% 30 g (1oz) open with no open date. An interview with LPN CC on 7/10/19 at 9:32 a.m. confirmed that the medications listed above were not properly labeled. LPN CC stated these reusable medications should have been labeled with open dates and she does not know why this did not happen. Observation on 7/10/19 at 10:22 a.m. of Unit 3- Medication Cart, Long Hall with LPN FF revealed the following non-labeled and expired medications: [REDACTED] two tubes of Proctozone-HC 2.5% 30 g (1.1 oz.) (cream) with no open date, two tubes of Aspercreme w/ [MEDICATION NAME] 4.7 oz. open with no open date, Bio freeze Gel 3 oz. open with no open date, [MEDICATION NAME] 15 g (cream) open with no open date, [MEDICATION NAME] 1 oz. (cream) open with no open date, mupirocin 2% 22 g (ointment) expired on 4/2019, [MEDICATION NAME] sodium Topical Gel 1% with no open date, Sore Throat Spray 6 oz. with dates cannot be read, [MEDICATION NAME] 180 tablets with no open date, and 8 packs of ipratromin [MEDICATION NAME] and [MEDICATION NAME] sulfate 3 milligram (mg), with an expiration date of 5/2019. An interview on 7/10/19 at 10:32 a.m. with LPN FF confirmed that the medications listed above were not properly labeled/expired or contained an expiration date that could not be read. She further revealed that when meds are opened a label showing the date they were opened should be placed on those medications and when meds are expired, they are to be removed from supply and put in the medication disposal box located on Unit One. Observation on 7/10/19 at 10:48 a.m. of Unit 2- Medication Cart, C with LPN RR revealed the following non-labeled medications: [REDACTED] Bio freeze Gel 3 oz. open with no open date, three tubes of [MEDICATION NAME] and [MEDICATION NAME] Cream, 30 g, open with no open date, [MEDICATION NAME] ointment, 30 g, open with no open date, and two containers of miconazorb AF antifungal powder 2.5 oz, open with no open date. An interview with LPN RR, at this time, verified that the medications listed above were not properly labeled. She stated when meds are opened a label showing the date they were opened should be placed on that medications and when meds are expired, they are removed from supply and put in the medication disposal box located on Unit One. An interview with the Assistant Director of Nursing on 7/11/19 at 9:26 a.m. revealed that all open medications should be labeled with a tag that has the date in which the medication was opened. She also states that all expired medications should be removed from the cart or storage upon expiration which should be done daily and checked by the night nurse. She acknowledges that the expired medications found in medication carts should not have been there and should have been removed and placed in the designated expired medications container located on Unit 1. She further revealed that her expectations are that staff should ensure there are no expired medications and that medications have an opened date label.",2020-09-01
283,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,812,F,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy titled Skilled inpatient Services: Food Preparation and Distribution the facility failed to ensure food was delivered to residents receiving meals on the hallway in a sanitary manner related to proper hand sanitation and covering of food items when transported down the hallway. This deficient practice was observed for three of three meals service observations. Findings include: Review of policy titled Skilled Inpatient Services: Food Preparation and Distribution 6.Distribution a. All items transported from the kitchen to designated service areas or patient rooms will be covered. 1. Observation on 7/8/19 beginning ay 12:44 p.m. on 100 hall revealed the meal cart was placed at the top of the hall near room [ROOM NUMBER] and delivered to rooms [ROOM NUMBERS]. The food cart door remained opened while trays were being delivered. Further observation of meal tray delivery, revealed that the cart was placed on the other end of the hall between rooms [ROOM NUMBERS] and Certified Nursing Assistant (CNA) AA was observed carrying a meal tray to room [ROOM NUMBER] at the other end of the hallway. There was a piece of pie on the meal tray for each tray delivered and it was not covered. Observation on 300 hall on 7/9/19 at 5:29 p.m. revealed that the fruit cup on each meal tray was noted to be uncovered. The trays was carried from the first room on the hall (room [ROOM NUMBER]) to the last room on the hall (room [ROOM NUMBER]) for a total of five trays served that had uncovered fruit cups. Observation on the 300 hall on 7/10/19 at 12:18 p.m. revealed that the food cart was in the hallway between rooms [ROOM NUMBERS]. Meal trays were delivered to rooms [ROOM NUMBER] and the dessert on each tray was uncovered. Observation on 7/10/19 at 12:26 p.m. the food cart was parked at double doors at the top of the hall near room [ROOM NUMBER]. Meal trays were delivered to rooms 103, 105, 108, and 109 with the dessert on each tray uncovered. An interview with the Food Service Manager (FSM) on 7/10/19 at 1:57 p.m. revealed that items are considered covered when leaving the kitchen because they are in the food cart. The FSM further revealed that the CNAs are to take cart from room to room and not carry trays down the hall. A interview with the Assistant Director of Nursing (ADON) on 7/10/19 at 3:00 p.m. revealed that during orientation the procedure for meal delivery is addressed and the food cart should be pushed down the hall from one room to the other. She further revealed that food should be covered when in the hallways and that if items come on the food cart uncovered this would not be a problem if the food trays are not taken directly from the cart and into the resident's room. 2. An observation of the resident's lunch meal tray delivery and set up was conducted on 7/8/19 at 12:57 p.m., observing two Certified Nurse Assistants (CNAs) on Unit I delivering trays to residents that choose to dine in their rooms, rooms 114-129. Trays were delivered from a centrally located kitchen food cart, near the nurse's station. Fourteen residents were served and assisted with tray set up by CNA AA and CNA DD. Observation at this time revealed that CNA DD failed to wash her hands or use gel hand sanitizer after assisting with tray set up for R#485 after assisting tray set up for R##38 . The CNA was also observed delivering a regular tray with regular utensils to room [ROOM NUMBER] for R#480 in contact isolation. All trays delivered were observed removed from the kitchen cart and carried to each individual room at both ends of the hall with uncovered lemon meringue pie/dessert. An observation was conducted on 7/9/19 at 5:30 p.m. to observe delivery and set up of the dinner meal trays for residents choosing to dine in their rooms. Observation of delivery by CNA II and CNA HH on Unit 1, rooms 101-129 revealed that trays were delivered to 13 rooms with an uncovered fruit desert during the tray pass, including to both ends of the hall. Certified Nurse Assistant II was observed delivering and assisting with tray set up that included- removing lids from drinks, opening salt and pepper packets and applying to the food, opening straws and cutting up food for residents in rooms 103, 104, 109, 112, and 118, leaving each of those rooms without using hand sanitizer or washing her hands prior to going to assist the next resident. 3. Observation of dining for 200-hall on 7/8/19 at 1:18 p.m. revealed that the pie on several meal trays was uncovered. The meal cart was parked at the halfway point in the hall and trays were carried up the hallway over 25 feet with the uncovered pie.",2020-09-01
284,NEWNAN HEALTH AND REHABILITATION,115138,244 EAST BROAD STREET,NEWNAN,GA,30263,2019-07-11,880,E,0,1,8NL611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to ensure proper precautions were used while removing trays from the room of two residents (R#57 and R#480) of three residents on transmission based precautions, failed to use proper sanitation when cleaning glucometers on two of three halls, and failed to use sanitary techniques when administering medications on one of three halls. Findings include: 1. An Observation of R#57 on 7/8/19 at 12:14 p.m. revealed that resident (R) #57 was on contact precautions. Observation revealed signage on the entrance door to the resident's room and a table outside of the room containing personal protective equipment. An observation on 7/9/19 at 9:05 a.m. revealed that the resident had regular dishes in their room. The signage for contact precautions on the resident's door documented that patient dedicated equipment was to be used. An observation and interview on 7/9/19 at 9:33 a.m. of Certified Nursing Assistant (CNA) KK revealed that she donned a gown and gloves before entering the resident's room but did not sanitize her hands prior to entering the room. CNA KK was then observed to removed the resident's tray after eating then walking down the hall carrying the uncovered tray with bare hands. An interview with the CNA KK, at this time, confirmed that the resident was on contact precautions. She further revealed that protective equipment was stored outside the door in the bedside table. She stated that all equipment for the resident had to be left inside the resident's room. She further revealed that they used to cover the trays that came out of a resident room who was on contact precautions with a plastic bag, but they no longer cover the tray because the temperature of the dishwasher was supposed to completely sanitize the tray and utensils. The CNA confirmed that she carried the tray down the hall uncovered with bare hands. She stated that it was not uncovered because it had a lid. She also said that they were told to sanitize once they put the tray down. An observation on 7/10/19 at 9:31 a.m. revealed that the resident had regular dishes in their room. The CNA donned a gown and gloves to enter the resident room. The meal cart was parked beside the room door for R#57 but facing the hallway. The CNA handed the tray out to Laundry Aide LL who placed the tray on the cart. Laundry Aide LL did not have gloves on and was not observed sanitizing hands after handling the tray. An interview on 7/10/19 at 10:00 a.m. with Laundry Aide LL confirmed that she did carry the tray from the door of the room to the cart. An interview on 7/11/19 at 10:05 a.m. with the Assistant Director of Nursing (ADON) revealed that they do not use disposable dishes for residents on contact precautions to protect the dignity of the resident and because the chemicals/temperature of the dishwasher kill the bacteria. She stated that it was her expectation that when the food tray was picked up from the resident's room and placed on the cart, that the CNAs had already sanitized, donned a gown and gloves prior to entering the room. She stated that the meal cart was to be parked in front of the door and facing the door, the CNA would then place the tray directly on the meal cart from the room and it should be the last tray placed on the cart. She also stated that the meal cart should go directly to dietary. When told about the observations of trays being picked up from the isolation room, she said that was not the facility's process. A post survey telephone interview on 7/23/19 at 3:37 p.m. with the Administrator, Director of Nursing (DON), ADON (also the Infection Control Nurse), and the Dietary Manager revealed that the kitchen staff are trained to treat all trays as infectious. They use disposable aprons and gloves to place all trays into the dishwasher which is a high temp dishwasher that includes sanitization chemicals to kill all organisms. Once the tray carts are empty, they are taken outside the building, decontaminated, then after sitting for the required time, the carts are washed with hot water and allowed to air dry prior to re-use. The ADON revealed that both the CNAs and the staff nurses are trained to pull the meal carts, for resident's on isolation, to the resident's room so that staff can place the isolation trays on the cart without leaving the room. Isolation trays should be the last trays placed in the carts. The ADON revealed that should the meal tray be contaminated by liquids such as vomitus that the CNAs should decontaminate the tray before placing it in the cart. This process is not included in a written policy although she states the staff are trained upon hire for this process. 2. Observation and interview on 7/10/19 at 4:30 p.m. with Licensed Practical Nurse (LPN) PP on 200-hall of FSBS for R#28 revealed that she gathered the glucometer and supplies in her ungloved and unsanitized hand. LPN PP then placed the glucometer and supplies on the resident's bed without placing a barrier, she sanitized her hands, then placed a barrier down, sat the supplies and glucometer on the barrier, donned her gloves, cleaned the resident's finger with alcohol and pricked the resident's finger. LPN PP then sat the glucometer on the medication cart without a barrier, and recorded FSBS, allow she did not clean and/or disinfect the glucometer after use. LPN PP confirmed that she sat the glucometer and supplies down on the resident's bed without a barrier and had not sanitized the glucometer after using it. 3. An observation on 7/10/19 at 1:50 p.m. of the lunch meal tray removal from room [ROOM NUMBER] by CNA HH for a resident in contact isolation. The CNA HH was observed wearing an isolation gown and gloves, placing the tray with standard dishes and utensils on a stand located outside of the room, CNA HH then returned to the room to remove gloves, isolation gown and wash her hands. The CNA HH returned the meal tray to the kitchen transport cart which was located down the hall near the nurse's station. An observation on 7/10/19 at 1:58 p.m. for the lunch meal tray removal from room [ROOM NUMBER] tray by CNA DD, for a resident in contact isolation. The CNA was observed coming out of room [ROOM NUMBER] wearing an isolation gown and gloves, carrying a standard meal tray down the hall to the kitchen transport cart located near the nurse's station, setting the tray on the top of the cart, then returning to the room to remove gloves, gown and use gel hand sanitizer. The CNA then came back down the hall to place that resident's tray into the kitchen transport cart. An observation during a medication pass on 7/9/19 at 4:54 p.m. of an insulin subcutaneous injection conducted by LPN EE for R#22. The nurse removed from the medication cart a multi-dose vial of [MEDICATION NAME] 100/units/ml insulin. The nurse was observed injecting the needle into the vial to aspirate the dose of 10 units out of the vial; however, she did not clean/wipe the top of the vial with an alcohol pad prior to injecting. In addition, R#22 also received Humalog insulin 100 units/ml-7 units by an insulin injection pen. An Observation on 7/9/19 at 4:58 p.m. revealed upon return to the medication cart, LPN EE dropped the Humalog insulin pen to the floor. She was then observed to pick it up from the floor and place it in the medication cart drawer without sanitizing the pen or her hands. An observation on 7/9/19 at 5:25 p.m. revealed upon return to the medication cart, LPN EE was observed obtaining a multi-use glucometer from a case in the medication cart and obtaining a blood sugar sample for glucose testing from R#22. The glucometer was cleaned after use with the facility provided 2-minute anti-microbial wipe although the glucometer was placed on the medication cart to dry without a barrier. LPN EE confirmed she did not clean the glucometer prior to using it and did not think that she had to prior to use although, she always cleans it after use. An interview on 7/10/19 at 3:07 p.m. with LPN FF, Unit III Short-Hall, revealed that each medication cart has one glucometer, the same type of glucometer is on each medication cart, to be used on the residents located on their specific hall. She confirmed several LPNs use the medication cart including agency staff. An observation on 7/10/19 at 4:16 p.m. with LPN GG, Unit 1, revealed glucometer cleaning as follows: LPN GG obtained the multi-use glucometer from a case in the top drawer of the medication cart; was observed wiping off the glucometer with an alcohol prep-pad and placing the glucometer on a paper towel barrier. LPN GG then washed her hands and donned gloves and tested R#39's blood sugar, removed her gloves, washed her hands, then carried the glucometer to the medication cart on the same paper barrier, then donned gloves and cleaned the glucometer with an alcohol prep-pad and when air dried, placed the glucometer in the case and returned it to the drawer. The facility required anti-microbial 2-minute wipe located in the bottom drawer of the medication cart was not used. An interview on 7/11/19 at 5:06 p.m. with the Director of Nursing (DON) confirmed that it was not acceptable for an employee to pick an insulin pen up off the floor without sanitizing before placing it back in the drawer. She also confirmed that it was not acceptable for a nurse to use a multi-dose vial without cleaning it between residents. She confirmed it was not acceptable to put the glucometer or supplies down on a surface without a barrier, and it was not acceptable for the entire glucometer to not be cleaned in a two-step process where it was wiped with alcohol and allowed to dry and then wiped with the sani-wipe and allowed to dry before and after use. The DON confirmed is also not acceptable for a gown and gloves worn in a resident room on precautions to be worn out in the hallway. She stated that education and detailed orientation with check-offs were provided to each staff member including agency staff. A review was conducted of the facility policy titled Transmission-Based Precautions (Contact, Droplet, Airborne), updated (MONTH) 2019, provided on 7/10/19 by the DON. It documents under Contact Precautions that the facility uses Contact Precautions as recommended in Appendix A for residents with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. Policy Section 3. (a) documents to remove gown and observe hand hygiene before leaving the resident care area. (b) After gown removal, ensure that clothing and skin do not contact potentially contaminated environmental services that could result in possible transfer of microorganism to other residents or environmental surfaces. Section 4. (b) documents to use disposable non-critical resident equipment (e.g. blood pressure cuffs) or implement resident-dedicated use of such equipment. If common use of equipment for multiple residents is unavoidable, clean and disinfect such equipment before use on another resident. The policy does not give specific instructions and/or a procedure for handling meal tray delivery and subsequent return to the kitchen transport carts for residents on contact isolation. The policy documents in Section 4. to use disposable non-critical resident equipment. No further policy was provided. A review was conducted of the provided facility policy titled Skilled Inpatient Services-Glucometer Disinfection updated (MONTH) 2019. Documentation reflects in a section titled Intent, that it is the policy of this facility that all glucometers shall be thoroughly cleaned and disinfected between resident uses if individual glucometers are not available. Section titled Diabetes Care Procedures & Techniques No. 6 documents that when a glucometer has been used for one resident, and must be reused for another resident, the device must be cleaned and disinfected.",2020-09-01
285,RIVERDALE CENTER FOR NURSING AND HEALING,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2018-05-10,565,D,0,1,W3R211,"Based on review of resident council minutes and resident and staff interviews, it was determined the facility failed to provide a space that ensured privacy for the residents during their Resident Council Meetings and free of staff interruptions. The findings include: On 05/08/18 at 2:00 p.m., a group meeting was conducted with the Resident Council members. Nine alert and oriented residents attended the meeting. The meeting was held in the facility's dining room. The group was asked if this was the usual location for their Resident Council meetings. The residents all reported it was. The dining room had one main entrance door, with a partially closed in area at the end of the dining room. The room contained the ice machine, next to this area was a door that led into the kitchen. Observation during the group meeting revealed Certified Nursing Assistant (CNA) FF was in the ice machine area filling an ice chest for the secured unit. During the meeting five dietary staff workers and one therapy staff member walked through the dining room, interrupting the meeting. CNA FF was informed of it being a private Resident Council Meeting. CNA FF stated, I did not know, I didn't hear them make an announcement about the meeting. The residents were asked if there had been disruptions like that during their monthly Resident Council Meetings. They all reported that it happened all the time and they were irritated by the interruptions. R#A was in the Resident Council Meeting and spoke up, saying some residents would not attend the meeting due to fear of repercussion due to the meeting not being private. During an interview with R#A, after the meeting in the dining room in private. The resident was asked if she was aware of the identity of the residents she was referring to or the nature of the complaints. R#A reported she was not aware of what the complaints were about or the identity of the residents. However, she reported she felt their problems were not related to abuse or neglect. A couple of the Resident Council group voiced they felt the announcement prior to the meeting helped with the meeting not being disrupted by as many staff. But they still felt there needed to be a sign posted, so staff would know not to enter. Review of the Resident Council minutes for the months prior to the last survey revealed a paper in the front of the book containing the minutes which stated, Please do not enter during resident council meeting or you will be fined 25 cents, thanks in advance. The sheet had been signed by the Resident Council President. During an interview on 5/10/18 at 10:00 a.m., the Administrator interviewed in his office, revealed that the Administrator was informed of the lack of privacy during the Resident Council meeting. The Administrator reported he would talk with the Activity Director regarding this concern.",2020-09-01
286,RIVERDALE CENTER FOR NURSING AND HEALING,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2018-05-10,641,D,0,1,W3R211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure the Minimum Data Set (MDS) assessment accurately reflect the status of two of 32 sampled residents (Residents {R} #42, R#347). Findings include: 1. Record review revealed that R #42 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of annual comprehensive MDS assessment, dated 5/15/17, revealed the resident had no limitations in range of motion of upper or lower extremities. Review of care plan dated 2/6/18, documented, Restorative Nursing: PROM (passive range of motion) to bilateral upper extremity for six days a week daily for 15 minutes with ADLs (activity of daily living) to prevent further contractures. Review of quarterly Minimum Data Set (MDS) assessment, dated 2/15/18, revealed the resident had limitations in range of motion (ROM) on one side of upper extremities and no limitations of lower extremities. Review of the (MONTH) (YEAR), monthly physician's orders [REDACTED]. Observation on 5/7/18 at 10:14 a.m., revealed the resident sitting in a geri-chair in the dining area. The resident was observed wearing bilateral hand splints. Observation on 5/7/18 at 3:30 p.m. revealed the resident lying in her bed. The resident did not have the splints on currently. Observation on 5/8/18 at 9:30 a.m. revealed the resident was sitting in a geri-chair in the dining area. The resident was observed wearing bilateral hand splints. Interview on 5/9/18 at 9:30 a.m., LPN GG was interviewed, in the dining room in the secured unit, revealed that LPN GG was aware of when the splints were applied to the resident's hands. She reported night shift put them on her when they did her PROM, early in the morning, before getting her out of bed. LPN GG further reported the resident would wear the splints during the day when she was out of bed, to keep the contractures from getting worse. Interview on 5/9/18 at 9:57 a.m., MDS Coordinator DD, was interviewed in the MDS office, revealed that it was an incorrect entry on the MDS, that it should had identified the resident with bilateral upper extremity contractures. The MDS Coordinator DD further reported that the system should had pulled the information over from the nursing assessment, but she had failed to go back and check the assessment to make sure it was correct. 2. Record reviewed revealed that R#347 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS dated [DATE] revealed the resident was moderately impaired in cognitive skills in daily decision-making. Review of section O0100 Special Treatment, Procedures and Programs revealed R#347 was coded as receiving [MEDICAL TREATMENT] while a resident in the facility. Review of physician's orders [REDACTED]. Review of East Wing [MEDICAL TREATMENT] book revealed that there was no [MEDICAL TREATMENT] communications sheets for R#347. Review of the resident's care plans dated 4/9/18 revealed no care plan for [MEDICAL TREATMENT]. Interview on 5/4/18 at 4:30 p.m. with RN Unit Manager EE, on Northeast Hall, revealed the resident is not receiving [MEDICAL TREATMENT]. Interview on 5/4/18 at 4:40 p.m. in the conference room, MDS Coordinator DD revealed she entered a modification MDS for correction of the resident's admission MDS because she realized she miscoded him as receiving [MEDICAL TREATMENT].",2020-09-01
287,RIVERDALE CENTER FOR NURSING AND HEALING,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2019-07-11,578,D,0,1,B0JM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled OPS117 Health Care Decision Making, and interviews, the facility failed to establish documentation of Do Not Resuscitate code status in the resident's electronic chart and failed to communicate the code status to the interdisciplinary team and to staff responsible for the resident's care for one resident (R) (#88) of 46 sampled residents. Findings include: Review of the policy titled OPS117 Health Care Decision Making revised date 7/1/19 revealed policy stating all patients have the right to formulate an advance directive. The purpose is to assure that patients' wishes concerning health care decisions are communicated to all staff so that patients' rights will be honored, and their wishes will be executed at the appropriate time. Review of the clinical record for R#88 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the undated document titled Admission Record for R#88 revealed page two under advanced directive reads; FULL CODE. Review of document titled Physician order for [REDACTED].>Review of Progress Notes dated 6/3/19, from social services titled Post Admission Pt/Family Conference (SPN) revealed Attendees: Family, Social Services, Nurse, UM, Rehab, Recreation, Case Manager, Dietitian, Other, Business Office Manager (sic). Expectations: Advanced Directives in place include; full code.(sic) Review of residents Care Plan dated 6/7/19, revealed resident has an established advanced directive, with a goal of the resident or healthcare decision maker shall participate in decisions regarding medical care and treatment, (revised on 6/26/19), Interventions include; activate resident's advanced directive as indicated, allow opportunities for expression of feelings and ask questions, and inform resident and or healthcare decision maker of any change in status or care needs. Review of the Order Recap Report (Physicians Orders) document dated 5/28/19 through 7/31/19, revealed a verbal order from Dr.[NAME] as FULL CODE on 5/29/19, order status; active. A telephone interview with the family of R#88 on 7/11/19 at 10:20 a.m. revealed she wants the resident to be do not resuscitate code status, and stated she signed the paperwork for Do Not Resuscitate code status when the resident was admitted to the facility. An interview on 7/11/19 at 10:55 a.m. with Assistant Director of Nursing (ADON) revealed if the nurses need to find a code status for a resident the fastest way to find it, is to look the resident up on the computer, the code status shows under the resident name. An interview on 7/11/19 at 1:15 p.m. with the Unit Manager (UM) for East and North East Wing revealed if she entered R#88's room and the resident had no pulse and was unresponsive, she would look at the resident's Medication Administration Record [REDACTED]. An interview on 7/11/19 at 4:15 p.m. with Director of Nursing (DON) stated the process for advanced directives on admission is automatic full code until the facility receives the POLST, once the POLST is received, the Social Worker gives the completed and signed form to Nursing Department who then in turn changes the full code status to a DNR code status in the resident's electronic record. DON stated once the Physician signs the POLST, that is the new order. The DON revealed R#88's POLST form never got to nursing to be changed in the resident's electronic chart, which should have reflected the DNR status and did not.",2020-09-01
288,RIVERDALE CENTER FOR NURSING AND HEALING,115144,315 UPPER RIVERDALE ROAD,RIVERDALE,GA,30274,2019-07-11,880,D,0,1,B0JM11,"Based on observation, staff interview, and review of policy titled, Hand Hygiene, and, Dining Service Standards, the facility failed to ensure proper hand sanitation during meal service, and passing ice, on one of four halls (East hall). Sample size was 46 residents. Findings include: Review of the policy titled, Hand Hygiene, revealed adherence to hand hygiene practices by all personnel included hand washing with soap and water when hands were visibly soiled, and the use of alcohol-based hand rubs for routine decontamination in clinical situations. Alcohol based hand rubs will be placed near entrances and in common areas. Section titled Process, included staff shall perform hand hygiene as follows: 1.1 before patient care; 1.2 before an aseptic procedure; 1.3 after any contact with blood or other body fluids; 1.4 after patient care; 1.5 after contact with the patient's environment. Review of policy titled, Dining Service Standards, revealed #3 under Process included, All staff involved with meal service is trained on the general server tasks, including safe handling practices, and #4 included Proper handwashing and glove usage is utilized when serving food to patients/residents. No bare hand contact is made with ready to eat food. Observation on 7/9/19 at 4:30 p.m., revealed an unknown Certified Nursing Assistant (CNA) pushed a cart from room to room passing ice, and did not wash, or sanitize hands, between three rooms on East (E) hall, room E21, E23, E24. The CNA did not wear gloves, did not use individual hand sanitizer from her pocket, hand sanitizer from the mounted dispenser in the hallway, hand sanitizer from the nurses medication (med) cart, did not wash hands with soap and water before leaving the resident rooms, and hand sanitizer was not mounted in residents rooms. Observation on 7/10/19 at 10:24 a.m. revealed CNA EE come out of room E18 with two ice containers, filled container from ice cooler, returned and placed one on resident A's table, went into the bathroom with resident B's and filled with water, then placed on table, then went into next room. The CNA did not use hand sanitizer, or wash hands between rooms, or after handling containers. Observation on 7/10/19 between 1:20 p.m. and 1:45 p.m., revealed CNA FF, GG, and HH, passed lunch trays in multiple rooms on [NAME] hall, did not use hand sanitizer, or wash hands with soap and water, between trays/rooms/residents. Observation on 7/11/19 between 7:45 a.m. and 8:20 a.m., revealed CNA II passed breakfast trays on [NAME] hall, and did not wash hands, or use hand sanitizer. An interview on 7/10/19 at 1:45 p.m. with Licensed Practical Nurse (LPN) BB revealed they had hand sanitizer mounted in three places on [NAME] hall, on both ends, and at the center, and she pointed them out. She also revealed, staff were supposed to use the mounted hand sanitizer or wash their hands with soap and water. An interview on 7/11/19 at 8:20 a.m., with the Director of Nursing (DON), confirmed staff did not use individual hand sanitizer, they washed their hands with soap and water between residents rooms when delivering meal trays. The DON revealed that she expected staff to wash their hands with soap and water before leaving one resident room, getting the next meal tray, serving the next resident, passing ice, or providing care. An interview on 7/11/19 at 8:26 a.m. with LPN BB revealed staff are supposed to wash hands with soap and water before leaving a room and going to the next room, when passing out meal trays or providing resident care Follow up interview on 7/11/19 at 1:43 p.m., with the DON, revealed all staff are educated on infection control measures, hand hygiene, and her expectation that staff wash hands with soap and water after providing care and services, before leaving a room, every time.",2020-09-01
289,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,157,J,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the Physician of Finger Stick Blood Sugar (FSBS) assessment monitoring results as ordered for fifteen (15) residents (#122, #286, #39, #55, #133, #130, #155, #142, #300, #57, #136, #119, #232, #365, #318) of the forty-seven (47) sampled. It was determined that the noncompliance with one or more requirements of participation has caused one (1) resident (V) actual harm, and is likely to cause, serious injury, harm, impairment, or death to residents. The census was one-hundred-forty (140). It was determined that the noncompliance with one or more requirements of participation is likely to cause harm, and is likely to cause, serious injury, harm, impairment, or death to resident, related to the administration of insulin to diabetic residents. The census was one-hundred-forty (140). This noncompliance was identified to have existed as of 9/1/2015, and remains ongoing. The facility's Administrator and Director of Nursing were informed of this immediate jeopardy on 1/19/2016 at 4:30 p.m. Cross Reference to F309, F279, F282 Findings include: 1. Review of the medical record for Resident #122 revealed a [DIAGNOSES REDACTED]. The resident had been admitted to the facility on [DATE] and discharged on [DATE]. The Minimum Data Set (MDS) assessment, completed on 10/6/15, indicated the resident required insulin injections daily. Review of the Physician (MD) orders, dated 9/30/15, revealed an order to administer Humalog insulin per sliding scale, call MD for blood sugar (BS) less than ( ) than 400, no HS coverage, call MD if BS greater than (>) than 200, subcutaneously four times a day for Diabetes. Review of the Medication Administration Record [REDACTED]> 200 at HS and > 400, however there was no evidence of MD notification as ordered. 2. Review of the medical record for Resident #286 revealed admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] revealed the resident required insulin injections each day. Review of the MD orders, dated 10/18/15, revealed to administer [MEDICATION NAME]per sliding scale, call MD for BS 400, no HS coverage, call MD for BS > 200, subcutaneously four times a day for Diabetes Mellitus (DM) before meals and nightly. Review of MAR from 10/8/15 through 1/19/16 and Nurses Progress Notes from 10/8/15 through 1/19/16 revealed the Physician was not notified of BS > 200 at HS. 3. Review of the medical record for Resident #39 revealed a [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] indicated the resident received insulin injections daily Review of the MD orders revealed to administer HumaLog insulin per sliding scale, call MD for BS 400, no HS coverage, call MD BS > 200, subcutaneously four times a day. Review of MAR indicated [REDACTED]> 200 at HS, and > 400. 4. Review of the medical record for Resident #55 revealed a [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] indicated the resident received daily insulin injections. Review of Physician orders, dated 2/23/15, revealed orders to administer [MEDICATION NAME]per sliding scale, call MD for BS 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of MAR indicated [REDACTED]> 200 at HS times and failed to notify the Physician of BS 400. 5. Review of the clinical record for Resident #133 revealed [DIAGNOSES REDACTED]. The MDS assessment dated [DATE] required insulin administration daily. Physician orders [REDACTED]. 400, no HS coverage, call MD BS > 200, subcutaneously four times a day. Review of MAR indicated [REDACTED]> 200 at HS, and of BS > 400. 6. Review of the medical record for Resident #130 revealed [DIAGNOSES REDACTED]. The MDS, dated [DATE], revealed the resident required insulin administration daily and had no cognitive impairments. Nutritional assessment, dated 1/26/15, revealed the resident was at risk for weight fluctuations related to therapeutic diet, Diabetes, and Dysphasia. Physician orders, dated 6/9/15, revealed orders to administer Humalog insulin per sliding scale QID, call MD for BS 400, no HS coverage, call MD BS > 200,subcutaneously four times a day for DM Give four times a day before meals and nightly. Review of Nursing Progress Notes dated 9/1/15 through 1/19/16 and MAR from 9/1/15 through 1/19/16 revealed no MD notification for BS > 200 at HS and for BS > 400. 7. Medical record review for Resident #155 revealed a [DIAGNOSES REDACTED]. Review of Physician orders, dated 11/4/15, revealed administer Humalog per sliding scale, call MD for BS sugar 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of Nurses Progress Notes dated 11/5/15 through 1/19/16 and MAR indicated [REDACTED]> 200 at HS. 8. Medical record review for Resident #142 revealed a [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], revealed insulin administration daily. Review of MD orders, dated 6/1/15, revealed orders to administer [MEDICATION NAME]per sliding scale, call MD for BS 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of MAR indicated [REDACTED]> 200 at HS. 9. Medical record review for Resident #300 revealed a [DIAGNOSES REDACTED]. Quarterly MDS, dated [DATE], revealed the resident received insulin injections. Physician orders [REDACTED]. 400, no HS coverage, call MD BS > 200, subcutaneously two times a day for DM. Review of Nurses Progress Notes dated 9/24/15 through 1/19/16 and MAR from 9/24/15 through 1/19/16 revealed the facility failed to notify the Physician of BS > 200 at HS. 10 . Review of the clinical record for Resident #57 revealed a [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated the administration of insulin daily. The nutrition assessment, dated 6/17/15, revealed a MD order dated 8/31/15 to administer [MEDICATION NAME]per sliding scale, call MD for BS 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of Nurses Progress Notes dated 9/1/15 through 1/19/16 and MAR from 9/1/15 through 1/19/16 revealed the MD was not notified of BS > 200 at HS. 11. Review of the clinical record review for Resident #136 revealed a [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], revealed daily insulin administration. Review of the MD orders dated 11/24/15 revealed orders to administer [MEDICATION NAME]per sliding scale, call MD for BS 400, no HS coverage, call MD BS > 200, subcutaneously four times a day. Review of Nurses Progress Notes dated 11/24/15 through 1/19/16 and MAR from 11/24/15 through 1/19/16 revealed the MD was not notified of BS > 200 at HS. 12. Review of the clinical record for Resident #119 revealed [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment, dated 9/25/15, revealed the resident required insulin administration daily. Review of the MD orders dated 9/6/15 revealed orders to administer Humalog per sliding scale, call MD for BS 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM II. Review of MAR indicated [REDACTED]> 200 at HS and of BS > 400. 13 Clinical record review for Resident #232 revealed a [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 9/11/15, required the administration of insulin daily. Physician orders [REDACTED]. 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for DM. Review of the MAR indicated [REDACTED]> 200 at HS thirty-seven (37) times, and was not notified of BS 400. 14 Review of the clinical record for Resident #365 indicated a [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], revealed the resident required the administration of insulin daily. Review of the MD orders, dated 11/12/15, included Humalog administer insulin per sliding scale, call MD for BS 400, no HS coverage, call MD BS > 200, subcutaneously four times a day for Diabetes. Review of Nursing Progress Notes from 9/5/15 through 1/19/16 and MAR from 9/5/15 through 1/19/16 revealed the facility failed to notify the Physician of BS > 200 at HS. 15. Review of the clinical record for Resident #318 revealed [DIAGNOSES REDACTED]. The quarterly MDS, dated [DATE], indicated administration of insulin daily. Review of the MD orders dated 9/2/15 include administer [MEDICATION NAME]per sliding scale, call MD for BS 400, no HS coverage, call MD BS > 200, subcutaneously before meals and at bedtime for DM. Review of the MAR from 9/2/15 through 1/19/16 and Nursing Progress notes from 9/2/15 through 1/19/16,revealed the MD was not notified of BS > 200 at HS and of BS > 400. Interview on 12/2/15 at 1:17 p.m. with Licensed Practical Nurse (LPN) CC revealed the facility standard parameter for insulin coverage at 8 p.m. is to call the Physician for blood sugar results > 200 and not to give the sliding scale coverage. LPN CC indicated most of the Diabetic residents with sliding scale insulin coverage have this order but some do not, and there is no written policy or guidelines regarding this parameter. LPN CC acknowledged that if the residents have an order for [REDACTED].> 400. Interview on 12/2/2015 at 3:11 p.m. with the Primary Care Physician for Residents #122, #286, #55, #133, #130, #155, #142, #300, #57, #119, #232, #365, and #318 revealed the nurses know they should call him at HS for FSBS results > 200, and not to give sliding scale insulin coverage to the residents with the order not to give HS covearge. He could not definitively say he was called each time the residents blood sugars were > 200 at bedtime. Interview on 12/2/15 4:25 p.m. with LPN CC revealed she had searched for documentation of Physician notification of BS > 200 at 8:00 p.m. for Resident #122 and if the Physician was notified, this should appear in the Nurses Progress Notes and of the 16 blood sugar results > 200, no Physician notification was documented. Interview on 12/2/15 at 5:20 p.m. with LPN EE revealed their initials appear on the MAR indicated [REDACTED]. LPN CC acknowledged the sliding scale coverage had been administered without Physician notification. Interview conducted on 12/2/15 at 5:32 p.m. with LPN FF revealed they do not remember calling the Physician for Resident #122, to notify of FSBS > 200 at HS, and acknowledged they gave the sliding scale coverage at HS without a Physician order.",2020-09-01
290,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,241,G,0,1,ET9511,"Based on record review, review of the Bowel and Bladder Management Policy, resident interview and staff interviews, the facility failed to promote toileting in a manner that maintained or enhanced the dignity and respect for one (1) resident ( V ) of the fourty-seven (47) residents. The census was one-hundred-forty (140). This failure resulted in actual harm for Resident V when she stated The staff put an adult diaper on me and tell me to just go to the bathroom in my diaper. It is embarrassing to use the bathroom in a diaper, I'm not used to doing that. Cross reference F242, F279, F315 Findings include: Interview conducted on 12/1/15 at 8:49 a.m. with the Resident V revealed never being assisted to the bathroom since admission. Resdient V stated, the staff put an adult diaper on me and tell me to just go to the bathroom in my diaper. It is embarrassing to use the bathroom in a diaper, I'm not used to doing that. I am able to go on the toilet if someone will just help me. At home I was able to transfer from my wheel chair to the toilet. Review of the Admission Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) documented in Section B-Hearing, Speech, Vision that the resident had clear speech with distinct, intelligible words, is able to make self-understood and was able to understand others with clear comprehension. Section C-Cognitive Patterns documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate impairment. Section G-Functional Status documented no urinary toileting trials were attempted since admission. Review of the Bowel and Bladder Management Policy documented the services are provided to restore or improve bladder function to the extent possible, after the removal of a catheter. Review of the Caring for Residents with Dignity & Respect program guide documented when residents are able to participate in their own care, it can give them a sense of independence and self-worth. You should assure them if they have difficulty, you will provide them with the help they need. By encouraging residents to participate in their own care, some may actually show improvement. Review of the Employee Completing A Specific Course log revealed one hundred twenty (120) employee entries of completion of the online course for Dignity from (MONTH) 16, (YEAR) through (MONTH) 24, (YEAR). Some of the employess listed completed the course more than once. Interview conducted on 12/2/15 at 2:30 p.m. with the direct care Certified Nursing Assistant (CNA) revealed she takes care of Resident V on a regular basis during the dayshift. The resident requires extensive assistance for transfers with two (2) person assistance and mechanical lift device. When Resident V is in bed, she is able to push the call light to let her know when she needs to use the bathroom and bedpan is provided. When Resident V is out of bed in her wheelchair, she wears a brief and goes to the bathroom in her brief. Resident V is then taken back to her room, put back into the bed and cleaned up. Resident V has never been assisted to the toilet until yesterday.",2020-09-01
291,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,242,G,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, review of the 200 Hall Shower Schedule and review of the (MONTH) (YEAR) Shower Forms, the facility failed to honor the method of bathing for one (1) resident (V) from a sample of forty seven (47) residents. The census was one-hundred-forty (140). This failure resulted in actual harm for Resident V who stated The staff put adult diapers on me and tell me to just go to the bathroom in my diaper. They wipe me up but since I never get a shower I do not feel clean. Cross reference F241, F315 Findings include: An interview conducted on 12/01/2015 at 8:49 a.m. with resident V revealed she had received bed baths but had never received a shower since her admission. She preferred a shower over a bed bath but the staff never offered her a choice and she did not know she could have one. V stated The staff put an adult diaper on me and tell me to just go to the bathroom in my diaper. They wipe me up but since I never get a shower I do not feel clean. She lived independently at home with visiting aids that showered her three (3) times a week. Record review for Resident V indicated an admitted (MONTH) 13, (YEAR) after a hospitalization , with multiple [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) which documented in Section C- Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate impairment. Section F- Preferences for Customary Routine and Activities documented it was very important to choose between a shower, bed bath or tub bath. Section G- Functional Status documented the resident required physical help in part of bathing. Staff Assessment of Daily and Activity Preference was not conducted to indicate if the resident received a shower, bed bath or tub bath. Review of the Care Plan dated (MONTH) 23, (YEAR) identified Resident V had an Activities of Daily Living (ADL) self-performance deficit with an intervention that included, but not limited to, assist by two (2) staff for bathing/showering and encourage the resident to participate to the fullest extent possible with each interaction and observe/document/report any changes, any potential for improvement, reasons for self-care deficit, expected course or declines in function. A review of the Shower Schedule indicated for Resident V, the resident was scheduled to receive a shower on Wednesday and Saturday evenings. A review of the Shower forms from November-December (YEAR) in the Bath Book revealed no evidence of completed Shower Forms for Resident V. An interview conducted on 12/02/2015 at 2:30 p.m. with the Direct Care Certified Nursing Assistant (CNA) MM revealed she had never taken Resident V to the shower because they are scheduled for every Wednesday and Saturday on the evening shift. An interview conducted on 12/02/2015 at 2:40 p.m. with the 300 Hall Unit Manager revealed the CNAs use the Shower Form when a resident receives a shower. They document on the shower form the date, the resident's name and if the resident received a shower or refused. The shower form is given to the nurse and signed by the nurse. The form is then kept in the Bath Book. They also document in the computer that bathing occurred, however, this documentation does not indicate the type of bathing that occurred. She confirmed there are no Shower Forms in the Bath Book for Resident V.",2020-09-01
292,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,278,D,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to assure accurate Minimum Data Set (MDS) assessments for one (1) resident (#8) that received insulin injections and for one (1) resident (#138) designated as Pre Admission Screening Resident Review (PASRR) Level II, from fourty-seven (47) sampled residents. The census was one-hunded-fourty (140). Findings include: 1. Review of the clinical record for Resident #8 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed resident requires feeding assistance, receives a therapeutic diet and is incapable of communicating. Resident #8 was not coded in the Section N -Medications as receiving insulin or injections. Review of the Medication Administration Record [REDACTED]. Resident #8 also receives [MEDICATION NAME]twenty-five (25) units at breakfast, thirty (30) units at lunch and fifteen (15) units at dinner. Interview on 12/03/15 at 12:29 p.m. with the MDS Coordinator revealed the annual assessment Section N - Medications was coded incorrectly and should have included injections and insulin for seven (7) days of the 7 day look back period. 2. Record review for resident #138 indicated an admitted (MONTH) 5, 2012 with multiple [DIAGNOSES REDACTED]. The resident was approved by Level II PASRR without specialized services on (MONTH) 6, 2012. Review of the Admission Minimum Data Set (MDS) assessment dated (MONTH) 12, 2012, the Annual MDS assessment dated (MONTH) 20, 2013, the Annual MDS assessment dated (MONTH) 29, 2014 and the Annual MDS assessment dated (MONTH) 6 (YEAR), did not indicate in Section A- Identification Information that the resident had been evaluated by Level II PASRR to determine serious mental illness and/or mental [MEDICAL CONDITION] or a related condition. An interview conducted on 12/03/2015 at 4:27 p.m. with the MDS Coordinator confirmed the assessment for Level II PASRR was inaccurately assessed.",2020-09-01
293,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,279,K,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to develop a comprehensive care plan for Diabetes, Insulin administration, antipsychotic medication use and to restore bladder function for five (5) residents (V, #226, #55, #142, and #300) of the sampled forty-seven (47) residents. The census was one-hundred-forty (140). This failure to develop an individualized comprehensive care plan for incontinence resulted in actual harm for Resident V when interventions and approaches did not promote care and services in a manner to restore or improve bladder function, and caused actual harm. It was determined that the provider's noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The noncompliance is related the administration of insulin to diabetics, in which the facility failed to follow specific doctor orders. The doctor orders indicated parameters related to notification, and to with hold insulin at HS, however the facility failed to notify the doctor as specified and administered insulin at HS. This noncompliance related to the Immediate Jeopardy was identified to have existed as of 9/1/2015, and remains ongoing. The Administrator and Facility District Clinical Consultant were informed of this immediate jeopardy on 1/19/2016 at 4:30 p.m. Cross reference to F241, F242, F309, F315 Findings include: 1. Record review for resident V revealed an Admission Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) which documented in Section G-Functional Status that the resident required extensive assistance of two person physical assist with transfers and toileting. No urinary toileting trials were attempted since admission and the resident was always incontinent of bladder and always incontinent of bowel. Further record review of the Care Plan for Resident V identified a focus on incontinence on (MONTH) 30, (YEAR), however, the Care Plan Goal documented was: skin breakdown due to incontinence and brief use. There is no evidence of Measurable Goals related to restoring or improving bladder function. The interventions include: 1. Encourage fluids during the day to promote prompted voiding responses 2. Have call light within easy reach. 3. Check for incontinence, wash, rinse and dry perineum. Change clothing as needed after incontinence episodes. 4. Observe/document for signs and symptoms or Urinary Tract Infection [MEDICAL CONDITION]: pain, burning, cloudiness, no output, deepening of urine color, increased pulse, increased temperature, urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, and change in eating patterns. 5. Refer the Therapy as needed. There is no evidence of individualized interventions or approaches to restore or improve bladder function. Review of the Bowel and Bladder Management Policy documented: Each resident who is incontinent is identified, assessed and provided appropriate treatment and service. Services are provided to restore or improve normal bladder function to the extent possible, after the removal the catheter. The intent of the Bowel and Bladder Management System is to clearly define the process for providing care and treatment for [REDACTED]. Interview conducted on 12/2/15 at 4:45 p.m. with the MDS/Registered Nurse (RN) LL confirmed the Care Plan Goal for Resident V was more related to skin breakdown and could see how it should have been more specific to improving bladder function. The interventions for incontinence is selected form the computer system with preset interventions to choose from. They typically select and click the same selections for residents when creating goals and interventions for incontinence. 2. Record review for resident #226 indicated an admission date of [DATE], with multiple [DIAGNOSES REDACTED]. Review of the 14 Day Minimum Data Set (MDS) assessment dated [DATE], documented in Section N- Medications that the resident received an antipsychotic medication seven (7) out of seven (7) days of the assessment period. Review of the Physician order [REDACTED]. [MEDICATION NAME] 0.5 mg at bedtime was ordered on [DATE] and discontinued on 07/01/2015. Review of the Medication Admiration Records (MAR) from March-July (YEAR) indicated the [MEDICATION NAME] 0.5 mg was administered as ordered. Review of the Care Plans revealed no evidence of a comprehensive care plan for the use of antipsychotic medication. An interview conducted on 12/03/2015 at 8:40 a.m. with the MDS/LPN AA confirmed there was no care plan for antipsychotic medication use for resident #226 and that one should have been developed when the resident began receiving the antipsychotic. 3. Review of the clinical record for Resident # 55 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. Review of care plans dated 11/24/15 revealed care plans for nutrition, [MEDICAL CONDITION] [MEDICAL CONDITIONS], Asthma, pain, fall risk, skin breakdown risk, activities of daily living, impaired cognitive function and independence in meeting emotional, intellectual, physical and social needs. There was no care plan developed regarding the [DIAGNOSES REDACTED]. 4. Record review for Resident #142 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of care plans dated 7/1/15 revealed care plans for fall risk, skin integrity, ADL self care performance deficit, antianxiety medication, bladder incontinence and [MEDICAL TREATMENT]. There was no care plan to address the [DIAGNOSES REDACTED]. 5. Record review for Resident #300 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of care plans dated 8/19/15 revealed care plans for falls , skin integrity, ADL self care performance deficit, antibiotic therapy, potential alteration in nutrition. There was no care plan to address the [DIAGNOSES REDACTED]. Interview on 12/3/15 at 1:01 p.m. with the Director of Nurses (DON) revealed there was no Diabetic care plan. The DON acknowledged any resident with a [DIAGNOSES REDACTED].",2020-09-01
294,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,282,K,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure the care plans were followed for twelve (12) residents (#122, #286, #39, #133, #130, #155, #300, #57, #136, #232, #365, and #318) of the forty-seven (47) sampled residents. The census was one-hundred-forty (140). It was determined that the noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The noncomplaince related to insulin dependent diabetics in which the facility failed to administer insulin as ordered and failed to notify the medical doctor for specific ordered finger stick blood sugar assessments. This noncompliance related to the Immediate Jeopardy was identified to have existed as of 9/1/2015, and remains ongoing. The Administrator and District Clinical Consultant were informed of this Immediate Jeopardy on 1/19/2016 at 4:30 p.m. Cross reference to F279 and F309 Findings include: Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS), dated [DATE], revealed the resident required insulin injections every day. On review of Resident #122's care plan, dated 10/7/15, a problem was identified which read, (Resident ' s name) has Diabetes Mellitus. The goal that was documented read, (Resident ' s name) will have no complications related to Diabetes through the review date. The interventions listed included: Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Additional interventions included Observe/document/report as needed (PRN) any signs or symptoms (S/SX) of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, kussmaul breathing, [MEDICATION NAME] breath, stupor,coma. Review of Physician orders for Resident #122, dated 9/30/15, revealed an order for [REDACTED]. Review of medication administration records (MAR's) dated 10/1/15 through 10/31/15, Nurses Progress Notes dated 10/1/15 through 10/31/15, and Location of Administration Reports from 10/1/15 through 10/31/15 revealed the care plan of Resident #122 was not followed related to the intervention to give Diabetes medications as ordered by doctor. Resident #122 received insulin coverage at HS, with an order for [REDACTED]. 2. Resident #286 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent MDS assessment, dated 9/21/15, revealed the resident was not able to complete cognitive assessment, rejected care, and required insulin injections daily. Nutritional assessment, dated 9/10/15, revealed the resident required enteral feedings by percutaneous endoscopic gastrostomy (PEG) tube. Review of the care plan for Resident # 286, dated 9/22/15, indicated the facility had identified a focus of Diabetes Mellitus. The goal for this focus was as follows (resident ' s name) will have no complications related to Diabetes through the review date . The interventions listed included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders for Resident #286, dated 10/8/15, revealed orders for [MEDICATION NAME]per sliding scale, call MD for blood sugar less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for Diabetes Mellitus (DM) before meals and nightly. Review of MAR's dated 10/8/15 through 1/19/16 , Nursing Progress Notes dated 10/8/15 through 1/19/16, and Location of Administration Reports from 10/8/15 through 1/19/16 revealed the facility failed to follow the care planned intervention to administer Diabetes medication as ordered, by failing to follow the Physician order for [REDACTED].>3. Review of the clinical record for Resident #39 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Nutritional assessment dated [DATE] indicated resident has a low body mass index (BMI) of 19.1, has restricted fluid intake and receives oral feeding and enteral feeding through PEG tube. The quarterly MDS assessment dated [DATE] indicated the resident had mild cognitive impairment and required insulin injections every day. Review of the care plan for Resident #39 dated 5/29/15 revealed the facility identified a focus of Diabetes Mellitus for Resident #39 with a goal reading, (resident name) will have no complications related to Diabetes through the review date. The interventions listed included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders dated 9/18/15 revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day. Review of MAR's dated 9/18/15 through 1/19/16, Nurses Progress Notes dated 9/18/15 through 1/19/16, and Location of Administration Reports dated 9/18/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of administering Diabetes medications as ordered by doctor by failing to follow the Physician order for [REDACTED].>4. Resident #133 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Most recent MDS assessment dated [DATE] revealed this resident had no cognitive impairment, required supervision with eating and received insulin injections every day. Review of nutritional assessment dated [DATE] revealed the Resident #133 had a BMI of 39.8, indicating Grade 2 obesity and was considered a potential nutritional risk due to diagnoses, medications, and therapeutic diet. Review of the care plan for Resident #133, dated 10/26/15, indicated the facility identified a focus of Diabetes Mellitus, with a goal of no complications related to Diabetes through the review date. Interventions included the following: Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of physician orders for Resident #133, dated 10/16/15, indicate orders for Humalog insulin sliding scale coverage, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day. Review of MAR's dated 10/16/15 through 1/19/16, Nursing Progress Notes dated 10/16/15 through 1/19/16, and Location of Administration Reports for 10/16/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of administering diabetes medication as ordered by the Physician, by failing to follow the Physician order for [REDACTED].>5. Resident #130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nutrition assessment dated [DATE] reveal the resident had excessive oral intake that exceeded estimated needs, was obese, and a goal was established for no significant weight gain while meeting estimated needs. The quarterly MDS dated [DATE] indicated no cognitive impairment and required insulin administration every day. Review of the care plan for Resident #130 indicated the facility had identified a focus of Diabetes Mellitus on 6/22/15 with a goal for no complications related to Diabetes through review date. The interventions listed included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders dated 6/9/15 revealed orders for Humalog insulin per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for DM Give four times a day before meals and nightly. Review of the MAR's dated 9/1/15 through 1/19/16, Nursing Progress Notes dated 9/1/15 through 1/19/16, and Location of Administration Reports from 9/1/15 through 1/19/16 revealed the care planned intervention of Diabetes medication as ordered by Physician related to the physician order of no HS coverage, was not followed and the resident was administered covearge at HS. 6. Resident #155 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission MDS assessment, dated 11/11/15, indicated severe cognitive impairment, required extensive assistance in all areas of ADL and required insulin administration six (6) days out of seven (7). Nutrition data collection dated 11/15/15 revealed resident was obese, with a BMI of 30.3 and consumed 51 to 75% of meals daily. The resident was identified as a potential risk for nutrition with anticipated weight fluctuations related to daily diuretic therapy. Review of the care plan dated 11/12/15 for Resident #130 revealed a focus of Diabetes Mellitus. The goal for this focus was No complications related to Diabetes through the review date. Interventions included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Physician orders dated 11/4/15 revealed an order for [REDACTED]. Review of MAR's dated 11/5/15/ through 1/19/16, Nurses Progress Notes dated 11/5/15 through 1/19/16, and Location of Administration Reports for 11/5/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medication as ordered by Physician, related to the Physician order for [REDACTED]. 7. Resident #57 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Nutrition data collection completed by the Registered Dietitian on 6/17/15 revealed the resident had poor dentitian with weight above desired weight parameters and the current diet regimen providing adequate nutrition. The MDS quarterly assessment, dated 9/4/15, revealed mild cognitive impairment and required insulin administration daily. The care plan dated 6/9/15 for resident #57 indicated the facility identified a focus of Diabetes Mellitus, with a goal for No complications related to Diabetes through the review date. Interventions for this focus included the following Diabetes medication as ordered by doctor. Observe/document the side effects and effectiveness. Physician orders for Resident #57 revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for DM. Review of MAR's for 9/1/15 through 1/19/16, Nurses Progress Notes dated 9/1/15 through 1/19/16, and Location of Administration Reports from 9/1/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medication as ordered by doctor, related to the Physician order for [REDACTED]. 8. Resident #136 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of nutritional assessment dated [DATE] revealed Resident #136 was expected to have weight fluctuations related to [MEDICAL TREATMENT], and was obese with a BMI of 30.6. The quarterly MDS assessment dated [DATE] revealed mild cognitive impairment, was able to eat independently and required daily insulin injections. Review of care plan dated 10/16/15 indicated the facility identified a focus of Diabetes Mellitus with a goal of No complications related to Diabetes through the review date. Interventions included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders for Resident #136, dated 11/24/15, revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MS BS greater than 200, subcutaneously four times a day. Review of MAR's dated 11/24/15 through 1/19/16, Nurses Progress Notes dated 11/24/15 through 1/19/16 and Location of Administration Reports from 11/24/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medication as ordered by doctor, related to the Physician order for [REDACTED]. 9. Review of the clinical record for Resident #119 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment and required insulin administration daily. Review of nutritional assessment dated [DATE] revealed the resident had skin tears and [MEDICAL CONDITION], a BMI of 40.4, and was considered a potential risk for nutrition related to [MEDICAL CONDITION]. The care planned focus of Diabetes Mellitus was dated 12/17/15 with a goal of No complications related to Diabetes through the review date. Included was an intervention of Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Additional interventions included observe/document/report as needed (PRN) any signs or symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, kussmaul breathing, [MEDICATION NAME] breath, stupor,coma. Review of Physician orders dated 9/6/15 revealed orders for Humalog per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD for BS greater than 200, subcutaneously four times a day for DM II. Review of MAR's dated 9/6/15 through 1/19/16 , Nurses Progress Notes dated 9/6/15 through 1/19/16, and Location of Administration Reports from 9/6/15 through 1/19/16 revealed the facility failed to follow the care planned intervention to administer diabetes medications as ordered by the Physician, related to the Physician order for [REDACTED]. 10 Resident #232 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission MDS assessment, dated 9/11/15, revealed the resident had no cognitive impairment, required extensive assistance in all areas of activities of daily living except eating and required daily insulin injections. Review of the nutritional assessment dated [DATE] revealed a low BMI of 19.9, poor dentition, had dehydration risk factor of daily use of laxative, an average meal intake of 70% daily, and healing gastrostomy and [MEDICAL CONDITION] site. The facility identified a care planned focus for Resident #232 on 9/16/15 of Diabetes Mellitus. The goal for this focus was for the resident to have No complications related to diabetes through the review date. Care planned interventions included Diabetes medication as ordered by doctor. Oserve/document for side effects and effectiveness. Additional interventions included Observe/document/report as needed any signs or symptoms of [DIAGNOSES REDACTED]: sweating, tremor, increased heart rate, pallor, nervousness, confusion, slurred speech, lack of coordination, staggering gait. Review of Physician orders dated 9/5/15 revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for DM. Review of MAR's dated 9/5/15 through 1/19/16 ,Nurses Progress Notes dated 9/5/15 through 1/19/16, and Location of Administration Reports from 9/5/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medications as ordered by Physician, related to the Physician order of no HS insulin coverage, by administering HS covearge. Additionally the facility failed to follow the care planned intervention to report signs of [DIAGNOSES REDACTED], related to the Physician order to notify the physician of FSBS results less than 70, indicating [DIAGNOSES REDACTED], one time. 11. Resident #365 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The admission MDS assessment, dated 11/19/15, revealed no mental status summary score could be obtained because the resident was rarely or never understood, required extensive assistance and total dependence in all areas of activity date of daily living (ADL) and required daily insulin injections. A review of the nutritional assessment dated [DATE] revealed the resident was comatose and received enteral feedings by pump. The resident was considered a potential nutritional risk due to mental status and tube feedings. Review of the care plan dated 11/20/15 revealed Resident #365 had an identified focus of Diabetes Mellitus with a goal of No complications related to Diabetes through the review date. Care planned interventions included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Review of Physician orders dated 11/12/15 revealed orders for Humalog insulin per sliding scale, call MD for BS less than 70 or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously four times a day for Diabetes. Review of the MAR's dated 9/5/15 through 1/19/16, Nurses Progress Notes dated 9/5/15 through 1/19/16, and Location of Administration Reports from 9/5/15 through 1/19/16 revealed the facility failed to follow the care planned intervention to administer diabetic medications as ordered by Dr., related to the physician order for [REDACTED]. 12. Resident #318 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of nutritional assessment dated [DATE] revealed a low BMI of 18.7, poor dentition, and extensive assistance required to eat. The resident consumed 26 to 51% of meals and intake was not meeting caloric needs. No further assessments were available. Review of the quarterly MDS assessment dated [DATE] indicated the resident had moderate cognitive impairment, and required insulin injections daily. Review of the care plan dated 9/9/15 for Resident #318 revealed the facility identified a focus of Diabetes Mellitus, with a goal of No complications related to diabetes through the review date. Interventions for this focus included Diabetes medication as ordered by doctor. Observe/document for side effects and effectiveness. Additional interventions included Observe/document/report as needed any signs or symptoms of [MEDICAL CONDITION]: increased thirst and appetite, frequent urination, weight loss, fatigue, dry skin, poor wound healing, muscle cramps, abdominal pain, kussmaul breathing, [MEDICATION NAME] breath, stupor, coma. Physician orders dated 9/2/15 revealed orders for [MEDICATION NAME]per sliding scale, call MD for BS less than 70, or greater than 400, no HS coverage, call MD BS greater than 200, subcutaneously before meals and at bedtime for D.M Review of MAR's dated 9/2/15 through 1/19/16, Nurses Progress Notes dated 9/2/15 through 1/19/16, and Location of Administration Reports from 9/2/15 through 1/19/16 revealed the facility failed to follow the care planned intervention of Diabetes medication as ordered by doctor, related to the physician order for [REDACTED]. 13. Record review for Resident #136 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of Nutritional Assessment revealed Resident #136 had a BMI of 30.6 and was expected to have weight fluctuations related to [MEDICAL TREATMENT]. Review of Physician orders dated 11/24/15 revealed an order for [REDACTED]. Review of the Diabetes care plan dated 10/16/15 indicated the following interventions: Diabetes medication as ordered by doctor, discuss meal times, portion sizes, dietary restrictions, snacks, Fasting Serum Blood Sugar as ordered by doctor, if infection is present consult doctor, observe/document/report as needed any signs or symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED], refer to podiatrist or foot care nurse, refer to Registered Dietician (RD) as needed. No Physician ordered interventions were included on the care plan for no HS coverage , call MD BS greater than 200. Review of Nurses Progress Notes dated 11/24/15 through 1/19/16, MAR indicated [REDACTED] 13. Record review for Resident # 119 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of nutritional assessment dated [DATE] revealed a BMI of 40.4, skin tears and [MEDICAL CONDITION] and was at potential risk for nutrition related to [MEDICAL CONDITION]. Review of Physician orders dated 9/6/15 revealed orders for Humalog per sliding scale, call MD for BS less than 70 or greater than 400, No HS coverage, call MD BS greater than 200, subcutaneously four times a day. Review for Diabetes Care plan dated 12/17/15 revealed interventions for diabetes medications as ordered by doctor, check all body for breaks in skin, observe/document report as needed any signs or symptoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED], and refer to podiatrist or foot care nurse. No interventions were listed regarding the Physician orders to notify MD of BS less than 70 or greater than 400, no HS coverage, or call MD BS greater than 200 at HS. Review of Nurses Progress Notes dated 9/6/15 through 1/19/16, MAR indicated [REDACTED] The facility failed to notify the Physician of FSBS greater than 200 at HS, failed to follow the Physician order for [REDACTED]. Interview on 1/19/16 at 4:35 p.m. with the Administrator revealed the care plans for the Diabetic residents were not been followed because HS insulin was not being administered as ordered.",2020-09-01
295,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,309,K,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interview, the facility failed to follow medical doctor (MD) orders related to sliding scale insulin coverage administration, titration of an antidepressant medications and failed to access a [MEDICAL TREATMENT] port site for seventeen for (17) residents (#122, #286, #55, #57, #318, #365, #232, #119, #142, #155, #130, #133, #39, #300, #136, #1 and #221) of the forty-seven (47) sampled residents. It was determined that the noncompliance with one or more requirements of participation has caused, is likely to cause, serious injury, harm, impairment, or death to residents. The census was one-hundred-forty (140). The failure was related to the medical doctors orders not to administer insulin at bedtime, and specific parameters at which the doctor wanted to be notified. However the facility failed to follow the doctor orders for notification and bedtime insulin, as detailed below. The Administrator and Facility District Clinical Consultant were informed of Immediate Jeopardy on 1/19/16 at 4:30 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 9/1/15, and remains ongoing. Findings include: 1. Review of the clinical record for Resident #122, revealed an admission date of [DATE] and discharge on 10/31/15, with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED].#122 revealed an order for [REDACTED]. 400. Review of the Medication Administration Record [REDACTED]> 200 at HS, and the MD was not notified and no insulin was administered: In (MONTH) (YEAR): On 10/1/15 at 8:00 p.m., the FSBS results were 300, without MD notification or insulin administered; on 10/2/15 at 8:00 p.m., the FSBS results were 347, without MD notification or insulin administration; on 10/3/15 at 8:00 p.m., the FSBS results were 323, with 8 units of insulin administered, without a MD order; on 10/4/15 at 8:00 p.m., the FSBS results were 233 with 4 units of insulin administered, without a MD order; on 10/5/15 at 8:00 p.m., the FSBS results were 313, without MD notification or insulin administration; on 10/7/15 at 8:00 p.m., the FSBS results were 281, with 6 units of insulin administered, without a MD order; on 10/8/15 at 8:00 p.m., the FSBS results were 248, with 4 units of insulin administered, without a MD order; on 10/9/15 at 8:00 p.m., the FSBS results were 244, with 4 units of insulin administered, without a MD order; on 10/11/15 at 8:00 p.m., the FSBS results were 237 with 4 units of insulin administered, without a MD order; on 10/13/15 at 8:00 p.m., the FSBS results were 170 with 2 units of insulin administered, without a MD order; on 10/15/15 at 8:00 p.m., the FSBS results were 209, without notification of MD, or insulin administration; on 10/16/15 at 8:00 p.m., the FSBS results were 182 with 2 units of insulin administered, without a MD order; on 10/23/15 at 8:00 p.m., the FSBS results were 246 with 4 units of insulin administered, without a MD order; on 10/26/15 at 8:00 p.m., the FSBS results were 249 with 4 units of insulin administered, without a MD order; on 10/28/15 at 8:00 p.m., the FSBS results were 321, without MD notification or insulin administration; on 10/29/15 at 8:00 p.m., the FSBS were 300, without MD notification or insulin administration, and; on 10/30/15 at 8:00 p.m., the FSBS results were 404 with 12 units of insulin administered without a MD order. Interview on 12/2/2015 at 3:57 p.m. with the Director of Nurses (DON) acknowledged a nurses note entry should be made each time a MD is called. Continued interview revealed he had been unable to find any documentation of MD notification of blood sugars > 200 at HS for Resident #122 from 10/1/2015 until 10/30/2015. Interview on 12/2/2015 at 4:25 p.m. with LPN CC revealed she had searched through nursing progress notes for MD notification of blood sugars > 200 at bedtime and of the blood sugar results > 200 for resident #122, no MD notification could be found. LPN CC acknowledged any call to a MD should always be documented. Interview on 12/2/2015 at 5:20 p.m. with LPN EE revealed their initials appeared on the MAR indicated [REDACTED]. LPN EE indicated they always document MD notification and if the MD had been notified they would have recorded this in the Nurses Progress Notes. LPN EE acknowledged the Physician had not been notified and the sliding scale insulin coverage had been administered with no order. Interview on 12/2/15 at 5:32 p.m. with LPN FF revealed they did not remember notifying the Physician of HS BS > 200 for resident #122 and gave the insulin coverage without an order. 2. Review of the clinical record for resident #286 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the MDS assessment dated [DATE] indicated resident #286 requires insulin injections every day. Review of MD orders dated 10/8/15, for resident #286 revealed an order for [REDACTED]. 400. Review of the MAR indicated [REDACTED] In (MONTH) (YEAR): On 11/9/15 at 9:00 p.m., the FSBS results were 219, there was no insulin administered, however the MD was not notified, and; on 11/18/15 at 9:00 p.m. the FSBS results were 156, with 2 units of insulin administered, without a MD order. In (MONTH) (YEAR): On 12/1/15 at 9:00 p.m. the FSBS results were 179, with 2 units insulin administered, without a MD order; on 12/14/15 at 9:00 p.m. the FSBS results were 349, with 8 units of insulin administered, without a MD order; on 12/21/15 at 9:00 p.m. the FSBS results were 152 with 2 units insulin administered, without a MD order; on 12/25/15 at 9:00 p.m. the FSBS results were 165, with 2 units of insulin administered, without a MD order, and; on 12/27/15 at 9:00 p.m. the FSBS results were with 2 units of insulin administered. 3. Review of the clinical record for Resident #39 revealed an admission date of [DATE], with [DIAGNOSES REDACTED]. Review of MDS quarterly assessment dated [DATE] revealed the resident requires insulin injections every day. Review of the MD orders dated 9/18/15 revealed for resident #39 to receive sliding scale insulin coverage, to notify the MD of FSBS > 200 at HS, administer no insulin at HS, and call Physician for FSBS 400. Review of the MAR indicated [REDACTED] In (MONTH) (YEAR): On 9/20/15 at 9:00 p.m., the FSBS results were 185 with 2 units of insulin administered, without a MD order, and; on 9/25/15 at 9:00 p.m., the FSBS results were 230, with no insulin administered, however the MD was not notified. In (MONTH) (YEAR): On 10/3/15 - 9:00 p.m., the FSBS results were 320, with 8 units of insulin administered, without an MD order; on 10/9/15 at 9:00 p.m., the FSBS were 372, with 10 units of administered, without a MD order; on 10/19/15 at 9:00 p.m., the FSBS results were 201, without insulin was administered, however the MD was not notified; on 10/21/15 at 9:00 p.m., the FSBS results were 212, without insulin administered, however the MD was not notified; on 10/23/15 at 9:00 p.m., the FSBS results were 318, with 8 units of insulin administered, without a MD order; on 10/26/15 at 9:00 p.m., the FSBS results were 323, without insulin administered, however the MD was not notified, and; on 10/27/15 at 9:00 p.m., the FSBS results were 212, without insulin administered, however the MD was not notified. In (MONTH) (YEAR): On 11/2/15 at 9:00 p.m., the FSBS was 202, without insulin administered, however the MD was not notified; on 11/7/15 at 9:00 p.m., the FSBS result were 207, without insulin administered, however the MD was not notified; on 11/9/15 at 9:00 p.m., the FSBS result were 387, with 10 units of insulin administered, without a MD order; on 11/12/15 at 9:00 p.m., the FSBS results were 210, without insulin administered, however the MD was not notified; on 11/15/15 at 9:00 p.m., the FSBS results were 288 without insulin administered, however the MD was not notified; on 11/20/15 at 9:00 p.m., the FSBS results were 155 with 2 units of insulin administered, without a MD order; on 11/21/15 at 9:00 p.m., FSBS results were 222, without insulin administered, however the MD was not notified, and; on 12/5/15 at 9:00 p.m., FSBS results were 232, without insulin administered, however the MD was not notified. In (MONTH) (YEAR): On 12/26/15 at 9:00 p.m., FSBS results were 251, with 6 units of insulin administered, without a MD order, and; on 12/27/15 at 9:00 p.m., the FSBS results were 294 with 6 units of insulin administered, without a MD order. In (MONTH) (YEAR): On 1/18/16 at 9:00 p.m., the FSBS results were 350, with 10 units of insulin administered, without a MD order. Interview on 1/19/16 at 4:00 p.m. with the Administrator revealed the medical records of Resident #286 had been searched for indications of Physician notification of blood sugars > 200 at bedtime and resulting Physician orders [REDACTED]. The Administrator acknowledged insulin administration had occurred without Physician order. The Administrator confirmed insulin administration at bedtime was ordered not to be given for the above resident and the Physician should have been notified of FSBS > 200 and no indication of Physician notification could be found. 4. Record review for Resident #55 reveals an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment for Resident #55, dated 11/17/15, indicated the resident receives injections of insulin every day. Review of MD orders dated 2/23/15 revealed an order for [REDACTED].> 400, administer no HS insulin coverage, and call the MD for FSBS > 200 at HS. Review of the MAR indicated [REDACTED] In (MONTH) (YEAR): On 9/6/15 at 9:00 p.m. the FSBS results were 194, with 2 units of insulin administered, without MD order; on 9/11/15 at 9:00 p.m. 362, without insulin administered, however the MD was not notified; on 9/15/15 at 9:00 p.m., the FSBS results were 292 with 6 units insulin administered, without a MD order; on 9/20/15 at 9:00 p.m. the FSBS results were 197, with 2 units of insulin administered, without order; on 9/24/15 at 9:00 p.m. the FSBS results were 165, with 2 units of insulin administered, without MD order; on 9/25/15 at 9:00 p.m. the FSBS results were 245, without insulin administered, however the MD was not notified; on 9/27/15 at 12:00 p.m. the FSBS results were 468, there was no evidence the MD was notified; on 9/27/15 at 9:00 p.m. the FSBS results were 310, with 8 units of insulin administered, without a MD order, and; on 9/28/15 at 9:00 p.m. the FSBS results were 340, without insulin administered, however the MD was not notified. In (MONTH) (YEAR): On 10/2/15 at 9:00 p.m. the FSBS results were 199, with 2 units of insulin administered, without MD order; on 10/4/15 at 9:00 p.m. the FSBS results were 185, with 2 units of insulin administered, without MD order; on 10/12/15 at 9:00 p.m. the FSBS results were 223, without insulin administered, however the MD was not notified; on 10/13/15 at 9:00 p.m. the FSBS results were 165, with 2 units of insulin administered, without MD order; on 10/17/15 at 9:00 p.m. the FSBS results were 224, with 4 units insulin administered, without MD order; on 10/23/15 at 9:00 p.m. the FSBS results were 254, with 6 units insulin administered, without MD order; on 10/26/15 at 9:00 p.m. the FSBS results were 345, without insulin administered, however the MD was not notified, and; on 10/31/15 at 9:00 p.m. the FSBS results were 321, with 8 units of insulin administered, without MD order. In (MONTH) (YEAR): On 11/9/15 at 9:00 p.m. the FSBS results were 346, with 8 units of insulin administered, without a MD order; on 11/14/15 at 9:00 p.m. the FSBS results were 232, with 4 units of insulin administered, without a MD order; on 11/15/15 at 12:00 p.m. the FSBS results were 458, without MD notification; on 11/20/15 at 5:00 p.m. the FSBS results were 525 without MD notification;on 11/16/15 at 9:00 p.m. the FSBS results were 202, without insulin administered, however the MD was not notified; on 11/19/15 at 9:00 p.m. the FSBS results were 167,with 2 units of insulin administered, without MD order; on 11/23/15 at 5:00 p.m. the FSBS results were 456, without MD notification; on 11/23/15 at 9:00 p.m. the FSBS results were 213, with 4 units of insulin administered, without a MD order; on 11/26/15 at 8:00 a.m. the FSBS results were 482, there was no evidence the MD was notified; on 11/26/15 at 9:00 p.m. the FSBS results were 221, with 4 units of insulin administered, without a MD order; on 11/28/15 at 9:00 p.m. the FSBS results were 155, with 2 units of insulin administered, without MD orders, and; on 11/29/15 at 9:00 p.m., the FSBS results were 168, with 2 units of insulin administered, without a MD order. In (MONTH) (YEAR): On 12/1/15 at 9:00 p.m. the FSBS results were 255, with 6 units insulin administered, without a MD order; on 12/4/15 at 8:00 a.m. the FSBS results were 68 without MD notification; on 12/8/15 at 12:00 p.m. the FSBS results were 437 without MD notification; on 12/18/15 at 8:00 a.m. the FSBS results were 434 without MD notification; on 12/20/15 at 9:00 p.m. the FSBS results were 270, with 6 units insulin administered, without a MD order; on 12/21/15 at 9:00 p.m., the FSBS results were 172, with 2 units of insulin administered, without MD order; on 12/22/15 at 8:00 a.m. the FSBS results were 404, without evidence of MD notification. on 12/25/15 at 9:00 p.m. the FSBS results were 255, with 6 units insulin administered, without MD order; on 12/26/15 at 9:00 p.m. the FSBS results were 388 with 10 units insulin administered, without MD order, and; on 12/27/15 at 9:00 p.m., the FSBS results were 199, with 2 units of insulin administered, without MD order. In (MONTH) (YEAR): On 1/5/16 at 12:00 p.m. the FSBS results were 63, and; on 1/10/16 at 8:00 a.m. the FSBS results were 66, without evidence of MD notification; on 1/10/16 at 9:00 p.m. the FSBS results were 286, with 6 units of insulin administered, without MD order, and on 1/15/16 at 9:00 p.m. the FSBS results were 180 with 2 units of insulin administered, without MD order. 5. Record review for Resident #133 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the MDS admission assessment dated [DATE] revealed the resident receives insulin injections every day. Review of MD orders, dated 10/16/15, for resident #133 revealed an order for [REDACTED].> 400, administer no insulin at HS, and call MD for FSBS result >200. In (MONTH) (YEAR); On 10/17/15 at 9:00 p.m. the FSBS results were 310, with 8 units of insulin administered, without a MD orders; on 10/18/15 at 9:00 p.m., the FSBS results were 159 with 2 units of insulin administered, without MD order; on 10/19/15 at 9:00 p.m. the FSBS results were 184, with 2 units of insulin administered, without MD order; on 10/20/15 at 9:00 p.m. the FSBS results were 262 with 6 units insulin administered, without a MD order; on 10/22/15 at 9:00 p.m. the FSBS results were 234, with 4 units of insulin administered, without a MD order; on 10/23/15 at 9:00 p.m. the FSBS results were 168, with 2 units of insulin administered, without MD order; on 10/24/15 at 9:00 p.m. the FSBS results were 323, with 8 units of insulin administered, without a MD order; on 10/26/15 at 9:00 p.m. the FSBS results were 191, with 2 units of insulin administered, without MD order; on 10/27/15 at 9:00 p.m. the FSBS results were 190 with 2 units of insulin administered, without a MD order; on 10/28/15 at 9:00 p.m. the FSBS results were 157, with 2 units of insulin administered, without MD order; on 10/29/15 at 9:00 p.m. the FSBS results were 233,with 4 units of insulin administered, without a MD order; on 10/30/15 at 9:00 p.m. the FSBS results were 188, with 2 units of insulin administered, without MD order, and; on 10/31/15 at 9:00 p.m. the FSBS results were 298, with 4 units of insulin administered, without a MD order. In (MONTH) (YEAR): On 11/2/15 at 9:00 p.m. the FSBS results were 201, with 4 units of insulin administered, without a MD order; on 11/3/15 at 9:00 p.m. the FSBS results were 225, without insulin administered, however the MD was not notified; on 11/4/15 at 5:00 p.m. the results of the FSBS was 417, without evidence of MD notification; on 11/6/15 at 9:00 p.m. the FSBS results were 206, with 4 units of insulin administered, without a MD order; on 11/7/15 at 9:00 p.m. the FSBS results were 210 with 4 units of insulin administered, without a MD order; on 11/9/15 at 9:00 p.m. the FSBS results were 161,with 2 units of insulin administered, without a MD order, and; on 11/10/15 at 9:00 p.m. the FSBS results were 207, without insulin administered and without MD notification. 6. Review of the clinical record for Resident #130 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of the quarterly MDS assessment dated [DATE] revealed Resident #130 receives insulin injections every day. Review of Physician orders [REDACTED]. 400, no insulin administration at HS, call MD FSBS > 200. Review of the MAR indicated [REDACTED] In (MONTH) (YEAR): On 9/1/15, at 8:00 a.m. the FSBS result were 403, without MD notification; on 9/1/15 at 9:00 p.m. the FSBS results were 289 with 6 units of insulin administered, without MD order; on 9/2/15 at 9:00 p.m. the FSBS results were 412, with 12 units of insulin administered, without MD order; on 9/3/15 at 9:00 p.m. the FSBS results were 468 with 12 units of insulin administered, without MD order; on 9/4/15 at 9:00 p.m. the FSBS results were 282 with 6 units of insulin administered, without MD order; on 9/5/15 at 9:00 p.m. the FSBS results were 383, without insulin administered, and evidence of MD notification; on 9/6/15 at 9:00 p.m. the FSBS results were 245, with 4 units of insulin administered, without MD order; on 9/7/15 at 9:00 p.m. the FSBS results were 182, with 2 units of insulin administered, without a MD order; on 9/8/15 at 9:00 p.m. the FSBS results were 208, with 4 units of insulin administered, without MD order; on 9/9/15 at 9:00 p.m. the FSBS results were 363, without insulin administered, without evidence of MD notification; on 9/10/15 at 9:00 p.m. the FSBS results were 310, without insulin administered or MD notification; on 9/11/15 at 8:00 a.m. the FSBS result were 439 without MD notification; on 9/11/15 at 9:00 p.m. the FSBS results were 225, with 4 units insulin administered, without MD notification; on 9/12/15 at 9:00 p.m. the FSBS results were 260 with 6 units of insulin administered, without a MD order; on 9/13/15 at 8:00 a.m. the FSBS result were 409 without MD notification; on 9/13/15 at 12:00 p.m. the FSBS result were 412 without MD notification; on 9/15/14 at 9:00 p.m. the FSBS results were 398, without insulin administered; on 9/16/15 at 9:00 p.m. the FSBS results were 201, 4 units of insulin administered, without a MD order; on 9/17/15 at 5:00 p.m. the FSBS result were 407 without MD notification; on 9/17/15 at 9:00 p.m. - the FSBS results were 332, with 8 units of insulin administered, without MD order; on 9/18/15 at 9:00 p.m. the FSBS results were 268 with 6 units of insulin administered, without a MD order; on 9/19/15 at 9:00 p.m. the FSBS results were 356 with 10 units of insulin administered, without MD order; on 9/20/15 at 5:00 p.m. the FSBS result were 402 without MD notification; on 9/20/15 at 9:00 p.m. the FSBS results were 345, with 8 units of insulin administered, without a MD order; on 9/21/15 at 9:00 p.m. the FSBS results were 309, with 8 units of insulin administered without a MD order; on 9/22/15 at 9:00 p.m. the FSBS results were 233 with 4 units of insulin administered, without a MD ordered; on 9/23/15 at 9:00 p.m. the FSBS results were 270 with 6 units of insulin administered, without a MD order; on 9/24/15 at 9:00 p.m. the FSBS results were 300 without insulin administered or MD notification; on 9/25/15 at 9:00 p.m. the FSBS results were 207 with 4 units insulin administered, without a MD order; on 9/26/15 at 9:00 p.m. the FSBS results were 208 with 4 units of insulin administered, without a MD order; on 9/27/15 at 9:00 p.m. the FSBS results were 189, with 2 units of insulin administered, without a MD order; on 9/29/15 at 9:00 p.m. the FSBS results were 253 with 6 units insulin administered, without a MD order, and; on 9/30/15 at 9:00 p.m. the FSBS results were 308 with 8 units of insulin administered without a MD order. In (MONTH) (YEAR): On 10/1/15 at 12:00 p.m. the FSBS result were 430 without MD notification; on 10/1/15 at 5:00 p.m. the FSBS result were 403 without MD notification; on 10/1/15 at 9:00 p.m. the FSBS results were 162, with 2 units of insulin administered, without a MD order; on 10/2/15 at 9:00 p.m. the FSBS results were 255, with 6 units of insulin administered, without a MD order; on 10/3/15 at 9:00 p.m. the FSBS results were 235 without insulin administered, without MD notification; on 10/4/15 at 9:00 p.m. the FSBS results were 305, without insulin administered; on 10/5/15 at 9:00 p.m. the FSBS results were 195, with 2 units of insulin administered, without a MD order; on 10/6/15 at 5:00 p.m. the FSBS result were 414 without MD notification; on 10/6/15 at 9:00 p.m. the FSBS results were 394, with 10 units of insulin administered, without a MD order; on 10/7/15 at 9:00 p.m. the FSBS results were 203 with 4 units of insulin administered, without a MD order; on 10/8/15 at 9:00 p.m. the FSBS results were 381 without insulin administered or notification of MD; on 10/9/15 at 9:00 p.m. the FSBS results were 248 without insulin administered, without MD notification; on 10/10/15 at 9:00 p.m. the FSBS results were 226 with 4 units of insulin administered, without MD order; on 10/11/15 at 9:00 p.m. the FSBS results were 274 with 6 units of insulin administered, without MD order; on 10/12/15 at 9:00 p.m. the FSBS results were 279 with 6 units of insulin administered, without MD order; on 10/13/15 at 9:00 p.m. the FSBS results were 289, with 6 units of insulin administered, without MD order; on 10/14/15 at 9:00 p.m. the FSBS results were 276 with 6 units of insulin administered, without MD order; on 10/14/15 at 5:00 p.m. the FSBS result were 422 without MD notification; on 10/15/15 at 9:00 p.m. the FSBS results were 335 with 8 units of insulin administered, without MD order; on 10/16/15 at 9:00 p.m. the FSBS results were 334 with 8 units of insulin administered, without MD order; on 10/17/15 at 9:00 p.m. the FSBS results were 225 without insulin administered, or MD notification; on 10/17/15 at 8:00 a.m. the FSBS results were 401 without MD notification; on 10/18/15 at 9:00 p.m. the FSBS results were 363 without insulin administered, without MD notification; on 10/19/15 at 12:00 p.m. the FSBS results were 444 without MD notification; on 10/20/15 at 8:00 a.m. the FSBS results were 406 without MD notification; on 10/20/15 at 12:00 p.m. the FSBS results were 467 without MD notification; on 10/20/15 at 9:00 p.m. the FSBS results were 207, with 4 units of insulin administered, without MD order; on 10/21/15 at 9:00 p.m. at the FSBS results were 315 without insulin administered, without MD notification; on 10/22/15 at 8:00 a.m. the FSBS results were 430 without MD notification;on 10/22/15 at 9:00 p.m. the FSBS results were 379, without insulin administered or MD notification; on 10/23/15 at 9:00 p.m. the FSBS results were 382, without insulin administered, or MD notification; on 10/24/15 at 9:00 p.m. the FSBS results were 300, with 8 units of insulin administered, without a MD order; on 10/25/15 at 9:00 p.m. the FSBS results were 180, with 2 units of insulin administered, without a MD order; on 10/26/15 at 9:00 p.m. the FSBS results were 292, with 6 units of insulin administered, without MD order; on 10/27/15 at 9:00 p.m. the FSBS results were 235, without insulin administered or MD notification; on 10/28/15 at 9:00 p.m. the FSBS results were 254, with 6 units of insulin administered, without a MD order; on 10/29/15 at 9:00 p.m. the FSBS results were 282, with 6 units of insulin administered, without a MD order, and; on 10/30/15 at 9:00 p.m. the FSBS results were 191, with 2 units of insulin administered without a MD order. In (MONTH) (YEAR): On 11/1/15 at 9:00 p.m. the FSBS results were 202, with insulin administered; on 11/2/15 at 9:00 p.m. the FSBS results were 4 units of insulin administered, without a MD order; on 11/5/15 at 9:00 p.m. the FSBS results were 276, with 6 units of insulin administered, without MD order; on 11/4/15 at 9:00 p.m. the FSBS results were 218 with 4 units of insulin administered, without a MD order; on 11/5/15 at 9:00 p.m. the FSBS results were 316, without insulin administered or notification; on 11/6/15 at 9:00 p.m. the FSBS results were 242, with 4 units insulin administered, without MD order; on 11/7/15 at 9:00 p.m. the FSBS results were 231, with 4 units of insulin administered, without a MD order; on 11/8/15 at 9:00 p.m. the FSBS results were 239, with 4 units of insulin administered, without a MD order; on 11/10/15 at 9:00 p.m. the FSBS results were 285,without insulin administered or MD notification; on 11/11/15 at 9:00 p.m. the FSBS results were 220 with 4 units of insulin administered, without MD order; on 11/12/15 at 9:00 p.m. the FSBS results were 245, with 4 units of insulin administered, without a MD order; on 11/14/15 at 9:00 p.m. the FSBS results were 224,without insulin administered, without MD order; on 11/15/15 at 9:00 p.m. the FSBS results were 332 with 8 units of insulin administered, without a MD order; on 11/16/15 at 9:00 p.m. the FSBS results were 193 with 2 units of insulin administered, without a MD order; on 11/17/15 at 9:00 p.m. the FSBS results were 256 with 6 units of insulin administered without a MD order; on 11/18/15 at 9:00 p.m. the FSBS results were 263 with 6 units of insulin administered, without a MD order; on 11/19/15 at 9:00 p.m. the FSBS results were 270 with 6 units of insulin administered, without a MD order; on 11/20/15 at 9:00 p.m. the FSBS results were 200, with 4 units of insulin administered, without a MD order; on 11/21/15 at 9:00 p.m. the FSBS results were 258 with 6 units of insulin administered, without a MD order; on 11/23/15 at 9:00 p.m. the FSBS results were 209, with 4 units insulin administered, without a MD order; on 11/26/15 at 9:00 p.m. the FSBS results were 222, with 4 units of insulin administered, without a MD order; on 11/27/15 at 9:00 p.m. the FSBS results were 313, with 8 units of insulin administered, without a MD order; on 11/28/15 at 9:00 p.m. the FSBS results were 355, with 10 units of insulin administered without a MD order, and; on 11/30/15 at 9:00 p.m. the FSBS results were 162, with 2 units of insulin administered, without a MD order. In (MONTH) (YEAR): On 12/1/15 at 9:00 p.m. the FSBS results were 250 with 6 units of insulin administered, without a MD order; on 12/2/15 at 9:00 p.m. the FSBS results were 213, with 4 units of insulin administered, without MD order; on 12/3/15 at 9:00 p.m. the FSBS results were 249, with 4 units of insulin administered, with MD order; on 12/4/15 at 9:00 p.m. the FSBS results were 192, with 2 units insulin administered, without a MD order; on 12/5/15 at 9:00 p.m. the FSBS results were 209, with 4 units of insulin administered, without MD order; on 12/6/15 at 9:00 p.m. the FSBS results were 199, with 2 units of insulin administered, without a MD order; on 12/7/15 at 9:00 p.m. the FSBS results were 266, with 6 units of insulin administered, without MD order; on 12/8/15 at 9:00 p.m. the FSBS results were 249, with 4 units of insulin administered, without a MD order; on 12/9/15 at 9:00 p.m. the FSBS results were 250, with 6 units of insulin administered, without a MD order; on 12/10/15 at 9:00 p.m. the FSBS results were 223, with 4 units of insulin administered, without MD order; on 12/11/15 at 9:00 p.m. the FSBS results were 195, with 2 units of insulin administered, without a MD order; on 12/14/15 at 9:00 p.m. the FSBS results were 275, with 6 units of insulin administered, without a MD order; on 12/15/15 at 9:00 p.m. the FSBS results were 153, with 2 units of insulin administered, without a MD order; on 12/16/15 at 9:00 p.m. the FSBS results were 191, with 2 units of insulin administered, without a MD order; on 12/17/15 at 9:00 p.m. the FSBS results were 233 with 4 units of insulin administered, without a MD order; on 12/18/15 at 9:00 p.m. the FSBS results were 172, with 2 units insulin administered, without a MD order; on 12/19/15 at 9:00 p.m. the FSBS results were 195, with 2 units of insulin administered, without a MD order; on 12/20/15 at 9:00 p.m. the FSBS results were 174, with 2 units of insulin administered, without a MD order; on 12/21/15 at 9:00 p.m. the FSBS results were 179, with 2 units of insulin administered, without a MD order; on 12/22/15 at 9:00 p.m. the FSBS results were 186, with 2 units of insulin administered, without a MD order; on 12/23/15 at 9:00 p.m. the FSBS results were 309 with 8 units of insulin administered, without a MD order; on 12/24/15 at 9:00 p.m. the FSBS results were 151, with 2 units of insulin administered, without a MD order; on 12/25/15 at 9:00 p.m. the FSBS results were 225, with 4 units of insulin administered, without a MD order; on 12/26/15 at 9:00 p.m. the FSBS results were 375 with 10 units of insulin administered, without a MD order; on 12/27/15 at 9:00 p.m. the FSBS results were 210, with 4 units of insulin administered, without a MD order; on 12/29/15 at 9:00 p.m. the FSBS results were 290 with 6 units of insulin administered, without a MD order; on 12/30/15 at 12:00 p.m. the FSBS results were 460 without MD notification, and; on 12/30/15 at 9:00 p.m. the FSBS results were 281 with 6 units of insulin administered without a MD order. In (MONTH) (YEAR): On 1/2/16 at 9:00 p.m. the FSBS results were 281, with 6 units of insulin administered, without a MD order; on 1/4/16 at 9:00 p.m. the FSBS results were 244, with 4 units of insulin administered, without a MD order; on 1/5/16 at 9:00 p.m. the FSBS results were 296 with 6 units of insulin administered, without a MD order; on 1/6/16 at 9:00 p.m. the FSBS results were 173, with 2 units of insulin administered, without a MD order; on 1/7/16 at 9:00 p.m. the FSBS results were 168, with 2 units of insulin administered, without a MD order; on 1/8/16 at 9:00 p.m. the FSBS results were 263 with 6 units of insulin administered, without MD order; on 1/9/16 at 9:00 p.m. the FSBS results were 309 with 8 units of insulin administered, without MD order; on 1/10/16 at 9:00 p.m. the FSBS results were 346 with 8 units of insulin administered, without MD order; on 1/12/16 at 9:00 p.m. the FSBS results were 249 with 4 units of insulin administered without MD order; on 1/14/16 at 9:00 p.m. the FSBS results were 373 with 10 units of insulin administered, without a MD order, and; on 1/18/16 at 9:00 p.m. the FSBS results were 210 with 4 units of insulin administered, without a MD order. 7. Record review for resident #155 revealed an admission dat (TRUNCATED)",2020-09-01
296,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,314,D,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of physician orders, review of the Treatment Administration Record (TAR), review of the Skin Management Policy, review of the Grievance Log, resident interview and staff interviews, the facility failed to follow physician's orders [REDACTED].#313) of the fourty-seven (47) residents. The census was one-hundred-forty (140). Findings include: 1. Record review for Resident M revealed an admitted (MONTH) 4, (YEAR) and was admitted with Stage Four (IV) pressure ulcers to the sacrum, left buttock, right buttock, and a Unstageable pressure ulcer to the right posterior thigh. Review of the Medical History revealed a past history of multiple wound infections and [MEDICAL CONDITION] with [MEDICAL CONDITION]. The resident is morbidly obese and bed bound. Review of the Admission Minimum Data Set (MDS) assessment dated (MONTH) 11, (YEAR) documented in Section C-Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) summary score of fifteen (15) indicating the resident was cognitively intact. Review of the physician orders [REDACTED]. An order on 11/18/2015 documented to clean wound to the right posterior thigh with wound cleanser, pat dry, apply skin prep, apply Santyl Ointment and apply a dry dressing two times each day. Review of Treatment Administration Record (TAR) for resident M in (MONTH) and December, (YEAR) revealed a total of twenty-five (25) treatments that were not documented as administered per the physician orders [REDACTED]. Interview conducted on 11/30/2015 at 12:29 p.m. with Resident M revealed there had been a challenge getting her pressure wound dressings done in a timely manner. Resident M further indicated her dressings were supposed to be changed twice a day and they were only being changed once a day and occasionally twice a day. Resident M stated she spoke to the Director of Nursing (DON) and the unit manager approximately ten (10) days ago. Review of Grievance Log documented a complaint filed on 11/23/2015 by Resident M regarding her pressure wound dressings changes not being done twice a day as ordered. A follow up response was entered by the unit manager on 11/26/2015 which documented they were accompanied by the Wound Doctor to discuss preferred treatment for [REDACTED]. Review of the Skin Management Policy documented the Licensed Nurse will record his/her initials on the TAR to reflect monitoring of each wound regardless of the findings. The nurse will assure treatments, interventions, Care Plan and the appropriate skin documentation records are initialed in a timely manner. Daily treatment is entered in the TAR. Interview conducted on 12/02/2015 at 11:00 a.m. with the Director of Nursing (DON) revealed it is expected that all nursing staff and unit managers follow the facility policies as written. Per the facility policy the nurses should document treatment administered or treatment refused on the Treatment Administration Record (TAR). The DON acknowledged Resident M did voice concerns related to the wound dressings not being changed twice a day as ordered. The DON revealed the staff was educated regarding Resident M ' s concerns. 2. Record review for Resident #313 revealed an admitted (MONTH) 25, (YEAR) and was admitted with a Stage Two (II) pressure ulcer to the back, sacrum, right thigh, and left leg. Review of the physician orders [REDACTED]. Apply Providone Iodine ten percent (10%) to the left foot one time a day. Review of the TAR for resident #313 in (MONTH) and September, (YEAR) revealed a total of eleven (11) treatments that were not documented as administered per the physician orders [REDACTED].",2020-09-01
297,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,315,G,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to promote care in a manner to improve or prevent decline of normal bladder function for one (1) resident (V) from a sample of fourty-seven (47) residents. The census was one-hundred-forty (140). This failure resulted in actuall harm for Resident V who stated I do not like going to the bathroom in a diaper. It makes me feel helpless when I am not helpless. I am able to go on the toilet if someone will just help me. Cross reference F241, F242, F279 Findings include: An interview conducted on 12/01/2015 at 8:49 a.m. with resident V revealed she had a catheter in the hospital and it was removed before she came to the nursing facility. At home she was able to transfer herself from the wheel chair to the toilet. V said she had never been taken to the toilet since her admission. The staff put an adult diaper on her on her and when she asked to be taken to the toilet, the staff tell her that Physical Therapy (PT) said they cannot get her up because she would fall and they tell her to just go in her diaper. She said PT told her not to try to go by herself and make sure she calls for assistance. Further, V stated I do not like going to the bathroom in my diaper. It makes me feel helpless when I am not helpless. It is embarrassing to use the bathroom in a diaper, I'm not used to doing that. I am able to go on the toilet if someone will just help me. Record review for resident V indicated an admitted (MONTH) 13, (YEAR) after a hospitalization , with multiple [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated (MONTH) 20, (YEAR) documented in Section B-Hearing, Speech, Vision that the resident had clear speech with distinct, intelligible words, was able to make self-understood and was able to understand others with clear comprehension. Section C-Cognitive Patterns documented that the resident had a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate impairment. Section G-Functional Status documented the resident required extensive assistance of two person physical assist with transfers and toileting. No urinary toileting trials were attempted since admission and the resident was always incontinent of bladder and always incontinent of bowel. Review of the Care Plan dated 11/23/2015 identified resident V as receiving rehab therapy from the services of Occupational Therapy (OT) and Physical Therapy (PT) with an intervention that included, but not limited to, encouraging the resident to be as independent as possible. In addition, identified an Activities of Daily Living (ADL) self-performance deficit with the goal set to improve the current level of function of ADLs with interventions that included but not limited to, extensive assist by two (2) staff for toileting and encourage the resident to participate to the fullest extent possible with each interaction and observe/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Review of the Bowel and Bladder Management Policy documented: Each resident who is incontinent is identified, assessed and provided appropriate treatment and service. Services are provided to restore or improve normal bladder function to the extent possible, after the removal of the catheter. The intent of the Bowel and Bladder Management System is to clearly define the process for providing care and treatment for [REDACTED]. Review of the Nursing Admission Assessments revealed the Nursing Admission Data Collection assessment and the Bowel and Bladder Evaluation had not been conducted on admission and was not assessed until (MONTH) 2, (YEAR). Review of the Physical Therapy Evaluation Plan of Treatment dated (MONTH) 15, (YEAR) documented prior living description: Patient stated she lived alone in an apartment that was handicapped accessible. She was able to transfer from wheelchair to Bedside Commode (BSC) and back to wheelchair. An interview conducted on 12/2/2015 at 2:30 p.m. with the Direct Care Certified Nursing Assistant (CNA) MM revealed when the resident is in bed, she is able to push the call light and let her know when she needs to use the bathroom. When the resident is out of bed in her wheelchair, she wears a brief and goes in her brief, then she will take her back to her room and put her back in bed to clean her. She said the resident has never been assisted to the toilet until yesterday. She was not working yesterday and a different CNA cared for her. An interview conducted on 12/2/2015 at 2:55 p.m. with CNA OO revealed resident V called her yesterday to get up and go to the bathroom. She got her up with a lift and took her to the toilet and she was able to use the toilet successfully. An interview conducted on 12/2/2015 at 2:40 p.m. with the 300 Hall Unit Manager HH revealed the resident should have been evaluated for bowel and bladder function upon admission via the Admission Bowel and Bladder Evaluation. This assessment helps determine if a resident knows when they need to use the bathroom, if they are able to use the toilet and if they are a candidate for a toileting program. All residents should be checked every two (2) hours for toileting and to encourage toileting. She confirmed there is no evidence in the Electronic Medical Record (EMR) that the Nursing Admission Data Collection or the Bladder and Bowel Evaluation was conducted and should have been. Interview conducted on 12/3/2015 at 8:30 a.m. with the Director of Nursing (DON) confirmed the Admission Bowel and Bladder Assessment and the Nursing Admission Data Collection was not conducted. He said there is no written policy but the expectation is that all admission assessments which include, but are not limited to, Nursing Admission Data Collection and Bowel and Bladder Evaluation is to be conducted within 24 hours of admission. Interview conducted on 12/3/15 at 11:48 a.m. with the Rehab Program Manager PP revealed rehab would never instruct the staff not to get a resident up to use the bathroom, they would be giving strategies on safe transferring techniques. PP confirmed there have been miscommunication with the CNAs telling the residents something that is not accurate such as PT told them not to get them get out of bed. She has brought this concern to the Administrator and the DON last week during a weekly meeting. She said they do plan to re-educate the CNA staff. Further, a resident that is able to use the bathroom even when they need extensive assistance should still be toileted. The resident is able to use a bariatric bed side commode with the level of assistance indicated. This information for two (2) person assist is shared with the staff verbally and also shared in the IDT meetings. She has only been here three (3) weeks, she is not sure how it was communicated prior to that.",2020-09-01
298,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2016-01-20,329,D,0,1,ET9511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to consistently monitor behavioral symptoms or monitor side effects for one (1) resident (#226) with behavioral disturbances that received an antipsychotic medication of the sampled fourty-seven (47) residents. The census was one-hundred-forty (140). Findings include: Record review for Resident #226 indicated an admitted (MONTH) 17, (YEAR) with multiple [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated (MONTH) 3, (YEAR) documented in Section E- Behavior that the resident exhibited rejection of care 1-3 days of the assessment period. Review of the Physician order [REDACTED]. [MEDICATION NAME] 0.5 mg at bedtime was ordered on [DATE] and discontinued on 07/01/2015. [MEDICATION NAME] Suspension Reconstituted 12.5 mg Intramuscular (IM) Injection every fourteen (14) days was ordered on [DATE]. Review of the Medication Admiration Records (MAR) from March-July (YEAR) indicated the [MEDICATION NAME] 0.5 mg was administered as ordered, however, the resident refused the [MEDICATION NAME] injections. There was no evidence of documentation for monitoring behavioral symptoms or medication side effects. Review of the initial Psychiatric consultation dated 3/4/15 documented the reason for referral: Severe Depression, Dementia, and Behavioral Disturbances. He is cognitively very confused. According to staff, the resident is very resistive with the ADL care, and tries to slide out of his bed even when he is repositioned. Review of the Nursing Notes from March-July (YEAR) revealed inconsistent documentation of behavioral symptoms. Review of the [MEDICAL CONDITION] Management Policy documented an unnecessary drug is any drug when used without adequate monitoring. An interview conducted on 12/03/2015 at 8:30 a.m. with the Director of Nursing (DON) confirmed Resident #226 received antipsychotic medication and there was no monitoring each shift of potential side effects and inconsistent documentation of behavioral symptoms. They have now added side effect monitoring and behavior monitoring for antipsychotic medications on the MAR.",2020-09-01
299,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2018-09-27,684,D,0,1,6TQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, clinical record and facility policy reviews, the facility failed to meet professional standards of care for one sampled Resident (R)#224 by incorrectly transcribing an admission insulin order resulting in the R #224 being transferred back to the hospital with a [DIAGNOSES REDACTED]. This failure could potentially place all twenty-one (21) residents with diabetes at risk for harm. Total sample size of 29. Findings Include: R #224 is an [AGE] year-old female transferred to the facility from the hospital on (MONTH) 22, (YEAR) with a [DIAGNOSES REDACTED]. She is documented to have a history of Type II diabetes mellitus (DM). She is prescribed Humalog Insulin with instructions to Inject 0.01-0.12 milliliters(ml) (1-12 units total) under the skin 4 (four) times a day before meals and nightly. This prescription is dated (MONTH) 22, (YEAR) and signed by the hospital physician. The Hospital Medication Administration Record [REDACTED]. This indicates that blood glucose monitoring was necessary to know how much insulin R #224 should receive with each meal and nightly. The MAR indicated [REDACTED]. The 12 units of insulin is documented as given at each of these times until the 1700 dose on (MONTH) 26, (YEAR). This time is documented as not given with the reason being 5 the administration code for hospitalization . R #224's care plan dated (MONTH) 23, (YEAR) reflects a focus of DM with interventions that include Observe/document/ report as needed any signs/symptoms of [DIAGNOSES REDACTED] .confusion, slurred speech, lack of coordination . A Dietary Summary note dated (MONTH) 23, (YEAR) states R #224 is on a cardiac diet with a fluid restriction of 1500 cc's per day and has an average meal intake of 76-100% documented. The Dietary Summary states R #224 is at risk for possible dehydration related to fluid restriction and glycemic control related to DM and increased caloric demands from infection. The dietician recommended the monitoring of blood glucose, weight, intake and hydration. An interview with the Director of Nursing (DON) and the Medical Director (MD) (who is also R #224's primary care physician) on (MONTH) 25, (YEAR) at 3:00 p.m. in the facility conference room revealed that the facility had already identified the deficient practice however, the MD was not aware that he needed to order the blood glucose monitoring. He stated he thought the facility had a protocol in place. He also stated that this resident was new to him so he would have ordered accuchecks (blood glucose checks) had he known there was no protocol in place. He did acknowledge that he had signed the incorrect order for the insulin and that he had not ordered the blood glucose checks. He stated, I am responsible. An interview with the Unit Manager for the 300 and 600 Hallways on (MONTH) 26, (YEAR) at 2:40 p.m. in her office reveals that she was the one who incorrectly transcribed the insulin order. She stated that she had not seen an insulin order written that way, but she should have clarified the order and didn't. She, too, said she was responsible and was working toward preventing it from happening again. An interview on (MONTH) 27, (YEAR) at 1:00 p.m. revealed the Licensed Practical Nurse (LPN) EE was taking care of R #224 on (MONTH) 26, (YEAR) when her family called the Emergency Medical Services (EMS). LPN EE stated that he did not notice a change in R #244's condition since she was alert but confused and had been since arrival. He stated that R #224's family asked him to call 911 to have her transferred to the hospital because they didn't think she was acting normal. LPN EE said he explained to the family that he would have to page the doctor for an order. R #224's family asked how long it would take and the nurse told them he didn't know how long it would be before the doctor called back. R #224's family then called 911 themselves. LPN EE states this occurred at approximately 1:46 p.m. and the EMS arrived shortly after. He stated, I didn't have time to take vital signs and assess the resident (R #224) because the doctor called just as EMS was arriving. He stated he was not aware of what EMS did until he saw them leaving with the R #224. LPN #EE stated that EMS did not provide any paperwork or report for him. The final nursing note dated (MONTH) 26, (YEAR) at 2:22 p.m. states the Resident (R #224) is alert, verbal with confusion and forgetful; she does not appear to be in any distress at the time of transfer to the hospital. The facility was unable to provide any blood glucose levels for R #224 during her four day stay at the facility and were unable to provide any documentation from the EMS that transported R#224 to the hospital on (MONTH) 26, (YEAR). A review of the Emergency Department (ED), Medical Decision-Making Note dated (MONTH) 26th at 2:45 p.m. reveals Patient here for stroke alert. EMS called to Nursing Home (NH) for Altered Mental Status (AMS). Patient . semi-responsive Our glucose less than 50. Needs amp D50 (50% [MEDICATION NAME]) D50 given. Patient now becoming more alert. Neuro signed off since AMS more likely to low glucose versus stroke. Blood pressure low. A review of the ED physician progress notes [REDACTED].#224) was brought from NH with [DIAGNOSES REDACTED] (unknown outpatient value), hypothermia, [MEDICAL CONDITION] and admitted to ICU (Intensive Care Unit). It is documented that patient's family went to check on her at the nursing home and found her slumped over at the nurse's station desk and not responding. EMS was called and found hypoglycemic, hypotensive and hypothermic. A Hospital Resident physician progress notes [REDACTED].#224) was admitted to the ICU for [DIAGNOSES REDACTED], [MEDICAL CONDITION], and hypothermia and on (MONTH) 27, (YEAR) was transferred out of the ICU with confusion resolving. It was also revealed in this note under Assessment and Plan that the [DIAGNOSES REDACTED] was 2/2 (secondary to) insulin overdose versus decreased PO (oral) intake, s/p (status [REDACTED]. A review of the facility's policy tittled Diabetic Management, dated (MONTH) 2005 with revision in (MONTH) 2008 reflects that under the section Routine Care, Blood glucose measurements are taken per the physician order [REDACTED].#224 was hospitalized for [REDACTED]. She was discharged to another facility per family request.",2020-09-01
300,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2018-09-27,710,D,0,1,6TQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on physician interview and record and facility policy reviews, the Medical Director (MD) /facility physician failed to determine that one sampled Resident (R #224) needed to be monitored for blood glucose levels and signed an incorrect insulin order. This deficient practice resulted in R #224 being admitted to the hospital with [REDACTED]. Total sample size of 29. Findings Include: R #224 is an [AGE] year-old female transferred to the facility from the hospital on (MONTH) 22, (YEAR) with a [DIAGNOSES REDACTED]. She is documented to have a history of Type II diabetes mellitus (DM). She is prescribed Humalog Insulin with instructions to Inject 0.01-0.12 milliliters (ml) (1-12 Units total) under the skin 4 (four) times a day before meals and nightly. This prescription is dated (MONTH) 22, (YEAR) and signed by the hospital physician. An interview with the Medical Director (MD) who is also the R #224's primary doctor on (MONTH) 25, (YEAR) at 3:00 p.m. in the facility conference room revealed he was not aware that he needed to order the blood glucose monitoring. He stated he thought the facility had a protocol in place. He also stated that this resident was new to him so he would have ordered accuchecks (blood glucose checks) had he known there was no protocol in place. He did acknowledge that he had signed the incorrect order for the insulin and that he had not ordered blood glucose checks. He stated, I am responsible. A review of the facility policy Diabetic Management dated (MONTH) 2005 with revision in (MONTH) 2008 reflects that under the section Routine Care, Blood glucose measurements are taken per the physician order. Results outside of ordered parameters are communicated to the physician immediately. A Hospital Resident physician progress notes [REDACTED].#224 was admitted to the ICU (Intensive Care Unit) for [DIAGNOSES REDACTED], [MEDICAL CONDITION], and hypothermia and on (MONTH) 27, (YEAR) was transferred out of ICU with confusion resolving. It was also revealed in this note under Assessment and Plan that the [DIAGNOSES REDACTED] was 2/2 (secondary to) insulin overdose versus decreased PO (oral) intake, s/p (status [REDACTED]. According to the hospital records dated (MONTH) 30, (YEAR) the R # 224 was hospitalized for [REDACTED]. She was discharged to another facility per family request.",2020-09-01
301,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2019-01-17,550,E,0,1,NFDD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, the facility failed to ensure all 38 residents (R) who resided on the Garden View neighborhood out of a total of 175 residents in the facility were treated with dignity during meals. Residents were given plastic silverware to eat all their meals. Findings include: 1. Observations revealed residents in the Garden View neighborhood (locked dementia unit) were not provided with metal silverware to eat their meals, contrary to the residents on the other four neighborhoods. Residents on the Garden View neighborhood were provided with plastic silverware to eat their meals as follows: On 1/14/19 observations of the noon meal from 11:45 a.m. - 12:44 p.m. were made in all five neighborhoods. All the residents in the Garden View neighborhood were provided with plastic silverware to eat their meals. The residents eating in the other four neighborhoods were all provided with metal silverware. No aggressive behaviors were noted during the meal in the Garden View neighborhood. On 1/15/19 at12:20 p.m. observation of the lunch meal in the Garden View neighborhood was made. All residents had plastic silverware to eat their meals. No aggressive behaviors were noted during the meal. On 1/16/19 at 8:25 a.m. observation of the breakfast meal in the Garden View neighborhood revealed all residents were provided with plastic silverware to eat their meals. No aggressive behaviors were noted during the meal. An interview on 1/16/19 at 8:30 am. in the Garden View dining room, Certified Nurse Assistant (CNA)WW stated all residents received plastic utensils because it was a secure dementia unit and the metal utensils posed a safety hazard for the residents and staff. CNA WW stated she had received dementia training and the use of plastic cutlery was not mentioned in the training. CNA WW stated it was a facility rule to use plastic silverware in the dementia unit. An interview on 1/16/19 at 8:35 a.m.in the Garden View dining room, Licensed Practical Nurse (LPN) ZZ stated all residents received plastic silverware due to it being a secure unit and the residents having dementia and poor safety awareness. LPN ZZ stated there was a list given to families upon admission with all the items that residents on the dementia unit were not allowed to have. The LPN further stated the Unit Manager had the list. An interview on 1/16/19 at 8:41 a.m. in the closed door nurses' station, the Unit Manager of Garden View stated since the building opened (approximately three years ago), the dementia unit had not allowed residents to have metal utensils due to [DIAGNOSES REDACTED]. The Unit Manager stated the social services staff had the list of items not allowed in Garden View. An interview on 1/16/19 at 8:56 a.m. in the social service office, Social Service Staff XX stated she was not aware of the residents on the Garden View neighborhood using plastic cutlery. Social Service Staff XX stated the Director of Nursing (DON) would have the list of items that were not allowed on the unit. An interview on 1/16/19 at 9:02 a.m. in the DON's office, the DON stated there was a list of items that residents on the secured unit were not allowed to have. The DON was asked for a copy of the list which was provided later in the day. The DON stated staff discussed with families the items the residents were not allowed to have on the dementia unit. The DON stated she was aware all residents in Garden View used plastic cutlery for meals. The DON was asked about adaptive silverware and stated they would make an exception if a resident transferred from another unit and needed adaptive equipment such as silverware with built up handles to feed themselves. The DON stated since the facility was opened three years ago, residents had caused to injuries other people with metal silverware (residents and staff). The DON stated residents were not individually assessed to determine if they posed a safety hazard to others by having metal utensils at meals. An interview on 1/16/19 at 9:19 a.m. in his office, the Administrator stated he was aware that all residents on the secured unit used plastic cutlery, which was due to an incident that occurred in a sister facility. The Administrator stated it had been the practice at this facility since it opened, to provide plastic silverware to residents on the secure unit. The Administrator stated the facility would make an exception if a resident transferred from another unit and required adaptive equipment. He further stated, I can see where it could be undignified An interview on 1/17/19 at 8:26 a.m. in the surveyor conference room, the Dietary Director stated residents on Garden View had always used plastic silverware. The Dietary Director stated regular silverware posed a safety issue. The Dietary Director stated since he had been employed in his position over two years ago, this had always been the protocol. When asked about specific safety incidents with silverware, he stated there have been no incidents in the past two years regarding use of silverware. Review of the undated Philosophy and Facility Structure document revealed, Garden View: The Garden View neighborhood is designated for residents with Alzheimer's or related Dementia, as first priority. This includes those residents who are physically active and tend to wander and/or that present a risk to themselves. Once the resident no longer exhibits these behaviors, they will be reassessed for transfer to a more appropriate environment. On this unit, we encourage our staff, residents, and family members not to bring items such as metal cutlery, glass vases/jars, live plants, open containers (i.e. water pitchers) etc. for the safety and wellbeing of our residents. Review of the undated Philosophy and Facility Structure documented in pertinent part, At the Orchard View Rehabilitation and Skilled Nursing Center, our basic philosophy is to help each resident to be placed in the least restrictive environment possible under the development of person-centered care. Our efforts are aimed to deinstitutionalize long-term care and create a supportive and nurturing environment for our Residents. Review of the undated Dining Policy revealed, It is the policy of Orchard View to: serve meals in each dining room to residents who choose to eat in this setting. The meals will be served in the most timely, comfortable and attractive manner possible. The policy did not provide specific direction regarding use of silverware.",2020-09-01
302,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2019-01-17,604,E,0,1,NFDD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of facility policy, the facility failed to ensure four of 57 sampled residents (R) (R#3, R#60, R#64, R#260) were free from physical restraints imposed for purpose of discipline or convenience and that were not required to treat the resident's medical symptoms. The facility failed to use the least restrictive alternative for the least amount time and document ongoing re-evaluation of the need for restraints. Findings include: 1. R#3 was admitted to the facility on [DATE]. The Physician's Orders for (MONTH) 2019 revealed the resident had [DIAGNOSES REDACTED]. The resident received hospice services related to a [DIAGNOSES REDACTED]. Review of the 9/18/18 Significant Change Minimum Data Set (MDS) assessment revealed the resident was severely impaired in cognition with a Brief Interview for Mental Status (BIMS) score of seven. During the assessment period the resident did not exhibit any behaviors. The resident required extensive assistance with bed mobility, transfers, walking in the room, corridor, with dressing, toilet use, and hygiene. The resident's balance during transitions and walking was not steady, but she able to stabilize with assistance. The resident was determined as being frequently incontinent of bowel and bladder. The resident was documented as using a bed alarm and other alarm daily; however, the resident was not documented as using any restraints. In the Health Conditions section, the resident was not coded as having any falls since the previous assessment. Review of the Physician's Orders for (MONTH) 2019 revealed the following orders related to alarms: -A bed alarm was prescribed on 12/17/17, -A bed alarm was prescribed again on 9/1/18 due to history of fall. It was unknown why there were two current orders for a bed alarm. -A body alarm to the resident's wheelchair was prescribed on 9/10/18. Review of the resident's care plan dated 10/4/18 identified a problem of, At risk for fall/injury R/T (related to) weakness/impaired mobility D/T (due to) severe deconditioning/Hx (history) falls/has balance deficit, gait disturbance/Meds (medications)/(Fall Risk Assess 14). Currently on Restorative Nursing for Ambulation and Toileting transfers/Hx of transferring self from w/c (wheelchair) to toilet and from bed to w/c. Last noted fall 8/27/18 . The goal was for the resident to have no falls/physical injury. Approaches included in pertinent part use of a bed alarm and a body alarm. The medical record was reviewed and there was no documentation of any assessment for the use of the alarms to determine appropriate use and whether the alarms functioned as restraints (i.e. prohibiting the resident from moving). Furthermore, there was no documentation of a consent form from the responsible party having been completed for use of the alarms. Observation on 1/14/19 11:10 a.m. revealed that R#3 was seated in a wheelchair looking out the window near the nursing station on Vineyard View unit. R#3 had no footrests on the wheelchair. Her feet touched the floor and she was wearing slippers. The resident bent down towards the floor to reach for something and the alarm sounded a piercing noise. The Assistant Director of Nursing (ADON) immediately walked over to the resident and picked up a package of Kleenex tissue paper that had fallen on the floor, while silencing the alarm. The resident did not react to the alarm that sounded for less than five seconds. Additional observations during the survey showed the resident had the body alarm, a device attached to the back of the wheelchair and clipped to her clothing, in place when she was up in the wheelchair. The resident did not attempt to get up during the observations as follows: -On 1/15/19 at 9:40 a.m. R#3 was sitting in her wheel chair in the dining at the table where she ate her meals. The alarm was in place. -On 1/15/19 at 3:33 p.m. R#3 was sitting in her wheel chair in the dining at the table where she ate her meals. The alarm was in place. -On 1/16/19 at 8:27 a.m. R#3 was sitting in her wheelchair eating breakfast at the table. The alarm was in place. -On 1/16/19 at 1:05 p.m. - 2:59 p.m. R#3 p.m. sat near the window in the day room area near the nursing station on Vineyard View unit. The alarm was in place. Observation on 1/17/19 at 11:14 a.m. R#3 was in the day room area near the nursing station on Vineyard View unit. The alarm was in place. R#3 was asked about the alarm and stated she did not know that an alarm was attached to her clothing and the wheelchair and she had not noticed a loud sound when it went off. She stated she did not know anything about it. An interview on 1/16/19 at 1:34 p.m. in the Vineyard View nursing office, the Assistant Director of Nursing (ADON) revealed that R#3 required one person assistance with activities of daily living (ADLs), had a history of [REDACTED]. The ADON stated alarms were used if a resident had a fall or had a history of [REDACTED]. The ADON stated the assessment of alarms was informal and was not documented in the PAR (Patients at Risk) meetings. The ADON explained a body alarm had a box that was clipped to the resident's clothing and could be used in a chair or while the resident was in bed. When it came unclipped, the alarm sounded. The ADON stated a chair alarm was a pad that a resident sat on that sounded when he or she got up. The ADON stated the PAR team implemented the use of the alarms and then got the physician's order afterward, which was transcribed to the Medication Administration Record. When asked if the facility had a protocol to reduce the use of alarms, she stated if a resident continually removed the alarm or refused the alarm, they discontinued it. When asked if an alarm could function as a restraint, the ADON stated the facility staff, including herself, had not viewed alarms as potential restraints. The ADON stated there was no formal assessment process prior to using an alarm or on an ongoing basis. The ADON stated no consent was required of a resident's responsible party for use of alarms. CNA AAA was interviewed on 1/17/19 at 11:25 a.m. in the Vineyard View conference room revealed that R#3 required extensive assistance with most of her ADLs and had experienced increased confusion recently. CNA AAA stated the resident could stand and she transferred her with a gait belt. CNA AAA stated the resident could understand and follow directions but often forgot. CNA AAA stated R#3 had an alarm in place when she was in her wheelchair. CNA AAA stated, A few minutes ago she was leaning down, and it went off. CNA AAA stated R#3 was demented and she tried get out of the chair and walk in her room, which was located at the end of the hall. CNA AAA stated the alarm notified staff she was getting up. CNA AAA stated an alarm was also used when R#3 was in bed, although she did not set the bed alarm off very often. CNA AAA stated the resident did not know where the noise was coming from when the alarm sounded. 2. R#60 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed R#60 had been assessed by the facility with severe cognitive impairment and was independent with ambulation. The resident was documented with a chair alarm daily and free from falls. Continued review of the MDS revealed the resident had displayed wandering behaviors. Review of the care plan dated 11/19/18 revealed R#60 was at risk for falls; a chair alarm was to be placed in his/her chair when in the dining room to alert staff to assist with transfer. Review of the Fall Risk assessment dated [DATE] revealed R#60 was at high risk for falls. Review of the clinical record revealed the resident was not assessed for use of the alarm. Furthermore, there was no restraint consent completed. Observation on 1/17/19 at 9:50 a.m. in the secured unit dining room revealed an alarm sounded when R#60 stood up from his/her chair to walk with a rolling walker. An interview on 1/17/19 at 10:45 a.m. in the secured unit nursing station with a Registered Nurse (RN) Unit Manager (UM) BB revealed the facility did not view an alarm as a restraint. She stated the facility did not do an initial assessment when an alarm was applied to a chair or a bed, nor did they obtain permission from the resident or the significant other or provide education on the risks and benefits of a restraint. UM BB stated if a resident was admitted to the facility with a history of falls, an alarm may or may not be applied, depending on who the nurse supervisor was at the time. She stated a Physician's Order was needed at the time an alarm was applied. UM BB stated she could see why an alarm would be considered a restraint, especially if it scared a resident or prevented them from moving. 3. R#64 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Observation on 1/15/19 at 3:00 p.m. revealed R#64 resting quietly in bed with eyes closed. Further observation revealed R#64's bed was in a low position with fall mats on both sides and a bed alarm was in place. Observation on 1/16/19 at 11:40 a.m. revealed R#64 sitting in dining area eating lunch. A chair alarm was noted to be connected to the resident. Review of Significant Change MDS dated [DATE] revealed: R#64 was assessed as moderately impaired in cognitive skills for daily decision-making; was assessed as not having any behaviors; was assessed as requiring extensive physical assistance of one person for bed mobility, locomotion on and off the unit, dressing, toilet use and personal hygiene. The resident was assessed as requiring total physical assistance of two or more people for transfers; walk in room and in corridor did not occur; did not have any range of motion impairments of the upper or lower extremity and used a wheelchair (w/c). The resident was assessed as having no falls and used bed and chair alarms daily. Review of the Care Area Assessment Summary (CAAS) revealed the resident was triggered for care plan in [MEDICAL CONDITION], cognitive loss/dementia, visual function, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, activities, falls, and nutritional status. Review of the resident's Care Plan with an Onset date of 11/12/18 revealed Problem - Resident at risk for falls/injuries r/t (related to) impaired mobility and cognition, inability to understand safety needs, incontinence, meds. Hx (history) of falling (last in (MONTH) (YEAR)) Fall risk 14. Goal: Resident will be free from physical injury/no falls/ no contusions. Review in 90 days and prn (as needed). Interventions: Staff will provide frequent reminders to not get up unassisted; chair and bed alarms as ordered, check proper placement and function every shift; remove w/c from bedside when not in use; ambulate/transfer with appropriate devices - mechanical lift and two assist, handle gently; assess room for safety hazards; mop up any liquids spills immediately; encourage resident not to attempt to transfer/ambulate unassisted; place call light within easy reach at all times/answer promptly; bed in low/locked position/apply W/C brakes during transfer; side rails up in bed as desired by resident to facilitate; positioning/define parameters; wear legible armband; cleanse and change in timely manner after incontinent episode; assess meds with hypotensive effect; handle gently during all transfers and positioning; document/report all falls/injury per Facility Protocol - assess for shock. Review of Physician's Orders revealed the following: 7/17/18 - chair alarm when OOB (out of bed) - staff to check intact and functioning each shift. Review of Fall Risk Assessment revealed the resident was assessed as having a fall risk score of 14 on 10/26/18 indicating the resident was a high risk. Review of R#64's electronic medical record and hard chart revealed no restraint assessment or consent form for use of chair alarm. Interview with RN/Unit Manager EE, in Grove Terrace's Nurse's Office, on 1/17/19 at 10:58 a.m. revealed R#64 tended to fall and get out of her wheelchair. R#64 was given a chair and bed alarm to notify the staff when she got out of her wheelchair or bed. RN/Unit Manager EE said the interdisciplinary team had quarterly meetings to discuss the chair and bed alarms used by the resident. RN/Unit Manager EE said consent forms were not obtained. RN/Unit Manager EE said quarterly conferences were held and that the resident and family were invited to the quarterly conferences 4. Review of the clinical record revealed R#260 was admitted to the facility on [DATE], with the following Diagnoses: [REDACTED]. Review of the Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/10/19 documented the resident's Brief Interview for Mental Status score was 15 indicating the resident's cognition was intact. The resident was assessed as not having any behaviors; was assessed as requiring extensive assistance of two or more people for bed mobility and transfers; was assessed as requiring limited assistance with one person physical assist for walk in the room and corridor and locomotion on and off the unit. R#260 was assessed as having range of motion impairment on both sides of the upper extremities and used a wheelchair. R#260 was assessed as having a fall in the last month (prior to admission) and having fractures related to a fall in the six months prior to admission/entry to the facility. The resident was assessed as having no falls in the facility since admission. Review of the Care Area Assessment Summary (CAAS) revealed the resident was triggered for care plan in activity of daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer, pain, and return to community referral. Further review of the MDS revealed no alarms were in use. Contrary to the 1/10/19 MDS, review of the current baseline care plan dated 1/3/19 indicated a bed alarm was in use. Review of R#260's medical record revealed no restraint assessment or consent for the bed alarm were present. A review of the Physician Orders revealed no order for a bed alarm had been obtained. A review of the nursing notes revealed notes on 1/5/19 at 12:34 a.m., 1/5/19 at 4:32 p.m., 1/6/19 at 7:55 p.m., 1/7/19 at 10:32 p.m., 1/9/19 at 12:00 a.m., 1/9/19 at 12:46 a.m., 1/9/19 5:21 p.m., and 1/10/19 at 4:17 p.m., revealed the bed alarm was in place and functioning. An interview on 1/16/19 at 10:00 a.m. with the resident, in her room, revealed that she had an alarm on her bed. The resident stated she had no issue with the alarm and it reminded her to call for help. An interview on 1/17/19 at 10:18 a.m., in the Rehab unit nurses' station with RN GG the Rehab Unit Manager, revealed that the resident was admitted to the facility with two fractured wrists and needed extensive assistance with transfers and care. Upon admission, the resident's family wanted an alarm placed to remind the resident to call for help. RN GG stated the facility discussed the bed alarm in the morning meeting and during the care plan meeting with the resident and the resident's family. The nurse stated there was no documentation in the resident's medical record about the morning meeting and care plan meeting discussion of the bed alarm. RN GG stated before placing the bed alarm the facility received an order from the physician. RN GG reviewed the residednt's medical chart and verified there was no physician's order for the bed alarm. There were a total of 34 residents in the facility that had alarms in place. All five units in the facility had residents with alarms. There was no assessment process to determine whether the alarms functioned as restraints and no formal process to review alarms for reduction. The Facility Matrix completed during the survey showed no residents were restrained; however, without an assessment to determine the impact of the alarm it was unclear whether the alarms functioned as restraints. Review of the undated facility document titled Restraint Use Policy Statement revealed, Orchard View creates and maintains an environment that fosters minimal use of restraints. The purpose of selective restraint use is to enhance resident quality of life by assuring safety while promoting an optimal level of function. It is the intent of this facility to attain and maintain a restraint free environment. The policy directed staff to utilize alternatives prior to restraint use, obtain a physician's order for restraints, have the family complete a consent form for short term use of restraints, document in the care plan use of restraints, and document monthly in clinical notes the type of restraint, date and time of use, reason for use and resident tolerance. Review of the undated facility document titled Restraint Reduction/Elimination Policy Statement revealed the need for restraint use was to be assessed at care plan conferences and as needed. The policy read in pertinent part, Vehicles to facilitate restraint reduction and promote safety include but are not limited to: scheduled ambulation, diversional activities, scheduled exercise, use of lounge chair, adaptive scheduled exercise from OT/PT (Occupational Therapy/Physical Therapy), use of bedside tables, wedge cushions, Velcro seatbelts and personal alarms. The restraint policies failed to identify alarms as potential restraints. The Restraint Reduction/Elimination Policy Statement revealed alarms were an alternative to restraints regardless of the impact of the alarm on the resident (such as whether it limited the resident from moving or getting up).",2020-09-01
303,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2019-01-17,761,E,0,1,NFDD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure expired medications and supplies were not available to be administered to the residents from two of six medication rooms. Findings include: 1. On 1/16/19 at 10:30 a.m. during an inspection of the South Rehab (rehabilitation) Unit medication room with Licensed Practical Nurse (LPN) KK the following expired supplies were noted: -One enteral feeding tube 20 French with an expiration date of 12/11/18 -One female urinary specimen catheter kit with an expiration date of 9/2018. An interview with LPN KK verified and was given the expired supplies. An interview on 1/16/19 at 10:30 a.m., with LPN KK in the South Rehab Unit medication room, revealed that the nurses on the unit looked for expired medications and supplies in the medication room once a week. However, there was no documentation such as assignment sheets to sign off for checking the medication room for expired supplies and medications. 2. On 1/16/19 at 11:45 a.m. during inspection of the Meadow Terrace unit medication room with LPN DD, one open multidose vial of [MEDICATION NAME] Purified Protein Derivative Diluted [MEDICATION NAME] had no open date on the bottle; most of the vial was gone. The box had the following direction, Once entered vial should be discarded after 30 days. An interview on 1/16/19 at 12:05 p.m. with Registered Nurse (RN) AA, the Unit Manager of Meadow Terrace revealed that the Unit Secretary was responsible for checking the medication room for expired supplies. The Unit Secretary did this when new supplies came into the unit. The nurses on the unit checked the medication room and carts for expired medications. LPN DD received the vial of [MEDICATION NAME] from the Infection Control Nurse opened and without an open date documented on the box or vial. LPN DD did not ask the Infection Control Nurse to put an open date on the box/vial. An interview on 1/16/19 at 2:30 p.m. in the conference room, the Assistant Director of Nursing (ADON) revealed that the facility had no policy for expired medications and supplies. An interview on 1/16/19 at 4:00 p.m. in the Director of Nursing (DON) office, revealed that the facility had no policy for expired medications or supplies.",2020-09-01
304,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2019-01-17,804,E,0,1,NFDD11,"Based on observation, interview, and record review the facility failed to ensure pureed foods for 22 residents (R) prescribed pureed diets out of a total of 175 residents (R#7, R#8, R#19, R#23, R#26, R#31, R#35, R#51, R#58, R#60, R#81, R#85, R#88, R#94, R#107, R#113, R#123, R#130, R#136, R#154, R#209, R#312) were prepared in a manner preserving the nutritive value and flavor. These failures created the potential for resident dissatisfaction and weight loss. Findings include: Review of facility document titled Roster Report dated 1/16/19 revealed there were 22 residents who were prescribed pureed diets: R#7, R#8, R#19, R#23, R#26, R#31, R#35, R#51, R#58, R#60, R#81, R#85, R#88, R#94, R#107, R#113, R#123, R#130, R#136, R#154, R#209, R#312. Observation on 1/16/19 at 11:33 a.m., for preparation of pureed foods for the lunch meal was observed in the main kitchen. Cook QQ was preparing the pureed foods. Cook QQ stated she determined how much of the meat, vegetable or starch was placed in the processor bowl to be pureed based on the level of the food in a specific sized steamtable pan. Cook QQ incorrectly stated there were about 40 residents who received pureed diets. Cook QQ stated the designated steam table pan should be half full of whatever food she was going to puree. Cook QQ used a six-ounce ladle to scoop the entire contents of the beef tips with gravy from the steam table pan (that was between a third to a half full) into the Commercial food processor bowl. The Cook QQ scooped six ladles of the beef tips into the food processor for a total of 36 ounces. 36 ounces divided by 22 portions revealed the portion size would be 1.6 ounces of beef tips per resident although the menus called for a three to four-ounce portion. Cook QQ took a gallon pitcher and filled it with hot tap water and placed it on the counter and took a quart pitcher and filled it with Thick and Easy thickener and placed it on the counter. Cook QQ processed the beef tips and then added approximately a quart of water, processed the mixture, then added approximately a cup of thickener. This process was completed four times until all the water and all the thickener was added to the processor. The final product was semi-liquid and Cook QQ poured it out of the processor into the steamtable pan, stating it would continue to thicken. The level of the food was near the top of the steam table pan, with the volume more than doubling with the addition of the water and thickener. When asked if there were recipes for the pureed menu items, Cook QQ stated there were no recipes and stated she added a gallon of water and a quart of thickener to whatever she was pureeing, and it yielded the correct amount which was a full steam table pan. The total amount of the ingredients being pureed was: beef tips - 36 ounces, thickener - 32 ounces, and water - approximately 128 ounces. The pureed beef tips were light to medium brown in color. The surveyor asked for a plastic spoon to taste the finalized pureed meat and invited the cook to taste it. The pureed beef tips were sampled by the surveyor and the flavor of the meat was diluted and bland. Cook QQ did not taste the pureed food. The steamtable was slightly less than half full of the beef tips prior to making the pureed item. Following the preparation of adding water and thickener, the same steam table pan was full, indicating half of the volume of the pureed beef tips consisted of water and thickener. Continued observation revealed that Cook QQ followed the same procedure when preparing the pureed noodles. Cook QQ started with noodles in the designated steamtable pan at a level between one third and half full. Cook QQ scooped the noodles into the food processor bowl and followed the same procedure with approximately a gallon of hot tap water and a quart of thickener. Cook QQ processed the food adding thickener, processing, adding water, processing a total of five times until all the water and thickener had been added. Cook QQ poured the mixture that was smooth and thin into the steamtable pan which was near the top level of the steamtable pan. The pureed noodles were white. The pureed noodles were tasted by the surveyor and were bland with little discernable flavor of noodles. Cook QQ declined to taste the pureed food when invited to by the surveyor. Cook QQ followed the same procedure when preparing the pureed California blend vegetables (a mixture including cauliflower, carrots, broccoli). Cook QQ took the contents of the steamtable pan that was half full of vegetables floating in hot water and transferred the mixture into the food processor bowl. Cook QQ used three and a half quarts of hot water and a quart of thickener, adding to the vegetable/water mixture in the processor bowl. Cook QQ processed the food adding thickener, processing, adding water, processing approximately five times until all the water and thickener had been added. Cook QQ poured the mixture that was smooth and thin into the steamtable pan which was near the top level of the pan. The pureed vegetables were a brownish yellow color. The vegetables were tasted by the surveyor and were bland with little discernable flavor of vegetables. Cook QQ declined to taste the pureed food when invited to by the surveyor. Cook QQ was asked if there are any additional items to be pureed and she stated there were not. When asked about pureeing the sugar cookies per the Week 2 menu, she stated, No, I don't puree the dessert. Observation and interview on 1/15/19 from 11:48 a.m. - 12:15 p.m. meal service was observed on the Vineyard View neighborhood. Observations of the tray line in the Vineyard View kitchen revealed residents on puree diets were served three ounces of pureed rice, three ounces of pureed peas, and three ounces of pureed meat. Dietary Aide RR and Dietary Aide SS were interviewed together in the Vineyard View kitchen and were asked what size serving portions they should use for the pureed menu items. When asked if they had a menu or other guide directing what the serving sizes were supposed to be, Dietary Aide RR and SS stated they used whatever utensils were available and indicated the three ounce portion scoops were typically what they used. Observation and interview on 1/16/19 lunch at approximately 12:15 p.m. on the Vineyard View neighborhood revealed residents on puree diets were served three ounces of pureed noodles, three ounces of pureed California blend vegetables, and three ounces of pureed beef tips. Dietary Aide RR and SS verified they were using three ounce portion utensils to serve the pureed foods. 4. The Dietary Director provided the surveyor with recipes for the pureed foods that were observed being prepared on 1/16/19. The pureed beef tips recipe called for the desired number of beef servings to be placed into the food processor. The mixture should be blended until smooth. Broth or gravy should be added if the beef needed thinning and a commercial thickener should be added if it needed thickening. The recipe did not provide any information regarding how much liquid or thickener should be added. The pureed vegetable recipe called for the desired number of vegetable servings to be placed into the food processor. The mixture should be blended until smooth. Water should be added if the vegetables needed thinning and a commercial thickener should be added if it needed thickening. The recipe did not provide any information regarding how much liquid or thickener should be added. The pureed pasta garlic recipe called for the desired number of pasta noodles servings to be placed into the food processor. The mixture should be blended until smooth. Water should be from the pasta should be added if the pasta needed thinning and a commercial thickener should be added if it needed thickening. The recipe did not provide any information regarding how much liquid or thickener should be added. An interview on 1/17/19 at 8:26 a.m. in the surveyor conference room, the Dietary Director revealed that when preparing pureed foods, the cook should add the portions to the food processor as specified in the menu. For example, with the four ounce portion of beef tips on the menu, the cook should multiply three or four ounces by 22 servings (66 - 88 ounces) to get the amount of meat to be pureed. The Dietary Director was notified that 36 ounces of meat were pureed. The Dietary Director stated recipes were available and the cook should have followed the recipes. The Dietary Director was notified of the addition of water rather than gravy or broth as directed in the recipe for the pureed beef tips. The Dietary Director stated he was aware the recipe called for gravy or broth but thought it was acceptable to use water because the food already had gravy as part of the recipe. When asked how the pureed beef tips should be prepared, the Dietary Director stated the beef tips should be put into the processor, and if it was too thick, a little bit of water could be added. If it was too thin, a little bit of thickener could be added to get the desired consistency. The Dietary Director stated the Cooks were trained to add the liquid gradually, no more than a half a cup at a time. Cooks were also trained to add the thickener gradually, using a two ounce ladle. The Dietary Director stated the Cook should taste the pureed item after adding thickener and water to ensure it was acceptable. When the Dietary Director was notified of a quart of thickener being added and a gallon of water, he stated that was too much water and too much thickener and the Cook would need to be re-educated. The Dietary Director stated Cook QQ was a relatively new cook in her position no more than 90 days. In a telephone interview on 1/17/19 at approximately 10:00 a.m., the Registered Dietitian revealed that puree diet preparation should consist of adding a small amount of fluid to the food in the processor to get the correct consistency if the pureed menu item was too thick or a small amount of thickener at a time if the menu item was too thin. The RD stated pureed menu items should be the consistency of applesauce or pudding. When the pureed diet preparation observations for lunch on 1/16/19 were described to the RD, he stated that was too much water and too much thickener and verified the addition of a quart of thickener and a gallon of water for the number of pureed portions prepared would dilute the amount of nutrition provided. The RD verified the portions on the menu corresponded to the amount a resident should be served to meet nutritional needs. The Manufacturer's Usage Chart for Thick and Easy Instant Food and Beverage Thickener revealed two teaspoons of thickener per four ounce serving should be added to pureed foods. For 22 pureed portions, these instructions revealed approximately 44 teaspoons should be added, which is almost equivalent to one cup (48 teaspoons equal a cup). Observations of pureed meal preparation revealed four cups of thickener were added, which was four times more than the Thick and Easy Instant Food and Beverage Thickener chart called for.",2020-09-01
305,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2017-01-20,280,D,0,1,Z3P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to revise the care plan to include interventions to prevent reoccurrence of incident for one resident (R) (R#290) out of 34 sampled residents. Findings include: Record review for R#290 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] that indicated admission to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Review of the nurse ' s notes for R#290 dated 1/12/17 revealed resident's daughter at bedside reported 1.5 cm x 0.5 cm dark abrasion with 2.5 cm x 2.5 cm raised area to forehead. Site cleaned with normal saline and left open to air. Nurse Manager informed of resident's condition. Review of the Care Plan/ Patient at Risk (PAR) Conference Sheet for R#290 dated 1/13/17 revealed purpose: raised area to right side of forehead. The care plan revised on 1/13/14 revealed resident at risk for impaired skin integrity related to PAR discussing abrasion to forehead. Intervention implemented: treatment to forehead as ordered. Review of the Physician orders [REDACTED].#290 ' s abrasion to the forehead. Interview with the Director of Nursing (DON) on 01/19/2017 at 3:45 p.m. confirmed that her expectation is that something be put into place to prevent the resident from continuing to scratch at the bonnet. DON informed that during the Interdisciplinary Team meeting, she suggested to check the residents fingernails routinely to ensure that they do not continue to cause abrasions to the residents head. DON could not provide an explanation of why a more appropriate intervention was not put into place to prevent reoccurrence of the incident. Cross Reference F323",2020-09-01
306,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2017-01-20,323,D,0,1,Z3P611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to thoroughly investigate an incident and develop appropriate interventions to prevent reoccurrence of injury for one resident (R) (R#290) out of 34 sampled residents. Findings include: During an interview on 1/18/17 at 10:45 a.m. R#290 ' s daughter revealed that her mother had a raised area noted to her forehead. R#290 ' s daughter stated that she was concerned that one of the Certified Nursing Assistant ' s may have accidentally hit the resident in the head with the lift. She stated that nothing was done for her mother and the staff had not followed up with her about regarding the incident. Observation on 1/18/17 at 10:50 a.m. revealed R#290 with a small darkened area noted to the right side of forehead. It was not raised at this time. Review of the nurse ' s notes for R#290 dated 1/12/17 revealed resident's daughter at bedside reported 1.5 cm x 0.5 cm dark abrasion with 2.5 cm x 2.5 cm raised area to forehead. Site cleaned with normal saline and left open to air. Nurse Manager informed of resident's condition. Interview with Licensed Practical Nurse (LPN) AA on 01/19/2017 at 11:48 a.m. revealed that on 1/12/17, R#290 ' s daughter reported an abrasion that was raised to the right side of forehead. LPN AA informed that the resident's daughter felt the abrasion could have been from the mechanical lift. LPN AA reported to his nurse manager and accompanied the nurse manager to R#290 ' s room to assess the resident's forehead. Interview with the Registered Nurse (RN) Manager BB on 01/19/2017 at 12:08 p.m. revealed that she assessed the R#290 ' s forehead on 1/12/17 and the area of concern did not appear to be anything new. RN BB informed that she was not aware of the daughter's claim that the injury was from the lift until returning from the holiday weekend of 1/17/16. Witness Statement dated 1/19/17 written by RN BB documented that on 1/12/17 she was advised by LPN AA that R#290 had a raised area on her forehead. She accompanied LPN AA to the residents room and observed a small raised area to the residents right upper forehead along a vein that had brown (dark brown) pigmented linear areas, questionably scratched, scraped that did not appear to be a new area, no bruising noted around the area. Resident wears a bonnet that had caused indentations on the resident's forehead and was verified as not being excessively tight. Review of the Incident Log dated 1/12/17 documented R#290 ' s daughter reported an abrasion with raised area at right forehead. Daughter stated she noticed area Tuesday when resident was transferred from rehab. Injury described as 1.5 x 0.5 cm abrasion with 2.5 cm x 2.5 cm raised surrounding area. Review of the Complaint Form dated 1/14/17 revealed R#290 ' s daughter made complaint that resident was hit in the head by the lift - two hematomas were noted on the forehead and that staff failed to notify the nurse or call the family. Stated resident did not receive any care after the injury. Findings from complaint investigation documented daughter feels that resident's forehead hit lift however daughter denies resident being out of bed prior to 1/13/17. Record review for R#290 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] that indicated admission to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Section C- Cognitive patterns, documented that the resident was not interviewed for a Brief Interview for Mental Status (BIMS) summary score. Section G- Functional Status documented the resident required two person total dependence with transfers and totally dependent with bathing. Section J - Health Conditions documented no history of falls. Section V- Care Area Assessment (CAA) triggered Falls with the decision to be care planned. Review of the Care Plan/ Patient at Risk (PAR) Conference Sheet for R#290 dated 1/13/17 revealed purpose: raised area to right side of forehead. The care plan revised on 1/13/14 revealed resident at risk for impaired skin integrity related to PAR discussing abrasion to forehead. Intervention implemented: treatment to forehead as ordered. Review of the Physician orders [REDACTED].#290 ' s abrasion to the forehead. Interview with the Director of Nursing (DON) on 01/19/2017 at 3:45 p.m. revealed that to her knowledge, it was believed as informed per RN BB that the raised area possibly came from R#290 scratching at the bonnet on her head. DON confirmed that her expectation is that something be put into place to prevent the resident from continuing to scratch at the bonnet. DON informed that during the Interdisciplinary Team meeting, she suggested to check the residents fingernails routinely to ensure that they do not continue to cause abrasions to the residents head.",2020-09-01
307,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,550,E,0,1,I6B011,"Based on observation and staff interviews, review of the facility policy titled, Dining Service the facility failed to promote an environment that maintained dignity by not ensuring that all residents eating meals at the same table in the Garden View dining room were served together in a timely manner; the facility also failed to promote an environment that maintained dignity by not ensuring residents dependent with meals in the Grove Terrace dining room were served meals in a timely manner. The facilty census was 184. Findings include: 1. During observation at lunch in the Garden View dining room on 2/7/18 beginning at 11:59 a.m., eight Certified Nursing Assistants (CNA) were noted to distribute the lunch trays and feed the dependent residents (R). The following observations were made at each of the four tables in the dining room: Table 1: Eight residents were seated at this table, and six of the residents were served within a few minutes of each other. Observation of R #18 revealed that he was alert, and watching the six other residents at the table eat their lunch. At 12:11 p.m., approximately 12 minutes after the other residents had been served, R #18 was observed to wave his hand in the air. Staff was then observed to serve his tray to him at 12:12 p.m., and he immediately began to feed himself. The last resident at this table was observed to be served their lunch tray at 12:15 p.m. Table 2: Eight residents were seated at this table, and five of the residents were served by 12:05 p.m. Seven of the residents were served by 12:14 p.m., but the last resident, who was alert and seated at the end of the table, was served her tray and assisted to eat at 12:25 p.m. Table 3: Eight residents were seated at this table, and the first two were served their lunch by 12:02 p.m. Six residents were observed to have been served by 12:14 p.m., and all eight had been served by 12:25 p.m. Table 4: Six residents were at this table, and two residents were observed to be served quickly at the beginning of the meal service at 11:59 a.m. Further observations revealed that four residents had been served by 12:15 p.m., and all but one resident had been served by 12:24 p.m. Observation of R #171 revealed that she had been seated at this table since the beginning of the meal observations, was alert, and looking around the room including looking at the other residents seated at her table who were eating. Further observations revealed that R #171 was the last resident in the dining room to be served her lunch at 12:35 p.m., at which time she was fed by staff. Review of the facility policy: Dining Service (undated) revealed: The meals will be served in the most timely, comfortable and attractive manner possible. Each tray will be served in a timely manner. Any problem with delivery of food in a timely manner will be addressed immediately by the nursing staff and/or dietary staff. Every effort will be made to serve each resident at a table before proceeding to the next table. 2. An observation on 02/05/18 beginning at 11:30 a.m. revealed residents dependent with meals were served 45 minutes after independent residents during lunch meal. The following was observed: 11:35 a.m.--residents began to enter dining area for lunch meal 12:02 p.m.--resident lunch trays beginning to be served for residents sitting at the tables. 12:05 p.m. three residents (R) (R43, R44, and R46) noted in front of the television during dining--Two residents noted at table without a meal tray 12:28 p.m. facility staff plating hall trays 12:42 p.m. facility staff prepping meals for residents requiring assistance with meals 42 minutes lapsed from the time meal pass began until residents requiring assistance were fed An observation on 2/6/18 beginning at 8:25 a.m. revealed residents dependent with meals received at 9:12 a.m., 42 minutes after trays pass began. The following was observed: 8:32 a.m. staff plating and passing breakfast meal 8:47 a.m. staff still passing tray meals 8:48 a.m. Family A feeding her father 8:50 a.m. R43, R44, and R46 noted in front of the television 9:00 a.m. R46 sitting in merry walker; moved to table by CNA UU 9:04 a.m. CNA AA began feeding R46 9:10 a.m. CNA TT began feeding R44 9:12 a.m. CNA YY began feeding R43 An interview with Family A on 2/6/18 at 8:40 a.m. revealed she comes to the facility almost daily to feed her father so he doesn't have to wait on staff to feed him; the facility needs help during dining. An interview with Unit Secretary XX on 2/7/18 at 3:47 p.m. revealed some of the residents on the hall who eat in there rooms were complaining on waiting too long to receive meal trays, so staff began feeding residents who are total care last. An interview on 2/8/18 at 9:56 a.m. with Certiffied Nursing Assistant (CNA) WW revealed our unit has a lot of vocal residents who were upset about waiting for trays, so we began feeding residents who are total care last. The interview also revealed it would be too much work to put the total care residents back in their rooms prior to dining and then bring the residents back to the dining area after everyone else eats. This will also will leave the dining room unattended. An interview on 2/8/18 at 10:10 a.m. CNA SS revealed the residents on the halls want trays quick, and will get mad. CNA SS further revealed they feed the total care residents last while some staff finishing passing hall trays and helping those who eat in their rooms. CNA SS also revealed residents requiring assistance with meals are faced towards the television so they will not have to watch others eat. A record review of a sign located the chart room on Grove Terrace revealed the following: all trays to be served in dining room to people that are able to feed self first, then trays to people in rooms that are able to feed self, and then feeders will be fed An interview on 2/8/18 at 3:20 p.m. with the Administrator revealed he was unaware of the dining process sign on Grove Terrace. He further revealed during the interview that he expects tables during dining to be served similar to a restaurant, the whole table gets their plate at the same time. 3. During observations at lunch in the Garden View dining room on 2/5/18 beginning at 11:45 a.m., several residents were noted to wait 30 to 45 minutes to be served after other residents at the same table had already been served, were eating, and/or finished with their meal. At 12:20 p.m., one resident (R) #127 was observed to be brought in the dining room, seated by R #16, and served his tray. R #16 had been sitting at the table since 11:45 a.m., and not yet served her meal tray. During interview with Certified Nursing Assistant (CNA) ZZ on 2/8/18 at 1:30 p.m., she stated that usually all of the residents ate in dining room, except one resident who had a wound. She stated during further interview that they tried to organize the meal tray tickets by tables so that the food could be plated in that order and all residents at a table served at once, unless someone rearranged the tickets. During interview with Registered Nurse (RN) Unit Manager MM on 2/8/18 at 2:10 p.m., she stated that almost all of the residents on the unit ate in the dining room except for a few that didn't want to, or who were on a turning schedule. She stated during further interview that the residents independent for eating were served first, followed by the the dependent residents who had to be fed, assisted, and/or encouraged and prompted to eat.",2020-09-01
308,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,558,D,0,1,I6B011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the right to receive services in the facility with reasonable accommodation of resident needs and preferences by not providing a urinal for one resident, Resident #146 (R #148) out of 38 sampled. Findings include: R #148 was admitted to the facility his current [DIAGNOSES REDACTED]. Review of the care plan, dated 1/10/18, revealed planning for self-care deficit related to right-sided stroke. R#148 needed extensive assist with personal hygiene, toileting, and other needs. He was incontinent of bowel and bladder. Further review revealed the resident's privacy and dignity will be maintained at all times. The facility will provide needed supplies for bathing and hygiene. Resident was non-ambulatory at this time and required a wheelchair. Review of MDS 14 day tracking, dated 1/10/18, revealed a Brief Interview for Mental Status (BIMS) score of 15. He was noted to require extensive assistance for toileting. He was totally dependent for toileting hygiene, Review of Accommodation of Needs policy, undated, page 27, revealed the resident had a right to arrange his room in a manner that is consistent with his preference and personal needs. Further review of this same policy, page 29, revealed the resident had the right to receive services in the facility with reasonable accommodation of individual needs and preferences. The resident had a right to receive care, treatment and services that are adequate and appropriate. Interview with R#148 in his room on 2/7/18 9:15 a.m. His urinal was in the bathroom. R#148 stated he had a sudden urge to urinate late last night after he went to bed and could not find his urinal. He did not call for help because the need was urgent. He urinated in his brief. He stated further he certainly would have tried to use his urinal had he been able to reach it. Observation was made on 2/7/18 10:10 a.m. of R#148 in his room. The resident's urinal was in the bathroom. Certified Nursing Assistant (CNA) EE stated out of earshot of the resident that he was incontinent of bladder this morning. She also said R#148 has tried to use the urinal in the past, but often makes a mess. EE also stated the night shift will not leave the urinal at his bedside, because he is messy with it. EE then left the room. She did not move the urinal from the bathroom. Observation of R#148's bathroom was made on 2/7/18 at 12:50 p.m. revealed a urinal on the grab bar in the bathroom. Interview with R#148 in his room on 2/7/18 at 1:55 p.m. He stated he would like his urinal to be hung on his assist bar on his bed at night so he can use it, and that he has told the staff several times. The urinal is hung on a grab bar in the bathroom. Direct observation of R#148's bathroom on 2/8/18 at 8:05 a.m. revealed his urinal was on the grab bar in the bathroom. Interview with Registered Nurse (RN) FF, Unit Manager, on 2/8/18 at 10:00 a.m. for the Rehab South Nurse's Station revealed that a resident should always be given a urinal if they ask for it even if the resident cannot use it. The resident would be incontinent one way or the other, so he should get the urinal.",2020-09-01
309,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,582,B,0,1,I6B011,"Based on record review and staff interview, the facility failed to provide evidence that the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) was issued for two of three residents (R) reviewed (R #73 and #166), who were discharged off Medicare Part A services and remained in the facility. The sample size was 38 residents. Findings include: Review of a SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review (Form CMS- ) revealed that R #73 was discharged off Part A services on 12/7/17, with 69 benefit days remaining. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that she remained in the facility after skilled services ended. Review of her Beneficiary Notices revealed that only the Notice of Medicare Non-Coverage form (NOMNC)(Form CMS- ) was provided, which was signed by the responsible party (RP) on 12/4/17. Review of the Form CMS- revealed that R #166 was discharged off Part A services on 1/12/18, with 55 benefit days remaining. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that he remained in the facility after skilled services ended. Review of his Beneficiary Notices revealed that only the NOMNC was provided, which was signed by the resident on 1/8/18. During interview with Bookkeeper KK on 2/7/18 at 2:31 p.m., she stated that none of the residents that remained in the facility after Part A services ended were issued a SNFABN. During interview with Social Worker (SW) JJ on 2/8/18 at 9:07 a.m., she stated that she did not see a SNFABN in R #73's file since (YEAR). She stated during further interview that she was sure she issued it, but could not find documentation that a SNFABN was provided for R #166 for his services ending on 1/12/18. SW JJ further stated that all residents coming off Part A were issued a NOMNC two days prior to termination of services, and that the case worker assigned to a particular unit also issued the SNFABN if the resident remained in the building. She further stated that they kept the NOMNCs issued in a binder, but that they did not keep copies of the SNFABNs, as the hardcopies were supposed to go in the residents' files in the Business Office. During interview with SW LL on 2/8/18 at 12:09 p.m., she stated that she recalled going over both the NOMNC and SNFABN with R #73's family member, but that she did not make a copy of the SNFABN after it was signed, and took it directly to the Bookkeeping office to be filed. She further stated that the SNFABNs for both R #73 and #166 could not be located in their files. Interview with the Social Services Director at this time revealed that she was able to locate SNFABNs provided for residents that came off Part A services around the same time R #73 and #166 did, but could not locate these two residents' forms. Review of the facility's Form Instructions Advance Beneficiary Notice of Noncoverage (ABN) (undated) revealed: The ABN is a notice given to beneficiaries in Original Medicare to convey that Medicare is not likely to provide coverage in a specific case. Once all blanks are completed and the form is signed, a copy is given to the beneficiary or representative. In all cases, the notifier must retain the original notice on file.",2020-09-01
310,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,604,D,0,1,I6B011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the Policy titled Restraints, the facility failed to ensure that one resident (R) (#120) was free from restraints out of 38 sampled residents. Findings include: Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#120 with a Brief Interview for Mental Status (BIMS) score of 6, indicating that the resident was cognitively impaired; required two-person extensive assistance with transfers and no restraints used. The clinical record for R#120 revealed [DIAGNOSES REDACTED]. Observation on 2/5/18 at 10:38 a.m. revealed bed bolsters on each side of R#120's bed. Resident was observed toward the end of the bed. Review of the care plan last revised on 12/19/17 revealed R#120 at risk for fall/ injury related to medical factors/ history of falls. Resident had a fall on 8/25/17 in which resident was noted on the floor outside the bathroom. The resident stated she was trying to go to the bathroom. Intervention implemented: bolster pads to bed at all times. Review of the Physician order [REDACTED]. During an interview on 2/8/18 at 9:21 a.m., Certified Nursing Assistant (CNA) HH described the pads on R#120's bed as bolster pads. When asked what they were used for, CNA stated that the bolster pads were used to keep the resident from getting out of bed by herself. Interview with the Director of Nursing (DON) on 2/8/18 at 12:46 p.m. revealed that bed bolsters are typically used for resident's that have a habit of rolling out of the bed. She stated that the bed bolsters for R#120 should have been considered as a restraint and assessed quarterly for the continued use. She revealed that bolsters should not have been used for this resident as an intervention for a fall due to the resident trying to get up and go to the bathroom. Review of the Policy titled Restraints initiated on 11/28/16 revealed: the facility creates and maintains an environment that fosters minimal use of restraints. The purpose of selective restraint use is to enhance resident quality of life by assuring safety while promoting an optimal level of function. It is the intent of this facility to attain and maintain a restraint free environment. 1) The need of each resident for alternatives to restraint use is assessed on occasion, at regularly scheduled interdisciplinary care plan conference reviews, and as needed. 7) The interdisciplinary approved plan for restraint use is outlined in Resident Care plans and is revised as needed.",2020-09-01
311,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,637,D,0,1,I6B011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) after one resident (R) (#144) developed an unstageable pressure ulcer, and experienced an 18.4-pound one-month significant weight loss (SWL). The sample size was 38 residents. Findings include: Review of an Encounter-Nursing Home Visit dated 11/27/17 noted that R #144 was readmitted following a hospitalization for acute metabolic [MEDICAL CONDITION], urinary tract infection, and influenza. Further review of this physician visit note revealed that she was in declining health. Review of her Quarterly MDS dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment). Review of R #144's Vital Sign Sheet revealed that she weighed 165.2 pounds on 12/7/17, and 146.8 pounds on 1/8/18, an 11.14% (per cent) one-month SWL. Review of a Skin Integrity-Pressure Ulcers report for the dates of 1/25/18 through 1/31/18 revealed that R #144 had an unstageable wound to her left buttock with an onset date of 12/11/17. Observation of wound care performed by Licensed Practical Nurse (LPN) Treatment Nurse CC on 2/7/18 at 9:39 a.m. revealed that R #144 had a 3.5 centimeter (cm) by 5.6 cm wound to her left medial buttock that was covered with slough (non-viable tissue). Review of R #144's Care Plan/PAR (Patients at Risk) Conference Sheet revealed that she was discussed at a meeting on 12/11/17 related to a pressure ulcer to her sacrum and right gluteal area; on 1/12/18 for a Care Plan Conference; and on 1/18/18 related to an RD (Registered Dietician) recommendation. During interview with Registered Nurse (RN) MDS staff OO on 2/8/18 at 3:17 p.m., she stated that residents were discussed in PAR meetings if they had something like a SWL. Interview with LPN MDS staff PP at this time revealed that if a resident had an overall decline in areas such as ADLs (activities of daily living), they may wait a couple of weeks to see if the resident's status improved before doing a Significant Change MDS. She verified that if a resident developed an unstageable pressure ulcer as well as a significant weight loss, that a Significant Change assessment should have been done within two weeks. She verified during further interview that R #144 had a SWL on 1/8/18, and a recently-developed unstageable pressure ulcer, and that a Significant Change MDS should have been done.",2020-09-01
312,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,656,D,0,1,I6B011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview,, the facility failed to follow the care plan related to treatment to the sacrum as ordered for one resident (#144). The sample siz the facility failed to implement the care plan related to documenting behaviors and mood indicators and to assess for side effects from [MEDICAL CONDITION] drug use for two residents (R) (R #144 and #128). In additione was 38 residents. Findings include: 1. Review of R #144's physician's orders [REDACTED]. During an interview with Registered Nurse (RN) Unit Manager MM on 2/8/18 at 11:00 a.m., she stated that she was unable to find any behavior monitoring or monitoring for side effects done for R #144 since she was readmitted from the hospital (on 11/24/17), and verified that R #144 was receiving [MEDICATION NAME] (Duloxetine) and [MEDICATION NAME] ([MEDICATION NAME]). 2. Review of R #128's care plans included one developed on 5/4/17 for routine [MEDICAL CONDITION] medication use including [MEDICATION NAME], and [MEDICATION NAME], with Approaches that included to document behavior/mood indicators in resident chart, and to evaluate effectiveness and side effects for possible decrease/elimination. Review of her physician's orders [REDACTED]. During interview with RN Unit Manager MM on 2/8/18 at 11:42 a.m., she verified that there was no documentation that monitoring for behaviors and side effects for the [MEDICAL CONDITION] drugs were being done for R #128. Cross-refer to F 758 3. Review of a Skin Integrity-Pressure Ulcers report with a date of 1/25/18 to 1/31/18 revealed that R #144 had an unstageable pressure ulcer with an onset of 12/11/17 that measured 5 centimeters (cm) by 2.5 cm to the left buttock, with yellow/brown tissue color and a medium amount of purulent exudate, and no wound healing progress. Review of R #144's risk for altered skin integrity care plan dated 8/14/17 revealed that it was updated on 12/11/17 to reflect a DTI (deep tissue injury) to her sacrum, and Approaches included to perform the treatment to the sacrum as ordered. Review of R #144's physician's orders [REDACTED]. (an antiseptic) 1/4 (one-quarter) strength BID (twice a day) and PRN (as needed) for soiling. On 2/5/18 at 2:41 p.m., Licensed Practical Nurse (LPN) RR was observed performing wound care, and was noted to mix Mupirocin ointment together with Santyl ointment, and placed them on a four-inch by four-inch gauze dressing and placed it in the wound bed. During interview with LPN RR after the wound care was completed, she verified that she had not used the H-Chlor-12 0.125% solution (same as Dakin's solution) during the wound care. During interview with LPN Treatment Nurse CC on 2/8/18 at 11:39 a.m., she stated that the [MEDICATION NAME] order for [REDACTED]. Cross-refer to F 686",2020-09-01
313,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,686,D,0,1,I6B011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide wound care per physician's orders for one resident (R)(R #144) on one of two observations. The sample size was 38 residents. Findings include: Review of a Skin Integrity-Pressure Ulcers report with a date of 1/25/18 to 1/31/18 revealed that R #144 had an unstageable pressure ulcer with an onset of 12/11/17 that measured 5 centimeters (cm) by 2.5 cm to the left buttock, with yellow/brown tissue color and a medium amount of purulent exudate, and no wound healing progress. Review of R #144's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had one unstageable pressure ulcer with slough (non-viable tissue). Review of her risk for altered skin integrity care plan dated 8/14/17 revealed that it was updated on 12/11/17 to reflect a DTI (deep tissue injury) to her sacrum, and Approaches included to perform the treatment to the sacrum as ordered. Review of a wound culture from the pressure ulcer dated 1/5/18 revealed that it was positive for proteus mirabilis, and review of a Physician Order dated 1/8/18 revealed an order for [REDACTED].#144's Physician's Orders included an order dated 1/29/18 to discontinue [MEDICATION NAME] (Mupirocin) ointment 2% (a topical antibiotic) to her left inner buttock wound, and a new order to clean the left inner buttock area with NS (normal saline), apply Santyl ointment (a [MEDICATION NAME] agent) and Dakin's solution (an antiseptic) 1/4 (one-quarter) strength. Moisten gauze to wound and cover with a dry dressing and secure with foam border dressing BID (twice a day) and PRN (as needed) for soiling. On 2/5/18 at 2:41 p.m., Licensed Practical Nurse (LPN) RR was observed performing wound care, after R #144's pressure ulcer dressing had become soiled. After removing the old dressing, LPN RR was observed to cleanse the wound, which contained slough, with normal saline. She was then observed to mix Mupirocin ointment together with Santyl ointment, and placed them on a four-inch by four-inch gauze dressing and placed it in the wound bed. During interview with LPN RR after the wound care was completed, she verified that she had not used the H-Chlor-12 0.125% solution (same as Dakin's solution) that she had prepared along with the other treatment supplies, and wasn't sure what it was used for. On 2/7/18 at 9:39 a.m., LPN Treatment Nurse CC was observed to do R #144's daily pressure ulcer dressing change. LPN CC was observed to cleanse the wound and peri-wound with sterile normal saline, then applied Santyl ointment to the wound bed. She was further observed to moisten a 4 X 4 gauze with H-Chlor-12 0.125 % solution, fluffed out the gauze, and placed it on top of the wound bed and covered the wound with a dry dressing. During interview with LPN Treatment Nurse CC on 2/8/18 at 11:39 a.m., she stated that the [MEDICATION NAME] order for [REDACTED].",2020-09-01
314,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,725,E,0,1,I6B011,"Based on observation, record review, and staff interview, the facility failed to provide sufficient nursing staff to assure the needs of five of 38 residents (R#43, R#44, R#46, and R A) were met for residents to achieve the highest practicable level of well-being. Specifically: Totally dependent residents waited extended time frames for assistance with eating on one of four units, due to insufficient staff. Findings include: Observation during lunch on 2/5/18 from 11:35 a.m. to 12:42 a.m. revealed the following: 11:35 a.m. - Residents entering the dining area. 12:02 p.m. - Trays being served for residents sitting at tables. 12:05 p.m. - R#43, R#44, R#46, and R A sitting in front of the television (TV) in the dining room. 12:42 p.m. - Staff preparing and assisting with meals for the totally dependent residents. Observation during breakfast on 2/6/18 from 8:32 a.m. through 9:12 a.m. revealed the following: 8:32 a.m. - Staff plating and passing breakfast trays to residents sitting in the dining room. 8:48 a.m. - R A being assisted with meal by a family member. 8:50 a.m. - R#43, R#46, and R#44 sitting in front of the TV in the dining room. 9:00 a.m. - R#46 received assistance with meal. 9:10 a.m. - R#44 received assistance with meal. 9:12 a.m. - R#43 received assistance with meal. Interview with family member of R A on 2/6/18 at 8:40 a.m. revealed that she comes in to feed her family member so he does not have to wait on the tray. She stated that they need more help during dining. Review of the feeding process sign posted on Grove Terrace revealed that all trays are to be served first in the dining room to people that can feed self, then trays to people in rooms that can feed self, and then feeders will be fed. During an interview on 2/7/18 at 3:47 p.m., Unit Secretary XX stated that residents on the halls were complaining that it was taking too long to receive trays; so, staff began feeding residents who are total care last. An interview was conducted with Certified Nursing Assistant (CNA) WW on 2/8/18 at 9:56 a.m. CNA stated that Grove Terrace has many vocal residents who got upset about waiting for trays, so staff began feeding resident who are total care last. CNA further revealed that it was too much work to put residents back in their rooms prior to dining and then bring the residents back out after everyone else eats; and that would leave the dining room unattended. Interview on 2/8/18 at 10:10 a.m. with CNA SS revealed total care residents are served last while some staff finish passing hall trays and assist those in their room. CNA stated that the residents are facing the TV so they will not have to watch others eat. An interview was conducted with Staffing Coordinator (SC) II on 2/8/18 at 1:00 p.m. SC stated that two people left from that unit and were replaced by using agency. He stated that an attempt was made to use the same agency staff to keep consistency for the residents. Interview with the Administrator on 2/08/18 at 3:00 p.m. revealed that he was not aware of the way that the dining was being conducted where resident's needing assistance with meals were sitting and waiting for 45 minutes or more while others were eating. He stated that it was a dignity issue. He further revealed that people left grove terrace and that a good bit of agency staff was being used. He decided to pull from a hat and assign those staff to work grove terrace as their regular placement and they were disgruntled. He also stated that the unit manager had surgery and has been out. Interview with the Director of Nursing (DON) on 2/08/18 at 3:15 p.m. revealed that her expectation for the dining was for residents to be served per the table at a time and staff should be assisting residents as needed timely. She stated that residents should not be sitting waiting while other people are eating.",2020-09-01
315,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,758,D,0,1,I6B011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, and review of the facility's [MEDICAL CONDITION] Medications policy the facility failed to document that monitoring was being done for two residents (R) (#144 and #128), who were receiving [MEDICAL CONDITION] drugs, to determine the efficacy of the medications and to observe for adverse consequences from their use. The sample size was 38 residents. Findings include: 1. Review of R #144's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her physician's orders [REDACTED]. Review of her care plan for psychoactive drug use, including [MEDICATION NAME] and [MEDICATION NAME] dated 8/14/17, revealed approaches to document behavior and mood indicators in the resident chart, and to assess psych ([MEDICAL CONDITION]) meds every shift on the MAR (Medication Administration Record) for behaviors and side effects. Observations of R #144 on 2/5/18 at 11:46 a.m., 12:00 p.m., 12:33 p.m., 1:01 p.m. and 2:41 p.m.; 2/6/18 at 9:01 a.m., 10:49 a.m., 12:03 p.m., 2:05 p.m., and 3:07 p.m., 2/7/18 at 9:14 a.m., 12:16 p.m., and 2:31 p.m.; and 2/8/18 at 8:20 a.m., 9:33 a.m., and 10:14 a.m., revealed that R #144 was lying quietly in the bed without any apparent behaviors. During interview with Certified Nursing Assistant ZZ on 2/8/18 at 10:26 a.m., she stated that R #144 slept a lot, but could be easily aroused, and that she had not noticed any behaviors. During interview with Registered Nurse (RN) Unit Manager MM on 2/8/18 at 11:00 a.m., she stated that when a resident was on a [MEDICAL CONDITION] drug, the nurses monitored for behaviors and side effects from these medications every shift, and documented it in the e-MAR (electronic MAR). During further interview, she stated that she was unable to find any behavior monitoring or monitoring for side effects done for R #144 since she was readmitted from the hospital (on 11/24/17), and verified that R #144 was receiving [MEDICATION NAME] (Duloxetine) and [MEDICATION NAME] ([MEDICATION NAME]). During continued interview, RN MM stated that whenever behavior monitoring had to be done, the e-MAR would prompt the nurse to do so. During interview with Licensed Practical Nurse (LPN) NN on 2/8/18 at 11:42 a.m., she stated that at the end of her shift the computer prompted her to document behaviors for residents on [MEDICAL CONDITION] meds. During interview with Registered Nurse (RN) Unit Manager MM at this time, she stated that if this monitoring was being done, that there was no report she could find nor any documentation of behavior monitoring found in the computerized documentation system for R #144. She verified during further interview that the physician and/or pharmacist would not be able to determine if a GDR (gradual dose reduction) could be attempted if they were basing their decision on what the nurses were documenting related to behaviors and side effects. 2. Review of R #128's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly MDS dated [DATE] revealed that she received an antipsychotic, antianxiety, and antidepressant all seven days of the assessment period. Review of her care plans included one developed on 5/4/17 for routine [MEDICAL CONDITION] medication use including [MEDICATION NAME], and [MEDICATION NAME], with Approaches that included to document behavior/mood indicators in resident chart, and to evaluate effectiveness and side effects for possible decrease/elimination. Review of her physician's orders [REDACTED]. Observations of R #128 on 2/7/18 at 12:19 p.m. and 3:42 p.m.; and 2/8/18 at 8:38 a.m. and 10:06 a.m. revealed that R #128 was alert with no behaviors observed. During interview with RN Unit Manager MM on 2/8/18 at 11:42 a.m., she verified that there was no documentation that monitoring for behaviors and side effects for the [MEDICAL CONDITION] drugs were being done for R #128. Review of the facility's [MEDICAL CONDITION] Medications policy, updated (MONTH) (YEAR), revealed the following: Patients who receive antipsychotic, anxiolytic, sedative, hypnotic, antidepressant or any other medications prescribed to modify behavior, are evaluated to determine the effectiveness of the medication for the identified problems. A [MEDICAL CONDITION] drug is defined as any drug that affects brain activities associated with mental processes and behavior. When [MEDICAL CONDITION] therapy is initiated, the patient is monitored quantitatively and qualitatively to determine the effectiveness of the medication and the presence of side effects (per shift per day).",2020-09-01
316,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2018-02-08,880,D,0,1,I6B011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility's policy titled, Contact Precaution , the facility failed to help prevent the development and transmission of communicable diseases and infections by contaminating a staff uniform, contaminating clean linen with dirty gloves, and exposing bare skin on caregiver's wrists during wound care for one resident out of 38 sampled. Findings include: Resident (R) #525 was admitted to the facility with [DIAGNOSES REDACTED]. Review of a Physicians Order, dated 1/31/18, revealed R#525 had a [MEDICAL CONDITION] Resistant Stapholoccocus Aureus (MRSA) infection of a [MEDICAL CONDITION] wound on her right leg and that contact precautions were ordered. Observation on 2/5/18 at 11:47 a.m. revealed Certified Nursing Assistant (CNA) AA, was in R#525's room wearing only gloves. She was not wearing an isolation gown. Further Observation at 11:54 a.m. revealed CNA AA entered R#525's room, she put on gloves, and that no hand hygiene was observed. CBA AA did not put on a gown. CNA AA stripped old, not soiled, linen off the bed. The used linen was observed to touch the front of her uniform top. She placed the old linen in red linen receptacle. She did not perform hand hygiene or change gloves. She then took clean linen and made the bed, wearing the same gloves she handled the old linen with. Still wearing original gloves, she then positioned overbed table for lunch. AA removed gloves and washed hands at sink in bathroom and leaves the room. This observation is direct and continuous. Observation on 2/7/18 at 9:00 a.m. revealed a contact precaution sign on R#525's room that revealed instructions on the sign that all who enter the room must perform hand hygiene, and don gown and gloves prior to entering room. Observation was made on 2/7/18 at 9:10 a.m. of dressing change on R#525's right calf. Licensed Practical Nurse (LPN) CC, donned gloves and gown. There was a gap exposing her bare wrists between the end of the gown sleeve and the cuff of the gloves on both arms. CC then entered room, discarded gloves, washed hands, and donned fresh gloves. The wrist exposure was still noted. She removed the dressing on right calf, revealing a dark colored superficial wound, mostly healed. Scant drainage was obseved. CC discarded gloves and washed hands, then puts on fresh gloves. The wrist exposure was still there. She dressed the wound. Interview with Registered Nurse (RN) DD, Infection Control Nurse on 2/7/18 at 2:55 p.m. in her office She stated all employees at all times must perform hand hygiene, and don gowns and gloves before entering a contact precaution room at any time, no exceptions. She stated further that a gap exposing bare skin between the end of the gown sleeve and the glove would be substandard practice. She stated any employee changing linen and touching used linen on uniform would contaminate their uniform and this would be substandard practice. She also stated the signs on the doors of the contact precaution rooms are correct. Hand hygiene, gloves, and gowns must be used every time. Review of Contact Precaution policy, undated, revealed that gloves should be worn when entering the resident's room. After glove removal, hands should not touch any potentially contaminated surfaces. A gown should be worn when entering the room if it is anticipated that clothing will have substantial contact with the resident, environmental surfaces, or items in the resident's room, or if the resident is incontinent or wound drainage is not contained by a dressing. Interview with LPN GG, Unit Nurse, near R#545's room on 2/8/18 at 8:53 a.m She stated she always performs hand hygiene, dons gloves and a gown every time she enters a contact precaution room. She does this without exception. She further stated if she saw a staff member enter a contact precaution room without a gown she would call them back out, do hand hygiene and start over. She recalled she has had several in-services during the last year on Contact Precautions and knows the policy well.",2020-09-01
317,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2019-06-28,580,D,1,0,EDYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review the facility failed to notify the physician and/or the Responsible Party (RP) for two residents out of five, Resident (R)#5 and R#16, after significant change in medical conditions occurred with each resident. Progress note review revealed R#5 presented concerning vital signs on [DATE] at 10:33 a.m. and was discharged to the hospital on [DATE] at 8:37 p.m. Further review of the Progress notes and multiple interviews with facility personnel, including R#5's physician, revealed the physician was not notified of the change in R#5's condition, even after she was discharged to the hospital. Progress note review also revealed R#16 had bloody stool on [DATE] and [DATE]. Further review of the progress notes and staff interviews revealed no evidence the physician or RP were notified. Director of Nursing (DON) interview revealed that the only place a significant change of condition was documented would be in the progress notes. Findings include: 1. Review of the undated face sheet in the Electronic Health Record (EHR) revealed R#5 was admitted to the facility on [DATE] and discharged on [DATE]. Further review revealed her [DIAGNOSES REDACTED]. Review of an admission progress note dated [DATE] at 4:12 p.m. revealed her [DIAGNOSES REDACTED]. Review of R#5's [DATE] at 10:33 a.m. progress note revealed Respiratory Therapist (RT) HH wrote that R#5 had a low oxygen saturation (the amount of oxygen dissolved in the blood) of 84 - 88% and the resident was lethargic. Further review revealed the residents pulse rate was 140 - 155 beats per minute. Further review revealed RT HH notified the nurse. Review of the Mayo Clinic website found at: www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym- 930 revealed oxygen saturation (pulse ox) Values under 90 percent are considered low. Interview on [DATE] at 3:45 p.m. with Respiratory Therapist (RT) HH in the surveyor's workroom revealed that RT HH said that he had been an RT for [AGE] years and had been coming to this facility for three years. He stated he recalled R#5 and he had reviewed his note of [DATE] at 10:33 a.m. and agreed he wrote it. He stated the clinical picture was concerning at the time, especially the [MEDICAL CONDITION](high heart rate). He stated he shared his concern with LPN II, who was R#5's nurse that morning. He stated he advised her to check her vital signs in 30 minutes and to call the doctor if they had not improved. He stated he left the building shortly after that and did not know if she checked the vital signs or if she called the doctor. He stated, if the vital signs did not improve, the doctor should have been called. Review of the [DATE] 4:08 p.m. Physical Therapy progress note revealed Physical Therapist (PT) GG wrote he completed 63 minutes of exercise for R#5 and he monitored heart rate and O2 sat during session. He wrote he had checked with the nurse about the possibility of adding medication to bring down heart rate. Review of the [DATE] Physical Therapy Plan of Care revealed the PT GG provided physical therapy for R#5. Further review revealed R#5 had recently been in the hospital with [MEDICAL CONDITION] and declining condition. Further review revealed the family told PT GG R#5's heart rate had been in the 200s when she was in the hospital. Further review revealed R#5's vital signs were 84% oxygen (O2) saturation on room air and 96% with oxygen mask at 6 liters/minute (L/M), 150 beat per minute (BPM) heart rate with an irregularly irregular rhythm, blood pressure (B/P) ,[DATE], and no respiratory rate documented. Further review revealed PT GG listened to R#5's lungs and found diminished breath sounds, and mild bilateral rhonchi (coarse, rattling respiratory sound). Interview on [DATE] at 4:10 p.m. with PT GG in the surveyor's workroom revealed that PT GG stated he recalled R#5. He stated he saw R#5 two times on [DATE] in the morning and in the afternoon. He stated her vital signs, especially her heart rate and oxygen saturation were concerning, but he assessed the resident as able to do physical activity. He stated she was short of breath and had a low blood pressure but often the best way to improve blood pressure is to give the resident some exercise. He stated, looking back on it, the doctor should have been called. Review of the [DATE] at 8:37 p.m. progress note revealed the Assistant Director of Nursing (ADON) wrote she was called to R#5's room and R#5 was in bed with face mask O2 at 6 L/M, respirations 28 - 30, B/P ,[DATE], heart rate 133, temp 98.8, and O2 sat ,[DATE]%. Further review revealed 911 was called and resident left the faciity on [DATE] at 8:45. Review of a [DATE] at 8:36 p.m. physician's orders [REDACTED]. On [DATE] at 3:00 p.m. the ADON was interviewed in her office. She stated she was working late on [DATE] and s a CNA came and said they needed a nurse in R#5's room. She stated she assessed R#5 and called 911. She stated she did not get a doctor's order, nor did she need to. She stated, upon reviewing the progress notes for R#5, that the doctor or Nurse Practitioner (NP) should have been called after the RT assessed the resident at 10:33 a.m. on the morning of [DATE] because it was a significant change of condition and the clinical picture was concerning. On [DATE] at 3:15 p.m. the DON was interviewed in her office. She reviewed R#5's progress notes with the surveyor and stated the doctor should have been called on [DATE] at 10:33 a.m. because the vital signs and clinical picture were concerning. She stated she agreed there was nothing in the record that indicated the doctor, or the NP was called. The DON agreed the clinical picture amounted to a significant change of condition. On [DATE] at 4:45 p.m. Licensed Practical Nurse (LPN) II was interviewed in the surveyor's work room. She stated she had been a nurse for one year. She stated she was R#5's nurse on the morning of [DATE]. She stated she did confer with RT HH that morning about R#5's vital signs. She stated she agreed these vital signs amounted to a significant change of condition and the doctor should have been notified. She stated she did not notify the physician or the RP of the change of condition. She stated she checked the vital signs at about noon and again at about 2:00 p.m. and found the heart rate had improved to about 120 and she was no longer concerned. She stated she agreed 120 was still a high heart rate. She stated she could not remember if she documented those vital signs. An interview was conducted with Registered Nurse (RN) JJ in the surveyor's workroom on [DATE] at 5:00 p.m. She stated she was the Unit Manager of the Rehab Unit where R#5 resided. She stated she had been reviewing the records and there was no question about it: the assessment the RT did on R#5 on [DATE] at 10:33 a.m. revealed a significant change of condition and the doctor should have been notified. She stated she expected her staff to assess accurately and to notify the physician or the NP when a concern was identified A telephone interview was conducted on [DATE] at 3:20 p.m. with the Medical Director (MD). He stated he had worked for the corporate entity for [AGE] years and knew the facility well. He stated he was R#5's physician. He stated the vital signs taken on [DATE] at 10:33 a.m. by the RT were concerning and he should have been called. He stated this would be considered a significant change of condition. He stated he did not recall being notified at any point about R#5's condition on [DATE], or even after she went to the hospital. He stated he expected to be notified of any change of condition for any of his patients. On [DATE] at 10:30 a.m. a telephone interview was conducted with the R#5's son. He stated he was R#5's Responsible Party (RP) and Power of Attorney (POA). He stated on [DATE] at 8:14 p.m. he went to visit R#5 at the facility. He stated he knew the exact time because he had just checked his iPhone. He stated when he entered R#5's room she was gasping for breath and in a bad way. He stated he went out in the hall and asked a staff member to get a nurse. He stated the nurse assessed R#5 and called 911. He stated no one called him at any time on [DATE] to advise him about R#5's condition. On [DATE] at 2:50 p.m. the MD was further interviewed in the conference room. He stated, upon reviewing R#5's progress notes and her admitting diagnoses, the RT should have notified him of R#5's [MEDICAL CONDITION](rapid heartbeat) on [DATE] after his 10:33 a.m. encounter. On [DATE] at 3:10 p.m. the ADON was further interviewed in the Rehabilitation hall. She stated she did not call the doctor after she sent R#5 to the hospital on [DATE]. 2. Review of the undated face sheet in the EHR revealed R#16 was admitted to the facility in (YEAR). Review of the progress notes revealed he was discharged to the hospital on [DATE], where he expired on [DATE]. Review of the [DIAGNOSES REDACTED]. Review of his [DATE] Annual Minimum Data Set (MDS) section C revealed he had a Brief Interview for Mental Status (BIMS) score of 8 out of 15, signifying moderate-to-severe cognitive impairment. Review of section H revealed he was always incontinent of bowel and bladder. Review of section N revealed he received anticoagulant medication. Review of R#16's [DATE] physician's orders [REDACTED]. Review of the [DATE] 9:37 a.m. nurses note revealed R#16 had one bloody stool during the night. Further review revealed that there was not any evidence the physician or RP were notified of this occurrence. Review of the [DATE] 3:54 p.m. nurses note revealed R#16 had rectal bleed on 11p.m. - 7 a.m. shift the night before and the [MEDICATION NAME] was not administered by the ,[DATE] shift. The oncoming nurse was made aware. Further review revealed no evidence the physician or RP were notified of this occurrence. Review of R#16's [DATE] care plan revealed he was at risk for bleeding/bruising related to anticoagulant therapy, rectal fistula, and history of rectal bleeding. Approaches included to monitor for bleeding and to notify spouse of rectal bleeding (sic). On [DATE] at 2:30 p.m. LPN PP was interviewed over the telephone. She stated she only worked as needed (PRN) but had worked for the facility for several years. She stated she recalled R#16. She stated she recalled R#16 having bloody stools but did not recall if she notified anyone about it. On [DATE] at 1:20 p.m. the DON was interviewed in her office. She stated the facility did not have documents that were specific to notifying the physician or RP of a significant change in condition. She stated these notifications should be in the progress notes. On [DATE] at 2:50 p.m. the MD was interviewed in the conference room revealed that he should be notified of rectal bleeding for any resident, whether on anticoagulants or not and that he would consider rectal bleeding to be a significant change.",2020-09-01
318,ORCHARD VIEW REHABILITATION & SKILLED NURSING CTR,115146,8414 WHITESVILLE ROAD,COLUMBUS,GA,31907,2019-06-28,880,D,1,0,EDYH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections by allowing oxygen tubing to be on the floor, as well as the tubing being undated and unlabeled, making it impossible to know when the tubing had been changed or if the correct resident was using it. Multiple observations on two different dates revealed four out of 10 residents were affected: (Resident (R)#7, R#9, R#11, and R#14). Oxygen policy review revealed these practices were against facility policy and Director of Nursing (DON), acting as infection control nurse, revealed these practices could be a cause of introducing disease-causing bacteria into residents' nasal cavities. Findings include: Review of the 8/2018 Use of Oxygen policy revealed oxygen tubing would be kept off the floor and if tubing or cannula were found on the floor they would be replaced. Further review revealed it was the responsibility of the licensed nurse to replace the nasal cannula, tubing, and humidifier bottle every 48 hours whether O2 was used continually or as needed (PRN). Review of the undated Oxygen Administration policy statement in the section entitled Infection Control revealed the humidifier bottle and tubing should be dated with the date they were changed. Further review revealed the resident's name and date should be on each bag (sic). 1. Review of R#7's 6/26/19 physician's orders [REDACTED]. On 6/26/19 at 3:15 p.m. R#7 was observed in her room. She was sitting in a wheelchair using oxygen via a nasal cannula (oxygen tubing connected to an oxygen-providing device with prongs to be inserted in the nostrils). The tubing was connected to a humidifier (a small bottle of sterile distilled water to humidify the oxygen to prevent mucous membrane damage), which was connected to an oxygen concentrator (a machine which derives pure oxygen from room air). The nasal cannula (NC) tubing was lying on the floor, coiled up, about half-way between the humidifier connection and the resident's nostrils. The NC tubing did not have the resident's name on it or a date. The humidifier did not have the resident's name or a date on it. 2. Review of R#9's 6/26/19 physician's orders [REDACTED]. On 6/26/19 at 3:25 p.m. R#9 was observed in her room. She was seated in a wheelchair. She was not using her oxygen. An oxygen concentrator with a humidifier and NC connected to it was at bedside. The NC was on the floor, including the nasal prongs touching the floor, and the NC tubing did not have the resident's name or a date on it. The humidifier did not have the resident's name or a date on it. R#9 stated she only used her oxygen when she needed it. 3. Review of R#11's 6/26/19 physician's orders [REDACTED]. On 6/26/19 at 3:35 p.m. R#11 was observed in her room. She was seated in a wheelchair. She was not using her oxygen. She stated she only used her oxygen if she needed it. An oxygen concentrator was observed at bedside with a humidifier connected to it. An NC was observed connected to the humidifier with the tubing on the floor and the nasal prongs on top of the concentrator. Neither the humidifier nor the NC with tubing had the resident's name or a date on them. On 6/28/19 from 10:15 a.m. until 10:40 a.m. the following oxygen concentrators, oxygen humidifiers, and oxygen tubing were directly observed by the surveyor and the DON: 1. R#7 was observed in her room using her oxygen, with the NC in her nostrils. The humidifier was dated 6/27/19. The tubing was on the floor, connected to the humidifier at one end and the NC at the other. The humidifier was connected to an oxygen concentrator. The humidifier did not have the resident's name on it. The tubing did not have the resident's name or a date on it. The DON picked the tubing off the floor and placed it on the bedside table. 2. R#9 was observed in her room. Her oxygen was not being used. The humidifier was dated 6/27/19 and did not have the resident's name on it. The tubing was on the floor, including the NC. The NC tubing was not labeled with the resident's name or a date. The tubing was connected to the humidifier, which was connected to the bedside oxygen concentrator. The DON picked up the tubing and NC and discarded them in the wastebasket. 3. R#11 was observed in her room. She was using her oxygen via an NC connected to a humidifier, which was connected to a bedside oxygen concentrator. The humidifier did not have a date or the resident's name on it. The NC tubing went from R#11's nostrils, to the floor where it rested, and then to the humidifier. The NC tubing was not labeled with R#11's name or a date. 4. R#14 was observed in her room. She was using her oxygen via an NC connected to a humidifier, which was connected to a bedside oxygen concentrator. The humidifier was dated 6/26/19 and did not have the resident's name on it. The tubing was noted to go from R#14's nostrils, to the floor where it rested, then to the humidifier. The tubing had 6/26/19 written on it in black marker ink. The tubing did not have the resident's name on it. On 6/28/19 at 10:45 a.m. the DON was interviewed in her office. She stated the Infection Control Nurse was unavailable, but she would be happy to answer infection control questions. She stated she agreed with the oxygen equipment observations on R#7, R#9, R#11, and R#14 that was completed on 6/28/19 from 10:15 a.m. until 10:40 a.m. She stated she believed the nurses were changing the tubing and humidifiers because it was recorded in the Medication Administration Records (MARs). She stated she agreed it was possible for pathogens (disease-causing organisms) to grow in the humidifiers and tubing if they were not changed as scheduled. She stated she could not remember how often the humidifiers and tubing should be changed. She stated she agreed oxygen tubing on the floor was unsanitary. On 6/28/19 at 3:00 p.m. the Administrator was interviewed in his office. He always stated of course he expected facility policy to be followed at all times.",2020-09-01
319,KENTWOOD NURSING FACILITY,115147,1227 WEST WHEELER PARKWAY,AUGUSTA,GA,30909,2017-02-16,281,D,0,1,6YHY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident record review, review of the Georgia Practical Nurses Practice Act and staff interviews, the facility failed to ensure that one resident (R) (R#151), order for [MEDICAL TREATMENT] was transcribed by nursing staff upon the resident's admission to the facility, in accordance with professional standards of quality in a sample of twenty-six residents. Findings include: Record review for R#151 revealed admission to the facility on [DATE]. Since there is no Minimum Data Set (MDS)or care plan available at this time, the hospital discharge records and Physician order [REDACTED]. The hospital discharge records documented in Physicians Recommendations, had a hand written statement at the bottom of the page saying [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday at 9:30 a.m. at Grovetown. During an interview on 2/15/17 3:15 p.m. with Licensed Practical Nurse (LPN) AA she stated that she was aware that the resident went to [MEDICAL TREATMENT] on Tuesday, Thursday and Saturday but was unable to say where the resident went for [MEDICAL TREATMENT]. LPN AA she was unable to provide evidence of an order for [REDACTED].>During an interview on 2/15/17 at 3:25 p.m. with Registered Nurse (RN) BB she stated that R#151 goes to Grovetown on Tuesday, Thursday and Saturday at 9:30 a.m. for [MEDICAL TREATMENT] but was unable to provide evidence of an order for [REDACTED].>During an interview 2/15/17 at 3:27 p.m. with the Interim Director of Nursing (DON) she said that when someone is admitted to the facility, she and the RN supervisors have a meeting and go over the hospital discharge records and transfer all orders to their Physician order [REDACTED]. The DON confirmed the Physician Recommendations with [MEDICAL TREATMENT] Tuesday, Thursday and Saturday at 9:30 a.m. at Grovetown was hand written on the document but transferring the order to the physician's orders [REDACTED]. Review of the Georgia Registered Professional Nurse Practice Act revealed that The practice of nursing as a registered professional nurse means to practice nursing by performing for compensation the following: (A) Seeks clarification of orders when needed (B) Evaluates the impact of nursing care, the client's response to therapy, the need for alternative interventions and the need to communicate and consult with other health team members. Review of the Georgia Practical Nurses Practice Act revealed that The practice of licensed practical nursing means the provision of care for compensation, such care shall relate to the maintenance of health and prevention of illness through acts which shall include, but not be limited to, the following: (A) Seeks clarification of orders when needed (B) Administers medication accurately",2020-09-01
320,KENTWOOD NURSING FACILITY,115147,1227 WEST WHEELER PARKWAY,AUGUSTA,GA,30909,2017-02-16,282,D,0,1,6YHY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow interventions in accordance with the care plan for one resident (R) (R#158) that had an indwelling catheter and for one resident (R#7) that received insulin per sliding scale. The sample was 26 residents. Findings include: R#158 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Admission Care Plan for R#158 dated 2/13/17 revealed the Certified Nursing Aide (CNA) is to notify nurse if output is less than 200 cc every shift. Review of the input/output (I/O) records for R#158 revealed the following urine outputs: 2/5/16- 11-7-100 ml, 3-11-175 ml 2/6/16-11-7 150 ml 2/13/1-11-7-150 ml There is no evidence or documentation in the clinical record for R#158 that the nurse was notified of the above documented urine output measurements. Interview with the Interim Director of Nursing (DON) on 2/16/17 at 6:24 p.m. confirmed that there was no evidence or documentation that the nurse was notified when the urine output for R#158 was less than 200 cc. The DON further stated that the CNA is expected to notify the nurse at the end of the shift what the resident's I/O was for that shift. 2. Review of the updated Care Plan for R#7 dated 8/6/16 included and intervention to administer sliding scale insulin as ordered. Review of Physician orders [REDACTED].= 2u (units), 251-300 = 4u, 301-350 = 6u, 351-400 = 8u, If BS (blood sugar) is greater than 400 call MD/NP (Medical Doctor/Nurse Practitioner). Review of Medication Administration Record [REDACTED] On 8/17/16- BS = 504, there was no evidence that the Physician was notified On 8/28/18-BS =408, 8u Humalog was administered. There was no evidence that the Physician was notified. On 10/12/16- BS = 464, 10u Humalog was administered. No evidence of a Physician order [REDACTED].= 343, 4u Humalog was administered. The Physician ordered sliding scale indicated that 6 u Humalog to be administered for BS 301-350. On 12/1/16- BS = 217, there is no evidence that insulin coverage was administered 12/26/16- BS = 323, 65u of Humalog was administered. No adverse reaction to this dose was documented. Interview with the Interim DON on 2/16/2017 at 6:14 p.m. confirmed the above concerns on the MAR for R#7. The DON further stated that she expected the nurses to notify the MD and to transcribe the physician order [REDACTED].",2020-09-01
321,KENTWOOD NURSING FACILITY,115147,1227 WEST WHEELER PARKWAY,AUGUSTA,GA,30909,2017-02-16,329,D,0,1,6YHY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor behaviors for one resident (R) (R#152) regarding the use of an anti-psychotic medication from a sample of 26 residents. Findings include: R#152 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Admission/5-day PPS Minimum Data Set ((MDS) dated [DATE] revealed in Section N: Medications, that the resident received four (4) days of an anti-psychotic medication, out of the seven (7) day look back period. Review of the Situation Background Assessment Request (SBAR) Communication dated 1/22/17 revealed that the resident has been having episodes of anxiety and daughter states she was on [MEDICATION NAME] at home. Continued review revealed that the physician was contacted and a new order was given. Review of physician's orders [REDACTED]. Continued review revealed on 2/3/17 to discontinue (D/C) [MEDICATION NAME] prn per family request; however, on 2/6/17, the [MEDICATION NAME] was reordered prn for four (4) days. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview with the Interim Director of Nursing (DON) on 2/15/17 at 1:50 p.m., confirmed that there was no behavior monitoring for the use of an anti-psychotic medication for this particular resident. Continued interview revealed that she knows this is an ongoing concern, that is why when the Pharmacist came in yesterday, he went over everyone in the facility that was on a [MEDICAL CONDITION] medication and suggested behavior monitoring sheets.",2020-09-01
322,KENTWOOD NURSING FACILITY,115147,1227 WEST WHEELER PARKWAY,AUGUSTA,GA,30909,2017-02-16,441,D,0,1,6YHY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of policy and procedure and staff interview, the facility failed to ensure that proper infection control techniques were maintained during catheter care of a resident (R) (R#158) that was in isolation for Clostridium Difficile (C-diff). Additionally, the facility failed to properly dispose of the soiled adult brief after providing catheter care to R#158. The sample was 26 residents. Findings include: Reviewing of facility infection control policy titled Contact Precaution documented in Section II, page 6: Gloves and Hand Hygiene states Contact precautions may be considered for Clostridium difficile. Gloves should be changed after having contact with infective material. Gloves should be removed and hand hygiene should be performed immediately. Record review for R#158 revealed the resident is a 95 y/o female admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Continued record review for R#158 revealed a positive stool sample on 2/14/17 for Clostridium Difficile (C-diff). Contact isolation was ordered and implemented at this time. Observation on 2/16/17 at 12:42 p.m. of Certified Nursing Assistant (CNA EE) providing catheter care to R#158 revealed CNA EE was wearing a protective gown and gloves. CNA EE explained to R#158 what she was going to do. CNA EE used soapy water, wiped the resident from front to back and changed wash clothes six times. CNA EE was observed touching the resident's bed and rails with soiled gloves. Additionally, CNA EE discarded the soiled adult brief in a regular trash can that did not have a red isolation bag. Interview conducted on 2/16/2017 at 6:24 p.m. with the Director of Nursing (DON) confirmed that staff is expected to change their gloves going from dirty to clean. The DON stated that all biohazardous material is discarded into the bins with red bags.",2020-09-01
323,KENTWOOD NURSING FACILITY,115147,1227 WEST WHEELER PARKWAY,AUGUSTA,GA,30909,2017-02-16,514,E,0,1,6YHY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure that the medical records were accurate and complete for five of 26 residents (R) sampled. Specifically, R#40 related to documentation of skin integrity, R#152 related to documentation of physician notification for blood sugars greater than 200 at bedtime, R#58 related to consistent documentation of FBS (fasting blood sugars) and insulin administration, R#158 related to consistent documentation of urine output and R#7 related to consistent documentation of blood sugars. Findings include: 1. R#40 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Nursing Evaluation/Data Collection dated 12/19/16 revealed red, blanchable buttocks; however, no evidence of any other skin concerns. Review of the Skin Integrity Review Form dated 12/19/16 revealed [MEDICAL CONDITION] in the lower legs, and red, blanchable buttocks; however, no surgical site and/or wounds. Review of the Skin Integrity Review Form dated 2/4/17 revealed a Stage 3 wound to coccyx and to clean with Normal Saline (NS), apply Santyl and [MEDICATION NAME] cover with Allevyn Life when needed (PRN). Continued review revealed left hip surgical site with an ABD pad secure with [MEDICATION NAME] tape. Review of the care plan dated 1/10/17 revealed no evidence of a wound and/or surgical site. Review of the Nurses Notes dated 12/19/16-Present revealed no evidence of a wound and/or surgical site. Review of the Physician Order's dated 12/19/16-Present revealed no evidence of a wound and/or surgical site. Observation with the Treatment Nurse and Registered Nurse (RN) Supervisor (RN CC) on 2/14/17 at 1:12 p.m., revealed no current pressure sores and/or left hip surgery site; however, a friction tear was noted to her gluteal cleft, that the Treatment Nurse confirmed. During observation, the treatment nurse said that she would call this a Moisture-Associated Skin Damage (MASD) on the gluteal cleft and was going to notify the physician and order some cream. Interview with the Treatment Nurse on 2/14/17 at 1:45 p.m., confirmed that this resident did not have a stage 3 and/or left hip surgery site. Continued interview revealed that on 1/28/17 there was a complete skin assessments done by the previous Director of Nursing (DON) and there was no concerns with this resident. 2. R#152 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the signed Physician order [REDACTED]. Continued review revealed [MEDICATION NAME] five (5) units (u) with lunch daily with calling the physician if HS FSBS is greater than 200. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]., 1/26: 302, 1/27: 355, 1/28: 382, 1/29: 346, 1/30: 356, and 1/31: 322. Continued review revealed no evidence of the physician being notified. Review of the (MONTH) (YEAR) MAR for FSBS at HS revealed the following: 2/1: 327, 2/2: 316, 2/3: 383, 2/4: 225, 2/5: 257, 2/6: 303, 2/7: 308, 2/8: 297, 2/9: 227, 2/10: 263, 2/11: 287, 2/12: 212 and 2/14: 304. Continued review revealed no evidence of the physician being notified. Review of the Nurses Notes dated 1/25/17-Present revealed no evidence of the physician being notified of FSBS at HS over two hundred (200). Interview with the Interim Director of Nursing (DON) on 2/15/17 at 1:50 p.m., confirmed that there is no documentation for the physician being notified for FSBS at HS greater than two hundred (200) since 1/25/17. Continued interview revealed that the nurses should write this in the nursing notes and place on the MAR. Interview with the Interim DON on 2/16/17 at 8:15 a.m., revealed that last evening she spoke with the physician of this resident and he confirmed that the nurses had been notifying him of the FSBS; however, stated that there is no documentation in the medical record to support this. 3. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed R#58 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Medication Administration Record [REDACTED]. During an interview on 2/16/17 at 6:00 p.m., with the Interim DON, she could not provide an explanation for the missing documentation for the above dates. The Interim DON stated that education and in-service was started on 2/16/17 related to the importance of documentation. 4. Record review for R#158 revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Intake and Output (I/O) record for R#158 revealed no no evidence or documentation for I/O on 1/27/17, 1/30/17, 2/1/17,2/2/17, 2/3/17, 2/13/17. 5. Record review for R#7 revealed Physician orders [REDACTED]. Sliding scale coverage: 201-250 = 2u (units), 251-300 = 4u, 301-350 = 6u, 351-400 = 8u, If BS (blood sugar) is greater than 400 call MD/NP (Medical Doctor/Nurse Practitioner). Review of the Medication Administration Record [REDACTED]. During an interview on 2/16/2017 at 6:24 p.m., the Interim Director of Nursing (DON) confirmed the above concerns for R#158 and R#7. The DON on MAR indicated [REDACTED]. The Interim DON further stated that education and in-service was started on 2/16/17 related to the importance of documentation.",2020-09-01
324,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2020-01-30,657,D,0,1,G24811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to update the comprehensive care plan to reflect interventions related to right [MEDICAL CONDITION] for one resident (R) (#89) of 40 sample residents. Findings include: Review of Significant Change Minimum Data Set ((MDS) dated [DATE] for R#89 revealed a Brief Interview for Mental Status (BIMS) Assessment score of nine out of 15 which indicates moderate cognitive impairment, and had [DIAGNOSES REDACTED]. Review of R#89 Physician order [REDACTED]. Review of the care plan for R#89 revised 12/30/19 revealed activities of daily living care plan included a [DIAGNOSES REDACTED]. Interventions do not address the precautions for the [MEDICAL CONDITION]. During an interview on 1/30/2020 at 10:05 a.m., the Care Plan Coordinator and Regional Care Plan Coordinator revealed care plans are updated as needed, on admission, with significant changes, and quarterly. During an interview on 1/30/2020 at 10:10 a.m., the Director of Nursing (DON) revealed she expects care plans to be updated as needed. She stated Certified Nursing Assistants (CNA) have a separate CNA care plan book located at the nurse's station for their review. DON confirmed the interventions concerning R#89's [MEDICAL CONDITION] are not addressed on any care plans.",2020-09-01
325,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2020-01-30,761,D,0,1,G24811,"Based on observations, policy review entitled Storage of Medication, and staff interview the facility failed to ensure disposal of expired medications by the appropriate expiration date on one of five medication carts. Findings Include: Observation for medication cart at station one A Hall on 1/29/2020 at 9:56 a.m. revealed one bottle of Vitamin D 3 50,000 I. U. with expiration date of (MONTH) 2019. All expired medications were confirmed to be out of date by nurse BB whom was present at time of observation. Interview with Director of Nursing (DON) on 1/30/2020 at 9:06 a.m. revealed that the expectation is for all expired drugs are to be removed from the medication cart and discarded when expiration date is reached. Facility policy review entitled Storage of Medication dated (MONTH) 2007 revealed under Policy Interpretation and Implementation: The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the dispensing pharmacy or destroyed.",2020-09-01
326,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2019-04-24,609,D,1,0,9MY511,"> Based on staff interviews, review of the facility's Incident/Accident Report form, review of the facility's Prevention, Detection and Reporting of Resident Mistreatment, Injuries of Unknown Origin, Neglect, Abuse, Exploitation of Resident, and Misappropriation of Resident's Property policy and review of the facility's Guidelines for Facility Self-Reporting (effective 11/28/2016), it was determined that the facility failed to report an allegation of physical abuse within two hours after Resident (R) #1 reported being hit in the eye. The sample size was seven residents. Findings include: Review of the Nurses' Note dated 4/20/19 at 2:00 p.m. revealed that a family member (Durable Power of Attorney) for R#1 reported to the Licensed Practical Nurse (LPN) AA that R#1 alleged that someone was rough with him and had hit him in the eye. LPN AA assessed R#1 and noted that the corner of his right eye was a little red. R#1 told the LPN that the person who had hit him was a new face. Continued review of the Nurses' Note revealed that LPN AA told the family that she would follow-up on the allegation. Review of the subsequent Nurses' Note dated 4/21/19 (no time) revealed that LPN CC was notified by the resident's Power of Attorney that R#1 had alleged that he had been hit in the right eye and handled roughly on the previous shift (7 a.m. to 3:00 p.m.). R#1 told the nurse the alleged perpetrator was a tall African American female. However, he was unable to give a specific date of the incident. Continued review of the Nurses' Note revealed that R#1 did not know the day of the week and could not provide the date of his birthday. R#1 was observed reaching for something in the air and when asked what he was doing, stated that he was reaching for his coffee. Further review of the Nurses' Note revealed that the LPN would continue to monitor the resident. During an interview with the Administrator on 4/23/19 at 11:29 a.m. she stated that she was unaware of the allegation of abuse by R#1 made on 4/20/19. Continued interview revealed that staff should have notified her of the allegation immediately on 4/20/19 so that she could report the allegation to the State Survey Agency (SSA) within two hours as mandated and initiate an investigation at that time. Interview with LPN AA on 4/23/19 at 11:35 a.m. revealed that after she assessed R#1 on 4/20/19 for any injuries, she completed an incident report, notified the Registered Nurse (RN) Weekend Supervisor DD who was in the facility of the allegation, called the Administrator and left a message on LPN Supervisor BB's voice mail. She also notified LPN CC who worked the next shift. Continued interview revealed that she placed the completed incident report under LPN Supervisor BB's door on Saturday; however, administrative staff had not spoken to her about the resident's allegation of abuse. Further interview revealed that she had received in-service on Abuse Prevention and to report all allegations of abuse to the Administrator immediately. Interview with LPN Supervisor BB on 4/23/19 at 11:40 a.m. revealed that LPN AA had left a voice message on her personal cell phone on Saturday 4/20/19 but, she did not hear the message until today. Continued interview revealed that LPN AA should have left a voice message on her work cell phone. Interview with LPN CC on 4/23/19 at 11:55 a.m. revealed that she provided care for R#1 on Saturday 4/20/19 on the 3:00 p.m. to 11:00 p.m. and 11:00 p.m. to 7:00 a.m. shifts. LPN CC stated that LPN AA and the resident's Power of Attorney notified her about the resident's allegation of abuse. She stated that she assessed R#1 and his right eye had a line of pink but, no bruising or swelling. Continued interview revealed that R#1 was confused but stated that the incident of abuse had occurred weeks ago. During a telephone interview with Registered Nurse (RN) Weekend Supervisor DD on 4/24/19 at 8:45 a.m., she stated that she had not been notified about R#1's allegation of physical abuse. Continued interview revealed that if she had been notified she would have notified the Director of Nursing (DON) and Administrator immediately and initiated an investigation into the allegation. Interview with LPN Supervisor BB on 4/24/19 at 4:00 p.m. revealed that she did not receive the completed Incident/Accident Report about the allegation by R#1 until after surveyor inquiry on 4/23/19. Interview with The Director of Nursing (DON) on 4/24/19 at 4:05 p.m. revealed that she had not been notified of the allegation of abuse by R#1 until after surveyor inquiry on 4/23/19. Review of the Guidelines for Facility Self-Reporting (Effective 11/26/16) provided by the Administrator revealed that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury .to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State Law through established procedures. Review of the facility policy titled Prevention, Detection and Reporting of Resident Mistreatment, Injuries of Unknown Origin, Neglect, Abuse, Exploitation of Resident, and Misappropriation of Resident's Property (last revised 11/2016) revealed that all investigations of alleged abuse will be conducted by the Director of Nurses and or designee, and/or the Administrator. In the event an alleged violation occurs when neither of these people is in the facility, the charge nurse is responsible for initiating the investigation procedure .investigations will include interviews with person reporting the violation, interviews with other staff members, visitors, family members or residents who may have knowledge of the alleged incident any facility employee who suspects an alleged violation or discovers any injury of unknown origin, or has witnessed an actual violation will immediately notify the Director of Nurses or Designee and /or Administrator. The DON or Administrator will notify the appropriate state agency in accordance with state law within 24 hours. The facility failed to notify the SSA within two hours of receiving the allegation of abuse from R#1 on 4/20/19. The facility also failed to revise their Abuse Policy to include the mandated two hour notification to the SS[NAME]",2020-09-01
327,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2017-07-20,156,E,0,1,TDOI11,"Based on record review, and staff interviews, the facility failed to provide complete Advance Beneficiary Notices and Notices of Medicare Non-Coverage letters when changes in services were introduced which affected liability for two of three residents reviewed (R#4 and R#37). Three residents were reviewed for Liability Notices and Beneficiary Appeal Rights. Findings include: 1. Review of the Notice of Medicare Non-Coverage form issued to Resident (R) R#4 on 2/1/17, revealed the resident's services Will end on 2/4/17. Review of the form revealed the type of current services ending section, Insert type was blank. Further review revealed, per the form, Medicare probably will not pay for after the effective date indicated on the form, was blank. Review of the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) issued to R#4 on 2/1/17, revealed the form was not completed revealing the resident/responsible party could not make an informed choice about the services they wished to receive by not knowing what they might have to pay for. The section about cost of the items/services for which Medicare would probably no longer pay for was blank. The section about secondary insurance, and contact information for the Medicare Contractor were also blank. Further review of the SNFABN revealed it contained a section in which the resident/responsible party was to mark whether they wanted to receive the items/services that might no longer be covered, or instead, declined these items/services. Per the form, the resident/responsible party was to Choose one option, check one box, and date and sign this notice. Review of the form revealed it was not signed/dated by the resident/responsible party, but instead, stated that Verbal understanding provided by telephone by a family member. Neither option on the form was marked, and there was no indication as to whether the resident/responsible party wanted non-covered services to continue or end. 2. Review of the SNFABN issued to R#37 on 3/7/17 revealed the form was not completed revealing the resident/responsible party could not make an informed choice about the services they wished to receive by not knowing what they might have to pay for. The section about cost of the items/services for which Medicare would probably no longer pay for was blank. The section about secondary insurance, and contact information for the Medicare Contractor were also blank. Interview with Registered Nurse (RN) AA on 7/19/17 at 1:56 p.m., revealed she was the staff member responsible for creating/issuing notices of Notice of Medicare Non-Coverage and Skilled Nursing Facility Advance Beneficiary Notice. She further indicated she recently took over this duty and was not aware all required information on the form needed to be completed.",2020-09-01
328,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2017-07-20,159,E,0,1,TDOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to establish and maintain an accounting system which met generally accepted practices of accounting, which included crediting and dispersing interest earned on resident accounts to the resident, and/or providing quarterly financial statements to 67 current or past residents whose personal funds were handled by the facility since 7/1/16. In addition, the facility failed to notify two of five residents (R#66 and R#69) reviewed for personal funds when the amount of money in their resident account reached $200 less than the resource limit and provide notification that as a result, they could lose their Medicaid eligibility. The sample size was 63. Findings include: 1. Interview with Resident (R) R#66's family member via telephone on 7/17/17 at 3:04 p.m., revealed the facility handled personal funds for the resident, whose [DIAGNOSES REDACTED].#66's family member indicated the facility did not provide financial statements of how much money was in the resident's account. Review of the facility's Trust Fund Trial Balance ledger confirmed that the facility handled R#66's personal financial account. The ledger also included the names and trust fund balances for 66 other current and past residents of the facility who had allowed the facility to handle their personal funds at some time between 7/1/16 -7/1/17. As part of the Personal Funds review, the facility was asked to provide evidence that quarterly financial statements were provided to each resident. Review of the facility's Trust Fund Trial Balance report revealed between 7/1/16 - 6/30/17, 51 current or past residents had a balance of at least $50 upon which interest should have been earned, credited, and dispersed. Interview with the Billing Coordinator on 7/19/17 at 9:18 a.m., revealed the facility had not been sending out quarterly financial statements prior to 7/1/17. She stated the facility had recently identified this problem and just started sending financial statements out the previous week. Interview with the Administrator, who was present during the interview, confirmed the facility had not previously been sending out quarterly statements to each resident whose personal funds they handled. Further review of the facility financial records titled, Statement Register for R#66, revealed from 6/9/17 - 7/19/17 the resident's personal fund balance remained over $50 throughout this time. The Statement Register, which listed all financial transactions, revealed there was no evidence the interest earned from this account had been credited or paid to the R#66. Review of the resident's clinical and financial records revealed no evidence that the family and/or her responsible party were notified at the time, the resident's resources could cause her to lose her Medicaid eligibility. Interview with the Billing Coordinator on 7/19/17 at 9:47 a.m., indicated the interest monies accrued on R#66's account from (MONTH) (YEAR) - (MONTH) (YEAR) had not been credited or disbursed to her account. The Billing Coordinator indicated the interest payments for each of the individual resident accounts had originally gone to the facility's previous owners until (MONTH) (YEAR), when the current owners opened a new interest-bearing account for the resident funds. She continued the previous owners had made wire transfers of these interest payments back to the facility on [DATE], 12/8/16, 1/10/17, and 5/5/17. However, the facility had not yet posted or dispersed these earned interest payments to each resident's personal account. She further indicated the facility had been unable to determine the actual breakdown of how to allocate the interest that each resident was due on their personal account balance, and the owner's accountants were currently working on these figures. 2. Review of the facility financial records titled, Statement Register for R#69, revealed on 6/5/17, the resident's personal account balance went within $200 of the resource limit for Medicaid eligibility. Review of R#69's clinical and financial records revealed no evidence the family and/or his responsible party were notified at this time that the resident's resources could cause him to lose Medicaid eligibility. Interview on 7/19/17 at 10:18 a.m., with the Billing Coordinator revealed her statement that she had notified R#69's family by telephone when a lump sum deposit on 6/15/17 put her over the eligibility limit, however, she did not document the call and could not confirm when it was made. Interview with the Administrator who was also present during this interview revealed, We don't send out written notices - we would just call on the phone and let them know that they were close to the $200 (eligibility limit). Further interview with the Administrator revealed the facility would continue to review facility records for documentation to verify that that residents/responsible parties were notified at the time their account balance reached $200 less the resource limit for program eligibility. Interview with the Administrator on 7/19/17 at 1:38 p.m., revealed when she assumed her position in (MONTH) (YEAR), the business office was a mess. She indicated when the current billing coordinator was hired in (MONTH) (YEAR), the facility identified the interest that each resident should have earned on their personal account had not been allocated or dispersed to the them. The Administrator further indicated, although they were trying to correct the accounting problems that had accrued under the previous owner, the facility had not yet allocated and dispersed the interest each resident had earned on the personal fund accounts. Additional interview with the Billing Coordinator and the Administrator on 7/20/17 at 9:30 a.m., revealed there was no documentation to verify that the facility had provided spenddown notification to either R#66 or R#69 at the time they went within $200 of eligibility limits. Review of the facility policy titled, Resident Trust Account, dated 10/01, revealed . The residents of the facility have the right to manage their own financial affairs. Their personal funds will be deposited in the Resident Trust Account, if they request in writing. Interest will be accrued for accounts that exceed $50.00. The facility maintains a separate interest-bearing check account for the residents who want their monies to be managed by a Trust Account Representative. Accurate records will be kept of residents' monies and a quarterly accounting of financial transactions will be available, upon request. All residents receiving Medicaid benefits will be notified when the trust account reached $2000, less the amount due for monthly share of cost.",2020-09-01
329,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2017-07-20,247,D,0,1,TDOI11,"Based on record review, staff and resident interview, and review of the facility's policy and procedure titled, Room to Room Transfer, revealed the facility failed to ensure notification prior to a room change. The deficient practice was evidenced by one resident (R#128) from a total of 63 sampled residents evaluated for admission/transfer and discharge. (R#128) was moved from one room to another without being informed. The deficient practice had the potential to affect all residents. Findings include: An interview with Resident (R) R#128 on 7/17/17 at 4:46 p.m., revealed he was recently moved from Station I to Station II. R#128 indicated he was not informed of the move prior to his belongings being packed and moved to a different room. Review of R#128's clinical record revealed R#128 had a Significant Change Minimum Data Set (MDS) assessment completed on 4/27/17, in section C he was assessed and coded for a score of a 14 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated he was not cognitively impaired. Review of the Nurse's Notes dated 7/7/17 at 12:05 p.m. for R#128, revealed the following information: new order noted to transfer pt (patient) to Station II room (number) ., .Resident transferred to Station II room (number) with belongings and medications. Will cont (continue) plan of care. The nursing note did not include why R#128 was moved, if it was discussed with him, if he agreed with the move, nor if he was satisfied with the move. An interview with Social Services (SS) BB on 7/19/17 at 2:30 p.m., revealed the facility had a form they used when residents were transferred from one room to another. The form was titled, Notification of Room Change, and included information as to why the resident was moved and if the move was satisfactory to the resident. Further interview revealed, the facility failed to complete the form prior to moving R#128 from one room to another room. Review of the facility's policies and procedures revealed a document titled, Room to Room Transfer, dated 2/2002, which provided the following information and procedure: The purpose of this procedure is to provide guidelines for transferring residents from one room to another when such transfer has been approved in accordance with facility policies. Further review revealed the Preparation portion of the facility policy included the following steps: 1. The resident should be consulted about the room transfer .2. Inform the resident about the transfer . An interview with the Administrator on 7/19/17 at 3:00 p.m., revealed the facility had a policy and procedure related to room changes for their residents, however the facility failed to follow the policy and procedure when they transferred R#128 from Station I to Station II. There was no documentation related to why R#128 was moved and there was no documentation related to the preparational steps that were to be completed prior to the actual transfer was made per the facility's Room to Room Transfer policy and procedure.",2020-09-01
330,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2017-07-20,280,D,0,1,TDOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility's policies and procedures, the facility failed to review and revise care plans for two residents (R#77 and R#45) and failed to ensure that one resident (R#66) or their responsible party was included in the preparation, development, and revision of the care plan. R#77's care plan was not revised related to the use of [MEDICAL CONDITION] medications and R#45's care plan was not revised related to a living will. The sample was 63 residents. Findings include: 1. Review of Resident (R) R#45's clinical record, revealed she was readmitted to this facility on 2/13/12 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment, section C dated 5/31/17, revealed R#45 was assessed and coded a score of 9 out of 15 for cognition, which indicated her cognition was moderately impaired. Review of R#45's clinical record document titled, Physicians Orders, revealed a telephone order dated 6/8/17, which included the following information; Consult social worker- daughter to bring copy of living will which states pt (patient) request is DNR (do not resuscitate) status . Review of R#45's care plan dated 3/1/17, revealed the document titled, Advance Directive Plan of Care, had not been reviewed or revised. R#45's care plan was marked as has no advance directives FULL CODE STATUS. An interview with Social Services (SS) BB and the Minimum Data Set (MDS) Coordinator on 7/19/17 at 9:00 a.m., revealed the consult information on the Physicians Orders document was not communicated to either of them, consequently the consult was not completed and the care plan was not reviewed and revised. An interview with the Administrator on 7/19/17 at 9:15 a.m., indicated the facility failed to follow their MDS policies and procedures when they had not consulted either of their social services workers, AA and BB, and the MDS Coordinator, of the physician's telephone order regarding R#45's living will to change and update. 2. Review of R#77's demographic information revealed the resident was admitted to the facility in 12/2016, with [DIAGNOSES REDACTED]. The physician admission orders [REDACTED]. Review of the resident's most current Physician Orders, dated 6/30/17, revealed the resident continued to receive this dose of medication each day. Review of R#77's care plan, with a review date of 4/5/17, revealed it included a Potential for drug toxicity. Resident is at risk for side effects associated with [MEDICAL CONDITION] drug use. Resident has a [DIAGNOSES REDACTED]. The goals for this problem included, Resident will not have disruptive behaviors or inappropriate verbalizations through next review. Further review of the care plan revealed no revision to identify specific target behaviors, approaches related to the possible reduction of the resident's antipsychotic medication, nor non-pharmacological interventions which would be used in place of an antipsychotic medication. (Refer to F329). There was no evidence the facility had identified the resident did not display any behaviors during the previous 90-day review period, and therefore, the previous goal was met and the care plan should have been revised. Interview with the MDS Coordinator on 7/19/17 at 8:08 a.m., revealed she began work at the facility in (MONTH) (YEAR), and had not been the nurse to originate the [MEDICAL CONDITION] medication care plan when R#77 was admitted . However, she was the nurse responsible for the (MONTH) care plan review. The MDS Coordinator indicated, except for adding the note 4/5/17 ongoing goals x (times) 90 days, she made no revisions to the original care plan and just carried it through from the prior care plan. The MDS Coordinator further indicated she normally includes a plan to determine the need for antipsychotic medication reduction however, she had not revised the original care plan to include this approach. The MDS Coordinator revealed both the approaches (which did not include any non-pharmacological interventions related to behaviors) and the care plan goal were also carried through with no revisions, even though the resident had already met the goal of no disruptive behaviors. 3. Interview via telephone with the family of R#66 on 7/17/2017 at 3:04 p.m., revealed she and her husband, the resident's responsible party, were not included in the care planning decisions for R#66. The family member stated she thought, It's been at least 6 months since the family was invited to participate in a care plan meeting. Review of the clinical record for R#66, revealed the resident's last comprehensive MDS assessment was a Significant Change assessment on 6/12/17 and the care plan development and revision meeting was held on 6/21/17. The document titled, Care Plan Meeting form provided signatures lines for multiple staff, including the MDS Coordinator, Dietary, Activities, Social Services, Certified Nursing Assistant (CNA), Rehab, and other disciplines. However, documentation showed the MDS Coordinator was the only signature on the form. The form also asked if the resident and/or interested party/family/significant other attended the care plan meeting and provided a space for their signatures if present. However, these sections were blank, and there was no explanation located on either the form nor in the clinical record. Interview with the MDS Coordinator on 7/19/17 at 8:32 a.m., revealed although she was the only staff to sign the care plan meeting attendance record, a CNA, social services, dietary, and activities staff were present at the care plan meeting. Further interview revealed that a registered nurse (RN) responsible for the resident's care was not present at the care plan meeting. The MDS Coordinator indicated she was unaware of changes in the federal regulation from 11/2016 which required that the interdisciplinary team preparing the care plan include an RN with responsibility for the resident's care. Further interview with the MDS Coordinator confirmed that neither the resident, nor her family were involved in the 6/21/17 care plan meeting. She revealed there was no documentation in the record to explain why the resident nor the family were not involved in the development of the care plan. The MDS Coordinator indicated she was also unaware of the changes in federal regulation from 11/2016 which required an explanation in the clinical record if the participation of the resident and/or the family in care planning was not practicable. Further interview with the MDS Coordinator revealed that the facility's social services staff was responsible for sending out a letter to the family to inform them of the date/time of care plan meetings. Interview with SS AA on 7/19/17 at 8:50 a.m., revealed she was the staff member responsible for sending letters to the families to invite them to care plan meetings. She provided an undated form letter with R#66's name, and stated the facility had not received a response to it. However, further interview with the SSD revealed she had no evidence to verify when or to where the letter went. The SS AA indicated she, also, was unaware of the regulatory changes in 11/2016, and had not been documenting an explanation if the resident and/or their family's involvement in care planning was not practicable. Review of the facility's policies and procedures revealed a document titled, Minimum Data Set (MDS) Completion, dated 12/16, with the following information; .7. Care plans will be updated at the time of the conference and/or as needed when a change occurs. Review of the facility policy titled, Interdisciplinary Care Plan Team dated revised 12/2016 revealed, The Interdisciplinary care planning team will include, but not be limited to: representatives of Social Services, Dietary, Rehabilitation Services, Activities and Nursing. Nursing members are to include staff nurses and CNAs responsible for the assigned resident's care. Residents, family members, or other responsible persons will be invited to attend the interdisciplinary care planning conference and when not in attendance, will be documented in the medical record. Care conference minutes will be completed for all meetings in which all or portions of the care plan is reviewed - Indicate if the resident or representative were invited, have the resident/responsible party sign the form, have all participating IDT (interdisciplinary team) members sign the form, and if resident/responsible party are unable to attend, brief explanation as to why. Further review of the facility policy titled, Interdisciplinary Care Plan Team, dated revised 12/2016 revealed, Care plans will be updated at the time of the conference and/or as needed when a change occurs.",2020-09-01
331,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2017-07-20,309,D,0,1,TDOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the facility's Long Term Care Facility [MEDICAL TREATMENT] Services Agreement, the facility failed to 1) complete their own [MEDICAL TREATMENT] Communication Form, and 2) routinely communicate with the [MEDICAL TREATMENT] Clinics to ensure they could provide a continuum of care and services for the residents who had a [DIAGNOSES REDACTED]. The deficient practice had the potential to affect two Residents (R#63 and R#127) who were receiving for [MEDICAL TREATMENT] care and services of 63 sampled residents. Findings include: 1. Review of the clinical record for Resident (R) R#63, revealed she was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical record revealed R#63 received [MEDICATION NAME] (a medication to increase red blood cells), [MEDICATION NAME] (an anticoagulant to prevent blood clotting, and Iron (a medication for [MEDICAL CONDITION]) during her [MEDICAL TREATMENT] treatments. Each of these medications required monitoring due to potential adverse side effects. An interview with the Licensed Practical Nurse (LPN) AA on 7/19/17 at 3:00 p.m., revealed R#63 went to the [MEDICAL TREATMENT] Clinic for treatments three days each week and on 5/1/17 she was hospitalized after her [MEDICAL TREATMENT] treatment. LPN AA indicated after R#63 came back from the [MEDICAL TREATMENT] Clinic on 5/1/17, she experienced some [MEDICAL CONDITION] activity and was confused. When interviewed about how R#63 tolerated her [MEDICAL TREATMENT] treatment that day, LPN AA revealed she was unsure because the [MEDICAL TREATMENT] Communication Form had not been completed. LPN AA added that R#63 was cognitively intact, however on that day she was confused. LPN AA further indicated the facility had a [MEDICAL TREATMENT] Communication Form they and the [MEDICAL TREATMENT] clinic were to complete to ensure a continuum of care between the two facilities, however, LPN AA indicated it was not routinely completed and consequently, the facility staff was unable to monitor the resident when they returned to the facility for signs and symptoms such as: side effects from their medications, how the residents' tolerated the treatment, if they had an incident of hypo/[MEDICAL CONDITION], experienced hypo/hypertensive episodes, had cramps or chest pain, or if their pre/post weight and vital signs changed significantly. Review of a [MEDICAL TREATMENT] Communication Form revealed the facility was to complete the top portion of the form and the [MEDICAL TREATMENT] clinic was to complete the bottom portion of the form. The top portion, when completed, provided the following information to the [MEDICAL TREATMENT] Clinic about the resident: The patients/residents: a. Name and caregiver b. Physician c. Date/Time of Arrival: d. Facility's name and phone number e. Pre-[MEDICAL TREATMENT] vital signs f. Medications given g. Last meal, snacks needed, diet h. Fluid restriction i. Significant alerts j. Facility Nurse Signature The [MEDICAL TREATMENT] Clinic was to complete the bottom portion which, when completed would provide the following information about the resident's [MEDICAL TREATMENT] treatment: a. Name of the [MEDICAL TREATMENT] Clinic and telephone number b. Time of discharge and blood sugar c. Disposition d. Pre/post weight and the amount of fluid removed e. Vital signs f. Lab drawn and results g. Medications given h. Patient's tolerance to procedure i. Follow up orders j. Appointments made k. Problems/alerts l. [MEDICAL TREATMENT] nurse signature Further interview with LPN AA on 7/19/17 at 3:00 p.m., revealed that each nursing unit had a [MEDICAL TREATMENT] Communication Notebook and staff were to put each resident's communication form either in that notebook or in their medical record once the resident returned from their [MEDICAL TREATMENT] treatments. Review of the clinical record and the [MEDICAL TREATMENT] Communication Notebook revealed there was only one communication form, dated 3/18/17, for R#63. R#63 had been receiving [MEDICAL TREATMENT] treatments three times each week for over a year. 2. Review of R#127's demographic information revealed the resident was admitted to the facility on [DATE]. Admission [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the clinical record revealed R#127 left for [MEDICAL TREATMENT] as scheduled on 2/27/17 and returned to the facility. Nurse's Notes dated 2/27/17 at 11:00 p.m., revealed R#127 vomited before dinner, and then again at 10:00 p.m. Nurse's Notes dated 2/28/17 at 1:00 a.m., revealed R#127 vomited three times with a complaint of stomach pain. R#127 was transported to the hospital and admitted and remained hospitalized until 3/3/17, when he was readmitted to the facility with new [DIAGNOSES REDACTED]. The Physician's Readmission orders [REDACTED]. Orders for [MEDICAL TREATMENT] continued through the resident's discharge to home on 6/2/17. Review of R#127's clinical record revealed no evidence that the facility obtained a [MEDICAL TREATMENT] Communication Form from the [MEDICAL TREATMENT] clinic on any days the resident received [MEDICAL TREATMENT] from his admission on 2/18/17 - through his hospitalization on [DATE]. There was no evidence the facility obtained all pertinent communication about the resident's [MEDICAL TREATMENT] treatments, including factors such as the resident's condition, pre- and post-[MEDICAL TREATMENT] weights, amount of fluid removed, medications received, tolerance to the procedures and problems/alerts that the nursing facility should be aware of, based on the resident's response to the [MEDICAL TREATMENT] treatment. Further review of the clinical record revealed, although R#127 continued to receive [MEDICAL TREATMENT] three times per week after his readmission on 3/3/17 through his discharge on 6/2/17 (for a potential of up to 39 treatments), the facility could only provide 12 [MEDICAL TREATMENT] Communication Form reports for this time, ranging in date from 3/13/17 - 5/24/17. Review of the [MEDICAL TREATMENT] Communication Forms revealed they were not consistently filled out with all required information to ensure ongoing communication between the [MEDICAL TREATMENT] clinic and facility. For example; the [MEDICAL TREATMENT] Communication Forms for 3/13/17, 4/12/17, 4/19/17, 4/24/17, and 5/15/17, failed to include the amount of fluid withdrawn during [MEDICAL TREATMENT]. The forms for 3/13/17, 3/20/17, 3/31/17, 4/12/17, and 5/15/17 failed to document the resident's tolerance to the procedures completed that day. Other information that was not communicated included whether the resident received medications/treatments at [MEDICAL TREATMENT] on 3/20/17, 4/12/17, and 4/19/17. The facility failed to communicate resident care needs that would be present while the resident was at [MEDICAL TREATMENT] such as if the resident had fluid restrictions and/or food needs on 3/13/17, 3/31/17, 4/12/17, and 4/24/17. An interview with the Administrator on 7/19/17 at 3:30 p.m., revealed the completion of the [MEDICAL TREATMENT] communication forms had been problematic. When interviewed about how the facility could ensure a continuum of care and services for each resident who received [MEDICAL TREATMENT] treatments without effective communication between the two facilities, the Administrator stated, we cannot. The Administrator stated that she had called the [MEDICAL TREATMENT] clinics many times to request that they complete the [MEDICAL TREATMENT] communication forms; to no avail. She added that the facility had three different [MEDICAL TREATMENT] clinics that they sent their residents to for treatment and the facility had a similar contract with each clinic. Review of the facility's [MEDICAL TREATMENT] Contracts, dated 11/03/04, 8/26/15 and 3/11/14 revealed each [MEDICAL TREATMENT] clinic would, provide the long-term care facility with all the appropriate information and guidance regarding the renal condition of residents who are patients of the [MEDICAL TREATMENT] clinic, including administration of medications, directions for handing medical and nonmedical emergencies such as bleeding or hemorrhage, bacterial infection, septic shock, the care of shunts and fistulas. The facility failed to ensure that each of the [MEDICAL TREATMENT] clinics complied with their contracts by allowing them to send incomplete communication forms back to the facility after the resident's [MEDICAL TREATMENT] treatments.",2020-09-01
332,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2017-07-20,329,D,0,1,TDOI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and record review, the facility failed to assure one of five residents (R#77) reviewed for unnecessary medication use was free from an unnecessary drug. The facility administered an antipsychotic without indication for use of the medication, failed to identify an individualized targeted behavior related to the use of the medication, and failed to attempt non-pharmacological interventions prior to the use of medication. The facility failed to attempt a gradual dose reduction when no evidence was provided such an attempt would be clinically contraindicated. The sample size was 63. Findings include: Review of the policy revealed: Residents will only receive antipsychotic medication when necessary to treat specific conditions for which they are indicated and effective. Nursing staff will document in detail an individual's target symptoms. Antipsychotic medications will not be used if the only symptoms are one or more of the following .verbal expressions or behavior that are not due to conditions listed above under indication and do not represent a danger to the resident or others. The Physician shall respond appropriately by changing or stopping problematic doses or medications or clearly documenting (based on assessing the situation) why the benefits of the medication outweight he risks or suspected or confirmed adverse consequences. Observation on [DATE] at 1:24 p.m., 4:01 p.m., and [DATE] at 10:21 a.m. revealed Resident (R) R#77 was in bed. During each observation, the resident's television was on a Home and Garden television show (HGTV). Interview with R#77 on [DATE] at 10:21 a.m., revealed the resident was pleasant, and had no complaints. Although she displayed some memory loss, she displayed no behaviors, signs of delusions or hallucinations. When asked about her medications, R#77 indicated she did not know the names, but thought she took a medication at night to help her sleep. Review of R#77's demographic information revealed the resident was admitted to the facility in (MONTH) (YEAR), with diagnosed including: [DIAGNOSES REDACTED]. The Physician admission orders [REDACTED]. Review of R#77's most current Physician Orders, dated [DATE], revealed the resident continued to receive this dose of medication daily. a. Indication for use: On [DATE], a Consultant Pharmacist Communication to Physician letter was sent to the attending physician, stating Anti-pscyhotic (sic) dx (diagnosis) needed: [MEDICATION NAME]. The Registered Pharmacist (RPh) provided a list of federally-approved diagnoses for which an antipsychotic could be used in a long-term care facility. Review of the list revealed depression (the indication previously provided by the physician) was not an approved diagnosis. Further review of the RPh letter revealed it included instructions to Please check below and, if the physician agreed, Please write order. Review of the physician's response, signed [DATE], revealed that the physician marked I agree to the recommendation, however, further review of the letter revealed no [DIAGNOSES REDACTED]. Review of a Psychiatric Consult, dated [DATE], revealed Staff reports that she often says she is on a cruise and she wants wine and she is. (sic) She is sometimes entitled, but she is not aggressive .She was smiling and pleasant. She denied hallucinations. There is (sic) no paranoid delusions voiced. On [DATE], the RPh sent another Consultant Pharmacist Communication to Physician letter to the attending physician, again stating Anti-pscyhotic (sic) dx (diagnosis) needed: [MEDICATION NAME]. On this form, the diagnoses of delusional disorder and dementia with delusions were checked. The physician marked I agree to the recommendation, however, no order to add these diagnoses was provided and the indication for the use of the antipsychotic on the PO sheet remained depression as of [DATE]. Although the diagnoses of delusional disorder and dementia with delusion, were checked on the [DATE] RPh letter, except for the [DATE] Psychiatric Consultation, review of the clinical record revealed no evidence that the resident displayed delusions. Neither her admission Minimum Data Set (MDS) with as Assessment Reference Date (ARD) of [DATE], nor the most recent quarterly MDS (ARD of [DATE]) documented the resident had any delusions. Daily behavior monitoring records documented on the Medication Administration Record (MAR) as well as nurses' notes also documented no evidence of delusions. Interview on [DATE] at 2:21 p.m., with Licensed Practical Nurse (LPN) AA, revealed she was R#77's charge nurse and was very familiar with the resident. She indicated the resident had not experienced any delusions since her admission to the facility in (YEAR). LPN AA further indicated the resident had previously been a resident of the facility ,[DATE] years ago, was discharged , and then returned to the facility for a new admission in (MONTH) (YEAR). When asked about the [DATE] Psychiatric Consultation note which indicated the resident says she is on a cruise, LPN AA stated, The thing about being on a cruise was ,[DATE] years ago, and explained this occurred during the previous admission after the resident's husband died . LPN AA reiterated, She has no delusions. b. Target Behaviors/Non-Pharmacological Interventions: Review of R#77s's most recent Physician Orders, dated [DATE], revealed staff were to monitor for behaviors, however, the order failed to note a resident-specific targeted behavior related to the use of an antipsychotic. Review of the resident's current Care Plan, (CP) last revised on [DATE], revealed it also failed to include any target behaviors related to the need for an antipsychotic medication. Review of the (CP) also revealed it failed to include non-pharmacological interventions to be attempted in the event the resident displayed distressed behavior. Review of Monthly Nursing Summaries for (YEAR) showed documentation the resident's behavior was appropriate and cooperative and no behaviors were noted. Review of the daily behavior documentation on the MAR for (MONTH) - [DATE] revealed no evidence of any behaviors that justified the use of an antipsychotic. For these 199 days, only one behavior - hitting on [DATE], was documented. No other behaviors were noted. Further review of the clinical record revealed no documentation about the [DATE] behavior. There was no description of what occurred, with specifics documented to assess underlying issues of distressed behavior. There was no documentation that non-pharmacological interventions were attempted relative to this one instance of behavior. Interview on [DATE] at 2:19: p.m., with Certified Nursing Assistant (CNA) AA, revealed R#77 has no behaviors. CNN AA stated, She's real sweet and added the resident, Never acts up and isn't aggressive. Interview on [DATE] at 2:21 p.m., with LPN AA, revealed the resident has had no behaviors since her return in December. She stated that the resident likes to stay in bed and watch HGTV. She wants to stay in her room and watch HGTV -she used to be a realtor - that's her joy and we let her live it. LPN AA added, She doesn't have any behaviors - she's wonderful. LPN AA stated that a specific target behavior should be identified if a resident was receiving an antipsychotic, however, she continued, She doesn't have any behaviors, so there's no target one to watch for. Interview on [DATE] at 2:42 p.m., with the Director of Nursing (DON) indicated there should be a target behavior related to the need for an antipsychotic. In addition, she indicated, the facility should have identified non-pharmacological interventions to deal with resident behaviors. She also indicated there was a Behavior Management book on the unit which would contain this information. On [DATE] at 3:02 p.m., the DON then went to the unit to review this book. After a review of the Behavior Management book, both she and LPN AA (who was also present) confirmed there was no Behavioral Management Documentation for R#77. Although it was not listed as a non-pharmacological intervention on either the care plan or the Behavior Management Documentation forms, interview on [DATE] at 3:02 p.m. with LPN AA revealed, As long as they let her stay in her room and watch HGTV, there is no behavior. Interview on [DATE] at 7:28 a.m., with LPN EE, revealed she was the 3rd shift charge nurse, and was familiar with R#77. She indicated the resident did not display behaviors, slept well throughout the night, and she was not aware of any individualized target behaviors to be monitoring for. Interview with the MDS Coordinator on [DATE] at 8:08 a.m., revealed the resident did not have behaviors, and therefore had no target behaviors for which staff were to monitor. She confirmed that R#77's Care Plan failed to include resident-centered individualized non-pharmacological interventions that were used to keep the resident content such as allowing her to stay in her room and watch HGTV. (Refer to F280.) c. Gradual Dose Reduction (GDR): Review of R#77 s Care Plan, revision date [DATE], revealed the resident had a Potential for drug toxicity. Resident is at risk for side effects associated with [MEDICAL CONDITION] drug use. The goals related to this problem included, Resident will show no side effects from the medications through next review. Further review of the care plan revealed that it failed to provide any approaches related to a GDR of the resident's antipsychotic medication. Review of R#77's clinical record revealed that on [DATE], the RPh provided a Consultant Pharmacist Communication to Physician. This letter stated there was a need for an antipsychotic dose evaluation. Per the form, This communication is to prompt response to regulatory requirements for dose and side effect evaluation for patients receiving these drugs . Drug to Evaluate: [MEDICATION NAME]. The form then asked the physician to Select one of the following or document your own evaluation: ( ) The Patient is receiving the lowest effective does of this medication and/or the risk of reducing the dose is greater than the possible benefit. ( ) A dose change may be attempted. Please write order. Further review of the Consultant Pharmacist Communication to Physician letter revealed that as of [DATE], the physician had not completed the form and no response was provided. The resident remained on the same dose of [MEDICATION NAME] she was admitted on without evidence of an attempt at a GDR. There was no documentation in the clinical record as to why a GDR attempt would be clinically contraindicated for this resident. Interview on [DATE] at 2:21 p.m., with LPN AA, revealed the resident was due for a GDR. She stated, I think they need to wean her, and were waiting for (psychiatrist name) to come in evaluate her. Further interview with LPN AA revealed the psychiatrist had been at the facility the previous week, but did not give any new orders for R#77. Interview on [DATE] at 2:42 p.m., with the DON revealed, I requested her to be on the list to be seen by the psychiatrist, but when he came in last week, he felt like there was no change and he did not need to see her. The DON reviewed the resident's record, including physician progress notes [REDACTED]. After a review of facility records, interview with the DON on [DATE] at 3:13 p.m., revealed she could not find anything to show a GDR would be clinically contraindicated for R#77. She indicated she would continue to research the issue and provide any further information as it became available, On [DATE] at 3:56 p.m., LPN AA indicated she had just spoken to the physician and he declined the [DATE] recommendation for a GDR because the resident was stable, wasn't trying to stand up or be aggressive so She should stay on the current dose. She further indicated the physician had a copy of his response and would fax it to the facility for review. Review of the response to the Consultant Pharmacist Communication to Physician letter faxed by the physician revealed that it was not completed until [DATE], after surveyor intervention. Further review of the physician's response revealed that he declined a GDR because the Pt (patient) is stable on this dose. There was no documentation in the resident's response as to why a GDR was clinically contraindicated for this resident, or why the risks of using a medication with black-box warning (Risk of death for elderly residents with dementia) outweighed the benefits of the medication. Interview on [DATE] at 8:08 a.m., with the MDS Coordinator revealed the resident's Care Plan did not include approaches which dealt with possible reductions of her antipsychotic. She indicated she normally includes than approach to determine whether there was a need for a GDR; however, she had not included this approach when she reviewed/revised the care plan in (MONTH) (YEAR). Interview on [DATE] at 1:19 p.m., with the DON revealed the facility did not have a policy on the use of [MEDICAL CONDITION] medications. She indicated she had checked with the pharmacy and the only policy she could provide was for Pharmacy Consulting. Review of the undated Pharmacy Consulting policy revealed that: The Consultant Pharmacist will provide reporting each month that will document the pharmacist concerns, irregularities identified or any clinically significant risk or adverse consequence identified may result from or be associated with medications. The reports will be provided to the Administrator and DON within three (3) working days from the review. A recommendation letter will be provided to the attending physician regarding any significant potential or actual medication therapy concerns. The healthcare center staff will notify the attending physician and obtain a response to this letter within a timely manner. The attending physicians, as stated in the CMS regulations, must report on the pharmacist's recommendations including rationale for their decisions to either follow or reject the pharmacist recommendation. A timely manner is to be determined by the Administrator, DON, and/or Medical Director of the healthcare center with suggested time being approximately 30 days. Although an interview on [DATE] with the DON revealed the facility did not have policies on [MEDICAL CONDITION] medication use, on [DATE] at 11:47 a.m., the facility provided a policy titled, Antipsychotic Medication Use, revised ,[DATE].",2020-09-01
333,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2017-07-20,460,D,0,1,TDOI11,"Based on observations and staff interviews, the facility failed to ensure a bedroom was equipped to afford full visual privacy for each resident during personal care, treatment or as necessary for the resident. This deficient practice was noted with one resident (R#66) of 62 sampled residents. Individual ceiling track for privacy curtains and the actual curtains for R#66 were not in place during the initial tour. The sample was 63. Findings are: During observation of Resident (R) R#66's room on 7/17/17 at 3:09 p.m., revealed the area where the bed was positioned lacked privacy as there were no privacy curtains. An interview with a Certified Nursing Assistant (CNA) AA, on 7/19/17 at 9:30 a.m., revealed she was assigned to R#66 on the morning shift and she did not get R#66 up that morning for dressing. CNA AA further revealed she noted that third shift staff gets the resident up prior to her arrival on first shift, however, CNA AA indicated she would provide privacy for R#66 by pulling the privacy curtain if she were to get her up. CNA AA indicated she could not recall if the privacy curtain for R#66 was in place. An interview with the Maintenance Supervisor (MS) on 7/19/17 at 1:50 p.m., revealed he noticed on 7/18/17 the track for a privacy curtain and the actual curtains were not in place for R#66. Further interview with MS revealed that he put a track in place at the ceiling of R#66's bed area around 5:00 p.m. on 7/18/17 and attached new privacy curtains. He stated, the new shiny bolts in place were the ones I secured to the track. An interview with the Administrator on 7/19/17 at 3:45 p.m., revealed she provided a copy of the facility's undated policy titled, Admission Criteria. The policy indicated the following; .residents have the right to privacy regarding accommodations, medical treatment, written and telephone communications, electronic device communication visits, and meeting with family and of resident groups.",2020-09-01
334,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2018-08-10,657,D,0,1,ZM2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to update the care plan when the Comprehensive Assessment was completed to reflect the resident's self-care deficit for one resident (R#5) of 19 sampled residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 7/18/2018 revealed R#5 was assessed with [REDACTED]. The resident's mood severity score was Zero (0) indicating minimal depression and was assessed as having no behaviors. The resident was assessed as being independent with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toileting, and personal hygiene. He was assessed as needing supervision of one staff member with bathing. Walking in room or corridor did not occur and his balance was not steady, but he was able to stabilize himself without staff assistance. He did not have upper or lower extremity limited range of motion (ROM). He used a wheelchair for mobility. He was continent of bowel and bladder. He was assessed as having pain and was on scheduled and as needed (prn) pain medication. He was assessed as having no falls. He was receiving physical, occupational and speech therapy. R#5 has a [DIAGNOSES REDACTED]. Observations made on 7/24/2018 at 9:33 a.m. revealed R#5 was asleep in his bed, his bed sheets were pulled off his bed, his urinal was full of urine and it was on the floor. Resident's door was closed, and a strong odor of urine was present in his room. Observation on 07/24/2018 at 1:45 p.m. revealed R#5 sitting in his wheel chair in his room dressed only in a white t-shirt and a pull-up. His hair in not brushed and he has facial hair growth. A strong odor of urine is present in his room. A pile of cloths was located on a chair in the resident's room. The resident was attempting to put on a shirt by himself. The privacy curtain was pulled, and the door was shut. The resident's wash basin (no water) was on the floor in his room with a bottle of liquid soap and a dry dirty wash cloth in it. His fingernails are ragged with dark matter underneath his nails. A yellowed colored washcloth was located on the floor under the resident's bed next to the window. The floor by the window was very sticky. A bowl with dried matter was located on the resident's floor by his dresser. A strong odor of urine was present in the hall outside of the resident's door. Record review for R#5 revealed a care plan updated 7/18/18 for a self-care deficit due to his inability to do his ADL's independently and due to a [DIAGNOSES REDACTED]. Resident prefers to bathe in his room and not in the shower room. His goals include resident will continue to feed himself, propel his own wheelchair independently, move in bed and transfer independently, and dress, toilet and groom himself independently through next review. Care plan approaches include to bath resident as scheduled and PRN, and nail care on bath days. Interview on 8/10/2018 at 12:15 p.m. with the (Minimum Data Set) MDS Coordinator revealed after she completed the residents MDS she updated the care plans according to the information that was triggered on Care Area Assessment (CAA). She agreed the residents ADL care plan was incorrect and should have indicated a potential for a self-care deficit and not a self-care deficit. Cross refer to F677",2020-09-01
335,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2018-08-10,677,D,0,1,ZM2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to ensure that care was provided for one resident (R#5) who is unable to carry out Activities of Daily Living (ADL) to maintain proper grooming and personal hygiene for one (1) resident. The sample size was 19 residents. Finding include: Observations on 7/23/2018 at 10:29 a.m. revealed R#5 sitting on the side of his bed, in a private room, dressed only in a pull up and white t-shirt, his hair was not combed, facial hair was present, and a strong odor of urine was noted in and outside of his room. Observations made on 7/24/2018 at 9:33 a.m. revealed R#5 was asleep in his bed, his bed sheets were pulled off his bed, his urinal was full of urine and it was on the floor. Resident's door was closed, and a strong odor of urine was present in his room. Observation on 07/24/2018 at 1:45 p.m. revealed R#5 sitting in his wheel chair in his room dressed only in a white t-shirt and a pull-up. His hair in not brushed and he has facial hair growth. A strong odor of urine is present in his room. A pile of cloths was located on a chair in the resident's room. The resident was attempting to put on a shirt by himself. The privacy curtain was pulled, and the door was shut. The resident's wash basin (no water) was on the floor in his room with a bottle of liquid soap and a dry dirty wash cloth in it. His fingernails are ragged with dark matter underneath his nails. A yellowed colored washcloth was located on the floor under the resident's bed next to the window. The floor by the window was very sticky. A bowl with dried matter was located on the resident's floor by his dresser. A strong odor of urine was present in the hall outside of the resident's door. Observation on 7/24/2018 at 2:12 p.m. revealed R#5's call light was on and it was answered by a (Certified Nursing Assistant) CNA, the CNA put a hospital gown over the resident's white undershirt and pull up. She did not assist R#5 with any ADL care. She did not pick up the dirty bowl or dirty wash cloth up off the floor. Interview and observation on 7/24/2018 at 4:45 p.m. with the Occupational Therapist (OT) revealed R#5 was normally independent with dressing and toileting. She revealed he has had a decline. Resident is still only dressed in an undershirt and pull-up. Observation on 7/25/2018 at 8:53 a.m. revealed that R#5 was in bed, bed sheets in disarray on bed, brown matter noted on the top sheet, and no blanket was on bed. The resident was dressed in plaid shirt, undershirt and pull-up. An orange stain was noted on his plaid shirt. His food tray was next to his bed, uneaten, the milk carton not opened, juice container empty. His water cup was on the floor, with the water spilled on the floor. The empty used plastic bowl with dried matter was still observed on floor. The wash basin with a liquid soap bottle and dirty wash cloth still in same spot. Very strong odor of urine in the room, bathroom and hallway outside his room. Interview on 7/25/2018 at 12:50 p.m. with CNA BB revealed resident was usually independent with all his ADL's. He usually toilets himself, and dresses himself. He will use the call light occasionally if he needs assistance. He is difficult to understand at times. He likes to stay in his room with the door shut, likes to be by himself, and he is not a morning person. He gets his showers on the 3-11 shift. He uses the urinal to urinate during the night. She has not noticed a change in his condition today. Interview on 7/25/2018 at 1:02 p.m. with (Licensed Practical Nurse) LPN AA revealed that the medical doctor ordered an urinalysis and an urine culture on R#5. She revealed resident is usually independent with his ADL's. Interview on 7/26/2018 at 10:42 a.m. with the Administrator revealed R#5 prefers to stay in his room with the door shut and is independent with his ADL's. She agreed there was a strong odor of urine in his room. She verified that the dirty food bowl, dirty washcloth, and the resident's urinal and wash basin should not be stored on the floor. Interview on 7/26/2018 at 11:06 a.m. with the Director of Nursing (DON) revealed that wash basins, urinals and bed pans are to be labeled with the residents first initial and last name and placed in a bag and stored in the resident's closet. She agreed that bed pans, wash basins and urinals are not to be stored on the floor. She Agreed there was a strong odor of urine in the room and that the dirty food bowl, dirty washcloth, and the resident's urinal and wash basin should not be stored on the floor. Interview on 8/10/2018 at 12:15 p.m. with the (Minimum Data Set) MDS Coordinator revealed after she completed the residents MDS she updated the care plans according to the information that was triggered on Care Area Assessment (CAA). She agreed the residents ADL care plan was incorrect and should have indicated a potential for a self-care deficit and not a self-care deficit. Record review for R#5 revealed an Annual Minimum Data Set ((MDS) dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of four (4) indicating severe cognitive impairment. R#5 requires supervision with bathing, independent with personal hygiene, dressing and toileting. Resident is always continent of bowel and bladder. R#5 has a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 7/18/2018 revealed R#5 was assessed with [REDACTED]. His mood severity score was Zero (0) indicating minimal depression. He was assessed as having no behaviors. He was assessed as being independent with bed mobility, transfers, locomotion on and off the unit, dressing, eating, toileting, and personal hygiene. He was assessed as needing supervision of one (1) staff member with bathing. Walking in room or corridor did not occur and his balance was not steady, but he was able to stabilize himself without staff assistance. He did not have upper or lower extremity limited range of motion (ROM). He used a wheelchair for mobility. He was continent of bowel and bladder. He was assessed as having pain and was on scheduled and as needed (prn) pain medication. He was assessed as having no falls. He was receiving physical, occupational and speech therapy. R#5 has a [DIAGNOSES REDACTED]. Record review for R#5 revealed a new medical team note dated 7/2/2018 with a new [DIAGNOSES REDACTED]. Record review for R#5 revealed the document titled ADL Flow Sheet dated for (MONTH) 16 through (MONTH) 24, (YEAR) indicated resident required limited assistance with personal hygiene on the day shift and independent on the night and evening shift. The document indicated that bathing activity did not occur. Review of the document titled CNA Care Plan reveals R#5 requires help with bathing and finger nail care on shower days and as needed (PRN). Document last reviewed 12/4/2015. R#5's shower days are scheduled three (3) times a week on Tuesday, Thursday and Saturday on the 3:00 p.m.-11:00 p.m. shift. Record review for R#5 revealed a care plan updated 7/18/18 for a self-care deficit due to his inability to do his ADL's independently and due to a [DIAGNOSES REDACTED]. Resident prefers to bathe in his room and not in the shower room. His goals include resident will continue to feed himself, propel his own wheelchair independently, move in bed and transfer independently, and dress, toilet and groom himself independently through next review. Care plan approaches include to bath resident as scheduled and PRN, and nail care on bath days. Review of the policy titled Shower/Tub Bath revised (MONTH) 2002 revealed the purpose is to promote cleanliness, provide comfort, and to observe the condition of the resident's skin and to notify the supervisor if the resident refuses care.",2020-09-01
336,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2018-08-10,692,D,0,1,ZM2H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to maintain acceptable parameters of nutritional status as evidenced by significant weight loss for one resident, resident (R) #14. The sample size was 19. Findings include: Resident #14 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of monthly weights provided by the facility include the following: (MONTH) (YEAR)=95 pounds; (MONTH) (YEAR)=91.4 pounds; (MONTH) (YEAR)=90.8 pounds, (MONTH) (YEAR)=90 pounds; (MONTH) (YEAR)=92.4 pounds; (MONTH) (YEAR)=93.2 pounds; (MONTH) (YEAR)=85 pounds. These weights revealed R#14 sustained a significant weight loss of 8.8% or 8.2 pounds in 30 days (June to (MONTH) (YEAR)) and a 10.5% weight loss or 10 pounds in 180 days (six months) (January to (MONTH) (YEAR)). Additional information was provided by the facility on 8/10/18 that included a weight of 89.6 pounds for the month of (MONTH) and a reweigh of 91 pounds. Significant weight loss is defined by the Minimum Data Set (MDS), a Resident Assessment Instrument (RAI), as 5% or greater in 30 days, 7.5% or greater in 90 days and/or 10% or greater in 180 days. Review of the interdisciplinary care plan, R#14 was assessed by the facility as at risk for alteration in nutritional status and a care plan developed on 10/26/17 with a goal to maintain her current weight within plus or minus five (5) pounds through the next review. The care plan was reviewed on 1/25/18 and 4/26/18 and the goal noted as ongoing times 90 days. Interventions included dietitian to evaluate and follow up as needed, Low Concentrated Sweet (LCS) diet, set up tray in the common area on Station 3, allow resident ample time to consume food, monitor food intake at each meal and report any decline to the physician and dietician, weigh as ordered, report any weight loss to the physician and dietician, promptly offer resident food alternatives when appropriate for any meal served. The care plan did not address actual weight loss. Resident #14 was noted with a Body Mass Index (BMI) of 18.4 in (MONTH) of (YEAR) by the Registered Dietitian (RD) in a Nutritional Assessment. The BMI is a commonly used calculation of weight and height to indicate whether an individual is normal, below or above a healthy weight. Normal weight BMI is between 18.5 and 25. Below 18.5 is considered underweight. R#14's (MONTH) (YEAR) weight of 90 pounds equates to a BMI of 17.57 and the (MONTH) (YEAR) weight of 85 pounds equates to a BMI of 16.6. Both weights and BMI indicate a downward trend and that R#14 was below normal weight. A review of the current Physician order [REDACTED]. Observation on 7/23/18 at 12:30 p.m. of R#14 seated in the dining room revealed that staff served the meal on the the tray and warming base and the resident feed herself. The resident was noted to have a vanilla flavor SF shake on the tray. Staff cut up the resident's food items and encouraged her verbally to consume lunch. Observation revealed that the resident consumed approximately 75% of meal and 100% of the shake. An interview was conducted with Licensed Practical Nurse (LPN) GG on 7/25/18 at 11:40 a.m. revealed that residents are routinely weighed monthly and that residents who are considered at risk are weighed weekly. The Restorative Nursing Assistants (RNAs) obtain both the weekly and monthly weights and give a copy to the nurses and they put it on the chart. Monthly weights are usually obtained around the first of the month. LPN GG further revealed that the facility at risk meetings on Thursdays when the weights are compared weekly. The at risk meetings are held with nurses on the unit, the Director of Nursing (DON), Assistant Director of Nursing (ADON), the Dietary Manager (DM), RNA and the treatment nurse. She stated they discuss residents with weight loss, skin/wound problems, falls, behaviors and follow up on appointments. A review of a facility policy dated (MONTH) 2008 entitled Weight Assessment and Intervention included (but was not limited to) the following: Weight Assessment: 1. The nursing staff will measure resident weights on admission. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. 4. The Dietitian will respond within 24 hours of receipt of written notification. 5. The Dietitian will review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria . a. 1 month - 5% weight loss is significant; greater than 5% is severe. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 6 months - 10% weight loss is significant; greater than 10% is severe. Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding the: a. Resident's target weight range (including rationale if different from ideal body weight); b. Approximate calorie, protein, and other nutrient needs compared with the resident's current intake; c. The relationship between current medical condition or clinical situation and recent fluctuations in weight; and d. Whether and to what extent weight stabilization or improvement can be anticipated. 2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss or increasing the risk of weight loss. For example: a. Cognitive or functional decline; b. Chewing or swallowing abnormalities; c. Pain; d. Medication-related adverse consequences; e. Environmental factors (such as noise or distractions related to dining); f. Increased need for calories and/or protein; g. Poor digestion or absorption; h. Fluid and nutrient loss; and/or i. Inadequate availability of food or fluids. Care Planning: 1. Care planning for weight loss or impaired nutrition will be a multidisciplinary effort and will include the Physician, nursing staff, the Dietitian, the Consultant Pharmacist, and the resident or resident's legal surrogate. 2. Individualized care plans shall address, to the extent possible: a. The identified causes of weight loss; b. Goals and benchmarks for improvement; and c. Time frames and parameters for monitoring and reassessment. Interventions: 1. Interventions for undesirable weight loss shall be based on careful consideration of the following: a. Resident choice and preferences; b. Nutrition and hydration needs of the resident; c. Functional factors that may inhibit independent eating; d. Environmental factors that may inhibit appetite or desire to participate in meals; e. Chewing and swallowing abnormalities and the need for diet modifications; f. Medications that may interfere with appetite, chewing, swallowing, or digestion; g. The use of supplementation and/or feeding tubes; and h. End of life decisions and advance directives. During an interview conducted with the Director of Nursing (DON) on 7/26/18 at 9:00 a.m., she confirmed the staff meet each week at the at risk meetings to review residents with weight loss. She provided copies of the At Risk meeting minutes related to R#14 dated 12/28/17, 1/11/18 and 1/18/18. The DON confirmed that R#14 was changed from weekly weights to monthly weights at the 1/18/18 At Risk meeting as her weights had stabilized for the prior 30 days. She also confirmed there is no evidence R#14 was discussed at the At Risk weekly meetings related to weight loss trend based on monthly weights from Feb, March, (MONTH) and (MONTH) of (YEAR); and she confirmed there are no Nurse's Notes addressing weight loss after 1/18/18. She reviewed the documented weights for R#14 and confirmed the significant weight loss. In addition, the DON confirmed the Registered Dietitian (RD) visited every Tuesday and reviewed residents with identified weight loss; she also confirmed the RD's last note for R#14 was dated 12/19/17. Review of a form entitled Nutritional Review revealed the Dietary Manager (DM) documented an evaluation of R#14's weights and nutritional status in January, (MONTH) and (MONTH) (YEAR). The (MONTH) (YEAR) note reveals R#14 with weight steady and the addition of Magic Cup (a nutritional supplement) at breakfast as well as a change in diabetic medication. The (MONTH) (YEAR) evaluation revealed R#14 with a trend down of 5.263% in 90 days and notes no new orders. She notes consumption of all three meals at 50-75%. The (MONTH) 25, (YEAR) evaluation revealed a continuing trend down of 8.798% in 30 days, 5.556% in 90 days and 10.338% in 180 days. It also notes no new orders and consumption of all three meals at 50-75%. The back of the form entitled Summary of Review is blank. There is no evidence the weight loss trend was reported to the Registered Dietitian (RD), Director of Nursing (DON) or attending physician. An interview was conducted on 7/26/18 at 9:29 a.m. with the DM. She confirmed that she had conducted a Nutrition Review in January, (MONTH) and (MONTH) of (YEAR). She also confirmed her evaluation of a weight loss trend in both (MONTH) and (MONTH) of (YEAR). She could not provide any documentation that the RD was notified or asked to evaluate R#14 for weight loss as required by the facility policy. She could not provide any documentation to support R#14's weight loss trend having been discussed and reviewed at the At Risk meetings as required by the facility policy. She also could not provide any documentation of notification of the DON or other interdisciplinary team members including the attending physician as required by the facility policy. Additional information provided by the facility on 8/10/18 included a Dietitian Progress Note dated 7/30/18. The note confirms R#14's significant weight loss. After observing the resident, the RD recommended providing a Mighty Shake (a nutritional supplement) three times a day with meals, finger foods at all meals, an Occupational Therapy evaluation for adaptive equipment, alerting the MD of weight loss and weekly weight for four weeks or until weights are stable. A telephonic interview was conducted with the attending physician on 8/10/18 at 11:30 a.m. He confirmed R#14's [DIAGNOSES REDACTED]. He also confirmed the NP's evaluation of moderate protein-calorie malnutrition in her (MONTH) (YEAR) progress note but stated that the resident's weight and condition had stabilized by the end of the month.",2020-09-01
337,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2019-02-03,656,J,1,0,JJVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and review of the clinical records, it was determined that the facility failed to follow the plan of care related to wound care of the left pinky finger for one resident (#1) from three residents sampled for wounds. This resulted in the resident being hospitalized with dry gangrene of the area. 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). Findings include: Review of the clinical records revealed Resident (R) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the records revealed orders for R#1 which included: Eliquis 5 mg twice a day; [MEDICATION NAME] 75 mg daily; and an order dated 12/27/18 to cleanse the wound on the resident's left pinky finger with normal saline, pat dry, apply triple antibiotic ointment, and cover with a dry dressing every three days and as needed until healed. A review of an Event Evaluation dated 12/27/18 revealed that R#1 sustained the injury to his left pinky finger while clipping his fingernails that day. The Event Evaluation further documented that the Physician and family were notified and that first aid was completed; this included cleansing of the wound with normal saline, the application of triple antibiotic ointment, and coverage with a dry dressing. A care plan was developed on 12/27/18 for a clipped left 5th digit tip. The goal was for the resident's wound to remain free of infection and show evidence of healing in 30 days. Staff interventions included: report changes in skin status to physician; wound care as ordered, see current treatment record and physician's orders [REDACTED]. It was documented on the Medication Administration Record (MAR) dated 12/27/18 included a Treatment Procedure order Cleanse wound to left pinky finger with NS (normal saline) ,pat dry, apply TAO (triple antibiotic ointment) and cover with dry drs(dressing) Q (every) 3 days and PRN (as needed) until healed. The MAR was signed treatment administered on 12/27, 12/28, 12/29, 12/30 and 12/31. There was no documented evidence with a description of the wound on the left pinky finger. During an interview on 1/10/19 at 2:20 p.m. with Licensed Practical Nurse (LPN) AA she revealed R#1 clipped the pinky finger on his left hand with a nail clipper while he was attempting to clip his own nails on 12/27/18. The wound was bleeding, so this nurse cleansed the area with normal saline and applied triple antibiotic ointment and a 4x4 pressure dressing. This nurse said further that the pressure dressing would not stay in place so she also wrapped the finger with a self-adhesive bandage to cover it. She called the Physician some time before the end of her shift (she could not recall what time) and advised him of the injury. LPN AA stated the Physician agreed with the treatment she had provided when she called and did not give any new orders. Therefore, she wrote the wound care treatment (minus the Self- Adhering Wrap ) she had provided on a telephone order sheet and then added the order to the electronic records to be completed on the evening shifts. The telephone order sheet was left on the resident's chart to be signed by the Physician when next he came to the facility. Review of the Nurse's Notes dated 1/1/19 at 10:49 p.m. documented that the resident's family came to visit that day and became concerned at the finger's appearance. A family member ask when had staff last looked at the finger or changed the dressing. Staff informed the family that the dressing was due to be changed that same day. Upon being summoned by the family, two nurses went to the resident's room to assess the finger. When the dressing was removed in the presence of the family, the nurse observed the finger to be discolored. The nurse called the Physician and advised him of the situation, and the Physician gave orders for the resident to be transported to the hospital to rule out schema of the left pinky finger.",2020-09-01
338,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2019-02-03,658,J,1,0,JJVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of policy and procedures, review of the Georgia Nurse Practice Act (chapter 410-10), family and staff interviews, the facility failed to ensure services met professional standards as evidenced by the provision of ongoing wound care to one resident (#1) without a physician's orders [REDACTED]. Failure to follow the physicians orders for wound care resulted in the resident being hospitalized , subsequently, with a [DIAGNOSES REDACTED]. R#1 had an AV shunt on the left arm at the time that a self-adhering (constrictive) dressing was applied. The sample size was three. 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). Findings include: Review of the Georgia Nurse Practice Act, chapter 410-10, revealed that licensed and registered nurses are required to: assess their patients in a systematic, organized manner; initiate nursing actions to assist the patient to maximize his/her health capabilities; evaluate with the patient the status of any goals as a basis for reassessment and reordering of priorities; function within the legal boundaries of nursing practice; and determine that care performed is based on the orders/directions of a licensed physician or other similarly licensed professional. Review of the clinical records revealed Resident (R) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the electronic medical (EMR) records revealed orders for R#1 which included: Eliquis 5 mg twice a day; [MEDICATION NAME] 75 mg daily; and an order dated 12/27/18 to cleanse the wound on the resident's left pinky finger with normal saline, pat dry, apply triple antibiotic ointment, and cover with a dry dressing every three days and as needed until healed. During an interview on 1/10/19 at 10:58 a.m. with A, the family member of R#1, revealed the resident was admitted to the facility in early (MONTH) for rehabilitation. On (MONTH) 27, another family member B received a call from the facility saying the resident had sustained a cut the tip of one of his fingers with a finger nail clipper. During the call, staff reported to family member B that the injury was bleeding, but that the injury was being taken care of. Family member B reported this to family member A who visited the facility the following day, 12/28/18, where he saw the resident's finger wrapped in a bandage. Family member B accompanied by another member of the family visited with R#1 on 1/1/19. When these family members pulled the bandage away to peek at the finger, they reported to A that there was a noticeable difference in the area below the bandage when compared with the area around the bandage. The finger, in question, looked smaller than the resident's other fingers, and was black while the surrounding areas and other fingers were white. When the family members had the nurses remove the outer bandage, they discovered that there were two bandages wrapped on top of each other - the wound was covered by a Band Aid, then the Band Aid was wrapped in gauze, then the gauze was wrapped in an elastic bandage (family member A described this as a bandage similar to what one would use to wrap one's knee). The nurses took the bandages away before the family could take them. However, family member A said the bandage/dressing the family found on the resident's finger when they visited on 1/1/19 appeared to be the same one he saw on the resident's finger when he visited on 12/28/18. He was convinced it was the same bandage because the family members that visited on 1/1/19 took pictures which they forwarded to him. In those pictures, the bandage appeared the same. Family member A met the resident and other family members at the hospital later that day. The resident was admitted to the hospital for a couple of nights and was seen by the surgeon. The surgeon advised that surgery would be too dangerous, given the resident's health conditions, and recommended that the finger be left to wither and fall off on its own - let the body expel it - because it had dry gangrene. During a telephone interview on 1/11/19 at 3:01 p.m., family member B said R#1 was still wearing what appeared to be the original bandage when the family visited on 1/1/19 and this prompted them to ask when it was last changed. Family member B also said he remembered the wound was wrapped in several layers. A review of an Event Evaluation dated 12/27/18 revealed that R#1 sustained an injury to his left pinky finger while clipping his fingernails that day. The Event Evaluation further documented that Physician BB and family member B were both notified and that first aid was completed; this included cleansing of the wound with normal saline, the application of triple antibiotic ointment, and coverage with a dry dressing. There is no documentation in the clinical record of an assessment with a description of the extent of the injury to the finger. On 1/1/19 the resident was transferred to the hospital for evaluation of the left pinky finger. Review of the Nurse's Notes dated 1/1/19 at 10:49 p.m. documented that the resident's family came to visit earlier that day. Sometime after the family arrived in the facility, one of the family members went to the nurses' station asking for staff to take a look at the resident's injured finger because the family was concerned about the finger's appearance. The family member asked when had staff last looked at the finger or changed the dressing, and staff informed the family that the dressing was due to be changed that same day. Upon being summoned by the family, two nurses went to the resident's room to assess the finger. The staff removed the dressing in the presence of the family and the same family member began to scream, asking whether the nurse had seen the finger before that moment and demanding that the family be allowed to speak to the Physician. The note documented that nurse told the family that staff would call the Physician. The nurse called the Physician and advised him of the situation, and the Physician gave orders for the resident to be transported to the hospital to rule out ischemia of the left pinky finger. A review of a Nursing Home to Hospital Transfer Form dated 1/1/19 revealed under the clinical information field: check for ischemia on left pinky finger A review of the report from the hospital to which the resident was transported revealed the resident was seen on 1/1/19 beginning at 11:54 p.m. with a chief complaint: necrosis. The resident presented with discoloration of the left fifth finger, and a history taken from the resident/family revealed the resident had sustained a cut to his finger about a week before and a dressing was applied. When the dressing was removed earlier in the day, discoloration was noted. An examination completed by hospital staff revealed dry gangrene of the resident's left fifth finger from the metacarpophalangeal (MP) joint. The rest of the hand was described as well perfused, warm, and pink. The hospital record also documented the resident has an AV fistula to the lower left arm with a positive thrill bruit. The report from the hospital also documented that the resident was discharged from that facility in early (MONTH) following a cardiac valve procedure with complications of cardiogenic shock and left lower leg ischemia. During an interview on 1/10/19 at 2:20 p.m. with Licensed Practical Nurse (LPN) AA she revealed R#1 clipped the pinky finger on his left hand with a nail clipper while he was attempting to clip his own nails on 12/27/18. The wound was bleeding, so this nurse cleansed the area with normal saline and applied triple antibiotic ointment and a 4x4 pressure dressing. LPN AA further stated that the pressure dressing would not stay in place so she also wrapped the finger with a self-adhering bandage to cover it. She called the Physician some time before the end of her shift (she could not recall what time) and advised him of the injury. LPN AA stated the Physician agreed with the treatment she had provided when she called and did not give any new orders, so she wrote the wound care treatment (minus the self-adhering bandage) she had provided on a telephone order sheet and then added the order to the electronic records to be completed on the evening shifts. The telephone order sheet was left on the resident's chart to be signed by the Physician when next he came to the facility. LPN AA said this process was customary. LPN AA said she provided care for the resident on the day following the injury - 12/28/18 - and again on 12/31/18. Based on the orders she received (change every three days or as needed), the wound was required to have a dressing change on the evening shift on 12/30/18. She did not work at the facility on the evening shift, nor did she work on 12/30. Further, unless there was swelling, redness, or bleeding, she would not have needed to change the dressing on an as needed basis. Review of the facility's User Learning form revealed that LPN AA started a training course titled Skin integrity Systems (SIS) What Every Facility Has to Know and DO, the form revealed a due date of 10/19/18, it was noted on the form that LPN AA completed the training on 1/3/19 (after the incident with R#1). An interview on 1/10/19 at 3:35 p.m. with LPN EE revealed that she never treated R#1 during the time he had his injury. However, when a resident in the facility sustains a minor injury such as a cut or skin tear, the charge nurses (such as herself) are allowed to clean the area with normal saline and place a dry dressing on the area. The nurse will then write a telephone order for the treatment that was done. The nurse also calls the Physician. When the Physician is called, if he/she makes changes to what the nurse has done, then those orders are written. If not, the original telephone order written by the nurse stands. If a resident sustains an injury, the nurse should monitor that injury/area every day. If there are signs of bleeding or swelling, then the nurse should check the injury. If the dressing appears to be too tight, or the resident complains of discomfort, then the nurse should also check the area/injury. This is just common/standard practice. A review of a Nurses' Note 12/28/18, the day following the injury, revealed the nurse documented only that the resident had a skin tear to finger, dressing intact. A review of a Weekly Skin Integrity Evaluation dated 12/28/18 revealed the resident was described as having a skin tear to the left finger with dressing in place. There was no evidence of an assessment to determine the extent of the injury. A review of a Daily Skilled Nurses' Notes of 12/31/18 and 1/1/19 revealed the nurses documented on both days that the resident had no skin conditions. Review of (MONTH) (YEAR) Medication Administration Record (MAR) revealed that three nurses had signed off on the order for wound care of the pinky finger on 12/28, 12/29, 12/30, and 12/31/18. During an interview on 1/10/19 at 4:45 p.m. with the Director of Nursing (DHS) it was revealed if the nurses signed off on the order for the dressing to be changed every three days and as needed, she could only assume that they provided the care ordered on those days. There was no way to know the exact care that was provided without talking to the nurses in question. The self-adhering wrap bandage (which was used to wrap the resident's finger) is not usually used by the nurses in the facility to wrap wounds/injuries, nor is it kept on the carts. The facility does keep some in the supply area but this is usually used for wrapping venous wounds etc. With a minor injury, the nurse should have covered the area with a dressing, but not applied the self-adhering wrap bandage. However, the resident sustained [REDACTED]. The DHS said she would not normally recommend that type of dressing for a minor skin tear or cut, but under the previously outlined circumstances, she was not willing to say it was incorrect to do so. After the incident with R#1, the DHS said she educated the nurses in the proper use of the self-adhering wrap bandage because she wanted to be assured that, were they to use this type of bandage, they were well-versed in how to appropriately apply and periodically check its application. A further review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed that LPN CC was the nurse who signed on 12/30/18 and LPN DD signed on 12/29/18 and 12/31/18 as having completed the wound care orders for the resident's left pinky finger. There were no progress notes regarding the status of the residents injury until 1/1/19 when the resident required hospitalization to evaluate the wound. During a telephone interview on 1/11/19 at 10:30 a.m. with LPN CC it was revealed that he cared for R#1 the weekend of 12/29/18 and 12/30/18. He remembered changing the dressing on the resident's finger on one of those days, but he was not sure which. This nurse said he did not recall, the type of dressing he removed or applied to the resident's finger. In particular, he did not remember if it included a wrapped bandage. If a resident has a wound with a dressing, the nurse said it is his usual practice to check the dressing and area daily on his shift for signs of bleeding, swelling, etc. Normally, he would document that he had checked the area of the wound. However, he was unsure whether he had documented this on his shifts that weekend. During a follow-up interview on 1/11/19 at 11:09 a.m. with the DHS it was revealed if the Physician gives a wound care order that a dressing is to be changed as needed, it should be changed if soiled, bleeding, etc. This would involve the use of nursing judgment. The nurses are expected to monitor a wound/dressing area every shift. However, she would not expect them to document this unless there was a concern. If there were no concerns, they should also use their nursing judgment whether to document this or not. For a skin tear, the Physician would not normally order self-adhering wrap. However, if a self-adhering wrap or other such bandage is used, she expects staff to also check this bandage at least once every shift and as they encounter the resident throughout the shift. They should look for [MEDICAL CONDITION], redness, and check whether the resident is experiencing discomfort. For minor wounds, the wound care nurse would only be notified to assess the resident if the charge nurse has a concern. If the wound care nurse also has a concern, she will call the physician for new orders. The facility has no standing orders for wound care. If a resident is bleeding, then the nurse needs to take immediate steps to stop the bleeding before calling the Physician. At that point, the Physician will give a treatment order. The nurse will write the order and complete the treatment per the physician's orders [REDACTED]. During an interview on 1/11/19 at 11:36 a.m. with Physician BB, it was revealed that he was not notified on 12/27/18 that R#1 had sustained an injury to his finger, and had not given orders for the staff at the facility to treat the injury. He said that the nurses are expected, of course, to provide needed emergency treatment when a resident sustains an injury. However, they are required to then call and receive orders from the Physician. He was not aware that R#1 had sustained an injury to his finger until he received a call from one of the nurses at the facility around 8:00 p.m. on 1/1/19 stating that the resident's finger was discolored. He asked the nurse for additional information such as motor, pulse, pain, sensory and she left to reassess the wound/finger for the information he required. When the nurse called him again about 10 minutes later, she informed him that the finger was still discolored, despite the bandage having been removed, and that it was gray to black in color. He also learned at that time that the nurse had applied a self-adhering wrap or similar bandage to the affected area at the time the resident sustained [REDACTED]. Under those circumstances, it is possible he would have given an order for [REDACTED]. Knowing that the self-adhering wrap bandage was used, however, he felt that, in all likelihood, this contributed to the condition for which he gave orders for the resident to be sent to the emergency room . During a telephone interview on 1/11/19 at 1:39 p.m. with LPN DD it was revealed that she did not remember R#1, nor could she recall the wound care orders she completed on his behalf or whether his wound was covered with a self-adhering bandage. Unless the order directed that the resident's dressing was to be changed on a certain day, the nurse would only change it on an as needed basis if it was soiled, falling off, bleeding, etc. On a day-to-day basis during her shift, she would normally assess the area of a wound to see if it was clean, or if there was any drainage or similar circumstances that needed to be immediately addressed. She was educated during orientation that she did not need to document if no problems were observed on her assessment of a resident. Her signature on the MAR did not signify that she had changed the dressing on the days indicated. She would sign the MAR for the wound care on the days she worked even if the wound did not require a dressing change. Review of the undated policy, physician's orders [REDACTED]. The original order remains on the chart, the Director of Nursing gets the yellow copy, and the white copy is given to medical records to obtain the Physician's signature. A review of the paper chart for R#1 revealed the chart copy of telephone order written by LPN AA on 12/27/18 for the resident's wound on the left pinky finger remained unsigned. The attending Physician was listed as Physician BB. Review of the white copy of the telephone order dated 12/27/18 when retrieved from medical records revealed the Physician had documented in the signature field: Not notified until 1/1/19.",2020-09-01
339,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2019-02-03,684,J,1,0,JJVJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and family interviews and review of facilities Guidelines titled Care of Skin Tears & Abrasion, it was determined that the facility failed to ensure wound care was provided to one resident (R), #1 in accordance to the written physician's telephone order. This resulted in R#1 being hospitalized , subsequently, with a [DIAGNOSES REDACTED]. The sample size was three residents. 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). Findings include: Review of the clinical records revealed Resident (R) #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of the records revealed orders for R#1 which included: Eliquis 5 mg twice a day; [MEDICATION NAME] 75 mg daily; and an order dated 12/27/18 to cleanse the wound on the resident's left pinky finger with normal saline, pat dry, apply triple antibiotic ointment, and cover with a dry dressing every three days and as needed (PRN) until healed. A review of an Event Evaluation dated 12/27/18 revealed that R#1 sustained the injury to his left pinky finger while clipping his fingernails that day. The Event Evaluation further documented that the Physician and family were notified and that first aid was completed; this included cleansing of the wound with normal saline, the application of triple antibiotic ointment, and coverage with a dry dressing. During an interview on 1/10/19 at 2:20 p.m. with Licensed Practical Nurse (LPN) AA she revealed R#1 clipped the pinky finger on his left hand with a nail clipper while he was attempting to clip his own nails on 12/27/18. The wound was bleeding, so this nurse cleansed the area with normal saline and applied triple antibiotic ointment and a 4x4 pressure dressing. This nurse said further that the pressure dressing would not stay in place so she also wrapped the finger with a self-adhesive bandage to cover it. She called the Physician BB some time before the end of her shift (she could not recall what time) and advised him of the injury. LPN AA stated the Physician agreed with the treatment she had provided when she called and did not give any new orders. Therefore, she wrote the wound care treatment (minus the self-adhesive bandage) she had provided on a telephone order sheet and then added the order to the electronic records to be completed on the evening shifts. The telephone order sheet was left on the resident's chart to be signed by the Physician when next he came to the facility. A review of the Nurse's Note dated 1/1/19 at 10:49 p.m. documented that the resident's family came to visit that day and became concerned at the finger's appearance. A family member asked when had staff last looked at the finger or changed the dressing. Staff informed the family that the dressing was due to be changed that same day. Upon being summoned by the family, two nurses went to the resident's room to assess the finger. When the dressing was removed in the presence of the family, the nurse observed the finger to be discolored. The nurse called the Physician and advised him of the situation, and the Physician gave orders for the resident to be transported to the hospital to rule out ischemia of the left pinky finger. A review of a Nursing Home to Hospital Transfer Form dated 1/1/19 revealed under the clinical information field: check for ischemia on left pinky finger. A review of the report from the hospital to which the resident was transported revealed the resident was seen on 1/1/19 beginning at 11:54 p.m. with a chief complaint of necrosis. The resident presented with discoloration of the left fifth finger. History taken from the resident/family revealed the resident had sustained a cut to his finger about a week before and a dressing was applied. When the dressing was removed earlier in the day, discoloration was noted. An examination of the left fifth finger from the metacarpophalangeal (MP) joint revealed dry gangrene. During an interview on 1/11/19 at 11:36 a.m. with Physician BB, it was revealed that he was not notified by staff on 12/27/18 that R#1 had sustained an injury to his pinky finger, nor had he given the orders noted in the resident's record for the wound treatment that was applied. Physician BB said that he first became aware of the resident's injury when he received a call from a nurse at the facility around 8:00 p.m. on 1/1/19 stating that the resident's finger was discolored. He also learned at that time that the nurse had applied a self-adhesive or similar bandage to the affected area at the time the resident sustained [REDACTED]. Under those circumstances, it is possible he would have given an order for [REDACTED]. During a follow-up interview with the Physician BB on 1/11/19 at 11:47 a.m. he revealed that he could not say how long it might have taken for the bandage, in question, to create the ischemia he suspected when he sent R#1 to the emergency roiagnom on [DATE]. He said it could take several hours or even a day for the affected finger to get to that state, but without knowing how tightly the bandage was applied, it was difficult to say. Interview with the Director of Healthcare Service (DHS) on 1/30/19 at 10:30 a.m. revealed that she was notified of the injury to R#1 finger on 12/28/18 during morning meeting. She reviewed the incident report on 12/28/18 that stated that the Physician was notified and an order was given on the treatment and dressing of the wound. On 1/4/19 during morning meeting, she was informed that the resident was transported to the hospital on [DATE] to rule out ischemia and that the use of self-adherent dressing was used to dress the wound. On 1/30/19 at 11:00 a.m. with the Wound Care nurse revealed that she was on leave when resident #1 finger was injured and treated with the use of the self-adhesive dressing. However, she stated that the treatment cannot be used without a physician's orders [REDACTED]. An interview with the resident 's son A on 1/30/19 at 4:22 p.m., he stated that his father finger became infected and was surgically removed and continue to remain hospitalized . A second interview on 1/31/19 at 12:15 p.m. with LPN AA revealed that on 12/27/18 she was informed by a Certified Nursing Assistant (CNA) that R#1 had cut his finger and it was bleeding. The LPN went into R#1's room where she observed the tip of his left small finger, was bleeding and R#1 informed her that he was clipping his nails and accidentally clip the tip of his finger. She cleaned the area with normal saline and applied triple antibiotic ointment and covered it with a 4 x 4 and a self-adhesive dressing and dated it. LPN AA stated that she notified the resident son of the incident. LPN AA initiated treatment for [REDACTED]. The schedule dressing change was placed on the 3-11 shift. (sic) A review of the paper chart for R#1 revealed the chart copy of telephone order written by LPN AA on 12/27/18 for the resident's wound (minus the Self- Adhering Wrap ) on the left pinky finger remained unsigned. The attending Physician was listed as Physician BB. Review of the telephone order dated 12/27/19 revealed that Physician BB had documented in the signature field: Not notified until 1/1/2019. During a post survey interview on 2/13/19 at 2:45 p.m. with Administrator CC regarding the morning meeting the DHS referred to learning of R#1 hospitalization on [DATE]. The Administrator states that Clinical Morning Meetings were held on 1/2/19 and 1/3/19 and the DHS was in attendance on both days. It was also learned that all notification of accidents and incidents are done via 24 hour report books which are reviewed at the morning meetings. Review of the Situation Background Assessment Recommendation (SBAR) communication form and progress form revealed documentation that the resident wound dressing was changed on 12/27/18, 12/29/18 and on 1/1/19 on the 3-11 shifts. Review of the clinical record dated 1/1/19 at 8:12 p.m. the nurse described the finger as being discolored on the lower part of the finger and had blood flow. At 8:20 p.m. the Physician orders [REDACTED]. Review of the hospital record revealed a [DIAGNOSES REDACTED].#1 was admitted to the hospital for treatment and was discharged from the facility. Review to the facility's Guidelines dated 6/1/15 titled Care of Skin Tears & Abrasion. Step #15 c. states If the abrasion is draining moderate to large amount of fluid, cover the wound with a non-adherent transparent film or non adhesive dressing (not a sterile dressing or strip) as per Physicians order. Change the film every seven (7) days or as needed as per Physicians order.",2020-09-01
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
341,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2019-11-14,567,D,1,0,VEPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, the facility failed to obtain written authorization to open a Resident Trust Fund (RTF) account and failed to obtain written authorization to deduct funds from an RTF account to pay for facility care costs for one resident (R) (#10) of three residents reviewed who had trust accounts. Findings include: During an interview on 10/29/19 at 8:35 a.m., R#10 stated the facility is keeping his Social Security check without his signed authorization. R#10 went on to say he never signed anything allowing the facility to keep his Social Security check. During an interview on 10/30/19 at 9:09 a.m., the facility Finance Director (FD) stated the Social Security checks, received at the facility, addressed to R#10 each month since (MONTH) 2019 have been deposited into the facility account. FD went on to say she does not know why but, R#10 did not sign an authorization for the facility to manage his funds and the facility has not applied to become representative payee for R#10. During an interview on 10/29/19 at 9:35 a.m., Social Worker (SW) SS revealed R#10 brought her several letters from the Social Security office about checks the facility cashed and she explained to R#10 that the facility kept the money for room and board, and he could keep a portion. SW SS added, R#10 never agreed to pay to stay at the facility in her presence and R#10 felt he should not have to pay his whole check to stay at the facility. During an additional interview on 10/30/19 at 10:46 a.m., the FD revealed she spoke directly with R#10 and explained to him that while he is in the facility, his check comes to the facility, minus his allowance. The FD added, she could not recall when or if the paperwork was given to R#10 to sign or if he agreed with the arrangement. The FD also revealed the facility does not have any written agreement from R#10 to manage his funds and the finance staff should have made sure they had a signed copy of the approval form from him. The FD further added, we do not have documentation that we followed our policy. During an interview on 10/30/19 at 11:15 a.m., R#10 revealed he did not remember giving the facility authorization to cash his check. R#10 further stated. I don't mind paying them. I just want to make sure I have money to move at the beginning of the month. During an interview on 10/30/19 at 5:05 p.m., R#10 revealed two ladies from the business office came into his room yesterday and said he will not have to pay anything to stay a few days into November. They gave him the authorization form to sign so he could receive his $70 deposit each month and he signed it. During an interview on 11/4/19 7:20 a.m., R#10 revealed the facility staff spoke to him on 10/30/19 and told him he never signed the paper about them giving him $70 a month and taking the rest. He added they told me it would go into an account so I can draw it out. They just told me about the account a few days ago and I withdrew $50.00 last week. They told me I never authorized them to take the money out my check. They gave me a financial statement (can't locate it) that showed they were putting the money in my account since they have been cashing my checks. It showed what was due each month and what I paid. I believe this was last Wednesday (10/30/19). Two ladies (doesn't know names) came and talked to me and said I had to give them permission to put money in my account. They said they would waive any fees for the month, and they would give me my check for (MONTH) when it came. I saw where my check has hit my account direct deposit on (MONTH) 1st. It's in an account outside the facility so I have the full (MONTH) check in my personal bank account. They can't get to it. I called to check, and the money is there. It will be direct deposit on the 3rd of each month. During an interview on 11/4/19 at 2:30 p.m., the facility Administrator revealed he was not initially aware R#10 had not signed off on the authorization and it was his understanding that R#10 received the checks directly and signed them over to the facility. The Administrator added, It is our policy that the business office would let him know the check came in. If there are concerns, the resident should let the business office know. I cannot validate if they had a conversation. I do agree that the business office should have had R#10 sign the authorization prior to depositing his check into the facility account. The Administrator further revealed he agreed to waive payment for R#10 for (MONTH) pursuant to him discharging the facility this week and he did not require that R#10 sign the authorization for the waiver to be approved. The Administrator added I had a discussion with him. There is nothing in writing. Review of R#10's Resident Face Sheet (no date) revealed he is responsible for self and his payer source is Medicaid. Review of R#10's Minimum Data Set Brief Interview for Mental Status (BIMS) assessment dated [DATE] revealed a summary score of 15, indicating R#10 is cognitively intact. Review of R#10's Resident statement dated 10/30/19 indicated the transferring account was opened on 9/3/19 and the following transactions were listed: A Social Security Credit of $879.00 was made into the account on 9/4/19. Two additional social security credits of $879.00 were made into the account on 10/9/19. An $809.00 care cost debit was made against the account on 9/4/19 and again on 10/9/19. An $879.00 care cost debit was made against the account on 10/9/19. Review of the policy titled Resident Trust Fund revised 12/1/18 indicated, any resident desiring to open an RTF account must sign the National Data Care Resident Fund Management Services (RFMS) Authorization and Agreement to Handle Resident Funds form. The policy further indicated, a copy of the form must be maintained and held in a designated business office binder for all active facility accounts. The original of these forms should be maintained in the facility's Financial Folder. The policy further indicated, in order to deduct funds from a resident's RTF account to pay for facility care costs, the facility must obtain written approval from the resident or authorized representative. The signed agreement should state the total amount outstanding that the resident owes for care costs, amount of monthly deduction, date deduction will begin, and date deduction will end. The description from the resident's RTF account will state Payment Plan.",2020-09-01
342,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2019-11-14,607,D,1,0,VEPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Abuse, Neglect, and Misappropriation of Property, and interviews, the facility failed to implement its abuse policy related to reporting verbal abuse for one resident (R) (#6) of five sampled residents. Findings include: Review of the facility policy titled Abuse, Neglect, and Misappropriation of Property dated (MONTH) 2019 revealed that allegations of abuse or neglect should be reported immediately to the Administrator and the SA (state agency). The policy describes the definition of verbal abuse to include the use of any disparaging language to any resident or within earshot of residents, regardless of their disability. Each facility Stakeholder (employee) should intervene immediately to interrupt any incident and provide for resident safety. Further review revealed each Stakeholder was required to report any actual or suspected abuse immediately. Any abuse allegation must be reported to the SA within two hours of the report being received. Review of the clinical record revealed R#6 was admitted to the facility 7/10/19 and the 10/11/19 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score to be 14, indicating cognition intact. During an interview on 10/24/19 at 1:00 p.m., R#6 stated there were two incidents between Licensed Practical Nurse (LPN) II and himself. R#6 stated LPN II only worked every other weekend so the incidents happened about two weeks apart, with the second incident being on 9/8/19, a Sunday. R#6 stated the first time they argued he asked for his pain medication for his ankle. R#6 stated LPN II told him disrespectfully he would have to wait his turn because she had other patients. R#6 stated he raised his voice to LPN II and she raised her voice to him, but she did not curse him on that first argument. R#6 then stated another argument occurred between himself and LPN II on or about 9/8/19. R#6 stated he never got his morning pain medication so around 1:00 p.m. he wheeled himself out to the nurses' station and found LPN II there working on a computer. R#6 stated this made him angry because he wondered why she was working on the computer when she had not given him his morning medication. R#6 stated he started to ask for his medication when LPN II slammed the nurses station door in his face. R#6 stated he opened the door and he and LPN II went at it. R#6 stated at some point during this heated exchange he called LPN II a [***] and R#6 stated then LPN II said in a loud voice, Your mama's a [***] ! R#6 said several staff members were present and heard all this. He stated he never saw the Administrator until he himself filed a grievance later. R#6 stated he did not file a grievance about the first argument because it did not really bother him. Review of a hand-written 9/10/19 Statement #1, which was signed by Certified Nursing Assistant (CNA) III, revealed she wrote on 9/7/19 and 9/8/19 she witnessed LPN II engage in a verbal disagreement with R#6. The disagreement was loud, described as a commotion, and went off and on for both 9/7/19 and 9/8/19. LPN II used profanity during at least one exchange and R#6 told CNA III he was very upset. There was no evidence that CNA III reported what she had witnessed until 9/10/19. Review of a hand-written undated Statement #2, which was signed by CNA GG revealed CNA GG overheard a confrontation between LPN II and R#6 during which LPN II called R#6's mother a B. Review of a 9/9/19 handwritten statement by LPN HH revealed she wrote an argument between R#6 and LPN II on 9/8/19 was related to a prior argument they had on 9/1/19. Further review revealed R#6 and LPN II called each other names. Review of a 9/9/19 Complaint/Grievance Report revealed R#6 filed a grievance against LPN II to the Administrator. Further review revealed LPN II was observed by staff having a loud disagreement with R#6. During an interview with the Administrator and Director of Nursing (DON) on 10/24/19 at 10:00 a.m., the Administrator stated the arguments between LPN II and R#6 were at least suspicious for verbal abuse. The Administrator agreed the statements of CNA GG and LPN HH about LPN II raising her voice and using profanity to a resident was suspicious for verbal abuse. The Administrator stated no report of this incident was made to the state because, at the time, he did not think it abuse, but now he did. The Administrator stated all staff were trained in matters of abuse/neglect and any of the staff that witnessed the verbal altercation between LPN II and R#6 should have notified him immediately, even though 9/8/19 was on a Sunday. The Administrator stated he was not informed of the incident of alleged verbal abuse involving LPN II until Monday, 9/9/19. The Administrator stated, at that time, he wrote up LPN II, provided in-servicing, and re-assigned LPN II to another unit. The Administrator stated LPN II continued working on the same hall where the involved resident lived on 9/7/19 and 9/8/19 because the alleged abuse was not reported to him until 9/9/19. The Administrator stated this incident should have been reported to the state within two hours. The Administrator also stated facility policy was that suspected or alleged abuse must be reported within two hours, and his nurses failed to notify him timely of the 9/8/19 incident. The DON stated she agreed the facility failure to report this incident to the state was contrary to facility policy. Interview with the Medical Director on 10/24/19 at 2:30 p.m. revealed he stated he was unaware of the alleged abuse incident involving LPN II on or about 9/8/19 because the facility did not notify him until the present day. The Medical Director stated he expected to be notified of any possible resident abuse and he should have been notified immediately.",2020-09-01
343,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2019-11-14,609,D,1,0,VEPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to notify the State Agency (SA) within the required two hours of an incident involving suspected verbal abuse of one resident (R) (#6) of five sampled residents. Findings include: Review of a 9/9/19 Complaint/Grievance Report revealed R#6 filed a grievance against LPN II to the Administrator. Further review revealed LPN II was observed by staff having a loud disagreement with R#6. Review of the clinical record revealed R#6 was admitted to the facility 7/10/19 and the 10/11/19 Quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score to be 14, indicating cognition intact. Interview with R#6 on 10/24/19 at 1:00 p.m. revealed an argument occurred between himself and LPN II on or about 9/8/19. R#6 stated he never got his morning pain medication so around 1:00 p.m. he wheeled himself out to the nurse's station and found LPN II there working on a computer. R#6 stated this made him angry because he wondered why she was working on the computer when she had not given him his morning medication. R#6 stated he started to ask for his medication when LPN II slammed the nurses station door in his face. R#6 stated he opened the door and he and LPN II went at it. R#6 stated at some point during this heated exchange he called LPN II a [***] and LPN II said in a loud voice, Your mama's a [***] ! R#6 said several staff members were present and heard all this. He stated he never saw the Administrator about this until he (R#6) filed a grievance later. During an interview on 10/24/19 at 10:00 a.m., the Administrator stated the arguments between LPN II and R#6 were at least suspicious for verbal abuse. The Administrator agreed the statements of CNA GG and LPN HH about LPN II raising her voice and using profanity to a resident was suspicious for verbal abuse. The Administrator stated no report of this incident was made to the state because, at the time, he did not think it abuse, but now he did. Further interview with the Administrator on 11/14/19 at 1:00 p.m. revealed the incident involving suspected verbal abuse of R#6 has now been reported to the S[NAME] Review of the facility policy titled Abuse, Neglect, and Misappropriation of Property dated (MONTH) 2019 revealed facility policy that allegations of abuse or neglect should be reported immediately to the Administrator Further review revealed any abuse allegation must be reported to the SA within two hours of the report being received.",2020-09-01
344,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2019-11-14,658,D,1,0,VEPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, observations, record review, review of facility policy titled Medication Administration and review of the Georgia Nurse Practice Act (chapter 410-10), the facility failed to provide supervision with the administration of medications for one of five sampled residents (R) (#10). Findings include: The Practice of Nursing includes, but is not limited to, provision of nursing care; administration, supervision, evaluation, or any combination thereof, of nursing practice; teaching; counseling; the administration of medications and treatments as prescribed by a physician [MEDICATION NAME] medicine in accordance with Article 2 of Chapter 34 of this title. Guideline #20 of the facility's Administering Medications General Guidelines policy documented the resident is always observed after administration to ensure that the dose was completely ingested. Review of the clinical record revealed R#10 has [DIAGNOSES REDACTED]. R#10 is his own responsible party. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed R#10 with a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact. A Physician's Note dated 10/15/19 revealed R#10 with intermittent confusion, staff documented that he gets belligerent and aggressive at times. He is a bit demanding about his medications. During an interview on 10/29/19 at 7:30 a.m., R#10 revealed Licensed Practical Nurse (LPN) QQ gave him all his morning medication at 6:00 a.m. He then opened the drawer to his bedside table and produced a clear dosage cup, containing 10 pills. R#10 stated LPN QQ left the pills for him to take later. During an interview on 10/29/19 at 7:42 a.m., LPN QQ stated R#10 is medication seeking and she did not leave any pills with him. LPN QQ went to R#10's room and R#10 stated he had taken the pills because he didn't want anyone to take them from him. He then reached underneath his bed covers and produced the cup of medication. He also reached into the cup, removed and ingested one white, round pill that he stated was Klonopin. During continued interview on 10/29/19 at 7:42 a.m., LPN QQ stated if you don't start with his medications immediately on your med pass, he will make you miserable. He can get all the medications he was given at once. I gave him his 6:00 a.m. meds about 5:00 a.m. because he was asking for them. He was right in front of me with the water. I thought he took it. I was supposed to watch the resident take the medicine, but I didn't. He was pressing me to give him his medication. I gave it to him and left. I should have waited for him to take it. I was busy with a [MEDICAL TREATMENT] patient; the transportation was rushing me. The Certified Nursing Assistant was helping me but, there was a lot going on. During an interview on 10/29/19 at 8:16 a.m., Unit Manager (UM) AA revealed R#10 is very meticulous about his medications. UM AA was unaware of any pills in his nightstand drawer. UM AA stated that residents are not allowed to keep medications in their rooms. The nurse has to make sure they take the medications before leaving the room. R#10 can safely have his morning medications all at once but, he has to take them. The nurse should not have just left them with him. No matter how alert a resident is, it's against facility policy. During further interview on 11/4/19 11:14 a.m., UM AA revealed that R#10 does not have physician orders [REDACTED]. During an observation on 10/29/19: 7:57 a.m., with LPN QQ, a comparison was made with the remaining medications in the dosage cup and R#10's ordered medications in the medication cart. The following medications were identified: [MEDICATION NAME] 30 milligram (mg) Losartan Potassium 100mg [MEDICATION NAME] 5mg [MEDICATION NAME] ER 30 [MEDICATION NAME] 7.5mg [MEDICATION NAME] 25mg Vitamin C OTC (over the counter) Aspirin 81 mg [MEDICATION NAME] tablet 75mg During further interview on 10/29/19 at 8:35 a.m., R#10 revealed that he took the [MEDICATION NAME] pill and pain meds at the cart along with the muscle relaxers. LPN QQ asked him if he wanted the rest of his morning pills. He said yes, she gave it to him, and he walked away with the cup. R#10 stated that he usually gets his pills, goes to his room, makes sure they are all there, and then takes them. Some of the nurses just set them down, turn around and walk out. During an interview on 10/30/19 at 4:07 p.m., the Medical Director (MD) revealed, it is not the facility's operation that a nurse leaves medication with a resident.",2020-09-01
345,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2018-11-16,550,D,0,1,G69611,"Based on observation, interview and review of facility policy, it was determined the facility failed to ensure all meals were served in a manner which enhanced resident's quality of life for all residents that consumed meals in the main dining room of the facility. During lunch meal services on 11/13 and 11/14/18, there were 33 and 34 residents, respectively, who ate their lunch meal in the main dining room at two settings. At the end of the first meal service, staff stacked dirty dishes with half eaten food, cups, glasses, eating utensils and dirty napkins on the first table on the left side of dining room. These dirty food items remained on the table and were visible throughout the dining room during the second dining service for both lunch meals on 11/13/18 and 11/14/18, thus not providing a dignified dining experience for seven of 127 residents of the facility. The findings include: Review of facility policy, Resident Rights (void of date) policy statement documented all residents have the right to be treated with dignity and respect. All residents will be treated in a manner that promotes maintenance or enhancement of quality of life. Dining Observation of Main Dining Room on 11/13/18 (lunch meal) at 12:30 p.m. revealed 26 residents were seated in the dining room for the first meal service. Dietary staff HH reported the noon meal is served in two settings: and residents are never rushed, the first group of residents are more independent, and the second group needs assistance from staff with feeding. The first group of residents began eating at 12:35 p.m. from food plated from the steam table in the dining room. The first group of residents began leaving dining room at approximately 1:00 p.m. Staff proceeded to take plates with half eaten food, cups, glasses, eating utensils and used napkins; placing the items on the first table near the steam table in the dining room. At 1:30 p.m. plates, cups, glasses, eating utensils and used napkins for 26 residents were stacked on a table in the dining room while the second setting of residents were being seated in the dining room. The soiled plates with half-eaten food, dirty eating utensils, dirty cups, glasses dirty napkins and food debris on the floor was visible during the entire meal service for the second group of seven residents as they were fed/assisted with their meal by staff. Observation of lunch meal 11/14/18 (main dining room) at 12:30 p.m. revealed Dietary staff HH began plating food from steam table for 27 residents. At 12:55 p.m. as residents began leaving; the dining room staff began cleaning tables and stacking plates with uneaten food, cups, glasses with straws, dirty napkins and eating utensils on a table in dining room closest to the steam table. The table with dirty plates, cups, glasses, eating utensils and dirty napkins was visible from all areas of the dining room. At 1:05 p.m. staff began bringing seven residents to dining room for lunch meal service. During the entire meal service of 45 minutes in which the residents were assisted with their meals, the table with the dirty food item was visible to anyone in the dining room. Interview with Dietary staff HH in the Main Dining Room on 11/14/18 at 1:35 p.m. revealed the dining room had recently been renovated. She said staff had been instructed not to bring a dirty cart into the dining room to remove dirty dishes at any time during meal time service. Dietary Manger JJ (DM) acknowledged on 11/14/15 at 1:40 p.m., leaving soiled dishes and debris in the dining room during meal service was not providing food service to the residents in a dignified manner. The DM said he would not eat in any food establishment with dirty food items in view. Interview with Registered Dietician II (RD) on 11/16/18 at 9:40 a.m. revealed she was at the facility two days a week or as needed. She stated she had not observed dirty food items on the dining tables during meal service, and further said since the renovation approximately one month ago a lot of staff had been reassigned. The RD concluded dietary staff are still in the process of getting their systems in place since renovation of the dining room.",2020-09-01
346,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2018-11-16,636,D,0,1,G69611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete the periodical comprehensive assessments with in the timeframes prescribed for three of 36 sampled residents (R) (R#2, R#73 and R#347). Findings include: 1. Review of the clinical record revealed R#2 was admitted to the facility on [DATE]. R#2 name and birthdate was changed to the correct spelling in the computer by the business office on 7/6/18. The entry modification was completed and submitted by RN KK on 11/15/18 for R#2. An interview was conducted on 11/15/18 at 1:35 p.m. with Registered Nurse (RN) KK. RN KK stated the change by the business office was missed. The Resident Assessment investigation of Minimum Data Set (MDS) greater than 120 days was determined to be correct. Review of the entry modification that was completed and submitted by RN KK on 11/15/18 was shown to be correct for R#2. The care plan was in place for R#2. 2. Review of the clinical record revealed R#73 was admitted to the facility on [DATE], sent to the emergency department on 11/4/18. R#73 was readmitted to the facility on [DATE]. The admission MDS for 10/10/18 was not completed. An interview was conducted on 11/16/18 at 12:30 p.m. with RN LL in her office. RN LL stated I am behind when asked about submissions of MDS. RN LL stated the resident's MDS significant change was due to the resident being taken off Hospice Care per the resident's representative decision. The MDS was completed up to section [NAME] Section G and further areas of the assessment were blank. The care plan had been updated to reflect the status of R#73, the MDS was not complete. 3. Review of the clinical record revealed R#347 was admitted to the facility on [DATE] and the admission MDS had not been completed. The care plan was in place for R#2. An interview was conducted on 11/16/18 at 9:00 a.m. with RN LL in the conference room. RN LL revealed the R347's admission MDS had not been completed. RN LL said the department has been behind on their MDS assessments. She said currently there are four MDS Coordinators and one just hired. An interview was conducted on 11/16/18 at 12:35 p.m. with RN LL in her office. RN LL stated there is no policy for MDS entry and admission, the resident assessment instrument (RAI) is used. An interview was conducted on 11/16/18 at 1:00 p.m. with RN KK in her office. RN KK stated we noticed last month that some assessments had not been completed on time and was unsure of how many. Administrative and consultant are aware, and we developed a Quality Assessment Performance Improvement (QAPI) plan and presented to administrator. We currently have four MDS nurses and are in the process of hiring another nurse. I am aware of what is required with the MDS submission. We all have calendars to remind us when MDS are due, we are just behind. Review of the Quality Performance/Peer Review Facility Process Improvement Plan/Continuous Quality Improvement documentation. The plan was developed on 10/15/18 with revisions on 11/1/18 and 11/16/18. The Goal of the plan was to ensure clinical assessments, care and services are completed timely and communicated to the clinical team. The target date listed on the plan for all MDS assessments to be completed was 12/17/18. The facility failed to complete the periodical comprehensive assessments in the timeframes prescribed for three of 36 sampled residents.",2020-09-01
347,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2016-12-02,248,D,0,1,S1LU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, family interview, and staff interview, the facility failed to provide for an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being for each resident. This affected one of three sampled residents (Resident (R) #217) who were observed for activities. Findings include: Review of R#217's clinical record revealed the resident had a [DIAGNOSES REDACTED]. The admission Minimum Data Set (a standard screening and assessment tool used for long term care residents) was completed on 5/27/16 indicated in Section F: Preferences for Customary Routines and Activities were obtained by an interview with the resident ' s family. The very important activities for R#217 included reading, music, animals, keep up with the new, doing things in a group of people, going outside and participating in religious services. Section G: Functional Status revealed the resident required extensive assistance of two staff for bed mobility, transfers and total assistance for transfer off the unit. Review of R#217 plan of care for activities indicated the goal for the resident was to participate as desired in self-directed activities of choice daily, attend group activity of interest once a week and will express satisfaction with type of activities and level of activity involvement. The approaches were to provide leisure supplies for self-directed pursuits and introduce to other residents with similar interest, disabilities, and/or limitations. Review of R#217's one to one participation log for (MONTH) (YEAR) revealed the resident had received four visits from activities for one to one activities. The activities included tactile stimulation and music. The (MONTH) (YEAR) log revealed the resident had received 10 visits from activities for one to one activities. The activities included visual stimulation and music. The resident was observed on 11/28/16 at 3:57 p.m. The resident was observed a reclined wheel chair at the nursing station on C-wing. The resident was awake. On 11/29/16 at 10:22 a.m. the resident was observed in bed with the head of the bed elevated. The resident was awake and the television was not on and there was no music in the room. On 11/30/16 at 10:50 a.m. R#217 was in bed, awake, picking at his right leg splint. There was no television or music playing in the room. At 5:36 p.m., the resident was in bed, awake and the head of the bed was elevated. The television was not on and there was no music in the room. On 12/1/16 at 10:08 a.m. activity staff went into the resident room with an activity cart, staff was giving the resident care and the activity staff stated they would be back. At 10:48 am the resident was awake in his bed, the activity staff had not returned to the resident's room. There was no music on nor was the television on. At 3:07 p.m. the resident was observed in a reclined wheel chair at the nursing station on C-wing. In the activity room a visitor was singing Christmas Songs to the residents. Interview with R#217's wife on 11/29/16 at 2:10 p.m. revealed she visits several times a week and her husband does not attend activities. She stated she thought he would like the music or church activities. Interview with the Quality of Life (Activity) Director on 12/02/2016 9:03 a.m. indicated R#217 ' s plan of care for activities was not individualized. She further stated the resident is unable to do any self-directed activities. She also indicated the one to one visits last approximately 15 minutes per visit. She also confirmed he was not invited to the music activity on 12/1/16 because the resident was going to be put in bed by the nursing staff.",2020-09-01
348,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2016-12-02,279,D,0,1,S1LU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations clinical record review, review of the policy and procedure for Care Plan-Comprehensive, and staff interview, the facility failed to develop a comprehensive care plan for each resident's needs that were identified in the comprehensive assessment. This affected one of three sampled residents (Resident (R) #217) who were reviewed for activities. The sample was 27. Findings include: Review of R#217's clinical record revealed the resident had a [DIAGNOSES REDACTED]. The admission Minimum Data Set (a standard screening and assessment tool used for long term care residents) was completed on 5/27/16 indicated the Brief Mental Interview for Mental Status had a score of 1- (indicating severely cognitively impaired.) Section F: Preferences for Customary Routines and Activities were obtained by an interview with the resident's family. The very important activities for R#217 included reading, music, animals, keep up with the new, doing things in a group of people, going outside and participating in religious services. Section G: Functional Status revealed the resident required extensive assistance of two staff for bed mobility, transfers and total assistance for transfer off the unit. Review of R#217 plan of care for activities indicated the goal for the resident was to participate as desired in self-directed activities of choice daily, attend group activity of interest once a week and will express satisfaction with type of activities and level of activity involvement. The approaches were to provide leisure supplies for self-directed pursuits and introduce to other residents with similar interest, disabilities, and/or limitations. Refer to F248 activities for observations (11/28/16 at 3:57 p.m.; 11/29/16 at 10:22 a.m.; 11/30/16 at 10:50 a.m. and 5:36 p.m.; and 12/1/16 at 10:00 a.m., 10:40 a.m. and 3:07 p.m.) of R#217 in which staff failed to provide activities that interested the resident. R#217 was observed in either his room or in the main areas of the facility without any activity being provided that met his interest. Refer to F248 for the interview of the Quality of Life (Activity) Director on 12/02/2016 9:03 a.m. in which the Quality of Life (Activity) Director confirmed that R#217's care plan had not been individualized. She further stated that based on assessment and interview with R#217's wife, R#217's care plan did not address specific activities that interested R#217.",2020-09-01
349,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2016-12-02,431,D,0,1,S1LU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, review of the facility policy for Storage of Medications and review of the Par Pharmaceutical Company for medication specifications, the facility failed to remove one multi-dose vial (a vial of injectable mediation which contains more than one dose of medication) in use for the past 28 days. The facility failed to date 4 multi-use vials of medication when opened. This affected one of three medication rooms located in the facility (West wing). Findings include: Observation on [DATE] at 5:00 p.m. of the medication storage room on the West Wing found a multi-dose vial of Pneuomax 25 micrograms in the medication refrigerator which had expired on [DATE], 28 days after the expiration date. Observation of the multi-dose vials of Tubercular Purified Protein medications indicated four vials were open and there was no date to indicate when the medication was opened. Review of the facility's policy for Medication Storage dated ,[DATE] indicated when medications were outdated they were to be immediately removed from stock, disposed of according to procedure for medication disposal. Review of the Par Pharmaceutical Company's Aplisol (Tuberculin Purified Protein Derivative) medication specifications (no date) indicated any vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. Interview with Licensed Practical Nurse (LPN) TTT confirmed the Pneuomax had expired on [DATE] and the Tubercular was open and was not dated to indicate when the vial was opened.",2020-09-01
350,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2017-12-21,693,D,0,1,CJ2111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to give medications and water flushes by gravity through a gastrostomy tube (GT) for two of two residents (R) with GTs observed (R #38 and #104) during medication pass. The sample size was 33 residents. Findings include: 1. Review of R #38's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a feeding tube. Review of R #38's care plans revealed one for aspiration risk due to tube feedings and increased secretions developed on 10/21/17, and one for need for a feeding tube with a potential for complications developed 10/17/17. During medication pass on 12/20/17 at 9:08 a.m., Licensed Practical Nurse (LPN) BB was observed giving R #38 her morning medications via her GT. During continued observations, LPN BB drew up 30 milliliters (mL) of water into a 60-mL syringe, and pushed it into the resident's GT using the syringe plunger, instead of allowing it to flow in the GT by gravity. LPN BB was then observed to separately draw up in the syringe two medications, each diluted in 30 mL water, and pushed them one at a time into the GT with the syringe plunger. In addition, LPN BB was observed to push 30 mL of water flush in the GT after each medication given. During interview with LPN BB on 12/21/17 at 9:10 a.m., she verified that she gave the medications and water flush to R #38 by pushing them in with a syringe and plunger. She further stated that she always gave medications this way, but that she did not push them in forcefully. 2. Review of R #104's Quarterly MDS dated [DATE] revealed that he had a feeding tube. Review of his care plans revealed one for risk for aspiration due to bolus tube feeding, developed on 3/13/17. On 12/21/17 at 8:39 a.m., LPN AA was observed giving R #104 his morning medications via his GT. The LPN was observed to draw up 50 mL of water into a 60-mL syringe, and push it into the resident's GT with the plunger, instead of allowing it to flow in by gravity. Further observations revealed that all of the medications and water flushes that followed this initial water flush were allowed to flow in the GT by gravity. During interview with LPN AA on 12/21/17 at 8:59 a.m., she stated that she did not realize she had pushed the initial water flush for R #104 with the plunger, as she usually gave anything through a GT by gravity. During interview with the Director of Nursing on 12/21/17 at 10:21 a.m., she stated that her expectation was that all medications and fluids be given by gravity through a GT, and not pushed in with a syringe. Review of the facility's pharmacy policy Medication Administration Enteral Tubes, dated 2007, revealed to allow medication to flow down the tube via gravity.",2020-09-01
351,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2017-12-21,755,D,0,1,CJ2111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to ensure that a medication was obtained from the pharmacy in a timely manner for one resident (R) (R Q). The sample size was 33 residents. Findings include: Review of R Q's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of a Nurse Practitioner progress note dated 12/14/17 revealed that R Q had an acute right mid superficial [MEDICAL CONDITION] ([MEDICAL CONDITION] (blood clot)) and left popliteal [MEDICAL CONDITION]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she was not on a scheduled pain program, received pain medicine as needed during the assessment period, and had frequent moderate pain. Further review of this MDS revealed R Q had a Brief Interview for Mental Status (BIMS) score of 11 (a score of 8 to 12 indicates moderate cognitive impairment). Review of R Q's physician's orders [REDACTED]. During interview with R Q on 12/19/17 at 8:10 a.m., she stated that the facility ran out of her [MEDICATION NAME] on Saturday night (12/16/17), and she was only given Tylenol until the [MEDICATION NAME] was available on Monday afternoon (12/18/17) around 4:30 p.m. She further stated that even with the [MEDICATION NAME] her back pain was never totally relieved, and rated her average pain as a 5 on a scale of 0 to 10. Review of R Q's (MONTH) Medication Administration Record [REDACTED]. During interview with Licensed Practical Nurse (LPN) BB on 12/21/17 at 2:40 p.m., she stated that when a resident had about ten doses of a narcotic pain medication left, the nurses were responsible for contacting the physician for a new prescription, so that the supply would not run out before the medicine could be refilled. She further stated that she noted that R Q had only four or five [MEDICATION NAME] tablets left on Friday afternoon (12/15/17), so she told the 3:00 p.m. to 11:00 p.m. nurse to contact the pharmacy to see if any refills were available. During continued interview, LPN BB stated that when she came back to work on Monday (12/18/17), she noted on the 24-hour report that R Q had been out of her pain medicine over the weekend. Review of the 24-Hour Report/Change of Condition Report dated 12/17/17 noted that staff were awaiting the [MEDICATION NAME] for R Q, and that the Rx (prescription) was faxed by the physician. Review of the 24-Hour Report dated 12/18/17 noted that staff were still awaiting the [MEDICATION NAME] from the pharmacy for R Q. During further interview with LPN BB, she stated that she did not know what delayed the delivery of the [MEDICATION NAME], but that the Medical Director could be contacted for a prescription if the attending physician could not be reached. LPN BB further stated that R Q complained of leg pain a lot, and asked for pain medicine around the clock. During interview with R Q on 12/21/17 at 3:18 p.m., she stated that she was given Tylenol when the [MEDICATION NAME] was not available, and that it took the edge off her pain. She further stated that the doctor had ordered a muscle relaxer for her the previous week, but she did not want to take it. Review of R Q's Nurse's Notes between 12/15/17 and 12/18/17 revealed no mention of the resident being out of [MEDICATION NAME], as well as no documentation that the attending physician and/or Medical Director had been called for a prescription. This was verified during interview with the Director of Nursing (DON) on 12/21/17 at 3:36 p.m.",2020-09-01
352,SIGNATURE HEALTHCARE OF MARIETTA,115206,811 KENNESAW AVENUE,MARIETTA,GA,30060,2017-12-21,809,E,0,1,CJ2111,"Based on observation, record review, and staff interview, the facility failed to provide meals at regular times and according to the schedule in the main dining room and on five of nine halls. Findings include: Review of the facility's Dining Schedule revealed that breakfast on the East Wing (halls A, B, and C) began at 7:40 a.m., and lunch on the East Wing began at 12:40 p.m. Review of the resident council minutes revealed two documented complaints 1/5/17 and 5/11/17 of meals arriving to the halls late. Observation on 12/18/17 at 12:30 p.m. of the main dining room during lunch revealed residents that require minimal assistance with feeding. The staff started serving meals at 12 :35 IP. AM. for the first dining, but the first lunch serving was not completed in the main dining room until 1:20 p.m p.m The second dining was scheduled for 1:30 p.m. in the main dining room, but the meals were not started being served until 1:45 p.m. Observation on 12/18/17 at 1:28 p.m. on the East Wing Lunch has not arrived for 4 residents on C Hall R#15, R#42 R#76 and R#78. The scheduled meal time is 12:40 p.m. During interview with resident (R) R on 12/18/17 at 1:39 p.m., who resided on the A-hall, she stated that her lunch tray had not come yet. She further stated that the meal trays seemed to be coming late recently. During observations of the lunch service on the A-hall on 12/18/17, the meal trays were noted to be delivered at 2:00 p.m. Further observation revealed that R R received her lunch tray at 2:12 p.m. Observation on 12/18/17 at 1:44 p.m. lunch delivered to the East Wing C Hall. The scheduled meal time is 12:40 p.m. Observation on 12/18/17 at 1:46 p.m. lunch trays are being distributed to the residents by three staff on East Wing C hall. The scheduled meal time is 12:40 p.m. During an interview with resident (R) A on 12/18/17 at 2:35 p.m. Resident A revealed that the meals are late, the staff are talking, and the door on the cart is not shut. Resident A further revealed the food is cold by the time it arrives to the room. During interview with R Q on 12/19/17 at 8:30 a.m., she stated that she ate dinner at the first seating in the dining room which was scheduled for 5:30 p.m., but that it was usually 6:30 p.m. before the food was served. She further stated that she just had to sit there and wait until the food came out. During further interview, R Q stated that she ate breakfast in her room on the A-hall, and it usually came around 9:00 a.m. On 12/19/17, breakfast trays were observed to be delivered to the A-hall at 9:01 a.m., and two staff started to distribute the food to the residents at 9:10 a.m. Observation on 12/19/17 at 9:51 a.m. RC has not received breakfast tray. The scheduled meal time is 7:40 a.m. Interview on 12/19/17 at 9:52 a.m. R C confirmed that the breakfast had not been delivered. The scheduled meal time is 7:40 a.m. During interview with R S on 12/19/17 at 9:53 a.m., she stated that she usually ate in her room on the A-hall, and that her food was cool when she got it at all three meals. Observation on 12/19/17 at 10:45 a.m. R C breakfast was delivered to the room by staff. Interview on 12/19/17 at 1: 40 p.m. with EE, certified nursing assistant (CNA) on the East hall revealed that meal trays are generally late getting to the unit sometimes as much as an hour or more from their scheduled time. Interview on 12/19/17 at 2:15 p.m. with FF, registered nurse (RN) on the F hall revealed that the trays are generally late getting out to the units. She stated that several of the staff are back in the dining room helping residents that eat in the main dining room and when that meal is started late it causes them all to be late. Interview on 12/19/17 at 10:15 p.m. with the Dietary Manager (DM) revealed the facility does have a dining schedule. The DM further states that he is aware of the time it takes for the trays to be delivered. The DM initiated a Delivery Sheet for the trays to be signed for once they are delivered on the units. He states the facility has nine halls plus the main dining room. He has six food carts to cover all the halls. There are times when all the trays must be delivered on the C & D halls before the other units are able to receive their trays. The DM further stated that he was fully staffed and he thought the dietary department needed more food carts. Observation on 12/20/17 at 8:52 a.m. breakfast cart delivered to the East Wing Hall C. The scheduled meal time is 7:40 a.m. Breakfast distributed to the residents by several staff. Observation on 12/20/17 revealed that the first cart of breakfast trays was delivered to the A-hall at 9:03 a.m., with a second cart of trays arriving at 9:12 a.m. On 12/20/17, the lunch trays were observed to be delivered to the A-hall at 1:08 p.m. Observation on 12/21/17 at 8:27 a.m. revealed that a cart with breakfast trays was taken to the C-hall, but no trays had arrived on the A-hall yet. Review of the Dietary Cart Delivery Sheet for the dates of 12/18/17, 12/19/17 ,12/20/17 and 12/21/17 revealed that the trays were consistently late as evidenced by the following observations: Observation on 12/18/17 on the East Hall revealed the lunch trays delivered to the unit at 1:45 p.m. The facilities' scheduled time for meal time for lunch delivery was 12:50 p.m. Observation on 12/19/17 at 1:00 p.m. on the D Hall revealed the lunch trays delivered to the unit. The facilities' scheduled meal time for lunch delivery is 12:40 p.m Observation on 12/19/17 at 1:20 p.m . on the East Wing revealed the lunch trays delivered to the unit. The facilities' scheduled meal time for lunch delivery is 12:40 p.m. Observation on 12/20/17 at 8:53 a.m on the East Hall revealed the breakfast trays delivered to the unit. The facilities' scheduled meal time for breakfast delivery is 7:50 p.m. Observation on 12/21/17 at 1:28 p.m. on the East Hall revealed the lunch trays delivered to the unit. The facilities' scheduled meal time for lunch delivery is 12:40 p.m.",2020-09-01
353,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2020-01-02,641,D,1,0,SFYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for three residents (R) Z, R S, and R T for respiratory treatment use of a Continuous Positive Airway Pressure ([MEDICAL CONDITION] provides constant airflow which holds the airway open so that uninterrupted breathing is maintained during sleep) machine of five sampled residents. Findings include: 1. Review of the clinical record for R Z revealed a History and Physical dated 12/22/19 indicating the resident has a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section O: O0100 Special Treatments and Programs, Respiratory Treatments [NAME] [MEDICAL CONDITION]/[MEDICAL CONDITION], was not assessed. An interview with the MDS lead on 1/2/20 at 3:27 p.m. confirmed that R Z, had a [MEDICAL CONDITION] machine that was used prior to admission and after admission to the facility. She also confirmed that R Z has a [DIAGNOSES REDACTED]. [MEDICAL CONDITION]/[MEDICAL CONDITION], was not coded accurately. The MDS lead revealed she would make the necessary correction to R Z assessment. 2. Review of the clinical record for R S revealed a History and Physical dated 11/17/19 indicating the resident has a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed Section O: O0100 Special Treatments and Programs, Respiratory Treatments [NAME] [MEDICAL CONDITION]/[MEDICAL CONDITION], was not assessed. An interview on 1/2/20 at 3:29 p.m. with MDS lead. The MDS lead confirmed that R S had a [MEDICAL CONDITION] machine that was used prior to admission and after admission to the facility. She also confirmed that RS has a [DIAGNOSES REDACTED]. 3. Review of the clinical record for R T revealed a History and Physical dated 12/6/19 indicating the resident has a [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Review of the Minimum Data Set (MDS) admission assessment dated [DATE] revealed Section O: O0100 Special Treatments and Programs, Respiratory Treatments [NAME] [MEDICAL CONDITION]/[MEDICAL CONDITION], was not assessed. An interview with the MDS lead on 1/2/20 at 3:31 p.m. confirmed that R T had a [MEDICAL CONDITION] machine that was used prior to admission and after admission to the facility. She also confirmed that R T has a [DIAGNOSES REDACTED]. The MDS Lead revealed she would make the necessary correction to R T assessment.",2020-09-01
354,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2020-01-02,695,D,1,0,SFYC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident and staff interviews, record review, review of the facility policy titled, BI-PAP/[MEDICAL CONDITION] the facility failed to ensure that three Resident (R) Z, R T, and R S Continuous Positive Airway Pressure ([MEDICAL CONDITION] provides constant airflow which holds the airway open so that uninterrupted breathing is maintained during sleep) machine, mask/nasal pillow, and tubing was cleaned and sanitize. In addition, R U Bilevel Positive Airway Pressure (Bi-PAP Provides assistance during inspiration and expiration) machine, mask, and tubing was cleaned and sanitize for four of four residents reviewed with [MEDICAL CONDITION]/Bi-PAPA machines. Findings include: Review of the policy titled, BI-PAP/[MEDICAL CONDITION] dated 12/2009 indicated Note: Manufacturer's recommendations should be followed. BI-PAP/[MEDICAL CONDITION] should be cared for and replaced per manufacturer's recommendations. Filters-foam usually clean weekly. Wash mask with soap and water after each use and pat dry. 1. Review of R Z the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 13 of 15, indicating the resident was cognitively intact. Further review of the electronic health record revealed a [DIAGNOSES REDACTED]. Review of the Physician Order included: (MONTH) use home [MEDICAL CONDITION] settings 12.0 centimeters (cm) worn every night as needed for sleep comfort. Record review of the resident's care plan focus area has risk for respiratory impairment related to [MEDICAL CONDITION] and sleep apnea revealed an intervention for [MEDICAL CONDITION] use per Physician's Order however the care plan did not address cleaning or who was responsible to clean the [MEDICAL CONDITION] equipment. An interview with R Z on 12/30/19 at 10:15 a.m. revealed that the resident was using a [MEDICAL CONDITION] machine at night. The resident revealed that since admission to the facility staff has not provided the necessary solution to clean the machine, mask or tubing. The patient also revealed the facility has never inquired if the machine, mask/nasal pillow or tubing has been cleaned. Review of the manufactures user manual of R Z [MEDICAL CONDITION] machine section on cleaning revealed: Cleaning the Device: Proper upkeep of your [MEDICAL CONDITION] machine can help ensure the device functions properly. It is vitally important to keep everything as clean as possible, as hoses/tubing and masks can be a prime breeding ground for bacteria and mold, unplug the device, and wipe the outside of the device with a cloth slightly dampened with water and a mild detergent. Clean the flexible tubing daily. Clean the flexible tubing, gently wash the tubing in a solution of warm water and a mild detergent. Rinse thoroughly. Air dry. 2. Review of T the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Further review of the electronic health record revealed a [DIAGNOSES REDACTED]. Review of the Physician Order dated 12/6/19 included: [MEDICAL CONDITION] settings 12.0 cm worn every during night time hours every evening and night shift for OS[NAME] Observation on 12/30/19 at 11:30 a.m. revealed in the resident's room, a [MEDICAL CONDITION] machine at the bedside. An interview with the resident on 12/30/19 at 11:30 a.m. revealed the [MEDICAL CONDITION] machine is used every night. The resident revealed no one has cleaned the tubing or provided any type of chemical/solution needed to clean the machine since admission to the facility. The resident revealed when at home the tubing and mask were cleaned daily. Review of the manufactures user manual of the resident's [MEDICAL CONDITION] machine revealed: Cleaning the Device: Proper upkeep of your [MEDICAL CONDITION] machine can help ensure the device functions properly. It is vitally important to keep everything as clean as possible, as hoses/tubing and masks can be a prime breeding ground for bacteria and mold, unplug the device, and wipe the outside of the device with a cloth slightly dampened with water and a mild detergent. Clean the flexible tubing daily. Clean the flexible tubing, gently wash the tubing in a solution of warm water and a mild detergent. Rinse thoroughly. Air dry. 3. Review of R S Admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Further review of the electronic health record revealed a [DIAGNOSES REDACTED]. Review of the Physician Order dated 12/6/19 included: [MEDICAL CONDITION] settings 12.0 cm worn during the night time hours every evening and night shift for OS[NAME] Record review of the resident's care plan focus area has risk for respiratory impairment related to sleep apnea initiated on 11/21/19, revealed an intervention for [MEDICAL CONDITION] use per Physician's Order however the care plan did not address cleaning or who was responsible to clean the [MEDICAL CONDITION] equipment. An interview with R S on 12/31/19 at 12:40 p.m. revealed that prior to selecting the facility the resident confirmed if the facility had the necessary supplies and staff to assist with cleaning/caring of the [MEDICAL CONDITION] machine. The resident was told by the liaison that there were qualified staff to assist with the [MEDICAL CONDITION] machine. The resident revealed since admission to the facility no one has offered to clean the mask/nasal pillow, machine or tubing. The resident also revealed no one has never inquired if the machine, mask/nasal pillow or tubing has been cleaned. Review of the manufactures user manual of R S [MEDICAL CONDITION] machine section on cleaning revealed: Warning regularly clean your tubing assembly, water tub and mask to receive optimal therapy and to prevent growth of germs that can adversely affect your health. 4. Review of R U Admission Minimum Data Set (MDS) assessment revealed the resident had a BIMS of 13 indicating the resident was cognitively intact. Further review of the electronic health record revealed a [DIAGNOSES REDACTED]. Review of the Physician Order dated 11/14/19 included: [MEDICAL CONDITION]: home settings 4 cm water worn at night hours for sleep apnea. An interview with R U on 12/30/19 at 11:15 a.m. revealed the resident used the BI-PAP machine every night. The resident revealed the staff places the mask on the resident each night and is not aware of who is cleaning the mask, tubing or machine. The resident revealed she does not touch the machine. Review of the manufactures user manual of RU Bi-PAP machine section on cleaning revealed: Cleaning and wash the tubing and mask before use and daily. An interview with the Assistant Director of Nursing (ADON) on 12/30/19 at 2:30 p.m. revealed the residents are responsible for cleaning their own mask/nasal pillow, and tubing. The ADON revealed there is no screening to assess if the resident can clean the [MEDICAL CONDITION]/Bi-PAP machine, mask/nasal pillow and tubing. The ADON revealed the facility does not have a cleaning schedule or audit to assess if the residents are of cleaning the [MEDICAL CONDITION]/Bi-PAP machines, mask/nasal pillows or tubing. An interview was conducted on 12/31/19 at 2:40 p.m. Director of Nursing (DON). The DON revealed the residents are responsible for cleaning the [MEDICAL CONDITION]/Bi-PAP machine. She revealed the facility policy address only the cleaning of the mask. She revealed it is not the responsibility of the facility to clean the [MEDICAL CONDITION]/Bi-PAP tubing. A post survey telephone interview with the DON on 1/14/2020 at 10:18 a.m. revealed that the facility does have a few [MEDICAL CONDITION] machines for residents, if needed, but that most resident's bring their own to the facility. She further revealed that the resident or their families are responsible for cleaning their own equipment and confirmed that the facility does not have a procedure to ensure that the [MEDICAL CONDITION] equipment is cleaned.",2020-09-01
355,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-01-26,582,D,0,1,KI5R11,"Based on record review and staff interview the facility failed to provide a Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) to two (2) residents (R) #50 and (R) [NAME] of three (3) residents who were reviewed after being discharged from Medicare Part A Services and remained in the facility. Findings include: Review of the records for R#50 revealed the resident started to receive physical therapy and occupational therapy services on 9/5/17 and these services ended on 10/31/17. Review of the records for (R) [NAME] revealed the resident started to receive physical therapy, occupational therapy and speech therapy services on 9/8/17 and these services ended on 11/9/17. During an interview with Social Worker, AA on 1/26/18 at 10:58 a.m she stated she did not issue a SNFABN to (R)E or R#50. She also stated she did not know that a SNFABN had to be issued to residents who did not exhaust their coverage days of skilled services and who remained in the facility.",2020-09-01
356,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-01-26,689,D,0,1,KI5R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of the facility Falls Practice Guide, review of the facility Clinical Services FYI for Post-Fall Evaluation, process, Air and Water Temperature Log, Accident Logs, staff and resident interviews, the facility failed to ensure one resident (R) (R#34) was assessed after experiencing falls and failed to maintain safe water temperatures in four resident bathrooms on two of two floors and at the sink area in one of two common-use shower rooms. The sample size was 38. Observation on 01/24/18 at 9:48 a.m. revealed the hot water in the bathroom of 146 was uncomfortably hot to the hand and could not be run over the bare skin for more than ten seconds. Observation of the water temperature taken by the maintenance director in several resident bathrooms between 10:00 a.m. and 10:32 a.m. on 1/24/18 revealed the following: 10:01 a.m. - the water in room [ROOM NUMBER] was 126 degrees Fahrenheit 10:04 a.m. - the water in room [ROOM NUMBER] was 128.8 degrees Fahrenheit, 10:10 a.m. - the water in room [ROOM NUMBER] was 121.5 degrees Fahrenheit 10:13 a.m. - the water at the sink in the shower room on the first floor was 123 degrees Fahrenheit 10:32 a.m. - the water in bathroom [ROOM NUMBER] was 127 degrees Fahrenheit Interview on 1/24/18 at 10:44 a.m. with the Maintenance Director revealed that the facility maintains a temperature range between 110 degrees Fahrenheit and 120 degrees Fahrenheit for the hot water. However, he likes to keep the hot water temperatures closer to 110 degrees Fahrenheit. Currently the temperature has been adjusted to 105 degrees Fahrenheit on the gauge in the boiler room to get the hot water temperatures down in the resident rooms. He monitors the water temperatures one day each week by picking random rooms on the first and second floor on each side to check water temperatures. If during this monitoring, a hot water temperature is found to be below 100 degrees, he considers that to be too cold, and if the hot water temperature is above 120 degrees Fahrenheit, then he considers that to be too hot. If the temperature of the hot water is outside of these parameters, then he adjusts the gauge in the boiler room - either upwards or downwards. He keeps a log of temperatures and enters them into the computer and this is sent to the corporate office. The last such temperature check was done the previous week. He is the person primarily responsible for adjusting water temperatures, but the plumber was in the facility to fix a clogged sink on the day of the interview and was, therefore, assisting with adjustments of the water temperature. He could not say why the temperatures were varying like they were from room to room, but since the temperatures were above 120 degrees Fahrenheit, he planned to check the gauges on the boiler and would attempt to lower the temperature by using the mixer. Once the adjustment was made, he planned on waiting for 15 minutes before rechecking the temperatures in the residents' rooms. Interview on 1/24/18 at 10:55 a.m. with the administrator revealed that she was aware of the situation with the hot water temperatures and the maintenance director and the plumber were working to fix the problem. She had placed notices in each resident's room advising them not to use the hot water and to ask for staff assistance if there was a need for hot water. She was aware of no indents wherein a resident, staff, or visitor had been burned or scalded from the hot water in the building. Review of the Air & Water Temperature Logs for the months of (MONTH) (YEAR) to (MONTH) (YEAR) revealed the facility recorded weekly water temperatures taken in random rooms on both resident floors and that these temperatures ranged between 109 degrees F and 120 degrees F. Review of the weekly water temperatures for (MONTH) (YEAR) revealed similar ranges in water temperatures were documented for random rooms on both floors of the facility on 1/5/18, 1/12/18, and 1/19/18. Review of the Accident Logs for the months of (MONTH) (YEAR) through (MONTH) (YEAR) revealed there were no accidents related to high water temperatures in the facility. On 1/24/18, observation of the water temperature during a recheck of resident bathrooms on the first and second floors revealed: 3:24 p.m. - the water in bathroom [ROOM NUMBER] was 128 degrees Fahrenheit 3:35 p.m. - the water in bathroom [ROOM NUMBER] was 109 degrees Fahrenheit, 3:39 p.m. - the water in bathroom [ROOM NUMBER] was 117 degrees Fahrenheit 3:44 p.m. - the water at the sink in the shower room on the first floor was 118 degrees Fahrenheit 3:56 p.m. - the water in bathroom [ROOM NUMBER] was 117 degrees Fahrenheit 3:59 p.m. - the water in bathroom [ROOM NUMBER] was 118 degrees Fahrenheit, 4:01 p.m. - the water in bathroom [ROOM NUMBER] was 116 degrees Fahrenheit. Interview on 1/24/18 at 4:05 p.m. with the maintenance director revealed that he had adjusted the temperature in the boiler room down to 105 degrees Fahrenheit at 1:30 p.m. He then checked the hot water temperatures in some rooms between 2:00 p.m. and 3:00 p.m. During those checks, the water in room [ROOM NUMBER] was 101 degrees Fahrenheit and in room [ROOM NUMBER] was 102 degrees. After adjusting the gauge on the boiler, the highest temperature he obtained in any of the rooms was 105 degrees Fahrenheit. Review of the medical record for R#34 revealed an admission date of [DATE] with a diagnosis, including but not limited to, [MEDICAL CONDITION] and collapse. According to R#34's most recent Minimum Data Set (MDS), Quarterly assessment of overall status dated 11/28/17, the resident's (Brief Interview of Mental Status (BIMS) score of 11 out of 15 which indicates moderate cognitive impairment. The resident required one-person extensive assistance to complete all Activities of Daily Living (ADLs). Review of the Care Plan revealed that R#34 is at risk for falls due to history of falls, impaired balance/poor coordination, unsteady gait with a date initiated of 5/22/17. Interventions include bed in low position, encourage to transfer and change positions slowly, evaluate medications if patient demonstrates changes in mental status, ADL function, appetite, neurological status, etc., Have commonly used articles within easy reach, provide assist to transfer and ambulate as needed, reinforce need to call for assistance, reinforce wheelchair safety as needed such as locking brakes. The facility's Clinical Services FYI/Falls Practice Guide, dated (MONTH) 2011, read, in pertinent part, Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient has hit their head; following an un-witnessed fall when a head injury may be suspected and following non-fall patient events which result in known or suspected head injury such as a suspected hemorrhagic stroke. Nursing Progress Note dated 7/16/17 read, Walking down hall near room [ROOM NUMBER]. I heard someone calling out help me. Upon entering room [ROOM NUMBER], noted patient on floor in a sitting position at the foot of her roommate`s bed. Active bleeding from left eye. Saying, I can`t see. Blood noted to left side of head. Blood noted on floor at foot of her bed. I call for help. Evaluated patient for further injuries prior to assisting her up from floor to her wheelchair. When asked what happened, she stated I was going to open the door and fell . Dry dressing placed to laceration on head and tissue given to patient to hold pressure on left eye. Vital signs taken, Blood Pressure 125/63; Pulse 81; Respirations 20; Pulse Oxygen Saturation 98%. No oxygen on at this time. Doctor and son, notified. Order obtained to send patient to emergency room for further evaluation. She voiced no pain. She only voiced not being able to see out of her left eye. Transferred out to the Medical Center related to fall incident with minor injury. Resident family made aware. Nursing Progress Notes dated 9/8/17 read, Resident noted in sitting position on floor beside of her bed. Stated that she slipped and fell to the floor as she stood up to ambulate to adjust her television volume. Medical Doctor (MD) aware and no new orders given. Resident family made aware. No sign of distress/injuries noted. Vital signs 96.1; 82; 20; 136/70. Neurological checks in progress. Nursing Progress Notes dated 12/12/17 IDT note read: Continues to try to do tasks independently increasing her risk for falls. Ongoing education to minimize falls and injury. Certified Nursing Assistant (CNA) answered call for help found resident on floor in sitting position beside low positioned bed. She reports she got out of bed to get her shoes and felt herself sliding and sat on floor. She was assisted to the bed and assessed. No injuries noted. She denied pain/discomfort. MD informed via voice mail. Resident family informed via telephone conversation. Vital signs 130/69; 70; 18; 98.2. Nursing Progress Notes dated 1/16/18 read, Resident noted on floor in sitting position. Stated that she was sitting on the edge of the bed and slid to the floor. Total assessment done per Nurse. No sign of injury/distress noted. Denies pain. Neuro checks in progress. MD made aware. Resident family made aware. Vital signs 124/60; 66; 20; 98.0. Will continue to monitor. Review of Falls Practice Guide revealed that an evaluation of the patient is completed timely following a fall or change in patient condition that increases the patients risk for falls. Post fall evaluations are documented in the patient's clinical record. The interdisciplinary care plan team reviews the patient's most current falls Care Area Assessment (CAA) or fall evaluation in the electronic record to determine if the patient's present condition or status has changed and therefore requires the completion of a new fall evaluation. If the current fall evaluation still describes the patient accurately, then a narrative summary of the patient's condition and circumstances surrounding the event are documented in the patient's clinical record. The care plan is revised as clinically indicated to meet the patient's current needs. 01/26/18 04:11 p.m. Interview with the Director of Nursing (DON) revealed that when a resident goes out, acutely, to the hospital after a fall there is no assessment done and upon their return to the facility the resident is monitored. On 01/26/18 at 05:29 p.m. Interview with Administrator revealed that the facility does not have a fall evaluation tool in the electronic record. She states they only keep the Post-Fall Evaluation for a quarter as well as the minutes from the Review Room and they do not have the evaluation/assessments from R#34's fall from 7/16/17, 9/8/17, 12/12/17, and 1/16/18. No documentation or post fall evaluations were found anywhere in R#34's clinical record for the fall dates 7/16/17, 9/8/17, 12/12/17, and 1/16/18.",2020-09-01
357,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2018-01-26,761,D,0,1,KI5R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow the policy titled Storage of Medications and Biological ' s, and failed to reconcile narcotic medications for one of six medication carts, failed to date an opened multi-use Polythylene [MEDICATION NAME] 3350 medications for two residents in one of six medication carts, to ensure disposal by the appropriate expiration date, failed to date an opened multi-use vial of [MEDICATION NAME] Purified Protein Derivative Diluted in one of two medication refrigerators to ensure disposal by the appropriate expiration date. The facility census was 111. Finding include: An observation on 1/24/18 at 12:00 p.m. of the 1st floor Medication Storage Room revealed the following opened not dated/unlabeled medication and /or expired in the medication refrigerator: 1. One [MEDICATION NAME] Purified Protein Derivative Diluted [MEDICATION NAME] 5TU/0.1ml with an expiration date of 4/2019, opened, not dated and administered to two residents on 1/22/18 An observation on 1/25/18 at 10:00 a.m. with the of the 2nd floor Medication Cart 2 revealed the following opened not dated/unlabeled medications and /or expired in the medication cart: 2. [MEDICATION NAME] 0.25% eye drop with an expiration date of 6/2019, opened, not dated administered to one resident on 1/25/18 3. Two big containers of Polyethylene [MEDICATION NAME] 3350, NF Powder for oral Solution with an expiration date of 7/2019, opened, not dated administered to two residents on 1/25/18 An observation on 1/25/18 at 10:15 a.m. with the of the 2nd floor Medication Cart 2 revealed the following giving narcotic medication failed to signed/or do the count between changing of shift: 4. [MEDICATION NAME] 75mg oral was administered to a resident by Licensed Practical Nurse (LPN) EE failed to sign the narcotic book, the book revealed 13 capsules but the bubble pack revealed 12 capsules Licensed Practical Nurse (LPN) DD states she didn ' t give the medication she took over from (LPN) EE at 8:30 a.m .and they did not do the narcotic count. A record review of the facility ' s Storage of Medications and Biologicals /Medication Administration policy with an issue date of (MONTH) 1st, 2007 and a review/revision date of (MONTH) 1st, 2010/ (MONTH) 1st, 2013, revealed the facility shall ensure that the medications and biologicals are stored and label properly and securely at any given time. An interview on 1/24/18 at 12:00 p.m. with Licensed Practical Nurse (LPN) BB revealed staff are expected to date/label all medications when opened and check for expired medications in the medication carts and refrigerators. An interview on 1/24/18 at 12:30 p.m. with Registered Nurse (RN) CC revealed staff are expected to date all medications when opened. An interview on 1/24/18 at 12:35 p.m. and 1/25/18 at 11:00 a.m. with the Director of Nursing (DON) revealed staff were in-serviced on medication storage, medication administration and narcotic medication count, DON initiated in-services immediately to all Licensed Nurses.",2020-09-01
358,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,157,D,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, family and staff interviews, the facility failed to ensure notification of change in resident status was appropriately made for two residents (R) (R#357 and R#355) of 38 sampled residents. Specifically, the Power of Attorney (POA) for R#357 was not notified in a timely manner after the resident experienced a fall, and the physician of R#355 was not notified when the resident's blood sugar was high or low in accordance with the physician's orders [REDACTED]. Findings include: 1. Review of the clinical record for R#357 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. According to R#357's most recent Minimum Data Set (MDS), a comprehensive admission assessment of overall status dated 12/4/15, the resident was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 3 out of 15), required extensive assistance to complete all of her Activities of Daily Living (ADLs), and had experienced a fall with injury prior to her admission to the facility. The Fall Care Plan, dated 11/27/15 and revised on 1/13/16 read, Problem: At risk for falls due to impaired balance/poor coordination. Staff was to reinforce wheelchair safety as needed such as locking breaks and reinforce need to call for assistance. The resident was assessed as being at high risk for experiencing falls per the Patient Admission Screen dated 11/27/16. A Physician's Progress Note dated 12/16/15 at 10:10 a.m. read, Nursing reports, last night, the patient was standing up unassisted and went to sit back down and she fell and hit her head on the desk. Nursing also reports this morning, the patient has been sleeping during the day, which is outside of her usual status. No documentation could be found in the clinical record to indicate R#357's POA was notified of her fall. During an interview, conducted with R#357's POA on 12/14/16 at approximately 3:00 p.m., he stated the facility had not notified him of the resident's fall until a day after the fall. He stated, She had a big lump on her head. She was there because she had fallen prior to being admitted and had a head injury from that fall. He stated he should have been notified sooner. During an interview, conducted with the Director of Nursing (DON) on 12/14/16 at 3:00 p.m., she acknowledged the lack of documentation to indicate the resident's POA had been notified of the fall in a timely manner. 2. Review of the Order Summary Report dated 12/15/16, for an admission of 2/12/16, revealed R#355 had a physician's orders [REDACTED]. Inject as per sliding scale: if 0 - 65 if fasting sugar (FS) is below 65 call physician; 65 - 200 do not give any insulin; 201 - 250 give 4 units; 251 - 300 give 6 units; 301 - 350 give 8 units; 351 - 400 give 10 units; 401+ if BS greater than 400, call physician. Review of R#355's Care Plan dated 2/12/16, revealed a focus on the endocrine system related to insulin dependent diabetes. The goal was to minimize/be free of complications related to disease process. The care plan interventions included: administer medication per physician orders, obtain glucometer readings and report abnormalities as ordered, obtain lab results as ordered and notify physician of results, report symptoms of [MEDICAL CONDITION]: excessive thirst/urination, hunger, weakness, nausea/vomiting (N/V) and [MEDICATION NAME] breath, report symptoms of [DIAGNOSES REDACTED]: weakness, pallor, diaphoresis, vision changes, change in consciousness. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Further review of the MAR indicated [REDACTED] Review of the Progress Notes dated 2/21/16 revealed R#355's blood sugar was 490 at 11:45 a.m., and insulin was administered per orders. R#355's blood sugar level at 12:45 p.m. was 410 and at 2:20 p.m. R#355's blood sugar was 220. The progress note failed to reveal the physician was notified regarding the abnormal blood sugar levels. Further review of the progress notes failed to reveal that the physician was notified of the blood sugar level of 60 at 4:30 p.m. on 2/21/16. During an interview with the Director of Nursing (DON) on 12/15/16 at 3:15 p.m., the DON acknowledged the abnormal blood sugar levels on 2/21/16. The DON stated nurses were expected to follow the physician's orders [REDACTED]. Nurses should document the residents blood sugar levels, notify the physician and the responsible party.",2020-09-01
359,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,278,D,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of out-of-State hospital records, Minimum Data Set (MDS) assessments (MDS - a federally mandated comprehensive assessment tool used for development of an individualized care plan), Radiology Reports, Progress Notes, and staff interviews the facility failed to ensure MDS assessments for one resident (R) R#316, of 38 sampled residents, from a total of 40 residents, who were reviewed for MDS assessment accuracy, were accurate and reflected the resident's history of falls and falls related injury. Findings include: Review of R#316's admission/Medicare 5 day MDS assessment dated [DATE], section J1700A (fall history on admission/entry or reentry), was coded 0. This indicated that the resident did not have a fall anytime in the last month prior to admission/entry or reentry. Section 1700B was coded 0, which indicated the resident did not have a fall anytime in the last 2-6 months prior to admission/entry or reentry. Review of R#316's clinical record revealed an untitled hospital document dated 9/30/16. The section titled pertinent medical history, revealed R#316 had a history of [REDACTED]. Note dated 10/7/16, which revealed R#316 was admitted from (name of out of state hospital) related to a right MCA (middle cerebral artery) infarct (small localized area of dead tissue resulting from failure of blood supply) with left sided weakness status [REDACTED]. Review of R#316's modified Medicare 30 day MDS assessment dated [DATE], section J1800 (any falls since admission/entry or reentry or prior assessment, whichever is more recent) revealed R#316 had falls since admission/entry or reentry or the prior assessment. Section J1900A (number of falls since admission/entry or reentry or prior assessment, whichever is more recent) revealed the resident had two falls with no injury (no evidence of any injury is noted on physical assessment by the nurse or primary care clinician; no complaints of pain or injury by the resident; no change in the resident's behavior is noted after the fall). Section J1900C, major injury (bone fractures, joint dislocations, closed head injuries with altered consciousness, subdural hematoma) was coded 0, which indicated the resident did not have any falls with major injury since admission/entry or reentry or prior assessment, whichever is more recent). However, progress notes (see below) and radiology reports (see below) revealed the resident had a fractured left hip. Review of the Progress Notes in R#316's medical record dated 11/5/16 revealed the resident was found, by the Certified Nursing Assistant (CNA) in his room lying on the floor with his head up. He was trying to get his coat from the chair. Resident #316 stated that his left hip was hurting, when asked by the nurse. The medical doctor (MD) was notified and an x-ray of R#316's left hip was ordered. Review of the Radiology Report dated 11/6/16, revealed R#316 had an acute minimally displaced intertrochanteric [MEDICAL CONDITION] left femur. Review of the Medicare 5 day MDS assessment dated [DATE], section A1600 (entry date), A1700 (type of entry), and A1800 (entered from) revealed R#316 re-entered the facility on 11/10/16 from an acute care hospital. Section I (active [DIAGNOSES REDACTED].#316's recent left [MEDICAL CONDITION]. Further review of the MDS assessment, section J1700C (did the resident have any fracture related to a fall in the 6 months prior to admission/entry or reentry?) was coded 0 (no). However, the radiology report (see above) dated 11/6/16 and the physician's admission visit dated 11/17/16 (see below) revealed R#316 sustained a left [MEDICAL CONDITION]. Review of the physician's Rehabilitation Medicine Re-Admission Visit dated 11/17/16, revealed R#316 was readmitted to the facility on [DATE] related to functional mobility disorder secondary to a [DIAGNOSES REDACTED]. During an interview with Registered Nurse (RN) AA, who was also the Resident Assessment Coordinator (RAC), on 12/15/16 at 10:17 a.m., RN AA acknowledged the MDS assessments dated 10/12/16, 11/6/16, and 11/17/16 were inaccurately coded and did not accurately reflect the resident's fall and injury status. During an interview with the Director of Nursing (DON) on 12/15/16 at 1:42 p.m., the DON stated that the expectation was for the MDS assessments to be accurately coded.",2020-09-01
360,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,280,D,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility Incident Reports, Care Plans, Radiology Reports, Progress Notes, the physician's Rehabilitation Medicine Re-Admission Visit Report, Physician Orders, and Kardex medical information system; the facility failed to revise the care plan for three residents (R) (R#316, R#132, and R#122), out of 38 sampled residents. 1) The facility failed to revise R#316's care plan after sustaining a fall with major injury. 2) The facility failed to revise R132's care plan regarding use of a splint. 3) The facility failed to revise R#122's care plan related to range of motion to preserve current level of functioning. Findings include: 1. Review of the Incident Report dated 11/5/16, revealed resident R#316 had a fall without major injury; however, the resident had sustained a [MEDICAL CONDITION] (see below). R#316 was found (by Certified Nursing Assistant (CNA)) lying on the floor with his head up. R#316 stated he was trying to get his coat from off the chair, so he got out of bed. R#316 stated his left hip hurts and he hit the back of his head. The facility's action listed indicated pending x-rays and neurological assessments were initiated. Review of the Radiology Report dated 11/6/16 revealed the resident sustained [REDACTED]. Review of R#316's Care Plan dated 10/5/16, revealed the resident was at risk for falls due to impaired balance/poor coordination, and unsteady gait. Further review of R#316's care plan revealed the facility failed to update the care plan to reflect the 11/5/16 fall, which resulted in a major injury and subsequent hospitalization . The care plan failed to reveal new fall interventions upon R#316's return to the facility on [DATE]. Review of the Minimum Data Set (MDS) assessments dated 11/6/16 and 11/17/16 revealed upon readmission to the facility, on 11/10/16, R#316's eating ability changed from supervision of one staff member to extensive assist of one staff member and his incontinence status changed from occasionally incontinent to frequently incontinent of bowel and bladder. Further review of the MDS dated [DATE] coded the resident without having sustained a fracture; when in fact the resident was discharged to the hospital on [DATE] related to a fall that occurred at the facility on 11/5/16, which resulted in a fractured left femur. During an interview with Registered Nurse (RN) AA, who was also the Resident Assessment Coordinator (RAC), on 12/15/16 at 10:17 a.m., RN AA reviewed R#316's care plan and acknowledged the care plan did not reflect the fall sustained on 11/5/16 and stated that she thought it may have been resolved and would need to check. RN AA returned at 11:07 a.m. and stated there were no other fall care plans for the resident after he returned from the hospital. During an interview with the Director of Nursing (DON) on 12/15/16 at 1:42 p.m., the DON stated that resident falls were reviewed and discussed during the Eagle Room (morning and afternoon meetings) and resident care plans were updated. The DON was asked what the facility did when the resident was discharged to the hospital over the weekend after a fall. The DON stated that they would have reevaluated the resident upon return to the facility and update the care plan if there were changes. The DON reviewed R#316's care plan, acknowledged that the care plan was not updated to reflect the 11/5/16 fall with major injury nor was the care plan updated upon R#316's return from the hospital. The DON stated that she would expect R#316's care plan to have been updated. 2) On record review R#132 had an initial admission date of [DATE] and a current readmitted on 11/6/15, with [DIAGNOSES REDACTED]. The Care Plan with a start date 4/28/16 for R#132 documented a goal of: Will receive assistance necessary to meet ADL (Activities of Daily Living) needs. The interventions included: splint to right hand daily as tolerated, may remove for hygiene. The goal and intervention remained the same for each quarterly care plan update with start dates of 7/18/16 and 9/20/16. On 12/13/16 at 9:53 a.m. observation of R#132 revealed that the fingers on her right hand did not open and her hand remained in fist position. A splint device was not present. On 12/14/16 at 10:13 a.m. during interview with the Director of Rehabilitation (DOR), she stated When we discharged her (from therapy on 11/10/14), our recommendation was for her to use the right elbow and hand splint for 4 to 6 hours as tolerated every day. After that therapy is not aware; that was the last time we saw her in 2014. The last time she was evaluated was in 10/1/2014 and the last treatment was 11/9/14. We have not gone back to see her. If there is a change, we are notified. The splint was given to nursing and training was done with the nursing staff to put it on and off and what our recommendations were (put it on for 4 to 6 hours as tolerated daily if possible). When she was in therapy she was tolerating wearing the right elbow splint and hand splint for 4 to 6 hours with no skin breakdown and no discomfort, no pain and no redness. She mostly used her left hand for grooming and hygiene activities and bed mobility. On 12/14/16 at 11:45 a.m. observation of R#132 in the presence of the DOR revealed R#132 held a rolled cloth in her right hand. The DOR stated they were going see if they could pick her up for therapy. On 12/14/16 at 3:38 p.m. during interview with the Certified Nursing Assistant (CNA) AA she revealed that R#132 was total care, and you have to do everything for her. She moves her left hand, she will wave at you with the left hand. Her right hand was contracted a little, doesn't straighten her fingers; you have to actually move that hand and arm, because of a stroke. On 12/15/16 at 7:15 a.m. during interview with the DOR she revealed that R#132 was evaluated and she ordered another splint. Not all staff knew where her splint was. The Care Plan was revised on 12/15/16 that identified an intervention for the ADL Goal Eval (evaluate) for right hand splint fitting; carrot to right hand daily as tolerated. Date Initiated: 12/14/16; Created on: 12/14/16. On 12/15/16 at 12:30 p.m. the care plan intervention as identified on 3 Care Plans (splint to right hand daily as tolerated, may remove for hygiene) was shared with Registered Nurse (RN) CC. She revealed that documentation of use should be on the Kardex for the CNAs. If there is a physician order, the nurses will check to make sure it is on. On review of the physician orders, the splint was not included as an order. On review of the Nurses Progress Notes and the CNAs Kardex charting Documentation Survey Report from (MONTH) through (MONTH) (YEAR) did not include documentation for use of the splint. 3) The initial admission of R#122 was on 6/21/11 with a current readmitted on 11/28/16. Review of the 11/18/16 History and Physical [DIAGNOSES REDACTED]. Review of the Occupational Therapy services notes dated 12/30/14 to 2/24/15 for R#122 included a progress note dated 1/16/15 that identified Range of Motion techniques to increase functional task performance. Strengthening activities to increase functional task performance and initiation cues to facilitate skill performance. The Discharge Summary note on 2/24/15 identified Patient and Caregiver training on positioning maneuvers, positioning/pressure relieving techniques, safety sequencing techniques, safety precautions and use of adaptive equipment in order to facilitate improved functional abilities, and prevent decline from current level of skill performance facilitate increased opportunities for functional task participation and preserve current level of function. The Care Plan for R#122 on 10/10/16 and 7/21/16 related to range of motion included a goal to Decrease/minimize skin breakdown risks with interventions to reposition as needed; float heels as able; observe skin condition with ADL care daily, report abnormalities; pressure redistributing device on bed and chair; and, use pillows/positioning devices as needed. A second related goal was Will receive assistance necessary to meet ADL needs. Intervention: Assist with daily hygiene, grooming, dressing, oral care and eating as needed. On 12/13/16 at 10:52 a.m. observation of R#122, his right hand and fingers were in a fist position; and a splint device was not in place. On 12/14/16 at 10:57 a.m. interview with the DOR revealed, We don't have him on any splints or braces. The last time we saw him was (YEAR) (12/30/14 to an 2/24/15 discharge date ). There is increased tone plus resistance with any type of mobility. She identified that when he was last seen he was helping with self feeding; fluctuated from supervision to moderate assistance. There is no mention of any type of splint being done with him. Our recommendation was for 24 hour care, provide range of motion as tolerated, positioning, pressure relieving techniques, safety precautions and increase opportunities for functional task participation and preserve current level of function. Whatever he could do, encourage him to do that. When they provide him with ADLs (Activities of Daily Living), provide him with the passive range of motion. When he thinks he was getting exercise, he would resist. On 12/14/16 at 4:30 p.m. interview with CNA BB revealed that R#122 Does not use his hands. You need 2 people to handle him, because he can be difficult, aggressive. He is total care, doesn't assist. On 12/14/16 at 4:40 p.m. interview with CNA CC revealed that when R#122's sister comes, She talks to him about the family, and she does some range of motion. CNA CC revealed that the sister and CNA CC Does it (range of motion) sometimes; turning him; she can keep him calm. His right leg is contracted and is painful even with the care that I give. I tell him from step to step of what I am doing. She revealed that she does range of motion; he can straighten his left leg more, and for his right leg, she gently inserts a pillow in between his legs. There is a program to do Range of Motion but, with (R#122) he can move his arms back and forth whenever he wants to and desires to. If I need to turn him, I will ask for assistance to turn him over from side to side. Not sure where the program is, we have a book. I have not documented it, is just natural during care. CNA CC shared the Kardex report for R#122 where there were instructions for the CNAs to include ADL assist 1-2 person, total level of care, mobility device, geri chair with cushion as tolerated, bed in low position, may be physically abusive, and Fall risk. On 12/15/16 at 11:09 a.m. interview with RN CC revealed that R#122 received passive range of motion. She stated that MDS revises Care Plans and that care plans are revised daily as things change with the patient. On 12/16/16 at 6:42 a.m. while reviewing the 7/21/16 and 10/26/16 Activities of Daily Living Care Plans, that were the same, with the RN AA she was asked if R#122 was to receive Range of Motion to assist in functional skills and how it was reflected on the Care Plan. RN AA revealed they have a therapy follow-up communication form. When they are coming off therapy and where they are at from X, Y, Z. She was not sure if it goes to the chart, and was going to look for the form. No additional information was provided by the conclusion of the survey.",2020-09-01
361,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,282,D,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Medication Administration Records, Physicians Orders, Care Plans, and staff interviews the facility failed to provide services for one resident (R) #355 out of 38 sampled residents, by qualified staff, in accordance with their care plan related to the administration of medications. As a result, the resident received several incorrect doses of insulin. There was no adverse outcome to the resident. Findings include: Review of resident R#355's Care Plan revealed the resident had a focus on the endocrine system and was insulin dependent. The care plan indicated staff was to administer the mediations as ordered by the physician (cross reference F157 - Notification of Change for full endocrine care plan). Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Records (MAR) revealed staff failed to administer the resident's insulin as ordered. Staff failed to follow physician orders [REDACTED]. Specifically, staff administered 2 units of [MEDICATION NAME] 70/30 insulin on 2/23/16 at 5:00 p.m. In addition, staff administered 6 units of [MEDICATION NAME] 70/30 insulin on 2/23/16 at 5:00 p.m.; however, the 2 units of [MEDICATION NAME] 70/30 insulin was discontinued on 2/22/16. Therefore, R#355 received 2 units of [MEDICATION NAME]70/30 in error on 2/23/16 at 5:00 p.m. Further review of the MAR indicated [REDACTED]. In addition, staff administered 16 units of [MEDICATION NAME] 70/30 insulin at 7:30 a.m. on 2/24/16, 2/26/16, and 2/29/16. However, the physician discontinued the 12 units of [MEDICATION NAME] 70/30 on 2/22/16 and wrote an order to begin 16 units of [MEDICATION NAME] 70/30 (see physician orders [REDACTED].#355 received 12 units of [MEDICATION NAME]in error on 2/23/16, 2/24/16, 2/26/16, 2/27/16, 2/28/16, and 2/29/16. R#355 should have received 16 units of [MEDICATION NAME] 70/30 insulin. Additionally, staff administered 12 units of [MEDICATION NAME] 70/30 insulin on 2/23/16, 2/27/16, and 2/28/19, when the resident should have received 16 units of [MEDICATION NAME] insulin, thus the resident received 4 units less that what was ordered (cross reference F333 - Significant Medication Error) Review of the Progress Notes dated 2/22/16, 2/27/16 and 2/29/16 revealed the resident had concerns regarding her uncontrolled blood sugars while at the facility, her insulin dose was changed, and staff administered [MEDICATION NAME] 70/30 insulin 12 units instead of the ordered 16 units (cross reference F333 - Significant Medication Error for full progress note information). The Director of Nursing (DON) was interviewed on 12/15/16 at 3:52 p.m. and 12/16/16 at 6:42 a.m., the DON acknowledged the medication errors and stated the nurses are expected to administer the resident's medications as ordered (cross reference F333 - Significant Medication Error for full DON interview).",2020-09-01
362,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,323,D,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, review of the facility Clinical Services/Falls Practice Guide, review of the facility Clinical Services FYI for Post-Fall Evaluation process and staff interviews, the facility failed to ensure three residents (R) (R#203, R#357 and R#316) of 38 sampled residents were appropriately assessed after they experienced falls. Findings include: The facility's Clinical Services/Falls Practice Guide, dated (MONTH) 2011, read, in pertinent part, Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient has hit their head; following an un-witnessed fall when a head injury may be suspected and following non-fall patient events which result in known or suspected head injury such as a suspected hemorrhagic stroke. 1. Review of the medical record for R#203 revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. According to R#203's most recent Minimum Data Set (MDS), a comprehensive admission assessment of overall status dated 10/18/16, the resident was severely cognitively impaired (Brief Interview of Mental Status (BIMS) score of 5 out of 15) and required extensive assistance to complete all of his Activities of Daily Living (ADLs). The Fall Care Plan, dated 10/12/16 read, Problem: At risk for falls due to impaired balance/poor coordination. The goal was to minimize risk for injury related to falls, and staff was to provide assistance with toileting and transfer and ambulation as needed, reinforce the need to call for assistance, provide therapy evaluation and treatment per orders, and reinforce safety as needed such as locking the brakes on the wheelchair. The resident's Fall Risk was assessed as being High per the Patient Admission Screen dated 10/12/16. Nursing Progress Notes dated 12/14/16 at 10:00 a.m. read, Pt (patient) awake, alert, oriented to self was found sitting on the floor of his room. When asked patient wat happened, he verbalized that he was coming out to find out where he was. Patient denies pain related to fall. Patient assessed from head to toe. No new skin alteration noted. Neurological assessments were not found in the resident's clinical record. The assessments were requested, but were not provided prior to survey exit on 12/16/16. During an interview, conducted with the Director of Nursing (DON) on 12/14/16 at 3:00 p.m., she acknowledged neurological assessments were to be completed any time a resident had an un-witnessed fall. She indicated that since the resident's fall on 12/14/16 was not witnessed, neuro checks should have been done. She stated, We have looked everywhere, and we are unable to find them. 2. Review of the medical record for R#357 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. According to R#357's most recent Minimum Data Set (MDS), a comprehensive admission assessment of overall status dated 12/4/15, the resident was severely cognitively impaired (BIMS score of 3 out of 15), required extensive assistance to complete all of her Activities of Daily Living (ADLs), and had experienced a fall with injury prior to her admission to the facility. The Fall Care Plan, dated 11/27/15 and revised on 1/13/16 read, Problem: At risk for falls due to impaired balance/poor coordination. Staff was to reinforce wheelchair safety as needed such as locking breaks and reinforce need to call for assistance. The resident was assessed to be at high risk for experiencing falls per the Patient Admission Screen dated 11/27/16. A Physician's Progress Note dated 12/16/15 at 10:10 a.m. read, Nursing reports, last night, the patient was standing up unassisted and went to sit back down and she fell and hit her head on the desk. Nursing also reports this morning, the patient has been sleeping during the day, which is outside of her usual status. No documentation could be found in the nurses' notes to indicate the resident had fallen on the evening of 12/15/16 or that any type of physical assessment had been conducted after the fall occurred, including the required neurological checks or the Post Fall Assessment required by the facility. During an interview, conducted with the Director of Nursing (DON) on 12/15/16 at approximately 1:00 p.m., she stated no neuro checks had been initiated because the night supervisor working on the night of the fall was not aware the resident had hit her head. She stated no documentation of assessment of the resident after the fall could be found. She acknowledged the assessments should have been done. On 12/14/16 at 11:33 a.m. a request was made to the DON for the facility's Fall Policy. On 12/14/16 at 11:33 a.m. the DON stated the facility does not have a policy regarding falls and staff follow the Clinical Services FYI for Post-Fall Evaluation. The Clinical Services FYI Post-Fall Evaluation document, dated (MONTH) 2011, read in part, Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs throughout a patient's stay. In the event that a patient does experience a fall, a comprehensive clinical evaluation by the nurse supervisor is important to determine the extent of the injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Clinical system areas of focus for post-fall evaluation may include: Clinical Evaluation Focus - vital signs (blood pressure including orthostatic; apical pulse rate and rhythm, radial pulses-bilateral, femoral pulses - bilateral, respiratory rate and rhythmed, temperature, oxygen saturation -pulse oximetry, blood sugar - if indicated; o Rationale: compare vital signs to baseline readings. Note changes especially orthostatic hypotensive changes or significant elevations. Patients with diabetes may have had a change in blood sugar levels - mental status (orientation - person, place, time, situation, affect, mood, memory, cognition, level of consciousness - alert, lethargic, semi-comatose, comatose) dizziness and headache. o Rationale - changes in mental status may be indicative of acute neurological or cardiovascular changes. Compare to baseline o Patients with suspected head or neck injury should not be moved until evaluated by emergency personnel - Sensory (pain - conduct comprehensive pain evaluation noting new onset, location, and intensity, duration), response to touch, pupillary response - equality, reactivity, to light, visual changes, numbness, reports of aura. o Rationale - completion of neurological evaluation may indicate acute change in status. Compare to base line. Review of the Minimum Data Set (MDS) Assessment, dated 10/12/16, revealed resident #316 required extensive assistance from two staff members for bed mobility, transfers, and toileting. He required extensive assistance from one staff member for walking in the corridor, locomotion on and off the unit, dressing, bathing and personal hygiene. He was occasionally incontinent of bowel and bladder. Section J1700 failed to reveal the resident had a fall history on admission; however, the resident was admitted from an out-of-state hospital related to a right MCA (middle cerebral artery) infarct (small localized area of dead tissue resulting from failure of blood supply) with left sided weakness status [REDACTED]. Review of the resident's care plan dated 10/5/16 revealed R#316 was at risk for falls. The care plan was updated on 11/2/16 after the resident reported a fall, while at home with his daughter; however, the care plan was not revised after the resident sustained [REDACTED]. Review of the Progress Notes dated 11/5/16 revealed R#316 sustained an unwitnessed fall at the facility. R#316 was found by the Certified Nursing Assistant (CNA) in his room on the floor with his head up. When asked by the nurse, the resident reported that he hit his head and that he was experiencing left hip pain. The progress note failed to reveal staff completed a comprehensive assessment of R#316's head or left hip. Review of the Patient Admission / Readmission Screen, dated 10/5/16, revealed the resident was at risk for falls; however, the screen failed to identify the resident had a history of [REDACTED]. Review of the incident report dated 11/5/16, which was signed by a Licensed Practical Nurse (LPN), revealed the resident sustained [REDACTED]. Further review of the incident report, under the section Center Action: Patient's Care revealed the care provided to the resident following the fall included pending x-rays and neuro checks initiated. The incident report failed to reveal the resident was assessed by a registered nurse after he sustained an unwitnessed fall, hit his head, and complained of left hip pain. Additionally, the incident report failed to reveal the LPN completed an evaluation of the resident after sustaining an unwitnessed fall. Review of the Radiology Report dated 11/6/16 revealed the resident had sustained an acute fracture of his left femur. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) failed to reveal R#316 was assessed or medicated for pain on 11/5/16 at 10:55 p.m., when he complained of left hip pain after an unwitnessed fall; however, the MAR revealed R#316 was medicated for pain on 11/6/16 at 1:18 a.m. (two hours and 23 minutes after first reporting pain) for pain rated at six of 10 on a numeric pain scale, which was effective. Review of R#316's clinical record failed to reveal staff completed a comprehensive pain assessment/evaluation after the resident sustained [REDACTED]. Review of R#316's clinical record failed to reveal staff completed a comprehensive assessment or evaluation of the resident after he sustained an unwitnessed fall, hit his head, and complained of left hip pain. Review of the Acute Care Transfer form dated 11/6/16 at 2:10 p.m., which was completed by a Registered Nurse (15 hours and 45 minutes after the resident fell , hit his head, and complained of left hip pain), revealed the resident's vital signs were obtained, the blood pressure was 124/70, pulse was 97, respiration were 18, temperature was 97.8, glucose (blood sugar) was 152 and the resident rated his pain as a five (very severe/horrible pain) out of 10 on a numeric pain scale. The reason for the transfer was related to an orthopaedic issue and the additional notes section read, acute minimally displaced intertrochanteric fracture of the left femur. An attempt to interview Licensed Practical Nurse (LPN) EE was made during the survey; however, the nurse was not available. A call was placed to LPN EE to illicit an interview on 12/15/16 at 4:45 p.m. A voice mail message was left for a return call. LPN EE did not return the call and an interview could not be completed prior to the survey exit. During an interview with LPN AA on 12/14/16 at 11:22 a.m., LPN AA stated when a resident falls, the nurse obtains vital signs and does a head-to-toe body assessment to ensure there was no injury. LPN AA stated if the fall was unwitnessed the nurse would initiate neuro checks, notify the physician and family, complete an incident report, document the fall in the computer and complete a pain evaluation. LPN AA stated that the LPN completes everything, including the assessment of the resident. LPN AA stated that residents can be assessed by an LPN; however, sometimes the LPN will have a registered nurse, unit manager or supervisor complete the assessment. LPN AA stated if the patient was critical, the LPN could not assess the patient, but this resident fell and was not critical. Although the resident had an unwitnessed fall, hit his head and fractured his hip. During an interview with the DON on 12/14/16 at 11:28 a.m. the DON stated that the nurse completes a head-to-toe assessment. If the nurse was an LPN, the LPN would complete an evaluation, incident report and follow the steps of the incident report. The DON stated that residents who have fallen can be evaluated by the LPN, who then notifies the physician and follows the physician's orders [REDACTED].",2020-09-01
363,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,329,D,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Medication Administration Records (MAR), Mood/Behavior Symptom Logs, Nursing Progress Notes, the facility's [MEDICAL CONDITION] Medication Use Policy and interviews, the facility failed to document indications for use of as needed (PRN) antipshychotic medications for 3 of 5 sampled residents (R#203, R#349 and R#357) reviewed for unnecessary medications. This deficient practice had the potential to allow residents to receive antipsychotic medications without indication as to the need for the medications. The sample was 38 residents. Findings include: The facility's [MEDICAL CONDITION] Medication Use Policy, dated 12/1/07 and most recently revised on 11/28/16 read, in pertinent part, [MEDICAL CONDITION] medications may be used to address behaviors only if non-drug approaches and interventions were attempted prior to their use, and [MEDICAL CONDITION] medications to treat behaviors will be used appropriately to address specific underlying medical or psychiatric causes of behavioral symptoms. 1. Review of the clinical record for R#349 revealed an admission date of [DATE] with diagnoses of rhabdomyolysis (muscle breakdown), anxiety disorder, major [MEDICAL CONDITIONS], transient cerebral ischemic attacks (a brief stroke like attack), and [MEDICAL CONDITION]. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the nursing progress notes dated 12/7/16 revealed no indication why the [MEDICATION NAME] was given. Review of the Mood/Behavior Symptom Log, dated (MONTH) (YEAR) indicated no behaviors noted on 12/7/16. On 12/15/16 at 7:30 a.m., the Director of Nursing (DON) was asked where the behaviors would be documented if the resident received [MEDICATION NAME]. She stated she expected them to be documented on the progress notes or in the Mood/Behaviors Symptom Log. On 12/16/16 at 7:40 a.m., Registered Nurse (RN) BB was asked if she had given the injection. She stated, Yes. The resident was agitated and combative and going in and out of other residents' rooms .I should have documented what was going on in the progress notes. I think I messed up there and did not document in the progress notes. 2. Review of the clinical record for R#203 revealed an admission date of [DATE] with diagnoses of [MEDICAL CONDITION], depression, and unspecified [MEDICAL CONDITION]. No [DIAGNOSES REDACTED]. According to R#203's most recent Minimum Data Set (MDS), a comprehensive admission assessment of overall status dated 10/18/16, the resident was severely cognitively impaired (Brief Interview for Mental Status (BIMS) score of 5 out of 15), required extensive assistance to complete all of his Activities of Daily Living (ADLs), had wandering behaviors, and received an antipsychotic medication daily. The [MEDICAL CONDITION] Medication Care Plan, dated 10/12/16 and revised on 12/14/16 read, Problem: At risk for side effects related to use of [MEDICAL CONDITION] medication (anti-anxiety). The goal was for the resident to show no signs of hallucinating or delusional thinking, and staff was to evaluate side effects and effectiveness of medication for possible decrease/elimination of [MEDICAL CONDITION] drugs. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Nursing Progress Notes dated 12/6/16 at 9:38 p.m. read, Patient was agitated during shift. Patient wanted to call daughter. Patient remained agitated after daughter was called. IM of [MEDICATION NAME] was given. Will continue to monitor patient. There was no documentation in the notes to indicate staff attempted to calm the resident using non-pharmacological interventions prior to giving the dose of [MEDICATION NAME]. Nursing Progress Notes dated 12/11/16 at 9:54 p.m. read, At (9:30 p.m.) resident yelling, using profanity and hitting staff. Several attempts to reach (Power of Attorney name). Left voicemail message to call facility to assist talking to resident to calm him down. Awaiting call back. 0.5 mg [MEDICATION NAME] given in right deltoid and resident placed at nurses' station to monitor. No complaints of pain or distress. Continues to yell out at this time. There was no documentation in the notes to indicate staff attempted to use non-pharmacological interventions prior to giving the dose of [MEDICATION NAME]. Review of the Mood/Behavior Symptom Log, dated (MONTH) (YEAR) indicated no behaviors were noted on 12/6/16. 3. Review of the clinical record for R#357 revealed an admission date of [DATE] with diagnoses of traumatic subdural hematoma and [MEDICAL CONDITION], anxiety, and [MEDICAL CONDITION] disorder. According to R#357's most recent Minimum Data Set (MDS), a comprehensive admission assessment of overall status dated 12/4/15, the resident was severely cognitively impaired (BIMS score of 3 out of 15), required extensive assistance to complete all of her Activities of Daily Living (ADLs), and was not exhibiting any behaviors. The Behavior Care Plan, dated 1/6/16 and revised on 1/13/16 read, Problem: At risk for behavior symptoms related to [MEDICAL CONDITION]. Patient observed with increased agitation, removing clothing, attempting to ambulate and transfer without assistance, yelling out for help. Staff was to redirect as needed when confused or agitated, use consistent approaches when giving care, administer medications per physician order, assist to bed when fatigued, and attempt [MEDICAL CONDITION] drug reduction per physician orders. Review of the (MONTH) (YEAR) physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Nursing Progress Notes dated 12/15/15 at 8:57 p.m. indicated 2 ML of [MEDICATION NAME] was given to the resident. No documentation could be found in the clinical record to indicate why the [MEDICATION NAME] was given. There was no documentation in the nurses' notes to indicate the resident had [MEDICAL CONDITION] activity or any behaviors at the time the [MEDICATION NAME] was given Staff was unable to provide the Mood/Behavior Symptom Log for (MONTH) (YEAR). During an interview, conducted with the Director of Nursing (DON) on 12/14/16 at approximately 3:20 p.m., she stated she thought the staff was providing other interventions prior to giving residents IM (intramuscular) [MEDICAL CONDITION] medications, but she was unable to indicate what interventions were being provided and where the interventions were documented in the resident's medical record.",2020-09-01
364,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,333,D,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Discharge Medication Orders List, Medication Administration Records, Progress Notes, Phsycian Orders, Orders Summary Report, and staff interviews the facility failed to ensure one resident (R) #355, out of five residents reviewed for unnecessary medications, from a total of 38 sampled residents were free from significant medication errors. Findings include: Review of the hospital Discharge Medication Orders, dated 2/12/16, for R#355 revealed the following pertinent medication orders [REDACTED] - [MEDICATION NAME] 70/30 subcutaneous (SQ) solution 12 unit(s) SQ once a day (before a meal) - [MEDICATION NAME] 70/30 SQ solution 2 unit(s) SQ once a day (in the evening) Review of the PhysicianTelephone Orders dated 2/22/16, for R#355, revealed the following pertinent medication orders [REDACTED] - Discontinue (DC) [MEDICATION NAME] 70/30 12 units subcutaneous every (q) a.m. - DC [MEDICATION NAME] 70/30 2 units subcutaneous every afternoon - [MEDICATION NAME] 70/30 16 units subcutaneous with breakfast - [MEDICATION NAME] 70/30 6 units subcutaneous with dinner Review of R#355's Progress Notes dated 2/22/16, revealed a Nurse Practitioner's (NPs) progress note that read in part: the patient was very concerned that her blood sugars have been uncontrolled since she admitted to the facility. She states she has been controlled at home, so this was new for her . Plan: call placed to endocrinologist office, faxed recent glucose reading. New order to discontinue current [MEDICATION NAME] 70/30 12 units SQ every (q) a.m. and 2 units SQ q afternoon . Further review of the Progress Notes revealed a general progress note dated 2/22/16 at 5:37 p.m., which read in part: new order received from NP to discontinue sliding scale (ss) insulin with accu-checks before meals (ac) and bedtime (hs), call md for blood glucose of 400 or greater. dc (discontinue) [MEDICATION NAME] 70/30 12 units SQ q a.m., dc [MEDICATION NAME] 70/30 2 units SQ q afternoon. Start [MEDICATION NAME] 70/30 inject 16 units SQ with breakfast, [MEDICATION NAME] 70/30 inject 6 units SQ with dinner Review of the Progress Note dated 2/27/16, revealed a note that read: [MEDICATION NAME] mix 70/30 suspension 100 unit/ml inject 16 units SQ in the morning for diabetes mellitus (DM) type 2 with breakfast. Patient had 12 units at 6:30 a.m. order to clarify. Further review of the progress notes failed to reveal the order was clarified or that the resident was given the additional 4 units of insulin to equal 16 units as ordered (see physician's orders [REDACTED]. Review of the Progress Note dated 2/28/16 at 8:24 a.m., revealed a note that read, [MEDICATION NAME] mix 70/30 suspension 100 unit/ml inject 16 units SQ in the morning for DM type 2 with breakfast. Duplicate order; patient states she received insulin early a.m., will clarify order with MD (physician). Further review of the Progress Notes failed to reveal the medication was clarified or that the resident received the additional 4 units of insulin to equal 16 units as ordered (see physicians order above). Further review of the progress notes revealed the resident was discharged home on[DATE] at 4:00 p.m. Review of R#355's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Thus, the R#355 received 2 units of [MEDICATION NAME]70/30 in error on 2/23/16 at 5:00 p.m. Further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In addition staff administered 16 units of [MEDICATION NAME] 70/30 insulin at 7:30 a.m. on 2/24/16, 2/26/16, and 2/29/16. However, the physician discontinued the 12 units of [MEDICATION NAME] 70/30 on 2/22/16 and the wrote an order to begin 16 units of [MEDICATION NAME] 70/30 (see physician orders [REDACTED].#355 received 12 units of [MEDICATION NAME]in error on 2/23/16, 2/24/16, 2/26/16, 2/27/16, 2/28/16, and 2/29/16. R#355 should have received 16 units of [MEDICATION NAME] 70/30 insulin. Additionally, staff administered 12 units of [MEDICATION NAME] 70/30 insulin on 2/23/16, 2/27/16, and 2/28/19, when the resident should have received 16 units of [MEDICATION NAME] insulin, thus the resident received 4 units less that what was ordered. Review of the Order Summary Report, printed upon request on 12/16/16, revealed staff failed to discontinue the 12 units of [MEDICATION NAME] 70/30 insulin, as ordered by the physician on 2/22/16 (see telephone orders above). During an interview with the Director of Nursing (DON) on 12/15/16 at 3:52 p.m., the DON reviewed the MAR. The DON stated that she would need to look into the identified issue further regarding the resident's insulin. On 12/16/16 at 6:49 a.m. the DON stated that the resident received both insulins in error according to the physician's orders [REDACTED].#355's blood sugars remained elevated even with the medication error. The DON stated that the 12 units of [MEDICATION NAME] 70/30 insulin should have been discontinued on 2/23/16 and that the medication was not given on 2/23/16 or 2/24/16, but was given the medication in error on 2/26/16, 2/27/16, 2/28/16 and 2/29/16.",2020-09-01
365,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,431,E,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility's Storage and Expiration of Medications, Biologicals, Syringes and Needles policy, observations, staff interviews, and review of manufacturer's instructions the facility failed to ensure medications were: 1) dated appropriately when opened in 2 of 2 medication storage rooms, and 2) removed expired medication and biologicals from use in 2 of 2 treatment carts. The facility census at the time of the survey was 116 residents. Findings Include: 1. Review of the policy titled Storage and Expiration of Medications, Biologicals, Syringes and Needles, last revised on [DATE], revealed in section 4, the facility should ensure that medications and biologicals have an expiration date on the label; have not been retained longer than recommended by manufacturer or supplier guidelines; or have not been contaminated or deteriorated, are stored separate from other medications until destroyed or returned to the pharmacy. Section 5 of the policy revealed once any medication or biological package is opened, facility should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. Facility staff should record the date opened on the medication container when the medication has a shortened expiration date once opened. a. Failure to Appropriately Date Medications Once Opened An audit of the first-floor medication room was conducted on [DATE] at 10:28 a.m. in the presence of Licensed Practical Nurse (LPN) A[NAME] The audit revealed two opened and used multiuse vials of Tuberculin Purified Protein Derivative (PPD) solution (lot number 1). The containers and used vials of PPD solution were not dated when opened. The manufacturer's instructions on the side of the medication container revealed the medication should be discarded 30 days after being opened. During an interview with LPN AA on [DATE] at 12:16 p.m. LPN AA acknowledged the two used vials of PPD solution were not dated when opened. LPN AA stated the medication should be dated when opened and the medication was only good for 30 days after being opened. LPN AA removed the two opened and undated multiuse vials of PPD solution from use. An Audit of the second-floor medication room was conducted on [DATE] at 10:35 a.m. in the presence of the second-floor Unit Manager (UM) A[NAME] The audit revealed three opened and used multiuse vials of Tuberculin PPD solution (lot #'s 6 and 1). The containers and used vials of PPD solution were not dated when opened. The manufacturer's instructions on the side of the medication container revealed the medication should be discarded 30 days after being opened. During an interview with the Unit Manager (UM) AA on [DATE] at 10:35 a.m., UM AA stated that the medication was only good for 30 days after being opened and would not be able to say when it had expired, because the medications were not dated when they were opened. b. Expired Medication and Biologicals An audit of the first-floor nurses' treatment cart was conducted in the presence of LPN AA on [DATE] at 10:16 a.m. The audit of the nurses' treatment cart revealed three packs of Xeroform occlusive gauze strips with a use by date of ,[DATE], available for use. During an interview with LPN AA on [DATE] at 10:16 a.m., LPN AA acknowledged the three packs of expired Xeroform occlusive gauze strips and removed them from the cart. An Audit of the second-floor nurses' treatment cart was conducted in the presence of UM AA on [DATE] at 10:55 a.m. The audit of the nurses' treatment cart revealed one open and used tube of Silvasorb wound gel, which expired ,[DATE], seven packets of Xeroform occlusive gauze strips with a use by date of ,[DATE], two packs of steri-strip skin closures with an expiration date of ,[DATE], one Tegaderm super boarder gauze with an expiration date of ,[DATE], one Tegaderm AG mesh dressing with an expiration date of ,[DATE] and one Foley anchor with an expiration date of ,[DATE], available for use. During an interview with UM AA on [DATE] at 11:00 a.m., UM AA acknowledged the expired medication and biologicals. UM AA stated staff try to go through the carts daily and that all shifts are responsible for checking for expired items. UM AA stated she would expect expired items to be removed from the cart immediately. UM AA removed the expired items from the nurses' treatment cart.",2020-09-01
366,MANOR CARE REHABILITATION CENTER - DECATUR,115246,2722 NORTH DECATUR ROAD,DECATUR,GA,30033,2016-12-16,514,D,0,1,F5ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, resident clinical records and review of the facility policy and procedure titled Medication and Treatment Administration Guidelines, the facility failed to ensure resident clinical records were complete and accurate for three residents (R) (R#316, R#355 and R#132) of 38 sampled residents. Specifically the facility failed to: 1) consistently document the administration of medication for R#316 and R#355; and 2) document the use of a hand and arm splint for R#132. Findings include: Review of the policy and procedure titled Medication and Treatment Administration Guidelines, last revised (MONTH) 2014, read in part, .medications and treatments administered are documented immediately following administration or per state specific standards; medications not administered according to physician orders are reported to the attending physician and documented in the clinical record including the name and dose of the medication and reason; administration of PRN (as needed) medications include the specific reason for the PRN medication and the effectiveness. The licensed nurse is responsible for validating documentation is completed for any medication administered during the shift. 1. According to the Minimum Data Set (MDS) assessment dated [DATE] R#316 was admitted to the facility on [DATE], his pertinent [DIAGNOSES REDACTED]. Review of the (MONTH) and (MONTH) (YEAR) Medication Administration Records (MARs), for resident R#316, revealed multiple holes in documentation for ordered medications. The medications lacking documentation included the following: - [MEDICATION NAME] (xanthine oxidase inhibitor), the MAR revealed staff failed to document the medication was administered at 6:00 a.m. on 10/7/16, 10/14/16, and 10/28/16, as ordered; - [MEDICATION NAME] (anti-gout medication), the MAR revealed the staff failed to document the medication was administered on 10/7/16, 10/14/16 and 10/28/16 at 6:00 a.m., as ordered; - Humalolg (insulin) Solution 100 units/ml, inject as per sliding scale. The MAR revealed the staff failed to document whether R#316's blood glucose levels were checked, whether sliding scale insulin was required or administered on 10/7/16 at 6:30 a.m., 10/14/16 and 10/28/16 at 6:00 a.m., as ordered; and - Artificial Tears solution 1.4%, the MAR revealed the staff failed to document the administration of the artificial tears solution at 6:00 a.m. on 10/7/16, 10/14/16, 10/28/16 and at 9:00 a.m. on 12/2/16, as ordered. Review of the Progress Notes for R#316, dated 10/5/16 through 12/13/16, failed to reveal documentation regarding why the medications were not signed out or if they were administered as outlined above. During an interview with the Director of Nursing (DON) on 12/15/16 at 1:42 p.m., the DON reviewed R#316's MAR and progress notes and acknowledged the medications were not signed out as being administered by staff, the DON also stated that this may have occurred during a time when the computer system was down and would need to verify this. On 12/16/16 at 6:46 a.m. the DON stated that the holes in the MARs did not correlate with the down times of the computer system. The DON stated that she would expect the nurses to sign out the medication after the medication was administered. 2. Review of the MDS assessment dated [DATE], revealed R#355 was admitted to the facility on [DATE] from an acute care hospital. Her pertinent [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record (MAR), for R#355, revealed multiple holes in documentation for ordered medications and treatments. The medications and treatments lacking documentation included the following: -Humalog Solution Insulin (a diabetic medication), inject per sliding scale. The MAR revealed the staff failed to document whether the blood glucose (BG) levels were checked and if sliding scale insulin was required or administered on: 2/18/16 at 11:30 a.m., 2/19/16 at 6:30 a.m. and 11:30 a.m., and 2/20/16 at 6:30 a.m. Further review of the MAR documented R#355 had a blood glucose level of 220 on 2/21/16 at 11:30 a.m., when in fact, according to the Progress Notes on 2/21/16 the resident's BG was 490 at 11:45 a.m. and did not decrease to 220 until 2:20 p.m. Additionally, the MAR revealed R#355 had a blood sugar level of 321 on 2/22/16 at 11:30 a.m.; however, staff did not document the amount of sliding scale insulin administered to the resident; - Accu-check (blood glucose monitoring), the MAR revealed staff failed to document whether the blood glucose level was checked on 2/25/16 at 6:30 a.m.; - Keflex (antibiotic), the MAR revealed staff failed to document whether the antibiotic was administered to the resident as ordered on [DATE] at 6:00 a.m.; - [MEDICATION NAME] HCL, the MAR revealed staff failed to document whether the medication was administered on 2/18/16 at 9:00 a.m.; - [MEDICATION NAME] (supplement), the MAR revealed staff failed to document whether the supplement was administered on 2/18/16 at 9:00 a.m. and 1:00 p.m., and 2/19/16 at 1:00 p.m.; - Vitamin C (supplement), the MAR revealed staff failed to document whether the supplement was administered on 2/18/16 at 9:00 a.m., as ordered; - [MEDICATION NAME] Solution (low molecular weight [MEDICATION NAME]), the MAR revealed staff failed to document whether the medication was administered, on 2/20/16 and 2/25/16 at 6:00 a.m., as ordered; - Pain evaluation, staff failed to document whether the resident was assessed for pain on 2/18/16 at 9:00 a.m.; and - [MEDICATION NAME](diabetic medication), the MAR revealed staff failed to document whether the medication was administered on 2/17/16 and 2/20/16 at 6:00 a.m., as ordered; - [MEDICATION NAME] (angiotensin II antagonist), the MAR revealed staff failed to document whether the medication was administered on 2/18/16 at 9:00 a.m., as ordered; - [MEDICATION NAME] (diuretic), MAR revealed staff failed to document whether the medication was administered on 2/18/16 at 9:00 a.m., as ordered; and - Monitor temperature every four hours, notify the physician if the temperature is greater than 100.3. The MAR revealed staff failed to document whether the resident's temperature was checked on 2/14/16 at 2:00 p.m.; 2/18/16 at 10:00 a.m., 2:00 p.m., and 10:00 p.m.; 2/19/16 at 10:00 a.m. and 2:00 p.m.; 2/20/16 at 2:00 a.m. and 6:00 a.m.; and 2/25/16 at 6:00 a.m. Review of R#355's Progress Notes dated 2/12/16 through 2/29/16 revealed there was no documentation related to the missing blood glucose levels, medications, supplements, and treatments as outlined above. During an interview with the Director of Nursing (DON) on 12/15/16 at 3:52 p.m., the DON acknowledged the missing information on R#355's (MONTH) (YEAR) MAR. The DON stated that the nurses are expected to sign out the medication after it was administered. If the medication could not be administered, the nurse should determine the reason the medication could not be administered, have pharmacy deliver the medication, if needed, and notify the physician and responsible party. During an interview with Licensed Practical Nurse (LPN) BB on 12/16/16 at approximately 9:30 a.m., LPN BB stated after the medications were administered and depending on whether or not the resident took all their medications, then she would document that the medications have been administered. If the resident refused a medication, LPN BB would then document the refusal on the MAR and notify the physician. LPN BB stated, if there are holes in the MAR, that means the medication was not administered. During an interview with LPN CC on 12/16/16 at 9:59 a.m. LPN CC stated the administration of medications were documented on the MAR after the resident received the medication. LPN CC stated that if there are holes on the MAR, supposedly that means it was not given; however, it could also mean that it was a new medication that was started or forgotten. LPN CC stated that the computer system will alert the nurse when medications have not been administered (indicated in red). LPN CC stated that if the medication was not available, LPN CC would contact the physician, pharmacy, update the patient and contact the responsible party and document in the resident progress notes. LPN CC added that there was no way to forget a medication. 3. On record review R#132 had an initial admission date of [DATE] and a current readmitted on 11/6/15, with [DIAGNOSES REDACTED]. Review of the Occupational Therapy (OT) evaluation, progress notes and Discharge Summary contained the following information: The Occupational Therapy Evaluation certification period was 10/1/14 to 12/25/15 with the following goals related to the contracture: Patient will tolerate RUE (right upper extremity) elbow and hand splint for 2 hours with no redness, discomfort, pain, skin breakdown (Target 10/14/14). Patient will increase LUE (left upper extremity) strength to perform hygiene and grooming tasks while seated in wheelchair with Maximum Assistance using LUE (Target: 10/15/14). The reason for the OT referral was functional decline. The reason for skilled services: Patient requires skilled OT services to facilitate tone in UE, provision of pain management techniques and provision of modalities and strengthening. The Discharge Summary on 11/9/14 identified the patient was able to tolerate RUE elbow and grip hand splint for 4-6 hours with no skin breakdown redness, discomfort, or pain. Patient's RUE joint mobility, and flexibility have potential to improve further as a result of skilled therapeutic interventions with splint management and passive sustained stretching. Recommendation: Patient provided with elbow and hand splint and able to tolerate 4-6 hours. Caregiver training, on and off splint devices and wear schedule. On 12/13/16 at 9:53 a.m. observation of R#132 revealed that her fingers on her right hand did not open and remained in a fist position; a splint device was not present. On 12/14/16 at 10:13 a.m. during interview with the Director of Rehabilitation (DOR), she stated When we discharged her (from therapy on 11/10/14), our recommendation was for her to use the right elbow and hand splint for 4 to 6 hours as tolerated every day. After that therapy is not aware; that was the last time we saw her in 2014. The last time she was evaluated was in 10/1/2014 and the last treatment was 11/9/14. We have not gone back to see her. If there is a change, we are notified. The splint was given to nursing and training was done with the nursing staff to put it on and off and what our recommendations were (put it on for 4 to 6 hours as tolerated daily if possible). When she was in therapy she was tolerating wearing the right elbow splint and hand splint for 4 to 6 hours with no skin breakdown and no discomfort, no pain and no redness. She mostly used her left hand for grooming and hygiene activities and bed mobility. On 12/14/16 at 11:45 a.m. observation of R#132, in the presence of the DOR, revealed R#132 held a rolled cloth in her right hand. The DOR revealed they were going see if they could pick R#132 up for therapy. On 12/14/16 at 3:38 p.m. interview with CNA AA revealed that R#132 was total care, you have to do everything for her. She moves her left hand, she will wave at you with the left hand. Her right hand was contracted a little, doesn't straighten her fingers, you have to actually move that hand and arm, because of a stroke. She stated that in the morning (7:00 a.m. to 3:00 p.m.) the CNA would put it (the hand splint) on. If she (R#132) points to it, she is not comfortable, we take it off. Mainly first shift places the splint on her. CNA AA and the surveyor visited with R#132 and she was holding a rolled cloth in her right hand. CNA AA showed the surveyor a blue fabric covered splint for the arm and hand that was located in the resident's bedside night stand. They (staff) may take it off before I (CNA AA) get here. CNA AA worked the 3:00 p.m. to 11:00 p.m. shift. On 12/15/16 at 7:15 a.m. interview with the DOR revealed that R#132 was evaluated and she ordered another splint. She stated, Not all staff knew where her splint was. When asked about documentation of wearing the splint 4 hours as tolerated, the DOR stated she would find out. On 12/15/16 at 12:30 p.m. Registered Nurse (RN) CC was asked about R#132 wearing the splint to the right hand as noted on the Care Plan intervention (splint to right hand daily as tolerated, may remove for hygiene) and monitoring to ensure implementation. She revealed that It should be on the Kardex for the CNAs. If there is a physician order, the nurses will check to make sure it (the splint) is on. Review of the physician orders with RN CC revealed the splint was not included on the physician orders. On 12/14/16 review of the Nurses Progress Notes and CNAs Kardex charting Documentation Survey Report from (MONTH) through (MONTH) (YEAR) revealed there was no documentation for use of the splint. Interventions/Tasks on the Documentation Survey Report included bed mobility and transfers. The Care Plans (with start dates of 4/28/16, 7/28/16 and 9/20/16) goal identified R#132, Will receive assistance necessary to meet ADL (Activities of Daily Living) needs. The interventions included, Splint to right hand daily as tolerated, may remove for hygiene. There was no documentation available to demonstrate the dates and times the splint was applied or taken off and if R132 tolerated the splint.",2020-09-01
367,WELLSTAR PAULDING NURSING CTR,115258,600 WEST MEMORIAL DRIVE,DALLAS,GA,30132,2018-04-27,812,F,0,1,XRVI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview, the facility failed to ensure opened food items in the walk-in cooler/freezer were securely covered, labeled and dated, failed to discard one food item by expiration date, and failed to ensure beard/hair restraints were worn. This has the potential to effect 162 residents receiving an oral diet. Findings Include: Observation on [DATE] at 11:30 a.m. revealed that the cook CC and the Chef DD had beards longer that one inch with no beard restraints in place. Observation at this time also revealed that Inventory Specialist EE in the kitchen, with a cap on, hair hanging out of the back of the cap that was to the base of his neck and was unrestrained and that Dietary Aide BB was observed to be standing at the back employee hand wash sink, in the kitchen, with long braided hair and no hair restraint on. Observation and interview on [DATE] at 11:40 a.m. of the cooler with Operation Assistant Manager FF revealed there was one 4 ounce container of Thickened Water with an expiration date of [DATE] that had not been discarded. Operation Assistant Manager FF confirmed, at this time, that the product was expired and should have been discarded. Observation and interview on [DATE] at 11:50 a.m. of the walk-in freezer connected just off the back of the cooler, with Operation Assistant Manager FF revealed there was one box of Chicken Breast, one box of Premium Pork Sausage Links, one box of Tortilla Crusted Fish, and one box of white chocolate macadamia nut cookies that were not securely covered, labeled, or dated. Operations Assistant Manager FF confirmed the items above should have been securely covered, labeled and dated. An interview on [DATE] at 3:00 p.m. with dietary Leader 2 AA revealed that kitchen staff who have beards have been told their facial hair can be a certain length before a beard guard must be worn. She further states that the Inventory Specialist EE should have the long hair hanging out of the back of his cap secured. Review of The Hair Restraint policy dated [DATE] revealed that hair longer than chin length must be pulled back into a ponytail. Shoulder length or longer hair must be styled to keep loose hair off of neck and shoulders. Rubber bands and/or clips that effectively restrain hair can be used for this purpose and that beards must be restrained with a beard restraint. Review of the Food Storage policy dated [DATE] revealed that it is the responsibility of the department storing the food to monitor, and discard all out of date food and all perishable food from Nutrition and Food Service must be dated with a Manufacturer's Expiration Date or Manually labeled and dated per department Serve Safe Guidelines.",2020-09-01
368,WELLSTAR PAULDING NURSING CTR,115258,600 WEST MEMORIAL DRIVE,DALLAS,GA,30132,2017-05-25,280,D,0,1,3WZK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews it was determined the facility failed to review and revise the care plan to address a new onset of right shoulder pain for one Resident (R) #5 out of three residents reviewed for pain. Findings include: On 5/23/17 at 10:00 a.m., R#5 was observed in her room with her eyes closed and her left hand holding her right shoulder. She had a grimace on her face and complained of right shoulder pain. (Cross refer F309 for complete interview on 5/23/17 at 10:00 a.m., resident describes pain as an 8 on pain scale of 1-10). It is documented in the Nurses Note and on a fax cover sheet to the physician dated 4/12/17, Resident reports hurt right shoulder while reclining her chair, would like X-ray and the physician ordered a right shoulder X-ray in am due to decrease range of motion (ROM) and pain. On 4/26/17 the physician ordered a Physical Therapy (PT) evaluation and treat for right shoulder pain. Review of the current care plan identified the problem onset date as 9/17/15. Potential for pain related to restless leg syndrome, chronic back pain, neuropathic leg pain, chronic BLE (bilateral lower extremity) lymph [MEDICAL CONDITION]. The goal and target dates noted on the care plan were 12/17/15, 3/17 and 6/17. Approached included: Encourage Resident to inform staff of pain, obtained/administer pain medications as indicated and ordered by MD. Monitor effectiveness of pain medications, inform MD If medication not effective, monitor for potential for injury associated with pain symptoms. During review of the PT notes regarding R#5's pain prior to and after therapy treatment was coded on a scale of 1-10. On 4/28/17, 5/5/17, 5/8/17 and 5/12/17, it was documented that R#5 stated her pain was at level 8 out of 10. It was also noted in the PT documentation the resident saying, my shoulder has kept me up at night and on 5/5, it is noted Oh it hurt so bad last night I was crying. During interview on 05/24/2017 at 9:16 a.m., with the CNA QQ she stated, I work day shift. I am assigned to R#5, she complains of shoulder and sometime her legs have pain. A few different times in the last 2 weeks she has complained of shoulder pain. She told me and I informed the nurse. When asked if she reviews R#5's care plan, she stated, I'm not sure where the care plans are located. During an interview with Licensed Practical Nurse (LPN) OO on 05/24/2017 9:34 a.m., she was asked how the Certified Nursing Assistance (CNA's) received communication regarding R#5's plan of care. LPN OO replied, the CNA care plans are in the closet of each resident's room. An observation of the CNA care plan in R#5's closet was titled Daily Care Guide and dated 12/29/16. The Daily Care Guide included the following instructions: Monitor for changes in ADL participation, frequently will change due to endurance, pain or swelling. Notify nurse of any changes. (Role CNA). There was no evidence the care guide was updated to include the current status of R#5's shoulder pain. During an interview with the Director of Nursing (DON) on 5/24/17 at 12:19 p.m., regarding R#5's shoulder pain not addressed on the current care plan, the DON acknowledged the care plan had not been updated since the resident complaint of right shoulder pain in (MONTH) (YEAR).",2020-09-01
369,WELLSTAR PAULDING NURSING CTR,115258,600 WEST MEMORIAL DRIVE,DALLAS,GA,30132,2017-05-25,309,D,0,1,3WZK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews and review of the facility's Pain Management assessment policy Sub-Category Pain Management dated 1/31/1994, the facility failed to ensure ongoing evaluation and treatment for one resident (R) #5 who complained of right shoulder pain. This failure resulted in actual harm for R#5 who continued to exhibit pain in the right shoulder during therapy sessions and after therapy was placed on hold on 5/15/17. One of three residents reviewed for pain out of a sample of 35 residents. Findings include: Upon entering the resident's room on 5/23/17 at 10:00 a.m., the resident was observed with her eyes closed and her left hand holding her right shoulder. She had a grimace on her face. The resident complained of right shoulder pain. When asked if she had told anyone about the pain she replied, They put a patch on my shoulder but it was ordered when I first had pain in my knees. I told them it does not work for this pain in my shoulder. They give me one pill, and say that's the doctor's orders. I am going to see an Ortho (Orthopedic) doctor on (MONTH) 31, (YEAR). I hope I get some relief by then. When asked if she injured her shoulder, she continued, I used to have one of those chairs that you pull the handle to lay back (recliner) and my arm starting hurting because you know, it's hard to push that handle back and get my feet up. This chair has an electric button to recline but my shoulder is hurting. When asked to rate her pain on a scale of 1-10, with 10 being the worst the resident responded, It's an 8. During an interview with Registered Nurse (RN) CC on 5/23/17 at 10:05 a.m., regarding the resident's shoulder pain she stated, She has several medications for pain. I will be going to her room next. During a follow up interview with RN CC on 5/23/17 at 2:00 p.m., she stated, I called the doctor who would not order anything additional and told us to put a warm pad on the right shoulder. Review of the Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR), the only pain medication on the MARs was [MEDICATION NAME] 25MCG (microgram) Patch apply one patch topically every 72 hours . with original order date of 2/11/17; Depo-[MEDICATION NAME] injections every 3 months with original order date of 10/28/2010; and Tylenol Arthritis 650mg (milligram) take one tablet every 12 hours with original order date of 6/22/16. According to R#5's most recent quarterly Minimum Data Set ((MDS) dated [DATE] in section C0500 Brief Interview for Mental Status (BIMS) Summary Score was coded 15 for cognition (having no problems with recall and/or orientation to day and time). The resident's [DIAGNOSES REDACTED]. On 4/12/17, the physician was faxed a cover sheet which indicated, Resident reports hurt right shoulder while reclining her chair, would like X-ray. Can we get x-ray of the right shoulder? No bruising or swelling, has limited range of motion (ROM). The physician ordered a right shoulder X-ray in am (morning) due to decrease range of motion (ROM) and pain. The x-ray report of the right shoulder dated 4/13/17 at 8:00 a.m. indicated, No significant radiographic abnormality identified. On 4/26/17 (14 days later) it was documented in the Nurses Notes at 6:11 p.m., New order (N/O) Physical Therapy (PT) evaluation and treat for right shoulder pain, PT aware of order. On 4/28/17 it was documented in the Nurses Notes, N/O, noted to treat 3 x week x 8 weeks, PT aware. Review of the form titled, Plan of Treatment for Rehabilitation revealed, . Problem List: decreased active range of motion (ROM) and decreased strength right shoulder. Patient Subjective Complaint: my arm hurts all the time; nothing helps it, patient report pain 8/10. Patient describes pain for over a month likely from repetitive use of manual recliner chair handle to raise and lower feet. X-ray taken on 4/12 is negative. Documented on the Treatment Encounter Notes dated 5/1/17, Physical therapist (PT) noted the resident stated. It's the first time my shoulder has kept me up. It woke me up at 1:30 this morning. Documented on the Treatment Encounter Notes dated 5/7/17, the resident told the therapist, Oh it hurt so bad last night I was crying. Review of the Treatment Encounter Notes dated 5/15/17 indicated that a physical therapist documented, Patient (Pt) wants to HOLD PT and speak with the Doctor, or nurse contact him to see what she should do. Pt wears a pain patch but she informs that it doesn't help anymore either. Review of a Nurses Note dated 5/15/17 at 5:00 p.m. revealed, PT informed this nurse that pt refused PT today due to not helping and continue to have pain. Requesting to see Doctor before continue. The nurse faxed the physician and noted on the fax face sheet dated 5/15/17, Pt (patient) refused PT to right shoulder today not helping, cont. (continue) to have pain, pain patch not helping. Requesting to see doctor before cont. There was no further documentation in the medical record regarding follow up with the doctor and no assessment or interventions to address R#5's pain in the right shoulder until 5/23/17 at 11:00 a.m. Review of the Nurses Notes dated 5/23/17 at 11:00 a.m., indicated, Resident complained of right shoulder area upper pain/discomfort, offered to contact Doctor for PRN (as needed) pain medications and the resident refused. Resident stated discomfort on 1-10 (10 worst) pain was 8. Resident will be seeing the orthopedic doctor on Friday (MONTH) 31st. Applied ice pack to right shoulder area per PRN orders. Resident states some relief at this time will continue to monitor for changes. On 05/24/2017at 1:05 p.m., the resident's attending physician was at the nursing station. When asked about the resident's shoulder pain and the documentation in the therapist notes that R#5 continued to complain of pain with no relief from therapy or the [MEDICATION NAME] he stated, I'm going in to see her now. The physician increased the [MEDICATION NAME] 25 MCG/hour patch to 50 MCG/hour every 72 hours. During interview with the Rehabilitation Manager on 05/24/2017 at 9:58 a.m., regarding the resident's continuous complaints of pain when in therapy and her refusal to continue therapy he stated, The patient stated she wanted to hold PT. It was not the MD (medical doctor) that said do not do therapy until seen. When asked how information regarding R#5's complaints of pain was communicated to the clinical team, he replied, Each week we have a Facility Review meeting with the Nurse Manager who leads the meeting. The Minimum Data Set (MDS) nurse, Social Services and Admission are all at the meetings. I do not remember if pain was discussed during the meeting. During an interview with Licensed Practical Nurse (LPN) OO on 05/24/2017 at 1:53 p.m., regarding the resident's pain, she stated, The resident had a long history of pain medication use. We go with what she says and we call the physician to see if he wants to order something else. During an interview with the RN Unit Manager (UM) BB on 05/24/2017 at 3:03 p.m. she stated, She told me in (MONTH) that her shoulder hurt. I told the MD and we got an X-ray. It was completely normal no [MEDICAL CONDITION] changes. Told her about X-ray and asked if she wanted PT and she refused PT at that time then consented to it in late April. When asked if R#5's refusal for PT was documented in the medical record, she replied, No. UM BB continued, I just found out about the pain in PT notes today and I updated the care plan to address the shoulder pain. When asked about the weekly Facility Review meetings she replied, I head the weekly meeting. We talk about frequency of therapy but pain never came up. She tells the nurse half hour before the medication is due and we give her medication. When she has pain they (the nurses) do an assessment. She told me that day, but I did not complete a pain assessment. When asked do you expect the nurses to complete a pain assessment if a resident complains of pain. UM BB replied, Yes. Review of the medical record revealed the last, Pain Assessment was dated 3/13/17. During interview 5/24/17 at 2:00 p.m., with the Director of Nursing (DON) and UM BB on 5/25/17 at 3:03 p.m., they both stated pain assessments are completed quarterly unless there was an incident or new onset of pain, then an assessment will be done. There was no evidence that a Pain Management assessment was completed in accordance with the facility's policy Sub-Category Pain Management dated 1/31/1994 specifically under Step Two 1.2 Evaluate each resident with new onset of pain, Utilize the pain assessment form. Further review of the medical record revealed a form titled Supplements dated 4/17 and 5/17. The following was noted. Assess for indications of pain, verbal and non-verbal, Y=yes, N=No and S=sleep. From (MONTH) 1 through (MONTH) 22, (YEAR), the form was coded N or S each shift. During an interview with R#5 on 5/25/17 at 10:00a.m., regarding whether the nurses assessed her pain level each shift. The resident replied, No. During an interview with Certified Nursing Assistant (CNA) QQ on 05/24/2017 at 9:16 a.m., she stated, She works on the day shift with the resident and that the resident complains of pain in her shoulder and sometimes her legs. A few different times in the last two weeks she has complained of shoulder pain. She told me and I informed the nurse. I know PT put an ice pack on her yesterday and she has not been complaining as much. I guess the ice pack may have helped her yesterday. During an interview with the DON on 05/24/2017 at 2:19 p.m., The staff should respond to pain. It is what the resident states. The pain assessment should have been done again when she stated she had shoulder pain.",2020-09-01
370,WELLSTAR PAULDING NURSING CTR,115258,600 WEST MEMORIAL DRIVE,DALLAS,GA,30132,2017-05-25,371,F,0,1,3WZK11,"Based on observations and staff interviews, it was determined the facility failed to store, distribute and serve food under sanitary conditions, and in a manner minimizing the risk for food borne illness. This deficient practice had the potential to affect all of the residents who resided in this Long-Term Care (LTC) facility. The census was 172 residents with one resident on tube feeding. Findings include: Observations on 5/22/17 at 9:00 a.m., during the initial tour of the kitchen with Dietary the Manager (DM) revealed: 1. The walk-in refrigerator had hotel pans of cooked food items that were not labeled and dated to include three - 2 quart pans of scrambled eggs, four - 2 quart pans of cooked bacon and three - 2 quart pans of cooked ham. One large bag of chopped chicken and one large bag of chicken nuggets. 2. Further observations included the following: two - 6 pound cans of sauerkraut, one - 6 pound can of pinto beans, one - 6 pound can of mixed vegetables and two cans of vanilla ensure, all of the cans were dented. Upon inquiry with the DM regarding the process for monitoring for dented cans, she replied, We have someone who is responsible for checking cans and if they are dented they are not to be on the selves for use. There was a heavy build-up of grease and spilled food on the foil under the stove top below the pilot lights. Interview with the DM regarding their process for checking the grease trays, she replied they should be checked daily and the foil should be changed. 3. Stacks of hotel pans were wet and not dried before storing on the shelves. On 5/24/17 at 4:00 p.m., observations of unlabeled and not dated cooked breakfast items were noted in the walk-in refrigerator. During an interview with the DM who was present during the observation she stated, I did an in-service after your first visit the other day ( 5/22/17) and told them they must label and date this food, she further stated, This is breakfast that is prepped for the next day. Observations of food delivery service during dinner on the C hall on 5/23/17 5:00 p.m., reveled the entire food delivery truck and all trays taken off the truck had uncovered fruit cocktail and cookies on the trays as they were transported by staff to the residents room. Approximately ten trays were on the food cart. During interview with the DM on 5/24/17 at 12:00 p.m., she stated, all items on the trays should be covered and not transported to the resident's rooms uncovered.",2020-09-01
371,WELLSTAR PAULDING NURSING CTR,115258,600 WEST MEMORIAL DRIVE,DALLAS,GA,30132,2017-05-25,431,D,0,1,3WZK11,"Based on observations and staff interviews, the facility failed to ensure an environment that is free from accident hazards over which the facility has control and provides supervision. There were 2 of 8 medication carts found unlocked in an unsecured area accessible to residents and unauthorized persons. Findings include: Observations on 5/22/17 during the initial tour of the facility a medication cart was observed unlocked and unsupervised in the hallway on Nursing Unit (NU 1). The medication cart was accessible to residents and other unauthorized persons/staff. The surveyor observed the cart unlocked and unattended from 9:45 a.m., to 9:55 a.m., The Unit Manager (UM), who was at the station became aware the cart was unlocked, went to find the Licensed Practical Nurse (LPN) assigned to the cart. LPN KK returned to the cart at 9:55 a.m., and realized the cart was unlocked, she immediately secured the medication cart. During an interview on 5/22/17 at 10:00 a.m., LPN KK stated she had accidentally left the cart unlocked during her haste to send a resident out of the facility. LPN KK said the cart is usually locked, this is not my normal. I was in a hurry getting the medication out of the med cart drawer to give to a resident who was being sent out, that I forgot to lock the drawer. On 5/23/17 from 9:40 a.m., to 10:20 a.m., a mediation cart was observed unlocked and unsupervised on the hallway of the secured Braly (BA) unit. An unidentified resident was observed walking around the cart and touching articles on the unlocked medication cart. When a staff member noticed the cart was unlocked they left to find the nurse assigned to the cart, they did not secure the medication cart prior to leaving. LPN AAA returned to the medication cart at 10:20 am, realized the cart was unlocked, and secured the cart. During an interview on 5/23/17 at 10:30 a.m., LPN AAA stated that the cart was usually locked when he leaves it in the hallway. LPN AAA said he knows the cart is supposed to be locked at all times, this is one of the things the team discussed in their monthly safety meetings. LPN AAA said he was trying to assist one of the residents' in their room, when he left the cart unlocked. During an interview on 5/23/17 at 11:30 a.m., with the Staff Developmental Coordinator (SDC) stated, the unlocked medication carts should have never occurred. The facility practices accountability 200%. 100% for yourself and 100% for your team. The managers do random audits and checks for medication security. During new employee orientation medication/treatment cart safety policy was reviewed and was discussed at the monthly safety meeting. During an interview on 5/24/17 at 12:30 p.m., the Director of Nursing (DON) stated all carts should be locked at all times. The DON stated that the facility managers are supposed to be doing monitoring and audits on a routine base and should have found the unlocked carts as they were conducting their monitoring.",2020-09-01
372,WELLSTAR PAULDING NURSING CTR,115258,600 WEST MEMORIAL DRIVE,DALLAS,GA,30132,2019-06-13,656,D,1,1,9P0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and review of the facility policy titled Care Plan - Person-Centered, Baseline Interim and Comprehensive, the facility failed to follow the care plan related to contact precautions for one resident (R) (#12) of six residents requiring isolation. Findings include: Review of the clinical record revealed R#12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan last revised 3/7/19 revealed R#12 with a history [MEDICAL CONDITION] wound on leg. Interventions included but were not limited to: orange dot to be placed on door, over bed, and daily care record, alert staff of infection, wear gown as needed, if soiling is likely, and notify all resident's visitors as to the importance of following contact precautions and guidelines at all times. Observation on 6/11/19 at 9:56 a.m. revealed an orange dot on the name tag on the door of R#12's room. There was no personal protective equipment (PPE) or sign indicating to check with the nurse before entering the resident's room. During an interview on 6/12/19 at 9:21 a.m., the Certified Infection Control Manager (CIC) BB stated there is no way for a visitor, family member, or other resident to know if a resident is on isolation. He stated the orange dot on the name sheet on the door only alerts staff that the resident is on isolation. CIC BB confirmed that there is nothing in the area or on the resident's door to indicate to a visitor or family member that they should speak to a nurse before entering R#12's room. He also stated that if the resident had something like a draining wound there would be PPE available to use. In the instance of R#12, because she does have a draining wound, he stated this resident should have all staff gowning and donning PPE if working with the wound. During an interview with the wound care Licensed Practical Nurse (LPN) CC on 6/12/19 at 9:45 a.m., she stated that she always comes in R#12's room without PPE and there has never been anything outside her room such as PPE. She stated the orange dot tells her to go check in the MAR indicated [REDACTED]. She continued by saying if there is PPE at the room she will use it if she believes there is a risk of splatter or spills and that she will put on the gown, gloves and shield if necessary. LPN CC was unaware of how the facility alerts visitors or other residents when a resident is on isolation. During an interview on 6/12/19 at 10:30 a.m. the Director of Nursing (DON) stated when a resident is admitted with infectious types of concerns, the Infection Control Nurse BB is notified. An orange dot is then placed on the door that triggers them to go to the care plan. She stated there should be designated equipment for the staff to use outside of the resident room. She stated there is no way to educate all visitors and other residents per the facility policy. The DON confirmed that R#12 did not have PPE outside the room. Further interview with the DON on 6/12/2019 at 2:27 p.m. revealed that R#12's care plan should have been more specific related to the isolation precautions. Review of the facility policy titled Care Plan - Person-Centered, Baseline Interim and Comprehensive dated 11/22/16 revealed: Purpose: To define a process where person-centered baseline interim and/or individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed and implemented .Care plan developed and implemented by, but not necessarily limited to,: RN (Registered Nurse) who has responsibility for the resident, Director of Nursing (as applicable), and charge nurse responsible for resident care. Cross Refer F880",2020-09-01
373,WELLSTAR PAULDING NURSING CTR,115258,600 WEST MEMORIAL DRIVE,DALLAS,GA,30132,2019-06-13,880,D,1,1,9P0011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and review of the facility policies titled Control of Resistant Organisms and Documentation of Transmission-Based Precautions, the facility failed to implement contact precautions for one resident (R) (#12) of six residents requiring isolation. Findings include: Review of the clinical record revealed R#12 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Observation on 6/11/19 at 9:56 a.m. revealed an orange dot on the name tag on the door of R#12's room. There was no personal protective equipment (PPE) or sign indicating to check with the nurse before entering the resident's room. Review of the care plan last revised 3/7/19 revealed R#12 with a history [MEDICAL CONDITION] wound on leg. Interventions included but were not limited to: orange dot to be placed on door, over bed, and daily care record, place orange precaution sheet on MAR (medication administration record), provide dedicated orange stethoscope and BP (blood pressure) cuff in room, alert staff of infection, wear gown as needed, if soiling is likely, and notify all resident's visitors as to the importance of following contact precautions and guidelines at all times. During an interview on 6/12/19 at 8:20 a.m., Unit Manager (UM) AA stated R#12 came into the facility with [MEDICAL CONDITION] and was taken off isolation in (MONTH) 2019. She stated the orange dot on the door means precautions. However, when asked the difference between those precautions and standard precautions for those without the orange dot, UM AA stated she would let the Infection Control Manager provide that information. During an interview on 6/12/19 at 9:21 a.m., the Certified Infection Control Manager (CIC) BB stated there is no way for a visitor, family member, or other resident to know if a resident is on isolation. He stated the orange dot on the name sheet on the door only alerts staff that the resident is on isolation. He stated there is no way a visitor would know if any resident is on isolation. CIC BB confirmed that there is nothing in the area or on the resident's door to indicate to a visitor or family member that they should speak to a nurse before entering R#12's room. He also stated that if the resident had something like a draining wound there would be PPE available to use. In the instance of R#12, because she does have a draining wound, he stated this resident should have all staff gowning and donning PPE if working with the wound. He stated he did not know why some residents with orange dots on this hall had PPE available and others did not. During an interview with the wound care Licensed Practical Nurse (LPN) CC on 6/12/19 at 9:45 a.m., she stated that she always comes in R#12's room without PPE and there has never been anything outside her room such as PPE. She stated the orange dot tells her to go check in the MAR indicated [REDACTED]. She continued by saying if there is PPE at the room she will use it if she believes there is a risk of splatter or spills and that she will put on the gown, gloves and shield if necessary. LPN CC was unaware of how the facility alerts visitors or other residents when a resident is on isolation. During an interview on 6/12/19 at 10:30 a.m. the Director of Nursing (DON) stated when a resident is admitted with infectious types of concerns, the Infection Control Nurse BB is notified. An orange dot is then placed on the door that triggers them to go to the care plan. She stated there should be designated equipment for the staff to use outside of the resident room. She stated there is no way to educate all visitors and other residents per the facility policy. The DON was unaware of why some residents having orange dots on their doors have PPE hanging on their doors and others do not. The DON confirmed that R#12 did not have PPE outside the room; and when the Infection Control Nurse BB became aware of the problem, he then placed the equipment on R#12's door. She stated she expects the staff to follow this concern closely to keep the residents, staff and family members safe. She agreed that it would be difficult for anyone to know the difference between those doors with orange dots that had PPE hanging and those that did not. The DON could not explain why this was happening. Review of the facility policy titled Control of Resistant Organisms last reviewed (MONTH) (YEAR) revealed: Policy: Residents with identified resistant organisms, (e.g.,[MEDICAL CONDITION] .), will have additional precautions (in addition to Standard Precautions) instituted to prevent and control the spread/transmission to others. Procedure: 1) A color code will be used to identify residents with specific infections needing transmission-based precautions in addition to standard precautions. To alert facility staff, tangerine (orange) colored dot will be placed on the resident's door, over the bed, and in the daily care record. 6) Depending on the organism and whether it is known to colonize these individuals for prolonged periods, the resident may stay on extra precautions indefinitely. Review of the facility policy titled Documentation of Transmission-Based Precautions reviewed (MONTH) (YEAR) revealed: Procedures: [NAME] It is the responsibility of the charge nurse to institute the precautions indicated. 2) Provide education to resident/family and document on education form in medication record. There is no indication of how education to visitors and other residents will be provided or that any education was ever provided to visitors.",2020-09-01
374,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2017-06-22,333,E,0,1,P0SU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical records review and interviews the facility failed to ensure that repeated errors in the amount of insulin administered per the physician ordered sliding scale for two (2) of three (3) residents reviewed (R#9, R#76). The sample size was 25 residents Findings include: 1. Resident #9 was admitted to the facility on (MONTH) 23, (YEAR) with [DIAGNOSES REDACTED]. Medications for his diabetes were [MEDICATION NAME] flextouch 100 units/milliliters (u/ml), [MEDICATION NAME] R 100 units / ml per Dr J's sliding scale. Dr J's sliding scale was written on the MD Sliding Scale Orders sheet under his name and was as follows: Finger stick blood sugar (FSBS) FSBS 150-200 give 2 units FSBS 201-250 give 4 units FSBS 251-300 give 6 units FSBS 301-350 give 8 units FSBS 351-400 give 10 units FSBS over 400 call MD Review of the (MONTH) (YEAR) MAR for [MEDICATION NAME] R 100 units/ml vial revealed that the wrong amount of insulin was administered on the following days and times for R#9: 1. (MONTH) 1, (YEAR) at 8:00 p.m the FSBS was 322. the amount of insulin administered was 10 units but per the sliding scale (SS) for Dr J the it should have been 8 units. 2. (MONTH) 2, (YEAR) at 6:00 a.m., the FSBS was 281. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 6 units 3. (MONTH) 3, (YEAR) at 6:00 a.m. the FSBS was 207. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 4 units. 4. (MONTH) 3, (YEAR) at 8:00 p.m. the FSBS was 288. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 6 units. 5. (MONTH) 4, (YEAR) at 6:00 a.m. the FSBS was 224. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 4 units. 6. (MONTH) 5, (YEAR) at 6:00 a.m. the FSBS was 238. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 4 units. 7. (MONTH) 5, (YEAR) at 8:00 p.m. the FSBS was 343. The amount of insulin administered was 10 units but per Dr. Dr J's SS it should have been 8 units. 8. (MONTH) 6, (YEAR) at 6:00 a.m. the FSBS was 209. The amount of insulin administered was 5 units, but per Dr. Dr J's SS it should have been 4 units. 9. (MONTH) 6, (YEAR) at 8:00 p.m. the FSBS was 325. The amount of insulin administered was 10 units but per Dr. Dr J's SS it should have been 8 units. 10. (MONTH) 7, (YEAR) at 6:00 a.m. the FSBS was 268. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 6 units. 11. (MONTH) 7, (YEAR) at 8:00 p.m. the FSBS was 446. The MD was notified and the dose directed by him. 15 units of [MEDICATION NAME] R 100 was administered. 12. (MONTH) 8, (YEAR) at 8:00 p.m. the FSBS was 423. The MD was notified and the dose directed by him. 15 units of [MEDICATION NAME] R 100 was administered. 13. (MONTH) 9, (YEAR) at 6:00 a.m. the FSBS was 193. The amount of insulin administered was zero but per Dr. Dr J's SS it should have been 2 units. 14. (MONTH) 9, (YEAR) at 8:00 p.m. the FSBS was 419. The MD was notified and the dose directed by him. 15 units of [MEDICATION NAME] 100 was administered. 15. (MONTH) 10, (YEAR) at 6:00 a.m. the FSBS was 220. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 4 units. 16. (MONTH) 10, (YEAR) at 8:00 p.m. the FSBS was 408. The MD was notified and the dose directed by him. 10 units of [MEDICATION NAME] 100 was administered. 17. (MONTH) 11, (YEAR) at 6:00 a.m. the FSBS was 206. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 4 units. 18. (MONTH) 12, (YEAR) at 6:00 a.m. the FSBS was 225. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 4 units. 19. (MONTH) 13, (YEAR) at 6:00 a.m. the FSBS was 225. The amount of insulin administered was 5 units but per [DOCTOR]on' SS it should have been 4 units. 20. (MONTH) 13, (YEAR) at 8:00 p.m. the FSBS was 341. The amount of insulin administered was 10 units but per Dr. Dr J's SS it should have been 8 units 21. (MONTH) 14, (YEAR) at 6:00 a.m. the FSBS was 167. The amount of insulin administered was zero units but per Dr. Dr J's SS it should have been 2 units. 22. (MONTH) 14, (YEAR) at 8:00 p.m. the FSBS was 408. The MD was called and directed the dosage. 10 units of [MEDICATION NAME] R 100 was administered. 23. (MONTH) 15, (YEAR) at 6:00 a.m. the FSBS was 151. The amount of insulin administered was zero but per Dr. Dr J's SS it should have been 2 units. 24. (MONTH) 15,2017 at 8:00 p.m. the FSBS was 308. The amount of insulin administered was 10 units but per Dr. Dr J's SS it should have been 8 units. 25. (MONTH) 16, (YEAR) at 6:00 a.m. the FSBS was 225. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 4 units. 26. (MONTH) 16, (YEAR) at 8:00 p.m. the FSBS was 403. The MD was called and directed the dosage. 10 units of [MEDICATION NAME] R 100 was administered. 27. (MONTH) 17, (YEAR) at 6:00 a.m. the FSBS was 274. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 6 units. 28. (MONTH) 17, (YEAR) at 8:00 p.m. the FSBS was 335. The amount of insulin administered was 10 units but per Dr. Dr J's SS it should have been 8 units. 29. (MONTH) 18, (YEAR) at 8:00 p.m the FSBS was 276. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 6 units. 30. (MONTH) 19, (YEAR) at 6:00 a.m. the FSBS was 159. The amount of insulin administered was zero but per Dr. Dr J's SS it should have been 2 units. 31. (MONTH) 19, (YEAR) at 8:00 p.m. the FSBS was 254. The amount of insulin administered was 5 units but per Dr. Dr J's SS it should have been 6 units. 32. (MONTH) 20, (YEAR) at 6:00 a.m. the FSBS was 175. The amount of insulin administered was zero but per Dr. Dr J's SS it should have been 2 units. During an interview with the Director of Nursing on (MONTH) 21, (YEAR), at 11:38 a.m., she stated there was only one form with the sliding scale information on it, (MD Sliding Scale Orders), used to calculate the insulin dosages per the FSBS. At 11:56 a.m. on (MONTH) 21, (YEAR), the DON reviewed the insulin dosages for R#9 and agreed that the units of insulin that had been administered were incorrect and that she did not know why there were so many errors. She stated that on (MONTH) 20, (YEAR), after having a request for a copy of the sliding scale for the facility residents, she went through the diabetic Medication Administration Records (MARS) and wrote all sliding scale orders out on the MAR per the specific physician orders. 2. Resident #76 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The medications R#76 received for her [DIAGNOSES REDACTED]. Beginning (MONTH) 1, (YEAR) through (MONTH) 13, (YEAR) the sliding scale (SS) used for resident #76 was FSBS with SS per Dr. F's SS, as follows: FSBS 0-50 call MD FSBS 51-150 give zero units FSBS 151-200 give 2 units FSBS 201-250 give 4 units FSBS 251-300 give 6 units FSBS 301-350 give 8 units FSBS 351-400 give 10 units FSBS over 400 call MD Review of the (MONTH) (YEAR) MAR for [MEDICATION NAME] flex pen use reveals the wrong amount of insulin was provided on the following days and times for R#76 1. (MONTH) 2, (YEAR) at 4:30 p.m. the FSBS was 202. The amount of insulin administered was 2 units but per Dr. Dr F's SS it should have been 4 units. 2. (MONTH) 6, (YEAR) at 4:30 p.m. no FSBS was obtained therefore no insulin was administered. 3. (MONTH) 15, (YEAR) at 4:30 p.m. no FSBS was obtained therefore no insulin was administered. Review of the Physician order [REDACTED]. During an interview with the DON on (MONTH) 21, (YEAR) at 2:29 p.m. she stated that the nurses are supposed to check the MARs at the end of the month during change over for accuracy and any changes needed. She stated these issues should have been caught at that time. On (MONTH) 21, (YEAR) at 3:30 p.m. during an interview with the ADON she stated she did not understand why the insulin's were inaccurately given when the sliding scale is written right on the MAR for R#76. She stated her expectations were for the nurses to follow the sliding scale ordered by the physician. On (MONTH) 22, (YEAR) at 12:56 p.m. an interview was conducted with the Medical Director. He stated that his expectations are for the nursing staff to follow the MD orders and he doesn't understand how this happened. He stated the pharmacist is supposed to check these and he expects this. Further interview revealed that although the correct amount of insulin was not administered that there were no negative outcomes.",2020-09-01
375,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2017-06-22,428,E,0,1,P0SU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews the pharmacist for the facility failed to ensure accurate amounts of insulin were being administered for two (2) of three (3) residents (R#9, #76). The sample size was 25 residents. 1. Resident #9 was admitted to the facility on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Medications for his diabetes were glipizide, Levemir flex touch 100 units/milliliters (u/ml), Novolin R 100 u/ml per Dr. J's sliding scale. Dr J's sliding scale was written on the MD Sliding Scale Orders sheet under his name and was as follows: Finger stick blood sugar (FSBS) FSBS 150-200 give 2 units FSBS 201-250 give 4 units FSBS 251-300 give 6 units FSBS 301-350 give 8 units FSBS 351-400 give 10 units FSBS over 400 call MD Review of the (MONTH) (YEAR) MAR for Novolin R 100 units/ml vial revealed that the wrong amount of insulin was administered thirty-two times for R#9: 2. Resident #76 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The medications R#76 received for her [DIAGNOSES REDACTED]. Beginning (MONTH) 1, (YEAR) through (MONTH) 13, (YEAR) the sliding scale (SS) used for resident #76 was FSBS with SS per Dr. F's SS, as follows: FSBS 0-50 call MD FSBS 51-150 give zero units FSBS 151-200 give 2 units FSBS 201-250 give 4 units FSBS 251-300 give 6 units FSBS 301-350 give 8 units FSBS 351-400 give 10 units FSBS over 400 call MD Review of the (MONTH) (YEAR) MAR for Novolog flex pen use revealed that the wrong amount of insulin was administered to R#76 three times. Review of the Physician order [REDACTED]. On (MONTH) 22, (YEAR) at 11:06 a.m. during an interview with the Pharmacist for the facility and he revealed that normally he checks the insulin amounts, but obviously there was an oversight in this area and that he did not put as much attention to this as he should have. On (MONTH) 22, (YEAR) at 12:56 p.m. an interview was conducted with the Medical Director revealed that his expectations are for the nursing staff to follow the MD orders and he doesn't understand how this happened. He further stated that the pharmacist is supposed to check these and he expects this. Further interview revealed that although the correct amount of insulin was not administered that there were no negative outcomes.",2020-09-01
376,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2018-07-12,582,D,0,1,802511,"Based on observation, record review and administrative staff interview, the facility failed to provide evidence that the required Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) was issued for two out of three sampled residents (R) (R 57 & R 86) that were discharged from Medicare Part A services. The sample size was 50 residents. Findings include: On 7/11/18 at 10:28 a.m. the Administrator returned the three completed ANF ABN forms that had been requested; however, two of the forms had an explanation unable to locate the notice given to the family. An interview with the Administrator, at this time, revealed that the Social Services Director (SSD) would have completed these notices but that the SSD had recently left the job and that these notices could not be located. Interview on 7/12/18 at 10:00 a.m. with Director of Nursing (DON) revealed they do not have a policy for completing Advanced Beneficiary Notices (ABN). Interview on 7/12/18 at 10:35 a.m. with the Administrator revealed that the two notices were unavailable although she felt they were completed by the former Social Services Director who resigned from her position (MONTH) 29, (YEAR). The Administrator revealed that she had contacted the former employee SSD who believed they were completed but does not know where they would be. The Administrator stated it was their practice to complete all ABN's at the appropriate time to assure that residents and families are kept informed of their rights to Medicare coverage and discharge from Medicare.",2020-09-01
377,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2018-07-12,584,D,0,1,802511,"Based on observation and interviews the facility failed to ensure the upkeep of resident wheelchairs related to dirt and build up. This affected five residents (R#44, R#47, R#52, R#81, and R#83). The facility census was 101 residents. Findings include: Observation on 7/9/18 at 11:51 a.m. revealed dirt and build up on wheelchair wheels for R# 81. Observation on 7/9/18 at 12:09 p.m. and at 3:05 p.m. of the wheelchair for R# 83 revealed that it had a thick grey coating on the wheels and on the undercarriage of the wheelchair. Observation on 7/9/18 at 1:07 p.m. of the wheelchair for R# 47 revealed that the resident was observed sitting in wheelchair and there was a white and brown buildup on front left wheel. Observation on 7/9/18 at 1:16 p.m. of the wheelchair for R# 44 revealed that the wheelchair had a buildup of dirt on the spokes of the wheelchair. Observation on 7/10/18 at 9:29 a.m. of R#47 ambulating down Hall B. Observation revealed that there was a white and brown buildup on the left wheel of residents wheelchair. Observation on 7/11/18 at 12:07 p.m. of the wheelchair for R# 83 revealed that it was observed to have a grey buildup. Observation on 7/11/18 at 4:15 p.m. of the wheelchair for R# 52 revealed that the wheelchair had dirt buildup on the wheels. Interview on 7/12/18 at 11:07 a.m. with Unit Manager AA revealed that all staff are responsible for the cleaning of wheelchairs and that there is no cleaning schedule. It was further revealed that typically the managers pressure wash the wheelchairs once or twice a year but have not done so this year. Unit Manager AA revealed that on A hall 3-11 staff pull wheelchairs to the hall when residents are in bed and that the 11-7 shift staff cleans the wheelchairs in the shower. However, this has not been done in over a month. Unit Manager AA confirmed dust and dirt buildup on wheelchairs on 7/12/18 from 10:20 a.m. through 10:25 a.m. for R#44, R#47, R#52, R#81, and R#83. An interview with the Director of Nursing (DON) on 7/12/18 at 11:03 a.m. revealed that wheelchairs are to be cleaned as needed and that there is no current schedule for cleaning wheelchairs. The DON revealed that in the past staff have pressure washed the wheelchairs but that has not been done this year. The DON observed and confirmed the buildup on the wheelchairs for residents (R#44, R#47, R#52, R#81, and R#83). She reported that the 11-7 shift CNAs should be wiping down chairs at night. It was reported that the nurse manager from the hall and herself should also be looking at the wheelchairs daily. DON revealed that she had not been looking at the wheelchairs as she should.",2020-09-01
378,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2018-07-12,607,D,0,1,802511,"Based on record review and staff interview, the facility failed to obtain reference checks for four of ten employee files reviewed who were hired in the past four months. The sample size was 50 residents. Findings include: Review of the personnel files of new employees hired between 4/1/18 and 7/6/18 revealed that reference checks could not be located for four of the ten files reviewed. During an interview with the Administrator on 7/12/18 at 11:31 a.m., revealed that the Administrator verified that reference checks had not been completed for four employee files. She further revealed that the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) are the one's responsible for checking the references and she doesn't know why these files do not have reference checks on them. She stated there is not a policy on new hire requirements related to reference checks. During an interview with the DON on 7/12/18 at 12:45 p.m., revealed that she and the ADON, normally only verify employment of new hires because facilities will only tell you dates of employment. She further revealed that two of the new hired employees had worked here before and she called for another but just forgot to write it down.",2020-09-01
379,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2018-07-12,656,D,0,1,802511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and policy review, the facility failed to ensure a patient centered care plan with measurable goals and interventions was developed to meet the residents medical needs for the use of oxygen for one resident (R) R#50. The sample size was 50 residents. Findings include: Review of the clinical record for R#50 revealed she was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Review of R#50 Medication Administration Record [REDACTED]. Based on review of the care plan for R50, there was not anything documented for the use of Oxygen therapy; subsequently no care plan interventions or goals were found. Interview on 7/11/18 at 9:45 a.m., with Unit Manager AA, revealed that MDS is the one responsible for creating care plans and making additions to the care plans. She stated she can add medications and procedural changes to care plans only. She stated she does not know why R50 does not have a care plan for Oxygen use. Interview on 7/12/18 at 8:46 a.m., with MDS nurse LL, revealed that any of the floor nurses can add care plan problems to the comprehensive care plan. She stated that they are not allowed to create initial care plans, but can make revisions and modifications as new [DIAGNOSES REDACTED].#50 does not have a care plan for Oxygen use, that the MDS department would have picked it up on her next quarterly assessment, which she stated is due next week. Interview on 7/12/18 at 2:01 p.m., with Director of Nursing (DON), stated that medication nurses and unit managers should be updating resident care plans as new issues are identified. She stated that the MDS nurses are responsible for the quarterly updates, and they look for any area of concern or newly identified diagnoses, and will add them to the updated care plan. She stated that she does not know why the unit manager didn't add the Oxygen use to resident's care plan. Review of the policy titled, IDT/Care Plan Activities, with an effective date 0f 11-1-2017, revealed the purpose is to evaluate, implement and maintain a thorough plan of care for each resident ensuring that he/she maintains the highest quality of life possible. The Nursing Services Responsibilities indicated updates to care plans as changes occur and communicates updates with Minimum Data Set (MDS) coordinator and communicates the need for additional care plans. cross refer F695",2020-09-01
380,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2018-07-12,695,D,0,1,802511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews and review of the policy titled Oxygen Therapy, the facility failed to ensure that a clean nasal cannula was used fro two residents (R) (R#50 and R#85); and failed to ensure an oxygen concentrator filter was clean for one resident (R) (R#50). The sample size was 50 residents. Findings include: 1. Review of the clinical record for R#50 revealed she was admitted to the facility with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Review of R#50 Medication Administration Record [REDACTED] Physician's order dated 7/10/18 revealed order for order to change and label oxygen tubing every two weeks and to clean concentrator and filter weekly. Observation on 7/9/18 at 2:55 p.m. revealed Oxygen concentrator set on two liters being delivered via Nasal Cannula (N/C). No date noted on the Oxygen tubing. Filter on Oxygen concentrator was observed to be layered dust. Observation on 7/10/18 at 3:18 p.m., revealed that the oxygen concentrator in use delivering two liters via N/C. Tubing does not have date on it and the concentrator filter remains layered dust on it. Interview on 7/10/18 at 3:25 p.m., with Licensed Practical Nurse (LPN) BB, revealed that the night shift 7:00 p.m. to 7:00 a.m. (7p-7a) is responsible for changing the Oxygen tubing every two weeks. She stated she does not recall which day of the week they are changed, but she stated they are to document on the Medication Administration Record [REDACTED]. She further stated she was not sure if they are to date the tubing or not. When asked about cleaning the concentrator filter, she stated the night shift nurses are responsible for cleaning them as well and documenting that the concentrators have been cleaned on the MAR. She was unable to find documentation on the residents MAR indicated [REDACTED] Interview on 7/10/18 at 3:35 p.m., with Unit Manager AA, stated that it is the responsibility of the night shift nurses to change the Oxygen tubing every two weeks and to date it with date changed. She further stated they are supposed to clean the concentrators and filters every week on the night shift also. She further stated that they were cleaned on Sunday. She could not find documentation on the residents MAR indicated [REDACTED]. She verified that the oxygen tubing did not have a date when changed and that the oxygen concentrator filter had a thick layer of dust on it. Review of the facility policy titled Oxygen Therapy with effective date of 6/10/2009 and revision date of 10/1/2017, revealed the purpose is to give information for the care of residents on oxygen therapy and the equipment used. The care of the resident indicated that cannula's and masks should be changed weekly or as necessary. Care of the concentrator, to be documented in the resident's clinical record, indicated to wash filters weekly and as needed, change oxygen tubing bi-weekly and clean concentrators weekly. 2. Resident #85 was admitted to the facility on [DATE] with Physician Orders to apply oxygen two liters by nasal cannula for shortness of breath or oxygen saturation of less that 92% on room air and for oxygen saturation levels to be obtained every shift. The order was hand written on the (MONTH) (YEAR) Physician's Orders and was printed on the Physician's Orders for (MONTH) through (MONTH) of (YEAR). During an observation on 7/09/18 at 12:45 p.m. the oxygen tubing on resident #85 was labeled 4/6/18 and oxygen was infusing at two liters per minute by nasal cannula. During an observation on 7/09/18 at 02:30 p.m. the oxygen tubing was labeled 4/6/18 and the oxygen was infusing at two liters per minute by nasal cannula. During an observation on 7/10/18 02:06 p.m. the oxygen tubing was dated 7/10/18 and the oxygen was infusing at two liters per minute by nasal cannula During an interview on 7/10/18 at 02:18 p.m. with Licensed Practical Nurse (LPN) HH, revealed that the cannula's should be changed monthly and does not recall the date on the cannula that was changed on Resident # 85. During an interview on 7/11/18 at 12:03 p.m. with LPN II, revealed the oxygen tubing needs to be changed every 2 to 3 weeks and knows when to change the tubing because it should be dated. She further revealed she has not changed the tubing since starting here and believed that you document this on the Medication Administration Record. During an interview on 7/11/18 at 1:45 p.m. with the Nursing Manager for 300 hall revealed that the change tubing order should have been written on the Medication Administration Record [REDACTED].",2020-09-01
381,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2018-07-12,758,D,0,1,802511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that [MEDICAL CONDITION] medications were not ordered as needed (PRN) for more than fourteen (14) days unless clinically indicated for one resident (R) (#7). The sample size was fifty (50). The facility census was 101. Findings include: Review of the medical record for R#7 revealed that there was a prescription for [MEDICATION NAME] 1mg tablet in which 1 tablet is taken by mouth as needed with a start date of 1/17/18. There was also an order [REDACTED]. Review of the Medication Administration Record [REDACTED]. [MEDICATION NAME] was not received in June. Review of MAR for (MONTH) (YEAR) revealed: [MEDICATION NAME] was received 6 times in (MONTH) (twice on 23rd, 24th, 25th, 27th, and 31st. [MEDICATION NAME] was not received in June. Review of MAR for (MONTH) (YEAR) revealed: [MEDICATION NAME] was received on 1st, three times on 2nd, 3rd, twice on 4th, twice on 5th, 6th, twice on 7th, twice on 8th, twice 9th, 10th, and 11th. [MEDICATION NAME] was not received in July. Review of physician progress notes [REDACTED]. Interview on 7/11/18 at 10:04 a.m. with Licensed Practical Nurse (LPN) FF who reported that R#7's doctor has spoken to her regarding the need of antianxiety medicines. It was further reported that R#7's physician is receptive to suggestions when informed of possible need to discontinue medication use. LPN FF was unsure of guidelines related to the 14-day PRN use of antianxiety medications. Interview on 7/11/18 at 10:07 a.m. with LPN DD who reported that resident's medication needs are communicate to the physician through communication forms. LPN DD reported that if a resident is not taking meds the physician is notified during rounds. LPN was not fully knowledgeable the 14 day rule for [MEDICAL CONDITION] medication use. On 7/11/18 at 11:45 a.m. LPN FF provided a copy of communication form to doctor dated 6/25/18 requesting to discontinue the use of [MEDICATION NAME] due to non use by the resident but the physician responded back on 7/11/18 to not discontinue [MEDICATION NAME]. Interview with the Director of the nursing on 7/11/18 at 5:14 who revealed that staff have been instructed to try other interventions prior to calling the physician. It was further reported that typically after 30 days of not using PRN medications. R#7's physician does not allow this. DON reported that the facility has been working on discharging and as needed [MEDICAL CONDITION] medication use. Interview with the Assistant Director of Nursing (ADON) on 7/11/18 at 5:18 p.m. who reported that the medial director has been informed of regulations related to the 14 day usage of psychotic medication use. Interview on 7/12/18 at 8:15 a.m. with the ADON who reported that every month she reviews the [MEDICAL CONDITION] drugs for all residents. The findings on the [MEDICAL CONDITION] drug worksheet is then reviewed and the nurse manager and pharmacy consultant receives a copy. It was reported that the Pharmacy consultant has not provided any directives to nursing or physician to address prn medication usage. All residents with [MEDICAL CONDITION] are identified and this is reviewed with the physician. The medical director has been informed about the need for documentation for PRN medication usage. ADON reported that she tries to educate the physicians on everything and has recently began educating all physicians. It was reported that there is one physician in particular that is hard to educate. ADON reported that this physician has informed staff that she does not want to discontinue antianxiety medication as the resident would ask for it and it would have to be rewritten. ADON acknowledged that she has been mostly focused on educating the Medical Director on PRN usage of the antipsychotic drugs. On 7/12/18 at 12:10 p.m. ADON provided copies of sign off sheets in which medical staff confirmed receiving copy of regulations regarding [MEDICAL CONDITION] medications and the documentation that is required dated 7/12/18. Interview on 7/12/18 at 12:20 p.m. with the Medical Director who reported that meetings are held with the Director of Nursing (DON), Administrator, and hall managers almost weekly on Wednesdays. He reported that they discuss residents on [MEDICAL CONDITION] and ADON is constantly talking about decreasing of antipsychotics. He further Reported that he does not know that PRN medications and timeframes has been discussed. The Medical Director reported that he was not aware of new medication regulations related to the use of PRN [MEDICAL CONDITION] medications. Done",2020-09-01
382,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2018-07-12,761,D,0,1,802511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. 07/11/18 an observation on C Hall Licensed Practical Nurse (LPN) GG at 7:56 a.m. LPN GG was observed to walk down the C hall towards the rotunda and administer medications to a resident in the hall way leaving stock medications on top of the medication cart and his back was to the cart. At 7:58 a.m. LPN GG was observed to go into room [ROOM NUMBER] and left the same medication on top of the medication cart, unsupervised with stock medications in closed bottles, on top of the medication cart (no observed residents on hall). Further observation revealed that LPN GG was in room [ROOM NUMBER] approximately 3 minutes before returning to the unsupervised cart, the cart was parked outside of the room and to the right on the wall, not in view of LPN G[NAME] On 07/11/18 at 8:13 a.m. Interview with LPN GG reported that medications should not be left on top of the medication unsupervised. 07/12/18 10:10 AM Interview with LPN Nurse Manager AA on A hall reported that it is not acceptable to leave medications on the top of the med cart out of view. Also stated that she educates nurses on policies and procedures. In continued interview with nurse manager AA revealed that nurses receive orientation on hire and also the Director of Nurses (DON) does in-service education on needed areas of concern or skills that need addressed. 7/12/18 10:37 a.m. Interview with the DON revealed that she expects the nurses to lock all medications in the medication cart when they are not by their cart and follow the medication administration policy. 7/12/18 11:19 a.m. Interview with the Assistant Director of Nursing (ADON) reported that licensed practical nurse GG received education related not leaving medication on the cart unsupervised. The ADON provided education material signed and dated on 4/27/17 and 5/15/18; Medication Pass Guidelines. Review of the A monthly pharmacy Medication Pass Guidelines, dated 6/18/18; 1. Medication Cart and Drug Security; c. Appropriate drug security maintained; cart always visible to the nurse or is locked. Based on observation, policy review and staff interviews the facility failed to remove expired medications by the expiration date in two out of three medication (med) storage rooms and failed to keep medications in locked medication cart during medication administration. The facility census was 101 residents. Findings included: 1. Observation on 7/11/18 at 3:00 p.m. of the C Hall Medication (med) storage room, with the Registered Nurse (RN) Unit Manager JJ, and a surveyor-trainee, revealed (12) expired medications. Inside a mini-refrigerator in the med storage room, a small emergency med box (e-box) contained emergency meds that needed to be refrigerated. The label on the outside of the e-box had expiration date 6/2018, two (2) [MEDICATION NAME] ([MEDICATION NAME]) suppositories inside the e-box had expiration date 6/2018 on each individual suppository package. Further Observation of C Hall med storage room & mini refrigerator also revealed a box of ten (10) [MEDICATION NAME] Quadrivalent (Influenza Vaccine) prefilled syringes. The expiration date on the box and on the ten (10) individual syringes were 6/12/18. Interview at that time with the RN Unit Manager JJ, and the surveyor-trainee, confirmed (12) medications were expired. Observation on 7/11/18 at 3:25 p.m. of the B Hall med storage room with Licensed Practical Nurse (LPN) KK, and a surveyor-trainee, revealed two (2) expired medications inside a mini-refrigerator in the small med e-box. The label on the e-box had expiration date 6/2018 and inside were two (2) [MEDICATION NAME] ([MEDICATION NAME]) suppositories with the expiration date 6/2018 on each individual suppository package. Interview at that time with LPN KK, and the surveyor-trainee, confirmed the meds were expired. Observation on 7/11/18 at 3:50 p.m. of the A Hall med storage room & mini-refrigerator with LPN Nurse Manager AA, and a surveyor-trainee, revealed no expired medications. Observation on 7/11/18 at 5:00 p.m. of three medication carts, from A, B & C Hall, revealed no issues with storage or labeling, and no expired meds. On 7/12/18 review of the Medication Storage policy revealed medication rooms are routinely inspected by the DON, Assistant Director of Nursing (ADON), or nurse managers, for discontinued and outdated meds. Discontinued and outdated narcotics are kept locked until picked up for destruction. Discontinued and outdated non-narcotic meds are logged and stored in designated area until picked up by pharmacy for destruction. Interview on 7/12/18 at 12:00 p.m. with the ADON revealed all nurses are responsible for dating meds when opened & monitoring for expired, & discontinued meds. All med storage rooms are inspected monthly by the hall nurse with follow up by the nurse manager or the ADON. During medication room inspection any outdated meds are pulled, logged and stored in the ADON office. A Medication check-off inspection form is completed every month for all med storage rooms, signed by hall nurse and nurse manager or ADON and kept in the Pharmacy (monthly review) notebook. Continued interview revealed nurses are educated on med administration, labeling, storage and monitoring for expiration dates during new hire training and periodically. The ADON revealed she does facility education and will review with nursing staff what to do if they find a medication that will soon expire, the importance of removing it by the last day, or either go ahead and pull it so it won't get missed. She also revealed she will start putting med expiration dates on a calendar on her computer that will send her a reminder alert. Interview on 7/12/18 at 12:15 p.m. the with the DON and Minimum Data Set (MDS) Coordinator LL revealed every hall nurse is responsible for monitoring for expired medications & supplies all the time. A monthly inspection is done on all med storage rooms, the nurse manager, ADON, & DON follows up, a inspection form titled Medication Area checklist is completed and signed by both. The completed inspection forms are kept in the Pharmacy (monthly review) notebook. Expired non-narcotic meds are pulled, logged, and put in a bin in the ADON office until the pharmacy picks them up, monthly. The DON said her expectation would be, if the check was done on 6/18 and meds were expiring the last day of June, staff go ahead and pull the medication so it won't get missed and left beyond the expiration date. Review of the Pharmacy notebook revealed the Medication Area checklist inspection forms had been completed for (MONTH) through (MONTH) (YEAR), with two signatures and no issues. The inspection form for (MONTH) (YEAR) revealed B Hall and C Hall med storage rooms were inspected on 6/18/18 with no out of date meds found and were signed by the hall nurse & ADON.",2020-09-01
383,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2018-07-12,880,D,0,1,802511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews the facility failed to ensure storage of washbasins, urinal hats, and toothbrushes in a manner to prevent cross contamination. This affected one of three halls (Hall B). The facility census was 101 residents. Findings include: Observation on 7/9/18 at 12:19 p.m. in room [ROOM NUMBER] and 228 in the bathroom there was one wash basin on the dresser that was not bagged or labeled. Observation on 7/9/18 12:50 p.m. in the shared bathroom for room [ROOM NUMBER] there was one toothbrush and 2 denture brushes in a holder that were not labeled or covered, there is an un-bagged wash basin on dresser in room [ROOM NUMBER]. Observation on 7/9/18 at 1:21 p.m. in the shared bathroom for 226 and 228 there were two toothbrushes that were not covered or labeled sitting on the shelf over sink. Observation on 7/9/18 at 1:24 p.m. there was one wash basin with one urine hat sitting inside of it. Neither of the items were bagged or labeled in the shared bathroom for 225 and 227. Observation 7/10/18 at 9:20 a.m. in the bathroom for room [ROOM NUMBER] and 228 there were two toothbrushes on the shelf over sink in bathroom that were not covered or labeled and a cup with dentures that was not labeled. Interview and hall tour with Unit Manager MM on 7/11/18 from 2:32 p.m. to 2:39 p.m. In room [ROOM NUMBER] and 228 Unit Manager confirmed that tooth brushes should be in a covered and dentures in the container should be labeled. In room [ROOM NUMBER] and 227 Unit Manager MM reported that she would put urine hat in plastic bag with name on it but she was unsure of how they should be stored per the facility policy. In room [ROOM NUMBER] and 232 Unit Manager MM confirmed uncovered toothbrushes in the bathroom and the unbagged wash basin on dresser containing a water pitcher. Interview on 7/11/18 at 2:40 p.m. with Certified Nursing Assistant (CNA) CC who reported that wash basins and urine hats should be stored in plastic bags and further revealed that toothbrushes should be covered. Interview on 7/11/18 at 2:44 p.m. with Licensed Practical Nurse (LPN) DD revealed that wash basins and urine hats should be cleaned and placed in bags. LPN DD also reported that toothbrushes should be covered in bathroom. It was reported that the facility has provided toothbrush covers in the past but family also provides. Interview on 7/11/18 at 2:47 p.m. with CNA EE revealed that toothbrushes should be labeled with resident name and covered. CNA EE also reported that wash basins and urine hats are stored in the bathroom and should be bagged and labeled. Interview on 7/11/18 at 2:53 p.m. with LPN FF revealed that wash basins and urine hats should be bagged and toothbrushes should be covered. LPN FF further revealed that whoever uses the wash basin is responsible but anyone in contact with the resident would be responsible for assuring that the items are bagged and labeled. Policy: Bed Bath revision date 3/17/15 Procedure: Discard bath water, rinse and dry basin, place in plastic bag and store in resident's bathroom.",2020-09-01
384,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2019-10-24,567,E,0,1,KT5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and facility policy review titled, Management and Protection of the Resident Personal Fund Account the facility failed to have residents' funds available for withdrawal afterhours and on weekends 78 of 97 residents with accounts in the facility. Findings include: Review of facility policy titled, Management and Protection of Resident Personal Fund Account effective date 4/01/1996 revealed under procedure section number four states The Pavilion will ensure that residents who have a personal Fund Account will have ready and reasonable access to their funds when needed. Review of the Annual Minimum Data Set ((MDS) dated [DATE] for R#84 Section C: Cognitive Patterns on 10/22/19 at 11:30 am revealed that she has a Brief Interview of Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact and able to make her own decisions. Interview with resident (R) R# 84 on 10/22/19 at 9:12 a.m. revealed resident is unable to get money on weekends and after hours. Further interview also revealed that R#84 must get money on Friday for money needed throughout the weekend. Interview on 10/23/19 at 11:35 a .m. with the Social Services Director in reference to residents receiving money on weekends revealed that residents are to ask for their money before Friday and in turn Social Services Director will leave money for them with charge nurse on the nursing cart. If a resident does not let them know a head of time, they will not receive any money for the weekend. Continued interview also revealed that if the resident's family member purchases something for the resident and brings in the receipt the family member will be reimbursed. Interview on 10/24/19 at 9:00 a.m. with the Administrator in reference to process of resident access to personal funds revealed the residents are to ask social services for all money wanted for the weekend if Social services is not available the billing office will give residents money requested to leave with nursing for the weekend. Further interview revealed that if residents do not ask for money on or before Friday, they cannot have any money until the following Monday morning.",2020-09-01
385,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2019-10-24,578,D,0,1,KT5M11,"Based on record review, staff interview, and policy review titled, Advanced Directives the facility failed to communicate code status for one of seven residents (R) (R#84) reviewed for Advanced Directives. Findings include: Review of facility policy titled, Advanced Directives effective date 10/6/2016 revealed under definition section of policy number three; Upon admission, should the resident have an advanced directive, copies will be made and placed on the charts as well as communicated to staff. Record review revealed there is no documentation on chart that indicates R#84 code status rather they are a full code or DNR Interview on 10/22/19 at 2:21 p.m. with LPN FF on 200 Hall in reference to where the advanced directives are generally located on residents chart revealed that the code status for each resident is identified by a sticker in the very front of residents chart that say DNR or Full Code as well as the advanced directive checklist with residents request acknowledged with a signature of resident and or the residents representative. Interview on 10/22/19 at 2:24 p.m. with LPN JJ medication nurse for 200 Hall confirmed that advanced directive information was not accessible for review for R#84. Interview on 10/23/19 at 10:18 a.m. with the Director of Nursing in reference to expectation of advance directives placement on charts revealed that advanced directives should never be removed from chart and should be place in a plastic sleeve in the front of chart for accessibility.",2020-09-01
386,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2019-10-24,584,D,0,1,KT5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and review of the facility policy titled, Cleaning of Medical Equipment the facility failed to ensure one of four residents (R#82) receiving continuous feeding had a clean feeding pump, pole and pole base and one of three residents (R#78) who require oral suctioning had a clean suction machine. Findings include: 1. Review of the facility policy titled, Cleaning of Medical Equipment, reviewed 9/2019, revealed: 2.c. Direct care staff are responsible for cleaning single-resident equipment when visibly soiled, and according to routine schedule (where applicable) 2.e. Most equipment may be cleaned/disinfected in the areas in which the equipment is used. Record review revealed that R#82 requires nutrition through a feeding tube for a [DIAGNOSES REDACTED]. She has a physician order for [REDACTED]. On 10/21/19 at 2:17 p.m. an observation of R#82 feeding pump, pole and pole base revealed dried brown spots on them. On 10/22/19 at 10:27 a.m. and 4:04 p.m. observations of R#82 feeding pump, pole and pole base revealed dried brown spots on them. On 10/23/19 at 8:23 a.m. an observation of R#82 feeding pump, pole and pole base revealed dried brown spots on them. An interview on 10/24/19 at 9:50 a.m. with Housekeeper II revealed she does not know who is responsible for cleaning the resident's medical equipment. She stated if she saw a spillage or dust, she would wipe it down or let someone know to get it cleaned. An interview on 10/24/19 at 10:00 a.m. with Licensed Practical Nurse (LPN) HH revealed the nurses usually clean the feeding pumps and poles. They do not have a schedule to clean them. An interview held on 10/24/19 at 10:15 a.m. with the Director of Nursing (DON) revealed she would expect the nurses to clean the feeding pumps and poles when the spillage happens. The do not have a schedule to clean the pumps. She revealed it was unacceptable to have the pump dirty. An interview held on 10/24/19 at 1:14 p.m. with the Administrator revealed she would expect the nurses to keep the feeding pumps clean. If they spill something on the pump or pole it should be cleaned right away. The do not have a scheduled cleaning time to clean them. 2. Observation on 10/22/19 at 12:56 p.m., 10/23/19 at 9:30 a.m.,1:04 p.m., and 10/24/19 at 10:43 a.m. revealed a suction machine positon on a bedside table in Resident (R)#78's room with dried yellowish brown substances splattered all over the machine and inside the vents of the machine. During an observation of the suction machine on 10/34/19 at 10:43 a.m. with the Director of Nursing (DON). The DON revealed being unaware of the condition of R#78's suction machine. She described the substances as brown sticky and yellowish color substances as dirt and possible rust. She further stated that her direct staff care staff, certified nursing assistant (CNA) and licensed nursing staff (RN or LPN) are responsible for ensuring the suction machine or clean. During an observation and interview on 10/24/19 at 1:34 p.m. with Licensed Practical Nurse (LPN) J[NAME] LPN JJ use a white disposable sanitize cloth (Santi-cloth wipe) to wiped the brown sticky substances. In the observation, the yellowish and brown substance was removed from the machine during each wipe. She agreed that the brown yellowish substance was not rust. LPN JJ revealed receiving in-services on the cleaning of suction machine and resident care equipment. She further stated being unaware of the unclean condition of the machine. LPN JJ stated that she cleaned the machine a few weeks ago using the Santi wipe disposable cloth. LPN JJ stated that R#78 use the suction machine prn (as needed) and daily. S Interview on 10/24/19 at 1:42 p.m. CNA KK revealed being unaware of the uncleanliness of the suction machine. She revealed being knowledgeable and receiving in services about using the Santi-cloth disposable wipe to wipe the machine daily and prn. CNA KK revealed cleaning the suction machine last week. She revealed failing to thoroughly clean the machine because she felt the brown yellowish substance was rust. On 10/24/19 at 1:46 p.m. during an interview with the DON and the Administrator, the dirty Santi-wipe cloth was shown to confirmed that the brown yellowish substance was not rust. The Administrator revealed going forward, the task of cleaning of the suction machine will be included on the resident's Medication Administration Record [REDACTED]. The Administrator further stated being unaware of the cleanliness of the suction machine. The Administrator revealed her expectation is for suction machine cleaning to occur on a routine basis.",2020-09-01
387,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2019-10-24,656,D,0,1,KT5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy titled, Nutrition and Weight Monitoring, the facility failed to follow the care plan and the for one of three residents (R) R#26 reviewed for nutrition. Finding include: Review of the facility policy titled, Nutrition and Weight Monitoring reviewed and revised 9/2018, revealed: 3. Information gathered from the nutritional assessment and current dietary standard of practice are used to develop and individualized care plan to address the resident's specific nutritional concerns and preferences. The care plan should address the following: e. updated as needed such as when the resident's condition changes, goals met, interventions are determined to inrffective or new cause of nutritional related problems are identified. f. If nutritional goals are not achieved, care planned interventions will be reevaluated for effectiveness and modified as appropriate. Record review revealed that R#26 [DIAGNOSES REDACTED]. Review of R#26 Quarterly Minimum Data Set ((MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate impaired cognition. Section G-Functional Status indicated resident is independent with eating. Section K-Nutrition indicated weight loss not prescribed by Physician. Review of R#26 care plan indicated the resident is on a regular diet and receives a vanilla supplement one can daily and ice cream with lunch. The care plan indicated to obtain dietary consult and follow recommendations, provide ice cream with lunch, provide vanilla supplement one can daily. Review of R#26 current Physician Orders include: vanilla supplement one daily and ice cream with lunch. Review of R#26 Medication Administration Record [REDACTED]. Review of R#26 Annual assessment dated [DATE] indicated a dietary vanilla supplement daily and ice cream daily with lunch, and a regular diet. An observation made on 10/22/19 at 12:10 p.m. of R#26 eating lunch in the main dining room revealed her feeding herself soup. There was no ice cream or vanilla supplement offered during the meal. R#26 meal slip stated ice cream with lunch. Review of R#26 meal card revealed ice cream with lunch, soup and crackers and sandwich with lunch and dinner. An observation and interview on 10/23/19 at 12:18 p.m. of R#26 eating lunch in the main dining room revealed she had a bowl of chicken noodle soup, crackers, peanut butter and jelly sandwich and strawberry short cake. There was no ice cream or vanilla supplement offered during the meal. R#26 indicated she likes soup and crackers. She likes only certain crackers and had the ones she likes on her tray. She consumed most of her meal. She fed herself. An interview held on 10/23/19 at 2:33 p.m. with the Director of Nursing (DON) revealed they do not record residents meal percent consumed. They just chart good/fair/poor. Review of R#26 RD note dated 8/8/19 recommended an appetite stimulant and she revealed the recommendation sheet was signed by the Physician but did not indicate to follow or not follow the recommendation. It was only initialed. The recommendation was not clarified with the Physician. An interview held on 10/24/19 at 10:30 a.m. with DD Dietary Manager (DM) revealed the residents meals are served according to the prescribed order. The line staff prepare the trays and the person at the end of the line checks the trays to ensure they are correct and have the correct added foods. She indicated R#26 has been refusing the ice cream so they don't put it on the tray any more. They give the ice cream to her as needed. The ice cream is not routinely put on the tray even though the card says to have ice cream with lunch. She then indicated the dietary staff should be putting the ice cream on the residents trays. An interview held on 10/24/19 at 1:01 p.m. with the Administrator revealed she would expect the lunch tray to have the ice cream on R#26 lunch tray.",2020-09-01
388,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2019-10-24,692,D,0,1,KT5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the facility policy titled Nutrition and Weight Monitoring, record review, observations and interviews the facility failed to follow the Registered Dietician (RD) recommendations to prevent weight loss for one of three residents (R) R#26 reviewed for weight loss. Finding include: Review of the facility policy titled Nutrition and Weight Monitoring reviewed and revised 9/2018, revealed: 1. The facility will utilize a systemic approach to optimize a resident's nutritional status. a. Identify and assessing each resident's nutritional status and risk factors, b. Evaluating/analyzing the assessment information c. Developing and consistently implementing pertinent approaches d. Monitoring and effectiveness of interventions and revising them as necessary 3. Information gathered from the nutritional assessment and current dietary standard of practice are used to develop and individualized care plan to address the resident's specific nutritional concerns and preferences. 4. Interventions will be identified, implemented, monitored and modified consistent with the residents assessed, needs, choices, preferences, goals and current professional standards of, to maintain acceptable parameters of nutritional status. 5b. Residents with weights loss-monitor weight weekly 7e. The RD or Dietary manager (DM) should be consulted to assist with interventions; actions are recorded in the nutritionsl progress notes. Record review revealed that R#26 had [DIAGNOSES REDACTED]. Review of R#26 quarterly Minimum Data Set ((MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate impaired cognition. Section G-Functional Status indicated resident is independent with eating. Section K-Nutrition indicated weight loss not prescribed by Physician. Review of R#26 care plan indicated the resident is on a regular diet and receives a vanilla supplement one can daily and ice cream with lunch. The care plan indicated to obtain dietary consult and follow recommendations, provide ice cream with lunch, provide vanilla supplement one can daily. Review of R#26 current Physician Orders include: vanilla supplement one daily and ice cream with lunch. Review of R#26 Medication Administration Record [REDACTED]. Review of R#26 weights recorded in her medical record revealed on 9/1/2019, the resident weighed 120 pounds (lbs) and on 10/1/2019, the resident weighed 112.4 lbs which is a -6.33 % weight loss in one month. On 4/1/2019, the resident weighed 132.8 lbs. and on 10/1/2019, the resident weighed 112.4 lbs which is a -15.36 % weight loss in six months. Review of R#26 Physicians progress notes for 10/14/19, 10/8/19, 9/13/19, 8/12/19, and 7/1/19 were reviewed. The Physician did not indicate the resident had any weight loss. Review of Doctors Office Communication for The Pavilion dated 8/8/19 revealed a dietary recommendation for R#26 to add appetite stimulant due to weight loss. The form was initialed by the Physician but did not indicate to follow or not follow the recommendation. Review of the Nurses Notes dated between 8/6/19-8/23/19 indicated on 8/8/19 a dietary recommendation to add a appetite stimulant due to weight loss of 17 lbs over last six months and the Physician was notified. Review of R#26 Nutrition Progress Notes revealed: 3/13/19 receives vanilla supplement and ice-cream daily 4/4/19 weight loss 5/2/19 see annual assessment 6/6/19 eats 50% meals 7/3/19 weight loss continues 8/8/19 requested to add appetite stimulant 9/5/19 weight loss continues 10/10/19 weight loss continues, recommended to increase supplement to two times a day Review of R#26 Annual assessment dated [DATE] indicated a dietary vanilla supplement daily and ice cream daily with lunch, and a regular diet. An observation made on 10/22/19 at 12:10 p.m. of R#26 eating lunch in the main dining room revealed her feeding herself soup. There was no ice cream or vanilla supplement offered during the meal. R#26 meal slip stated ice cream with lunch. An observation made on 10/23/19 at 12:18 p.m. of R#26 eating lunch in the main dining room revealed she had a bowl of chicken noodle soup, crackers, peanut butter and jelly sandwich and strawberry short cake. There was no ice cream or vanilla supplement offered during the meal. R#26 indicated she likes soup and crackers. She likes only certain crackers and had the ones she likes on her tray. She consumed most of her meal. She fed herself. Review of R#26 meal card revealed ice cream with lunch, soup and crackers and sandwich with lunch and dinner. An interview held on 10/23/19 at 2:25 p.m. with FF Licensed Practical Nurse (LPN) revealed they do not record meal percents on any residents. Further interview on 10/24/19 at 10:00 a.m. with FF LPN revealed R#26 refuses her medications and dietary supplements at times. The nurses give her the dietary supplement but the ice cream comes on the food tray from the kitchen. She doesn't eat all of her food. She snacks a lot. She eats breakfast well. She stated the R#26 always says she used to be fat but likes that she has lost weight. She indicated when the dietician makes a recommendation she fills out a doctors notification and either gives it to him or faxes it to him. An interview held on 10/23/19 at 2:33 p.m. with the Director of Nursing (DON) revealed they do not record residents meal percent consumed. They just chart good/fair/poor. Review of R#26 RD note dated 8/8/19 recommended an appetite stimulant and she revealed the recommendation sheet was signed by the Physician but did not indicate to follow or not follow the recommendation. It was only initialed. The recommendation was not clarified with the Physician. An interview held on 10/24/19 at 10:15 a.m. with the DON revealed when the RD makes a recommendation she would expect the nurses to inform the Physician and write a nurses note indicating that he was notified and what was the outcome. The DON indicated she was aware of the resident refusing her medications and supplements at times. She would expect the ice cream to be on the lunch tray as ordered. She stated if the resident was refusing the ice cream a nurses progress note should have been written, the Physician was notified and a new order written if indicated. She revealed R#26 will take her food off the food trays and put them in her pocket and take them back down to her room. She stated all residents weights are looked at monthly and discussed weekly in the Inter-Disciplinary Team (IDT) meetings. The DON indicated they are not doing weekly weights on R#26. An interview held on 10/24/19 at 10:30 a.m. with DD Dietary Manager (DM) revealed the residents meals are served according to the prescribed order. The line staff prepare the trays and the person at the end of the line checks the trays to ensure they are correct and have the correct added foods. She indicated R#26 has been refusing the ice cream so they don't put it on the tray any more. They give the ice cream to her as needed. The ice cream is not routinely put on the tray even though the card says to have ice cream with lunch. She then indicated the dietary staff should be putting the ice cream on the residents trays. An interview held on 10/24/19 at 10:45 a.m. with GG Assistant Dietary Manager (ADM) revealed they only put the ice cream on R#26 food tray at lunch if the nurses tell them too. They supply the dietary supplements daily and are taken to the units for the nursing staff to give to the resident. An interview held on 10/24/19 at 11:00 a.m. with RD revealed she documents on all of the residents monthly. She will look at the residents weights and make recommendations. She reviewed R#26 recommendations and indicated she made a recommendation for a appetite stimulant in 8/8/19 and to increase the residents dietary supplement to two times a day on 10/10/19. She stated she makes the recommendations and flags the paper in the chart. She would expect the nursing staff to inform the Physician to follow her recommendations or decline to do the recommendations. She is aware of the residents weight loss. She would expect the dietary staff to offer the resident the ice cream that is ordered for lunch. An interview held on 10/24/19 at 1:01 p.m. with the Administrator revealed the R#26 refuses the dietary supplements most of the time. When the RD makes a recommendation, she makes a recommendation and flags the chart. The nurses them look at the recommendations and calls the Physician or notify them by fax on a communication sheet. The Physician will decide to follow the recommendations or not. She would expect the nurses to document that the Physician was notified. She would expect the lunch tray to have the ice cream on R#26 lunch tray. She would expect her to be on weekly weights due to her weight loss in the last six months. Weights are discussed weekly at the IDT meetings. Cross reference F656",2020-09-01
389,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2019-10-24,758,D,0,1,KT5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and review of the facility policy titled, Medication Regimen Review the facility failed to ensure that [MEDICAL CONDITION] medication was not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) #95 reviewed for unncessary medications. Findings include: Record review of policy Medication Regimen Review dated 7/16/18 revealed 11. Based on a comprehensive assessment of a resident the facility will ensure. c. Resident do not receive [MEDICAL CONDITION] drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days unless the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days then he or she should document their rational in the rationale in the resident 's medical record and indicate the duration for the PRN order. e. PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. Record review of R#95 's medical record revealed diagnses of dementia, depression, agitation/combative behaviors, anxiety, and Alzheimer. Review of the Physician order for [REDACTED]. Record Medication Administration Record [REDACTED] Record review of nurse notes during the time of (MONTH) 2019 through (MONTH) 2019 reveals R#95 displayed behaviors of agitation, hollering out, attempting to get up without assistance, and hallucinations. Observations on 10/23/19 at 9:18 a.m., and 4:27 p.m., and 10/24/19 at 10:02 a.m., revealed R#95 lying in bed showing no signs of distress. Interview on 10/24/15 at 10:35 a.m., with the Director of Nursing (DON) reveal being unaware of R#95's prn medication being written without a stop date. The DON further revealed that prn medication was written due to R#95's behavior being described as random agitated behaviors (and sometimes the behavior occurs randomly up to 24 hours). She further revealed that the present approach is to educate the physicians on the policy that all prn medications require a stop date. The DON revealed her expectations effective today is that all prn [MEDICAL CONDITION] medications are written with a stop date. She revealed that this was not a part of the identified issues/concerns in QAA and will be added. Interview on 1/24/19 at 1:50 p.m. the Administrator revealed that her expectations are that prn medications are reviewed and written with a 14 day stop date. She revealed being unaware of the identified concerned. The Administrator further revealed that her Assistant Director of Nursing (ADON) is responsible for monitoring for all prn meds. Interview on 1/24/10 at 1:51 p.m., the ADON revealed being unaware of the regulations that all [MEDICAL CONDITION] and antipsychotic prn medications should be written with a stop date.",2020-09-01
390,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2019-10-24,812,E,0,1,KT5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review titled, Food Storage Guidelines the facility failed to properly label and date open food items, as well as discarding expired food items in the dried foods storage area in the main kitchen. Also, the facility failed to provide a hands-free trash can at the staff hand washing sink located between two ice machines located in the main kitchen. The deficient practice had the potential to effect 90 out of 97 total residents receiving an oral diet. Findings include: Review of the facility policy titled, Food Storage Guidelines section [NAME] iii. storage Guidelines revealed all food supply is marked with the date the item was received by the department. Dates guide the use of First-in, First-out procedures. Food times must be rotated so that those with the earliest use-by expiration dates are used before items with later dates. When product's storage or expiration date is in question; product is discarded. vii All food is checked for spoilage Observation on [DATE] at 10:00 a.m. of the dried good storage revealed the following food items unlabeled without an expiration date; Open package of Britta Spaghetti noodles, opened package of uncooked rice, Light golden Agave Syrup with no open or expiration date, Package of marshmallows in a zip lock bag with no open or expiration date, Pecan halves in open package with no open or expiration date, Jell-O cheese cake mix with expiration date of [DATE], opened bag of Oreo cookie pieces with expiration date of [DATE], opened bag of powdered sugar with open date of [DATE] with no expiration date. Interview on [DATE] at 10:15 a.m. with the Food Service Director (FSD) confirmed dried food items listed were not properly labeled with expiration date, The FSD also confirmed Jell-O cheesecake mix had expiration date of [DATE], and opened bag of Oreo cookie pieces was expired as of [DATE]. further interview with FSD revealed that the expectation is that foods be labeled properly with an expiration date and that all expired foods are to be discarded. Observation on [DATE] at 10:20 a.m. of staff hand washing sink located between two ice machines in the main kitchen revealed no evidence of a hands-free trash can for staff use. Interview with FSD, at this time, revealed that staff use the trash can near dish prep sink located in the back of the kitchen for disposal of used paper towels after hand washing. Observation on [DATE] at 8:58 a.m. of residents' nourishment refrigerator for 200 hall revealed the resident refrigerator did not have a temperature log posted on or near refrigerator. Interview with the Administrator on [DATE] at 9:00 a.m. revealed that she expects for all food items to be labeled properly and expired foods to be discarded.",2020-09-01
391,CALHOUN NURSING HOME,115264,265 TURNER STREET,EDISON,GA,39846,2016-08-11,253,D,0,1,7CY211,"Based on observation and interview, the facility failed to maintain an environment free from rust, dust, peeling paint, holes and scuff marks five (5) of thirty-eight (38) resident rooms. Findings include: 1. On 8/8/16 at 2:41 p.m., in room 31, there were areas of missing paint and scuff marks to the bottom section of the wall around the closets and dried circular stains on the floor tiles beneath the sink. The entrance door frame had multiple areas of peeling and chipped paint. 2. On 8/8/16 at 2:46 p.m., in room 19, there were rust colored stains to the floor edges beneath the closet for Bed B and around and under the air units, and there were scuff marks and areas of missing paint to the entrance door and door frame. In the bathroom, there was a collection of dust on the ceiling vent and scuffs and missing paint on the lower portion of the door. 3. On 8/8/16 at 2:56 p.m., in room 20, there were multiple scuff marks and areas of missing paint to the entrance door and door frame. 4. On 8/8/16 at 3:02 p.m., in room 18, there were scuff marks and areas of missing paint to the entrance door and door frame. 5. On 8/9/16 at 10:38 a.m., in room 30, there were multiple areas of peeling paint to the entrance and bathroom doors and door frames. In the bathroom, the metal shelf above the sink had large sections of peeled/chipped paint.",2020-09-01
392,CALHOUN NURSING HOME,115264,265 TURNER STREET,EDISON,GA,39846,2016-08-11,314,D,0,1,7CY211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, it was determined that the facility failed to identify pressure sores timely and failed to accurately assess one resident's (#41) skin during a weekly skin assessment from a sample of three residents with pressure sores of a total sample of twenty-five (25) residents. Findings include: Resident #41 was admitted to the facility on [DATE] with the following but not limited to Diagnoses: [REDACTED]. The resident was assessed and coded by the facility on the Quarterly Minimum Data Set with an assessment reference date of 7/18/16 as requiring extensive assistance with two person physical assistance with bed mobility, total dependence for transfers, frequently incontinent of bladder and as being at risk for pressure ulcers. Review of the (MONTH) (YEAR) electronic physician's orders [REDACTED].>The resident had a 2/16/15 care plan problem as being at risk for further skin breakdown related to decreased mobility, [MEDICAL CONDITION], non-compliant with hygiene and wound prevention, history of pressure ulcers and incontinent of bladder, with an approach for nursing to do a skin assessment weekly. Review of the 8/1/16 and the 8/8/16 Weekly Skin Assessments revealed that licensed nursing staff had documented there were no open areas noted. However, during an observation of the resident's skin two days later on 8/10/16 at 10:15 a.m., three previously unidentified pressure ulcers were observed. During an interview with the Director Of Nursing (DON) on 8/10/16 at 10:15 a.m., prior to doing a skin assessment on the resident, she stated that the resident currently did not have any pressure ulcers. However, during a skin assessment at that time with the DON, the resident was observed with two well defined re-opened Stage IV pressure ulcers and one well defined re-opened Stage 3 pressure ulcer. The pressure ulcer to the left ischium was a re-opened Stage IV and was approximately 3 cm x 2cm x 0.5cm with 100% red granulated tissue, the pressure ulcer to the right ischium was a re-opened Stage IV and was approximately 2cm x 2cm x 0.5cm with 100% red granulated tissue and the pressure ulcer to the right posterior upper thigh was a re-opened Stage 3. The pressure ulcer could not be fully visualized because the resident became extremely agitated and rolled herself onto her back and refused any further assessment of the wounds. The DON stated at that time that the wounds must have opened overnight since there was so much scar tissue from previous pressure ulcers. During an interview with the resident's Physician on 8/11/16 at 11:10 a.m., he stated that he found it hard to believe that these pressure ulcers opened overnight. He stated that the wounds probably started breaking down under the skin making it hard for someone to see but also stated that someone who was properly trained in wounds would have realized that something was going on. Although the pressure ulcers were unavoidable, the facility failed to identify the pressure sores timely and failed to accurately assess the resident's skin.",2020-09-01
393,CALHOUN NURSING HOME,115264,265 TURNER STREET,EDISON,GA,39846,2016-08-11,356,B,0,1,7CY211,"Based on observation and interview the facility failed to display the actual hours worked by the nursing staff. The facility census was fifty-seven (57) residents. Findings Include: During an observation on 8/11/15 at 4:00 p.m. the staffing form was posted. However, it did not document actual hours worked for nursing staff. An interview with the Director of Nursing on 8/11/16 at 4:08 p.m. confirmed the actual hours worked by the nursing staff was not posted correctly.",2020-09-01
394,CALHOUN NURSING HOME,115264,265 TURNER STREET,EDISON,GA,39846,2016-08-11,371,E,0,1,7CY211,"Based on observation and staff interviews the facility failed to assure that foods were dated and labeled, were used by expiration date, and failed to maintain a sanitary ice machine as evidenced by black build up on the dispensing lid of the ice machine. The census was fifty-eight (58) resident's, with four (4) residents who recieved tube feedings. Findings include: Initial kitchen tour on 8/8/2016 at 11:28 a.m. completed with Dietary Supervisor. The following was observed on 8/8/2016 11:28 a.m. and 8/11/2016 4:00 p.m.: 1. There was a 15 pound box of bacon in the refrigerator that had a received by date but did not have an open date. 2. Suncup juices had code on top but no expiration date. 3. In walk in freezer there was a bag of sweet potato fries opened but was not dated or labeled and there was no expiration date. 4. Ice buildup noted at the entry of walk in freezer 5. Seven (7) packages of Cheese Nips noted to be removed from box but still in original plastic bag. These items had a received on date but there was no expiration date. 6. Canned items marked with received on date but Dietary supervisor unable to interpret the code to know what the expiration date is. 7. Four (4) eight (8) ounce cans of Glucerna with expiration date of (MONTH) (YEAR) found in supply. 8. Macaroni and egg noodles opened and stored with no use by date or expiration date. Interview with DS on 8/8/2016 at 11:50 a.m. who revealed that he/she was unaware of how to read codes on canned items or code on juice cups. DS reported that vendor rep could be called for the dates however, acknowledged that he/she had never called. DS explained that items are removed from the original boxing and expiration dates are typically on the boxing. DS explained that items are typically rotated on a first in first out basis. It was explained that the ice machine is cleaned monthly by maintenance department. Telephone Interview on 8/8/2016 at 2:02 p.m. with food vendor representative from Sysco who reported that the facility does not receive the pack date but canned items are shipped a few months after packing. The representative then reported that once received in the facility the canned goods have a shelf life of 1.5 years. 08/11/2016 4:00 p.m. DS reported that he/she spoke with the representative for Suncup and was told to read the code backwards and that would determine the expiration date for the juices. However, the format did not work. Observation of Suncup juice box in the walk in cooler revealed to use within 14 days of thawing. The box in the cooler had a received on 7/27/16 date but DS reported that this box was removed from the freezer for thawing over the weekend. It was confirmed that the facility is not currently tracking the juice cups once thawed to assure that none are used beyond the 14 days. However, it was reported that once items are sent to the unit they do not return.",2020-09-01
395,CALHOUN NURSING HOME,115264,265 TURNER STREET,EDISON,GA,39846,2016-08-11,441,D,0,1,7CY211,"Based on observed, staff review and review of the facility Policy; Assisting the Resident with In-Room Meals and the Infection Control Policy, the facility failed to ensure proper hand hygiene for one (1) resident #13 during a meal observation and failed to clean the ice machine in one (1) of one (1) main kitchen. Census of fifty-eight (58) with four (4) residnet's recieving tube feeding. Findings Include: An observation on 8/8/16 at 2:33 p.m. AA Certified Nurse Aide (CNA) initially sanitized his/her hands and placed a lunch meal tray on the bedside table. Further observation revealed AA go into the resident ' s #13 dress drawer open the top drawer remove a straw, closed the drawer, then begin removing the cups lid. AA goes back to top drawer take out some seasoning from the drawer, then go back and sit down in a chair next to resident bed. He/She then pick up the bread and spread mayonnaise on the halves, then using the fork pick up the ham and using his/her fingers pushed the ham off the fork and unwrapped the straw, touching the plastic straw with his/her bare hands in several areas before putting the straw in the resident's #13 drink. AA pick up the ham sandwich with her unsanitized hands and place to resident's #13 mouth. An interview on 8/9/16 at 4:14 p.m. AA CNA stated he/she forgot to sanitized his/her hands between going into the resident ' s #13 dresser drawer for the straw, sugar and then preparing the ham sandwich. He/She also admitted to not sanitized hands prior to touching resident #13 food and placing the food items in resident #13 mouth. 2. Initial kitchen tour on 8/8/2016 at 11:28 a.m. completed with Dietary Supervisor. The following was observed on 8/8/2016 11:28 a.m. and 8/11/2016 4:00 p.m. The Ice machine was noted to have black build up on dispensing lid. Interview with DS on 8/8/2016 at 11:50 a.m. who stated that the ice machine is cleaned monthly by maintenance department.",2020-09-01
396,CALHOUN NURSING HOME,115264,265 TURNER STREET,EDISON,GA,39846,2018-11-01,761,D,0,1,9CGU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to provide safe and secure storage of medications during a medication pass for one resident, Resident (R) #20. The sample size was 33 residents. Findings include: During a medication administration pass observation conducted on 10/31/18 beginning at 5:30 p.m., the Licensed Practical Nurse (LPN) AA prepared medications for R#20 to be administered via a gastrostomy tube ([DEVICE]). The medication was a 300 mg capsule of [MEDICATION NAME]. LPN AA opened the capsule and dissolved the powder in five milliliters of water. Prior to administering the medication, the LPN AA checked the [DEVICE] for placement and attempted to flush the tube with water. The water would not infuse through the tube. LPN AA stated that she needed to obtain a de-clogger (a device for clearing obstructions from the [DEVICE]) and left the room at 5:42 p.m.; she left the [MEDICATION NAME] preparation sitting on the bedside stand. LPN AA returned to the room at 5:46 p.m. with the de-clogger and proceeded to clear the [DEVICE] of obstruction. She then flushed the [DEVICE] with water and administered the [MEDICATION NAME] preparation. LPN AA flushed the [DEVICE] with water after administering the medication as prescribed. Interview with LPN AA, at this time, confirmed she had left the medication preparation at the bedside unattended when she left the room.",2020-09-01
397,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2018-02-15,584,E,1,1,LMHT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review Facility B failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior by failing to repair drywall, leaky faucets, and broken floor tiles in 10 rooms out of 36 rooms on two out of two halls. The census for Facility B was 68 residents. Findings include: 1. Observation on 2/12/18 at 11:30 a.m. room [ROOM NUMBER] was observed revealed that there was bare T-shaped white spackle on beige-colored paint on the TV wall opposite the residents' beds. The baseboard near the bathroom was observed to be broken. There was peeling paint behind the heads of both beds. 2. Observation on 2/12/18 at 11:33 a.m. in room [ROOM NUMBER] revealed a leaky faucet was observed, and bare spackle on the window wall. 3. Observation On 2/12/18 at 11:36 a.m. inroom [ROOM NUMBER] evealed broken linoleum tile under the sink. 4. Observation on 2/12/18 at 11:38 a.m. room [ROOM NUMBER] revealed multiple patches of peeling paint on the air-conditioning unit below the window. 5. Observation on 2/12/18 at 11:40 a.m. of room [ROOM NUMBER] revealed multiple patches of peeling paint on the air-conditioning unit. 6. Observation on 2/12/18 at 11:45 a.m. of room [ROOM NUMBER] revealed broken ceramic tile on the sink, a leaky faucet, and broken linoleum tile under the sink. 7. Observation on 2/12/18 at 11:49 a.m. room [ROOM NUMBER] revealed gouged drywall on the doorway wall and on the TV wall of the room, opposite residents' beds. 8. Observation on 2/15/18 at 12:40 p.m. room [ROOM NUMBER] revealed cracked caulk on the sink. 9. Observatgion on 2/15/18 at 12:42 p.m. room [ROOM NUMBER] revealed a leaky faucet and a large spot of bare spackle near the sink. 10. Observation on 2/15/18 15 12:45 p.m. of the 100-hall shower room was noted to have a badly rust-colored sink and a leaky faucet. On 2/15/18 at 12:50 p.m. an interview and tour was made of the facility with the Director of Maintenance (DM) and revealed the following: 1. In room [ROOM NUMBER], the DM confirmed the faucet was leaky and there was bare spackle by the sink. 2. In room [ROOM NUMBER] the DM stated the cracked caulk on the sink could cause mold. 3. In room [ROOM NUMBER] the DM stated there was bare spackle on the walls. He stated this was done last week and there were plans to paint the spackle but he could not say when. The DM agreed the baseboard near the bathroom was broken. He further stated the peeling paint behind the heads of both beds needed repainting. He agreed the linoleum tile under the sink was broken, stating the tile in the entire facility was bad. 4. In room [ROOM NUMBER], the DM agreed there was a leaky faucet and the wrong color paint to fix a patch on the wall. 5. In room [ROOM NUMBER], the DM affirmed the tile under the sink was broken. 6. The DM agreed the paint on the air-conditioning unit in room [ROOM NUMBER] was peeling and needed re-painting. 7. In room [ROOM NUMBER], the DM agreed there were multiple patches of peeling paint and needed painting. 8. In room [ROOM NUMBER] the DM stated the ceramic tile above the sink was broken and the linoleum tile under the sink was also broken. 9. In room [ROOM NUMBER] the DM agreed there was gouged drywall on the entry wall and the wall opposite the residents' beds. He stated these gouges needed repair and paint. The DM further stated he does or directs repairs on an as needed basis. He stated he did have a plan for improvements but was not sure where it was or when it would start. An interview was held with Administrator on 2/15/18 at 1:15 p.m. She stated she did not have a written plan for repairs or upkeep, and they try to keep up with it as best they could. She could not produce any documentation that detailed a maintenance or upkeep plan. The Administrator stated further there was no organized system of checking and keeping up with repairs and upkeep.",2020-09-01
398,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2018-02-15,600,D,1,1,LMHT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review, and the facility policy titled, Abuse Policy Facility A failed to ensure one Resident (R) (R#19) was protected from physical abuse. Failure to ensure protection resulted in R#19 being hit on 12/12/17 at 8:30 a.m. by R#100 who resided in an adjoining room. The sample size was 49 residents for Facility [NAME] Findings include: Record Review revealed nurse's notes, for R#100, dated 12/12/17, the note documented that R#100 went into another resident's room (R#19) via wheelchair through the adjoining bathroom door and began to strike R#19 with a shoehorn. The nurses note further documented that, this incident was in response to R#100 being irritated at the R#19's continuous loud calling out to staff throughout the night and the day which interrupted his (R#100) sleep and all other ADL's. During an interview on 2/14/18 at 4:49 p.m. with Registered Nurse (RN) BB revealed that she believed R#100 fully intended to hurt R#19 and she told everybody that she could, she continued by saying the grabber used to assault R#19 was taken away because R#100 told us he would do it again. During an interview on 2/14/18 at 5:53 p.m. with the Social Service Director (SSD) revealed that she considered what happened between R#19 and R#100 on 12/12/17 at 8:30 a.m. to be abuse. Telephone interview on 02/14/18 at 4:49 p.m. with RN ZZ, revealed that she believed the incident on 02/12/17, happened due to R#100, who stated that he had been kept awake all night by R#19, but R#100 has his own behaviors. Interview on 02/14/18 5:38 p.m, with the Administrator, revealed that he was aware of the incident that occurred on 12/12/17 but that he wouldn't necessarily call this abuse. The Administrator reported that he did not report the incident because it was an incident that occurred between two residents and that there was no injury. Further interview revealed that based on his knowledge of the regulations, this was an incident that did not have to be reported to the State. The Administrator further revealed that R#19 was moved to a different room and that R#100 did not show any more aggression towards any other residents. The incident was not reported because no one was hurt. The resident was counseled by staff. Interview on 02/15/18 12:57 p.m., with R#100 about the incident that occurred between himself and R#19. R#100 revealed that he recalled that night and at the time of the incident, he was assigned to room [ROOM NUMBER] and that R#19 was assigned to room [ROOM NUMBER]. R#100 revealed that on the night prior to the incident, he was irritated by R #19 due to the resident hollering for help constantly. Resident stated that during the night and the early morning prior to the incident, R#19 was constantly hollering and yelling for a nurse. Resident stated that he could not recall the exact time of the incident, but it was later in the morning. Resident stated that he was tired of R#19. He stated that he took his shoe horn and wacked him over his head a couple times. R#100 also commented that R#19 was moved to another unit, Review of the facility Abuse Prevention Program (revised (MONTH) 2011) policy statement, policy interpretation and implementation reflects the following under the policy interpretation and implementation page 3, section 1: Our facility is committed to protecting our residents from abuse by anyone including, not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual. Continued review of page 3 reveals under section 3. Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. Identification of occurrences and patterns of potential mistreatment/abuse.",2020-09-01
399,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2018-02-15,609,D,1,1,LMHT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident and staff interviews, review of the facility's Abuse Policy's, and review of the facility policy titled, Abuse Investigations Facility A failed to ensure that an allegation of physical abuse was reported to the State Agency (SA) for one Resident (R) (R#19). The sample size for Facility A was 49 residents. Findings include: Record Review revealed nurse's notes, for R#100, dated 12/12/17, the note documented that R#100 went into another resident's room (R#19) via wheelchair through the adjoining bathroom door and began to strike R#19 with a shoehorn. Interview on 02/14/18 5:38 p.m, with the Administrator, revealed that he was aware of the incident and that he wouldn't necessarily call this abuse. The Administrator reported that he did not report the incident because it was an incident that occurred between two residents and there was no injury. The incident was not reported to the State because no one was hurt and the police were not notified. Interview on 02/14/18 at 5:53 p.m., with the Social Services Director (SSD), revealed that her definition of abuse is marks or things being thrown at them and that she asked questions regarding if it (this incident) should be reported to the state. She stated that she never received any paperwork on it. The SSD further revealed that in the past we have had In-services to educate the staff on being able to identify incidents of abuse. Staff reported that in the past, if an incident of this nature occurred, then the staff would all come together with the previous Director of Nursing (DON) and the previous Admininistrator and decide if it needed to be reported. The SSD further revealed that if the staff needed to be re-educated, the Director of Nursing (DON) provides books and huddles for training. The SSD further revealed that she would have considered this incident abuse. Review of the facility Abuse Investigations (revised (MONTH) 2014) policy statement, policy interpretation and implementation reflects the following under the policy interpretation and implementation page 2, section 14: The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and others as may be required by state or local laws, within five (5) working days of the reported incident. Review of the facility Abuse Prevention Program (revised (MONTH) 2006) policy statement, policy interpretation and implementation reflects the following under the policy interpretation and implementation page 3, section 3: Comprehensive policies and procedures have been developed to aid our facility in preventing abuse, neglect, or mistreatment of [REDACTED]. The reporting and filing of accurate documents relative to incidents of abuse.",2020-09-01
400,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2018-02-15,641,D,1,1,LMHT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interviews, it was determined that Facility A failed to ensure the Minimum Data Set (MDS) assessments accurately reflected the status of one Resident (R) (R#70). Specifically the facility failed to accurately assess the resident resulted in a comprehensive care plan that no longer matched the current health status for R#70. The sample size for Facility A was 49 residents. Findings include: A review of the significant status change MDS with an Assessment Reference Date (ARD) of 9/21/17 reflected in Section N0410E that anticoagulants were used 7 days during the seven (7) day lookback period. A review of the MDS quarterly assessment with a ARD of 12/21/17 reflected in Section N0410E that anticoagulants were used 7 days during the seven (7) day lookback period. Review of a Prescription Fax Request reflected a discontinue (DC) order dated 8/7/17 for Eliquis (an anticoagulant) tablet 5 milligrams (mg) to be given twice (bid) daily. Review of a Prescription Order start date of 8/12/17 reflects MEDICATION ORDERS FOR [REDACTED]. A review of the (MONTH) (YEAR) Medications Administration History record reflects MEDICATION ORDERS FOR [REDACTED]. Also reflected are orders for Eliquis tablet 5 mg bid to be given starting 8/12/17 and again discontinued on 8/24/17. The record reflects the medication was not signed off as administered as evidenced by the x located in the boxes for the appropriate dates and times. During an interview on 2/15/18 at 9:08 a.m. the MDS Coordinator requested her assistant review the list of discontinued medications for R#70. MDS coordinator assistant stated Eliquis tablet 5 mg bid order was discontinued 8/24/17. MDS coordinator confirms the significant MDS dated [DATE] and the MDS quarterly review dated 12/21/17 reflecting the use of the anticoagulants under Section N0410E is considered a charting discrepancy.",2020-09-01
401,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2018-02-15,812,F,1,1,LMHT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview, observation, and review of policy titled Food Receiving and Storage Facility A failed to assure that food prep equipment was clean and properly stored, maintain the cleanliness of the icemaker and fans, discard expired items, and label and date items in two reach in refrigerators. Facility B failed to assure that items in the dry storage area and in resident pantries were labeled and dated and discarded by the use by date. This included three of three food pantries at facility B and kitchens at Facility A and Facility B. The census for Facility A and Facility B was 161 residents. Findings include: Facility B [DATE] at 11:11 a.m. Brief kitchen tour of Facility B conducted with Dietary Manager revealed the following: 1. There was a box of shredded cheese with an in date of [DATE] but there was not way to determine the expiration date of the cheese. 2. There were eggs in the refrigerator but there was no way to determine the expiration date of the eggs. 3. Two 46 fluid ounce (oz) thickened water containers with an open date of [DATE] and (1) one thickened juice container that was open but did not have an open date on it. The directions for the items stated once opened store at ambient temperatures for up to 8 hours or refrigerate for up to 7 days. 4. The storage containers for rice, flour, and meal did not have an open or use by date. 5. In the reach in freezer there were (5) five 32 ounce (oz.) packages of frozen baby carrots with no expiration date. 6. Three bags of diced carrots with an in date of ,[DATE] and (MONTH) 26, (YEAR) listed on the package. 7. Six packages of 12 count hamburger buns with an expiration date of [DATE]. Interview on [DATE] at 11:35 a.m. with the Dietary Manager revealed that there should be a label on each container containing the flour, sugar, and corn meal. She further explained that when the items are placed in the plastic storage container a label should be added to the container identifying the use by date that is listed on the original package. Dietary Manager revealed that all items should be labeled and dated. Futher interview revealed that the buns were delivered on [DATE] and bread is delivered every Tuesday by the Bakery. The Dietary Manager went on to reveal that she typically is the person that would receive the bread at delivery but she was not at the facility on [DATE]. Dietary Manager reported that she would not have accepted the bread on [DATE] since it had an expiration date of [DATE]. Tour of Triana Hall pantry at facility B on [DATE] at 9:08 a.m. with Director of Nursing (DON) revealed the following: 1. Eight 3.5 ounce (oz.) containers of Smart gel Cherry flavored gelatin with an expiration date of [DATE]. 2. Two containers (one with graham crackers and the other with saltine crackers) that did not have expiration dates. Interview with the DON on [DATE] at 9:13 a.m. who reported that nursing staff and dietary check the pantry refrigerators daily for expired items in the refrigerator. Interview with the Dietary Manager on [DATE] at 9:23 a.m. revealed that graham crackers and saltines can be stored up to 6 months. Willet Pantry Tour with DON on [DATE] at 9:30 a.m. revealed: 1. One 20 fl oz Powerade with an expiration date of [DATE]. 2. Five 3.5 oz Cherry Smart gels with an expiration date of [DATE]. 3. Seven 4 fl. oz. 100% Prune juice containers with and expiration date of [DATE] in the refrigerator and (6) six 4 fl oz. containers with an expiration date of [DATE] located on the shelf in the pantry. 4. Three 1.2 oz. boxes of Kellog's Mini-Wheats that did not have an expiration date. 5. One dented can of Campbell's ready to serve Chicken with rice soup. Pavillion Pantry Tour on [DATE] at 9:47 a.m. with DON revealed: 1. One (1) 4 oz. Yoplait Strawberry banana yogurt with a use by date of [DATE]. 2. Four (4) 1.2 oz. boxes of Mini - Wheats with a no expiration date. Interview on [DATE] at 1:25 p.m. with the Dietary Manager who reported that all staff are responsible for checking food in the refrigerator and on the shelves in the pantry to assure food is labeled and not expired. Review of policy titled Dietary revealed the following: Policy Interpretation and Implementation 6. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in - first out system. After opening dry foods, they will need to be discarded after 60 days. 7. All food stored in the refrigerator or freezer will be covered, labeled and dated use by date). 13. Food items and snacks kept on the nursing units must be maintained as indicated below: a. All food items to be kept below 41 degrees F must be placed in the refrigerator located at the nurses' station and labeled with a use by date. b. All foods belonging to residents must be labeled with the resident's name, the item and the use by date. Facility A failed to ensure that preparation equipment was clean and properly stored, properly label and date foods in refrigerators, discard expired foods, clean ice maker and maintain cleanliness of fans in kitchen. Facility A: Observation and Interview with Dietary Manager on [DATE] at 11:34 a.m. revealed one mixture stored on a preparation counter uncovered with splattered light colored substances on the blades and guards. The Dietary Manager identified the substances as cake mix. She stated that staff had used the mixture earlier this morning. Observation on [DATE] at 11:36 a.m. of reach in refrigerator #1 revealed the following: 1. One package of open cheese wrapped in wrap partially uncover with no open date or expiration date. 2. Three limes in a bag with no open or expiration date. 3. One small container of cooked gravy with no open date or expiration date. 4. Pureed bake beans in a plastic Tupperware container with no open date or expiration date. 5. Peanut butter and jelly in a plastic Tupperware container with no open date or expiration date. 6. Pimento cheese in a plastic tupperware container with no open date or expiration date. 7. Chicken salad in a plastic tupperware container with open date of [DATE]. 8. Pimento cheese in a plastic tupperware container with open date of [DATE] and expiration date [DATE]. 9. Five pound plastic container of sour cream dated [DATE]. Observation on [DATE] at 11:38 a.m. of Reach in Refrigerator #2 revealed the following: 1. An 8 x 10 pan of Jell-O not dated or labeled. An interview with Dietary Aide (DA) UU at the time of the observation revealed that the jell-o in the square 8 x 10 pan was made on, [DATE] 2. Eleven paper plates of Jell-O fruit square not cover and dated on a cooking sheet Observation on [DATE] at 11:44 a.m. of one ceiling fan facing a preparation counter revealed a greyish substance covering the blades of the fan. During the interview at the time of the observation, the DM identified the greyish substances as dust. She also stated that the fan was not operable and should had been removed from the kitchen area. Observation of one ice machine on [DATE] at 11:42 a.m. revealed a black slimy substances on the top panel of the ice machine. When the Dietary Manager wiped with a white paper towel. The Dietary Manager identified the substance as mildew and stated that she only been with the facility since (MONTH) of (YEAR). She could not recall exactly the date the ice machine was last cleaned. She stated that the maintenance supervisor and one of her staff who is no longer employed did clean the ice machine , a while back. She stated that she will have someone clean the ice machine.She stated that Maintenance is responsible for cleaning the ice machine along with her kitchen staff. She furthere revealed that she did not have a schedule of when the ice machine was last cleaned Interview with the Administrator on [DATE] at at 12:10 a.m. revealed that the facility has another ice machine that the facility staff could use. He stated that he will instruct the dietary staff to discard of all the beverages on the tray carts . He stated that he will have the maintenance staff to clean the ice machine. Interview with the Maintenance Supervisor with the Administrator on [DATE] at 12: 25 a.m revealed that the facility uses a cleaning system Filter Monitor which detects how often the ice machine should be cleaned. This monitor strip is place inside the ice machine and registers on a 6 -12 months timer. Maintenance Supervisor stated that he does not log each time the ice machine is cleaned and was not sure when the last time the ice machine was cleaned. Observation of large fan covered with grey substance attached to the wall in the kitchen located on the in the dishwasher. The fan was facing dishwasher and counter top of the clean dishes. Interview with the Dietary Manager [DATE] at 8:21am revealed the fan is operable . She stated that maintenance is responsible for cleaning the dishwasher.Further reported have no policy on cleaning schedule and for how fans should be cleaned. Review of the facility's policy title Nutrition Services Manua/Food Labeling Reference Guide revealed that staff should keep items in original delivery cardboard cases from vendor whenever possible, put delivery date on cardboard case, put delivery date on individual item(cans, bags, etc.) when removed from cardboard delivery cases. When food iteme is opened and not completely sued writie the open date on the food container. Write a use by date on the food container. Review of policy title Maintenance Policy revealed that ice machines should be thoroughly cleaned and descaled monthly.",2020-09-01
402,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2019-02-21,657,D,0,1,L5UF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy titled Interdisciplinary Care Planning Team and resident and staff interview the facility failed to update care plans for one of two residents (R151) reviewed for falls in the B Building. The sample size was 56 residents. Findings include: 1. Review of the medical record for R151 revealed the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) for R151 dated 1/24/2019 revealed a Brief Interview for Mental Status Test (BIMS) revealed a score of 15 indicating no mental impairment. The residents Functional Status indicated needing limited assistance with one person assist for bed mobility, transfers, walking in room and corridors, locomotion in room and corridors, dressing, toileting and personal hygiene. She is independent for eating and requires physical help of one person for bathing. Resident is continent of both bowel and bladder. The assessment indicates falls since admission with one with a major injury. Resident is on a Restorative Nursing Program for walking and transfers six times a week. Review of the medical record for R151 revealed the resident had two falls on 1/9/2019 when her wheelchair flipped backwards and on 1/17/2019 when the resident lost her balance when transferring herself from the wheelchair to her bed. The resident's care plan did not reflect these falls. Review of the care plans for R151 revealed a care plan for: At risk for falls due to history of falls at home with injury, chronic pain, use of narcotic [MEDICATION NAME], and antidepressant ([MEDICATION NAME]) and antianxiety ([MEDICATION NAME]). Resident desires to maintain her independence which increases her risk for falls. Further review revealed that the resident's care plan had not been updated to reflect the resident's actual falls that occurred on 1/9/2019 and on 1/17/2019. Review of the facility policy number #2031 titled Interdisciplinary Care Planning Team last revised 1/2017 revealed the care plan reveals the care plan will be completed within 21 days of admission. The policy does not indicate when to up-date the care plans when a resident has a fall or has a change in condition. An interview with the resident on 02/20/2019 at 9:01 a.m. revealed the resident stated she was having a lot of falls when she lived at home by herself. She stated she has had a few falls since admission, but the staff reminds her to not get up without asking for assistance. She was just using a walker but now uses the walker only with therapy and uses the wheelchair other times. An interview on 2/21/2019 at 10:18 a.m. with the Minimum Data Set (MDS) Coordinator revealed she has a blanket type care plan for residents at risk for falls. The care plans do not indicate a date when a fall actually happens. She only updates the care plans when she completes a quarterly or an annual MDS. She stated she attends the daily morning meeting and they discuss the events from the previous day. She also stated they discuss falls at the monthly Patients at Risk (PAR) meetings. She also stated she is the only one that updates the care plans. The nurses do not update the care plans.",2020-09-01
403,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2019-02-21,880,D,0,1,L5UF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, the facility's policy titled, Dressing Change Procedure and Hand Washing and staff interview, the facility failed to wash/sanitize hands after glove removal and prior to donning clean gloves during wound treatment for one residents (R) (R#145) of 56 sampled residents in the B Building. In addition, the facility failed to store resident personal care items and specimen collection devices in a sanitary manner for 16 of 56 residents in the A Building. These 16 residents shared four bathrooms. This was observed for four of four days of the survey. The sample size was 56 residents. Findings include: Review of the policy titled Dressing Change Procedure last reviewed 5/2017 revealed the following procedure: 2. Wash hands and collect supplies 4. Wash hands and don gloves and apron, remove and discard old dressing, remove and discard gloves, perform hand hygiene and don new gloves. Review of the policy titled Hand Washing last reviewed 1/2011 revealed careful hand hygiene must be performed when moving from a dirty patient care task to a clean task. A review of the Treatment Record document revealed a physician's orders [REDACTED]. Pack with wet to dry dressing with Dakin's Solution in sacral wound, change two times a day (BID), cover with [MEDICATION NAME]. Order started on 2/21/2019. Documentation indicated the treatment was performed twice a day. An observation of wound care for R145 on 2/21/2019 at 10:20 a.m. LPN AA revealed the nurse brought the supplies needed for the residents wound care and placed them on the resident's bed. The bed was not protected by a barrier. Observation revealed that LPN AA took the dressings off the resident's bed and opened them and put them on the cleaned bedside table; however, LPN AA did not wash/sanitize her hands nor put on gloves. Without washing or sanitizing her hands LPN AA then put on gloves and repositioned the resident for the procedure. After repositioning the resident LPN AA then removed her gloves and put on sterile gloves. She did not wash or sanitize her hands before putting on the sterile gloves. LPN AA then took the 4x4 gauze with the Dakin's Solution on it and washed the inside of the wound and using the same 4x4 gauze she also cleaned the parameter of the wound. LPN AA then put the soiled 4x4 gauze on the pad that was under the resident and picked up another 4x4 gauze and packed the wound with it. LPN AA did not remove her gloves or wash/sanitize her hands between dirty to clean. She then applied the [MEDICATION NAME] dressing over the packing. She did not change her gloves or wash/sanitize her hands. She removed her sterile gloves, washed her hands and then repositioned the resident to get up to sit in her wheelchair. Review of the Nurse Competency completed on 12/13/2018 for LPN AA revealed she demonstrated knowledge of wounds and how to appropriately care for them. Part of the procedure states to wash hands after cleaning wound and applying new sterile gloves. An interview with LPN AA on 2/21/2019 at 2:34 p.m. revealed that wound care involves ensuring the area is clean and that the procedure is sterile. It also involves washing your hands prior to and after changing gloves. LPN AA stated that you have to be sure the scissors are cleaned before use and that the over the bed table is cleaned before use. LPN AA stated that you should not put soiled dressings on the bed. She stated if proper procedure is not followed this can put the resident at risk for infection. An interview with the Director of Nursing (DON) on 2/21/2019 at 2:38 p.m. revealed If a problem with wound care is identified a written corrective solution is completed with the nurse. This concern is documented on a form titled Problem Resolution Sheet and a follow up with re-educating the staff is completed. She further stated that there is a procedure in place that requires Doing a Weekly Inspection Control Round and this will include any identified concerns that involve infection control/wound care. 2. Observations conducted on 2/18/19 at 11:05 a.m., 2/19/19 at 12:00 p.m. and 2/20/19 at 12:10 p.m. revealed the shared bathroom between rooms [ROOM NUMBERS] with one unlabeled, unbagged bath basin containing dried white debris and one unlabeled, unbagged bedpan. Observations conducted on 2/19/19 at 12:03 p.m. and 2/20/19 at 12:46 p.m. revealed the shared bathroom between rooms [ROOM NUMBERS] with one unlabeled, unbagged bedpan sitting on the floor. Observations conducted on 2/18/19 at 11:05 a.m., 2/19/19 at 12:00 p.m. and on 2/20/19 at 12:10 p.m. revealed the shared bathroom between rooms [ROOM NUMBERS] contained one unlabeled, unbagged bedpan. Observations conducted on 2/18/19 at 11:19 a.m. and on 2/19/19 at 8:16 a.m. revealed the shared bathroom between rooms [ROOM NUMBERS] contained one unlabeled and un-bagged bath basin underneath the toilet. During a tour of the facility conducted on 2/21/19 beginning at 10:30 a.m. with the Director of Nursing (DON) and the Director of Housekeeping (DOH), revealed that the DON and the DOH validated the following areas of concern: the shared bathroom between rooms [ROOM NUMBERS] contained one unlabeled and unbagged bath basin with a moderate amount of white residue and one labeled but unbagged bedpan; the shared bathroom between rooms [ROOM NUMBERS] contained one unlabeled, unbagged bedpan sitting on the floor; the shared bathroom between rooms [ROOM NUMBERS] contained one unlabeled, unbagged bedpan; the shared bathroom between rooms [ROOM NUMBERS] contained one unlabeled, unbagged bedpan. During an interview conducted on 2/21/19 at 10:50 a.m., the DON confirmed that bedpans and bath basins are individual resident use items and should be labeled with the resident's room and bed number and stored in a clean, plastic bag off the floor.",2020-09-01
404,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2019-02-21,883,E,0,1,L5UF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to provide annual education for immunizations for four of five residents in Building [NAME] The census was 88 residents. Findings include: A review of the Influenza Prevention policy (undated), revealed; It is the policy of Long-Term Care to reduce the risk of influenza infection and transmission within the facilities. Page 1, item #2 indicates Education pertaining to the epidemiology, transmission and [DIAGNOSES REDACTED]. Page 2, item#1 indicates on admission, the resident/responsible party will be made aware of the availability of the influenza vaccination. Page 2, item#3 indicates Residents will be vaccinated annually for influenza, unless contraindicated. Interview on 2/19/19 at 1:25p.m. an interview with Infection Preventionist (IP), revealed the undated policy is the most current version, she dated and signed the current version. A review of Influenza vaccine policy with a revised date of 2012 from 2001 MED-Pass revealed; All residents will be offered the influenza vaccine annually and the facility shall provide pertinent information. Item #4 revealed prior to the vaccination, the resident will be provided information and education, and provision of such education shall be documented in the medical record. A review of the admission packet revealed a document labeled Harborview Health Systems labeled as item#1, revealed residents receive a written notice upon admission from Centers for Disease Control Vaccine Information. The admission packet contains Resident Immunization Consent or Refusal Form indicating the facility provides information regarding the risks and benefits of the influenza and pneumococcal immunization vaccines. Vaccine information statement, a 4-page document from CDC is included in the admission packet. 1. A review of the medical record for resident (R)#46 revealed an Informed Consent to Receive Vaccines signed and dated 8/1/14. An interview on 2/21/19 at 11:15 a.m. with IP revealed there is no additional evidence of education or administration of the flu vaccine for R#46. A Physician order [REDACTED]. 2. A review of the medical record for resident (R)#7 revealed a Resident Immunization Consent or Refusal Form signed and dated 1-7-19, there is an entry on this document indicating the annual influenza vaccine was administered 10-5-18 Physician order [REDACTED]. 3. A review of the medical record for resident (R)#6 revealed a Resident Immunization Consent or Refusal Form signed and dated 7-20-2017, there is an entry on this document indicating [MEDICATION NAME] lot yt was administered 10-5-2018. Physician order [REDACTED]. 4. A review of the medical record for resident (R)#52 revealed a Resident Immunization Consent or Refusal Form signed and dated 10-16-17, there is an entry on this document indicating [MEDICATION NAME] lot yT was administered 10-3-18. Physician order [REDACTED]. A review of the medical records for R#46, R#7, R#6, R#52 revealed that there was not any evidence of education prior to administration of vaccines for the flu season of (YEAR) Interview on 02/20/19 08:30 a.m. was conducted with the Director of Nursing (DON). She stated that the IP, and the Staff Education Nurse, are responsible for giving the residents education regarding immunizations, and that the (IP) nurse is responsible for administering the vaccinations to the residents. Interview on 02/20/19 08:40 a.m. with the IP nurse, revealed that on admission the residents and or responsible party receive education in regard to flu and pneumococcal vaccines. She stated that she usually calls the responsible party before giving the flu vaccine, but she did not do that this flu season, she also stated that she usually mails out education for vaccinations but did not do it this past year. She stated that yearly education for vaccinations is not documented anywhere. Interview on 2/20/19 at 9:35a.m. with the DON revealed her expectations in regard to yearly education for vaccinations are to verbally educate the residents before the vaccines are administered, and handouts are given for education. She stated this should be done yearly. DON also stated that documentation regarding vaccination education would be nice Interview on 2/20/19 at 3:55 p.m. with Staff Education Nurse, she stated that she has no role in the education for vaccinations. Interview on 2/20/19 at 4:00 p.m. with the Director of Nursing (DON) revealed that an education sheet for vaccinations is given upon admission to the resident and/or the responsible party. She stated that there is no signature page to prove they got the education sheet, nor is there any documentation to prove that an education sheet was given. She also clarified that IP nurse does the education for all residents, and that the staff education nurse is responsible for all staff education.",2020-09-01
405,HARBORVIEW SATILLA,115265,1600 RIVERSIDE AVE,WAYCROSS,GA,31501,2017-04-06,371,F,0,1,01P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy titled, Food Safety Standards and Requirements Facility A failed to assure that items were labeled and dated and items were used before the expiration date in two (2) reach in coolers in the kitchen and in two (2) of two (2) refrigerators in the resident food pantry. The facility also failed to assure that temperature logs were kept for freezer temperatures in two (2) of two (2) resident pantry. Facility B failed to label and date opened food items before storage in the walk-in freezer and failed to label and securely close one open food item in a walk-in dry good storage pantry to prevent cross contamination from environment debris. Facility A failed to label, date, and properly store food items in one refrigerator, discard of expired and label food item in nourishment refrigerator on East Hall and West Hall pantries, and to ensure all food items are stored at the appropriate temperature by placing a therometer in the freezer. This deficient practice had the potential to effect 2 two of 2 two pantry at the facility A and both kitchens. Total census of 162 with nine 9 tube feeders. A total census of 162. Findings forinclude: Facility A Observation during the initial tour on 4/3/17 at 9:35 a.m.of Facility A revealed the clear reach in cooler had one container of Silk Almond Milk (one quart) that did not have an open date with directions of stay fresh 7-10 days after opening. There was one (1) open container (no open date) of Nectar like consistency - Sweetened tea with lemon flavor (46 fluid ounces (fl. oz.)) with directions of refrigerate up to 7 days once opened. There was one half bag of Texas toast that did not have an expiration date or an open date on the bag. During kitchen tour on 4/5/17 at 12:19 p.m. of Facility A in the silver reach in cooler there was one container labeled to have black olives and had an opened date of 2/27/17 and a use by date of 3/6/17. There was also a five (5) pound (lb) container of small curd cottage cheese with a best by date of 4/2/17 (with a quarter (1/4) container remaining). Interview with Dietary Supervisor BB revealed that items in the refrigerator should be dated with an open date and use by date. It was further revealed that the expectation is that items will be used by the use by date or discarded. She further reported that she had discarded the items that were identified during initial kitchen tour that were not labeled with an opened date. Observation on 4/6/17 at 9:34 a.m. of Facility A in the East Wing resident pantry of facility A revealed there was no thermometer and one (1) bag of frozen fish not dated or no name in the freezer. In the refrigerator there were seven cans of Glucerna 1.2 cal (one (1) can with an expiration date (MONTH) (YEAR); two (2) cans with an expiration date of (MONTH) (YEAR); one (1) can with an expiration date of (MONTH) (YEAR); two (2) cans with an expiration date of (MONTH) (YEAR), and one (1) can with an expiration date of (MONTH) (YEAR)) that were eight (8) fl. oz. each. There were also three (3) cans [MEDICATION NAME] HN, eight (8) fl. oz. each, with and expiration date of (MONTH) (YEAR). There also was no evidence of freezer temperatures being logged. Interview with the Director of Nursing (DON) and Registered Nurse (RN) supervisor, at this same time, revealed that the shipment received from hospital on this Tuesday. It was further revealed that they had not been checking the dates on these items because they were coming directly from the hospital. The DON reported that she routinely checks the items in refrigerator. Observation on 4/6/17 at 10:02 a.m. of Facility A in the West wing resident pantry there was no evidence of freezer temperatures being logged. There was one (1) frozen 20 fl. oz. Sprite and one (1) frozen 16.9 fl. oz. container of Gold Peak unsweetened tea that were not labeled in the freezer. In the refrigerator there was one (1) to go plate that had a name but it was not dated, 1 (one) 20 oz. container of mustard with a best by date of (MONTH) 26, (YEAR), one (1) 16.9 fl. oz. container of Gold Peak unsweetened tea with an expiration date of (MONTH) 21, (YEAR), and three (3) tv dinners that were not labeled. Interview on 4/6/17 at 10:15 a.m. with the DON who reported that she is responsible for checking for labeling and dating of items as well as checking for expired items in the pantry on each wing. DON explained that a quick check is done daily of pantries and a thorough check is done every 10 days. She further explained that she observes the pantry to assure that no items are in the sink and no personal items in the pantry during a quick check. Thorough checks are completed every ten days and includes checking dates on supplements, assuring that the floors and sinks are clean. DON further reported that dietary staff are responsible for logging the temperatures daily. Interview on 4/6/17 at 11:00 a.m. with the RN Supervisor who reported that there are no residents currently receiving Glucerna. RN Supervisor further reported that there are separate guidelines for monitoring the temperatures of the refrigerators and freezers in the resident pantries. The guidelines for this was requested but was not received. Interview on 4/5/17 at 11:05 a.m. with the Administrator who reported that policy for monitoring the refrigerators and freezers in the pantries is the same as policy that is used in the kitchen. Review of policy titled Food Safety Standards and Requirements revealed that manufacturers expiration, use by or sell by dates, must be adhered to. Review of policy section E. HACCP/Food safety program and training training revealed temperature logs must be completed and kept on file for one year. This includes both refrigerator temperature log and freezer temperature log. Facility B Observation on 4/3/17 at 10:25 a.m. of the walk-in freezer for Facility B revealed the following food items with no open date and expiration date: a large opened package of chicken strips, an open package of french toast sticks, and a package of chicken breast. Observation on 4/3/17 at 10:40a.m. of the walk-in dry goods storage pantry area revealed an open 20/10 pound box shells of lasagna ridge placed on a bottom wire shelf with no open date. The box was open and not securely closed to prevent contamination from environment debris. Interview on 4/3/17 at 10:45 a.m. with the Dietary Manager DM for Facility BB revealed that her expectations are that the dietary staff label food properly once it is open and used. Further interview with the DM revealed that the dietary staff are responsible for labeling storage, and properly securing open food items on each shift to prevent cross contamination. Interview on 4/3/17 at 11:00 a.m. with the Director of Nursing for Facility B revealed that her expectations are that the dietary staff label food and date all food according to the facility policy. Review of the policy titled, Sanitation and Infection Control -Food Storage (Labels/Dates)-SS-1016, revealed, in pertinent part that All cooked foods, pre-packaged open containers, protient-based salads and deserts are labeled, dated, and securely covered.",2020-09-01
406,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2016-04-20,282,D,0,1,RJB311,"Based on record review the facility failed to follow the plan of care to routinely measure a pressure ulcer for one (1) resident (#27) of three (3) residents reviewed for pressure sores, from a total sample of thirty-seven (37) residents. Findings include: Unit 2 Resident #27 had an Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/23/16, that documented the resident had a stage 2 pressure ulcer that was present on admission. Further review of the clinical record revealed that the pressure ulcer was located on the sacrum and lower back. There was a 2/16/16 plan of care in place that the resident had a potential for impairment of skin intergrity with an intervention for nursing staff to measure the area. However, a review of the Weekly Wound assessments completed on 3/2/16, 3/9/16 and 3/16/16 revealed the measurements of the pressure ulcer included with the assessments were not thorough to include a length, width and depth. Cross reference to F314",2020-09-01
407,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2016-04-20,314,D,0,1,RJB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, it was determined that the facility failed to notify the physician of a change in a pressure ulcer for one resident (#187) and to thoroughly measure a pressure ulcer for one resident (#27) of three (3) residents reviewed for pressure ulcers, from a total sample of thirty-seven (37) residents. Findings include: Unit 2 1. Resident #187 was admitted to the facility on [DATE] with pressure ulcers to the sacrum and left heel. The pressure ulcer to the left heel was initially assessed as being necrotic and measuring six (6) centimeters (cm) by three (3) cm. A physician's orders [REDACTED]. The pressure ulcer was routinely assessed on 3/9/16, 3/16/16 and 3/23/16 with no changes noted to the progression of the wound. The assessment completed on 3/30/16 documented a change in the appearance of the pressure ulcer to include the left heel being red and boggy and the pressure ulcer extending to the left Achilles with a necrotic area noted to the Achilles. However, there was no evidence in the clinical record that the physician was notified of the change in the pressure ulcer until 4/6/16 During an interview with the Treatment Nurse on 4/20/16 at 12:40 pm, she acknowledged that there was a change in condition to the pressure ulcer on the left heel on 3/30/16, and she had not notified the physician of this change on 3/30/16 but should have. On 4/6/16, when the physician was notified of the change in the pressure ulcer to the left heel, he ordered a new treatment to irrigate the left heel/achilles with normal saline, pat dry, apply no sting barrier to the periwound and apply Santyl to the wound bed and cover with Allevyn dressing on Mondays, Wednesdays and Fridays. During an interview on 4/20/16 at 12:55 p.m., the physician stated the delay in notification did not cause the resident harm, but he should have been notified of the change in the pressure ulcer to the left heel on 3/30/16. 2. The facility's Pressure Ulcer/Skin Breakdown Clinical Protocol documented the nurse should describe and document /report a full assessment of the pressure ulcer including location, stage, length, width and depth, presence of exudates or necrotic tissue. Resident #27 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. An Admission Minimum Data Set (MDS) Assessment, with an Assessment Reference Date (ARD) of 2/23/16, documented the resident had a stage 2 pressure ulcer that was present on admission. A further review of the clinical record revealed that the pressure ulcer was located on the sacrum. There was a 2/16/16 plan of care in place that the resident had a potential for impairment of skin intergrity with an intervention for nursing staff to measure the area. However, a review of the Weekly Wound assessments completed on 3/2/16, 3/9/16 and 3/16/16 revealed the measurements of the pressure ulcer included with the assessments were not thorough to include a length, width and depth. Each assessment included one photograph of the pressure ulcer with a ruler present that only included a measurement of one dimension of the wound. During an interview and record review on 4/19/16 at 9:21 a.m, with the Director of Nursing (DON), she confirmed that there were no additional wound measurements, that the ruler did not show the width and there was no assessment of depth documented.",2020-09-01
408,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2016-04-20,329,E,0,1,RJB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and facility policy, the facility failed to ensure adequate monitoring for adverse consequences of potential behaviors for eight (8) of thirteen (13) residents (#2, #158, #10, #49, #173, #85, #107 and #155) who received an antipsychotic medication, from a total sample of thirty-seven (37) residents. Findings include: Unit 1 The facility's Behavioral Assessment, Intervention and Monitoring policy documented when medications are prescribed for behavioral symptoms, documentation will include monitoring for efficacy and adverse consequences. The policy also documented that the facility will comply with regulatory requirements related to the use of medications to manage behavioral changes and that if the resident is being treated for [REDACTED]. 1. Resident #2 had a Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/26/16, that documented [DIAGNOSES REDACTED]. The current (MONTH) (YEAR) Physicians Order Form (POF) for Resident #2 documented that the resident had an order for [REDACTED]. Review of the Electronic Medication Administration Record (eMAR) for Resident #2 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors for the [MEDICATION NAME] for (MONTH) (YEAR) and (MONTH) (YEAR). During an interview and record review on 4/19/16 at 11:30 a.m. with licensed practical nurse (LPN) BB, she stated that residents on antipsychotic medications are monitored for behaviors every shift and it is documented on the eMAR and also in the nurses notes. LPN BB confirmed that no behavior monitoring was documented on the eMAR for the [MEDICATION NAME]. During an interview on 4/19/16 at 11:50 a.m., the Director of Nursing (DON) stated it was facility policy that all residents on antipsychotic medications were monitored each shift for behaviors, and it was documented on the eMAR. The DON verified there was no behavior monitoring documented on Resident #2's eMAR and stated it was omitted in error. 2. Resident #158 had an order on the current (MONTH) (YEAR) POF for 5 mg of [MEDICATION NAME] (an antipsychotic) twice daily for mood stability. Review of the eMAR for Resident #158 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the [MEDICATION NAME] for (MONTH) (YEAR) and (MONTH) (YEAR). 3. Resident #10 had an order on the current (MONTH) (YEAR) POF for 0.25 mg of [MEDICATION NAME] (an antipsychotic) every other day for Monosymptomatic Hypochondriacal [MEDICAL CONDITION]. Review of the eMAR for Resident #10 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the [MEDICATION NAME] for (MONTH) (YEAR) and (MONTH) (YEAR). 4. Resident #49 had an order on the current (MONTH) (YEAR) POF for 50 mg of Quetiapine [MEDICATION NAME] (an antipsychotic) daily for [MEDICAL CONDITION]. Review of the eMAR for Resident #49 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors regarding the Quetiapine Furmarate for (MONTH) (YEAR) and (MONTH) (YEAR). 5. Resident #173 had an order on the current (MONTH) (YEAR) POF for 2.5 mg of [MEDICATION NAME] (an antipsychotic) daily for Dementia associated behavioral symptoms. Review of the eMAR for Resident #173 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the [MEDICATION NAME] for (MONTH) (YEAR) and (MONTH) (YEAR). 6. Resident #85 had an order on the current (MONTH) (YEAR) POF for 0.5 mg of [MEDICATION NAME] (an antipsychotic) twice daily for [MEDICAL CONDITION]. Review of the eMAR for Resident #85 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the [MEDICATION NAME] for (MONTH) (YEAR) and (MONTH) (YEAR). 7. Resident #107 had an order on the current (MONTH) (YEAR) POF for 20 mg of [MEDICATION NAME] (an antipsychotic) daily for Depressive Type [MEDICAL CONDITION]. Review of the eMAR for Resident #107 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the [MEDICATION NAME] for (MONTH) (YEAR) or (MONTH) (YEAR). 8. Resident #155 had an order on the current (MONTH) (YEAR) POF for 0.5 mg of [MEDICATION NAME] (an antipsychotic) twice daily for Mood Disorder. Review of the eMAR for Resident #155 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the [MEDICATION NAME] for (MONTH) (YEAR) or (MONTH) (YEAR). During an interview on 4/19/16 at 3:28 p.m., the DON and the Administrator revealed that the facility's computer system had an upgrade a few months ago and the behavior monitoring was deleted from the eMAR on residents receiving antipsychotic drugs. The error was not identified until after surveyor inquiry. The DON and the Administrator acknowledged that behavior monitoring was not completed on eight (8) of the thirteen (13) residents receiving antipsychotic medications.",2020-09-01
409,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2016-04-20,371,E,0,1,RJB311,"Based on observation, record review and staff interview the facility failed to maintain safe temperatures for ten (10) milk products on four (4) food service carts and failed to maintain safe temperatures in one (1) of two (2) nourishment refrigerators that served thirty-five residents. Findings include: Unit 2 1. On 4/17/16 at 4:50 p.m. there was a cart with sixteen (16) prepared meal trays, for residents, in the kitchen. Two of the trays contained milk products and the temperature of the two milk products was obtained. A half pint of Mayfield whole milk was 50.3 degrees Fahrenheit (F) and a milkshake was 60.6 F. On 4/17/16 at 4:53 p.m the Certified Dietary Manager (CDM) stated the temperature of the milk products should be 41 F or lower, and the milk and milk shake temperatures were too high to serve. The CDM revealed that three (3) food carts had already gone out to the units. On 4/17/16 at 5:23 p.m., the temperatures of the milk products were checked on the three (3) carts on the halls, prior to the residents being served. Ten (10) milk products were above 41 F and ranged from 43.3 F to 64 F. During an interview on 4/17/16 at 5:45 p.m., Dietary staff FF, stated he put the milk and milkshake on the resident trays. FF further revealed that when he took the milk out of the cooler, the temperature of the milk was thirty-nine degrees (39). Dietary staff FF also stated he took the milk out of the cooler a little after 4:00 p.m. but he did not document the milk temperature when it was taken out of the cooler. During interviews with General Manager of Nutritional Services EE on 4/17/16 at 5:50 p.m., 4/18/16 at 11:45 a.m. and on 4/20/16 at 7:42 a.m., he stated the procedure for cold beverages and refrigerated items including milk and milkshakes during meal service was as follows: twenty (20) minutes before meal service, the milk, milk products and refrigerated items go into the freezer. Then after twenty (20) minutes they are moved to the reach-in refrigerator cooler. After all the residents' trays on a cart are prepared, then the milk and refrigerated items are taken out of the cooler and placed on the residents' trays, on the cart. He stated that the dietary staff was not following the facility's procedure, and that is why the temperatures were too high for the milk products. He stated one milk should be taken out at a time and placed on the resident's tray before the cart leaves the kitchen. General Manager EE confirmed there was no documentation of the milk temperature prior to the dinner service (on 4/17/16), and the temperature should have been recorded. During an interview on 4/20/16 at 8:29 a.m., the CDM confirmed that there was no documentation of the milk temperature being checked prior to the evening meal on 4/17/16, but the staff should have been documenting milk and refrigerated items temperatures. 2. Review of the Policy Interpretation and Implementation documented the following: 1. Acceptable temperature ranges are 35 degrees Fahrenheit to 40 degrees Fahrenheit for refrigerators. 2. Monthly tracking sheets for all refrigerators will be posted to record temperatures. 3. Monthly tracking sheets will include time, temperature, initials and action taken. The last column will be completed only if temperatures are not acceptable. 4. Food Service Supervisors or designated employees will check and record refrigerator temperatures daily. 5. The supervisor will take immediate action if temperatures are out of range. Actions necessary to correct the temperatures will be recorded on the tracking sheet, including the repair personnel and or department contacted. 6. Appointed staff will inspect refrigerators weekly and report any maintenance issues to appropriate staff. However, on 4/19/16 at 3:50 p.m., in the 200 and 300 hall [NAME]in Roost pantry, the refrigerator thermometer read 45.3 degrees Fahrenheit (F). Review of the temperature logs for the refrigerator revealed the temperatures were greater than forty-one (41) degrees and documented as out of range for seven (7) of twenty-nine (29) days in (MONTH) (YEAR), twenty-four (24) of thirty-one (31) days in (MONTH) (YEAR) and nine (9) of nineteen (19) days in (MONTH) (YEAR). The temperatures ranged from forty-two (42) degrees to forty-eight (48) degrees F. During an interview on 4/20/16 at 11:00 a.m., Engineering Manager HH stated that his department does quarterly temperature checks on the refrigerators. However, he was not able to provide documentation of the quarterly temperature checks due to the facility switching systems and was unable to say when the refrigerator was last checked by maintenance. He stated that his department had not been notified of any temperature problems with the [NAME]ins Roost pantry refrigerator. During an interview on 4/20/16 at 11:25 a.m., the Assistant Director of Nursing (ADON) confirmed the above documented temperatures on the temperature log of the [NAME]ins Roose pantry refrigerator were out of range and stated the temperature should be 41 F or less. She further stated it is the responsibility of the 300 Hall nurse to check the temperature of the refrigerator daily, record the temperature, and record actions taken when the temperature is found to be out of range, but that the staff failed to do so in February, (MONTH) and (MONTH) (YEAR). .",2020-09-01
410,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2016-04-20,428,E,0,1,RJB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the Consultant Pharmacist failed to identify and report medication irregularities related to behavior monitoring for eight (8) residents (#2, #158, #10, #49 ,#173, #85, #107 and #155) of thirteen residents (13) receiving antipsychotic drug therapy, from a total sample of thirty-seven (37) residents. Findings include: Unit 1 1. Resident #2 had a Quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 1/26/16, that documented [DIAGNOSES REDACTED]. The current (MONTH) (YEAR) Physicians Order Form (POF) for Resident #2 documented that the resident had an order for [REDACTED]. Review of the Electronic Medication Administration Record [REDACTED]. However, there was no evidence of monitoring for adverse behaviors for the Geodon for (MONTH) (YEAR) and (MONTH) (YEAR). 2. Resident #158 had an order on the current (MONTH) (YEAR) POF for 5 mg of Zyprexa (an antipsychotic) twice daily for mood stability. Review of the eMAR for Resident #158 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the Zyprexa for (MONTH) (YEAR) and (MONTH) (YEAR). 3. Resident #10 had an order on the current (MONTH) (YEAR) POF for 0.25 mg of Risperidone (an antipsychotic) every other day for Monosymptomatic Hypochondriacal Psychosis. Review of the eMAR for Resident #10 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the Risperidone for (MONTH) (YEAR) and (MONTH) (YEAR). 4. Resident #49 had an order on the current (MONTH) (YEAR) POF for 50 mg of Quetiapine Fumarate (an antipsychotic) daily for Psychosis. Review of the eMAR for Resident #49 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors regarding the Quetiapine Furmarate for (MONTH) (YEAR) and (MONTH) (YEAR). 5. Resident #173 had an order on the current (MONTH) (YEAR) POF for 2.5 mg of Zyprexa (an antipsychotic) daily for Dementia associated behavioral symptoms. Review of the eMAR for Resident #173 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the Zyprexa for (MONTH) (YEAR) and (MONTH) (YEAR). 6. Resident #85 had an order on the current (MONTH) (YEAR) POF for 0.5 mg of Risperidone (an antipsychotic) twice daily for Psychosis. Review of the eMAR for Resident #85 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the Risperidone for (MONTH) (YEAR) and (MONTH) (YEAR). 7. Resident #107 had an order on the current (MONTH) (YEAR) POF for 20 mg of Geodon (an antipsychotic) daily for Depressive Type Psychosis. Review of the eMAR for Resident #107 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the Geodon for (MONTH) (YEAR) or (MONTH) (YEAR). 8. Resident #155 had an order on the current (MONTH) (YEAR) POF for 0.5 mg of Risperidone (an antipsychotic) twice daily for Mood Disorder. Review of the eMAR for Resident #155 revealed that the facility was providing ongoing monitoring for the potential side effects related to the antipsychotic drug therapy. However, there was no evidence of monitoring for adverse behaviors related to the Risperidone for (MONTH) (YEAR) or (MONTH) (YEAR). During an interview on 4/19/16 at 3:28 p.m., the Director of Nursing (DON) and the Administrator revealed that the facility's computer system had an upgrade a few months ago and the behavior monitoring was deleted from the eMAR on residents receiving antipsychotic drugs. The error was not identified until after surveyor inquiry. The DON and the Administrator acknowledged that behavior monitoring was not completed on eight (8) of the thirteen (13) residents receiving antipsychotic medications. During an interview on 4/20/16 at 8:49 a.m., the Pharmacy Consultant stated he/she did not know when the Electronic Medical Record (EMR) system dropped the behavior monitoring from the eMARs. He/she further stated he/she assumed behavior monitoring was conducted and did not look for it on the eMARs.",2020-09-01
411,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2018-07-20,608,D,1,0,67000000000000.0,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, record review and policy review, the facility failed to report an allegation of physical abuse to law enforcement for one resident (A), from a total sample of ten residents. Findings include: Review of the facility abuse policy entitled Abuse Prohibition Policy and Procedures. revealed the following: the policy documented that once a complaint or situation is identified involving alleged mistreatment, neglect or abuse the incident will be reported immediately, but not later than two hours after the allegation is made if the events that case the allegation involve abuse or result in serious bodily injury to the Administrator of the facility. The Administrator or designee will immediately notify the Investigation Intake and Referral Unit and the legal representative and/or interested family member of the incident and the pending investigation. The policy also included that the Police Department will also be notified as appropriate. Record review revealed that on 6/23/18, a family member of Resident (R) A alleged that someone had hit the resident. The resident was assessed and bruising was identified to the left thigh. The resident was transferred to the hospital emergency roiagnom on [DATE] for further evaluation. A review of the hospital documentation dated 6/23/18 at 20:23 (military time-8:23 p.m.) revealed that the resident arrived from the nursing home for concerned physical abuse/assault. The examination documented multiple deep contusions, appeared new, to the left anterior thigh and marked tenderness to the left shoulder extending to the left proximal humerus. Review of the radiology reports, dated 6/23/18, documented a minimally displaced surgical neck [MEDICAL CONDITION] humerus and a remote fracture involving the clavicle and mid humeral diaphysis. The resident was discharged from the emergency room , back to the facility on [DATE] with physician's orders [REDACTED]. Although the facility immediately initiated an investigation and reported the allegation of abuse to the Stage Agency, they failed to report the alleged physical assault to a law enforcement entity. During an interview on 7/20/18 at 3:20 p.m., the Administrator confirmed that law enforcement had not been notified of the allegation of physical abuse.",2020-09-01
412,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2018-07-20,656,D,1,0,67000000000000.0,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure that the appropriate method of transfer was utilized for one resident (A) as care planned, from a total sample of ten residents. Findings include: Review of the medical record for resident (R) A revealed the resident had [DIAGNOSES REDACTED]. Record review revealed that R A was admitted to the hospital on [DATE] due to abnormal laboratory results and remains out of the facility. Review of the Quarterly Minimum Data Set (MDS) assessment, dated 5/21/18, documented that the resident had functional limitations in Range of Motion to her upper extremities on one side. Review of the care plan with a care plan problem, dated 9/14/17, documented that the resident had a self care deficit. The care plan included an intervention for facility nursing staff to transfer the resident using a Hoyer lift. The care plan intervention for the use of a Hoyer lift was also documented on the Certified Nursing Assistant (CNA) Flowsheet, a form utilized for CNA documentation. A review of the clinical record revealed that RA was transferred to the emergency room (ER) on 6/23/18 for further evaluation of bruising to the left thigh and indications of pain to the left arm and left leg. Review of the hospital radiology reports, dated 6/23/18, documented a minimally displaced surgical neck [MEDICAL CONDITION] humerus and a remote fracture involving the clavicle and mid humeral diaphysis. A review of the facility's investigation of the origin of the fractures revealed that on 6/21/18 CNA AA used an inappropriate lift, a stand-up lift, to stand RA up, to provide incontinence care and change the adult brief. However, in the process of using the stand-up lift, the resident's feet slipped off the base of the lift and her arms were raised above her head. During an interview on 7/20/18 at 11:32 a.m., the Director of Nursing (DON) stated that RA had left-sided weakness and would not have been able to hold onto both handles of the stand-up lift. She stated that CNA AA should have transferred the resident to the bed using the Hoyer lift, then provided incontinence care. Cross reference to F689",2020-09-01
413,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2018-07-20,689,D,1,0,67000000000000.0,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure that the appropriate method of transfer was utilized for one resident (A) from a total sample of ten residents. Findings include: Review of the medical record for Resident (R) A revealed the resident had [DIAGNOSES REDACTED]. The 5/21/18 Quarterly Minimum Data Set (MDS) assessment documented that the resident had a Brief Interview for Mental Status of 99 indicating that an interview could not be completed. The resident was assessed as dependent on facility staff for care and had functional limitations in Range of Motion to her upper extremities on one side. Review of the resident's care plan revealed that there was a care plan problem in place, since 9/14/17, for a self care deficit, with an intervention for facility nursing staff to transfer the resident using a Hoyer lift. The care plan intervention for the use of a Hoyer lift was also documented on the Certified Nursing Assistant (CNA) Flowsheet, a form utilized for CNA documentation. Record review revealed that R A was admitted to the hospital on [DATE] due to abnormal laboratory results and remains out of the facility. A review of the clinical record revealed that RA was transferred to the emergency roiagnom on [DATE] for further evaluation of bruising to the left thigh and indications of pain to the left arm and left leg. Review of the hospital ER notes dated 6/23/18 at 20:00 (military time: 8:00 p.m.) revealed the primary complaint specified Suspected Assault onset prior to arrival, 1 day. Primary complaint details: patient with arrival from nursing home for concerned Physical Abuse/Assault. Patient found by family members with multiple bruises left thing and hip. Patient also complaining of left shoulder pain. Patient with left hemaparesis, no ambulation on baseline. Review of the hospital radiology reports dated 6/23/18 documented a minimally displaced surgical neck [MEDICAL CONDITION] humerus and a remote fracture involving the clavicle and mid humeral diaphysis. Review of the Diagnostic Impression: Arm Sling, Ortho consult and d/c (discharge) to nursing home. A review of the facility's investigation of the origin of the fractures revealed that on 6/21/18 CNA AA used the incorrect lift, a stand-up lift, to stand RA up, to provide incontinence care, and change the adult brief. However, in the process of using the stand-up lift, the resident's feet slipped off the base of the lift and her arms were raised above her head. The investigation revealed that CNA AA was suspended pending the results of the investigation due to not reporting the incident with the resident while using the incorrect lift. Repeated attempts were made by the surveyor to contact CNA AA without success. An interview with CNA DD on 7/20/18 at 3:25 p.m. revealed that she had been asked by CNA AA, as she walked down the hallway, to help in the shower room with R A on 6/21/18. When she entered the shower room, R A was in the stand up lift with her arms raised above her head. She assisted CNA AA to lower the resident into a wheelchair. CNA DD further revealed that she asked R A if she was ok or hurting and the resident said no. CNA DD then left the shower room. She did not report the incident to the nurse because she felt that CNA AA would report it. During an interview on 7/20/18 at 11:32 a.m., the Director of Nursing (DON) stated that RA had left-sided weakness and would not have been able to hold onto both handles of the stand-up lift. She stated that CNA AA should have transferred the resident to the bed using the Hoyer lift, then provided incontinence care. The DON confirmed that CNA AA did not report the incident to the nurse. A telephone interview with the Administrator during post survey Quality Assurance on 7/30/18 at 4:43 p.m. revealed that once the investigation was completed that CNA AA was terminated for utilizing the incorrect lift, even though the CNA was aware the resident required a hoyer lift for transfer, and for not reporting that the resident slipped, forcing her arms above her head. In addition, RA was also transferred, using an incorrect method on the morning of 6/23/18. During an interview on 7/20/18 at 12:24 p.m., CNA CC stated she provided care to the resident on the 6/22/18 being at 11:00 p.m. through 6/23/18 7:00 a.m. at the end of the shift and assisted the resident out of bed on the morning of 6/23/18. In response to how she knew what transfer method to use for a resident, CNA CC stated that it is documented on the care plan. However, she further stated that she transferred the resident from the bed to the wheelchair on 6/23/18 using a stand and pivot method.",2020-09-01
414,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2018-09-13,582,E,0,1,FP3S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, facility #1 failed to provide the correct notice to residents when Medicare Part A Services were terminated or denied by the facility (provider) prior to benefits being exhausted. Two out of three residents (R) reviewed, R#120 and R#118 were issued the wrong notice and three out of three residents reviewed, R#153, R#120 and R#118, had no proof the resident or their responsible party ever received the notices or the information contained in them. The sample size was 55. The census was 151. Findings include: A review of R#120's Advanced Beneficiary Notice dated 8/17/18 provided by the facility Business Office Manager (BOM). is titled Notice of Exclusions from Medicare Benefits Skilled Nursing Facility (NEMB-SNF). This form was discontinued from use by CMS effective 5/7/18. The correct form is the Notification of Medicare Non-Coverage (NOMNC), form from CMS. A review of R#118's Advanced Beneficiary Notice dated 5/30/18 provided by the facility BOM is entitled Notice of Exclusions from Medicare Benefits Skilled Nursing Facility (NEMB-SNF). This form was discontinued from use by CMS effective 5/7/18. The correct form is the NOMNC, form from CMS. CMS issues very specific instructions along with the NOMNC form including the following: CMS requires that notification of changes in coverage for an institutionalized enrollee who is not competent be made to a representative acting on behalf of the enrollee. Notification to the representative may be problematic because that person may not be available in person to acknowledge receipt of the required notification. Providers are required to develop procedures to use when the enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee's representative through direct personal contact. If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. Confirm the telephone contact by written notice mailed on that same date. When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. Place a dated copy of the notice in the enrollee's medical file. When notices are returned by the post office with no indication of a refusal date, then the enrollee's liability starts on the second working day after the provider's mailing date. A review of R#153's notice reveals a handwritten note stating Mailed 5-4-18. The form notes R#153 was discharged home on[DATE]. There is no signature of the resident or the authorized representative on the form indicating receipt of the information nor the form itself. A review of R#120's notice reveals a handwritten note stating Mailed 8-17-18. There is no signature of the resident or the authorized representative on the form indicating receipt of the information nor the form itself. A review of R#118's notice reveals a handwritten note stating Mailed 5-30-18. There is no signature of the resident or the authorized representative on the form indicating receipt of the information nor the form itself. The facility failed to develop procedures to use when the enrollee is incapable or incompetent, and the provider cannot obtain the signature of the enrollee's representative through direct personal contact. The facility failed to provide proof (certified mail) that the notices were mailed and received. During an interview with the BOM conducted on 9/11/18 at 10:45 a.m., he reported the facility mails the notices to the responsible party. He stated he includes a statement requesting the representative to mark the form for option one, two or three, sign and date the document and return it to the facility. He said they provide a self-addressed, stamped envelope with the form to facilitate the return of the document. However, he reports representatives don't usually return the form. The BOM confirmed that the facility is not using the correct notification form and that he was unaware of the form being changed effective 5/7/18. During a second interview with the BOM conducted on 9/11/18 at 2:00 p.m., he confirmed that the facilty does not have a policy and/or a procedure related to the issuing of notices of Medicare non-coverage to beneficiaries or their representatives. He stated that currently the rehab department is issuing the actual notice based on when therapy is being discontinued. He also confirmed that they do not currently send notices out via certified or registered mail and that they do not currently phone the representative to discuss the denials.",2020-09-01
415,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2018-09-13,640,D,0,1,FP3S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview facilty #2 failed to submit one resident, (R) R#506 minimum data assessment (MDS) timely. The sample size was 55. Findings include: Record review revealed resident (R)#506 was admitted [DATE]. However, R#506 residents minimum data assessments (MDS) could not be located in the computer. On 09/13/18 at 9:05 a.m. in an interview with Registered Nurse Minimum Data Assessment Care Plan Coordinator (RN MDS) (RN BB) reported that there was a glitch in the system before (MONTH) and that the facilty had corrected the error. However, we went back through the batch last night 9/12/18 and checked the assessments and it had not been submitted and that we thought it had been accepted but it had not. Interview on 9/12/18 at 9:15 a.m. with Registered Nurse Minimum Data Assessment resident assessment certified (MDS RAC-CT) AA revealed that after they had such a fiasco related to assessments early in the summer they have been proactive and put in personal insurance plan (PIP) in (MONTH) and all the resident assessments had been transmitted and accepted and that they transmit weekly. RN AA also revealed that she gets a print out that the assessments have been accepted. RN AA Reported that RN BB came to her and stated she transmitted R#506 assessment last night and it was accepted and it should have been caught in August. Review of the Centers for Medicare and Medicaid Services (CMS) Submission Report MDS 3.0 NH Final Validation Report dated 9/12/18 revealed that R#506 target date of 6/22/18, with a Submission Date 9/12/18. Record submitted late: The submission date is more than 14 days after on this new comprehensive assessment.",2020-09-01
416,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2018-09-13,655,D,0,1,FP3S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review and interviews facility #2 failed to ensure that each resident and/or resident representative was provided a copy of the Baseline Care Plan for four (4) residents; Residents (R#) R#155 and R#80 , R#4 and R#503 out of a sample of 55 residents. This Baseline Care Plan includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The facility census was 151 . Findings include: R#155 was admitted to the facility on [DATE]. She had multiple debilitating [DIAGNOSES REDACTED]. Upon review of R#155's medical record it was revealed that no documentation existed indicating that a copy of the Baseline Care Plan was given to the resident or her family representative. R#80 was admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. Upon review of R#80 medical record it was revealed that no documentation existed indicating that a copy of the Baseline Care Plan was given to the resident or her family representative. During an interview with the Director of Nursing (DON) on 9/12/18 at 8:53 a.m., she stated that she was unaware if the resident or their family representative received a copy of the Baseline or Comprehensive Care Plan. During an interview with the Minimum Data Set (MDS) Coordinator, RN BB on 9/12/18 at 9:05 a.m. she stated that she was unaware of this regulation and that no resident in the building or their representative had been provided a copy of their Baseline Care Plan. During an interview with the MDS Coordinator RN AA on 9/12/18 at 9:18 a.m. she stated that neither the residents or their family representative receives a copy of the Baseline Care Plan unless they request one. The following review of the Policies and Procedures for care planning revealed that the policy entitled: Care Plans - Baseline, Number 4 stated, The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a) The initial goals of the resident, b) A summary of the resident's medications and dietary instructions; c) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d) Any updated information based on the details of the comprehensive care plan, as necessary. 2. Resident (R) #508 [DIAGNOSES REDACTED]. In an interview on 9/12/18 at 12:02 p.m. with R#503's husband he stated that as far as he knew he had not received anything in writing related to the plan of care for his wife. Interview on 9/12/18 at 9:18 a.m. with Registered Nurse (RN) AA who revealed that we do not send or give a copy of the base line care plan unless the family or resident request it. Also reported that they mail a care plan out quarterly to those residents who do not come to care plan but they have no record of doing that. Review of the Policies and Procedures for care planning revealed that the policy entitled: Care Plans - Baseline, Number 4 stated, The resident and their representative will be provided a summary of the baseline care plan that includes but is not limited to: a) The initial goals of the resident, b) A summary of the resident's medications and dietary instructions; c) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility; and d) Any updated information based on the details of the comprehensive care plan, as necessary.",2020-09-01
417,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2018-09-13,657,D,0,1,FP3S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview facility #2 failed to involve one resident R#69 in attending or developing their plan of care. The sample size was 55. The census was 151. Findings include: Resident (R) #69 was admitted on [DATE] with a Quarterly Minimum Data Assessment (MDS) cognitive score on 6/28/18 of 12. In an interview on 09/11/18 at 9:26 a.m. with R69,reported that they had never gone or been invited to a care plan meeting. On 9/12/18 at 4:45 p.m. an interview with the Registered Nurse RN /Care Plan Coordinators stated that residents are sent a schedule of when care plan is going to be held. Stated that the residents that reside in the facility are given verbal information of when the care plan meeting will be held but she does not keep a record of who is or who is not coming or who refused to come. Continued interview revealed that they have a care plan conference sheet that the family or the resident will sign when they come. At this time, review of the care plan conference sheet for Resident # 69 revealed care plan conferences had been held on 3/22/18 and 6/28/18 and revealed no signatures of the resident or family member that they attended. The care plan coordinators revealed there was not any documentation to confirm that R#69 had been invited to the care plan meetings. Review of the facility Care Plan Conference sheet for R#69 dates of 3/22/18 and 6/28/18 revealed that R#69 or a family member had not signed that they had attended any care plan meeting.",2020-09-01
418,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2018-09-13,758,D,0,1,FP3S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, facility #2 failed to ensure that [MEDICAL CONDITION] medications were not ordered as needed (PRN) for more than fourteen (14) days unless clinically indicated for one resident (R) #503. The sample size was 55. Findings include: Review of Resident #503 physician orders [REDACTED]. R#503 received doses in (MONTH) (YEAR) on; 8/24/18 at 6:57 p.m. 8/25/18 at 7:08 p.m. 8/26/18 at 7:41 p.m. 8/29/18 at 10:10 p.m. 8/30/18 at 1:48 p.m. and on 8/31/18 at 7:13 p.m. and 11:35 p.m. and in (MONTH) (YEAR) on; 9/1/18 at 6:49 p.m. 9/4/18 at 7:37 p.m. and 9/5/18 at 6:57 p.m. Resident # 503 received 10 doses of as needed (PRN) [MEDICATION NAME] from 8/24/18 through 9/5/18. On 9/12/18 12:04 p.m. an interview with Licensed Practical Nurse (LPN) DD, reported that Resident # 503's husband comes everyday and that he didn't like the way the [MEDICATION NAME] was making his wife be all drowsy so it was discontinued. On 9/12/18 at 5:09 p.m. in an interview with the Director of Nurses (DON) and observation of Resident # 503 Medication Administration Record [REDACTED]. In continued interview the DON reported that we have a wellness team that meets and discusses PRN [MEDICAL CONDITION] medications and if the resident is still in need we get the team to assess and we reevaluate. If the medication is not needed then the order is discontinued. Review of the MAR indicated [REDACTED]. On 9/13/18 8:37 a.m. an interview with the DON revealed that there was an order written [REDACTED]. The DON stated that they have a new person in medical records and the person that had been there for [AGE] years just retired and the new person is in orientation and we have not gone to pick up the folder at the doctor's office since last Friday. The DON confirmed that the new order also did not have a 14 day stop for the [MEDICAL CONDITION] medication.",2020-09-01
419,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2019-09-20,580,J,1,0,5G2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and Responsible Party and Physician interviews Facility #2 failed to notify the attending Physician and Responsible Party of newly developed pressure ulcer for one of 12 residents (R#1) reviewed for pressure ulcers. On (MONTH) 17, 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 and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: Record review revealed that Resident #1(R#1) was readmitted to Facility #2 on 2/26/18 with [DIAGNOSES REDACTED]. The resident's brother is the Resident's Responsible Party. Review of the Body Check documentation, which was completed by the Certified Nurse Aide's (CNA's) from 5/1/19 through 6/15/19 revealed that on 6/1/19 an entry documented that R#1 had abnormal body check for the sacrum area. The CNA documented that this finding was reported to a License Practical Nurse (LPN). On 6/19/19 a photo of the sacral wound was obtained. The narrative describes the wound tissue type/color as slough and pink. The measurement was 3.5 centimeters (cm) x 1.2 cm and depth unknown. Review of the Nurses' Notes from 6/1/19 through 6/30/19 revealed an entry on 6/24/19 noted that the Physician and family will be notified. An entry dated 6/25/19 documented family was not contacted but a message was left for a non-family member which further investigation revealed was an assisted living facility where R#1 previously resided. Review of the inpatient hospital records dated 7/16/19 revealed a family member was contacted for consent for the diverting [MEDICAL CONDITION] surgery. This was the only documentation that indicated a family member was notified of R#1 sacral wounds. During an interview on 9/10/19 at 2:27 p.m. with Physician HH (R#1's Attending Physician and Medical Director) revealed that any staff concerns about the residents, the staff are s to notify him. Physician HH stated that at one time he received monthly wound reports; however, now he receives sporadic wound reports from the facility. Physician HH revealed that the first time he became aware of the pressure ulcer on R#1's sacrum, was on 6/24/19 when he received a fax. During an interview on 9/26/19 at 5:46 p.m. with the Responsible Party for R#1 revealed that he received a call from the hospital on [DATE] requesting consent for R#1 to have surgery and he was told about R#1's sacral wound at that time. The Family Member confirmed that he had no prior knowledge that R#1 had a pressure ulcer to her sacrum.",2020-09-01
420,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2019-09-20,641,D,1,0,5G2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, Facility #2 failed to accurately assess and code the Minimum Data Set (MDS) assessments for three of 12 residents (R) (R#1, R#4 and R#6) that were reviewed for pressure ulcers. Findings include: 1. Record review revealed that R#1 was readmitted to Facility #2 on 2/26/18 with [DIAGNOSES REDACTED]. Record review revealed that R#1 was sent to an acute care hospital on [DATE] and returned to the facility on [DATE]. Review of the 7/30/19 hospital Discharge Summary revealed that R#1 had a sacral decubitus with [DIAGNOSES REDACTED]. However, the facility failed to code the pressure ulcer as an unhealed pressure ulcer in Section M0210: Unhealed Pressure Ulcers/Injury on the 8/19/19 Significant Change MDS Section M1200: Skin and Ulcer/Injury Treatments. The facility also failed to code the resident as having a Stage 4 pressure ulcer in Section M0300 which asks for the following information: Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage in the 8/19/19 MDS assessment. During an interview on 9/6/19 at 2:39 p.m. with Licensed (LPN) NN MDS Coordinator revealed that when R#1 returned from the hospital on [DATE], and it was discussed during the morning meeting to classify the sacral pressure ulcer as a surgical wound. 2. Review of the (MONTH) 2019 Treatment Administration Record for R#4 revealed staff were providing daily wound care to the resident's surgical wound on the left stump. However, the surgical wound care was not coded in the Section M1200: Skin and Ulcer/Injury Treatments on the 8/22/19 Quarterly MDS. Further review of the 8/22/19 Quarterly MDS revealed the facility incorrectly coded the resident as having four unstageable pressure ulcers in Section M0300 (Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage.) Record review revealed that R#4 only had one Stage 2 pressure ulcer which was on his sacrum. During an interview on 9/10/19 at 12:26 p.m. with LPN NN MDS Coordinator revealed that the Dietary Manager, Social Services, Registered Dietitian Nutritionist (RDN)/Licensed Dietitian Nutritionist (LDN) and Activities Director completes each section of the MDS assessment and that the information for wounds came from LPN FF Treatment Nurse's documentation. 3. Review of the 8/18/19 through 8/24/19 Wound Report for R#6 revealed the resident had a Stage 2 pressure ulcer to the left buttock and a Stage 2 pressure ulcer to the left heel. However, only one Stage 2 pressure ulcer was coded on the 8/23/19 Quarterly MDS Section M0300: (Current Number of Unhealed Pressure Ulcers/Injuries at Each Stage). During an interview on 9/10/19 at 12:26 p.m. LPN NN MDS Coordinator revealed that care plans are done on admission, and updated within 14 days after an admission, quarterly, and as needed.",2020-09-01
421,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2019-09-20,657,J,1,0,5G2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews, Facility #2 failed to revise and individualize care plans to reflect the current stage of actual pressure ulcers and the facility failed to evaluate care planned interventions to ensure interventions were effective for six of 12 residents (R#1, R#2, R#4, R#5, R#6, R#10) reviewed for pressure ulcers. On (MONTH) 17, 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 and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: 1. Record review revealed R#1 had the following [DIAGNOSES REDACTED]. The skin care plan dated 8/16/19 revealed that R#1 had potential for impairment of skin integrity related to environmental factors, internal factors and disease process. A pressure ulcer is present on the sacrum. The Approach listed administer pain medication before treatment as need; assess skin daily and note any changes; treat as ordered; monitor medication effect; monitor use of skin protective device; develop and monitor turning schedule; monitor vital signs as needed; keep clean and dry; measure area; change dressing; instruct on the importance of good skin care; monitor diet intake and ensure adequate hydration; treatment as ordered. There is no evidence of any documentation that the resident's actual Stage IV pressure ulcer had been addressed. Further review revealed that the care plan interventions were not specific for R#1 and there was not any evidence of documentation that the care plan interventions were evaluated for effectiveness. 2. Record review revealed that Resident #2 had the following [DIAGNOSES REDACTED]. Record review revealed that even though wound documentation dated 8/27/18 documented that R#2 had a Stage II and on 9/25/18 and documented that this pressure ulcer had progressed to a Stage III pressure ulcer. Review of the skin impairment integrity care plan dated 4/23/19 does not reflect the actual Stage III pressure ulcer. The interventions listed were treat as ordered; monitor use of skin protective devices; bandage as appropriate; keep clean and dry; change dressing; and instruct on the importance of good skin care. turn every two hours. Further review revealed that the care plan interventions were not specific for R#2 and there was not any evidence of documentation that the care plan interventions were evaluated for their effectiveness. 3. Record review revealed that R#4 had the following [DIAGNOSES REDACTED]. During an observation on 9/6/19 at 8:45 a.m., Observed that R#4 has a left AKA surgical amputation that has an opening on edge of the inner portion along the surgical scar. A sequential observation on 9/10/19 at 11:25 a.m. observed with Licensued (LPN) FF treatment nurse that R#4 had three small open areas (three small Stage II presure ulcers) to the sacrum. Review of the care plan dated 8/30/19 revealed impaired skin related to environmental factors and internal factors. R#4 has a surgical stump wound and pressure ulcer present on his sacrum without mention of the three small openings on R#4's sacrum. The Approach noted is administer pain medication before treatment; treat as ordered; monitor medication effect; monitor use of skin protective devices; bandage as appropriate; develop and monitor turning schedule; keep clean and dry; measure area and change dressings. Further review revealed that the care plan interventions were not specific for R#4 and there was not any evidence of documentation that the care plan interventions were evaluated for effectiveness or that the care plan had been revised to relect the three Stage II pressure ulcers on the residents sacrum. During an interview on 9/10/19 at 12:26 p.m. with LPN NN Minimum Data Set (MDS) Coordinator regarding R#4's pressure ulcer not being stage on the care plan was because it was an oversight. 4. Record review revealed R#5 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Pressure Wound report revealed that R#5 developed a Stage IV pressure ulcer on 10/10/18 review of the care plan for R#5 dated 9/5/19 revealed R#5 has impairment related to environmental factors and internal factors. A pressure ulcer to the sacrum was listed. The Approach noted are treat as ordered; monitor use of skin protective devices; bandages as appropriated; keep clean and dry; change dressing; instruct on the importance of good skin care. Further review revealed that the care plan revealed that the interventions were not specific for R#5 and there was not any evidence of documentation that the care plan interventions were evaluated for their effectiveness and the care plan was not revised to reflect the pressure ulcer stage and measurements. During an interview on 9/10/19 at 12:26 p.m. LPN NN MDS Coordinator revealed that the stage of R#5's pressure ulcer was not listed on the care plan because it was an oversight. 5. Record review revealed R#6 had [DIAGNOSES REDACTED]. During an observation on 9/6/19 at 9:29 a.m. LPN FF Treatment Nurse and Registered Nurse (RN TT) it was observed that R#6's left fourth toe had black eschar on the bottom. Record review that there was not any evidence of documentation that this pressure ulcer had previously been addressed). There was brownish-black eschar to the outer left heel, surrounded by a pinkish skin tone. LPN FF Treatment Nurse obtained wound measurement which were: Length (L) 8.5 centimeters (cm) x Width (W) 3.5 cm x Depth (D) unknown. LPN FF Treatment Nurse stated that the wound on the resident's heel had resolved; however, it had reopened. Review of the skin integrity care plan dated 8/23/19 A pressure ulcer is present left heel. The care plan Approach listed treat as ordered; monitor use of skin protective devices; bandages as appropriate; keep clean and dry, change dressing. Instruct on the importance of good skin care. Further review revealed that the care plan interventions were not specific for R#6 and there was not any evidence of documentation that the care plan interventions were evaluated for their effectiveness and that the care plan was not revised to reflect the re-opened pressure ulcer on the residents heal or the stage of the pressure ulcer on the resident's toe. During an interview on 9/10/19 at 12:26 p.m. LPN NN MDS Coordinator revealed that the stage of R#6's pressure ulcers were not staged on the care plan because that was an oversight. 6. Record review revealed that R#10 was admitted to the facility with [DIAGNOSES REDACTED]. During a wound care observation on 9/18/19 at 12:22 p.m. with LPN FF Treatment Nurse revealed that R#10 had a stage IV sacral wound. The measurements were L 2.0 cm x 1.6 cm x 2.2 cm. Review of the care plan dated 8/19/19 revealed R#10 has impairment of skin related to environment factors and internal factors. A pressure ulcer is listed as present on the sacrum. The Approach (Interventions) were noted to treat as ordered; monitor use of skin protective devices; bandage as appropriate; keep clean and dry; change dressing; and instruct on the importance of good skin care. Further review revealed that the care plan interventions were not specific for R#10 and there was not any evidence of documentation that the care plan interventions were evaluated for their effectiveness and the care plan was not revised to reflect the Stage IV pressure ulcer on the residents sacrum. During an interview on 9/10/19 at 12:26 p.m. with LPN NN MDS Coordinator revealed that care plans are done on admission, are updated within 14 days, quarterly and as needed and that the stage of R#10's pressure ulcer was not listed on the care plan because it was an oversight. Further interview with LPN NN MDS Coordinator revealed that the interventions for each of the resident's care plans are generic interventions.",2020-09-01
422,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2019-09-20,658,J,1,0,5G2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews, record review, and review of the Georgia Nurse Practice Act, Facility #2 failed to ensure that accepted standards of clinical practice were followed to ensure that a newly recognized pressure ulcer received follow up care and ensure that treatment was provided timely for one of 12 (R#1) residents reviewed for pressure ulcers. On (MONTH) 17, 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 and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: Review of the Rules and Regulations of the State of Georgia, Rule 410-10-.01 Standards of Practice for Registered Professional Nurse addressed Rule 410-10-.01 (1) The Georgia Board of Nursing defines the minimal standards of acceptable and prevailing nursing practice as including, but not limited to the following enumerated standards of competent practice. (2) The Board recognizes that assessment, nursing diagnosis, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The Standards of Practice for Registered Professional Nurses delineate the quality of nursing care which a patient/client should receive regardless of whether it is provided solely by a registered nurse in collaboration with other licensed or unlicensed personnel. The Standards are based on the premise that the registered nurse is responsible for and accountable to the patient/client for the quality of nursing care rendered. The Standards of Practice for Registered Professional Nurses shall establish a baseline for quality nursing care; be derived from the Georgia Nurse Practice Act; apply to the registered nurse [MEDICATION NAME] in any setting; and, govern the practice of the licensee at all levels of competency. (a) Standards related to the registered nurse's responsibility to apply the nursing process (adapted from American Nurses Association Code for Nurses and Standards of Practice). The registered nurse shall: 1. Assess the patient/client in a systematic, organized manner; 2. Formulate a nursing [DIAGNOSES REDACTED]. systematic and continuous manner); 3. Plan care which includes goals and prioritized nursing approaches, or measures derived from the nursing diagnoses; 4. Implement strategies to provide for patient/client participation in health promotion, maintenance and restoration; 5. Initiate nursing actions to assist the patient/client to maximize her/his health capabilities; 6. Evaluate with the patient/client the status of goal achievement as a basis for reassessment, reordering of priorities, new goal-setting and revision of the plan of nursing care; 7. Seek educational resources and create learning experiences to enhance and maintain current knowledge and skills appropriate to her/his area of practice. (b) Standards related to the registered nurse's responsibilities as a member of the nursing profession. The registered nurse shall: 3. Communicate, collaborate and function with other members of the health team to provide optimum care. 410-10-.03 Definition of Unprofessional Conduct (1) Nursing conduct failing to meet standards of acceptable and prevailing nursing practice, which could jeopardize the health, safety, and welfare of the public, shall constitute unprofessional conduct. This conduct shall include, but not be limited to, the following: (2) Practice (a) Using inappropriate or unsafe judgement, technical skill, or interpersonal behaviors in providing nursing care; (3) Documentation (a) Failing to maintain a patient record that accurately reflects the nursing assessment, care, treatment, and other nursing services provided to the patient. Review of the undated Standards of Performance Clinical Coordinator - PPNH (Pelham Parkway Nursing Home - effective for Facility #1 and Faciltiy #2) documents that this position requires the following: skill the ability to establish and maintain effective working relation and administrative and medical personnel, employees, the public and other agencies. Must be able to multi-task and meet deadlines and be organized and dependable to monitor and follow through on due dates. Must be highly accountable. Review of the undated Standards of Performance Registered Nurse (PPNH) effective for Facility #1 and Facility #2 revealed the position require the following: skill must possess leadership and supervisory skills and be able to plan, organize, develop, implement and interpret the programs, goals, objectives, policies and procedures that are necessary to providing high quality care. Long Term Care Nurse Core Demonstrate effective clinical skills and utilize the nursing process in planning or providing care for residents of all ages. Review of the 7-3 Assignment Sheet, for Facility #2, dated 6/1/19 through 6/2/19 revealed that Registed Nurse (RN) PP was listed as the RN weekend supervisor and the on call nurse). Review of the Body Check documentation which is completed by the Certified Nurse Aide (CNA) staff dated 5/1/19 through 6/15/19 revealed that on 6/1/19 an entry was documented that R#1 had an abnormal body check for her sacrum. The CNA documented that this finding was reported to a License Practical Nurse (LPN). Further investigation revealed that, due to staff shortage for that shift, that RN PP worked this date as a CNA and performed CNA duties. During an interview on 9/16/19 at 9:36 a.m. with Registered Nurse (RN) PP revealed that on 6/1/19 she worked as a Certified Nursing Assistant (CNA) that day and that she was providing care for R#1, when she saw what looked like an intertriginous lesion, located in the crack of the resident buttocks midway up from the resident's rectum. RN PP described the area as missing skin and looked raw. RN PP stated that she reported this open area to LPN QQ. RN PP stated that normally, she would have informed the treatment nurse but that she could not recall for sure if she had informed the treatment nurse of the skin impairment but that she did tell Licensued Practical Nurse (LPN QQ). Continued interview with RN PP revealed that RN PP emphasized that she worked as a CNA that day, and that it was not her job that day to address the wound, but it was the responsibility of the nurse assigned to the resident to ensure that the opened area was followed up on. A subsequent interview on 9/19/19 at 3:04 p.m. with RN PP revealed that, in addition to working as a CNA, she was the RN supervisor for that weekend, and it was not her job to address the wound, because she had reported the findings to LPN QQ. A subsequent interview on 9/20/19 at 10:05 a.m. with RN PP revealed that the nurse on the hall, should have looked at the wound on R#1's sacrum, taken a picture of the wound, called the family and the doctor. RN PP stated that the Charge Nurse should have followed-up and made sure that this was done. RN PP stated again that she had worked as a CNA and that she reported the wound to the Charge Nurse assigned to that hall. During an interview on 9/20/19 at 10:07 a.m. with the Director of Nursing (DON) revealed that what should have happened, was once the wound was found, a photo should have been taken, the Physician and Family should have been informed, the wound protocol order or physician order [REDACTED].",2020-09-01
423,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2019-09-20,686,J,1,0,5G2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, review of the facility policies titled, No. 86 Subject: Pressure Ulcer Prevention and Treatment Program, NH 151 form 10/10 Nursing Home - Pressure Ulcer Prevention (BRADEN SCORE 18) and/or Wound Treatment Order - For Admission or Status Changes, and the facility policy titled, Integumentary Skin Photographic Documentation, POLICY NO. 1.0 titled, Infection Control Subject: Hand Hygiene, and review of the POLICY NUMBER; 10:01 titled, Subject: Infection Prevention and Control Program, Facility #2 failed to conduct head to toe skin assessments weekly as ordered by the Physician; failed to perform skin checks to identify breakdown timely; and failed to consistently assess the status of the developing sacral pressure ulcer until it was a Stage IV pressure ulcer which required two surgical debridements, a wound VAC (negative pressure wound treatment) and a [MEDICAL CONDITION] for one of 12 (R#1) residents reviewed for pressure ulcers. Facility#2 also failed to perform weekly assessments and failed to document weekly wound descriptions for three of 12 (R#2, R#3, R#4) residents reviewed for pressure ulcers. In addition, Facility #2 failed to ensure that one staff member implemented standard precautions when providing wound care for five of five (R#2, R#3, R#4, R#5, R#6) residents observed for wound care as evidenced by staff failing to wash and/or sanitize hands, and failing to clean scissors before and after use, failing to clean wounds using a clean technique by going from dirty area to clean area while providing wound care. Facility #1 failed to document weekly wound descriptions for two of 12 residents (R#11, R#12) reviewed for pressure ulcers. On (MONTH) 17, 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 and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: Review of a Policy No. 86 Subject: Pressure Ulcer Prevention and Treatment Program dated (MONTH) 1996 used by Facility #1 and Facility#2, in pertinent part documents: I. Purpose to standardize a system-wide protocol that identifies those patients at risk for breakdown and to provide guidelines to prevent pressure ulcer occurrence. III. Prevention [NAME] Procedure 1 documents that patients will be assessed according to each care setting for the risk of breakdown by using the Braden scale. These patients with a score less than or equal to 18 will be placed on the Pressure Ulcer Prevention Order (Pressure Ulcer Prevention Orders NS 660) Procedure 2. Maintain and improve tissue tolerance to pressure in order to prevent injury. a. All individual at risk should have a skin inspected every shift, paying particular attention to the bony prominences and areas under medical devices. Bariatric patients should have skin assessed between skin folds. IV. Treatment: 1. Consult the Wound Clinic for a Stage II or greater pressure ulcer. Review of an undated Nursing Home - Pressure Ulcer Prevention (BRADEN SCORE 18) and/or Wound Treatment Order - For Admission or Status Changes documents used for Facility #1 and Facility #2, in pertinent part: 1. Inspect skin for reddened areas and skin breakdown every shift and document changes. If wounds present continue with #17 - #20 18. Photograph wounds every seven days and per policy, mount in binder, document per protocol. 19. Measure wound every week, with change in status, and/or any readmission to facility. Review of the Adult Pressure Ulcer Prevention Orders documents the following, in pertinent part: 1. Assess skin on admission and each shift, 2. Minimize skin exposure to moisture due to incontinence and / or perspiration. 11. Turn and tilt patient every two hours while in bed, wheelchair, or chair bound patients should change position every hour. 15. Photograph wound every seven days and per policy. 17. For complex wound consult Wound Management to evaluate and manage patient's wounds. 1. Resident #1 was readmitted to Facility #2 on 2/26/18 with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed the following: R#1 had a Brief Interview for Mental Status (BIMS) score of 14 indicating that she was cognitively intact, she required extensive assistance for bed mobility, was totally dependent on staff for transfers, G0400 documents that the resident did not have any functional limitation of her upper extremities but that she had limitation with one side of her lower extremities, in section M0150 the resident was assessed to be at risk for developing pressure ulcers. Review of the Quarterly MDS dated [DATE] documented that R#1 had a BIMs score of 14 indicating that she was cognitively intact, required extensive assistance for bed mobility, totally dependent on staff for transfers, G0400 documented that the resident had functional limitation of bilateral upper and lower extremities. Record review revealed a Physician order [REDACTED].#1 to receive weekly head to toe assessments on Saturday mornings and a Physician order [REDACTED]. Review of a Braden scale (a tool used to assess a resident's risk of developing a pressure ulcer) dated 5/8/19 documented a score of 15 (a score less than 16 is considered to be at risk for pressure ulcers). Review of the Body Checks (which is documentation that the Certified Nursing Assistants (CNA's) complete when they provide incontinent care and/or baths) 5/1/19 through 6/15/19 revealed that on 6/1/19 an entry was documented that R#1 had an abnormal body check for her sacrum area. The CNA documented that this finding was reported to License Practical Nurse (LPN) QQ. Further record review revealed that there was not any evidence of any documentation that LPN QQ followed up on the open area on R#1's sacrum. Further review revealed that the CNA who documented the open area to R#1's sacral area was actually a Registered Nurse (RN) that was working as a CNA and was also working, on that date, as the RN Weekend Supervisor. Review of the Treatment Administration Record (TAR) from 5/1/19 through 9/4/19 revealed that the first treatment orders written to provide wound care to the opened area on R#1's sacrum was dated 6/10/19 and documented: Remove dressing from sacral, clean with sal jet, pat dry. Apply Allevyn three times a week. Monday, Wednesday and Friday morning and as needed. This treatment was continued from 6/10/19 until 6/28/19 by the Treatment Nurse. The first wound description of the opened area on R#1's sacrum was not documented until 18 days later on 6/19/19 when a photo of the sacral wound was obtained and documented the following: Location: Sacrum-Lower Spine, Wound Tissue Type/Color: Slough pink, Surrounding Tissue: normal, Healing Progress: Worse. The area of the wound was documented to be: Length: 3.5 centimeters (cm) x width 1.2 cm, with the depth documented as being: Unknown. Review of the weekly Pressure Wounds report (a report used to document pressure ulcers in the facility) for the following dates: 6/9/19 through 6/15/19, and 6/16/19 through 6/22/19 revealed that R1#'s sacral wound was not documented on the Pressure Wound report. On the report dated 6/23/19 through 6/29/19 documented, in error, that the wound to R#1's sacrum was a facility acquired pressure ulcer that developed on 6/14/19 that had worsened and was unstageable. Documentation on the 6/1/19 Body Check documented an open area on 6/1/19. Review of a Resident Care Fax dated 6/24/19 revealed that LPN FF Treatment Nurse faxed Physician HH regarding R#1's sacral pressure ulcer. The fax documented the following: Resident had an intertriginous lesion ([MEDICAL CONDITION] condition of skin folds) on her sacral that has become worse and is now an unstageable wound secondary to slough in wound. I am going to consult PT (Physical Therapy) for possible debridement of slough. If you would like something different please let me know. I will also send picture to wound care for their guidance (sic). Further review revealed that Physician HH (R#1 Attending Physician and Medical Director) responded on 6/27/19 via fax and wrote orders to obtain a wound care consult for R#1. LPN FF Treatment Nurse also sent an email on 6/24/19 to the wound care clinic stating that R#1 had an intertriginous lesion that had turned into an unstageable wound. LPN FF Treatment Nurse asked if they (the wound care clinic) had any suggestions. The wound care clinic responded the same day (6/24/19) with instructions for Facility #2 to start quarter strength Dakin's wet to dry dressing daily. However, further record review revealed that the order for quarter strength Dakin's wet to dry dressing daily was not implemented until 7/1/19 which was seven days later. Review of the Wound Care Clinic Progress notes dated 7/12/19, revealed R#1 went to the scheduled appointment to the wound care clinic as ordered by the Physician. In the Progress Note Details revealed the following documentation: Resident presents with an unstageable pressure ulcer at the sacrum. Documentation under the History of Present Illness revealed the following: that the wound location was on the sacrum with a duration documented to be since (MONTH) 2019. And that it (the resident's pressure ulcer to her sacrum) appears as though they (the facility) have been covering the wound with a foam dressing. The sacral wound measurements obtained by the wound care clinic on 7/12/19 were Length: 11.5 cm x Width: 4 cm x Depth: 2 cm. Further review revealed that the entire wound was malodorous (very unpleasant smell). The wound care clinic recommendation was to cleanse the wound with normal saline, apply skin barrier film to the intact skin surrounding the wound, wet to dry dressings using half strength Dakin's moistened gauze followed by dry gauze, a thick absorbent pad, and [MEDICATION NAME] tape. And to change the dressing daily and as needed for soilage. Continued review of the 7/12/19 Progress note from the Wound Clinic, the patient (R#1) was noted to be [MEDICAL CONDITION] with a heart rate of 118 beats per minute and with a mildly elevated temperature at 99.5 degrees Fahrenheit. The Physical Exam documents: Sacrum with unstageable pressure ulcer. The actual wound entrance is relatively small but there is a fair amount of undermining. The entire wound walls and base is dark and necrotic. I am unable to tap bone today but there is likely only a few mm (millimeters) of tissue covering. The wound's periphery is maroonish in color with sloughy patches and beginning to breakdown, indicating the injury is deep and the wound will likely be much larger as it fully declines. The entire wound is malodorous. The following Physician orders [REDACTED]. Diet: Increase Protein Intake. General Note: Wound is entirely necrotic and malodorous. Will initiate Dakin's for now to see if we can get some of the necrosis cleaned up and for odor management. Review of a Physician order [REDACTED].#1) to an acute care hospital for evaluation. Review of the emergency room record dated 7/15/19 at 12:49 a.m. documents that the Final Primary [DIAGNOSES REDACTED].#1 [MEDICAL CONDITION] secondary to infected sacral decubitus with and additional [DIAGNOSES REDACTED]. Review of a photograph of R#1's sacral pressure ulcer dated 7/15/19 at 1:50 p.m. documents that R#1's pressure ulcer measured the following: Length (L): 20 cm x Width (W): 8 cm x Depth (D): 6.7 cm. Review of an inpatient lab report documents that a wound culture of R#1's sacrum on 7/15/19 with the results documented to be a moderate amount of gram-negative rods, a moderate amount positive cocci, and a few gram-positive rods. The report documented that the bacteria was susceptible to meropenem (an antibiotic). Wound Consultation dated 7/17/19, documents that R#1 underwent debridement of her sacral wound and had placement of a diverting loop [MEDICAL CONDITION]. On 7/18/19 a wound VAC (a negative pressure wound treatment) was placed. Wound culture from the sacral wound grew Pseudomonas aeruginosa and an anerobic culture grew Prevotella. Infectious disease was consulted for assistance with antibiotics. She (R#1) is currently on IV (intravenous) Meropenem (antibiotic). Review of an Infectious Disease Consultant Note dated 7/22/19 documents: Upon presentation, it is noted that the sacral wound had surrounding eschar and a foul smell. She (R#1) was also febrile and had an altered mental status. Review of an Inpatient Wound Progress Note dated 7/30/19 documents the following, in pertinent part: R#1 is a [AGE] year-old female who was sent from the nursing home due to a fever and AMS (altered mental status). She (R#1) was noted to have a foul-smelling sacral ulcer, urinary tract infection, [MEDICAL CONDITION] and leukocytosis and was admitted [MEDICAL CONDITION]. Patient is now s/p (status [REDACTED]. The Physician has asked for wound vac therapy which was started on 7/19/19. Patient is status [REDACTED]. Patient was seen 7/12/19 (in the Wound Clinic) and the wound significantly worsened over the weekend prior to admission (to the acute care hospital). During a wound observation on 9/6/19 at 10:26 a.m. with Physical Therapist Assistant (PTA) EE who was assisted by Licensed Practical Nurse (LPN) FF treatment nurse revealed that the Stage IV pressure ulcer to R#1's sacrum had a pink wound bed with reddish granulation; and that the pressure ulcer measured 16 centimeters (cm) x 6.5 cm x 2.7 cm, there is tunneling at 7-9 o'clock that measured 5.5 cm and tunneling at 3-5 o'clock that measured 1.2 cm. Observation revealed that bone was exposed. During an interview on 9/6/19 at 11:34 a.m. with LPN FF Treatment Nurse revealed that on 6/19/19 she identified the wound on R#1's sacrum to be an unstageable pressure ulcer. However, review of the facility's Treatment Administration Record (TAR) with LPN FF Treatment Nurse revealed that a treatment order was documented on the TAR on 6/10/19. LPN FF Treatment Nurse initially indicated that she did not know who entered the order; however, on further review of the data history information LPN FF Treatment Nurse confirmed that, although she had not notified the Physician of the pressure ulcer until 6/24/19 she had entered a treatment order, for the pressure ulcer to R#1's sacrum, into the TAR on 6/10/19. LPN FF Treatment Nurse stated that the wound started out as an intertriginous lesion but that it got worse. LPN FF Treatment Nurse stated that on 6/24/19 that she sent a care fax to the Physician to let him know of the pressure ulcer and to request if PT (Physical Therapy) could do a wound debridement and she also sent an email to the Wound Care Clinic to ask for advice for the sacrum wound. LPN FF stated that she also implemented the Wound Protocol on 6/24/19. LPN FF continued and stated that the Physician sent instructions on 6/27/19 to send R#1 for a wound care consult. During an interview on 9/10/19 at 11:47 a.m. with Physician GG (Surgeon at the acute care hospital) revealed that R#1 was a nursing home resident with a large infected decubitus ulcer that extended into the buttock and toward the resident's hip then downward toward the resident's rectum. Physician GG stated that he conducted two surgical debridements on R#1's sacral wound. Physician GG stated the resident was incontinent of stool and that the resident had to have a diverting [MEDICAL CONDITION] to keep feces out of the residents sacral wound. Physician GG stated that they had to place a wound Vac on the resident's sacral wound after the [MEDICAL CONDITION] was placed. Physician GG stated that the sacral wound is not a surgical wound but remains a pressure ulcer. During an interview on 9/10/19 at 2:27 p.m. with Physician HH (R#1's Attending Physician and Medical Director) revealed that if staff have any concerns about residents, they are to notify him. Physician HH continued to state that he currently receives sporadic wound reports from the facility. Physician HH revealed that he first became aware of the wound on R#1's sacrum when he received a fax related to the wound and in the fax, the facility was requesting that R#1's wound be debrided. Physician HH explained that he did not want the facility to do a debridement because it was unknown what was under the resident's wound. Physician HH felt that it was in the best interest for R#1 to be seen by the Wound Care Clinic. During an interview on 9/11/19 at 3:01 p.m. with Nurse Practitioner (NP) II at the Wound Care Clinic revealed that R#1 was seen in the clinic on 7/12/19 and she had early signs of the anaerobic bacteria infection and that she initially thought the Dakin's solution would be sufficient. NP II stated that based on the hospital report that they (the Wound Care Clinic) received the anaerobic bacteria was the primary bacteria in the wound and this was caused from R#1 being incontinent of bowel. Subsequent interview on 9/12/19 at 3:30 p.m. with Physician GG revealed that the cause of the infection in the resident's sacral decubitus was most likely due to fecal contamination and that R#1 also had a urinary tract infection. Physician GG stated that if the resident had not had the infected Stage IV pressure ulcer that she would not have needed to have a [MEDICAL CONDITION] placed. Physician GG explained that when he saw R#1 her sacral wound was at an advanced state of decline and that the resident's Stage IV pressure ulcer would be difficult to heal without the diverting [MEDICAL CONDITION]. Physician GG further stated that early interventions for the wound would have helped the wound from declining to the extent that it did. During an interview on 9/16/19 at 9:36 a.m. with Registered Nurse (RN) PP revealed that on 6/1/19 she worked as a Certified Nursing Assistant (CNA) that day and that she was providing care for R#1, when she saw what looked like an intertriginous lesion, located in the crack of the resident buttocks midway up from the resident's rectum. RN PP described the area as missing skin and looked raw. RN PP stated that she reported this open area to LPN QQ. RN PP stated that normally, she would have informed the treatment nurse but that she could not recall for sure if she had informed the treatment nurse of the skin impairment but that she did tell LPN QQ. Continued interview with RN PP revealed that RN PP emphasized that she worked as a CNA that day, and that it was not her job that day to address the wound, but it was the responsibility of the nurse assigned to the resident to ensure that the opened area was followed up on. A subsequent interview on 9/19/19 at 3:04 p.m. with RN PP revealed that, in addition to working as a CNA, she was the RN supervisor for that weekend, and it was not her job to address the wound, because she had reported the findings to LPN QQ. A subsequent interview on 9/20/19 at 10:05 a.m. with RN PP revealed that the nurse on the hall, should have looked at the wound on R#1's sacrum, taken a picture of the wound, called the family and the doctor. RN PP stated that the Charge Nurse should have followed-up and made sure that this was done. RN PP stated again that she had worked as a CNA and that she reported the wound to the Charge Nurse assigned to that hall. During a phone interview on 9/16/19 at 9:55 a.m. LPN QQ revealed that she had resigned and Friday (9/13/19) had been her last day. When asked about R#1's sacral wound that RN PP observed on 6/1/19, LPN QQ revealed that RN PP had come to her and told her that R#1 had a small crack between her buttocks. LPN QQ stated that when she looked at the very top of the resident's tail bone that she didn't see anything that needed treatment. LPN QQ stated she did not inform the treatment nurse of the area because she did not see an open area. During an interview on 9/20/19 at 10:07 a.m. with the Director of Nursing (DON) revealed that what should have happened for R#1, was once the sacral wound was found, a photo should have been taken, the family and the Physician should have been notified, and that the Wound Protocol should have been implemented and treatment should have been started, and that the wound should have been reported to us (us defined as the Administrator and the DON). 2. Resident #2 was admitted to Facility #2 on 8/23/18 with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the following: R#2 had a Brief Interview for Mental Status (BIMS) score of 00 indicating that she was severely cognitively impaired, she required limited assistance for bed mobility, was totally dependent on staff for transfers, in section M0150 the resident was assessed to be at risk for developing pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk dated 5/23/19 revealed a score of 17 indicating at risk for pressure ulcers. Review of the Nurses Notes dated 8/23/18 revealed that on admission R#2 had a knot with discoloration to the left forehead, discoloration to inside of right leg/left lower leg. There was not any documentation that the resident had any opened skin areas. Review of the CNAs Body Check dated 8/23/18 through 9/30/18 revealed an entry dated 8/27/18 R#2 had an abnormal body check for sacrum. Review of the Weekly Skin Assessments revealed that there were Weekly Skin Assessments dated 9/22/18, 12/13/18, 8/1/19, and 9/5/19 (which documented a dressing to the sacral and a dark area noted to right foot); however, there was not any evidence of documentation that any other skin assessments had been completed for R#2. Review of the Wound Report from 8/24/18 through 9/4/19 revealed that R#2 was admitted on [DATE] without any skin impairments; however, on 8/27/18 the Wound Report there was a photo of the residents pressure ulcer and the following wound description information: Wound Type: Pressure Ulcer, Pressure ulcer has partial thickness loss of skin layers that presents as an abrasion or blister (Stage II), Location: Sacrum-Lower Spine, Wound Tissue Type/Color: pink, Surrounding Tissue: normal, Healing Progress: N/A (new area), Area: Wound measurements were documented to be L 9 cm x W 3 cm x D 0.1 cm. Review of the 9/12/18 Wound Report for R#2 documented the following wound description: Pressure Ulcer: unstageable - wound bed covered by slough and /or eschar, Location: Sacrum-Lower Spine, Wound Tissue Type/Color: Slough Granulation, Surrounding Tissue: normal, Healing Progress: improving, Wound measurements are documented to be: L 7.5 cm x W 7.6 cm x D 3.4 cm. Further record review revealed that from 9/12/18 until 9/25/18 there was not any wound documentation and/or wound photos for this pressure ulcer. On 9/25/18 there is a photo of the wound and a wound description that documents the pressure ulcer is now a Stage III. Wound description documents the following: Wound Type: Pressure Ulcer, Pressure Ulcer: has full thickness of skin lost exposing the Sub Q (subcutaneous: the third innermost layer of skin) tissues(presents as a deep crater (Stage III), Location: Sacrum-Lower Spine, Wound Tissue Type Color: Granulation reddened, Surrounding Tissue: epibole (rolled edges of wound) white, Healing Progress: Improving. Wound measurements are documented to be: L 5.6 cm x W 4 cm, D 2.4 cm, Drainage Type: Sero-Sanguineous, Drainage Amount: heavy. Record review revealed that even though the pressure ulcer had changed from a Stage II to a Stage III the documentation noted that the wound is improving. During a wound care observation on 9/5/19 at 1:36 p.m. with LPN FF Treatment Nurse and Registered Nurse (RN TT) who was assisting LPN FF Treatment Nurse, by holding and positioning the resident during wound care, the following observations were made: During the preparation of the wound supplies, without washing or sanitizing her hands LPN FF Treatment Nurse was observing taking scissors from the top of the uncleaned treatment cart and observed to the cut calcium alginate to be placed on the wound bed of R#2. LPN FF Treatment Nurse took a bundle of paper measuring tapes and removed two measuring tapes from the adhesive binder. LPN FF Treatment Nurse then placed the items needed for wound care on a blue disposable drape. LPN FF Treatment Nurse placed the scissors back on top of the unclean treatment cart and then LPN FF Treatment Nurse entered the resident's room. When LPN FF Treatment Nurse measured the wound bed, LPN FF Treatment Nurse placed the corner of the paper tape directly into the wound bed to obtain the depth. LPN FF measured the pressure ulcer which measured 2.0 cm x 0.8 cm x 0.3cm. However, LPN FF Treatment Nurse did not check the pressure ulcer for any tunneling or undermining. Further observation revealed that LPN FF Treatment Nurse did not wash or sanitize her hands while proving wound care until after she had completed the wound care for R#2 and then after wound care she was observed to use hand sanitizer that was on the wall in the resident's room. During an interview on 9/6/19 at 11:34 a.m., LPN FF treatment nurse revealed that resident developed the Stage 2 in the facility and that R#2 will remain in the same position without moving. During an interview on 9/6/19 at 12:42 p.m. LPN FF Treatment Nurse was asked to explain why the scissors were not cleaned before cutting the calcium alginate and LPN FF Treatment Nurse stated that the scissors were on top of the treatment cart, and that the scissors were left on top of the cart. LPN FF Treatment Nurse continued to state that she never took the scissors into the resident's room. LPN FF Treatment Nurse stated the scissors were to be cleaned before and after use. 3. Resident #3 was admitted to Facility #2 on 11/20/18 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the following: R#3 had a Brief Interview for Mental Status (BIMS) score of 5 indicating that he was severely cognitively impaired, he required total assistance for bed mobility, required extensive assistance for transfers, in section M0150 the resident was assessed to be at risk for developing pressure ulcers. Review of the Braden Scale for Predicting Pressure Sore Risk dated 6/12/19 and 7/19/19 revealed a score of 15 indicating R#3 is at risk for pressure ulcers. Review of the CNAs Body Check form dated 4/1/19 through 5/31/19 revealed that on 4/26/19 an abnormal body check for the sacrum and other being the left heel. There was no documentation to support that a follow-up to this finding was addressed until 5/20/19. Record review revealed that there was not any evidence of documentation of the left foot prior to 5/20/19. Review of the Wound Report dated 5/20/19 revealed the following wound description: Assessment Type: New Wound, Pressure Ulcer: Unstageable - Wound bed covered by slough and /or eschar, Pressure Ulcer: Has partial thickness loss of skin layers that presents as an abrasion or blister (Pressure Stage II) , Location Other Side Left foot, Location Left Heal, Location: left ankle-outer: Lateral Malleolus, Wound Tissue Type/color: Slough Necrotic Eschar, Wound Tissue Type/Cor: pink, Surrounding Tissue: reddened, Surrounding Tissue: normal, Healing Progress: N/A (new area), the flowing wound measurements for these wounds are documented: Left lateral foot: L 3.5 cm x W 3 cm x D Unknown, Area: Left heel: L 2 cm, x W 2.5 cm x D 0.1 cm. Review of the (MONTH) 2019 TAR (Treatment Administration Record) revealed treatment orders dated 5/20/19 to remove dressing form left lateral foot and left heel, clean with normal saline. Apply Allevyn AM (morning) and as needed three times a week. Monday, Wednesday and Friday indicating that there had not been any previous treatments provided for these areas. In addition, further record review revealed that the only evidence of any documentation of weekly skin assessments for R#3 were for the following dates: 6/26/19, 8/7/19, and 9/5/19. Other than these skin assessments there was not any evidence of documentation that R#3 had any other weekly skin assessments completed in the facility. During a wound care observation on 9/5/19 at 1:41 p.m. with LPN FF Treatment Nurse for R#3 revealed the following observations. LPN FF Treatment Nurse cleaned the resident's bedside table top and placed her clean supplies on a blue disposable drape on the bedside table. LPN FF Treatment Nurse put on gloves and removed the tape from the old dressing. Observation revealed that the resident's left lateral foot had an irregular circular shaped with black eschar with approximately 30% yellow slough present. Without washing or sanitizing her hands, LPN FF Treatment Nurse removed her gloves and donned a new set of gloves and then took a vial of normal saline and squirted the normal saline over the wound. The normal saline drained from the wound onto the gauze. Using the same gauze, LPN FF Treatment Nurse wiped the wound and was observed to go from dirty area to clean area, and from clean area to dirty area using the same gauze. During an interview on 9/10/19 at 3:52 p.m. with LPN NN MDS Coordinator revealed that the facility did not have any other skin assessments for R#3 as there had not been any other skin assessments completed for R#3. During an inte",2020-09-01
424,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2019-09-20,867,J,1,0,5G2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based record review, staff interviews, and review of the facility policy titled, Quality Assurance Performance Improvement, Facility #2 failed to have a Quality Assessment and Assurance (QAA) committee that effectively provided oversight and monitoring to ensure that staff were performing weekly skin assessments to ensure timely identification and treatment of [REDACTED].#2 failed to ensure that weekly photographs and weekly wound description documentation was being completed and failed to ensure that the Physician and Responsible Party were notified of pressure ulcers in a timely manner. Facility #1 failed to ensure weekly wound descriptions were being completed from 7/1/19 through 8/14/19. On (MONTH) 17, 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 and Director of Nursing for both Facility #1 and Facility #2, and the System Administrator were informed of the Immediate Jeopardy on (MONTH) 17, 2019 at 2:51 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on (MONTH) 1, 2019. The Immediate Jeopardy is outlined as follows: During the complaint investigation it was identified that R#1, which resided in Facility #2, was identified as having an open area to her sacrum on (MONTH) 1, 2019; however, treatment was not provided for this wound until (MONTH) 10, 2019. The Physician was not notified of the wound until (MONTH) 24, 2019. The Physician ordered for R#1 to have a wound consultation on (MONTH) 27, 2019. R#1 was seen at the Wound Clinic on (MONTH) 12, 2019, at which time it was observed that the wound was infected, and the resident's wound treatment was changed to Dakin's solution. On (MONTH) 15, 2019, R#1 was sent to the hospital and was admitted to the hospital. The resident's primary admitting [DIAGNOSES REDACTED]. R#1 had to have a central line placed to receive antibiotic treatment. In addition, on (MONTH) 17, 2019, R#1 had to undergo surgical debridement of the Stage IV pressure ulcer on her sacrum and the resident had to have surgery to have a diverting loop [MEDICAL CONDITION]. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. F580 -- S/S: J -- 483.10(g)(14)(i)-(iv)(15) -- Notify Of Changes (injury/decline/room, Etc.); F657 -- S/S: J -- 483.21(b)(2)(i)-(iii) -- Care Plan Timing And Revision; F658 -- S/S: J -- 483.21(b)(3)(i) -- Services Provided Meet Professional Standards; F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcer; F867 -- S/S: J -- 483.75(g)(2)(ii) -- Qapi/qaa Improvement Activities Additionally, Substandard Quality of Care was identified with the requirements at F686 -- S/S: J -- 483.25(b)(1)(i)(ii) -- Treatment/svcs To Prevent/heal Pressure Ulcers. At the time of exit on (MONTH) 20, 2019, an acceptable Immediate Jeopardy Removal Plan had not been accepted therefore the Immediate Jeopardy remains ongoing. Findings include: Review of the policy titled, SUBJECT: Quality Assurance Performance Improvement Effective Date 11/01/2017 documents the following: It is the policy of the facility to develop a QAPI plan in accordance with Federal Guidelines to describe how the facility will address clinical care, resident quality of life and residents' choice and is based on the scope and complexity of services defined by the Facility Assessment. Procedure 2. The plan describes the process for identifying and correcting quality deficiencies and contains the necessary components such as: a. tracking and measure performance: b. establishing goals and thresholds for performance measurement; c. Identifying and prioritizing quality deficiencies; d. Systematically analyzing underlying causes of systemic quality deficiencies; e. Developing and implementing corrective action or performance improvement activities; and f. Monitoring or evaluating the effectiveness of corrective action/performance improvement activities, and revising as needed. Review of the Facility Assessment Tool revealed the following documentation: Our QAPI plan addresses: Clinical Care, Quality of Life and Resident. Data Sources revealed that pressure ulcers and wounds data analysis frequency is weekly. The Staff meetings, occurrence reporting, QAPI Meeting is noted to include residents, families, staff, QAPI Committee. Facility #2 1. Review of Quality Assurance Performance Improvement (QAPI) for Facility #2 dated (MONTH) 31, 2019 revealed a QA meeting was held. In attendance were the RN QA/PI Coordinator, Clinical Coordinator, DON, ADON, RN Clinical Coordinator and CNA Nursing Services. The meeting was called to order (MONTH) 31, 2019 at 2:30 p.m. The RN Quality Assurance Coordinator, reported on the following QAPI measures, quality measures were looked back for the months of (MONTH) 2019 & (MONTH) 2019. In the minutes, pressure ulcers were discussed. After the discussion of all data submitted as a team, we decided we would develop three PIP's (Performance Improvement Plans) - Pain, UTI's and Pressure ulcers. These PIPs will be initiated during the month of (MONTH) and staff will be educated on current PIPs as they are developed. Further record review revealed that there was not any evidence of any documentation that these three PIP's were developed or rolled out to the facility Facility #2 did not ensure that weekly skin assessments were conducted for R#1, did not ensure thorough wound assessments was completed for R#1, did not ensure that the Physician was notified of the pressure ulcer to R#1's sacrum in a timely manner. Facility #2 failed to ensure that treatment for [REDACTED].#2 failed to revise and update R#1's care plan to reflect the actual pressure ulcer. In addition, Facility #2 did not ensure that daily Certified Nursing (CNA) Body Checks were completed, did not ensure that weekly skin assessments were completed, and failed to ensure that weekly wound assessments descriptive wound documentation was completed for (R#1, R#2, R#3, R#4). In addition, Facility #1 failed to ensure that weekly wound descriptive documentation was completed for R#11 and R#12. (Cross Refer to F580, F657, F658, F686) Facility #2 During an interview on 9/10/19 at 2:27 p.m. with Physician HH (Medical Director) revealed that he does attend the Quality Assurance (QA) meetings. When the meetings were held on Thursday he would attend. The facility cancelled some of the meetings without notifying him. He would arrive to the facility to be informed that the QA meeting was cancelled. He continued that if he cannot attend in person, he will participate via phone to communicate his input. Record review revealed that each facility has their own QA meetings. During an interview on 9/11/19 at 9:56 a.m. RN OO Infection Control/QA at Facility #2 revealed that the concerns that the facility currently has in QA are: Admission, H&P, Monthly charting, Weight audits, Care plans are still ongoing, and that wound care was not in QA and did not have a QAPI plan. During an interview on 9/20/19 at 10:10 a.m. the Administrator DD for Facility #2 revealed that he attended the QA meetings. And that wound care did not trigger for a QAPI. Facility #1 Review of a Pressure Ulcer P & I report for Facility #1 that was held on 8/14/19 with 45 residents in house. The facility completed head to toe assessments. And the facility found one new pressure ulcer was identified with no evidence of any documentation that anything was put in place to address that weekly wound descriptions were not being completed. During an interview with Director of Nursing (DON) BB on 9/9/19 at 3:00 p.m., she stated when she started work at Facility #1 in (MONTH) 2019 and she noticed a problem with the pressure ulcer documentation. She stated the previous treatment nurse was only taking pictures of the wounds with the measurements, but she was not completing weekly descriptive documentation.",2020-09-01
425,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2019-09-20,912,E,1,0,5G2B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews Facility #2 failed to ensure that three of four residents (R) (R#7, R#8 and R#9) who resided in a four-bed ward had a minimum of 80 square feet of living space per resident in the room. Findings include: During an observation on 9/6/19 at 8:45 a.m., four residents in room [ROOM NUMBER] were observed sharing a room with the beds in close proximity to each other. On 9/6/19 at 11:02 a.m., the Maintenance Director measured the room with a tape measure. The distance between Bed A mattress and Bed B mattress was 38 inches. The distance between Bed B footboard and the head of Bed C was 31 inches. The distance between Bed C mattress and Bed D mattress is 54 inches. The total room measurement was 22 feet 10 inches by 17 feet 4 inches. The storage closet was included in the measurement and was not subtracted from the living space per resident. During an interview with the Maintenance Director on 9/6/19 at 1:44 p.m., he stated the residents in that room did not have 80 square feet of living area per resident. During an interview with Administrator DD, for Facility #2 on 9/6/19 at 1:49 p.m., he stated that there was not a waiver and that room and the room had been like that since 1961. During an observation with the Administrator on 9/11/19 at 11:29 a.m., the Maintenance Director re-measured the room and obtained 17 feet 6 inches by 21 feet as the total room size. The measured living space for Bed A, for R#7, was 9 feet by 5 feet for a total of 45 square feet. However, the wall closet occupied 4.7 feet leaving R#7 with 40.3 square feet of living area. The measured living space for Bed B, for R#8, was 9 feet by 8 feet for a total of 72 square footage living area. The measured living space for Bed C was 12 feet 1 inch by 8 feet for a total of 96.8 square footage of living area. The measured living space for Bed D, for R#9, was 9 feet by 3.5 feet for a total of 27 square feet. However, the wall closet occupied 4.7 feet leaving R#9 with 22.3 square footage of living area.",2020-09-01
426,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2017-09-21,272,D,0,1,P90P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to accurately assess the presence of a nephrostomy tube for one resident (#183) from a total sample of 32 residents. Findings include: Unit 2: Resident #183 was admitted to the facility on [DATE]. An 8/18/17 nurse's note entry documented that the resident had a right nephrostomy with indwelling Foley catheter. An Admission Mimimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/29/17, was completed by facility staff. However, a review of this Admission MDS assessment, including the accompanying Care Area Assessments (CAA's), revealed that facility staff failed to accurately assess the presence of the resident's urinary appliance. During an interview on 9/20/17 at 2:40 p.m., MDS Coordinator HH confirmed that the presence of the urinary appliance was not accurately coded on the Admission MDS or included in the Urinary CA[NAME]",2020-09-01
427,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2017-09-21,279,D,0,1,P90P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to develop a care plan to address the dental status of one resident (#183) from a total sample of 32 residents. Findings include: Unit 2: Resident #183 was admitted to the facility on [DATE]. An Admission Mimimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/29/17, was completed by facility staff. The resident was assessed as having obvious or likely cavity or broken natural teeth on the assessment. The accompanying Dental Care Area Assessment (CAA) documented that the resident had obvious missing and broken teeth, but did not complain of mouth pain. The CAA Summary section was checked to include dental status in care planning. However a review of the care plan revealed that a care plan had not been developed to address the resident's dental status. During an interview on 9/20/17 at 2:40 p.m. with MDS Coordinator HH, they confirmed that a care plan had not been developed to address the resident's dental status.",2020-09-01
428,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2017-09-21,282,D,0,1,P90P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow the care plan for the wound care dressing change for one (1) resident, Resident (R) #32, out of 32 sample residents. Findings include: Unit 2: Review of the care plan for R#32 revealed care plan for impaired skin integrity was updated on 8/31/17. Under nurses, the intervention is treat as ordered, bandage as appropriate. During an observation of wound care on 9/20/17 at 9:30 a.m., Licensed Practical Nurse (LPN) AA failed to adequately prepare for the dressing change and did not have three (3) of the ordered wound care items available on the field. Wound care orders were as follows for right heel, cleanse with normal saline, apply no sting barrier, apply [MEDICATION NAME] and calcium alginate and wrap with [MEDICATION NAME] three times a week on Monday, Wednesday and Fridays and as needed. LPN AA did not have the [MEDICATION NAME], the calcium alginate and the [MEDICATION NAME] on the field. Observation of wound care on R#32 on 9/20/17 at 11:30 a.m. by LPN AA Wound Care Nurse with assistance of Registered Nurse (RN) BB. LPN AA removed dressing and disposed of properly. Hands were sanitized and nurse donned gloves, area on heel was measured and cleaned and photographed. Hands were sanitized and nurse donned gloves, nurse opened package of skin barrier and applied around wound, reached over and opened drawer on dressing cart. She reached inside and took out a packet of [MEDICATION NAME], opened the package and removed contents. She folded dressing and placed over wound and while holding in place with one hand, nurse opened dressing cart drawer again and took out 4 x 4s and placed over dressing, then opened drawer again and reached in and took out roll of [MEDICATION NAME] and wrapped foot. She then opened the drawer again and took out a pad of dressing strips and placed over [MEDICATION NAME] to hold [MEDICATION NAME] in place. Nurse removed gloves and sanitized hands. it was noted that nurse failed to place calcium alginate over wound during dressing change as ordered. Interview with LPN AA on 9/20/17 at 11:45 a.m. revealed she realized that she had not removed all the supplies from the dressing cart only after she started dressing change and had to open the cart and remove them. She stated she didn't realize that she had put her gloved hand in the drawer until she had finished the dressing change. LPN AA did not realize that she had missed putting calcium alginate on the wound as ordered. Interview with RN BB on 9/20/17 at 11:55 a.m. revealed that she was the nurse that taught LPN AA protocols for wound care and that she should not have reached back into the cart with dirty gloves to remove items. Discussed with RN BB that nurse failed to put calcium alginate on wound as ordered. She stated she would change the dressing and correct the error. Interview with Assistant Director of Nursing (ADON) on 9/20/17 at 1:20 p.m. revealed that her expectations of the wound care nurses are that they provide the care as ordered. When asked about training for wound care nurses and review of their training she stated that if the infections of wounds start to trend upward she will look at what is going on with the wound care, if a resident's wound is getting worse she will look to see what the issue is and they will discuss at weekly wound meetings. Discussed observation of wound care for resident. ADON stated that the wound care nurses are taught to get everything they need out ahead of time and organized so they don't have to stop and get something they forgot. She stated that going back into the drawer with a gloved hand that had been touching the skin or wound was not acceptable.",2020-09-01
429,MITCHELL COUNTY NURSING HOMES,115266,37 SOUTH ELLIS STREET,CAMILLA,GA,31730,2017-09-21,314,D,0,1,P90P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow orders for the wound care dressing change and failed to use infection control technique for one resident, Resident (R) #32, out of 32 sample residents. Findings include: Unit 2: Review of medical record for R#32 revealed wound care orders as, remove old bandage from heel, cleanse with normal saline, apply no sting barrier, apply Activoat and calcium alginate and wrap with [MEDICATION NAME] three times a week on Monday, Wednesday and Friday and as needed. During an observation of wound care on 9/20/17 at 9:30 a.m., Liscensed Practical Nurse (LPN) AA failed to adequately prepare for the dressing change and did not have three of the ordered wound care items available on the field. Wound care orders were as follows for right heel, cleanse with normal saline, apply sting barrier, apply [MEDICATION NAME] and calcium alginate and wrap with [MEDICATION NAME] three times a week on Monday, Wednesday and Fridays and as needed. LPN AA did not have the [MEDICATION NAME], the calcium alginate and the [MEDICATION NAME] on the field. Observation of wound care on R#32 on 9/20/17 at 11:30 a.m. by LPN AA Wound Care Nurse with assistance of Registered Nurse (RN) BB. LPN AA removed dressing and disposed of properly. Hands were sanitized and nurse donned gloves, area on heel was measured and cleaned and photographed. Hands were sanitized and nurse donned gloves, nurse opened package of skin barrier and applied around wound, reached over and opened drawer on dressing cart, reached inside and took out a packet of [MEDICATION NAME]. She then opened the package and removed contents, folded the dressing and placed over wound. While holding in place with one hand, nurse opened dressing cart drawer again and took out 4 x 4s and placed over dressing. She then opened dressing cart drawer again and reached in and took out roll of [MEDICATION NAME] and wrapped foot. She again opened the dressing cart drawer and took out a pad of dressing strips and placed over [MEDICATION NAME] to hold [MEDICATION NAME] in place. Nurse removed gloves and sanitized hands. it was noted that nurse failed to place calcium alginate over wound during dressing change as ordered. Interview with LPN AA on 9/20/17 at 11:45 a.m. revealed she realized that she had not removed all the supplies from the dressing cart only after she started dressing change and had to open the cart and remove them. She stated she didn't realize that she had put her goved hand in the drawer until she had finished the dressing change. LPN AA did not realize that she had missed putting calcium alginate on the wound as ordered. Interview with RN BB on 9/20/17 at 11:55 a.m. revealed that she was the nurse that taught LPN AA protocols for wound care and that she should not have reached back into the cart with dirty gloves to remove items. Discussed with RN BB that nurse failed to put calcium alginate on wound as ordered. She stated she would change the dressing and correct the error. Interview with Assistant Director or Nursing (ADON) on 9/20/17 at 1:20 p.m. revealed that her expectations of the wound care nurses is that they provide the care as ordered and use appropriate infection cpntrol techniques. When asked about training for wound care nurses and review of their training she stated that if the infections of wounds start to trend upward then she will look at what is going on with the wound care. She stated if a resident's wound is getting worse she will look to see what the issue is and they will discuss at weekly wound meetings. Discussed observation of wound care for resident. ADON stated that the wound care nurses are taught to get everything they need out ahead of time and organized so they don't have to stop and get something they forgot. She stated that going back into the drawer with a gloved hand that had been touching the skin or wound was not acceptable.",2020-09-01
430,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2019-03-13,812,D,1,0,NFKM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to distribute and serve food in a safe and sanitary manner by not ensuring three members of the dietary staff, including the Dietary Manager (DM), wear their bouffant caps and/or beard guards in a manner that would prevent hair or other contaminants from falling into resident food during preparation and serving. Findings include: On 3/12/19 at 10:35 a.m. the DM was interviewed in the kitchen. The DM wore a hairnet and a beard guard with his thick mustache uncovered. The DM stated he had worked for the facility for two years. He also stated the kitchen prepared and served food for the entire facility. On 3/12/19 at 11:30 a.m. the lunch tray assembly line was observed. Kitchen worker AA was observed working assembling spaghetti and meatballs. He wore a bouffant paper head cover and no beard guard over his short beard and mustache. He stated he had worked for the facility for [AGE] years. Kitchen Worker BB was directly observed working on the tray assembly line. She wore a bouffant cap that only partially covered her hair, leaving large lengths of hair out around her face hanging beneath her chin. On 3/12/19 at 2:00 p.m. Kitchen worker AA was observed in the food preparation area with no beard guard covering his short beard and mustache. Kitchen worker BB was observed in the food preparation area with a bouffant cap not covering all her hair with long strands hanging out of the sides of her cap. On 3/12/19 at 2:25 p.m. the DM was observed in the food preparation area of the kitchen wearing a bouffant cap and a beard guard. The beard guard was noted to not cover the DM's moustache. On 3/13/19 at 9:00 a.m. Kitchen worker BB was observed in the kitchen mopping the floor. Her bouffant cap did not cover the hair above her forehead. Review of Staff Attire document dated (MONTH) (YEAR) revealed staff was to have their hair contained in a hair net or cap and facial hair was to be entirely restrained. On 3/13/19 at 10:05 a.m. the Administrator was interviewed in the conference room. He stated he had worked for the facilities for three days. He stated his expectation for hair nets in the kitchen was for all hair to be entirely covered. He stated he expected a beard guard to be worn over any facial hair, including mustaches. On 3/13/19 at 10:30 a.m. the Regional Dietary Consultant for the corporate owner of the facility was interviewed in the DM's office. He stated he always expected all food service workers or anyone else in the kitchen to wear effective hair covering, as a matter of sanitation. He stated a beard guard should cover the moustache. On 3/13/19 at 1:30 p.m. the DM was observed in the food preparation area of the kitchen wearing a bouffant cap and a beard guard. The beard guard was observed to not cover his thick moustache. He stated he usually wore his beard guard over his moustache, but it slipped off when he talked. He further stated this happened often.",2020-09-01
431,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2019-04-04,657,J,1,0,KBNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, staff interviews, and review of the facility policies titled Elopement Management dated (MONTH) (YEAR) and Comprehensive Care Plan with a Revision date of (MONTH) (YEAR) the facility failed to revise the care plan related to exit seeking behaviors for one Resident (R#8) out of six residents reviewed with wandering behaviors. This failure to revise R#8's care plan contributed to the resident exiting the facility undetected. On 4/2/19, 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. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F657 Scope and Severity: J). CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). CFR 483.90 (d)(2) Essential Equipment, Safe Operation Condition (F908 Scope and Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25(d))1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). A Removal Plan was received on 4/4/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/4/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the undated face sheet revealed R#8 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of R#8's Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C revealed a Brief Interview for Mental Status (BIMS) score to be 8 out of 15, signifying impaired cognition. Review of Section G revealed she required supervision for nearly all Activities of Daily Living (ADLs). Further review revealed she could only walk with supervision. Review of the policy titled Elopement Management dated (MONTH) (YEAR) revealed impart; The goal of the Elopement Management System is to identify residents with potential exit-seeking behavior, to assure the Care Plan and Kardex reflect effective and consistent interventions and safety measures and to assure staff are educated regarding the Elopement Management system and resident specific interventions. Review of a progress note dated 1/31/19 revealed the Physician wrote the patient was confused at baseline and wanders the floor. (sic) Review of another progress note dated 2/12/19 revealed R#8 wanders on the floor and a Wander Guard in place. A progress note dated 2/27/19 notes; resident continues to pack her belongings walking towards the EXIT doors. Resident asking every person on the unit to take her home. Sometimes is difficult to redirect and sometimes easily redirected. Review of the policy titled Comprehensive Care Plan dated (MONTH) (YEAR) inpart states; Purpose: To provide effective and person-centered care plan for each resident. and #5 The care plan is reviewed on an ongoing basis and revised as indicated by the resident's needs, wishes, or a change in condition. Review of R#8's Comprehensive care plan dated 1/31/19 revealed the resident was at risk for elopement related to adjustment to nursing home, disorientation to place, and she wandered aimlessly. Interventions in part included, observe location at regular and frequent intervals, check placement and function of wander/elopement alarm every shift and resident picture was to be placed in elopement book. Despite a notation in the clinical record on 2/27/19 regarding R#8 packing her belonging and going to the exit door and asking every person to take her home, the facility did not revise the residents care plan to address exit seeking behavior. On 3/28/19 at 11:30 a.m. interview with the Director of Nursing (DON) revealed on 3/26/19 at about 2:50 p.m., per staff interviews during subsequent investigation, R#8 was observed near the elevator and was redirected by the staff. She stated R#8 was demented but could ambulate independently and was a brisk walker. She stated on 3/26/19 at about 3:00 p.m. Licensed Practical Nurse (LPN) BB told her in an interview that she directly saw R#8 in the bathroom. She stated around 3:15 p.m. the receptionist received a call from the acute hospital across the street from the facility. The DON stated at that point two facility staff, the second-floor Unit Manager (UM) and the Assistant Director of Nursing (ADON) went to the hospital in a facility vehicle and picked R#8 up in the ED. She stated she wasn't sure how R#8 was able to leave the second floor and out of the building without supervision. She stated she thought the system for preventing elopement before R#8 eloped was adequate because her elopement could not have been foreseen. On 3/28/19 at 3:05 p.m. interview with Licensed Practical Nurse (LPN) BB revealed on 3/26/19 at around 2:30 p.m. or 2:45 p.m. she was helping another resident when she saw R#8 heading for the elevator. She stated R#8 was pleasant and easily re-directed and she took R#8 to the bathroom. She stated then around 3:00 p.m. (she recalled the time because the next shift was coming on), she was told R#8 was missing and they started looking for her. Review of the 3/26/19 police department Communications Event Report revealed a 911 call was received at 2:32 p.m. on 3/26/19 to report an elderly person was observed by passers-by to be walking in the road and the officer arrived on-scene at 2:37 p.m. Further review revealed the officer identified the subject as R#8 and noted a bracelet on her left ankle and R#8 was on the ground. Review of the Facility Incident Report Form dated 3/27/19 revealed R#8's elopement occurred on 3/26/19 at 3:15 p.m. On 4/1/19 at 2:50 p.m. the DON was further interviewed and stated her investigation of the R#8 elopement on 3/26/19 was complete and she was satisfied with its conclusions. She stated all she had to go on was that her staff told her R#8 was in the building at 2:50 p.m. on 3/26/19. She stated she could not answer for the discrepancy between what her staff told her and the police report and the ED notes. She stated she agreed R#8's care plan called for frequent observation, as she expected for every resident. She stated she agreed, obviously, R#8 eloped unobserved even though she had a functional Wander guard (elopement bracelet) on at the time. Cross Refer to F 689 Based on further review by DCH it was determined the F657 was cited in lieu of F656. The facility implemented the following actions to remove the Immediate Jeopardy: SS= IJ F 656 Development/Implement Comprehensive Care Plan Immediate Corrective Measures: The Unit Manager re-evaluated Resident #8's elopement risk factors on 3/26/19. Per her Elopement Risk assessment, she is deemed to be at risk. Resident #8's was also evaluated per the psychiatric Nurse Practitioner to identify any further psychosocial needs on 3/28/19. The ID team reviewed Resident #8's current plan of care on 3/26/19 with applicable revisions to include her daughter increasing opportunities to take the resident on desired outings for shopping, recreational walks and eating at desired restaurants. Staff will also offer the resident additional opportunities to participate in supervised outdoor recreational activities at the facility. The resident's falls risk assessment was also reviewed with revisions as indicated. Resident #8's is currently receiving rehab services and her plan of care has been revised to include modalities to address enhancing safety with outdoor ambulation; to include maneuvering sidewalks, inclines and curbs. Identification of Others Residents identified as being at risk for elopement have the potential to be affected. There are six residents identified. These six residents wear a Wander guard device. Residents who utilize a Wander guard will be supervised per a staff member when off the unit. No other residents were affected. The ID Team reviewed 100% of the care plans of the six residents identified as being at risk for an elopement on 3/26 & 3/27/19. The Licensed nurses conducted a current elopement risk evaluation of the six identified residents. Systemic Changes Nurse Managers initiated education on 3/26/2019. All ID team members received education on 4/3/19 regarding the policy for Comprehensive Care Plan. The Nurse Managers provided education to the direct care staff regarding the facility's policy governing the development and implementation of comprehensive care plans. This education includes a review of the process for how the Certified Nursing Assistants access the resident plan of care via the electronic medical record. Staff accesses the residents' plan of care via the electronic medical record in Point Click Care. Kiosks are located throughout the unit as well as at the nurse's station for staff access to the electronic medical record. Resident centered interventions, including the use of a Wander guard device, are communicated to the Certified Nursing Assistant via the plan of care contained in the resident's electronic medical record. A list of residents who wear a Wander guard device is also maintained in a Red Binder at the 2 ND Floor nursing station. This information is communicated to new employees during the General Orientation process. The Nurse Managers utilized educational content as outlined in the following Policy & Procedure Practice Guidelines: * OP 4 0208.00 Development of the Comprehensive Care Plan Education has been provided to 91% of the staff. Current facility staffing consists of: 45 LPNs (1 on LOA), 68 CAN's (2 on LOA), 16 RN's, Dietary Services 13, Environmental Services 13, Social Services 2, Administration 12, Activities 4, Maintenance 3, and Rehabilitation Services 25. Of the facility's current employee roster the following have received education: LPN's 44, CAN's 66, RN's 15, Dietary Services 12, Environmental Services 8, Social Services 2, Administration 12, Maintenance 3, and Rehabilitation Services 21. The Nurse Managers will continue to provide education to current staff prior to the start of their next scheduled shift and to new staff members during the orientation process. No staff shall work in the resident care area prior to receiving this required education. The ID team which consisted of Administrator, Director of Nursing, Medical Director, Assistant Administrator, Clinical Managers, Social Services, Activities, and MDS has conducted a review of the established facility policy governing Comprehensive Care plans with no revisions indicated. Through an Ad-Hoc Quality Assurance meeting held on 03/27/2019 the ID team which consisted of Administrator, Director of Nursing, Medical Director, Assistant Administrator, Clinical Managers, Social Services, Activities, Maintenance, and MDS has conducted a review of the established facility policy governing Resident Elopement with no revisions indicated. The State Survey Agency (SSA) validated the facility's Removal Plan as follows: Review of R#8's care plan revealed revision on 3/26/19 with changes including outings as noted above, frequent and regular supervision, and redirection. Fall risk assessments on the six at-risk residents effective 3/26/19 were reviewed and found to be revised Checklists for six residents with Wander Guard's titled sensory stimulation participation response records were reviewed from 2/27/19 through 3/29/19 with varying degrees of participation recorded. Review of a progress note dated 3/28/19 at 4:20 p.m. revealed a psychiatric assessment for R#8 including memory stimulation plan of care. No medications were recommended. Review of the care plan for R#8 revealed falls risk and was updated 3/28/19. Interventions included walking on sidewalks and curbs. Identification of Others On 3/29/19 at 5:00 p.m. observation and interview with CAN DD revealed she was sitting in a chair observing the dining area and R#8's room. She stated R#8 had gone to the bathroom and she was keeping an eye on her and the dining room. Review of the six residents' care plans in the Electronic Medical Record (EMR) revealed their care plans had been reviewed and updated for elopement risk between 3/26/19 and 4/3/19. Further review revealed elopement risk assessments (evaluations) were completed for these residents on 3/26/19 or 3/27/19. CAN DD stated that she did attend the in-services. Systemic Changes Review of the Comprehensive Care Plan policy revealed policy for ensuring comprehensive person-centered care plans for the residents. Review of the care plan in-services were conducted with all disciplines as stated in the removal plan. On 4/4/19 at 7:15 p.m. interview with the DON revealed the Resident Care Specialists (CNAs) could access the resident care plan in their EMR kiosks and were expected to do so every shift. She stated the nursing staff could make changes to the care plan which would show up immediately in the CAN kiosks. She stated further the CNAs get report from the off-going CNAs every shift as well as from the nurse. On 4/4/19 at 6:50 p.m. interview with CAN QQ revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN QQ stated she did attend the in-services. On 4/4/19 6:55 p.m. interview with CAN RR revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN RR stated that she did attend the in-services. On 4/4/19 at 7:05 p.m. interview with CAN SS revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN SS stated that she did attend the in-services. On 4/4/19 at 7:10 p.m. interview with CAN TT revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN TT stated she did attend the in-services. On 4/4/19 at 7:12 p.m. interview with CAN UU revealed she made a daily check on the Kardex on the EMR kiosk to see if there were any changes with their residents. She then demonstrated the use of the kiosk and showed safety information related to wandering behaviors and Wander Guard devices. CAN UU stated that she did attend the in-services. Observation revealed binders entitled Elopement Book were found at each nursing station and at the reception desk at the main entrance. On 4/1/19 at 11:45 a.m. interview with Receptionist GG revealed the Elopement book had been at her desk for a long time, over a year. The Receptionist stated she did attend the in-services. Review of the Comprehensive Care Plan policy revealed policy for ensuring comprehensive person-centered care plans for the residents. Review of the care plan in-services were held as stated in the facility's Removal Plan. Review of the Comprehensive Care Plan document revised 11/2017 revealed policy that each resident should have a comprehensive and person-centered care plan. Further review revealed care plans were to include the resident or responsible party's participation, goals interventions, and rehab services. The ID team was responsible for care plan development. Review of the attendance sheet for the Ad-hoc meeting regarding Resident Elopement was held on 3/27/19 all committee members in attendance. Review of the Elopement Management document dated 7/2017, revealed elopement policy. Further review revealed the resident and RP would be notified of the Wander Guard placement. Further review revealed if the resident at risk for elopement exhibits exit-seeking behavior it must be documented in the 24-hour report and additional interventions must be considered. Further review revealed the facility must develop a consistent method for tracking the expiration of devices and ensure the devices were replaced prior to expiration. Further review revealed residents were to be assessed for elopement quarterly. Further review revealed exit doors were to be monitored daily for function.",2020-09-01
432,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2019-04-04,689,J,1,0,KBNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, clinical record review, resident and staff interviews, and review of the facility policy titled Resident Elopement dated (MONTH) 2012 the facility failed to prevent one Resident (R), #8 out of six residents reviewed who wear Wander Guards from eloping from the facility. The facility failed to comply with established policies and procedures regarding resident elopement. R#8 exited the facility undetected and was found by passers-on a busy urban street near an interstate ramp. The facility also failed to identify potential hazardous areas residents could access due to unsecured doors. On 4/2/19, 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. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F657 Scope and Severity: J). CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). CFR 483.90 (d)(2) Essential Equipment, Safe Operation Condition (F908 Scope and Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25(d))1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). A Removal Plan was received on 4/4/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/4/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the undated face sheet revealed R#8 was admitted to the facility on [DATE] her [DIAGNOSES REDACTED]. Review of R#8's Quarterly Minimum Data Set ((MDS) dated [DATE], Section C revealed her Brief Interview for Mental Status (BIMS) score to be 8 out of 15, signifying impaired cognition. Review of Section G revealed she could walk with supervision. Review of R#8's progress notes dated 1/31/19 the Physician wrote patient is confused at baseline and wanders all over the floor (sic). Review of a nursing progress dated 2/12/19 revealed R#8 had a Wander Guard on the left ankle because she wandered within the unit. A progress note dated 2/27/19 notes; resident continues to pack her belongings walking towards the EXIT doors. Resident asking every person on the unit to take her home. Sometimes is difficult to redirect and sometimes easily redirected. On 3/28/19 at 11:10 a.m., Case Manager AA was interviewed over the telephone. She stated she was a case manager at a local acute care hospital. She stated on 3/26/19 and Emergency Department (ED) nurse called her and asked her to file a complaint with the State Agency because of an elopement from the facility. She stated the nurse told her R#8 eloped from the facility on 3/26/19 in the afternoon and made it almost all the way to the Interstate when she fell . She stated Emergency Medical Services (EMS) then picked her up and took her to the ED. She stated she did not know who called EMS. She stated she was told R#8 was demented so the ED nurse started calling the nursing homes in the area, including the facility R#8 lives at. She stated the ED nurse told her when she called the facility she was told R#8 did not reside there. She stated the ED nurse told her sometime after that staff from the facility showed up at the ED and took R#8 back to the facility. Review of the 3/26/19 police department Communications Event Report revealed the police were notified of a person (R#8) revealed a 911 call was received at 2:32 p.m. on 3/26/19 and the officer arrived on-scene at 2:37 p.m. Further review revealed the officer identified the subject as R#8 and noted a bracelet on her left ankle and R#8 was on the ground. Further review revealed witnesses reported she was walking in the bike lane with a walker before she fell and she was transported to the hospital. On 3/28/19 at 11:27 a.m. interview with Registered Nurse (RN) DD revealed she was one of two Assistant Directors of Nursing (ADONs) for the facility. She stated on 3/26/19 at around 3:15 p.m. she saw the second-floor UM (unit manager) getting on the elevator and the UM told her R#8 was at the acute hospital ED and she and Licensed Practical Nurse (LPN) BB were going to pick her up. She stated they got into a car and she was dropped off at the building, part of the acute hospital campus, next door to the facility to see if R#8 was there. She stated R#8 was not in that building and while she was walking around in that building she was called on the phone and was told R#8 was at the ED in a building farther away. She stated she walked back to the facility from where she was and was not involved in picking R#8 up from the ED. She stated this all happened in a very short period of time, maybe 15 minutes. On 3/28/19 at 11:30 a.m. interview with the Director of Nursing (DON) revealed on 3/26/19 at about 2:50 p.m. per staff interviews during subsequent investigation, R#8 was observed near the elevator and was redirected by the staff. She stated R#8 was demented but could ambulate independently. She stated R#8 had a Wander Guard elopement alarm on. She stated the Wander Guard would not trigger an alarm if a resident on the second floor tried to get on the elevator, only for the front and side exit doors on the first floor. She stated she did not know why the second-floor elevators could only be accessed by a keypad since the second floor was not a locked unit. She stated on 3/26/19 at about 3:00 p.m. Licensed Practical Nurse (LPN) BB told her in an interview that she directly saw R#8 in the bathroom, then around 3:15 p.m. the receptionist received a call from the acute hospital across the street from the facility. She stated at that point two facility staff, the second-floor Unit Manager (UM) and the Assistant Director of Nursing (ADON) went to the hospital in a facility vehicle and picked R#8 up in the ED. She stated R#8 walked the short distance from the facility to the ED on her own. She stated shortly after this R#8 arrived back at the facility with the staff members and she stopped in her (DON's) office. She stated R#8 told her she had fallen on the sidewalk and a man helped her up. She stated she noted R#8 had a small abrasion on each knee and on her left lateral eye. She stated she assessed the resident thoroughly, even though the ED assessed her and ordered x-rays, which came back negative. She stated after that she checked the Wander Guard system on the front door and the side doors and found the front door to be good but when she checked the side door she found the alarm did not go off until after the resident was out the door. She stated she informed the Administrator and the Maintenance Director about it on the same day. She stated a human monitor had been watching the side door 24/7 since the elopement until the mechanical improvements were made. She stated she thought it was most likely R#8 had gone out the side door. She stated the alarm would be heard all over the large lobby area of the side door. She stated the only way to silence the side door alarm would be to enter in a code on a keypad near the door (the key pad is inside of the building to the right of the door). She stated some unknown person would have had to silence the alarm after R#8 left the facility. The DON revealed the Interdisciplinary Team (IDT) met on the evening of 3/26/19 and the morning of 3/27/19 and determined the plan included human monitoring and placing or strengthening the magnets on the side door. She stated she thought the system for preventing elopement before R#8 eloped was adequate because her elopement could not have been foreseen. Observation on 3/27/19 at 10:00 a.m. revealed no staff member was monitoring the side exit door (also known as the side smoking door) located on the first floor. The door was identified by facility staff as the door that R#8 eloped out of on 3/26/19. According to the DON during the previous interview on 3/28/19 at 11:30 a.m. the door was monitored 24/7 since the incident occurred on 3/26/19. Review of the Pre-hospital (ambulance trip sheet) dated 3/26/19 revealed the ambulance was on the scene at R#8's side on 3/26/19 at 2:55 p.m. Further review revealed they left the pick-up location at 3:08 p.m. and they arrived at the acute care hospital at 3:14 p.m. on 3/26/19. Further review revealed R#8's chief complaint to be a fall from standing to ground. Further review revealed R#8 had a facial abrasion and altered mentation. Further review revealed R#8 was observed by a witness to fall into the dirt on the road; this witness called 911. The report revealed the resident was lying in the roadway when the ambulance arrived. Further review revealed R#8 stated she was in Florida and had just left work at the nursing home; the ambulance crew noted the presence of a Wander Guard bracelet which led them to conclude R#8 had eloped from a nursing home. Review of the acute care hospital face sheet dated 3/26/19 at 3:20 p.m. revealed R#8 arrived at the ED at that time. The ED notes revealed the Physician wrote that caregivers from the facility arrived to pick R#8 up and no further care was needed - the Physician electronically signed this note on 3/26/19 at 4:33 p.m. Review of an audio recording of a 911 call dated 3/26/19 at 2:32 p.m. revealed the first report of a black elderly female walking in the road with a walker wearing glasses and a green cardigan. Review of an additional audio recording of a 911 call dated 3/26/19 at 2:42 p.m. revealed the caller reported a black female in a green cardigan to have fallen in the road. Review of the Interdisciplinary Post Fall Review dated 3/26/19 at 6:06 p.m. revealed R#8 eloped from the facility and sustained an unwitnessed fall on 3/26/19 at 4:00 p.m. Further review revealed R#8 sustained two small superficial abrasions on the left knee and left eye which were cleansed, and no further treatment was required. Further review revealed no changes to baseline range of motion (ROM) were noted on all extremities and R#8 was also assessed at the acute ED. On 3/28/19 at 1:30 p.m. interview with Door Service Technician CC revealed he worked for an outside contractor specializing in commercial doors. He stated he was installing a magnetic lock on the side door designed to lock the door if a Wander Guard elopement bracelet should activate the lock. He stated the door would automatically lock to prevent a resident from going through the door if they had a Wander Guard device on their person. He stated prior to the installation of this lock the door would alarm but not lock and would not prevent a resident with a Wander Guard from leaving the facility. On 3/28/19 at 3:05 p.m. interview with LPN BB revealed that the second floor where R#8 lived, of the facility had mostly demented residents. She stated on 3/26/19 at around 2:30 p.m. or 2:45 p.m. she was assisting another resident when she saw R#8 heading for the elevator. LPN BB stated that she approached R#8 and asked her what she was doing. She stated R#8 told her she was going to the bathroom. She stated R#8 was pleasant and easily re-directed and she took R#8 to the bathroom herself. She stated then around 3:00 p.m. (she recalled the time because the next shift was coming on), she was told R#8 was missing and they started looking in every room of the entire building. She stated she went up to the fourth floor because she thought she might be there and the staff there would not know her. She stated she then heard the receptionist got a call from an acute care hospital about a block or a little more up the street. She also stated she heard the receptionist did not know the resident and told the hospital R#8 did not live at the facility. She stated when they got to the ED they found the doctor was just finishing with R#8 and R#8 had bandages on both knees and her left eye. She stated R#8 told her she fell , and she was glad to see her nurse. She stated the ED nurse told her she had been calling the other nursing homes in the vicinity since she had been told R#8 did not live at the original facility. She stated they then took R#8 back to the facility. On 3/28/19 at 3:25 p.m. a tour was made of the second-floor accompanied by LPN BB. There was a main elevator with a keypad that was in front of the nurse's station and easily visible. LPN BB then showed the surveyor an elevator in an alcove out of sight of the nursing station. She stated it would be easy for a demented resident to wait by this elevator unobserved then get on the elevator when a visitor or some person who did not know not to let these residents on. She stated some of the visitors had the access codes to the elevator. She stated there were no alarms for the Wander Guard on the second-floor, so no one would notice if a resident got on the elevator unobserved. She stated she did not think this was a good situation and she thought they should lock the unit down. On 3/29/19 at 12:45 p.m. interview with the Director of Maintenance revealed he checked the Wander Guard system every day and kept records of that, which he would provide. He stated he checked it by taking a Wander Guard bracelet and walking near the sensors with it to be sure the alarm went off. He stated there were Wander Guard sensors on the front door on the first floor, on the side (smoking) door on the first floor, and on the second floor at the ends of the hall near the elevator where the nurses could not see. He stated before 3/28/19 the front door and the second-floor sensors would give an audible alarm but not lock any door. He stated that before 3/28/19 the sensor on the side smoking door would give an audible alarm and swing the double doors closed but would not lock them. He stated a resident could push through the smoking doors even if they were closed because the doors did not lock. He stated the only way to mute the alarm was to enter in a code on the keypad next to the door. He stated R#8 either went through the door with a non-functioning Wander Guard and the alarm did not go off or somebody silenced the alarm without checking outside. He stated as the Facility Safety Officer he would expect anyone hearing an alarm to check and see what set the alarm off. He stated to not check would be unacceptable. He stated the second-floor audible alarm was not audible at the nurse's station for about the past week. He stated you could not consider an inaudible alarm to be a functioning system. He stated you could not consider the old system to be perfect since, obviously, R#8 got out of the building. He stated he thought the new system was pretty good, since it had keypads on the second floor backed up by the Wander Guard system. Review of the policy titled Resident Elopement document revised (MONTH) 2012 page 2 of 4 revealed in part; 1. If an employee hears a door alarm he or she should: a. immediately go to the site of the alarm c. If no resident is found to be exiting the facility, the employee should; i. Exit the facility, walk around the building, and ensure that a resident has not already exited the facility; IMPORTANT: Be sure to search locked rooms and in stairwells. ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure that all residents are accounted for. On 3/29/18 at 3:15 p.m. R#8 was interviewed as she was walking with a rolling walker accompanied by a staff member. She stated she went for a walk a couple of days ago and she fell . She stated the traffic was whooshing by. She stated she was mighty embarrassed, and a nice man came and picked her up. She stated she did not go to the hospital. It was readily apparent during the interview that R #8 was cognitively impaired. On 3/29/19 at 5:00 p.m. observation and interview with CNA DD revealed she was sitting in a chair observing the dining area and R#8's room. She stated R#8 had gone to the bathroom and she was keeping an eye on her. She stated she knew R#8 well. She stated R#8 would often go up to the elevator and try to get on it when the door opened. She stated R#8 would say she had to go out or to catch a bus or to see someone. She stated when that happened she would redirect her which was easy to do. She stated the Wander Guard would not alarm on the second-floor, only on the first-floor doors. On 3/29/19 at 5:15 p.m. observation of the front entrance of the facility, the side entrance (smoking door) on the first floor of the facility, and the elevator at the end of a second-floor hall, accompanied by the Director of Nursing (DON). The DON provided the surveyor with a Wander Guard bracelet. There was an elevator on the second-floor, out of sight of the nursing station. As the surveyor approached this elevator a dim alarm sound was heard. The DON stated she agreed this alarm could only be heard in the vicinity of the elevator but not at the nursing station. The elevator could only be accessed by a keypad. The access code was entered in by the DON and the elevator door opened. No second-floor personnel responded to the nearly inaudible alarm. On 4/1/19 at 11:45 a.m. interview with Receptionist GG revealed the Elopement book had been at her desk for a long time, over a year. She stated she was on duty on 3/26/19 when R#8 eloped. She stated she thought around 1:00 p.m. the acute care hospital called and asked if R#8's name sounded familiar, (but she did not check the elopement book). She stated she knew R#8 by face but not by name up until that day. She stated she told the nurse from the hospital it didn't sound familiar and the nurse hung up before she could get another word in. She stated she thought to herself let me check on that and found R#8 in the computer. She stated she then called the second-floor, where R#8 lived, and asked if they had R#8 up there. She stated she was told yes but she told the person on the phone she needed someone to directly see R#8 right now. She stated she hung up and the next thing she knew several staff members went flying past her desk out the front door to look for R#8. She stated she said y'all, if you'll just stop, I'll tell you where she is. She stated she then told them she was at the acute care hospital nearby and then staff left to go pick R#8 up. She stated she had seen and spoken to R#8 in the lobby on two other occasions. On 4/1/19 at 2:50 p.m. interview with the DON was conducted and she stated her investigation of the R#8 elopement on 3/26/19 was complete and she was satisfied with its conclusions. She stated she had no knowledge until now about the ambulance being called for R#8 or her being found on the road. She stated all she had to go on was that her staff told her R#8 was in the building at 2:50 p.m. on 3/26/19. She stated she could not answer for the discrepancy between what her staff told her and the ambulance trip sheet and the ED notes. She stated the second-floor Unit Manager (UM) told her the hospital told her R#8 walked in and had not come by ambulance. She stated the hospital staff gave the UM ED records but the records they got were incomplete. She stated she never sought hospital or ambulance records because she had no reason to. She stated she agreed the alarm on the second-floor was very hard to hear but a large alarm sounded on the second-floor nurses station when a Wander Guard resident got on the elevator. She stated she was not sure why the second-floor nurses did not respond to this loud alarm when R#8 got on this elevator. She stated it was unlikely R#8 left through the main entrance because the Wander Guard would have set off the automatic lock on the front door. She stated the receptionist was also monitoring that door. She stated it was more likely R#8 left through the side (smoking) door on the first-floor. She stated she was certain R#8's Wander Guard worked that day (3/26/19) because when she returned from the ED she set off the alarms at the front and side doors. She stated she agreed the only other way out for R#8 was through the side door. DON interview revealed the elopement alarm on the side door of the facility did not sound until the resident was several feet outside the door. She stated, since she knew R#8 had a functioning Wander Guard, the alarm would have sounded when she went through the door. She stated some staff member or even a resident could have silenced the alarm. She stated they changed the door codes recently, per policy, because of the possibility of code compromise, but she was not sure when the codes were changed. She stated the policy was if an employee heard an alarm they were to find out who set off the alarm even if it meant going outside and looking for the resident. She stated to silence the alarm without finding who set it off was against policy and her expectations. On 4/3/19 at 3:55 p.m. interview with the Administrator revealed he had been the Administrator since 3/1/19. He stated he was aware of R#8's elopement and arrival at the hospital on [DATE]. He stated he did not become aware the resident had made her way to the intersection of an interstate and a busy road until the surveyor shared his investigation with the DON on 4/1/19. He stated the DON's investigation could have been better, being that it did not reveal the ambulance involvement, the fall, and how R#8 got to the hospital. He stated the DON's assertion R#8 had walked across the street to the ED was incorrect. He stated the QAPI (Quality Assurance Process Improvement) committee had an ad hoc (when necessary or needed) meeting on 3/26/19 the day R#8 eloped. He stated he did not know R#8 had experienced exit-seeking behaviors for several weeks because he did not always attend the daily meeting in which these matters were discussed. He stated he expected the DON to have this knowledge and he considered her his delegate. He stated there was no formal process to ensure he knows of resident behaviors, but he heard about many of them and he expected the DON to know. He stated he did not know R#8's care plan had been updated on 1/31/19 to reflect exit-seeking behavior. He stated there was a process to ensure the committee was made aware of resident behaviors or incidents. Additional Hazardous areas and means of Egress were identified during tour of the facility: On 4/3/19 from 12:15 p.m. until 12:30 p.m. DON and Administrator interviews revealed the access codes were changed on or about 4/1/19. At 1:10 p.m. the elevators, stairwell doors, and the door to the rehab part of the facility were all checked by direct observation. The access code on all devices was found to be 1810#. This was the same code as was used by the surveyor on 3/26/19 and subsequent days. Further direct observation revealed the stairwell door at the end of the east hall of the second floor also had a code of 1810#. This door was opened to access the stairwell. On the other side of this door was a door to the outside of the facility with a panic bar. On the metal panic bar were the words alarm will sound. The door was slightly larger than the door frame and was stuck open. The surveyor pushed the door open using the panic bar and no alarm sounded. A tour of the outside of the building on 4/3/19 from 4:20 p.m. - 4:55 p.m. revealed a fenced courtyard on the east side of the building. The gate was open to this courtyard and a door leading inside the building was unlocked. The door was opened, and no alarm sounded. Inside the door was a maintenance room. A door from the maintenance room lead to the hallway and the door to the hallway was unlocked and no alarm sounded when the door was opened. In the hallway to the left were 2 doors, one where cleaning supplies were kept, not locked and electrical equipment, with a sign on the door indicating Danger High Voltage. Double doors lead to the common area outside the dining room and were marked Employees Only. The common area adjacent to the doors marked Employees Only was easily accessible by residents and provided access to high voltage, cleaning chemicals and an unlocked exit from the facility to the above-mentioned courtyard which was open to the parking lot and then to the public sidewalk and street. These double doors did not lock and had no alarm and were located immediately to the left of the two elevators leading to the resident care areas. On 4/3/19 at 5:15 p.m. the Administrator was interviewed in the conference room after touring the unlocked double doors marked Employees Only adjacent to the lobby, the unlocked room marked Danger High Voltage and the unlocked outside door leading to the courtyard from the electrical room. He stated he agreed a resident could exit the facility using this route. He stated he agreed the route included electrical and other hazards. He stated this route had not been considered during the QAPI evaluation of R#8's elopement. On 4/4/19 at 9:15 a.m. - 9:25 a.m. the double doors in the lobby common area adjacent to the dining area were directly observed. These two wooden doors had a sign on them on which was written Employees Only. No staff member was guarding or observing the doors. Two residents were in the lobby sitting in wheelchairs. The surveyor found the doors to be unlocked and he passed through them easily. These doors led to a hallway with multiple doors observed. One door had a sign on which was written Danger High Voltage. This door was unlocked and easily entered. This led to a small room filled with industrial-type circuit boards and circuit breakers. Just past this room was an unlocked louvered door that easily opened to an outside courtyard. The surveyor then retraced his steps to the hall adjacent to the double wooden doors marked Employees Only. Another unlocked door was found on this hall which led to a room with a large machine. The machine suddenly came on with a loud noise. Just past this machine was a partly open door that led to the maintenance shop which led to the courtyard described above. The door could not be opened completely because it was blocked with a wheeled cart that had a portable hot dog air compressor on top of it. The shop was observed to have multiple tools and other maintenance objects in it. The surveyor retraced his steps and made his way back to the lobby through the double wooden doors marked Employees Only. These doors were not observed to be monitored by any staff member, nor was any staff member visible on 4/4/19 at 9:25 a.m. On 4/4/19 at 9:30 a.m. the east end of the second-floor was directly observed. The exit had a keypad on the wall. To the left of this door was an outside door partially open. The building was observed to be on a hill making the second-floor level with the ground at this point. The egress door was metal with a panic-bar on which was written Warning Alarm Will Sound. The panic-bar was pushed by the surveyor and the alarm did not sound. The stairwell was further observed and found to be accessible from the first floor. On 4/4/19 at 12:00 p.m. interview with the DON revealed the lock on the wrought iron gate of the courtyard was always in place and the gate was always locked. She stated she personally laid eyes on this lock on several occasions. She stated the Interdisciplinary Team met on 3/26/19 and again on 3/27/19 to discuss performance improvement regarding R#8's elopement on 3/26/19. She stated she personally inspected the inside of the building on or about 3/27/19 and did not find any concerns about other egress routes. She stated she instructed the Maintenance Director to make a thorough inspection for egress routes of the entire building and he did so. She stated every door in the facility was checked. She reviewed the door check documentation with the surveyor and agreed the door check log only showed checks for the main entrance door and the side smoking door. She stated those checks included checking the other doors also. She stated the side smoking entrance was not the only focus of the QAPI process as an egress route. She stated further she could not explain why the double wooden doors marked Employees Only were not under observation this morning and she could not explain why the courtyard gate was not locked when the surveyors observed it. She stated she did agree this was a possible egress route for a resident. A tour of the facility and interview with the Director of Maintenance was conducted on 4/4/19 at 1:10 p.m. The tour began with the Employees Only section on the first floor. The Director of Maintenance went through the double wooden doors marked Employees Only and stated the room marked Danger High Voltage was unlocked. He stated he agreed the door past the electrical panel led to the courtyard. He stated the courtyard had a lock on the gate every day, but if the gate was not locked a resident could get to the street. He stated the room marked Equipment was dangerous for a resident to be in and it would be possible for a resident to be in a hazardous environment or to leave the facility if they got past the wooden double doors to the lobby common area marked Employees Only. He stated the doors to the courtyard were not checked every day because they were not considered exit doors. He stated he agreed the residents could get out that way. Cross Refer to F908 The facility implemented the following actions to remove the Immediate Jeopardy: SS=IJ F689 Free of Accident Hazards (Supervision/Devices Immediate Corrective Action Resident #8 is an [AGE] year old female resident who was admitted to the facility on [DATE] with a DX of Altered Mental Status, [MEDICAL CONDITION], and Hypertension. She is alert and verbal with confusion noted. She is alert to self without prompting. She ambulates independently with the use of her walker. Resident #8 is oriented to place, day and time with prompting. She presents with short term memory deficits. On 3/26/19, she was observed per the staff around the change of shift near the elevator between 2:45-2:50 p.m. She was easily redirected per the staff and stated that she was going to her room to use the bathroom. She was observed by both a certified nursing assistant and licensed nurse going into her room at approximately 2:50 p.m. Resident #8 stated to the nurse, as she entered her room, that she was going to the bathroom. Resident #8 is independent in toileting. The staff was notified at approximately 3:11p.m-3:20 p.m. that Resident #8 was at the ho",2020-09-01
433,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2019-04-04,908,J,1,0,KBNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure the first floor side exit door was working properly to alert staff when a resident was exiting the building unattended. This failure resulted in one Resident (R#8) out of six residents eloping from the facility undetected. On 4/2/19, 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. The facility's Administrator was informed of the Immediate Jeopardy on 4/2/19 at 4:30 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed as of 3/26/19. The Immediate Jeopardy continued through 4/3/19 and was removed on 4/4/19. The Immediate Jeopardy is outlined as follows: On 3/26/19 resident (R) #8 exited the facility undetected through an exit door on the first floor that was not functioning properly. The resident was found on the ground by a bystander near a busy road. The bystander called 911 and Emergency Medical System (EMS) arrived at the scene. The resident was taken to the local hospital and treated for [REDACTED]. The facility was unaware of the resident's elopement until they were notified by the emergency roiagnom on [DATE]. R#8 has a history of wandering and was wearing a Wander Guard bracelet on her ankle when she left the facility. It was determined that a handicap assessable door on the first floor which has an alarm system was not working properly and therefore, the resident was able to elope from the facility undetected. The Immediate Jeopardy was related to the facility's non-compliance with the program requirements as follows: CFR 483.21(b)(2) Comprehensive Person-Centered Care Plans (F657 Scope and Severity: J). CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). CFR 483.90 (d)(2) Essential Equipment, Safe Operation Condition (F908 Scope and Severity: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR:483:25(d))1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J). A Removal Plan was received on 4/4/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/4/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the undated face sheet revealed Resident (R) #8 was admitted to the facility on [DATE] and her [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set (MDS) assessment dated [DATE], section C, revealed her Brief Interview for Mental Status (BIMS) score to be 8 out of 15, signifying impaired cognition. Review of section G revealed she required supervision for all Activities of Daily Living (ADLs). Further review revealed she could walk with supervision. Review of R#8's progress notes dated 1/31/19 revealed the Physician wrote the resident was confused at baseline and wandered the floor. Review of another progress note dated 2/12/19 revealed R#8 wandered on the floor and a Wander Guard (safety bracelet) was in place. On 3/28/19 at 11:30 a.m. interview with the Director of Nursing (DON) revealed on 3/26/19 R#8 eloped from the facility undetected. She stated R#8 was demented but could ambulate independently. The DON revealed that R#8 had a Wander Guard elopement alarm on. She stated the Wander Guard would not trigger an alarm if a resident on the second floor tried to get on the elevator, only for the front and side exit doors on the first floor. She stated after the elopement she checked the Wander Guard system on the front door and the side doors and found the front door to be good. Continued interview with the DON revealed she checked the side door to the smoking area she found the alarm did not go off until after the resident was out the door. On 3/28/19 at 1:30 p.m. Door Service Technician CC was interviewed and stated he worked for an outside contractor specializing in commercial doors. He stated he was installing a magnetic lock on door designed to lock the door if a Wander Guard should activate the lock by proximity. He stated the door would automatically lock to prevent a resident from going through the door if they had a Wander Guard device on their person. He stated prior to the installation of this lock the door would alarm but not lock and would not prevent a resident with a Wander Guard from leaving the facility. He stated you could say the door prior to the addition of the lock the door was not effective in keeping residents with a Wander Guard bracelet in the facility. He stated the alarm would be going off, but all the resident had to do was push on the unlocked door. On 3/29/19 at 12:45 p.m. interview with the Director of Maintenance revealed he checked the Wander Guard system every day and kept records of that, which he would provide. Review of the Wander Guard records revealed no concerns. He stated he checked it by taking a Wander Guard bracelet and walking near the sensors with it to be sure the alarm went off. He stated there were Wander Guard sensors on the front door on the first floor, on the side (smoking) door on the first floor, and on the second floor at the ends of the hall near the stairwells where the nurses could not see. He stated before 3/28/19 the front door and the second-floor sensors would give an audible alarm but not lock any door. He stated that before 3/28/19 the sensor on the side smoking door would give an audible alarm and swing the double doors closed but would not lock them. He stated a resident could push through the smoking doors even if they were closed because the doors did not lock. He stated the only way to mute the alarm was to punch in a code on the keypad next to the door. He stated R#8 either went through the door with a non-functioning Wander Guard and the alarm did not go off or somebody silenced the alarm without checking outside. He stated the second-floor audible alarm was not audible at the nurse's station for about the past week. He stated you could not consider an inaudible alarm to be a functioning system. He stated on 3/28/19 the side smoking door was modified to have an automatic lock and the door would lock down anytime anyone with a Wander Guard came near it. He stated you could not consider the old system to be perfect since, obviously, R#8 got out of the building. On 4/4/19 at 11:50 a.m. interview with the Administrator revealed he had never personally made an inspection of possible exit routes from the facility until after 3/26/19, the date of R#8's elopement. He stated he inspected inside the building only and had never inspected the outside of the facility because he had no concern up until recently about who could get in the building only how to get out. On 4/4/19 at 1:00 p.m. interview with Maintenance Tech KK revealed he checked every door of the facility every morning. He stated the computer documentation system was not set up for documenting these checks except for the main entrance and the side smoking door. Cross Refer to F689 The facility implemented the following actions to remove the Immediate Jeopardy: IJ F908 Essential Equipment Safe Operating Condition Immediate Corrective Measures: On (MONTH) 26, 2019, Resident #8 exited the facility without notification or supervision via the side entrance door. The resident wears a wander guard alert bracelet secondary to her risk of elopement. The side entrance door is equipped with a Wander Guard Alert system. The Wander Guard Alert System was functioning per Maintenance Director's routine 7 day per week operational check pre-event on 3/26/19 at 8:30am. The door was also noted to be functioning per Maintenance Director checks post event on 3/26/19. The Licensed Nurse validated that the resident's alarm was in place and functioning at approximately 10:00 am prior to the resident exiting the facility on 3/26/19. The Director of Nursing validated that the resident's alarm was in place and functioning appropriately upon the resident's return to the facility on [DATE]. The ID team which consists of the Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, Nurse Managers, Activities, Social Services, and Maintenance has identified an opportunity to enhance safety in the resident care environment by the addition of a Maglock to the existing Wander Guard door alert system. The NHA contacted the vendor for immediate installation on 3/26/19. Installation of the Mag-Locks was initiated 3/27/19 with completion of installation on 3/28/19. Staff assignment was initiated for continual visual observation on 03/27/2019 at 3pm and monitoring of the door. Proper functioning of the Mag-Locks post installation was validated via a Certified Inspector on 3/28/19. See above for validation. Certification review dated 3/28/19 revealed DH Pace validated all inspection points on the Maglocks were functional. The Maintenance Director updated the code for the silencing of the Wander Guard Alert System door alarm on 04/01/2019. The Nurse Managers (Director of Nursing, Assistant Director of Nursing, Unit Managers, Unit Coordinators and Staff Development Nurse) initiated education on 3/26/19. Education has been provided to 91% of the staff regarding the facility's policy governing Elopement Prevention and Management. This included education regarding the updated code for proper silencing of the door alarm. Staff also received education on the expectation of maintaining the confidentiality of the door alarm codes. Current facility staffing consists of: 45 LPNs (1 on LOA), 68 CNA's (2 LOA), 16 RN's, Dietary Services 13, Environmental Services 13, Social Services 2, Administration 12, Activities 4, Maintenance 3, and Rehabilitation Services 25. Of the facility's current employee roster the following have received education: LPN's 44, CNA's 66, RN's 15, Dietary Services 12, Environmental Services 8, Social Services 2, Administration 12, Maintenance 3, and Rehabilitation Services 21. Identification of Others At Risk The Nurse Managers reviewed 100% of the medical records of six residents identified as being at risk for an elopement on 3/26/19. These six residents wear a wander guard device. The Licensed Nurses conducted a current elopement risk evaluation of the six identified residents on 3/26/19 and 3/27 /19. The ID Team (Director of Nursing, Nurse Managers, Social Services, Activities, Dietician, Therapy) has reviewed the plan of care for these residents with revisions as indicated on 04/02/2019. The Licensed Nurses also validated the placement and functionality of the wander guard devices placed on current residents on 3/26/19. Residents who utilize a wander guard will be supervised per a staff member when off the unit. Systemic Changes The Nurse Managers initiated education on 3/26/2019. The Nurse Managers provided education to the staff regarding the facility's policy governing Elopement Prevention & Management. Education also included managing residents with exit-seeking behaviors. The Nurse Managers utilized educational content as outlined in the following Policy & Procedure Practice Guidelines: * Resident Elopement Policy (OP2 0401.04) Education has been provided to 91% of the facility's staff members. Current facility staffing consists of: 45 LPNs (1 on LOA), 68 CNA's (2 on LOA), 16 RN's, Dietary Services 13, Environmental Services 13, Social Services 2, Administration 12, Activities 4, Maintenance 3, and Rehabilitation Services 25. Of the facility's current employee roster the following have received education: LPN's 44, CNA's 66, RN's 15, Dietary Services 12, Environmental Services 8, Social Services 2, Administration 12, Maintenance 3, and Rehabilitation Services 21. The Nurse Managers will continue to provide education to current staff prior to the start of their next scheduled shift and to new staff members during the orientation process. No staff shall work in the resident care area prior to receiving education on facility elopement policy. The Maintenance Director will continue to perform operational quality checks 7 days per week on the entry doors in conjunction with the established routine Maintenance Inspection of the doors and alarms systems. The IDT team (Administrator, Nurse Managers, Social Services, Activities, Dietician, Therapy) will continue to adhere to the established process for Elopement Prevention & Management in accordance with organizational policy and regulatory guidelines. The Licensed Nurse will conduct an Elopement Risk assessment upon admission, quarterly and with a Significant Change in Condition. The IDT team will develop and implement an individualized resident centered plan of care to address the residents identified risk factors. The Licensed Nurse will obtain and implement utilization of wander guard alert devices as indicated when the residents exhibit exit seeking behaviors. The devices will be monitored 7 days per week for placement and functionality per the Licensed Nurse. How will you monitor and sustain compliance The IDT team has identified an OFI (Opportunity For Improvement) on 03/26/2019 in the delivery of resident-centered care in regards to promoting an environment of care that enhances safety and is free of risk of accidents. This is in accordance with regulatory guidelines as outlined in F908, F689 & F656. This OFI is evidenced as a result of a resident exiting the facility without staff supervision or notification. Through an Ad-Hoc Quality Assurance meeting held on 03/27/2019 the ID team which consisted of Administrator, Director of Nursing, Medical Director, Assistant Administrator, Clinical Managers, Social Services, Activities, Maintenance, and MDS has conducted a review of the established facility policy governing Resident Elopement with no revisions indicated. The State Survey Agency (SSA) validated the facility's Removal Plan as follows: These six residents wear a Wander Guard device. The Licensed Nurses conducted a current elopement risk evaluation of the six identified residents on 3/26/19 and 3/27/19. Review of the undated Wanderguard Resident document revealed a list of six residents on wander guard anti-elopement bracelets. Review of the Elopement Book confirmed this. Review of the six residents' care plans in the EMR revealed their care plans had been reviewed and updated for elopement risk between 3/26/19 and 4/3/19. Further review revealed elopement risk assessments (evaluations) were completed for these residents on 3/26/19 or 3/27/19. The ID Team (Director of Nursing, Nurse Managers, Social Services, Activities, Dietician, Therapy) has reviewed the plan of care for these residents with revisions as indicated on 4/2/19. Review of the six residents' care plans in the EMR revealed their care plans had been reviewed and updated for elopement risk between 3/26/19 and 4/3/19. The Licensed Nurses also validated the placement and functionality of the wander guard devices placed on current residents on 3/26/19. Residents who utilize a Wander Guard will be supervised per a staff member when off the unit. Review of the second-floor Elopement Book revealed daily check sheets for wander guard placement and function on all six Wander Guard residents. On 3/27/19 these residents' Medication Administration Records (MARs) began documenting Wander Guard placement and function for these residents. On 4/1/19 at 10:15 p.m. observation and interview with LPN BB revealed she demonstrated the electronic device used to check the functionality of the Wander Guard on R#8. The device beeped when brought near R#8's device on her shoe and the nurse explained she did this every day. Systemic Changes Review of the 3/26/19 - 4/4/19 in-service sign-in sheet revealed 153 signatures on an in-service entitled Wandering and Elopement. On 4/4/19 at 1:00 p.m. the Maintenance Technician stated in interview a resident asked him for the access code yesterday and he told him that only staff were allowed to have the codes. On 4/4/19 at 10:10 a.m. CNA HH was interviewed, she stated they had class on not giving the residents or visitors the access codes. Managers also conducted additional Wandering and Elopement Drills on all three shifts for validation of education provided from 3/26/19-4/1/19. On 4/3/19 the side smoking door on the first floor was approached with a Wander Guard. Upon approaching the door a click could be heard in the door lock and the doors did not open. The door would not open when pushed hard. An alarm was heard. Shortly after the words Code Yellow could be heard from the speakers overhead. Two staff members came and stated they were looking for a resident. One of them entered the code on the key pad and opened the doors. Both staff members went outside and looked for a resident. Record review of education attendance revealed on 3/26/19 an elopement drill was conducted and on 3/29/19, 4/1/19 and 4/3/19. Both staff members verified that they attended the in-service training. On 3/29/19 at 12:45 p.m. interview with the Director of Maintenance revealed he stated he checked the Wander Guard system every day and kept records of that, which he would provide. He stated he checked it by taking a Wander Guard bracelet and walking near the sensors with it to be sure the alarm went off. He stated there were Wander Guard sensors on the front door on the first floor, on the side (smoking) door on the first floor, and on the second floor at the ends of the hall near the stairwells where the nurses could not see. He stated that he attended the in-services. Review of the door check logs revealed the main entrance doors and the side smoking door were checked for functionality every day from 1/1/19 until 4/4/19 with no concern. On 4/4/19 at 1:00 p.m. interview with Maintenance Tech KK revealed he worked for the company a long time and at this facility for five months. He stated he checked every door of the facility every morning. He stated that he attended the in-services. Multiple Elopement Risk Assessments were reviewed during the survey and found to be done upon admission, quarterly, and with a significant change. On 4/4/19 at 5:04 p.m. interview with LPN LL revealed he received education recently in wandering/elopement management and completion of elopement risk assessments. He stated he completed these assessments on admission, re-admission, quarterly, and with any change. On 4/4/19 at 5:08 p.m. interview with LPN MM revealed he received education recently in wandering/elopement management and completion of elopement risk assessments. He stated he completed these assessments on admission, re-admission, quarterly, and with any change. Review of the Elopement Management document dated 7/2017, revealed elopement policy. Further review revealed the resident and RP would be notified of the Wander Guard placement. Further review revealed if the resident at risk for elopement exhibits exit-seeking behavior it must be documented in the 24-hour report and additional interventions must be considered. Further review revealed the facility must develop a consistent method for tracking the expiration of devices and ensure the devices were replaced prior to expiration. Further review revealed residents were to be assessed for elopement quarterly. Further review of the second-floor elopement book revealed each resident with a Wander Guard had the serial number and the expiration date of the devices. Review of manufacturer's documentation of Wander Guard usage revealed the devices would alert the tester as the expiration date approached or if the batteries became low.14 resident care plans were reviewed and found to be reasonable person-centered and identified risk factors such as falls, elopement, or isolation. Review of the six residents' who used the Wander Guard system revealed their care plans had been reviewed and updated for elopement risk between 3/26/19 and 4/3/19. Review of the second-floor Elopement Book revealed daily check sheets for Wander Guard placement and function on all six Wander Guard residents. On 3/27/19 these residents' Medication Administration Records (MARs) began documenting Wander Guard placement and function for these residents. On 4/1/19 at 10:15 p.m. observation and interview with LPN BB revealed. She demonstrated the electronic device used to check the functionality of the Wander Guard on R#8. The device beeped when brought near R#8's device on her shoe and the nurse explained she did this every day. She stated that she attended the in-services. Certification review dated 3/28/19 revealed DH Pace technician validated all inspection points on the Maglocks were functional. How will you monitor and sustain compliance Review of the Ad Hoc QAPI Meeting /Four Point Plan of Correction Agenda and Summary dated 3/27/19 revealed a meeting of the ad-hoc meeting to consider R#8's elopement of 3/26/19. The meeting consisted of root-cause analysis, a corrective action plan, identification of other residents who might be at risk, changes to be communicated to staff, continued monitoring and sustaining compliance. The Survey Pathway document dated 4/1/19 revealed the six residents in the facility using the Wander Guard devices to be at risk. .",2020-09-01
434,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2019-04-26,656,J,1,0,REZN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of facility policies titled Comprehensive Care Plan revised (MONTH) (YEAR) and Elopement Management revised (MONTH) (YEAR) the facility failed to develop a comprehensive care plan with interventions that specify the frequency of service(s) provided and failed to implement the care plan related to provision of monitoring of one resident (R) (R#1) sufficiently to prevent elopement. Seven residents were reviewed for risk of elopement. These failures to provide a care plan that specifically identified how often R#1 should be monitored, and provide sufficient monitoring to prevent elopement resulted in the elopement of R#1. who was found by a bystander at a busy intersection on 4/8/19 at 6:20 p.m. This failure resulted in Immediate Jeopardy. On 4/23/19, 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. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the handicap assessable/smoker exit door on the first floor allowed the resident to elope from the facility undetected. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: J) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 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 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) On 4/25/19 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/24/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/25/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the clinical record for R#1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the progress notes for R#1 revealed on 3/23/19 at 10:05 a.m. LPN VVVV had observed R#1 wandering in the hallways, walking to stairwells, and to elevators waiting for the door to open. LPN VVVV documented that this behavior was noted several times during the shift and that she placed a Wander Guard and had reported this information to the oncoming shift. An Elopement Risk assessment dated [DATE] was completed by LPN VVVV at 2:30 p.m. with a score of twelve (12) indicating R#1 was at risk for elopement. A review of the care plan for R#1 revealed a focus for elopement risk dated 3/26/19 related to an elopement risk score of 12, new admission to the facility and exit seeking behaviors. Interventions included in part as follows: Monitor resident for wandering and offer pleasant diversions, structured activities, food, conversation, television, book . he enjoys large puzzles, playing basketball and yardwork/gardening. Date initiated 3/27/19. An interview was conducted on 4/16/19 at 3:15 p.m. with LPN VVVV second floor wound care nurse, charge nurse and unit coordinator, related to the assessment of R#1 as an elopement risk. LPN VVVV revealed she had worked 7-3 on 3/23/19 and had observed R#1 attempting to open doors and standing in front of the elevator doors several times and each time she redirected him to his room, to an activity, or gave him a snack. She stated she had told the Certified Nursing Assistant's (CNA's) and others on the second floor such as housekeeping and activities. She stated she had also alerted the Minimum Data Set (MDS) nurse that she knew was developing the comprehensive care plan. She revealed she had applied a Wander Guard to his right ankle after notifying the Physician and obtaining an order and called the family, and updated the elopement books on the first floor in the reception area and the second, third and fourth floor nurses stations. An interview was conducted on 4/17/19 at 1:05 p.m. with the Director of Nurses (DON) related to elopement and care planning for R#1. The DON revealed she expects the nurses and the CNA's to alternate rounds on all residents every hour, with the CNA's ensuring the residents are accounted for and have not become ill or injured every two hours and the nurses visualizing the residents every two hours. The DON acknowledged the residents who are at risk for elopement should be checked more often than this but did not give any length of time between rounds. The DON stated she expected the care planning to reflect the residents elopement risk and guidance related to how often the resident needs to be checked and visualize residents frequently enough to prevent elopement. On 4/17/19 at 4:10 p.m. CNA II was interviewed she revealed she checked the care tracker for each of her residents at the start of every shift and was aware from being assigned to the care of R#1 occasionally that he was at risk from elopement. CNA II revealed the Care Tracker did not mention any specific time frame to monitor R#1 but she had checked his location every time she walked down the hall, sometimes every twenty (20) to thirty (30) minutes to ensure he was able to be located and had not fallen or become ill. CNA II revealed she had worked 4/8/19 3-11 and had taken R#1 to the first floor Bistro to get a snack at about 3:50 p.m. An interview was conducted on 4/18/19 at 8:20 a.m. with CNA EEE related to the elopement of R#1. CNA EEE revealed he checked Care Tracker for all his residents after report from the nurses and the CNA's. He also was familiar with R#1 and was aware of prior exit seeking and wandering. CNA EEE revealed he had been assigned to the care of R#1 the day he eloped and R#1 had been escorted down to the first floor dining area known as the Bistro, by 2 of his coworkers, for a snack at approximately 4:00 p.m. CNA EEE revealed the 2 coworkers brought R#1 back to the second floor a short time later and he went to his room, then when dinner trays came he brought R#1 his dinner in his room. After getting R#1 settled and setting up the tray he left him sometime from 5:30 p.m. to 5:45 p.m. and did not see him again until the paramedics brought him back to the facility. CNA EEE was not sure of the time the Paramedic called and asked if they had a missing resident or what time R#1 returned. An interview on 4/18/19 at 9:29 a.m. with LPN DDD was conducted related to the last time she observed R#1 on 4/8/19. LPN DDD revealed she was told in report that R#1 wandered, and had looked for exits in the past. LPN DDD revealed she also checked care plans for the residents on her assignment. LPN DDD stated she had seen R#1 before his elopement a little before 5:00 p.m. and returned with him to his room to administer two oral medications and a fingerstick blood sugar (FSBS). She stated she had checked to see that R#1 had his Wander Guard in place and it was on his left ankle. LPN DDD revealed she was not aware R#1 was missing until the Unit Manager asked her if she knew where R#1 was and she does not have any recollection of what time that was or what time the Paramedics returned him to the second floor. LPN DDD revealed she does not have any specific amount of time she thinks is adequate to check on residents with a risk of elopement, but thinks they should be in view of the staff or monitored as much as possible. Review of the Facility Incident Report Form revealed R#1 was noted outside of the facility without supervision on 4/8/19 at approximately 6:50 p.m. Review of the 911 Communications Event Report revealed on 4/8/19 at 6:12 p.m. 911 received two calls related to an elderly male at the intersection of two high traffic city streets. The first call revealed he had fallen into the road. The second call revealed he was lying in the road. A third call was received at 6:13 p.m. and revealed he kept falling down. The call was answered with local police on the scene at 6:20 p.m. An observation on 4/23/19 at 5:20 p.m. was made by the surveyor related to the time dinner trays arrive on the second floor and the time dinner tray is delivered to the room that R#1 resided in. The first cart arrived at 4:26 p.m. and the tray for R#1's former room. The second cart arrived at 5:35 p.m. and the tray was delivered to the resident currently residing in room at 5:44 p.m. A review of the facility policy titled Comprehensive Care Plan revised (MONTH) (YEAR) revealed on page 3 of 4 , #9 That care plans must be developed within 7 days after completing the comprehensive assessment and must include interventions that specify the frequency of service(s) provided. A review of the facility policy titled Elopement Management revised (MONTH) (YEAR) revealed the following: While alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. Refer to F689 The facility implemented the following actions to remove the Immediate Jeopardy: SS=IJ F656 Develop/Implement Comprehensive Care Plan Immediate Corrective Measures: On (MONTH) 8th, 2019, Resident #1 exited the facility without notification or supervision via the side entrance door. The resident wears a Wander Guard alert bracelet secondary to his risk of elopement. The side entrance door is equipped with a Wander Guard Alert system. The Unit Manager validated that the resident's alarm was in place and functioning appropriately upon the resident's return to the facility on [DATE] and Resident #1 was immediately placed on 1:1 continuous supervision. A review of the plan of care revealed the facility failed to implement a comprehensive care plan to address Resident #1's elopement risk and subsequently led to the resident exiting the facility without staff knowledge or supervision. A review of Resident #1's plan of care revealed that Resident #1's care plan was revised by MDS Nurse on 04/10/19 post-elopement to include 1:1 supervision and resident's triggers for wandering/eloping and how staff can assist in de-escalating wandering and exit seeking behaviors by being offered a snack and or calling his daughter so he can talk to her. Resident #1 was discharged to another facilty with a secure until on 4/11/2019. Identification of Others At Risk Residents who utilize a Wander Guard have the potential to be affected. There is one resident who utilizes a Wander Guard currently in the facility. This resident's Wander Guard is reviewed for placement and functionality daily 7 days per week and door monitors remain at elevators 24/7 on the floor which this resident resides. No other residents were affected. The Licensed Nurse reviewed this resident's plan of care on 04/10/2019. On 04/23/2019 a revision was made to include redirection when the resident states she has to go pick up her children. Resident #1 and Resident #5 were discharged to another facility with a secure unit on 04/11/2019. Resident #4 was discharged to another facilitiy with a secure unit on 04/12/2019. Resident # 6 remains in the facility and utilizes a Wander Guard. Residents #11, #2,and #3 were reviewed by nursing leadership on 04/17/2019 and were determined to not be at risk for elopement and care plans revised. Systemic Changes The Nurse Managers (Director of Nursing, Assistant Director of Nursing, Unit Managers, Unit Coordinators and Staff Development Nurse) initiated education on 4/08/19 to the staff regarding the facility's policies governing Elopement Prevention & Management and Development of the Comprehensive Care Plan to include identification of residents with behaviors and development and accessing the resident's plan of care. This education includes a review of the process for how the Certified Nursing Assistants access the resident plan of care via the electronic medical record. Staff accesses the residents' plan of care via the electronic medical record in Point of Care. Kiosks are located throughout the unit as well as at the nurse's station for staff access to the electronic medical record. Resident centered interventions, including the use of a Wander Guard device, are communicated to the Certified Nursing Assistant via the plan of care contained in the resident's electronic medical record. A list of residents who wear a Wander Guard device is also maintained in a Red Binder at the 2 nd Floor nursing station. An Elopement Risk binder is maintained at each nurses station and at the Receptionist Desk. This education also included maintaining the integrity of the door and Wander Guard codes. Education has been provided to 93% of the facility's staff members including the 2 receptionist (1 classed under CNA, 1 classed under Administration). Current facility staffing consists of: 49 LPNs (1 on LOA), 72 CNA's (1 on LOA), 16 RN's, Dietary Services 18, Environmental Services 16, Social Services 2, Administration 14, Activities 5, Maintenance 3, and Rehabilitation Services 27. Of the facility's current employee roster the following have received education: LPN's 48, CNA's 71, RN's 16, Dietary Srvcs 15, Environmental Services 11, Social Services 2, Administration 13, Maintenance 3, and Rehabilitation Services 26. The Nurse Managers will continue to provide education to current staff prior to the start of their next scheduled shift and to new staff members during the orientation process. No staff shall work in the resident care area prior to receiving education. The IDT team (Administrator, Director of Nursing, Medical Director, Nurse Managers, Social Services, Activities, Dietician, Therapy, and Maintenance Director) will continue to adhere to the established process for Elopement Prevention & Management in accordance with organizational policy and regulatory guidelines. A letter was mailed to resident representatives providing education regarding elopement prevention on 04/17/2019 and added to the admission packet on 04/23/2019. This is documented in the Ad-Hoc QA/PI Plan held on 04/08/2019. Education to alert, oriented, and ambulatory residents was provided on 04/24/2019 to 27 of 46 residents. Education will continue until all of the identified residents are educated. This is documented via in-service education sheets. Through an Ad-Hoc Quality Assurance meeting held on 04/08/2019 the ID team which consisted of Administrator, Director of Nursing, Medical Director, and clinical managers conducted a review of the established facility policy governing Resident Elopement and Development of the Comprehensive Care Plan with no revisions indicated. The Administrator is responsible for the implementation of and adherence to this removal plan. The State Survey Agency (SSA) validated the implementation of the facility's Plan of Immediate Jeopardy Removal as follows: A review of an incident report dated 4/9/19 revealed on 4/8/19 R#1 was noted outside the building without supervision. A review of the care plan dated 3/26/19 for R#1 revealed he was at risk for elopement related to exit seeking behaviors and on 3/23/19 began to wear a Wander Guard device. Review of the Nurses Progress Notes for R#1 revealed that after he was returned to the facility on [DATE], with no time documented, he was placed on one to one monitoring. This was verified by an interview with the second floor Unit Manager during an interview on 4/ 16/19 at 9:45 a.m. The Unit Manager revealed she had checked the Wander Guard as soon as R#1 was back in the building and the device was on and functioning and she had immediately kept him at the desk with her or with a CNA to stay with him one to one until all the door and elevator monitors were in place. An interview with MDS Nurse CCCC on 4/26/19 at 11:10 a.m. revealed she had revised the care plan for R#1 on 4/10/19 to include useful and individualized information for the staff on how to help R#1 to remain safe by offering food and calling his daughter if needed to redirect his attention in another direction. During interviews with CNA EEE on 4/18/19 at 8:20 am, CNA II on 4/17/19 at 4:10 p.m., CNA KK on 4/17/19 at 4:15 p.m., LPN DDD on 4/18/19 at 9:29 a.m. revealed they had worked on the second floor on the 3-11 shift the evening of 4/8/19 when R#1 eloped and they had not seen him from 5:30 p.m. - 5:45 p.m. until the EMS paramedics returned him to the floor after 7:00 p.m. The CNA's and LPN revealed they were all aware of the residents need for monitoring due to the Care Plan and Care Tracker that revealed he was at risk for elopement and were also aware of interventions for diverting him from exit seeking behaviors. A review of the elopement books on the second, third and fourth floors and in the reception area of the first floor, each with listings of residents who are provided with Wander Guards, face sheets, their elopement risk care plans, and daily Wander Guard Checks listing the location of the device, the state of the device, the date of the check, the name of the nurse performing the check and the signature of the nurse, revealed on 4/19/19 there was one resident in the facility with a Wander Guard, R#6. The Wander Guard checks were reviewed from for R#6 and were completed daily. A review of the three residents care plans was completed and they had been revised to reflect the risk of elopement had been resolved. A review of residents utilizing Wander Guard devices on 4/8/19 revealed there were seven residents listed. Three residents, R#2, R#3, and R#11 were reviewed by the survey team and had documented elopement risk assessments that were negative for risk on 4/17/19, and when observed were not wearing Wander Guard devices. A review of the clinical record for R#1 revealed he was discharged to a nearby sister facility with a Life Engagement Program on 4/11/19. An interview with the legal guardian of R#1 on 4/17/19 at 10:15 a.m. revealed she had approved of the transfer of R#1 to a facility with a dedicated program for residents who were at risk of elopement and had not felt any pressure to transfer her father. On 4/17/19 at 2:23 p.m. R#5's brother was interviewed on the telephone. He stated he was the Power of Attorney for R#5 and his RP, though his daughter handled many of his day-to-day affairs. He stated his daughter texted him to advise him of the transfer and he understood the new facility offered care for dementia and was a better placement for him. He stated the facility did not pressure him in any way to accept the transfer. He stated if R#5's daughter was against it she certainly would have told him. On 4/19/19 at 9:00 a.m. R#4's family member was interviewed over the telephone. She stated she was R#4's daughter, RP, and PO[NAME] She stated she did not feel pressured to agree to the transfer because the Administrator explained everything about the new facility to her and she agreed it was a better place. She stated she was satisfied with the facility's response to her mother's elopement and she thought it was too bad her mother had to leave the facility, but she did agree to the transfer. Interviews were conducted with the following staff on the fourth floor on 4/25/19. RN GG 10:40 p.m., 3-11 shift, length of service (LOS) two years, LPN DDD 10:45 p.m., 11-7 shift, LOS 30 days, CNA JJJ 10:55 p.m. 11-7 shift, LOS three years, the ADON 11:05 p.m. LOS three weeks, CNA KKK, 11:15 p.m. LOS 10 months, LPN LLL 11:25 p.m., 11 - 7 shift, LOS three weeks - agency nurse, CNA EEE 11:35 p.m., 11-7 shift, LOS one year, CNA MMM 11:45 p.m., 11-7 shift, LOS eight months, LPN NNN 11:55 p.m., 11-7 shift, LOS four years, and LPN OOO 4/25/19 12:00 a.m., 11-7 shift, LOS [AGE] years. Interviews were also conducted with LPN AAAA on 4/26/19 at 10:55 a.m., fourth floor, 7-3 shift, LOS [AGE] years, and LPN BBBB on 4/26/19 at 10:55 a.m. in the conference room, third floor staff, 7-3 shift, LOS one year. On 4/26/19 at 11:30 a.m. CNA HHHH, 2nd floor, 3-11 shift, LOS two years, and CNA JJJJ, third floor, 7-3 shift, LOS three months were interviewed in the conference room. On 4/26/19 at 11:45 CNA KKKK, Staffing Coordinator, LOS one year and CNA LLLL, fourth floor, day shift, LOS [AGE] years, were interviewed in the conference room. Interviews were conducted confirming education received related to Elopement Prevention and Management, Development of the Comprehensive Care Plan, identification of residents with behaviors and development and accessing the resident's plan of care, maintaining the integrity of the door and Wander Guard codes, and monitors for doors and elevators are never to leave their posts unless a relief staff person is present from 4/8/19 through 4/24/19 with the following staff: Night Receptionist PPP at the front door on 4/25/19 at 10:30 p.m. LOS 3.5 years hours 7:00 p.m. to 8:30 a.m., CNA KK who works all shifts at 10:35 p.m. monitoring at the first floor side entrance LOS one year, LPN QQQ second floor at 10:40 p.m. 3-11 shift , CNA RRR at 10:45 p.m. on the second floor monitoring the main elevators, works 3-11 shift, Maintenance Assistant AA at 10:50 p.m. monitoring the second floor ambulance elevator and was called in to monitor the first floor side entrance on 4/8/19 at 7:00 p.m., LPN SSS second floor 11-7 shift at 10:52 p.m., LPN TTT at 10:53 p.m. second floor 3-11 shift, CNA UUU at 11:00 p.m. second floor main elevator monitor for 11-7 shift, LOS 5 years, CNA VVV at 11:25 p.m. third floor CNA 11-7, LOS [AGE] years, CNA VV at 11:20 p.m. 11-7, LOS 8 years, CNA WWW at 11:35 p.m. float 11-7, CNA KKK at 11:27 p.m. second floor, CNA XXX at 11:28 p.m. fourth floor 11-7. On the fourth floor the following staff were interviewed and confirmed knowledge of the above education provided to them between 4/8/19 and 4/24/19: CNA YYY 11-7 shift at 11:40 p.m. , LPN ZZZ at 11:55 p.m. 11-7 shift LOS [AGE] years All of the above employees affirmed they had attended multiple in-services, online trainings, and education by telephone from 4/8/19 and as recently as 4/24/19, with informal discussions of elopement during shift report. All affirmed they participated in one or two elopement drills in the past week. These employees confirmed if there was a Code Yellow (resident elopement) called over the paging system, the would do an eyes-on head count of their assigned residents even if they had to go to another area such as the dining room to lay eyes on them. The affirmed they would then report their head count to the charge nurse who would then declare all clear or continue the search for the missing resident. The employees affirmed if they were in the lobby on the first floor and heard a Wander Guard alarm they would find out the reason the alarm went off and would look outside for the missing resident if the resident was not in the lobby. All employees affirmed that facility staff were the only ones authorized to possess the keypad access codes and would report any visitor or resident possession so the codes could be changed. All affirmed they could access the residents' care plans in shift report, communication with the resident's nurse, or by accessing it in the electronic health record (EHR). All CNAs interviewed demonstrated on the CNA kiosks how they accessed care plans the electronic Kardex. Nurse interviews in this group revealed the nurses had access to the Point, Click, Care (PCC) EHR software suite and they demonstrated proficiency. Nurse interviews further revealed they could make changes to the care plans when there was a change of condition, such as exit-seeking behaviors, and the policy was to bring these changes up at morning report and it would be discussed at the daily interdisciplinary team meeting. All employees agreed the training offered on elopement was mandatory and they were not allowed to work without it. On 4/26/19 at 11:00 a.m. the Director of Maintenance was interviewed in the conference room. He stated he had three mandatory in-services in the last three weeks, with the last one being on 4/24/19. He stated his role during a Code Yellow was to be sure the equipment on the doors was working properly. He stated he would go to the affected area to check the door alarm. He stated if a resident was not found quickly inside the building an outside search would be started fast. He further stated multiple jobs had been done to upgrade the door locks, panic bar alarms, daily checks of all outside doors to ensure they were locked, and to improve the Wander Guard system. On 4/26/19 at 11:10 a.m. the following staff were interviewed in the conference room: RN CCCC, MDS nurse, day shift, LOS [AGE] years, RN DDDD, Wound Care Nurse, day shift, LOS two years, and RN EEEE, MDS nurse, LOS four years. These nurses all agreed recent elopement in-service training was essentially an on-going daily project, consisting of daily in-service briefing and formal classes. They affirmed if a Code Yellow was called they would be assigned a role by the unit affected charge nurse. Their roles would involve a head count or assisting with the search. The affirmed if they heard a door alarm they would not leave that door until the cause of the alarm was ascertained. They agreed any nurse in the facility could easily access and change any residents' care plan and the CNAs were kept in the know by their kiosks and verbal communication. RN EEEE stated they often got calls from the floor nurses to advise MDS of the changes; the MDS nurses would give assistance with care plan format and of course to update the MDS. On 4/26/19 at 12:00 p.m. the Assistant Administrator, Medical Records Tech XX, and the Human Resources Director were interviewed in the conference room. They affirmed they had had three in-services on elopement in the past two weeks with the last in-service being on 4/24/19. MRT XX stated if she heard a Code Yellow she was to stop what she was doing, leave her office on the first floor and to search for the resident or at least find out why the alarm was going off and to keep at it until the Code Yellow was cleared. The Assistant Administrator stated they would continue to have a person guarding the elevators and doors until they believed the building to be safe. He stated further they had discharged the residents with exit-seeking behaviors because the facility could not meet their needs. The Human Resources Director stated her job during a Code Yellow was to man the door where the alarm was going off and to call for help. She stated an outside search would be conducted if they did not find the resident quickly. On 4/26/18 at 12:30 a.m. Physical Therapy Assistant (PTA) MMMM, LOS one year, PTA NNNN, LOS 18 months, and Physical Therapist (PT) OOOO, LOS [AGE] years, were interviewed in the conference room. They all affirmed they had three recent trainings on elopement, with the latest one being on or about 4/21/19. The stated their role in elopement prevention consisted of assisting with the search, redirecting residents, guarding doors, and to report their observations to the facility staff running the code yellow. On 4/26/18 at 1:15 p.m. Social Worker (SW) PPPP, LOS seven years, SW QQQQ, LOS six years, the Activity Manager, Activities Assistant SSSS, and Activities Assistant TTTT were interviewed in the conference room. Each of these employees affirmed there had been three elopement-based inservices in the last two weeks, with the last one being several days ago. The Activities Manager stated these inservices were mandatory and no worker could clock in without having completed the training by the deadline. All further agreed their roles during a Code Yellow elopement alarm were situational, but involved first ensuring resident safety, searching for the missing resident, responding to the particular door alarm and not leaving the door unattended. On 4/26/18 at 1:40 p.m. R#13 was interviewed in the lobby near the side smoking doors. He was sitting in an electric wheelchair and wearing clean clothes and shoes. He was noted to have left-sided [MEDICAL CONDITION]. No odors were noted. He stated he lived in the facility for three years and was a retired Navy man. He stated after the elopement UM OO came to his room and explained the elopement and how she was keeping the building and the residents safe. He stated he had no problem with this. On 4/26/18 1:55 p.m. R#12 was interviewed with a family member near the Administrator's office. She was in an electric wheelchair and wearing clean clothes and shoes with no odors noted. She was clean and well-groomed. She stated she had lived at the facility for a while. She stated she heard about the elopement and the facility was safe from someone on the staff. The family member stated there was a letter from the facility, but she had not opened it yet. On 4/26/18 at 2:00 p.m. Cook UUUU, LOS [AGE] years, Dietary Aide BB, LOS two years, and Dietary Aide CC were interviewed in the dining room near the kitchen. They affirmed three recent in services on elopement, with the last one being two or three days ago. Cook UUUU stated the first thing she would do during a Code Yellow would be to secure her work station and shut down her oven. She would then go to the front of the house, find out who was missing, and search inside and outside the building until the resident was found or there was a Code Yellow Clear on the overhead speaker. All affirmed this and that the trainings were mandatory. Dietary Aide BB stated he would first shut down his dishwasher and search for the resident after he found out who was missing up front. He stated he could not clock in without taking the elopement classes. On 4/26/19 at 2:10 p.m. R#14 was interviewed on the fourth floor. He was seated in a wheelchair wearing clean clothes and shoes with no odors noted. He was accompanied by a gentleman who identified himself as R#14's son and his Responsible Party. He stated the facility sent him a letter about the elopement and he was satisfied with the response of the facility. Education sign in rosters were compared with the list of all current employees in all departments provided by the Administrator. The listing of all current employees included two hundred and twenty four names and was divided by the number of employees signing the rosters, which included two hundred and ten names and resulted in confirmation of 93.75% of all employees educated as alleged in the Plan of Removal from 4/8/19 through 4/24/19. A letter with no date was submitted to the survey team by the Administrator that explained important tips to ensure the safety of the residents. The Administrator was interviewed on 4/19/19 at 8:20 a.m. and revealed he had mailed this letter to the families, responsible parties, and first contacts listed for each resident on 4/17/19, and the letter would also be included in each admission packet. A review of the Ad Hoc Quality Assurance Performance Improvement Committee Plan Meeting minutes dated 4/8/19 revealed the Interdisciplinary t",2020-09-01
435,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2019-04-26,689,J,1,0,REZN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, clinical record review, staff and Emergency Medical Services (EMS) interview and review of facility policy and practice guidelines titled Elopement Management dated (MONTH) (YEAR), the facility failed to provide supervision and monitoring to prevent the elopement of one resident (R), (R#1) from a sample of seven (7) residents identified by the facility to be at high risk for elopement. The facility failed to ensure the first floor side entrance/exit door Wander Guard system functioned adequately to prevent the elopement of one resident (R) (R#1) who exited the building undetected on 4/8/19. In addition, the facility failed to provide a safe and secure environment related to a first-floor side entrance door that was not in view of staff on 4/8/19, the day R#1 eloped and was found by a bystander. On 4/23/19, 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. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the handicap assessable/smoker exit door on the first floor allowed the resident to elope from the facility undetected. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: J) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 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 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) On 4/25/19 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/24/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/25/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures Findings include: Review of facility policy titled Elopement Management revision date (MONTH) (YEAR) page 1 of 2 revealed in part: Fundamental Information Unsafe Wandering or Elopement According to the Center for Medicare and Medicaid Services, wandering is random or repetitive locomotion. This movement may be goal-directed (e.g., the person appears to be searching for something such as an exit) or may be non-goal directed or aimless. Non-goal directed wandering requires a response in a manner that addresses both safety issues and an evaluation to identify root causes to the degree possible . while alarms can help to monitor a resident's activities, staff must be vigilant in order to respond to them in a timely manner. Alarms do not replace necessary supervision. Review of the clinical record for R#1 revealed an original admission date of [DATE]. [DIAGNOSES REDACTED]. An elopement risk assessment completed by Licensed Practical Nurse (LPN) VVVV on 3/23/19 revealed R#1 was at high risk for elopement. LPN VVVV was interviewed on 4/16/19 at 3:15 p.m. and revealed she was working on 3/23/19 and mid-morning R#1 started to try to open doors and seemed to be looking for a way off the second floor. She had redirected him with food and the activities staff were there and helped to involve him in the activities room, but he was observed several more times trying doors. She then notified the Physician and was given an order for [REDACTED].#1's face sheet and Wander Guard checklist to the elopement books on the three resident care floors and the front lobby. LPN VVVV revealed she had also given the next shift nurses and CNA's the information in report and discussed the behavior with the Minimum Data Set (MDS) Nurse CCCC who was developing a comprehensive care plan. LPN VVVV revealed she had documented this information in Nurse's Progress Notes. LPN VVVV confirmed she had not added this information to the baseline care plan or documented the behavior on the 24 Hour Report. LPN VVVV acknowledged she should have documented this behavior on the 24 Hour Report and on the Baseline Care Plan. Further review of Nurse's Progress Notes revealed on 3/29/19 at 2:17 p.m., 4/1/19 at 11:50 a.m., 4/1/19 at 7:39 a.m., and 4/1/19 at 5:40 a.m.,4/3/19 at 4:06 p.m., 4/3/19 at 10:44 a.m., 4/4/19 at 11:14 a.m., there was documentation of R#1 wandering in the hallways. On 4/4/19 at 11:05 p.m. LPN QQQ documented that R#1 was noted wandering from his room attempting to go on elevator and was angrily aggressive to staff, and had removed the furniture from his room and attempting to hit staff and threw water on them. His daughter was notified and spoke with him but he remained angrily aggressive. A therapist came and spoke and he remained in his room that night. Review of the Progress Notes for R#1 dated 4/8/19 at 9:35 p.m. revealed LPN DDD documented that R#1 was wandering in the halls of the second floor at dinner time and was redirected back to his room and meal tray. The staff was later notified that R#1 had been found by Emergency Medical Service (EMS) with no noted injuries and returned to the facility. No time was documented for the notification from EMS or the return of R#1 back to the facility. An interview was conducted with the Administrator on 4/16/19 at 9:15 a.m. The Administrator revealed he was called by staff at approximately 7:00 p.m. on 4/8/19 and was informed that R#1 had eloped and been found at the intersection of two streets with heavy traffic. The Administrator revealed he immediately gave orders to have staff posted at the side entrance/exit door, and at the main and ambulance elevator doors on the second floor. The Administrator revealed there is no way to determine how R#1 entered the elevator on the second floor or exited through the side entrance/exit door. He revealed there is always a receptionist at the front lobby desk 24 hours a day 7 days a week and they do not leave that desk until someone comes to relieve them. The Administrator revealed there are two alarm sensors that the resident would have to go through on the second floor and one on the first floor to travel to the front lobby by way of the ambulance elevator, then when exiting that elevator a resident with a Wander Guard would activate the front door locks and the alarm system, and they would be directly in front of the reception desk, so an exit through that door is very unlikely. The Administrator revealed that on 4/8/19 at 10:35 p.m. he and the door technician and the Maintenance Director had determined that the Wander Guard system on the side entrance/exit could be disabled by a person without a Wander Guard opening the door and standing or sitting in the doorway. The Wander Guard system was over ridden by a door sensor so there was no alarm, door closure or locking when a resident with a Wander Guard approached if someone was in the doorway. The Administrator revealed he and the Maintenance Director, and the door technician had no knowledge of the over ride on the Wander Guard system and he and the Maintenance Director had not been employed here when the system was installed. He revealed the door had not been tested with someone standing or sitting in the doorway without a Wander Guard device before 4/8/19 at 10:35 p.m. The Administrator revealed this is a very high traffic door with independent residents and families with their residents gathering outside this door. He did not know there was a way for a resident with a Wander Guard to exit through this door without activation of the alarm, door closure, and the recently installed magnetic locks. The Administrator revealed he had this override removed from the door sensor on 4/16/19 prior to the surveyor's entrance and could not demonstrate on this door how the override had deactivated the Wander Guard system. The Administrator revealed he had investigated the elopement of R#1 and determined that he had last been observed on 4/8/19 between 5:30 p.m. and 5:45 p.m. He was unable to determine what time the EMS paramedic called to ask if there was a missing resident with the name of R#1 because no one documented the time. A review of door and elevator maintenance statements revealed on 4/8/19 at 10:35 p.m. the Administrator signed an invoice from a door company acknowledging satisfactory work and that the Wander Guard system was not detecting devices correctly and the customer was to call Information Technology (IT) to correct the issue. On 4/16/19 another invoice was reviewed from a door and lock company to replace a function lever on a first floor side door. Review of door and elevator monitoring (staff)schedules for the first floor side entrance, the main entrance which was the receptionist, the second floor main elevator and the second floor ambulance elevator were reviewed from 4/8/19 at 7:00 p.m. through 4/25/19 at 7:00 a.m. On 4/16/19 at 9:32 a.m. the main elevators on the second floor were observed by the surveyor. The surveyor stood outside the elevator doors for four (4) minutes and one elevator door opened and the surveyor was able to get on the elevator without entering a 4 digit code on the keypad outside the elevator. On 4/18/19 at 8:40 a.m. the surveyor again waited outside the second-floor main elevators for the door to open and in eight (8) minutes the door opened and the surveyor was able to use the elevator with no numeric code. On 4/19/19 at 8:50 a.m. the surveyor was again able to exit the second floor by the main elevator by waiting for ten (10) minutes for someone to come to the second floor and boarding the elevator when they exited. On 4/23/19 at 10:33 a.m. the surveyor observed the second-floor main elevators and the door remained open for seventeen (17) seconds before closing. The surveyor was again able to travel to the first floor without entering any numeric code into the key pad. This would allow an independent mobile resident enough time, if there was no staff at the desk or if the staff were not observing the elevator, to enter the elevator door and travel to the first floor. Interview on 4/16/19 at 9:45 a.m. with the second floor Unit Manager LPN WWWW revealed she had been on the second floor when R#1 eloped on 4/8/19. She is often in the building throughout the dinner meal. Unit Manager LPN WWWW revealed there could have been times when no one was at the desk because they all have to attend to passing trays, feeding, supervising the residents in the dining area and call lights. Unit Manager LPN WWWW revealed she also assists with the dinner service, works at the desk or in her office. Unit Manager LPN WWWW confirmed there could have been brief periods from 5:30 p.m. through 7:00 p.m. when the main elevator area was not observed, and it is possible for a resident to board the elevator without using the key pad and travel to the first floor if the elevator stopped and the doors opened on the second floor. Unit Manager LPN WWWW revealed she had not documented the time EMS called to ask if the facility was missing a resident, thinks the time was approximately 7:00 p.m. Unit Manager LPN WWWW was present when R#1 was returned and he was assessed with [REDACTED]. Unit Manager LPN WWWW had observed his Wander Guard in place on his left ankle and had verified the function with the scanner that is used daily to verify function of all the Wander Guards in use. On 4/16/19 at 5:10 p.m. the Administrator was interviewed and revealed that on 4/8/19 at 10:35 p.m. he and the Maintenance Director and the Wander Guard consultant had discovered that if someone without a Wander Guard activated the door button to open the automatic door at the side entrance and stood or sat in a wheelchair in the doorway the Wander Guard system would be disabled and no alarm would sound and the door would not close or lock if someone with a Wander Guard approached the door. The Administrator revealed he had this corrected on 4/16/19 prior to the surveyor's arrival and could not be observed for this door now. An interview was conducted with the Director of Nurses (DON) on 4/17/19 at 1:05 p.m. The DON revealed she expects the Charge Nurse's to coordinate rounds with the CNA's every 2 hours so that someone sees the residents every hour to determine if they are present, clean, not ill and have not fallen. If a resident cannot be found there should be a Code Yellow called. An interview was conducted on 4/18/19 at 8:20 a.m. with CNA EEE who was assigned to the care of R#1 on 4/8/19 on the 3-11 shift. CNA EEE revealed he was aware from the CNA Care Tracker, from report and from working with R#1 previously that he was at risk for elopement. CNA EEE revealed he had not observed R#1 to be exit seeking that afternoon. He was just walking in the halls like he always did. He was aware of ways to divert R#1 from exit seeking like helping him to find something to watch on TV, take him to activities, or with a snack. CNA EEE revealed R#1 had been in the bathroom when he brought him his dinner tray between 5:30 p.m. and 6:00 p.m. CNA EEE revealed he had assisted R#1 out of the bathroom and to wash his hands and then to sit beside the bed, set up the tray and left the room. He had then continued to pass trays with the other staff and to assist residents to eat and had not seen R#1 again until the EMS paramedics were returning him to the second floor after 7:00 p.m. CNA EEE revealed there is a lot of coming and going at that time of the evening with families visiting for dinner, residents returning from appointments, and the independent residents going to the first floor to socialize and go to the dining room on the first floor, then returning to the second floor. CNA EEE revealed he tried to see R#1 at least every hour to make sure he was not ill and had not fallen, to check his foot wear and to make sure he was on the second floor, and had not disappeared. CNA EEE revealed there is usually someone at the desk that could observe the elevators but not always and he was aware that anyone could travel in the elevators by waiting for the door to open, without having the code for the key pad. An interview was conducted with LPN DDD on the phone, 3-11 Charge Nurse on the second floor, on 4/18/19 at 9:29 a.m. LPN DDD revealed she was assigned to the care of R#1 the night he eloped 4/8/19. LPN DDD revealed he had not seemed unusually restless or exit seeking that afternoon, just his normal wandering behavior, ambulating in the halls. He had not been trying doors or standing near the elevators. LPN DDD revealed she had been told in report and knew from checking the care plan that R#1 was at risk for elopement and she coordinated her rounds with the CNA's to observe him at least every hour. She revealed she was assisting with feeding residents and picking up trays and the Unit Manager had found her and asked if she knew where R#1 was and she did not. The last time she had observed him was just before 5:00 p.m. when she had performed a finger stick blood sugar (FSBS) and checked to see if his Wander Guard was present and functioning and administered two oral (PO) medications scheduled for 5:00 p.m. An interview was conducted with Occupational Therapist (OT) WW on 4/18/19 at 12:10 p.m. She revealed R#1 had been discharge from Physical Therapy and Occupational Therapy that day. R#1 was physically able to do everything but his cognition was at about 10%. During a meeting with the family of R#1, OT WW had told them he required a one to one caregiver because he would not be safe if left alone for more than a few minutes. He received therapy for about two weeks and was not able to make any progress with safety awareness and he was at maximum potential physically. He did not fatigue easily, his balance was not the best, but his strength was fine. Interview on 4/19/19 at 3:42 p.m. with the Maintenance Director revealed the first floor side entrance use to have an over ride on the Wander Guard system, that would prevent the door from closing and the alarm from sounding if the door was approached by someone with a Wander Guard and there was someone without a Wander Guard in the doorway. He revealed this was not known by anyone in the building until 4/8/19 after R#1 eloped and he, the Administrator and the Wander Guard consultant had tested this door in several different ways. The Maintenance Director revealed this over ride had been removed from the door earlier this week. He stated he checks every door for closing, locking and alarming when approached with a Wander Guard every day and provided his daily logs which were reviewed with no concerns. An interview was conducted on 4/19/19 at 4:20 p.m. with Receptionist QQ. Receptionist QQ revealed she had been on duty on 4/8/19 from 8:00 a.m. to 7:00 p.m. Receptionist QQ revealed she had received a phone call from an EMS paramedic asking if there was a missing resident and they gave the resident's name. She thinks this call occurred sometime around 6:30 p.m. because she looked at her watch because she was supposed to go home at 7:00 p.m. She transferred the call to the second floor after checking the elopement book to determine the resident's room number and did not document the time. Receptionist QQ revealed R#1 was returned to the facility by EMS a few minutes later but did not document the time. Interview on 4/19/19 at 11:00 a.m. with one of the two Emergency Medical Service (EMS) Paramedics who had accompanied R#1 back into the facility on [DATE]. The Paramedic revealed when he first observed R#1 he was in the back of a police patrol car. EMS had been called by the police officer after responding to three 911 calls related to an male who had appeared lost on the sidewalk of a busy intersection. One called had revealed he had fallen and hit his head. The Paramedics assisted him out of the patrol care and into their ambulance and had checked him for injuries and there were no signs of any injuries. The Paramedics had noted the residents name when looking inside his clothing and had also noted the Wander Guard device on his ankle and they knew he was from a local nursing home. They brought him to another nursing home first because it was closet and then when they were told he did not belong there the Paramedic had called the facility and brought him back. The Paramedic revealed he had tried to communicate with him using a translator, but R#1 did not make any response. The Paramedic revealed R#1 did not seem to be upset or traumatized in any way. The Paramedic revealed he had no idea of any of the times because he did not have access to past Patient Care Reports, but the whole call took about 20 to 25 minutes. He stated that the location where R#1 was found was about a half mile from the facility. One of the two Paramedics remembers responding to the call from the police at 6:21 p.m. The Paramedic was unable to remember the time he had called the facility to ask if they were missing a resident with the last name of R#1. Review of the 911 Communications Event Report revealed the first call to 911 related to R#1: alone and looking lost at a busy intersection was received at 6:12 p.m. and the police officer arrived at 6:20 p.m. Multiple attempts were made to obtain the patient care reports from EMS without a response, therefore no time is available for the EMS call to the facility to verify the length of time R#1 left the facility undetected and the time that EMS returned R#1 to the facility. Review of the 911 tapes of calls related to the elopement of R#1 revealed the first caller at 6:12 p.m. requested assistance for an elderly male who had fallen into to road. The second call was also received at 6:12 p.m. and the called stated there was a man lying in the road and he had gotten up and fell again. The third caller at 6:13 p.m. revealed an elderly male was alone and at a busy intersection and kept falling down. An interview was conducted with the Corporate Vice President of Operations on 4/26/19 at 2:40 p.m. regarding the function of the side entrance/exit door. He stated he had been notified of the elopement of R#1 on 4/8/19. The Corporate Vice President revealed he had been notified of the malfunctioning Wander Guard system on this door and had observed the malfunction when visiting the facility. He revealed the system was disabled by anyone exiting the side door without a Wander Guard standing in the doorway and was not aware the system had been installed with an override. He stated he had never seen a Wander Guard system that was disabled by anything other than entering the correct numeric code on the key pad. Cross refer to F656 The facility implemented the following Removal Plan to remove the Immediate Jeopardy: SS=IJ F 689 Free of Accident Hazards/Supervision/Devices Immediate Corrective Measures: On (MONTH) 8th, 2019, Resident #1 exited the facility without notification or supervision via the side entrance door. The resident wears a Wander Guard alert bracelet secondary to his risk of elopement. The side entrance door is equipped with a Wander Guard Alert system. The Unit Manager validated that the resident's alarm was in place and functioning appropriately upon the resident's return to the facility on [DATE] and Resident #1 was immediately placed on 1:1 continuous supervision. The Physician was notified at 8:00pm and Responsible Party at 7:00pm on 4/08/19 by the Licensed Nurse. Orders were obtained for an X-Ray of the skull and pelvic/bilateral hips per the Physician at the facility. The X-Ray results revealed no fracture. Staff was placed at the second floor elevators for continual visual monitoring on 4/8/2019 at 7pm. Service elevator located on all floors and 1st floor service corridor function was disabled on 4/08/2019 at 7:00 p.m Staff was also placed at the front and side entrance/smoking door 1st floor for continual visual monitoring on 4/8/2019 at 7pm. Visual monitoring of both the second floor elevators and the front and side entrance is being maintained 24/7 and assignments for door coverage are managed by the Director of Nursing via the Door Monitoring Assignment Tool. Door monitoring of the above mentioned doors will be maintained indefinitely 24/7 until appropriate modifications of the current safety features of the facility are completed and functionality validated by the Vice President of Operations and District Director of Facility Engineering. The ID team which consists of the Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, and Nurse Managers completed an AD-Hoc QAPI meeting on 4/08/2019 at 7:00 p.m. with an immediate corrective action of placing door monitors at the main entrance door, side entrance door, 2nd floor main elevator, and 2nd floor center elevators. The service elevator was suspended on 4/08/2019 at 7:00 p.m. and remains suspended. Resident #1 was discharged to another facilty with a secure until on 4/11/2019. Identification of Others At Risk Residents who utilize a Wander Guard have the potential to be affected. There is one resident who utilizes a Wander Guard currently in the facility. This resident's Wander Guard is reviewed for placement and functionality daily 7 days per week and door monitors remain at elevators 24/7 on the floor which this resident resides. No other residents were affected. The Licensed Nurse validated the placement and functionality of this resident's device on 4/8/2019. Resident #1 and Resident #5 were discharged to another facility with a secure unit on 4/11/2019. Resident #4 was discharged to another facility with a secure unitl on 4/12/2019. Resident # 6 remains in the facility and utilizes a Wander Guard. Residents #11, #2, and #3 were reviewed by nursing leadership on 4/17/2019 and were determined to not be at risk for elopement and care plans revised. Systemic Changes The Nurse Managers (Director of Nursing, Assistant Director of Nursing, Unit Managers, Unit Coordinators and Staff Development Nurse) initiated education on 4/08/19 to the staff regarding the facility's policies governing Elopement Prevention & Management and Development of the Comprehensive Care Plan to include identification of residents with behaviors and development and accessing the resident's plan of care. This education also included maintaining the integrity of the door and Wander Guard codes. Education has been provided to 93% of the facility's staff members including the 2 receptionist (1 classed under CNA, 1 classed under Administration). Current facility staffing consists of: 49 LPNs (1 on LOA), 72 CNA's (1 on LOA), 16 RN's, Dietary Services 18, Environmental Services 16, Social Services 2, Administration 14, Activities 5, Maintenance 3, and Rehabilitation Services 27. Of the facility's current employee roster the following have received education: LPN's 48, CNA's 71, RN's 16, Dietary Services 15, Environmental Services 11, Social Services 2, Administration 13, Maintenance 3, and Rehabilitation Services 26. The Nurse Managers will continue to provide education to current staff prior to the start of their next scheduled shift and to new staff members during the orientation process. No staff shall work in the resident care area prior to receiving education. The IDT team (Administrator, Director of Nursing, Medical Director, Nurse Managers, Social Services, Activities, Dietician, Therapy, and Maintenance Director) will continue to adhere to the established process for Elopement Prevention & Management in accordance with organizational policy and regulatory guidelines. A letter was mailed to resident representatives providing education regarding elopement prevention on 4/17/2019 and added to the facility admission packet on 4/23/2019. This is documented in the Ad-Hoc QA/PI Plan held on 4/08/2019. Education regarding elopement prevention was provided through an ad-hoc resident council meeting held on 04/09/2019. This is documented via Resident Council Minutes. Education to alert, oriented, and ambulatory residents was provided on 4/24/2019 to 27 of 46 residents. Education will continue until all of the identified residents are educated. Through an Ad-Hoc Quality Assurance meeting held on 4/08/2019 the ID team which consisted of Administrator, Director of Nursing, Medical Director, and clinical managers conducted a review of the established facility policy governing Resident Elopement and Development of the Comprehensive Care Plan with no revisions indicated. The Administrator is responsible for the implementation of and adherence to this removal plan. The State Survey Agency (SSA) validated the implementation of the facility's Plan of Immediate Jeopardy Removal as follows: A review of an incident report dated 4/9/19 revealed on 4/8/19 R#1 was noted outside the building without supervision. A review of the care plan dated 3/26/19 for R#1 revealed he was at risk for elopement related to exit seeking behaviors and on 3/23/19 began to wear a Wander Guard device. Review of the Nurses Progress Notes for R#1 revealed that after he was returned to the facility on [DATE], with no time documented, he was placed on one to one monitoring. This was verified by an interview with the second floor Unit Manager on 4/16/19 at 9:45 a.m. The Unit Manager revealed she had checked the Wander Guard as soon as R#1 was back in the building and the device was on and functioning and she had immediately kept him at the desk with her or with a CNA to stay with him one to one until all the door and elevator monitors were in place. A review of the Situation, Background, Assessment, Recommendation (SBAR) communication tool related to the elopement of R#1 dated 4/8/19 confirmed the time of family notification of the elopement was documented at 7:00 p.m. on 4/8/29, and the Physician was notified on 4/8/19 at 8:00 p.m. and X rays of bilateral hips, skull and lumbar spine were ordered. Review of the X ray reports dated 4/9/19 revealed there were no acute findings. The Administrator revealed in an interview on 4/25/19 at 8:45 a.m. that he had instructed the Maintenance Director to disable the utility elevator on 4/8/19 and it will remain disabled because it is not really needed, and it will remain disabled. This was verified by observation of the utility elevator during tours on 4/16/19 at 9:25 a.m., 4/17/19 at 8:45 a.m., 4/18/19 at 8:10 a.m., 4/19/19 at 8:30 a.m., 4/23/19 at 8:45 a.m., 4/24/19 at 12:20 p.m. and 4/25/19 at 12:30 p.m. The Maintenance Director was interviewed on 4/26/19 at 11:07 a.m. and revealed he had been instructed to shut down the utility elevator on 4/8/29 at 7:00 p.m. and also instructed to leave it shut down. During tours of the reception area, the first floor side entrance, the second floor main visitor elevators and area surrounding the second floor ambulance elevator on 4/16/19 at 9:25 a.m., 4/17/19 at 8:45 a.m., 4/18/19 at 8:10 a.m., 4/19/19 at 8:30 a.m., 4/23/19 at 8:45 a.m., 4/24/19 at 12:20 a.m. and 4/25/19 at 12:30 a.m. the above areas were being observed by a staff person assigned to monitoring. Record review of the door and elevator monitoring schedules and assignments revealed from 4/8/19 through 4/25/19 at 7:00 a.m. the four areas were monitored twenty four hours a day. An interview on 4/24/19 at 10:20 a.m. with the Director of Nurses (DON) revealed the schedule was still in progress and twenty-four hour monitoring would continue indefinitely, she was currently calling to fill the monitoring needs for 4/25/19 at 7:00 a.m. through the next week. Observations conducted 4/25/19 from 10:30 p.m. through 4/26/19 at 12:15 a.m. revealed Receptionist PPP seated at front desk in lobby at 10:30 p.m. with Elopement Book in view. CNA KK at 10:35 p.m. was seated across the foyer in full view of the first floor side entrance doors. At 10:45 p.m. CNA RRR was observed seated in front of the second-floor main visitor elevators and at 10:50 p.m. Maintenance Assistant AA was seated beside the second-floor ambulance elevator. The service elevator was not functioning on the second, third and fourth floors and was not accessible from the first floor because there was a key pad lock system installed and the door was locked. An interview on 4/26/19 at 2:40 p.m. with the Corporate Vice President of Operations revealed he fully supports the Administrator continuing providing door and elevator monitoring by staff until he is satisfied the building is as secure as possible and will continue to over see the process of monitoring the doors and elevators and will also over see the modifications needed to secure the doors and elevators. A review of the elopement books on the second, third and fourth floors and in the reception area of the first floor, each with listings of residents who are provided with",2020-09-01
436,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2019-04-26,835,J,1,0,REZN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of the Administrator Job Description revised 1/29/03, the facility failed to be administered in a manner to ensure there was an effective elopement prevention program that consistently monitored residents at risk for elopement and determine the root cause of resident elopements, and failed to ensure that all staff were knowledgeable regarding how the first floor side entrance /exit door functioned with a Wander Guard system which had an override function allowing residents identified at risk for elopement to exit the facility undetected. From a sample of seven residents assessed as elopement risk (R) (R#1 left the facility undetected on 4/8/19. This failure resulted in Immediate Jeopardy. On 4/23/19, 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. On 4/23/19 at 4:00 p.m. the facility's Administrator was informed of the Immediate Jeopardy (IJ). The noncompliance related to the Immediate Jeopardy was identified to have existed on 4/8/19 when R#1 eloped from the facility undetected through an exit door on the first floor. The Immediate Jeopardy is outlined as follows: On 4/8/19 resident (R) #1 exited the facility undetected through an exit door on the first floor. The resident was found by a bystander near a busy road after falling to the ground. The bystander called 911 and the Police and Emergency Medical Service (EMS) arrived at the scene. The resident was assessed by EMS to be unharmed. The facility was unaware of the resident's elopement until they were notified by EMS. R#1 has a history of wandering and was wearing a Wander Guard bracelet on his ankle when he left the facility. It was determined that the mechanical function of the handicap assessable/smoker exit door on the first floor allowed the resident to elope from the facility undetected. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements as follows: CFR 483.21(b)(1) Comprehensive Care Plans (F656 Scope and Severity: J) CFR 483.25(d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 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 (d) (1)(2) Free of Accident, Hazards/Supervision/Devices (F689 Scope and Severity: J) On 4/25/19 the facility provided an Immediate Jeopardy Removal Plan alleging that interventions had been put into place to remove the immediacy on 4/24/19. Based on interviews, record reviews, and review of facility policies as outlined in the Removal Plan, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 4/25/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight as well as develops and implements a Plan of Correction (P[NAME]). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. Findings include: Review of the facility Administrator Job Description revised 1/29/03, revealed a Summary as follows: Responsible for the overall management of a facility. Plans, develops, directs, monitors and supports all operational, administrative, clinical, human resources, customer service and fiscal activities for the facility's programs and services. Essential Duties and Responsibilities include the following: Other duties may be assigned .Makes sure facility is a safe, clean, comfortable and appealing environment for residents, patients, visitors and staff in accordance with company guidelines. An interview was conducted with the Administrator on 4/16/19 at 5:10 p.m. related to the Wander Guard system on the first-floor side entrance/exit. The Administrator revealed on 4/8/19, after he had learned of the elopement of R#1, he had contacted the vendor for maintenance of the facility doors. The Administrator arrived at the facility and with the vendor and the Maintenance Director had determined at approximately 10:35 p.m. that the Wander Guard alarm and lock on this side door did not function if someone without a Wander Guard was in the door opening. He stated this was the first time this door had been tested by someone without a Wander Guard standing in the doorway and someone with a Wander Guard approaching from a distance. The Administrator revealed he and the Maintenance Director had no knowledge that the Wander Guard system had been installed with an override. He revealed the front door was also installed this way, but there was a receptionist at that door twenty-four (24) hours a day seven (7) days a week. The Administrator revealed he had staff stationed at the side door for two days after the last elopement but had stopped the monitoring on 3/28/19 at 7:00 p.m. after magnetic locks were installed. The Administrator revealed he could not demonstrate the override on the side door now because it had been corrected this morning (4/16/19). A review of invoices for work by door and lock companies revealed an invoice dated 4/8/19. The invoice description of work revealed the following: Arrived to find the mag (magnetic) locks holding properly. However, found that Wander Guard System not detecting fobs correctly. Customer to call IT company to resolve issue. The time out on the invoice was 10:35 p.m. An invoice from a door and lock company dated 4/16/19 revealed the following: Replaced function lever on first floor. A interview was conducted with the Maintenance Director on 4/19/19 at 3:40 p.m. related to the first floor side entrance/ exit door. The Maintenance Director revealed he tested the Wander Guard systems and door locks at every door each day by approaching the doors and alarms with a Wander Guard. He stated he had never tested the doors with someone without a Wander Guard standing in the doorway and was unaware the system had been installed this way. The door vendor that came the night R#1 eloped had said the door sensor that kept the door from closing on someone in the doorway was overriding the system, and it disabled the whole Wander Guard system including the alarm. He revealed the two recent elopements must have been through this door because the other door always has a receptionist there day and night. Refer to F 656 and F689 The facility implemented the following actions to remove the Immediate Jeopardy: SS=IJ F 835 Administration Immediate Corrective Measures On (MONTH) 8th, 2019, Resident #1 exited the facility without notification or supervision via the side entrance door. The resident wears a Wander Guard alert bracelet secondary to his risk of elopement. The side entrance door is equipped with a Wander Guard Alert system. The Unit Manager validated that the resident's alarm was in place and functioning appropriately upon the resident's return to the facility on [DATE] and Resident #1 was immediately placed on 1:1 continuous supervision. The ID team which consists of the Administrator, Director of Nursing, Medical Director, Assistant Director of Nursing, and Nurse Managers completed an AD-Hoc QAPI meeting on 04/08/2019 at 7pm with an immediate corrective action of placing door monitors at the main entrance door, side entrance door, 2 nd floor main elevator, and 2 nd floor center elevators. The service elevator was suspended on 04/08/2019 at 7:00pm and remains suspended. Staff was placed at the second floor elevators for continual visual monitoring on 4/8/2019. Staff was also placed at the front and side entrance/exit door for continual visual monitoring on 4/8/2019. Visual monitoring of both the second floor elevators and the front and side entrance is being maintained. The vendor for maintenance of the entrance door was immediately contacted and did arrive at the facility on 4/8/2019 to perform a quality check of the door. At this time it was validated that the Wander Guard system on the first floor side exit was over ridden by the automatic door closure sensor making it possible for a person without a Wander Guard to open the door with the wheel chair button, stand in the doorway on the sensor pad and the Wander Guard alarm would not sound, the door would not close or lock thus allowing a resident at risk for elopement to exit the door undetected. Staff visual monitoring of the door is continuous. Visual monitoring of both the second floor elevators and the front and side entrance is being maintained 24/7 and assignments for door coverage are managed by the Director of Nursing via the Door Monitoring Assignment Tool. The Director of Nursing met with the Resident Council on 4/9/2019 to provide education on safety in the living environment; to include not assisting unfamiliar residents on/off the elevators and the exit doors. The members verbalized understanding. The Maintenance Director updated the codes to the entrance doors, elevators and stairwells on 4/9/2019. Resident #1 was discharged to another facility with a secure unit on 4/1/19. Identification of Others at Risk Residents who utilize a Wander Guard have the potential to be affected. There is one resident who utilizes a Wander Guard currently in the facility. This resident's Wander Guard is reviewed for placement and functionality daily and door monitors remain at elevators 24/7 on the floor which this resident resides. No other residents were affected. Resident #1 and Resident #5 were discharged to another facility with a secure unit on 4/12/19 Resident #4 was discharged to another facility with a secure unit on 4/12/19 Resident # 6 remains in the facility and utilizes a Wander Guard. Residents #11, #2, and #3 were reviewed by nursing leadership on 04/17/2019 and were determined to not be at risk for elopement and care plans revised. Systemic Changes Education was provided to the facility administrator on 04/23/2019 by the District Director of Clinical Services regarding the regulatory and interpretative guidelines for F 835. On 04/24/2019 the Vice President of Operations reviewed the Licensed Nursing Home Administrator job description to include ensuring the facility is safe and in accordance with company policy and regulatory guidelines. The Licensed Nursing Home Administrator job description was reviewed on 04/24/2019 with the Vice President of Operations and Administrator with no revisions. The District Director of Clinical Services or Vice President of Operations will attend the QA/PI meeting monthly for additional recommendation to the Administrator related to elopement management and facility administration. The Administrator is responsible for the implementation of and adherence to this removal plan. The State Survey Agency (SSA) validated the facilities Plan of Immediate Jeopardy Removal as follows: A review of an incident report dated 4/9/19 revealed on 4/8/19 R#1 was noted outside the building without supervision. A review of the care plan, dated 3/26/19 for R#1 revealed he was at risk for elopement related to exit seeking behaviors and on 3/23/19 began to wear a Wander Guard device. Review of the Nurses Progress Notes for R#1 revealed that after he was returned to the facility on [DATE], with no time documented, he was placed on one to one monitoring. This was verified by an interview with the second floor Unit Manager during an interview on 4/ 16/19 at 9:45 a.m. The Unit Manager revealed she had checked the Wander Guard as soon as R#1 was back in the building and the device was on and functioning and she had immediately kept him at the desk with her or with a CNA to stay with him one to one until all the door and elevator monitors were in place. A review of the Ad Hoc Quality Assurance Performance Improvement Committee Plan Meeting minutes dated 4/8/19 revealed the Interdisciplinary team had identified an opportunity for improvement in regards to promoting enhanced safety and freedom from risk of accidents. The root cause analysis related to R#1, with a Wander Guard in place and functioning, identified the likelihood of R#1 entering the main elevator with another independent resident or a visitor, traveling to the first floor and exiting the building through the side entrance/exit door. The root cause analysis also identified that post event testing had identified that exiting the side entrance/exit was possible when a staff member walked through this door while a staff member with a Wander Guard was also going through the door, and the alarm failed to be activated. The Administrator revealed in an interview on 4/25/19 at 8:45 a.m. that he had instructed the Maintenance Director to disable the utility elevator on 4/8/19 and it will remain disabled because it is not really needed, and it will remain disabled. This was verified by observation of the utility elevator during tours on 4/16/19 at 9:25 a.m., 4/17/19 at 8:45 a.m., 4/18/19 at 8:10 a.m., 4/19/19 at 8:30 a.m., 4/23/19 at 8:45 a.m., 4/24/19 at 12:20 p.m. and 4/25/19 at 12:30 p.m The Maintenance Director was interviewed on 4/26/19 at 11:07 a.m. and revealed he had been instructed to shut down the utility elevator on 4/8/29 at 7:00 p.m. and also instructed to leave it shut down. During tours of the reception area, the first floor side entrance, the second floor main visitor elevators and area surrounding the second floor ambulance elevator on 4/16/19 at 9:25 a.m., 4/17/19 at 8:45 a.m., 4/18/19 at 8:10 a.m., 4/19/19 at 8:30 a.m., 4/23/19 at 8:45 a.m., 4/24/19 at 12:20 a.m. and 4/25/19 at 12:30 a.m. the above areas were being observed by a staff person assigned to monitoring. Record review of the door and elevator monitoring schedules and assignments revealed from 4/8/19 through 4/25/19 at 7:00 a.m. the four areas were monitored twenty four hours a day. An interview on 4/24/19 at 10:20 a.m. with the Director of Nurses (DON) revealed the schedule was still in progress and twenty-four hour monitoring would continue indefinitely, she was currently calling to fill the monitoring needs for 4/25/19 at 7:00 a.m. through the next week. Observations conducted 4/25/19 from 10:30 p.m. through 4/26/19 at 12:15 a.m. revealed Receptionist PPP seated at front desk in lobby at 10:30 p.m. with Elopement Book in view. CNA KK at 10:35 p.m. was seated across the foyer in full view of the first floor side entrance doors. At 10:45 p.m. CNA RRR was observed seated in front of the second-floor main visitor elevators and at 10:50 p.m. Maintenance Assistant AA was seated beside the second-floor ambulance elevator. The service elevator was not functioning on the second, third and fourth floors and was not accessible from the first floor because there was a key pad lock system installed and the door was locked. On 4/18/19 at 1:30 p.m. a door technician from the local automatic door company was interviewed while he was working on the main entrance door. He stated he was working on the front door to make it better integrated with the Wander Guard system. He stated you could not put a magnetic lock on a sliding door, such as the main entrance door because if another person approached from the other side and triggered the motion sensor the lock would activate and burn out the electric motors of the door as it tried to open. He stated instead the doors were functionally locked because for fire code reasons they would automatically close if they were open but could then be opened by applying great force to the doors and they would go from sliding to opening. He stated he did not think a frail senior could get through the doors on his own if his Wander Guard shut the door. He stated a further concern was if a person coming in had activated the doors to open the Wander Guard would override the safety system in the door and it might close when a person was in the doorway. He stated the door could keep a Wanderguard resident in the facility by sounding an alarm and by closing the door or it could keep from closing on a visitor or other person if they were in the doorway, possibly causing an accident, but it could not do both at the same time. He stated he was pretty sure he could come up with something. During an observation on 4/19/19 at 3:40 p.m. the Maintenance director and the surveyor observed the first floor side door, where R#1 was suspected of exiting the building on 4/8/19 at approximately 6:00 pm. The surveyor stood in the open doorway of the exit door. The Maintenance Director approached with the Wander Guard and the door closed and the alarm sounded. The Maintenance Director revealed the safety over ride that prevented the door from closing on someone in the open doorway had been removed after R#1 eloped. He revealed no one at the facility had been aware of the override and the system had been installed before he and the administrator had worked here. The Maintenance Director was interview on 4/26/19 at 11:07 a.m. and revealed he had changed the key pad codes for every door in the facility approximately five times, possibly more, since 4/8/19 to keep the code from residents and visitors. Resident Council meeting minutes dated 4/9/19 were reviewed and the former Director of Nurses, Activities Director and Resident Council President attended the meeting, related to only facility staff having the door codes, and observation of who is near, and notification of staff if another resident attempts to get on the elevator. The Director of Nurses, Resident Council President and Activities Director all confirmed this meeting and also confirmed no one had kept any attendance record and no one could remember who was there. Additional resident education, related to the elopement prevention was provided on 4/24/19 to twenty-seven of forty-six residents identified as alert, oriented and ambulatory. An interview with the Administrator on 4/25/19 at 12:35 p.m. revealed the interdisciplinary team had met and identified residents who were alert, oriented, independently mobile and left their rooms and their units to socialize and attend activities in other parts of the building. The team identified forty six residents. The Administrator provided the list, which was compared with the resident education roster and education was confirmed by interview with R#7, R#12, R#13, and R#14 as above. An interview with the Administrator on 4/26/19 at 12:01 p.m. revealed he had been provided with education regarding his responsibilities to implement and maintain safety of the residents and a review of his job description on 4/24/19 by the Vice President of Operations. The Administrator revealed he was responsible for the implementation and adherence to the Plan of correction and would be provided with over sight from the Vice President of Operations as well as the District Director of Clinical Services to ensure compliance with company policy and regulatory guidelines. An interview with the Corporate Regional Vice President of Operations on 4/26/19 at 2:40 p.m. revealed the Administrator would be responsible for the implementation and adherence to the Plan of Immediate Jeopardy Removal. The Corporate Regional Vice President revealed he would be responsible for the oversight and support of the implementation and adherence to the Plan of Immediate Jeopardy Removal. The Vice President confirmed he or the District Director of Clinical Services will attend monthly QA/PI meetings to provide additional guidance and recommendations related to elopement management and facility administration. A review of the elopement books on the second, third and fourth floors and in the reception area of the first floor, each with listings of residents who are provided with Wander Guards, face sheets, their elopement risk care plans, and daily Wander Guard Checks listing the location of the device, the state of the device, the date of the check, the name of the nurse performing the check and the signature of the nurse, revealed on 4/19/19 there was one resident in the facility with a Wander Guard, R#6. The Wander Guard checks were reviewed from for R#6 and were completed daily. A review of the three residents care plans was completed, and they had been revised to reflect the risk of elopement had been resolved. A review of residents utilizing Wander Guard devices on 4/8/19 revealed there were seven residents listed. Three residents, R#2, R#3, and R#11 were reviewed by the survey team and had documented elopement risk assessments that were negative for risk on 4/17/19, and when observed were not wearing Wander Guard devices. A review of the clinical record for R#1 revealed he was discharged to a nearby sister facility with a Life Engagement Program on 4/11/19. An interview with the legal guardian of R#1 on 4/17/19 at 10:15 a.m. revealed she had approved of the transfer of R#1 to a facility with a dedicated program for residents who were at risk of elopement and had not felt any pressure to transfer her father. On 4/17/19 at 2:23 p.m. R#5 ' s brother was interviewed on the telephone. He stated he was the Power of Attorney for R#5 and his RP, though his daughter handled many of his day-to-day affairs. He stated his daughter texted him to advise him of the transfer and he understood the new facility offered care for dementia and was a better placement for him. He stated the facility did not pressure him in any way to accept the transfer. He stated if R#5 ' s daughter was against it she certainly would have told him. On 4/19/19 at 9:00 a.m. R#4 ' s family member was interviewed over the telephone. She stated she was R#4 ' s daughter, RP, and PO[NAME] She stated she did not feel pressured to agree to the transfer because the Administrator explained everything about the new facility to her and she agreed it was a better place. She stated she was satisfied with the facility ' s response to her mother ' s elopement and she thought it was too bad her mother had to leave the facility, but she did agree to the transfer. An interview with the Administrator on 4/26/19 at 12:01 p.m. revealed he had been provided with education regarding his responsibilities to implement and maintain safety of the residents and a review of his job description on 4/24/19 by the Vice President of Operations. The Administrator revealed he was responsible for the implementation and adherence to the Plan of correction and would be provided with over sight from the Vice President of Operations as well as the District Director of Clinical Services to ensure compliance with company policy and regulatory guidelines. During interview the Corporate Regional Vice President of Operations on 4/26/19 at 2:40 p.m. revealed the Administrator would be responsible for the implementation and adherence to the Plan of Immediate Jeopardy Removal. The Corporate Regional Vice President revealed he would be responsible for the oversight and support of the implementation and adherence to the Plan of Immediate Jeopardy Removal. The Vice President confirmed he or the District Director of Clinical Services will attend monthly QA/PI meetings to provide additional guidance and recommendations related to elopement management and facility administration",2020-09-01
437,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2016-06-03,247,D,0,1,93KK11,"Based on record review, policy and procedure review and interviews, the facility failed to notify residents of a new roommate for two (2) residents (R25 and 179) out of thirty-four (34) sampled residents. Findings include: Review of the Policy: Guidelines for Transfer of Resident within the Facility, revised on 05/03/16, revealed that staff were to notify all roommates affected by the transfer. Guidelines for documentation included noting the date/time the resident and/or responsible party were notified. Review of the Policy: Resident Room Relocation revised on 03/31/16 revealed the social services staff would develop a plan to include informing the resident or his/her legal representative when he or she was receiving a new roommate. Review of the information provided as part of the admission packet to the residents/ families, revised in (MONTH) 2010 documented residents have the right to be promptly notified when there is a change in room or roommate assignment. Further documentation revealed the facility must also promptly notify the resident's legal representative or interested family member, if known. Interview on 06/01/16 at 8:56 a.m. revealed R25 received a new roommate in (MONTH) of (YEAR) and was not notified prior to the roommate arriving. Review of the Quarterly Minimum Data Set (MDS) Assessment for R25 having an assessment reference date of 03/28/16 revealed a Brief Interview of Mental Status (BIMS) score of fifteen (15), indicating the resident was cognitively intact. Review of the facility's census records revealed R25 received a new roommate on 02/29/16. Interview on 06/01/16 at 1:43 p.m. revealed R179 was not notified of receiving a new roommate. R179 stated that the roommate just showed up one day. Review of the Quarterly MDS Assessment having an assessment reference date of 05/23/16 revealed the resident had a BIMS score of nine (9), indicating moderate cognitive impairment. Review of the facility's census records revealed that resident #179 received a new roommate on 05/15/16. Review of clinical record for R25 and 179 revealed no documentation indicating that notification was given to the resident by social services or nursing services of receiving a new roommate. An interview on 06/02/16 at 1:30 p.m. with Social Worker (SW) AA revealed that the facility's practice was for the SW to inform a resident (or the resident's family, if the resident is cognitively impaired) of a room change or roommate change, prior to the change and that this notification should be documented in the Point-Click-Care (PCC) system as a progress note. An interview on 06/02/16 at 3:20 p.m. with the Social Services Director (SSD) revealed that the facility's social service staff informs residents or their representative of a roommate change prior to the arrival, and this notification should be documented as a progress note. The SSD informed that if the room assignment is not known by social services in advance of a new admission's arrival, the nurse will notify the resident of the new roommate's arrival; and this could be done the day of the roommate's arrival. SSD stated that all staff are expected to document that the resident is notified of a new roommate prior to the roommate's arrival. An interview on 06/03/16 at 9:55 a.m. with the SW BB revealed that it is facility procedure that the social workers notify all parties - the resident and family - prior to the arrival of a new roommate and that this notification should be documented in the resident's records in the PCC system. SW BB informed that she recalled notifying R25 that she was to receive a new roommate on 02/29/16, but acknowledged that she had failed to document this notification in the resident's records via the PCC system. An interview on 06/03/16 at 10:10 a.m. with Licensed Practical Nurse (LPN) CC revealed that the nurses are required to notify the resident and/or representative prior to receipt of a new roommate if a member of the social service staff is not available and this notification should be documented in the resident's records in the PCC system. An interview on 06/03/16 at 12:45 p.m. with the SSD revealed social services or nursing should have given notification of a roommate change to R25 and 179 prior to the arrival of the new roommates. SSD confirmed that there was no documentation in the PCC system to indicate that this was done by either social services or nursing services.",2020-09-01
438,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2016-06-03,282,D,0,1,93KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow the care plan related to securing a Foley catheter tubing for one (1) resident (#426), to conduct weekly skin inspections for two (2) residents (#426 and #154), and to monitor for side effects of antipsychotic medications for one (1) resident (#423). The sample size was thirty-four (34) residents. Findings include: 1. Review of resident #426's physician's orders [REDACTED]. Further review of this care plan revealed an intervention to secure the catheter and tubing appropriately. During observations of wound care on 06/02/16 at 9:55 a.m. and on 06/03/16 at 9:47 a.m., resident #426's urinary catheter tubing was noted to not be secured to the resident's leg in any manner to prevent tension at the insertion site. This was verified by Licensed Practical Nurse (LPN) Unit Manager DD on 06/03/16 at 10:37 a.m. Cross-refer to F 315. 2. Review of resident #426's care plans revealed a problem statement of an unstageable pressure ulcer to the right buttock. Review of the interventions for this care plan revealed an intervention to conduct weekly skin inspections. Review of the computerized patient care documentation system revealed that there was no documentation that skin assessments were performed between 04/06/16 to 05/04/16, nor between 05/25/16 and 06/03/16. This was confirmed by LPN GG on 06/03/16 at 3:28 p.m. Cross-refer to F 314. 3. Review of resident #154's care plans included problem statements of actual pressure ulcers to the left and right buttocks and sacrum, and for alteration in non-pressure skin integrity, revealed interventions to conduct weekly skin inspections, and skin assessment to be completed per facility policy. Review of resident #154's computerized records revealed documentation that only seven skin assessments were documented as having been done since the resident's admission to the facility on [DATE]. This was confirmed by LPN Unit Manager DD on 06/03/16 at 12:35 p.m., who stated that he should have had a total of seventeen skin assessments done since admission. During further interview, she stated that the resident refused care at times, but if he had refused the skin assessment the nurse should have documented this. Review of the facility's Weekly Skin Review policy noted that a skin reviews would be completed weekly on all residents. Review of the facility's Skin Integrity Guidelines policy noted that the licensed nurse would be responsible for performing a skin evaluation/observation weekly. 4. Review of the care plan for resident #423 revealed a Focus area, dated 4/5/16, of potential for drug related complications associated with use of [MEDICAL CONDITION] medications related to antipsychotic medication. Interventions included monitoring for the side effects of sedation, drowsiness, dry mouth, constipation, blurred vision, extrapyramidal symptoms (EPS), weight gain, [MEDICAL CONDITION], postural [MEDICAL CONDITION], sweating, loss of appetite and [MEDICAL CONDITION]. Review of the electronic Medication Administration Record, [REDACTED]. An interview with LPN Unit Manager DD on 6/3/16 at 2:30 p.m. confirmed that monitoring for side effects for the antipsychotic medication Olazapine was being done for resident #423 per the care plan.",2020-09-01
439,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2016-06-03,314,D,0,1,93KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility and hospice staff interview, the facility failed to assess for the provision of pressure reduction devices for the chair; provide heel protection; and do weekly skin assessments as per facility protocol for one (1) resident (#426). The sample size was thirty-four (34) residents. Findings include: Review of resident #426's clinical record revealed that she was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of her Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that the resident was assessed as extensive assist for bed mobility, the activity of walking did not occur, was a pressure ulcer risk, had one (1) unstageable pressure ulcer, and was receiving hospice care. Review of a Wound Evaluation Flow Sheet noted that she had an unstageable pressure ulcer to the right buttock that was identified on 05/29/16, and preventative interventions included a wheelchair cushion. During observation on 06/02/16 at 9:55 a.m., the resident was in bed and had on socks, with no heel protection noted. Observation of wound care on 06/03/16 at 9:47 a.m. revealed that there was an approximate four-by-four inch square area of redness to the resident's right buttock. Observed in the center of this area of redness, at this time, was an unmeasured narrow and shallow open area of skin. Observation of the heels after the wound care revealed a previously unidentified clear fluid-filled blister to the left lateral heel, measured by Licensed Practical Nurse (LPN) Treatment Nurse SS as being 1 centimeter (cm) by 1.7 cm in size. During an interview with Treatment Nurse SS at this time, revealed that she would classify this blister as an unstageable pressure ulcer. During observation and interview with the resident's hospice Registered Nurse (RN) FF at this time, revealed that she was able to find only one heel protector, and did not know for which foot it was used. Observation of the resident's gerichair at this time revealed that it had no cushion in the seat. During interview with the RN hospice nurse FF on 06/03/16 at 11:01 a.m., she stated that staff found the resident's other padded heel boot in the closet. Upon further interview, she stated that the resident was usually up in the gerichair during the six weeks she had worked with the resident, and she did not recall the resident ever wearing heel protection. During interview with Certified Nursing Assistant (CNA) TT on 06/03/16 at 12:28 p.m., revealed that she knew what a resident's care needs were by looking in the computerized system. Review of the CNA care sheet in the computerized system revealed that skin care interventions for the resident included turning and repositioning and moisture barrier, but no interventions for heel protection or any cushion for the seat of the gerichair. During interview with the LPN Unit Manager DD on 06/03/16 at 12:35 p.m., revealed that skin assessments were completed weekly by the charge nurses, and documented in the computerized system under Assessments. Upon further interview, she stated that they didn't necessarily put things like seat cushions or heel protectors on the computerized care sheets for the CNA's, and verified there was nothing on the resident's care sheet for heel protection or a seat cushion. During observation on 06/03/16 at 3:20 p.m., the resident was in a reclining gerichair in the hall, and there was no cushion in the seat of the gerichair, nor any heel protection on. This was verified during interview with LPN Unit Manager DD at this time, who stated that she would definitely expect a seat cushion if the resident was in a wheelchair, but not for the seat of a gerichair as the seat was already soft. Review of the resident's care plan revealed a problem statement of an unstageable pressure ulcer to the right buttock. Review of the interventions for this care plan revealed an intervention to conduct weekly skin inspections, and to provide a pressure-reducing wheelchair cushion. Review of the computerized patient care documentation system revealed that there was no documentation that skin assessments were performed between 04/06/16 to 05/04/16, nor between 05/25/16 and 06/03/16 (there were four missing assessments since admission on 04/13/16, 04/20/16, 04/27/16, and 06/01/16). This was confirmed during interview with LPN GG on 06/03/16 at 3:28 p.m. Review of the facility's Weekly Skin Review noted that a skin review will be completed weekly on all residents to check for any new skin issues not previously identified. Review of the facility's Skin Integrity Guidelines policy noted that if there was a decline in skin integrity, pressure redistribution surfaces will be reviewed for appropriateness and implemented as indicated by the individualized plan of care. If identified at risk or with actual alterations in skin integrity of feet, footwear will be addressed for fit and appropriateness. Licensed nurse will be responsible for performing a skin evaluation/observation weekly. During interview with LPN Treatment Nurse EE on 06/03/16 at 4:00 p.m., she stated that she did not know what may have caused the resident's heel blister, but that for a resident with a heel wound they should have heel protection. During further interview, revealed that she thought that a pressure-reduction cushion in the seat of the gerichair would be beneficial for the resident.",2020-09-01
440,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2016-06-03,315,D,0,1,93KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to secure a Foley catheter tubing to prevent tension on the insertion site for one (1) resident (#426). The sample size was thirty-four (34) residents. Findings include: Review of resident #426's physician's orders [REDACTED]. Review of a care plan for potential or actual urinary tract infection [MEDICAL CONDITION], related to a history of chronic UTI's and use of an indwelling catheter, revealed an intervention to secure the catheter and tubing appropriately. During observations of wound care on 06/02/16 at 9:55 a.m., the tubing of the resident's urinary catheter was observed to not be secured to the leg in any manner. During further observations at this time, the catheter tubing was noted to be pulled taught under her buttocks and between her bottom leg and the mattress when the resident was turned to the left side during the dressing change. During observations of wound care on 06/03/16 at 9:47 a.m., the urinary catheter tubing was again noted to not be secured to the leg in any manner. During observation and interview with Licensed Practical Nurse (LPN) Unit Manager DD on 06/03/16 at 10:37 a.m., she stated that any resident with a catheter should have it secured with a catheter strap, and verified that the resident's catheter tubing was not secured in any way. During further observation and interview, the Unit Manager obtained a catheter anchor and secured the catheter tubing to the resident's left inner thigh, and stated that any staff who saw that there was no catheter strap, whether a Certified Nursing Assistant (CNA) or nurse, should apply one. Review of the facility's Catheter Care, Indwelling Catheter policy and procedure noted to ensure that the catheter was anchored using a strap or other anchoring device.",2020-09-01
441,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2016-06-03,329,D,0,1,93KK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to monitor behavioral symptoms or side effects for one (1) resident (#423) with behavioral disturbances that was administered an antipsychotic medication of the sampled thirty-four (34) residents Findings include: Record review for Resident #423 indicated an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] documented in Section E: Behaviors - that the resident exhibited physical and verbal behaviors one (1) to three (3) days during the assessment period that put the resident at significant risk for physical illness or injury. Review of Physician order [REDACTED].#423 was to be administered [MEDICATION NAME] Tablet 10 milligrams (mg,) Give 5 mg by mouth two times a day for behaviors. On 04/05/16 this order was discontinued and the current order was written on 04/05/16 for administration of [MEDICATION NAME] Tablet 5 mg, Give 1 tablet by mouth two times a day related to [MEDICAL CONDITION] Due To Known Physiological Condition. Review of the Medication Administration Records (MAR) from 03/24/16 through 06/03/16 indicated the [MEDICATION NAME] was administered as ordered. There was no evidence of monitoring for behavioral symptoms or medication side effects. Review of the Psychiatric consultation dated 04/25/16 documented there was no change for medications. The goals were to decrease agitation and there was poor rehabilitation potential. Review of electronic Nurses Notes from 03/24/16 through 06/03/16 revealed inconsistent documentation of behavioral symptoms and no documentation of the presence or absence of side effects from the antipsychotic medication. Review of the corporate policy Antipsychotic Medication Review documented behaviors are to be monitored and documented on a behavior sheet that is easily accessible and Nurses Notes are to record side effects. Interview on 06/03/16 at 9:00 a.m. with Certified Nursing Assistant (CNA) JJ revealed Resident #423 has had the behaviors of hitting, kicking, and cursing since admission. Interview on 06/03/16 at 2:30 p.m. with the second floor Unit Manager, Licensed Practical Nurse (LPN) DD confirmed behavioral and side effect monitoring has not been provided for Resident #423 since admission. The Unit Manager indicated this was the policy for any resident on an antipsychotic medication and is initiated in the physician orders [REDACTED]. The Unit Manager revealed the behavioral monitoring and side effects are to be recorded every shift on the Medication Administration Record (MAR.) Continued interview revealed that if the behaviors and side effects were not recorded on the MAR then they were not monitored. Interview on 06/03/16 at 3:13 p.m. with the Director of Nurses (DON) confirmed there had been no monitoring of behaviors or side effects of antipsychotic medications administered to Resident #423 since admission on 03/24/16, according to the policy Antipsychotic Medication Review. The DON acknowledged the monitoring was to be recorded on the MAR and there was no evidence of monitoring on the MAR. The DON revealed the monitoring of behaviors and side effects should be initiated by the Unit Manager, and the monitoring should be recorded each shift by the licensed staff.",2020-09-01
442,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2016-06-03,371,E,0,1,93KK11,"Based on observation, record review, and staff interview, the facility failed to consistently cover or seal, and/or label and date food items in the walk-in cooler, walk-in freezer, and dry storage. In addition, the facility failed to check the internal temperature of a food served from the tray line in the Bistro dining room at one (1) meal observed. There were a total of 187 residents that consumed an oral diet. Findings include: 1. During observations in the walk-in freezer on 05/31/16 at 12:00 p.m., an uncovered tray of individual scoops of ice cream in bowls were noted. During further observations, there were opened bags of french fries and carrots, with no open date, and the bags were not tied or sealed leaving the contents open to air. During further observations, there was an opened box of ravioli that was not dated. In addition, there was an open bag of tater tots and a second bag of french fries that were not labeled or dated. These observations were verified by the Dietary Manager at this time, who had to identify the contents of the tater tots and fries by opening the plastic wrapping. During continued observations at this time in the walk-in cooler, there was a bag of Polish sausage that was open but not labeled with the open date, and the bag was not closed with the contents open to the air. In addition, there was a box of patty sausage and a box of link sausage, and the bags inside the boxes had been opened but neither one secured closed, exposing the meats to air. These observations were confirmed by the Dietary Manager at this time, who stated the bag of Polish sausage needed to be sealed, dated and labeled. During further interview, he stated the tops of the bags of link and patty sausage should be rolled over to enclose them. During continued observations in the dry storage room, an opened package of cheesecake mix and one of brownie mix were noted with no open date. This was verified during interview with the Dietary Manager at this time, who stated that the mixes were good for thirty days after opening, and should be labeled. Review of facility policies revealed the following: Storage of Frozen Foods: Properly reseal packages of frozen foods that have been opened to prevent freezer burn and spoilage. Freeze extra portions in small, airtight packages for quick freezing, all items must be labeled with specific product name, date frozen and use by date. Storage of Refrigerated Foods: Foods Storage: Store all extra portions in sealed shallow (2 inches deep), approved containers. Label, note use by date and refrigerate immediately. Do not re-use disposable or non-approved plastic containers for storage after food is emptied out of its original container. Use only sealed airtight approved containers. All items not stored in original container must be labeled and noted with use by date according to storage chart, used or discarded within allowed days. 2. During observation of steam table temperatures (temps) in the first floor Bistro dining room taken by the Dietary Manager using the facility's calibrated thermometer on 06/02/16 at 12:04 p.m., the temps taken of two different chicken tenders were noted to be 128 degrees and 130 degrees. During interview with the Dietary Manager at this time, he stated that the temps should be taken for all the food items when placed on the steam table. Review of the Food Temperature Log for lunch on 06/02/16 noted that the temperature of the chicken tenders had not been recorded. During interview with dietary employee II on 06/03/16 at 1:16 p.m., she stated that the Bistro dining room was usually full with 33 to 37 residents. During interview with dietary employee HH on 06/02/16 at 4:15 p.m., she stated that any item placed on the steam table should have the temperature recorded on the temp log, and verified that the chicken tenders were not recorded on the log at lunch that day, and should have been. During interview with the Dietary Manager on 06/03/16 at 1:18 p.m., he stated that the chicken tenders on the tray line at lunch in the Bistro dining room on 06/02/16 were not generally kept on hold at the steam table as they were an alternate, but only prepared at the time a resident requested them. Review of the facility's policy on Infection Control-Holding and Serving noted: Monitoring of the temperature by Dining Services workers while food is on the steam table is essential. Holding temperatures of all hot and cold items must be taken and recorded after full preparation and immediately before starting meal services. Record a temperature for each food item on the meal line on the appropriate form.",2020-09-01
443,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2016-06-03,456,D,0,1,93KK11,"Based on observation, record review and staff interview, the facility failed to ensure that the walk-in freezer was maintained in proper working condition as evidenced by the build-up of ice on the freezer condenser equipment for one (1) of one (1) walk-in freezers. There was a total of one-hundred and eighty-seven (187) residents who consumed an oral diet. Findings include: During observations on 05/31/16 at 12:00 p.m., a large area of frozen water was noted on a pipe coming from the condenser inside the walk-in freezer. During further observation, shallow pools of frozen water were noted on top of unopened boxes of hush puppies and strawberry shakes. This was confirmed during interview with the Dietary Manager at this time. During interview with the Dietary Manager on 06/02/16 at 12:40 p.m., he stated that all of his kitchen equipment was currently functional except for a steam kettle, and that he would place a computerized work order with the Maintenance Department if he had a problem with a piece of kitchen equipment. During observations in the walk-in freezer at this time, the frozen water from the pipe coming from the walk-in freezer condenser was still present, and there were coatings of ice on top of unopened boxes of French Baguettes and hushpuppies, as well as an open case of strawberry shakes. In addition, observed on the bottom shelf below the condenser, was an open case of cheese pizza. Further observations inside the box revealed that all pizzas were sealed in plastic except for one bag that was open to air and not sealed after opening. Further observations revealed that the bottom of the box contained chunks of ice. This was verified during interview with the Dietary Manager at this time, who stated he did not know if a work order had been placed to fix the leak. Review of a Work Order provided by the Dietary Manager on 06/02/16 at 4:15 p.m. revealed that the work order was submitted on 06/02/16 at 4:04 p.m. for a leak in the freezer with ice build-up. Review of the facility's Storage of Frozen Foods policy noted that freezers must be free of frost or ice buildup.",2020-09-01
444,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-08-30,580,D,1,0,IJ9V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and Physician interview, and review of facility education and policy, the facility failed to notify Physicians of unavailable medications for two (2) residents (R) (R#3 and R#5) from a sample of five (5) residents reviewed for controlled medication administration. Findings include: 1. Record review for R#3 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of Nurse's Progress Notes indicated on 6/25/18 at 7:18 a.m. R#3 did not have a [MEDICATION NAME] Patch applied because it was not available, and the Physician and Pharmacy were notified. On 6/28/18 at 8:31 a.m. Nurse's Notes again indicated R#3 did not have a [MEDICATION NAME] Patch applied pending pharmacy delivery. A physician progress notes [REDACTED].#3 and he was experiencing phantom limb syndrome with pain. On 7/4/18 at 11:53 a.m. Nurse's Progress Notes revealed R# 3 did not have a [MEDICATION NAME] Patch applied because the pharmacy would deliver. On 7/7/18 at 12:48 p.m. a Nurse's Progress Note indicated R#3 did not have a [MEDICATION NAME] Patch applied because the medication was not available. On 7/10/18 at 9:26 a.m. R#3 did not have a [MEDICATION NAME] Patch applied because the pharmacy was to deliver the patch. The Medication Administration Records (MAR's) for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed and the omissions above were confirmed. R#3 had missed five of seven Physician ordered applications of [MEDICATION NAME] Patches from 6/25/18 through 7/10/18. The next [MEDICATION NAME] 72 hour 25 mcg/hr patch applied was on 7/13/18 at 9:00 a.m. An interview conducted on 8/14/18 at 3:58 p.m. with R#3's Physician revealed she was not notified when she came to the facility to see R#3 that there was no prescription for the [MEDICATION NAME] Patch. The Physician revealed the transfer orders from the hospital usually come with the appropriate prescriptions so they can be sent to the Pharmacy immediately. The Physician revealed she visits each floor at the facility twice a week. The Physician confirmed she was unaware R#3 had missed three consecutive applications of the [MEDICATION NAME] Patch. 2. Review of the clinical record for R#5 revealed he was admitted to the facility on [DATE] and was discharged on [DATE]. Resident #5's admission [DIAGNOSES REDACTED]. Review of Physician's Progress Notes for R#5 revealed the Physician had visited on 6/21/18 and R#5 had complained of [MEDICAL CONDITION]. The Physician had written a prescription, dated 6/21/18, [MEDICATION NAME] mg one by mouth at bedtime, and the quantity prescribed was thirty (30). The prescription was on the chart. Review of the Controlled Substance Proof of Use forms for R#5'[MEDICATION NAME] mg tablets revealed the medication was administered as ordered at bedtime until 7/7/18. Review of the Sum of Quantity Shipped sent by the pharmacy that listed every medication dispensed by the pharmacy for R#5, with quantity and date sent, revealed seven (7)[MEDICATION NAME] mg tablets had been sent for R#5 on 6/23/18. Seven [MEDICATION NAME] mg tablets were sent on 6/29/18. This was depleted on 7/6/18. According to the Sum of Quantity Shipped no [MEDICATION NAME] mg tablets had been received by the facility for R#5 until 7/18/18. The pharmacy was contacted for information regarding emergency dispenses for R#5 and on 8/28/18 at 2:22 p.m. sent a list that did not include any emergency dispenses [MEDICATION NAME] R#5 from 7/7/18 through 7/17/18. An interview was conducted with the Physician for R#5 on 8/30/18 at 6:55 p.m. The Physician revealed he usually leaves prescriptions to cover medications at least until the next weeks visit and remembered leaving a prescription for this medication. The Physician acknowledged if he had been notified the pharmacy was not sending this medication he would have told the nurse the prescription was on the chart and to resend it, or authorized an Emergency dispense until the problem could get straightened out. The Physician for R#5 confirmed the nurses usually call if there is a problem obtaining medications for his residents, but he was not aware R#5 was not administered his prescribed sleeping medication for ten days. Review of facility pharmacy policy, dated 12/1/07, titled Medication Shortages/Unavailable Medication, revealed if an emergency delivery is unavailable, facility nurse should contact the attending Physician to obtain orders or directions. If facility nurse is unable to obtain a response from the attending physician/prescriber in a timely manner, facility nurse should notify the nursing supervisor and contact facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage. An interview was conducted with the Unit Manager for R#3 and R#5 on 8/30/18 at 3:00 p.m. The Unit Manager revealed the nurses had not followed the policy to call the Physician when medications were not available. The Unit Manager confirmed that all the nurses administering medications were aware of the policy.",2020-09-01
445,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-08-30,602,E,1,0,IJ9V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of facility policy the facility failed to ensure that controlled medications were free from misappropriation for four (4) residents (R) (R#2, R#3, R#4 and R#6) from a sample of five (5) residents reviewed for controlled medication administration. The facility census was two hundred six (206). Findings include: Review of facility policy titled Abuse and Neglect Prohibition revised (MONTH) (YEAR), revealed each resident has the right to be free from abuse, neglect, mistreatment, injuries of unknown origin, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the residents\'s medical symptoms. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary of permanent use of a resident's belongings or money without the residents consent. The facility Quality Assurance and Performance Improvement (QAPI) Committee will review available data to identify patterns and trends that may indicate the presence of abuse, neglect, mistreatment, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. 1. Review of the clinical record for R#2 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED].#2 had lumbar sacral surgery in the past and had exhausted all options for control of pain and symptoms including exercise, therapy, injections, oral medications and electrical stimulation. On 6/28/18 R#2 had removal of hardware from the second and third lumbar discs and a fusion of the ninth [MEDICATION NAME] disc. Review of the Minimum Data Set (MDS) Brief Interview for Mental Status (BIMS) score completed on 7/24/18 revealed a score of fourteen (14) indicating no cognitive impairment. Review of Physician orders [REDACTED]. [MEDICATION NAME] 1 mg was scheduled on the (MONTH) (YEAR) Medication Administration Record (MAR) to be administered at 9:00 a.m., 1:00 p.m., and 9:00 p.m. Review of the controlled Substance Proof of Use forms for R#2, revealed forty-five (45) [MEDICATION NAME] 1 mg tablets were received from the pharmacy on 7/18/18. The 45 [MEDICATION NAME] were depleted on 8/3/18 at 1:00 p.m. Review of the Sum of Quantity Shipped for R#2 revealed ninety (90) [MEDICATION NAME] 1 mg were sent to the facility on [DATE]. The Physician orders [REDACTED]. Review of the Controlled Substance Proof of Use forms for R#2 revealed there were no Controlled Substance Proof of Use forms for the 90 [MEDICATION NAME] 1 mg tablets. Review of the MAR for (MONTH) (YEAR) revealed [MEDICATION NAME] 1 mg tablet po administrations were documented on 8/4/18 at 9:00 p.m., 8/5/18 at 9:00 a.m., 1:00 p.m., and 9:00 p.m., 8/6/18 at 9:00 a.m., 1:00 p.m. and 9:00 p.m. and on 8/7/18 at 9:00 a.m. These eight (8) administrations should have been documented on the missing Controlled Substance Proof of Use form. There was no documentation to account for eighty-two(82) [MEDICATION NAME] 1 mg tablets. Physician orders [REDACTED]. This order was discontinued on 8/8/18. Review of the pharmacy Sum of Quantity Shipped for R#2 revealed thirty [MEDICATION NAME] IR 15 mg tablets were sent to the facility on [DATE]. Review of the Controlled Substance Proof of Use form revealed the supply of [MEDICATION NAME] IR 15 mg tablets was depleted on 7/31/18 at 5:00 p.m. The Sum of Quantity Shipped revealed 15 [MEDICATION NAME] IR 15 mg were shipped to the facility on [DATE]. There is no Controlled Substance Proof of Use form to account for these 15 [MEDICATION NAME] IR 15 mg. The Sum of Quantity Shipped revealed 15 [MEDICATION NAME] IR 15 mg were sent to the facility on [DATE]. There is no Controlled Substance Proof of Use form to account for these 15 [MEDICATION NAME] IR 15 mg. The Sum of Quantity Shipped revealed 15 [MEDICATION NAME] IR were shipped to the facility on [DATE], the day after the order was discontinued . Review of the (MONTH) (YEAR) MAR for R#2 revealed [MEDICATION NAME] IR 15 mg po every 6 hours prn was administered on 8/1/18 at 4:24 a.m., 9:58 a.m. and 11:00 p.m., on 8/2/18 at 9:12 p.m., 8/3/18 at 5:00 a.m., 8/4/18 at 6:09 a.m. and 8:41 p.m. and 8/5/18 at 8:40 a.m. There is no documentation to account for thirty-seven (37) [MEDICATION NAME] 15 mg tablets. Physician orders [REDACTED]. The order was discontinued on 8/9/18. The MAR for (MONTH) (YEAR) revealed the [MEDICATION NAME] 80 mg 1 po every 8 hours was scheduled for 6:00 a.m., 2:00 p.m. and 10:00 p.m. Review of the Sum of Quantity Shipped for R#2 revealed the pharmacy sent 45 [MEDICATION NAME] 80 mg tablets on 7/17/18. Review of the Controlled Substance Proof of Use forms for R#2 revealed this supply was depleted on 8/2/18 at 6:00 a.m. The Sum of Quantity Shipped revealed 45 [MEDICATION NAME] 80 mg tablets were sent to the facility on [DATE]. There was no Controlled Substance Proof of Use to account for the 45 [MEDICATION NAME] 80 mg tablets sent to the facility on [DATE]. The MAR for (MONTH) (YEAR) included documented administrations of [MEDICATION NAME] 80 mg po tablets on 8/2/18 at 10:00 p.m., on 8/3/18 at 6:00 a.m., 2:00 p.m. and 10:00 p.m., on 8/4/18 at 6:00 a.m., 2:00 p.m., and 10:00 p.m., on 8/5/18 at 6:00 a.m., 2:00 p.m. and 10:00 p.m., on 8/6/18 at 6:00 a.m., 2:00 p.m. and 10:00 p.m., and on 8/7/18 at 6:00 a.m. and 2:00 p.m. There were fifteen (15) administrations of [MEDICATION NAME] 80 mg tablets documented on the (MONTH) (YEAR) MAR . There is no documentation to account for thirty (30) [MEDICATION NAME] 80 mg tablets. An interview conducted with R#2 on 8/13/18 at 11:21 a.m. revealed his medications for pain and anxiety change frequently and he does not try to keep track of his medications. R#2 confirmed the nurses and Physician tell him when his medications change. R#2 revealed he asks for what he wants for pain and anxiety, and the nurses administer one of the medications he has ordered. 2. Review of the clinical record for R#3 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A facility Physicians Progress note dated 6/29/18 at 7:05 p.m. revealed a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed R#2 had moderate cognitive impairment with a BIMS score of ten (10). Review of Physician orders [REDACTED]. Review of the pharmacy Sum of Quantity Shipped revealed on 7/11/18 the pharmacy sent thirty (30) [MEDICATION NAME] 5-325 mg to the facility. Review of the Controlled Substance Proof of Use documented this supply was depleted on 7/17/18 at 9:00 p.m. The Sum of Quantity Shipped revealed 30 [MEDICATION NAME] 5-325 mg were sent for R#3 on 7/19/18. Review of the (MONTH) (YEAR) MAR revealed [MEDICATION NAME] 5-325 mg administrations were documented on 7/20/18 at 8:11 p.m., on 7/22/18 at 8:47 p.m. on 7/24/28 at 7:58 a.m., on 7/24/18 at 7:58 p.m., on 7/25/18 at 4:17 a.m. on 7/25/18 at 10:46 p.m., on 7/28/18 at 8:02 a.m., on 7/28/18 at 10:21 a.m. and on 7/29/18 at 8:27 p.m There was documentation on the (MONTH) (YEAR) MAR to account for eighteen (18) [MEDICATION NAME] 5-325 mg from 7/20/18 at 8:11 p.m. through 7/29/18 at 8:271 p.m. There was no documentation on the (MONTH) (YEAR) MAR to account for twelve (12) of 30 [MEDICATION NAME] 5-325 mg. that were delivered from the pharmacy on 7/19/18. 3. Review of the clinical record for R#4 revealed he was admitted to the facility on [DATE] and discharged for m the facility on 6/14/18. Review of hospital records for R#4 prior to facility admission revealed R#4 had surgery on 3/22/18 to correct contractures of the right foot, ankle and calf muscles, an iliac bone graft, triple arthrodesis and application of a biplane [DEVICE] to the right foot. Physician orders [REDACTED]. The Sum of Quantity Shipped on 5/12/18 indicated 15 [MEDICATION NAME] 10-325 mg were sent to the facility. There was no Controlled Substance Proof of Use to account for the 15 [MEDICATION NAME] 10-325 mg tablets sent from the pharmacy on 5/12/18. There were no administrations of [MEDICATION NAME] 5-325 mg tablets not accounted for on the (MONTH) (YEAR) MAR. Fifteen [MEDICATION NAME] 10-325 mg tablets were missing. 4. Review of the clinical record for R#6 revealed admission to the facility on [DATE]. R#6 was a 3 day respite admission. R#6 had [DIAGNOSES REDACTED]. R#6 was transferred to the hospital on [DATE] and review of the hospital records revealed a [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. Review of the (MONTH) (YEAR) MARs for R#6 revealed the [MEDICATION NAME] 30 mg 1 po every 12 hours was to be administered at 9:00 a.m. and 9:00 p.m. Review of the Sum of Quantity Shipped for R#6 revealed on 8/15/18 fourteen (14) [MEDICATION NAME] 30 mg tablets were sent. There is no Controlled Substance proof of Use form for the 14 [MEDICATION NAME] 30 mg tablets sent on 8/15/18. Review of the (MONTH) (YEAR) MAR for R#6 revealed [MEDICATION NAME] 30 mg po tablet administrations were documented on 8/15/18 at 9:00 a.m. and 9:00 p.m., on 8/16/18 at 9:00 a.m. and 9:00 p.m., Additional [MEDICATION NAME] administrations were documented on the MAR and on another Controlled Substance Proof of Use form that corresponded to [MEDICATION NAME] 30 mg 14 tablets that were received by the facility on 8/16/18. There was no documentation on the (MONTH) MAR or any Controlled Substance Proof of Use form to account for ten (10) [MEDICATION NAME] 30 mg tablets. During an interview conducted on 8/30/18 at 10:15 a.m. regarding the missing Controlled Substance Proof of Use forms for R#2, R#3, R#4 and R#6, the Administrator revealed that the facility had been searching for them since they were first requested on 8/13/18, and had looked everywhere and they could not be found. The Administrator confirmed the facility had not been aware any records were missing and had been unaware that nursing documentation of controlled medication administration had not been monitored by the former Directors of Nursing (DON's). The Administrator revealed she did not check behind the DON and had just expected them to find any discrepancies in documentation and narcotic administration. The Administrator confirmed the consultant pharmacist had been asked to audit controlled medications on her last visit on 8/15/18 due to the surveyor asking about documentation of controlled medication administration. The Administrator confirmed the consultant pharmacist had not been requested to do this before and only monitored controlled medications on request. The Administrator revealed the consultant pharmacist had reported the documentation on the MAR's did not always correspond to the documentation on the Controlled Substance Proof of Use forms, but there was no report of missing medications on the ten residents she audited. The Administrator revealed a District Quality Team visit had audited medication storage and labeling from 6/25/18 to 6/29/18 and had audited the fourth floor for maintaining detailed records of receipt and disposition of controlled medications to enable an accurate reconciliation, and an account of all controlled medications was maintained and periodically reconciled. The second and third floors were not audited for controlled medications. An ad hoc Quality Assurance Performance Improvement meeting was held on 6/29/18 when the District Quality Team left, but no Opportunity for Improvement had been identified regarding controlled medication administration. The District Quality Team and the consultant pharmacist had not identified the possibility of missing controlled medications. During an interview regarding controlled medication reconciliation conducted on 8/30/18 at 3:00 p.m. the Unit Manager of the third floor revealed there has never been a process for facility staff to compare the controlled medications that are delivered from the pharmacy with the Controlled Substance Proof of Use Forms and MARs. The Unit Manager revealed she checks the narcotic count records that are completed at the end of each shift, comparing the amount of medication remaining in the blister pack with the amount remaining on the Controlled Substance Proof of Use forms, to make sure the counts are correct and complete. The Unit Manager revealed there had been no system for keeping track of Controlled Substance Proof of Use forms and they were just stored in boxes and not compared to the MARs or pharmacy delivery information.",2020-09-01
446,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-08-30,684,E,1,0,IJ9V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff, Physician and Nurse Practitioner interviews, and review of facility policy and education, the facility failed to follow Physician orders [REDACTED].#2, R#3, R#4, R#5, and R#6) from a sample of five (5) residents reviewed for administration of controlled substances. Findings include: 1. Record review for R#2 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) Assessment on 7/24/18 revealed a score of fourteen (14), indicating R#2 had no cognitive impairment. Review of admission Physician orders [REDACTED]. The order was discontinued on 8/7/18. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MAR's) from admission to 8/14/18 revealed [MEDICATION NAME] 1 mg was scheduled to be administered at 9:00 a.m., 1:00 p.m. and 9:00 p.m The MAR's were compared with the Controlled Substance Proof of Use records and the following discrepancies were found: On 7/25/18, 7/26/18, 7/27/18, 7/28/18 and 8/2/18 [MEDICATION NAME] 1 mg was initialed on the MAR at 1:00 p.m., but it was not signed out on the Controlled Substance Proof of Use form. The Nurse's Progress notes were reviewed for these dates and the resident was not out of the building or experiencing sedation on these dates, and there was no explanation for why these administrations were omitted. Review of the Nurse's Progress Notes revealed the [MEDICATION NAME] was not available for administration on 8/4/28 at 1:00 p.m. Continued review revealed R#2 did not experience any symptoms of anxiety during the day his [MEDICATION NAME] supply was depleted. Review of the emergency supply dispense log indicates no [MEDICATION NAME] was dispensed on 8/4/18 for R#2. Review of the list given by the pharmacy of medications available for emergency dispense indicated there is a supply of three (3) [MEDICATION NAME] 1 mg available. Resident #2's Physician orders [REDACTED]. Review of the MAR's for these dates indicated [MEDICATION NAME] 80 mg was scheduled at 6:00 a.m., 2:00 p.m., and 10:00 p.m Comparison of administrations recorded on the MAR's and Controlled Substance Proof of Use forms indicated the following: On 7/23/18 the [MEDICATION NAME] 80 mg scheduled at 6:00 a.m. was signed out correctly on the Controlled Substance Proof of Use, and signed out again at 9:00 a.m., then no further [MEDICATION NAME] was signed out until 10:00 p.m. on 7/23/18. The Nurse's Progress notes did not explain why the [MEDICATION NAME] 80 mg was documented administered at 6:00 a.m., 9:00 a.m. and 10:00 p.m. and the 2:00 p.m, dose was omitted. Review of the [MEDICATION NAME] 80 mg Controlled Substance Proof of Use form documented administrations on 7/31/18 at 6:00 a.m., 9:00 a.m. and 10:00 p.m. The 2:00 p.m. dose was omitted. Review of the Nurse's Progress notes for 7/31/18 did not document an explanation for why the [MEDICATION NAME] 80 mg was not administered every 8 hours as ordered. On 8/1/18 [MEDICATION NAME] 80 mg was signed as administered at the correct times on the MAR, 6 a.m., 2:00 p.m., and 10:00 p.m., but on the Controlled Substance Proof of Use form an extra [MEDICATION NAME] 80 mg was signed out at 9:00 a.m. There were no symptoms of sedation recorded in the Nurse's Progress Notes, or changes in the vital signs recorded on the MAR, that day. Review of Physician orders [REDACTED]. The MAR's and Controlled Substance Proof of Use forms for these dates were reviewed and compared as follows: On 7/23/18 at 6:00 a.m., 8:00 a.m. and 10:00 p.m., 7/27/18 at 1:00 p.m. and 7/28/18 at 6:00 a.m. and 12:00 a.m., [MEDICATION NAME] IR 15 mg was signed out on the Controlled Substance Proof of Use form, but not recorded on the MAR or the Nurse's Progress Notes. Review of Physician orders [REDACTED]. The MAR indicated the Modafinil was scheduled for 6:00 a.m. Review of the Controlled Substance Proof of Use form for Modafinil revealed it was signed out twice at 6:00 a.m. On 7/28/18. Review of R#2's vital signs, taken twice a day did not reveal any increase in heart rate or blood pressure on 7/28/18. Review of the Nurse's Progress Notes for 8/28/18 did not reveal any excitability or agitation on 7/28/18. An interview regarding medication administration was conducted with R#2 on 8/13/18 at 11:21 a.m. R#2 revealed the nurses tell him when his medications change, but he has so many medication changes and adjustments that he can not keep it all straight. R#2 revealed he was told one or two of his medications were out but the nurse gave him something else and he did not experience any problems that he can recall and is administered his medications as ordered as far as he knows. 2. Review of the clinical record for R#3 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. A BIMS assessment dated [DATE] indicated R#3 had mild cognitive impairment, with a score of ten (10). Review of Physician orders [REDACTED]. Review of the MAR for R#3 for 6/21/18 through 8/14/18 revealed the [MEDICATION NAME] Patch was scheduled to be removed and a new patch applied every 3 days at 9:00 a.m. Pharmacy Sum of Quantity Shipped records revealed one (1) [MEDICATION NAME] was shipped on 6/21/18, and five (5) patches were shipped on 7/12/18, 7/26/18, and 8/13/18. The emergency box dispense record revealed an emergency box dispense was initiated on 6/21/18 at 8:00 p.m., but no patch was removed. Continued review of the (MONTH) (YEAR) and (MONTH) (YEAR) MAR's, compared to Controlled Substance Proof of Use forms for R#3 revealed a [MEDICATION NAME] was applied at 6:00 a.m. on 6/22/18. The MAR for (MONTH) (YEAR) did not document a [MEDICATION NAME] 72 hr 25 mcg/hr patch was applied as ordered on [DATE] and 6/28/18. Nurse' Progress Notes and Sum of Quantity Shipped indicate there was no [MEDICATION NAME] Patch available for R#3 on these dates. The MAR for (MONTH) (YEAR) documents a patch was applied on 7/1/18, but there is no [MEDICATION NAME] Patch signed out on a Controlled Substance Proof of Use form and there was no record the emergency supply was accessed, and no indication the pharmacy shipped [MEDICATION NAME] Patches for R#3 until 7/12/18. The (MONTH) (YEAR) MAR revealed no patch was applied on 7/4/18, 7/7/18, or 7/10/18, as ordered. The [MEDICATION NAME] application was not documented on the (MONTH) (YEAR) MAR again until 7/13/18. R#3 had no [MEDICATION NAME] for nine days. Nurse's Progress Notes indicate on 6/25/18, the [MEDICATION NAME] Patch was not available, and the pharmacy was contacted and told the nurse that a prescription was needed. There is no indication the Physician was notified of the need to transmit a prescription. On 6/28/18 at 8:31 a.m. a nurse's note indicated the [MEDICATION NAME] was pending pharmacy delivery. There was no indication the Physician was notified. On 6/29/18 the Progress Notes indicate the residents Physician, who is also the Medical Director, examined R#3 and entered notes at 7:05 p.m., with a [DIAGNOSES REDACTED]. The Nurse's Progress Notes indicate on 7/7/18 at 12:49 p.m. the [MEDICATION NAME] Patch was not available, with no indication of any action taken. The Nurse's Progress Notes on 7/10/18 at 9:26 a.m. reveal the [MEDICATION NAME] Patch was to be delivered, with no reference to any action taken. A [MEDICATION NAME] Patch was scheduled to be applied on 7/28/18 at 8:59 a.m. and the (MONTH) (YEAR) MAR indicated no [MEDICATION NAME] applied on that date. The Nurse's Progress Notes indicated on 7/28/18 at 12:02 p.m. that R#3 was not in his room. The next [MEDICATION NAME] Patch application was documented on the MAR on 7/31/18. Review of Physician order [REDACTED]. Controlled Substance Proof of Use forms revealed R#3 had an order for [REDACTED]. An interview with R#3 regarding the administration of his pain medications, conducted on 8/14/18 at 8:10 a.m. revealed he did not remember the nurses telling him he had run out of any of his medication, and he is asked by the nurses if he has pain three or four times a day and if he indicates he has pain they will give him a pain pill. R#3 revealed the pain pills are effective, but his amputation is healing now and hurts less than when he first was admitted here. An interview was conducted with the Physician for R#3, regarding administration of [MEDICATION NAME] Patches for R#3, on 8/14/18 at 3:58 p.m. revealed she had not been made aware R#3 had not received [MEDICATION NAME] Patches as ordered on [DATE], 6/28/18, 7/4/18, 7/7/18, and 7/10/18. The Physician revealed the hospitals almost always send prescriptions for the medications on the transfer orders, such as the [MEDICATION NAME] Patch. The Physician confirmed she comes to the facility at least twice a week and no one told her R#3 did not have any [MEDICATION NAME] Patches for 3 consecutive applications, and the pharmacy needed a prescription. The Physician confirmed if she is called about a resident running out of a controlled medication she will transmit a prescription to the pharmacy as soon as possible. The Physician revealed she was aware the resident was receiving another pain medication as needed and not having the [MEDICATION NAME] did not result in any increased pain. The Physician acknowledged the emergency supply box did have a supply of [MEDICATION NAME] Patches and she had not received any requests for authorization to access the emergency supply. The Physician indicated the nurses usually do notify her if a resident has run out of medication. 3. Review of the clinical record for R#4 revealed admission to the facility on [DATE] and discharge from the facility on 6/14/18, with [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. The MAR's indicated the medication was scheduled for 9:00 a.m., 1:00 p.m. and 9:00 p.m. until 5/2/18, when it was rescheduled for 9:00 a.m., 1:00 p.m. and 5:00 p.m. until discharge on [DATE]. Review of the MAR's from 3/29/18 through 6/14/18, compared with the Controlled Substance Proof of Use records and Nurse's Progress Notes for (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed the following: On 4/14/18 at 9:00 p.m. Nurse's Progress Notes indicate the [MEDICATION NAME][MEDICATION NAME] was not administered and the pharmacy was to deliver. On 4/20/18 Nurse's Progress Notes revealed the [MEDICATION NAME][MEDICATION NAME] was not administered and the pharmacy was notified. The Controlled Substance Proof of Use record revealed [MEDICATION NAME][MEDICATION NAME] was not documented as administered on 5/6/18 at 5:00 p.m., 5/7/18 at 5:00 p.m., 5/9/18 at 5:00 p.m., and 5/10/18 at 5:00 p.m. Administrations were all documented as administered on the MAR. On 5/11/18 two [MEDICATION NAME][MEDICATION NAME] were documented administered at 8:00 a.m. Nurse's Progress Notes do not account for missing these administrations. On 5/9/18 at 8:20 p.m. Nurse's Progress Notes revealed the [MEDICATION NAME][MEDICATION NAME] was not documented as administered because R#4 was off the unit. On 5/17/18 [MEDICATION NAME][MEDICATION NAME] 20 mg was signed off on the Controlled Substance Proof of Use form at 9:00 a.m. and 5:00 p.m., indicating the 1:00 pm dose was not signed off, however it was documented as administered on the (MONTH) (YEAR) MAR. There are no Nurse's progress notes to account for missing this administration. On 6/12/18 the Controlled Substance Proof of Use form indicated the 5:00 p.m. [MEDICATION NAME][MEDICATION NAME] was not signed out at 5:00 p.m. There is no initial on the MAR at 5:00 p.m. and there is no nursing documentation to indicate why this administration was omitted. An interview was conducted with the Physician of R#4 regarding administration of [MEDICATION NAME][MEDICATION NAME] on 8/29/18 at 5:07 p.m. The Physician revealed he had not been aware of R#4 running out of [MEDICATION NAME][MEDICATION NAME], and that he had left prescriptions to cover R#4's stay at the facility, so there was no reason for him to run out. The Physician revealed that the omitted administrations would have indicated the order for administration of the [MEDICATION NAME][MEDICATION NAME] had not been followed. The Physician confirmed that the nurses usually call when medications are not administered. The Physician revealed the [DIAGNOSES REDACTED]. The Physician also revealed the resident had insisted he was prescribed this medication to be taken at 9:00 a.m., 1:00 p.m. and 9:00 p.m. but the Physician had changed the evening time of administration to 5:00 p.m. after about a month due to the resident requesting additional sleeping medication. An interview was conducted on 8/30/18 at 3:45 p.m. with Licensed Practical Nurse (LPN) FF regarding administration of [MEDICATION NAME][MEDICATION NAME] for R#4. LPN FF revealed she had been assigned to give medication for R#4 on 5/6/18, 5/10/18 and 5/18/18 and acknowledged the Controlled Substance Proof of Use form indicated the [MEDICATION NAME][MEDICATION NAME] had been signed out twice on those dates, missing the 5:00 p.m. administrations, and the medication was ordered three times a day. The LPN then revealed that if the medication is ordered three times a day, then she gives it three times a day. LPN FF could not account for how the narcotic count came out correct if she gave the medication more times than she signed it out. 4. Review of the clinical record for R#5 revealed admission to the facility on [DATE]. R#5 was discharged to the hospital on [DATE]. The admission [DIAGNOSES REDACTED]. The BIMS admission assessment score for R#4 on 6/21/18 was ten (10), indicating moderate cognitive impairment. Review of Physician orders [REDACTED]. A signed prescription was on the chart for thirty (30)[MEDICATION NAME] mg. R#5 was also prescribed [MEDICATION NAME] 6 mg by mouth at bedtime on 6/21/18 , and this was discontinued on 6/27/18. Review of the MAR for (MONTH) (YEAR) and (MONTH) (YEAR), compared with Pharmacy Sum of Delivery sheets, emergency dispense log, Nurse's Progress Notes and Controlled Substance Proof of Use forms, indicate as follows: A Nurse's Progress Note, dated 7/8/18, time 10:56 p.m. indicated [MEDICATION NAME] mg was not available. Additional Nurse's Progress notes dated 7/9/18, 7/11/18, 7/15/18 and 7/16/18 [MEDICATION NAME] mg was not available. Sum of Delivery sheets from the Pharmacy indicate [MEDICATION NAME] sent for R#5 from 6/29/18, when seven (7) were sent, through 7/17/18, when [MEDICATION NAME] mg were sent to the facility, and delivered on 7/18/18. There were no emergency dispenses during these dates. Review of a list sent from pharmacy of medications available for emergency dispense [MEDICATION NAME] mg was available. The list of available medications in the emergency dispense system included [MEDICATION NAME] mg. The MAR [MEDICATION NAME] mg was administered as ordered at bedtime on 7/12/18, 7/13/18, 7/14/18, and 7/17/18 but there was [MEDICATION NAME] by the Pharmacy until 7/18/18. On 6/29/18 the Physician for R#5 gave an order for [REDACTED]. Four [MEDICATION NAME] were removed from the emergency box for R#5 at 1:00 p.m. on 6/29/18. Three (3) [MEDICATION NAME] were administered from the emergency supply on the MAR on 6/30/18 at 12:00 p.m., 6:00 a.m. and 12:00 a.m. The next administration was signed off on the Controlled Substance Proof of Use form on 6/30/18 at 6:00 p.m. On 7/2/18 and 7/7/18 at 12:00 p.m. the [MEDICATION NAME] was documented administered on the MAR, but not signed out on the Controlled Substance Proof of Use form. On 7/10/18 the 12 a.m. was not signed out on the Controlled Substance Proof of Use form until 3:00 p.m. and none signed out at 6:00 p.m. The Physician for R#5 was interviewed on 8/30/18 at 6:55 p.m. regarding administration [MEDICATION NAME] for R#5, and indicated he had left a prescription [MEDICATION NAME] would have covered all the dates of his stay at the facility, and there was no reason for this medication to not be administered as ordered. The Physician had not been notified the medication was not administered as ordered from 7/8/18 through 7/18/18. The Physician indicated the nurses usually call when medications run out, but he had not been notified about the Ambien, and would have authorized the use of the supply in the emergency box if someone had told him. The Physician revealed he had ordered the [MEDICATION NAME] every 6 hours around the clock because the family had indicated to him the resident would not complain of pain to anyone but the family, and he expected it to be given the way he ordered it unless there was a good reason. An Interview with LPN HH was conducted on 8/30/18 at 6:45 p.m. regarding administration of [MEDICATION NAME] for R#5. LPN HH reviewed the Nurse's Progress Notes and MAR's for 7/15/18 and 7/16/17 and revealed she was medication nurse for R#5 on those nights. LPN HH revealed she could not remember why she did not get an authorization code to access the emergency box [MEDICATION NAME] R#5 on those nights but is sure she notified the pharmacy when she discovered he had run out of his sleeping medication and the pharmacy had not sent any more. LPN HH revealed sometimes the Pharmacy does not keep the emergency box supplied with all the medications and they run out there as well. 5. Record review for R#6 revealed he was admitted to the facility on [DATE] and was discharged to a hospital on [DATE]. Admission [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated the [MEDICATION NAME] was documented as administered at 9:00 a.m. and 9:00 p.m. on 8/15/18, 8/16/18, and 8/17/18. The MAR indicated [MEDICATION NAME] was refused by the resident at 9:00 a.m. on 8/18/18, and was documented as administered at 9:00 p.m. The emergency dispense log indicated there were no dispenses for R#6. The Pharmacy dispense records indicated [MEDICATION NAME] 30 mg had been sent to the facility three times, on 8/15/18 fourteen (14) were sent. On 8/16/18 thirty [MEDICATION NAME] 30 mg and an additional fourteen were sent. The facility was able to find two Controlled Substance Proof of Use forms, for the [MEDICATION NAME] filled by the pharmacy on 8/16/18, for the cards of 30 and 14. There was no Controlled Substance Proof of Use form for the card of 14 [MEDICATION NAME] sent on 8/15/18. The Controlled substance Proof of Use form for 14 [MEDICATION NAME] was reviewed and had 2 signed out, one on 8/17/18 at 9:00 p.m and one on 8/18/18 at 9:00 p.m. There were no Nurses Progress Notes indicating administration of this scheduled medication during his stay at the facility. An interview was conducted with the Nurse Practitioner (NP) for R#6 regarding administration of [MEDICATION NAME] for R#6. The NP revealed she did not see R#6 in obvious pain and had not been informed if there were any problems obtaining or administering the [MEDICATION NAME] as ordered. An interview was conducted with LPN FF on 8/28/18 at 12:45 p.m. LPN FF confirmed she was medication nurse for R#6 on day shift 8/17/18 and was giving medications with a new nurse to R#6. on 8/18/18 on day shift. LPN FF was not able to remember if she had given the [MEDICATION NAME] to R#6. LPN FF revealed she remembers assessing him for pain on 8/17/18 and 8/18/18 and he was not showing any signs of pain and denied being in pain. Review of Pharmacy Policy titled Medication Shortages/Unavailable Medications dated 12/1/07, revealed that upon discovery that the facility has an inadequate supply of a medication the facility staff should immediately initiate action to obtain the medication from pharmacy. The facility nurse should call pharmacy to determine the status of the order. If the medication has not been ordered, the licensed facility nurse should place the order, or reorder for the next scheduled delivery. If the next available delivery causes delay or a missed dose in the resident's medication schedule, the facility nurse should obtain the medication from the Emergency Medication Supply to administer the dose. If the ordered medication is not available in the Emergency Medication Supply the licensed facility nurse should call the pharmacy's emergency answering service and request to speak with the registered pharmacist on duty to manage the plan of action. When a missed dose is unavoidable the facility nurse should document the missed dose and the explanation for such missed dose on the MAR or TAR and in the nurse's notes per facility policy. Education records were reviewed for Medication re-ordering, presented to nurses on 4/25/18, 6/19/18, 6/21/18, and 8/14/18. Education included instructions to reorder medications when there are 3-5 days supply remaining, and to fax or transmit the order to pharmacy and call if the cut off time to reorder the medication has been missed and let them know the time the resident needs the medication. When removing a controlled substance from the emergency box the nurse should document removal on the appropriate usage form. Rosters for the education were reviewed and LPN FF signed the roster on 8/14/18. LPN HH had not signed any education roster for this education An interview was conducted with the Unit Manager for the 3rd floor on 8/30/18 at 3:00 p.m. regarding medication documenetaion and administration discrepancies and the above discrepancies were reviewed. The Unit manager acknowledged there had been no process to review administrations of controlled medications by comparing Controlled Substance Proof of Use Forms to the MAR's and Nurse's Progress Notes, and that the medications had not been administered according to Physician orders. The Unit Manager confirmed that the nurses had not followed education given on 4/25/18, 6/20/18 and 8/14/18, which included the Pharmacy Policy for obtaining missing medications from the emergency dispense system, ordering medications and reordering medications. The Unit Manager revealed she was sure all nurses working on the 3rd floor had been educated on the policy and procedures for the emergency dispense system, ordering and reordering medications, either in one of the classes or in orientation. The Unit Manager revealed medication Omission Reports have been checked for each resident every day since 7/25/18, but the nurses use a code that indicates an explanation is included in a progress note on the MAR, then do not document anything in the progress note related to the medication administration. The Unit Manager revealed that prior to 7/25/18 she had printed a paper copy of every resident's MAR, every day, and tried to find missing documentation and administration omissions but thinks she may have missed many omissions and concerns regarding lack of documentation. Cross Refer to F580, F755, F842, F602",2020-09-01
447,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-08-30,755,E,1,0,IJ9V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and review of pharmacy contract, the facility failed to provide medications to meet the needs of three (3) residents (R), (R#3, R#4, and R#5) from a sample of five (5) residents reviewed for administration of controlled medications. Findings include: Review of Pharmacy Products and Services Agreement, dated 4/8/18 and signed by Senior Legal Counsel for the pharmacy on 4/9/18, revealed the pharmacy was responsible to provide Pharmacy Products to Facility and its residents in a prompt and timely manner in compliance with applicable local, state and federal law, rules and regulations. 1. Clinical record review for R #3 revealed admission to the facility on [DATE]. The admission orders [REDACTED]. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR for (MONTH) (YEAR) indicated one patch was applied as ordered on [DATE], then no patch applied on 7/4/18, 7/7/18 or 7/10/18. Review of the pharmacy Sum of Quantity Shipped revealed one patch was shipped on 6/21/18, then five (5) patched were shipped on 7/12/18. The emergency box dispense log revealed access for the [MEDICATION NAME] Patch for R#3 was initiated on 6/21/18 at 8:00 p.m. but there was no patch removed. There were no other attempts to obtain [MEDICATION NAME] Patches from the emergency supply for R#3. Nurse's Progress Notes were reviewed and indicated the pharmacy was contacted on 6/25/18 at 7:18 a.m. the [MEDICATION NAME] Patch was not available. The Notes indicated a prescription was needed. There was no notification of the Physician documented. The Nurse's Progress Notes indicated the [MEDICATION NAME] Patch was pending pharmacy delivery on 6/28/18 at 8:41 a.m. The Progress Notes revealed the Physician visited R#3 on 6/29/18 at 7:05 p.m. but do not document notifying the Physician that a prescription for [MEDICATION NAME] Patched was needed. The Nurses Progress Notes revealed on 7/4/18 at 11:53 a.m., 7/7/18 at 12:49 p.m. and 7/10/18 at 9:26 a.m. the [MEDICATION NAME] Patch was pending pharmacy delivery, with no indication of any actions related to obtaining [MEDICATION NAME] Patches for R#3. 2. Review of the clinical record for R#4 revealed an admission physician's orders [REDACTED]. Review of the MAR for (MONTH) (YEAR) revealed [MEDICATION NAME][MEDICATION NAME] administrations were omitted on 4/14/18 at 9:00 p.m. and 4/20/18 at 9:00 p.m. Review of Nurse's Progress Notes for R#4 revealed on 4/14/18 at 10:42 p.m. the pharmacy was to deliver [MEDICATION NAME][MEDICATION NAME] for R#4. No pharmacy delivery records were available prior to 4/23/18. Nurse's Progress Notes on 4/20/18 at 8:24 p.m. revealed the nurse had notified the pharmacy the [MEDICATION NAME][MEDICATION NAME] was not available. Review of the Controlled Substance Proof of Use forms for these dates was not possible because the forms were missing. 3. A review of the medical record review for R#5 revealed an order dated 6/21/18 [MEDICATION NAME] mg one (1) by mouth (po) at bedtime (hs). Nurse's Progress note, written 7/8/18 at 10:56 p.m. indicated [MEDICATION NAME] not available. Nurse's Progress notes on 7/9/18 at 7:23 p.m. and 7/11/18 at 8:39 p.m., 7/15/18 at 8:57 p.m. and 7/16/18 at 9:18 p.m. [MEDICATION NAME] not available. Review of the Sum of Quantity Shipped, received from pharmacy, revealed on 6/29/18 the pharmacy sent seven (7)[MEDICATION NAME] the facility for R#5. The Controlled Substance Proof of Use forms for R#5 indicated the facility's supply [MEDICATION NAME] mg for R#5 was depleted on 7/7/18. According to the Sum of Quantity Shipped no [MEDICATION NAME] sent to the facility for R#5 until 7/17/17. A review of the emergency dispense log sent by the pharmacy revealed there were no emergency dispenses [MEDICATION NAME] R#5 between 7/8/18 and 7/18/18. The list of medications available for emergency dispense by the facility included ten (10)[MEDICATION NAME] mg tablets. An interview conducted on 8/30/18 at 3:00 p.m. with the Unit Manager for R#3, R#4 and R#5, after reviewing their Nurse's Progress Notes, Sum of Quantity Shipped forms, emergency dispense logs, and Controlled Substance Proof of Use forms revealed the facility had exhausted supplies of medications for R#3, R#4, and R#5 and had not taken the necessary steps to obtain the above medications without missing administrations. The Unit Manager revealed nursing education had been provided three times, giving the detailed steps for obtaining medications that were not available, and the nurses had not followed these instructions. Cross Refer to F580, F684, F602, F865 and F842",2020-09-01
448,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-08-30,842,E,1,0,IJ9V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and review of facility policy, the facility failed to maintain complete and accurate clinical records, related to missing Controlled Substance Proof of Use forms for four (4) residents (R), (R#2, R#3, R#4, and R#6) from a sample of five (5) residents reviewed for administration of controlled substances. Findings include: Review of facility policy titled Medical Record Management date (MONTH) 2005, revealed the facility must maintain medical records on each resident, in accordance with accepted professional standards and practice and state and federal law. Medical records must be complete, accurately documented, readily accessible, systematically organized and maintained in a safe and secure environment. A complete medical record contains an accurate and functional representation of the resident's actual experience in the facility. 1. Review of the clinical record for R#2 revealed admission to the facility on [DATE] with orders for [MEDICATION NAME] 1 mg by mouth three times a day. Review of the Controlled Substance Proof of Use forms revealed from 8/3/18 until the medication was discontinued on 8/7/18, there is no Controlled Substance Proof of Use form to account for the administrations documented on the Medication Administration Record (MAR) on 8/3/18 at 9:00 p.m., 8/4/18 at 9:00 p.m. 8/5/18 at 9:00 a.m. 1:00 p.m. and 9:00 p.m., 8/6/18 at 9:00 a.m., 1:00 p.m. and 9:00 p.m. and at 8/7/18 at 9:00 a.m. Review of a list sent by the Pharmacy titled Sum of Quantity Shipped revealed on 8/7/18 ninety (90) [MEDICATION NAME] 1 mg were sent to the facility, and there was no Controlled Substance Proof of Use form for this 90 [MEDICATION NAME] 1 mg dated 8/7/18. According to the (MONTH) (YEAR) MAR nine administrations should have been documented on the missing Controlled Substance Proof of Use form. R#2 had an order dated 7/17/18 for [MEDICATION NAME] Instant Release 15 mg one tablet by mouth every six (6) hours as needed. Review of the Sum of Quantity Shipped for [MEDICATION NAME] Instant Release (IR)15 mg for R#2 indicated on 7/31/18, 8/1/18 and 8/9/18 fifteen (15) tablets were sent each time to the facility. After 7/31/18 there were no Controlled Substance Proof of Use forms to account for administrations of this medication, which was administered eight times from 8/1/18 until it was discontinued on 8/8/18. The emergency dispense log was reviewed and no [MEDICATION NAME] IR 15 mg was dispensed for R#2. The missing Controlled Substance Proof of Use form would have accounted for eight of 45 [MEDICATION NAME] IR 15 mg. Review of Physician orders [REDACTED]. Review of the Sum of Quantity Shipped for [MEDICATION NAME] 80 mg for R#2 indicated on 7/26/18 the pharmacy filled an order for [REDACTED]. Review of the MAR revealed from 8/2/18 at 2:00 p.m. until 8/7/18 at 2:00 p.m. the [MEDICATION NAME] 80 mg was documented as administered sixteen times, but there was no documentation accounting for any of the administrations on a Controlled Substance Proof of Use form. There was no Controlled Substance Proof of Use form for the 45 [MEDICATION NAME] 80 mg the pharmacy sent on 7/26/18. The order was discontinued on 8/9/18, and the [MEDICATION NAME] 80 mg had not been administered due to hold orders and sedation from the 10:00 p.m dose on 8/7/18. 2. Review of the clinical record for R#3 revealed admission to the facility on [DATE] with an order dated 6/21/18, for [MEDICATION NAME] 5-325 mg two every 6 hours as needed for pain. Review of the Sum of Quantity Shipped indicated on 7/19/18 thirty (30) [MEDICATION NAME] were sent to the facility. There was no Controlled Substance Proof of Use for this dispense. Review of the MAR's revealed nine administrations of [MEDICATION NAME] from 7/18/18 through 8/1/18, eighteen (18) tablets, with no signatures on a Controlled Substance Proof of use. The Controlled Substance Proof of Use form should have accounted for eighteen (18) of the thirty (30) [MEDICATION NAME]. 3. Record review for R#4 revealed admission to the facility on [DATE] and discharge on 6/14/18. Review of Physician orders [REDACTED]. Review of Controlled Substance Proof of Use forms for [MEDICATION NAME][MEDICATION NAME] revealed the clinical record did not include any Proof of Use forms dated prior to 4/20/18. A Sum of Quantity Shipped was received from the current Pharmacy, that began to supply the facility's medication on 4/23/18, but there was no information available regarding the former pharmacy's shipment of medications. The Physician orders [REDACTED]. This order was discontinued on 4/6/18 and reordered on [DATE] at bedtime. There were no Controlled Substance Proof of Use forms available for [MEDICATION NAME] prior to 4/23/18. The Physician orders [REDACTED]. There was no Controlled Substance Proof of Use form for [MEDICATION NAME] 5-325 prior to 4/23/18. There was no information available regarding the dates and amounts sent prior to 4/23/18, when the current pharmacy sent fifteen (15) [MEDICATION NAME] 5-325 mg for R#4. The Physician orders [REDACTED]. There was no Controlled Substance Proof of Use available prior to 4/23/18, and no information from the previous pharmacy regarding amounts and dates sent. On 5/12/18 the Sum of Quantity Shipped indicated 15 [MEDICATION NAME] 10-325 mg were sent to the facility for R#4, but there was no Controlled Substance Proof of Use to account for the 15 [MEDICATION NAME] 10-325 mg sent from the pharmacy. The Physician orders [REDACTED]. The clinical record did not include any Controlled Substance Proof of Use forms prior to 4/23/18. 4. Review of the clinical record for R#6 revealed admission to the facility on [DATE]. R#6 was transferred to a hospital on [DATE]. Orders for R#6 included an order dated 8/14/18 to administer [MEDICATION NAME] 30 mg one tablet by mouth every 12 hours. Review of the Controlled Substance Proof of Use forms compared to the Sum of Quantity Shipped provided by the pharmacy, indicated one Controlled Substance Proof of Use form for 14 [MEDICATION NAME] 30 mg, sent to the facility on [DATE], was missing. The MAR for R#6 indicated [MEDICATION NAME] 30 mg had been administered eight times during R#6's admission to the facility, but the available Controlled Substance Proof of Use forms indicated [MEDICATION NAME] 30 mg was administered once on 8/17/18 at 9:00 p.m. and 8/18/18 at 9:00 p.m. The Pharmacy sent an email message on 8/28/18 at 2:22 p.m. indicating there were no emergency dispenses for R#6. An interview was conducted with the Administrator on 8/30/18 at 10:15 a.m. The Administrator revealed there were no additional Controlled Substance Proof of Use forms available for R#2, R#3, R#4 and R#6. The Administrator acknowledged the forms for R#2, R#3 and R#4 had been searched for since 8/13/18 when they were first requested, and the forms that were available had been found in multiple locations. The Administrator confirmed the Controlled Substance Proof of Use records time and date of administration should correspond with the time and date of administration on the MAR and in many instances for the five sampled residents they do not coincide. The Administrator also confirmed that the Controlled Substance Proof of Use forms are according to policy, a part of the permanent clinical record and are necessary to give an accurate representation of the resident's experience at the facility. The Administrator revealed there has not been any process for the facility staff to compare the MAR's to the Controlled Substance Proof of Use forms and Sum of Quantity Shipped for assurance of quality care and monitoring of narcotic administration, and there has been no system in place for filing and storage of these forms. An interview was conducted with the Unit Manager for R#2, R#3, R#4, and R#6 on 8/30/18 at 3:00 p.m. The Unit Manager confirmed the Controlled Substance Proof of Use forms for R#6 had been lost after the facility had been aware of the missing forms for R#2, R#3 and R#4. Cross refer to F580, F602, F684, F755, and F865",2020-09-01
449,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-08-30,865,E,1,0,IJ9V11,"> Based on Administrator interview and review of facility policy, the facility failed to maintain a Quality Assurance and Performance Improvement Committee that identified, developed and implemented corrective action plans for five (5) residents (R), (R#2, R#3, R#4, R#5, and R#6) related to medication omissions, documentation of medications on the Medication Administrations Records (MAR's) and Controlled Substance Proof of Use forms, administration of controlled medications according to Physician orders, prevention of misappropriation of resident's medication and maintenance of complete and readily accessible clinical records . The facility census was two hundred six (206) residents. The sample size was five (5) residents reviewed for administration of controlled medications. Findings include: Review of facility policy titled Quality Assurance and Performance (QAPI) Improvement Process, no date, revealed the QAPI process is ongoing and comprehensive, addressing the full range of care and services provided by the facility. It must address all systems of care and management practices. It must include clinical care, quality of life and resident choice. Opportunities for Improvement (OFI) are identified, prioritized for high risk, high volume and problem prone opportunities, root cause of identified OFIs is determined, and appropriate plans of action are implemented. An interview conducted on 8/30/18 at 4:47 p.m. with the Administrator, who is also the QAPI Coordinator. The Administrator revealed she had been aware of a problem with residents running out of medications and changed pharmacy providers in response to this problem on 4/23/18. Since that time she was aware medications were again being depleted and residents were missing scheduled medications. A pharmacy problem log was given to each floor's unit manager in (MONTH) (YEAR), for all nurses to use to record running out of medications, or any other problem with the new pharmacy. The Unit Managers were instructed to ensure any problems were recorded in the log. The new Director of Nurses (DON), who started in June, gave education to the nurses regarding the process of obtaining missing medications on 6/20/18. The DON was instructed in (MONTH) to develop an action plan regarding unavailable medications and use the pharmacy problem log to identify issues regarding the new pharmacy. The Administrator acknowledged she had not checked with the DON on the progress of the action plan. The Administrator revealed there had not been many issues identified in the pharmacy problem logs, so she thought the problem was resolved. The Administrator indicated she expected the DON to check all forms of nursing documentation, and this had not been done. The Administrator revealed that all missed doses of medication due to unavailability, refusal, holding due to Physician orders, resident out of the building, or any other reason, should be specifically documented in the Nurse's Progress Notes and should match the appropriate code documented on the MAR, and this is not being done. The Administrator confirmed she had never known there were any problems with resident's medications not being administered as ordered for any reason except the medication was not available. The Administrator revealed she had not been aware of the Physicians not being notified of medications that were not available for administration according to orders. The Administrator confirmed she had been unaware of missing Controlled Substance Proof of Use forms. The Administrator acknowledged the facility staff had not had any process she was aware of to check the amount of controlled medications sent by the pharmacy against the amount of medications documented as administered on Medication Administration Records (MARs) and compare the MARs with the Controlled Substance Proof of Use Forms and Nurse's Progress Notes. The Administrator revealed this was managed by a team of corporate auditors quarterly, and the last time they audited they only checked one floor. The Administrator revealed she had never brought concerns regarding missing medications to the QA committee because she thought it was being handled. Cross refer to F580, F684, F755, F602 and F842.",2020-09-01
450,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2017-10-05,226,E,0,1,957M11,"Based on review six employee personnel files the facility failed to obtain a criminal background check prior to hire for one employee and failed to obtain reference checks for three of six employees. Findings include: During interview with the Assistant Administrator on (MONTH) 5, (YEAR), she stated the facility employed three employees without receiving reference checks prior to employment date; one employee began employment before criminal background check was returned. 1. Review of employee files on 10/5/17 revealed that Registered Nurse (RN) HH began employment with the facility on 8/7/17 without the return of criminal background check until 8/11/17. 2. Review of employee file on 10/5/17 revealed that Licensed Practical Nurse (LPN) II began employment with the facility on 8/21/17. Prior to employment, facility failed to obtain reference checks. 3. Review of employee file on 10/5/17 revealed that Resident Care Specialist (RCS) LL began employment with the facility on 9/18/17. Prior to employment the facility failed to obtain reference checks. 4. Review of personal files on 10/5/17 revealed that RCS MM began employment with the facility on 7/10/17. Prior to employment, the facility failed to obtain reference checks. Review of facility Leadership Reference Guide: New Hire Requirements, undated, revealed that the Director of Nursing is to ensure that all employees hired in the Nursing Department meet federal, state and company requirements before beginning work. Review of Human Resources Policy titled, Background Checks, revised (MONTH) (YEAR), revealed that Background checks are conducted for all applicants, rehired employees, or transferring employees after an offer of employment is made. Successful completion of the background check is required for employment. Review of Human Resources Policy titled, Employee Reference Checks, revised (MONTH) (YEAR), revealed that offers of employment are contingent upon the successful and satisfactory completion of the reference check process.",2020-09-01
451,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2017-10-05,253,D,0,1,957M11,"Based on observations, resident and staff interviews, the facility failed to maintain a clean and comfortable living environment in eight resident rooms on two resident floors. Findings include: Initial observation of Resident (R#160) 10/2/17 at 1:02 p.m. in room 207 revealed the hot water was cold to the touch after running for five minutes, the resident stated the hot water was too cold to bathe or wash her hair. Initial observations on 10/2/17 of five resident rooms revealed pale to dark brown stains on the bathroom ceilings. These observations occurred for room 227 at 1:52 p.m., room 233 at 1:52 p.m., room 237 and at 4:52 p.m. During an nterview with Resident (R#229) on 10/2/17 at 4:22 p.m. revealed the room temperature for is often too cold because staff members decrease the air conditioning temperature when they are working with him because when they work, they get hot. They forget to adjust the temperature back to R#229's preference. Interview with second floor nursing unit manager, LPN AA, revealed she has asked staff not to adjust any resident's room temperature without permission. If allowed to make a temporary temperature adjustment, to please be sure to re-adjust the heating/air conditioning unit back to resident's preference. She further stated she will remind all her staff about residents' preferences and their rights and to refrain from sitting on heating/air conditioning units anywhere in the facility. Initial observation of room, 243, on 10/2/17 at 4:52 p.m. revealed white debris on top of the heating/air conditioning unit which matched the color and texture of fragments missing from the ceiling directly above. Initial observation of room, 410, on 10/3/17 at 8:00 a.m. there was a large cob web, approximately five to six inches in diameter, located on top of the frame of the lower window pane. During observations on 10/3/17 at 8:24 a.m. and at 8:58 a.m. room, 252 there was a yellow-orange colored stain on the bathroom floor completely surrounding the commode. Initial observations of two, rooms 212 on 10/2/17 at 4:38 p.m. and room 237 on 10/3/17 at 8:58 a.m., had a thick layer of dark gray dust on the air vents in each bathroom. Initial observation,10/3/17 at 9:47 a.m. room 402 had brown stains splattered on the ceiling along the privacy curtain track close to the bathroom. During a room-to-room tour with the maintenance manager on 10/5/17 from 5:00 p.m. to 6:00 p.m. on the second, third and fourth resident floors. He checked the water temperature in the bathroom of room 207 with the facilities digital thermometer which reached a maximum temperature of 90 degrees Fahrenheit after running for five minutes. He stated he would increase the hot water temperature in small increments to achieve a more comfortable temperature for R#160. Second observation and room-to-room tour with the housekeeping manager on 10/5/17 from 6:00 p.m. to 7:00 p.m. on the second, third and fourth floors. The housekeeping manager confirmed the presence of the above-mentioned circumstances but could provide no explanation why these issues were still present after all resident rooms had been cleaned for the day. He stated he made rounds of the resident floors throughout each day but had not identified these issues. He also could not provide evidence that his staff was trained to identify and clean areas of the resident rooms other than the standard tables, floors, sinks and toilets. There was no schedule to clean walls, ceilings or air vents. The maintenance manager stated he and his staff follow a schedule of rounds throughout the calendar month to assess the needs of resident rooms, common areas and the physical grounds. The maintenance manager was aware of issues involving the integrity of the walls, damaged or displaced ceiling tiles, air conditioning units, curtain rods, room furniture and others. The facility uses an electronic system to report needed repairs to the maintenance department. Maintenance staff check this system each morning and throughout the day to address work orders by priority and their ability to handle these issues in house.",2020-09-01
452,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2017-10-05,278,B,0,1,957M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospice and facility staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessment for hospice services for one resident (R) #197, and for Level II PASRR (Preadmission Screening and Resident Review) for one resident #182. The sample size was 33 residents. Findings include: 1. Review of R #197's insurance information revealed that her primary payer source was hospice since 1/28/17. Review of the physician's orders [REDACTED]. Review of her significant change MDS dated [DATE], and the quarterly MDS dated [DATE] was not coded as receiving hospice services. During interview with Licensed Practical Nurse (LPN) Unit Manager PP on 10/3/17 at 4:37 p.m. she stated that R #197 was receiving hospice services. During interview 10/5/17 at 10:23 a.m.with Registered Nurse (RN) RR the Hospice Case Manager stated, R #197 was on hospice services for [MEDICAL CONDITION]. During interview with the MDS Director on 10/5/17 at 6:06 p.m. she verified that R #197 was not coded as receiving hospice services on the significant change assessment dated [DATE] or the quarterly MDS dated [DATE] and that it was an error. Review of R#181's clinical records noted upon admission to the facility on [DATE] the residents [DIAGNOSES REDACTED]. Review of the Level II PASRR Outcome Notification dated 11/19/15 revealed a PASRR level II review was completed for R#181 to determine whether nursing facility placement was appropriate and to determine what mental illness/intellectual disability services the resident would need, including what services could be provide by the facility, and what specialized services should be arranged for through another entity. Review of the significant change (MDS) completed with a reference date of 5/7/17 documented in Section A1500 - Preadmission Screening and Resident Review (PASRR) noted R#118 had not been evaluated by Level II PASRR and found to have a serious mental illness.",2020-09-01
453,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2017-10-05,279,D,0,1,957M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to develop a care plan for activities of daily living (ADL) for one resident (R) W, who was assessed on the Minimum Data Set (MDS) to be extensive to totally dependent on staff for most ADLs. The sample size was 33 residents. Findings include: Review of Resident (W) annual MDS dated [DATE] revealed that the resident was assessed as needing extensive assistance for personal hygiene, which included brushing teeth. Review of the Care Area Assessment (CAA) Worksheet for the MDS revealed that the resident was at risk because of functional decline from complications of immobility, including contractures, incontinence, and depression. Further review of the CAA 's and the CAA summary noted ADL Functional/Rehabilitation Potential would be addressed in the care plan. Review of R W's care plans revealed that the facility did not developed a care plan for ADL assistance, including mouth care. Review of the resident's quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10 (a score of 8 to 12 indicates moderate cognitive impairment). Review of the facility's contracted mobile dentistry service Dentist's Progress Notes dated 5/26/17 documented R W had heavy calculus and plaque. Observations on 10/3/17 at 8:58 a.m. and 5:09 p.m. and on 10/4/17 at 9:13 a.m. and 10/5/17 at 8:34 a.m. revealed that R W had a moderate amount of debris along the lower teeth and gumline. During interview with R W on 10/3/17 at 8:47 a.m. they stated that they were bedbound, and would like to have their teeth brushed twice a day. Review of the facility's contracted mobile dentistry service Dentist's Progress Notes dated 5/26/17 revealed R W had heavy calculus and plaque. During interview with the MDS Director on 10/5/17 at 5:55 p.m. she verified that no ADL care plan had been developed for Resident W, and did not know why.",2020-09-01
454,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2017-10-05,431,D,0,1,957M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews with facility staff and policy review, the facility failed to ensure opthalmic medications were dated appropriately when opened to determine the discard date, in one of 5 medication carts. Also, the facility failed to discard expired biologicals prior to expiration date. The sample size was 33. Findings include: 1. During observations on [DATE] at 4:52 p.m. on the second floor medication cart rooms ,[DATE], revealed three opened and used Opthalmic solutions: Moxifloxacin, Timolol, and Latanprost. The Opthalmic solutions were not dated when opened. Interview on [DATE] at 5:05 p.m. with Licensed Practical Nurse (LPN) CC she stated that she didn't open the eye drops and she doesn't know when they were opened. She stated that she puts open dates on all the meds that she opens. She was not sure how long the eye drops were good after opening, without looking at the policy. She printed a copy of the policy and stated the eye drops should be discarded and reordered after 30 days of being opened. Interview on [DATE] at 5:07 p.m. LPN DD stated she always puts an open date on the medications that she opens. She stated that for eye drops, they are to be discarded 30 days after opening. Interview on [DATE] at 5:23 p.m., Unit manager (UM) AA stated it was her expectation that all med nurses will place open dates on all medications on the med carts once they have been opened. She further stated that as the Unit manager, she is the one ultimately responsible for how the unit is run. Reveiew of Pharmacy Services-Policies and Procedures for Nursing Facilities , revised Novemeber 2011, indicated that certain medications or package types, such as IV solutions, multiple dose injectable vials, opthalmics, nitroglyerin tablets, blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency. Further indicated, the nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regualtions/guidelines require different dating. Interview on [DATE] at 3:51 p.m. with Pharmacist EE confirmed the Facility policy for dating Ophthalmic solutions once the manufacturer seal has been broken. She further stated that once the seal for Opthalmic solutions has been broken, the medication should be disarded after 30 days, to insure the potency of the medications. 2. Observation on [DATE] at 5:19 p.m., with UM AA revealed second floor medication storage room had no freezer or refrigerator temperture documented for the day. There was no visible thermometer in the freezer. The bottom drawer in refrigerator had dried sediment and the bottom glass shelf had dried tan material on it. There were a total of 8 cans of Jevity tube feeding solution with expiration date of Septemeber 18, (YEAR). Interview on [DATE] at 5:23 p.m. with UM AA stated it's the responsibility of all the med nurses to make sure that the med room is kept clean and stocked with non-expired supplies. She further stated that as the Unit manager, she is the one who is ultimately responsible for how the unit is run. She stated she would take care of those med storage issues.",2020-09-01
455,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2017-10-05,441,D,0,1,957M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and policy review titled [DIAGNOSES REDACTED] Screening For Employees, the facility failed to promote resident and employee safety and well-being by obtaining screenings for [DIAGNOSES REDACTED] for two out of 8 new hire employees. The sample size was 33. Findings include: 1. Review of employee files on 10/5/17, revealed the Director of Nursing (DON) began employment with the facility on 9/11/17 without the administration and result of required [MEDICATION NAME] skin test, Purified Protein Derivative (PPD). 2. Review of employee files on 10/5/17 revealed that RN JJ began employment with the facility on 9/25/17 with the administration and result of PPD. Review of facility policy Infection Prevention Manual for Long Term Care: [DIAGNOSES REDACTED] Screening for Employees, copyright 2012, revealed that new employees who have been made a conditional offer of employment shall be screened for the presence of infection with M. [DIAGNOSES REDACTED] using the Mantoux TST. Skin testing will employ the two-step procedure. Interview with Assistant Administrator on 10/5/17, revealed that all employee files are to be complete, including PPD test with results, prior to beginning employment with the facility.",2020-09-01
456,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-11-01,656,D,0,1,SD5N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of the policy titled Comprehensive Care Plan, resident and staff interviews, the facility failed to follow the plan of care for activities for two of 62 sampled residents (R) (#87 and #100). Findings include: Review of the facility policy titled Comprehensive Care Plan with a revised date of (MONTH) (YEAR) documented: The facility will develop a comprehensive person centered care plan that identifies each resident's medical, nursing, mental, and psychosocial needs within 7 days after completion of the comprehensive assessment. The care plan is developed with the resident or the resident's representative and reflects the resident's goals, wishes and preferences. The plan includes measurable objectives and timetables agreed by the resident to meet such objectives. 1. Record review for R#87 revealed a Significant Change Minimum Data Set (MDS) assessment dated [DATE] which staff assessed the resident preferred listening to music, doing things with groups of people, participating in favorite activity and participating in religious activities or services. Review of the Care Plans for R#87 identified the following: The resident has limited mobility related to disease process with a revision date of 9/20/18. Interventions included, but not limited to; provide supportive care, assistance with mobility as needed and invite the resident to activity programs that encourage physical activity, physical mobility, such as exercise group and walking activities to promote mobility. The resident is dependent on staff for meeting emotional, intellectual, physical and social needs dated 7/18/18. Interventions included but not limited to; Ensure that the activities the resident is attending are: Compatible with physical and mental capabilities; Compatible with known interests and preferences; Adapted as needed (such as large print, holders if resident lacks hand strength, task segmentation), Compatible with individual needs and abilities; and age appropriate. The resident prefers to watch TV when the resident chooses not to participate in organized activities. The resident has little or no involvement in activity r/t to end stage disease dated 9/6/18. Interventions included but not limited to; Establish and record the resident's prior level of activity involvement and interests by talking with the resident, caregivers, and family on admission and as necessary. Modify daily schedule, treatment plan PRN to accommodate activity participation as requested by the resident. Observe/document for impact of medical problems on activity level. Remind the resident that he/she may leave activities at any time, and is not required to stay for entire activity. Observations on 10/29/18 at 4:10 p.m., 10/31/18 at 10:52 a.m., 10/31/18 at 1:35 p.m. and 11/1/18 at 11:08 a.m. revealed the resident alone in her room, in bed. The curtains were closed, the room was dim, there was no TV, music or obvious activity. Review of the Sensory Stimulation Participation Record revealed R#87 had not attended any large or small group activities. R#87 was provided One-to-One (1:1) activities nine times in three months on 8/3/18, 8/15/18, 9/7/18, 9/19/18, 9/21/18, 10/5/18, 10/22/18, 10/25/18 and 10/29/18 that consisted of hand and foot massages, except for music stimulation activity on 9/7/18. Interview on 10/31/18 at 1:52 p.m. with Certified Nursing Assistant (CNA) AA revealed she does not typically see the Activities staff in the room with the resident providing One-to-One activity and that the resident rarely leaves her room. Interview on 11/1/18 at 9:00 a.m. with the Activity Director (AD), revealed R#78 R#87 is rarely out of bed and they can't take her to group or social activities. She stated the resident receives 1:1 activities but was not sure what type or how often stating she would have to check with the Activity Assistants. Interview on 11/1/18 at 9:35 a.m. with the Activities Assistants BB and CC revealed R#87 did not attend groups activities because the CNAs do not get her out of bed. CC stated the resident receives 1:1 activity and stated it had only been conducted three to four times a month. 2. Record an Annual MDS assessment for R#100 dated 12/9/17 revealed it was very important to her to listen to music she likes, to do things with groups of people and do her favorite activities. Review of the Care Plans for R#100 identified the following: The resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to medical condition with a revised date of 9/6/18. Interventions included, but not limited to; Invite resident and family to Special Social/Holiday Events, invite resident to scheduled activities, provide program of activities that is of interest and empowers the resident by encouraging/allowing choice, self-expression and responsibility, the resident needs assistance/escort to activity functions and the resident's preferred activities are: Social events, trivia/cognitive activities. During an interview on 10/29/18 at 3:21 p.m. with R#100 in her room in bed, she stated she likes to attend group activities and enjoys games such as basketball, music events and church services. The resident stated the staff do not read the activity schedule for the day to her and rarely get her out of bed for activities of her choice. R#100 stated she would love to attend more group activities. Further interview on 10/31/18 at 10:45 a.m. with the R#100 revealed there is an activity calendar on her wall but she has [MEDICAL CONDITION] and cannot read it. R#100 stated the staff do not read the daily activities to her so that she may choose if she would like to attend an activity that day or stay in her room. Review of the Sensory Stimulation Participation Response Record for R#100 revealed the resident attended three group/social activities in three months on 10/19/18, 10/25/18 and 10/31/18. The resident received 1:1 activities 13 times in three months on 8/7/18, 8/14/18, 8/20/18, 8/22/18, 9/3/18, 9/6/18, 9/7/18, 9/19/18, 10/2/18, 10/5/18, 10/15/18, 10/24/18 and 10/29/18. Interview on 11/1/18 at 10:18 a.m. with Activity Assistants BB and CC revealed they work on the second floor. Both BB and CC confirmed there has been a problem with CNAs getting residents that require extensive to total assistance out of bed so they can attend activities. BB stated R#100 likes exercise and although she is limited due to one paralyzed hand, she likes to try and she likes to have her nails done. They both BB and CC confirmed R#100 likes to be up in groups but the failure is that she is not up. BB stated she goes to the resident's room about two times a week and mention an activity they are doing and the resident will tell her if she wants to or not. BB further stated R#100 only likes to be up for about two hours and sometimes the staff just don't want to bother if she can't stay up long. BB stated they just try to visit the residents and do as much for them as they can. CC stated they try to do 1:1 twice a week but it's hard because they have so many residents and it's hard to have the group activities and go to every room. (Refer F679)",2020-09-01
457,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-11-01,679,D,0,1,SD5N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of policies titled Activities Program, One-to-One Activities and Group Activities and staff interviews, the facility failed to ensure an ongoing program of activities for two residents (R) (#87 and #100) that required extensive to total staff assistance with Activities of Daily Living (ADL). The sample was 62 residents. Findings include: Review of the facility's policy titled Activities Program with a revised date of (MONTH) (YEAR) documented: The facility provides an activities program designed to meet the interests, preferences, and physical, mental and psychosocial well-being off each resident as indicated on the comprehensive assessment and care plan. Individual (one-to-one) and group activities, plus on and off site activities are included in the activities program. Activity Program- The activity program is designed to encourage restoration to self-care and maintenance of normal activity, which is geared to the individual resident's needs. When developing the resident's activity and social plans, the resident will be given an opportunity to choose when, where, and how he or she will participate in activities and social events. Documentation- Individual Activity Participation Record and One-to-One Activity Participation Record. Review of the facility's policy titled One-to-One Activities with a release date of (MONTH) 2007 documented: One-to-One visits do not have to occur in the resident's rooms. These visits can occur in the lounge area, in the hallway, outdoors, in an office area etc. Ensure that the frequency and types of activity services provided are reflected in the resident's care plan. Use the comprehensive assessment, the interests and the physical, mental and psychosocial needs of the resident as the basis for formatting One-to-One activities. Review of the facility's policy titled Group Activities with a release date of (MONTH) 2007 documented: Group activities are encouraged to assist residents in overcoming feelings of loneliness, isolation and self-pity, which often accompany long-term care and illness. 1. R#87 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) was not conducted, the resident was rarely or never understood. The resident was not assessed with [REDACTED]. The staff assessment of daily activities and preferences assessed that R#87 preferred listening to music, doing things with groups of people, participating in favorite activity and participating in religious activities or services. The resident required total assistance with all ADLS. The Care Area Assessment revealed the facility made the decision to care plan psychosocial well-being and activities. Observation on 10/29/18 at 4:10 p.m. revealed R#87 in her bed wearing a hospital gown. The room was dim and there was no obvious activity in place. The resident smiled when spoken to but did not communicate. Observation on 10/31/18 at 10:52 a.m. revealed R#87 in her bed on her left side asleep. The lights were out, the curtains were drawn, the room was dark and there was no obvious activity in place. and the resident was in a hospital gown. The resident awakened and attempted to communicate by smiling and making mumbled noises. Observation on 10/31/18 at 1:35 p.m. revealed R#87 in her bed on her left side. The resident was wearing a red shirt and covered with a sheet and blanket. The curtains were closed and an overbed light was on but the room remained dim with the curtain closed. There was no obvious activity in place and the room was quiet. The resident opened her eyes and smiled. Interview on 10/31/18 at 1:52 p.m. with Certified Nursing Assistant (CNA) AA revealed she is familiar with the R#87 and cares for her a lot. She stated she opened the curtains and turned the TV on this morning and was not sure why the curtains were closed and the TV was off. She stated she thought the TV may turn itself off after a certain length of time and that the room gets bright with the curtain open and perhaps the roommate's family closed the curtains. CNA AA further stated she does not typically see anyone from activities come to the resident's room or provide one-to-one activity and R#87 typically attends group or out of room activities two or three times a month. CNA AA stated when she is assigned to the resident, she gets her out of bed. She stated the residents are taken to the dining room and the activities staff will come and take them to the back day room or do activities in the dining room. She stated she could not get the R#87 up today because she did not have any clothing, only a red t-shirt and that her clothing had not yet returned from laundry. CNA AA stated I'm not going to lie, they don't take her out of her room. CNA AA stated R#87 can only passively participate and it's good for her to get out of her room. During an interview on 11/1/18 at 9:00 a.m. with the Activity Director (AD), she stated R#87 is on hospice services and based on her level of cognition, she is on the Sensory Stimulation Program which includes small group activities, music activities, light exercises and one-to-one (1:1) activity. The AD stated R#87 is rarely out of bed and they can't take her to group or social activities. She stated she is unsure of exactly what one-to-one activity is provided the resident, she would have to check with the two activity assistants. Interview on 11/1/18 at 9:35 a.m. with the Activities Assistants BB and CC revealed R#87 has had a recent decline and they provide 1:1 activities with the resident. Both Activity Assistants stated the resident did not attend groups activities because the CNAs do not get her out of bed. Activity Assistant CC provided copies of the activity records for R#87 and confirmed that one-to-one activity had only been provided three- four times a month in the last three months and had not attended any group or small group activities. Review of the Sensory Stimulation Participation Record for R#87 revealed the following: In (MONTH) (YEAR), R#87 had 1:1 activity on 8/3/18 documenting Resident hand massage, she was resistant to touch on 8/15/18 documenting Massages on legs and feet and on 8/7/18 documenting Resident in hospital. In (MONTH) (YEAR) R#87 had 1:1 activity on 9/7/18 documenting Resident smiles while getting hand massages, music stimulation on 9/19/18 documenting Hand Massages and on 9/21/18 documenting Hand Massages. In (MONTH) (YEAR) R#87 had 1:1 on 10/5/18 documenting Resident had hands stimulated for activities on 10/22/18 documenting R.O.M. resident became agitated on 10/25/18 documented Hand exercises and on 10/29/18 documented hand & feet massages. Observation on 11/1/18 at 11:08 a.m. revealed R#87 awake in her bed. The windows curtains were closed, the over bed light was on but the room was very dark/dim with no obvious activity such as TV or music. The resident reached for surveyor's hand and kissed hand. The resident kept holding surveyor's hand to her cheek and began to cry. Observation on 11/1/18 at 1:20 p.m. revealed R#87 dressed and sitting in a wheel chair near the nurses' station. The resident was awake and alert. The resident saw surveyor and spoke asking how are you? and called out the surveyor's name. R#87 had not spoken during observations in her room. When asked if she was glad to be up, the resident shook her head yes and stated yes. The resident also began laughing with surveyor and her demeanor was completely opposite of previous observations. 2. R#100 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed a BIMS summary score of six, indicating severe cognitive impairment. The resident was not assessed with [REDACTED]. Interview with R#100 revealed it was very important to her to listen to music she likes, to do things with groups of people and do her favorite activities. The resident required extensive to total staff assistance with ADLS. The CAA triggered ADL Function with the decision to be care planned. Review of the Quarterly MDS assessment dated [DATE] documented a BIMS summary score of 11, indicating moderate cognitive impairment. The resident required extensive to total staff assistance for ADLS. During an interview on 10/29/18 at 3:21 p.m. with R#100, she stated she likes to attend group activities and stated if someone would come and get me. She stated there is one staff member that comes and asks her if she wants to attend, but nobody else. R#100 stated she would love to attend more often and enjoys the games such as basketball, music events and church services. Interview on 10/31/18 at 10:45 a.m. with R#100 revealed staff from activities came to her room and said she was going to get her a wheel chair. She stated she was not sure if she was just getting up or maybe she was going to take her to activity. R#100 further stated she cannot read the activity calendar on the wall because she has [MEDICAL CONDITION] and can barely see. She stated no one comes to her to read the daily activities to her. Observed an activity calendar hanging on the wall parallel to the resident's bed. Observation on 10/31/18 at 1:25 p.m. revealed R#100 in the dining room waiting for lunch. The resident was dressed and in geriatric chair. Interview with r#100 at the time of the observation revealed she had been up for about 30 minutes and had not attended a group activity. At 1:26 p.m. an overhead announcement was made that a Halloween and pumpkin carnival and contest would be held on the 2nd floor dayroom at 2:30 p.m. followed by refreshments. R#100 resides on the 2nd floor. Further interview with R#100 revealed she did not hear the announcement for the Halloween party but she would like to stay up and attend the event. Observation on 10/31/18 at 2:40 p.m. revealed R#100 being pushed in a geriatric chair to the Halloween party. Further observation at 3:08 p.m. revealed the R#100 attending the Halloween party and was playing a bean bag toss game. The resident was active, smiling and laughing. Interview on 11/1/18 at 9:00 a.m. with the Activity Director (AD) revealed R#100 enjoys games, religious groups, gospel and music activities. She stated they have these activities almost every day. She stated the resident attends group activity about once a week. When asked if the activities the resident enjoys are available throughout the week, why was the R#100 only attending once a week, she stated they can't take her to activity if she is not out of bed. She stated they know the resident's likes and what she likes to attend and they do go to her room about an hour before an activity she likes and ask if she wants to attend. She stated that gives the CNAs plenty of time for her to get out of bed. When asked do the activities staff communicate that to the CNA, she stated she was unsure and that they probably need to be more proactive in communicating that. The AD stated that she has identified a problem with CNAs not getting up residents that require extensive to total assistance but stated she had not reported that in morning meetings. She stated they have only discussed a specific individual that would benefit from getting out of the room more often. The AD stated she is a member of the QA Committee but rarely gets to attend the QA Meetings because it is held at the same time as Resident Council Meetings and she attends that. The AD further stated they provide 1:1 with R#100. The resident likes to sing with the staff, listen to music, get hand massages etc. Interview on 11/1/18 at 10:18 a.m. with Activity Assistants BB and CC revealed they work on the second floor. Both BB and CC confirmed there has been a problem with CNAs getting residents that require extensive to total assistance out of bed so they can attend activities. CC stated she has been in activities for six months and she feels the residents would benefit better form out of the room and group activities because they can see different faces, hear music and sounds and not just seeing walls in a room or a TV on that they do not even watch. BB stated she has been an Activity Assistant for two years and they can work with resident much better when they are up in a chair. BB stated they tried to speak with the CNAs but they would always say they were busy and couldn't get them up right now, then it would turn into all day. BB stated we have basically given up. Both BB and CC stated they have reported to the Activity Director that the CNAs were not being compliant with getting the residents out of bed. BB further stated the process is that the CNAs will get the residents up and put them in the dining room, and they go get them from the dining to go to activity. If the resident is not up for activity, they don't go to group activity but they will see them 1:1. BB stated she knows R#100 loves gospel and loves socials, such as parties held two or three times a month. Stated R#100 likes exercise and although she is limited due to one paralyzed hand, she likes to try. They do this with her in her room and she likes to have her nails done. They both BB and CC confirmed R#100 likes to be up in groups but the failure is that she is not up. They both stated that they do not communicate to the CNAs when the she wants to get up and attend activity. BB stated she goes to the resident's room about two times a week and mention an activity they are doing and the resident will tell her if she wants to or not. She stated the resident often says yes and sometimes no, if it's right after breakfast but stated she does not return later to ask again. BB further stated R#100 only likes to be up for about two hours and sometimes the staff just don't want to bother if she can't stay up long. BB stated they just try to visit the residents and do as much for them as they can. CC stated the same way the residents depend on the CNAs, they depend on the CNAs to get residents up for activities. CC stated R#100 has rarely attended group activities but she did yesterday for the Halloween party. BB and CC stated that R#100 was so happy yesterday, she was smiling, singing, eating food and she can't throw very good but she tries! BB stated the resident enjoyed it and should be able to enjoy it regularly. CC stated they try to do 1:1 twice a week but it's hard because they have so many residents and it's hard to have the group activities and go to every room. CC stated if the residents were up and could attend some group activities, even for passive participation, it would be much easier. She stated about half of the residents on the floor are on 1:1 program. CC stated a 1:1 activity is about 15 minutes and the rest of the time, the residents are just in their rooms. CC provided the activities record for R#100 and confirmed R#100 was only seen for 1:1 activity three to four times a month in the last three months and only attended three group actvities. CC stated that if the residents were in group activities, it would be good for social stimulation and they could also do sensory stimulation with them while in the group activity. Review of the Sensory Stimulation Participation Response Record for R#100 revealed the following: In (MONTH) (YEAR), the resident had 1:1 activity on 8/7/18 documenting Resident had nail care on 8/14/18 documenting Exercise/hand massage on 8/20/18 that did not document the type of activity, on 8/22/18 documenting Resident responded to exercise. In (MONTH) (YEAR), the resident had 1:1 activity on 9/3/18 documenting Resident did exercises/and massages on 9/6/18 documenting hand massage on 9/7/18 documenting hand exercises and massages and on 9/19/18 documenting music stimulation. In (MONTH) (YEAR), the resident had 1:1 activity on 10/2/18 documenting exercises on 10/5/18 documenting music stimulation and massages on 10/15/18 documenting exercise and music stimulation on 10/24/18 documenting exercises and massages on 10/29/18 documenting gospel music stimulation and the resident attended group activities on 10/19/18 documenting exercise and dominos on 10/25/18 documenting birthday party and on 10/31/18 documenting Halloween party. Interview on 11/1/18 at 11:58 p.m. with the Administrator revealed it had not been brought to her attention that the resident's requiring extensive to total staff assistance were missing social/group activities due to CNAs not getting the resident's out of bed. She confirmed that the Activities Director (AD) was on the QA Committee and was not in attendance of the QA meetings due to attending the Resident Council Meetings scheduled at the same time. The Administrator stated that she would correct that and change the schedule of the QA Meetings and Resident Council Meetings so that the AD could attend the meetings regularly.",2020-09-01
458,DUNWOODY HEALTH AND REHABILITATION CENTER,115270,"5470 MERIDIAN MARK ROAD, BLDG E",ATLANTA,GA,30342,2018-11-01,880,D,0,1,SD5N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and review of the facility's policy titled, Infection Prevention Manual for Long Term Care, the facility failed to ensure infection control practices were implemented related to proper labeling and storage of resident personal care equipment in addition, the facility failed to ensure a staff member followed contact isolation precautions and proper hand hygiene when entering and exiting the room of Resident (R) (#48). The facility census was 213 residents. Findings include: Observation on 10/29/18 at 4:27 p.m. of the bathroom in room [ROOM NUMBER], for which two residents share, revealed two wash basins in the same bag hanging on the wall. The bath basins were not labeled and there was brownish thin liquid in the bag. Observation on 10/30/18 at 12:18 p.m. of the bathroom in room [ROOM NUMBER], for which two residents share, revealed three bags hanging off the hand rails. The first bag had a bath basin and urinal in it that was unlabeled, the second bag had an unlabeled bed pan and a catheter bag with urine in it and urine in the bag, and the third bag had two bath basins stacked inside each other that were not labeled. Observation on 10/30/18 at 1:06 p.m. of the bathroom in room [ROOM NUMBER] revealed a urinal hat sitting on the back of the toilet tank lid that was not bagged and unlabeled and there was dried yellow drops with the appearance of urine on the toilet tank lid. Interview on 11/1/18 at 12:35 p.m. with the Interim Director of Nursing (DON) revealed that personal care equipment such as bed pans, wash basins and urinals hats should be labeled, cleaned, dried and stored in a bag in the bathroom off the floor. The DON reviewed the photos of the identified concerns in rooms 219, 212 and 249. She stated that was not the facility's standard and the staff have been trained about infection control and proper labeling and storage of personal care equipment. The DON further stated never should there be a catheter bag with urine stored in a bag in the bathroom. The DON stated the personal care equipment should be cleaned and dried before placing it in a bag. The DON stated they recently held in-services on infection prevention and discussed proper labeling and storage of personal care equipment. The DON stated they do not have a policy specific to labeling and storage of personal car equipment. Review of the Education Course Attendance Sign-in Sheet dated 9/26/18 - 9/28/18 with topic Infection Prevention revealed 76 staff signatures in attendance. On 10/31/18 at 11:00 a.m. during the observation of R#48, housekeeping staff DD walk into the resident's room and picked up the trash can without gloves or a gown. Staff DD brought the trash can out of the room and emptied it. He then changed the bag in the waste basket and returned the waste basket to the room. He did not wash his hands. It was observed outside of R#48's room a red isolation cart to the left of the door. The isolation cart included red bags, yellow bags, yellow gowns and a box of gloves. There was also a sign posted on the door of R#48's room which noted, Visitors: Please see the nurse before entering. On 10/31/18 at 11:04 a.m. an interview was conducted with Nurse EE a Licensed Practical Nurse (LPN) who was standing outside R#48's room on the medication cart when Staff DD entered. She confirmed that R#48 was on contact isolation for Extended Spectrum Beta Lactamase (ESBL) resistance in her urine. LPN EE was asked what should staff do when entering R#48's room. She stated staff should place on a gown and on gloves. Nurse EE was asked should housekeeping staff DD have placed on a gown and glove when he entered R#48's room. She confirmed that housekeeping staff DD should have placed on a gown and gloves before entering R#48's room. On 10/31/18 at 11:07 a.m. an interview was conducted with housekeeping staff DD regarding his knowledge of what he should do before entering the room of R#48's. He stated, Are you talking about putting on a gown and gloves? Staff DD stated, he was told when he sees a cart like that, (while he pointed to the isolation cart outside resident room), I should put on a gown and gloves but, I forgot. It is all on me. It is my fault because they told me. My manager and a CNA told me. I am not usually in this position. I am the floor technician but when we are short we help clean rooms. I was also told to wash my hands. On 11/1/18 at 11:17 a.m. an interview with the Interim Director of Nursing (DON) and the Interim Assistant Director of Nursing (ADON) who is also in the role of the Infection Control Nurse. The DON stated in relation to contact isolation, our process is to make sure that the room is set up to accommodate whatever the type of precautions the resident is on. For a resident on ESBL, the isolation cart in the hallway would be stocked with gloves, gowns, masks, face shields, googles as well as red and yellow bags. Inside the rooms there are red receptacles that are labeled for linen and trash. We have provided education to the staff to include nursing and all other departments. Our in-services included education on standard precautions, contact precautions, appropriate Personal Protective Equipment (PPE), proper donning on and off of PPE. Housekeeping staff is contracted and are educated by their company but we educate them as well. Infection prevention is also a part of general orientation. In regards to the process for entering the room of a resident on contact isolation for ESBL the DON stated, the staff should don proper PPE. Handwashing should be done before entering the room as well as the use of gloves. For housekeeping staff, they should be donning with a gown and gloves. My expectations would be that they would follow proper procedure. When we find that staff are not following procedure then we review the education with the person. We observe staff by doing spot checks to ensure that proper procedure is being followed. On 11/1/18 at 11:51 a.m. n interview was conducted with the Environmental Services Manager and the District Manager for Housekeeping Services. The District Manager for Housekeeping Services stated, we have a contract with the facility however, we in-service our staff on infection control. In-services are conducted monthly for housekeeping staff, floor techs and laundry staff. In regards to contact isolation, it is done in general orientation as well throughout the year as a refresher. The Environment Services Manager stated, we do Quality Care Insurance (QCI) daily and inspect all isolation rooms to assure my staff are using the proper PPE as well as that they are using the proper chemicals based on the type of infection when sanitizing. Staff are also educated on handwashing before entering and exiting the room. Our staff are educated about removing PPE before exiting the room. Staff are reeducated when we find that they have not followed proper protocol. It is our expectations that staff follow protocol. Per District Manager the Environmental Services Manager was brought to this facility a month ago to make changes. Since he has been here, things have gotten on the right track.",2020-09-01
459,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-01-10,677,D,1,0,GLOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews and record review, it was determined that the facility failed to provide nail care to two residents (R) (R#1 and R#3) from a sample of four residents. Findings include: 1. R#1 was assessed and coded by the facility staff on the 10/29/18 Annual Minimum Data Set (MDS) assessment as having no behaviors or rejection of care and as being provided limited assistance with personal hygiene. On 1/10/19 at 10:15 a.m., 12:00 p.m. and 1:50 p.m., the resident's fingernails on both hands were long and dirty with a brown substance under the nails. Review of the 1/19 Aides' Record revealed the resident had received shower on 1/9/19. During an interview with Certified Nursing Assistant (CNA) AA on 1/10/19 at 1:20 p.m., she stated that the resident was scheduled for showers on Wednesday and Friday and the resident received a shower on 1/9/19. She stated that she had shaved the resident today but had not done nail care. She also stated that nail care could be done anytime, not just on shower days. She stated at times the resident would go into the bathroom and smear feces after having a bowel movement. During an interview with CNA BB on 1/10/19 at 1:34 p.m., she stated that she could not remember when the resident last had his fingernails cut. She stated that she gave the resident a shower on 1/9/19 and usually cleans nails during the shower or when they are dirty. She stated that the resident will go into the bathroom and smear feces all over the bathroom almost on a daily basis. During an observation of the resident's fingernails with the Director of Nursing (DON) on 1/10/19 at 1:50 p.m., he stated that the resident's nails were a little longer than he would like them to be and they needed to be cleaned. He stated that he has talked to the staff about checking and cleaning the resident's nails since the resident had a history of [REDACTED]. 2. R#3 was assessed and coded by the facility staff on the 10/8/18 Quarterly MDS assessment as having no behaviors or rejection of care and as needing setup help for personal hygiene and extensive assistance for bathing. On 1/10/19 at 10:30 a.m., 12:05 p.m. and 2:00 p.m., the resident was observed with long, jagged and dirty fingernails on both hands. A brown substance was observed under the resident's fingernails. Review of the 1/19 Aides' Record revealed the resident received a bed bath on 1/9/19. During an observation of the resident's fingernails on 1/9/19 at 2:00 p.m. with the DON, he stated that the resident's nails were long and there was a brown substance under the fingernails. Review of the policy titled, Nail Care dated 10/10/17 indicated routine cleaning and inspection of nails will be provided on an ongoing basis. It also indicated routine nail care, to include trimming and filing, will be offered to the resident regularly or as desired.",2020-09-01
460,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2017-04-28,161,D,0,1,S3GR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review the facility failed to assure that resident funds were bonded. The facility's census was 86 residents. Findings include: Interview on [DATE] at 5:10 p.m. with the Administrator who reported that the company did not have financials in order to cover the bond at the time the bankruptcy was completed. As a result, they (the facility) were only able to get a bond through [MEDICATION NAME]'s and it expired in (MONTH) (YEAR). The Administrator reported that once the sale of the company is completed the facility should be able to purchase a bond in May. The Administrator provided a copy of a long term care facility residents' fund bond which revealed an expiration date of (MONTH) 2, (YEAR). Interview on [DATE] at 3:18 p.m. with the Chief Executive Officer (CEO) revealed that the facility is in the process of trying to get another bond. However, audited adjusted financials were not available because of the bankruptcy filed by Pioneer. [MEDICATION NAME]'s Insurance would not renew the bond beyond this past December. The CEO reported that she has tried to get a bond with four or five other companies but have been denied by all. The CEO reported that they are continuing to look for a company to assure the bond.",2020-09-01
461,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2017-04-28,253,D,0,1,S3GR11,"Based on observation and interview the facility failed to provide an environment free from cracking and missing paint on walls and in a window, loose baseboards, dust build up and debris in vents of air conditioner, black build up in the grout in bathrooms, brown circular stains on the ceiling, stained privacy curtains, and a cracked window in 10 of 74 resident rooms. The facility census was 86. Findings include: 1. Observation on 4/25/17 at 10:51 a.m. in room 123 revealed that there was a build up in the grout in the bathroom, missing paint from air conditioning unit, brown circular stains in ceiling tiles, white stains on a dresser, and brown coloring on the tile rails. 2. Observation on 4/25/17 at 11:39 a.m. in room 127 revealed that there was a black build up in the grout on the bathroom floor, there was missing paint from air conditioner unit, dust build up in the vent beneath the air conditioner unit, brown spots on the ceiling tile track, rust on the legs of the over the bed table and the feeding tube stand, cracking and missing paint in the window, and loose baseboard at the entrance to the bathroom. 3. Observation on 4/25/17 at 1:09 p.m. in room 111 revealed that there was a build up on floor in the bathroom, chipped missing paint on the air conditioning unit with rust revealed, dust build up in the vents under the air conditioning unit, scuff marks on wall near the bathroom, and missing paint from the doorframe to bathroom. 4. Observation on 4/25/17 at 1:39 p.m. in room 110, revealed that in the bathroom the over the toilet seat had a brown substance on it, there was a buildup on floor in the bathroom, dust buildup in the vent in the bathroom, missing paint from the air conditioner unit, dust build up in the vents under the air conditioner, brown stains in the ceiling tiles, stained and discolored privacy curtains for both A and B beds, dust build up in the vent at the door entrance, and loose paneling to closet doors. 5. Observation on 4/25/17 at 2:07 p.m. in room 115 revealed that there was a build up on the floor in the bathroom, there was missing paint from the wall near the door, brown stains on the ceiling tracks, missing paint and rust on the air conditioner vents, dust build up on the vents under the air conditioner, and dust buildup in the vent in the bathroom. 6. Observation on 4/25/17 at 2:54 p.m. in room 234 revealed that there was a discoloration to the privacy curtain between bed A and B and black stains on the privacy curtain for Bed A, there was also missing paint from doorway to the bathroom, missing paint around the light in the bathroom, and missing paint from the wall near the sink. 7. Observation on 4/26/17 at 11:05 a.m. in room 133 revealed that there was a black build up on the floor in the room and the bathroom, debris in the air conditioner, dust build up in the vent in the bathroom, and missing paint on wall near the right side of the sink. 8. Observation on 4/26/17 at 8:56 a.m. in room 138, in the bathroom, revealed that there was a black buildup in the grout on the floor, cracked tile by the toilet, dust build up in the vent in the bathroom, and a black build up along the edges of the floor and the baseboards. 9. Observation on 4/26/17 at 10:12a.m. in room 205 revealed that there was a dresser with jagged edges, missing wood finishing, the air conditioner (ac) vent was broken and missing a vent, debris and dirt was observed the inside of ac vent, the cracked window pane was in two places on the upper window, missing paint and scuff marks was on the wall in front of the bathroom door, and a nail was extending from the wall. 10. Observation on 4/26/17 at 10:18 a.m. in room 209 revealed that there was missing paint and scuff marks on the wall. Interview and observation on 4/28/17 at 12:34 p.m. with the Maintenance and the Administrator who confirmed the findings in rooms 110, 111, 115, 123, 127, 133, 205, 209, and 234. Maintenance reported that rooms are refurbished based on which room is in the worst condition and 10 or 12 rooms have been updated over the past year. This includes repainting, stripping and waxing of floors, paint door frames, repairing baseboards, and repairing holes. Last room repaired was 204 last week. Maintenance staff is back up to four people so that they can continue to refurbish one room per week. Short staff one person for 6 months. The Administrator reported that her expectation is that staff will clean so that there will not be build up. It was reported that hospital staff in-serviced nursing home housekeepers on how to manage buildup on the floors. Housekeeping manager and the Director of Nursing (DON) have been providing go behinds of housekeeping staff to assure that housekeeping tasks are completed. Periodically privacy curtains are checked. The Administrator reported that she was not aware that bleach stains were on some of the privacy curtains and will have them replaced. Further interview revealed that housekeepers are to report to their supervisor whenever they view stained privacy curtains and the supervisor will then take to them to the laundry. The expectation is that housekeeping staff are expected to pull curtains and check for stains when in the rooms. CNAs and LPNs can report stains if they see them as well. This task will be added to supervisor list when completing checking behinds. The Administrator reported that in the past department heads have done rounds but they are not currently doing this and this will be restarted. Interview on 4/28/17 at 12:55 p.m. with Housekeeper AA revealed that tasks in the room include sweeping, wiping down the sink, and cleaning the mirror. It was further revealed that if someone goes into hospital or is someone dies in a room, then that room is terminally cleaned. This includes wiping down the walls and the overhead lights, the bed, mattress, and the floors are stripped and waxed. Privacy curtains are reported as being taken down if they are dirty so that they can be cleaned and replaced. Interview on 4/28/17 at 1:01 p.m. with Housekeeper BB revealed that room tasks included emptying trash, looking for spills to clean, mopping, wiping down the room, cleaning the bathroom, and other basic cleaning. Housekeeper BB reported that if stains are identified on a privacy curtain then it is reported to the housekeeping team leader. The team leader will then remove curtain and give to laundry to wash.",2020-09-01
462,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2017-04-28,356,C,0,1,S3GR11,"Based on observation and staff interviews the facility failed to display and accurately report correct nurse staffing data. The facility census was 86 residents. Findings include: Observation and interview on 4/26/17 at 3:40 p.m. with the Administrator who directed who revealed that the nurse staff posting was located on the glass by the main entrance into the facility. The Administrator reported that the Unit secretary is responsible for posting the nurse staff posting each day. The form titled, Daily Staffing Report was observed to no have total staff hours listed. Interview on 4/26/17 at 3:45 p.m. with the Wing I Unit Secretary (Unit Secretary) revealed that she is responsible for the daily posting of the nurse staffing. It was reported that the daily posting is kept in a file on the unit. The Unit Secretary was not aware of the need to keep 18 months of postings and reported that she would look for the requested information. Interview on 4/27/17 at 8:42 a.m. with the Unit Secretary who provided documentation of daily staffing report for 18 months. However, the data on the forms was not complete. The total staff hours was not listed. The Unit Secretary revealed that she was given the form when she began her position and she was not aware that any other information was needed on the form. Interview on 4/28/17 at 10:15 a.m. with the Director of Nursing (DON) revealed that they were in the process of updating the nurse staffing form. The DON further revealed that she did not realize that any data was missing as the facility had been using the Daily Staffing Report for a long time.",2020-09-01
463,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2018-05-24,732,C,0,1,CFZN11,"Based on observation and staff interview, the facility failed to post the nurse staffing information in a prominent place readily accessible to residents and visitors on four of four days of the survey. The facility census was 100. Findings include: Observation during the initial tour of the facility on 5/21/18 at 12:25 p.m. revealed that a listing of key personnel, nurse's names and shifts they work was posted behind the nurse's station on both units in the facility. The information didn't have the facility's census or the number of hours for nurses and CNS's. During an interview with the Director of Nursing on 5/24/18 at 11:30 a.m., he verified that the nurse staffing information that included the facility's census and the number of hours for nurses and CNA's, was posted on a window next to the door of the main entrance of the facility seventy-nine inches from the floor. He stated during further interview that it was not posted in a place readily accessible and visible to residents or visitors.",2020-09-01
464,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2018-05-24,758,D,0,1,CFZN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to respond to a consultant pharmacist recommendation to consider to decrease the use of PRN (as needed) anti-anxiety drug ([MEDICATION NAME]) past 14 days for one (R#38) of five residents. The sample size was 43 residents. Findings include: Review of R#38's clinical record revealed that he had the [DIAGNOSES REDACTED]. Review of his Quarterly Minimum Sata Set ((MDS) dated [DATE] revealed that he received an anti- anxiety drug five of seven days of the assessment period. Review of a Consultant Pharmacist Communication to Physician dated 8/3/2017 revealed that R #38 had an order for [REDACTED]. Review of his physician's orders [REDACTED]. Review R #38's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of a physician Nursing Home Visit dated 5/2/18 noted that R #38 was followed by (psychiatric services provider) for a past psychiatric history significant for [MEDICAL CONDITION]; however, there was not any evidence of any documentation for the clinical rationale for continuing the PRN [MEDICATION NAME] past 14 days. During an interview with R #38's attending physician on 5/24/18 at 1:24 p.m., he stated that the [MEDICATION NAME] was for treating R #38's anxiety and verified that the continued use of the PRN [MEDICATION NAME] on the 8/3/2017 pharmacist recommendation was not addressed. The physician also stated that he had never seen another pharmacist recommendation about the [MEDICATION NAME] since 8/3/2017.",2020-09-01
465,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2018-05-24,761,F,0,1,CFZN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, observation of medication room and medication carts and staff interviews the facility failed to ensure that drugs used in the facility were labeled in accordance with currently accepted professional principles, specifically the expiration date. Resident census was 100. Findings include: Observation and tour on [DATE] at 11:25 a.m. of the facilities medication room (one of two) and carts (three of four) with RN AA, RN Educator, and LPN BB, LPN on north hall, revealed multiple medication cards/pill packs that did not have expiration dates on the packages. Observation of Wing 1 South medication cart on [DATE] at 11:35 a.m. with RN AA, RN Educator, revealed the following: 1) Donepezil 5 mg tablets 28 tablets with no expiration date. 2) [MEDICATION NAME] 5 mg tablets, 28 tablets with no expiration date. 3) [MEDICATION NAME] 50mcg, 28 tablets with no expiration date. 4) Tamsulosin 0.4mg capsule, 28 capsules with no expiration date. 5) [MEDICATION NAME] 20mg, 116 tablets with no expiration date. 6) [MEDICATION NAME] 1MG, 84 tablets with no expiration date. Observation of Wing 2 North medication cart on [DATE] at 11:55 a.m. with RN AA, RN Educator, and LPN BB, LPN on north hall, revealed: 1) [MEDICATION NAME] 88 mcg, 10 tablets with no expiration date. 2) [MEDICATION NAME] 20mg, 13 tablets with no expiration date. 3) [MEDICATION NAME] 15mg, 26 tablets with no expiration date. 4) [MEDICATION NAME] 75mg, eight tablets with no expiration date. 5) [MEDICATION NAME] 40mg, 11 tablets with no expiration date. 6) Enal[DATE]-25, 19 tablets with no expiration date. 7) [MEDICATION NAME] 10mg, 25 tablets with no expiration date. 8) Memantine 10mg, 54 tablets with no expiration date. 9) [MEDICATION NAME] 40mg, 10 tablets with no expiration date. 10) Pioglitazone 45mg, 11 tablets with no expiration date. 11) Pantoprazole 40mg, 27 tablets with no expiration date. 12) [MEDICATION NAME] 1mg, 18 tablets with no expiration date. 13) Potassium chloride 20 meq, 23 tablets with no expiration date. 14) [MEDICATION NAME] 40mg, seven tablets with no expiration date. 15) [MEDICATION NAME] 2mg, 32 tablets with no expiration date. 16) [MEDICATION NAME] ,[DATE]mg, 64 tablets with no expiration date. 17) [MEDICATION NAME] 150mg, 20 capsules with no expiration date. 18) [MEDICATION NAME] 1GM, 120 tablets with no expiration date. 19) Sevelamer 800mg, 30 tablets with no expiration date. 20) [MEDICATION NAME] 1,000mg, 30 tablets with no expiration date. 21) [MEDICATION NAME] 625mg, 60 tablets with no expiration date. Observation on [DATE] at 12:35 p.m. with staff AA of Wing 2 South medication cart revealed no findings. Total of 930 individual pills/capsules/medications with no expiration dates on the labels. The medications without expiration dates were found on two of the four carts. The scope and severity will be 2 and F respectively. Interview on [DATE] at 9:45 a.m. with RN AA revealed the expectation of the consulting pharmacist was to review and identify outdated medications on their monthly facility review of the medication carts and medication rooms. It is also expected that the nurses giving the medications check for expiration dates on medications. Review of the facility policy titled Medication Storage dated [DATE], no revised date revealed under article 6 Unused Medications, requires the pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective or deteriorated medications with worn, illegible or missing labels these medications are destroyed in accordance with our Destruction of Unused Drugs Policy. Review of the facility policy titled Medication Administration Policy, there was no effective or revised date on the policy. Under Medication Administration #12. Identify expiration date. If expired, notify nurse manager.",2020-09-01
466,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2018-05-24,880,F,0,1,CFZN11,"Based on observation, staff interview and record review, the facility failed to provide Personal Protective Equipment (PPE), ensure the safe handling of dirty laundry, ensure that the appropriate amount of detergent and chlorine bleach were used to prevent transmission based infections for 89 out of 100 residents that the facility provides laundry services for. Findings Include: Observation and interview on 5/24/18 at 12:08 p.m. with Laundry Aide CC revealed that there was no clean side or dirty side in the laundry room. Observation revealed a stack of folded towels on a table next to the washing machine. Observation revealed that the two washing machines and dryers were separated by approximately two feet and they were facing each other. The washing machine was in use and the temperature of the water was set on the cool cycle. Observation revealed that the washer and drier were both currently in use. Interview on 5/24/18 at 12:19 p.m. with the Housekeeping Supervisor DD and the Laundry Aide CC revealed that the linens were sent out to Southern Linen Services. The interview also revealed that the residents personal clothing and washable items that the housekeeping department utilizes for cleaning, were washed in the facility machines. Observation and interview also confirmed there were no goggles or protective aprons that were utilized when handling soiled clothing. Observation revealed that they use Dynamo laundry detergent that was supplied by a Laundry Detergent Company. Interview with the Housekeeping Supervisor DD and the Laundry Aide CC revealed that neither one knew what was in the laundry detergent. They stated that they did not know if the detergent contained an antibacterial, enzyme, stain remover or softener. Observation revealed two machines on the wall with clear tubes. Interview with Laundry Aide CC revealed that these machines send a premeasured amount of detergent into the washing machine when a tube that was connected to the bucket of detergent was placed in the washing machine at the beginning of wash cycle. Observation revealed that the dispensing tube that dispensed the appropriate amount of detergent and was placed in the washing machine with each load was visibly dirty. The dispensing tube was orange/brown in color with dried lint clogging tube. Observation revealed that the laundry aide was unable to get the machine that dispenses laundry detergent to work. Interview revealed that the dispensing machine and tube had not worked for a while and that the laundry aide would pour laundry detergent and bleach in by hand. She stated that she doesn't measure out a specific amount that she just pours. She stated that she was unaware that she needed to use a specific amount. She also stated that she was unaware of how personal clothing was to be handled for a person on transmission based precautions. Observation and interview on 5/24/18 at 12:23 p.m. with the Head of Housekeeping DD and the Hospital Administrator confirmed that the dispensing machines for the washing machines do not work and there was no way to know if the appropriate amount of detergent and disinfectant were being used. Review of policy revealed that the facility was to provide staff with Personal Protective Equipment (PPE), when a low temperature cycle was used for the washing machine that the staff would wash with chemicals suitable for low temperature washing (less than 160 degrees) at the proper concentration and that if chlorine bleach was used as an anti-infective that it was to be used at 125-part-per-million (ppm).",2020-09-01
467,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,584,D,0,1,RUW911,"Based on observation and staff interviews the facility failed to ensure the upkeep of resident wheelchairs related to dirt and debris build up for three of 41 residents (R) #26, R#30, R#80) that utilized wheelchairs in the facility, and the facility failed to ensure one of 41 wheelchairs was in good repair for one resident (R#34). Findings include: Observation on 8/13/19 at 8:22 a.m. revealed the left armrest on the wheelchair for R#34 had exposed cushioning. Observation on 8/13/19 during the 1:00 p.m. smoke break revealed dust and buildup on the wheelchair spokes and the undercarriage of the wheelchair for R#26. Observation on 8/13/19 at 1:39 p.m. revealed that dust and dirt buildup were observed on the undercarriage of the wheelchair for R#80. Observation on 8/13/19 at 1:41 p.m. revealed dust and dirt buildup on the spokes and undercarriage for the wheelchair for R#30. Interview on 8/16/19 at 12:57 p.m. with the Assistant Director of Nursing (ADON) revealed that housekeeping staff cleans wheelchairs during the day. Further interview with the ADON confirmed the dust and dirt buildup on the wheelchair spokes and undercarriage for R#26, R#30, and R#80. The ADON also confirmed the exposed cushioning on wheelchair of R#34.",2020-09-01
468,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,609,D,1,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews, and review of the facility policy titled, Abuse, neglect, Exploitation the facility failed to report an allegation of abuse for one of 39 residents reviewed for abuse (Resident (R) #291). Findings include: Abuse, neglect, exploitation 11/1/17 6. Identification of abuse, neglect, and exploitation - the facility will consider factors indication possible abuse, neglect, exploitation of residents, and /or misappropriation of resident property including but not limited to, the following possible indicators: a. resident, staff or family report of abuse 7. Investigations of alleged abuse, neglect, and exploitation - all allegations of abuse must be reported immediately, but no later than 2 hours after the allegation is made, allegations of neglect or exploitation to be reported to the Administrator of the facility immediately but no later than 2 hours after from the suspicion, if the events that cause the suspicion result in serious bodily injury or 24 hours if the events that cause the suspicion do not result in serious bodily injury. When suspicion of abuse, neglect, exploitation, mis app of resident property or reports of abuse, misappropriation of resident property occur, an investigation is immediately warranted. once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Review of the medical record revealed that R#291 had [DIAGNOSES REDACTED]. Further review of documents supplied by the facility a revealed police incident report made by R#291 on 7/7/19 in which R#291 reported to law enforcement that a nurse tried to stab him with a pen. During an interview on 8/12/19 at 2:36 p.m. with R#291 revealed that Registered Nurse (RN) Supervisor II, tried to stab him with a pen. An exact time for when this incident took place was not expressed but it took place a few months ago. During an interview on 8/14/19 at 3:10 p.m. with the Director of Nurses (DON) revealed that that he was informed that there was an incident with R#291 so he left the morning meeting to assess the situation. The DON reported that R#291 was found to be holding RN Supervisor II's arm and once R#291 and RN Supervisor II were separated R# 291 was taken to his room. The DON acknowledged that at the time of the incident R#291 reported that the RN Supervisor II had stabbed him with a pen. The DON revealed that for an allegation of abuse that the process is an investigation is completed, and it is reported within 5 days to the State Agency. The DON further reported that he realized afterward the incident occurred that a report should have been made and that is why RN Supervisor II reported the incident to the police. Interview on 8/14/19 at 4:45 p.m. with RN Supervisor II confirmed that the incident with R#291 in (MONTH) 2019 in which R#291 grabbed her arms and later made statements that she stabbed him with a pen occurred. RN Supervisor II revealed that the previous Administrator informed her to file a police report due to R# 291 continuing to say that she tried to stab him. During an interview on 8/16/19 at 5:39 p.m. with the DON revealed that he the Nurse Practitioner, and the former Administrator went into room with R#291 on the day of the incident in (MONTH) to discuss what happened with the resident. The DON explained that while in the room R#291 took a blue pen and marked on his arm and then said that the RN Supervisor II had done that to him. The DON reported that he now understands that he should have reported it but at the time because R#291 marked on himself he did not think it was necessary to report. Interview on 8/16/19 at 7:08 p.m. with the Chief Executive Officer (CEO) revealed that her expectation is if abuse is alleged by a resident staff will report the incident to the state and investigate the incident. Review of the Police Department Incident Report dated 7/10/19 revealed the following: Incident occurred on 7/6/19. On 7/7/10 police officer responded to 911 call R#291 made. R#291 told the officer that a nurse tried to stab him with a pen. Continued review of the Police Report revealed that the officer conducted an investigation. The officer informed R#291 that there was no evidence or witnesses of any crime and charges could not be pressed. Further review of the Police Report revealed R#291 called 911 four additional times demanding the officer return to the facility while cursing and yelling at dispatchers. The officer went back to the facility and spoke with R#291 two additional times. The report revealed that the resident had called 911, 14 times from 7/9/19 through 7/10/19. The officer returned to the facility on [DATE] and spoke with R#291 regarding calling 911 for non-emergencies. The officer revealed while speaking with R#291, he became belligerent and would not calm down. The Police Report stated based on his erratic behavior and violence towards the staff a 1013 involuntary evaluation order was signed.",2020-09-01
469,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,625,D,0,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility Policy and Procedure titled, Resident Leave of Absence the facility failed to ensure that two of 20 residents, residents (R) (R#59, R#291) were made aware of the facility's bed-hold and reserve bed payment policy before and upon transfer to a hospital or when taking a therapeutic leave of absence from the facility. Findings include: A record review of the facility Policy and Procedure titled, Resident Leave of Absence date (developed) 8/14/19 revealed the policy does not address the residents right to have a bed hold notice provided to them or their responsible party when they are on a therapeutic leave of absence. A record review of the facility's Resident Leave of Absence Record revealed R#59 left the faciity on a therapeutic leave 7/4/19. A review of the nursing notes dated 7/4/19 at 5:29 p.m. revealed the resident signed the leave of absence (LOA) book for a two night stay out of the facility. A further review of the nursing notes revealed that the resident returned to the facility on (MONTH) 6th, 2019. During an interview on 8/16/19 at 2:22 p.m. with the Business Office Manager (BOM) revealed that the bed-hold notice is given to residents after they have been discharged from the facility. A staff person will take it to them, or the notice will be mailed. She further stated if a resident is out on a therapeutic leave she has never issued a bed hold policy. During an interview on 8/16/19 at 7:11 p.m. with the Chief Executive Officer (CEO) she confirmed the bed hold policy had not been given prior to a therapeutic leave and/or hospital leave for any resident. 2. Review of the medical record for R#291 revealed resident was transferred from the facility to the hospital on the following dates: 6/9/19, 7/6/19. 7/7/19, 7/8/19, 8/2/19, 8/13/19, and on 8/15/19. Review of the hospitalization s during the past 90 days revealed that the only time a bed hold notice was provided to R#291 was when the resident was transferred to the hospital on [DATE]. During an interview with the Business Office Manager (BOM) on 8/16/19 at 2:21 p.m. revealed that the Bed hold form is given to residents once admitted into the hospital. It was further revealed that the bed hold form is mailed or taken to the resident while in the hospital. The BOM reported that once she is notified of a hospitalization , she contacts the family, Power of Attorney, or resident to inform them of the bed hold policy. The BOM further disclosed that she has not issued a bed hold policy for any therapeutic leaves due to residents not being gone for 7 days when on leave. She further confirmed that the bed hold form was not provided to residents prior to leaving the facility when going to the hospital. Interview on 8/16/19 at 5:51 p.m. with the Director of Nursing (DON) revealed that the bed hold policy notifications are done through the business office. The DON further revealed that he thinks that prior to transfer someone is talking to the resident and then someone would go to the hospital to get residents to sign the form once admitted in the hospital. Interview on 8/16/19 at 7:09 p.m. with the Chief Executive Officer (CEO) revealed that financial services were responsible for bed hold notifications. The CEO reported not being aware that the bed hold notices should be provided prior to the transfer to the hospital.",2020-09-01
470,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,644,D,0,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to have a resident re-evaluated for Level II Preadmission Screening and Resident Review (PASRR) by the appropriate state - designated authority for evaluation and determination of specialized services for one resident of 16 residents (R B) screened for PASRR). Findings include: Record review for R B revealed a PASRR Level II assessment dated [DATE] with the following recommendations: Given there is no known history of Severe Mental Illness, and current minimal symptoms of depression and anxiety, specialized psychiatric services are not recommended. In the event R B exhibits active symptoms of a Severe Mental Illness, the SNF may submit a Level I application for a status change to request specialized psychiatric services. R B has the current [DIAGNOSES REDACTED]. Care plan review also revealed care plan for refusal of dressing changes. Further review revealed R B showed a picture of his genitals to staff on 6/7/19. On 6/12/19 R B was reported as grabbing the arm of Registered Nurse (RN) Supervisor II with another staff person having to assist before letting the arm go. On 6/27/19 R B was found to be recording staff and uploading it to social media. Review of police report revealed R B called 911 a total of 14 times from 6/9/19 to 7/7/19. Record review revealed that 911 was called a total of five times on 7/7/19. Review of the police incident report revealed that R 'B became belligerent with the officer and had erratic behavior and violence towards staff. As a result of this R B was sent out of the facility. Interview on 8/14/19 at 5:14 p.m. with the Social Services Director (SSD) revealed that behaviors with R B began after going on a home visit for 3 or 4 days and that after return to the facility the resident had an increase in behaviors. Interview on 8/15/19 at 11:09 a.m. with the Director of Nursing (DON) revealed that R B made statements of self-harm and a CNA is providing one on one with R B until transportation arrives to take him to the hospital to be reassessed. Interview on 8/15/19 at 12:15 p.m. with SSD revealed that R B received psych services at one time but often refused. The SSD was not sure if any Level II services were provided for R B. Interview on 8/16/19 at 5:34 p.m. with the DON revealed that based on the Level II recommendations the SSD should have resubmitted an application for a change of services due to resident's behavioral changes.",2020-09-01
471,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,656,D,0,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to develop a care plan related to anticoagulant use for one resident of five residents (R) A) reviewed for care plans as related to medications. Findings include: Review of medical record for RA revealed [DIAGNOSES REDACTED]. Further review of the medical record revealed RA was readmitted to the facility on [DATE] after being hospitalized for [REDACTED]. Further review of the medical record revealed that there was not any evidence of documentation that a care plan for anticoagulant drug usage had been developed for R A upon readmission to the facility on [DATE]. During an interview with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) OO on 8/16/19 at 4:31 p.m., revealed that LPN OO confirmed that an anticoagulant care plan was not developed for RA after the resident was readmitted to the facility on [DATE]. During an interview on 8/16/19 at 6:14 p.m. with the Director of Nursing (DON) revealed that his expectations are that the care plans should be developed and updated to match the residents needed care. Cross-refer F684",2020-09-01
472,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,684,D,0,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, and review of the facility policy titled, Medication Administration Policy and Procedure the facility failed to follow Physician's orders related to the administration of Xarelto 2.5 milligrams (mg) for one of five Resident (RA) reviewed for medications. Findings include: Medication Administration Policy and Procedure 11.Compare medication source (bubble pack, vial, etc.) with MAR {Medication Administration Record}to verify resident name, medication name, form, dose, route, and time. 13. Remove medication from source. 14. Administer medication as ordered with proper amount of food or liquid. 17. Sign MAR indicated [REDACTED] Review of medical record for RA revealed [DIAGNOSES REDACTED]. Further review of the medical record revealed RA was re-admitted to the facility on [DATE] after being hospitalized for [REDACTED]. Review of a Summary of Incident report dated 12/27/18 documents, in pertinent part, that RA was not getting her Xarelto 2.5 mg as ordered by her doctor. Even though the Medication Administration Record [REDACTED]. The medication was placed in the overstock drawer of the medication cart on 12/24/18 when the pharmacy delivered the medication; however, the medication was not found and administered to the resident until 12/26/18. During an interview on 8/14/19 at 1:15 p.m. with a Family of RA it was revealed that RA returned to the facility from the hospital with a new order for Xarelto 2.5 mg; however, the resident did not receive this medication when the resident was readmitted to the facility on Friday (12/21/18) but the resident was informed that the medication was on order from the pharmacy. During an interview on 8/15/19 4:57 p.m. with Licensed Practical Nurse (LPN) HH, revealed that the Xarelto was not available for RA when the resident was admitted to the facility from the hospital on [DATE]. LPN HH could not recall when the medication was received. LPN HH reported that the Physician was notified that the Xarelto would not be available until the following Monday, 12/24/18. The Physician did not give any new orders when told the Xarelto would not be available until 12/24/18. During an interview on 8/16/19 at 6:14 p.m. with the Director of Nursing (DON) revealed that the Xarelto 2.5 mg was in the overflow cart and had been in the facility since 12/24/18. Further interview revealed that the nurse receiving the medication from the pharmacy put the medication in the bottom drawer of the medication cart when the medication was delivered and did not notify the oncoming nurse that the medication was available. The DON confirmed that RA missed receiving Xarelto 2.5 mg from 12/21/18 through 12/26/18.",2020-09-01
473,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,689,D,0,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews, and a review of the facility's policy and procedure titled, Smoke Free Facility it was determined that the facility failed to adequately monitor two of eight residents (R#59, R#291) reviewed for safe smoking. Findings include: Smoke Free Facility Policy: It is the policy of this facility to establish and maintain safe resident practices, while ensuring nonsmoking residents' alternate locations for activities/gatherings to prevent secondhand smoke. Tobacco products include cigarettes, cigars, pipes, smokeless tobacco, electronic cigarettes (vaping), etc. Procedure 4. Smoking restrictions shall be strictly enforced in all nonsmoking areas. 11. No resident may have or keep any types of smoking articles, including cigarettes, tobacco, etc., except under strict supervision. 12. They may not keep any smoking articles in their room. 1. Record review revealed a Quarterly Minimum (MDS) data set [DATE] that documented R#59 had a Brief Interview for Mental Status score of 15 indicating that the resident was cognitively intact. Section G revealed the resident did not have any impairments to his bilateral upper extremities but had impairment to his bilateral lower extremities. Review of a Smoking Evaluation dated 6/11/19 for R#59 revealed that a smoking evaluation will be completed on all new admission, readmission, and those residents undergoing a significant change in status. All residents will be reviewed quarterly. Evaluations may be completed by any member of the IDT (Interdisciplinary Team). Type of assessment was documented to be a quarterly review. A check mark is noted beside the question: Has the resident ever smoked without supervision before. The evaluation documented that the resident was able to light a cigarette safely, hold cigarette safely, extinguish cigarette safely, and that safety devices needed was an apron. Record review revealed a Nurses note dated 11/15/18 that the Director of Nursing had given R#59 a verbal warning about smoking. During an observation on 8/15/19 at 9:20 a.m. R#59 was observed to be outside under the breezeway/walkway that leads to the main doors of the nursing facility, a non-designated smoking area. The resident was observed lighting and smoking a cigarette without staff supervision and without a smoking apron During an observation on 8/15/19 at 9:28 a.m. R#59 was again observed to be outside under the breezeway/walkway that leads to the main doors of the nursing facility, a non-designated smoking area. The resident was observed lighting and smoking another cigarette without staff supervision and without a smoking apron. During an observation and interview on 8/15/19 at 9:43 a.m. R#59 was observed handing staff a blue lighter and a cigarette that had been lit and partially smoked. He confirmed he had been smoking without staff supervision in a non-designated smoking area. During an interview on 8/15/19 at 9:43 a.m. with Therapy Staff AA revealed that she did ask R#59 if he had a lighter and R#59 gave her a lighter and a partially smoked cigarette, which was given to the nursing staff. During an interview 8/15/19 at 10:48 a.m. with Licensed Practical Nurse (LPN) LPN MM, revealed R#59 is non-compliant and hides his smoking material. LPN MM further stated that the resident is hard to re-direct. During a telephone interview on 8/15/19 at 12:26 p.m. with the Ombudsman, she revealed there are two residents that smoke in front of the facility in the non-designated smoking area, she further stated she has seen them smoking without staff supervision and without aprons. The Ombudsman confirmed that she had reported it to the former Administrator and the Director of Nursing (DON). During an interview on 8/15/19 at 1:22 p.m. with the Director of Nursing (DON) concerning the smoking policy and procedures, he stated R#59 would go out and smoke, the DON further revealed the hospital Chief Operating Officer (CEO) has warned him. The DON stated he has spoken to R#59 but it's a pattern that has been going on for at least a year. The DON further revealed R#59 has not been issued any discharge notice due to his continued non-compliance with the smoking policy. The DON confirmed it is a problem if a resident keeps their smoking material. During an interview on 8/16/19 at 10:34 a.m. with the Administrator confirmed that he was aware that R#59 smoked in front of the facility without staff and in an area that is not designated for smoking. 2. Record review revealed a Quarterly Minimum (MDS) data set [DATE] that documented R#291 had a Brief Interview for Mental Status score of 15 indicating that the resident was cognitively intact. Section G revealed the resident did not have any impairments to his bilateral upper extremities but had impairment to his bilateral lower extremities. Review of a Smoking Evaluation dated 8/1/19 for R#291 revealed the type of assessment was a Readmission assessment. A check was noted beside the question: Has the resident ever smoked without supervision before. The evaluation documented that the resident was able to light a cigarette safely, hold cigarette safely, extinguish cigarette safely and that the resident refused to follow the facility policy on location and time of smoking. Review of the medical record for R#291 revealed resident was non-compliant with the smoking policies of the facility as evidenced by not wearing smoking apron, not following the designated smoking times, and smoking along the entrance walk area. Further review of the medical record indicated a smoking assessment date 8/1/19 that also indicated that R#291 smoked without supervision. Observation on 8/14/19 at 4:20 p.m. revealed that R#291 had a vape pen in his possession in a non-designated smoking area (front walkway of the facility). Observation on 8/14/19 at 5:35 p.m. revealed that R#291 was sitting outside in a wheelchair with a vape pen in his possession. R#291 was also observed to have a water bottle with a cigarette butt in it. R#291 reported that someone had given him a cigarette and a light, but he denied having a lighter or cigarette at that time. During a smoking observation on 8/13/19 at 4 p.m. the staff person monitoring the smoke break reported that R#291 smokes by himself and signs himself out to smoke. Interview on 8/14/19 at 4:45 p.m. with Registered Nurse (RN) Supervisor II revealed that it was her understanding that the Administrator and DON informed R#291 that if he signs out, he can smoke on his own. Further interview with RN Supervisor II revealed that upon return to the building R#291 is to turn in his lighter. Review of the smoking materials box did not reveal any smoking materials for R#291. Interview on 8/14/19 at 4:58 with Unit Clerk JJ revealed that R#291 keeps his cigarettes and lighter on him. Unit Clerk JJ stated that R#291 does not always sign in or out to smoke but only when he leaves the premises. During an interview on 8/15/19 at 7:15 a.m. with Certified Nursing Assistant (CNA) KK revealed that R#291 keeps his smoking materials on him in his bookbag. During an interview with the Social Services Director on 8/15/19 at 11:37 a.m. revealed that residents are encouraged to follow the smoking policy. When questioned how the facility ensures the safety of residents who are not cognitively intact from getting cigarettes and lighter out or R#291's room the SSD reported that R#291 has been told several times to return his lighter and cigarettes when he returns from smoking. SSD acknowledged that she has observed R#291 with cigarettes and a lighter. Interview with the Ombudsman on 8/15/19 at 12:25 p.m. revealed that she has observed R#291 smoking and not wearing a smoke apron. Interview on 8/15/19 at 1:19 p.m. with the Director of Nursing (DON) revealed that R#291 will not follow rules and will not sign out when he wants to go smoke. R#291 had been told he could leave the premises to smoke, but it has gotten to the point now that R#291 does not leave the premises to smoke. The DON reported that he has not told R#291 that he could not have the vape pen in his possession because he has not seen him using it in the building. The DON was unsure of what the facility smoking policy said regarding vaping. Interview with Licensed Practical Nurse (LPN) BB on 8/15/19 at 4:23 p.m. revealed that she was aware that smoking should be in the designated smoking areas at the designated times per the smoking policy, but R#291 has never been observed smoking in the designated smoking areas. LPN BB reported that she has observed R#291 with a vape pen, lighter, and a cigarette and that R#291 likes to smoke under the breezeway, under the tree in the parking lot, or at the entrance door to the nursing home. Interview with the Administrator on 8/16/19 at 10:35 a.m. revealed that he has previously observed R# 291 smoking unsupervised and without a smoking apron.",2020-09-01
474,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,712,D,0,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of the facility policy titled, Physician Visits and Physician Delegation Policy revealed the facility failed to ensure residents were seen by a physician in the facility at least once every 30 days for the first 90 days after admission, and at least once every 60 days thereafter, for two of 20 residents (R#26 and R#1) reviewed for frequency of Physician visits. Findings include: A record review of the facility policy and procedure titled, Physician Visits and Physician Delegation Policy dated 2019 revealed under section: 2. The Physician should: a. See resident within 30 days of initial admission to the facility. b. The resident must be seen at least once every 30 calendar days for the first 90 calendar days after admission and at least every 60 days thereafter by physician or physician delegate as appropriate by State law. d. Date, write and sign a progress note for each visit. Record review revealed that R#26 was admitted to the facility on [DATE]. Further review revealed that there were only physician progress notes [REDACTED]. During an interview on 8/16/19 12:25 p.m. with the Medical Director revealed that he visits his residents at least every other month. As for the newly admitted residents the Medical Director stated he has not been as good at that, I miss some of the newly admitted residents, but my Nurse Practitioner catches them. During an interview on 8/16/19 at 5:25 p.m. the Director of Nursing (DON) confirmed that the Physician visits in a timely manner was something the facility was having a problem with. The DON further stated he had a recent talk with the Medical Director, and the Medical Director agreed to visit every other month. The DON added they have had the same Medical Director for the last three years. 2. Review of the medical record for R#1 revealed the resident was admitted to the facility on [DATE]. Further review revealed that the first visit with the Physician was on 6/20/18 with the next visit occurring on 8/22/18. Record review also revealed that between 10/24/18 and 2/12/19 that there were not any documented physician visits. There were also no documented physician visits between 2/14/19 and 6/28/19. Review of the progress notes revealed only the following Physician visits: 6/20/18, 8/22/18, 10/24/18, 2/13/19, 6/28/19, and 7/31/19. Interview on 8/16/19 at 12:31 p.m. with the Medical Director revealed that he has been seeing residents at the facility at least every other month. However, the Medical Director reported that he has not been seeing new residents according to the guidelines of once a month for the first three months. Interview on 8/16/19 at 5:26 p.m. with the Director of Nurses (DON) confirmed that R#1 had not been seen monthly for the first 90 days after admission. The DON also confirmed that R#1 had not been seen every 60 days between (MONTH) (YEAR) through (MONTH) 2019 and from (MONTH) 2019 through (MONTH) 2019. The DON reported that he was aware that the Physician visits were a problem area and had recently spoken to the Medical Director related to the frequency of visits.",2020-09-01
475,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,758,D,0,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, and record review the facility failed to ensure [MEDICAL CONDITION] medication (med) was not ordered as needed (prn), beyond 14 days, without the intended duration of therapy, for one of five residents (R#68) reviewed for unnecessary medications. Findings include: Record review revealed that R#68 was admitted to the facility with [DIAGNOSES REDACTED]. Review of a physician progress notes [REDACTED]. Review of a Physician order [REDACTED]. Review of the order for this medication indicated a start date of 1/16/19, but the end date was indefinite. Review of the Medication Administration Record [REDACTED]. R#68 was out of the facility between (MONTH) 16-23, 2019 for behavioral evaluation. Review of a Consultant Pharmacy communication to the Physician dated 2/4/19, revealed a recommendation to decrease the use of [MEDICATION NAME] on a prn basis, and that it required reevaluation by the Physician after 14 days. The Physician indicated that the medication improved the quality of the resident's life, the resident was responding to therapy, and was experiencing no adverse effects from this therapy, but he did not document a duration or stop date. The communication was signed by the physician on 2/6/19. Interview on 8/16/19 at 10:18 a.m. with Licensed Practical Nurse (LPN) MM, confirmed a current order for [MEDICATION NAME] 1.0 mg bid prn, with a start date of 1/16/19, but no end date. LPN MM also verified R# 68's prn medication documentation sheet and confirmed [MEDICATION NAME] prn was administered 15 times in (MONTH) 2019. Interview on 8/16/19 at 10:24 a.m. with the education nurse, confirmed R#68 had a current order for [MEDICATION NAME] 1.0 mg bid prn, and it had been ordered since 1/16/19 without a stop date. Interview on 8/16/19 at 10:28 a.m. with the Director of Nursing (DON) confirmed [MEDICATION NAME] was ordered bid prn for R#68 and revealed if prn meds were not administered after seven days, they were discontinued. He verified a current order for [MEDICATION NAME] prn, ordered since 1/16/19, with no stop or discontinue date. Interview on 8/16/19 at 10:50 a.m. with Registered Nurse (RN) NN, revealed that R#68 had a current order for [MEDICATION NAME] 1.0 mg bid prn, it had been ordered since (MONTH) 2019 with no documented duration, or end date.",2020-09-01
476,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2019-08-16,919,D,0,1,RUW911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews the facility failed to ensure that all components of the nurse call system in four of 49 resident shared bathrooms (bathrooms for rooms: 213 and 215, 209 and 211, 205 and 207, 229 and 231) were fully functional and the facility failed to ensure that there was a monitoring system in place to identify call light issues in resident bathrooms. Findings include: Observation on 8/13/19 at 8:40 a.m. revealed the call light string did not work when pulled in the shared bathroom for room [ROOM NUMBER] and 215. Observation on 8/13/19 at 8:49 a.m. revealed the call light did not work when the string was pulled in the shared bathroom for room [ROOM NUMBER] and 211. Observation on 8/13/19 at 8:51 a.m. revealed the call light did not work when the string was pulled in the shared bathroom for room [ROOM NUMBER] and 207. Observation on 8/13/19 at 9:09 a.m. revealed the call light did not work when pulled for the shared bathroom for room [ROOM NUMBER] and 231. During a tour of 200 hall north with the Maintenance Director on 8/13/19 from 2:10 p.m. until 2:33 p.m. revealed the following: 1. In the shared bathroom for room [ROOM NUMBER] and 207 the call light came but only when force was used to pull the string. 2. In the shared bathroom for room [ROOM NUMBER] and 211 call light came on but only after force was used to pull the string. 3. In the shared bathroom for room [ROOM NUMBER] and 231 the call light came on but only after force was used to pull the string. Interview on 8/13/19 at 2:33 p.m. with the Maintenance Director revealed that the call lights at the bedside are checked monthly to assure functionality but he reported that the call lights in the bathrooms are not checked on a monthly basis. The Maintenance Director revealed that the call lights in the bathroom are only checked when he or his staff are notified that there is an issue. He further reported that the bathroom call lights are not used much and have corroded over time. The Maintenance Director confirmed that the call lights in the bathrooms should come on with ease when string is pulled. Interview on 8/14/19 at 8:12 a.m. with the Maintenance Supervisor revealed that he checks all aspects of residents' rooms three times a year which includes checking the call lights at the bedside, but he has not been checking the functionality of the call lights in residents' bathrooms. Maintenance Supervisor reported that these checks are done quarterly; however, there was not any evidence of any documentation that these checks had been completed. Observation on 8/14/19 at 8:45 a.m. of R#341 in the shared bathroom for room [ROOM NUMBER] and 211 revealed that the resident was not able to pull the string to turn the call light on in the bathroom. Interview with the Administrator on 8/14/19 at 9:49 a.m. revealed that his staff had not indicated to him that there was a problem with the call lights in resident's bathrooms. He reported that his expectations are that call lights are checked weekly and the call lights in the bathroom are on the list of things that should be checked when staff perform rounds.",2020-09-01
477,EARLY MEMORIAL NURSING FACILITY,115271,11740 COLUMBIA STREET,BLAKELY,GA,39823,2018-10-29,686,D,1,0,JQLH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews,and review of a facility policy titled Completing an Accurate Assessment Regarding Pressure Injuries it was determined that the facility failed to thoroughly assess pressure sores for two of three sampled residents (R) (R#1 and R#3) with pressure sores. The total sample was three residents. Findings Include: Review of an undated policy titled Completing an Accurate Assessment Regarding Pressure Injuries revealed a qualified health professional will document the presence, number, stage and pertinent characteristics of any pressure injury on the wound documentation form in the medical record. 1. R#1 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the care plan dated 7/13/18 revealed the resident had a Stage II pressure ulcer to the right ankle. An approach in the care plan was for staff to measure the wound at least weekly, record width and length, appearance, amount and odor of any drainage. Review of the 7/13/18 Wound Assessment Notes revealed the resident had a Stage II to the right ankle with green foul odor drainage noted. The area measured 1.0 x1.0 x 0.2 centimeters (cm). There was no documentation describing the appearance of the wound bed. Review of the Weekly Wound Report from 9/5/18 to 10/29/18 noted the resident had a Stage II pressure sore to the right ankle. The documentation included measurements and staging of the wound. However, the documentation did not include a description of the wound bed and if there was any drainage or odor present. During an interview with Registered Nurse (RN) AA on 10/29/18 at 2:30 p.m., she stated that she documents the measurements of the wounds every week. She stated that she only documents a description of the wound if there has been a change in the wound. 2. R#3 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the 7/4/18 Interdisciplinary Progress Notes noted the resident had a deep tissue injury (DTI) to the right lateral foot and the right medial foot with open areas or drainage. It further noted there was maroon tissue present. The documentation included measurements of each wound. During an interview with RN AA on 10/29/18 at 2:30 p.m., she stated the resident's right lateral foot has had some slough present in the wound bed for the past month. She stated that she did not reclassify the wound from a DTI to an unknown stage because either way she did not know what was under the slough or the DTI. During an interview with the Director of Nursing (DON) on 10/29/18 at 3:15 p.m., he stated that they had identified some issues with the wounds in the facility. He stated that the treatment nurse was overwhelmed from the amount of wounds that were inherited from other facilities. He stated the treatment nurse was basically doing the treatments and measuring the wounds every week.",2020-09-01
478,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,161,E,0,1,O35L11,"Based on interview and record review, the facility failed to ensure that the surety bond covered the daily balances for the Resident Trust Account for six (6) of 6 months reviewed. Findings include: The facility managed sixty-four (64) accounts and had a surety bond in the amount of $50,000 effective until 3/8/17. A review of the Resident Trust Account bank statements revealed that from (MONTH) (YEAR) to (MONTH) (YEAR), the daily balances exceeded the Bond amount every month for the following number of days each month: March (YEAR): eight (8) of thirty-one (31) days April (YEAR): fifteen (15) of thirty (30) days May (YEAR): sixteen (16) of 31 days June (YEAR): nineteen (19) of 30 days July (YEAR): seven (7) of 31 days August (YEAR): eleven (11) of 31 days During an interview on 9/22/16 at 2:30 p.m., the Business Office Manager confirmed the balances in the Resident Trust Account exceeded the surety bond and stated that the facility would be increasing the bond.",2020-09-01
479,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,241,E,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and the facility policy, Dining the facility failed to provide a dignified dining experience for the residents and failed to serve meals in a systematically manner to prevent random selection of residents at the tables for meal delivery in one of two dining rooms and failed to maintain the privacy of posted care instructions for eleven (11) resident's room. Findings include: 1. It was observed on 9/19/16 from 11:40 a.m. to 12:38 p.m. that twenty (20) residents and four staff members were in the main dining room for lunch. Facility staff did not serve or assist table one that had nine residents to eat in a consistent and timely manner. It was observed that staff removed resident ' s lunch meal trays from a meal cart and served four of the nine residents at 11:40 a.m. at table one. These four residents were being assist by staff with eating lunch, and staff had not served lunch to the other five residents seated. The last resident of the five received their lunch at 12:38 p.m. At table 2, staff served one of four residents lunch, seated at the table at 11:50 a.m. Three residents seated at this table had not received their lunch tray and was watching this resident eat their lunch. The last resident of the three received their lunch at this table at 12:22 p.m. At table 3, Staff served one of the four residents seated at the table at 11:50 a.m. Three residents seated had not received their lunch tray and was looking in the direction of the meal cart. The last of the three residents at this table was served at 12:25 p.m At table 4, staff served one of three residents seated at the table at 11:51 a.m. Two residents seated had not received their lunch tray. The last of two resident received lunch at this table at 12:21 p.m. At table 5, staff had served one of one resident at 12:25 p.m. However, it was observed that staff removed the remainder of the lunch trays from the meal cart for resident who had not receive their lunch. The longest wait from the first resident and last resident seated at the same table was fifty-eight (58) minutes. It was observed on 9/20/16 from 11:43 a.m. to 12:29 p.m. that twenty-eight (28) residents and four staff members were in the main dining room for lunch; At table 1, staff served four of nine residents at 11:43 a.m. The four residents were being assisted by staff with eating. Staff had not served lunch to the other five resident seated at the same table. The five residents remained at the table watching the four residents eating being assisted by staff. The five residents received lunch at this table at 12:29 p.m. At table 2, staff served two of four residents at 11:49 a.m. These two residents were independently eating while the two other resident had not received their lunch. The last of the two resident received lunch at this table at 12:03 p.m. At table 3, staff served nine of nine residents at this table. At table 4, staff served two of seven residents at 11:51 a.m. The other five residents had not been served and was seated at the table. The last of the two remainder resident received their lunch at 12:20 p.m. It was observed on 9/21/16 from 11:30 a.m. to 12:38 p.m. that twenty (20) residents and three (3) staff members were in the main dining room for lunch. At table 1, staff served three of eight residents at 11:30 a.m. These three resident were being assist by staff with eating and staff had not served lunch to the other five residents seated at the table. The last of the five residents was served lunch at this table at 11:46 a.m. At table 2, staff served two of four residents at 11:47 a.m. The other two resident had not been served and was seated at the table. The last of the two resident was served lunch at 12:07 p.m. At table 3, staff served two of four residents at 11:40 a.m. The other two residents had not been served and was seated at the table. The last of the two resident were served lunch at this table at 12:03 p.m. Observation of one resident without lunch at this table was trying to get food off the resident plate sitting next to her. At table 4, staff served four of four residents. At table 5, staff served one of five residents at 11:43 a.m. The other four residents had not been served and was seated at this table. The last of the four residents was served lunch at this table at 12:05 p.m. An observation and interview with Director of Nursing (DON) on 9/21/16 at 12:01 p.m. revealed that she did not know why some residents had received lunch and other resident at the same table had not been served lunch. It was observed on 9/22/16 at 11:48 a.m. to 12:20 p.m. that twenty (20) residents and two staff were in the main dining room for lunch. The two staff each remove one lunch tray from the meal cart and begin to assist two residents with eating. A third staff entered the dining room and removed a lunch tray from the meal cart and begin to assist another resident with eating at the same table. The other four residents had not been served at the table and were watching the other residents eating. Also observed the remaining residents seated in the main dining at the other tables had also not been served their lunch at this time. Review of the Nursing Home Policy Title: Dining, read; Food is served soon as practicable after it arrives in the nursing home. 2. Observation on 09/19/16 at 12:25 p.m. there were twenty-one (21) of twenty-one (21) residents eating meals on trays in the main dining room. Observation on 09/21/16 8:38 a.m. seventeen (17) residents were observed in the main dining with eleven (11) residents eating meals on trays. Observation on 09/21/16 at 11:37 a.m. in the Restorative dining room six (6) of six (6) residents eating meals on trays. Observation on 09/22/16 at 12:04 p.m. in the restorative dining room eight (8) of nine (9) residents eating meals on trays. Interview on 09/22/16 at 2:01 p.m. with Licensed Practical Nurse (LPN) FF , who reported that the residents who require staff to feed them are placed at one table. Staff are then to feed each resident as the tray arrives. Once the resident has been fed another resident at the table is fed. If a resident has to be fed and no one is available to help feed the resident's tray should not be placed in front of the resident. LPN FF reported that most of the time all residents at the table have someone to feed them so that they all are fed at the same time. LPN FF reported that some residents request for their meal to be off the tray. However, for others it may be easier for residents to have their plate directly in front of them on a tray. Observation on 09/19/16 at 2:02 p.m. and 09/20/16 at 12:03 p.m. in room [ROOM NUMBER] there is a sign on over bed light for bed b stating I CANNOT LAY FLAT HOB ELEVATED 30-45 DEGREE ANGLE Observation on 09/19/2016 at 2:26 p.m. and 9/22/16 at 8:48 a.m. in room [ROOM NUMBER] signs posted in room PLEASE TOILET RESIDENT: BEFORE AND AFTER BREAKFAST BEFORE AND AFTER LUNCH BEFORE AND AFTER DINNER AND AT BEDTIME PRN and Safe Swallow Guidelines dated 12/9/15 stating 1. Feed all meals very slowly at 90 degree position, 2. STOP feeding if choking or s/s aspiration, 3. Small bites, 4. Pipe liquids by straw to mouth to get swallowing started if not able to suck liquids, 5. All liquids by straw . Observation on 9/22/16 at 8:49 a.m. in room [ROOM NUMBER] there were signs posted stating I CANNOT LAY FLAT HOB ELEVATED 30-45 DEGREE ANGLE as well as safe swallow strategies being posted with a date of 8/26/16. 9/22/16 at 2:59 p.m. Administrator reported that signs should not be displayed in resident ' s rooms as this is a dignity issue. The above listed rooms were confirmed as well as the following rooms: In room [ROOM NUMBER] the sign read Please use lift pads at all times. In room [ROOM NUMBER] the sign read Please put gown on for sleep. In room [ROOM NUMBER] the sign read Look .Please put resident 128B on night clothes! Resident has pajamas in drawer. 9/22/16 at 4:03 p.m. with Director of Nursing (DON) who reported that he/she does not think that having signs posted in rooms are a dignity issue as the signs are giving cues to staff for the care that needs to be provided. In regards to the dining experience the DON stated that the facility has always served meals on trays to residents. 3. During observation on 09/19/2016 11:43 a.m., resident # 83 was observed sitting in the main dining room waiting on her lunch tray to be served resident stated, she ain't gonna ever come over here. During observation on 09/19/2016 12:03 p.m., resident # 83 was observed sitting in the dining room and asking staff for a piece of sausage. During observation on 09/19/2016 12:22 p.m., resident # 83 was observed receiving her tray and eating independently. During observation on 09/20/2016 11:56 a.m., resident# 83 was observed sitting in the dining room with her head laid over the table as if she was sleep. During observation on 09/20/2016 12:03 p.m., resident # 83 received tray and was feeding herself. During observation on 09/21/2016 11:51 a.m., resident # 83 was observed sitting at the dining table with her head laid over appearing to be sleep, waiting for her lunch tray. During observation 09/21/2016 11:51 a.m., resident # 83 attempted to get food off of another resident's tray. During observation on 09/21/2016 12:03 p.m., resident # 83 received her tray and began eating independently. Resident #83 was the last at the table to be served the other residents at the table had been served at 11:45 a.m. and 11:48 a.m. During observation on 09/19/2016 11:43 a.m., resident # 83 was observed sitting in the main dining room waiting on her lunch tray to be served resident stated, she ain't gonna ever come over here. During observation on 09/19/2016 12:03 p.m., resident # 83 was observed sitting in the dining room and asking staff for a piece of sausage. During observation on 09/19/2016 12:22 p.m., resident # 83 was observed receiving her tray and eating independently. During observation on 09/20/2016 11:56 a.m., resident# 83 was observed sitting in the dining room with her head laid over the table as if she was sleep. During observation on 09/20/2016 12:03 p.m., resident # 83 received tray and was feeding herself. During observation on 09/21/2016 11:51 a.m., resident # 83 was observed sitting at the dining table with her head laid over appearing to be sleep, waiting for her lunch tray. During observationon 09/21/2016 11:51 a.m., resident # 83 attempted to get food off of another resident's tray. During observation on 09/21/2016 12:03 p.m., resident # 83 received her tray and began eating independently. Resident #83 was the last at the table to be served the other residents at the table had been served at 11:45 a.m. and 11:48 a.m. Observation on 09/19/16 at 12:25 p.m. there were twenty-one (21) of twenty-one (21) residents eating meals on trays in the main dining room. Observation on 09/21/16 8:38 a.m. seventeen (17) residents were observed in the main dining with eleven (11) residents eating meals on trays. Observation on 09/21/16 at 11:37 a.m. in the Restorative dining room six (6) of six (6) residents eating meals on trays. Observation on 09/22/16 at 12:04 p.m. in the restorative dining room eight (8) of nine (9) residents eating meals on trays. Interview on 09/22/16 at 2:01 p.m. with Licensed Practical Nurse (LPN) FF , who reported that the residents who require staff to feed them are placed at one table. Staff are then to feed each resident as the tray arrives. Once the resident has been fed another resident at the table is fed. If a resident has to be fed and no one is available to help feed the resident's tray should not be placed in front of the resident. LPN FF reported that most of the time all residents at the table have someone to feed them so that they all are fed at the same time. LPN FF reported that some residents request for their meal to be off the tray. However, for others it may be easier for residents to have their plate directly in front of them on a tray. Observation on 09/19/16 at 2:02 p.m. and 09/20/16 at 12:03 p.m. in room [ROOM NUMBER] there is a sign on over bed light for bed b stating I CANNOT LAY FLAT HOB ELEVATED 30-45 DEGREE ANGLE Observation on 09/19/2016 at 2:26 p.m. and 9/22/16 at 8:48 a.m. in room [ROOM NUMBER] signs posted in room PLEASE TOILET RESIDENT: BEFORE AND AFTER BREAKFAST BEFORE AND AFTER LUNCH BEFORE AND AFTER DINNER AND AT BEDTIME PRN and Safe Swallow Guidelines dated 12/9/15 stating 1. Feed all meals very slowly at 90 degree position, 2. STOP feeding if choking or s/s aspiration, 3. Small bites, 4. Pipe liquids by straw to mouth to get swallowing started if not able to suck liquids, 5. All liquids by straw . Observation on 9/22/16 at 8:49 a.m. in room [ROOM NUMBER] there were signs posted stating I CANNOT LAY FLAT HOB ELEVATED 30-45 DEGREE ANGLE as well as safe swallow strategies being posted with a date of 8/26/16. 9/22/16 at 2:59 p.m. Administrator reported that signs should not be displayed in resident ' s rooms as this is a dignity issue. The above listed rooms were confirmed as well as the following rooms: In room [ROOM NUMBER] the sign read Please use lift pads at all times. In room [ROOM NUMBER] the sign read Please put gown on for sleep. In room [ROOM NUMBER] the sign read Look .Please put resident 128B on night clothes! Resident has pajamas in drawer. 9/22/16 at 4:03 p.m. with Director of Nursing (DON) who reported that he/she does not think that having signs posted in rooms are a dignity issue as the signs are giving cues to staff for the care that needs to be provided. In regards to the dining experience the DON stated that the facility has always served meals on trays to residents.",2020-09-01
480,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,242,D,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interview and record review, the facility failed to honor the shower preference for one (1) resident V and failed to honor a shampoo of the hair request for one (1) resident S from a sample of twenty-four (24) residents. Findings Include: 1. Interview with resident V on 9/22/16 at 8:37 a.m. revealed that resident Vs preference was to take three showers per week. Further interview revealed that V is scheduled for two showers a week, but stated they had not been to the shower in a while. Resident V stated that he/she had been doing sponge bath's in the bathroom sink. Review of the Quarter Assessment Minimum (MDS) data set [DATE] revealed Section C of the Brief Interview Mental Status (BIMS) is 14, which indicated a good cognitive ability. Section G for Bathing revealed the resident requires physical help in part of bathing activity. Review of the Bathing Report by Resident, dated 7/1/6 through 9/21/16 revealed resident V had received only three showers during this time period. Review of Nursing Progress Noted dated 7/2/16 through 9/6/16 revealed that resident V did not have any documented refusal of showers. An interview on 9/22/16 at 8:29 a.m. the Certified Nurse ' s Aide (CNA) AA revealed that the resident V needed help to set up water in the sink for a sponge bath. And that this is done about four (4) times a week. Continued to state that the resident's shower day is every other Wednesday. An interview on 9/22/16 at 8:39 a.m. Registered Nurse (RN) BB stated that the CNAs are to asked resident's daily if they want a shower, and that normally residents are showered twice a week, unless a resident request additional showers. An interview on 9/22/2016 9:30 a.m. CNA CC stated that they documented under performance because the resident will do a sponge bath in the bathroom sink. The CNA stated that the resident will ask for showers and if any refusal for a shower that she would have informed the nurse. An interview on 9/22/16 at 9:50 a.m. the DON revealed that residents are scheduled to shower twice a week, however, if a resident requests a shower, the CNA's are to honor any resident request for a shower regardless of the schedule bath days. Any residents that refuse a bath/shower is to be documented in the progress notes by the nurse. Further stated that bath schedules are subject to change and it is unacceptable for a resident to have only three shower's in a three-month time period and did not know this happened to this resident. 2. Resident S was admitted to the facility on [DATE]. The 9/6/16 admission Minimum Data Set(MDS) assessment documented that it was very important to the resident to choose between a tub bath, shower or sponge bath. The 9/6/16 MDS documented that the resident was cognitive with a Brief Interview of Mental Status (BIMS) score of 12 and dependent on facility staff for bathing. During an interview on 9/20/16 at 10:18 a.m., resident S stated that he/she received a sponge bath every day in the facility . However, the resident stated that if he/she were home he/she would take a shower so they could wash their hair. Resident S further revealed he/she had not had her hair washed since he/she was admitted to the facility. The resident stated they asked a staff member about washing their hair and the staff member informed them that he/ she would have to buy some dry shampoo. During an observation and interview on 9/20/16 at 4:40 p.m., the resident was observed to have oily looking hair. Resident S stated their hair felt terrible and greasy and further revealed he/she felt dirt when he/ she rubbed his/her hands through their hair. Resident further revealed that it would make him/her feel better if their hair was washed and stated he/ she had asked his/her son to go to Walmart to buy some dry shampoo. The resident revealed no one had asked if he/she wanted to go to the beauty shop and no one had offered to take him/ her to the shower. The resident stated he/she had asked before today to have his/ her washed and was told to have someone get her some dry shampoo. During observations and resident interviews on 9/21/16 at 9:30 a.m., 9/21/16 at 12:00 p.m., 9/22/16 at 11:30 a.m., 9/22/16 at 2:00 p.m and 9/22/16 at 3:00 p.m., the resident was observed to have his/ her hair in need of washing and it appeared oily. The resident stated at the above times his/ her hair had not been washed. On 9/21/16 at 12:00 p.m. , the resident stated his/ her son was going to buy some dry shampoo and stated he/ she wished he/she could take a shower On 9/22/16 at 11:30 a.m., the resident revealed her hair felt terrible. During an interview with the resident on 9/22/16 at 2:00 p.m., the resident stated that no one had washed her hair but stated someone said they were going to wash it . The resident further revealed the no one had offered to take her to the beauty shop. The resident further stated his/ her hair felt terrible but to forget about it. During an interview on 9/22/16 at 5:30 pm, the resident stated that staff told her they would take her to the shower the next day and wash her hair. During an interview on 9/22/16 at 2:35 p.m., Certified Nurses Assistant (CNA),II revealed that he/she talked to the resident and explained that because of the resident having the boot on her leg, the resident would have to have a bed bath and not a shower and stated the resident understood. CNA,II' revealed he/she did not give the resident a choice of a shower or bed bath because the resident had the boot on. CNA,II further stated that because the resident had a boot on her leg he/she could not go in the shower. II'',CNA revealed he/she had not thought about covering the boot and taking the resident in the shower. During the interview,CNA II stated that he/she had not washed the resident's hair during the time he/she had been assigned to provide the resident's bath. CNA , II further stated that last week he/ she asked the resident if he/she wanted to go to the beauty shop and the resident did not say he/she wanted to go . CNA, ''II further stated he/she told the resident this week that he/she could wash it using a bag in the bed and the resident said her son was bringing dry shampoo. The CNA revealed that yesterday 9/21/16 he/she was trying to figure out how to wash the resident's hair and the resident said his/ her son was getting dry shampoo. CNA,II confirmed the resident's hair was dirty looking and needed to be washed. The CNA further revealed he/ she had not discussed with her Charge Nurse how to bathe the resident or wash the resident's hair. During an interview on 9/22/16 at 3:00 p.m., the residents son revealed that he had asked a staff member to wash his mother's hair the first week he/ she came in the facility and also had asked the last couple of days and they said they would wash it but it still had not been washed. The resident's son further revealed he brought the dry shampoo today but had not had a chance before today. During an interview on 9/22/16 at 3:30 p.m., Licensed Practical Nurse (LPN),FF revealed he/she was the the resident's nurse today but did not take care of this resident everyday. FF, LPN revealed he/she had not noticed the condition of the resident's hair. LPN, FF revealed the resident has a fractured ankle but stated the CNA could have wheeled the resident in the shower and washed his/her hair. FF, LPN also revealed the facility has a no rinse shampoo that could have been used. During an interview on 9/22/16 at 3:45 p.m., Charge Nurse BB revealed the resident's bathing preferences are included in the admission nursing assessment and should be on the CNA care plan. The CNA care plan was reviewed with BB and she confirmed the resident's bathing preference was not on the CNA care plan. BB, Charge Nurse further revealed that part of the activities of daily living care bathing, included washing a resident's hair and the resident's hair should have been washed. The Charge Nurse further revealed the staff could have put the resident in a shower chair and taken her to the shower to bathe. BB, Charge Nurse further revealed the shower had a removable shower head the staff could have used to shower the resident and wash her hair. The Charge NurseBB, further revealed the LPN should have observed the resident's hair and addressed it . . During an interview on 9/22/16 at 4:00 p.m., the Director of Nursing (DON) confirmed the resident's hair was dirty and needed washing. The DON revealed the CNA's are supervised by a nurse and the nurse should have observed the resident's hair needed to be washed and intervened. The DON further revealed that she can understand the CNA being concerned about taking the resident to the shower because of the resident's leg. The DON further revealed that there are other staff the CNA's could have discussed with on how to manage the resident showering and having his/ her hair was and the resident could have been taken into the shower with the boot covered. The DON revealed the resident's bathing method and preference should be on the CNA care plan. During interview ,the DON revealed she expects the resident's bathing preference to be honored if possible and the resident's hair should be washed as part of the activity of daily living care, bathing. During an interview on 9/22/16 at 5:35 p.m. , the DON revealed the assessment of the resident's bathing preference she believed comes from the admission nursing assessment. Review of the resident's admission nursing assessment with the DON revealed the nursing assessment did not include the resident's bathing preference. During an interview on 9/22/16 at 6:00 p.m., the ADON stated she spoke with the MDS nurse and she stated the resident's bathing preference was part of the MDS but he/she was not sure which section it was in. However, review of the MDS did not reveal an assessment of the resident's bathing preference but only how important it was to choose the type of bath they received. The resident stated it was very important when asked this question in the 9/6/16 MDS assessment .",2020-09-01
481,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,253,D,0,1,O35L11,"Based on observation and staff interview, it was determined that the facility failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior. This failure was evidenced by: heavy build up on two residents wheelchairs , stained privacy curtains, stained window curtains, cracked paint, buildup on over bed tables, stains on the floor, and broken/stained ceiling tile. This failure affected eleven (11) of forty-six (46) rooms. The findings include: 1. Observation on 09/19/2016 at 2:02 p.m. and 09/20/2016 12:03 p.m. in room 122 there are brown marks on floor under large green oxygen tank, stained curtains in window, able to, stained privacy curtains, brown circular stain in ceiling near wall of bed B. 2. Observation on 9/19/16 3 p.m. in room 116 there were multiple stains on the middle privacy curtain between Bed A and Bed B. 3. Observation on 09/19/2016 at 2:26 p.m. in room 137 bed A has stained privacy curtain, stained curtains, white stain on right side of blue blanket on bed, cracked paint on wall between bed A and B, brown circular stain over Bed A, and brown stains on floor at head of A bed. 4. Observation on 09/19/16 at 3:04 p.m. in room 133 there are stained curtains, stained privacy curtain, build up on base of over bed tables, red stain on floor at foot of bed B, black stains on floor throughout the room, and build up on wheel chair for resident # 29. 5. Observation on 09/19/2016 at 2:37 p.m. in the bathroom of 104 bathroom there brown discoloration on tile on walls, shower, and floor. 6. Observation on 09/19/16 at 2:42 p.m. in room 136 there is a stained privacy curtain for bed A, stained curtains, missing wood pieces from dresser drawers, and buildup on base of over bed tables. 7. Observation on 09/20/16 at 9:01 a.m. in room 135 there are stains on floor near dresser, stained A bed privacy curtain, stained curtains, loose handle on drawer for bed B, stains on black chair at desk in room, brown stain around base of toilet, cracked tile in ceiling in bathroom, buildup on wheelchair for resident #59 and wheelchair has loose right armrest with exposed cushioning. 8. Observation on 9/20/16 at 9:31 a.m. in room 115 the wall mounted air control box is missing a plastic cover and there are black spots on the window curtains. 9. Observation on 09/20/16 10:43 a.m. in room 119 there are multiple stains to the window curtains. 10. Observation on 09/20/2016 11:56 a.m. in room 121 there was a brown substance on the floor by bed b, stained curtain in window, seal hanging from around window, and buildup on bottom of over bed table. 11. On 09/20/2016 12:31 p.m. in room 120 there were stained curtains and privacy curtain. An environmental observations on 09/22/16 from 2:36 p.m. to 3:35 p.m. with the Administrator, Maintenance HH , and Housekeeping Team Lead (HSK) GG confirmed concerns identified. The Administrator stated that staff are expected to report any damages to resident equipment so that items can be fixed and also reported that wheelchairs are cleaned on regular schedules. HSK GG reported that privacy curtains and curtains are removed and washed every other month. It was revealed that rooms are cleaned daily and a check list is used for cleaning the rooms. HSK GG and that he/she monitors housekeeping staff's work at least every other day. However, HSK GG acknowledged that he/she had not identified the buildup on floors, build up on over bed tables, or stained curtains and privacy curtains. HSK GG reported that some of the curtains have rust stains that will not come out. On 09/22/16 at 3:33 p.m. Maintenance HH reported that maintenance staff watch staining in tiles daily and also rely on staff to report if there are issues. On 09/22/16 at 3:35 p.m. Interview with the Administrator stated that he/she depends on housekeeping to report any issues related to stained privacy curtains and curtains. It was further reported that the Registered Nurses (RN) provide rounds related to resident ' s rooms. Futher interview with Assistant Director of Nursing at this time reported that (RNs) tour resident ' s rooms daily however, they had not identified stained privacy curtains or stained curtains at windows. On 9/22/16 at 6:38 p.m. the Administrator reported that the housekeeping checklist forms have not been completed daily. A blank copy of the checklist was then provided that entailed: Form Title: Environmental Checklist: Daily Cleaning to be check off by Environmental Services Team Leader/Manager Instructions: Turn in daily to team leader Daily Clean Floor: Dust mop floor Wet mop floor Replace as needed: Hand Sanitizer/Hand Soap Tissue/Paper Towels Soiled Curtains.",2020-09-01
482,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,279,D,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop a care plan for palliative care for one (1) resident (#11) out of a sample size of thirty-one (31). Findings include: Review of the Face Sheet for resident #11 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Consult Note from the hospital dated 08/02/2016 revealed that resident #11 had a consult for palliative care related to end stage [MEDICAL CONDITION] disease and a consult for Hospice referral and comfort measures. Review of Admission Nurses Note dated 08/09/2016 revealed that resident #11 was admitted to the Nursing Home from the hospital. Interview on 09/22/2016 at 10:00 a.m. with the Director of Nursing (DON) revealed that on the hospital discharge tehy had placed a consult for either hospice or palliative care for resident #11 and the facility doctor accepted the resident as his patiet and the resident elected to have the doctor manage his care. The DON stated that the doctor was certified as a palliative care physician. The DON futher stated that resident was receiving palliative care at the facility. . Review of MDS revealed that resident was not listed as receiving Hospice Care. Review of Physician order [REDACTED].#11 had an order for [REDACTED]. There was an order for [REDACTED]. Review of Care plan for resident #11 revealed that resident was at risk for complications and/or discomfort related to [DIAGNOSES REDACTED]. Interview on 09/22/2016 at 1:03 p.m. with the Minimum Data Sets (MDS) Coordinator revealed that she was unaware that the resident was admitted to palliative care per the hospital discharge orders. She stated that due to being unaware that resident #11 was placed on palliative care, that a care plan had not been developed for palliative care. Interview on 09/22/2016 at 1:12 p.m. with the DON revealed that she would expect an order to be written to communicate to the MDS Coordinator that the resident needed a care plan for palliative care. The DON confirmed that there was no care plan for palliative care and no order for palliative care. Review of the policy for MDS assessment and care plan development states that the care plan was developed based on assessment of the resident that includes but was not limited to the MDS and physician orders. The policy stated that the MDS certified LPN was responsible for conducting and coordinating the development and completion of the resident MDS assessment. Interview on 09/22/2016 at 4:08 p.m. with the DON revealed that the MDS Coordinator was the person ultimately responsible for seeing that the care plan was developed for each resident.",2020-09-01
483,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,282,D,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to obtain laboratory tests for one resident (#64), notify the physician of an abnormal laboratory test result for one resident (#25) and implement fall interventions for one resident (#84) as care planned, from a total sample of thirty-one (31) residents. Findings include: 1. Resident #64 had a care plan problem for being at risk for altered nutrition with an intervention for nursing staff to monitor laboratory tests as ordered. There was also a care plan problem that the resident had a potential for complications related to [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. However, the laboratory tests were not obtained, when due in (MONTH) (YEAR), as ordered and as care planned. During an interview on 9/22/16 at 4:50 p.m., the Director of Nursing (DON), confirmed that there was no evidence that the laboratory tests had been obtained when due in (MONTH) (YEAR). Cross-refer to F502 2. Resident #25 had a care plan problem, since 8/4/16, for being at risk for altered nutrition related to [DIAGNOSES REDACTED]. The care plan problem included an intervention for nursing staff to monitor laboratory tests as ordered and report abnormal results to the physician. There was a physician's orders [REDACTED]. The 8/11/16 laboratory test results documented an abnormal TSH level of less than 0.30. However, there was no evidence in the clinical record that the physician was notified. During an interview on 9/22/16 at 4:50 p.m., the DON confirmed that there was no evidence that the physician had been notified of the abnormal TSH laboratory test result. Cross-refer to F505. 3. Review of the Medical Records revealed resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] Section J revealed resident had one fall in the facility. The care plan has interventions listed as be sure call light is within in reach and encourage resident to use it for assistance as needed. An interview and observation on 9/22/16 at 8:10 a.m. the DON revealed that the care plan interventions was for the call light to be within reach. DON stated she could not explain why the staff had wrapped the call light to bed frame out of reach of the resident. Cross Reference to 323",2020-09-01
484,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,314,D,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility staff failed to thoroughly measure a pressure ulcer for one resident (#75) of two (2) residents reviewed for pressure ulcers, from a total sample of thirty-one (31). Findings include: 1. An Admission Minimum Data Set (MDS) assessment dated [DATE], documented the resident had one (1) unstageable pressure on admission. A further record review revealed the pressure ulcer was located on the sacrum. Review of the facility policy Skin Integrity revealed the following: Procedure: The treatment nurse implements a program of Pressure Management used routinely on all resident beds. Document the condition of areas being treated once a week including size,depth,drainage,healing,medication and devices. However,a review of the weekly Pressure Ulcer Scale for Healing (PUSH) tool and documentation in the skin condition report notes by the treatment nurse revealed that from 5/31/16 when the eschar from the pressure ulcer was documented as being completely gone from the wound through 9/15/16 , the weekly measurements were not thorough to include the depth and location of the undermining that was documented as being present by Physical Therapist (PT) and Wound Consultant,LL on 6/9/16 ,7/14/16 ,8/4/16 and 9/8/16. Review of the documentation in the clinical record, skin condition report revealed a note dated 8/31/16 that included the pressure ulcer measurements as 1.6 centimeters (cm ) length by 1.5 cm width and depth 0 cm. Documentation further revealed tunneling noted to be 3.5 with no documentation of the location of the documented tunneling. Further review of the skin condition reports revealed documentation by the treatment nurse on 9/15/16 weekly skin assessment pressure ulcer measurements as 1.6 cm length by 1.6 cm width and depth 0 cm. Documentation further revealed undermining measuring 3.1 on return from hospital with no documentation of the location of the undermining. Documentation in the note further revealed the resident returned from a hospital stay on 9/14/16. Record review revealed from 5/31/16 through 9/15/16, the weekly wound assessment documentation only included a measurement of tunneling on 8/31/16 and undermining on 9/15/16 with the location of the tunneling and undermining not documented on 8/31/16 and 9/15/16. During an interview on 9/21/16 at 9:51 a.m., the treatment nurse revealed she uses the PUSH tool for tracking wound progression and assessment. The treatment nurse further revealed that he/she has not measured the undermining in the resident's pressure ulcer during the weekly wound assessments but did measure the undermining in the pressure ulcer upon his/her return from the hospital. The treatment nurse further stated that he/ she does not measure the undermining because it is not included in the PUSH tool. The treatment nurse stated the wound specialist/PT performs a wound assessment monthly and measured the undermining. During an interview on 9/21/16 at 4:06 p.m., with the Wound Consultant and PT,LL he/she revealed that it is his/her expectation that the weekly measurements done by the treatment nurse include the same assessment and measurements as the ones he/she does monthly. Review of the Wound Consultant monthly wound assessment documentation on 6/9/16, 7/14/16 ,8/4/16 and 9/8/16 revealed the location and measurement of the undermining of the resident's pressure ulcer in addition to length, width and depth of the wound. Wound Consultant LL further revealed that he/she has told the treatment nurse if there is not a spot on the PUSH tool to document to document in the narrative note. During further interview on 9/22/16 at 7:45 a.m., the treatment nurse revealed he/she assesses the pressure ulcer for tunneling/undermining when he/she does the wound care and during her weekly wound assessment but does not measure or document her findings. The treatment nurse further revealed that if the pressure ulcer was worse she would notify the wound care consultant or the physician. During an interview on 9/22/16 at 9:50 a.m., the DON confirmed that the treatment nurse was not measuring the depth of the undermining or location weekly of the resident's pressure ulcer. The DON further confirmed that without measuring the undermining/ tunneling weekly, the nurse would not be able to assess if the wound was detoriating . The DON revealed the treatment nurse's focus has been on the PUSH tool.",2020-09-01
485,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,323,D,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interviews and record review, the facility failed to ensure the safety of one (1) resident T by using three fourth side rails bilaterally after being assessed at risk for injury and failed to ensure fall interventions were implemented for one (1) resident (#84), from a total sample of thirty-one (31). Findings include: 1. An Admission Minimum Data Set (MDS) Assessment, dated 5/17/16 revealed [DIAGNOSES REDACTED]. Further review of the MDS revealed resident T was documented to have a Brief Interview of Mental Status (BIMS) score of eight (8), which indicated moderate cognitive impairment. Further review of the MDS revealed the resident was dependent on staff for transfer and required extensive assistance for bed mobility. The Admission MDS further documented the resident had experienced one(1) fall since admission with no injury. Review of the 5/12/16 Admission Fall Risk Assessment determined resident T to have a score of eighteen (18). Documentation revealed a resident whose score was over nine (9) at risk for falls. Review of the Admission Nursing Assessment revealed the resident was alert , confused, bedfast all or most of the time, and used half bed rails for positioning aid only and mobility . Review of the progress note dated 5/12/16 at 1:39 a m., revealed documentation that staff was called to the resident's room by housekeeping who stated the resident was trying to get out of bed without assistance. That upon entering the resident's room the resident was observed to have one (1) leg over the left side rail and the right leg under the side rail. Documentation further revealed the resident stated he was trying to get up. The nurses note further documented a bed alarm was placed on the bed and the resident was placed in a chair and taken to the dining room. Review of the Certified Nurses Assistant (CNA) care plan worksheet revealed documentation that the resident transfers with two (2) person assist and uses a recliner chair/geriatric chair with a notation present: resident will climb out of bed, slips out of bed. Review of the care plan also listed fall and accident prevention: bed in lowest position, non skid socks/shoes and a bed alarm call light. Review of the CNA care plan revealed no documentation regarding side rails Review of the Side Rail Assessment form revealed the resident was assessed for the use of side rails on 5/17/16, 5/26/16 and 7/7/16. Review of the Side Rail assessment dated [DATE] and 5/26/16 revealed the following documentation: family requested to have side rails while in bed for own safety and /or comfort, a history of fluctuation in level of consciousness or a cognitive deficit, able to get in and out of bed, a problem with balance or poor trunk control, history of falls, currently receives medications that would require safety precautions, possibility of resident climbing over the side rail and side rail alternatives/interventions create more risks than side rail use. The assessments dated 5/17/16 and 5/26/16 further revealed documentation the resident was not able to get in/out of bed safely and the rails are not up for positioning or support. Alternative interventions listed were low bed Further review of the assessment revealed recommendations: three fourth rails bilateral. A comment dated 5/17/16 revealed documentation side rails not indicated due to risk for injury with resident climbing over rails, however family requested the rails. Review of an incident report dated 5/17/16 at 1:50 p.m., revealed the resident was found on the floor in his room, was alert but disoriented with two (2) full rails up. No apparent injury was documented. Narrative documentation on the incident report revealed rails up on bed and bed alarm patent and intact. Documentation on the incident report revealed corrective measures taken by facility educated to call for assistance and use call light. Review of an incident report dated 5/23/16 at 5:25 p.m., revealed the resident was found on the floor in his/her room, was alert but disoriented. The side rail section of the incident report was blank. Documentation on the incident report revealed the resident had no apparent injury. Incident details in the narrative of incident report revealed the writer was called to the room by the CNA and the resident was sitting on the floor with his legs stretched out, non skid socks were in place and the resident had pulled his gastrostomy tube out. Documentation further stated Physical Therapy(PT) would be notified. Documentation on the incident report revealed corrective measures taken by facility call light placed with reach, encouraged resident to call for any additional assistance needed and to call staff before trying to up,down from bed and resident voiced understanding. The incident report documentation under corrective measures revealed bed in lowest position and bed alarm in place. Review of the Physical Therapy/Occupational Therapy team conference sheet dated 5/24/16 revealed documentation that this resident had two (2) falls in one week getting out of bed with recommendations for a geriatric chair. Review of the (MONTH) (YEAR) root cause analysis referenced the resident's falls on 5/17 and 5/23/16 with contributing factors listed as cognition. Corrective actions listed: ordered geriatric chair, CNA's are getting resident up daily now to geriatric chair and keeping resident in the dining room for close supervision during wakeful hours. Review of the Side Rail assessment dated [DATE] revealed the following documentation with affirmative answers: family expressed a desire to have side rails while in bed for own safety and/or comfort, history of fluctuation in levels of consciousness or a cognitive deficit, able to get in/out of bed, able to get in/out of bed safely, history of falls and currently receiving medications that would require safety precautions. Alternative interventions listed on the assessment form were low bed. Review of the 8/7/16 MDS assessment revealed resident T was documented to have a BIMS score of twelve (12) indicating moderate cognitive impairment and required limited assistance for transfers which was an improvement from the Admission MDS assessment. Review of the current CNA care plan worksheet revealed mobility status transfers: independent with supervision, ambulation: independent supervise gait belt, fall and accident prevention bed in lowest position, non skid socks/shoes, bed alarm. Documentation on the CNA care plan also listed individual care plan needs as out of bed daily for therapeutic exercises, range of motion and restorative dining and encourage use of urinal/ bedside commode. Review of the CNA care plan for resident T revealed no documentation regarding side rails An interview on 9/20/16 at 4:30 p.m., resident T was observed in be in bed with both of the three fourth side rails raised and the bed in the low position. The resident stated the rails do not keep him from getting out of bed and he/she can get out of bed where there is an opening near the end of the bed and the resident pointed to the space between the end of the three fourth rail and the foot of the bed. Resident T' further stated he/she gets up with help most of the time but gets up alone at times. An interview on 9/21/16 at 2:15 p.m., Certified Nurses Assistant(CNA) KK stated the resident ambulates with a walker and requires stand by assistance of one (1) for ambulation and transfers. CNA KK further stated the resident has the side rails raised because the resident ask him/her to put them up. The CNA further stated the resident uses the side rails to move around in the bed. CNA,KK further stated the resident does not get out of bed by himself/herself but he/she thinks the resident could safely do so. An interview on 9/21/16 at 5:00 p.m., CNAMM stated he/she was not aware of the resident trying to get out of bed and go over or through the side rails. CNAMM further revealed the resident has not attempted to get out of bed by himself/herself and always uses the call light. An interview on 9/21/16 at 2:34 p.m , Licensed Practical Nurse EE revealed the resident has progressed greatly and would probably be safe to ambulate in his/her room but stated the resident is fearful and likes assistance. LPN EE further revealed the resident likes the side rails raised on his/ her bed and can safely get out of bed now. EE further revealed the resident uses the rails to help him/her move and turn in the bed on his/her own. Further interview and record review of the 5/12/16 nursing progress note and the side rail assessments with LPN EE revealed that after the 5/12/16 incident when the resident was observed with one leg over the left side rail and the right leg under the side rail the intervention he/she put in place was for one rail to be left down and the other one raised and a bed alarm placed on the bed. LPN EE revealed there was no documentation of the side rail intervention for one up and one down had been done. Further interview with LPN EE regarding the 5/17/16 side rail assessment he/she completed, he/she revealed the resident's daughter requested the rails be raised so he/she honored her request. LPNEE further revealed that he/she spoke with the daughter and explained that there was less risk of injury if no rails were raised. EELPN confirmed the resident's daughter was aware of the earlier incident involving the side rails. LPNEE revealed the facility started using the three fourth rails raised on both sides after the family requested their use on 5/17/16. LPNEE revealed to be honest he/she did not feel it was safe to have both the three fourth side rails raised based on his/her assessment. During continued interview with EE he/she revealed that he/she did not discuss the situation and family request regarding the side rail usage with her supervisor despite feeling it was not safe. The LPN ,EE'' revealed he/she was concerned with resident and family rights and this is why the decision was made to use the bilateral three fourth rails. LPN EE revealed the 7/7/16 side rail assessment changed from the previous ones and the resident was assessed to be able to get out of bed safely, there was no problem with balance and no possibility of the resident climbing over the side rails because the resident's general health had improved and he/she had improved with therapy. LPN EE further stated the bed alarm was not going off, the resident was not trying to get out of bed by himself/herself, was using the call light for assistance and was able to get out of bed safely. An interview on 9/21/16 a 5:45 p.m., with the Director of Nurses (DON) she revealed at the time of the 5/12 incident the resident was cognitively impaired, was not able to walk and used the rails to roll over and reposition themselves. The DON further revealed that after the 5/12/16 incident, a bed alarm was used and one side rail was up and one was down. The DON stated she was not aware the family requested the use of both side rails and they were being used. During further interview the DON stated she would have expected the nurse to discuss the side rail usage and the family request with her and she would have discussed it with the Administrator, the Georgia Health Care Association (GHCA) and the unit managers, because of the resident's rights and the facility wants family involvement but further stated the resident's safety is critical. The DON revealed the resident was not able to make decisions at that time. During an interview on 9/22/16 at 7:50 a.m., CNA KK revealed that way he/she knows about a resident's side rail usage and what side rails the resident is suppose to have is that it is on the CNA care plan. The resident's CNA care plan was reviewed with him/her and he/she confirmed side rail instructions were not on the care plan. KK further stated the nurse tells her also. During an interview on 9/22/16 at 11:09 a.m., LPN EE confirmed that after the 5/12/16 incident with the resident's leg being over the side rail he/she made the decision independently to use a bed alarm and put one three fourth rail up and one down. EE revealed the staff would have known to put one side rail up and one down because it would be on the CNA care plan, the old one. Upon review of the old and current CNA care plan, LPNEE confirmed the side rail use was not present on the resident's care plans. LPNEE confirmed that without the side rail instructions for one three fourth rail to be raised and the other rail down on the CNA care plan the CNA would not know what rails where to be used. LPNEE revealed the side rail interventions he/she initiated after the 5/12/16 incident should have been put on the CNA care plan and he/she failed to do so. During continued interview and review of the 5/17/16 incident report EE revealed that documentation of two (2) full rails up at the time of the incident would have been three fourth rails because that is only side rails they have. LPNEE' stated the rails would have been up at the time of the incident because she failed to update the CNA care plan and that would have been the only reason they were up. LPNEE revealed he/she does the side rail assessments on admission and quarterly and makes the decisions regarding the side rail use. LPN EE further revealed the side rail use other than on admission and quarterly is suppose to be an Interdisciplinary Team (IDT) decision but he/she does not recall having a meeting about this resident's side rails. EE further stated that the resident's side rails have been the three fourth rails since admission. During an interview and review of the 5/17/16 and 5/23/16 incident report regarding the resident's falls on 9/22/16 at 11:15 a.m., the ADON stated she is responsible for collecting the incident reports after an incident and taking them to the morning huddle the following morning to review with the IDT team which consist of herself, the DON, the treatment nurse, the charge nurse and sometimes the floor nurse and a CN[NAME] The ADON revealed she remembers a discussion about how the resident got of bed and whether it was over the rails, under the rails or around the rails rails on 5/17 and 5/23 but she does not have documentation about the discussion. The ADON further revealed the root cause analysis listed cognitive status as the reason and documentation confirmed the finding During further interview, the ADON confirmed the 5/23/16 incident report failed to document the side rail status at the time of the incident and revealed the section should have been completed . 2. Review of the Medical Record revealed resident #84 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE] Section J revealed resident had one fall in the facility. Review of a Care Plan dated 8/25/16 revealed that resident #84 is at risk for falls related to impaired cognition, short and long term memory problems and inability to ambulate. The care plan has interventions listed as; be sure call light is within in reach and encourage resident to use it for assistance as needed. An observation on 9/20/16 at 10:58 a.m. revealed the call light cord in room 144 wrapped around the head of the bed frame and resident # 84 lying in bed and bed in a high position. An observation on 9/21/16 at 9:05 a.m. revealed that call light cord remain wrapped around head of bed frame on left side as standing at the foot of bed. The bed is in the high position. Review of the medical record a Neurological Assessment Flowsheet dated 5/31/16 revealed resident 84 a fall from his bed. Further investigation revealed that resident #84 after falling from his bed with bilateral 3/4 side rails in the up position and complaining that his head hurt was sent to the hospital for a cat scan. The cat scan report dated 5/31/16 indicated no acute cranial pathology. An interview on 9/22/16 at 8:23 a.m. CNA OO revealed that ways to help prevent falls for this resident was to make sure call light is within in reach, keep the bed low bed and the side rails are up. An interview on 9/22/16 at 8:10 a.m. the DON revealed that the care plan interventions for resident #84 are: the call light to be within reach, a bed alarm device and the bed in the lowest position. The DON stated she could not explain why the call light was wrapped around the top of the bed frame, or why the bed alarm was not plugged in or that the bed was not in the lowest position. Cross Reference to F282",2020-09-01
486,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,441,E,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, it was determined that the facility failed to properly store resident ' s personal care items to prevent possible contamination in eleven (11) of forty-six (46) resident's rooms. The sample size was thirty-one (31). Findings include: During observation on 9/19/2016 at 2:01p.m., in room [ROOM NUMBER], three (3) wash basins on the counter in the bathroom not bagged, one (1) urinal on the floor in the bathroom not bagged or labeled. During observation on 9/20/2016 at 11:58 a.m., in the bathroom of room [ROOM NUMBER], bedside commode bucket sitting on floor under sink, urinal hat on floor under sink not bagged, and two (2) toothbrushes uncovered on sink in bathroom. During observation on 9/19/2016 at 2:29 p.m., in room [ROOM NUMBER], there were two (2) wash basins sitting on the floor under the sink, one (1) wash basin on was on the counter not bagged or labeled, two (2) bed pans were on the floor in the bathroom not bagged or labeled. During observation on 9/19/2016 at 3:06 p.m., in the bathroom for room [ROOM NUMBER] there were four (4) wash basins on the counter by the sink that were not bagged, six (6) razors and one uncovered toothbrush stored in a wash basin on the sink, and one (1) urine hat sitting on the floor under the sink. During observation on 09/19/2016 3:00:23 p.m., in the bathroom of room [ROOM NUMBER], wash basin not bagged or labeled; toothbrush uncovered. On 09/20/2016 9:40 a.m., observed wash basins not bagged or labeled; toothbrush uncovered. During observation on 9/19/2016 at 2:46 p.m. in bathroom of room [ROOM NUMBER] there were three (3) wash basins not labeled or bagged sitting on counter in sink; 9/20/2016 at 12:11 p.m. three (3) wash basins sitting on counter in sink not bagged. During observation on 9/20/2016 at 9:05 a.m. in the bathroom of room [ROOM NUMBER], there are two (2) wash basins sitting on counter not bagged or labeled. During observation on 9/20/2016 at 12:09 p.m., two (2) wash basins on counter not bagged and not labeled. During observations on 9/19/2016 at 2:17p.m., in room [ROOM NUMBER], wash basins were neither bagged nor labeled. On 09/20/2016 9:38 a.m., wash basins observed to neither bagged nor unlabeled. During observation on 9/20/2016 at 9:15 a.m. in bathroom of room [ROOM NUMBER] there were four (4) wash basins on sink not bagged nor labeled, urine hat on floor, one (1) was basin in chair, one (1) urinal on sink not bagged or labeled. During observation on 09/20/2016 2:41 p.m., in bathroom of room [ROOM NUMBER], two (2) wash basins were observed in resident's bathroom not bagged and not labeled. During observation on 9/19/2016 2:53 p.m., in bathroom of room [ROOM NUMBER], four (4) wash basins were observed to be not bagged and not labeled in resident's restroom. During observation on 9/22/2016 at 3:24 p.m., in the bathroom of room [ROOM NUMBER], the wash basin was not bagged or labeled. During observation on 9/22/2016 at 3:03 p.m., in the bathroom of room [ROOM NUMBER], the wash basins were neither bagged nor labeled. On 09/22/2016, between 2:46 p.m. to 3:49 p.m., it was confirmed by the Administrator, Maintenance Director and House Keeper Supervisor that the following rooms had wash basins, urinal hats, and urinals that were not bagged and not labeled; rooms 121, 122, 124, 125, 126, 128, 133, 135, 136, 137, and 144 and that these items should have been labled, bagged or disposed. On 9/22/2016 at 3:32 p.m., interviewed Administrator, which stated that it is her expectation for the Certified Nursing Assistants (CNA ' s) to label and bag each wash basin, urinal hat, and urinal after bathing and treatment of [REDACTED]. On 9/22/2016 at 4:52 p.m., Director of Nursing (DON) confirmed that facility does not have a policy to address storage of personal care equipment of residents. Observation on 9/19/16 at 11:15 a.m. and 9/20/16 at 7:40 a.m., in room [ROOM NUMBER],revealed two (2) gray wash basins stacked on top of each other that were not bagged and one (1) gray wash basin on the bathroom counter with a resident's name on it that was not bagged. Observation on 9/19/16 at 11:15 a.m. and 9/20/16 at 7:43 a.m. in room [ROOM NUMBER], revealed one (1) gray wash basin on the bathroom counter that was not labeled and was not bagged and two (2) pink wash basins stacked on top of each other that had a resident's name on the basin that was not bagged. During initial observations on 9/19/16 at 11:43 a.m. revealed in room [ROOM NUMBER] bathroom there are three (3) wash basin (two are stacked together) in bathroom that are unlabeled, and unbagged. Observation in room [ROOM NUMBER] bathroom there is one (1) wash basin on bathroom counter top, and a urinal on the floor the under sink not unlabeled or unbagged. Observation in room [ROOM NUMBER] bathroom there are two (2) wash basin on floor under sink, one (1) bed pan, and one (1) fracture pan unbagged and unlabeled. Observation in room [ROOM NUMBER] bathroom there are two (2) wash basin unbagged and unlabeled. Observation in room [ROOM NUMBER] there are three (3) wash basin on floor unbagged and unlabeled. Observation In room [ROOM NUMBER] bathroom there are three (3) wash basin unbagged and unlabeled. Observation In room [ROOM NUMBER] bathroom there one (1) wash basin unbagged, and unlabeled sitting in a chair in the bathroom. Observation In room [ROOM NUMBER] bathroom, there are two (2) wash basin that are unbagged and unlabeled. An observation on 9/19/16 at 11:20 a.m. revealed Certified Nurse Aide (CNA) DD in room [ROOM NUMBER] carrying a urinal with urine without wearing gloves going into the resident's bathroom and poured the urine into the toilet. An interview on 9/22/16 at 11:24 a.m. Certified Nurse Aide (CNA) DD regarding room [ROOM NUMBER] urinal, stated she had gotten distracted during a conversation with the resident and didn't realize she had not put on her gloves and stated that normally she would put on gloves.",2020-09-01
487,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,468,E,0,1,O35L11,"Based on observation and staff interview, the facility failed to ensure that handrails were securely fixed to the wall on four (4) halls and one (1) solarium. The facility census was seventy-three (73) residents. The findings include: On 9/22/16 between 8:40 a.m. and 9:00 a.m. loose handrails observed on the following: 1. On Tulip Lane between rooms 134 and 132, 136 and 138, 140 and 142, 143 and 145, outside of room 146, and at the end of Tulip Lane near the fire extinguisher. 2. On Orchid Lane at the nurse ' s desk and the railing in hall outside of the main dining room. 3. Handrails in the solarium near the air conditioning unit. 4. On[NAME]Lane between rooms 109 and 111. 5. On Daisy Lane at the right of room 104 going towards the solarium. Environmental tour began on 09/22/16 at 2:36 p.m. with the Administrator, Maintenance HH, and Housekeeping Team Lead (HSK) GG at this time confirmed the identified loose handrails. On 09/22/16 at 3:33 p.m. Maintenance HH reported that handrails are checked twice a year and anytime there is a report that he receives if there are loose hand rails. HH was not aware or notified of any loose handrails prior to surveyor. On 9/22/16 at 6:00 p.m. the Administrator reported that Maintenance were unable to find documentation related to the twice a year where hand rails are checked by maintenance or a policy related to maintenance of handrails. There was no evidence of any residents falling as a result of loose handrails.",2020-09-01
488,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,502,D,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to obtain laboratory tests as ordered for one resident (#64), from a total sample of thirty-one (31) residents. Findings include: Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a care plan problem in place, dated 7/28/16, that the resident was at risk for altered nutrition with an intervention for nursing staff to monitor laboratory tests as ordered. There was also a care plan problem, dated 7/28/16, that the resident had a potential for complications related to [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. A review of the clinical record revealed that the laboratory tests were obtained as ordered on admission, on 11/18/16. However, there was no evidence in the clinical record, that the laboratory tests were obtained, when due again in (MONTH) (YEAR), as ordered and as care planned. During an interview on 9/22/16 at 4:50 p.m., the Director of Nursing (DON), confirmed that there was no evidence that the laboratory tests had been obtained when due in (MONTH) (YEAR) or that the resident had refused for the tests to be obtained.",2020-09-01
489,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2016-09-22,505,D,0,1,O35L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician of an abnormal [MEDICAL CONDITION] Stimulating Hormone (TSH) level for one resident (#25), from a total sample of thirty-one (31) residents. Findings include: Resident #25 had a [DIAGNOSES REDACTED]. There was a care plan problem in place, dated 8/4/16, that the resident was at risk for altered nutrition related to [DIAGNOSES REDACTED]. The care plan problem included an intervention for nursing staff to monitor laboratory tests as ordered and report abnormal results to the physician. There was a physician's orders [REDACTED]. The 8/11/16 laboratory test results documented an abnormal TSH level of less than 0.30. However, there was no evidence in the clinical record that the physician was notified. After surveyor inquiry, nursing staff notified the physician and an order was obtained on 9/22/16 to discontinue the 100 mcg daily dose of [MEDICATION NAME] and begin a daily dose of 75 mcg. During an interview on 9/22/16 at 4:50 p.m., the DON confirmed that there was no evidence that the physician had been notified of the abnormal TSH laboratory test results until 9/22/16. She stated she would have expected nursing staff to have notified the physician sooner than 9/22/16.",2020-09-01
490,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2018-09-27,584,D,0,1,KLJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that it was maintained in a safe, clean comfortable environment related to stained ceiling tiles for two of six halls, a hole in the wall in restorative dining, and one fall mat that was stained and in disrepair. Findings include Observation on 9/24/18 at 11 a.m. revealed that there were brown circles in ceiling tiles near rooms 121 -123. Observation made on 9/24/18 at 11:20 a.m. revealed that there were brown and black circular stains on ceiling tile in the hallway between rooms [ROOM NUMBERS]. Observation of restorative dining room on 9/24/18 at 11:43 a.m. revealed that there was a hole in the wall near the floor under the hand sanitizer. Observation on 9/25/18 at 8:44 a.m. in room [ROOM NUMBER] there is a brown substance observed on blue fall mat by the bed. There is also build up on the tube feeding monitor and brown rusted areas on the base of tube feeding pole. Environmental tour began on 9/27/18 at 9:48 a.m. with the Maintenance Supervisor and Housekeeping Supervisor. It was reported by the Maintenance Supervisor that the stained ceiling tiles in the hallways are due to condensation. He further reported that the ceiling tiles on the front hallway have been changed out twice this week and that there is a plan in place to replace the covering on the water pipes. During an interview and observation on 9/27/18 at 9:54 a.m. in the restorative dining room with the Maintenance Supervisor reported that the hole in the wall in restorative dining was noticed this week but has been patched in the past. It was further reported that the food cart is the cause of the hole and to repair this area will require the replacement of the entire piece of sheetrock, but it must be done at night due to dust. He further reported that the person who would complete this task returned to work on today. During an interview and observation with Maintenance Supervisor on 9/27/18 from 9:57 a.m. to 9:59 a.m. he confirmed the four stained ceiling tiles across from room [ROOM NUMBER]. The Maintenance Supervisor confirmed the stained ceiling tiles between room [ROOM NUMBER] and 130 but reported that he had not been made aware of the stained ceiling tiles in this area. During an interview and observation on 9/27/18 at 10:22 a.m. in room [ROOM NUMBER] the Housekeeping Supervisor confirmed that the fall mat bedside Bed B was stained and ripped. The Housekeeping Supervisor also reported that it is her expectation that her staff will remove stains from floor as they are identified. She further reported that the fall mat should be taken out and replaced. Interview on 9/27/18 at 10:35 a.m. with the Assistant Director of Nursing (ADON) who reported that she expects staff to report and let someone know if items are dirty or in disrepair related to fall mats or other equipment. Interview on 9/27/18 at 10:40 a.m. with the Director of Nursing (DON) related to the stained and torn fall mat. It was reported that the expectation is that any staff, that saw that fall mat, to notify someone so that it could be removed. The DON further reported that spills they should be cleaned up as they happen. During interview on 9/27/18 at 11:03 a.m. with the Maintenance Supervisor he provided documentation of a quality measures meeting from (MONTH) in which stained ceiling tiles were addressed as old business from July. At this time, he reported that they are waiting on reports from two contractors so that they will best know how to proceed with fixing this issue. Maintenance Supervisor was to provide more information related to contractors and when notified to provide services, but this documentation was not received when surveyors exited on 9/27/18.",2020-09-01
491,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2018-09-27,756,D,0,1,KLJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review the facility failed to ensure that the Consultant Pharmacist Communications were signed and addressed in a timely manner and that the policy included time frames for different steps in the process. Findings include: R#38 has [DIAGNOSES REDACTED]. Medications include but not limited to [MEDICATION NAME] 40mg daily started 1/31/18, [MEDICATION NAME] 45mg QHS started on 1/31/18, [MEDICATION NAME] 100mg QHS started on 2/23/18, [MEDICATION NAME] 30 units BID started on 5/2/18 and [MEDICATION NAME] R SS 4 times daily with glucose checks before meals and at QHS started 2/20/18. Quarterly MDS section N dated 7/25/18 revealed R#38 received an antipsychotic, antidepressant and diuretic for 7 days of the look back period. Section I revealed that R#38 has dementia. Care plan dated 7/19/18 revealed behavior problems r/t dementia with goals and approaches including but not limited to anticipate and meet needs, praise all progress and keep routines familiar and consistent. Dated 7/20/18 potential for hyper/[DIAGNOSES REDACTED] r/t diabetes with goals and interventions including but not limited to administer medications as ordered by MD and monitor for s/s of hyper/[DIAGNOSES REDACTED]. Dated 7/20/18 potential for drug related complications associated with use of [MEDICAL CONDITION] medications with goals and interventions including but not limited to monitor for target behaviors and report hallucinations and delusions. GDR's reviewed with issues noted, GDR's are not signed and recommendations are not addressed for the month of (MONTH) and no recommendation noted for the month of August. Consultant Pharmacist communication to Physician dated 7/26/18 revealed RE: CMS-F329duplicate antidepressant drugs Use of two antidepressants simultaneously may increase the risk of side effects and require additional documentation concerning the rationale under CMS F-329. With 4 check box answers, with the physician checking: Duplicate agents are being used d/t differing mechanisms of action that result in augmentation in managing symptoms of depression. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. Signed 9/25/18 after surveyor inquired about signatures and addressing issues. In an interview with the Assistant Director of Nursing (ADON) RN on 9/25/18 at 3:21 p.m. she said that she is the nurse that usually does rounds with the doctors to ensure that the recommendations get signed and addressed, however the rounds were completed on the weekend in the months of (MONTH) (YEAR) and (MONTH) (YEAR) and that the recommendations did not get addressed or signed. The ADON revealed that the nurses' that are responsible for their residents with recommendations are responsible to get the recommendation signed and follow up with new orders if any are given. The ADON revealed that she is the one that is responsible for ensuring that the nurses do their jobs. The ADON revealed that she is ultimately responsible for making sure the doctors sign and address the recommendations. In an interview with Licensed Practical Nurse (LPN) AA on 9/25/18 at 3:26 p.m. revealed that the nurses' have roles, LPN AA does not see the pharmacy recommendations, they are responsible for pulling the orders off the charts and transcribing them to the Medication Administration Record [REDACTED]. In an interview with LPN BB on 9/25/18 at 3:29 p.m. revealed that if she sees the Pharmacy recommendations on the fax machine at the nurses' station that she will either call the doctor or go see the doctor and inform him of anything that needs to be addressed. Further interview with LPN BB revealed that she is not sure if it is the LPN's responsibility, LPN BB revealed that she just addresses the Pharmacy recommendations when they are left on the fax machine. LPN BB Continued by stating that she did not see any pharmacy recommendations for the months of (MONTH) (YEAR) and (MONTH) (YEAR) and does not know why they were not addressed or signed. In an interview with the Administrator on 9/25/18 at 3:38 p.m. revealed that the recommendations are usually addressed and signed every month during rounds. When asked what happened in (MONTH) (YEAR) and (MONTH) (YEAR) she said they must have been overlooked. She stated that her expectation is for the recommendations to be addressed and signed as soon as possible but definitely before the next review date. Policy titled Pharmacy Services revised 11/28/17 under heading Drug Regimen Review revealed: The pharmacist must report any irregularities to the attending physician and the Director of Nursing (DON) and these reports must be acted upon. The facility must develop and maintain policies and procedures for the monthly drug regimen review that include, but are not limited to, time frames for the different steps the process and steps the pharmacist must take when he/she identifies an irregularity that requires urgent action. Policy titled Pharmacy Policy and Procedure for[NAME]Anne Burgin Nursing Home revised 9/12/17 revealed Consultant pharmacist will conduct Medication Management Reviews of each resident of the LTC facility monthly and as needed per CMS regulations. The consultant pharmacist must report any irregularities to the attending physician and/or director of nursing (DON). The pharmacy consultant reports to the Physician must be submitted to the physician by the facility staff and acted upon. Consult reports to nursing staff or DON need to also be read and acted upon.",2020-09-01
492,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2018-09-27,812,F,0,1,KLJS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and review of the facility policy titled Sanitary Food Storage the facility failed to discard expired items, failed to label and date items upon delivery, failed to maintain temperatures of food during community dining service. This included storage and refrigeration areas in the kitchen and emergency food supply. The facility census was 73 residents. Findings include: During the initial tour on [DATE] at 10:08 a.m. there were 21 loaves of bread on bread rack that did not have a thaw date or a use by date identified. During an observation of Cooler #13 on [DATE] at 10:20 a.m. there was a plastic container that contained multiple containers of individual cranberry juice cartons and there was no use by date. During community dining on [DATE] at 11:40 a.m. in the main dining room there were 14 residents being served lunch. The Certified Dietary Manager (CDM) provided the following food temperatures: Broccoli and Cheese Casserole 127 degrees Fahrenheit (F), Creamed corn 134.9 degrees F, Fried pork chops 118.9 degrees F, and the banana pudding was 52 degrees F. Emergency food storage tour on [DATE] at 12:45 a.m. revealed that there was no way to identify expiration dates for tuna in the pouch. There were some cans of emergency food items that were dated for (YEAR) as an in date but there was no way to indicate an expiration date. During observation of the emergency water storage area on [DATE] at 12:50 a.m. there were 23 cases with 6 gallons of water in each case with an expiration date of [DATE]. There were also two 35 count packages of water with a use by date of [DATE]. During an interview on [DATE] at 10:29 a.m. with Dietary Team Leader revealed that the cranberry juice was delivered on Friday and further reported that the juice is typically gone in three days. During an interview on [DATE] at 10:34 a.m. with CDM revealed that they have about a week to use the bread but acknowledged that there is no expiration date on the bread. The CDM revealed that she is unsure of when the cranberry juice expires. During an interview on [DATE] at 11:40 a.m. with the CDM revealed that the banana pudding was 41 degrees F when taken out of the refrigerator and they have two hours to use it. The CDM further reported that the containers that the food is in should be insulating the food to help maintain the temperatures, but the items had been uncovered for 20 minutes and the temperature drops once uncovered. The CDM reported that the containers should be maintaining food temperatures as they come from the kitchen at the correct temperature. During an interview with the CDM on [DATE] at 12:55 p.m. she reported that she had checked the emergency water supply earlier this week but had not opened the boxes to check for expiration dates. During an interview on [DATE] at 12:29 p.m. with the CDM it was reported that during community dining there is a two hour time frame for using the food. It is reported that food is to be checked every two hours when on the steamtable, but their food does not stay on the steam table that long. The CDM reported that when food for community dining is sent to the dining room from the kitchen it is 135 degrees F or greater. She reported that they have been using the insulated container to keep foods hot. However, she acknowledges that the food did not maintain temperature once opened on Tuesday. The CDM further reported that she will have to come up with another plan for assuring that temperatures remain at 135 degrees F or higher when holding. The CDM acknowledged that cranberry juice and bread were not labeled in such a way as to determine the expiration date for consumption. The CDM also reported that after checking she confirmed that the tuna and other identified canned items in emergency food was expired. The CDM reported that ultimately, she is responsible for assuring that emergency foods, water, and other items are used prior to expiration. Frozen food that has been thawed shall be used within the date range and never refrozen. 2. Foods that are frozen and used as needed should be taken out as needed, labeled with a use by date: a. Bread (already cooked) - use within 5 days of thawing b. Pasteurized juices - used with 7 days of thawing (sic)",2020-09-01
493,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2017-10-19,274,D,0,1,L94811,"Based on record review and staff interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment to address a decline in Activities of Daily Living (ADL's) for one resident (#57) from a total sample of 26 residents. Findings include: Resident (R) #57 had Quarterly MDS assessments, with Assessment Reference Dates (ARD) of 1/19/17 and 4/19/17, completed by facility staff. A review of the MDS assessments revealed that the resident's self performance declined from the 1/19/17 to the 4/19/17 MDS, in the area of ADL's. The resident was documented as being provided with more assistance from staff for bed mobility, transfers, ambulation, dressing, toileting, and performing personal hygiene. Although interventions were implemented to address the decline, there was no evidence that a Significant Change MDS was completed. During an interview on 10/19/17 at 12:35 p.m. the Director of Nursing (DON) confirmed that a Significant Change MDS assessment was not completed but should have been for R #57.",2020-09-01
494,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2017-10-19,279,D,0,1,L94811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facilty failed to develop a plan of care for the use of [MEDICAL CONDITION] medications for two residents (R), (#76, and #57) from a sample of 26 residents. Findings include: 1. Record review of resident R#76 Admission assessment on 8/7/17 coded under section V-Care triggered for [MEDICAL CONDITION] Drug use. R#76 physician orders [REDACTED]. On 10/19/17 at 1:48 p.m. in a interview with Registered Nurse AA she reviewed resident R#76's care plan and reported that she usually does a care plan on all resident's that receive antipsychotic's and that she could not find where she had done a care plan to reflect that resident R#76 was receiving antipsychotic. RN AA also reported that we do not have a system in place to catch all the changes on residents. We have morning meetings and management meetings but we do not get everything. Sometimes we get information from the nurses as well. I will usually update or revise the residents care plan when we have that specific resident's care plan meeting and we do those quarterly. 2. R #57 had been receiving [MEDICATION NAME], and antipsychotic medication, since 3/17/16 for [DIAGNOSES REDACTED]. The medication was increased from the initially ordered dose of 1 milligram (mg) daily at bedtime to 1 mg twice daily on 4/14/16. On 9/16/16 the [MEDICATION NAME] was increased again to the current dose of 1.5 mg twice daily. Licensed nursing staff completed an Annual Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 10/23/16. The use of antipsychotic medication was documented on the MDS assessment, and staff also documented that the use of [MEDICAL CONDITION] medication would be included in the care plan. However, there was no evidence that a care plan was developed to address the use of the [MEDICATION NAME] until 10/19/17, after surveyor inquiry. During an interview on 10/19/17 at 4:17 p.m. Registered Nurse AA confirmed that the care plan had not been developed.",2020-09-01
495,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2017-10-19,280,D,0,1,L94811,"Based on observation, record review, and staff interview the facility failed to update/revise the plan of care for one resident R#35, from a sample of 26. Findings include: Review of resident R#35's the care plan for R#35 with a start date: 3/07/17 Resident R#35 has alteration in skin related to Pressure ulcer of buttocks. Review of R#35's the medical record for R#35 revealed that on 8/14/17 resident was assessed and documented on the Skin Condition/Wound Progression form: New (1st recording) Present on the Left Heel is a Abrasion. On 8/31/17 documentation on the Skin Condition/Wound Progression Form: The following findings were documented, Weekly skin assessement. Abrasion noted to left heel. Area cleansed every 3 days and prn (as needed). Dressing intact. Area healing. On 9/28/17 documentation on the Skin Condition/Wound Form: Skin and Wound update. Condition changed (from: Abrasion To: Pressure ulcer) Reason: Pressure ulcer present on the left heel is a pressure Ulcer. The following findings were documented, unable to accurately stage-suspected deep tissue injury in evolution. Length in centimeters (cm)=2.8, Width in cm=1.8, depth in cm=0, skin is not blanchable, no odor is apparent, no drainage is apparent. On 10/19/17 1:48 p.m. Interview with Minimum Data Assessment (MDS RN) Registered Nurse AA and review of resident #35's plan of care AA reported that the plan of care had not been updated to reflect the pressure area to the residents left heel. At this time AA also reported that they do not have a process in place to receive information that has changed on residents. That sometimes she may get information in the morning or from management meetings but usually its when everyone meets to discuss the residents plan of care and that is quarterly.",2020-09-01
496,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2017-10-19,313,D,0,1,L94811,"Based on observation, interview and record review, the facility failed to obtain vision services to address the light sensitivity of one resident (#57) from a total sample of 26 residents. Findings include: Resident (R) #57 was observed wearing sunglasses, while inside the facility, on 10/17/17 at 3:45 p.m., 10/18/17 at 1:15 p.m. and on 10/19/17 at 11:16 a.m. A review of the clinical record revealed multiple care plan meeting notes that documented the resident's aversion to light. A 2/18/16 note documented the resident liked to stay in his room with no lights on. A 5/12/16 note documented that the resident needed shades for brightness. A 10/20/16 note documented that the resident was sensitive to light. A 1/17/17 note documented that the resident wears sunglasses due to light aversion. A 4/11/17 note documented that the resident stated that the light hurt his eyes. However, there was no evidence that facility staff had attempted to obtain vision services to address and evaluate the possible cause for the resident's aversion and sensitivity to light. During interviews on 10/18/17 at 3:34 p.m. and on 10/19/17 at 11:30 a.m., the Director of Nursing (DON) stated that she could not find where facility staff had offered vision services to the resident. She stated that the resident had been wearing sunglasses since admission and was on his third pair, that she brought for him. After surveyor inquiry, an appointment was obtained for an eye exam for R #57.",2020-09-01
497,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2017-10-19,314,D,0,1,L94811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facilty failed to prevent possible cross contamination for one resident, R#35 during wound care treatment observation from a sample of 26. Findings include: On 10/18/17 at 8:35 a.m. observation of wound care on resident R#35 observed sitting up in geri chair in room, Registered Nurse (RN) BB described the left heel at having 100% granulation, and was 1 centimeter (cm) x 0.6 cm and healing and it was initially coded as an abrasion. RN BB had all clean supplies in a plastic bag when entering the room BB sanitized her hands and applied gloves. She then removed the soiled bandage from R#35's left heel, and reached into the bag of clean supplies with dirty gloves and pulled out the gauze and sprayed it with wound cleanser, wiped the heel and laid the soiled gauze on the geri chair, then removed her soiled gloves and applied new gloves and reached back into the bag of clean supplies and removed the skin prep and applied it around the wound, holding the residents foot/ankle during application of the skin prep the wound started with moderate drainage of sanguineous drainage and BB picked the soiled gauze up from where she laid in on the surface of the geri chair and re-wiped were the wound with the same soiled gauze that she had laid on the geri chair surface. She then reached back into the plastic bag with soiled gloves, and removed the [MEDICATION NAME] bandage and [MEDICATION NAME] to apply to the left heel. Placed a dab of [MEDICATION NAME] on the clean [MEDICATION NAME] dressing and placed it on the left heel. On 10/18/17 8:45 a.m. in an interview with RN BB after the observation of resident R#35's wound care, RN BB stated that she normally changes the dressing while the resident is in bed but the resident is going out of the facility today and was up in the geri chair. RN BB reported I usually have my bag for soiled dressings and gloves and my clean field set up on the bed. RN BB also reported that she knows and has received training to not cross contaminate by reusing soiled gauze or reusing contaminated gauze or placing contaminated/soiled gauze on the geri chair or reuse the already soiled gauze to wipe off a cleaned wound bed. Cross reference to F280",2020-09-01
498,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2017-10-19,441,D,0,1,L94811,"Based on observation, record review and staff interview, the facility failed to clean blood glucose meter's per the manufacturer's instruction; McKesson True Metrix Pro. Profession blood glucose monitoring meter, for two (2) residents (R#4, R#77) observed during medication administration pass . The sample size was 26. On 10/18/17 at 10:35 a.m. observation of medication administration pass, with Licensed Practical Nurse (LPN) CC obtained a finger stick blood sugar on resident #77. LPN CC removed the blood glucose meter off the side of the open medication cart, did not clean the meter before obtaining the residents finger stick and then placed the blood glucose meter back on the top of the medication cart without cleaning after obtaining the finger stick. On 10/18/17 10:45 a.m. observed LPN DD obtain a finger stick blood sugar on resident #4, she removed the blood glucose meter from a basket on side of the medication cart and laid it on top of the medication cart, gloved her hands and obtained the fingerstick from resident #4. The residents fingerstick was 150 and did not require insulin coverage. LPN DD then placed the blood glucose meter on top of the medication cart and wiped it with a alcohol prep and placed it in the basket on the side of the medication cart. On 10/19/17 at 10:36 a.m. observation of finger stick blood sugar being obtained during medication administration on R#77. LPN DD did not clean the blood glucose meter prior to or after obtaining the finger stick on R#77. LPN DD laid the blood glucose meter on top of the mediation cart and left it there without cleaning it. On 10/19/17 11:14 am. observation revealed three (3) medication carts each having a McKesson True Metrix Pro, Professional blood glucose monitoring meter, that was in a basket, on the side of the medication cart in plane view and not stored. Interview with LPN DD on 10/19/17 at 11:31 a.m. reported, we are suppose to clean our glucose machines after each resident use. We use saniwipes and let them sit for 1 minute. LPN DD then looked for the sanipedi wipes on her medication cart but could not locate the sanipedi wiped on her cart. She then reported that the sanipedi wipes are at the nurses desk. I just set the monitor machine right back here on the cart ( LPN pointed to side of open cart) until I get back down to the nurses desk, then I clean the blood glucose machine with the sanipedi wipe. Interview and observation with LPN DD on 10/19/17 at 11:47 a.m. observed blood glucose meter sitting on side of the medication cart. DD reported that after she does fingerstick blood sugars on her residents and when she gets back to the nurses desk after all fingerstick's have been done, she cleans the machine with sanipedi wipes, and stated that while she is doing finger stick blood sugars on residents she will just wipe off the blood glucose machine with an alcohol prep. Interview and observation with LPN DD on 10/19/17 at 2:30 p.m. LPN DD reported the name of the blood glucose meter was McKesson True Matrix Pro and then pointed to the name on the meter and said these are the blood glucose monitors we use here at the facility. On 10/19/17 at 12:33 p.m. during interview with the DON she reported that the blood glucose machines are to be cleaned with a sanipedi wipe at night and the nurses are to use alcohol wipes to clean the blood glucose machines between resident use. Review of the manual for McKesson pg. 4 instructions as follows; IMPORTANT INFORMATION (cont.): WARNING! Healthcare Professionals should adhere to standard precautions and disinfection procedures when handling or using this device for testing . Multiple patient use devices such as blood glucose meters should be used on only one patient and not shared. If dedicating blood glucose meters to a single patient is not possible, the meters must be properly cleaned and disinfected after every use following the guidelines found in Meter Care, Cleaning/Disinfecting. Pg. 36- To Clean and Disinfect the Meter: 1. Wash hands thoroughly with soap and water. Wear a clean pair of gloves. 2. To Clean: Make sure meter is off and a test strip is not inserted. With ONLY PDI Super Sani Cloth Wipes (or any disinfectant product with the EPA* reg. no. of 9480-4), rub the entire outside of the meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter. Repeat as needed until all surfaces are visibly clean. Discard used wipes. (*Environmental Protection Agency.) 3. To Disinfect: Using fresh wipes, make sure that all outside surfaces of the meter remain wet for 2 minutes. Make sure no liquids enter the Test Port or any other opening in the meter.",2020-09-01
499,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2017-11-14,157,D,1,0,IEJT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to notify the physician timely of an unavailable medication for one resident (A) from a total sample of four residents. Findings include: Resident (R) A had a physician's orders [REDACTED]. There was also a physician's orders [REDACTED]. During an interview on 11/14/17 at 1:15 p.m., RA stated that she had run out of her inhaler and went without it for a few days. During an interview on 11/14/17 at 1:55 p.m., the Director of Nursing (DON) confirmed, after speaking with Licensed Practical Nurses (LPN) BB and CC, that the resident did not recieve the [MEDICATION NAME] inhaler as scheduled, because it was unavailable, for the evening dose on 10/27/17 and for both ordered doses on 10/28 and 10/29/17. The nurses administered the [MEDICATION NAME] medication via nebulization instead, on 10/28/17 and 10/29/17. However, there was no evidence that the physician was notified of the unavailability of the [MEDICATION NAME] inhaler. During an interview on 11/15/17 at 10:50 a.m., the physician stated that not receiving the [MEDICATION NAME] medication would not have caused a severe consequence. However, the nurses should have contacted the physician on call of the medication unavailibility to receive an order for [REDACTED].",2020-09-01
500,JOE-ANNE BURGIN NURSING HOME,115272,321 RANDOLPH STREET,CUTHBERT,GA,39840,2017-11-14,514,D,1,0,IEJT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and record review, the facility failed to ensure that licensed nursing staff documented medication administration accurately for one resident (A) from a total sample of four residents. Findings include: Resident (R) A had a physician's orders [REDACTED]. During an interview on 11/14/17 at 1:15 p.m., RA stated that she had run out of her inhaler and went without it for a few days. During an interview on 11/14/17 at 1:55 p.m., the Director of Nursing (DON) confirmed, after speaking with Licensed Practical Nurses (LPN) BB and CC and DD, that the resident did not recieve the [MEDICATION NAME] inhaler as scheduled, because it was unavailable, for the evening dose on 10/27/17 and for both ordered doses on 10/28 and 10/29/17. However, a review of the (MONTH) (YEAR) Medication Administration Record [REDACTED].",2020-09-01
501,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,568,D,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and the review of the facility policy Resident Trust Fund the facility failed to provide resident trust fund account quarterly statements for three of three resident (R) A, R B, and R C reviewed. One hundred and eleven (111) resident trust fund accounts are managed by the facility. Findings included: Review of the policy updated 4/2014 titled, Resident Trust Fund revealed send statements to the resident or responsible parties, at a minimum on a quarterly basis. 1. Record review for R A was admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 7 out of 15 which indicates the resident is severe impairment. During an interview on 12/16/18 at 12:41 p.m. with R A regarding his trust fund account that the facility manages. Resident A revealed he has a trust fund account with the facility. Resident A revealed he does not receive a quarterly statement for his trust fund account that the facility manages. 2. Record review for R B was admitted to the facility on [DATE]. Review of an MDS quarterly assessment dated [DATE] revealed a BIMS of 13 out of 15 which indicates the resident is cognitively intact. During an interview on 12/16/18 at 1:01 p.m. with R B regarding his trust fund account that the facility manages. Resident B revealed he does not receive a quarterly statement for his trust fund account that the facility manages. Resident B revealed if he asks for his balance the staff will verbally tell him how much he has in his account. An Interview was conducted on 12/7/18 at 2:50 p.m. with QQ Business office Assistant regarding resident trust funds account. QQ Business office Assistant verified that R A and R B has a trust fund accounts that the facility manages. An Interview was conducted on 12/7/18 at 3:00 p.m. with RR the Business Office Manager (BOM) regarding resident's trust funds accounts that the facility manages. The BOM could not confirm that R A or R B received their quarterly statement. An interview was conducted on 12/20/18 at 12:43 p.m. with SS Business Office Assistant who is responsible for resident trust funds, sends statements to the responsible Person/resident. Business Office Assistant SS revealed she does not have proof that the resident/family are receiving quarterly statements. An interview was conducted 12/20/18 at 2:30 p.m. on the BOM. The BOM revealed the office has no written proof that the resident received their statement. The facility failed to provide quarterly statement as required. 3. Record review revealed that Resident (R) C admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated he was cognitively intact. In an interview with R C on 12/17/18 at 11:08 a.m., he stated he did have a Resident Trust Fund (RTF) Account with the facility. He stated he did not receive quarterly statements on this account. He further stated he held a credit union account which was missing money. He stated the Social Services Director (SSD) had all the information. In an interview with the Business Office Manager (BOM) on 12/20/18 at 1:28 p.m. regarding the RTF account for R C, she stated she issued monthly statements to her RTF account holder-residents. She stated she did not require residents to sign for their statements and could provide no documentation to corroborate her actions. She stated R C was his own Responsible Party (RP) and no statements were sent to his family members. In an interview with Social Worker (SW) XX on 12/20/18 at 2:31 p.m. regarding the RTF account for R C, she stated she was aware of the resident's concern about his credit union account but this facility had nothing to do with that account. She confirmed R C was his own RP and there was little family involvement.",2020-09-01
502,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,656,D,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, resident, and family interview the facility failed to follow the care plan for one resident (R) (R#224) related to providing diabetic ulcer treatment as order. The sample size was 87 residents. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating R#224 to be cognitively intact. Section G Functional Status revealed R#224 requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed R#224 is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem onset date of 11/21/18 related to pressure ulcer/potential for skin breakdown related to impaired mobility, incontinent of bowel and bladder, frequent diarrhea, multiple diabetic ulcers of the right foot and first and second fingers. Left below the knee [MEDICAL CONDITION]. Has abdominal abscess. History of reversal ostomy. Fragile skin. Resident noted to pick at skin; [DIAGNOSES REDACTED]. Approaches: Labs/Meds/Treatments as ordered. Notify the MD/NP of abnormal findings. An interview on 12/16/18 at 1:37 p.m. with the resident revealed that he has a wound on his right foot and it is supposed to be changed every other day but the last time it was changed was last week. Observation during this time of dressing on the right foot revealed a date of 12/12 (2018) written on tape attached to the dressing. A second interview on 12/17/18 at 1:15 p.m. with the resident revealed that the dressing to his right foot has not been changed. Observation of the dressing, at this time, revealed a date of 12/12 (2018) written on tape attached to the dressing. During an interview on 12/17/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) KK in the resident's room, revealed that the dressing to the resident's right foot is dated 12/12 (2018). During an interview on 12/17/18 at 1:22 p.m. with Unit Manager FF revealed that the dressing to the resident's right foot is dated 12/12 (2018). Continued interview revealed that the Physician order [REDACTED]. Unit Manager FF stated that she expects the nurses to be checking dates on dressing changes as part of the assessment. During an interview on 12/18/18 at 4:00 p.m. with LPN MM revealed that she did the wound care on the resident on 12/12/18. She stated that the dressing is to be done every other day and as needed (prn) and on (MONTH) 14, (YEAR) and that she was going to do the dressing change when he came back from [MEDICAL TREATMENT] but when she got to the rehab floor there was an ambulance there to get him to take him to a doctor appointment and she wasn't able to do the dressing change. She stated that she forgot to tell the oncoming nurse that she wasn't able to do his dressing change and stated she is not here on the weekend and that is why the dressing change was missed. On 12/18/18 the resident was discharged to the hospital due to swelling in his left arm which prevented wound care observation on that date. Review of Physician order [REDACTED]. Review of the policy Wound Care Treatment Protocol revealed the wound is to be evaluated for signs and symptoms of infection and for signs of healing while performing treatment. Document/report findings. Provide treatment as per physician's orders [REDACTED].>",2020-09-01
503,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,657,D,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the care plan to include a change from Foley catheter to Suprapubic catheter for one resident (R#137) of 87 sampled residents. Findings include: Review of the medical record for R#137 revealed the resident was admitted on [DATE]. Further review revealed the resident had a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 99 indicating severe cognitive impairment. Review of the resident's care plan, updated on 10/30/18, revealed that the resident had an indwelling catheter with supporting diagnosis. Goals and approaches include but not limited to change Foley as directed in catheter policy and monitor for signs and symptoms of Urinary Tract Infection [MEDICAL CONDITION]. Review of the nephrology Consult dated 8/13/18 revealed recommendations for the resident to return for further tests. Review of the nephrology assessment and plan include but is not limited to; problem: [MEDICAL CONDITION] with chronic Foley; plan: Urology planning for Suprapubic catheter. In an interview on 12/19/18 at 10:45 a.m. with the dayshift unit manager of 300 hall, LPN AA, confirmed that the care plan has not been up-dated to show the suprapubic catheter that was inserted on 11/5/18 before this time. LPN AA further revealed that it is ultimately her responsibility to ensure that the care plan is updated with new and changing information and that the staff were made aware of the change in report that is held every shift.",2020-09-01
504,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,684,D,1,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff, resident, and family interview the facility failed to follow the care plan for one resident (R) (R#224) related to providing diabetic ulcer treatment as order. The sample size was 87 residents. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating R#224 to be cognitively intact. Section G Functional Status revealed R#224 requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed R#224 is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem onset date of 11/21/18 related to pressure ulcer/potential for skin breakdown related to impaired mobility, incontinent of bowel and bladder, frequent diarrhea, multiple diabetic ulcers of the right foot and first and second fingers. Left below the knee [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Approaches: Labs/Meds/Treatments as ordered. Notify the MD/NP of abnormal findings. An interview on 12/16/18 at 1:37 p.m. with the resident revealed that he has a wound on his right foot and it is supposed to be changed every other day but the last time it was changed was last week. Observation during this time of dressing on the right foot revealed a date of 12/12 (2018) written on tape attached to the dressing. A second interview on 12/17/18 at 1:15 p.m. with the resident revealed that the dressing to his right foot has not been changed. Observation of the dressing, at this time, revealed a date of 12/12 (2018) written on tape attached to the dressing. During an interview on 12/17/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) KK in the resident's room, revealed that the dressing to the resident's right foot is dated 12/12 (2018). During an interview on 12/17/18 at 1:22 p.m. with Unit Manager FF revealed that the dressing to the resident's right foot is dated 12/12 (2018). Continued interview revealed that the Physician order [REDACTED]. Unit Manager FF stated that she expects the nurses to be checking dates on dressing changes as part of the assessment. During an interview on 12/18/18 at 4:00 p.m. with LPN MM revealed that she did the wound care on the resident on 12/12/18. She stated that the dressing is to be done every other day and as needed (prn) and on (MONTH) 14, (YEAR) and that she was going to do the dressing change when he came back from [MEDICAL TREATMENT] but when she got to the rehab floor there was an ambulance there to get him to take him to a doctor appointment and she wasn't able to do the dressing change. She stated that she forgot to tell the oncoming nurse that she wasn't able to do his dressing change and stated she is not here on the weekend and that is why the dressing change was missed. On 12/18/18 the resident was discharged to the hospital due to swelling in his left arm which prevented wound care observation on that date. Review of Physician order [REDACTED]. Review of the policy Wound Care Treatment Protocol revealed the wound is to be evaluated for signs and symptoms of infection and for signs of healing while performing treatment. Document/report findings. Provide treatment as per physician's orders [REDACTED].>",2020-09-01
505,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,689,E,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to maintain safe water temperatures in resident rooms (sinks) on three of five units. The census was 220. Findings include: Observation on 12/16/18 at 2:47 p.m. revealed the hot water at the sink of room [ROOM NUMBER] on the MT unit was uncomfortably hot to the hand and could not be run over the bare skin for even a few seconds. Observation on 12/16/18 between 3:15 p.m. and 3:51 p.m. of the water temperatures taken by the maintenance assistant XX at the sink in resident rooms on the MT unit revealed the following: 208=124.3 degrees Fahrenheit (F) 205= 121.8 degrees F 204= 136.5 degrees F 209= 121.9 degrees F 206= 131.5 degrees F 203= 132.4 degrees F 211= 121.2 degrees F 202=128.1 degrees F 210= 128.4 degrees F 224=122.1 degrees F 222= 122.3 degrees F 220=124.7 degrees F 218=123 degrees F 236=139.2 degrees F 234=146 degrees F 233=138.9 degrees F 232=142.1 degrees F 231=145 degrees F 239=138.5 degrees F 240=144.5 degrees F 241 Near shower) = 80.5 degrees F 242= (near shower) 81.5 degrees F 243= 83 degrees F (near shower) 244= 84.5 degrees F (near shower) Shower room = 81.1 degrees F During an interview on 12/16/18 at 4:29 p.m. with the Administrator, it was revealed that the maintenance department checks both showers and rooms but she was not sure how often these checks were one. Residents on the West unit had complained of the water on that unit being cold a few weeks before. As a result, the administrator had called the plumbers in and they had adjusted and/or replaced the existing hot water valves during their visit. She had not been made aware of any concerns with the water being too hot on any of the units. She planned immediately inform the staff to keep the residents from using the hot water on all the units until the water temperatures could be adjusted to comfortable and safe ranges. During a follow up interview on 12/16/18 at 4:42 p.m. with the Administrator revealed that she had notified the staff that residents should not be allowed to use the hot water in the residents' rooms until further notice. She had placed signs to that effect on the units and the maintenance director was on his way in to oversee any further adjustments. During an interview on 12/16/18 at 5:02 p.m. with the Maintenance Director revealed he checks the hot water in the rooms at least once each week and the water in the showers daily. During his weekly checks, he takes the temperature of the water in one room on each side (north and south) of each hallway. He checks rooms closest to the shower rooms. His aim is for the water temperatures on the hallways to range between 95 degrees F and 110 degrees F. If the water temperatures are found to be below 95 degrees F, he goes to the mixing valve associated with that unit and adjusts the value up, and if it is more than 110, he adjusts it downward. His aim is to achieve temperatures at the mixing valve of approximately 130 degrees F because that temperature works well to attain an appropriate temperature in the rooms on that hallway. He checks the temperature at the mixing valve each day and that value was 132 degrees F on the morning of 12/16/18. He is not alarmed if only one or two rooms are above the desired temperature. However, should the hot water in rooms that he checks be higher than 118 degrees or so, then he checks more rooms and adjusts the mixing valve as necessary. His plan was to immediately adjust the temperature downwards at the valves on the affected units downward. A review of the maintenance records titled Water Temperatures revealed that water temperatures recorded in the rooms on the MT, 300, and Vent units in the week prior to 12/16/18 showed several temperatures over 120 degrees F on some days. However, no hallway showed a pattern of high temperatures on consecutive days. A review of the accident log for the previous six months revealed no accidents associated with elevated water temperatures. The Maintenance Director had adjusted the values upon arrival at the facility, therefore a recheck of the following rooms on 12/16/18 at 7:45 p.m. with Maintenance Assistant XX revealed that the water temperatures were not at a safe level at this time on the Memory Unit (MT). The highest water temperature was 145 degrees F and the lowest was 129 degrees F. During an interview on 12/20/18 at 1:29 p.m. with the Maintenance Director revealed that the water was shut off on the evening of 12/16/18 and that waster temperatures were monitored for 24 hours after the plumber visited on 12/17/18. Review of the 24-hour water temperature monitoring log of 12/17/18 to 12/18/18 revealed all rooms on the halls were monitored during that period; the highest temperature logged over 24 hours was 114 degrees F, on the Vent Unit, and the log documented the final temperature for that room was 105.5. Observation on 12/16/18 of the 300 hall water temperatures with Maintenance Assistant XX revealed: room [ROOM NUMBER] at 4:10 p.m. was 133 degrees F, room [ROOM NUMBER] at 4:11 p.m. was 138.8 degrees F, room [ROOM NUMBER] at 4:12 p.m. was 140 degrees F, room [ROOM NUMBER] at 4:13 p.m. was 136 degrees F, room [ROOM NUMBER] at 4:14 p.m. was 118 degrees F, room [ROOM NUMBER] at 4:15 p.m. was 113 degrees F, room [ROOM NUMBER] at 4:17 p.m. was 134 degrees F, room [ROOM NUMBER] at 4:18 p.m. was 115 degrees F, room [ROOM NUMBER] at 4:19 p.m. was 126 degrees F, room [ROOM NUMBER] at 4:22 p.m. was 134 degrees F, room [ROOM NUMBER] at 4:25 p.m. was 123 degrees F, room [ROOM NUMBER] at 4:27 p.m. was 132 degrees F, room [ROOM NUMBER] at 4:30 p.m. was 130 degrees F, room [ROOM NUMBER] at 4:31 p.m. was 128 degrees F, room [ROOM NUMBER] at 4:33 p.m. was 132 degrees F, room [ROOM NUMBER] at 4:33 p.m. was 140 degrees F, room [ROOM NUMBER] at 4:35 p.m. was 137 degrees F, room [ROOM NUMBER] at 4:36 p.m. was 132 degrees F, room [ROOM NUMBER] at 4:40 p.m. was 102.2 degrees F, room, 313 at 4:41 p.m. was 136 degrees F, room [ROOM NUMBER] at 4:42 p.m. was 103 degrees F, room [ROOM NUMBER] at 4:43 p.m. was 139 degrees F, room [ROOM NUMBER] at 4:45 p.m. was 104 degrees F, room [ROOM NUMBER] at 4:46 p.m. was 140 degrees F, room [ROOM NUMBER] at 4:50 p.m. was 138 degrees F, room [ROOM NUMBER] at 4:51 p.m. was 116 degrees F, room [ROOM NUMBER] at 4:52 p.m. was 140 degrees F, room [ROOM NUMBER] at 4:43 p.m. was 116 degrees F, room [ROOM NUMBER] at 4:55,p.m. was 140 degrees F. A recheck of rooms on the 300 hall, with Maintenance Assistant XX, after the Maintenance Director made changes to water heater values revealed: room [ROOM NUMBER] at 7:16 p.m. was 123 degrees F, room [ROOM NUMBER] at 7:17 p.m. was 109 degrees F, room [ROOM NUMBER] at 7:18 p.m. was 116 degrees F, room [ROOM NUMBER] at 7:19 p.m. was 121 degrees F, room [ROOM NUMBER] at 7:27 p.m. was 140 degrees F, room [ROOM NUMBER] at 7:29 p.m. was 142 degrees F. An interview with the Administrator at 7:31 p.m. revealed that all hot water to building will be shut off until master plumber can come fix it. and is planned for 5:30 a.m. 12/17/18. Disposable products will be used for breakfast. The water temperatures on 12/17/18 between the hours of 5:04 p.m. through 5:59 p.m. with Maintenance Assistance XX confirmed that the water temperatures on the 200 and 300 hall were all below 110 A recheck of rooms on the 300 hall, with Maintenance Assistant XX, after the Maintenance Director made changes to water heater values revealed: room [ROOM NUMBER] at 7:16 p.m. was 123 degrees F, room [ROOM NUMBER] at 7:17 p.m. was 109 degrees F, room [ROOM NUMBER] at 7:18 p.m. was 116 degrees F, room [ROOM NUMBER] at 7:19 p.m. was 121 degrees F, room [ROOM NUMBER] at 7:27 p.m. was 140 degrees F, room [ROOM NUMBER] at 7:29 p.m. was 142 degrees F. A recheck of rooms on the 300 hall, with Maintenance Assistant XX, after the Maintenance Director made changes to water heater values revealed: room [ROOM NUMBER] at 7:16 p.m. was 123 degrees F, room [ROOM NUMBER] at 7:17 p.m. was 109 degrees F, room [ROOM NUMBER] at 7:18 p.m. was 116 degrees F, room [ROOM NUMBER] at 7:19 p.m. was 121 degrees F, room [ROOM NUMBER] at 7:27 p.m. was 140 degrees F, room [ROOM NUMBER] at 7:29 p.m. was 142 degrees F. Observation on 12/17/18 between 5:04 p.m. and 5:59 p.m. of the 100, 200, 300 halls and the vent unit with Maintenance Assistant XX revealed that all water temperatures were below 110 degrees F. Observation of the water temperatures with the Maintenance Director (MD) began on 12/16/18 at 5:55 p.m. in the ventilator unit revealed the following by room number with temperatures expressed in Fahrenheit degrees using a digital thermometer: Rooms: 101=120.5 degrees Fahrenheit (F) 102=116.5 degrees F 103=124 degrees F 104=121 degrees F 105=118.5 degrees F 106=112.4 degrees F 107=117 degrees F 108=112 degrees F 109=107 degrees F 110=108 degrees F 111=107.9 degrees F 112=109 degrees F 113=108 degrees F 114=109 degrees F 115=108 degrees F Shower room: Stall 1=98.4 9 degrees F (right); Stall 2=97.5 degrees F (left) Shower room sink=106 degrees F The boiler's mixing valve temperature was 120 degrees F on 12/16/18 at 6:00 p.m. The MD decreased the temperature of the mixing valve to 115 degrees F at 6:10 p.m. The temperatures which exceeded 110 degrees F were re-checked beginning at 6:45 p.m. and revealed the following: Rooms: 101=111 degrees F 102=113 degrees F 103=110 degrees F 104=110 degrees F 105=113 degrees F 107=114 degrees F In an interview with the Administrator on 12/17/18 at 9:05 a.m., she stated the plumber arrived at 5:30 a.m. this morning to service or replace the existing mixing valves in the facility's main building. She stated the plumber began his evaluation in the ventilator unit (separate building). She stated the dietary staff were instructed to use paper products were used for serving meals until safe hot water temperatures could be re-established.",2020-09-01
506,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,690,D,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interview, and record review, the facility failed to remove a Foley catheter when clinically warranted for one resident (R) (R#205). The sample size was 87 residents. Findings Include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#205 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that R#205 was cognitively intact. Section G Functional Status revealed that R#205 required extensive one person assist with toilet use and managing catheter care. Section H Bowel and Bladder revealed R#205 has an indwelling Foley catheter, is always incontinent of bowel, and no toileting program has been used. Section I revealed Active [DIAGNOSES REDACTED]. An interview on 12/16/18 at 3:56 p.m. with a family member of R#205 revealed that she took the resident to the Urologist on Thursday, 12/6/18. She stated that the Urologist told her the catheter needed to come out and he would write the order for the nursing home to take it out on Monday. The family member asked that the date be changed to 12/11/18 due to other upcoming physician appointment, which the Urologist agreed. The Urologist office sent her a large envelope and a paper with the order to remove the catheter on Tuesday, 12/11/18, to give to the nursing home. The family member stated that the envelope was given to the nurse, at the medication cart, on return to the nursing home. The family member revealed that the catheter was still in and had not been removed yet. She stated that nurse FF told her that she had called the Urologist office but has not gotten a response back from them but stated that was several days ago. Observation on 12/17/18 at 6:00 p.m. and 12/18/18 at 12:00 p.m. revealed the resident in his bed with Foley Catheter in place. Review of the Urologist, History and Physical dated 12/6/18. Instructions: We will have his nursing home remove his urethral catheter on Tuesday (MONTH) 11, (YEAR) at seven in the morning. They can insert if he is unable to void or he can follow up at the local office of the urologist. We will give him a prescription to start Tamulosin 0.4 milligrams (mg) daily. A written order from the Urologist was not found in the medical record. Review of the Medication Administration Record [REDACTED]. The same day as the order to remove the catheter. An interview on 12/18/18 at 1:20 p.m. with Unit Manager FF revealed that she had to call and ask the Urologist office to fax over the order to remove the resident's catheter. She stated that the resident's family member told her that the family brought in the order and paperwork from the visit with the Urologist on 12/6/18 and gave it to the nurse, but she could not find it. Unit Manager FF stated that she started this job last Thursday and the paperwork was not on the chart until yesterday and she was not aware the catheter was supposed to be removed and can't explain where the documentation was before yesterday. Record review revealed a telephone Physician order [REDACTED]. Patient to increase fluids. Insert Foley catheter if patient isn't able to void that afternoon.",2020-09-01
507,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,695,D,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of Physician's Orders and facility policies titled Oxygen Therapy and Guidelines for Frequency Changes of Respiratory Supplies, the facility failed to change disposable oxygen equipment in a timely manner for one resident (R), R#178. The sample size was 87. Findings include: Review of the clinical record revealed R#178 was [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a comatose resident (Section B-Hearing, Speech and Vision) who required total/two-person assistance (Section G-Functional Status) for all activities of daily living (ADLs); and required oxygen (O2), suctioning, [MEDICAL CONDITION] (Section O-Special Treatments and Programs). Review of the care plan, reviewed 11/23/18, documented the problem/need related [MEDICAL CONDITION] was: risk for respiratory complications to include respiratory distress, infection, dehydration, and accidental decannulation. The goals included patent and adequate air exchange and freedom from recurrent infections, dehydration and decannulation. The interventions included: monitor for symptoms of respiratory infection-cough, increased secretions, change in color/odor, fever, abnormal laboratory values;[MEDICAL CONDITION] per Respiratory Therapy (RT). Review of the Physician's Orders, updated 7/31/18, revealed an order (originally dated 9/27/17) to [MEDICAL CONDITION] or t-piece every week. Review of the facility policy titled, Oxygen Therapy, revealed under Procedure, #8: change tubing weekly. Review of the policy titled, Guidelines for Frequency Changed of Respiratory Supplies, revealed [MEDICAL CONDITION]/collar, refillable humidifiers, aerosol corrugated tubing, and drainage bag should all be changed weekly. Observation of R#178 on 12/16/18 at 7:00 p.m. revealed a trach-dependent female, spontaneously breathing via a 35% (O2) aerosol t-piece (ATP), lying in her bed in no apparent respiratory distress. The date written on the drainage bag was 11/26/18. Observation of R#178 on 12/18/18 at 12:01 p.m. revealed she continued with the 35% ATP in no apparent respiratory distress. The date marked on the drainage bag was 11/26/18. Observation of R#178 on 12/19/18 at 11:15 a.m. revealed she continued the 35% ATP without apparent respiratory distress. The drainage bag was dated 11/26/18. In an interview with Respiratory Therapist (RT) YY on 12/19/18 at 11:21 a.m. regarding the frequency of disposable O2 supplies, she [MEDICAL CONDITION], aerosol corrugated, drainage bags, and nebulizer (sterile water) bottles are due for change out every Saturday and as needed (PRN) by RT staff per facility protocol. During an interview with the RT Manager on 12/19/18 at 11:36 a.m. regarding changing out disposable O2 supplies in R#178's room, he confirmed the date on the drainage bag was 11/26/18. He clarified the date as the day the O2 supplies were last changed. He acknowledged the facility policy and physician orders called for the disposable O2 supplies to be changed weekly. He stated his staff were directed to change disposable O2 supplies on Saturdays. The RT Manager further stated he would change the disposable O2 supplies as soon as possible (ASAP) and could offer no explanation for the delay in change-out for R#178. The RT Manager stated he would re-educate his staff on the schedule for changing disposable O2 supplies, cleaning of reusable equipment and supplies and the importance of performing and maintaining effective infection control practices. In an interview with the Infection Control Nurse (ICN) on 12/19/18 at 1:40 p.m. regarding respiratory supplies and equipment, she stated there was no infection control policy specifically related to RT equipment cleaning, air filters or disposable supplies. She stated she asked the RT Manager, about a month ago, to provide her with a log indicating the RT cleaning equipment/supplies schedule with documentation of compliance. She stated she had not received those items but would work closely with the RT Manager to obtain the data, monitor staff for compliance with facility policy and protocol, and update infection control policies related to respiratory residents as indicated.",2020-09-01
508,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,758,D,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the behavior management policy, and staff interview, the facility failed to monitor behaviors for two residents (#169 and #16) receiving [MEDICAL CONDITION] medications. The sample size was 87 residents. Findings include: (1) Review of the policy Behavior Management and Psycho-pharmacological Medication Monitoring Protocol last updated 3/18 revealed that for each residents admitted on or receiving psycho-pharmacological medication, planned interventions for that resident's behaviors will be communicated to the appropriate staff members and those interventions and the responses to them are to be documented. The policy also revealed that those residents receiving psycho-pharmacological medications will be referred to the Behavior Management Committee. The committee will establish a behavior management program and review behavior monitoring documentation as part of that program as long as the resident continued to receive psycho-pharmacological medication. 1. A Review of the clinical records for Resident (R) #169 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED].#169 to receive: [MEDICATION NAME] (an antipsychotic) 50 mg twice a day (this was increased from 25 mg bid on 12/5/18); [MEDICATION NAME] (an anxiolytic) 1mg every six hours for agitation (this was increased from 0.5 mg on 11/14/18) ; [MEDICATION NAME] (an antidepressant) 40 mg daily; and [MEDICATION NAME] (an antidepressant) 75 mg daily (increased from 50 mg on 12/14/18). A review of the Minimum Data Set (MDS) assessment records for the resident revealed an Admission MDS assessment of 6/14/18 which revealed the resident had behavioral symptoms directed at himself which occurred daily. However, these behaviors were judged to not have a significant impact on the resident, his care, or his interaction with others. He was also assessed as exhibiting rejection of care behaviors 1-3 days during the assessment period. His active [DIAGNOSES REDACTED]. The assessment also documented that the resident was receiving daily doses of antipsychotic and antidepressant medications. A further review of the MDS records for R#169 revealed a Quarterly MDS of 9/8/18 which documented that his behavioral symptoms (verbal and physical) were now directed at others 1-3 days during the assessment period, and that the resident was still receiving daily doses of antidepressant and antianxiety medications; A review of the pharmacy records for R#169 revealed a review on 8/21/18 which documented that, since the previous review, the resident had been sent on a 1013 document to the emergency room with combative/aggressive/threatening behaviors, but had returned with no new orders. The following review on 9/14/18 documented that [MEDICATION NAME] and [MEDICATION NAME] were increased during the physician's visit of 8/22/18, and the most recent pharmacy review of 12/13/18 documented that the resident's [MEDICATION NAME] was increased related to increasing behaviors. A review of a nurses' note for 7/29/18 revealed the resident was sent to the emergency room under a 1013 order following behaviors such as lashing out at staff, pulling of staff's hair, getting out of his wheelchair and placing himself on floor, and making threats towards a female resident. He could not be calmed or redirected by staff. He returned from the emergency room with no new findings. A review of a physician's progress note of 11/14/18 revealed that the resident was seen following a report by the nurse that the resident was exhibiting increased aggression and anxiety. A further review of the nurses' notes revealed two episodes of the resident throwing himself to the floor, being resistive to care and combative on the evening of 12/16/18. After an order for [REDACTED]. A review of the Behavior/Intervention Monthly Flow Records revealed that R#169 was being monitored for depression, and changes in mood. The log required nursing staff to document any of these behaviors observed on each of two shifts. Besides documenting the number of episodes (including zero), staff were also to record what intervention(s) were used to address the behavior, and the resident's response to the intervention(s). A review of the (MONTH) (YEAR) Behavior/Intervention Monthly Flow Record for R#169 revealed that staff had documented the absence/presence of behaviors only 5/30 times on the day shift and only 21/30 times on the evening shifts. During an interview on 12/19/18 10:49 with Registered Nurse (RN) OO it was revealed that R#169 exhibits a number of challenging behaviors. For example, staff sometimes hear him yelling down the hallway, but and when they rush to his room he might say he usually denies needing assistance with anything. At other times he removes himself from his wheelchair and lies on the floor in the dining room. Family members have reported that these are behaviors the resident exhibited in childhood and to which he seemed to be reverting. He is, therefore, monitored for various behaviors which can change from day-to-day. 2. Review of the clinical records for R#16 revealed she was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the MDS records for the resident revealed an Admission MDS of 9/7/18 which documented a depression score of 4 (minor symptoms), but no behavioral symptoms. The assessment also documented active [DIAGNOSES REDACTED]. A review of the nurses' notes revealed a note on 12/11/18 which documented that R#16 continued to have mood and behavior issues related to her [DIAGNOSES REDACTED]. Review of the Behavior/Intervention Monthly Flow Records revealed the resident should be monitored for anxiety and mood changes and receives [MEDICATION NAME] 10 mg daily and [MEDICATION NAME] 0.5 mg on an as needed basis. Review of the (MONTH) (YEAR) Behavior/Intervention Monthly Flow Records for R#16 revealed staff did not consistently document the resident's targeted behaviors. During that month, staff had documented the absence/presence of anxious behaviors only 4/30 times on the day shift and 3/30 times on the evening shifts. For mood changes the staff had documented only 5/30 times on both the day and evening shifts. During an interview with Certified Nursing Assistant (CNA) PP it was revealed that the CNA has worked with R#16 since she was admitted and currently knows of no behaviors that should be a concern. The resident did sometimes cry in evenings saying she wanted to go home, the CNA said. However, she was easily soothed with a brief hug during those episodes. During an interview on 12/19/18 at 10:56 a.m. with RN OO, it was revealed that the Behavior/Intervention Monthly Flow Sheets are kept to track interventions that can be used with a resident experiencing troubling behaviors prior to ordering/administering medications. The behavior logs are to be filled out by the nurses on every shift. However, the nurses have not always been consistent with this documentation and management has had to provide education on remembering to complete the logs and reminding nurses of the importance of documenting the behaviors and interventions apart from any documentation they might make in the nurses' notes. The flow sheet is one part of the decision piece for the physician (others include talking with staff/residents) in making decisions whether residents need to receive medications for behaviors. During an interview on 12/19/18 01:50 p.m. with the Director of Nursing (DON) it was revealed that she was aware that there were issues with the nurses not documenting consistently on the behavior monitoring flow sheets and, as a result, she had provided education earlier that day to the nurses to remind them of the reason for the logs, review the appropriate policy with them, and remind them to consistently document the residents' targeted behaviors. The behavior logs are used by staff to document what targeted behaviors are occurring for each resident being monitored, what interventions are tried, and how effective those interventions are. The flow sheets are also helpful when making decisions related to what interventions would be used to manage the targeted behaviors - whether pharmacological or non-pharmacological. The behavior flow sheet is one of the considerations the MD uses in making medication determinations.",2020-09-01
509,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,812,E,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of policy Food Storage (Dry, Refrigerated, and Frozen), the facility failed to discard expired food items, and failed to sanitize the thermometer probe between the taking of the temperatures of various food items on the steam table. These deficient practices had the potential to affect 210 residents receiving an oral diet, of whom six received thickened liquids. Findings include: Review of the policy titled Food Storage (Dry, Refrigerated, and Frozen) dated (YEAR), staff are to discard food that has passed the expiration date. Observation of the walk-in refrigerator while accompanied by the dietary manager during initial kitchen tour on [DATE] at 11:30 a.m. revealed three 46-ounce cartons of (brand) Nectar-like Thickened Orange juice with a use-by date of [DATE] and one 46-ounce (brand) Thickened Cranberry Cocktail with a use-by date of [DATE]. Interview on [DATE] at 11:40 a.m. with the dietary manager (DM) revealed that all food items in the kitchen have either a best by/use by manufacturer's date or a received on date added by staff when those foods are delivered. Most foods received in the kitchen are used or discarded within a year, or discarded by the manufacturer's expiration date. However, if opened at any time during that period, the staff add a discard by date and this is usually 3 or 7 days, depending on the food item. The thickened juices that were past the use-by date should have been used or discarded by the date indicated by the manufacturer. The employee responsible for stocking/restocking the shelves should have noticed the date and discarded these products. Observation on [DATE] at 11:49 a.m. of the DM taking the temperatures of various food items on the steam table revealed the DM sanitize the shaft of the thermometer using an alcohol wipe before wiping the shaft with a disposable napkin. Next, she proceeded to insert the shaft of the thermometer into a succession of food items on the steam table - meat sauce, then spaghetti, then mixed vegetable, pureed spaghetti, and pureed vegetables. Between taking the temperature of each of these items, the DM did not sanitize the thermometer shaft but wiped it clean with the same soiled paper napkin. At that point, the dietary manager discarded the soiled napkin before inserting the thermometer into chicken noodle soup, then sweet and sour pork on the steam table. Observation on [DATE] at 8:30 a.m. of the Cook NN taking the temperature of various food items on the steam table revealed she sanitized the shaft of the thermometer with an alcohol wipe, took the temperature of grits and wiped the shaft with a paper napkin before inserting the shaft into scrambled eggs. Next, she sanitized the shaft of the thermometer again with an alcohol wipe before inserting into pureed meat. After taking the temperature of the pureed meat, NN wiped the thermometer shaft with a paper napkin, before inserting it into oatmeal. During an interview on [DATE] 08:55 a.m. with Cook NN it was revealed that one of her responsibilities as cook is to monitor the temperature of the food items on the steam table. During this process, she should sterilize the shaft of the thermometer with an alcohol pad before drying it off with a napkin. This process should take place between and before taking the temperature of every item on the steam table if those items are different foods. During an interview on [DATE] at 9:00 a.m. with the DM it was revealed that she does not require staff to sanitize the thermometer between taking the temperature of different food items on the steam table. Once the shaft is sanitized at the start of taking the temperatures, staff can simply wipe the thermometer shaft with a paper towel between taking the temperature of different food items on the steam table. The DM further said that it was probably a good practice to sanitize the thermometer between different food items, but her staff had not been trained to do so. There was no policy or procedure related to this practice.",2020-09-01
510,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,842,D,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview the facility failed to ensure that medications were recorded in the electronic Medication Administration Record [REDACTED]. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident to be cognitively intact. Section G Functional Status revealed the resident requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed the resident is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Departmental Notes for (MONTH) (YEAR) revealed that [MEDICATION NAME] 2.5 mg given on 11/26/18 at 7:59 a.m., 11/25/18 at 1:18 a.m., 11/28/18 at 2:30 p.m.,, 11/29/18 at 4:33 a m., 11:29 at 2:22 p.m., 11/29/18 at 7:08 p.m. and 11/30/18 at 4:46 a.m. Review of the (MONTH) (YEAR) Department Notes revealed that [MEDICATION NAME] 2.5 mg was given at 12/2/18 at 4:23 p.m., 12/3/18 at 6:46 a.m., 12/14/18 at 4:24 a.m., 12/15/18 at 7:35 a.m., 12/21/18 at 8:14 a.m. and 12/24/18 at 4:02 a.m. An interview with the Director of Nursing (DON) on 1/11/19 at 5:10 p.m. revealed that the facility has a new electronic record for medications and that they are aware of recording errors on the Electronic MAR. She did confirm that the nurses had made notes in their nursing notes (Departmental Notes) but not on the MAR indicated [REDACTED].",2020-09-01
511,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-01-11,880,F,0,1,ZVL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy reviews the facility failed to provide evidence that infection control surveillance data was collected in (MONTH) of (YEAR). Failed to provide documentation that infection control data collected in (MONTH) of (YEAR) was analyzed for trends and appropriate actions taken in response. In addition, the facility failed to do the following; conduct annual review and update their policies and infection prevention control program (IPCP); failed to don appropriate personal protective equipment (PPE) when entering a resident's room on transmission-based precautions; failed to use hand hygiene prior to donning PPE and during medication administration. The facility census was 220. Findings included: Review of an undated policy titled, Surveillance For Healthcare Associated Infections revealed; Policy Surveillance for Healthcare Associated Infections will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infection (HAI). Procedure 3. Complete the Monthly Control Surveillance Log utilizing a new form each month. 1. Review of the Monthly Healthcare-Associated Infection (HAI) Report dated (MONTH) (YEAR)-November (YEAR) revealed facility did not have collected surveillance data for the month of (MONTH) (YEAR). Review of the Monthly Healthcare-Associated Infection (HAI) Report dated (MONTH) (YEAR) 18 revealed total infection cases; 1 UTI's with a Foley, 8 UTI's without a Foley, 3 URI, 2 LRI, 2 pressure ulcers, 2 skin, 1 [MEDICAL CONDITION], 1 other. Further review of the (MONTH) infection control data revealed that no infection control surveillance log was done nor summary of the infections. An interview was conducted on 12/19/18 at 11:45 a.m. with the Director of Nursing (DON) confirmed that the Monthly Infection Control Surveillance log should be used/completed per the policy. 2. Review of the IPCP no evidence that the facility was conducting an annual review of their program. An Interview was conducted on 12/17/18 at 5:15 p.m. with Infection Control Preventionist (ICP). The ICP revealed the infection control policies and manual is updated annually and as needed. The following Policy were provided to the surveyor by the DON and reviewed by the surveyor: 1. Surveillance For Healthcare Associated Infections undated policy 2. Communicable Disease Reporting dated 10/09 3. Management Of Communicable Diseases dated 10/09 4. [MEDICAL CONDITION] Surveillance dated 10/09 5. Standard Precautions dated 10/09 6. Contact Precautions dated 10/09 7. Droplet Precautions dated 10/09 8. Regulated Infectious Waste dated 10/09 9. Stool Specimen dated 10/09 10. Laundry Handling dated 10/09 11. Multi Drug Resistant Organisms (MDROs) dated 10/09 12. Hand Washing dated 8/17 13. Ear Culture dated 8/11 14. Eye Culture dated 8/11 15. Throat Culture dated 8/11 16. Wound Culture dated 8/11 17. Sputum Culture dated 8/11 18. Immunization/Vaccination Protocol-Resident dated 10/09 19. Influenza and Pneumococcal Vaccination-Resident dated 10/09 20. [MEDICAL CONDITION] Skin Testing-Employee & Resident dated 1/16 21. Exposure Control Plan dated 1/16 22. Engineering and Work Practice Controls for Bloodborne Pathogens dated 8/13 23. Training on Exposure Control Plan and Bloodborne Pathogen Education dated 8/13 The facility is not annual reviewing and updating policy to ensure effectiveness and that they are in accordance with current standards of practice for preventing and controlling infections. Observation on 12/17/18 at 9:00 a.m. revealed Certified Nursing Assistant (CNA) TT carry a breakfast tray into the room of R#151, who is on Transmission Based Precautions for Extended Spectrum Beta-Lactamase (ESBL) in her urine, without putting on Personal Protective Equipment (PPE). CNA TT sat the tray down on the bedside table and moved the table toward the resident then walked out of the room, put on gloves, reentered the room, and assist with meal set up without washing or sanitizing her hands. During an observation on 12/18/18 at 9:25 a.m. during medication pass on R#232 on Magnolia wing, with Transmission Based Precautions for ESBL in the urine, with LPN UU she sanitized her hands, put on a gown and put a pair of gloves in her hand, gathered meds for R#232, entered the residents room and placed the meds and water on the bedside table and moved the table next to the residents bed. She then turned off the feeding pump, used the control to lower the head of the bed of the resident, then walked around to the bedside table and put her gloves on. She did not wash or sanitize her hands before putting on her gloves. When she finished administering the medications, via the feeding tube, she replaced the feeding, removed her gloves and gown and threw them away in the trash can, raised the head of the bed, restarted the feeding, washed her hands and used the paper towels she dried her hands with to wipe off the bedside table and move it back to the window and exited the room. During an observation on 12/18/18 at 12:55 p.m., during lunch in the rehab unit, revealed CNA GG sanitize her hands and take a tray from the cart and go into a residents room, R#158, who is on contact isolation for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in a surgical wound without putting on PPE. During this time a staff member informed the CNA that the resident was gone to [MEDICAL TREATMENT]. During an interview on 12/18/18 at 1:00 p.m. with CNA GG revealed that she should have put on a gown and gloves prior to entering the room of R#158 but stated she just forgot. During an interview on 12/19/18 at 9:00 a.m. with the DON revealed that she spoke with CNA GG and that she expects all staff to use PPE prior to entering a room of a resident on transmission-based precautions. During a medication pass on 12/19/18 at 9:10 a.m. with LPN VV on C-Hall she did not wash or sanitized her hands before administering medication to the resident. After administration and before leaving the room she washed her hands in the resident sink. During an interview on 12/19/18 at 11:15 a.m. with the DON, in her office, she stated she expects the nursing staff to follow the policy on Transmission Based Precautions. She stated when staff see the sign that says Stop and See Nurse the staff know that they lift the sign and the other side will instruct them exactly what PPE is needed for that resident and she expects them to wash or sanitize their hands, put on the appropriate PPE, enter the resident room and take care of their needs, remove the PPE and dispose of it in the room, wash their hands, and exit the room. She stated that she expects nurses who are doing med pass to wash or sanitize their hands, prepare the medication, sanitize their hands, administer the medication to the resident and wash their hands prior to leaving the room. DON stated that she expects the nurse giving medications to follow the transmission-based precaution policy as she previously stated to this surveyor.",2020-09-01
512,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2018-02-15,761,D,0,1,VR1H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, policy reviews, and staff interview the facility failed to ensure disposal of expired medications by the appropriate expiration date on one of 11 medication carts. The census was 226 residents. Findings include: Observation administered on 02/12/18 at 10:00 a.m. of the second floor, West unit of Medication Cart A revealed one (1) open bottle of Aspirin [MEDICATION NAME] coated 325 milligrams (mg) opened (MONTH) 11, (YEAR) and expired (MONTH) 1, (YEAR). One (1) open bottle of Vitamin B-12 100 microgram (mcg) lot # 856F01, not dated, and expired 12/2017. One (1) open bottle of Vitamin E200 International Units (IU) capsules not dated, and expired 11/2017. A record review of the facility's Storage of Medications and Biologicals policy with a review/revision date of (MONTH) (YEAR) states the facility will ensure all medications and biologicals are stored, labeled/dated, and disposal of expired medications properly and securely at any given time. An interview conducted on 02/12/18 at 8:50 a.m. with Licensed Practical Nurse (LPN) AA, revealed all staff were in-serviced, and are expected to date and label all medications immediately when opened, and check for expired medications in the medication carts and refrigerators. An interview conducted on 02/12/18 at 9:10 a.m. with Licensed Practical Nurse (LPN) BB, revealed staff is expected to date all medications when opened and to monitor expired medications in medication carts. An interview conducted on 02/12/18 at 12:35 p.m. and also on 02/14/18 at 10:30 a.m. with the Director of Nursing (DON), Maintenance Director and Pharmacy Consultant revealed staff were recently in-serviced on medication storage and disposal of expired medications.",2020-09-01
513,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2017-05-18,166,D,0,1,DXTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with resident and staff, record review and review of Policy on Grievance/Missing Property, the facility failed to promptly resolve grievances and complaints from the resident about missing dentures for 1 of 3 residents (R) #212 identified for dental services during Stage 2 of the survey for the improvement of oral care. Findings include: On 5/15/17 at 5:11 p.m., observation and interview with R #212 revealed that he was missing lower front teeth. R #212 stated that he has upper dentures and removed them in front of the surveyor. He also stated that the lower dentures were lost. On 5/17/17 at 9:58 a.m. interview with Certified Nursing Assistant (CNA) DD revealed that R #212 is able to dress self, ambulate by self and is self-sufficient. He is very social and intelligent. CNA DD stated she has not brushed his teeth. He eats very well, he will tell you he is hungry; he forgot that he had breakfast. He has not complained about pain of teeth, gums, or dentures, not that I am aware of. CNA DD revealed she was not aware if he had seen the dentist. On 5/17/17 at 10:17 a.m. interview with Licensed Practical Nurse (LPN) BB, in the presence of the LPN II regarding missing dentures for R#212, LPN BB revealed that she didn't know his dentures were discovered missing. A missing item report revealed On 5/6/17 reported that dentures could not be found by wife. They checked his room and a friend's room and could not be found. The LPN II stated that they call the kitchen and laundry to let them know; missing property report is filed. On 5/18/17 at 11:10 a.m. review of the 3/6/17 to 5/6/17 Departmental Notes in the presence of the LPN II included the following: 5/6/17 at 8:52 p.m. identified RP (resident representative) reported that resident's clothings (sic), shoes and a pair of slippers, and lower denture were missing. Nurse searched acquaintance's dresser and wardrobe but found nothing. Promised RP we will keep searching until they are found. On 5/17/17 at 1:50 p.m., interview with R#212, about his lunch meal, R#212 revealed that he wanted the lower dentures and opened his mouth to display the missing lower front teeth. This conversation consisted of the same information as identified during a 5/15/17 at 5:11 p.m. interview with R#212 about his oral health status. On 5/17/17 at 3:50 p.m. interview with Social Service Director (SSD) about the missing dentures for R#212, she stated that his wife said that she reported it to a staff member. Staff member did not send it down the line. We found out about it today. The SSD stated that the Social Service Assistant (SSA) called the wife and she (wife) reported the same thing that it was missing since the sixth (5/6/17). He has Dementia and walks around with a female resident; she said to check in another resident's room. He walks all over the building all day. If the Social Worker is not in the computer every day, reading every note that they write, she will not know. We have a form available at the Nurses' station, Missing Property Report (green form). The SSD revealed they will talk to the Executive Director about replacing the dentures. We have a mobile dental service (Dynamic Mobile Dentistry) that comes to the facility. Unit Manager and Social Worker will in-service staff on how to report missing items and the forms that should be used. On review of R#212 [DIAGNOSES REDACTED]. The Dietary History on 11/21/16 nutritional status included: feeds self, regular diet with no salt added and DM precaution, no chewing difficulties, no swallowing difficulties, and regular fluid consistency. Dentures upper and lower; no problems or concerns noted at this time per resident. Potential risk factors for weight loss from [DIAGNOSES REDACTED]. On 5/18/17 at 9:50 a.m. interview with Minimum Data Set (MDS) Licensed Practical Nurse (LPN) (MDS LPN) and MDS Registered Nurse (MDS RN), about the MDS for R#212, the MDS LPN revealed that Dietary would assess him when there is a missing denture. There was no note by Dietary. On 5/18/17 at 9:50 a.m., interview with the Dietitian revealed When they make us aware of the issue (i.e., missing denture), I would ask the resident or staff if they are having problems chewing, we could down grade the diet to dental soft or puree. If they are not having problems we would leave it the same. I wasn't aware of the issue (missing denture). I have seen him in the dining room and he doesn't have any problems chewing; still clearing his plate clean. Review of the facility policy, Grievance/Missing Property dated 12/2016 revealed: Residents and resident representatives have the right to voice concerns or grievances, which affect their lives at this facility, without fear of discrimination or reprisal. All residents, resident representatives and families also have the right to report property/items that may be missing. The purpose of the policy: To provide an opportunity for residents, resident representatives, and/or family to present concerns or grievances to the proper authorities at the facility and to receive responses to the issue(s) raised. On review of monthly tracking log (complaints and grievances) and missing property report, the missing dentures for R#212 were not included on these documents. During the 5/17/17 at 3:50 p.m. interview with the SSD, revealed that the missing dentures was reported to staff on 5/6/17 by R#212's wife, but they found out about it today (5/17/17).",2020-09-01
514,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2017-05-18,253,E,0,1,DXTP11,"Based on observation of 5 Units (300 Unit, Central Unit, Magnolia Unit, West Unit, and the Transition Pulmonary Care (TPC) (Vent Unit), interview with staff and resident, and, review of maintenance call logs, the facility failed to ensure that the residents bedrooms' walls, floors and ceiling were clean and in good repair at 3 of 5 Units in 8 of 40 resident rooms observed during Stage 1 (5/15 -5/16/17) of the survey. Findings include: On 5/18/17 from 8:30 a.m. through 9:30 a.m., observation of the resident bedrooms was conducted in the presence of the Maintenance Assistant (MA) with the following identified in 8 bedrooms: Central Unit: Room 5-Casing that covered electrical cords was smashed/housing for cable was broken. 300 Unit: [RM #]4 W-Bed is very loud when it is adjusted up and down through the remote control by the resident. On 5/18/17 at 8:40 a.m., while observing bedroom 304, Resident (R) (R#227) demonstrated her bed moving up and down and stated that it was too loud. Magnolia Unit Room 208-Deep cracks were located around the sink (missing calking). Room 218-Wall behind the television had two white patches on the green wall, approximately 4 inches by 4 inches and 2 inches by 2 inches respectively. Floor around the toilet had black marks and was not clean; air conditioning vent on the ceiling had dust; and white ceiling light cover in the bathroom had black marks. Room 219-Ceiling tile in the bathroom had a hole located near the sprinkler, and ceiling tile was not secured to the ceiling. Room 222-Paint was peeling off the wall located next to the door of the bathroom and above the dresser drawer. Paint was peeling behind the toilet seat in the bathroom; ceiling vent in the bathroom had dust; and the baseboard was not clean surrounding the floor in the bedroom. Room 223-Sink was cracked located in the bedroom. Room 224-Air conditioning vent on the ceiling in the bathroom had dust. On 5/18/17 at 8:45 a.m., interview with the MA revealed that they are out of a director, left three weeks ago, our new director should be here on the sixth of June. The process for repairs is they call and let us know or he (Director) would write and order the part and get everything needed. If there was a complaint, they check out and see what needs to be done. Work orders are on the computer; they print and we take care of them. When the surveyor asked for a cleaning or maintenance schedule; the MA responded that he will find a schedule. Normally pick a day to clean filters and everything. On each floor there is a Maintenance Call Log, located at each Nursing Work Station On review of the Maintenance log, the following information was included on the form: the date, room/area, explain the maintenance issue and employee name. A schedule for cleaning and maintaining the bedrooms in good repair was not available. On 5/18/17 at 12:40 p.m., interview with the Executive Director, she stated that there is no Maintenance Policy and Procedure; there are Maintenance Logs at the desks of the Nurses Stations.",2020-09-01
515,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2017-05-18,279,D,0,1,DXTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview with resident and staff, and record review, the facility failed to develop and implement a care plan for 1 of 3 resident's resident (R) #212 identified for dental services during Stage 2 of the survey, for the improvement of oral health. Findings include: On 5/15/17 at 5:11 p.m., observation and interview with R#212 revealed that he was missing lower front teeth. R#212 stated that he has upper dentures and removed the dentures in front of the surveyor. He also stated that the lower dentures were lost. On 5/17/17 at 9:58 a.m. interview with Certified Nursing Assistant (CNA) DD revealed she makes sure that he eats his breakfast, has clean clothes on, supplies are in his room, and he has clean sheets, resident does his own oral care. He is very social and intelligent. She has not brushed his teeth. He has not complained about pain of teeth, gums, or dentures, not that I am aware of. Cross reference F166 for 5/17/17 at 10:17 a.m. interview with Licensed Practical Nurse (LPN) BB and LPN II regarding R#212 missing dentures. Wife reported on 5/6/17 dentures could not be found, room checked and the kitchen and laundry were notified, missing property report was filed. On 5/17/17 at 1:50 p.m., interview with R#212, about his lunch meal, he revealed that he wanted the lower dentures and opened his mouth to display the missing lower front teeth. On review of R#212 [DIAGNOSES REDACTED]. hemorrhagic [MEDICAL CONDITION], and [MEDICAL CONDITION]. The Dietary History on 11/21/16 nutritional status included: feeds self, regular diet with no salt added and DM precaution, no chewing difficulties, no swallowing difficulties, and regular fluid consistency. Dentures upper and lower; no problems or concerns noted at this time per resident. Potential risk factors for weight loss from [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) of 11/21/16 Assessment Review Date (ARD) on section L identified Oral/Dental Status as none of the above were present; the above items included: A) Broken or loosely fitting full or partial denture. B) No natural teeth or tooth fragment(s) (edentulous). C) Abnormal mouth tissues (ulcers, masses, oral [MEDICAL CONDITION], including under denture or partial if one is worn. D) Obvious of likely cavity or broken natural teeth. E) Inflamed or bleeding gums or natural teeth. F) Mouth or facial pain, discomfort or difficulty with chewing. The MDS Annual Assessment on 11/21/16 on Section B0700 identified R#212 with clear comprehension, makes self understood; and B0800 ability to understand others. On 5/18/17 at 10:30 a.m., the Social Service Assistant (SSA) provided the surveyor with a Dental Screening completed on 3/22/17 from Dynamic Mobile Dentistry that identified R#212 had inflamed or bleeding gums or loose natural teeth; partial upper and lower appliance, and condition of denture or appliance was acceptable. The signature at the bottom of the form was not legible. Surveyor placed a phone call to Dynamic Mobile Dentistry, but did not speak with a representative (placed on hold, then a second phone call went to voice mail, recorded message and surveyor requested a return phone call). On 5/18/17 at 11:00 a.m., interview with the SSA, she stated that Dynamic Mobile Dental gives you a list of who is on their dental plan; he (R#212) was one of their screenings, seen for free. As far as I know he was not seen for the inflamed or bleeding gums or loose natural teeth. We are just given the sheets after the dentist has come. There was no follow-up from dental and I don't know if Nursing followed up. On 5/18/17 at 11:10 a.m. review of the 3/6/17 to 5/6/17 Departmental Notes with LPN II included the following: (a) 3/6/17 note from Nursing MDS Quarterly Assessment for ARD (Assessment Review Date) 2/21/17; (b) 3/6/17 quarterly note from Social Service; (c) 4/11/17 note from Social Service, (d) 4/13/17 note from Nursing about a Podiatry new Order; and, (e) 5/6/17 note from nursing that rp (resident representative) reported R#212 clothing, shoes, and lower denture were missing. There was no documentation about the 3/22/17 Dental Screening that identified inflamed or bleeding gums or loose natural teeth. The LPN II stated that the doctor or NP (Nurse Practitioner) would be notified to see if they want to do a mouth wash or treatment. We don't always get the consults in timely manner. Review of Physician order [REDACTED]. Review of the interdisciplinary care plan from on 3/8/17 included the following goals related to oral health: Resident will have ADL (Activities of Daily Living) needs met AEB (as evidenced by) being neat, clean, and odor free thru next review. The oral intake will remain greater than 75% of meals through next review period, no significant wt (weight) changes and nutrition related labs will remain wnl (within normal limits) through next review period. There wasn't a care plan for R#212 to address the 3/22/17 dental screening of inflamed or bleeding gums or loose natural teeth. On 5/18/17 at 12:45 p.m. interview with the Director of Nursing (DON), she stated that we don't know if bleeding gums; I will follow-up and call them (Dynamic Mobile Dentistry) today to find out if bleeding gums, inflamed or loose teeth. The DON revealed that she was not familiar with this dentistry, not aware of any free dental service; and will contact the dentistry about their follow-up procedure.",2020-09-01
516,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2017-05-18,311,D,0,1,DXTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, and staff interview, and record review, the facility failed to provide the appropriate treatment and service related to transfer and ambulation for 1 of 41 sampled residents (R) A to maintain Activities of Daily Living (ADL) functioning for the resident who has the potential to maintain or improve. Findings include: Review of the Admission Record indicated the facility admitted R A on 4/16/15. The 69-years old resident had [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set ((MDS) dated [DATE] indicated R A had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. For locomotion and transfers with wheelchair (w/c), the resident required no setup or physical help from staff. Transfers from w/c to standing position required supervision and oversight with encouragement or cueing. Moving to standing position - not steady, only able to stabilize with human assistance. Walking activity did not occur during this entire period. Review of R A's PT- Therapist Progress & Discharge Summary dated 1/18/17 indicated Gait Task: Negotiation of surfaces- The patient will ambulate 15 requiring front wheeled walker with min assist (25% assist) to improve the ability to ambulate throughout SNF (Skilled Nursing Facility). ROM (Range of Motion): Knee Extension - the patient will exhibit AROM (Active Range of Motion) of bilateral knee extension at 25 degree to improve the ability to normalize gait pattering to avoid falls. Review of the R A's Discharge Plan & Instructions revealed R A was discharged from physical therapy on 2/11/17 due to meeting maximum rehabilation potential to remain in same SNF. Progress ceased. The therapist recommended discharge to restorative program on 2/11/17. In an interview conducted on 5/17/17 at 11:15 a.m., R A stated the therapy program had not been successful enough and more strengthening was needed. R A said the therapist had released him to the restorative program and there was no restorative program. The person in charge of the program had left the facility. R A said the facility had lied about having a restorative program. R A said that going out with family had become too hard. R A said that family had tried to transfer him into a vehicle, but resident's leg weakness was a problem and it made transfer too difficult for them to handle. In an interview conducted on 5/17/17 at 1:15 p.m., Therapist BB said, R A had been picked up by therapy for ambulation and bilateral knee contracture's. The resident had some progress with therapy, increased ambulating with wheeled walker from 5' to 20' with moderate assist. The resident continued to have problem with excessive knee flexion which would cause the resident's legs to give out without warning, which was a safety issue. Therapist BB said he discharged R A from the therapy program on 2/11/17 and recommended the resident for the restorative program. Therapist BB said he was not aware the restorative program was not available when he made the recommendation. In an interview conducted on 5/17/17 at 1:15 p.m., the Director of Rehabilation (DR) stated she was not aware that the restorative program was not available when R A was discharged from therapy and referred to the restorative program. The DR stated therapy had dropped the ball in not knowing the restorative program was not available for R [NAME] In an interview conducted on 5/17/17 at 2:00 p.m., LPN FF said she started with the restorative program in February. LPN FF stated the restorative program had been restarted and R A's name had not been on the list of residents recommended for the restorative program. On 5/18/17 at 8:51 a.m., Executive Director said the former restorative nurse last day was 11/24/16 and the ADON (Assistant Director of Nursing) of the facility at that time had overseen the program. The program Included on going ambulation, Range of Motion (ROM) and other exercises, until a new restorative nurse was hired and the full program was restarted. The ED said she did not know why R A's name had not been referred to restorative since the restart.",2020-09-01
517,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2017-05-18,371,F,0,1,DXTP11,"Based on observation and staff interview, the facility failed to ensure food was stored, prepared, distribute and served in a sanitary manner to minimize the risk for food born illness for all residents that reside in the Long Term Care (LTC) facility. Findings include: 1. The initial kitchen inspection was conducted on 5/15/17 at 9:20 a.m., with Dietary Manager (DM) present. The kitchen had one fryer located next to the stove, with a steel covering. The DM uncovered the fryer and revealed it was filled with used cooking oil, with food particles and debris and grime at the top. 2. Counter preparation tables not wiped, trash on and behind the counters. 3. Cooking equipment not cleaned, toaster oven covered with old dried food particles and grime. 4. The floor between the stove and fryer was covered with thick layers of grease. 5. Plate warmer left with no covering had trash on the plates set out for the next tray line. Review of the Food Code U.S. Public Health, Food and Drug Administration, U.S. Department of Health and Human Services. Food Code 4-601.11 Equipment, Food-Contact Surfaces, Nonfood Contact Surfaces, and Utensils. (A) Equipment Food-Contact Surfaces and Utensils shall be clean to sight and touch. (B) The Food-Contact Surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Non- Food-Contact surfaces of Equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. The DM was interviewed on 5/15/17 at 10:30 a.m., said she usually checks the fryer when she comes in, but had not been able to check before the initial tour. The kitchen staff has a schedule which they are to follow for routine and deep cleaning. All cooks are trained on the proper procedure of filtering and cleaning of the fryer. The cooks are also responsible for cleaning the fryer, cooking equipment, counter and prep area. The kitchen crew is responsible for the detail of cleaning of the floors between the equipment and picking up all trash.",2020-09-01
518,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2017-05-18,502,D,0,1,DXTP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and review of the facility's policy and procedure, the facility failed to obtain a laboratory sputum specimen for one resident (R#130). The facility failed to ensure the residents sputum was rechecked to determine when isolation precautions could be discontinued. The sample size was 41 residents. Findings include: Review of Facility policy titled: Sputum Collection dated (9/2003) revealed sputum specimens will be obtained for pathological examination as needed. Responsibility: All nursing personnel, /respiratory therapy personnel Procedure 10. Document in interdisciplinary notes the date, time and the residents condition when obtaining the specimen. Record review revealed R#130 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review of a comprehensive Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was severely impaired cognitively, required total dependence of two staff members for all activities of daily living (ADL's). Continued review revealed R#130 had a tracheotomy tube in place that connects her to the ventilator and requires suctioning whenever necessary (prn) by the respiratory therapist (RT). Observation of R#130 on 05/17/17 at 6:30 [NAME]M. revealed resident in bed connected to ventilator via trachea. Droplet Isolation signs visible on the doorway as well as isolation gown, mask and gloves visible on door. Further review of R#130's physician orders [REDACTED]. Continued review of the residents' medical record revealed a signed physicians order dated 02/15/17 and again on 03/29/17 for Droplet/Airborne precautions for multi drug resistant organisms (MDRO) (type of infection) present in the sputum. Interview with Registered Nurse (RN) AA, on 05/17/17 at 6:35 a.m., revealed R#130 was currently in respiratory isolation precautions due to multiple drug resistant infection in the sputum. He further revealed the facility policy is to notify the physician when laboratory results are received, also notify the staff involved related to the isolation precaution and to let the physician know when the antibiotics are completed to regulate when to get a repeat specimen to determine when the isolation precautions can be discontinued. Further review of R#130's medical record on 05/17/17 at 7:00 a.m. revealed a signed physicians telephone order dated 05/08/17 to re-culture sputum to clear resident from isolation. After reviewing the residents medical record and lab results there was no documentation to show the specimen was collected. Interview with Administration Clerk (AC) on 05/17/17 at 8:30 a.m., revealed the sputum specimen had not been collected. Interview with RN BB on 5/17/16 at 9:00 a.m., revealed R#130 is not currently taking any antibiotics and she was unsure when they were discontinued. She further revealed she only worked part time. Interview with Respiratory Therapist (RT) AA on 5/18/17 at 9:30 a.m., revealed the nurse that wrote the order was contacted yesterday and she did not realize the order was not completed as written. He further revealed the nurse indicated that she told the respiratory therapist and thought it was done. Interview with Director of Nursing (DON) on 05/18/17 at 12:54 p.m., revealed her expectations were that if a nurse takes off an order they follow through with whatever the order was. She further revealed the next shift should follow through to ensure it was completed when they were informed of the order during the twenty-four hour shift report. Interview with Physician BB on 05/18/17 at 1:40 p.m., revealed his expectation was that the sputum test be completed when it was ordered. He further revealed he ordered the test as a re-check to determine if he could remove the resident from isolation and this will set back the process. He continued to reveal this will affect the ability to move residents around, to give her a roommate.",2020-09-01
519,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-05-23,580,D,1,0,RVC911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews, and facility policy review entitled [MEDICAL TREATMENT] Information Update Transfer, the facility failed to notify the family of a resident's admission to the hospital from [MEDICAL TREATMENT] for one resident (R) (R#2) of three sampled [MEDICAL TREATMENT] residents. Findings include: Record review for R#2 revealed that the resident was admitted to the facility with End Stage [MEDICAL CONDITIONS] and was receiving [MEDICAL TREATMENT] three times per week. Review of the Departmental Notes dated 3/21/19 revealed that a local emergency room (ER) contacted the facility and requested his Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Interview with the Assistant Director of Nursing (ADON) on 5/22/19 at 4:30 p.m., she revealed that this resident has been sent out to the hospital several times from the [MEDICAL TREATMENT] center, confirming that he goes from the facility to [MEDICAL TREATMENT], from [MEDICAL TREATMENT] to vascular, and then to the hospital; however, it is the [MEDICAL TREATMENT] center responsibility to inform the facility and/or family of any admissions to the hospital. She confirmed that the facility will conduct a follow up to the [MEDICAL TREATMENT] center, if the resident has not returned, but may not always get information that day, it may take a few days, which at that point the facility will contact the responsible party (RP). During another interview with the ADON on 5/23/19 at 12:00 p.m., she confirmed that there is nothing written in the nursing notes; however, she recalls speaking with the nurse that wrote both of the notes, after the family brought this concern to the facilities attention. She stated that the nurse said she thought the family was aware and that they were at the hospital with him, but agreed that she would be following up in more detail with her future notes. Review of the [MEDICAL TREATMENT] Information Update Transfer policy with updated date of 2/19 revealed no evidence of how the [MEDICAL TREATMENT] center will notify the family of admission to the hospital. Review of the [MEDICAL TREATMENT] Contract dated 3/18/11 revealed no evidence of who is responsible for notifying the family if the resident is admitted to the hospital directly from [MEDICAL TREATMENT].",2020-09-01
520,DOUGLASVILLE NURSING AND REHABILITATION CENTER,115273,4028 HWY 5,DOUGLASVILLE,GA,30135,2019-05-23,759,D,1,0,RVC911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews, the facility failed to ensure the medication error rate was less than five percent (5%). A total number of 26 medication opportunities were observed, and there were two errors for one of three residents (R) (R#9) by one of three nurses observed giving medications, for an error rate of 7.69%. Findings include: On 5/23/19 at 8:53 a.m., Licensed Practical Nurse (LPN) AA was observed giving R#9's scheduled morning medication, which included giving [MEDICATION NAME] 20 milligrams (mg), two tablets, along with a total of 10 other medications. Review of the Physician order [REDACTED].#9 had [MEDICATION NAME] NR 40 mg ordered daily however, continued review revealed no evidence of [MEDICATION NAME] being ordered. Review of the Electronic Medication Administration Record [REDACTED]. Interview with LPN AA on 5/23/19 at 9:45 a.m., confirmed that [MEDICATION NAME] DR 40 mg was on her medication computer screen, and she thought it was for [MEDICATION NAME] 40 mg. Continued interview revealed that when there is an order, the nurses take off the order and place in the computer, which goes directly to the pharmacy. A follow up interveiw on the same day at 9:55 a.m., she confirmed there was no [MEDICATION NAME] on her medication cart after the unit supervisor, LPN BB was noticed to be at her cart, and the unit supervisor stated that [MEDICATION NAME] was for [MEDICATION NAME], and that [MEDICATION NAME] was not the same medication. Interview with the Unit Supervisor, LPN BB at 10:06 a.m. on 5/23/19, she stated that she found a box of [MEDICATION NAME] from central supply.",2020-09-01
521,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2020-01-16,554,D,0,1,3CHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to ensure that one cognitively impaired resident (R) (#65) did not have access to and self-administer an over the counter medication of 48 sampled residents. Findings include: Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed in section (C) a Basic Interview for Mental Status score of 99 indicating severe cognitive impairment. Review of the care plan dated 8/22/19 for R#65 revealed she is at risk for impaired communication due to impaired cognition. R#65 was noted with meds, spices and other items in closet. Patient/family teaching done, items removed and given to family. During an observation on 1/13/2020 at 12:45 p.m. revealed R#65 sitting in a wheelchair in her room. She was noted to have a square shaped, opened packet in her hand and was coughing. An orange colored powder substance was observed on her lap. The packet was an Emergen-C Packet. During this time, a small three drawer plastic chest was observed next to R#65's bed. The drawers to the chest were clear allowing the ability to see inside without having to open the drawers. Inside the third drawer was a box of Emergen-C Packets that was not labeled with the resident's name or dated with an open date. The top of the box was observed to be open and there were unopened packets inside. During an observation on 1/14/2020 at 10:30 a.m., Emergen-C Packets box observed in the bottom drawer of the plastic chest sitting next to the bed of R#65. Review of the package insert information for Emergen-C Packet includes but is not limited to: Emergen-C is a nutritional supplement that contains vitamin C and other nutrients designed to boost your immune system and increase energy. It can be mixed with water to create a beverage and is a popular choice during cold and flu season for extra protection against infections. During an interview on 1/15/2020 at 10:00 a.m. with Licensed Practical Nurse (LPN) BB revealed the daughter of R#65 brings things in to the resident and stated this issue has been discussed with the daughter. During this time LPN BB entered the room of R#65 and took the over the counter medication from the drawer. During an interview on 1/15/2020 at 10:10 a.m., the Director of Nursing (DON) stated he was not aware R#65 had over the counter medication in her room. He stated staff may have discussed this with the ADON. Review of the Progress Note for R#65 dated 9/25/19 by LPN CC reads: Writer noted resident having several tea bags, health drinks, herbs, containers of crushed red peppers, black pepper, season salt, basil, maple syrup, almond milk, lemon line hydration packets, four containers of nutritional supplements and a large container of thick it. Writer informed (name) that the following items are not within resident diet and fluid consistency and this can lead to her mother having possible complications of aspiration due to her [DIAGNOSES REDACTED]. During a telephone interview on 1/16/2020 at 10:28 a.m. the Pharmacist stated that R#65 is on a Multi-Vitamin daily and stated the extra Vitamin C would not hurt her. She stated if the resident has an order to keep the medication next to her bed it isn't a problem for her to keep it and administer it to herself. Pharmacist stated with a BIMS score of 99, and the fact she is on thickened liquids, she should not be self-administering. Review of (MONTH) 2020 Physician order [REDACTED]. Review of the medical record for R#65 there was no assessment done for medication self-administration. During an interview on 1/16/2020 at 11:48 a.m., the Social Worker stated that the BIMS score is determined based on how the resident answers the assessment questions. She stated R#65 is not alert and oriented to time, place, person, and situation all the time, but stated she has a moderate amount of confusion. Social Worker stated, based on her interviews with the resident, R#65 is not capable of having medications in her room or self-administering medications. Review of the Administering Medications policy revised (MONTH) 2012 revealed medications shall be administered in a safe and timely manner, and as prescribed. Residents may self-administer their own medications only if the Attending Physician, in conjunction with the Interdisciplinary Care Planning Team, has determined that they have the decision-making capacity to do so safely.",2020-09-01
522,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2020-01-16,585,D,0,1,3CHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident/staff interviews, and review of the facility policy titled, Grievances and Enforcement the facility failed to communicate and document grievance decisions to resident's family for two residents (R) (A and B) of 48 sampled residents. Findings Include: Review of the facility policy titled, Grievances and Enforcement dated (MONTH) 2014 revealed the Administrator or his/her designee shall act to resolve the complaint or shall respond to the complaint within three business days, including in the response a description of the review and appeal rights. 1. Review of the Grievance/ Concern Report dated 12/3/19 revealed family of R A filed a grievance with the facility. Corrective action included in-services for staff. The section of the grievance titled For Office Use Only was completely blank including notification of the date the facility responded to the person filing the grievance and if the complaint was resolved to the satisfaction of the resident/ resident's representative. Interview with the family of R A on 1/15/2020 at 12:20 p.m. revealed a grievance was filed. Family of R A denied receiving written or oral communication regarding the status or conclusion of the grievance. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed R A with a Brief Interview of Mental Status (BIMS) score of 7 indicating severely impaired cognition. 2. Interview with the family of R B on 1/15/2020 at 12:15 p.m. revealed a grievance was filed. Family of R B denied receiving written or oral communication regarding the status or conclusion of the grievance. Review of the MDS Significant Change assessment dated [DATE] revealed R B was unable to complete the BIMS assessment. Review of the Grievance Log from (MONTH) 2019 through (MONTH) 2020 revealed no documentation of associated grievances filed by the family of R B. All forms in the log did not address or specify what the status of grievances were, if the incidents had been resolved, and communication with the complainant. During an interview on 1/15/2020 at 11:00 a.m., the Administrator reviewed the grievance forms and acknowledged they were not completed under the section For Office Use Only. The administrator stated the forms should have been completed and follow up should have been done. During an interview on 1/16/2020 at 9:25 a.m., Social Services HH stated that the administrator and Director of Nursing (DON) follow up with the family. Interview on 1/16/2020 at 9:45 a.m. with Grievance Coordinator EE revealed that grievances go to the Social Service Director GG and she will determine if there needs to be an in-service. She then follows up with the family as far as what the conclusion is. It's about a three-day turnaround.",2020-09-01
523,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2020-01-16,812,F,0,1,3CHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy titled, Food Storage and Handling, the facility failed to ensure opened frozen food items in the walk-in freezer and food items in the dry storage area were securely wrapped, labeled and dated; and failed to discard a food item by the use by date. In addition, the facility failed to maintain sanitary conditions of the two stand-alone ovens and the fryer. This practice had the potential to effect 127 of 131 residents receiving an oral diet. Findings Include: A review of the undated facility policy titled, Food Storage and Handling revealed that it is the policy of the Dining Services Department to cover, label, date, and store all foods in a safe, and appropriate manner to prevent food borne illness. Procedure: all cooked foods, pre-packaged open containers, protein-based salads, desserts and canned fruits are labeled, dated, and secure covered. Food Storage: unopened foods in refrigerator or dry storeroom, storage life is per manufacturer's guideline or supplier labeled guidelines (i.e. used by date). Procedure: Dating System for Open Foods, documented the facility will follow the U-Labeling P&P, to always securely cover food item. Using a label, complete the following: write the expiration date on the product using the guide, clearly write the products name, then return to designated storage (refrigeration, freezer or storeroom.) Check labels daily and discard outdated food. An initial observation and tour of the kitchen was conducted with the Food Service Director (FSD). The observational tour conducted on [DATE] from 9:50 a.m. to 10:20 a.m. of the kitchen and food storage areas revealed two ovens attached to the gas stove not in use. Two double stacked stand-alone ovens in use were dirty, containing old food debris and baked on grease on all shelves and the bottom of both ovens. The fryer oil appeared dirty with small particles of food debris floating in the oil. An open trash receptacle located at the kitchen hand washing sink lacked a covering lid and a hands free, foot pedal device. Further observation with the FSD revealed the following food items to be opened, unlabeled or expired as follows: Walk-in Freezer: One opened half used bag of frozen okra, no label or date when opened, and unable to determine discard date. A large opened 25-ounce bag of frozen bread sticks with a label dated [DATE] and with a label expiration date of [DATE]. Dry Storage Room: -one large box of partially used, opened Swiss Miss hot chocolate mix packets, no label or date when opened, unable to determine discard date -one large box of partially used, opened cheddar cheese packets, no date when opened, unable to determine discard date -two partially used, opened large containers of bulk parsley flakes, no label or date when opened, unable to determine discard date -one partially used, opened large container of bulk bay leaves, no label or date when opened, unable to determine discard date -one opened half used large bag of egg noodles, no label or date when opened, unable to determine discard date -one opened half used bag of tube-shaped pasta, no label or date when opened, unable to determine discard date -one opened bag of wheat bread with two slices remaining, no label or date when opened, unable to determine discard date -two partially used, opened bags of hot dog buns, no label or date when opened, unable to determine discard date -five partially used, opened bags of hamburger buns, no label or date when opened, unable to determine discard date A follow up observation of the kitchen was conducted on [DATE] at 10:49 a.m. with the FSD and the Registered Dietician present during the pureed food process for 20 residents that eat a mechanically altered meal at lunch time with Dietary Aide A[NAME] At this time, the two stand-alone ovens were observed to be clean; no baked-on food or grease was found. The fryer had clean oil, with no food debris present. The FSD confirmed that the vendor came [DATE] and changed out the oil. A follow up observation of the kitchen was conducted on [DATE] at 12:29 p.m. with the FSD of the dry storage room that revealed the following: Dry Storage Room: Five containers of 32-ounce of Imperial Med Plus 2.0 supplement, no expiration or discard date documented on the plastic containers. The FSD confirmed that the supplement should have been marked with a use by date and instructed a Dietary Aide to label them. A brief interview was conducted on [DATE] at 3:07 p.m. with the FSD in her office where she confirmed her staff have staggered shifts from 5:30 a.m. until the evening shift finishes at 8:30 p.m. All staff have tasks that are assigned. The FSD provided a sample form of tasks assigned weekly and confirmed cleaning is daily, weekly and as needed, confirming that ovens and floor mats are cleaned weekly. She confirmed that dietary staff that open food items, or stock the shelves, are responsible for labeling and dating food items. The FSD revealed that task audits are also conducted. A review was conducted of the provided sample form titled, Weekly Sanitation Audit. The facility form lists general areas of tasks to be conducted with satisfactory and needs improvement areas and a suggestion column, to be check marked during the audit. Kitchen staff task areas were listed, but not limited to the following: ovens/hoods; refuse containers, covered, clean; unused open foods sealed and stored properly; leftovers-labeled and dated, refrigerated food stored properly; and bins-clean and labeled.",2020-09-01
524,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2020-01-16,814,F,1,1,3CHC11,"> Based on observation, staff interview, and review of the facility policies titled, Grounds Cleanliness Policy and Disposal of Garbage and Refuse, the facility failed to ensure that trash was disposed of in a sanitary manner and failed to ensure that areas surrounding the compactor were free of trash debris. The facility census was 131. Findings include: A review conducted of the undated policies titled, Disposal of Garbage and Refuse revealed: Policy Explanation and Compliance Guidelines: 7. Refuse containers and dumpsters kept outside the facility shall be designed and constructed to have tightly fitting lids, doors, or covers. Surrounding areas shall be kept clean so that accumulation of debris and insect/rodent attractions are minimized. 8. Garbage should not accumulate or be left outside the dumpster. Review of the facility policy titled, Grounds Cleanliness Policy revealed: 5. The ground's crew clean the entire campus at least weekly. 6. Daily/weekly rounds are made by maintenance staff to make sure that grounds are clean and safe. An initial tour and observation was conducted on 1/13/2020 from 9:50 a.m. to 10:30 a.m. with the Food Service Director (FSD). The tour was of the kitchen, the kitchen back door area, the loading dock, the grease trap, and the garbage/refuse disposal area surrounding the compactor. The grease trap container located on the loading dock outside the back-kitchen door had a moderate amount of scrap wood and broken down/flat cardboard boxes lying on top of the trap. Access was blocked for any disposal of oil/or grease into the trap. Discarded plastic wrappings were observed on the floor behind the grease trap. The FSD explained that when the grease trap is full, she will call the vendor. She then confirmed the wood and cardboard should not be on the trap and she would have the Maintenance Director (MD) remove the items. Further observations of the kitchen loading dock revealed the trash compactor on the lower level. Observation of trash debris included but was not limited to the following: plastic bottles, food wrappers, cardboard, disposable cups, disposable gloves, scrap wood, cardboard boxes, a plunger and other trash debris was found on three sides of the trash compactor. A follow up observation was conducted on 1/15/2020 at 11:12 a.m. with the FSD and Dietary Aide AA present. The kitchen back door area was clean from trash debris, the grease trap was observed without trash on top of the lid. The loading dock was free from trash debris. The area around the compactor was observed now to be free from trash debris; only fallen leaves were present. An interview was conducted with the Maintenance Director (MD) on 1/15/2020 at 2:48 p.m. when he confirmed that he is responsible for maintenance, housekeeping and laundry services with around 21 employees. The MD confirmed a pest control service comes out twice monthly to spray, that also includes the kitchen. The MD stated pests had been a problem about a year ago, they changed their agreement to have them come twice monthly then, and it is continuing. He stated that ants have been an off and on problem in some areas but has improved. He confirmed having rodent traps outside, around the perimeter of the buildings, stating the pests have been field mice and chipmunks, not rats. The MD confirmed their department can also spot treat some areas, explaining the many courtyards contribute to pests. The MD further confirmed his department is responsible for the loading dock and clean up around the compactor. He explained that over the weekend facility staff had thrown out trash and were not careful, that trash falls out of bags on the loading dock; that they clean it up on Mondays. He explained that the neighborhood residents were recently dumping trash on the property, and that the police had to be called once. The MD confirmed that the wood from pallets are picked up on Wednesdays by a local man that collects them to repurpose them; that the wood pieces on top of the grease trap were probably for him. He confirmed the back area has been cleaned up. An observation conducted on 1/15/2020 at 4:45 p.m. revealed the loading dock was recently swept and hosed down with water. The trash debris around the sides of the compactor has been removed. No trash was found on the loading dock; the grease trap is accessible to dispose grease and oil, and free from wood and trash debris. An interview was conducted on 1/16/2020 at 12:13 p.m. with the Administrator where she explained that multiple departments are responsible and contribute to bringing trash to the loading dock and compactor. The Administrator explained that the Dietary, Housekeeping and Central Supply Departments usually throw the trash away outside. She stated that the Dietary Department has food deliveries in cardboard boxes, and Central Supply has supply deliveries on pallets and in carboard boxes. That housekeeping also brings loose trash and bagged trash to the compactor.",2020-09-01
525,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2020-01-16,880,D,0,1,3CHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and resident interview, record review, and review of the Isolation - Notices of Transmission-Based Precautions, the facility failed to initiate contact precautions in a timely manner for one resident (R) (#86) on one of three floors. Findings include: During an interview on 1/15/2020 at 10:30 a.m. with R#86 she pulled her blouse away from her left shoulder to reveal blistering going down her shoulder. She stated she was diagnosed with [REDACTED]. During this time an observation was made of the resident's door, and outside the door, for a sign indicating to check with the nurse prior to entering, and there was no sign, and no Personal Protective Equipment (PPE) cart located outside of the room of R#86. During an interview on 1/15/2020 at 10:35 a.m. with Licensed Practical Nurse (LPN) DD she stated when someone is on transmission-based precautions there is a sign on the door stating, Check with nurse before entering room. She stated she was made aware that R#86 is on transmission-based precautions and confirmed there is no sign on the door and there is no PPE cart located outside the door. During an interview on 1/15/2020 at 10:40 a.m. with the DON he stated he was not made aware R#86 was diagnosed with [REDACTED]. During an interview on 1/15/2020 at 10:50 a.m. with the ADON and LPN CC, the ADON stated that he was made aware that R#86 was diagnosed with [REDACTED]. He stated putting a sign on the door would be a dignity issues so the staff advise visitors before they enter the room, they will need PPE. He stated that contact precautions should be considered and used on all residents and a PPE cart and sign was not needed. During an interview on 1/15/2020 at 11:10 a.m. with the DON he provided a copy of the facility isolation policy and stated that R#86 should have had a sign placed on the door and a PPE cart placed just outside the door when the [DIAGNOSES REDACTED]. During an interview on 1/16/2020 at 1:19 p.m. with the Infection Preventionist she stated LPN CC called her some time on the 14th of (MONTH) and told her that R#86 had been diagnosed with [REDACTED]. She stated that LPN CC told her she would go ahead and initiate contact precautions as they had discussed. Infection Preventionist stated she did not know why it was not done. She stated the policy is to place a sign on the door of the resident that states See Nurse before entering room and place a PPE cart outside of the resident's room door, but again stated she does not know why it was not done. Review of the Isolation - Notices of Transmission-Based Precautions policy revised 2019 revealed notices will be used to alert personnel and visitors of transmission-based precautions, while protecting the privacy of the resident. Policy Interpretation and Implementation: 1. When transmission-based precautions are implemented, the Infection Preventionist (or designee) determines the appropriate notification to be placed on the room entrance door and on the front of the resident's chart so that personnel and visitors are aware of the need for and type of precautions.",2020-09-01
526,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2018-08-30,656,D,0,1,S7OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the plan of care related to [MEDICAL CONDITION] medications and behaviors for one resident (#68) from a sample of 44 residents. Findings include: A review of the clinical records revealed that Resident (R) #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician order [REDACTED]. A review of the Minimum Data Set (MDS) assessment records for Resident (R) #68 revealed a quarterly assessment dated [DATE] which revealed an active [DIAGNOSES REDACTED]. A further review of the MDS records for R#68 revealed an Admission assessment of 1/3/18 which also documented the resident had an active [DIAGNOSES REDACTED]. Under the Care Area Assessment Summary (CAAS) of that assessment, [MEDICAL CONDITION] drug and behavioral symptoms use triggered and the decision was made to complete a plan of care for those areas. Review of the Plan of Care records for R#68 revealed a plan of care, last updated on 6/15/18, for behaviors and a risk for complications/side effects related to the resident's use of [MEDICAL CONDITION] medications. Interventions included an attempt by the pharmacy consultant and physician of a gradual dose reduction unless the physician documented that a further reduction was contraindicated. A review of the pharmacy records revealed a recommendation on 7/11/18 for the resident's order for [MEDICATION NAME] 50 mg at bedtime to be reduced to 25 mg. A further review of the records revealed that the physician agreed with this recommendation on 7/17 18. A further review of the pharmacy records revealed that during the next medication review visit on 8/2/18, the consultant pharmacist documented that the physician agreed with the dose reduction for the [MEDICATION NAME] on 7/17/18, but that the dose reduction had not been carried out. Review of the Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) revealed the resident continued to receive [MEDICATION NAME] 50 mg at bedtime as of August29, (YEAR).",2020-09-01
527,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2018-08-30,758,D,0,1,S7OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the pharmacy agreement, the facility failed to reduce the dose of an antidepressant medication for one resident (#68) from a sample of 44 residents after the pharmacist recommended and the physician agreed on a dose reduction. Findings include: A review of the Consultant Pharmacist Agreement dated 1/1/17 revealed that unnecessary drugs, including those given for excessive duration, will be identified by the pharmacist and reported to the attending physician, medical director, and director of nursing for action. A review of the clinical records revealed that Resident (R) #68 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the physician order [REDACTED]. A review of the pharmacy records revealed a recommendation by the consulting pharmacist on 7/11/18 for the resident's order for [MEDICATION NAME] 50 mg at bedtime to be reduced to 25 mg. A further review of the records revealed that the physician agreed with this on 7/17 18 and indicated that orders should be written to that effect. A further review of the pharmacy records revealed that during the next medication review visit on 8/2/18, the consultant pharmacist documented that the physician agreed with the dose reduction for the [MEDICATION NAME] on 7/17/18, but that the dose reduction had not been carried out. Review of the Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) revealed the resident continued to receive [MEDICATION NAME] 50 mg at bedtime as of August29, (YEAR). A review of the nurses' notes after (MONTH) 17, (YEAR) revealed no reference to the requested dose reduction, nor any explanation of why the dose reduction was not done. During an interview on 8/30/18 at 10:58 a.m. with Licensed Practical Nurse (LPN) AA it was revealed that the nurses ensure the physician/nurse practitioner sees all dose reduction recommendations as soon as possible after the pharmacist writes them. If the physician/nurse practitioner(NP) agrees with the recommendation, he/she usually writes the new order or gives a verbal order and this is initiated by staff soon thereafter. During an interview on 8/30/18 01:45 p.m. with the Director of Nursing (DON) it was revealed that the NP immediately writes the new for a dose reduction if she is in-house when she reviews the pharmacist's recommendation. If she is not on the premises when a recommendation for a dose reduction is made, and she agrees with the recommendation, the NP provides a telephone order for the staff. The new order is then implemented immediately. When the pharmacist returns the following month, she follows up on the dose reduction recommendations from the previous month to see if there are any that has not been addressed. The DON said further that he did not know why the pharmacy recommendation and physician request to reduce the [MEDICATION NAME] order for R#68 had not been carried out, but he would investigate the matter to determine what had occurred. Review of a copy of a document presented by the DON on 8/30/18 at 3:02 p.m. revealed it to be a late nurses' note dated 7/18/18 at 2:15 p.m. This note documented that the nurse had received the pharmacy recommendation to decrease the [MEDICATION NAME] to 25 mg at bedtime and had notified the nurse practitioner. The note further documented that the family requested that the resident remain on the current dose because she was doing well on that dose. A review of this note in the electronic records system revealed it was added in the system by the DON on 8/30/18 at 2:47 p.m. Interview on 8/30/18 at 3:48 p.m. with the consultant pharmacist, BB revealed she made the recommendation to reduce the [MEDICATION NAME] from 50 mg to 25 mg at bedtime on 7/11/18. During her next visit in 8/2/18, she became aware that the NP had agreed with the recommendation but that the dose reduction had not occurred. She consulted with the unit manager, LPN AA to determine why the dose reduction had not been done, and LPN AA informed the pharmacist that she had spoken to family and the family did not wish to have the resident's [MEDICATION NAME] dose reduced. During a follow-up interview on 8/30/18 at 4:10 p.m. with LPN AA it was revealed that, following the agreement by the NP to reduce the dosage for the resident's [MEDICATION NAME] from 50 mg to 25 mg, the nurse who cares for the resident on a regular basis informed LPN AA that it was not a good idea to reduce the resident's [MEDICATION NAME] dose based on her experience with the resident's behaviors. As a result, LPN AA contacted the NP via telephone, and the NP said she would not reduce the dose of [MEDICATION NAME]. LPN AA said she also called the resident's family and the family did not wish to have the resident's [MEDICATION NAME] dose reduced. LPN AA said she documented the family's decision in R#68's records. LPN agreed to furnish a copy of the note she made after she conversed with the family and they refused to have the resident's [MEDICATION NAME] reduced. Review of the copy of the nurses' note provided by LPN AA on 8/30/18 at 4:18 p.m. revealed it was the same note created by the DON on 8/30/18 as a late note for 7/18/18. Interview on 8/30/18 at 4:59 p.m. with Nurse Practitioner CC revealed she had initially agreed with the pharmacist's recommendation of 7/11/18 to reduce the dosage of the [MEDICATION NAME] being administered to R#68 from 50 mg to 25 mg at bedtime. However, she later realized this was an error. She had not intended to reduce the dose of [MEDICATION NAME] since she did not believe that the resident would do well on a reduction in dosage. A member of the nursing staff did call to clarify her intentions after she had agreed to the recommendation and she stated that she did not wish to reduce the dose. Usually, if the NP signs a dose reduction recommendation in error, the nursing staff will flag the recommendation and have the NP make the correction on the next visit. The nursing staff never flagged this recommendation. Therefore, the NP never made the documented that the recommended dose reduction should not be carried out. During a telephone interview on 8/30/18 at 5:13p.m. with A, family member for R#68, it was revealed the family had not been contacted by facility staff related to a possible dose reduction in the resident's [MEDICATION NAME]. Family member A said the family was not in favor of the resident being on any [MEDICAL CONDITION] medication and should they have been contacted and told of a recommended reduction or discontinuation of the resident's [MEDICATION NAME], they would have immediately opted to have the medication reduced or discontinued.",2020-09-01
528,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2020-02-26,609,D,1,0,CR9111,"> Based on staff interview, record review and review of the facility's policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to report an allegation of abuse to the State Survey Agency (SSA) within the required time frame for one resident (R#1) of 4 sampled residents. Findings include: During an interview on 2/25/2020 at 10:10 a.m., R#1 stated to this surveyor that he refused to allow Certified Nursing Assistant (CNA) AA in his room or allow her to touch him. He reported that he is legally blind and CNA AA was mean and rude to him. The resident angrily states that he is blind but CNA AA treated him like he was stupid. The resident further stated that he informed the Social Worker (SW) regarding how he was being treated and did not want CNA AA back in his room. An interview with the SW on 2/25/2020 at 11:30 a.m. revealed that she spoke with the R#1 on 2/24/2020 in which he reported to her that CNA AA was mean to him and did not want her to come back into his room or provide him any care. SW further stated that she completed a grievance report at that time and reported the incident to the Administrator. An interview on 2/25/2020 at 11:40 a.m. with the Administrator revealed that according to the report the facility became aware of the allegation on 2/24/2020. He further stated that he did not consider the incident as an allegation of abuse and therefore did not report the incident to the State agency. Review of the facility policy titled Reporting Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property revised on 4/26/2017, stated that mental abuse: includes but is not limited to humiliation, harassment, threats of punishment or deprivation. The suspected abuse will be reported within two hours to the State Survey Agency.",2020-09-01
529,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2020-02-26,690,D,1,0,CR9111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, record review, and facility policy review Lippincott indwelling urinary catheter care and management, the facility failed to provide appropriate indwelling urinary catheter care for one resident (R) #3, of three sampled residents. Findings include: Review of the facility policy for Indwelling urinary catheter (Foley) care and management revised 3/24/2017 indicated in the Implementation section to Provide routine hygiene for meatal care; note that cleaning the meatal area with antiseptic solutions isn't necessary. To avoid contaminating the urinary tract, always clean by wiping away from-never toward- the urinary meatus. Use soap and water or a perineal cleaner to clean the [MEDICAL CONDITION] area after each bowel movement. Avoid frequent and vigorous cleaning of the area. Review of the Quarterly Minimum Data Set (MDS) for R#3 dated 2/02/2020 revealed that his [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) indicated a score of 15 indicating the resident was cognitively intact. R#3 had an indwelling foley catheter on admission to the facility. Review of the Care Plan for R #3 dated 10/15/2019 revealed a care plan for an Indwelling Foley Catheter. Approaches included: Provide perineal care every day and PRN Report redness, swelling, discharge or urinary related odor to supervisor Follow aseptic technique with Cath insertion and irrigation Observe and report the change in color, odor, presence of cloudiness or sediment in urine to charge nurse Report complaints of pain/discomfort from cath to charge nurse Record intake and output as ordered Check Cath q (every) shift for patency, proper position of tubing and bag. Report Cath leakage to charge nurse. Review of the Medication Administration Record [REDACTED]. A review of the Quarterly MDS dated [DATE] revealed a BIMS score of 15 indicating that he was cognitively intact. The resident required total care for all activities of daily living and had an indwelling urinary catheter upon admission. Review of the Physician's Orders for R #3 dated 12/5/2019 revealed orders for: May change indwelling foley cath monthly as needed for blockage, clogging, dislodgement, sedimentation, s/s (signs and symptoms) of bleeding, or infection. Catheter: Diagnosis, [MEDICAL CONDITION] bladder and pressure injury to the sacrum. Observation of Certified Nursing Assistant (CNA) BB a indwelling foley catheter care was provided to R #3 on 2/25/2020 at 10:40 a.m. revealed: 1. Failed to use warm water or a basin to provide catheter care 2. Using wet wipes he washed the base of the penis and top of the scrotum. 3. He failed to wash the meatus of the penis. 4. Failed to wipe down the catheter tubing. Interview with CNA BB conducted on 2/25/2020 at 10:45 a.m. revealed that he was last trained on catheter care was December 2019. He also revealed that it was ok to wet wipes while providing catheter care but did not have any explanation regarding washing the meatus or the catheter tubing. Interview with the Nurse Consultant on 2/26/2020 at 1:49 p.m. revealed that the Clinical Competent Coordinator (CCC), provides a skill check-off annually which includes catheter care. Review of a Skills Competency Checklist Form: CNA Annual for CNA BB dated 12/9/19 included catheter care. The skill checks off include Lippincott Procedure dated 3/24/2017 and included washing the meatus/catheter insertion site.",2020-09-01
530,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2018-04-19,585,D,0,1,2G1211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record, and facility policy review, the facility staff failed to ensure personal clothing were returned when sent to the laundry and when items were reported missing there was an effective and timely process in place to replace items that were not found for one sampled resident (Resident {R}#71) out of 21 residents reviewed for missing personal items. Findings include: On 4/16/18 at 2:57 p.m., in the facility's conference room` an interview was conducted with the Administrator concerning laundry and missing items. The Administrator stated Anyone can write up the grievance form for the missing items. We look in the resident's room and if it's a laundry issue, we look in laundry and take the resident down to the laundry to look. If we don't find it, we reimburse them. Review of the facility's Concerns/Grievances policy, revised 6/2/2017 revealed the following: . A concern/grievance may be filed verbally or in writing. Grievance forms will be kept at the Administrator's office and./or in other area designated by Administrator in the center. If the resident files a grievance to any person, the staff person should immediately inform the Administrator or his/her designee. Procedure: 1. The staff member taking the grievance: The staff person will provide assistance in completing the Concern/Grievance Form should the person making the filing need assistance. Grievances should be resolved within three business days with the Administrator's signature and reported back to the person filing the grievance. The grievance form should be given back to the Administrator or his/her designee to be logged and placed in the grievance book. 2. The Administrator or his/her designee will be responsible for tracking all grievances. The Administrator or his/her designee will enter the grievance form information into the Grievance Log Form and place the original form in the log book. This will provide a central place for all grievances. 3. The Administrator or his/her designee is responsible for following up with the complainant to make sure that the grievance has been resolved or that they understand what actions have been taken. The Administrator or on-site manager will complete the log and form accordingly. On 04/17/18 at 2:58 p.m., R#71, who was admitted into the facility on [DATE] and responded to interview questions appropriately was asked about personal property and if any of his belongings ever been missing. R#71 responded Since I have been here I have had five pairs of my shorts missing, from the laundry. I told the Charge Nurse, and nothing was done, that was in (MONTH) of this year. On 4/18/18 at 9:30 a.m. in the facility's laundry area, the Laundry Manager was asked how he found about resident's missing items and what is done to locate those items. The Laundry Manager replied Morning stand-up meeting is when I find out about missing items. I come back and let my staff know. I also post it on the board back there. Observation of a bulletin board in the laundry area, there were two hand written notes on lined paper with no date that read: (resident name and room number, not R #71): missing shorts, (resident name): missing clothes;(resident name): black blouse, white shirt, two gray pants, white tennis shoes. Also, a large gray bin on wheels, full of clothing was pointed out by the Laundry Manager who stated Those are unlabeled clothing. At the end of the week, we take those up to the units, walk around to see if anyone can identify these things. On 4/18/18 at 10:15 a.m., at the nurse's station of the Cambridge Unit the Unit Nurse Manager QQ (Nurse Manager QQ) was queried concerning R#71's five pairs of missing shorts from the laundry. Nurse Manager QQ stated I spoke with him this morning and he told me he thinks he had five pairs of shorts missing. When asked if she knew about the missing shorts from laundry in January, Nurse Manager QQ replied He wasn't on this floor in January, he used to be downstairs. We should have filled out a form, but to be honest we don't have those forms up here. There were a lot of things that weren't here on the unit when I first got up here as the manager and slowly I have been getting them. When something is missing I usually go to the laundry to look for it At 11:10 a.m., Nurse Manager QQ left the unit and returned with a Missing Items-Laundry Services Form and stated, This is the form that should be filled out for missing laundry When asked where the form would be kept, Unit Manager QQ replied in the med room. When asked how would staff other than nurses have access to the forms since the medication room was locked. Nurse Manager QQ replied they would have to ask the nurses for the form. On 4/19/18 at 8:20 a.m., the facility's Grievance/Complaint log book was reviewed. The logs contained multiple residents and families' grievances from (MONTH) (YEAR) to (MONTH) (YEAR). The log indicated the staff member taking the grievance, an explanation of what the grievances was as well as the facility's resolution. There was no grievance log for R #71's missing shorts. The Administrator stated that these were all the grievances that she was aware of. On 4/19/18 at 8:45 a.m., in the facility's conference room during an interview with the Administrator concerning the facility's laundry process and handling of reported missing personal items, the Administrator who had come to the facility in (MONTH) of (YEAR) stated when I came the laundry person was only here for 4.5 hours a day on day and afternoon, that is s what we were budgeted for. I increased it to 7.5 hours. When someone is admitted we are supposed to complete a clothing inventory and make sure all their items are labeled. When family brings in new items or the resident goes out to shop and get new items they are supposed to make sure staff labels the item and that could be anyone (nurse, CNA). That doesn't always happen, and we end up with clothing in the laundry that we don't know who it belongs to. In the past we were reimbursing or purchasing the item from our petty cash card here at the facility. But corporate changed that policy and we now submit to them (corporate office) and they reimburse and that it could be a family member because they are the Power of Attorney. I am in the process of purchasing a good clothing labeler.",2020-09-01
531,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,568,D,1,1,I5PG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident and staff interviews and review of the policy titled Resident Trust Policy, the facility failed to provide quarterly financial statements for two of two cognitively intact residents (R) reviewed that had a trust fund account managed by the facility (R#14, R#61). The facility managed 93 resident trust fund accounts. Findings include: Review of the facility policy titled Resident Trust Policy dated (MONTH) 2009, revealed number 6. Quarterly statements will be provided in writing to the resident or the resident's responsible representative within 30 days after the end of the quarter. 1. Record review for R#14 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, which indicates the resident is cognitively intact. Interview on 7/21/19 at 12:53 p.m., R#14 revealed she does not receive a quarterly statement for her trust fund account that the facility manages. Review of printed Resident Fund Management Service dated 7/24/19 at 10:21 a.m., revealed on page three (3), R#14 has an active trust fund account that is managed by facility. 2. Record review for R#61 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, which indicates the resident is cognitively intact. Interview on 7/22/19 at 11:13 a.m., R#61 revealed she does not receive a quarterly statement for her trust fund account that the facility manages. Review of printed Resident Fund Management Service dated 7/24/19 at 10:21 a.m., revealed on page two (2), R#61 has an active trust fund account that is managed by facility. Interview on 7/23/19 at 4:55 p.m. with Accounts payable/Financial Counselor, responsible for the resident trust fund accounts, stated during the admission process, the residents are given the choice to have the facility manage a trust fund for their money. If the resident elects the facility to manage their trust fund, an agreement is signed and she sets up the account. She stated that residents are informed they have access to their money 24 hours per day. She further stated that she gives the residents quarterly statements in person within the month after the quarter ends, if the resident is their own responsible party. She stated the residents sign a ledger to acknowledge receipt of their quarterly statement. She confirmed the facility was managing resident trust for both R#14 and R#61. She further stated she was unable to find any documentation that R#14 or R#61 had acknowledged receiving their quarterly statement for the past four quarters.",2020-09-01
532,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,577,B,1,1,I5PG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, it was revealed that the facility failed to post notice of the availability of state survey results in prominent places in the facility. Findings include: During a group interview with members of the resident council on 7/23/19 at 10:10 a.m., it was revealed that few members of the resident council knew of the whereabouts of the state survey results and how they could access them. One resident said he believed they were to be found in the lobby area, but could not be sure of the exact location. An observation on 7/23/19 at 12:30 p.m. of the lobby area of the facility accompanied by the Regional Nurse Consultant, revealed a cherry wood cabinet attached to the wall at the left of the main entrance. A green sign attached to the closed door of the cabinet read: Please drop kudo cards here; please deposit payments here; please place [MEDICATION NAME] contact cards here. Inside the cabinet, once the doors were opened, was a binder labeled: Results of Past 3 Surveys; (MONTH) 27, (YEAR), (MONTH) 30, (YEAR), (MONTH) 12, (YEAR). During an interview with the Regional Nurse Consultant at the time of this observation, she revealed that the residents are supposed to be educated on the availability of the survey results and where to find them. She agreed that there was no indication in the area as to where the survey results were kept and that visitors/families/residents would not necessarily know the results were available in the cabinet when the door was closed. An observation of the lobby area on 7/23/19 at 4:29 p.m. revealed a new sign had been placed on the closed door of the cabinet containing the survey results. The new sign stated: Survey Results. During an interview on 7/24/19 at 2:57 p.m. with the Activity Director (AD) it was revealed that she usually educates the residents and family members after surveys that state survey results are available, and that they are entitled to see new results after they are received. The AD said the survey results were also once available in a book in the sitting area on the second floor and she often directed families and visitors to those results. However, she was not sure if the results were still displayed in that area. Observation on 7/24/19 at 3:12 p.m. of the sitting area accompanied by the AD revealed that the survey results were not displayed anywhere in that area.",2020-09-01
533,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,689,D,1,1,I5PG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review and interviews, the facility failed to provide supervised smoking for one resident (R#7) reviewed for smoking. The sample size was 55. Findings include: Review of the facility policy titled Smoke Free Policy with a revised date of 11/5/18, revealed the policy statement to be as of (MONTH) 1, (YEAR), smoking is not allowed on the healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to (MONTH) 1, (YEAR). Procedure bullet 10: when the patient/resident is identified as needing supervision, the supervision shall be provided by a partner who is physically present in the designated smoking area for all residents who need supervision based on their Smoking Observation Form or electronic documentation. Review of the clinical record for R #7 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Section J revealed resident was a current smoker. Review of facilities Smoker Worksheet, revealed R#7 name was on the list of identified smokers in the facility. Review of Smoking Observation Form documented that residents were to be assessed on admission, re-admission, or with a significant change. Review of Quarterly Smoking Observation Form for R#7, dated 3/12/19 and 7/22/19, revealed question one: Does the resident smoke? Yes column is checked. Question two: Does the resident have a past history of smoking? Yes column is checked. Supervision will be required at all designated smoking times when the patient/resident observation identifies any potential hazard risk, as evidenced by any boxes checked Yes. Patient/resident smoking status upon observation: Supervised Smoker. Review of document titled Smokers in the Facility undated, provided by facility, revealed that R#7 name was on the document. Review of document titled Smoking Location of the Facility undated, provided by the facility, revealed the court yard on the first floor as the designated smoking area. Based on review of R#7's comprehensive care plan a provided, resident is a current smoker and wished to continue to enjoy smoking with supervision, initiated on 3/12/19 and revised on 7/22/19. Observation on 7/21/19 at 2:00 p.m., resident was observed smoking in the designated smoking area (court yard on first floor). He was smoking one cigarette and holding a second cigarette in his hand. He was wearing a smoking apron. There was no evidence of any staff members present during the smoking period. Surveyor remained with resident until he was finished smoking. Interview on 7/21/19 at 2:00 p.m. with R#7, stated he smokes by himself most of the time, but staff give him cigarettes and light them for him, and then they leave. Observation on 7/21/19 at 2:10 p.m., staff member GG removed resident smoking apron, upon re-entry into facility. Staff member stated that he just gets the cigarettes from the nurses station and lights them for resident and puts the apron on and takes it off. He asked surveyor Is someone supposed to be outside with him when smoking? Interview on 7/23/19 at 8:45 a.m. with housekeeping aide HH, stated she was asked to start sitting with resident today, during the 8:30 smoking break. Interview on 7/23/19 at 1:21 p.m with Admininistrator, stated the facility is a non-smoking facility, but there is one resident who was grandfather in. He stated that there is not a formal schedule as to who is supposed to attend smoke breaks with the resident. He further stated that staff from housekeeping, dietary, activities and nursing are supposed to supervise the resident during smoke breaks. He further stated that he makes sure someone is with resident while smoking. On the weekends and when he is not in facility, he stated it is the responsibility of the Nursing Supervisor to ensure a staff member is with resident during smoke breaks. When questioned about Sunday episode when resident was observed in courtyard smoking unsupervised, he responded that the weekend Supervisor called out on Sunday, and he does not know who would or should have made sure the resident had supervision for smoking.",2020-09-01
534,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,692,D,1,1,I5PG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews, record review and review of the facility policy Hydration: Dietary Service. The facility failed to provide hydration (ice/water) at the bedside for two of fifty-five sampled residents, (R) (R#61 and R#304). Findings include: 1. Review of the clinical record for R#61 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 15, which indicated no cognitive impairment. Interview on 7/22/19 at 11:20 a.m. in R#61 room, she stated she rarely gets fresh ice water. No visible water pitcher in R#61 room. Observation on 7/23/19 at 8:05 a.m., there is no visible water pitcher or drinking cup on residents side of the room. Observation on 7/23/19 at 3:06 p.m., resident sitting at her beside. She stated that no-one brought her any ice water today. There is no visible water pitcher or water cup on her over bed table. Interview on 7/24/19 at 8:26 a.m. with R#61, stated she was given a pitcher of ice water today, when she hasn't had a pitcher for ice water in a long time. She could not remember exactly how long it has been since she had ice water. Interview on 7/24/19 at 9:34 a.m. with Certified Nursing Assistant EE stated that she passes ice twice daily on her shift. She further stated that she offers R#61 ice water everyday, but resident refuses and throws her water pitcher in the trash. 2. Medical record review for resident R#304 revealed she was admitted to the facility on [DATE]. She readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for R#304 admission Minimum Data Set (MDS) assessment dated [DATE] which documented a BIMS summary score of 15, indicating cognitively intact. An interview and observation on 7/22/19 at 9:53 a.m. R#304 did not have a water pitcher in the room. The resident revealed that they she has liquids on the meal tray and she saves the liquids to have to drink throughout the day. An observation on 7/22/19 at 3:42 p.m. R#304 had no water pitcher visible. An observation on 7/23/19 8:42 a.m. R#304 had no water pitcher visible. An observation on 7/23/19 at 9:07 a.m. R#304 sitting up in bed eating breakfast noted one glass of water on tray. no water picture visible. An observation on 7/23/19 at 10:54 a.m. of two certified nursing assistant (CNA) KK and PP passing ice, water, and juice on first floor hall [NAME] The CNA KK entered R#304 room and came out no ice, water, or juice was provided to R#304. An interview was conducted on 7/23/19 at 11:03 a.m. with R#304. The resident revealed the staff came in and ask her did she have a pitcher for ice water and she informed them she did not have one. Resident revealed the staff told her they would get a water pitcher for her. An interview was conducted on 7/23/19 at 11:48 a.m. with CNA KK regarding provided hydration to the residents in the facility. The CNA revealed when passing hydration to the residents the residents are asked if they would prefer Ice, water, and/or juice. The CNA also revealed Ice, water, juice is passed/offered to the residents each shift and at the resident request. The CNA revealed If the resident does not have a pitcher one will be provided. An interview was conducted on 7/23/19 at 12:15 p.m. with PP CN[NAME] The CNA revealed she assisted with passing ice water on C hall and was aware that R#304 did not have a pitcher. The CNA revealed she did not provide a pitcher to R#304 and was not sure if the CNA KK provided the residents with a pitcher. An observation on 7/23/19 4:42 p.m. R#304 had no water pitcher visible. An interview was conducted 7/23/19 at 4:55 p.m. with the Administrator and the Senior Nurse Consultant LL. The Senior Nurse Consultant confirmed that R#304 did not have a pitcher at her bedside. Both the Administrator and Senior Nurse Consultant revealed that their expectations are that the ice water is passed to all residents to ensure that they stay hydrated. Review of the facility policy titled Hydration: Dietary Service. with a revised date of 10/18/17 revealed: Each resident/patient will be provided a drinking glass and water pitcher in their room unless they are on fluid restriction. Water pitchers are filled with ice/water at least but limited to twice per day.",2020-09-01
535,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,725,F,1,1,I5PG11,"> Based on observation, review of facility records, and resident and staff interview, it was determined that the facility failed to provide staff in sufficient numbers to care for the needs of seven Residents (R) #13 , R A, R B, R C, R#23, R#24, R D on two of two units as identified in resident and facility assessments. Findings include: A review of the Facility assessment dated (MONTH) 2019 revealed that the facility cared for a very high percentage of residents that required the assistance of two-plus persons with daily care such as bed mobility, transfers, toilet use, and dressing. The assessment also documented that the facility had high percentages of residents with cognitive impairments and behavioral health needs that impacted resident care. A review of the facility's Alphabetical census of residents dated 7/21/19 revealed that there were 106 residents onsite - 55 on the 200 Hall and 51 on the 100 Hall. A review of the Daily Staffing Schedule for 7/21/19 revealed two nurses and two certified nursing assistants (CNAs) were scheduled to care for residents on the 200 Hall, and an equivalent number on the 100 Hall. Observation on 7/21/19 at 11:30 AM of the staff on the 200 Hall confirmed that two CNAs were available to provide care to the 55 residents on that hall. During an observation on 7/22/19 at 11:15 a.m., the family of Resident #13 was seen to arrive at the facility for a visit. A few minutes into the visit, one of the family members was observed to remove a manicure set from her bag and proceed to trim the nails of the resident. The resident's nails were observed to be about a centimeter long. During an interview with the family member, at the time of this observation it was revealed that she trims his nails during her weekly visits because the staff are busy and not able to get to it. During a group interview on 7/23/19 at 11:10 a.m. with members of the resident council it was revealed that residents were dissatisfied with the number of staff available on the various shifts to care for their needs. Resident (R) A said sometimes staff say there are not enough of them available to get her roommate up. When this happens, her roommate remains in bed. Resident A also said that, during meal services, the CNAs come to the residents' rooms and turns off their call lights, telling them that staff will return to assist them when they are done with serving the meal. When this happens, she must wait a long time for assistance if she needs to go to the bathroom. During such waits, she sometimes wets herself. Other times, she is left in the bathroom and it is the nurse who comes after a considerable amount of time to get her off the potty. A review of the most recent minimum data set (MDS) assessment for Resident A revealed a Brief Interview for Mental Status (BIMS) score of 15. A score of 13-15 indicates a resident is cognitively intact. The assessment also documented that this resident needed extensive assistance of two-plus persons for activities of daily living (ADLs) such as transfers, bed mobility, toilet use, and personal hygiene. A review of the most recent minimum data set (MDS) assessment for the roommate of Resident A revealed the roommate was assessed as having a severe cognitive deficit and needed extensive to total assistance with ADLs such as transfers, dressing, and toilet use. Resident B said, during the same interview, that it sometimes take more than an hour for staff to respond to her call for assistance to be taken to the bathroom. The resident said she takes a water pill, so when she (I) need(s) to go, she (I) need(s) to go, and she has accidents when she must wait an hour or more for staff to respond to her call. A review of the most recent MDS assessment for Resident B revealed a BIMS score of 15 revealing the resident to be cognitively intact. The resident was assessed as needing extensive assistance with transfers, dressing, toilet-use, and personal hygiene. During the same group interview, Resident C said that he did not believe that staff was simply reluctant to come when the residents called. Instead, he believed that they are short-staffed. Thus, when the staff took a long time to respond to the residents' call lights, it meant they were with another resident. Resident C said there was usually only one CNA on each hallway. Sometimes, the nurse would come in, turn his call light off, and say she is working with another resident and would be back when she could. He said he receives the care he needs, it just takes much longer than is warranted. Resident A said this state of affairs has existed for several months. A review of the most recent MDS assessment completed for Resident C revealed a BIMS of 15, indicating that he was cognitively intact. Resident C was assessed as needing extensive assistance with bed mobility, transfer, eating, and toilet use. During an interview on 7/24/19 at 3:36 p.m. with CNA MM, it was revealed that she normally works the 3:00 p.m. to 11:00 p.m. (evening) shift, and was one of four CNAs scheduled and available to work on the 200 Hall that evening. The CNA said three of those four CNAs had also worked during the previous shift and was held over to work on the evening shift. CNA MM said the evening shift usually had four CNAs, but occasionally five were scheduled. However, though rare, sometimes there were only two. If only two CNAs are scheduled to provide care on that hall, then the nurses are expected to help with providing showers etc. On the weekends, staff are expected to pick up extra shifts so that there is not less than four CNAs on the evening shift. During an interview on 7/24/19 at 5:11 p.m., CNA NN revealed she has been responsible for the daily scheduling of nurses and CNAs for the facility since (MONTH) 2019. CNA NN said she schedules staff for each day/each shift based on the daily census. Depending on that census, the minimum number of CNAs she will schedule on the day and evening shifts are four on each hall; the minimum amount for the night shift are three on each floor/hall. However, 4-5 CNAs are usually scheduled on each floor/hall on the day shift and 3-4 on the evening shift. On the night shift, she usually schedules 2-3 CNAs on each floor/hall. The numbers are the same 7 days a week. When there are call-outs for the CNAs, she tries to replace them with part-time staff. If she is not able to replace them with part-time staff, then the nurses are expected to help. Sometimes she will fill in on the shift for a CNA who cannot come in. For example, she was scheduled as one of the five CNAs, scheduled to work the 100 hall/first floor on that shift. CNA NN admitted that, of the five CNAs scheduled for the upstairs (200) hall, three were CNAs from the previous shift who had agreed to work an extra shift that day. During an interview on 7/24/19 at 5:34 p.m. with CNA OO, it was revealed that five CNAs had indeed been scheduled for the 200 hall on the 3-11 shift that day. However, one of those scheduled CNAs was the activity director who was not, at the time, working on the floor. Another of the scheduled CNA was the medical records clerk who was also not working on the floor. CNA OO said the only CNAs working on the hall during the shift were three CNAs who were not listed on the original schedule provided by the facility, but who had worked during the previous shift and was then working extra hours. This CNA said many of the CNAs had worked extra shifts for several months During initial screening on 7/22/19 at 11:54 a.m., with resident #23, stated that there is not enough staff to put him to bed when he wants to go to bed. He has to sit for hours in wheelchair, waiting for someone to put him back to bed. During initial screening on 7/22/19 at 1:45 p.m. with resident #24, stated that there is not enough staff to change his diaper but once per shift. He further stated staff come in and turn off his call light, without asking him what he needs. He stated that he does not get up out of bed, because there is not enough staff to put him back to bed, causing him to sit up longer than he desires. Interview on 7/21/19 at 1:45 p.m., with Certified Nursing Assistant (CNA) FF, stated that she was called in today to help work on the floor. She stated that she does get pulled to work on the floor at times, when they are short staffed. She stated that she will work some extra hours when they ask her too. Interview on 7/21/19 at 2:48 p.m. with CNA II, stated she has 28 residents to care for today, because they are short staffed. She stated she normally would have help on the A Hall and she would have about 15 residents. She stated that today, she is on the floor by herself. Interview on 7/24/19 at 9:34 a.m. with CNA EE, stated that she has on average of 10-12 residents per shift. She stated that when staff call in (a lot on weekends), then she will have about 18 residents by herself. She stated that she does work extra shifts, when she is able, working about six extra shifts per month, sometimes they are double shifts. Interview on 7/24/19 at 10:05 a.m. with Housekeeping Aide DD, stated that she has helped the residents with requests, when she sees that the staff are busy helping others. She stated she answers call lights and will get residents drinks and snacks when they ask. An interview was conducted on 7/22/19 9:29 a.m. with D regarding sufficient staffing. She revealed the facility does not have enough staff. D revealed she was incontinent of both bowel and bladder and had to wait over an hour for staff to come and provide incontinence care. D revealed she will place her light on and it may take up to an hour. D revealed on 11p.m.-7a.m. there is one CNA for the entire hall.",2020-09-01
536,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,732,B,1,1,I5PG11,"> Based on observation and staff interview, the facility failed to post the nurse staffing information on one of four days of the survey. The facility census was 106. Findings include: During an observation on 7/21/19 at 11:06 a.m. it was revealed that the posted nurse staffing information displayed in a glass at the front of the first floor of the facility carried the date of 7/20/19. During random observations of the posted nurse staffing information on 7/21/19 between 11:06 a.m. and 5:30 p.m., it was revealed that the information displayed was from 7/20/19 - the previous day's numbers. During an interview with the administrator on 7/22/19 at 9:48 a.m., it was revealed that the posting of the daily staffing is the responsibility of the weekend nursing supervisor. The administrator said that the weekend nursing supervisor did not come in to work on 7/21/19. Thus, the staffing for 7/21/19 was completed but not posted, and senior staff were distracted with the survey and overlooked posting the information later in the day.",2020-09-01
537,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,812,E,1,1,I5PG11,"> Based on observation, staff interview, and review of facility provided data, the facility failed to ensure kitchen staff were wearing hair protectors in the food preparation area. In addition, the facility failed to ensure the dish machine room was safe and sanitary; specifically, free from broken floor tiles and free from dirty water containing food debris accumulating on the floor. This practice had the potential to affect 103 residents receiving an oral diet. The census was 108 residents. The findings include: An initial tour of the kitchen was conducted on 7/21/19 at 11:20 a.m. with Cook CC, Kitchen Aide BB, and Kitchen Aide AA, the Food Service Manager (FSM) was unavailable. The kitchen staff was observed in the process of cooking and preparing for the lunch meal. A small amount of food debris was observed on kitchen floor tiles, walls were clean. The dish machine wash and rinse cycle was tested twice by a Kitchen Aide with two (2) small batches of dirty dishes. The wash and rinse cycle were within required range for a low temperature machine. The floor drain in the dish machine room was not draining water. Floor tiles around the drain area in the middle of the floor, appeared loose, and broken. A large amount of cloudy pooled water containing food debris was noted in the middle of the room, approximately five (5) inches deep at the drain site. Water was also observed pooled over two black rubber safety mats. A brief interview was conducted with Kitchen Aide AA on 7/21/19 at 11:50 a.m. during the tour in the dish machine room, where she confirmed the floor drain has not been draining right for some time that maintenance was aware of it. A second tour of the kitchen was conducted on 7/22/19 at 4:00 p.m. with the FSM, where she confirmed there were broken tiles and water pooling around the drain area in the dish machine room, she confirmed maintenance was aware of the drainage problem. During the continued tour, Cook MM was observed working in the kitchen, on the dinner meal preparation, without a beard net. The staff's beard, mustache and goatee facial hair were uncovered. An interview was conducted with the Maintenance Director (MD) on 7/23/19 at 16:40 p.m. where he stated that a local plumbing company came out on Thursday. He explained the first he knew about the drain problem was on Wednesday. The plumber snaked the drain on Thursday, but it didn't work. He confirmed loose and broken tiles but did not know how long the problem was there. He stated that on Friday they were supposed to have the jetting of the drain conducted by the plumbing company, but he could not come, he called to say he was sending a subcontractor, but confirmed it wasn't done. The MD confirmed they would wet vac the area. Observation of the drain area with the MD reveals a larger pooled area from what was observed on 7/21/19, the water appearing cloudy, with food debris. Two safety mats located along the side of the dish machine were covered with water. A request was made from the MD for a copy of the work orders and/or invoices for plumbing repairs. During a brief observation in the kitchen on 7/23/19 at 12:48 p.m. Cook MM was observed in the lunch meal tray line dishing up food items with a hair protector/net on, a beard guard on that covered his lower beard, however, facial hair in the goatee and mustache areas were not covered. A brief interview was conducted on 7/23/19 at 4:00 p.m. with Nurse Consultant LL during the request for the facility policy regarding kitchen staff attire, to include hair requirements. The Nurse Consultant confirmed the kitchen staff know that hair and beard nets are an expectation, that all hair needs to be covered. A review was conducted of the provided facility policy titled, Dietary Partner Hygiene and Dress Code, revised date, 6/2016. Policy Statement: it is the policy for partners working in the Dietary Department to dress in a manner appropriate for preparing, handling and serving food that prevents contamination and spread of bacteria. Scope: This applies to all dietary partners, and any person(s) who handles and serves food employed by the facility. Hygiene: No. 2 documented- hair is covered with hair net and/or cap. Facial hair is completely covered with a hair net or beard guard. A review was conducted of two (2) facility provided plumbing invoices. The invoice date of 4/2/19, note documentation reflects- jet service related to the kitchen sink floor was backing up. The line was jetted and it was discovered to have a separation down the line. The line needs to be dug up and repaired. The invoice date of 7/18/19, documentation note reflects- jet service for the kitchen line floor drain by the dishwasher was snaked first and cleared up of a cup and knife. It was still backing up when it had to be jetted and cleared, 30-day warranty.",2020-09-01
538,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,814,E,1,1,I5PG11,"> Based on observation and staff interviews, the facility failed to ensure the sanitary handling of used cooking oil/refuse, and failed to ensure that kitchen staff had adequate accessibility to the grease trap grounds area for disposal. The census was 108 residents. Findings include: An initial tour of the kitchen was conducted on 7/21/19 at 11:20 a.m. with Cook CC, Kitchen Aide BB, and Kitchen Aide AA, the Food Service Manager (FSM) was unavailable. The kitchen staff was observed in the process of cooking and preparing for the lunch meal. The latest health inspection dated 7/12/19, was posted, documenting a score of 98%. Food prep areas, kitchen equipment and food storage areas were observed to be clean and in order. The initial tour continued to the loading dock area, dumpster area, and the grease trap area with Kitchen Aide BB. The back door was closed to the kitchen. During the observation of the walk-through area to the outside, used as a pass through to the kitchen back door, revealed seven (7) dead insects and a box-like mouse trap. At 12:00 p.m. while the tour continued outside, near the dumpster area, Kitchen Aide BB explained they dump the grease and oil in the grass behind the dumpster. The grease trap container was observed located behind a six (6) foot fence. The fence door was unlatched; however, the Kitchen Aide was unable to open the gate fully, less than 1.5 feet. A large number of weeds and Kudzu vines were surrounding the grease trap container and the surrounding area. The grease trap container was observed to be the size of a tall, large barrel-type trash receptacle with a lid. Several broken wheelchairs were noted under the Kudzu vine, along with other old equipment not fully visible under the vines. The weeds and vines prevented access to the grease trap container to observe it more closely. A second tour of the kitchen was conducted on 7/22/19 at 4:00 p.m. with the FSM, where she confirmed that the fryer oil is changed on Saturday. The cooking oil in the fryer appeared clean upon observation. Tour of the back door walk through area was observed to be free of dead insects. Tour of the outside grease trap area, revealed the fence gate to the grease trap area could be opened half-way, some of the weeds near the gate were observed to be stomped down. The FSM explained they are not using the grease trap, that the weeds are too high, they have saved the oil. Observation revealed two large uncovered metal pots containing dark colored cooking oil, was stored under the warming oven on the floor tile, located next to the gas stove. The FSM stated another place like on the back covered porch area, or in the walk thru area would be better place to store it. The back-porch area is open on one side, and is an area where the oxygen tanks are stored. A brief interview was conducted with the Administrator on 7/23/19 at 8:45 a.m. in his office, where he explained that the facility utilizes two community organizations that they donate equipment to. The organization will pick up discarded equipment quarterly that might be used for parts; that items that need to be fixed are kept in the maintenance shed. During an interview on 7/23/19 at 4:30 p.m. the Maintenance Director (MD) was asked who was responsible for the area around the grease trap. The MD explained that he was just told about it yesterday afternoon, that the facility's landscaping contractor will be called, they will have them cut them (the weeds) back. He stated the landscaping crew was due out this week. He confirmed he did not know how long the grease trap area has looked that way. He confirmed old wheelchairs were put out there by therapy for repurposing, an outside company was to pick up them for repurposing, stating that the equipment out there, are not fixable items. The MD also confirmed the weeds and Kudzu are thick, as tall as four (4) feet high in places, and confirmed that he had looked yesterday. He also confirmed they have a pest control contractor that comes out frequently, the last time was on 7/17/19, that they have a running contract with them. He again confirmed the responsibility for the weeds is the landscaping company. A request was made from the MD for a copy of the pest control policy and a policy for grease trap maintenance. The MD stated he did not have a policy to ask the FSM, that she may have one. An observation was conducted on 7/23/19 at 11:30 a.m. with the FSM present, for the lunch meal pureed food process, with Cook CC. During this time, the two metal pots of old cooking oil were no longer observed under the warming oven. The FSM confirmed the oil was put in the trap, with help last night. On 7/23/19 at 12:30 p.m. during observation of food temperature testing with the FSM, she confirmed there is no facility policy for the dumpsters and grease trap, or cooking oil disposal. An interview and tour of the grease trap area was conducted on 7/24/19 at 9:10 a.m. with the Rehab Director (RD). During the tour of the grease trap area behind the gate, she explained that the old rehab equipment is given to maintenance to take to the shed. She confirmed that no one in her department placed the broken wheelchairs and other items out there. She explained what the process for old and broken equipment to be removed is; that they fill out a maintenance request, in the shared maintenance log book located on each nursing unit. Then maintenance picks up the equipment, then fixes the equipment, if possible. The RD confirmed the staff in her department do not take away equipment, that she doesn't know what happens to unusable equipment, their department only gets back usable, fixed equipment. The RD then walked to the nurse's station to the maintenance book and pointed to a recent request dated 7/16/19 for a resident wheelchair that was broken and needed replaced. The Maintenance Request form had a date of 7/16/19 and a note documenting replaced brakes.",2020-09-01
539,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2019-07-24,914,D,1,1,I5PG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview the facility failed to ensure that privacy curtains were clean and provided full visual privacy, which included a total of six of 119 beds on one of two units. The facility census was 108 residents. Findings include: Observation on 7/21/19 at 2:16 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/21/19 at 3:33 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/22/19 at 10:53 a.m., revealed in room [ROOM NUMBER], bed A and bed B had no privacy curtain at all. Observation on 7/22/19 at 11:04 a.m., revealed in room [ROOM NUMBER], privacy curtain on bed B dirty with dried food particles. Observation on 7/22/19 at 12:11 p.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Observation on 7/23/19 at 11:55 a.m., revealed in room [ROOM NUMBER], center privacy curtain approximately two feet too short. Interview on 7/24/19 at 10:05 a.m. with Housekeeping Aide DD, stated she inspects the privacy curtains daily to make sure they are clean. She stated if the privacy curtains need to be changed, she notifies the floor tech, to take down to be laundered. She stated she was not sure if there was a routine schedule for laundering the privacy curtains. She stated that she has not noticed any privacy curtains that were too short or missing in any of the rooms on A-Hall. Interview on 7/24/19 at 6:05 p.m. with Housekeeping Supervisor, stated her expectation is that the housekeeping aides look at the privacy curtains every day. If a curtain is identified as being dirty, they are to notify the floor tech to remove the curtain and replace it with a clean one. She stated there is not a routine schedule of laundering the privacy curtains. She further stated that if the housekeeping staff are checking the privacy curtains daily, she is not sure how there could be a room that didn't have a curtain at all, or some rooms with short curtains in the middle.",2020-09-01
540,PRUITTHEALTH - MARIETTA,115276,70 SAINE DRIVE SW,MARIETTA,GA,30008,2017-07-27,242,D,0,1,4OJ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to allow the choice of bathing frequency for one of three sampled residents (Resident (R)#70) reviewed for choices. The sample size was 26 residents. Findings include: Review of R#70's clinical record revealed the [DIAGNOSES REDACTED]. The MDS revealed the resident did not display behaviors and required total assistance of one person for bathing . Review of the updated care plan dated 5/25/17 revealed the intervention for one Certified Nurse Aide (CNA) to assist the resident with showers on scheduled shower days and as needed. Review of the Shower Schedule revealed R#70 should receive a shower two times a week on the evening shift. Interview with R#70, in his room, on 7/25/17 at 10:03 a.m. revealed the resident did not get to choose how often he received a bath. The resident stated he received a shower one to two times a month. He further stated he would like one at least two times a week . Interview with CNA CC on 7/26/17 at 12:16 p.m. revealed each resident received a shower two times a week and staff completed a skin sheet when they complete the shower . Interview with Unit Manager AA on 7/26/17 at 12:38 p.m. revealed each resident received a shower two times a week. The CNA should document on the skin sheets and on the Kiosk (CNA computer charting) after each shower. Interview with the Director of Health Services (DHS) on 7/26/17 at 4:40 p.m. revealed the CNA should complete a skin sheet with each shower and document the shower on the Kiosk. Interview with Corporate Nurse BB on 7/27/17 at 8:40 a.m. revealed the residents should receive showers based on their choice. Corporate Nurse BB also stated the facility did not have a policy regarding bathing choices but would refer to Resident's Rights. Review of the Bath Report from the Kiosk and the Skin Monitoring sheets from 5/1/17 to 7/26/17 at 4:30 a.m. (a period of 13 weeks and two days) revealed the resident only received 12 showers, instead of 26 based on two showers a week. Interview with the resident, in his room, on 7/27/17 at 9:03 a.m. revealed the resident stated he was happy because he received a shower the day before. The facility failed to provide showers per the resident's choice.",2020-09-01
541,FLORENCE HAND HOME,115277,200 MEDICAL DRIVE,LAGRANGE,GA,30240,2018-06-07,578,D,0,1,K05K11,"Based on record review, review of policy Advance Directives, and staff interviews, the facility failed to provide written documentation for one of four Residents (R#396) reviewed. Findings include: Review of medical record for R#396 revealed Full Code Status. Review of progress notes did not reveal that written information was provided to resident related to right to formulate an Advance Directives. An interview was conducted on 6/6/18 at 11:10 a.m. with Patient Financial Services (PFS) Representative, who reported that she does not discuss advance directives during the admissions process but social services does this. During interview on 6/6/18 at 11:40 a.m. with the facility Social Services Director (SSD) she explained the facility process for providing information regarding Advance Directives revealed that she discusses this with the resident and family on admission. She reported that she explained what a full code and each code status means and explained to residents what a Do Not Resuscitate (DNR) means and what do they want to happen. It was explained that if a resident asked for written information about advanced directives then the packet titled Georgia Advance Directive For Health Care would then be provided to the resident. The Social Services Director states she puts a note in the progress notes section of the resident's chart. She also stated that the admitting nurse on the floor also discusses Advance Directives with the resident and charts this information on the Long Term Care Admissions Assessment. An interview on 6/6/18 at 3:10 p.m. with SSD who reported that advance directive information forms were found in Meditech, which was the system that was used previously but not being used now. However, the advance directive information forms are no longer being utilized. It was further expressed that these forms have not been utilized in over a year. An interview on 6/7/18 at 12:27 p.m. with the Executive Director who reported that the facility talks with residents on admission and during the admission nursing assessment regarding the desire to formulate an advanced directive. When questioned about written information provided to residents the Executive Director reported that she thought the regulations required only having a written policy. An interview on 6/7/18 at 2:15 p.m. with PFS Representative who reported that there is no advance directives information provided in the admissions packet provided to residents. She further reported that she thought social services was responsible for discussing this information with the residents. Advanced directives policy reviewed. Policy: #8205-16 page 2 of 6 Informing of patient of rights and options [NAME] During the inpatient, outpatient surgery, or the emergency department admitting process the patient must be asked if he/she has an advance directive. 1. Included in the admission material is information regarding advance directives and the directive for final health care. 3. If the patient desires not to discuss the issue further, the fact that the patient has no advance directive must be documented in the medical record at the time of assessment.",2020-09-01
542,FLORENCE HAND HOME,115277,200 MEDICAL DRIVE,LAGRANGE,GA,30240,2018-06-07,582,D,0,1,K05K11,"Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for two of three residents (R) reviewed (#9 and #23). Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #9 was discharged off Medicare Part A skilled services on 3/9/18 and remained in the facility afterwards with benefit days remaining. Further review of this form revealed that R #23 was discharged off skilled services on 1/518, and remained in the facility with benefit days remaining. There was no evidence provided that the SNFABN was provided to either R#9 or R#23. During an interview on 6/7/18 at 8:35 a.m. with Minimum Data Set (MDS) representative GG it was reported that prior to surveyors coming into the facility she was not aware to use SNFABN form when residents discharged from Medicare Part A services. MDS GG confirmed that she did not provide SNFABN forms for R#9 and R#23. It was reported that copies of the SNFABN forms were provided to her on 6/5/18 to begin using.",2020-09-01
543,FLORENCE HAND HOME,115277,200 MEDICAL DRIVE,LAGRANGE,GA,30240,2018-06-07,695,D,0,1,K05K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, review of the facility policy titled Self-Administration of Medications, and record review, the facility failed to assess the ability to self-administer [MEDICATION NAME] nebulizer treatments for one resident (R) (#62) out of 48 sampled residents. Findings include: Observation on 6/4/18 at 8:48 a.m. revealed one unopened package of individual [MEDICATION NAME] sulfate inhalation solution and six loose solution vials in a cup. During an interview at this time, R#62 stated that he does his own nebulizer treatments and that he did one last night. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented R#62 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact and active [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Physician Orders revealed an order dated 3/3/18 for [MEDICATION NAME] inhalation solution 2.5 milligram (mg)/ 3 milliliter (ml), one unit dose vial per nebulizer every three hours as needed for shortness of breath. Review of the Medication Administration Record [REDACTED]. Observation on 6/07/18 at 9:13 a.m. revealed [MEDICATION NAME] nebulizer solutions were no longer in R#62's room. Interview with Licensed Practical Nurse (LPN) AA on 6/7/18 at 9:17 a.m. revealed that R#62 was doing his own nebulizer treatments but the medication has now been removed from the room. She stated that he is a very difficult resident who insists on doing the treatments himself and will curse at staff if not allowed to do things his way. Interview with the Director of Nursing (DON) on 6/07/18 at 11:17 a.m. revealed that R#62 has not been assessed to self-administer nebulizer treatments because he used to be a nurse and thinks he can do whatever he wants to do without understanding current practice. DON stated staff should not be leaving any medications in the room for him to self-administer. Policy titled Self-Administration of Medication with no revision date documented the following: [NAME] If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility. The resident is reassessed at each quarterly care plan review. D. Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. The following conditions are met for bedside storage to occur: 1) the manner of storage prevents access by other residents. Lockable drawers or cabinets are required. 2) the medications provided to the resident for bedside storage are kept in the containers dispensed by the dispensing pharmacy.",2020-09-01
544,FLORENCE HAND HOME,115277,200 MEDICAL DRIVE,LAGRANGE,GA,30240,2018-06-07,880,D,0,1,K05K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and review of the facility's Infection Control Isolation Precautions Policy, the facility failed to ensure staff members followed contact isolation procedures when entering the room of one Resident (R) (#38) of 48 sampled residents. Findings include: During observation of the East Hall on 6/4/18 at 10:55 a.m. revealed that Certified Nurse Aide (CNA) DD was observed entering R#38's room with gloves on but no gown. Observed on the outside of R#38's room there was a yellow cart labeled isolation cart that was noted to the right of the door. There was also a sign that was posted to R#38's door which indicated, Stop Infection Prevention Contact Isolation in addition to standard precautions, visitors see nurse before entering; clean hands upon entering and leaving; wear a gown; wear gloves. Observation on the same day at 11:05 a.m. revealed CNA GG entering R#38's room wearing a gown and gloves. It was observed while the door was open CNA DD was providing care to R#38. Further observation at 11:08 a.m. of CNA DD exiting the room along with CNA G[NAME] CNA DD did not use the sanitizer which was located on the isolation cart outside of R#38's room. CNA DD went to the nurse's station restroom and was observed washing her hands. Another observation on the same day at 11:10 a.m. revealed that CNA DD re-entered R#38's room wearing gloves but no gown. CNA GG summoned CNA DD out of the room and was heard instructing CNA DD to place a gown on and to carry a red bag into the room to place items that come in contact with the resident. A review of R#38's Admission Record, dated 5/25/18, noted pertinent [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of two, and the resident was assessed as always incontinent of bladder. The resident was admitted from an acute hospital. Review of the resident's care plan dated 6/4/18 and revised on 6/5/18 reveals Isolation: Resident has drug resistance bacteria in urine. Need contact isolation. Interventions for the above include: Assist family and visitors to follow isolation precautions; keep resident's room tidy; Keep resident's hands clean, give resident bath daily (date initiated 6/5/18); Isolation cart outside door. Staff to maintain isolation (date initiated 6/4/18); nursing to give antibiotics as ordered. Resident has dementia. Nursing to remind her that she is isolation at this time. A record review of the document titled, Health Status Progress Note dated 6/2/18 at 13:43 (military time) noted, Patient resting quietly in bed. Is alert and oriented x2 respirations are even and unlabored. Skin is warm and dry to touch. No present c/o (complaint) any pain or discomfort. Takes medications crushed in pudding without difficulty. Can make all needs known to staff and requires moderate to complete assistance with activities of daily living. Patient has a Heplock (a device for ongoing intravenous therapy) to left forearm is patient and intact for intravenous (IV) therapy. Patient is on contact isolation for [MEDICAL CONDITION] (MRSA). Patients son at bedside (sic). An interview was conducted with CNA DD on 6/6/18 at 8:24 a.m. regarding her understanding of what she should do when entering and exiting a resident's room that is on contact isolation. CNA DD stated, that she would put on a gown and gloves. She further stated that she removes her gown and gloves before she leaves the room and places them in a biohazard red bag. When asked how she determined whether or not a resident is on isolation she stated, whenever they have a cart and sign on the door this indicates they are on isolation and from that I determine what I need to put on. CNA DD states, she received training on how to care for a resident on contact isolation during orientation. She indicates that she has been working at the facility a little over a month. CNA DD confirmed that R#38 was on contact isolation. CNA DD was asked how was she aware of this resident being on contact isolation. She stated, because of the yellow cart outside the door. Observation on 6/6/18 at 7:53 a.m. during the observation of breakfast trays being passed physical therapy assistant (PTA) BB was observed taking a tray into R#38's room without gloves or a gown. There was a contact isolation sign posted on the resident's door as well as a yellow isolation cart with gloves and hand sanitizer sitting on top of the cart outside the door. Observation, at this time of PTA BB inside R#38's room touching the bedside table and moving the bed away from the wall and then placing it back against the wall in its previous position. PTA BB elevated the head of R#38's bed and set the food tray up and positioned the bedside table in R#38's reach. Further observation at 7:57 a.m. revealed PTA BB exited the room without washing or sanitizing his hands. An interview and observation at 8:00 a.m. on 6/6/18 with PTA BB who was asked to explain his understanding of the procedure he should follow when he enters a room of a resident on contact isolation. PTA BB stated, I would put on a gown and gloves, whatever the sign says. PTA BB was asked if he would walk back down the hall to point out the last room he came out of. He confirmed that he had just come out of R#38's room. PTA BB also confirmed that there was a contact isolation sign on R#38's door as well as an isolation cart outside of the door. PTA BB further revealed that I did not pay attention, I did not notice the cart. I was busy looking at the ticket and didn't even look at the cart. The door was open, and I did not notice the sign on the door. Maybe if the door was closed or pulled up, I would have saw the sign. I mainly work in the hospital. I was just helping pass trays. An interview on 6/6/18 at 8:30 a.m. with Charge Nurse CC, Registered Nurse (RN) regarding her expectations of her staff when they go into the room of a resident who is on contact isolation she revealed that she expects the staff to stop and observe what is on the door and follow the instructions listed on the sign outside of the door. Charge Nurse CC states she expects a cart with required personal protective equipment (PPE) to be located outside the resident's door and that the cart is properly stocked. She further stated, if my staff have any questions regarding a resident on contact isolation they can contact the Staff Development/Infection Control Nurse or myself. If it is a CNA they should ask the nurse or they can call us regarding infection control and PPE. An interview with the Staff Development/Infection Control Nurse Licensed Practial Nurse (LPN) on 6/6/18 at 8:38 a.m. revealed that I expect staff to follow the guidelines for whatever the particular infection is. The Staff Development/Infection Control Nurse further revealed that if we get someone who is incontinent [MEDICAL CONDITION] in their urine, I expect the staff to put on a gown, gloves and to use hand sanitizer. The Staff Development/Infection Control Nurse stated that this information is covered in general orientation. The Staff Development/Infection Control Nurse further stated the standards and expectations in the hospital are the same as the nursing home in regard to what is expected of staff in caring for a person on contact isolation. The Staff Development/Infection Control Nurse provided a copy of the facility's policy titled Infection Control Isolation Precautions and provided in-service records of staff working in the facility. An interview was conducted with the Director of Nursing (DON) on 6/6/18 at 9:11 a.m. revealed that she expects her staff to follow the precautions whatever the needed precautions may be. She further revealed that if a resident was incontinent and [MEDICAL CONDITION] in their urine then certainly gloves and if it is a risk of you having to come in contact with the resident then you should go ahead and follow precautions and place a gown on also. Review of the facility policy Infection Control Isolation Precautions with a release date of (MONTH) 2011 revealed on page four of 25 in the section Transmission Based Precautions the following, contact precautions apply when transmission occurs from one person to another or the transfer of an infectious agent through a contaminated intermediate object to a person. Hands of personnel are usually cited as the most important contributors to indirect contact transmission. Use hand hygiene before entering the room. Wear gloves and a gown to enter the patient's room. Remove gloves and gown and use hand hygiene before exiting the room. Review of the facility's in-service transcript log revealed CNA DD completed a course titled Course 63 Strategies to Prevent the Spread of Infection, on 4/12/18 with a score of 100. The objectives of the course included the following: Recognize the impact of the spread of infections on patients, team members and the environment. Discuss infection prevention strategies for standard and transmission (isolation) based precautions Describe the team member's role and responsibility in preventing the spread of infection.",2020-09-01
545,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2018-05-03,656,D,0,1,4Q5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to develop a care plan for one of 40 sampled residents identified with left upper extremity contracture, Resident (R) R#40. Findings include: Review of R#40's clinical record revealed a [DIAGNOSES REDACTED]. R#40's most recent Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 2/19/18, documented R#40 as being cognitively intact and requiring extensive assistance of one to two staff persons for bed mobility, transfers, dressing and toileting. R#40 was further coded as having Functional Limitation in Range of Motion affecting one side of the body. A review of Section O, Special Procedures, did not code R#40 as receiving therapy, restorative nursing or wearing any splints. On 5/2/18 at approximately 9:00 a.m. R#40 was observed seated in her wheelchair beside her bed. A positioning tray was observed to be installed on the left arm of the wheelchair and R#40 had her left arm positioned on the positioning tray. R#40 was further observed to have paralysis of her left arm, the left hand was closed in a tight fist. R#40 was asked if she could open her hand, she stated that she could not. R#40 was asked if she had any type of splint that she used on that hand and R#40 stated that she used to have one that she wore but she had no idea what had happened to it. On 5/3/18 at 8:47 a.m., R#40 was observed seated in her wheelchair inside of her room, beside her bed. The positioning tray was observed to be in place and her left arm resting on the positioning tray. R#40 was not observed to be wearing any type of splint device to the left hand. LPN AA was invited into the room at 8:55 a.m. and R#40 gave permission to have the nurse open her hand to assess her palm. Licensed Practical Nurse (LPN) AA assisted the resident with opening her left hand. LPN AA was able to open R#40's hand with some difficulty, the resident did not complain of any pain, LPN AA explained that the fingers were permanently contracted and closed into a fist. The skin on the palm of R#40's hand and the underside of the fingers were observed to be clean, dry and without any skin breakdown. When asked if R#40 wore any type of splint device to prevent further contractures LPN AA stated that she didn't. LPN AA was made aware that R#40 had stated that she had worn a splint in the past but now she couldn't find it, R#40 stated that the splint was lost when she moved rooms. LPN AA stated that she had not seen a splint and that therapy had been working with her. When asked how the staff were assessing R#40's left hand and keeping it clean and free from skin breakdown, LPN AA stated that the staff looked at the resident's hand all the time and the aides made sure that the inside of the hand stayed clean and dry. A review of R#40's comprehensive care plan dated 2/24/15 with a revision date of 3/5/18 did not reveal any documentation regarding R#40's left hand contracture or the care necessary to maintain current level of function or to prevent skin breakdown at the contracture site. On 5/3/18 at 9:45 a.m. an interview was conducted with LPN BB, the MDS Coordinator, revealed that the MDS coordinators were responsible for completing the initial residents' comprehensive care plans at the time of admission. When asked the purpose of the care plan, LPN BB stated that it was a written communication for everyone to know how to care for the patient, it provided the process/ guide to take care of the resident. LPN BB further stated that it was the facility's goal that the care plan to be an up to date reflection of the needs of the resident. At this time LPN BB reviewed R#40's comprehensive care plan specifically for documentation regarding the left-hand contracture and any interventions in place to prevent further range of motion decline or skin breakdown of the left palm. LPN BB stated that she knew that there was nothing in the care plan about the hand. I included positioning (of the body) and turning the resident while in bed but nothing about the hand. When asked if the hand should be care planned, LPN BB stated that it should have been. A policy was requested that addressed care planning. On 5/3/18 at 2:44 p.m. the Administrator and Corporate nurse were made aware that there was no care plan for R#40's left hand contracture. The Corporate nurse stated that this was something that should have been care planned and that neither the Corporate nurse or the Administrator understood why it was not. A review of the facility policy titled Patient's Plan of Care dated (MONTH) (YEAR) revealed, in part, the following documentation: Intent. It is the intent of this center to develop and maintain an individualized plan of care for each patient. 2. The care plan is developed from the patient assessment (MDS) and in coordination with the attending physician's regimen of care. All professional personnel involved in the care of the patient review the care plan as necessary, but at least quarterly. 3. The care plan is available for use by all personnel providing care/services to/for the patient. It includes, but is not limited to: F. Prevent declines in the patients (sic) functional status and/or functional levels; and [NAME] Enhance the optimal functioning of the patient by focusing on a rehabilitative program.",2020-09-01
546,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2018-05-03,688,D,0,1,4Q5M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to provide Resident (R) #40 with a splint / device to her left, contracted hand to prevent further functional decline. The facility further failed to provide evidence that the splint was no longer offered / provided to R#40 due to refusing to wear the splint. The sample size was 40. The findings include: R#40 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of R#40's most recent Minimum Data Set (MDS), a quarterly assessment with an Assessment Reference Date (ARD) of 2/19/18, documented that R#40 was cognitively intact with decisions regarding daily living and required extensive to maximum assistance in all activities of daily living except for eating. R#40 was further coded as having Functional Limitation in Range of Motion on one side of her body. Under Section E, Rejection of Care was coded as not occurring. R#40 was further coded as not wearing splints. Further review of R#40's MDS assessments revealed a comprehensive assessment with an ARD of 12/26/17. Under Section V, Care Area Assessments ADL (activities of daily living) Functional/Rehabilitation was checked as being triggered for care planning. A review of the therapy notes for R#40 revealed, in part, Occupational Therapy notes with a service date of 5/2/17 that documented, in part, the following: PROM (passive range of motion) provided to LUE (left upper extremity) into all planes followed by splint application. Encouragement provided for splint compliance. The 5/2/17 therapy note also included the following documentation: CNA (name of CNA CC) provided education and verbalized understanding regarding splint application at night as well as precautions. Review of R#40's comprehensive care plan dated 2/24/15 with a revision date of 3/5/18 revealed there was no documentation describing a contracture of R#40's left hand / fingers and the application of a splint and PROM (passive range of motion) exercises to prevent further contractures. A review of the Physician Orders did not reveal an order for [REDACTED]. An observation was made of R#40 in her room on 5/2/18 at approximately 9:00 a.m. R#40 was sitting in her wheelchair and had her left arm / hand, the side affected by her stroke, propped on a left sided positioning tray. R#40 was asked if she could move her hand and she stated that she could not move the hand or open the fingers on that hand. The fingers were observed to be contracted in a curled position inside the palm of her hand. R#40 was asked if she ever wore a splint to help position her fingers off the palm of her hand. R#40 stated that she used to but didn't know where the splint was any more. R#40 further stated that she didn't know what happened to it. R#40 was observed on 5/3/18 at 8:47 a.m. in her wheelchair at her bedside. Her left arm was positioned on the left sided positioning tray and she was not observed to be wearing a splint. R#40 provided permission for Licensed Practical Nurse (LPN) AA to open her left hand to assess the skin integrity of the palm. LPN AA opened R#40's fingers with difficulty stating that it was very difficult to open her hand as her fingers were so severely contracted. The palm of the hand was observed to be clean, dry and free from any skin breakdown. LPN AA was asked if she was aware of having a splint to lift the fingers from the palm of the hand. LPN AA stated that she was not aware of a splint and opened the top drawer of the cabinet beside R#40's bed stating that if there was a splint it would be in the drawer. The drawer was empty. LPN AA stated that therapy had worked with R#40 in the past but she was unaware of the splint or any type of recommendations. An interview was conducted on 5/3/18 at 2:00 p.m. therapy staff (TS) FF, seated in the therapy room. TS FF were asked to comment on R#40's refusal to wear a splint. TS FF stated that the therapy staff who had worked with R#40 was no longer at the facility and the current therapy staff could only provide the note documented on 5/2/17. TS FF were asked if R#40 was currently receiving therapy they stated she was being evaluated by physical therapy for wheelchair positioning, but they had not been asked to evaluate her hand. On 5/3/18 at 2:20 p.m. an interview was conducted with Certified Nursing Assistant (CNA) CC, an aide consistently assigned to care for R#40, at the nursing station. CNA CC was asked if she remembered R#40 wearing a brace/splint to the left hand. CNA CC stated that she did remember that R#40 used to have a brace but that she no longer had it. When asked what happened to the brace/splint CNA CC stated that she did not know, It's just not there (in her room) anymore. CNA CC was asked if she remembered receiving training in (MONTH) (YEAR) on applying the brace/splint to R#40's hand. CNA CC stated that she did and that the resident was wearing the device at that time. CNA CC further stated, I don't remember when the brace went missing or when it stopped being used. When I put the brace on her she would not leave it in place. I just can't say when the brace was no longer available. When asked what instruction she received to provide care to R#40's left hand contracture CNA CC provided her ADL sheet, the document was titled Baseline Care Plan, did not contain a date, and handwritten on the document was has hemi tray on left side of w/c and will have no skin break on left hand. There was no documentation regarding a splint, Passive Range of Motion (PROM) or cleansing of the left hand. When asked if she provided PROM to R#40's left hand, CNA CC stated that she did not. On 5/3/18 at 2:25 p.m. LPN AA approached this writer at the nursing station and stated, I remember that she (R#40) did have a splint but she wouldn't leave it on and therapy was trying something else out. LPN AA was unable to state whether or not R#40 was currently receiving therapy. LPN AA was asked if there was any documentation regarding R#40's refusal to wear the brace/ splint. LPN AA stated, The nurses should have documented her refusals in the nursing notes. I was told she (R#40) wasn't going to wear it anymore. LPN AA further stated that she was fairly new to the hallway and this information had been provided by other nursing staff, she was unable to recall which nursing staff. LPN AA reviewed R#40's clinical record and stated that she did not see any documentation regarding the resident's refusal to wear the splint. LPN AA stated that she thought that the splint issue had been resolved a while back. On 5/3/18 at 2:30 p.m. an interview was conducted with Registered Nurse (RN) DD, the Unit Manager, at the nursing station. RN DD was asked if there were any restorative notes for R#40 or any documentation regarding her refusal to wear a splint as recommended and initiated by occupational therapy. RN DD stated, I don't have any documentation to verify that the splint was discontinued because of the resident's refusal. RN DD also stated that she had no documentation that evidenced any refusals by R#40 to wear the splint. On 5/3/18 at 2:44 p.m. a meeting was conducted with the Administrator and RN EE, the Corporate Nurse in the Administrator's office. The Administrator and RN EE were made aware that the staff were unable to provide evidence that the resident had refused to wear the splint as recommended by occupational therapy and that the resident had not been wearing a splint on her left hand to prevent increased contractures to the left hand. RN EE stated that she would like to review the overflow chart stored in another building. On 5/3/18 at 3:06 p.m. RN EE stated that she was unable to find any documentation from nursing or therapy in the overflow chart to evidence that R#40 refused to the wear her splint and that the splint had been discontinued. A policy was requested regarding the use of assistive devices to maintain functionality. None was provided prior to the end of the survey.",2020-09-01
547,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2017-06-08,276,D,0,1,B6X811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Minimum Data Set (MDS)D assessments and staff interview, the facility failed to conduct a Quarterly MDS for one of 22 sampled residents (R) (R#101). Findings include: Record review for R#101 revealed an Annual MDS assessment dated [DATE]. Further review revealed no evidence that a Quarterly MDS assessment was conducted in May, (YEAR). Interview on 5/8/17 at 2:45 p.m. with the Registered Nurse (RN)/MDS Coordinator revealed that the former MDS Director would give her a calendar list of residents that were due MDS assessments each month. The RN/MDS Coordinator checked the calendar list for April, (MONTH) and (MONTH) of (YEAR) and R#101's name was not on the list. She stated that somehow R#101's name got missed and that she should have had a Quarterly Assessment in (MONTH) (YEAR), but one had never been conducted. Interview on 5/8/17 at 2:50 p.m. with the former RN/MDS Director ([NAME] Costello/RN) revealed that the process for knowing which residents are due for an MDS Assessments is by reviewing the MDS 3.0 Due Dates Report generated by the Keane computer program. She then transfers the names to the calendar list and splits the halls with the RN/MDS Coordinator. The former RN/MDS Director printed the (MONTH) and (MONTH) (YEAR) list of residents that needed an assessment for that month. Review of the MDS 3.0 Due Dates Report for (MONTH) and (MONTH) (YEAR) did not display R#101's name on the list. The former RN/MDS Director stated that the resident's name should have been on the (MONTH) (YEAR) list because her last OBRA assessment conducted was an Annual Assessment on 2/22/17. She stated that she thinks that she may have intended on combining the 5 day PPS assessment, after return from the hospital on [DATE], with the quarterly assessment that was due in May, (YEAR) but she did not. Review of the MDS 3.0 Due Dates Report for the month of (MONTH) and (MONTH) (YEAR) revealed no evidence of R#101's name on the list. Review of the untitled document that the RN/MDS coordinator called the Calendar List for the months of April, (MONTH) and (MONTH) (YEAR), revealed no evidence of R#101's name on the calendars.",2020-09-01
548,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2017-06-08,280,D,0,1,B6X811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to update the care plan with an intervention for an alternating pressure mattress (APM) for one resident (R) #28. In addition, the facility failed to update the care plan to reflect that one resident #119 became entrapped in the assist rail during a fall from the bed. The sample size was 22 residents. Findings include: 1. Review of R #28's Admission Minimum Data Set ((MDS) dated [DATE] and her Quarterly MDS dated [DATE] noted that she was a pressure ulcer risk, but had no unhealed pressure ulcers. Review of a care plan for risk for development of a pressure ulcer with a original development date of 6/29/16 noted that R #28 was unable to move self in bed to sufficiently relieve pressure over any one site, and was updated on 3/27/17 to reflect the development of an unstageable pressure ulcer to the right ischium. Review of the interventions for the care plans revealed that they did not include use of an APM mattress. Review of an SBAR (Situation-Background-Appearance-Review and Notify) form dated 3/27/17 revealed that the resident had developed an unstageable pressure ulcer to the right ischium, and revealed an intervention for an APM mattress. Review of a PAR (Patient at Risk) Review form dated 3/29/17 revealed R #28 developed an unstageable pressure ulcer to the right ischium, and assessed for care plan considerations of an APM mattress. Review of a PAR Review form dated 4/19/17 again assessed for the use of an APM mattress. Observation of R #28 in the bed on 6/6/17 at 3:10 p.m., 6/7/17 at 7:55 a.m. 1:00 p.m., and 2:06 p.m. revealed that there was no APM on the bed. During observation of wound care on 6/7/17 at 10:01 a.m., the Licensed Practical Nurse (LPN) Wound Care Coordinator stated that R #28 was admitted with very bony prominences, and that they put an APM mattress on the bed on admission. However, no APM mattress was observed on the bed at this time. Cross-refer to F 314. 2. Review of R #119's Quarterly MDS dated [DATE] revealed that she had two or more falls since the prior MDS assessment. Review of a Fall Risk Evaluation dated 5/24/17 revealed that she was assessed as being high risk for falls. Review of her Nurse's Notes revealed that on 5/24/17 at 2:15 a.m., a CNA (Certified Nursing Assistant) found that the resident had rolled out of the bed, and that her right arm and hand were hung in the assist rail with her legs on the ground. Review of the resident's high risk for falls care plan, as well as the Falls Intervention Plan, revealed that an intervention for a pool noodle (used to define the perimeter of the bed) was added as an intervention on 5/24/17, but there was no notation of the resident becoming entrapped in the assist rail, nor assessment for the rail's continued use. During interview with Licensed Practical Nurse (LPN) CC on 6/8/17 at 9:14 a.m., who was the falls coordinator, she stated that after R #119's fall on 5/24/17, that the only intervention implemented was for a pool noodle for the bed. Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revised date of 5/1/17 revealed: Each patient's risk for falls is evaluated by the interdisciplinary team. A plan of care is developed and implemented based on this evaluation with ongoing review. If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. Cross-refer to F 323.",2020-09-01
549,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2017-06-08,314,D,0,1,B6X811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to consistently assess and measure a pressure ulcer weekly per their Assessment of Wounds policy, and failed to consistently provide an alternating pressure mattress (APM) as assessed for one resident (R) #28. The sample size was 22 residents. Findings include: 1. Review of R #28's clinical record revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a Braden Scale (used to predict pressure sore risk) dated 3/23/17 noted a score of 10 (a score of 10 to 12 assessed a resident as being high risk for pressure ulcer development). Review of her Admission Minimum Data Set ((MDS) dated [DATE] noted that she was a pressure ulcer risk, but had no unhealed pressure ulcers. Review of her Quarterly MDS dated [DATE] revealed that she had short- and long-term memory problems, and severely impaired cognitive skills for daily decision making, was totally dependent for all activities of daily living including bed mobility, and was a pressure ulcer risk but had no unhealed pressure ulcers. Review of a care plan for risk for development of a pressure ulcer with a original development date of 6/29/16 noted that R #28 was unable to move self in bed to sufficiently relieve pressure over any one site, and was updated on 3/27/17 to reflect the development of an unstageable pressure ulcer to the right ischium. Review of the interventions for the care plans revealed that they did not include use of an APM mattress. Review of an SBAR (Situation-Background-Appearance-Review and Notify) form dated 3/27/17 revealed that the resident had developed an unstageable pressure ulcer to the right ischium that measured 2.0 by 2.5 by 0.2 cm (centimeters) with 40% slough. Further review of this SBAR revealed an intervention for an APM mattress. Review of a PAR (Patient at Risk) Review form dated 3/29/17 revealed R #28 developed an unstageable pressure ulcer to the right ischium, and assessed for care plan considerations of an APM mattress. Review of a PAR Review form dated 4/19/17 again assessed for the use of an APM mattress. Observation of R #28 in the bed on 6/6/17 at 3:10 p.m., 6/7/17 at 7:55 a.m. 1:00 p.m., and 2:06 p.m. revealed that there was no APM on the bed. During observation of wound care on 6/7/17 at 10:01 a.m., the Licensed Practical Nurse (LPN) Wound Care Coordinator stated that R #28 was admitted with very bony prominences, and that they put an APM mattress on the bed on admission. However, no APM mattress was observed on the bed at this time. During interview with the LPN Wound Care Coordinator on 6/7/17 at 2:29 p.m., she stated that something went wrong with the pump on the APM mattress over the weekend and the mattress deflated, and was replaced with a brand new foam mattress. During further interview, she stated that the facility's consultant said that the foam mattress would do the same thing as the APM mattress. During observation and interview with the Wound Care Coordinator on 6/7/17 at 3:20 p.m., she verified that R #28 had a regular pressure-reduction mattress on her bed, and not an APM mattress. During interview with the Environmental Services Supervisor on 6/8/17 at 7:13 a.m., she stated that she was responsible for ordering specialty mattresses. She further stated that R #28 had an APM but the motor broke on it about four weeks ago. During further interview she stated that the Wound Care Coordinator told her that it would be OK to put a therapeutic foam mattress on her bed as her wound was healing, and that they could put put an APM back on the bed if the wound got worse. She further stated that she had no documentation of when the APM mattress was applied or removed, and that the foam mattress currently on R #28's bed was the same as what all the other residents had on their beds (if they weren't on a specialty mattress). Review of a physician's Progress Note dated 5/29/17 revealed it was a follow-up visit to evaluate patient's pressure mood (sic), as a family member was very concerned about the fact they they do not seem to be healing. The sacral wounds were evaluated today. The stage III to IV ulcer was 3 by 3 cm with 0.5 cm undermining at 12 noon. Attempt to position to take pressure off her sacral area. Review of a physician progress notes [REDACTED]. Review of R #28's Interdisciplinary Progress Notes from 3/27/17 to 6/7/17 revealed that there was no mention of the presence of an APM mattress nor the removal of an APM mattress due to mechanical failure. Review of the Treatment Record-Wound Assessment notes from (MONTH) through (MONTH) revealed the only mention of a specialty mattress was on 4/24/17, which noted preventive measures in place included an APM mattress. Review of a Mattresses 1/2/2017 audit revealed that R #28 had an APM mattress on the bed at that time. On 6/8/17 at 7:03 a.m., R #28 was observed to have an APM mattress on her bed. 2. Review of Treatment Record-Wound Assessments revealed that R #28 was identified with an unstageable pressure ulcer to her right ischial area on 3/27/17, measuring 2.0 by 2.5 cm, and contained slough. The next measurement recorded was on 4/10/17, 14 days later, and was measured as 3.5 by 4.0 cm and contained slough. Review of the (MONTH) Treatment-Wound Assessment revealed that the ischial wound was assessed on 5/3/17, 5/10/17, and 5/17/17, but then not again until 5/29/17 (12 days since the previous assessment). At this time the wound was noted to have 0.5 cm of undermining (destruction of tissue extending under the skin edges so the the pressure ulcer is larger at its base than at the skin surface) for the first time. During observation of wound care with the LPN Wound Care Coordinator on 6/7/17 at 10:01 a.m., a wound containing approximately 50% slough was observed to the right ischial area. During interview with the Wound Care Coordinator at this time, she stated that she measured wounds weekly. She further stated that wounds were evaluated weekly, and if there was no healing progress that the treatment would be changed every two weeks. During interview with the LPN Wound Care Coordinator on 6/7/17 at 2:29 p.m., she stated that she was off work the first week in April, and when she was gone the Resident Care Coordinator (RCC) was responsible for doing the wound care. She further stated that the staff had recently been directed that only the wound care nurse could assess and measure wounds, so that there would not be anything contradictory to how the wound nurse was assessing the wounds. She stated during further interview that the RCC could put an approximate size of a wound in terms of something like the size of a quarter. She verified during further interview that there were no wound measurements between 3/27/17 and 4/10/17. Review of the facility's undated Assessment of Wounds (Treatment Record) policy revealed that it is the responsibility of a licensed nurse to complete the wound assessment and to document the findings on the Treatment Record-Wound Assessment. Assessment and documentation are completed upon admission, readmission, weekly and prn (as needed). The patient's wound is measured using a clean, disposable measuring guide and cotton tip applicator (as indicated).",2020-09-01
550,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2017-06-08,323,D,0,1,B6X811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to reassess for continued use of an assist siderail after one resident's (R) #119, of 22 sampled residents, arm got caught in the rail during a fall from the bed. The sample size was 22 residents. Findings include: Review of R #119's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Admission Minimum Data Set ((MDS) dated [DATE] revealed that she had a fracture related to a fall in the past six months prior to admission to the facility. Review of her Quarterly MDS dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment), and had two or more falls since the prior MDS assessment. Review of a Skilled Services Discharge Review dated 3/21/17 noted that the safest transfer method was a mechanical lift, and that R #119 was a high fall risk and had two falls without injury in the last week. Review of a Fall Risk Evaluation dated 5/24/17 revealed that she was assessed as being high risk for falls. Review of her falls care plan developed 1/13/17 revealed that she was high risk for falls, and was currently being treated by therapy for a right hip fracture. Review of her Nurse's Notes revealed that she had seven falls since admission to facility, including five falls from the bed. Further review of the Nurse's Notes revealed that on 5/24/17 at 2:15 a.m., a CNA (Certified Nursing Assistant) found that the resident had rolled out of the bed, and that her right arm and hand were hung in the assist rail with her legs on the ground. Slight red area noted to where the bar was pressing into her arm and hand, but no pain or injury. Review of a Physician's Progress Note dated 5/24/17 revealed that the resident had a fall early that morning, and had slight redness to the right arm where her arm was in the siderail. Further review of R #119's clinical record revealed that no assessment was found for use of the assist rail, including an assessment for it's continued use after the resident's arm had become entrapped in it. During observation on 6/5/17 at 3:10 p.m., 6/6/17 at 3:18 p.m., and 6/7/17 at 7:50 a.m., one assist siderail was noted to be attached to the top right side of R #119's bed which was in the low position. On 6/7/17 at 2:05 p.m., the assist rail was observed to be gone from R #119's bed, and interview with the resident's roommate at this time revealed that she observed staff remove the rail that morning. During interview with the Rehabilitation Director on 6/7/17 at 3:03 p.m., she stated that nursing referred all resident falls to them, and they would try to determine what caused the fall. She further stated that there was no form used to assess for siderail use to her knowledge, and that therapy educated residents on the use of siderails for bed mobility as indicated. During further interview, the Rehabilitation Director stated that she did not recall R #119 having a fall with her arm getting hung in the assist rail, and that if a rail was a safety risk, she would not recommend the further use of one. During interview with the Director of Nursing (DON) on 6/8/17 at 7:30 a.m., she stated that resident falls were discussed in morning meetings, and that she and the Resident Care Coordinators (RCC) reviewed the falls to make sure the interventions were appropriate to prevent future falls. She further stated that the nurse on duty at the time of the fall should put an immediate fall prevention intervention in place. During continued interview with the DON, she stated that the facility did not use any siderails, only assist bars, and that recently MDS staff began doing assist rail assessments so all residents would be assessed for their use. During further interview, she stated that she did not recall anything about R #119's fall on 5/24/17, and that if a resident got a body part caught in a rail she would involve therapy for evaluation. During interview with Registered Nurse (RN) BB on 6/8/17 at 7:48 a.m., she stated that she was assigned to start doing assist rail assessments since 6/1/17, and that these assessments had not been done prior to this. She further stated that she knew that R #119 did not use her assist rail, and so had it removed that day. During continued interview, RN BB stated that if she had been made aware that a resident got their arm hung in an assist rail, that she would recommend the rail be taken off the bed as it would be more of a risk to leave it on. During interview with Licensed Practical Nurse (LPN) CC on 6/8/17 at 9:14 a.m., who was the falls coordinator, she stated that after R #119's fall on 5/24/17, that the only intervention implemented was for a pool noodle for the bed (placed under the fitted sheet to define the perimeter of the bed). During interview with LPN CC and the DON at this time, they stated that the assist rail should have been taken off the bed after the fall on 5/24/17. During further interview with LPN CC, she stated that she could find no documentation of any discussion of R #119's fall on 5/24/17, and that any fall should be discussed in PAR (Patient at Risk) meetings. She further stated that the RCC completed the Fall Risk Evaluation after the fall on 5/24/17, and verified that there was no mention that the resident's arm had become entrapped in the assist rail. Review of an undated Residents Side Rail Utilization Audit revealed that R #119 had one assist rail on the right side of the bed. During interview with the DON at this time, she stated that she was not sure when this audit was done, and that they did not have a siderail policy. During interview with CNA DD on 6/8/17 at 9:40 a.m., she stated that during her 2:00 a.m. rounds on 5/24/17, that she had found R #119 with her bottom and legs on the floor, and her right arm through the siderail. She further stated that it looked like the resident slid out of the bed and got her arm hung inside the siderail, and couldn't get it out. During further interview she stated that she called for help, and that staff had to ease the resident up off the floor so that they could get her arm out of the siderail, but that her arm was not hurt and she had never known the resident to get caught in a siderail before. During interview with the Rehabilitation Director on 6/8/17 at 12:20 p.m., she stated that she was not asked to screen the resident after the fall on 5/24/17. Review of R #119's Report of Resident Fall dated 5/24/17 at 2:15 a.m. noted: Resident rolled partially out of bed with right arm hung down in siderail and legs on ground. States doesn't know how she got there. Unwitnessed fall to floor in resident room. Last known location in bed. Safety measures to prevent a fall in place prior to event. Preventative measures: Low bed; encouraged and taught use of call light; grab bar in bathroom; night light used; oriented to surroundings; assessed need for pain medication; room free of clutter; snacks offered; bed in low position; items placed within resident's reach; non-skid shoes/slippers; room well lit; strengthening exercises; toileted at least every two hours. What assistive devices and interventions were in use at the time of the event by the resident?: Assist rails. Was the resident injured?: Yes. Minor injury, red areas on arm where hung in siderail. No treatment. Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revised date of 5/1/17 revealed: If a fall occurs, the interdisciplinary team conducts an evaluation to ensure appropriate measures are in place to minimize the risk of future falls. When a patient is found on the floor, the facility is obligated to investigate to determine how he or she got there and put into place an intervention to minimize it from recurring. Patients experiencing falls should be reviewed in the morning meeting. Patients should be reviewed in the Patient at Risk (PAR) meeting as indicated. When a fall occurs: Implement intervention/s to prevent recurrence and maintain patient safety. Review falls with the IDT (interdisciplinary team) in the morning meeting to ensure appropriate actions have been taken and documentation is accurate and complete. Review the event and patient status at the next scheduled PAR meeting as indicated.",2020-09-01
551,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2017-06-08,371,E,0,1,B6X811,"Based on observation, record review, and staff interview, the facility failed to maintain the refrigerator, countertops and cabinets in one of one resident pantries in a manner to prevent the potential for food-borne illness. There were 87 residents that consumed an oral diet. Findings include: Observation and interview on 6/8/17 at 10:45 a.m. with the Dietary Manager and the Environmental Services Supervisor, revealed the refrigerator in the resident pantry was observed to contain a one-gallon jug of whole milk, stamped with a use by date of 6/7/17. Further observation revealed a clear plastic cylindrical container of fresh fruit labeled for a resident. Review of a sticky-note on the lid of this container revealed that it was dated 5/29/17, and it had a grocery store use by date of 5/6/17. Further observation in the refrigerator revealed a plastic bag that contained an opened package of cinnamon rolls, with two of the six rolls missing, and the package was not labeled or dated when opened. Observation of three of the three glass refrigerator shelves revealed that they were covered with a wet, clear liquid that clung to any item picked up in the refrigerator. Further observations in the resident pantry at this time revealed the following: -There was a one-gallon tub of peanut butter approximately two-thirds full on the countertop, with no labeling of when the container was opened, and the lid was not completely sealed. -There was a white liquid on the countertop close to the refrigerator with the approximate size of a half dollar. -There was a wad of wet paper towels on the countertop next to the sink. -There was a white paper bag containing a sandwich with bacon inside a plastic bag on the countertop close to the pantry door, with no labeling on any of the packaging or bags. -There was an unknown, unlabeled cream-colored substance in a sealed plastic bag with a spigot on the second shelf of the cupboard. -There was a red plastic drinking glass with a paper towel stuffed inside of it on a shelf in the cupboard. These observations were verified by the Dietary Manager and the Environmental Services Supervisor at this time. Continued interview with the Environmental Services Supervisor, she stated that her staff cleaned the pantry early every morning, and that she inspected the pantry twice a week. She further stated that housekeeping was responsible for the cleanliness of the countertops, and for anything stored in the cupboards. During continued interview with the Environmental Services Supervisor and Dietary Manager at this time, they stated that the clear liquid on the refrigerator shelving was probably condensation from staff opening the refrigerator, and that the housekeepers were responsible for wiping the shelves daily. During an interview with the Dietary Manager at this time, he stated that the dietary staff delivered food to the pantry, and they were responsible for labeling and dating all newly placed foods, and that any unlabeled, undated, or expired items were discarded. Review of a typed form taped to the front of the pantry refrigerator revealed the following: Any food placed in the refrigerator must have their names and room number and date when you put it in the refrigerator. If not, it will be discarded. Foods must have an open date. During interview with the Environmental Services Supervisor on 6/8/17 at 3:40 p.m., she stated that there was no specific policy related to cleaning of the pantry.",2020-09-01
552,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2018-07-25,580,D,1,0,REIB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff, family, Nurse Practitioner and Medical Director interview and review of facility policy, the facility failed to notify one Responsible Party of a [DIAGNOSES REDACTED].#3). The facility failed to notify a Physician of a medication that was not available for administration for three days for one resident,(R#3). The sample was five residents. Findings include: 1. Review of the clinical record for R#2 revealed a notice to the Nurse Practitioner dated 6/19/18 at 7:00 p.m. indicating the family had noticed a strong urine odor and requesting a urinalysis with culture and sensitivity. The urinalysis was collected as ordered on [DATE] and reported on 6/21/18. The results of the culture and sensitivity were reported to the facility on [DATE] and indicated R#2 had a urinary tract infection that was sensitive to [MEDICATION NAME]. Review of the Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED] The clinical record was searched for documentation related to notification of the Responsible Party (RP) of the urinary tract infection and the order for antibiotic administration and no documentation of notification could be found. An interview was conducted with the Director of Nurses (DON) on 7/23/18 at 9:05 a.m. and she was aware the urinalysis result and antibiotic order had not been reported to the family of R#2 and was unable to educate the nurse who had received the antibiotic order because she is no longer employed by the facility. The DON confirmed there was not one specific policy indicating the nursing staff are to notify the RP of any changes, but the staff all know to do this. During an interview conducted with two family members of R#2 on 7/23/18 at 4:20 pm and the Responsible Party for R#2 on 7/24/18 at 1:40 p.m., they revealed the facility had not notified them of the urinalysis results and the order for antibiotics that followed until they had asked one of the Resident Care Coordinators (RCC) and by then R#2 had completed the antibiotic therapy. An interview with the RCC II on 7/25/18 at 4:55 p.m. revealed she was aware of the antibiotic (ABX) order for the resident's UTI not being communicated to the family in a timely manner, The ABX was ordered 6/23/18 and started on that date, and she thinks the residents family was notified on 6/25/18 or 6/26/18, but there is no documentation to indicate they were notified at all. The RCC revealed there had been an education given to all nurses a few months ago regarding notification of families of any changes with the residents and documentation of the notifications, but the family was not notified. The nurse was working her last day of her notice and cannot be reached. 2. Review of the clinical record for R#3 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Continued review revealed a hospital Physician's Progress Note dated prior to the resident's initial admission to the facility, 4/12/18 indicating R#3 had been admitted to the hospital multiple times for elevated sodium levels. Continued review of the clinical record indicated a consulting Nephrologist closely managed her care, in conjunction with the facility Medical Director and Nurse Practitioners. The Nephrologist ordered Basic Metabolic Panels (BMP) to monitor her sodium and other electrolyte levels periodically. Review of a seven (7) page consultation note written by the Nephrologist revealed continued concern regarding R#3 requiring [MEDICATION NAME], a steroid medication used to treat [MEDICAL CONDITION] in conjunction with [MEDICATION NAME]. The Nephrologist explained in the consultation that [MEDICATION NAME] elevates sodium levels but R#3 requires the medication for [MEDICAL CONDITION], and increasing fluid intake to control elevated sodium levels has not been effective due to the residents dementia, resulting in erratic fluid intake. A physician's orders [REDACTED]. Additionally the Nephrologist ordered the facility to encourage 2200 milliliters (mls) of fluids every day, and to decrease the [MEDICATION NAME] to one half tablet daily. Review of the lab reports for R#3 revealed the BMP's were drawn by the laboratory, and the results were communicated to the Nephrologist on 5/24/18, and 6/7/18. The BMP results on 6/7/18 indicated a sodium level of 144, which is within the normal range of 136 to 145. On 6/21/18 the BMP was collected by the lab as ordered, and the results returned the same day, with an elevated sodium level of 155. The clinical record did not include any indication of this result being faxed or called to the Nephrologist. A note on the lab report indicated the results had been called to the facility Nurse Practitioner, who ordered fluids be encouraged. This order had been given four (4) weeks previously by the Nephrologist, and the sodium level had become elevated despite this continued order, as well as decreasing the [MEDICATION NAME] dosage by half. The clinical record was searched for any indication the elevated sodium level had been communicated to the Nephrologist who ordered the BMP and could not be found, until 7/9/18. During an interview with Resident Care Coordinator (RCC) II on 7/24/18 at 4:10 p.m. she revealed a Complete Metabolic Panel (CMP) was ordered on [DATE] by the Nurse Practitioner because R#3 had an appointment with the Nephrologist on 7/11/18 and needed to bring updated results. The CMP was drawn on 7/10/18 and the sodium result was 175, which was critically elevated. The Nurse Practitioner was advised of the results, and ordered intravenous fluids, and to repeat the CMP on 7/11/18 and to notify the Nephrologist. The Nephrologist was notified of the critical sodium level collected on 7/10/18, and the resident was transferred to the hospital on [DATE]. Attempts were made by the surveyor to communicate with the Nephrologist on 7/25/18 at 3:15 p.m. and 4:30 p.m. and on 7/26/18 at 12:05 p.m. and 1:00 p.m. and two (2) call back messages were received on 7/25/18 and 7/26/18 and were unable to be answered due to poor reception. The last call to the Nephrologist was not answered. The office staff revealed they were not authorized to speak to the surveyor. R#3 returned from the hospital on [DATE]. Review of the transfer orders from the hospital indicated R#3 was to continue receiving [MEDICATION NAME] 5 mg, two tablets by mouth at bedtime (hs). The transfer order was approved by the Medical Director, who managed the care of R#3. Review of the Medication Administration Record [REDACTED]. An interview with LPN EE on 7/24/18 at 6:35 p.m. revealed she had worked for the facility for three weeks and had administered medications with another nurse on day shift then on night shift for two and a half weeks for orientation and had not encountered any missing medications. LPN EE confirmed this had not been discussed in orientation. When she had discovered the [MEDICATION NAME] for R#3 was missing on 7/19/18 she had thought it would be delivered later that night and did notify the Physician or Pharmacy or the oncoming shift. When she discovered it was still missing on 7/20/18 she looked for it in the medications that were left over from R#3's previous admission, found it and administered the [MEDICATION NAME] as ordered. LPN EE acknowledged she still did not notify the Pharmacy they needed to deliver the [MEDICATION NAME]. During an interview conducted on 7/24/18 at 7:07 p.m. LPN JJ revealed he had worked 7/21/18 and 7/22/18 and had not administered R#3 [MEDICATION NAME] 5 mg two tablets by mouth on those nights because it was not in the drawer. LPN JJ indicated he ordered the [MEDICATION NAME] on 7/21/18 and gave the other medications. LPN JJ confirmed he did not notify the Physician of not having the medication to administer on 7/21/18 and 7/22/18. LPN JJ revealed he was aware that [MEDICATION NAME] should not be skipped or stopped suddenly. Review of facility policy titled Medication Unavailable for Administration, reviewed and updated (MONTH) (YEAR) indicated if at any time a medication is not available for a specific time of administration, the nurse shall notify the prescriber that the medication is not available. During an interview with the Medical Director conducted on 7/25/18 at 12:10 p.m. the Physician indicated he was not notified R#3 had missed three doses of [MEDICATION NAME] when she returned from the hospital. He would expect to be notified if any resident with daily administrations of [MEDICATION NAME] missed 3 administrations in six days. The Medical Director confirmed he would probably have ordered a higher dose for a day or two if he had been informed. The Medical Director further revealed he expects the nursing staff to notify families when the residents have new medication orders, medication changes and any change in condition such as urinary tract infections. The Medical Director revealed he expects the nursing staff to notify the Physician who orders lab work of the results. Revealed he had discussed the care of R#3 with the Nephrologist recently and the Nephrologist is very involved with her care and would not have ordered lab work if he had not wanted to be made aware of the results. An interview on 7/25/18 at 5:05 p.m. with the Administrator, revealed she expects the nursing staff to notify the physician who orders laboratory testing of the results as soon as the results are received. The Administrator confirmed she expects the Nursing staff to notify families of their residents being started on antibiotic therapy and the reason for the order, as soon as the order is received. She further revealed that nursing staff is expected to notify the Physician whenever a resident misses a medication. The Administrator revealed that education of the new nurses should have included this information.",2020-09-01
553,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2018-07-25,755,D,1,0,REIB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff, Pharmacy Director and Medical Director interview, and review of facility policy, the facility failed to provide a medication, as ordered by the prescriber to meet the needs of one resident (R) (R#3). The sample size was five residents. Findings include: Review of facility policy titled Medication Unavailable for Administration Reviewed and updated (MONTH) (YEAR), revealed if a medication is not found in the appropriate place at the time of administration, the administering nurse shall call the provider pharmacy and inquire about the last dispensing date. The provider pharmacy may assist in obtaining the medication from a back up pharmacy, if available. The provider pharmacy may send the medication via a STAT delivery, if needed prior to the regularly scheduled delivery. Review of the clinical record for R#3, revealed on return from a hospital admission from 7/11/18 through 7/18/18, a Transferring Physician order [REDACTED]. The facility attending Physician approved the orders, and the [MEDICATION NAME] was to be continued. Review of the Medication Administration Record [REDACTED]. Review of the Pharmacy Delivery Sheet, dated 7/19/18 revealed no [MEDICATION NAME] was delivered for R#3. A resupply order was transmitted electronically on 7/22/18, indicating the [MEDICATION NAME] had been ordered by the Physician on 7/18/18. A note handwritten on the resupply order by a pharmacist indicated that unchanged medications were not delivered on return from the hospital 7/18/18. An interview with LPN EE on 7/24/18 at 6:35 p.m. revealed she had worked here for three weeks and had passed medications with another nurse on day shift then on night shift for two and a half weeks and did not have any medication that was ordered that was not available. LPN EE indicated this was not covered in orientation. She confirmed she noted the medication was ordered for R#3 on 7/19/18 and expected it to be brought that night or the next day. When the [MEDICATION NAME] was not found on 7/20/18, she had found the medication in the resident's previous admission medications and administered it. LPN EE confirmed she had not called the pharmacy or the Physician regarding the missing medication and was not aware that medications can be delivered from the pharmacy at any time they are needed. An interview with the DON revealed on 7/24/18 at 6:40 p.m. that medications are very seldom not available for administration and this may not have been covered in orientation of LPN EE who has only been employed here for three weeks. During an interview on 7/24/18 at 7:07 pm, LPN JJ revealed he had worked 7/21/18 and 7/22/18, and had not administered R#3 [MEDICATION NAME] 5 mg po on 7/21/18 or 7/22/18 at 9:00 pm, because it was not in the drawer. LPN JJ ordered the medication on 7/21/18, and gave the other medications. LPN JJ acknowledged he was aware that [MEDICATION NAME] administrations should not be omitted or stopped suddenly. LPN JJ confirmed he was aware that emergency deliveries from the pharmacy are available by calling the pharmacist on call, and revealed he thought the emergency deliveries were just for narcotics and antibiotics. During an interview conducted on 7/25/18 at 9:05 a.m. with the Director of Pharmacy, the Director revealed the pharmacy received notification of R#3's hospitalization on [DATE] and due to the new electronic medication administration system the discharge was not stopped on 7/18/18 when she returned to the facility. The new medications had been provided, but the medication continued from her previous admission was not delivered until 7/23/18. The Director of Pharmacy revealed the facility had all the medications for R#3 except the [MEDICATION NAME] and had pulled from what was left from her previous admission but it was not enough. There is a pharmacist on call twenty four hours a day, but the pharmacist had not been notified that the medication was needed, and a nurse had completed a resupply order on Sunday 7/22/18 and resupply orders are not reviewed until Mondays. The Director of Pharmacy confirmed there was no [MEDICATION NAME] in the Emergency Box. During an interview conducted on 7/25/18 at 5:05 p.m. the Administrator revealed she expects the nursing staff to obtain missing medications from the pharmacy day or night and on weekends and holidays. The Administrator acknowledged she expects the pharmacy to review orders for medications and deliver medications whenever they are needed. The Administrator confirmed the education of newly employed nurses should include this information.",2020-09-01
554,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2018-07-25,801,D,1,0,REIB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, Registered Dietician interview, interview with the Medical Director, and review of facility policy, the facility failed to ensure an admission nutritional assessment was provided in a timely manner for one resident (R) (R#3), determined to be at nutritional risk related to diagnoses, from a sample of five residents. Findings include: Review of facility policy titled Nutrition Screening, Assessment and Monitoring, Reviewed and updated for release (MONTH) (YEAR), revealed the Registered Dietician (RD) will complete a nutritional assessment after admission, annually, and as determined by the patient's needs and plan of care. Review of the clinical record for R#3 revealed admission to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the hospital record for R#3 revealed a Physicians Progress Note dated 4/12/18 that indicated R#3 had been hospitalized multiple times for [MEDICAL CONDITION]. Continued review of the clinical record revealed there was no Registered Dietician Admission Assessment, or any ongoing nutritional assessments. The Registered Dietician Assessments were requested from the Director of Nurses (DON) on 7/24/18 at 7:25 p.m. An interview conducted with the Medical Director on 7/25/18 at 12:10 p.m. revealed he expected all residents to have Registered Dietician admission assessments when they are admitted . The Medical Director confirmed he would consider a resident with a [DIAGNOSES REDACTED]. During an interview with the Regional Registered Dietician, conducted on 4/25/18 at 4:08 p.m., the dietician revealed she did not think it was necessarily a priority for a resident who has a [DIAGNOSES REDACTED]. The dietician indicated that an evaluation by the Dietary Manager was sufficient. The Regional Registered Dietician revealed that there is no specific time frame for newly admitted residents to be assessed for nutritional needs and these admission assessments can be completed any time during the first three months after admission. The facility RD had provided an admission assessment today by review of R#3's electronic clinical record. An interview on 7/25/18 at 4:17 p.m. with the Director of Nursing (DON) revealed that the DON is responsible for making a list of new admissions for the RD to see and the DON was sure she made this list and included R#3 when she was admitted in (MONTH) (YEAR). The DON confirmed there had been no RD admission assessment for R#3 until the surveyor had requested it on 7/24/18. The DON confirmed an RD had been in the facility on 4/25/18, 4/26/18, 5/30/18, 5/31/18, 6/1/18, and 6/25/18. During an interview on 7/25/18 at 5:05 p.m. the Administrator revealed she expects the RD to assess the nutritional needs of any newly admitted resident within two or three days of admission.",2020-09-01
555,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2019-07-25,582,D,0,1,Q8M711,"Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ) to 2 residents (R) (R #39 and R #66) who remained in the facility from a sample of three (3) residents reviewed who were discharged from Medicare Part A services in the last 6 months. Findings include: 1. Record review revealed that R #39 was discharged from Medicare Part A services on 7/8/19 and remained in the facility. However, the only notice that was provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence the facility issued an SNFABN (Form CMS- ) to R#39 or her responsible party, which would provide the opportunity to continue with skilled services, at her cost, if Medicare did not reimburse. 2. Record review revealed that R #66 was discharged from Medicare Part A services on 7/16/19 and remained in the facility. However, the only notice provided to the resident was the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ). There was no evidence that the facility had issued the SNFABN (Form CMS- ) to R#66 or his responsible party, which would provide the opportunity to continue with skilled services, at his cost, if Medicare did not reimburse. During and interview on 7/25/19 at 8:45 a.m., the Financial Controller (FC) AA confirmed that R#66 and R#39 had not been issued the SNFABN (Form CMS- ) although both had remained in the facility. She further stated she needed more training in this area. She stated she only gave them the generic CMS 3 form. A follow up interview on 7/25/19 at 12:12 p.m., with FC AA revealed that she was unable to locate the Beneficiary Protection Notice policy for the facility.",2020-09-01
556,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2019-07-25,585,E,0,1,Q8M711,"Based on observations, record reviews, review of facility policies and staff interviews, the facility failed to investigate 12 out of 82 grievances received. Findings include: A review of the facility policy titled Skilled Inpatient Services Grievance/Concern Guidelines for Patients with an updated for release date of (MONTH) 2019, copyrighted 2004-2018 GHSGa, revealed the center shall appoint a Grievance Officer who is responsible for overseeing the grievance process, receiving and tracking grievances, leading any investigations, and issuing written grievance decisions to the patient. If, at anytime during an active investigation, there is evidence that abuse may have occurred, this will immediately be reported to the administrator. The Social/Patient Services Director should be responsible for tracking all complaints. Once the concern is referred to the responsible discipline, the discipline is responsible for conducting a thorough investigation. A review of the facility polity titled Grievances Abuse Prohibition with an updated for release date of (MONTH) (YEAR); copyrighted 2004-2017, revealed it is the intent of the center to actively preserve each patient's right to be free from mistreatment, neglect, abuse or misappropriation of patient property. The center will identify, correct, and intervene in situations in which abuse, neglect and/or misappropriation of patient property is more likely to occur. A review of the facility Concerns Log for grievances received from 5/7/2018 through 7/16/2019, revealed the facility received 82 grievances, during that time, related to nursing care, courtesy and respect, missing/lost items, and/or other. Of the 82 incidents reviewed, 12 of the incidents were not investigated. A review of the facility policy titled Skilled Inpatient Services Reporting and Investigating Abuse with an updated for release date of (MONTH) 2019, copyrighted 2004-2018 GHSGa, revealed once a complaint is identified involving alleged mistreatment, neglect, or abuse .the incident will be immediately reported (within 2 hours). A review of facility grievance reports revealed the following 12 reports were not investigated: 5/23/2019, two grievances on 5/8/2019, 4/29/2019, 4/4/2019, 4/2/2019, 4/1/2019, 3/14/2019, 3/1/2019, 2/26/2019, two grievances on 2/19/2019. An interview with the facility Administrator, Social Worker, and Regional Nurse, on 7/24/19 at 9:06 a.m., the Administrator reported, when she came to the facility in (MONTH) 2019, she realized the grievance process at the facility needed some improvement. She began an improvement process and realized a lot of people did not have access to the software program used for entering and tracking grievances. She reported there were many open reports to review and that she decided to begin with the (MONTH) 2019 open reports. Continued interview with the facility Administrator, Social Worker, and Regional Nurse, on 7/24/19 at 9:15 a.m., the Social Worker reported the process for grievances has been the same since the three years she has been in the role as social worker and the facility has used the same grievance software program. She reported it was realized, recently, the Director of Nursing, the Activity Director, and the Admissions Coordinator needed access to the grievance software program, and they needed to get the automatic alerts to let them know there was a grievance to review and investigate. She reported the software program indicates if the report is 'satisfied' or 'not satisfied' to indicate an open or closed status. She reported they counted 20 open grievances that no action was taken on and they did not go back, instead they went to speak with the interviewable residents and asked if they had any outstanding grievances. She reported if there is no action on a report, the system will not close the grievance. An interview with the facility Regional Vice-President, Administrator, Director of Nursing, and Regional Nurse, on 7/25/19 at 9:45 a.m., the Regional Vice-President reported the grievance process in the facility was broken. They confirmed there were 12 open reports that had not been investigated.",2020-09-01
557,HIGH SHOALS HEALTH AND REHABILITATION,115279,3450 NEW HIGH SHOALS RD,BISHOP,GA,30621,2019-09-25,761,E,1,0,0KMB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and policy review, the facility failed to ensure medications were dated appropriately when opened to determine the discard date, in three of four medication carts; also failed to maintain correct narcotic count in one of four medication carts observed. Findings include: Review of the undated facility policy titled Pharmacy Services-Medication Administration-General revealed Procedural Guidelines 7. Medications dispensed for multi-use, e.g. blister/punch cards, large volume liquids, multi-dose vials, shall be labeled by the nurse as to the date of first use or first administration. Procedural Guidelines 18. During routine medication administration of medications, the medication cart is kept in the doorway of the patient's room, with open drawers inward and all other sides closed. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to patients and others passing by. Procedural Guidelines Observation on 9/24/19 at 12:00 p.m. with Licensed Practical Nurse (LPN) AA revealed on the 400 Hall medication cart one opened multi use vial of insulin with sticker that indicated to discard after 28 days. There was not a date indicating on vial or box of when the insulin vial was first used. Observation on 9/24/19 at 12:00 p.m. with Licensed Practical Nurse (LPN) AA revealed on the 400 Hall medication cart narcotic count of [MEDICATION NAME] was incorrect, revealing 17 pills in Kardex, with count sheet revealing 16 pills. An interview on 9/24/19 at 12:05 p.m. with LPN AA revealed that she knows that insulin's are supposed to be dated when they are opened. LPN AA futher revealed that she would not know when to discare the insulin, because it did not have an opened date. She further stated that when there are discrepancies with the narcotic count, she notifies the Director of Nursing (DON). Observation on 9/24/19 at 12:11 p.m. with LPN BB revealed on the 300 Hall medication cart, one insulin pen with pharmacy sticker indicating to discard after 28 days. There was no date marked on the pen to indicate the date in which the insulin was first used. There was one bottle of [MEDICATION NAME] eye drops, with pharmacy sticker that indicated to discard after 30 days of opening although there was no indication to show when the [MEDICATION NAME] eye drops were first used. An interview on 9/24/19 at 12:11 p.m. with LPN BB revealed that she knows that insulin should be dated when they are opened. She further revealed that without a date when the insulin is opened she would not know when it should be removed. Observation on 9/24/19 at 12:31 pm with LPN CC revealed on the 200 Hall medication cart, one bottle of [MEDICATION NAME] eye drops and one bottle of Lantaprost without open date on the bottle. An interview on 9/24/19 at 12:31 p.m. with LPN CC revealed that she does not give the two eye drops to the residents as they are ordered at bedtime, so she is not sure of when they were opened. She further stated that if the medications were not labeled with an open date, then she would discard them and order new ones from the pharmacy. An interview on 9/24/19 at 4:06 p.m. with Pharmacist DD, revealed that the pharmacy places discard stickers on the insulin's and certain eye drops, as a reminder for the staff that the medications should be discarded within the time frame indicated by the sticker. During further interview the Pharmacist stated that if the medications are not dated as to when they were first used, the staff should discard and re-order the medication, to ensure the potency of the medications. An interview on 9/24/19 at 4:36 p.m. with Director of Nursing (DON) stated it is her expectation that the nurses label the insulin and eye drops when opened and that they sign out narcotics at the time they are administered.",2020-09-01
558,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,561,E,1,1,MLO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, review of the facility's policy titled Dining and Food Preferences, resident interviews, family interviews and staff interviews, the facility failed to ensure that food preferences were honored for 11 of 61 sampled residents (R) (G, H, I, J, K, N, O, P, A, C and E). Findings include: Review of the facility's policy titled Dining and Food Preferences dated (MONTH) 2014 and revised (MONTH) (YEAR) documented: Individual dining, food and beverage preferences are identified for all residents/patients. #2- The Dining Services Director, or designee, will interview the resident or resident representative to complete a Food Preference Interview within 48 hours of admission. The purpose of identifying individual preferences for dining location, meal times, including times outside of routine schedule, food and beverage preferences. #3- The Food Preference Interview will be entered into the medical record. #7- The individual tray assembly ticket will identify all food items appropriate for the resident/patient based on diet order, allergies and intolerances and preferences. #8- Upon meal service, any resident/patient with expressed or observed refusal of food and/or beverage will be offered and alternate selection of comparable nutrition value. Review of the Food Preferences Interview form revealed two pages with detailed information to be completed. Page one included: admitted , Interview Date, Current Diet Order, Food Allergies, Informant (Resident or Other), Food Intolerance, Ethnic/Religious Preferences. Beverages (Please circle the beverages that you would prefer with each meal)- Whole Milk, 2% Milk, Skim Milk, [MEDICATION NAME] Milk, Orange Juice, Apple Juice, Cranberry Juice, Other Juice, Coffee, Decaffeinated Coffee, Tea, Decaffeinated Tea, Water. Between meal beverage preference. Snacks: 1. Did you have between meal snack at home? 2. Any requested snacks? Page two included: Diet History, Breakfast: Juices, Fruit, Breads, Cereals, Eggs/Meat and Beverages. Lunch & Supper: Meats & Protein, Salads, Mixed Casseroles, Starches, Breads, Vegetables, Fruits, Desserts, Soups, Gravies & Sauces, Condiments and Other. 1. Record review for R G revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of nine (a score of 8-12 indicates moderate cognitive impairment). The resident was assessed as making himself understood with clear speech and distinct intelligible words and understood others with clear comprehension. Despite a BIMS summary score of nine, R G could hold sensible conversation and answer all screening questions appropriately. Further record review revealed no evidence of a Food Preference Interview form on the resident's medical record. Observation 6/5/18 at 8:25 a.m. of the breakfast for R G revealed a sausage patty, one biscuit, scrambled eggs, a bowl of oatmeal, a small glass of orange juice and a four-ounce carton of milk. Review of the Tray Assembly Ticket read: NAS (no added salt), 1000 ml (milliliter) Fluid Restriction. Monday (W4-D23) Breakfast 6/4/18. French Toast, Margarine, Syrup, Sausage Patty, Brown Gravy, Fortified Hot Cereal of Choice, Biscuit, Margarine, Scrambled Eggs, Milk, Orange Juice. No salt packet, Large Portions. There were no condiments noted on the resident's tray, no French toast and syrup and the portion size appeared to be the same as other meal observations. During an interview with R G at the time of the observation, he stated he is used to eating a biscuit with white gravy and scrambled eggs every day. R G stated I reckon they don't have any gravy because I haven't been getting any. The resident stated We used to get what we like but lately we don't get what we like anymore. R G stated they used to have hotdogs on the menu and they don't anymore. He stated they bring him oatmeal that has no taste and never bring sugar or butter to put in it. R G stated he got milk with his breakfast this morning and they never get milk on their tray. R G stated that the prior evening's dinner came with a bread stick that was so hard, you could have knocked on the door with it. R G further stated that no-one has discussed his food preferences, likes and dislikes with him. Observation on 6/6/18 at 8:50 a.m. of the breakfast for R G revealed scrambled eggs, one biscuit with gravy, hashbrowns, a sausage patty a small orange juice and a four-ounce carton of milk. There was one packet of sweetener noted on the tray. Review of the Tray Assembly Ticket for 6/6/18- Breakfast read: Western Scrambled Eggs, Sausage Patty with Brown Gravy, Fortified Hot Cereal of Choice, Biscuit, Margarine, Shredded Hashbrown Potatoes, Milk, and Orange Juice. No salt packet, Large Portions. Interview with R G at the time of observation revealed he was happy he got gravy with his biscuit today. Observation on 6/6/18 at 1:25 p.m. of the lunch for R G revealed turkey with gravy, dressing, carrots, a dinner roll, pear dessert and iced tea. There was one packet of pepper noted on the resident's tray. Review of the Tray Assembly Ticket dated 6/6/18- Lunch listed margarine as a condiment that was not noted on the resident's tray. All other foods listed matched the food on the resident's tray. During an interview with R G at the time of the observation, he stated that his lunch Is really good today! R G stated he ate his dinner roll and it was soft. R G stated I hope they keep this up after the surveyors leave. R G stated he got rice cereal with his breakfast this morning and he doesn't like rice but further stated also got his biscuit and gravy this morning and his sausage patty was bigger than it has ever been and it was really good! Observation on 6/7/18 at 8:05 a.m. of the breakfast for R G revealed a sausage patty, scrambled eggs, pancakes, oatmeal, syrup, jelly, biscuit, butter, pepper, orange juice and a four-ounce carton of milk. During interview with R G at the time of the observation, he stated My breakfast is awesome! The resident was stating look how big my piece of sausage is! The resident stated My belly is full! The resident stated he didn't get any sugar for his oatmeal but he doesn't like oatmeal and does eat much of it. 2. Record review for R H revealed a Quarterly MDS dated [DATE] which documented a BIMS summary score of 12 (a score of 8-12 indicates moderate cognitive impairment). The resident was assessed as making herself understood with clear speech and distinct intelligible words and understood others with clear comprehension. Further record review revealed no evidence of a Food Preference Interview form on the resident's medical record. Interview on 6/4/18 at 12:39 p.m. with R H revealed she rarely gets any meat with her breakfast. Stated she gets the same thing all the time, usually a biscuit with gravy. She stated she sent her breakfast back this morning because she didn't even want it. R H further stated they serve noodles all the time and same things over and over. Observation on 6/5/18 at 7:27 a.m. of the breakfast for R H revealed one biscuit, scrambled eggs, corn flakes cereal, coffee and a four-ounce carton of milk. There were no condiments noted on the resident's tray. Review of the Tray Assembly Ticket read: NAS, Fortified Foods. Monday (W4-D23) Breakfast 6/4/18. Sausage Patty, Cold Cereal of Choice, Biscuit, Margarine, Bacon, Scrambled eggs, Water, Hot Coffee. Ticket Note: Two biscuits (special request). Interview with R H at the time of the observation revealed she likes to have bacon with her breakfast if it is cooked good. She stated she likes sausage too but she never gets that. 0n 6/6/18 at 10:45 a.m. a family member of R H wanted to speak with this surveyor. The family of R H stated that the food for all three meals has gone down-hill since before Thanksgiving of last year. She stated that she and two other siblings visit R H on a regular basis. She stated the biscuits are hard as a rock, the gravy is like water and there are never any juices or milk on R H's tray, just a cup of water. The family of R H stated she was visiting during lunch yesterday and the pork chop was so hard she could barely cut it up for R H. She stated that the everyday menu, such as the hamburgers, is rarely available. She stated the staff brought R H a snack yesterday and she thought that was so weird stating it is just because the State is in the facility. The family of R H stated she attended a care plan meeting around three to four months ago, and she expressed her concerns about the food and the lack of snacks. She stated that the Social Worker commented to her She must be eating something because she is gaining weight. The family of R H stated she told them her mother is gaining wait because she and her siblings bring her food and snacks to eat. She stated nothing happens and the Administrator and prior Director of Nursing (DON) just treat her like a complainer. Interview with R H on 6/6/18 at 1:05 p.m. revealed she ate her lunch today and stated it was pretty good. She stated she didn't get bacon or a biscuit with her breakfast tray this morning but a staff member went and got it for her. She stated she was very pleased with that today and she ate her biscuit and her bacon. Observation on 6/7/18 at 7:57 a.m. of the breakfast tray for R H revealed two biscuits, sausage patty, bacon, oatmeal, juice and coffee. The resident stated during the time of the observation that her breakfast was really good this morning and she got both a sausage patty and bacon. There was a margarine packet and grape jelly on the tray. 3. Record review for R I revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 15 (a score of 13-15 indicates no cognitive impairment). Further record review revealed no evidence of a Food Preference Interview form on the resident's medical record. Interview on 6/5/18 at 11:56 a.m. with R I revealed every day breakfast is the same thing. She stated she gets scrambled eggs, gooey oatmeal, a hard biscuit and a little dab of gravy. R J stated she occasionally will get ground up bacon or sausage on her breakfast plate but hardly ever. She stated that sometimes her roommate will have bacon and she won't. R I stated they rarely have condiments such as margarine, jelly or sugar. She stated no one has interviewed her related to her food likes and dislikes. Observation on 6/6/18 at 7:40 a.m. revealed R I eating her breakfast. Her breakfast consisted of she scrambled eggs, one biscuit, hashbrowns, juice, milk. There was a margarine and jelly packet on her plate. R I stated at the time of the observation, that her breakfast was okay this morning. Review of the Tray Assembly Ticket read: Renal- Mechanical Soft. Fluid Restriction. Wednesday (W4-D25) Breakfast 6/6/18. Scrambled Eggs, Cream of Rice Cereal, [NAME] Toast, Jelly, Margarine, Milk, Apple Juice. The meal ticket did not match the food items on the resident's tray. 4. Record review for R J revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 14 (a score of 13-15 indicates no cognitive impairment). Further record review revealed no evidence of a Food Preference Interview form on the resident's medical record. Interview on 6/4/18 at 12:20 p.m. with R J revealed most of the time she gets plenty to eat but once she got a little tiny pizza and a piece of lettuce. She stated she was still hungry but she did not want any more food stating I just didn't want any more of that! R J stated that often the food is delivered two hours late and several times she did not get supper until 8:00 p.m. She stated that sometimes she gets what is on the menu and sometimes she does not. Observation on 6/5/18 at 7:35 a.m. of the breakfast for R J revealed toast, scrambled eggs, oatmeal, milk and coffee. There were no condiments noted on the resident's tray or cranberry juice. Review of the Tray Assembly Ticket read: CCD, Tuesday (W4-D24) Breakfast 6/5/18. Scrambled Eggs, Oatmeal, Wheat Toast, Diet Jelly, Margarine, Milk and cranberry juice. Interview with R J at the time of the observation revealed she does not get meat (bacon or sausage) with her breakfast stating I guess they don't have any. The resident stated no one has ever talked with her about her likes and dislikes of food preferences and further stated I just eat what they bring me. Interview on 6/7/18 at 10:45 a.m. with R J revealed she had a good breakfast. R J stated she had a sausage patty, two pancakes with syrup and oatmeal. The resident stated it was good. The resident further stated she had barbecue pork last night that was really good too. R J stated the meals have gotten a little better the last couple of days. 5. Record review for R K revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 15 (a score of 13-15 indicates no cognitive impairment). Further record review revealed no evidence of a Food Preference Interview form on the resident's medical record. Interview on 6/5/18 at 8:00 a.m. with R K in his room revealed he never knows what time his meals are going to be delivered to his room. He stated sometimes his breakfast doesn't come until 9:00 a.m. R K stated he does not eat in the dining room because he ends up sitting in there for a long time waiting for the food to come out and then they don't bring what you wanted so he would rather eat in his room. He stated the dining services is a mess and so disorganized. The resident further stated the dinner is often delivered late too. R K stated no-one from the kitchen has ever asked him what he likes and does not like related to food preferences. At 8:10 a.m. the resident's breakfast arrived. Review of the Tray Assembly Ticket read: CCD (Carbohydrate Controlled Diet) NAS. Unsweet Tea. Tuesday (W4-D24) Breakfast 6/5/18. Scrambled Eggs, Oatmeal, Wheat Toast, Diet Jelly, Margarine, Cold Cereal of Choice, Milk and Cranberry Juice. Observation of the resident's breakfast revealed scrambled eggs, oatmeal and toast. There was no milk or cranberry juice on the resident's tray. R K stated he loves bacon and he doesn't get bacon. The resident stated he is still hungry and he does not usually ask for more stating It ain't going to do any good and there should be enough on my plate in the first place. Observation on 6/6/18 at 8:45 a.m. revealed R K in his room eating breakfast. The breakfast consisted of scrambled eggs, hashbrowns, oatmeal, coffee, milk and cranberry juice. There was a packet of pepper and sweetener on the resident's plate. Observation on 6/6/18 at 1:20 p.m. revealed R K in his room eating his lunch. His lunch tray consisted of turkey, gravy, dressing, one roll, zucchini, pear crisp dessert and a glass of iced tea. During the observation, the resident stated his lunch was good, the dinner roll was soft and he could eat his lunch today. Review of the Tray Assembly Ticket dated 6/6/18- Lunch revealed the items on his plate matched the food items on his plate. Observation on 6/7/18 at 8:00 a.m. revealed R K in his room eating his breakfast. His breakfast consisted of pancakes and diet syrup, oatmeal, one sausage patty, cold cereal, cranberry juice, milk and coffee. During the observation, R K stated he got plenty to eat on his tray this morning. He further stated the meals have gotten a little better since yesterday. Interview on 6/7/18 at 9:50 a.m. with the representing Ombudsman, who came to the facility to discuss her concerns with the surveyors, revealed she had received complaints related to the food in the facility. She stated a complainant reported to her that the facility never has any condiments on the trays and serve very little liquids with the tray and rarely serve meats with breakfast. The Ombudsman stated she had several previous complaints about the food that she had not yet addressed. She stated she met with the residents in a group on 5/9/18 and the residents confirmed the food concerns. The Ombudsman stated she spoke with the Administrator and the Dietary Manager (DM) to discuss the concerns. She stated the DM told her that breakfast meat (sausage and bacon) is available every day if a resident request it. The Ombudsman stated she explained to the DM that this process discriminates against all residents that do not have the cognitive ability or understanding that they must ask for sausage or bacon to receive it. The Ombudsman stated the new Dietary Manager is doing the best she can but they do not have any staff in the kitchen to help her. Interview on 6/7/18 at 3:02 p.m. with the Dietary Manager (DM) revealed she started work in the facility as the Dietary Manager in (MONTH) (YEAR). She stated that when she came to the facility, resident preferences were already established at least with likes and dislikes on the meal tickets. She stated was her goal to update all residents' food preference interviews at least five a week but it has been hard. The DM stated that the food preference interview should be conducted on admission and quarterly. The DM stated there is no current process in place for knowing when a resident is due for a quarterly food preference interview. The DM stated they do have a detailed food preference interview form that they use which is dated but she has not consistently used the form and does not keep record of it once she enters the information in the computer for the meal tickets. The DM stated she speaks to the resident and writes it on the piece of paper and inputs it on the meal ticket or sometimes a resident will stop her in the hall about a food they may like or dislike and she will add it in the computer at that time. She stated the meal ticket is to let the dietary staff know what to put on a resident's tray but it does not document the date of the interview or when an update is due. She further stated the likes and dislikes are not listed on the meal ticket. The computer generates the food items based on dislikes and replaces with another item on the menu for that meal. The DM stated they have breakfast meats such as sausage and bacon every day and it is available upon request and based on the resident's preferences. She stated it is not sent out on the resident's plate everyday only if they request it. When asked if it is not listed as a dislike, why doesn't a resident get the sausage or bacon that is available every day? The DM did not have an explanation or answer to this question. The DM further stated that she has only had three days off from work since she started this job and does not have enough help in the kitchen. She stated that for the most part, she has had to be the cook and has had very little time for managing the kitchen. The DM stated she had no record of the Food Preference Interview forms for residents G, H, I, J, K, N, O, P, A, C or E. Interview on 6/7/18 at 6:19 p.m. with the Administrator revealed they had changed dietary managers several times and have had increased staff turnover in the kitchen off and on since the takeover in (MONTH) (YEAR). He stated at first it was just an adjustment period with new managers and new staff. The Administrator stated when the current Dietary Manager started, the residents became really vocal. The Administrator stated dietary concerns were placed in QAPI (Quality Assurance Performance Improvement) on 5/10/18. He stated the identified concerns were related to meal ticket accuracy, timeliness of meal delivery and food portion sizes. He stated it was not placed in QAPI earlier because the complaints were sporadic previously and they tried to address each complaint on an individual basis at that time. The Administrator stated that the provision of snacks was previously in QAPI and had been resolved. He stated that the prior Director of Nursing (DON) was ensuring that snacks were available to residents but since she had been gone it has fallen back apart. 6. Record review for RN revealed a quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 99 (a score of 0 or 99 indicates resident is severly cognitively impaired.) She was coded as totally dependant with eating. Further record review did not offer evidence of any food preferences. On 6/4/18 at 12:00 p.m. R Ns daughter at bedside, stated there is not enough food, especially on the weekend. When they run out of food they serve oatmeal and biscuit. I have to bring lunch and supper for my mother every weekend. The portion sizes are small. No one is looking at her likes or dislikes. The budget has been cut twice in the kitchen. During a recent meeting, the man in charge of the dietary department refused to tell us what the allocation was for food. They also do not provide condiments with meals. When asked if she has discuss RNs preferences with dietary staff, daughter stated yes, but they don't seem to listen. Review of Tray Assembley ticket states sausage patty, cold cereal of choice, yogurt, vanilla ice cream, scrambled eggs , whole milk, orange juice . Also states no raw fruit /vegetable, yogurt with every meal. On 6/4/18 at 1:38 p.m. observation of RNs lunch plate offered healthy portion sizes however; no condiments noted. Tray assembly ticket states crispy baked chicken, broccoli floret with cauliflower, macaroni and cheese dinner roll, peach shortcake. RNs daughter stated mother can't eat this. On 6/5/18 at 8:32 a.m. noted breakfast trays had not yet served on the 400 hall. An interview with two Certified Nursing Assistants (CNAs), LL and MM, when asked what time should breakfast trays be served on the 400 hall, both stated breakfast should have been here. It usually comes by 8:00 AM. RN and RP were both asking where breakfast was. , On 6/5/18 at 8:41 a.m. R Ns daughter stated mother is to receive scrambled eggs and gravy for breakfast everyday. Observation of breakfast tray noted RN received cornflakes, scramble eggs , sausage patty, which daughter states was tough, and hard toast which she broken in half and it crumbled. Further interview revealed daughter did not ask for something different beacuse it would take too long and they don't listen. Tray assembley ticket states scrambled eggs, sausage patty, cold cereal of choice, wheat toast, diet jelly, margarine yogurt, vanilla ice cream, whole milk. On 6/6/18 at 2:27 p.m. an interview with RNs daughter revealed the breakfast meal was good today however; lunch was not good. The lunch menu included turkey, dressing, zucchini, cranberry sauce and peach cobbler. Daughter stated resident did not eat anything on the tray except the cranberry sauce. When asked if she asked for something else from the kitchen she stated no, I just gave her some yogurt I brought from home. Tray assembly ticket states roast turkey, poultry gravy, zucchini, bread dressing, dinner roll, margarine, pear crisp, vanilla ice cream yogury whole milk. On 6/6/18 at 2:01 p.m. an interview with Dietary Manager (DM) revealed that she tries to see at least four resident's a day to discuss likes and dislikes. When asked how do dietary aides and Certified Nursing Assistants (CNAs) know what the resident likes and dislikes are. DM stated that she inputs the information into the computer and when the diet cards are printed it automatically substitutes another item. As an example, if the resident doesn't like the vegetable on the main menu, the computer program automatically lists the substituted vegetable from the alternative menu, on the diet card. DM also stated she attends resident council meetings to determine if there are any concerns with dietary service. Per DM a weekly meeting occurs on Mondays with members of the resident council to discuss the meal service. When asked why is it that many residents do not receive meat with their breakfast trays, DM stated that she was informed by her corporate office to strictly follow the diet cards. When asked again, why are there a large number of residents that don't get breakfast meat she stated because it is not on their ticket. When asked who inputs the information on to the resident's meal ticket, she stated she did. When asked if there were times when food has run out she stated yes, especially when she first started because she was relearning how to order supplies however; she felt she has improved in this area. On 6/6/18 at 2:37 p.m. further review of R Ns record evidences no significant weight loss in the last six months. Resident has maintained a weight of 149-154. A Registered Dietician's most recent note dated 1/25/18 states, Jan weight ; 149.6, three months -5.8%and six months -7%. Diet; Regular CCD, fortified supll QD. PO is usually good . Episode of N/V/D on 1/3 may have affected the weight status. Recommend increasing nutrients at this time. PLAN 1. REGULAR CCD FORTIFIED SUPPL BID 7. Record review for RO revealed an annual MDS assessment dated [DATE] which documented a BIMS summary score of 0 ( a score of 0 or 99 indicates severe cognitive impairment). She was coded as independent with eating. Further record review offered no food preferences. On 6/5/18 at 8:46a.m R O noted to have no meat noted on breakfast tray. Biscuits gravy and scrambled eggs. Unable to voice what her preferences were. 8. Record review of RP offered no MDS assessment. admitted [DATE]. Interview with RP evidenced she was able to have a sensible conversation and answered all screening questions appropriately. On 6/5/18 at 8:46 a.m R #P, while in bed was served scrambled eggs biscuits with gravy and oatmeal. Stated I don't eat oatmeal. Asked CNA for some bacon. Also, asked can you have the dietician come speak to me so that I can tell her what I want and do not want. At 11:42 a.m. further interview with RP revealed no one had yet come in to speak with her about her food preferences. 9. Record review for R A reveled she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R A most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. She is non-verbal and unable to express any needs. She was coded as total dependence with eating. Further record review revealed no evidence of a Food Preference Interview form on the resident's medical record. On 6/5/18 at 3:13 p.m., interview with R A spouse stated that residents are not given a menu choice of meals to choose what they would like to eat. He stated he would select foods that he knows his wife likes, since she can't do for herself, if only he were given the option. He further stated that he does not even recognize some of the food they send for her to eat. He stated that staff do not offer his wife evening snacks. 10. Record review for R C reveled she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R C most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 11, which indicated mild cognitive impairment. Resident is observed to be alert and oriented to person, place and time. She can express her needs. Further record review revealed no evidence of a Food Preference Interview form on the resident's medical record. On 6/7/18 at 9:30 a.m., R C stated she has told the dietary staff that she wants bacon for breakfast every day. She stated she never gets bacon and has to ask for bacon every day. 11. Record review for R [NAME] revealed an admission Minimum Data Assessment ((MDS) dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 12 (a score of 8-12 indicates moderate cognitive impairment). The resident was assessed as making himself understood with clear speech and distinct intelligible words and understood others with clear comprehension. Despite a BIMS summary score of 12, R [NAME] could hold sensible conversation and answer all screening questions appropriately. Interview on 6/4/18 at 8:30 a.m. with R [NAME] in his room revealed that he states his breakfast is always late and always cold when he finally gets it. R [NAME] states his toast is like a rock and is not able to eat it and states he loves toast. He states he would love to have bacon and sausage both but states it is rare that he is given any kind of meat on his breakfast tray. States he has never been asked what he would like to have to eat. R [NAME] states he never gets coffee with his meal and states breakfast isn't breakfast without coffee. Observation on 6/4/18 at 8:30 a.m. of R [NAME] breakfast tray revealed he had biscuits and gravy and scrambled eggs, a cup of orange juice, and a carton of whole milk. The meal ticket on his tray reads: Scrambled eggs, Oatmeal, Wheat toast, Diet Jelly, Margarine, Milk, Coffee or Tea, and Orange Juice. There was no condiments on the tray and no coffee.",2020-09-01
559,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,584,E,1,1,MLO511,"> Based on observations and staff interviews, the facility failed to provide a clean, safe and comfortable environment on two of four units. The facility census was 108. Findings include: Observation of the locked unit/200 hall on 6/4/18 at 12:55 p.m. revealed a day room at the end of the hall which had two small sofas and three large chairs, all with cloth upholstery, with gray stains on the seat cushions. Observation of the locked unit/200 hall dining room on 6/4/18 at 1:30 p.m. revealed two large chairs with cloth upholstery with gray stains on the seat cushions. Observation of the main day room on 6/5/18 at 8:15 a.m., used by residents of the 100, 300 and 400 halls, revealed two small sofas with cloth upholstery with gray stains on the seat cushions. Observation of the locked unit/200 hall dining room on 6/6/18 at 11:00 a.m. revealed a gap in the seal around the air conditioning/heating unit through which one could see light from the outside. Additionally, in the locked unit/200 hall, there were 11 holes in the floor along the seam where the floor and wall meet on two of four walls. Each hole was 1/2 to 1 inch deep revealing the floor board under the tiles. Wall 2 had five holes, two were 2 to 3 inches in width and three were 12 to 16 inches in width. Wall 3 had six holes, four were 3 to 6 inches in width and two were 12 to 16 inches in width. Interview and tour with the Housekeeping Supervisor (HS) and Administrator on 6/6/18 at 2:00 p.m. confirmed the presence of the soiled chairs in the locked unit/200 hall dining room and day room and the main day room. The HS stated he has attempted to clean these chairs and the stains clear for two to three days, then reappear. He stated his staff steam clean the chairs every three months which has removed the protective coating from the fabric. The HS could produce no documentation to confirm the cleaning schedule for the chairs and facility policy did not discuss the cleaning of any chairs. Interview and tour with the Maintenance Supervisor (MS) and Administrator on 6/7/18 at 2:00 p.m. confirmed the presence of the identified holes in the floor and the gap in the seal around the air conditioning/heating unit in the locked unit/200 hall dining room. The MS stated work was done within the last six months on that floor to strengthen its foundation and, perhaps, the identified holes were a result of the foundation continuing to settle. He stated since the previous foundation work was completed, he had not returned to inspect the floor to determine if additional work was needed.",2020-09-01
560,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,657,D,0,1,MLO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, the facility failed to [MEDICATION NAME] one of 61 residents (R) (#24) was invited to attend and particiapte in their quarterly scheduled care plan meeting. Findings Include: R#24 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#24's 3/20/18 quarterly Minimum Data Set (MDS) revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating R#24 to be cognitively intact. Interview with R#24 on 6/5/18 at 11:29 a.m., in her room, revealed that she doesn't know what a care plan meeting is and she has never been invited to attend a meeting. Interview with the MDS Coordinator on 6/6/18 at 9:15 a.m., outside of MDS office, revealed that it is the responsibility of the Social Worker to contact family members and invite Residents to care plan meetings. Interview with the Social Worker on 6/6/18 at 9:17 a.m., outside of her office, revealed that she calls family and speaks with residents regarding their care plan meeting and invites them to attend. She states she believes she has documentation of inviting R#24 to the meetings and states R#24 refused to attend once and she should have a paper of refusal signed by the resident. Social Worker stated she would look for the documentation. Interview with the Social Worker on 6/6/18 at 9:45 a.m., in the dining room, revealed that she does not have documentation of R#24 ever being invited to care plan meetings and there is no documentation that she refused to attend a meeting. She states that she documents all of the phone calls to the families in the progress notes of the resident chart but has not documented inviting the residents to the care plan meetings. Social Worker states she spoke with R#24 and invited her to a care plan meeting scheduled for today, 6/6/18, at 2:30 p.m. and the resident agreed to attend.",2020-09-01
561,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,689,E,0,1,MLO511,"Based on observation, review of the facility policy titled Smoking Policy- Residents, review of the policy titled Employee Smoking Policy, and staff interviews, the facility failed to ensure safe and appropriate ashtray receptacles were available in the designated smoking area. Additionally, the facility failed to ensure smoking occurred only in the designated smoking area and ensure the appropriate disposal of cigarettes as evidenced by countless cigarette butts on the ground outside of the 400 Hall entrance/exit door and in the tree line outside of the 400 Hall entrance/exit door. The facility census was 108 residents. Findings include: Review of the policy titled Smoking Policy- Residents dated (MONTH) 2014 and revised (MONTH) (YEAR) documented This facility shall establish and maintain safe resident smoking practices. #3 Smoking is only permitted in designated resident smoking areas, which are located outside the building. #5 Metal containers, with self-closing cover devices, are available in smoking areas. #6 ashtrays are emptied only into designated receptacles. Review of the policy titled Employee Smoking Policy date June1, (YEAR) documented: Employess are permitted to smoke during break and meal time in the designated area. Employees may smoke in the designated smoking area. Observation on 6/4/18 at 4:20 p.m. of a schedule smoking break revealed 28 cigarette butts on the ground along the walkway leading to the designated smoking patio. There were nine residents and two Certified Nursing Assistants (CNA) supervising the residents (CNA SS and CNA TT). All nine residents were wearing smoking aprons, were given a cigarette from a plastic container and their cigarettes were lit by the staff. No residents were observed smoking unsafely. The designated smoking area was eqipped with a fire retardant blanket and a fire extinguisher. There were three metal cylinder shape ashtray bins noted in the designated smoking patio. Only one of three ashtray receptacles had a self-closing cover/ashtray on top. Ashtray #1 had a metal ashtray on top that when a button was pushed, it would open and dispose the cigarette butt inside the bin. There were two wadded-up napkins and numerous cigarette butts noted inside the bin. Ashtray #2 did not have a self-closing cover/ashtray on top and had several wadded-up paper towels, an empty cigarette box, a clear plastic cup and numerous cigarette butts inside the bin. Ashtray #3 did not have a self-closing cover/ashtray on top and had two empty cigarette boxes, various trash, candy wrappers and numerous cigarette butts inside the bin. At 4:47 p.m. a resident sitting next to Ashtray #2 threw a lit cigarette directly into the bin. At 4:49 CNA SS crushed a cigarette butt on the side of Ashtray #2 bin then dropped the butt into the bin. After all nine residents' cigarettes were disposed of in the three ashtrays, there was smoldering noted coming from Ashtray #3 that did die out within 30-45 seconds. An interview with CNA SS and CNA TT was conducted on 6/4/18 at 4:55 p.m. CNA TT stated they were told by the Fire Marshall the year before that they couldn't have a trash can in the smoking area and everyone puts their trash in the cylinder ashtray bins. He stated they try to catch it and are doing the best they can. When asked if they checked the ashtrays before lighting cigarettes for this current smoking break, he stated no. CNA TT further stated they have replaced the ashtrays before but he does not know what has happened to the ashtray covers. CNA SS confirmed there was trash in the bin of Ashtray #2 cylinder and confirmed that she disposed cigarettes butts in it's bin and stated Yes, but I crushed them on the side first before discarding them in the ashtray. Both CNAs confirmed there was trash in Ashtray #3 and that the bin was smoldering after the residents had dsiposed thier cigarettes and exited the area. Observation on 6/4/18 at 4:59 of the entrance/exit door at the end of the 400 Hall with CNA SS and CNA TT revealed 25 cigarette butts on the ground outside around the concrete slab. Several feet away was a chain link fence in front of a heavily wooded area. There was a very large tree behind the fence with thick layer of dry leaves. There were so many cigarette butts around the base of the tree and in the natural debris, they could not be counted. During interview at the time of the observation, CNA TT stated that the cigarette butts cannot possibly be from the residents because they keep their cigarettes locked up at the nurses' station. He further stated that it must be from either staff or family members throwing the cigarette butts on the ground and in the woods. Interview on 6/4/18 at 5:12 p.m. with the Administrator revealed he had a discussion earlier today with the Fire Marshall related to the inappropriate ashtray receptacles and the numerous cigarette butts in the trees close to the building behind the 400 Hall entrance/exit door. He stated he was going to remove the ash trays right now and replace them and have the cigarette butts cleaned up. He stated the ashtrays did have the cover/ashtray tops and he does not know where they disappear to.",2020-09-01
562,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,691,D,0,1,MLO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to ensure care was provided consistent with professional standards of practice for one of one resident (R) (#56) with a [MEDICAL CONDITION]. The sample was 61 residents. Findings include: Review of the policy titled [MEDICAL CONDITION] / [MEDICAL CONDITION] care revised (MONTH) 2010 documented procedure on how to provide [MEDICAL CONDITION] care . Record review for R#56 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 12 (a score of 8-12 indicates moderate cognitive impairment). The resident was assessed as making herself understood with clear speech and distinct intelligible words and understood others with clear comprehension. R#56 exhibited behavioral symptoms not directed towards others one - three days of the seven day look back period. Rejection of care was not exhibited. The resident required extensive assistance with bed mobility and personal hygiene and required total staff dependence for transfers and toilet use. R#56 was assessed for a [MEDICAL CONDITION]. Review of the care plan for R#56 updated on 4/25/18 identified the resident is at risk for alteration in skin integrity related to having a [MEDICAL CONDITION]. The resident continues to remove [MEDICAL CONDITION] bag and wafer, allowing liquid stool to stay on her abdomen. She will pick at it so much/pull wafers off so that the skin is too excoriated for paste or other products to adhere. She will also sometimes pick at the ostomy and inside the stoma with her fingers, spoons, cups, etc. This behavior is not easily redirected so staff attempt to redirect as needed for problem behaviors. Approaches include, but not limited to; [MEDICAL CONDITION] care by nurses as ordered. Bag to be emptied q shift (each shift) and prn (as needed) when in use. Monitor skin during care/baths for redness/breakdown, if noticed, notify MD for prompt treatment. Observe her [MEDICAL CONDITION] site worsening or excoriation and notify MD as needed. Record number (#) of times her [MEDICAL CONDITION] bag is emptied or stool is noted q shift on activity of daily living (ADL) sheet, report to nurse if no bowel movement (BM) for 3 days. Redirect her if she is pulling off her [MEDICAL CONDITION] bag or digging in her stoma. Review of the behavior care plan dated 4/25/18 identified R#56 will pick at her [MEDICAL CONDITION]. She has a history of tearing holes in it, and pulling it off requiring that it be changed sometimes as many as 4-5 times daily. She continues to pick at her stool through her [MEDICAL CONDITION] area, keeping it red and irritated. She is delusional in that she seems to truly believe that she does not bother her [MEDICAL CONDITION] or stoma opening, despite staff having witnessed her digging in her ostomy with her fingers, cups, spoons, etc. She is very obsessive. Her family states that she has a long history of doing this at home. She has also been witnessed emptying her [MEDICAL CONDITION] into sandwich bags. She has a history of throwing feces at staff. She has [DIAGNOSES REDACTED]. She receives [MEDICATION NAME], trazadone and [MEDICATION NAME]. She does receive services for Mental Health. Approaches include but not limited to; Monitor mood/behavior on continuous basis q shift (every shift on behavior monitoring sheet, keep MD informed of significant changes in mood/behavior for possible medication changes. Staff interventions to redirect when picking at [MEDICAL CONDITION] is observed. Talk with her during care. Use calm approach when inappropriate behavior is exhibited. Review of the physician's orders [REDACTED]. Observation on 6/4/18 at 3:35 p.m. of the [MEDICAL CONDITION] stoma for R#56 revealed there was no [MEDICAL CONDITION] bag in place. The resident's [MEDICAL CONDITION] site was covered with two wash cloths in a crisscrossed fashion, then covered by a sheet that was tucked into the resident's disposable briefs. R#56 removed the wash cloths and sheet. Interview with the resident at the time of the observation revealed the facility had run out of [MEDICAL CONDITION] bags since Saturday, 6/2/18. Resident stated CNAs form the previous shift had placed the linens on her stoma to keep to it from leaking on her body and bed On 6/4/18 at 3:40 p.m. an interview with Licensed Practical Nurse (LPN) JJ who cared for R#56 revealed she had no idea the resident did not have a [MEDICAL CONDITION] bag in place. LPN JJ stated she was very surprised and was not told during shift report that there was no [MEDICAL CONDITION] bag in place for R#56. LPN JJ was unable to determine how long the [MEDICAL CONDITION] site had been covered with wash cloths and a sheet. On 6/4/18 at 3:45 p.m. an interview with the Unit Manager LPN KK revealed R#56 had been without a [MEDICAL CONDITION] bag for one day only. Also stated R#56 at times very excoriated skin around the stoma which prevents staff from applying a new bag. In reviewing the resident's record, she indicated the resident received [MEDICAL CONDITION] care the night before on the 11:00 p.m. - 7:00 a.m. shift. LPN KK further stated R#56 frequently removes her [MEDICAL CONDITION] bag and places items in the stoma and she had been care planned for this behavior. During further interview with R#56 on 6/5/18 at 7:42 a.m., she denied removing the [MEDICAL CONDITION] bag herself and denied putting the wash cloths and sheet over her [MEDICAL CONDITION]. The resident stated I don't take the bag off. Observation at the time of the interview revealed a [MEDICAL CONDITION] bag was in place at this time. Interview on 6/5/18 at 8:32 a.m. with Certified Nursing Assistants (CNA) LL and MM revealed they both had observed occasional redness around the [MEDICAL CONDITION] stoma site and difficulty with [MEDICAL CONDITION] bag adherence. CNA LL and CNA MM both stated R#56 had been without a [MEDICAL CONDITION] bag for about a week. Observation on 6/5/18 at 10:13 a.m. in the supply room with the Unit Manager KK revealed 18 available [MEDICAL CONDITION] bags. Review of (MONTH) (YEAR) treatment administration record documented (TAR) [MEDICAL CONDITION] care was provided 6/1/18 through 6/4/18 revealed there was no documentation noted of the skin integrity at the stoma site On 6/15/18 at 2:40 p.m. during a post survey interview with Director of Nurses (DON) for further clarification on the policy for [MEDICAL CONDITION] care. DON stated there was no other policy. The documentation on procedure is all there was.",2020-09-01
563,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,730,F,1,1,MLO511,"> Based on record review, staff interview and policy review, the facility failed to ensure that five (5) of five (5) Certified Nursing Assistants (CNA) received the minimum of twelve (12) hours of annual in-service training, including Dementia training; and failed to provide performance review to ensure competency for five (5) of five (5) CNA's. The facility census was 108. Findings include: Review of the facility policy titled Education: Required Inservices, dated (MONTH) 11, 2001, revealed it is the policy of the facility to conduct inservice training for all personnel on a regularly scheduled basis. Certified Nursing Assistants will be informed of the regulatory statute to maintain twelve (12) hours of continuing education hours each calendar year. Attendance at inservice education provided will be considered by supervisors when completing performance evaluations. Review of inservice education checklist for five CNA's employed greater than one year revealed that each CNA lacked receiving the required minimum 12 hours of educational training. Further review revealed they did not receive Dementia Care training necessary for competency during the year leading up to the anniversary of their date of hire. Furthermore, there were no performance reviews for the five sampled employees. On 6/6/18 at 8:39 a.m., interview with Director of Nursing (DON) stated that she does the staff training and competency/skills check-offs. She stated that the process is set up based on employee hire dates. They do two competency/skills check-off per year for staff. Employees hired January-June are all having competencies/skills checks offs by the end of June. Employees hired July-December are having competency/skills check-off by the end of December. She stated that she is not sure who was in charge of it before she was hired in (MONTH) (YEAR), but she was unable to find completed skills competencies for the CNA's. On 6/6/18 at 3:58 p.m., with Business Office Specialist, revealed that she was responsible for keeping track of the in-service education hours for the facility staff. She stated she was under the impression that CNA staff working on an as needed (PRN) status do not require educational training hours and part time CNA's only require six hours of educational training and full time CNA's require 12 hours of educational training per year. She further stated that she does not recall where she got that information, but it's been that way for the past three years, since she has been in charge of tracking the educational hours. On 6/7/18 at 5:25 p.m., with Administrator, stated that he was not aware that the CNA education hours had to be 12 hours per year for all CNA's. He stated he was under the impression that only the full time CNA's had to maintain 12 hours of educational training to maintain their certification. He stated that the DON was responsible for doing the educational in-services and doing competency/skills check-off for the CNA's. He stated he was not aware that she was not keeping complete records. He further stated that he supervises the DON position and her performance, but there is no formal evaluation. He stated the education responsibility will be delegated to the Assistant Director of Nursing (ADON), once one is hired.",2020-09-01
564,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,732,C,1,1,MLO511,"> Based on observation and staff interviews, the facility failed to post the daily nurse staffing information on two of four days (6/4/18 and 6/5/18) of the survey; and the two days posted had incomplete data. The facility census was 108 and the sample size was 61. Findings include: Observation during initial tour of the facility on 6/4/2018 at 1:30 p.m., revealed that the required nurse staffing information was not posted. Observation on 6/5/18 at 8:09 a.m. and 5:40 p.m. revealed the required nurse staffing information was not posted. Observation on 6/6/18 at 10:14 a.m. and 4:26 p.m. revealed the required nurse staffing information was not posted. Observation on 6/6/18 at 6:39 p.m., revealed the required nurse staffing information was posted on bulletin board across from dietary department. The posting had incomplete data and revealed only number of Registered Nurses (RN), number of Licensed Practical Nurses (LPN) and number of Certified Nursing Assistants (CNA) for 24 hour period of time. Phone interview on 6/6/18 at 4:40 p.m. with Payroll/Business Office Specialist, verified she is the person who is responsible for posting the daily nurse staffing. She stated that she just forgot to post the staffing on the bulletin board for three days. She further stated that she calculates the total hours worked on the following morning, so that she has an accurate number of employees with hours worked.",2020-09-01
565,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,804,E,1,1,MLO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, resident interview, staff interview, and family interview, and review of a sample test tray, the facility failed to ensure that meals served were palatable, attractive, and served at an appetizing temperature for 14 of 61 sampled residents (R) (E, F, Q, S, R, G, I, J, K, M, L, N, U and T). Findings Include: Record review for R [NAME] revealed an admission Minimum Data Assessment ((MDS) dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 12 (a score of 8-12 indicates moderate cognitive impairment). The resident was assessed as making himself understood with clear speech and distinct intelligible words and understood others with clear comprehension. Interview on 6/4/18 at 8:30 a.m. with R [NAME] in his room revealed that he states his breakfast is always late and always cold when he finally gets it. R [NAME] states his toast is like a rock and is not able to eat it and states he loves toast. Observation of R [NAME] on 6/4/18 at 8:30 a.m. revealed the resident is edentulous. Record review for R F revealed a quarterly MDS dated [DATE] which documented a BIMS score of 15, indicating the resident has no cognitive impairment. Interview on 6/5/18 at 2:00 p.m. with R F in her room revealed that she receives her meals late and it's always cold. She states she keeps her own refrigerator to keep sandwich stuff so she assures she has something to eat that is worth eating. R F states she gets cereal for breakfast on her tray but the milk is so warm she can't use it for cereal much less drink it. States the food is bland and she never gets salt and pepper. She states that she doesn't even like oatmeal and they send it anyway and never give her sugar or butter to go in it to give it any flavor. States the food is disgusting. Interview on 6/5/18 at 12:30 p.m. in the Dining Room (DR), on the phone, with family member of R Q revealed that she and her sibling visit daily and always bring R Q something to eat because they are always bringing him food that he cannot swallow. Family states R Q requires food that is soft and more times than not he receives food that is not soft and he gets strangled on it. States she has discussed this issue with not only the dietary staff but the Administrator as well. Observation on 6/5/18 at 12:30 p.m. of R Q revealed the resident eating Chili from [NAME] that his family brought for him. Record review for R S revealed a quarterly MDS dated [DATE] which documented a BIMS score of 13, indicating the resident has no cognitive impairment. Observation on 6/4/18 at 8:30 a.m. of R S, who is in the room with R E, revealed that the oatmeal they sent him for breakfast is not worth even trying to eat. He states the food just doesn't have any flavor and it's no good. He states, they treat me good here so I'll eat what I can and won't complain Interview on 6/5/18 at 12:00 p.m. in the DR with family member of R R revealed that she is here for lunch every day and every day R RR receives something on her tray that she cannot eat. States R R must have a soft diet because she has difficulty chewing and swallowing and today she was given cauliflower and it's so hard she cannot even cut it up much less feed it to R R. Family member states they just don't listen when she has told them over and over the meal must be soft. States last week there was sliced carrots on the tray and she tried to cut into one and it flew out from under the fork onto the floor but after she tasted of one she wouldn't have fed it to R R anyway because it tastes like dirt. Interview with DM on 6/4/18 at 10:00 a.m. revealed that she states every Monday at 10:30 a.m. in the DR she meets with the Residents that choose to come and they talk about their meals, likes, and dislikes. States she writes everything down and works to accommodate their request. States she was hired as the DM but has had to do most of the cooking because it's difficult to keep staff and states just when they get someone trained they quit. States she wasn't aware that there were complaints about the food not being good but she is working on customer satisfaction. She states for those residents who are not able to come to the meeting on Monday she picks so many and goes to their room and talks with them one on one and makes notes so she can assure customer satisfaction. The Dietitian was unavailable for interview. Observation in the kitchen on 6/5/18 at 4:30 p.m. of Dietary District Manager with HSG doing pureed green beans revealed he uses the calculation 15 residents x 3oz. serving size = 45 oz which equals 5.5 cups of green beans. He placed 11 tsp's of thickener in a cup and sat it to the side. He drained the water off of the 5.5 cups of green beans and put them into the mixer, placed the lid on and turned the mixer on. He stopped every 5 to 10 seconds and added thickener, turned the mixer on, waited another 5 to 10 seconds then stopped the mixer, checked the consistency and added more thickener as needed. He repeated this process until he got the right consistency for the puree. Observation on 6/6/18 at 11:45 a.m. in the kitchen revealed the Dietary District Manager with HSG retraining staff on how to calculate food portions. Dietary District Manager with HSG told this surveyor, they weren't calculating the portions correctly. Entered the kitchen at 5:25 p.m. on 6/7/18 and observed trays being prepared, and placed on the cart to go to the 200-hall. Dietary District Manager with HSG was serving plates from the buffet. At 5:43 p.m. the last tray was placed onto the cart going out to the 200-hall and a test tray was requested to be added to the cart. A test tray of bbq pork, au gratin potatoes, baked beans, baked chicken, stewed cabbage, and a piece of toast with a glass of tea. Another plate of puree bbq pork, cabbage, baked beans, and baked chicken were placed on the tray and added to the cart. At 5:46 p.m. the cart arrived on the 200-hall and staff began serving residents their tray's at 5:47 p.m. in the DR. At 6:00 p.m. staff began serving trays to the Resident's in their rooms. At 6:10 p.m. all resident trays had been served. The test tray was removed from the cart and taken it into the 200-hall DR by the surveyor. LPN XX and surveyor tasted each item on both plates. Surveyor states the bbq pork was okay, the au gratin potatoes were bland, the baked beans tasted dry and had no flavor, the baked chicken was dry and hard to swallow, the stewed cabbage had a lot of flavor and was very good, and the toast was very dry, hard around the edges and crumbled when picking it up. The puree baked chicken was dry and difficult to swallow, the baked beans were bland and gritty, the stewed cabbage was ok, and the bbq pork was bland. The tea had no ice and was warm. LPN XX states, None of it taste good. It did not look good and I certainly would not feed this to these residents. Record review for R G revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of nine (a score of 8-12 indicates moderate cognitive impairment). The resident was assessed as making himself understood with clear speech and distinct intelligible words and understood others with clear comprehension. Despite a BIMS summary score of nine, R G could hold sensible conversation and answer all screening questions appropriately. Interview on 6/5/18 at 4:29 p.m. with R G revealed the facility serves rice and noodles all the time. He stated that last night they had breadsticks with dinner that were so hard, you could have knocked on the door with it! Interview on 6/6/18 at 1:25 p.m. with R G revealed his lunch was good today. He stated he ate his dinner roll and it was soft. He stated he had a biscuit with gravy and a sausage patty bigger than he had ever seen. He stated his breakfast was good. R G stated I hope they keep this up after the surveyors leave! Record review for R I revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 15 (a score of 13-15 indicates no cognitive impairment). Interview on 6/5/18 at 11:56 a.m. with R I revealed the facility needs help delivering the food. She stated by the time it gets her room the food is cold and she stated the food sucks! R I stated sometimes the food is over cooked and sometimes the food is under cooked. She stated they always bring what they call capri vegetable mix and nobody likes it. She stated they bring broccoli stems that you can't eat and breakfast every day is the same thing. She stated breakfast always consist of scrambled eggs, gooey oatmeal, and a biscuit with a little dab of gravy. She stated the toast this morning was hard as a rock, and she couldn't eat it. She stated last night she had tubular ziti noodles with hardly any sauce on it so it was too dry. The dinner roll was hard as a rock. R I further stated the facility does not order enough food and runs out on weekends so they piece together odds and ends of food for a meal. Record review for R J revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 14 (a score of 13-15 indicates no cognitive impairment. Interview on 6/4/18 at 12:20 p.m. with R J revealed several times she did not get her supper until 8:00 p.m. She stated that once she got a little tiny pizza and a piece of lettuce for dinner and that was all. She stated she did not ask for more but was still hungry. She stated I just didn't want any more of that. Interview on 6/7/18 at 10:45 a.m. with R J revealed she had a good breakfast this morning. She stated she had a sausage patty, two pancakes and oatmeal stating it was good! The resident stated she had barbecue pork last night that was real good too! R J stated the meals have gotten a little better the last couple of days. Record review for R K revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 15 (a score of 13-15 indicates no cognitive impairment). Interview on 6/5/18 at 8:00 a.m. with R K revealed he never knows what time his meals are going to be delivered. At 8:10 a.m. a staff member delivered the resident's breakfast to his room. The resident stated his toast was so hard that he couldn't eat it. R K picked up the toast snapped it in half with his fingers and it broke into dusty brittle pieces on his plate. During an interview on 6/6/18 at 8:45 a.m. with R K, he stated that last night after the survey team left the building, the food served for dinner was horrible. Interview on 6/6/18 at 1:20 p.m. with R K revealed his lunch was good today and his dinner roll was soft. He stated he could eat the dinner roll today. Record Review for R M revealed a Significant Change MDS dated [DATE] which documented a BIMS summary score of 12 (a score of 8-12 indicates moderate cognitive impairment). The resident was assessed as making herself understood with clear speech and distinct intelligible words and understood others with clear comprehension. During an interview on 6/4/18 at 12:05 p.m. with R M, she stated sometimes the food delivered to her is not always what is on the menu and further stated the food is not very good. During an interview on 6/5/18 at 12:40 p.m. with R M, she stated that she doesn't have any problems and she enjoys being in the facility. R M stated the only problem for her is the food. She stated We feel like we pay to stay here and the food should be better than what we get and pay for! During an interview on 6/6/18 at 1:15 p.m., R M stated she can't complain about the lunch today stating it was so good! She stated the roll was soft and she got condiments with her meal. She stated Somebody is doing some good for us! Stated she had roast beef and gravy, mashed potatoes, a roll and dessert. During an interview on 6/7/18 at 7:48 a.m. with R M, she stated she had pancakes, sausage, syrup, oatmeal, coffee and juice. She stated she was so pleased with breakfast And I'm eating it all! Record review for R L revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 13 (a score of 13-15 indicates no cognitive impairment). Observation on 6/5/18 at 7:40 a.m. of the breakfast served to R L revealed chopped sausage on her plate that was over cooked into very crisp pieces. At 7:48 a.m. R L was overheard telling a nurse that the sausage was way over cooked and she couldn't eat it. The nurse apologized but did not offer any further assistance or offer to get her more sausage. Observation on 6/7/18 at 7:49 a.m. revealed R L in her room eating her breakfast. The resident's breakfast plate consisted of pancakes, one biscuit, scrambled eggs, a sausage patty, syrup, juice and coffee. During the observation, R L stated This is way more food this morning! The resident stated she ate all she could and she was full. Record review for RN revealed a quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 99 (a score of 0 or 99 indicates resident is severely cognitively impaired.) She was coded as totally dependant with eating. Further record review did not offer evidence of any food preferences. On 6/4/18 at 12:00 p.m. R Ns daughter at bedside, stated there is not enough food, especially on the weekend. When they run out of food they serve oatmeal and biscuit. I have to bring lunch and supper for my mother every weekend. The portion sizes are small. No one is looking at her likes or dislikes. The budget has been cut twice in the kitchen. During a recent meeting, the man in charge of the dietary department refused to tell us what the allocation was for food. They also do not provide condiments with meals. When asked if she has discuss RNs preferences with dietary staff, daughter stated yes, but they don't seem to listen. Review of Tray Assembly ticket states sausage patty, cold cereal of choice, yogurt, vanilla ice cream, scrambled eggs , whole milk, orange juice. Also states no raw fruit /vegetable, yogurt with every meal. On 6/4/18 at 1:38 p.m. observation of RNs lunch plate offered healthy portion sizes however; no condiments noted. Tray assembly ticket states crispy baked chicken, broccoli floret with cauliflower, macaroni and cheese dinner roll, peach shortcake. RNs daughter stated mother can't eat this. On 6/5/18 at 8:32 a.m. noted breakfast trays had not yet served on the 400 hall. An interview with two Certified Nursing Assistants (CNAs), LL and MM, when asked what time should breakfast trays be served on the 400 hall, both stated breakfast should have been here. It usually comes by 8:00 AM RN and RP were both asking where breakfast was. On 6/5/18 at 8:41 a.m. R Ns daughter stated mother is to receive scrambled eggs and gravy for breakfast everyday. Observation of breakfast noted RN received cornflakes, scramble eggs , sausage patty, which daughter states was tough, and hard toast which she broken in half and it crumbled. Further interview revealed daughter did not ask for something different because it would take too long and they don't listen. Tray assemble ticket states scrambled eggs , sausage patty, cold cereal of choice, wheat toast, diet jelly, margarine yogurt, vanilla ice cream, whole milk. On 6/6/18 at 2:27 p.m. an interview with RNs daughter revealed the breakfast meal was good today however; lunch was not good. The lunch menu included turkey, dressing, zucchini, cranberry sauce and peach cobbler. Daughter stated resident did not eat anything on the tray except the cranberry sauce. When asked if she asked for something else from the kitchen she stated no, I just gave her some yogurt I brought from home. Tray assembly ticket states roast turkey, poultry gravy, zucchini, bread dressing, dinner roll, margarine, pear crisp, vanilla ice cream yogurt whole milk Record review for R T revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of six (a score of 1-7 indicates severe cognitive impairment). In an interview with the husband of R T on 6/5/18 at 11:34 a.m., he stated the food situation in the facility was different since it contracted out the food service. He stated his understanding is the Administrator cannot tell the kitchen what to do. He stated the food often sits in the hall for 20-30 minutes after carts are delivered to the floor before staff can pass them out so meal times tend to sometimes run late. Observation of R T revealed she was seated in a Broda chair next to her husband in the lobby area. The resident's husband asked her questions to confirm his statements and R T could respond using her right thumb to point up for yes and down for no. R T was observed pointing her thumb upwards, indicating yes for her answer. Record review for R U revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 12 (a score of 8-12 indicates moderate cognitive impairment). In an interview with R U on 6/5/18 at 11:07 a.m., she stated the kitchen either served the same old thing or it's terrible. She explained using an example of fried chicken which is sometimes fried too hard to bite. She further stated this morning she received a scrambled egg, a little bowl of oatmeal without sugar and a slice of loaf bread which was barely toasted without butter and a small scoop of jelly. In an interview with R U on 6/7/18 at 9:22 a.m., she stated she was sleepy after her breakfast this morning but it was very good, she stated I ate it all up and she was very pleased about the larger portions this morning as well. (F561)",2020-09-01
566,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,809,E,1,1,MLO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, resident interviews, family interviews, staff interviews and policy review, the facility failed to ensure snacks were offered for 10 of 61 sampled residents (R) (A, B, H, I, K, M, L, E, Q and R). Findings include: During a group resident interview on 6/5/18 at 2:00 p.m., all of the residents in attendance stated that they were not consistently offered bedtime snacks, or snacks between meals. Several of these residents stated that they were diabetic and that they would like a bedtime snack. Review of Policy titled :Frequency of Meals revised (MONTH) 2013, policy statement revealed each resident shall receive at least three (3) meals and at least one (1) snack daily. Between meal snacks will be available for residents who need or desire additional food between meals. Evening snacks will be offered routinely to all residents not on diets prohibiting bedtime nourishment. Interview on 6/5/18 at 2:30 p.m., with Dietary Manager (DM), stated that snacks are sent to the floor once per day shift and once per evening shift. She stated that extra items are sent to cover the night shift should a resident want a night time snack. She was asked if enough snacks were sent to the floor for every resident to receive a snack, if they wanted one, and she avoided answering the question, despite being asked three times. She stated the types of snacks being delivered were cookies, little Debbie snacks and graham crackers. She further stated that were no juices, sodas, or milk provided as snack items. No sandwiches, chips, or fruits were offered as snack items. 1. Interview on 6/5/18 at 3:13 p.m. with the family of R A revealed that staff do not feed his wife evening snacks or offer her water throughout the day. Interview on 6/5/18 at 4:33 p.m., with Certified Nursing Assistant (CNA) AA stated that snacks are delivered on some days, but not consistently. She stated that its usually just cookies or Little Debbie pies. She further stated that she offers every resident a snack when they have them. She stated that a few residents will ask for certain snack items like peanut butter and jelly sandwiches or grilled cheese sandwiches, she will go to kitchen and see if they have them. She stated that the staff usually fixes the requests, unless they have gone for the day. She stated that they do not have access to the kitchen after the dietary staff are gone. Interview on 6/5/18 at 5:05 p.m., with Licensed Practical Nurse (LPN) EE stated that when snacks are available, its always the same things, with no variety. She stated the residents get tired of the same snack every day. 2. Interview on 6/6/18 at 2:20 p.m., with R B, stated that the facility is not passing out snacks during the day or the evening. She stated that sometimes they have cookies or peanut butter crackers in the pantry, but don't have any juice or milk to drink. She has never been offered a liquid to drink with her cookies. She has asked for fruits to eat, but the staff tell her they don't have any fruit. 3. On 6/6/18 at 10:45 a.m. a family member of R H wanted to speak with this surveyor. The family of R H stated she was visiting during lunch yesterday and the staff brought R H a snack. The family said she thought that was so weird stating it is just because the State is in the facility. The family of R H stated she attended a care plan meeting around three to four months ago, and she expressed her concerns about the food and the lack of snacks. She stated that the Social Worker commented to her She must be eating something because she is gaining weight. The family of R H stated she told them her mother is gaining wait because she and her siblings bring her food and snacks to eat. She stated nothing happens and the Administrator and prior Director of Nursing (DON) just treat her like a complainer. Record review for R H revealed an Admission MDS assessment dated [DATE] which assessed that it was very important to R H to receive snacks between meals. 4. Record review for R I revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 15 (a score of 13-15 indicates no cognitive impairment). It was assessed that it was not very important to R I to receive snacks between meals. Interview on 6/5/18 at 11:56 a.m. with R I revealed her daughter brings her food and snacks because they rarely get snacks from the facility. R I pointed to the basket of snacks provided by her family. R I further stated the facility had a meeting recently with the family and everyone complained about the food but it goes in one ear and out the other. 5. Record review for R K revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 15 (a score of 13-15 indicates no cognitive impairment). It was assessed that it was somewhat important to R K to receive snacks between meals. Review of a Quarterly MDS assessment dated [DATE] documented a BIMS summary score of 15. Interview on 6/5/18 at 8:00 a.m. with R K revealed the facility does not offer snacks throughout the day and sometimes he can get a peanut butter and jelly sandwich in the evening stating if they have any. R K stated he wakes up hungry every day. 6. Record Review for R M revealed a Significant Change MDS dated [DATE] which documented a BIMS summary score of 12 (a score of 8-12 indicates moderate cognitive impairment). The resident was assessed as making herself understood with clear speech and distinct intelligible words and understood others with clear comprehension. It was assessed that it was very important to R M to receive snacks between meals. Interview on 6/4/18 at 12:05 p.m. with R M revealed if she wants snacks, she has to buy them out of the vending machine with her own money. She stated the staff will bring a peanut butter and jelly sandwich at night stating if they have them. 7. Record review for R L revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 13 (a score of 13-15 indicates no cognitive impairment). It was assessed that it was somewhat important to R L to receive snacks between meals. Interview on 6/5/18 at 12:13 p.m. with R L revealed she can get a peanut butter and jelly sandwich or crackers at night but not always. R L stated she likes graham crackers but they don't always have them available. She stated the staff will tell her that after the kitchen is closed, they are not allowed in the kitchen for anything. 8.Interview with R Q's family member on 6/5/18 at 12:30 p.m. on the phone reveals that R Q is a big eater. She states she has ask time and time again that they put double portions on his tray and give him buttermilk to drink. Family states that it's rare he gets buttermilk. States she and her sibling visit daily and always bring R Q something to eat because the kitchen is always bringing him food that he cannot swallow and he seems to stay hungry. Family states R Q requires food that is soft and more times than not he receives food that is not soft and he gets strangled on it. States she has discussed this issue with not only the dietary staff but the Administrator as well. She states he never gets a snack at night and if he goes to bed hungry he is up all night and there are never any snacks o be offered. Interview on 6/5/18 at 12:40 p.m. with the DM revealed that R Q is supposed to receive two glasses of buttermilk with each meal. Review of R Q's meal ticket revealed that he is supposed to receive buttermilk and double portions. Observation on 6/5/18 at 12:45 p.m. of R Q's tray in the DR revealed there was a carton of whole milk but no buttermilk on his tray and no double portions.",2020-09-01
567,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2018-06-07,925,E,1,1,MLO511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the facility policy titled Pest Control, review of the pest control service records, resident and staff interviews, the facility failed to follow the pest control recommendations to help reduce flies and the potential for other pest in the facility. The facility census was 108 residents. Findings include: Review of the facility policy titled Pest Control dated May, 2008 documented: Our facility shall maintain an effective pest control program. Policy Interpretation and Implementation documented: This facility maintains an ongoing pest control program to ensure that the building is kept free of insects and rodents. Observation on 6/4/18 12:15 p.m. revealed a fly on R #91 while she was sleeping in her bed. Record review for R#91 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which indicated a Brief Interview for Mental Status (BIMS) was not conducted due to severe cognitive impairment. R#91 was not a candidate for interview. Observation on 6/4/18 at 12:59 p.m. revealed six flies on R#19 while the resident was in bed. An interview on 6/5/18 at 11:55 a.m. with the Family of R#19 revealed the resident's room gets quite dirty and there are flies in the resident's room at times. The Family stated she visits R#19 once a week and cleans up when she visits. Observation at the time of the interview revealed one fly on the resident's bed and one fly on the residents' bedside table. During an interview on 6/4/18 at 12:57 p.m. with R#4, he complained about flies in his room. Observation at the time of the interview revealed four to five flies on the resident's bed and landing on his face. There was a sticky fly strip noted above the resident's bed with six dead flies on it. During the interview with R#4, Housekeeper OO entered the room and stated there were a lot of flies because of the side door people use to come in and out of the facility. Record review for R#4 revealed a Quarterly MDS assessment dated (place date) which documented a BIMS summary score of seven (a score of 0 and 7 indicate severe cognitive impairment). Despite a BIMS score of seven, R#4 could hold sensible conversation and answered all screening questions appropriately. Interview on 6/5/18 at 12:00 p.m. with R#4 revealed a Certified Nursing Assistant (CNA) removed the fly strip from his room and told he was not allowed to have it. During an interview on 6/5/18 at 2:41 p.m. with CNA NN, she stated that she asked R#4 if she could remove the fly strip and he stated yes. CNA NN further stated that she asked the Charge Nurse and the Administrator and they told her R#4 could not have it in his room. Interview on 6/6/18 at 11:59 a.m. while R#4 sat on the edge of his bed, he stated the fly situation was a little better today but they still bother him. He stated the flies are especially bad when his meals are delivered to his room and he can't get up from his plate. R#4 stated if he leaves his plate, it will be full of flies. During the interview, one fly was observed on the resident's bed, one fly was observed on the roommate who was sleeping in his bed and one fly was observed in the bathroom. Interview on 6/6/18 at 12:13 p.m. with Licensed Practical Nurse (JJ) revealed that the flies seem to be more prevalent on the end of the 400 Hall. LPN JJ stated she has worked on the 400 Hall for one week and had noticed flies during this time. Asked how long has she noticed all the flies in resident rooms, she stated she has been working the 400 Hall for about a week. LPN JJ stated she had never notified anyone about the flies but stated the Maintenance Director and the Administrator know about the flies. Review of the pest control company service records revealed the following: On 5/22/18, evidence of filth flies and house mouse. Recommendations: cracks and crevices sealed. All wall air conditioning units in the rooms need to be sealed again because the old one's are becoming loose. Wall units need to be sealed. On 4/25/18, evidence of filth flies. Recommendations were cracks and crevices unsealed. All wall air conditioning units in the rooms need to be sealed again because the old one's are becoming loose. Wall units need to be sealed. On 3/10 /18, evidence of house mouse. Recommendations: cracks and crevices sealed. All wall air conditioning units in the rooms need to be sealed again because the old one's are becoming loose. Wall units need to be sealed. On 12/29/17, evidence of filth flies. No recommendations made. On 11/29/17, evidence of filth flies. No recommendations made. Interview on 6/7/18 at 8:12 a.m. with the Maintenance Director revealed he is not always made aware of when pest control comes to the facility so he does not always make rounds with the peat control. He further stated that he does receive the peat control service records and he does not see the pest control recommendations. He stated that the Administrator gets the pest control service records. The Maintenance Director confirmed the facility has numerous flies and stated a conversation has taken place about obtaining a fly fan screen for the kitchen, however that had not yet been done. Interview on 6/7/18 at 8:57 a.m. with the Administrator revealed he is made aware when the pest control company is in the facility. The Administrator stated he alerts the pest control person with the facility's current pest concern. The Administrator stated when the pest control person is finished he reports his findings and those findings are verbally forwarded by him to the Maintenance Director. During an interview on 6/7/18 at 12:53 p.m. with R#21, he stated that the flies are terrible today and I can't eat my food without them bothering me! Further interview on 6/7/18 at 12:59 p.m. with the Administrator revealed he is ultimately responsible for following up on the pest control recommendations. He stated he discusses the findings with the pest control person and passes it on to the Maintenance Director. The Administrator stated that he does follow up and spot check but he has no documentation or record of completing the pest control company's recommendations. Observation on 6/7/18 at 1:40 p.m. of 10 air conditioning units outside of resident rooms with the Maintenance Director and the Administrator revealed four of the 10 air conditioning units had obvious cracks and crevices around the unit/wall connection and needed caulking. The Maintenance Director stated he does not conduct maintenance rounds of the air conditioners outside of the building. On 6/5/18 at 8:00 a.m., there was one fly observed flying around in resident room [ROOM NUMBER]. During interview on 6/5/18 at 12:40 p.m. with R M, two flies were noted flying in her room. R M stated she has her own fly swatter and kills at least one fly every day and sometimes more. Record review for R M revealed a Significant Change MDS dated [DATE] which documented a BIMS summary score of 12 (a score of 8-12 indicates moderate cognitive impairment). On 6/6/18 at 9:50 p.m., two flies were noted flying around the nurses station. At 4:10 p.m., there was one fly was flying around the nurses station. On 6/6/18 at 5:10 p.m. in the kitchen during meal service observation, there were several flies noted flying around the steam table and crawling on the meal service carts.",2020-09-01
568,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2017-08-17,223,D,0,1,NFWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, a review of resident clinical records, and a review of the facility's abuse policy, the facility failed to ensure that one Resident (R #75) was free from physical abuse. The sample size was 25 residents. Findings included: A review of the demographics revealed that R#75 is a [AGE] year old resident. A review of the Nursing Progress Notes for R#75 dated 8/11/17 (11:29 p.m.) revealed the following: This nurse heard resident yelling get out of here and observed pushing a male residents (wheelchair) from her room. Male resident twisted resident's (right) arm/wrist and punched resident in stomach. Resident was taken into room and removed from male resident. Upon assessment resident had no (signs or symptoms) of redness or injury to areas in altercation. No (complaints of) pain or discomfort. Resident states I'm fine. He needs to stay out of my room. (Responsible Party) .and (Physician) notified. A review of the quarterly Minimum Date Set (MDS) assessment revealed that R#75 presents with a Brief Interview for Mental Status (BIMS) score of 12. A score in the range of 8-12 indicates that the resident presents with moderately impaired cognitive understanding. A review of the demographics revealed that R#133 is a [AGE] year old male admitted to the facility on [DATE] with a relevant active [DIAGNOSES REDACTED]. A review of the Nursing Progress Notes for R#133 dated 8/11/17 (10:55 p.m.) revealed the following: (R#133) was observed going into a female resident's room on 400 hall. Female resident requested for resident to remove himself from room and started pushing resident's (wheelchair) out of door. Resident witnessed by this nurse to twist female resident's right arm and punch her in the stomach. Resident redirected from area. A review of the quarterly MDS assessment revealed that R#133 presents with a BIMS score of 99. A score of 99 indicated that the resident was cognitively unable to answer the interview questions. During an interview with the Administrator (NHA) on 8/16/17 at 2:41 p.m. he provided the abuse policy. He confirmed that the policy was not dated and stated that he was not sure when it was implemented or when it was last revised. He stated that he was informed during the morning meeting on 8/14/17 that an incident occurred on 8/11/17 involving R#133 punching R#75 and twisting her arm. During an interview with R#75 on 8/16/17 at 4:42 p.m. she stated, That man hit me right in my stomach. She confirmed that she was not afraid of anyone at the facility. She stated that she just stays clear of men like that and that the man has never been back into her room. During an interview with Licensed Practical Nurse AA on 8/17/17 at 1:37 p.m. she stated that she worked on Friday 8/11/17 during the 3:00 p.m.-11:00 p.m. shift. She stated that at around 9:45 p.m. R#133 was observed going into R#75's room. She stated that R#75 was screaming at him to get out. She stated that before she was able to intervene, she witnessed R#133 twist R#75 right arm and R#133 punched R#75 in the stomach. She stated that she intervened and that R#133 got ahold of her and she was able to get him away from R#75. She stated that she checked both resident out and placed an incident report note in the Director of Nursing's (DON) door so that she would see it when she came back to work. She stated that she charted the incident in the Progress Notes and told the nurse coming on duty what had occurred. She stated that she did not consider the incident abuse because R#133 does not remember his actions and that he wasn't meaning to be harmful to R#75. She confirmed that she had not called the DON or the NHA to report the incident. A review of the Abuse Policy (no date) revealed that the facility actively supports and defends each resident's right to be free from any and all forms of abuse . Physical abuse is defined as hitting . Our facility will not condone abuse by anyone, including . other residents.",2020-09-01
569,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2017-08-17,225,D,0,1,NFWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to investigate and report alleged violation of abuse for one Resident (R #75). The sample size was 25 residents. Findings included: A review of the demographics revealed that R#75 is a [AGE] year old resident. A review of the Nursing Progress Notes dated 8/11/17 (11:29 p.m.) revealed the following: this nurse heard resident (R#75) yelling get out of here and (sic) observed pushing a male resident (wheelchair) from her room. Male resident twisted resident's (right) arm/wrist and punched resident (R#75) in stomach (sic). Resident was taken into room and removed from male resident. Upon assessment resident had no (signs or symptoms) of redness or injury to areas in altercation. No (complaints of) pain or discomfort. Resident states I'm fine. He needs to stay out of my room. (Responsible Party) .and (Physician) notified. A review of the Minimum Date Set quarterly assessment revealed that R#75 presents with a Brief Interview for Mental Status (BIMS) score of 12. A score in the range of 8-12 indicates that the residents presents with moderately impaired cognitive understanding. A review of the demographics revealed that R#133 is a [AGE] year old resident with a relevant active [DIAGNOSES REDACTED]. A review of the Minimum Date Set quarterly assessment revealed that R#133 presents with a BIMS score of 99. This indicated that the residents was cognitively impaired and unable able to answer the interview questions. During an interview with the Nursing Home Administrator (NHA) on 8/16/17 at 2:41 p.m. he provided the abuse policy. He confirmed that the policy was not dated and stated that he was not sure when it was implemented or when it was last revised. He stated that he was informed on Monday, during morning meeting, that an incident occurred on Friday, 8/14/17 between R#133 and R#75 and was that R#133 punched R#75 and twisted her arm. He confirmed that he had not reported the incident to the state. He was asked why he hadn't reported the incident to the state and he stated, This is not a new issue. He is care planned for behaviors. He then stated that he had thought that he reported the incident to the state although was unable to produce an incident report that was reported to the State Survey Agency. A review of the facility Incident report provide by the NHA revealed that the investigation was started on 8/16/17. During an interview with R#75 on 8/16/17 at 4:42 p.m. she stated, That man hit me right in my stomach. She confirmed that she was not afraid of anyone at the facility. She stated that she just stays clear of men like that and that the man has never been back into her room. During an interview with Licensed Practical Nurse AA on 8/17/17 at 1:37 p.m. revealed that she worked on Friday 8/11/17 during the 3:00 p.m.-11:00 p.m. shift. She further revealed that at around 9:45 p.m. during that shift, R#133 was observed going into R#75's room. She stated that R#75 was screaming at him to get out and that R#133 was facing her and R#75 was pushing him out of her room. She stated that before she was able to intervene, she witnessed R#133 twisted R#75 right arm and R#133 punched R#75 in the stomach. She stated that she intervened and was successful at separating the residents. She stated that she checked both resident out and placed an incident report note in the Director of Nursing's (DON) door so that she would see it when she came back to work. She also revealed that she charted the incident in the Progress Notes and told the nurse coming on duty what had occurred. She stated that she did not consider the incident abuse because R#133 does not remember his actions and that wasn't meaning to be harmful to R#75. She confirmed that she had not called the DON or the NHA to report the incident. A review of the Abuse Policy (no date) revealed that the facility actively supports and defends each resident's right to be free from any and all forms of abuse . Physical abuse is defined as hitting . Our facility will not condone abuse by anyone, including . other residents. Any alleged violations involving . abuse . must be reported to the administrator. The administrator will be responsible for overseeing and directing the course of the investigation. The person (s) observing an incident of resident abuse . must immediately report such incident to the charge nurse or his/her supervisor. Upon receipt of an Incident Investigation Report, the admininistrator or his/her designee will notify the Georgia Department of Human Resource, Long Term Care Section Intake and Referral Division by fax or telephone of the incident. An immediate investigation will be made with a final written report submitted to the State Agency within 5 working days.",2020-09-01
570,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2017-08-17,323,E,0,1,NFWB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, review of product labels and Material Safety Data Sheets (MSDS), the facility failed to ensure that potentially hazardous bath and hygiene products and treatments for head and body lice were kept secured in one of two shower rooms on one of four halls. The facility census was 105 residents. Findings include: Observations conducted on 8/14/17 at 11:00 a.m. revealed the door to the shower room on the 400 hall did not have a lock. No one was in the shower room and residents were ambulating and moving about in wheelchairs in the hallway outside the shower room door. Inside the shower room, the cabinet below the sink had a latch with no lock. The cabinet contained a gallon container of liquid soap with no cover, hair sprays, alcohol based hand gel and various shampoos including an opened 8.5 ounce plastic bottle of Theragel coal tar shampoo, a 2 ounce container of Nix cream rinse, opened and partially used, and an opened, partially used 4 ounce container of Perigo GoodSense Permethrin Lotion 1% Lice treatment. Review of the product label for Perigo GoodSense Permethrin Lotion 1% Lice treatment revealed if the product is ingested medical help should be obtained immediately. Review of product label for Nix Permethrin Lice Treatment indicated medical help should be contacted if swallowed. The MSDS for Theragel coal tar shampoo indicated ingestion could cause nausea, vomiting or diarrhea and a physician should be contacted. Further observations on 8/17/17 at 4:42 p.m. with the Assistant Director of Nursing (ADON) and the Resident Care Coordinator (RCC) revealed the cabinet under the sink in the unlocked shower room contained the gallon bottle of shower soap with no cover, 2 ounce container of Nix cream rinse, 8.5 ounce bottle of Theragel coal tar shampoo and Perigo GoodSense Permethrin Lotion 1% Lice Treatment. Residents were ambulating and moving about in the hallway out side the shower room. Interview 8/17/17 at 4:10 p.m. with the Infection Control Nurse revealed there had been two residents admitted to the facility last winter that required treatment for [REDACTED]. They had not required further treatment and no other residents were affected. Interview with the RCC on 8/17/17 at 4:45 p.m. revealed there were at least four residents on the 400 hall that were ambulatory but not cognizant and would be able to access the potentially hazardous lice treatments, bath soaps and hygiene items in the cabinet in the unlocked shower room. The RCC acknowledged the cabinet should be locked. Interview 8/17/17 at 4:50 p.m. with the DON revealed the cabinet containing lice treatments, bath and hygiene items under the sink in the shower room on the 400 Hall should be locked because these items could be hazardous to independently mobile non cognizant residents. The DON confirmed there was no facility policy to indicate how these items should be stored. .",2020-09-01
571,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2019-08-22,577,D,0,1,N9JM11,"Based on observation and staff interview, it was revealed that the facility failed to post notice of the availability of state survey results in prominent places in the facility. The facility census was 109 residents, and the sample size was 20. Findings include: Observation of the lobby area and resident accessible areas in the facility on 8/19/19 beginning at 12:20 p.m. revealed no signs of the recent state survey results or signage announcing the location or availability of those results. An observation on 8/20/19 at 10:30 a.m. of the lobby area of the facility accompanied by the Social Service Director, revealed a cherry wood cabinet attached to the wall at the right of the main entrance. Inside the cabinet, once the doors were opened, was a binder labeled: Chatsworth Healthcare Center State Survey Report. During a group interview with members of the resident council on 8/22/19 at 2:10 p.m., it was revealed that few members of the resident council knew of the whereabouts of the state survey results and how they could access them. One resident said she believed they were to be found in the lobby area but could not be sure of the exact location. 5 out of the 13 members of the council who were present agreed that they were not aware the results of the most recent state surveys were available for their viewing, nor did they know where these results were located. Review of the Brief Interview for Mental Status (BIMS) scores on the most recent Minimum Data Set (MDS) assessments completed for the members of the council attending the interview revealed that 5 of 13 had scores ranging between 10 and 15 indicating that they were considered to be cognitively intact. During an interview with the Regional Nurse Consultant (RNC) at 8/22/19 at 4:00 p.m. revealed the red binder inside a cherry wood cabinet near the front entrance, she revealed that the residents are supposed to be educated on the availability of the survey results and where to find them. She agreed that there was no indication in the area as to where the survey results were kept and that visitors/families/residents would not necessarily know the results were available in the cabinet when the door was closed. The RNC said the survey results were also once available in a book at the nurse's station and she often directed families and visitors to those results. However, she was not sure if the results were still displayed in that area. During an interview with the Social Services Director (SSD) on 8/22/19 at 2:58 p.m., she stated that she spoke to the Resident Council in (MONTH) (YEAR) about the State survey results. The SSD said she discussed the last survey results and the location of the red binders with residents last year. She submitted a copy of the resident council meeting minutes dated 7/19/18. Observation on 8/22/19 at 3:12 p.m. of the sitting area accompanied by the SSD revealed that the survey results were not displayed anywhere in that area.",2020-09-01
572,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2019-08-22,688,D,0,1,N9JM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to ensure the highest level of range of motion (ROM) and mobility related to application of splints and Passive Range of Motion (PROM) for one Resident (R) (R#68). The sample size was 33 Residents. Findings include: Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for R#68 revealed a (C) Basic Interview for Mental Status (BIMS) score of 2 indicating severe cognition. (E) Behaviors (E0200) (C) Other behavioral symptoms not directed toward others (eg., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, or verbal/vocal symptoms like screaming, disruptive sounds.) 4 to 6 days a week but less than daily. (E0800) Rejection of Care - Presence and Frequency, behavior not exhibited. (G) Functional Status, Total dependence. (H) Bowel and Bladder, Always incontinent. (I) Active Diagnosis (including but not limited to, arthritis, dementia, anxiety, and depression. (N) Medications, antianxiety 2/7 days a week, antidepressant and diuretic 7/7 days a week. Review of the care plan for R#68 dated 10/30/14 with a goal target date of 10/24/19 revealed a Category of Activities of Daily Living (ADL) Functional / Rehabilitation Potential. Alteration in ADL Status related to impaired mobility and requiring assistance with completing ADL tasks. R#68 is dependent for bed mobility, transfers, personal hygiene, bathing and toileting. She has contractures to both hands related to arthritis. At times she refuses to wear her hand splints. Interventions include (but is not limited to), Encourage R#68 to wear her hand splints, if care is refused attempt to calm and return later in a kind, understanding manner and attempt care again. Notify Medical Doctor (MD) / Family as needed related to refusals. Review of the Restorative Nursing Care Plan dated 4/9/19 revealed, under observation, nothing is checked. Interventions include PROM and Splint or Brace Assistance. Measurable Objectives include, PROM to Bilateral Upper Extremities 3 to 7 times weekly and Restorative Nursing Plan (RNP) to apply B hand splints 3 to 6 times a week to be worn as tolerated. There is no time as to how long PROM should be done at a time or how long the splints should be worn noted on the care plan. During an observation on 8/20/19 at 11:00 a.m. of R#68 in bed. She was not observed to be wearing splints. During an observation on 8/21/19 at 12:40 p.m. of R#68 in bed. She was not observed to be wearing splints. During an interview on 8/21/19 at 10:30 a.m. with Restorative Certified Nursing Assistant (CNA) DD she stated that R#68 has not refused restorative care and stated R#68 is very cooperative for her and Restorative CNA EE. During this time Restorative CNA DD stated that the Restorative Nursing Care Plan is also the Restorative order. Review of the Restorative Book revealed (MONTH) 30, 2019 through (MONTH) 6, 2019 R#68 received Restorative Services of Passive Range of Motion and had the splints applied 5 times during this week, (MONTH) 7th through (MONTH) 13th 5 times, (MONTH) 14th through (MONTH) 20th 2 times, (MONTH) 21st through the 27th no PROM or splints applied, (MONTH) 28th through (MONTH) 3rd 1 time, (MONTH) 4th through (MONTH) 10th 2 times, (MONTH) 11th through (MONTH) 17th 2 times, and as of 8/21/19 there is no documentation that R#68 has received PROM or had her splints applied. There were no documented refusals in the book and no notation that refusals were reported to the supervisor. During an interview on 8/21/19 at 11:02 a.m. with Restorative CNA DD she stated that when she receives orders from physical therapy for a resident it is her and Restorative CNA EE's responsibility to carry out the orders for Restorative care. During this time dates were reviewed with Restorative CNA DD and she agreed that R#68 was not always receiving restorative care as it was ordered. During an interview on 8/21/19 at 11:05 a.m. with the Corporate Consultant Nurse she stated that she has implemented a new policy and all staff are being in-serviced. She stated, beginning today, after Restorative receives a new order and they have worked with the resident and gotten them at their maintenance then the Restorative CNA's will turn their restorative care over to the resident's CNA on the floor after teaching them how to perform the care for the resident. During this time Corporate nurse verified the Restorative Order should read, Passive Range of Motion to Bilateral Upper Extremities 3 to 7 days a week. RNP to apply both hand splints 3 to 6 times a week to be worn as tolerated. Review of the medical record for R#68 revealed no documented refusals of application of splints or PROM care in the nursing notes. Review of the Rehabilitative Nursing Care policy revised (MONTH) 2013 revealed rehabilitative nursing care is performed daily for those residents who require such service. Such program includes but is not limited to: assisting residents with their routine range of motion exercises. Review of the Range of Motion Exercises policy revised (MONTH) 2010 revealed the purpose of this procedure is to exercise the resident's joints and muscles. Documentation should include the following information be recorded in the resident's medical record: 1. The date and time that the exercises were performed. 2. The name and title of the individual(s) who performed the procedure. 3. The type of ROM exercise given. 4. Whether the exercise was active or passive. 5. How long the exercise was conducted. 6. If and how the resident participated in the procedure or any changes in the resident's ability to participate in the procedure. 7. Any problems or complaints made by the resident related to the procedure. 8. If the resident refused the treatment, the reason(s) why and the intervention taken. 9. The signature and title of the person recording the data. Reporting: 1. Notify the supervisor if the resident refuses the exercises. 2. Report other information in accordance with the facility policy and professional standards of practice. The resident was not observed to have on hand splints at any time throughout survey.",2020-09-01
573,CHATSWORTH HEALTH CARE CENTER,115280,102 HOSPITAL DRIVE,CHATSWORTH,GA,30705,2019-08-22,757,D,0,1,N9JM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record review, staff interview, and review of the policies, Medication Monitoring and Management and Behavioral Assessment, Intervention and Monitoring the facility failed to provide adequate monitoring of behaviors related to antipsychotic medication for one Resident (R) (R#35). The sample size was 33 residents. Findings include: Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] for R#35 revealed a (C) Basic Interview for Mental Status (BIMS) score of 13 indicating intact cognition. (E) Behaviors (E0100) (B) Delusions (misconceptions or beliefs that are firmly held contrary to reality). (G) Functional Status, Supervision oversight. (H) Bowel and Bladder, Always incontinent. (I) Active [DIAGNOSES REDACTED]. (N) Medication, antipsychotic and antidepressant 7/7 days a week. Review of the care plan dated 6/22/19 with a goal target date of 7/24/19 for R#35 revealed a category of Mood State. Alteration in Mood/Behavior related to signs and symptoms of depression, exhibiting behaviors and [DIAGNOSES REDACTED]. R#35 has episodes of delusions. She exhibits signs and symptoms of depression and behaviors of resisting care, verbal abuse and socially inappropriate behaviors. Interventions include: Administer medications as ordered (see current MD orders/MAR). Observe for effectiveness/any adverse side effects and notify MD as needed for medication changes. Analyze key times, places, circumstances, triggers and what de-escalates behavior. Intervene as needed to protect the rights and safety of others; approach in a calm manner; divert attention, remove from situation and take to another location as needed. MD/Pharmacist to evaluate on a periodic basis for a gradual dose reduction or discontinuation of [MEDICAL CONDITION] medications. Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, person involved, etc. Monitor for effectiveness of [MEDICAL CONDITION] drugs (i.e. targeted symptoms/behaviors are controlled). Obtain referral for mental health evaluation as needed. Review of the Order Recap Report for R#35 dated 4/1/19 through 8/31/19 revealed an order dated 4/30/19 by the Medical Director for [MEDICATION NAME] 20 milligrams (mg) one by mouth daily related to Major [MEDICAL CONDITION] and [MEDICATION NAME] 400mg give 1/4 tablet by mouth three times a day related to [MEDICAL CONDITION] Disorder dated 7/23/19 by the Psychiatrist. There was no order for behavior monitoring noted. Review of the medical record for R#35 revealed a note by Licensed Practical Nurse (LPN) FF dated 7/21/19 that reads: Resident became very angry when her roommate had visitors earlier in the shift at approximately 5 p.m. that woke me up being so loud, laughing, and talking about me. Resident then threatened to kill her roommate stating, If yall don't get that trash out of my room, I'll kill her tonight. Resident was moved to a private room, 407, for the night. This nurse educated resident several times that this change was temporary and for tonight only. Responsible Party (RP) of R#35 was notified of the incident with voiced understanding. Social Services Note dated 7/22/19 for R#35 reads: Psychiatrist in and asked her to see resident as needed based on her behavior this weekend. She (Psychiatrist) met with me after assessment and stated that in her opinion the resident was not a threat to her roommate. She stated her (R#35's) threats were behaviors related to her [MEDICAL CONDITION] disorder and paranoia. Patient at Risk (PAR)/Interdisciplinary Team (IDT) note dated 7/26/19 reads: Resident made threatening remarks to roommate last weekend. Resident seen by Psychiatrist on 7/22/19,ordered [MEDICATION NAME] for resident and suggested lab work to rule out medical causes of behavior. MD deemed resident was not a threat 7/22/19. MD collaborated with a second MD about resident's medical condition. Resident was offered to move rooms and refused to do so. Resident has made no other threats to residents or staff at this time. During an interview on 8/21/19 at 2:30 p.m. with LPN/MDS CC she stated that behavior monitoring is done on the Medication Administration Record (MAR). During this time the (MONTH) 2019 MAR for R#35 was reviewed and LPN/MDS CC confirmed there was no behavior monitoring on the MAR. April, May, June, and (MONTH) 2019 MAR's were also reviewed and confirmed no behavior monitoring was done. She stated that the facility switched Electronic Medical Records and on (MONTH) 17, 2019 is when they began using the new EMR electronic Medication Administration Record (eMAR). During this time LPN/MDS CC reviewed the Physician order [REDACTED]. She then went into the previous EMR and searched the Physician order [REDACTED]. At the end of each shift mark Frequency-how often behavior occurred and Intensity-how resident responded to redirection. Intensity Code: 0=Did Not Occur; 1=Easily Altered; 2=Difficult to Redirect. Every shift 01:00 PM - 03:00 PM, 09:00 PM - 11:00 PM, 05:00 AM - 07:00 AM. LPN/MDS CC stated that whoever transcribed the orders over into the new system failed to put the behavior monitoring order in. During an interview on 8/22/19 at 8:30 a.m. with Resident Care Coordinator (RCC) AA for the 400 and 100 halls, she stated behavior monitoring is documented on the MAR. She stated that the order date for behavior monitoring on R#53's medical record is 8/21/19. She stated when there is an admission the Admissions Coordinator puts the orders in to the Resident's medical record then the infection control nurse goes behind her to verify all the orders received are in the medical record and are correct in the computer. She stated that she would have expected any nurse giving medication to R#35 to have caught there was no behavior monitoring on the MAR beginning (MONTH) 17, 2019 when the facility began using the new Electronic Medical Record (EMR). During an interview on 8/22/19 at 9:29 a.m. with LPN BB she stated she has been administering medications to R#35 for at least 10 months now. She stated she was doing behavior monitoring on R#35 at one point because of an issue that happened with her roommate. During this time the MAR's for R#35 from (MONTH) 2019 to (MONTH) 2019 were reviewed with the nurse and she stated there is no documented behavior monitoring beginning 4/17/19 until 8/22/19 and stated the order on the new EMR to do behavior monitoring is dated 8/21/19. LPN stated that she honestly never thought about the behavior monitoring not being on the MAR and didn't realize it until it was brought to her attention at this time. She stated she is aware that any resident on antipsychotic should be receiving behavior monitoring. During an interview on 8/22/19 at 10:12 a.m. with the Pharmacist she stated during monthly medication regimen reviews one of the things the pharmacist is ensuring is that, any resident who is on an antipsychotic, receives behavior monitoring as well. She stated she personally is not responsible for the facility R#35 is in but upon review of her (R#35) information it shows from (MONTH) 17, 2019 to today, (MONTH) 22, 2019 the resident has had numerous antipsychotic dosing changes and stated that when there is a dosing change it would cause the pharmacist to ensure behavior monitoring was ordered and being done. Pharmacist stated by reviewing R#35's information she cannot tell why behavior monitoring not being done wasn't caught during the Consultant Pharmacist monthly reviews. Review of the Medication Monitoring and Management policy dated (MONTH) 2007 reads, in part: In order to optimize the therapeutic benefit of medication therapy and minimize or prevent potential adverse consequences, facility staff, the attending physician/prescriber, and the consultant pharmacist perform ongoing monitoring for appropriate, effective, and safe medication use. When selecting medications and non-pharmacological interventions, members of the interdisciplinary team participate in the care process to identify, assess, address, advocate for, monitor, and communicate the resident's needs and changes in condition. Review of the Behavioral Assessment, Intervention and Monitoring policy revised (YEAR) revealed the nursing staff will identify, document, and inform the physician about specific details regarding changes in an individual's mental status, behavior, and cognition, including: Onset, duration, intensity and frequency of behavioral symptoms; Any precipitating or relevant factors, or environmental triggers (e.g., medication changes, infection, recent transfer from hospital); and appearance and alertness of the resident and related observations.",2020-09-01
574,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2018-06-07,755,D,0,1,HDY411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, facility failed to follow the policy titled Storage of Medications and Biological's. They failed to ensure disposal of expired medications in one of seven medication carts. Sampled size 23. Findings Include: On 6/5/18 at 9:40 a.m. four out of seven medication carts were observed, two expired medications found in one of seven carts. On 6/5/18 at 10:00 a.m. during an observation with Licensed Practical Nurse (LPN) BB expired medications were found in cart number one of the Magnolia Hall used for one resident eight various times in (MONTH) (YEAR). One bottle of Geri-Lanta regular strength Antacid and [MEDICATION NAME] 355 milliliters expired on 11/17. Lot number . A record review of the facility's Storage of Medications and Biologicals /Medication Administration policy with an issue date of (MONTH) 20th, 2010 and a review/revision date of (MONTH) 1, (YEAR) revealed facility will ensure medications and biologicals are stored, labeled, and disposed of properly by expiration date. An interview on 6/5/18 at 10:15 a.m. with the Licensed Practical Nurse (LPN) BB revealed staff are expected to date and label all medications when opened and check for expired medications in the medication carts daily prior to administering medication to all residents. Order was to administer Geri-Lanta 30 milliliters by mouth as needed for indigestion. Geri-Lanta expired 11/17, LPN BB administered the medication to one resident eight various times in (MONTH) (YEAR). LPN BB stated she did not check for expiration date of medications. An interview on 6/5/18 at 10:30 a.m. with Registered Nurse (RN) AA revealed staff are expected to date all medications when opened and check for expiration date. An interview on 6/5/18 at 11:18 p.m. with the Director of Nursing (DON) revealed staff are in-serviced on medication storage, medication administration, medication expiration date, DON initiates in-services to all Licensed Nurses. On 6/6/18 at 12:30 p.m. An interview with the Pharmacy Consultant states all License Nursing staff were in-service on medication administration, and medication expiration date.",2020-09-01
575,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2018-06-07,761,D,0,1,HDY411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** FACILITY Medication Storage and Labeling F761 Based on observation, interviews, and record review, the facility failed to follow the policy titled Storage of Medications and Biological's. Facility failed to ensure disposal of expired medications in one of seven medication carts, and one of three medication storage rooms. Sampled size 23. Findings Include: 6/5/18 9:40 a.m. Facility has seven medication carts, and three medication storage rooms, four medication carts and three medication storage rooms observed. Two bottles of expired medication were observed in one cart, and one expired medication in central medication storage room. 6/5/18 at 10:00 a.m. observation with Licensed Practical Nurse (LPN) BB found expired medications in cart number one of Magnolia Hall. One bottle of Moisturizing Lubricant 0.5% eye drops found in Magnolia hall medication cart one, opened on 1/9/17, expired on 9/9/18. One bottle of Geri-Lanta regular strength Antacid and [MEDICATION NAME] 355 milliliters expired on 11/17. Lot number . 6/5/18 at 10:30 a.m. observation with Registered Nurse (RN) AA found expired medications in one of three medication storage rooms. One bottle of Pink [MEDICATION NAME] regular strength 473 milliliters, lot number SBR001C, expired on 2/18. A record review of the facility's Storage of Medications and Biologicals /Medication Administration policy with an issue date of (MONTH) 20th, 2010 and a review/revision date of (MONTH) 1st, (YEAR) revealed facility will ensure medications and biologicals are stored, labeled, and disposed of properly by expiration date. An interview on 6/5/18 at 10:15 a.m. with the Licensed Practical Nurse (LPN) BB revealed staff are expected to date/label all medications when opened; and check for expired medications in medication carts on daily, prior to administering medication to all residents. An interview on 6/5/18 at 10:30 a.m. with Registered Nurse (RN) AA revealed staff are expected to date all medications when opened and check for expiration date. An interview on 6/5/18 at 11:18 p.m. with the Director of Nursing (DON) revealed staff are in-serviced on medication storage, medication administration, medication expiration date, DON initiates in-services to all Licensed Nurses. 6/6/18 at 12:30 p.m. An interview with[NAME]Bowlers (Pharmacy Consultant) states all License Nursing staff was in-service on medication administration, and medication expiration date. DONE.",2020-09-01
576,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2018-06-07,812,E,0,1,HDY411,"Based on observation, staff interview, and policy review titled Tray Service and Transport the facility failed to ensure food was served in a sanitary manner, desserts were served open to the residents receiving trays in their rooms. Facility failed to cover food that was distributed to one of two units. This deficient practice had the potential to affect 100 residents receiving an oral diet. Facility census was 102 residents. Findings include: On 6/4/18 at 1:00 p.m. when the staff started to deliver meals trays to residents on Magnolia wing, it was observed the dessert bowls containing strawberry and whipped topping uncovered. There were twelve (12) trays on the lunch cart. Several staff members distributed the trays to different rooms more than 15 feet from the lunch cart. On 6/6/18 at 6:04 p.m. there were eighteen (18) dinner trays on the cart on Magnolia wing and the trays had individual bowl some with marinated tomatoes, sliced peaches and green beans, and each of the bowls were not covered. Interview on 6/07/18 at 9:54 a.m. with the Dietary Manager revealed that the open food items should stay in a closed food cart and the cart should be pushed to the areas that the food is delivered. He stated he was aware of the items that were not covered but he also stated based on infection control all the items should be covered. Interview on 6/7/18 at 1:18 p.m. with the DON regarding food tray delivery, she said that she was not aware that the bowls on the closed cart on Magnolia wing were open. She stated the staff should be moving the cart next to the resident door and that would be equal to the dining room, but if the bowls are open then the kitchen should be covering the bowls for infection control purposes. Review of facility's Tray Service and Transport policy dated (MONTH) 2014 revealed guideline #6: Trays are transported in an enclosed cart whenever possible. Foods, beverages and eating utensils are covered with lids, plastic wrap or other suitable covering if tray are carried through patient care and public areas.",2020-09-01
577,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2018-06-07,880,D,0,1,HDY411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of records, staff interview, and Facility Infection Control Manual, the facility failed to ensure that contact precaution measures were maintained for two residents (#261 and #266) from a sample of 23 residents. The facility census was 102. Finding include: 1. 0n 6/6/18 at 8:30 a. m. housekeeper EE was observed going into the room of R#261 without applying personal protection equipment (PPE) and coming out of the room carrying trash in a plastic bag. The PPE cart was located outside of the room. Review of the Infection Control Manual: Chapter 2 - Practice Guidelines revealed that during contact precaution measures, personal protective equipment (PPE) such as gowns and masks are to be worn when clothing is anticipated to come in contact with residents, their environmental surfaces, or items in the room that are contaminated. The PPE is stored outside of the resident's room and is donned prior to providing care. The PPE should be removed before leaving the resident's room. Transmission-based precautions are discontinued when the infection is resolved or ruled out. Infections are resolved when the patient is free of clinical symptoms of the infection for 48 hours or meet criteria that is specified in the Type and Duration table laid out in the manual. The duration specified for [MEDICAL CONDITIONS] in this table was listed as the duration of the illness. For residents on transmission-based precautions, a sign saying to stop and see nurse for instruction is posted on a resident's room door. 2. Review of clinical records revealed resident (R) #266 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Interview on 6/4/18 at 2:04 p.m. with Registered Nurse (RN) DD revealed R#266 remained on contact precautions for [MEDICAL CONDITION]. Observation on 6/4/18 at 2:44 p.m. revealed Housekeeper CC cleaning the room of R#266. Housekeeper CC was not wearing PPE. A sign on the door of the room warned, Attention Visitors, please report to nurses' station before entering this room Interview on 6/4/18 at 2:50 p.m. with Housekeeper CC revealed she was not wearing PPE because she believed the resident was no longer on contact precaution because the resident was out of the room. The resident was given permission to leave her room and visit with her daughter in the courtyard. Interview on 6/4/18 at 2:55 p.m. with RN DD revealed the resident had not had any loose stools for a while and the Nurse Practitioner (NP) had given the resident permission to leave the room and visit with her family member outside in the courtyard. However, the NP still needed to check with Director of Nursing (DON) to see if the resident was eligible to be taken off of contact precautions. Until the NP give permission, contact precaution measures continued for the resident. Observation on 6/5/18 at 9:07 a.m. revealed the Attention Visitors, please report to nurses' station before entering this room sign remained in place on the resident's door. Interview on 6/7/18 at 10:05 a.m. with the DON/Infection Control Program Manager, if a resident is suspected of a having a transmissible infection such as [MEDICAL CONDITION]; staff will place that resident on contact precautions - the resident is placed in a separate room, the physician is notified, and any necessary laboratory tests are completed. As soon as a resident is placed on contact precautions for one of these transmissible infections, a sign requesting visitors to see the nurse is placed outside door, and a cart containing PPE is placed outside the room. The information regarding the resident's precaution measures is placed on 24-hour report and also passed on to the nurses on the other shifts during nurses' report. The incoming Certified Nursing Assistants (CNAs) receive report from their nurse. They are educated about the type of infection and the types of precautions needed. All department managers receive information about residents that are placed on contact precautions and they are then responsible for disseminating this information to their staff. Staff receive mandatory annual training on transmissible infections, and information such as signs/symptoms, use of PPE, etc. are also given periodically throughout the year. The criteria for removing a resident from contact precaution is dependent on the transmissible infection. For [MEDICAL CONDITION], the resident must be without loose stools for at least 48 hours. Then the physician must give an order for [REDACTED].>Interview on 6/7/18 at 11:37 a.m. with the housekeeping supervisor revealed that the housekeeping supervisor passes along information about which residents are on contact precautions to the housekeeping staff, or they are expected to check with the nurse if they see the do not enter note on the door. Housekeeping staff are expected to use PPE such as gowns and gloves every time they enter the room belong to a resident on contact precautions and they are to discard this equipment before they exit the room. When the housekeeping staff is notified that the resident is no longer on precautions, they are still expected to don PPE to enter the room to perform a final deep clean. This includes cleaning the bed, putting on new linens; basically, everything that the resident could have contaminated is cleaned.",2020-09-01
578,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2019-08-29,561,D,0,1,54BI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident, family, and staff interviews, the facility failed to ensure R#54 choice to eat in the residents room was honored. The sample size was 26. Findings: During an interview with R#54 on 8/27/19 at 2:49 p.m. States that she did not receive a lunch tray today. License Practical Nurse ( LPN) AA came around to give meds and she told her that she had not received her lunch yet. LPN AA came back after some time to see if she received a tray, but she had not. Stated that LPN AA offered her a sandwich, but she turned it down due to it being close to dinner time. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] Section C Brief Interview for Mental Status is coded 15/15 which indicates no cognitive impairment. During an interview on 8/27/19 at 3:40 p.m. with LPN AA regarding R#54 lunch she stated that she was going to deliver 1:30 p.m. meds when the resident informed her that she had not received her tray. Stated that she then went to the two aids who were responsible for delivering trays on the hall. One aid stated that she did not deliver trays on R#54's hall today and the other believes that her tray was accidentally picked up under the assumption that she was done eating. LPN AA states that resident usually eats in the dining room but today chose to eat in her room. States that there is no real process for communicating if a person eats in their room or the dining room. States that staff would find out if a person eats in their room by going through and checking to see if they received a tray or if a resident vocalizes that they have not ate. States that there are two aids on the hall responsible for delivering trays to the hall based off the trays that are on the cart. During an interview on 8/28/19 at 10:00 a.m. with Unit Manager (UM) BB stated that everybody that shows up to the dining room has a ticket. Once all tickets are served in the dining room the left-over tickets are assumed to be for the hall. Trays are then delivered to the hall based on the left-over tickets. States that there are two hall Certified Nursing Assistants (CNA's) are assigned to deliver trays. States that it was brought to her attention on yesterday by LPN AA that R#54 did not receive her tray. States that she is unsure as to what happened. States that she was not in hall when trays were delivered, because she is assigned to be in the dining room. States that she is unaware if a tray was created in the kitchen and delivered to the hall for the R#54. Once she was made aware that resident did not receive her tray she went to the resident to ask if she would like a sandwich and the resident stated that she was fine. States that the only way to know if a resident did not receive their tray is by them vocalizing or staff checking. States that the resident usually eats in the dining room and so it threw them off by her staying in her room to eat. During an interview on 8/28/19 at 10:40 a.m. with the Dietary Manager (DM) he explained the tray service delivery process. States that he prints meal tickets in dietary for the day. States that the tickets are separated by hall and then organized in alphabetical order. The CNAs who are assigned to dining come get the tickets. States the dining room opens at 12:00 p.m. and closes at 12:30 p.m. As residents enter the dining room and choose a seat a CNA goes over to take their order. The order is taken on the meal ticket and the ticket is given back to the kitchen to prepare the tray. Once the tray is prepared it is placed on a serving plate with the meal ticket, so the CNA knows who to deliver the tray to. After the dining room closes at 12:30 p.m. the left-over tickets are assumed to be for residents who eat on the hall, because they were not present in the dining room. States that CNAs go to the halls to ask the resident what they would like to eat. Dietary delivers trays to the halls and CNAs serve them. Stated he was not aware of R#54 not receiving her tray on Tuesday because he was absent. The Dietician in room at the time of the interview with the DM states that it was brought to her attention later in the day well after meal service. Both the DM and the Dietician confirmed that the kitchen was not made aware that R#54 did not receive her tray at the time it was identified.",2020-09-01
579,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2019-08-29,585,D,0,1,54BI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and Resident interview the facility failed to promptly resolve a grievance for one Resident (R) (R#36). The sample size was 27 Residents. Findings include: Review of the Minimum Data Set Quarterly assessment dated [DATE] for R#36 revealed a (C) Basic Interview for Mental Status (BIMS) score of 14 indicating intact cognition. (E) No Behaviors noted. (G) Extensive one person physical assistance with Activities of Daily Living (ADL). (I) Active [DIAGNOSES REDACTED]. (N) Receives an antidepressant 7/7 days a week. Review of the Care Plan for R#36 revealed no care plan in place that would indicate memory loss, dementia, or confusion. During an interview on 8/26/19 at 12:22 p.m. with R#36 she stated a couple of months ago she had 5- twenty dollar bills in her possession. She stated she was keeping the money in her personal folder that she has her social security and debit card in. R#36 stated someone took four of the twenty dollar bills then a couple of days later they took the other twenty. She stated she reported this to the social worker to file a complaint but she hasn't heard anything about it since. R#36 stated it most likely happened during the night and it couldn't have been her roommate because she doesn't have her mind enough to do something like that. She stated that it happened either at night or while she was gone to an activity but she believes it was an employee. Review of the Concern Form dated 7/23/19 revealed at 4:56 p.m. R#36 told Licensed Practical Nurse (LPN) AA that she was missing $80.00. She stated she had 5 $20.00 bills and only has 1 remaining. She voiced that the incident would have to occurred between 3:00 p.m. to 7:00 a.m. 7/22/19 to 7/23/19. There was nothing written under Documentation of Facility Follow-Up. Under Resolution of Concern yes or no was not checked to confirm if the concern was resolved but on the lines provided it stated, Social Worker to get back with family and discuss money as to missing/safe keeping but there is no signature or date. During an interview on 8/27/19 at 12:06 p.m. with the Social Worker, she stated she wrote a grievance last week in regard to a complaint from R#36 that she had money missing. Social Worker stated that she called R#36's son to verify that the resident had the money here in the facility but stated he has not returned her call. She stated she took the grievance to the Administrator. During an interview on 8/27/19 at 12:33 p.m. with the Administrator/Grievance Coordinator, she stated that she recalls the Social Worker meeting with her last week and discussing R#36 concern about money she had in her room that was missing and that the Social Worker called the son but he had not returned the call. Administrator stated when she receives a grievance she reviews the grievance and based on the area of concern she will pass the grievance on for investigation. She stated, for example, if there was a dining concern she would send it to dietary and they would investigate and report their findings to the Resident then inform her of the outcome. Administrator stated in regard to the concern with R#36 she would have gotten information from the resident as to how much money she had. She stated she would recommend to R#36 that she don't keep money on hand. She stated that she hopes an investigation related to a grievance would be completed within 24 hours. Administrator stated that the grievance outcome is usually given to the resident verbally. During an interview on 8/27/19 at 1:29 p.m. with LPN AA, she stated that around the end of (MONTH) R#36 informed her that she had money missing and stated she wrote the concern on a Concern Form and went to the Social Worker with it. She stated the social worker told her to give it to the Administrator. LPN stated that the Administrator was on vacation so she placed the grievance in her (the Administrators) box. She stated that there has been no follow up with R#36 that she is aware of. She stated that Misappropriation of Property should be reported to the State within 24 hours. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that R#36 grievance regarding missing money was not reported to the State Agency. She stated the resident is confused at times and the amount of money she had changed and the son was called to validate the amount of money she had. She stated that Misappropriation of Property should be reported within 24 to 48 hours to the State Agency. Administrator stated she spoke with R#36 today and apologized for the delay in getting back with her regarding the grievance she filed in (MONTH) 2019 about her missing money. She stated during her conversation with R#36 she (R#36) told her the amount missing was one hundred and fifty dollars and that she had a debit card, credit card, and a social security card. Administrator stated she discussed a trust account with the facility and allowing the facility to keep her things locked up for her. She stated that the Business Office Assistant went in and R#36 signed the paper for the trust account with the one hundred dollars to replace what was missing. She stated when the Business Office Assistant ask her about putting the debit card, credit card, and social security card in the safe R#36 told her she didn't have any of those. Administrator stated that R#36 initially filed the grievance with her nurse and the nurse went to the Director of Nursing (DON) and then Social Worker gave the grievance to her (Administrator). She stated that the grievance by R#36 dated 7/23/19 was not investigated thoroughly and it was an oversight. During an interview with R#36 she stated that the Administrator came in and spoke with her about the grievance she filed in July. She stated she told the Administrator when she first reported it she said it was $80.00 dollars missing but then the $20.00 that was left was taken a couple of days later so she told the Administrator that she had a total of $100.00 taken from her. R#36 stated that she now has a personal funds account with the facility so she doesn't have to keep money with her but can ask for it when she needs something. During this time the R#36 pulled out her wallet and with her check book in it along with her social security card and insurance cards. She stated that her debit card is not in there and she believes her son must have it. R#36 stated that she will speak to the Business Office Assistant about putting her wallet in the safe until she needs it. Review of the Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy dated 11/2016 revealed, on page 8, that Misappropriation of Resident Property means the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. Procedures for Reporting, on page 9, revealed the Concern process is the company's grievance process. The administrator is the designated grievance officer for the center. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that the facility Grievance policy, Misappropriation of Property policy, and the Reporting policy is all covered under their Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy. Employee files related to the 7/22/19 staffing sheet for 7:00 a.m. to 3:00 p.m., 3:00 p.m. to 11:00 p.m., and 11:00 p.m. to 7:00 a.m. shifts were requested and reviewed. All staff files were found to have clear criminal background checks and were vetted appropriately prior to hire. There was no employee warning notices written that would cause concern.",2020-09-01
580,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2019-08-29,610,D,0,1,54BI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to thoroughly investigate a Grievance related to Misappropriation of Property for one Resident (R) (R#36). The sample size was 30 Residents. Findings include: Review of the Minimum Data Set Quarterly assessment dated [DATE] for R#36 revealed a (C) Basic Interview for Mental Status (BIMS) score of 14 indicating intact cognition. (E) No Behaviors noted. (G) Extensive one-person physical assistance with Activities of Daily Living (ADL). (I) Active [DIAGNOSES REDACTED]. (N) Receives an antidepressant 7/7 days a week. Review of the Care Plan for R#36 revealed no care plan in place that would indicate memory loss, dementia, or confusion. Review of the Concern Form dated 7/23/19 revealed at 4:56 p.m. R#36 told Licensed Practical Nurse (LPN) AA that she was missing $80.00. She stated she had 5 $20.00 bills and only has 1 remaining. She voiced that the incident would have to occurred between 3:00 p.m. to 7:00 a.m. 7/22/19 to 7/23/19. There was nothing written under Documentation of Facility Follow-Up. Under Resolution of Concern yes or no was not checked to confirm if the concern was resolved but, on the lines provided it stated, Social Worker to get back with family and discuss money as to missing/safe keeping but there is no signature or date on that portion of the form. During an interview on 8/27/19 at 12:33 p.m. with the Administrator/Grievance Coordinator, she stated that she recalls the Social Worker meeting with her last week and discussing R#36 concern about money she had in her room that was missing and that the Social Worker called the son of R#36 but he had not returned the call. Administrator stated when she receives a grievance, she reviews the grievance and based on the area of concern she will pass the grievance on for investigation. She stated, for example, if there was a dining concern, she would send the grievance to dietary and they would investigate and report their findings to the Resident then inform her of the outcome. Administrator stated regarding the concern with R#36 she would have gotten information from the resident as to how much money she had. She stated she would recommend to R#36 that she don't keep money on hand. She stated that she hopes an investigation related to a grievance would be completed within 24 hours. Administrator stated that the grievance outcome is usually given to the resident verbally. During an interview on 8/27/19 at 1:29 p.m. with LPN AA, she stated around the end of (MONTH) R#36 informed her that she had money missing and stated she wrote the concern on a Concern Form and went to the Social Worker with it. She stated the social worker told her to give it to the Administrator. LPN stated that the Administrator was on vacation, so she placed the grievance in her (the Administrators) box. She stated that there has been no follow up that she is aware of. During an interview on 8/27/19 at 2:00 p.m. with the Administrator she stated that R#36 initially filed the grievance regarding missing money with LPN AA, who was her nurse, and she went to the Director of Nursing (DON). She stated last week she and the Social Worker discussed it. She stated that the grievance filed by R#36 dated 7/23/19 was not investigated thoroughly and it was an oversight. Review of the Patient Protection Abuse, Neglect, Exploitation, Mistreatment & Misappropriation Prevention policy dated 11/2016 revealed the Administrator is responsible for the investigating, reporting, and coordinating of the investigation process of any alleged or suspected abuse regardless of the source of the concern.",2020-09-01
581,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2017-09-21,279,D,0,1,N4J711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure the revision of care plans for non-pharmacological interventions occurred for three of six residents (R#49, R#71, and R#159) reviewed. Findings include: 1. Per the electronic clinical record review, R#159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A medical record Care Plan most recently revised on 1/26/16 identified R#159 was at risk for adverse effects related to the use of an anxiolytic ([MEDICATION NAME]). There was no mention to offer non-pharmacological interventions prior to the use of the as needed (PRN) anxiolytic. Another most recently revised Care Plan on 11/27/16 identified R#159 enjoyed activities and noted the resident had cognitive and communication impairments related to dementia. Under the interventions it was documented to offer R#159 1:1 visits, participation in group activities of interest, preferred food items, television in bed, and family visits when available. Again, this section of the plan of care in the medical record failed to identify if these activities were attempts to reduce R#159's anxiety prior to the administration of an anxiolytic medication. 2. Per the electronic clinical record review, R#49 was admitted to the facility on [DATE]. A medical record review of the Care Plan dated as revised on 6/8/17 identified R#49 was at risk for adverse effects related to the use of an antipsychotic ([MEDICATION NAME]). There was no mention to offer non-pharmacological interventions prior to the use of the as needed (PRN) antipsychotic. Another reveiw of the Care Plan dated as revised on 9/6/17, identified R#49 enjoyed activities and noted the resident had cognitive and communication impairments related to dementia. Under the interventions it was documented to offer R#49 .redirection and diversion as needed. Again, this section of the care plan failed to identify if the redirection and diversion, were attempts to reduce R#49's anxiety prior to the administration of an antipsychotic medication. 3. Per the electronic clinical record review, R#71 was admitted to the facility on [DATE]. A medical record review of the Care Plan dated as initiated 3/23/17, identified R#71was at risk for adverse effects related to use of a PRN antianxiety medication. There was no mention to offer non-pharmacological interventions prior to the use of the PRN antianxiety. In another Care Plan dated as revised 6/16/17, identified R#71 was not interested in attending activities. The intervention noted was to .redirect the resident as needed due to cognitive impairment. Again, there was no mention if this redirection was to be done prior to the administration of the PRN antianxiety. An interview was conducted with the Minimum Data Set (MDS) Coordinator on 9/20/17 at 11:23 a.m., The MDS Coordinator stated she completes the assessments and revises the care plans. She stated she typically updates and any changes on a resident would be discussed in the morning meetings. The MDS Coordinator further stated the floor nurses have the capability to update resident care plans as well. The facility policy entitled, INTERDISCIPLINARY CARE PLANNING dated 11/16 noted, The patient's care plan is a communication tool that guides members of the interdisciplinary healthcare team in how to meet each individual patient's needs. It also identifies the types and methods .Once the care plan is developed, the staff must implement the interventions identified in the care plan. These may include, but is not limited to: administering treatments and medications .As the care plan is implemented, members of the interdisciplinary team need to evaluate whether the interventions are effective or whether the care plan needs to be revised .",2020-09-01
582,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2017-09-21,329,D,0,1,N4J711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure three residents (R#49, R#71, and R#159) of a total of six sampled residents remained free of potentially unnecessary drugs. Specifically, resident #49 was receiving a PRN (as needed) antipsychotic medication and resident #71 and #159 were receiving PRN antianxiolytic medications without attempts to provide non-pharmacological interventions prior to the use of these drugs. Findings include: 1. Per the electronic clinical record review, R#159 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A medical record physician's orders [REDACTED]. The medical record quarterly Minimum Data Set (MDS) assessment dated [DATE], (section C) Cognition identified R#159 had a Brief Interview for Mental Status (BIMS) score of six out of 15 which indicated the resident was severely cognitively impaired. The medical record [MEDICAL CONDITION] Medication Use assessment dated [DATE], documented the following effective non-pharmacological interventions being used for R#159: .Music/art/drama therapy, exercise, recreation and activities, relaxation techniques, counseling, toileting program, pain management, sleep hygiene, redirection, and behavioral therapy. The medical record Medication Administration Record [REDACTED]. There was no documentation, such as Nursing Notes or on the MAR, to show R#159 was offered non-pharmacological interventions prior to the administration of the PRN anti-anxiolytic. The MAR for 9/2017 identified R#159 was administered doses of PRN [MEDICATION NAME] on 9/1/17, 9/13/17 (x2), and 9/16/17. There was no documentation, such as nursing notes or on the MAR, to show R#159 was offered non-pharmacological interventions prior to the administration of the PRN anti-anxiolytic. An interview was conducted with Licensed Practical Nurse (LPN) CC on 9/19/17 at 4:15 p.m., She stated staff would try to do non-pharmacological interventions prior to given [MEDICATION NAME] or any other prn psych meds to residents, like diverting their attention, but she was unable to recall any specific interventions for R#159, and she further stated interventions that were tried were not documented anywhere. 2. Per the electronic clinical record review, R#49 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A medical record review of the physician's orders [REDACTED]. The medical record quarterly Minimum Data Set (MDS) assessment dated [DATE], (section C) Cognition identified R#49 had a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. The medical record MAR for 1/17 identified R#49 was administered a dose of PRN [MEDICATION NAME] on 1/13/17. There was no documentation, such as nursing notes or on the MAR, to show R#49 was offered non-pharmacological interventions prior to the administration of the PRN antipsychotic. The MAR for 5/17 identified R#49 was administered a dose of PRN [MEDICATION NAME] on 5/24/17. There was no documentation, such as nursing notes or on the MAR, to show R#49 was offered non-pharmacological interventions prior to the administration of the PRN antipsychotic. The MAR for 7/17 identified R#49 was administered a dose of PRN [MEDICATION NAME] on 7/8/17. There was no documentation, such as nursing notes or on the MAR, to show R#49 was offered non-pharmacological interventions prior to the administration of the PRN antipsychotic. The MAR for 9/17 identified R#49 was administered a dose of PRN [MEDICATION NAME] on 9/2/17. There was no documentation, such as nursing notes or on the MAR, to show R#49 was offered non-pharmacological interventions prior to the administration of the PRN antipsychotic. 3. Per the electronic clinical record review, R#71 was admitted to the facility on [DATE]. A review of the medical record physician's orders [REDACTED]. The medical record quarterly MDS assessment dated [DATE], (section C) Cognition identified R#71 had a BIMS score of 3 out of 15 which indicated the resident was severely cognitively impaired. The MAR for 7/17 identified R#71 was administered a dose of PRN [MEDICATION NAME] on 7/3/17, 7/4/17, 7/7/17, 7/10/17, 7/13/17, 7/14/17, 7/16/17, 7/18/17, and 7/19/17. There was no documentation, such as nursing notes or on the MAR, to show R#71 was offered non-pharmacological interventions prior to the administration of the PRN antianxiety. An interview was conducted with Licensed Practical Nurse (LPN) AA on 9/9/17 at 1:20 p.m., LPN AA stated before she gives a PRN antipsychotic medication she attempts other interventions, such as one to one visits or to offer the resident something to drink. An interview was conducted with LPN BB on 9/9/17 at 1:21 p.m., LPN BB stated she attempts to redirect a resident, offers coffee prior to the administration of an antianxiety. LPN BB further stated she will document this information in the nursing notes. The Director of Nursing (DON) was interviewed on 9/20/17 at 9:01 a.m. The DON stated clinical staff should evaluate a resident and then provide non-pharmacological interventions. The DON continued stating the nursing staff do a nice job with interventions, but the staff need to document their efforts in the clinical record. The DON further stated she had reached out to her corporate nurse to see if the facility had policies regarding unnecessary medications and stated if the facility does not then they should follow the guidelines under F329. The DON did not provide facility policies by the end of the survey.",2020-09-01
583,MANOR CARE REHABILITATION CENTER - MARIETTA,115283,4360 JOHNSON FERRY PLACE,MARIETTA,GA,30068,2017-09-21,514,D,0,1,N4J711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and review of facility policy titled MEDICATION AND TREATMENT ADMINISTRATION GUIDELINES revised 12/2014, the facility failed to clarify and transcribe orders for a hypertensive medication for one of six sampled residents (R#405). Findings include: Review of R#405's admission medications dated 9/16/17 revealed two orders for [MEDICATION NAME] 2.5 mg (milligrams) Monday through Saturday and 5 mg on Sunday. On 9/17/17 the attending physician wrote an order for [REDACTED]. Nurses were documenting the 2.5 mg of both medications were being given. Interview with Registered Nurse (RN) DD on 9/19/17 at 12:35 p.m., revealed she documented giving both the [MEDICATION NAME] and [MEDICATION NAME] on 9/19/17. She stated it was a duplicate order and it was my bad, I should have discontinued one. She further stated she would follow up with the physician and clarify the orders. Interview with Licensed Practical Nurse (LPN) EE at 1:31 p.m. on 9/19/17, she confirmed someone should have clarified the order with the physician. Interview with the attending physician on 9/19/17 at 1:34 p.m., revealed he wanted the [MEDICATION NAME] to be given daily. He stated he had never seen two different dosages of [MEDICATION NAME] and he did not see any benefit to the resident. Review of the facility policy titled MEDICATION AND TREATMENT ADMINISTRATION GUIDELINES revised 12/2014 revealed Orders are transcribed and noted by the licensed nurse.The licensed nurse noting an order is responsible for accurate transcription and initiation of orders, including removal of discontinued medications from medication carts. Interview with the Assistant Director of Nursing (ADON) on 9/20/17 at 9:10 a.m., revealed she would have expected the nurse taking the order off to verify the medications, ensure it was not a duplicate and clarify if needed.",2020-09-01
584,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2018-08-02,640,B,0,1,QK7911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to transmit Minimum Data Set (MDS) assessments within 14 days after completion for 3 discharged residents (R) (R#1, R#2, and R#3). The sample size was 43 residents. During an interview on [DATE] at 4:45 p.m. with the MDS Coordinator, she stated she did not transmit the discharges on [DATE] for R#1 who died in the facility, [DATE] for R#2 who was discharged to the community, and on [DATE] for R#3 who was discharged to another facility. Review of the MDS, on the computer during the time of the interview, for each resident with the MDS Coordinator revealed that all three assessments stated they had been completed. When asked why other assessments stated received, the MDS Coordinator stated that once the assessment has been transmitted and is received by the State then it will change from completed to received, and she did not transmit these three discharges and stated, Just to be honest, I don't know why.)",2020-09-01
585,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2018-08-02,641,B,0,1,QK7911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and facility data, the facility failed to ensure that Minimum Data Set (MDS) assessments for four (4) residents were accurate, for the following: a facility acquired pressure ulcer status for two (2) residents, Resident (R) R#21 and R#60, the Hospice care status for two (2) residents, R#53 and R#87, and the hydration status for one (1) resident, R#87. The resident sample size was 43. The facility census was 89. 1. Review of R #87's Quarterly Minimum Data Set ((MDS) dated [DATE], and his Annual MDS dated [DATE], revealed that he had a [DIAGNOSES REDACTED].#87 was checked as having the condition of dehydration. During interview with the MDS Coordinator on 7/30/18 at 2:45 p.m., she stated that R#87 was in the hospital in January, and had a [DIAGNOSES REDACTED]. She stated during further interview that the dehydration was not a problem when his (MONTH) and (MONTH) MDSs were done, and that she should have removed that [DIAGNOSES REDACTED]. 2. Review of R#21's Significant Change MDS dated [DATE], and her Quarterly MDS dated [DATE], revealed that she had a Stage 2 pressure ulcer. Review of the CMS-802 dated 7/30/18 revealed that R#21 currently had a facility-acquired pressure ulcer. Review of a Pressure Wounds report dated 7/30/18 revealed that R#21 was not on this list as currently having a pressure ulcer. During interview with the the MDS Coordinator on 7/30/18 at 2:45 p.m., she verified that she had coded R#21 as having a Stage 2 pressure ulcer on the (MONTH) and (MONTH) MDSs. Review of a Daily/Weekly Ulcer Note dated 11/25/17 revealed that treatment was initiated to a Stage 2 pressure ulcer to R#21's right heel. Review of a Daily/Weekly Ulcer Note dated 12/15/17 revealed that this wound had resolved. This was verified during interview with Registered Nurse (RN) AA on 7/30/18 at 4:15 p.m., who stated that R#21 did not currently have a wound. 3. Review of R#21's Quarterly MDS dated [DATE], and the CMS-802 dated 7/30/18, revealed that she was not checked for receiving hospice services. During interview with the MDS Coordinator on 8/2/18 at 9:13 a.m., she stated that R#21 had a hospice consult on 1/3/18, and that she did a Significant Change MDS assessment on 2/2/18. She further stated that the Social Services Director let her know in morning meetings when a resident was admitted to hospice services. During interview with RN AA at this time, she stated that R#21 was admitted to hospice on 2/6/18. During further interview with the MDS Coordinator at this time, she verified that R#21 was not coded for hospice on the (MONTH) MDS, and that she should have been. A resident record review was conducted that reflected R#53 was initially admitted on [DATE], but had a re-entry from an acute hospital on [DATE] with a [DIAGNOSES REDACTED]. She was admitted to hospice services on 8/25/17. A review of the (MDS) with an Assessment Reference Date (ARD) of 6/8/18, signed as completed 6/12/18, reflected that in Section O-Special Treatments, Procedures and Programs, O0100, Section K for Hospice Care, was blank during the seven (7) day look back period. This MDS Quarter Assessment, dated 6/8/18 reflected the resident had a Brief Interview for Mental Status (BIMS) Cognitive score of 00- unable to be interviewed; Mood- 00; Behavior- 00; Vision and Hearing- hearing highly impaired; Functional- needing extensive assistance, 2-person assistance for transfers; Nutrition- 58 inches tall, 90 lbs. and requiring a mechanically altered diet; Bladder & Bowel- frequently incontinent of bladder, occasional incontinent of bowel. A record review was conducted of the 8/24/17 electronic nurse's note that reflected: Note Text: Resident admitted to Hospice today. Nurse (Hospice) came out assessed and admitted resident today. Per Hospice Nurse will be sending orders over to facility. Awaiting orders, at this time. Review of the physician's orders [REDACTED]. A review of the facility MDS Resident Matrix form, provided and dated 7/30/18 upon entrance to the facility, reflected R#53 was not receiving hospice care. A Social/Psychosocial note, dated 9/8/17, reflected: Late Entry: Note Text: Significant Change: Resident recently went onto hospice service after continuing to decline in functional status. At this time, resident is no longer walking, but rather gets up in a wheelchair daily and requires further staff intervention for all aspects of care. She is noted to have little interest or pleasure in daily life, feels tired often, increased periods of rest and napping throughout the day and displaying a poor appetite. Resident has no family, and remains under the guardianship of an attorney. No concerns with roommate situation. Review of the resident's care plan, completion date of 5/30/18, reflected: resident has a terminal prognosis [MEDICAL CONDITION] and has been placed on hospice. The resident's wishes will be respected. On 8/02/18 at 8:54 a.m. an interview was conducted with the certified MDS Coordinator in the MDS office regarding the MDS Quarterly Assessment information, dated 6/8/18, pertaining to R#53. The MDS Coordinator explained that her process is to gather information on each resident, starting in the morning meetings where she gets information from the incident and accident reports, from the reports from the treatment nurses, the unit managers and from admissions for the recent admissions and discharges. The coordinator confirmed she keeps a care plan calendar so she is aware of the 3-month assessment due dates, and has a list of the Medicare and Medicaid residents. She stated that it is the facility's policy to meet and do a 24 hour care plan with admissions, MDS, and the charge nurse. She confirmed that all care plan updates are the responsibility of the unit managers; that they document changes/updates on the care plan. They hand write the changes or updates on the resident's care plan, bring a copy to her to update the changes. She confirmed it is her responsibility to double check the information prior to doing any modifications or update changes. At this same time, a request was made for the MDS Coordinator to check the MDS and compare the resident's quarterly assessments on 3/9/18 and 6/8/18 in Section 0, K. Hospice Care. She confirmed that the resident was on Hospice Services and stated she thought it was strange that the 6/8/18 MDS did not reflect that the resident was receiving those services. She stated she did not know how that happened; that she would do a modification. A copy of the facility's MDS Policy and Procedure form was then requested from the Assistant Director of Nursing. A copy was later provided by the MDS Coordinator. Review of the facility form entitled MDS Completion & Submission Time Frames dated and revised, (MONTH) (YEAR), indicates the Assessment Coordinator or designee is responsible for ensuring that the resident assessment is submitted to CMS's QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines. During an interview on 7/31/18 at 10:33 a.m. with the MDS Coordinator revealed that R#60 was coded, on the MDS, as having three, stage 2 pressure ulcers, and two stage 2 pressure ulcers upon admission/reentry to the facility on [DATE], and a date of the oldest stage 2 pressure ulcer of (YEAR). Record review with Wound Care Nurse (WCN) and MDS Coordinator, determined that on 3/5/18 the resident developed a stage 2 facility acquired pressure ulcer on his left lateral ankle, and healed on 4/14/18. On 6/14/18 R#60 was noted to have a stage 2 pressure ulcer to his left ear and healed on 6/21/18. MDS Coordinator stated, I put wounds in the system that wasn't there, and I don't know where they came from. I get a weekly wound report, so I know I didn't just make this up. Maybe I got confused with another resident when entering the information. I will need to do a correction immediately. Continued interview with the MDS Coordinator, during the same time, revealed that, under section M of the MDS, M0300 Current Number of Unhealed Pressure Ulcers at Each Stage, she should have put the number 1 next to number of stage two pressure ulcers, a number 1 next to number of stage two pressure ulcers that were present upon admission/reentry, and that she should have answered yes to the question, Were pressure ulcers present on the prior assessment (OBRS or PPS), but she had placed a check by no.",2020-09-01
586,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2018-08-02,657,D,0,1,QK7911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility and hospice staff interview, the facility failed to ensure that the care plans reflected coordination of services between hospice and facility staff for one resident (R) receiving hospice services (R#21). The sample size was 43 residents. Findings include: Review of R#21's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#21's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had short- and long-term memory problems, and severely-impaired decision making, and needed extensive to total assistance with all activities of daily. Review of R#21's (MONTH) Medication Review Report revealed that she was admitted to hospice services on 2/6/18. Review of the facility's care plans included one initiated on 2/5/18 and last revised on 7/30/18 that R#21 had a terminal prognosis related to the resident has been placed on Hospice for hospice care for a [DIAGNOSES REDACTED]. Review of one of the interventions for this care plan revealed to work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met. Further review revealed that R#21 had 29 additional facility care plans that had been developed, but none of them reflected an integrated approach that included hospice staff participation. During interview with the MDS Coordinator on 8/2/18 at 9:13 a.m., she stated that she called hospice and let them know when a hospice resident's care plan meeting was scheduled, and invited them to attend, but that she had no documentation of this. She further stated that R#21's hospice provider had been invited to her care plan meetings, but they did not attend. She verified during continued interview that there was no integration of hospice participation into R#21's care plan, other than a separate hospice care plan that was developed. The MDS Coordinator stated during further interview that the facility Social Services Director (SSD) talked with hospice when they visited. During interview with the SSD on 8/2/18 at 9:35 a.m., she stated that she didn't deal with the hospice provider, or integration of the care plan with them. During interview with the hospice RN case manager BB on 8/2/18 at 11:48 a.m., she stated that she had never been invited to attend a care plan meeting for R#21, and would attend the meeting if she was invited. She further stated that she visited R#21 every two weeks, and talked with the Unit Manager to see if the resident had any changes or concerns, and to let the Unit Manager know if she made any changes. She stated during continued interview that the hospice care plan had always been in a notebook separate from the resident's facility chart, and thought that was just the way the facility wanted it done. She further stated that she had not sat down or talked to MDS or anyone at the facility to discuss and integrate the hospice and facility care plans. During interview with the MDS Coordinator on 8/2/18 at 3:02 p.m., she stated the only care plans they found for R#21 in her hospice binder was for Spiritual, Cognition, Communication, and Falls, and stated that this was pretty typical for this hospice provider's care plans. During interview with the Admissions Director at this time, she stated that the facility had no requirement that hospice put their records in a separate notebook, that's just what this hospice provider did. Review of R#21's full hospice Plan of Care faxed to the surveyor by the hospice provider on 8/2/18 revealed that the care plan was last updated two days ago, and effective on 7/31/18. Problem statements for the care plan included: -Social work services were refused. -The facility staff/caregiver to perform patient care 24/7. Hospice staff to perform patient care: RN (Registered Nurse)-once weekly and PRN (as needed); HHA (Home Health Aide) three times a week; chaplain monthly and prn; Social Worker monthly and prn. Educate that hospice is available 24/7 for all patient needs. Review of the Goal for this Problem statement was that facility staff is knowledgeable and involved in hospice plan of care for patient. Review of the Interventions revealed to review hospice plan of care with facility staff, and review responsibilities of nursing facility staff regarding hospice patient's plan of care. -Deficit related to cognitive alteration. -Inability to communicate effectively. -Deficit related to risk for injury related to falls. -Deficit related to affirmation of present spiritual comfort, acceptance of death, and utilization of spiritual resources. Further review of the hospice plan of care revealed the only integration of facility staff was on the risk for injury problem, with interventions for the SNF (Skilled Nursing Facility) staff to notify Hospice of falls or injuries, and toileting per SNF protocol. Review of the Hospice Inpatient, Respite & Home Care Services Agreement between the facility and R#21's hospice provider, dated 7/20/16, revealed the following: Hospice is engaged in providing interdisciplinary care and treatment of [REDACTED]. Initiation and Coordination of Inpatient and Respite Services: The Hospice shall furnish to the Facility, at the time of the patient's Hospice inpatient or respite admission or as soon thereafter as possible, a copy of the patient's Hospice Plan of Care. The Hospice nurse shall coordinate the services provided to each patient with Facility staff by reviewing the Hospice Plan of Care and scheduling interdisciplinary group meetings as necessary. With respect to the management of the patient's terminal illness, the Facility shall: Provide usual and customary services of the Facility subject to the Hospice Plan of Care for such patient. The Hospice and The Facility shall develop, at the time an eligible resident is admitted into the Hospice program, a Hospice Plan of Care for the management and palliation of the resident's terminal illness. The Hospice Plan of Care is a written document which will include a detailed description of the scope and frequency of hospice services and supplies to be provided by Facility and Hospice to meet the resident's needs. The Hospice Plan of Care will specify which services and supplies are related to the patient's terminal illness, and therefore, will be furnished by The Hospice. The Hospice shall furnish a copy of such Hospice Plan of Care for such resident to The Facility at the time of the resident's admission into The Hospice program. Such Plan of Care shall be furnished to The Facility in the form of physician orders. The Hospice Plan of Care will be incorporated into the Facility's standard resident care plan. With respect to the management of the patient's terminal illness, The Facility shall: Provide usual and customary services of The Facility subject to the Hospice Plan of Care for such patient.",2020-09-01
587,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2018-08-02,689,D,0,1,QK7911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that assist devices (bed canes) were free from potential entrapment hazards for two residents (R) (R#21 and R#33). There were three residents in the facility that had bed canes attached to their bed. The facility census was 89 residents, and the sample size was 43. Findings include: Review of the Guidance for Industry and FDA (Food and Drug Administration) Staff Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment report(https://www.fda.gov/downloads/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm 9.pdf) issued on 3/10/06 revealed the following: When evaluating the safe use of a hospital bed, component or accessory, manufacturers and caregivers should recognize that the risk for entrapment may increase if a hospital bed system is used for purposes, or used in a care setting, not intended by the maufacturer. Evaluating the dimensional limits of gaps in hospital beds may be one component of a bed safety program which includes a comprehensive plan for patient and bed assessment. Reassessment may be appropriate when .accessories such as mattress overlays or positioning poles are added or removed. Three key body parts at risk for life-threatening entrapment in the seven zones of a hospital bed system .are the head, neck, and chest. Country-specific anthropometric data show that a 1st percentile female head breadth may be as small as 3-3/4 inches. A dimension of 4-3/4 inches encompasses the 5th percentile female head breadth in all data sources used to develop these recommendations. FDA is therefore using a head breadth dimension of 4-3/4 inches as the basis for its dimensional limit recommendations. The body part dimensions used to develop FDA's dimensional limit recommendations are summarized: Head 4-3/4 inches Neck 2-3/8 inches Chest 12-1/2 inches 1. Review of R#21's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#21's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had short-term and long-term memory problems, with severely impaired decision making. Further review of this MDS revealed that she needed extensive assistance for bed mobility and transfers; had two or more falls with no injury and two or more falls with non-major injury since the last MDS assessment. Review of R#21's care plans included one for use of one-1/2 side rail as an enable for bed mobility, and that she was at risk for injuries related to side rail use. Review of the goal for this care plan revealed that the resident would have no injuries related to side rail usage through the next care review date. Review of a behavior care plan revealed that R#21 picked at clothing and blankets and attempted to grab items that were not there related to dementia, and was at risk for injuries and falls related to behaviors. Review of a [MEDICAL CONDITION] care plan with increased confusional episode related to hallucinations and delusions initiated on 5/22/18 revealed that R#21 was at risk for injuries related to hallucinations, and had injured her hand related to hallucination of seeing something under the bed. Review of a potential for injury and high risk for falls care plan revealed an intervention initiated 8/3/17 for a bed cane to assist with transfers, bed mobility, and sitting. Review of a terminal prognosis care plan initiated on 2/5/18 revealed that R#21 was admitted to hospice services for end-stage Alzheimer's. Review of the Incidents by Incident Type report revealed that R#21 had six falls in her room from 2/1/18 to 5/12/18. Review of a Siderail Screener assessment dated [DATE] revealed that R#21 had decreased safety awareness due to cognitive deficits or decline; was not immobile; was currently using side rails to enable positioning or support; and that side rails were indicated and served as an enabler to promote independence in positioning and bed mobility. Observation on 7/31/18 at 11:10 a.m. revealed that R#21 had one bed rail on the open side of her bed at the top that had an oval-shaped opening in the center. Observation of the inside measurements of this device taken with the surveyor's tape measure revealed 6-1/2 inches from the top to the bottom of the rail, and 12 inches from the left bar of the rail to the right section of the rail. During interview with the Assistant Director of Nursing (ADON) on 7/31/18 at 2:02 p.m., she stated that the rail on R#21's bed was called a bed cane, and was used to assist her in positioning. She verified the large opening in the inside of this rail, and stated there must be some sort of padding that could be put in the middle of the opening. She further stated that in the two years she had worked in the facility, she had never known of a resident to become entrapped in a bed rail. Observation on 8/1/18 at 8:00 a.m. revealed that the bed cane on R#21's bed had been covered with a sturdy canvas-type cover secured with snaps that appeared to be designed specifically for this type of device. During interview with the Director of Nursing (DON) on 8/1/18 at 2:35 p.m., she stated that there were six residents in the facility that had a bed cane on their bed. She further stated that two or three of these residents already had a cover for the opening on the bed cane, but the covers for the other bed canes must have gotten lost in the laundry. She verified during continued interview that these bed canes could possibly pose an entrapment risk, but that they have had no residents become entrapped in a rail. Review of a list entitled Bed Canes revealed that four residents were listed, including R#21. Observations beginning on 8/1/18 at 4:45 p.m. revealed that only three of four residents on the list had a bed cane. 2. Observation on 8/1/18 at 4:45 p.m. revealed that R#33 had a bed cane on one side of her bed, that had the same opening in the center of the rail as seen on R#21's bed before it was covered. During interview with R#33 at this time, she stated that this rail helped her to pull up in the bed and turn over, and denied ever getting caught in the rail. Review of R#33's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#33's Admission MDS dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 8 (a BIMS score of 8 to 12 indicates moderate cognitive impairment), and needed extensive assistance for bed mobility and transfer. Review of a limited physical mobility related to muscle weakness and history of rotator cuff tear care plan revealed that R#33 was at risk for further decrease in mobility and falls. Review of a potential for injury care plan revealed that R#33 was at high risk for falls, and non-compliant with calling for assistance at times. Further review of this falls care plan revealed that a bed cane to assist with transfers, bed mobility and sitting/positioning was added as an intervention on 5/2/18. Review of the Incidents by Incident Type report from R#33's admission on 5/9/18 to 7/30/18 revealed that she had three unassisted falls in her room during this time. Review of a Siderail Screener assessment dated [DATE] revealed: Decreased safety awareness due to cognitive deficits; history of falls; poor bed mobility; currently using side rails to enable positioning or support; resident expressed desire to have side rails. Side rails are indicated and serve as an enabler to promote independence in positioning and bed mobility. Observation of measurements taken of R#33's bed cane with the surveyor's tape measure on 8/1/18 at 5:07 p.m. revealed the inside measurement from one side to the other was 12 inches, and the measurement from the end of the curved part of the rail to the inside top of the rail was 9-3/4 inches. In addition, there was a measured gap of 5 inches from the bottom of the curved part of the rail to the top of the mattress. This was verified by the DON at this time, who stated that the resident refused a cover over the bed cane as it obstructed her view. During interview with the Administrator on 8/1/18 at 5:22 p.m., he stated that they had talked with R#33 the previous day, and that she did not want the bed cane removed. He further stated that there was no documentation of a discussion of the risk and benefit of the rail use with the resident or responsible party. During interview with the Maintenance Supervisor on 8/2/18 at 9:51 a.m., she stated that he checked bed rails to ensure they were securely fastened to the bed as he walked around the building checking other things like hot water temperatures, but that there was no documentation of this. During interview with the Maintenance Supervisor on 8/2/18 at 2:41 p.m., he verified the bed canes were manufactured by Stander. Review of Stander's bed cane product information revealed that pouches were included with all of their bed rails to keep you safe against entrapment. Review of the facility's Policy and Procedure on Positioning/Enabling Devices revised 10/17/08 revealed that examples of positioning/posture support devices did not specify a bed cane. Further review revealed that if a positioning/enabling device was determined necessary, the following steps will be taken: 1. The IDT (interdisciplinary) and/or therapy will assist in determining appropriate device to meet resident's needs. 2. Resident and or responsible party will be educated regarding the use of the device. 3. The positioning/enabling device will be care planned. Review of the facility's Policy and Procedure on Bed Safety revised 10/1/10 revealed: The facility will strive to prevent/reduce hazards such a patient entrapment associated with hospital beds. In an effort to reduce/prevent death/injuries from entrapment associated with hospital bed side rails: The Safety Director will inspect hospital bed frames, bedside rails, mattresses, and bed accessories at the time of installation to identify potential areas of possible entrapment between the device and the mattress. No gap between the mattress, bed frame, side rail, or bed accessory is wide enough to entrap a resident's head or body.",2020-09-01
588,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2018-08-02,909,C,0,1,QK7911,"Based on observation, record review, and staff interview, the facility failed to provide evidence that they were conducting regular inspections of bed frames, mattresses, and bed rails, as part of a regular maintenance program, to identify areas of possible entrapment. 71 residents in the facility had either half bed rails or other attached bed accessory such as a bed cane (including residents (R) #21 and R#33), and the facility census was 89 residents. Findings include: Observation on 7/31/18 at 11:10 a.m. revealed that R#21 had an enabler-type rail at the top of the open side of her bed that had a large oval-shaped opening in the center of the rail. The length inside the bars as measured with the surveyor's tape measure was 12 inches, and the inside measurement from the top of the rail to the bottom of the rail was 6-1/2 inches. During interview with the Assistant Director of Nursing (ADON) on 7/31/18 at 2:02 p.m., she stated that the rail on R#21's bed was called a bed cane, and it was used to assist her in positioning. She verified during observation the large opening in the center of the rail, and stated that there must be some sort of padding that could be put in the middle of the opening. Observation of R#33's bed on 8/1/18 at 4:45 p.m. revealed that she had the same type of bed cane on one side of her bed with similar interior measurements as R#21's device. During interview with the Maintenance Supervisor on 8/2/18 at 9:51 a.m., he stated that he checked bed rails to ensure they were securely fastened to the bed as he walked around the facility checking other things like the hot water temperatures. He further stated that all the rails in the facility were checked at least once a month, but that he did not have documentation of this. Review of the facility's Policy and Procedure on Bed Safety revised on 10/1/10 revealed: The facility will strive to prevent/reduce hazards such a patient entrapment associated with hospital bed. In an effort to reduce/prevent death/injuries from entrapment associated with hospital bed side rails: The Safety Director will inspect hospital bed frames, bedside rails, mattresses, and bed accessories at the time of installation to identify potential areas of possible entrapment between the device and the mattress. No gap between the mattress, bed frame, side rail, or bed accessory is wide enough to entrap a resident's head or body. Review of a list of residents that had either half bed rails or enablers attached to the bed provided by the Director of Nursing (DON) on 8/2/18 at 4:19 p.m. revealed that there were 71 residents that met this criteria. Cross-refer to F 689",2020-09-01
589,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2017-09-29,157,J,1,1,6HMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Change in a Resident's Condition or Status, family and staff interviews, the facility failed to ensure notification of a change in a resident's status was appropriately made for one of eight sampled residents (R#1). Specifically, the facility failed to notify the family/responsible party of R#1 that he had acute respiratory distress during the dayshift on [DATE] and required non-invasive ventilation. The family/responsible party of R#1 was not notified until [DATE] at 11:35 p.m. after R#1 had expired. Additionally, the facility failed to notify the Nurse Practitioner after R#1 was placed on non-invasive ventilation to provide an update of the resident's status and failed to notify the Registered Nurse (RN) Weekend Supervisor that the resident had a change in his condition. This failure resulted in actual harm for R#1 when at an undetermined time on the dayshift of [DATE], R#1 had a change in condition related to respiratory distress with an oxygen saturation (Sp02) of 74% and required non-invasive ventilation via [MEDICAL CONDITION] (Biphasic Positive Airway Pressure). Due to the lack of notification related to the resident's change in condition/status to the responsible party, Nurse Practitioner and RN Weekend Supervisor, the facility was unable to make a collaborative determination for possible further treatment and/or need for hospitalization . R#1 was found unresponsive on [DATE] at 11:20 p.m. and pronounced deceased at 11:30 p.m. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio [NAME]s Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 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 specifically for R#1 when at an undetermined time on the dayshift of [DATE], R#1 had a change in condition related to respiratory distress with an oxygen saturation (Sp02) of 74% and required non-invasive ventilation via [MEDICAL CONDITION] (Biphasic Positive Airway Pressure). Due to the lack of notification related to the resident's change in condition/status to the responsible party, Nurse Practitioner and RN Weekend Supervisor, the facility was unable to make a collaborative determination for possible further treatment and/or need for hospitalization . R#1 was found unresponsive on [DATE] at 11:20 p.m. and pronounced deceased at 11:30 p.m Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Refer F281 and F328 Findings include: Review of the undated policy titled Change in a Resident's Condition or Status documented: Our facility shall promptly notify the resident, his or her attending physician, and representative (sponsor) of changes in the resident's condition and/or status. Unless otherwise instructed by the resident, the nurse supervisor will notify the resident's next of kin or representative (sponsor) when: there is a significant change in the resident's physical, mental or psychosocial status. Except for medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's condition or status. The Nurse Supervisor will notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status; or when there is a need to alter the resident's treatment significantly; or deemed necessary or appropriate in the best interest of the resident. 1. Interview on [DATE] at 11:57 a.m. with the family of R#1 revealed she is the responsible party (RP) for R#1 and the person that would be contacted for any changes in the resident. The RP stated that she did not receive a call from the facility until after R#1 expired late Saturday on [DATE] and that the nurse did not have any details for her. The RP stated a couple of days later, she called the facility and spoke with someone else in charge and it was then that they told her that R#1 had declined that day and was having respiratory issues. The RP stated she was told that R#1's oxygen level dropped to 74% and they needed to put him on a [MEDICAL CONDITION] mask and when they checked on R#1 an hour later, he had passes away. The RP stated that she did not understand why they did not call her sooner or why R#1 was not sent to the hospital if he was having breathing problems all day. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via percutaneous endoscopic gastrostomy (PEG). [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. Review of the Admissions Packet revealed's family member was the RP for R#1. The RP signed the Treatment Consent on [DATE]. The RP signed the Do Not Resuscitate Order for Resident without Decision Making Capacity on [DATE] and was signed by two physicians on [DATE] and [DATE]. Review of the care plan for R#1 initiated on [DATE] identified that the resident had an Advanced Directive: DNR- Do Not Resuscitate with an intervention that indicated If skilled nursing is unable to meet the care needs, review with MD, family, and resident for possible need to hospitalize. Review of the clinical record for R#1 revealed the following Progress Notes: Licensed Practical Nurse (LPN AA) created a Nurse's Note on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% room air (RA). Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) LPN CC created a Nurse's Note on [DATE] at 12:21 a.m. with an effective date and time of [DATE] at 12:00 a.m. which documented At approximately 11:20 p.m. I was making my rounds and when I went into resident room. I notice that resident was unresponsive and gray in color. Resident a DNR. I assessed resident by checking pulse and then proceeded to have the RN supervisor from the vent unit to confirm resident status. Next of kin was notified and funeral home of family choice was notified. (sic) Registered Nurse (RN FF) created a Nurse's Note on [DATE] at 12:43 a.m. with an effective date and time of [DATE] at 11:25 p.m. which documented Called to resident's room by charge nurse. Resident was found to be non-responsive, pallid, and apneic. Apical pulse was auscultated and carotid pulse palpated simultaneously one full minute without results. Death was pronounce at 11:30 PM. Dr. (name) notified. (sic) RN FF created a Nurse's Note dated [DATE] at 12:48 a.m. with an effective date and time of [DATE] at 11:35 p.m. on [DATE] which documented Responsible party (RP), (name), notified of resident's expiration via telephone. (Name) stated she was out of town and could not come. She also stated that she would like for resident to be sent to (name) Funeral Home in Tallapoosa, G[NAME] (Name) expressed appreciation for the notification. (sic) Interview on [DATE] at 4:19 p.m. with the Respiratory Therapist (RT) BB revealed that he had not notified the family of R#1 on [DATE] related to his change in condition and that the nursing staff is responsible for notifying family of a change in a resident's condition. Further interview on [DATE] at 4:50 p.m. with RT BB revealed that he had another resident on a ventilator that was going bad at the same time that R#1 was having respiratory distress and the nurse (LPN AA) handled the situation and called the Nurse Practitioner. He said the LPN AA called him and reported that NP GG ordered [MEDICAL CONDITION]. He stated that he had set the resident up on [MEDICAL CONDITION] he thought around 4:45 p.m. RT BB stated he did check R#1 around 6:00 p.m. and his Sp02 was in the 90's but stated that he was unable to find any documentation of his assessments or when he initiated [MEDICAL CONDITION] therapy for R#1 in the electronic charting system. Interview on [DATE] at 5:17 p.m. with the Director of Nursing (DON) revealed she was on vacation when R#1 expired on [DATE] and returned to work on [DATE]. The DON stated she was made aware when she returned to work that the resident had respiratory distress and was placed on [MEDICAL CONDITION] and aware that the nurse did not notify the family/responsible party of R#1's change in condition. She stated the RP had called her on Monday [DATE] and wanted to know what happened to R#1. The RP had reported to her that no one had called her until after R#1 had already passed away. The DON stated the nurse should have called the RP when R#1's condition changed. The DON stated that typically the respiratory therapist would report a resident's respiratory status to the nurse and the nurse would report that status to the Physician. The DON further stated she educated the nursing staff on documenting in the e-Interact Tool- Change in Condition Evaluation Assessment pathway in the electronic charting system and notifying family in the event of a change in condition. Interview on [DATE] at 5:03 p.m. with the Licensed Practical Nurse (LPN AA) in care of R#1 revealed the morning of [DATE] on the dayshift (7:00 a.m. - 7:00 p.m.). She stated R#1 seemed to be very depressed and staring out of the window. She stated the resident wasn't really lethargic but not himself. LPN AA stated around 2:00 p.m. - 3:00 p.m., the resident seemed sleepy and when she checked his oxygen saturation (Sp02), it was 74%. She stated that she placed the resident on oxygen at 2 liters per minute (LPM) with a nasal cannula and there was no improvement. She stated she called the Respiratory Therapist (RT BB) and the Nurse Practitioner (NP GG) and received an order to place R#1 on [MEDICAL CONDITION] (Biphasic Positive Airway Pressure). LPN AA stated that RT BB placed the resident on [MEDICAL CONDITION] but she did not remember the time. She stated she did make a notation at the end of her shift, but not a detailed notation. She stated she did not document a change of condition and she did not call the resident's RP. LPN AA further stated that she never returned to re-assess the resident and had not seen the resident again after he was placed on [MEDICAL CONDITION]. She stated she had no good answer for why she did not re-assess or monitor the resident, It gets busy at the end of the shift but I know that is not a good excuse. Interview on [DATE] at 2:08 p.m. with the Nurse Practitioner (NP GG) revealed she was covering for the attending physician of R#1 on [DATE] while he was out of town. NP GG stated a nurse had called her one time on [DATE]. She stated it was reported to her that the residents C02 (carbon [MEDICATION NAME]) was elevated and his oxygen saturation was low. She stated that she ordered [MEDICAL CONDITION] with the agreed decision to see how he would do on [MEDICAL CONDITION] first, but she never heard back from anyone at the facility. NP GG stated she cannot remember exactly what time she received the call but she believed that it was in the morning sometime. NP GG further stated that she does not document the calls she receives and that the nurses' are responsible for documenting a change of condition, the time of the change of condition and that she had been notified. NP GG stated that she did not order a chest x-ray because she wanted to see how R#1 would respond to the [MEDICAL CONDITION] first. She stated the [MEDICAL CONDITION] was ordered as noninvasive ventilation secondary to respiratory distress. She stated if the resident continued to decline, she would have ordered a chest x-ray and possible antibiotics for potential aspiration pneumonia and that would have been verified by chest x-ray, however, no one ever called her back about the resident's condition. Interview on [DATE] at 4:14 p.m. with the Registered Nurse Weekend Supervisor (RN HH) revealed she was working on [DATE] covering for the regular RN weekend supervisor. She stated neither the nurse nor respiratory therapist in care of R#1 reported to her that he was having respiratory complications. RN HH stated she did not know that R#1 had a change in condition or expired until the Corporate Nurse called her during the complaint survey and wanted to know if she knew what happened. RN HH stated that the nurse caring for R#1 should have informed her of the situation. She stated she would have helped assess R#1 and that she would have pushed for the resident to be sent to the hospital in his condition. Review of the Pronouncement of Death indicated the resident expired in the facility on [DATE]. Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. 2. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her percutaneous endoscopic gastrostomy (PEG) tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. The Physician was notified and a transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. 3. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m. The Physician was called, again, at 12:15 p.m. and the resident was transferred to the hospital. The family and DON were notified at 12:05 p.m. 4. R#120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Respiratory Therapist was in the room and continued to work with the resident and at 10:10 a.m. the Nurse Practitioner was notified the resident was not improving and ordered R#120 transferred to the hospital. The family had been notified at 9:45 a.m. The Nurse Manager was notified at 10:20 a.m. as the resident was transferred. An interview on [DATE] at 11:04 a.m. with Respiratory Director revealed that since the incident occurred with R#1, the facility has reviewed the notification policy for Physician's and family, and staff is aware to follow up with the Physician or the Physician extender if the resident is not improving. The Respiratory staff is notified should a resident have respiratory issues to ensure that the resident is monitored and that the notification occurs. She confirms that R#18, R#120 and R#135 were monitored closely by Respiratory staff and the Physician was notified, timely, should the resident's condition not improve. The facility implemented the following actions to remove the Immediate Jeopardy: 1. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that the MD/NP, and/other responsible party were not notified of a change in condition- Audit to be completed on [DATE]. 2. There will be a QA meeting on [DATE] to review the findings. 3. 30 of 30 of nurses have been educated that the responsible party, MD or NP on call, a nurse manager or RN weekend supervisor if she/he is in the building on the weekend, and the on-call nurse if after hours or on the weekend is to be notified if there is a change in condition. If the change in condition is an acute respiratory change the Respiratory Therapist will be notified. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced, any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 4. Guidelines for notification of the nurse manager on call were developed on [DATE] by the Chief Nursing Officer(CNO) for Reliable Health Care Management, they include use of the Interact change in condition cards- if the resident meets the criteria for immediate notification or has a critical lab not covered by the change in condition cards and a nurse manager is not in the building or it is the weekend the nurse manager on call will be notified. The nurse manager will log this on the Nurse Manager On Call Log. The DON or ADON will obtain this log for verification and follow through of process the next business day. These have been submitted to the Quality Assurance Committee and added to the Licensed Nursing Orientation [DATE]. Review and follow-up guidelines for a change in condition for the nurse manager on call to follow were developed on ,[DATE] /17 by the CNO for Reliable Health Care Management to include notification of the responsible party, MD or NP on call, a nurse manager or RN weekend supervisor if she/he is in the building on the weekend, and the on-call nurse if after hours or on the weekend, completion of the Interact Change of Condition Form and use of the Interact Clinical Pathways if applicable. The Review and follow-up guidelines have been submitted to the Quality Assurance Committee and added to licensed Nursing Orientation [DATE] no one will be allowed to work until completion of in service. 5. 6 of 6 of the nurse managers were educated on the Guidelines for notification, their responsibilities while on call related to the review and follow up guidelines and documentation on the Nurse Manager On Call Log. This education was done by the DON on [DATE] nurse managers attended and were in serviced. 6. 30 of 30 nurses were educated by the DON on [DATE] regarding the guidelines for notification of the nurse manager in the building and the on-call nurse after hours and on weekends and the review and follow-up guidelines for a change in condition. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced, any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 7. A Change in Condition audit tool developed on [DATE] by the CNO for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends, as well as the RN supervisor on the weekend and that the guidelines for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 8. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE]. 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of audit including fifty-seven resident records with change in condition requiring transfer to the hospital, between [DATE] through [DATE] revealed thirteen records missing documentation of Physician notification, and seventeen records were missing documented notification of responsible party. The audit was completed on [DATE]. 2. The QA meeting held [DATE] sign in roster and minutes were reviewed. The audit review for fifty-seven resident records with thirteen records missing documentation of Physician notification, and seventeen records were missing documented notification of responsible party was discussed and nineteen signatures were included on the roster. Interview [DATE] at 4:30 p.m. with Corporate Chief Nursing Officer revealed during the QA meeting held [DATE] the audit of resident records regarding notification of change in condition requiring hospitalization between [DATE] and [DATE] was discussed. 3. In-service record reviewed. Dated [DATE], the in-service specified the procedure for notification of the Nurse Manager on call, the Physician, the Responsible Party and or family, and the Respiratory Therapist if the change in condition involves a respiratory issue, for any resident with a change in condition. The sign in roster and additional record of nurses educated by telephone included thirty nursing staff. Education provided on [DATE] regarding notification of Physician, family, Nurse Manager on call or in the building and the Respiratory Therapist was verified and understanding was confirmed by staff interviews. Interviews with License Practical Nurse (LPN) KK on [DATE] at 1:00 p.m., LPN LL on [DATE] at 1:12 p.m., LPN MM on [DATE] at 1:25 p.m., LPN NN on [DATE] at 1:30 p.m., LPN OO on [DATE] at 1:35 p.m., LPN FFF on [DATE] at 1:43 p.m., LPN UU on [DATE] at 1:50 p.m., LPN AAA on [DATE] at 2:15 p.m., LPN RR on [DATE] at 2:47 p.m., LPN GGG on [DATE] at 2:53 p.m., and LPN CCC on [DATE] at 7:50 p.m. revealed they had participated in in-services related to notification for change in conditions to the Physician, Nurse Manger on call or in the building and the Respiratory Therapist and were aware of the notification process for a change in condition of a resident. Interviews with Registered Nurses (RN) confirmed they had participated in the facility in-services on notification for a change in condition for a resident and were aware of their role in this process. RN DON on [DATE] at 1:40 p.m., RN PP on [DATE] at 1: 45 p.m., RN QQ on [DATE] at 2:00 p.m., and RN DDD on [DATE] at 7:45 p.m. 4. The guidelines for notification of the nurse manager on call, and follow up were reviewed and include use of Interact change in condition cards, and completion of the Nurse Manager on call log. The Nurse Manager on call log was reviewed. In-service records described on [DATE] revealed thirty of thirty nurses participated in this education. Nurse Managers were interviewed regarding receiving education and understanding the use of the Nurse Manager on call log. The roster for this in-service was signed by six Nurse Managers. 5. RN DON on [DATE] at 1:40 p.m. revealed she was educated regarding the duties of the Nurse Manager on call and understood the use of the on-call log and the guidelines for notification of Nurse Managers. LPN AAA on [DATE] at 2:15 p.m. indicated she had attended in-services describing her role as Nurse Manager on call and the appropriate use of the on-call log. LPN UU on [DATE] at 1:50 p.m. revealed she has been educated regarding the functions of the on-call Nurse Manager and understands how to use the on-call log. LPN FFF on [DATE] at 1:43 p.m. revealed she is a Nurse Manager and has received education regarding the guidelines of notification of the nurse manager and the on-call log. RN PP on [DATE] at 1: 45 p.m. revealed she is a weekend supervisor and takes call as a Nurse Manager and received recent education regarding the use of the on-call log and the guidelines for notification of Nurse Managers of residents change in condition. 6. In-service by the DON on [DATE] regarding guidelines for notification of Nurse Manager in and out of the building was reviewed. Dated [DATE], the in-service specified the procedure for notification of the Nurse Manager on call for any resident with a change in condition. The sign in roster and additional record of nurses educated by telephone included thirty nursing staff. 7. The Change in Condition audit tool, completed for five residents with a change of condition from [DATE] through [DATE] was reviewed. The Nurse Manager was notified, either in the building or by telephone for all five residents. The progress notes contain notification of Physician/ Nurse Practitioner and Responsible Party. Three of the five residents had a change in respiratory status and the Respiratory Therapist was notified. 8. The Change in Condition audit tool was reviewed by the QA committee. The sign in roster and content for the QA meeting was reviewed with nineteen signatures acknowledging review of the Change in Condition Audit on [DATE]. Interview on [DATE] at 4:30 p.m. with the Corporate Chief Nursing Officer revealed during the QA meeting held [DATE] the results of the audit of resident records regarding notification of change in condition between [DATE] and [DATE] was discussed. Additional education was provided to staff regarding negative findings, but there were no negative findings regarding notification of Physician, Responsible Party, Nurse Manager and Respiratory Therapy when applicable.",2020-09-01
590,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2017-09-29,281,J,1,1,6HMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the State of Georgia Rule ,[DATE]-.01 Standards of Practice for Registered Professional Nurses and Rule ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses, review of the facility policy titled Change in a Resident's Condition or Status and staff interviews, the facility failed to maintain professional nursing standards of quality and nursing standards of practice as evidenced by failing to conduct a skilled nursing assessment and by failing to re-assess and monitor one of five residents (R#1) with a change in condition related to acute respiratory distress. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio [NAME]s Health and Rehabilitation beginning [DATE] and concluding on [DATE]. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 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. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. Additional residents were reviewed during the Recertification survey conducted [DATE] through [DATE] related to licensed nurses accessing residents with a change in condition and no further issues were identified. The survey team reviewed the complaint findings related to R#1 which was identified as an immediate jeopardy existing on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Cross refer to F328 Findings include: Review of the Georgia Rule ,[DATE]-.01 Standards of Practice for Registered Professional revealed that: The Board recognizes that assessment, nursing diagnosis, planning, intervention, evaluation, teaching, and supervision are the major responsibilities of the registered nurse in the practice of nursing. The Standards of Practice for Registered Professional Nurses delineate the quality of nursing care which a patient/client should receive regardless of whether it is provided solely by a registered nurse or by a registered nurse in collaboration with other licensed or unlicensed personnel. The Standards are based on the premise that the registered nurse is responsible for and accountable to the patient/client for the quality of nursing care rendered. The Standards of Practice for Registered Professional Nurses shall establish a baseline for quality nursing care; be derived from the Georgia Nurse Practice Act; apply to the registered nurse [MEDICATION NAME] in any setting; and, govern the practice of the licensee at all levels of competency. (a) Standards related to the registered nurse's responsibility to apply the nursing process (adapted from American Nurses' Association Code for Nurses and Standards of Practice). The registered nurse shall: 1. Assess the patient/client in a systematic, organized manner; 2. Formulate a nursing [DIAGNOSES REDACTED]. 4. Implement strategies to provide for patient/client participation in health promotion, maintenance and restoration; 5. Initiate nursing actions to assist the patient/client to maximize her/his health capabilities; Review of the Georgia Rule ,[DATE]-.02 - Standards of Practice for Licensed Practical Nurses revealed that: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice; Review of the undated facility policy titled Change in a Resident's Condition or Status documented that the Nurse Supervisor will notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status; or when there is a need to alter the resident's treatment significantly; or deemed necessary or appropriate in the best interest of the resident. The policy does not address nursing assessments, re-assessments or monitoring of a resident with a change of condition. 1. Resident #1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via percutaneous endoscopic gastrostomy (PEG). [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. Review of the Weights and Vitals Summary documented the results of Sp02 and that R#1 was on room air from [DATE] through [DATE]. There was no further documentation after [DATE]. Review of the Quarterly Admission Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental status (BIMS) summary score of five, indicating severe cognitive impairment. Section G- Functional Status indicated the resident required extensive assistance with all Activities of Daily Living (ADL). Section J- Health Conditions assessed that R#1 had a condition of shortness of breath while lying flat. Section O- Special Treatments and Programs documented the resident received oxygen therapy and suctioning and had a [MEDICAL CONDITION]. Interview on [DATE] at 11:57 a.m. with the family/responsible party (RP) of R#1 revealed that she was told by a nurse via telephone, after R#1 expired on Saturday of [DATE], that he had been having difficulty breathing that day and his oxygen saturation was down to 74%. The RP stated they (staff) had put a [MEDICAL CONDITION] with mask on R#1 and the nurse told her when they checked him one hour later, he had passed away. The RP stated she did not understand why R#1 was not sent to the hospital if he was having breathing problems all day. Record review for R#1 revealed no evidence of a skilled nursing assessment on [DATE]. Review of the Weights and Vitals Summary revealed no evidence on [DATE] of Sp02 results or vital signs (heart rate, respiratory rate, temperature or blood pressure) for R#1. The last time the Sp02 and vital signs were documented was [DATE]. Review of the Medication Administration Record [REDACTED]. Further review of R#1's clinical record revealed the following Progress Notes: LPN AA created a Nurse's Note on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% R[NAME] Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) LPN CC created a Nurse's Note on [DATE] at 12:21 a.m. with an effective date and time of [DATE] at 12:00 a.m. which documented At approximately 11:20 p.m. I was making my rounds and when I went into resident room. I notice that resident was unresponsive and gray in color. Resident a DNR. I assessed resident by checking pulse and then proceeded to have the RN supervisor from the vent unit to confirm resident status. Next of kin was notified and funeral home of family choice was notified. (sic) Registered Nurse (RN FF) created a Nurse's Note on [DATE] at 12:43 a.m. with an effective date and time of [DATE] at 11:25 p.m. which documented Called to resident's room by charge nurse. Resident was found to be non-responsive, pallid, and apneic. Apical pulse was auscultated and carotid pulse palpated simultaneously one full minute without results. Death was pronounce at 11:30 PM. Dr. (name) notified. (sic) RN FF created a Nurse's Note dated [DATE] at 12:48 a.m. with an effective date and time of [DATE] at 11:35 p.m. on [DATE] which documented Responsible party, (name), notified of resident's expiration via telephone. (Name) stated she was out of town and could not come. She also stated that she would like for resident to be sent to (name) Funeral Home in Tallapoosa, G[NAME] (Name) expressed appreciation for the notification. (sic) Interview on [DATE] at 4:56 p.m. with the Director of Nursing (DON) revealed that R#1 was pronounced deceased at 11:30 p.m. on [DATE]. She stated the facility was aware that LPN AA did not document the resident's change of condition in the Change of Condition Evaluation Assessment pathway in the electronic charting system. The DON stated that in this section, documentation includes all pertinent information, notification of the Physician and if a resident is transferred to the hospital. In an interview with the Licensed Practical Nurse (LPN AA) on [DATE] at 5:08 p.m., she reported that the morning of [DATE], R#1 seemed to be very depressed and was just staring out of the window. LPN AA stated R#1 wasn't really lethargic but not himself so she did not administer his [MEDICATION NAME] and that his Sp02 was in the 90's. LPN AA stated around 2:00 p.m. - 3:00 p.m. the resident seemed sleepy and when she checked his Sp02, it was 74% (normal range is above 90%). She stated that she placed the resident on oxygen at two liters per minute (2 LPM) via nasal cannula and there was no improvement in the resident's condition. LPN AA stated she received an order from the Nurse Practitioner (NP) to initiate [MEDICAL CONDITION] therapy however, she could not remember the time. LPN AA stated that the Respiratory Therapist (RT BB) placed R#1 on [MEDICAL CONDITION] but she did not remember the time. LPN AA further stated that she never returned to re-assess R#1 and had not seen the resident again after he was placed on [MEDICAL CONDITION] for the remainder of her shift (7:00 a.m. - 7:00 p.m.). LPN AA stated she had no good answer for why she did not re-assess or monitor R#1, It gets busy at the end of the shift but I know that is not a good excuse. She stated she did make a notation at the end of her shift but not a detailed notation. LPN AA stated she gave report to the oncoming nurse (LPN CC) and told her that R#1 had a change in his condition and was placed on [MEDICAL CONDITION]. Further interview on [DATE] at 5:17 p.m. with the DON revealed she was on vacation when R#1 expired on [DATE] and returned to work on [DATE]. The DON stated she was aware R#1 had respiratory distress and was placed on [MEDICAL CONDITION]. She stated she was aware that a change in condition evaluation assessment had not been conducted and aware that the nurse did not notify the family/responsible party. The DON stated she was not aware that LPN AA had not re-assessed or monitored R#1 after his change of condition and being placed on [MEDICAL CONDITION] for the rest of her shift. She stated that her expectation would include a skilled nursing assessment and ongoing monitoring after R#1 had a change in his condition and after being placed on [MEDICAL CONDITION]. Telephone interview on [DATE] at 5:28 p.m. with the 7:00 p.m. - 7:00 a.m. LPN CC revealed the night of [DATE] she had received report from LPN AA that R#1 was placed on [MEDICAL CONDITION] due to respiratory distress. LPN CC stated she saw the resident first around 8:00 p.m. - 8:30 p.m. She stated she checked the resident's Sp02 and it was she believed 91%. She stated she attempted to suction the resident's mouth but he did not like it and pushed her hand away. She stated that she thought she had documented her assessment and the resident's Sp02 but she could not be sure without checking the computer. LPN CC stated that the next time she saw R#1 was about 10:30 p.m. and he seemed fine. She stated two Certified Nursing Assistants (CNA DD and CNA EE) changed the resident's brief around 10:45 p.m. before they left their shift. LPN CC stated around 11:15 p.m. she checked on R#1 and he was not responsive. She called RN FF to come and check R#1 and it was determined the resident had expired. Interview on [DATE] at 2:08 p.m. with the Nurse Practitioner (NP GG) revealed she was covering for attending physician of R#1 on [DATE] while he was out of town. NP GG stated a nurse had called her one time on [DATE]. She stated it was reported to her that the residents C02 was elevated and his oxygen saturation was low. She stated that she ordered [MEDICAL CONDITION] with the agreed decision to see how he would do on [MEDICAL CONDITION] first, but she never heard back from anyone at the facility. NP GG stated she cannot remember exactly what time she received the call but she believed that it was in the morning sometime. NP GG stated that since R#1 was having drops in his oxygen saturation, the resident's Sp02 should have been monitored to make sure the resident was improving. She stated the resident should have been re-assessed after being placed on [MEDICAL CONDITION] and ongoing assessments should have been conducted by both the nurse and the respiratory therapist. Interview on [DATE] at 2:17 p.m. with the attending Physician for R#1 revealed the resident was placed on [MEDICAL CONDITION] as a means of noninvasive ventilation secondary to respiratory distress. He stated that the impression was that the resident's C02 was elevated and oxygen alone was not improving his condition. The Physician stated that he was not aware that the resident had not been monitored or re-assessed after being placed on [MEDICAL CONDITION]. He stated that absolutely the resident should have been monitored and they usually get feedback on how the resident is doing. He stated the nurse and respiratory therapist should have assessed and monitored the resident. He stated that although R#1 was a DNR he was doing better, had increase awareness and was improving. He stated that he cannot say for certain that had the resident been properly monitored, the outcome would have been different but that without even trying, we would never know. Interview on [DATE] at 2:47 p.m. with the Certified Nursing Assistant (CNA DD) revealed she was the CNA assigned to R#1 on [DATE]. She stated that when she came on her shift at 3:00 p.m., R#1 was on the [MEDICAL CONDITION] with a mask on his face. She stated when she got there, the resident was not really responding and was mostly out of it on her shift (3:00 p.m. - 11:00 p.m.). She stated at around 10:15 p.m. on her third rounds, she and CNA EE changed the resident's brief and that R#1 was the same at that time stating he was not alert and not responding to conversation. Interview on [DATE] at 2:52 p.m. with CNA EE revealed she was not assigned to R#1 on [DATE] but she passed his room many times and stated the resident was wearing [MEDICAL CONDITION] mask at 3:00 p.m. when she came on her shift (3:00 p.m. - 11:00 p.m.). She stated that during her third rounds she assisted CNA DD with changing the resident after a bowel movement. She stated it was about 10:15 p.m. because they start third rounds at 10:00 p.m. CNA EE stated that R#1's eyes were open but he was not responding. She stated he would take a breath, then pause, then take another breath. She stated it was a noticeable pause and not normal breathing. She stated it was not reported at that time to the nurse because R#1 had been that way and on the mask since she started her shift and everyone already knew of his condition. Interview on [DATE] at 4:14 p.m. with the Registered Nurse Weekend Supervisor (RN HH) revealed she was working on [DATE] covering for the regular RN weekend supervisor. She stated neither the nurse nor respiratory therapist in care of R#1 reported to her that he was having respiratory complications. RN HH stated she did not know that R#1 had a change in condition or expired until the Corporate Nurse called her during the complaint survey and wanted to know if she knew what happened. RN HH stated that the nurse caring for R#1 should have informed her of the situation. She stated she would have helped assess R#1. She stated that the nurse would have been responsible for documenting a skilled nursing note and the change of condition. She stated had she performed any of her own assessments, she would document her own skilled nursing note. She further stated that she would have pushed for the resident to be sent to the hospital in his condition. RN HH stated that she left the facility at around 2:30 p.m. on [DATE]. Review of the Pronouncement of Death indicated the resident expired in the facility on [DATE]. Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. 2. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her PEG tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. Transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. 3. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m. The Physician was again called at 12:15 p.m. and the resident was transferred to the hospital. The family and DON were notified at 12:05 p.m. 4. R#120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Respiratory Therapist was in the room and continued to work with the resident and at 10:10 a.m. the Nurse Practitioner was notified the resident was not improving and ordered R#120 transferred to the hospital. The family had been notified at 9:45 a.m. The Nurse Manager was notified at 10:20 a.m. as the resident was transferred. An interview with RN DON on [DATE] at 1:40 p.m. revealed she was educated regarding the Respiratory Change in Condition Plan and the duties of the Nurse Manager on call and understood the use of the on-call log, follow up guidelines, and the guidelines for notification of Nurse Managers. An interview with LPN AAA on [DATE] at 2:15 p.m. indicated she had attended in-services regarding the Respiratory Change in Condition Plan and describing her role as Nurse Manager on call, follow up guidelines and the appropriate use of the on call log after the incident with R#1. She confirmed that the facility staff did not monitor the resident and did not follow up with the Physician/NP for R#1. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Pertinent Charting Policy was revised on [DATE] to include completion of a Nursing Skilled Observation/Assessment Note every shift for 72 hours following a change in condition. This has been added to the Licensed Nursing Orientation as of [DATE]. 2. 30 of 30 of Nurses will be educated by the Unit Manager on the revised pertinent charting policy beginning [DATE]. 18 of 34 nurses were in-serviced at the facility and ,[DATE] were in-serviced by telephone. The remaining 2 will be in-serviced by [DATE] prior to the start of their scheduled shift. 30 of 30 of nursing staff has been educated that they must observe/assess the resident when there is a change in condition, and that this assessment is to be documented in thee-interact Change in Condition Evaluation, and that follow-up monitoring, re-assessment, and any follow up communication with the family, and or responsible party will be documented in the nursing progress notes. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced , any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 3. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24 hour report, and if respiratory change in condition was respiratory assessment documented . 4. There will be a QA meeting on [DATE] to review the findings. 5. A respiratory change in condition plan was developed on [DATE] for resident ' s not on the ventilator unit. The following is the plan: a. For residents who have an acute change in respiratory status the respiratory therapist will be notified and the nurse will complete a change in condition (using information from the nurses assessment as well as the respiratory therapist), the respiratory therapist will complete respiratory assessment and follow the policy for Respiratory Assessment/Intervention for Non-Respiratory Caseload Patients. b. MD and family to be notified and documentation completed. If the person already has order for prn oxygen this will be applied, family will be notified. MD will be notified if the resident's 02 saturation does not improve within 15 minutes or immediately if the resident exhibits clinical signs or symptoms of acute respiratory distress. c. Resident will be moved to the vent unit if placed on NIV or [MEDICAL CONDITION]. If there is no bed available, then will be moved to 200 Hall, if no beds are available on either unit the MD will be contacted regarding possible transfer to the ER. d. If the resident remains in facility there will be charting at a minimum of,15 minute follow up, every 30 minutes x2 then hourly x2, then resume every shift pertinent charting if resident's respiratory condition has stabilized with rounding every two hours and documentation as needed in the chart related to status. 6. 30 of 30 of the nurses were educated regarding the respiratory change in condition plan by the DON. In service conducted on [DATE] by DON 22 of 30 nurses were in-serviced , any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 7. Guidelines for notification of the nurse manager on call were developed on [DATE] by the CNO for Reliable Health Care Management , they include use of the Interact change in condition cards- if the resident meets the criteria for immediate notification or has a critical lab not covered by the change in condition cards and a nurse manager is not in the building or it is the weekend the nurse manager on call will be notified. The nurse manager will log this on the Nurse Manager On-Call Log. These have been submitted to the Quality Assurance Committee and added to the Licensed Nursing Orientation [DATE]. Review and follow-up guidelines for a change in condition for the nurse manager on call to follow were developed on [DATE] by the CNO for Reliable Health Care Management to include notification of the responsible pai1y, MD or NP on call, a nurse manager or RN weekend supervisor if she/he is in the building on the weekend, and the on-call nurse if after hours or on the weekend, completion of the Interact Change of Condition Form and use of the Interact Clinical Pathways if applicable. The Review and follow-up guidelines have been submitted to the Quality Assurance Committee and added to Licensed Nursing Orientation [DATE]. 8. 6 of 6 of the nurse managers were educated on the Guidelines for notification , their responsibilities while on call related to the review and follow up guidelines and documentation on the Nurse Manager On Call Log. This education was done by the DON on [DATE] 6 out 6 nurse managers attended and were in-serviced. 30 of 30 of nurses were educated by the DON on [DATE] regarding the guidelines for notification of the nurse manager in the building and the on-call nurse after hours and on weekends and the review and follow-up guidelines for a change in condition. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced, any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in-serviced via telephone. 9. A Change in Condition audit tool developed on [DATE] by the CNO for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends, as well as the RN supervisor on the weekend and that the guidelines for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 10. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE]. 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. The Pertinent Charting Policy revised on [DATE] was reviewed. A pertinent daily charting list will be maintained at the nursing station. The list for pertinent charting will include Residents with a change of condition and will include a Skilled Nursing Note on all shifts. This requires documentation for a minimum of 72 hours. Nursing Management may determine that assessment/documentation is indicated for longer than the timeframe listed, but not less. This documentation will be completed on each shift and will include full vital signs. 2. On [DATE] education was conducted by the facility for 30 of 30 nursing staff. The policy revision conducted on [DATE] was included in an in-service education conducted on [DATE]. Rosters and education content were reviewed. Twenty-two nurses signed the roster on [DATE] and eight were educated by telephone. The education roster from [DATE] including revision to the policy for pertinent charting was signed by twenty of thirty-four nurses, and the roster indicated fourteen were educated by telephone. See below list of nursing staff verifying this education. 3. An audit of fifty-seven resident records for all residents transferred to the hospital between [DATE] and [DATE], completed on [DATE], was reviewed. Thirty-two records did not include a change in condition evaluation. Twenty-one records did not have a transfer form. Forty-nine records did not include a documented Physician order for [REDACTED]. 4. The roster and content of the QA meeting held on [DATE] to discuss the The minutes and roster of the QA meeting held on [DATE]. Findings related to the audit for all residents transferred to the hospital between [DATE] and [DATE] were discussed. The roster was signed by nineteen Quality Assurance Committee Members. 5. The Respiratory Change in Condition Plan was reviewed. The Respiratory Therapist is to be notified of any residents having an acute change in respiratory status. The nurse will complete a change in condition form. The Respiratory Therapist will complete a respiratory assessment and follow the policy for Respiratory Assessment/Intervention for Non-Respiratory Caseload Patients. The Physician and family are to be notified and the documentation completed. If the residents oxygen saturation does not improve the Physician is to be notified in 15 minutes or immediately if the resident exhibits signs of acute respiratory distress. If the resident is placed on non invasive ventilation (NIV) or bilevel positive airway pressure ([MEDICAL CONDITION]), they are to be moved to the ventilator unit. If there is no bed available on the ventilator unit the resident should be moved to the 200 hall. If there are no beds available on the 200 hall the Physician should be notified for possible transfer to the Emergency Department. If the resident is not transferred to the Emergency Department there will be charting at a minimum of fifteen minute follow up, then every thirty minutes twice, then every hours twice, then resume every shift if the respiratory status has stabilized, with rounding every two hours and documentation as needed. 6. Education content and rosters were reviewed for the respiratory change in condition plan, conducted on [DATE]. The roster included the signatures of twenty-two licensed nursing staff and indicated eight were educated by telephone. See below interviews of nursing staff confirming education regarding the respiratory change in condition plan and acknowledging understanding. 7. Guidelines, developed on [DATE] for notification of the nurse manager of resident change in condition, required notifications, completion of Interact Change of Condition form, follow up guidelines, and use of the Interact Clinical Pathways were reviewed. Interview conducted [DATE] at 4:45 p.m. with the Director of Nurses revealed the guidelines had been submitted to the QA committee and no revisions were recommended at the meeting held [DATE]. 8. Education content and rosters were reviewed regarding an in-service conducted on [DATE] including the guidelines of notification of Nurse Managers of resident change in condition, and follow up guidelines for a change in condition. The in-service was also presented",2020-09-01
591,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2017-09-29,282,J,1,1,6HMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, and staff interviews, the facility failed to follow the respiratory care plan interventions for one of eight sampled residents (R#1) that experienced acute respiratory distress. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio [NAME]s Health and Rehabilation beginning [DATE] and concluding on [DATE]. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 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. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for a change of condition was noted. There were no additional issues identified. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Cross Refer to F328 Findings include: 1. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via PE[NAME] [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE]. Record review for R#1 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) summary score of three, indicating severe cognitive impairment. Section J- Health conditions assessed that R#1 had a condition of shortness of breath while lying flat. Section O- Special Treatments and Programs documented the resident received oxygen therapy and suctioning and had a [MEDICAL CONDITION]. Further record review for R#1 revealed a Physician order [REDACTED]. Review of the Weights and Vitals Summary from [DATE] through [DATE] documented Sp02 results ranging from ,[DATE]% and indicated that R#1 was on room air. There was no further documentation after [DATE]. Review of respiratory care plan initiated [DATE] identified that R#1 has oxygen at four liters per minute (4 LPM) via nasal cannula (NC) related to [MEDICAL CONDITIONS]. The Goal documented the resident will have no signs or symptoms or poor oxygen absorption through the review date. Interventions included, but not limited to; 1. Monitor for signs and symptoms of respiratory distress and report to MD (Physician) PRN (as needed): respirations, pulse oximetry (Sp02), increased heart rate, restlessness, diaphoresis, headaches, lethargy, confusion, atelectasis, hemoptysis, cough, pleuritic pain, accessory muscle use and skin color. 2. Provide reassurance and allay anxiety. Have an agreed method for the resident to call for assistance (e.g. call light, bell). Stay with the resident during episodes of respiratory distress. Interview on [DATE] at 4:19 p.m. with RT BB) revealed that on the dayshift of [DATE], LPN AA asked him between 3:00 p.m. - 4:00 p.m. to evaluate R#1 due to the resident had coughed up some mucous and it was green. RT BB stated when R#1 was evaluated, the resident's respiratory status was stable and his oxygen saturation (Sp02) was in the 90'sand stated that he documented a note and that he had been unable to retrieve the note in the electronic charting system. RT BB further stated that he gave report to the oncoming nightshift Respiratory Therapist (RT JJ). Telephone interview on [DATE] at 4:40 p.m. with RT JJ revealed he worked the nightshift (7:00 p.m. - 7:00 a.m.) on [DATE] when R#1 expired but he had never seen the resident. He stated he never received report from the departing therapist RT BB that R#1 had a change in condition. He stated he did not set R#1 up on [MEDICAL CONDITION] and he did not receive report that the resident had been placed on [MEDICAL CONDITION] for respiratory distress. He stated he was never asked by the nurses during that shift to check or evaluate R#1. Further interview on [DATE] at 4:50 p.m. with RT BB revealed that he had another resident on a ventilator that was going bad at the same time that R#1 was having respiratory distress and the nurse (LPN AA) handled the situation and called the Nurse Practitioner. He stated that he had set the resident up on [MEDICAL CONDITION] he thought around 4:45 p.m. RT BB stated he did check R#1 around 6:00 p.m. and his Sp02 was in the 90's but stated that he was unable to find any documentation of his assessments or when he initiated [MEDICAL CONDITION] therapy for R#1 in the electronic charting system. Interview on [DATE] at 4:52 p.m. with the Respiratory Director revealed when R#1 was placed on [MEDICAL CONDITION] for noninvasive ventilation related to respiratory distress, the resident should have had a respiratory assessment and the facility protocol should have been followed. This is to be documented in the Respiratory Assessment area of the electronic charting and that a note should have been documented in the Progress Notes. She further stated that resident should have absolutely been monitored and re-assessed after being placed on [MEDICAL CONDITION] therapy. The Respiratory Director confirmed that there was no respiratory documentation in the resident's clinical chart related to the resident's change of condition, respiratory status, respiratory assessment, [MEDICAL CONDITION] use or settings, oxygen saturation checks or re-assessments/monitoring. In an interview with the LPN AA on [DATE] at 5:08 p.m., she reported that the morning of [DATE], R#1 seemed to be very depressed and was just staring out of the window. LPN AA stated R#1 wasn't really lethargic but not himself. LPN AA stated around 2:00 p.m. -3:00 p.m. the resident seemed sleepy and when she checked his Sp02, it was 74% (normal range is above 90%). She stated that she placed the resident on oxygen at two liters per minute (2 LPM) via nasal cannula and there was no improvement in the resident's condition. LPN AA stated she received an order from the Nurse Practitioner (NP) to initiate [MEDICAL CONDITION] and that the Respiratory Therapist (RT BB) placed R#1 on [MEDICAL CONDITION] but she did not remember the time. LPN AA further stated that she never returned to re-assess R#1 and had not seen the resident again after he was placed on [MEDICAL CONDITION] for the remainder of her shift (7:00 a.m. - 7:00 p.m.). LPN AA stated she had no good answer for why she did not re-assess or monitor R#1, It gets busy at the end of the shift but I know that is not a good excuse. Telephone interview on [DATE] at 5:28 p.m. with the 7:00 p.m. - 7:00 a.m. LPN CC revealed the night of [DATE] she saw the resident first around 8:00 p.m. - 8:30 p.m. She stated she checked the resident's Sp02 and it was she believed 91%. She stated that she thought she had documented her assessment and the resident's Sp02 but she could not be sure without checking the computer. LPN CC stated that the next time she saw R#1 was about 10:30 p.m. and he seemed fine. LPN CC stated around 11:15 p.m. she checked on R#1 and he was not responsive. She called RN FF to come and check R#1 and it was determined the resident had expired. Interview on [DATE] at 2:08 p.m. with the Nurse Practitioner (NP GG) revealed she was covering for the attending physician of R#1 on [DATE] while he was out of town. NP GG stated a nurse had called her one time on [DATE]. She stated it was reported to her that the residents C02 (carbon [MEDICATION NAME]) was elevated and his oxygen saturation was low. She stated that she ordered [MEDICAL CONDITION] with the agreed decision to see how he would do on [MEDICAL CONDITION] first, but she never heard back from anyone at the facility. NP GG stated she stated the [MEDICAL CONDITION] was ordered as noninvasive ventilation secondary to respiratory distress. She stated if the resident continued to decline, she would have ordered a chest x-ray and possible antibiotics for potential aspiration pneumonia and that would have been verified by chest x-ray, however, no one ever called her back about the resident's condition. NP GG stated that since R#1 was having drops in his oxygen saturation, the resident's Sp02 should have been monitored to make sure the resident was improving. She stated the resident should have been re-assessed after being placed on [MEDICAL CONDITION] and ongoing assessments should have been conducted by both the nurse and the respiratory therapist. An interview with the Director of Respiratory Therapy, LL, on [DATE] at 11:04 a.m. revealed that she was aware that both nursing and RT department did not follow the care plan for R#1 on [DATE] although her department has been in-serviced on care plans, monitoring and notification since that time. Interview of the ADON on [DATE] at 2:00 p.m. revealed that after the incident with R#1, when staff did not follow the Respiratory care plan, that all resident's care plans were reviewed to ensure the care plans were accurate and that staff was in-serviced to follow the care plans for residents. The facility implemented the following actions to remove the Immediate Jeopardy: 1. New policies and procedures developed by DON, Dir. of Respiratory Therapy, CNO for Corp Office, and Medical Director: 24 hour Respiratory Report; Respiratory Assessment /Intervention for Non-Respiratory Caseload Patients; Respiratory Pertinent Charting on [DATE]. 2. 6 of 6 of respiratory therapists were educated on the new polices by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone, ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. 6 of 6 of Respiratory therapists were educated on documentation expectations of Assessments, documentation of respiratory progress notes, and providing care according to the resident's comprehensive plan of care by the Director of Respiratory Therapy on [DATE] ,[DATE] were in-serviced in facility. 3. The policy for Non-Invasive Ventilation was revised by DON, Dir. Of Respiratory Therapy, CNO for Corp Office, and Medical Director and ,[DATE] of respiratory therapists were educated on the revised policy by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone , ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. 4. New policies and procedures: 24-hour Respiratory Report; Respiratory Assessment /Intervention for Non-Respiratory Caseload Patients; Respiratory Pertinent Charting, added to orientation for Respirator y Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 5. Revised policy for Non-Invasive Ventilation was added to orientation for Respirator y Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 6. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24 hour report , and if respiratory change in condition was respiratory assessment documented . 7. There will be a QA meeting on [DATE] to review the findings. 8. A Change in Condition audit tool developed on [DATE] by the Chief Nursing Officer for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends , as well as the RN supervisor on the weekend and that the guideline s for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 9. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE]. 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. A review of the new policies and procedures developed on [DATE] included the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients and Respiratory Pertinent Charting. 2. Review of the education content and rosters for education conducted for Respiratory Therapists revealed education was given on [DATE] for new policies regarding completion of the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients, and Respiratory Pertinent Charting. One Respiratory Therapist was in the building and was in serviced and five were in serviced by telephone. On [DATE] an in-service was conducted and six of six Respiratory Therapists were present and signed the roster. Interview with Respiratory Therapist JJ on [DATE] at 2:35 p.m. and Respiratory Therapist EE on [DATE] at 3:00 p.m. confirmed education given on [DATE] and [DATE] regarding new policies including the completion of the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients, and Respiratory Pertinent Charting, and acknowledged their understanding of the education. A review of the 24-hour Respiratory Report was conducted and R#18 and R#120 were included. Record review for R#18 revealed Pertinent Respiratory documentation occurred on [DATE] at 11:35 a.m. and 12:14 p.m. A skilled respiratory assessment was also completed at 11:30 a.m. Record review for R#120 revealed Pertinent Respiratory documentation recorded on [DATE] at 9:24 a.m. and [DATE] at 10:10 a.m. A full respiratory assessment was documented at 9:20 a.m. Documentation was completed according to policy and education for the two sampled residents with respiratory changes in condition. 3. The revised policy for Non-Invasive Ventilation was reviewed. Education content and rosters were reviewed. Interview with Respiratory Therapist JJ on [DATE] at 2:35 p.m. and Respiratory Therapist EE on [DATE] at 3:00 p.m. confirmed education given on [DATE] and [DATE] regarding the revised policy for Non-Invasive Ventilation, and acknowledged understanding. 4. During an interview conducted on [DATE] at 3:10 p.m. the Director of Respiratory Services confirmed there had been no new Respiratory Therapists hired since [DATE]. Any newly hired Respiratory Therapists will be educated to complete the 24-hour Respiratory Report, the Respiratory Assessment/Intervention for Non-Respiratory Caseload Patients, Respiratory Pertinent Charting before they are allowed to begin working with residents. 5. An interview conducted on [DATE] at 3:10 p.m. with the Director of Respiratory Services revealed the revised policy for Non-Invasive Ventilation will be a part of orientation for all newly hired Respiratory Therapists beginning [DATE]. There have not been any new Respiratory Therapists since [DATE]. 6. The audit for all residents transferred to the hospital between [DATE] and [DATE] was reviewed. Fifty-seven resident records were included. Thirty-two records did not include a change in condition evaluation. Twenty-one records did not have a transfer form. Forty-nine records did not include a documented Physician order [REDACTED]. 7. A review of the minutes and content of the QA meeting conducted on [DATE] revealed the findings of the audit of residents for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24-hour report and if respiratory change in condition was respiratory assessment documented. Nineteen QA committee members signed the roster. 8. Review of the Change in Condition Audit tool for the week of [DATE] through [DATE] revealed the Change in condition audit tool developed on [DATE] including five records of residents experiencing a change in condition. The Nurse Manager was notified of the five changes in condition. The on call log was not filled out by the Nurse Manager for one resident. Follow up call to family and follow up documentation per education were not completed for one resident with a respiratory change in condition. 9. Interview of the ADON on [DATE] at 2:00 p.m., the Administrator on [DATE] at 3:20 pm the DON on [DATE] at 4:45 p.m., and the Director of Respiratory Services on [DATE] at 3:10 p.m. acknowledged receiving education on conducting the Change in Condition audit tool from the Corporate Chief Nursing Officer, and confirmed their understanding. 10. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her PEG tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. Transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. The resident was monitored appropriately, the Physician and family were notified timely. 11. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m. The Physician was again called at 12:15 p.m. and the resident was transferred to the hospital. The family and DON were notified at 12:05 p.m. The resident was monitored appropriately, the Physician and family were notified timely. 12. R#120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Respiratory Therapist was in the room and continued to work with the resident and at 10:10 a.m. the Nurse Practitioner was notified the resident was not improving and ordered R#120 transferred to the hospital. The family had been notified at 9:45 a.m. The Nurse Manager was notified at 10:20 a.m. as the resident was transferred. The resident was monitored appropriately, the Physician and family were notified timely.",2020-09-01
592,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2017-09-29,328,J,1,1,6HMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the policy titled Respiratory Policy and Procedure- Subject: Non-Invasive Ventilation and staff interviews, the facility failed to implement its policy related to the use of non-invasive ventilation for the treatment of [REDACTED].#1). Specifically, the facility failed to implement protocols for non-invasive ventilation and failed to monitor and reassess R#1 after being placed on [MEDICAL CONDITION] therapy secondary to respiratory distress. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio [NAME]s Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 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. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.25(k)(6)- Standard Respiratory Care (F328, S/S; J) Cross Refer to F157, F281, F282, F490, F514 and F520 Findings include: Review of the undated facility policy titled Respiratory Policy and Procedure- Subject: Non-Invasive Ventilation documented: A Licensed Respiratory Therapist will establish safe and uniform standard of practice for the application of non-invasive ventilation in adult patients with acute respiratory distress. Initiate/Titrate the pressure support to patient comfort. With a bi-level ventilator the difference between the inspiratory pressure and the expiratory pressure determines the level of pressure support. Gradually increase the inspiratory pressure beginning at 10 cmH20 (centimeters of water) to a target pressure of no greater than 20 cmH20, while observing accessory muscle use and respiratory rate and ask the patient if breathing is becoming more comfortable. Initiate/Titrate expiratory pressure per trigger effort and Sp02. Begin with an expiratory pressure of 5 cmH20 and increase as tolerated, and not exceed an expiratory pressure of 10 cmH20. Remember that an increase expiratory pressure requires an equivalent increase in inspiratory pressure to maintain the same level of pressure support. Titrate the FI02 (concentration of oxygen inhaled) to achieve and Sp02 of 90% or greater, unless specified by a physician. Avoid inspiratory pressure greater than 20 cmH20, which decreases patient comfort and increases risk of gastric insufflation. Continue to coach and reassure the patient. Make adjustments per patient comfort and adherence to therapy. It is acceptable to give the patient a break from NIV if the patient does not acutely decompensate when the mask is removed. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via PE[NAME] [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. Record review for R#1 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which documented in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) summary score of three, indicating severe cognitive impairment. Section J- Health conditions assessed that R#1 had a condition of shortness of breath while lying flat. Section O- Special Treatments and Programs documented the resident received oxygen therapy and suctioning and had a [MEDICAL CONDITION]. Review of the Quarterly MDS assessment dated [DATE] documented a BIMS of five, indicating severe cognitive impairment. Section G- Functional Status indicated the resident required extensive assistance with all Activities of Daily Living (ADL). Section J- Health Conditions assessed that R#1 had a condition of shortness of breath while lying flat. Section O- Special Treatments and Programs documented the resident received oxygen therapy and suctioning and had a [MEDICAL CONDITION]. Interview on [DATE] at 11:57 a.m. with the family/responsible party (RP Z) revealed R#1 was transferred to the facility after a hospitalization . She stated the resident had a [MEDICAL CONDITION] and tube feeding when admitted to the nursing home facility. She stated the resident's [MEDICAL CONDITION] had been removed and his tube feeding had been removed and he began an oral diet. The RP Z stated that she was told by a nurse, after the resident expired late Saturday night of [DATE] that he had been having difficulty breathing that day and his oxygen saturation was down to 74%. She stated they had put a [MEDICAL CONDITION] with mask on R#1 and the nurse told her when they checked him one hour later, he had passed away. The RP Z stated that she did not understand why they did not send R#1 to the hospital if he was having breathing problems all day. Record review for R#1 revealed no evidence or documentation on [DATE] of a respiratory assessment, when the resident presented with acute respiratory distress, initiation of [MEDICAL CONDITION] therapy, non-invasive protocols implemented related to determination of appropriate [MEDICAL CONDITION] settings or toleration of [MEDICAL CONDITION], oxygen saturation results for R#1, and re-assessments and/or monitoring of R#1 after being placed on [MEDICAL CONDITION]. Further record review revealed an order for [REDACTED]. Interview on [DATE] at 2:33 p.m. with the attending Physician for R#1 revealed the resident's stay in the nursing facility was relatively un-eventful. The Physician stated that eventually the resident'[MEDICAL CONDITION] tube feeding was removed and R#1 was cleared by speech therapy for an oral diet. The physician stated that the resident was doing well and his condition had improved. The Physician further stated that he was out of town when R#1 expired and his Nurse Practitioner (NP GG) was covering the facility. He stated that it was reported to him when he returned. The Physician stated that the resident most likely had an aspiration event or pneumonia. The physician stated that R#1 was placed on oxygen and [MEDICAL CONDITION] therapy. The physician further stated that because the nursing facility has a Vent Unit with respiratory therapy on staff , respiratory distress is typically handled in the facility unless the nature of condition required hospitalization . The protocol for a resident in respiratory distress is administer oxygen, [MEDICAL CONDITION], appropriate labs and x-rays. He stated the R#1 was a Do Not Resuscitate (DNR) and there would have been no further treatment than that even if he would have been transferred to the hospital. Interview on [DATE] at 4:19 p.m. with the Respiratory Therapist (RT BB) revealed that he worked on the dayshift of [DATE] when the Licensed Practical Nurse (LPN AA) asked him between 3:00 p.m. - 4:00 p.m. to evaluate R#1 due to the resident had coughed up some mucous and it was green. RT BB stated when R#1 was evaluated, the resident's respiratory status was stable and his oxygen saturation (Sp02) was in the 90's. He further stated that respiratory works 12 hours shifts and he gave report to the oncoming nightshift Respiratory Therapist (RT JJ) and added that R#1 was still stable at the end of his shift (7:00 a.m. - 7:00 p.m.). RT BB stated that he documented a note and that he had been unable to retrieve the note in the electronic charting system. Telephone interview on [DATE] at 4:40 p.m. with RT JJ revealed he worked the nightshift (7:00 p.m. - 7:00 a.m.) on [DATE] when R#1 expired but he had never seen the resident. He stated he never received report from the departing therapist RT BB that R#1 had a change in condition. He stated he did not set R#1 up on [MEDICAL CONDITION] and he did not receive report that the resident had been placed on [MEDICAL CONDITION] for respiratory distress. He stated he was never asked by the nurses during that shift to check or evaluate R#1. He stated when he found out the resident had expired, he was very surprised because the resident had been improving and doing so well. Further interview on [DATE] at 4:50 p.m. with RT BB revealed that he had another resident on a ventilator that was going bad at the same time that R#1 was having respiratory distress and the nurse (LPN AA) handled the situation and called the Nurse Practitioner. He said the LPN AA called him and reported that NP GG ordered [MEDICAL CONDITION]. He stated that he had set the resident up on [MEDICAL CONDITION] he thought around 4:45 p.m. RT BB stated he did check R#1 around 6:00 p.m. and his Sp02 was in the 90's but stated that he was unable to find any documentation of his assessments or when he initiated [MEDICAL CONDITION] therapy for R#1 in the electronic charting system. Interview on [DATE] at 4:52 p.m. with the Respiratory Director revealed when R#1 was placed on [MEDICAL CONDITION] for noninvasive ventilation related to respiratory distress, the resident should have had a respiratory assessment and the facility protocol should have been followed. This is to be documented in the Respiratory Assessment area of the electronic charting and that a note should have been documented in the Progress Notes. She further stated that resident should have absolutely been monitored and re-assessed after being placed on [MEDICAL CONDITION] therapy. The Respiratory Director confirmed that there was no respiratory documentation in the resident's clinical chart related to the resident's change of condition, respiratory status, respiratory assessment, [MEDICAL CONDITION] use or settings, oxygen saturation checks or re-assessments/monitoring. In an interview with the Licensed Practical Nurse (LPN AA) on [DATE] at 5:08 p.m., she reported that the morning of [DATE], R#1 seemed to be very depressed and was just staring out of the window. LPN AA stated R#1 wasn't really lethargic but not himself so she did not administer his [MEDICATION NAME] and that his Sp02 was in the 90's. LPN AA stated around 2:00 p.m. -3:00 p.m. the resident seemed sleepy and when she checked his Sp02, it was 74% (normal range is above 90%). She stated that she placed the resident on oxygen at two liters per minute (2 LPM) via nasal cannula and there was no improvement in the resident's condition. LPN AA stated she called RT BB and he did some sort of C02 test and told her to call the Nurse Practitioner (NP GG). LPN AA stated she received an order from the NP GG to initiate [MEDICAL CONDITION] therapy however, she could not remember the time. LPN AA stated that RT BB placed R#1 on [MEDICAL CONDITION] but she did not remember the time. Review of the Progress Notes revealed LPN AA created a Nurse's Note on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% R[NAME] Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) Interview on [DATE] at 5:20 p.m. with the RT Director revealed that the resident was set up on [MEDICAL CONDITION] as a means of noninvasive ventilation secondary to respiratory distress. She stated they have a policy for noninvasive ventilation. The Respiratory Director stated she made some changes to the policy to move the resident to the 200 Hall to be closer to the Vent Unit if a room is available. She stated the resident is to be checked after initiating [MEDICAL CONDITION] and [MEDICAL CONDITION] checks Q3 hours. If the resident does not improve after one hour, the physician is to be called. She stated the physician would make a determination if the resident should be sent to the hospital. Interview on [DATE] at 11:05 a.m. with the Respiratory Director confirmed that the [MEDICAL CONDITION] order for R#1 was dated [DATE] at 12:00 p.m. after R#1 had already expired. She confirmed and that the [MEDICAL CONDITION] order did not indicate the settings for IPAP, EPAP or oxygen and stated it should have. She stated the protocol for [MEDICAL CONDITION] is to start IPAP at 10 cmH20 (centimeters of water) and EPAP at 5 cmH20 and that is what the order should have read. She stated this is an initial setting and the policy instructs to titrate the pressure until optimal benefit is obtained. The Respiratory Director stated that any changes from the initial settings would require a respiratory assessment and documentation. The Respiratory Director also confirmed that there is no documentation of oxygen saturations for R#1 since [DATE]. She stated that R#1 should have been assessed and monitored per the policy for noninvasive ventilation and that RT BB did not follow the policy. She stated that although continuous pulse oximetry was not addressed in the policy for Non-Invasive Ventilation, the standard of practice would have been to initiate continuous pulse oximetry on a resident in respiratory distress. She stated the policy does address 02 saturation spot checks. She stated they do not require a physician order [REDACTED]. Respiratory Director stated she revised the policy yesterday ([DATE]) and that the last paragraph is the only change made. She stated that added paragraph addresses implementation of a continuous pulse oximeter and assessment requirements for a patient placed on [MEDICAL CONDITION] for noninvasive ventilation. The Respiratory Director provided a copy of the policy titled Non-Invasive Ventilation with the added revision on [DATE] at 11:25 a.m. Review of the revised policy titled Non-Invasive Ventilation dated [DATE] revealed an added paragraph which documented Document procedure/initial respiratory assessment in electronic charting system. Patient should be placed on Continuous Pulse Oximetry while receiving NIV. Patient should be started on Pertinent Respiratory assessments as follows: 30 minutes x 2, hourly x 2 and then Q3 hours while receiving Non-invasive ventilation. Patient should be moved to the ventilator unit/200 hall if room available. If patient shows no signs of improvement 1 hour after initiation of NIV, contact MD and consider sending patient to ER for further evaluation. Interview on [DATE] at 2:08 p.m. with the Nurse Practitioner (NP GG) revealed she was covering for the attending physician of R#1 on [DATE] while he was out of town. NP GG stated a nurse had called her one time on [DATE]. She stated it was reported to her that the residents C02 (carbon [MEDICATION NAME]) was elevated and his oxygen saturation was low. She stated that she ordered [MEDICAL CONDITION] with the agreed decision to see how he would do on [MEDICAL CONDITION] first, but she never heard back from anyone at the facility. NP GG stated she cannot remember exactly what time she received the call but she believed that it was in the morning sometime. NP GG stated that she did not order a chest x-ray because she wanted to see how R#1 would respond to the [MEDICAL CONDITION] first. She stated the [MEDICAL CONDITION] was ordered as noninvasive ventilation secondary to respiratory distress. She stated if the resident continued to decline, she would have ordered a chest x-ray and possible antibiotics for potential aspiration pneumonia and that would have been verified by chest x-ray, however, no one ever called her back about the resident's condition. NP GG stated that since R#1 was having drops in his oxygen saturation, the resident's Sp02 should have been monitored to make sure the resident was improving. She stated the resident should have been re-assessed after being placed on [MEDICAL CONDITION] and ongoing assessments should have been conducted by both the nurse and the respiratory therapist. Further interview on [DATE] at 2:17 p.m. with the attending Physician for R#1 revealed the resident was placed on [MEDICAL CONDITION] as a means of noninvasive ventilation secondary to respiratory distress. He stated that the impression was that the resident's C02 was elevated and oxygen alone was not improving his condition. The Physician stated that he was not aware that the resident had not been monitored or re-assessed after being placed on [MEDICAL CONDITION]. He stated that absolutely the resident should have been monitored and protocols are in place and they usually get feedback from staff on how the resident is doing. He stated the resident should have been assessed immediately after being placed on [MEDICAL CONDITION] then again in 30 minutes to an hour after being placed on [MEDICAL CONDITION]. He stated the nurse and respiratory therapist should have assessed and monitored the resident. He stated that although R#1 was a DNR, he was doing better, had increased awareness and was improving. He stated that he cannot say for certain that had the resident been properly monitored, that the outcome would have been different but that without even trying, we would never know. The Physician further stated that he recently became the co-medical director and oversees the Vent Unit. Interview on [DATE] at 2:47 p.m. with the Certified Nursing Assistant (CNA DD) revealed she was the CNA assigned to R#1 on [DATE]. She stated that when she came on her shift at 3:00 p.m., R#1 was on the [MEDICAL CONDITION] with a mask on his face. She stated when she got there, the resident was not really responding and was mostly out of it on her shift (3:00 p.m. - 11:00 p.m.). She stated at around 10:15 p.m. on her third rounds, she and CNA EE changed the resident's brief and that R#1 was the same at that time stating he was not alert and not responding to conversation. Interview on [DATE] at 2:52 p.m. with CNA EE revealed she was not assigned to R#1 on [DATE] but she passed his room many times and stated the resident was wearing [MEDICAL CONDITION] mask at 3:00 p.m. when she came on her shift (3:00 p.m. - 11:00 p.m.). She stated that during her third rounds she assisted CNA DD with changing the resident after a bowel movement. She stated it was about 10:15 p.m. because they start third rounds at 10:00 p.m. CNA EE stated that R#1's eyes were open but he was not responding. She stated he would take a breath, then pause, then take another breath. She stated it was a noticeable pause and not normal breathing. She stated it was not reported at that time to the nurse because R#1 had been that way and on the mask since she started her shift and everyone already knew of his condition. Interview on [DATE] at 4:27 p.m. with RT BB revealed he set R#1 on [MEDICAL CONDITION] settings of 12 over 6 (IPAP/EPAP). He stated that oxygen was bled into the [MEDICAL CONDITION] he thought at 3 LPM but not completely sure. He stated that he is aware of a policy for noninvasive ventilation but could not verbalize exactly what the protocol was. He stated that he believed he assessed the resident and followed the protocol. Interview on [DATE] at 4:14 p.m. with the Registered Nurse Weekend Supervisor (RN HH) revealed she was working on [DATE] covering for the regular RN weekend supervisor. She stated neither the nurse nor respiratory therapist in care of R#1 reported to her that he was having respiratory complications. RN HH stated she did not know that R#1 had a change in condition or expired until the Corporate Nurse called her during the complaint survey and wanted to know if she knew what happened. RN HH stated that the nurse caring for R#1 should have informed her of the situation. She stated she would have helped assess R#1. She stated that the nurse would have been responsible for documenting a skilled nursing note and the change of condition. She stated had she performed any of her own assessments, she would document her own skilled nursing note. She further stated that she would have pushed for the resident to be sent to the hospital in his condition. RN HH stated that she left the facility at around 2:30 p.m. on [DATE]. Review of the Pronouncement of Death indicated the resident expired in the facility on [DATE]. Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. An interview with the Director of RT on [DATE] at 11:04 a.m. revealed that after the incident with R#1 and after the initial survey team entered the building on [DATE], that she reviewed the policies and had made changes for resident in respiratory distress. She confirmed that the previous policy did not include continuous monitoring of SaO2 after initating treatment for [REDACTED]. She is aware that the staff did not monitor this resident after starting the [MEDICAL CONDITION] and thererfore did not realize the resident was not improving in order to contact the Physician/NP timely. The facility implemented the following actions to remove the Immediate Jeopardy: 1. New policies and procedures developed by DON, Dir. of Respiratory Therapy, CNO for Corp Office, and Medical Director: 24-hour Respiratory Report; Respiratory Assessment/Intervention for Non Respiratory Caseload Patients; Respiratory Pertinent Charting on [DATE]. 2. The policy for Non-Invasive Ventilation was revised by DON, Dir. Of Respiratory Therapy, CNO for Corp Office, and Medical Director and 6 of 6 of respiratory therapists were educated on the revised policy by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone, ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. New policies and procedures: 24 hour Respiratory Report; Respiratory Assessment /Intervention for Non-Respiratory Caseload Patients; Respiratory Pertinent Charting, added to orientation for Respiratory Therapists on [DATE] 7. There have been no new respiratory therapists hired since [DATE]. Revised policy for Non-Invasive Ventilation was added to orientation for Respiratory Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 6 of 6 of respiratory therapists were educated by the Director of Respiratory Therapy on obtaining and entering physician orders [REDACTED]. 3. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24-hour report, and if respiratory change in condition was respiratory assessment documented. 4. There will be a QA meeting on [DATE] to review the findings. 5. A Change in Condition audit tool developed on [DATE] by the CNO for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends, as well as the RN supervi sor on the weekend and that the guidelines for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 6. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE]. 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. A review of the new policies and procedures developed on [DATE] included the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients and Respiratory Pertinent Charting. 2. Review of the education content and rosters for education conducted for Respiratory Therapists revealed education was given on [DATE] for new policies regarding completion of the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients, and Respiratory Pertinent Charting. One Respiratory Therapist was in the building and was in serviced and five were in serviced by telephone. On [DATE] an in-service was conducted and six of six Respiratory Therapists were present and signed the roster. Interview with Respiratory Therapist JJ on [DATE] at 2:35 p.m. and Respiratory Therapist EE on [DATE] at 3:00 p.m. confirmed education given on [DATE] and [DATE] regarding new policies including the completion of the 24-hour Respiratory Report, Respiratory Assessment and Intervention for Non-Respiratory Caseload Patients, and Respiratory Pertinent Charting, and acknowledged their understanding of the education. A review of the 24-hour Respiratory Report was conducted and R#18 and R#120 were included. Record review for R#18 revealed Pertinent Respiratory documentation occurred on [DATE] at 11:35 a.m. and 12:14 p.m. A skilled respiratory assessment was also completed at 11:30 a.m. Record review for R#120 revealed Pertinent Respiratory documentation recorded on [DATE] at 9:24 a.m. and [DATE] at 10:10 a.m. A full respiratory assessment was documented at 9:20 a.m. Documentation was completed according to policy and education for the two sampled residents with respiratory changes in condition. The policy for Non-Invasive Ventilation was revised by DON, Dir. Of Respiratory Therapy, CNO for Corp Office, and Medical Director and ,[DATE] of respiratory therapists were educated on the revised policy by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone , ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. The revised policy for Non-Invasive Ventilation was reviewed. Education content and rosters were reviewed. Interview with Respiratory Therapist JJ on [DATE] at 2:35 p.m. and Respiratory Therapist EE on [DATE] at 3:00 p.m. confirmed education given on [DATE] and [DATE] regarding the revised policy for Non-Invasive Ventilation, and acknowledged understanding. 3. The audit for all residents transferred to the hospital between [DATE] and [DATE] was reviewed. Fifty-seven resident records were included. Thirty-two records did not include a change in condition evaluation. Twenty-one records did not have a transfer form. Forty-nine records did not include a documented Physician order [REDACTED]. 4. A review of the minutes and content of the QA meeting conducted on [DATE] revealed the findings of the audit of residents for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for transfer, notes documenting follow up, or change of condition documented on the 24-hour report and if respiratory change in condition was respiratory assessment documented. Nineteen QA committee members signed the roster. 5. Review of the Change in Condition Audit tool for the week of [DATE] through [DATE] revealed the Change in condition audit tool developed on [DATE] including five records of residents experiencing a change in condition. The Nurse Manager was notified of the five changes in condition. The on-call log was not filled out by the Nurse Manager for one resident. Follow up call to family and follow up documentation per education were not completed for one resident with a respiratory change in condition. Interview of the ADON on [DATE] at 2:00 p.m., the Administrator on [DATE] at 3:20 pm the DON on [DATE] at 4:45 p.m., and the Director of Respiratory Services on [DATE] at 3:10 p.m. acknowledged receiving education on conducting the Change in Condition audit tool from the Corporate Chief Nursing Officer, and confirmed their understanding. 6. Interview of the ADON on [DATE] at 2:00 p.m., the Administrator on [DATE] at 3:20 p.m. the DON on [DATE] at 4:45 p.m., and the Director of Respiratory Services on [DATE] at 3:10 p.m. acknowledged receiving education on conducting the Change in Condition audit tool from the Corporate Chief Nursing Officer, and confirmed their understanding. Additional residents reviewed: 1. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her PEG tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. Transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. The resident was monitored appropriately, the Physician and family were notified timely. 2. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m",2020-09-01
593,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2017-09-29,490,J,1,1,6HMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the policy titled Quality Assessment and Assurance Program and staff interview, the facility failed to ensure that it was administered in manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and/or psychosocial wellbeing of each resident. Specifically, the Administrator was made aware on [DATE] that a resident (R#1) had a change in his condition on [DATE] secondary to respiratory distress and that the nursing staff failed to document the resident's change in condition and failed to notify the family/responsible party until after R#1 expired at 11:20 p.m. The Administrator failed to implement its Quality Assessment and Assurance Program and therefore, was not aware that R#1 had not been properly monitored and re-assessed by the nursing and respiratory staff after the R#1 was placed on [MEDICAL CONDITION] (Biphasic Positive Airway Ventilation) as a means of non-invasive ventilation secondary to acute respiratory distress. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio [NAME]s Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 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. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. (Refer F157, F281, F328, F514 and F520) Findings include: Review of the undated facility policy titled Quality Assessment and Assurance Program documented that It is the policy of Reliable Healthcare, Inc. that each facility actively participates in a formalized and written quality assessment, assurance and improvement program. The process is comprehensive (involving all departments) and includes monitoring, evaluation and follow up actions. All care provide residents/patients in the facility operations affecting resident/patient care shall be included in the Quality Assurance Program (QA). Section IV Meetings- Emergency meetings of the Committee may be called by the Chairperson or a quorum of the Committee. A quorum will be considered fifty (50%) of the membership. Section VI Responsibilities of the Administrator- follows the QA/CQI Programs. Ensures that each department carries out their QA/CQI program accurately and uniformly through report reviews: Each individual department will be responsible for monitoring and evaluating the resident/ patient care services they provide. Interview on [DATE] at 2:27 p.m. with the Administrator revealed he was aware that there was no change of condition documented for R#1 and that the nurse did not call the RP. He stated that he and the Director of Nursing (DON) got together and put a plan together to educate the nursing staff. He stated this concern and plan was not formally placed in QA and would have been discussed in the next QA meeting. The Administrator was asked that if an identified quality concern involved a resident death, should it have been placed QA, he responded that he was not sure and he would have to review the policy. The Administrator further stated he was not aware that the staff did not re-assess or monitor the R#1's condition after placing him on [MEDICAL CONDITION]. Further interview with the Administrator at 3:58 p.m. revealed the facility does not have a specific policy for governing body or job description for the Administrator. He stated the responsibilities of the Administrator is outlined in the policy titled Quality Assessment and Assurance Program. During a subsequent interview conducted on [DATE] at 3:08 p.m. with the Administrator, he stated that after he became aware that there was no change of condition documented for R#1 and that the responsible party was not notified until after R#1 had passed away, he and the DON got together and put a plan in place to educate the nursing staff but nothing further than that was implemented. He stated the concerns were not placed in QA and that an Emergency Meeting with at least 50% of the QA Committee in attendance was not conducted. The Administrator stated that when a concern is placed in QA, the committee discusses a route cause analysis to identify the underlying problem and will gather a sample of other residents for review. He stated that a plan of action or correction is put in place and followed through by the appropriate department head by means of data collection, monitoring and audits until the concern is resolved. When the Administrator was asked at 3:15 p.m. if they had placed these concerns in QA at the time they were identified to discuss the route cause and sample and review additional residents; would he have found that R#1 was not appropriately assessed and monitored by either the nursing staff or the respiratory staff and that respiratory staff did not document in R#1's clinical record and would he have potentially identified another resident (R#2) (Refer F514) that had a change in condition related to respiratory distress on [DATE] that did not have the appropriate documentation? The Administrator responded It's possible we would have. An interview conducted on [DATE] at 3:20 p.m. with the Administrator revealed that he had been made aware of the incident with R#1 although he had not put this into QA until after the complaint investigation had begun. He confirmed that staff education had been initiated although nothing further had been implemented until after being notified of the IJ related to change in condition, notification of the Physician/NP and family, monitoring by staff after a change in condition. he received education on [DATE] regarding F490, including the citation, regulation, definition, guidance and probes, by the Chief Nursing Officer. The facility implemented the following actions to remove the Immediate Jeopardy: 1. An emergency Quality Assurance Meeting was held on [DATE] regarding the quality concerns identified regarding the care of Res #1 and Res #2 related to change of condition related to acute respiratory distress. The Quality Assessment and Assurance Program policy was reviewed. An addendum was added to the Quality Assessment and Assurance Program Policy section IV. Meeting subsection C. Emergency. 2. The Administrator was in-serviced on the Quality Assessment and Assurance Program policy including the addendum to the policy addressing emergency meetings of the Quality Assurance Committee. The A Committee will conduct a root cause analysis to identify the underlying issues and any trends that contributed to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, Re-evaluate the plan and determine if the plan needs to be modified. This in-service was provided by the CNO of the Corp office on [DATE]. 3. The Quality Assurance Committee was in-serviced by the Administrator on the Quality Assessment and Assurance Program policy including the addendum to the policy addressing emergency meetings of the Quality Assurance Committee. The QA Committee will conduct a root cause analysis to identify the underlying issues and any trends that contributed to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, Re-evaluate the plan and determine if the plan needs to be modified . This in-service was provided on [DATE] by the administrator ,[DATE] were in-serviced in facility on ,[DATE], of the remaining 2, 1 is no longer an employee and the other 1 will be in-serviced today [DATE]. 4. The Administrator' s personnel file was reviewed and a signed job description dated [DATE] was present. Interview with the Administrator on [DATE] at 5:30 p.m. revealed his job description is included in the Quality Assurance Coordinator description. The Administrator was in-serviced on F490 to include citation, definition, guidance and probes by the CNO on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of the policy titled Quality Assessment and Assurance Program documented that it is the policy of Reliable Healthcare, Inc. that each facility actively participates in a formalized and written quality assessment, assurance and improvement program. The process is comprehensive (involving all departments) and includes monitoring, evaluation and follow up actions. All care provided residents/patients in the facility operations affecting resident/patient care shall be included in the Quality Assurance Program (QA). VI- Responsibilities of the Administrator follows the QA/CQI Programs. Ensures that each department carries out their QA/CQI program accurately and uniformly through report reviews: Each individual department will be responsible for monitoring and evaluating the resident/ patient care services they provide. Each Committee or Department will submit his/her reports. The addendum IV- Meetings documented that emergency meetings will of the Committee may be called by the Chairperson or quorum of the Committee. A quorum will be considered 50% of membership. 2. The in-service of the Administrator, conducted on [DATE] by the Corporate Chief Nursing Officer, with the Administrator's signature was reviewed. Review of education topics received by the Administrator on [DATE] by the Corporate Chief Nursing Officer included the Quality Assessment and Assurance Program policy, including the addendum addressing emergency meetings. An interview conducted on [DATE] at 3:20 pm with the Administrator revealed he received education on [DATE] regarding issues to be addressed by the Quality Assurance Committee are identified by audit schedules for areas such as laboratory orders and reports, treatments, and foot care. Other methods of identifying issues include infection control or other trends, quality indicator flags such as psychiatric medications, pain, survey results, complaints, grievances and [MEDICATION NAME]. The Administrator explained he recently had identified a need for emergency Quality Assurance meetings and educated the committee and the policy addendum was approved by the committee on [DATE]. Action plans are developed by the department associated with the issue. The plans, audits, monitoring, revisions to the plan and to policies are all approved by the medical director if the issue is clinical. The audits for desired outcomes are taken to Quality Assurance Committee and adjusted, continued, or determined to be resolved. The issues of family notification of change in resident condition, and lack of documentation regarding change in condition had been identified and the Director of Nurses had educated licensed staff on [DATE]. 3. Eighteen signatures, including the Administrator and the Medical Director were included. The minutes included Nursing and Respiratory Plans of Correction, with monitoring and submission of monitoring to the Quality Assurance Committee every month for 3 months. The addendum to the Quality Assurance Policy Addendum providing for emergency meetings to address issues that cannot be held until the next regularly scheduled meeting. An emergency meeting will be held for all identified quality issues/concerns with the potential for harm. The QA committee was instructed to cause a root cause analysis to identify the underlying issues and any trends that contribute to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, re-evaluate the plan and determine if the plan needs to be modified. The nineteenth signature was documented on [DATE]. 4. Interview with the Administrator on [DATE] at 5:30 p.m. revealed his job description is included in the Quality Assurance Coordinator description. 5. An interview conducted on [DATE] at 3:20 p.m. with the Administrator revealed he received education on [DATE] regarding F490, including the citation, regulation, definition, guidance and probes, by the Chief Nursing Officer.",2020-09-01
594,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2017-09-29,514,J,1,1,6HMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policies titled Change in a Resident's Condition or Status, Documentation- Skilled Nurses Note and Documentation- Pertinent Charting, family and staff interviews, the facility failed to ensure resident clinical records were complete and accurate for two of eight sampled residents (R#1 and R#2). Specifically, the facility failed to: 1. Document a change in condition and document nursing and respiratory assessments, document the initiation of [MEDICAL CONDITION] (Biphasic Positive Airway Pressure) therapy for non-invasive ventilation secondary to respiratory distress, document [MEDICAL CONDITION] settings, and document re-assessments and/or monitoring of R #1. Actual harm occurred when at an undetermined time during the dayshift of [DATE], R#1 had acute respiratory distress with an oxygen saturation of 74% and was placed on [MEDICAL CONDITION] therapy as a means of non-invasive ventilation. R#1 was found unresponsive on [DATE] at 11:20 p.m. and pronounced deceased at 11:30 p.m. (Refer F281 and F328) 2. Document a change in condition, document a nursing assessment and document transfer to the hospital for R#2 on [DATE]. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio [NAME]s Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 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. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Findings include: Review of the undated facility policy titled Change in a Resident's Condition or Status documented: The Nurse Supervisor will notify the resident's attending physician when there is a significant change in the resident's physical, mental, or psychosocial status; or when there is a need to alter the resident's treatment significantly; or deemed necessary or appropriate in the best interest of the resident. The Nurse Supervisor will record in the resident's medical record any changes on the resident's medical condition or status. Review of the facility policy titled Documentation- Skilled Nurses Note revised ,[DATE] indicated A head to toe assessment will be completed each shift and documented on the Skilled Nurses Note for all New Admissions, Readmissions, Re-entries; and residents on Medicare. The Director of Nursing or designee may determine that a skilled nurse's note is needed for reasons other than those listed in the policy, this will be noted in the pertinent charting list. Review of the facility policy titled Documentation- Pertinent Charting revised [DATE] indicated Pertinent charting will be completed on a daily basis to ensure care is given when a resident has a new or changed condition. The list for pertinent charting will include, but not limited to; change in condition. Situations require documentation for 72 hours or longer if needed. This documentation will be completed each shift and will include full vital signs. The family will be notified when a resident is placed on the list. 1. Interview on [DATE] at 11:57 a.m. with the family of R#1 revealed she is the responsible party (RP) and the person that would be contacted for any changes in the resident. The RP stated that she did not receive a call from the facility until after R#1 expired late Saturday night on [DATE] and that the nurse did not have any details for her. The RP stated a couple of days later, she called the facility and spoke with someone else in charge and it was then that they told her that R#1 had declined that day and was having respiratory issues. The RP stated she was told that R#1's oxygen level dropped to 74% and they needed to put him on a [MEDICAL CONDITION] mask and when they checked on R#1 an hour later, he had passed away. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via PE[NAME] [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. Record review for R#1 revealed no evidence of a skilled nursing assessment on [DATE]. Review of the Weights and Vitals Summary revealed no evidence on [DATE] of Sp02 results or vital signs (heart rate, respiratory rate, temperature or blood pressure) for R#1. There was no evidence of a Documentation- Pertinent Charting form or evidence that R#1 had been placed on the Pertinent Charting List. There was no evidence or documentation in the resident's clinical record of a Change in Condition Evaluation Assessment on [DATE]. Review of the Weights and Vitals Summary from [DATE] through [DATE] for R#1 documented Sp02 results ranging from ,[DATE]% and indicated that R#1 was on room air. There was no further documentation of vital signs or Sp02 results after [DATE]. Further record review for R#1 revealed no evidence or documentation on [DATE] of a respiratory assessment, when the resident presented with acute respiratory distress, when [MEDICAL CONDITION] therapy was initiated, documentation of the non-invasive protocols implemented related to determination of appropriate [MEDICAL CONDITION] settings or toleration of [MEDICAL CONDITION], oxygen saturation results, and re-assessments and/or monitoring of R#1 after being placed on [MEDICAL CONDITION]. Review of the electronic Physician Orders for [MEDICAL CONDITION] on [DATE] at 12:00 p.m., the day after R#1 had already expired. Further the [MEDICAL CONDITION] order did not specify the settings for IPAP (Inspiratory Positive Airway Pressure), EPAP (Expiratory Positive Airway Pressure) or an order for [REDACTED]. Further review of R#1's clinical record revealed the following Progress Notes: LPN AA created a Nurse's Note on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% R[NAME] Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) LPN CC created a Nurse's Note on [DATE] at 12:21 a.m. with an effective date and time of [DATE] at 12:00 a.m. which documented At approximately 11:20 p.m. I was making my rounds and when I went into resident room. I notice that resident was unresponsive and gray in color. Resident a DNR. I assessed resident by checking pulse and then proceeded to have the RN supervisor from the vent unit to confirm resident status. Next of kin was notified and funeral home of family choice was notified. (sic) There was no further documentation in the Progress Notes on [DATE] between the Nurse's Note that LPN AA created on [DATE] at 8:32 p.m. and the Nurse's Note created by LPN CC on [DATE] at 12:21 p.m. when R#1 was found unresponsive. Interview on [DATE] at 4:56 p.m. with the Director of Nursing (DON) revealed that R#1 was pronounced deceased at 11:30 p.m. on [DATE]. She stated the facility was aware that LPN AA did not document the resident's change of condition in the Change of Condition Evaluation Assessment pathway in the electronic charting system. The DON stated that in this section, documentation includes all pertinent information, notification of the Physician and if a resident is transferred to the hospital. Interview on [DATE] at 5:03 p.m. with the Licensed Practical Nurse (LPN AA) in care of R#1 revealed the morning of [DATE] on the dayshift (7:00 a.m. - 7:00 p.m.), R#1 seemed to be very depressed and staring out of the window. She stated the resident wasn't really lethargic but not himself. LPN AA stated around 2:00 p.m. - 3:00 p.m., the resident seemed sleepy and when she checked his oxygen saturation (Sp02), it was 74%. She stated that she placed the resident on oxygen at 2 LPM with a nasal cannula and there was no improvement. She stated she called the Respiratory Therapist (RT BB) and the Nurse Practitioner (NP GG) and received an order to place R#1 on [MEDICAL CONDITION] (Biphasic Positive Airway Pressure). LPN AA stated that RT BB place the resident on [MEDICAL CONDITION] but she did not remember the time. She stated she did make a notation at the end of her shift, but not a detailed notation. She stated she did not document a change of condition and she did not call the resident's RP. LPN AA further stated that she did not monitor or re-assess R#1 once he was placed on [MEDICAL CONDITION]. Interview on [DATE] at 5:17 p.m. with the Director of Nursing (DON) revealed she was on vacation when R#1 expired on [DATE] and returned to work on [DATE]. The DON stated she was made aware when she returned to work that the resident had respiratory distress and was placed on [MEDICAL CONDITION] over the weekend and aware that the nurse did not notify the family/responsible party of R#1's change in condition. The DON stated that she was aware that the resident's change of condition was not charted in the Change of Condition Evaluation Assessment in the electronic charting and that she educated the nursing staff. Telephone interview on [DATE] at 5:28 p.m. with the 7:00 p.m. - 7:00 a.m. LPN CC revealed the night of [DATE] she had received report from LPN AA that R#1 was placed on [MEDICAL CONDITION] due to respiratory distress. LPN CC stated she saw the resident first around 8:00 p.m. - 8:30 p.m. She stated she checked the resident's Sp02 and it was she believed 91%. LPN CC stated that she thought she had documented her assessment and the resident's Sp02 but she could not be sure without checking the computer. LPN CC stated that the next time she saw R#1 was about 10:30 p.m. and he seemed fine. LPN CC stated around 11:15 p.m. she checked on R#1 and he was not responsive. She called RN FF to come and check R#1 and it was determined the resident had expired. Interview [DATE] at 3:49 p.m. with the DON revealed the facility has a policy related to documentation of pertinent charting and stated that when a resident has a change in condition, they are placed on the pertinent charting list and it is kept at the nurse's station. She stated the residents vital signs are recorded on this list. The DON showed example of other residents on the list. The DON confirmed that R#1 was not on the pertinent charting list and should have been at the time he had a change in his condition. The DON stated that a Skilled Nursing Observation and Assessment should have been conducted and entered in the electronic charting system by both the dayshift LPN AA and the nightshift LPN CC. The DON confirmed there was no Skilled Nursing Observation/Assessment in the electronic charting for R#1 on [DATE]. Review of the Pronouncement of Death indicated the resident expired in the facility on [DATE]. Primary [DIAGNOSES REDACTED]. Secondary [DIAGNOSES REDACTED]. 2. Review of the Hospital Transfers list provided by the facility on [DATE] at 10:38 a.m. revealed R#2 was transferred to the hospital on the evening shift of [DATE] for abnormal vital signs and high respiratory rate. R#2 was a [AGE] year old admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. R#2 was admitted with a DNR (Do Not Resuscitate) order. Record review revealed a Discharge Minimum Data Set ((MDS) dated [DATE] with return anticipated. Review of the Progress Notes revealed the following: A Nurse's Note dated [DATE] at 12:54 a.m. created by LPN KK documented Noted decline in appetite. Did not eat supper, drank 25% of Boost, and very little Magic cup. Will continue to observe closely. A Nurse's Note dated [DATE] at 2:33 p.m. created by LPN LL documented Resident's POA (name) to facility with concerns. Requests medication options be explored. Dr. (name) notified and orders for [MEDICATION NAME] 7.5 mg received and entered in system. (POA name) notified. There is no evidence or documentation in the electronic charting system on [DATE] for a change in the resident's condition, skilled nursing assessment, or transfer to the hospital. Review of the electronic Physician Orders revealed no order to transfer R#2 to the hospital. Review of the Skilled Respiratory Assessment/Observation for R#2 dated [DATE] at 7:45 p.m. indicated the resident's heart rate was 102 and irregular and Sp02 was 97%. Unable to determine orientation. Mental Status- lethargic, confused, irregular RR (respiratory rate). Lung sounds clear but diminished in the right middle and bilateral lower lobes. Respiratory Character and Signs and Symptoms of Respiratory Distress- increases respiratory rate, possible Cheyne-Stokes. Oxygen at 2 LPM via nasal cannula. Review of the emergency transportation Patient Care report dated [DATE] indicated they arrived at the nursing facility 7:45 p.m. and departed at 8:10 p.m. The Narrative documented that Nursing staff advised patient's oxygen saturation and heart rate had not been consistent this date with heart rate dropping as low as 34. Patient was on oxygen via nasal cannula at 2 LPM. Patient was alert but unable to tell if patient oriented as patient could not answer questions and would just mumble. Patient was able to follow and appeared to have equal strength in hands and feet. Patient remained on oxygen via nasal cannula throughout transport at 2 LPM. Vitals obtained and monitored en route. 3-lead and 12-lead EKG obtained showing sinus rhythm with PACs. Patient heart rate were both irregular. Blood glucose obtained and noted to be 115. A Nurse's Note dated [DATE] at 4:13 p.m. created by LPN KK documented Resident expired at (name) Medical Center on [DATE]. Family picked up some of residents belongings. Orders discontinued and medications removed from medication cart. Review of the (name) Medical Center Death Summary dated [DATE] documented date of death [DATE]. Final Diagnosis: [REDACTED]. Interview on [DATE] at 11:25 a.m. with the DON revealed there should be a nurse progress note related to the R#2's change of condition on [DATE], when she was transferred to the hospital, a change of condition assessment and a hospital transfer form, all of which are documented in the electronic charting system. The DON reviewed the electronic charting for R#2 and confirmed that there was no nurse notes related to the residents change in condition, no Change of Condition Evaluation/Assessment documented and no physician order to transfer the resident to the hospital. The DON stated that there was an assessment by the respiratory therapist on [DATE] documented but that was all. The DON stated that notification to the Physician and responsible party is not documented in the respiratory assessments. The DON stated that based on the MDS, the resident was discharged to the hospital on [DATE] but there is no other way of knowing due to lack of documentation. Interview on [DATE] at 11:55 a.m. with the family/responsible party (RP) of R#2 revealed she really cannot remember the exact details on [DATE] or even if she was at the nursing home facility the day R#2 went to the hospital. RP stated that she was at the hospital on [DATE] with R#2 but really cannot remember any details, she stated her husband had recently passed and she just had been through a lot. Interview in [DATE] at 12:04 p.m. with Nurse Practitioner (NP YY) revealed she remembered seeing R#2 a couple days prior to her passing and that the resident had some decline related to dementia and weight loss secondary to her dementia. She stated that she cannot remember ever receiving a call about the resident's change of condition or ordering the resident to be transferred to the hospital. NP YY stated that she could call the attending Physician for R#2 but he is on vacation and he probably would not remember. Interview on [DATE] at 12:27 p.m. with attending Physician (Medical Director) for R#2 revealed that he does not remember the exact clinical situation or R#2 as it was three months ago. He stated he cannot say if the facility called him about a change of condition but that he does not recall being called about anything serious that sticks in his mind. He stated he does remember she was in the hospital. He stated he gets calls all the time form the facility, they are good about calling him for everything. Interview on [DATE] at 1:25 p.m. with the family of R#2 she could tell exactly what happened on [DATE] because she was there. She stated she visited R#2 on a regular basis. She stated when she came to the facility around 6:00 p.m. or 6:30 p.m. there were two Certified Nursing Assistants (CNA) in the room changing R#2's brief. She stated when they finished she noticed that R#2 was not communicating with her and her breathing was not right. She stated that R#2 would breathe really fast, then almost stop breathing or so shallow she could hardly tell, then she would start breathing fast again. Family T stated she asked to the CNA (did not know name) to please go get the nurse. She stated that she could not remember the name of the nurse but thought it was a head nurse. The family stated the nurse listened to the R#2's lungs and told her that she agreed and said something was wrong. She stated R#2 was transported to the hospital she thinks it was around 8:00 p.m. Interview on [DATE] at 2:10 p.m. with the Registered Nurse Weekend Supervisor (RN MM) revealed she worked the dayshift (7:00 a.m. - 7:00 p.m.) on [DATE]. She stated that it was at the end of her shift when the family T of R#2 was standing in the hall so she asked if the family needed something. The family T asked her if she would check on R#2. RN MM stated that the R#2 was breathing irregularly and she put a pulse oximeter on the resident. She stated the resident's heart rate was erratic and her oxygen saturation would drop low then come back up. RN MM stated she called the respiratory therapist and he placed R#2 on oxygen. RN MM She stated she reported to LPN LL, the nurse in care of R#2, that she was having problems and she needed to go and assess R#2. RN MM stated that she left and LPN LL took over. RN MM stated she was under the impression that LPN LL was her assigned nurse and would have documented an assessment and change of condition in the resident's clinical chart. RN MM stated that her shift was over and she left the building. Review of the 24 Hour Report/Change of Condition Report provided by the DON on [DATE] at 2:50 p.m. documented in Remarks- (name of Medical Center) [MEDICAL CONDITION]/[MEDICAL CONDITION], per family request. During interview at this time with the DON, she stated that the report is for internal use, it is not a part of the resident record, but shows that LPN LL filled in the report for R#2. Interview on [DATE] at 2:58 p.m. with LPN LL revealed she did not remember the incident on [DATE] with R#2 and did not remember RN MM coming to her to tell her R#2 was having respiratory complications. She stated it was a while ago and she just cannot remember the incident but if RN MM stated that is what happened, then that is what happened. LPN MM stated that in the event of a change in a resident's condition, she would be expected to document a skilled nurse's notes and complete a change of condition evaluation and notify the MD and the RP. 3. R#135 was admitted to the facility from her home on [DATE] with a [DIAGNOSES REDACTED]. On [DATE] at 10:40 p.m. her PEG tube was noted to be causing concern to the family members and the family thought it was protruding from her abdomen more than usual. The Physician was notified on [DATE] at 10:45 p.m. An X Ray was ordered but could not be completed due to inclement weather. Transfer to the local hospital was ordered. On [DATE] at 11:15 p.m. the family was notified of the transfer and refused. On [DATE] at 2:30 a.m. the family decided the resident was to be transferred and the resident was sent to the hospital of the family's choice. Review of the medical record for R#135 revealed the resident was monitored and documented in the resident's medical record. 4. R#18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On [DATE] at 11:00 a.m. he began to have [MEDICAL CONDITION] activity. The Physician was notified at 11:18 a.m. The Respiratory Therapist was notified at 11:30 a.m. when oxygen saturations began to drop. The family was notified at 11:42 a.m. The Physician was again called at 12:15 p.m. and the resident was transferred to the hospital. The family and DON were notified at 12:05 p.m. Review of the medical record for R#135 revealed the resident was monitored and documented in the resident's medical record. 5. R#120 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Respiratory Therapist was in the room and continued to work with the resident and at 10:10 a.m. the Nurse Practitioner was notified the resident was not improving and ordered R#120 transferred to the hospital. The family had been notified at 9:45 a.m. The Nurse Manager was notified at 10:20 a.m. as the resident was transferred. Review of the medical record for R#135 revealed the resident was monitored and documented in the resident's medical record. An interview with the Director of RT on [DATE] at 11:04 a.m. revealed that after the incident with R#1 and after the initial survey team entered the building on [DATE], that she reviewed the policies and had made changes for resident in respiratory distress. She confirmed that the previous policy did not include continuous monitoring of SaO2 after initating treatment for [REDACTED]. Interview of the DON and the ADON on [DATE] at 2:00 p.m. revealed that after the complaint investigation regarding R#1, they recognized that staff had not documented monitoring, interventions or the status for R#1 and R#2 and this should have been done. The staff has been in-serviced since the complaint investigation exit on [DATE] related to documentation of a change in condition, status, monitoring and notification of the Physician/NP and the family. The facility implemented the following actions to remove the Immediate Jeopardy: 1. The Pertinent Charting Policy was revised on [DATE] to include completion of a Nursing Skilled Observation/Assessment Note every shift for 72 hours following a change in condition. This has been added to the Licensed Nursing Orientation as of [DATE]. 2. ,[DATE] of Nurses will be educated by the Unit Manager on the revised pertinent charting policy beginning [DATE]. 18 of 34 nurses were in-serviced at the facility and ,[DATE] were in-serviced by telephone. The remaining 2 will be in-serviced prior to their next scheduled shift. 3. New policies and procedures developed by DON, Dir. of Respiratory Therapy, CNO for Corp Office, and Medical Director: 24-hour Respiratory Report; Respiratory Assessment /Intervention for Non- Respiratory Caseload Patients; Respiratory Pertinent Charting on [DATE]. 4. The policy for Non-Invasive Ventilation was revised by DON, Dir. Of Respiratory Therapy, CNO for Corp Office, and Medical Director and ,[DATE] of respiratory therapists were educated on the revised policy by the Director of Respiratory Therapy on [DATE]. ,[DATE] respiratory therapists were educated via telephone, ,[DATE] in facility. They were also reviewed again at the facility in-service on [DATE] and ,[DATE] attended. 5. New policies and procedures: 24-hour Respiratory Report; Respiratory Assessment/Intervention for Non-Respiratory Caseload Patients; Respiratory Pertinent Charting, added to orientation for Respiratory Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 6. Revised policy for Non-Invasive Ventilation was added to orientation for Respiratory Therapists on [DATE]. There have been no new respiratory therapists hired since [DATE]. 7. Six of six respiratory therapists were educated on documentation expectations of assessments/progress notes, entering complete orders, and signing off the RAR by the Director of Respiratory Therapy on ,[DATE] /17 ,[DATE] were in-serviced in facility. 8. 30 of 30 of nursing staff has been educated that they must observe/assess the resident when there is a change in condition, and that this assessment is to be documented in thee-interact Change in Condition Evaluation, that follow-up monitoring, re-assessment, transfer to the hospital, and any follow up communication with the family, and or responsible party will be documented in the nursing progress notes on [DATE] by the DON. In-service conducted on [DATE] by DON 22 of 30 nurses were in serviced, any nurses who did not attend were educated via telephone on [DATE] 8 of 30 were in serviced via telephone. 9. An audit was conducted for all residents transferred to the hospital between [DATE] and [DATE] to identify other residents with a change in condition that did not have a change in condition evaluation, transfer form, order for trans fer, notes documenting follow up, or change of condition documented on the 24-hour report, and if respiratory change in condition was respiratory assessment documented. There will be a QA meeting on [DATE] to review the findings. 10. Guidelines for notification of the nurse manager on call were developed on [DATE] by the CNO for Reliable Health Care Management, they include use of the Interact change in condition cards- if the resident meets the criteria for immediate notification or has a critical lab not covered by the change in condition cards and a nurse manager is not in the building or it is the weekend nurse manager on call will be notified. These have been submitted to the Quality Assurance Committee and added to the Licensed Nursing Orientation on ,[DATE] /17. 11. Review and follow-up guidelines for a change in condition for the nurse manager on call to follow were developed on [DATE] by the CNO for Reliable Health Care Management to include notification of the responsible party, MD or NP on call, a nurse manager or RN weekend supervisor if she/he is in the building on the weekend, and the on-call nurse if after hours or on the weekend, completion of the Interact Change of Condition Form and use of the Interact Clinical Pathways if applicable. The Review and follow-up guidelines have been submitted to the Quality Assurance Committee and added to Licensed Nursing Orientation on [DATE]. 12. 6 of 6 of the nurse managers were educated on the Guidelines for notification, their responsibilities while on call related to the review and follow up guidelines and documentation on the Nurse Manager On-Call Log. This education was done by the DON on [DATE], 6 out 6 nurse managers attended and were in-serviced. 13. 30 of 30 of nurses were educated by the DON on [DATE] regarding the guidelines for notification of the nurse manager in the building and the on-call nurse after hours and on weekends and the review and follow-up guidelines for a change in condition. In-service conducted on [DATE] by DON 22 of 30 nurses were in-serviced any nurses who did not attend were educated via telephone on [DATE], 8 of 30 were in-serviced via telephone. 14. A Change in Condition audit tool developed on [DATE] by the CNO for Reliable Health Care Management to ensure that the guidelines for notifying a nurse manage in the building, the on-call nurse after hours and weekends, as well as the RN supervisor on the weekend and that the guidelines for review and follow up for a change in condition are being followed. The audit tool will be completed weekly for 5 residents experiencing a change in condition, if there are changes in condition related to acute respiratory changes up to 2 of these will be included. This audit will be completed by the DON, if she is not available to complete the audit then it will be done by the ADON. 15. The CNO will in-service the DON, ADON, Director of Respiratory Services, and Administrator on completion of the Change in Condition Audit on [DATE], 4 out of 4 were present and in-serviced via conference call on [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. The Pertinent Charting Policy revised on [DATE] was reviewed. A pertinent daily charting list will be maintained at the nursing station. The list for pertinent charting will include Residents with a change of condition and will include a Skilled Nursing Note on all shifts. This requires documentation for a minimum of 72 hours. Nursing Management may determine that assessment/documentation is indicated for longer than the timeframe listed, but not less. This documentation will be completed on each shift and will include full vital signs. Rosters and education content were reviewed. The education roster from [DATE] including revision to the policy for pertinent charting, including a Skilled Nursing Note on all shifts, with required documentation for 72 hours, including full vital signs, was signed by twenty of thirty-four nurses, and the roster indicated fourteen were educated by telephone. See below interviews of nursing staff verifying this education. 2. Review of the education content and rosters for education conducted for Respiratory Therapists revealed education was given on [DATE] for new policies regarding completion of the 24-hour Respiratory Report, Respiratory Assessment and Interve",2020-09-01
595,CHULIO HILLS HEALTH AND REHAB,115287,1170 CHULIO ROAD,ROME,GA,30161,2017-09-29,520,J,1,1,6HMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the policy titled Quality Assessment and Assurance Program and staff interviews, the facility failed to maintain an effective Quality Assurance (QA) program which systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Specifically, the facility identified a quality concern on [DATE] related to lack of documentation of a resident's (R#1) change in condition and failure to notify the responsible party. The facility provided education to the nursing staff on [DATE] but failed to place the quality concern in the QA program and was unaware that in addition to a lack of documentation, R#1 was not appropriately assessed, re-assessed or monitored by the nursing and respiratory staff after being placed on [MEDICAL CONDITION] (Biphasic Positive Airway Pressure) as a means of non-invasive ventilation secondary to acute respiratory distress. Additionally, the facility was not aware that the respiratory staff failed to document respiratory assessments, document the implementation of [MEDICAL CONDITION] therapy or document [MEDICAL CONDITION] settings. A Recertification and Abbreviated Extended survey to investigate Complaint #GA 436 was conducted at Chulio [NAME]s Health and Rehabilitation beginning [DATE] and concluding on [DATE]. After review by the RO, a survey team re-entered on [DATE] through [DATE] to futher investigate the complaint and for a recertification survey. The facility was found not to be in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B - Requirements for Long Term Care Facilities. As indicated on the facility's Form CMS-672, Resident Census and Conditions of Residents Form, the facility's census on [DATE] was 93 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. Immediate Jeopardy was identified to exist on [DATE] and was abated on [DATE]. On [DATE] at 2:58 p.m. the Administrator and Director of Nursing (DON) were notified that immediate jeopardy was identified, and existed as of [DATE] when R#1 had a change in condition and expired on the same day at 11:30 p.m. During the Recertification Survey conducted on [DATE] through [DATE] additional residents were reviewed for notification when a change of condition was noted. There were no additional issues identified for notification. The previous findings for R#1 were reviewed and the determination of immediate jeopardy were confirmed on [DATE]. On [DATE], the facility provided a Credible Allegation of Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediacy on [DATE]. Based on validation of the A[NAME], the State Survey Agency (SSA) determined the Immediate Jeopardy was removed on [DATE]. The Scope and Severity were lowered to a D level while the facility develops and implements a Plan of Correction (P[NAME]) and the facility's Quality Assurance Committee monitors the effectiveness of the systematic changes. Cross refer to F328 Findings include: Review of the undated facility policy titled Quality Assessment and Assurance Program documented that It is the policy of Reliable Healthcare, Inc. that each facility actively participates in a formalized and written quality assessment, assurance and improvement program. The process is comprehensive (involving all departments) and includes monitoring, evaluation and follow up actions. All care provided residents/patients in the facility operations affecting resident/patient care shall be included in the Quality Assurance Program (QA). Each Committee or Department will submit his/her reports. IV- Meetings documented that Emergency meetings of the Committee may be called by the Chairperson or quorum of the Committee. A quorum will be considered 50% of membership. R#1 was admitted to the facility on [DATE] from an acute care hospital with a [MEDICAL CONDITION] and tube feeding via PE[NAME] [DIAGNOSES REDACTED]. On [DATE] the resident'[MEDICAL CONDITION] removed and on [DATE] the resident advanced to a puree diet, however, the PEG remained in place for the administration of medications. On [DATE] during the dayshift at an undetermined time, R#1 presented with acute respiratory distress that required non-invasive ventilation via [MEDICAL CONDITION]. Record review for R#1 revealed a Nurse's Note created by LPN AA LPN on [DATE] at 8:32 p.m. with an effective date and time of [DATE] at 10:17 a.m. which documented Resident coughing/spitting up thick greenish brown sputum. Mouth was suctioned out. Resident very sleepy. 02 sats 90% R[NAME] Gave all meds through feeding tube. Monitored resident throughout day. 02 sats started declining to 74. Resp. nurse informed, Dr. (name) NP called, [MEDICAL CONDITION] was ordered and placed on resident. Will continue to monitor resident. (sic) There was no further documentation in the clinical record for R#1 related to his change in condition until LPN CC created a Nurse's Note on [DATE] at 12:21 a.m. with an effective date and time of [DATE] at 12:00 a.m. which documented At approximately 11:20 pm I was making my rounds and when I went into resident room. I notice that resident was unresponsive and gray in color. Resident a DNR. I assessed resident by checking pulse and then proceeded to have the RN supervisor from the vent unit to confirm resident status. Next of kin was notified and funeral home of family choice was notified. (sic) Review of the Weights and Vitals Summary revealed the last recorded vital signs on [DATE]. Continued review of R#1's clinical record revealed no evidence or documentation on [DATE] of a respiratory assessment, when the resident presented with acute respiratory distress, initiation of [MEDICAL CONDITION] therapy, non-invasive protocols implemented related to determination of appropriate [MEDICAL CONDITION] settings, toleration of [MEDICAL CONDITION], oxygen saturation, and re-assessments and/or monitoring of R#1 after being placed on [MEDICAL CONDITION]. An electronic Physician order [REDACTED]. Interview on [DATE] at 4:19 p.m. with the Respiratory Therapist (RT BB) revealed that he worked on the dayshift of [DATE] when the Licensed Practical Nurse (LPN AA) asked him between 3:00 p.m. - 4:00 p.m. to evaluate R#1 due to the resident had coughed up some mucous and it was green. RT BB stated when R#1 was evaluated, the resident's respiratory status was stable and his oxygen saturation (Sp02) was in the 90's. He further stated that respiratory works 12 hours shifts and he gave report to the oncoming nightshift Respiratory Therapist (RT JJ) and added that R#1 was still stable at the end of his shift (7:00 a.m.- 7:00 p.m.). RT BB stated that he documented a note and that he had been unable to retrieve the note in the electronic charting system. Telephone interview on [DATE] at 4:40 p.m. with RT JJ revealed he worked the nightshift (7:00 p.m. - 7:00 a.m.) on [DATE] when R#1 expired but that he never assessed R#1 or monitored the resident because he did not receive report that R#1 had a change in condition or that he was placed on [MEDICAL CONDITION] for respiratory distress. Interview on [DATE] at 4:52 p.m. with the Respiratory Director revealed when R#1 was placed on [MEDICAL CONDITION] for noninvasive ventilation related to respiratory distress, the resident should have had a respiratory assessment and the facility protocol should have been followed. This is to be documented in the Respiratory Assessment area of the electronic charting and that a note should have been documented in the Progress Notes. She further stated that resident should have absolutely been monitored and re-assessed after being placed on [MEDICAL CONDITION] therapy. The Respiratory Director confirmed that there was no respiratory documentation in the resident's clinical chart related to the resident's change of condition, respiratory status, respiratory assessment, [MEDICAL CONDITION] use or settings, oxygen saturation checks or re-assessments/monitoring. In an interview with LPN AA on [DATE] at 5:08 p.m., she reported that the morning of [DATE], R#1 seemed to be very depressed and was just staring out of the window. LPN AA stated R#1 wasn't really lethargic but not himself so she did not administer his [MEDICATION NAME] and that his Sp02 was in the 90's. LPN AA stated around 2:00 p.m. -3:00 p.m. the resident seemed sleepy and when she checked his Sp02, it was 74% (normal range is above 90%). She stated that she placed the resident on oxygen at two liters per minute (2 LPM) via nasal cannula and there was no improvement in the resident's condition. LPN AA stated she received an order from the Nurse Practitioner (NP) to initiate [MEDICAL CONDITION] therapy however, she could not remember the time. LPN AA stated that the Respiratory Therapist (RT BB) placed R#1 on [MEDICAL CONDITION] but she did not remember the time. LPN AA further stated that she never returned to re-assess R#1 for the remainder of her shift (7:00 a.m. - 7:00 p.m.). LPN AA stated she had no good answer for why she did not re-assess or monitor R#1, It gets busy at the end of the shift but I know that is not a good excuse. She stated she did make a notation at the end of her shift but not a detailed notation. Interview on [DATE] at 5:17 p.m. with the Director of Nursing (DON) revealed she was on vacation when R#1 expired on [DATE] and returned to work on [DATE]. The DON stated she was made aware when she returned to work that the resident had respiratory distress and was placed on [MEDICAL CONDITION] and aware that the nurse did not notify the family/responsible party (RP Z) of R#1's change in condition. She stated that RP Z had called her on Monday [DATE] and wanted to know what happened to R#1. RP Z had reported to her that no one had called her until after R#1 had already passed away. The DON stated the nurse should have called RP Z when R#1's condition changed. The DON stated she was not aware that LPN AA had not re-assessed or monitored R#1 after his change of condition and being placed on [MEDICAL CONDITION] for the rest of her shift. She stated that her expectation would include a skilled nursing assessment and ongoing monitoring after R#1 had a change in his condition and after being placed on [MEDICAL CONDITION]. The DON further stated she educated the nursing staff on documenting in the e-Interact Tool- Change in Condition Evaluation Assessment pathway in the electronic charting system and notifying family in the event of a change in condition. on [DATE]. Telephone interview on [DATE] at 5:28 p.m. with the 7:00 p.m. - 7:00 a.m. LPN CC revealed the night of [DATE] she had received report from LPN AA that R#1 was placed on [MEDICAL CONDITION] due to respiratory distress. LPN CC stated she saw the resident first around 8:00 p.m. - 8:30 p.m. She stated she checked the resident's Sp02 and it was she believed 91%. She stated that she thought she had documented her assessment and the resident's Sp02 but she could not be sure without checking the computer. LPN CC stated that the next time she saw R#1 was about 10:30 p.m. and he seemed fine and around 11:15 p.m. she checked on R#1 and he was not responsive. She called Registered Nurse (RN FF) to come and check R#1 and it was determined the resident had expired. Interview on [DATE] at 11:05 a.m. with the Respiratory Director confirmed that the [MEDICAL CONDITION] order for R#1 was dated [DATE] at 12:00 p.m. after R#1 had already expired. She confirmed and that the [MEDICAL CONDITION] order did not indicate the settings for IPAP, EPAP or oxygen and stated it should have. She stated the protocol for [MEDICAL CONDITION] is to start IPAP at 10 cmH20 (centimeters of water) and EPAP at 5 cmH20 and that is what the order should have read. She stated this is an initial setting and the policy instructs to titrate the pressure until optimal benefit is obtained. The Respiratory Director stated that any changes from the initial settings would require a respiratory assessment and documentation. The Respiratory Director also confirmed that there is no documentation of oxygen saturations for R#1 since [DATE]. She stated that R#1 should have been assessed and monitored per the policy for noninvasive ventilation and that RT BB did not follow the policy. She stated the policy did not previously address documentation because that is just common sense and a standard of practice and she did not think she had to address that in the protocol. Respiratory Director stated she revised the policy yesterday ([DATE]) and that the last paragraph is the only change made. Interview on [DATE] at 2:27 p.m. with the Administrator revealed Dr. (name) is the Medical Director of the facility and Dr. (name) is the Co-Medical Director over the Vent Unit. The Administrator stated he was aware that there was no change of condition documented for R#1 and that the nurse did not call the RP. He stated that he and the DON got together and put a plan together to educate the nursing staff. He stated this concern was not placed in QA and would have been discussed in the next QA meeting. The Administrator stated they are currently transitioning into monthly QA meetings but currently hold QA meetings quarterly. He stated he was not aware that the staff did not re-assess or monitor the R#1's condition after placing him on [MEDICAL CONDITION]. Review of the Quality Assurance Meeting sign in sheets indicate QA meetings were held for quarters January/February/March (YEAR) and April/May/June (YEAR). (Date is not specific). The Medical Director was in attendance for both meetings. Interview on [DATE] at 4:27 p.m. with RT BB revealed he set R#1 on [MEDICAL CONDITION] settings of 12 over 6 (IPAP/EPAP). He stated that oxygen was bled into the [MEDICAL CONDITION] he thought at 3 LPM but not completely sure. He stated he was unable to locate documentation in the resident's electronic chart. Interview on [DATE] at 12:27 p.m. with the Medical Director revealed he has been the Medical Director for the nursing facility for [AGE] years and that he does attend the QA meetings. He stated that quality concern related to documentation has come up at meetings from time to time but he does not remember it ever being continuous problem that required ongoing monitoring. He stated it is more of reminding the staff to document. The Medical Director stated that it is his expectation that documentation occur when there is a change in a resident's condition. He stated a resident with a modest change is treated and managed in the facility as they have a respiratory department, however, if a patient is unstable and more than the facility can manage, they would be sent to the hospital. The Medical Director stated that prior to the survey, he was not aware that a resident in the facility was not appropriately assessed and monitored after being placed on [MEDICAL CONDITION] secondary to respiratory distress. An interview was conducted on [DATE] at 3:08 p.m. with the Administrator and DON. The Administrator stated that after he became aware that there was no change of condition documented for R#1 and that the responsible party was not notified until after R#1 had passed away, He and the DON got together and put a plan in place to educate the nursing staff but nothing further than that was implemented. He stated the concerns were not placed in QA and that an Emergency Meeting with at least 50% of the QA Committee in attendance was not conducted. The Administrator stated that the QA Committee consist of the Administrator, DON, all Department Heads (Assistant DON, Respiratory Director, Business Office Manager, Admissions Coordinator, Unit Managers, Treatment Nurse, MDS Coordinator, Activities Director, Dietary/Dietitian, Social Services, Therapy Director, Medical Records, Maintenance Director, Housekeeping/Laundry) and Medical Director. The Administrator stated that when a concern is placed in QA, the committee discusses a route cause analysis to identify the underlying problem and will gather a sample of other residents for review. He stated that a plan of action or correction is put in place and followed through by the appropriate department head by means of data collection, monitoring and audits until the concern is resolved. Interview with the DON at 3:12 p.m. revealed she was only aware that there was a lack of documentation of a change in condition for R#1 by the nursing staff and that the responsible party was not notified. The DON stated she was not aware, until the survey process, that R#1 had not been appropriately assessed and was not aware that the respiratory staff did not document in R#1's clinical chart either. She stated that the she educated the nurses and the Respiratory Director would be responsible for educating the respiratory department. She stated she had not conducted any audits or monitoring and did not review other residents charts. The DON further stated that prior to the survey, she was not aware that another resident (R#2) (Refer F514) had a similar situation in which she had a change in condition with no documentation of the change in condition, documentation of MD notification or documentation of hospital transport. When the Administrator was asked at 3:15 p.m. if they had placed these concerns in QA to discuss the route cause and sample and review additional residents, would he have found that R#1 was not appropriately assessed and monitored by either the nursing staff or the respiratory staff after a change in his condition or that respiratory staff did not document in R#1's clinical record and that R#2 did not have appropriate documentation when she had a change of condition on [DATE]. The Administrator responded It's possible we would have. An interview conducted on [DATE] at 3:20 p.m. with the Administrator revealed he received education on [DATE] regarding issues to be addressed by the Quality Assurance Committee are identified by audit schedules for areas such as laboratory orders and reports, treatments, and foot care. Other methods of identifying issues include infection control or other trends, quality indicator flags such as psychiatric medications, pain, survey results, complaints, grievances and reportable incidents. The Administrator explained he recently had identified a need for emergency Quality Assurance meetings and educated the committee and the policy addendum was approved by the committee on [DATE]. Action plans are developed by the department associated with the issue. The plans, audits, monitoring, revisions to the plan and to policies are all approved by the medical director if the issue is clinical. The audits for desired outcomes are taken to Quality Assurance Committee and adjusted, continued, or determined to be resolved. The issues of family notification of change in resident condition, and lack of documentation regarding change in condition had been identified and the Director of Nurses had educated licensed staff on [DATE]. The facility implemented the following actions to remove the Immediate Jeopardy: 1. An emergency Quality Assurance Meeting was held on [DATE] and the quality concerns identified regarding the care of Res #1 and Res #2 related to change of condition related to acute respiratory distress. An addendum was added to the Quality Assessment and Assurance Program Policy section IV. Meeting Subsection C. Emergency. Emergency meetings will be called to address issues that cannot be held until the next regularly scheduled meeting. An emergency meeting will be held for all Identified quality issues/concerns with the potential for harm. 2. The Administrator was in-serviced on the Quality Assessment and Assurance Program policy including the addendum to the policy addressing emergency meetings of the Quality Assurance Committee. The QA Committee will conduct a root cause analysis to identify the underlying issues and any trends that contributed to the recognized problem, develop a plan, execute the plan, review /study the results of the plan, Re-evaluate the plan and determine if the plan needs to be modified. This in-service was provided by the CNO of the Corp office on [DATE]. 3. The Quality Assurance Committee was in serviced by the Administrator on the Quality Assessment and Assurance Program policy including the addendum to the policy addressing emergency meetings of the Quality Assurance Committee. The QA Committee will conduct a root cause analysis to identify the underlying issues and any trends that contributed to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, Re-evaluate the plan and determine if the plan needs to be modified. This in-service was provided on [DATE] by the Administrator ,[DATE] were in-serviced in facility on [DATE], of the remaining 2, 1 is no longer an employee and the other 1 will be in-serviced today [DATE]. The State Survey Agency (SSA) validated the facility ' s Credible Allegation of Immediate Jeopardy Removal as follows: 1. Review of the policy titled Quality Assessment and Assurance Program documented that it is the policy of Reliable Healthcare, Inc. that each facility actively participates in a formalized and written quality assessment, assurance and improvement program. The process is comprehensive (involving all departments) and includes monitoring, evaluation and follow up actions. All care provided residents/patients in the facility operations affecting resident/patient care shall be included in the Quality Assurance Program (QA). VI- Responsibilities of the Administrator follows the QA/CQI Programs. Ensures that each department carries out their QA/CQI program accurately and uniformly through report reviews: Each individual department will be responsible for monitoring and evaluating the resident/ patient care services they provide. Each Committee or Department will submit his/her reports. IV- Meetings addendum developed on [DATE], documented that emergency meetings will of the Committee may be called by the Chairperson or quorum of the Committee. A quorum will be considered 50% of membership. 2. The in-service of the Administrator, conducted on [DATE] by the Corporate Chief Nursing Officer, with the Administrator's signature was reviewed. Review of education topics received by the Administrator on [DATE] by the Corporate Chief Nursing Officer included the Quality Assessment and Assurance Program policy, including the addendum addressing emergency meetings. An interview conducted on [DATE] at 3:20 p.m. with the Administrator revealed he received education on [DATE] regarding issues to be addressed by the Quality Assurance Committee are identified by audit schedules for areas such as laboratory orders and reports, treatments, and foot care. Other methods of identifying issues include infection control or other trends, quality indicator flags such as psychiatric medications, pain, survey results, complaints, grievances and reportable incidents. The Administrator explained he recently had identified a need for emergency Quality Assurance meetings and educated the committee and the policy addendum was approved by the committee on [DATE]. Action plans are developed by the department associated with the issue. The plans, audits, monitoring, revisions to the plan and to policies are all approved by the medical director if the issue is clinical. The audits for desired outcomes are taken to Quality Assurance Committee and adjusted, continued, or determined to be resolved. The issues of family notification of change in resident condition, and lack of documentation regarding change in condition had been identified and the Director of Nurses had educated licensed staff on [DATE]. 3. Eighteen signatures, including the Administrator and the Medical Director were included. The minutes included Nursing and Respiratory Plans of Correction, with monitoring and submission of monitoring to the Quality Assurance Committee every month for 3 months. The addendum to the Quality Assurance Policy Addendum providing for emergency meetings to address issues that cannot be held until the next regularly scheduled meeting. An emergency meeting will be held for all identified quality issues/concerns with the potential for harm. The QA committee was instructed to cause a root cause analysis to identify the underlying issues and any trends that contribute to the recognized problem, develop a plan, execute the plan, review/study the results of the plan, re-evaluate the plan and determine if the plan needs to be modified. The nineteenth signature was documented on [DATE].",2020-09-01
596,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2019-01-10,550,E,0,1,XQOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and interviews, the facility failed to ensure the exercise of rights to promote choice, independence and dignity for four residents (R) (R#27, R#62 R#84, R#176) of eight (8) sampled residents residing in the Memory Care Support Unit (Units G and H). Observations of meal service during the four days of the survey revealed residents were provided table spoons to eat all meals. The findings included: 1. On [DATE] at 1:15 p.m. R#27 was observed seated at a table with two other residents located in the center of the main dining room of the Memory Care Support Unit. The front of the resident's blouse was covered with spillage of red tomato meat sauce and spaghetti noodles. Long spirals of the spaghetti were observed to stretch from the resident's mouth to the resident's chest as the resident attempted to pick up the pasta with her fingers. A large silver spoon was observed on the right side of the resident's plate. Continuous observations revealed at no time did the resident pick up the spoon to eat the pasta. When asked why she was not using spoon, R#27 stated she could not keep the spaghetti on the spoon. Interview with Certified Nursing Aide (CNA) II at 1:23 p. m. in the dining room was conducted on [DATE]. During the interview CNA II explained the reason residents residing in the Memory Support Unit are only given spoons to eat their meals, is due to inappropriate behaviors of stealing food from other residents, wandering in the dining room from one table to another, yelling out loud or screaming. When the CNA was asked how many times the CNA observed residents displaying these inappropriate behaviors, the CNA stated about one or two times within the past three to four months. The CNA also stated, when displaying this type of behavior the resident is removed from the dining room and escorted to his/her room to calm down. When the resident calms down then they can return to the dining room and complete their meal or remain in room and complete his or her meal. Review of R#27's most recent quarterly Minimum Data Set Assessment ((MDS) dated [DATE] revealed the resident was assessed to have a BIMS score of 10. The resident was assessed as independent in eating/use of eating utensils. Also, R#27 did not display inappropriate physical behaviors directed towards others such as hitting, throwing objects of food at other residents and wandering. Observations of R#27 on [DATE] at 8:34 a.m. and again on [DATE] at 1:27p.m. revealed R#27 was provided a large table spoon to eat meals. 2. Record review revealed R#62 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set ((MDS) dated [DATE] is a Quarterly Assessment revealed the resident's Brief Interview for Mental Status (BIMS) score was 09 out of a score of 15 indicating resident's cognition is moderately impaired. The resident was assessed as independent in eating/use of eating utensils. The assessment documented R#62 as having no evidence of displaying inappropriate behaviors toward the resident or other residents. On [DATE] at 1:20 p.m. R#62 was observed sitting at a table with two other residents. R#62 was eating vegetables. The resident was unable to cut the vegetables with her spoon and attempted to push the vegetables with her fingers onto the spoon. The vegetables were observed to fall off the spoon onto her lap and onto the floor. On [DATE] at 8:45 a.m. the resident was served a large silver spoon to eat her breakfast. 3. Observations of the afternoon meal in the main dining room [DATE] at approximately 1:30 p.m. revealed R#84 seated at a table with three other residents located at the end of the hall on Unit H. R#84 with an eating utensil wrapped in a white napkin. The R#84 was served his afternoon meal, which consisted of spaghetti with meat sauce and bread. R#84 unwrapped his napkin revealing a large silver table spoon. The resident proceeded to eat his meal with the spoon, but was unable to scoop the spaghetti onto the spoon. R#84 attempted this process several times, with no success. R#84 finally used his fingers to slide the spaghetti onto the spoon and was able to eat approximately one third of the spaghetti portion served. Observations on [DATE] at approximately 8:45a.m.; on [DATE] at approximately 8:53 a.m.; and on [DATE] at approximately 8:50 a.m. revealed R#84 was seated in the Main Dining Room of Unit H eating his breakfast which consisted of grits, scrambled eggs and bacon. Resident ate all of his meals using a large table spoon. During an interview with R#84 in his room on [DATE] at 11:22 a.m. R#84 stated staff always give residents a spoon to eat meals. R#84 said prior to his admission he lived at home with his parents and always ate meals using a fork, knife and spoon. R#84 stated everyone should be treated as an adult, with the ability to make decisions and not be treated as a child. The resident expressed he felt like a little boy when given a spoon to eat meals. Record review revealed R#84 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's most recent annual Minimum Data Set (MDS) an Annual assessment dated [DATE] assessed the resident as independent in eating/use of eating utensils. The resident's BIMS score is 15 indicating resident's cognition was intact. The resident was assessed to have no aggressive behaviors towards himself and others. Interview with a CNA JJ on [DATE] at approximately 3:10 p. m. in the Main Dining room of Unit H, revealed the CNA has been employed and assigned to the Memory Care Support Unit for two years. Since employment CNA stated residents have always received large spoons to eat all their meals. CNA stated R#84 does not require any assistance to perform daily living skill of eating. Resident usually sits at table, located in the back of the dining room, with two other residents. They talk to each other, sometimes they get loud, but never physical nor verbally aggressive toward each other. 4. Review of R#176's clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's most recent MDS assessment dated [DATE] revealed the resident's Brief Interview for Mental Status (BIMS) score 15, indicating the resident was cognitively intact. The resident was assessed as requiring supervision (over sight) of meal set-up and was independent in the use of eating utensils. The resident did not display any signs of aggression or inappropriate behaviors during the assessment period. Interview with the Charge Nurse OO on [DATE] at approximately 10:06 a.m. at the G Hall Nurses' Station, revealed resident eats all meals in the Main Dining Room of the Unit. Since admission to the Unit, resident has not displayed any aggressive behaviors towards others. Observations of the afternoon meal on [DATE] at 1:45 p.m. revealed, the resident was given a tightly wrapped white napkin, which contained a large silver table spoon. The resident was served an afternoon meal consisting of spaghetti with meat sauce. R#176 attempted to eat the spaghetti with the spoon and was unable to bring spaghetti to mouth without the spaghetti falling from the spoon. The resident attempted to cut the spaghetti with the spoon which proved unsuccessful. R#176 picked the spaghetti up with her fingers and placed it on the spoon and ate the spaghetti before it fell on to the plate. R#176 was overheard saying to another resident seated at her table, I can't eat my food. When asked, if residents can request a fork or knife to eat their food, R#176 replied No, we are not allowed to have a fork or knife. No one has ever explained why. When I lived on the Rehabilitation Unit I used a knife, a fork and a spoon. But when I came to this unit I was not allowed to have a fork/knife. Observations of meal time for the days of [DATE] at 8:35 a.m. and on [DATE] at 1:00 p.m. revealed the resident was eating meals with a spoon. Interview with R#176 on [DATE] in her room at 2:21p.m., the resident stated when asked how does eating with a spoon all of the time make you feel. Resident replied, Stupid, because it is not necessary. The resident further stated I can eat with any utensils and wish the staff would let us. 5. During an interview on [DATE] at 1:55 p.m. in the Main Dining Room, the Activity Director (AD) MM stated she had been in her position for more than five years and as long as she has been in the position resident's residing in the Unit (Memory Care) have always been provided large spoons to eat their meals. When asked why this practice was implemented the AD replied, I guess they have behaviors that can become aggressive towards each other. The staff needs to keep the residents safe. Interviews with the following facility staff were conducted to confirm and validate the reason residents residing in the Memory Care Support Unit were given large silver spoons to eat their meals: Interview with Unit G's Medication Nurse PP at 2:29 p.m. on [DATE] nurse stated she has been assigned to the Memory Care Support Unit for over three years. According to her, the residents residing in the Unit are given spoons because of an incident that occurred years ago, when a resident attempted to hurt another resident in the Unit. She could not remember what occurred. Interview with the Assistant Dietary Manager QQ on [DATE] in the main kitchen at 11:10 a.m. revealed she has been employed for over [AGE] years and during her employment the dietary staff have always wrapped the silverware in napkins. The ADM stated the dietary staff is responsible for wrapping all of the eating utensils to include a fork/knife and spoon for each residential Unit, and the main dining room, with the exception of the Memory Care Support Unit. The utensils for the Memory Care Support Unit includes only spoons. She was not sure why the staff was instructed to wrap only spoons, no one informed her of the reason. On [DATE] at 2:47 p.m. an interview was conducted with the Director of Nurses (DON) in her office. She stated a resident originally admitted to the facility from the Georgia State Penal system, was being transferred from the Memory Care Support Unit, during the month of (MONTH) 2013, but could not recall the exact date. During the transfer, the resident became upset with an employee working in the office of Human Resources. According to the DON the resident used a metal fork with bent prongs to stab the employee. The resident was transferred to the hospital for psychological evaluation and later readmitted to the nursing home. The facility Administrator at the time of the incident and the Nurse Unit Manager of the Memory Care Support Unit decided to institute a protocol that no Memory Care Support Unit resident would receive forks/knives during meal time. Although the administrator enforced this practice, the facility did not have a written policy nor protocol. The protocol was implemented by word of mouth and continues to this day, according to the DON. Since the incident, both the Administrator and the Unit Nurse Manager have resigned and the resident is deceased . Although, a new Administrator was hired between their resignations and the current Administrator, the protocol has not changed nor discussed by the current facility's administration.",2020-09-01
597,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2019-01-10,656,D,1,1,XQOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, interviews and record reviews, the facility failed to implement Activities of Daily Living (ADLs) care plans for three (3) of 35 sampled residents (R) (R#40, R#138 and R#174). The findings included: Review of the clinical record revealed R#40 was admitted into the facility on [DATE]. Some of the resident's [DIAGNOSES REDACTED]. According to the resident's most recent Minimum Data Set (MDS) quarterly assessment dated [DATE], R#40 scored 15/15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. R#40 required the total assistance of one staff person for personal hygiene and bathing. 1. Review of R#40's self-care deficit care plan updated 9/26/18 revealed R#40 had self-care deficits related to (r/t) [MEDICAL CONDITION] from an old work injury and late effect [MEDICAL CONDITION], as follows: Resident needs extensive to total assistance for ADLs to be met .Interventions: explain procedures prior to delivering care; bath/shower as scheduled; daily grooming, oral, hair and skin care; nail care/shampoo; observe for signs/symptoms (s/s) of discomfort during ADL care, notify charge nurse if noted; call light in reach; provide privacy while delivering ADL care; notify physician (MD) as needed; OOB (out of bed) to electric wheelchair/scooter chair with cushion for pressure relief; one quarter side rails for positioning and bed mobility; resident can stand and pivot with two staff members at times; total assist with mechanical lift for transfers, with two staff members; encourage resident to accept ADL care; incontinent care as indicated. Review of R#40's CNA Care Interventions Record Form dated 12/1/18 noted under the category for bathing, R#40 required total care, shower, hair wash and trim fingernails/toenails with bath. Observations on 1/7/19 at 4:07 p.m. in R#40's room revealed R#40 wore a hospital gown. When asked about being assisted with showers and/or bathing, R#40 stated he hadn't had a bed bath in quite a while. Interview with R#40 on 1/9/19 at 9:45 a.m. in his room revealed the resident he could not remember the last time he had a shower. The resident stated he preferred to receive a bed bath everyday if (he) could get them. Interview at the nurses' station on 1/9/19 at 2:20 p.m. with Certified Nursing Assistant (CNA) DD revealed she was responsible for assisting R#40 with his ADLs on 1/9/19. CNA DD said she completed bed baths for R#40 today (1/9/19). The aide confirmed the resident's care needs were detailed on his CNA care plan. Follow-up interview on 1/9/19 at 3:00 p.m. with R#40 in his room revealed he had not received a bed bath or shower from CNA DD on 1/9/19. Interview outside of R#40's room with the Unit Manager (UM) BB on 1/10/19 at 9:10 a.m. revealed UM BB was aware of the CNA DD not meeting R#40' care needs, and stated R#40 would immediately be getting a bed bath/shower as he chose. UM BB confirmed the resident's care plan was not followed, as indicated. 2. Review of clinical record revealed R#138 was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R#138's quarterly MDS assessment was dated 11/27/18 indicated the resident had intact cognition. R#138 required the extensive assistance of two persons for personal hygiene; and required the total assistance of one staff person for bathing. R#138 was always incontinent of bladder and bowel. Review of R#138's self-care deficit care plan dated 7/31/17 revealed the following: R#138 had deficits in ADLs r/t impaired physical mobility. Resident requires extensive assistance to total assistance with ADLs .Interventions: bath/shower as scheduled; daily grooming, oral hair and skin care; nail care/shampoo as needed; incontinent care as needed Review of R#138's CNA Care Interventions Record Form undated noted under R#138 required total care for bathing. Interview on 1/07/19 at 11:30 a.m. with R#138 in her room revealed the resident had been on the unit for about three to four days and had not had a shower or a bed bath yet. Observation at the time of the interview revealed the resident was wearing a hospital gown and her hair appeared excessively oily. Follow-up interview on 1/9/19 at 9:03 a.m. in the resident's room revealed R#138's hair remained oily. When asked about receiving a shower, bed bath or shampoo, the resident stated her hair had not been washed and she had not received a bed bath or shower. During the interview, the resident was wearing a hospital gown. Interview at the nurses' station on 1/9/19 at 2:12 p.m. with CNA CC revealed she had given R#138 a partial bed bath and confirmed she had not washed the resident's hair. Interview at the nurses' station on 1/9/19 at 3:45 p.m. with UM BB stated the resident had not been added to the Bathing Guideline schedule; and confirmed the resident had not received a shower/bed bath, as indicated in R#138's care plan. 3. Review of R#174's clinical record revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. Admission MDS assessment dated [DATE], revealed R#174 was moderately cognitively impaired. R#174 required the total assistance of one for personal hygiene and bathing. Review of R#174's self-care deficit care plan dated 11/26/18 noted the following: (R#174) had a deficit in ADLs r/t poor cognitive and physical status. Resident requires extensive to total assistance with ADLs .Interventions: bath/shower as scheduled; daily grooming, oral, hair and skin care; nail care/shampoo as needed; incontinent care as indicated. Review of R#174's CNA Care Interventions Record Form undated noted under the category for bathing, R#174 required total care, shower, hair wash and trim fingernails/toenails with bath. Observation in R#174's room on 1/7/19 at 1:00 p.m. revealed the resident's bilateral fingernails were long. The resident's left-hand fingernails had what appeared to be dirt underneath the long nails. Interview on 1/9/19 at 9:27 a.m. with R#174 in his room revealed he could not remember when he last had a shower/bath. R#174 stated staff assisted him with cutting his nails. R#174 looked at the nails on his left hand and said, they are dirty right now. Observation at this time confirmed the resident's left-hand nails remained dirty. When asked about the nails on his right hand, the resident presented that his right hand was immobile. The nails on the right hand were long but not dirty. The resident was unable to use his right hand. Observation on 1/10/19 at 9:00 a.m. in the resident's room revealed his left-hand fingernails remained long and dirty. During an observation with UM BB in R#174's room on 1/10/19 at 9:03 a.m., UM BB observed the resident's long and dirty nails. During an interview at this time, UM BB confirmed the CNAs were responsible for assisting residents with nail care and R#174 should have been assisted with nail care, as indicated in his care plan. Cross reference F677",2020-09-01
598,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2019-01-10,677,D,0,1,XQOP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, clinical record review and review of facility policy, the facility failed to provide necessary assistance for Activities of Daily Living (ADLs) for three (3) of 35 sampled residents (R) (R#40, R#138 and R#174). The findings included: Review of the facility's policy titled Documentation: Charting Activities of Daily Living (ADLs) revised 5/5/16 defined Activities of Daily Living (ADLs) as tasks of everyday life. Certified Nursing Assistants (CNAs) assist residents with the ability or inability to perform ADLs (ex: hygiene and bathing), and the assistance provided is documented/charted. 1. Review of R#40's clinical record revealed the resident was admitted into the facility on [DATE] and had [DIAGNOSES REDACTED]. According to the resident's most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed R#40 scored 15/15 on the Brief Interview for Mental Status (BIMS), indicating the resident was cognitively intact. R#40 required the total assistance of two staff persons for bed mobility; required the total assistance of one staff person for eating, toileting, personal hygiene and bathing. R#40 utilized an indwelling catheter and was always incontinent of bowel. Review of R#40's self-care deficit care plan updated 9/26/18 revealed R#40 had self-care deficits related to (r/t) [MEDICAL CONDITION] from an old work injury and late effect [MEDICAL CONDITION]. Resident needs extensive to total assistance for ADLs to be met .Interventions: explain procedures prior to delivering care; bath/shower as scheduled; daily grooming, oral, hair and skin care; nail care/shampoo; observe for signs/symptoms (s/s) of discomfort during ADL care, notify charge nurse if noted; call light in reach; provide privacy while delivering ADL care; notify physician (MD) as needed; OOB (out of bed) to electric wheelchair/scooter chair with cushion for pressure relief; 1/4 side rails for positioning and bed mobility; resident can stand and pivot with 2 staff members at times; total assist with mechanical lift for transfers, with 2 staff members; encourage resident to accept ADL care; incontinent care as indicated. Review of R#40's CNA Care Interventions Record Form dated 12/1/18 noted under the category for bathing, R#40 required total care, shower, hair wash and trim fingernails/toenails with bath. Review of an undated document titled Bathing Guideline for Gar(denia) revealed R#40 was to be assisted with bathing on Mondays, Wednesdays and Fridays during the 7:00 a.m. - 3:00 p.m. shift. Review of the CNA Point of Care History from 12/20/18 through 1/9/19 for R#40 revealed during the survey week, the resident was assisted with personal hygiene on 1/7/19, 1/8/19 and 1/9/19. Continued review revealed R#40 was last assisted with a complete bed bath on 12/31/18. According to the document, R#40 had not had a bed bath or shower since 12/31/18. Observations on 1/7/19 at 4:07 p.m. in R#40's room revealed the resident was lying in a supine position in his bed with the head of the bed elevated approximately 30 degrees. The resident wore a hospital gown. When asked about being assisted with showers and/or bathing, R#40 stated he hadn't had a bed bath in quite a while. Interview with R#40 on 1/9/19 at 9:45 a.m. in his room revealed the resident preferred to get up from bed about once or twice each week. When asked how often he was assisted to get up for a shower, the resident stated, I never get up. R#40 further stated he could not remember the last time he had a shower, and the last time he remembered having a bed bath was approximately 3 weeks ago. The resident stated he preferred to receive a bed bath everyday if (he) could get them. Interview at the nurses' station on 1/9/19 at 2:20 p.m. with Certified Nursing Assistant (CNA) DD revealed she was responsible for assisting R#40 with his ADLs on 1/9/19. She said when she began her shift, her tasks were to assist residents in completing their personal hygiene, and to get them ready for their breakfast trays to be served. She stated she completed bed baths for R#40 and three (3) other residents today (1/9/19) and did not assist any residents with showers on this day. When asked if she was always able to complete her bathing/showering assignments, CNA DD said there were times when she had a difficult time getting the showers completed. CNA DD said when she was unable to complete the bathing tasks, she would let the oncoming shift know so that staff could follow-up. Follow-up interview on 1/9/19 at 3:00 p.m. with R#40 in his room revealed he had not received a bed bath or shower from CNA DD on 1/9/19. Interview outside of R#40's room with the Unit Manager (UM) BB on 1/10/19 at 9:10 a.m. revealed CNA DD was being written up for her failure to complete resident care tasks on 1/9/18. UM BB was aware of the aide not meeting residents' care needs, and stated R#40 would immediately be getting a bed bath/shower as he chose. 2. Review of R#138's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent MDS assessment was a quarterly dated 11/27/18 and noted R#138 scored 15/15 on the BIMS assessment indicating the resident was cognitively intact. According to the MDS, R#138 exhibited the behavior of rejecting care during the assessment period. R#138 required the total assistance of two persons for toileting; and required the extensive assistance of two persons for bed mobility, dressing, and personal hygiene. The resident required the total assistance of one staff person for bathing. R#138 was always incontinent of bladder and bowel. Review of R#138's self-care deficit care plan dated 7/31/17 revealed R#138 had deficits in ADLs r/t impaired physical mobility. Resident requires extensive assistance to total assistance with ADLs .Interventions: bath/shower as scheduled; daily grooming, oral hair and skin care; nail care/shampoo as needed; incontinent care as needed assure adequate rest periods as needed; observe for s/s of discomfort during ADL care, notify charge nurse if noted; call light within reach when in bed; explain all procedures before delivering care, even though patient may not totally comprehend; provide privacy while delivering ADL care; assist with transfers as needed; SR (side rails) as indicated. Review of R#138's CNA Care Interventions Record Form undated noted under the category for bathing, R#138 required total care. Review of an undated document titled Bathing Guideline for Gar(denia) revealed R#138 was not on the list for scheduled showers/baths. Review of the CNA Point of Care History from 12/20/18 through 1/9/19 for R#138 revealed during the survey week, the resident was assisted with personal hygiene on 1/9/19. Continued review revealed R#138 was last assisted with a partial bed bath on 1/5/19. According to the document, R#138 had partial bed baths on 12/20/18, 12/22/18, 12/25/18, 1/1/19 and 1/5/19. There was no documentation the resident received a complete bed bath or shower. Interview on 1/07/19 at 11:30 a.m. with R#138 in her room revealed the resident had recently moved to the unit from another hall. R#138 stated she had been on the new hall for about three to four days and had not had a shower or a bed bath yet. R#138 said she was giving them (the staff) time to get situated. Observation at the time of the interview revealed the resident was wearing a hospital gown and her hair appeared excessively oily. Follow-up interview on 1/9/19 at 9:03 a.m. in the resident's room revealed R#138's hair remained oily. When asked about receiving a shower, bed bath or shampoo, the resident stated her hair had not been washed and she had not received a bed bath or shower. During the interview, the resident was wearing a hospital gown. Interview at the nurses' station on 1/9/19 at 10:30 a.m. with Licensed Practical Nurse (LPN) AA confirmed R#138 had relocated to the unit on 1/4/19. Interview at the nurses' station on 1/9/19 at 11:25 a.m. with UM BB revealed there had been an issue with certain CNAs slacking off and exhibiting a mentality of saying I don't have the time to get the showers done and (they) spend more time doing other things that don't take as long. UM BB stated she has had to talk with the aides about getting their priority tasks done. She stated that a few times, residents reported that they did not get a bath or shower, so sometimes she will ask the next shift to get it done, and they were usually cooperative. Further interview revealed the CNAs were responsible for nail care, if the resident was not diabetic. Interview at the nurses' station on 1/9/19 at 2:12 p.m. with CNA CC revealed she was responsible for assisting R#138 with her ADLs on this day. CNA CC said she provided R#138 with a partial bed bath on 1/9/19. When asked what the partial bed bath entailed, CNA CC stated the partial bed bath included providing the resident with peri-care and applying a cream to the resident's buttock when she changed her brief. When asked about washing the resident's hair, she stated that was usually done on the 3-11 shift. CNA CC confirmed she did not assist the resident in washing any other parts of her body. Follow-up interview at the nurses' station on 1/9/19 at 3:45 p.m. with UM BB confirmed the shower/bathing schedule sheet did not include R#138's room and bed number. UM BB confirmed R#138 was admitted to the hall/unit on 1/4/19 and had not been added to the Bathing Guideline schedule sheet. UM BB said R#138 would be added to the schedule and staff would ensure the resident received a complete bed bath/shower. 3. Review of R#174's clinical record revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. According to the resident's Admission MDS assessment dated [DATE], R#174 scored 12/15 on the BIMS assessment, indicating the resident was moderately cognitively impaired. Section G of the assessment noted the resident required the total assistance of two (2) staff persons for transfers; required the total assistance on one staff person for dressing, eating, toileting, personal hygiene and bathing. The resident required the extensive assistance of one staff person for bed mobility. Review of R#174's self-care deficit care plan dated 11/26/18 noted the resident had a deficit in ADLs r/t poor cognitive and physical status. Resident requires extensive to total assistance with ADLs .Interventions: bath/shower as scheduled; daily grooming, oral, hair and skin care; nail care/shampoo as needed; incontinent care as indicated; assure adequate rest periods as needed; assess and observe for s/s of discomfort during ADL care, notify charge nurse if noted; call light within reach when in bed; explain all procedures before delivering care, even though patient may not totally comprehend; provide privacy while delivering ADL care; assist with transfers as needed; remove facial hair as needed unless other-wise requested. Review of R#174's CNA Care Interventions Record Form undated noted under the category for bathing, R#174 required total care, shower, hair wash and trim fingernails/toenails with bath. Review of an undated document titled Bathing Guideline for Gar(denia) revealed R#174 was to be assisted with bathing on Mondays, Wednesdays and Fridays during the 3:00 p.m. - 11:00 p.m. shift. Review of the CNA Point of Care History from 12/20/18 through 1/9/19 for R#174 revealed during the survey week, the resident was assisted with personal hygiene on 1/8/19 and 1/9/19. Continued review revealed R#174 was last assisted with a complete bed bath on Monday, 1/7/19. There was no documentation to indicate staff performed nail care for R#174. Observation in R#174's room on 1/7/19 at 1:00 p.m. revealed the resident was lying supine in his bed with the head of the bed slightly elevated. Observation at this time revealed the resident's bilateral fingernails were long and the resident's left-hand fingernails had what appeared to be dirt underneath the long nails. Interview on 1/9/19 at 9:27 a.m. with R#174 in his room revealed he could not remember when he last had a shower/bath. R#174 stated staff assisted him with cutting his nails and he didn't like them cut down to the quick (cut too short). R#174 looked at the nails on his left hand and stated they are dirty right now. Observation at this time confirmed the resident's left-hand nails remained dirty. When asked about the nails on his right hand, the resident presented that his right hand was immobile. The nails on the right hand were long but not dirty. The resident was unable to use his right hand. Observation on 1/10/19 at 9:00 a.m. in the resident's room revealed R#174 was in bed and appeared to be sleeping. R#174's right hand was under his blanket and his left-hand was above the blanket. His left-hand fingernails remained long and dirty. During an observation with UM BB in R#174's room on 1/10/19 at 9:03 a.m., UM BB observed the resident's long and dirty nails. During an interview at this time, UM BB was informed the resident's nails had been long and dirty since observed on the first day of the survey, 1/7/19. UM BB confirmed the CNAs were responsible for assisting residents with nail care and R#174 should have been assisted with nail care.",2020-09-01
599,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2018-02-02,690,D,0,1,79BC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review, it was determined the facility failed to provide appropriate indwelling urinary catheter care for one resident (R) #40, of 34 sampled residents. Findings include: Review of the facility policy for Indwelling urinary catheter (Foley) care and management revised 11/11/2016 indicated in the Implementation section to Provide routine hygiene for meatal care; note that cleaning the meatal area with antiseptic solutions isn't necessary. To avoid contaminating the urinary tract, always clean by wiping away from-never toward- the urinary meatus. Use soap and water or a perineal cleaner to clean the [MEDICAL CONDITION] area after each bowel movement. Avoid frequent and vigorous cleaning of the area. Review of the Admission Minimum Data Set (MDS) for R #40 dated 8/3/17 revealed that his [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) indicated a score of 12 of 15 indicating the resident was cognitively intact. R#40 had a catheter on admission to the facility. Review of the Care Plan for R #40 dated 8/14/17 revealed a care plan for an Indwelling Foley Catheter. Approaches included: Provide perineal care every day and PRN Report redness, swelling, discharge or urinary related odor to supervisor Follow aseptic technique with Cath insertion and irrigation Observe and report change in color, odor, presence of cloudiness or sediment in urine to charge nurse Report complaints of pain/discomfort from cath to charge nurse Record intake and output as ordered Check Cath q (every) shift for patency, proper position of tubing and bag. Report Cath leakage to charge nurse. Review of the Medication Administration Record [REDACTED]. Additionally, the MAR indicated [REDACTED]. Review of the Quarterly MDS dated [DATE] for R#40 revealed a BIMS score of 15 indicating that he was cognitively intact. The resident required total care for all activities of daily living and had an indwelling urinary catheter. Review of the Physician's Orders for R #40 dated 1/1/18-1/31/18 revealed orders for: Foley catheter (Cath) # 16 FR (French) With 10 milliliter (ml) bulb Change Cath monthly and PRN (as needed) D/T (due to) [MEDICAL CONDITION] Catheter care every shift. Review of the Physician's Interim Orders dated 1/26/18 revealed an order for [REDACTED]. Observation and interview of R #40 in his room on 1/30/18 at 9:50 a.m. revealed the resident sitting up in bed and the resident stated that he had a kidney infection. Observed, at this time, of about 60 ml of light yellow urine in the indwelling urinary catheter drainage bag which was inside a privacy bag. Observation of Certified Nursing Assistant (CNA) KK as catheter care was provided to R #40 on 1/31/18 at 10:32 a.m. revealed: 1. Washed around base of penis and top of scrotum then shaft of penis with warm soapy water. 2. Rinsed the wash cloth in the bath basin then rinsed around base of penis and shaft then dried the area with a towel. 3. Washed the meatus of the penis with warm soapy water (from the same basin of water). Then wiped the catheter tubing with an alcohol swab from penis down the tubing. 4. Changed gloves then applied Vaseline to head of penis. During an interview with CNA KK and Registered Nurse (RN) MM Unit Manager in the Administrator's office on 2/1/18 at 10:12 a.m. revealed that CNA KK stated that she washed the head of the resident's penis after washing the rest of the pubic area. RN Unit Manager MM stated that CNA should have washed the meatus/catheter insertion site before the rest of the pubic area.",2020-09-01
600,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2018-02-02,700,E,0,1,79BC11,"Based on observation, interview, policy review and record review, it was determined the facility failed to attempt appropriate alternatives, assess for risk of entrapment, review the risks and benefits and obtain informed consent prior to installing side rails on all residents' beds. This effected 38 of 38 residents reviewed (Residents (R)#157, R#83, R#134, R#128, R#44, R#101, R#81, R#148, R#23, R#378, R#161, R#131, R#36, R#141, R#142, R#126, R#3 R#109, R#146, R#377, R#163 R#28, R#40, R#284, R#89, R#45, R#27, R#169, R#75, R#79, R#119, R#50, R#168, R#283, R#159, R#22, R#55 and R#56) out of a total facility resident census of 202 on the day of the survey, for potential accidents related to side rail use. Findings include: Observations made on 1/29/18 during the initial tour, starting at 10:03 a.m., revealed the presence of side rails attached to 224 of the facility's 227 total beds. The three (3) beds without side rails were unassigned to any residents and located in rooms C10, G4B and G14B. Further observations made during the initial tour failed to reveal any side rails that were improperly installed. No observations were made of bed mattresses that did not fit tightly to side rails. Interview conducted on 1/31/18 at 3:20 p.m. at the Ventilation Nurses Station with Unit Manger (UM) AA revealed facility side rails are never removed from any resident beds. Side rails remain attached on all beds. At admission, residents are not assessed for alternatives to side rails prior to being assigned a bed with a side rail already attached. When residents are discharged by the facility, side rails are not removed before another resident is assigned to the available bed. Interview conducted on 2/1/18 at 9:49 a.m. at F Unit Nurses station with Unit Manager BB revealed facility side rails always remain attached to the bed. The side rails are never removed. Newly admitted residents are placed into beds already having side rails attached to the bed. At the time of admission, alternatives to side rails are never attempted prior to placing residents into their assigned bed. Interview conducted on 2/1/18 at 11:23 a.m. in the Administrator's Office with the Director of Nursing (DON) revealed side rails are attached to all but three (3) of the facility's 227 total beds. Side rails are never removed from facility beds, unless they need to be repaired. All newly admitted residents are assigned beds having side rails already attached. Alternatives to side rails are not attempted prior to placing residents in their assigned beds. An initial and annual assessment for a physical devices is conducted for all residents however, the assessment does not include a benefit verses risk evaluation and does not address alternatives to side rail use. The physical devices assessment merely contains documentation of what type of side rail is being used, verifies the side rail is not a restraint for the resident and indicates the rationale for use of the side rail. Interview conducted on 2/1/18 at 5:41 p.m. with the facility's Corporate Nurse, Senior Nurse Consultant revealed the facility does not have a side rail policy that directs clinical practice on how to conduct a side rail assessment. When asked for the facility's side rail policy for review the Corporate Nurse, Senior Nurse Consultant provided a copy of Lippincott Procedures - Restraint use, Long-Term Care (Revised: (MONTH) 12, (YEAR)). Review of the document revealed the following: Initial/Annual Observation for a Physical Device Form will be completed anytime a physical device is used with a patient/resident. For each device utilized by the patient, a separate page 2 should be completed. The Corporate Nurse, Senior Nurse Consultant acknowledged the document did not guide clinical practice of staff on the procedures they are to follow when conducting a side rail assessment. A second interview was conducted on 2/2/18 at 9:30 a.m. in the Conference Room with the DON and during the interview, the DON acknowledged all newly residents are placed into beds that already have side rails attached to the bed. Alternatives to side rails are not attempted prior to installing side rails, since to the side rails are never removed from beds following discharge of residents. No residents are assessed for risk of entrapment from side rails prior to installation of side rails since side rails are never removed. Review of benefits verses risk of side rail use is never conducted with residents or their representatives nor is informed consent obtained prior to side rail installation. A second interview was conducted on 2/2/18 at 10:50 a.m. in the conference room with the Corporate Nurse, Senior Nurse Consultant. During the interview the Corporate Nurse, Senior Nurse Consultant acknowledged side rails are attached to all 227 facility beds, except for beds located in rooms C10, G4B and G14B. Alternatives to side rails are never attempted, risk for entrapment is not assessed and informed consent is not obtained from the resident or their representative prior to the installation of side rails to their corresponding assigned bed. Interview conducted on 2/2/18 at 12:30 p.m. with the facility's Medial Director revealed she was aware of changes to Federal Long Term Care Regulations effective 11/28/17. However, the Medical Director stated she was not aware of the specific changes to the regulations regarding the use of side rails. The Medial Director acknowledged it is the practice of the facility to assigned newly admitted residents into beds that already have side rails attached. Side Rail assessments are conducted after newly admitted residents are assigned to a bed having side rails already attached. Record Review of medical records for Residents (R)#157, R#83, R#134, R#128, R#44, R#101, R#81, R#148, R#23, R#378, R#161, R#131, R#36, R#141, R#142, R#126, R#3 R#109, R#146, R#377, R#163 R#28, R#40, R#284, R#89, R#45, R#27, R#169, R#75, R#79, R#119, R#50, R#168, R#283, R#159, R#22, R#55 and R#56 revealed no documented evidence of appropriate alternatives for side rail use were attempted prior to being assigned a bed with side rails already attached. No reviewed medical record contained an assessment for risk of entrapment prior to being assigned a bed with side rails already attached. There was no documented evidence in any reviewed medical record of a benefits verses risk analysis being completed prior to assigning a resident to side rail attached bed. All reviewed medical records failed to contain a signed informed consent by either the resident or the resident's representative prior to assigning the resident to a bed with side rails already attached.",2020-09-01
601,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2018-02-02,842,D,0,1,79BC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined the facility failed to ensure the medical record for one (Resident(R)#131) of two residents was reviewed for position/mobility related to limited range of motion contained complete and accurately documented information in regards to application and removal of splints. Findings include: On 1/29/18 at 11:30 a.m. R#131 was observed in bed. The resident was observed to have contractures of bilateral wrists and hands. He did not have splints on either hand currently. Additional observations of R#131 were conducted on 1/31/18 at 8:45 a.m., 10:30 a.m. and 2:20 p.m. R#131 did not have splints on either hand during any of these observations. A fifth observation of R#131 on 2/1/18 at 11:52 a.m. revealed the resident was wearing bilateral hand splints and a left elbow splint. Review of the care plan in the medical record reveals an identified problem as R#131 requires restorative nursing for splint application related to impaired physical mobility. The measurable goal is to have Patient will apply splint/brace with staff assist of one. Approaches for the identified problem include 1. Offer cueing and positive feedback for adherence to application schedule 2. Apply bilateral resting hand splints four to six hours as tolerated 3. Passive range of motion to bilateral hands/wrists before and after applying/removing splint, 4. Observe skin and circulation under resting hand splints before/during and after application. A second identified problem is listed as decreased ability to care for splint/brace related to impaired mobility. The measurable goal for this problem is Patient will apply splint with staff assist of one. Approaches for this problem are: 1. Apply left elbow splint four to six hours daily as tolerated 2. Assess skin and circulation to elbow before/during/after 3. Offer positive feedback for adherence to application schedule 4. Passive range of motion before/after removing splint. There is no documentation of how long R#131 wears his splint daily as tolerated. There is also no documentation if R#131 does or does not tolerate wearing his splint. Review of the Minimum Data Set ((MDS) dated [DATE], Section G0110 for activities of daily living reveals he has total dependence for full staff performance of all activities of daily living Section G0400 indicates R#131 has total dependence in range of motion for bilateral upper and lower extremities. Review of the facility policy for Restorative Nursing Program dated 7/15/16 defines passive range of motion, active range of motion and splint or brace assistance. Splint or brace assistance is defined as verbal and physical guidance and direction that teaches the resident how to apply manipulate, and care for a brace or splint; or a scheduled program of applying and removing a splint or brace. The policy states in the section titled Documentation 1. Utilize one Restorative Flow Sheet for each service that is provided. Include the modality and shift specific information (e.g. ROM (passive) to upper extremity days/week. 2. Initial daily, in the appropriate space on the flow sheet or the electronic charting system, those restorative services that were provided. Document exact number of minutes in the appropriate space on the flow sheet. The person performing the restorative service may initial the flow sheet; however, the nurse in ultimately responsible that the services were provided. The facility did not follow their policy for daily documentation of the individual services provided to R#131 for each task provided to R#131. Review of the medical record for R#131 on 1/31/18 at 2:30 p.m. revealed the documentation was present in the care plan for the application and removal of bilateral hand splints and left elbow splints. Review of the Restorative Nurse's Notes in the electronic medical record reveals documentation monthly. None of the monthly notes for the past six months address the application and removal of any of the splints to be worn by R#131. Review of the Restorative Aide's Notes documented in the medical record reveals there is no mention of the application or removal of splint. Notes state Total number of minutes provided during this shift-Splint or brace assistance-15. The notes did not specify if the 15 minutes documented are for the application or removal of splints. This documentation is not documented daily. A review of the past three months of paper documentation on a facility form titled Restorative Nursing Flow Record Form effective 12/1/11 and most recently revised 1/20/15 in the medical record of R#131 has documentation of 15 minutes spent to perform 1. Active restorative for passive range of motion, 2. Passive range of motion to bilateral upper extremities as tolerated and 3. 10 reps for 2 sets as tolerated. Page two of the same form also notes 15 minutes spent to perform 1. Active restorative for splint/brace, 2. Apply restorative hand splint to bilateral hands four-six hours as tolerated, 3. Assess skin and circulation before/during/after application and 4. Offer cueing and positive feedback for successful attempts to apply/remove device. This form is not documented daily and does not indicate if the 15 minutes were spent applying or removing the splints worn by R#131. There is no documentation in the electronic medical record or the paper medical record in the past three months for 1/13/18, 1/14/18, 1/19/18, 1/20/18, 1/21/18, 1/22/18, 1/23/18, 1/24/18, 1/25/18, 1/26/18, 1/27/18, 1/28/18, 1/29/18, 12/1/17, 12/4/17, 12/5/17, 12/6/17, 12/8/17, 12/10/17, 12/11/17, 12/13/17, 12/16/17, 12/23/18, 12/24/17, 12/25/17, 12/27/17, 12/28/17, 11/1/17, 11/2/17, 11/4/17, 11/5/17, 11/10/17, 11/11/17, 11/12/17, 11/13/17, 11/15/17, 11/16/17, 11/19/17, 11/20/17, 11/23/17, 11/24/17, 11/25/17, 11/28/17, and 11/29/17. On 1/31/18 at 1:50 p.m. during an interview with the Unit Manager at the [NAME] wing nurses' station he reported the restorative certified nursing assistants (CNA) apply and remove the splint for R#131. On 1/31/18 at 2:25 p.m. during an interview with CNA CC in the restorative office, she stated she is one of the restorative CNAs that apply the splints to R#131. She stated she does this every day when she is at work. She acknowledged R#131 is to wear his splints for four-six hours as tolerated. After CNA CC reviewed the documentation in the electronic and paper record of R#131 she confirmed the documentation for application and removal of the splints were not done on a daily basis. She also confirmed she was unable to determine if the 15 minutes spent with R#131 for his restorative were for range of motion, application of splints or removal of splints. During an interview on 1/31/18 at 2:30 p.m. with the Licensed Practical Nurse (LPN) BB (the nurse responsible for the restorative program) in her office, she stated the 15 documented in the electronic and paper medical record for R#131 indicates how much time the restorative CNA spent with the resident. She confirmed the documentation did not indicate if this was the application of splints, removal of splint or a combination of both removal and application of the splints. She also confirmed there are multiple days when there is no documentation the restorative care and services were provided. She reviewed the electronic and paper documentation completed by the restorative CNA and acknowledged the documentation was very inconsistent and did not follow the facility policy. The facility failed to document daily the restorative treatment plan for R#131 as per their policy.",2020-09-01
602,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2019-05-28,584,E,1,0,F4GX11,"> Based on observation, interviews and record review, the facility failed to provide an environment free from peeling paint and grout, dirt/debris buildup, rust, stains, damaged floor tiles and doors in seven resident rooms on seven halls (A, B, C, D, F, G, H). Findings include: The facility had an Environmental Services Orientation guide for cleaning. The guide included detailed steps for pulling trash/linen, checking soap/paper dispensers, high dusting, damp wiping, dust mopping floor, cleaning the bathroom, damp mopping and inspecting the room for needed repairs. However, during environmental rounds on 5/28/19 starting at 11:10 a.m., the following concerns were identified: 1. In the bathroom of room A9 at 11:12 a.m. there were multiple scuffs and areas of missing paint to the bottom of the interior bathroom door. There was also a build up of dirt and debris on the bathroom floor threshold. 2. In the bathroom of room C1, at 11:15 a.m., the grout around the base of the toilet was observed to be discolored brown. There was also dirt and debris on the base of the toilet. 3. In room D5, at 11:30 a.m., there were brown smears on the wall between the window and the bathroom door. There were long sections of missing paint to a large piece of wood attached to the wall (and painted to match the wall) next to bed [NAME] In the bathroom, which was shared with room D6, there was a large section of missing paint to the interior lower portion of the bathroom door for D6. The grout around the toilet base was peeling and unsightly and there was an unpainted section of patched drywall near the toilet paper holder. These findings were also previously observed on 5/23/19 at 9:35 a.m. and 5/24/19 at 1:00 p.m. In addition, during the observation on 5/23/19 at 9:35 a.m., there were four to six very small live bugs crawling on the wall near the window. 4. In room F24, at 11:35 a.m. there was a large section of damaged drywall and peeling, partially detached baseboard to a corner section of two walls. In the bathroom, the unused tub had a buildup of multiple rust stains to the basin and drain areas of the tub. Water was continuously running in the sink and was uable to be turned off by the control knobs of the sink. In addition, the bathroom flooring was worn with multiple brown and and pink stains and there was peeling, discolored grout around the toilet base. These findings were also previously observed on 5/24/19 at 12:50 p.m. 5. In the bathroom of room H2, at 11:37 a.m., there was a section of of patched, but unpainted dry wall near the toilet paper holder and multiple stains and damage to the bottom of the bathroom doors. 6. In the bathroom of room G9, at 11:41 a.m., there was dirt/debris collected on the base of the toilet, the wall vent was rusted, and there were stains to the wall behind the toilet. 7. In the shared bathroom of rooms B11 and B12, there was a tennis ball sized section of damage to the flooring near the toilet. On 5/28/19 at 1:35 p.m., the above findings were observed again with the Administrator.",2020-09-01
603,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2019-05-28,656,D,1,0,F4GX11,"> Based on resident and staff interviews and record review, the facility failed to implement the care plan related to assisting with activity of daily living (ADL) for one resident (RC). The sample size was 19 residents. Findings include: Review of the 4/22/19 Annual Minimum Data Set (MDS) for R C revealed the resident was assessed as needing total assistance with transfers, dressing, and bathing and was non-ambulatory. Review of the resident's care plan dated 2/5/19 for self care deficit of ADLs revealed the resident preferred to take showers three times a week. There was an approach for bath/showers and shampoo as indicated. Review of the Point of Care History for 4/22/19-5/22/19 revealed the resident received a shower on Tuesday 4/23/19, then four days later on Saturday 4/27/19. The resident then received a shower six days later on 5/3/19. His next shower was four days later on Tuesday 5/7/19 then again on Thursday 5/9/19. The next shower was given five days later Tuesday 5/14/19. Cross refer to F677.",2020-09-01
604,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2019-05-28,658,D,1,0,F4GX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews and record review, review of the Georgia Nurse Practice Act, licensed nursing staff failed exercise competent independent judgement by not verifying the location of one resident (A) to ensure their safety, from a total sample of 19 residents. Findings include: Review of the Rules and Regulations of the State of Georgia, Rule 410-10-.02 Standards of Practice for Licensed Practical Nurse addressed Rule 410-10-.02 (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or health care facilities in area of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. (f) Performing other specialized tasks as appropriately educated. 2. Responsibility: Each individual is responsible for personal acts of negligence under the law. Licensed practical nurses are liable if the perform functions for which they are not prepared by education and experience and for which supervision is not provided. The facility had a job description for Licensed Practical Nurses (LPN). The job description included an essential supervisory function of exercising independent judgement. The job description acknowledgement was signed by LPN AA on 10/19/15. However, LPN AA failed to exercise competent independent judgement on 5/12/19 by not verifying the location of Resident (R) A, when the resident was not in her room. A 5/13/19 9:09 a.m. Nurse's Note documented that LPN AA was summoned by nursing staff on D hall that RA was lying on the ground in the courtyard. The resident was assisted back to her room and assessed. Review of facility investigation information revealed that the resident was observed on the ground in the courtyard on 5/13/19 at 7:10 a.m. by R#7 from his bedroom window. R#7 alerted nursing staff, who responded and assisted RA back to her room for further assessment and interventions. A further review of the investigation information revealed that it was determined that the RA had been outside, in the courtyard overnight. An interview on 5/20/19 at 10:33 a.m., LPN AA confirmed that she was assigned to RA from 5/12/19 at 7:00 p.m. through 5/13/19 at 7:00 a.m. She stated that she did not see RA during her shift and assumed she was out with her family for Mother's day. LPN AA further stated that she looked at the Leave of Absence (LOA) book to see if the resident had been signed out, and she had not been signed out as leaving the facility. She assumed the resident left with her family without signing the LOA book. However, LPN AA did not call the resident's family to verify her assumption. During an interview on 5/15/19 at 2:55 p.m. the Administrator stated that when LPN AA did not see RA in her room and the LOA book had not been signed out, she should have looked for the resident and if not found, should have called a code pink (missing person code). Cross refer to F689",2020-09-01
605,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2019-05-28,677,D,1,0,F4GX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident and staff interviews and record review, the facility failed to provide scheduled showers for one Resident (RC) dependent on staff for activities of daily living (ADLs) from a sample of 19 residents. Findings include: An interview with R C on 5/20/19 at 3:15 p.m., he stated that his scheduled shower days were on Monday, Wednesday and Friday on the evening shift. He stated that three times this past month he did not get his scheduled shower when one of his Certified Nursing Assistants (CNA) was off. During a subsequent interview with the resident on 5/21/19 at 9:45 a.m., he stated that he did not get his scheduled shower the previous night on 5/20/19 (Monday). Review of the clinical record revealed R C was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the 4/22/19 Annual Minimum Data Set (MDS) revealed the resident was assessed as needing total assistance with transfers, dressing, and bathing and was non-ambulatory. Review of the shower schedule sheet for the hallway on which the resident resides revealed his scheduled shower days were Monday, Wednesday and Friday on the evening shift. Review of the Point of Care History for 4/22/19-5/22/19 revealed the resident received a shower on Tuesday 4/23/19, then four days later on Saturday 4/27/19. The resident then received a shower six days later on 5/3/19. His next shower was four days later on Tuesday 5/7/19 then again on Thursday 5/9/19. The next shower was given five days later Tuesday 5/14/19. During an interview with CNA QQ on 5/22/19 at 3:00 p.m., she stated that she gave the resident a shower Tuesday, 5/21/19. She further stated she was on the shower team and that she goes to a different hall each day to help bathe residents. She stated that she did not have a resident bath schedule, she just goes to the hall and starts bathing residents. During an interview with the Director of Nursing on 5/22/19 at 2:30 p.m., she stated that the facility did not have a policy and procedure for baths/showers but she would expect the residents to be bathed on the scheduled days or when the resident wanted a bath.",2020-09-01
606,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2019-05-28,689,D,1,0,F4GX11,"> Based on interviews and record review, the facility failed to verify the location of one resident (A) to ensure their safety from a total sample of 19 residents. Findings include: A 5/13/19 9:09 a.m. nurse's note documented that Licensed Practical Nurse (LPN) AA was summoned by nursing staff on D hall that Resident (R)A was lying on the ground in the courtyard. The resident was assisted back to her room and assessed. A review of facility investigation information revealed that the resident was observed on the ground in the courtyard on 5/13/19 at 7:10 a.m. by R#7 from his bedroom window. R#7 alerted nursing staff, who responded and assisted RA back to her room for further assessment and interventions. A further review of the investigation information revealed that it was determined that the RA had been outside, in the courtyard overnight. An interview on 5/15/19 at 2:10 p.m., RA confirmed that she fell out of her wheelchair in the courtyard, in the evening time, a few days ago, and remained outside all night. She stated that she was trying to get on to the gazebo and her wheelchair tipped and she fell out and could not get up. She stated she had gone outside by herself. RA further stated that she felt fine. An interview on 5/20/19 at 10:33 a.m., Licensed Practical Nurse (LPN) AA confirmed that she was assigned to RA from 5/12/19 at 7:00 p.m. through 5/13/19 at 7:00 a.m. She stated that she did not see RA during her shift and assumed she was out with her family for Mother's day. LPN AA further stated that she looked at the Leave of Absence (LOA) book to see if the resident had been signed out, and she had not been signed out as leaving the facility. She assumed the resident left with her family without signing the LOA book. However, LPN AA did not call the resident's family to verify her assumption. She made no further attempts to confirm the whereabouts of R[NAME] An interview on 5/16/19 at 11:00 a.m., LPN CC confirmed that she assigned to RA from 5/12/19 between 7:00 a.m. tthrough 5/12/19 at 7:00 p.m. She stated that RA was in her room when LPN CC removed her supper tray between 6:00 p.m. and 6:30 p.m. LPN CC stated, as she was leaving around 7:15-7:20 p.m., and again saw the resident in her room as she passed by. LPN CC further stated that if the resident had gone out with her family and was still out at shift change, she would have put that on the 24 hour report for the next shift. During an interview on 5/15/19 at 2:55 p.m. the Administrator stated that when LPN AA did not see RA in her room and the LOA book had not been signed out, she should have looked for the resident and if not found, should have called a code pink (missing person code).",2020-09-01
607,PRUITTHEALTH - MACON,115288,2255 ANTHONY ROAD,MACON,GA,31204,2016-11-04,246,D,0,1,URSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to ensure reasonable accommodations were provided for a physically impaired resident who was cognitively intact in that the call light was observed to not be in reach nor the appropriate type of call light for 1 resident (R#10) of 40 residents observed for call light. Findings included: Review of the clinical record for R#10 revealed a [DIAGNOSES REDACTED]. Review of the Nursing Admission Assessment dated 4/4/08, stated R #10 has left arm paralysis. Review of the current Quarterly Minimum Data Set (MDS) assessment dated [DATE], had a Brief Interview of Mental Status (BIMS) score of 14indicating the resident was interviewable and cognitively intact. R #10 needed extensive assistance of two staff person for bed mobility. Limited range of motion on one upper side (The left arm). On 11/2/16 at 10:04 a.m., R #10 ' s call light was observed wrapped around the left bedrail. R #10 was observed attempting to reach the call light with his contracted right hand. R #10 ' s left arm was not able to lift. R #10 indicated was not able to reach the call light at that time. On 11/2/16 at 3:00 p.m., R #10 was observed asleep in the bed with the call light on the floor between the bed and the wall. On 11/3/16 at 9:31 a.m., R #10's call light was observed lying on his chest. The call light was not attached to anything. R #10 was observed not able to push the call light button. The (F) hall Unit Manager BB indicated the current call light was not appropriate for R #10 and she (F Hall Unit Manager BB) would change the call light to the pad light. On 11/3/16 at 11:22 a.m., R #10 was observed still to have the push button call light and unable to use. On 11/3/16 at 1:02 p.m., R #10 was observed in bed with the call light attached to the covers close to R #10's chest. R #10 was observed not to be able to activate the call light at this time. The call light had not been changed to a more appropriate call light as indicated by Unit Manager BB. On 11/3/2016 at 3:33 p.m., an interview in the conference room with Certified Nurse Assistant (CNA) AA indicated, Resident #10 was not capable of using a push button call light. CNA AA indicated when last worked R #10 had a flat pad call light. On 11/3/16 at 3:42 p.m., in R #10 ' s room with Certified Nursing Assistant (CNA) AA present R #10 was observed to have a flat pad call light in place. On 11/4/16 at 9:06 a.m., an interview with the Director of Health Services (DHS) CC in the conference room stated, the expectation for staff was to have all call lights within reach of the residents. The DHS indicated, R #10 probably could not use a push button call light and should have been evaluated by staff on which type of call light to use. On 11/4/16 at 9:35 a.m., interview with Certified Nurse Assistant (CNA) DD indicated R #10 was not able to use a push button call light and was aware of how to use call light. The DHS stated, there was no facility policy in regards to placement of the resident ' s call light.",2020-09-01
608,COMER HEALTH AND REHABILITATION,115289,2430 PAOLI ROAD,COMER,GA,30629,2017-06-29,309,D,0,1,4TNJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide eye drops as ordered for one resident (R) #56 for nine of 28 days in (MONTH) (YEAR). The sample size was 31 residents. Findings include: Review of R #56's Client [DIAGNOSES REDACTED].#56's (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the back of this MAR indicated [REDACTED]. Further review of the back of the MAR indicated [REDACTED]. During interview with LPN CC on 6/29/17 at 11:15 a.m., she verified that the Latanoprost eye drops were not provided for R #56 between 6/5/17 and 6/13/17, because the pharmacy said that it was not time to refill the medication. During interview with the Director of Nursing (DON) on 6/29/17 at 4:49 p.m., she stated that if a medicine was not available in the medicine cart, that the nurse should record this on the 24-hour report, so that the charge nurse could reorder the drug the next day. She further stated that the pharmacy would not refill R #56's Latanoprost because they said it was too soon to refill it, and she verified that the eye drops had not been given for nine days. During interview with LPN BB on 6/29/17 at 5:06 p.m., she stated that earlier that month she could not locate R #56's Latanoprost in the medicine cart, and so faxed an order slip to the pharmacy to reorder more of it. She further stated that she did not tell her supervisor that the eye drops were not available until nine days later.",2020-09-01
609,COMER HEALTH AND REHABILITATION,115289,2430 PAOLI ROAD,COMER,GA,30629,2017-06-29,463,E,0,1,4TNJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to ensure that the call lights were functioning adequately to allow residents to call for staff assistance through a communication system in six rooms (107-A, 111-A, 111-B, 206-B, 214-A and 214-B) on two of three halls (A Hall and B Hall). The facility census was 101 residents. Findings include: Observations on 6/26/17 of resident room call lights on the B Hall revealed the following: At 11:30 a.m. in room 206-B the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. R#52 resided in 206- B and was able to demonstrate how to use the call light and verbalize that the call light was used to call for assistance. At 11:35 a.m. in room 214-A the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. There was no resident currently residing in bed- A however, it was available for new admission. At 11:36 a.m. in room 214-B the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. R#66 resided in 214- B and was able to demonstrate how to use the call light and verbalize that the call light was used to call for assistance. R#66 further stated that he reported it to the maintenance man and was told the call light had a short in it. R#66 stated the call light had been that way for a while. Record review for resident R#66 revealed an Admission Minimum Data Set ((MDS) dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, indicating the resident was cognitively intact. Observation on 6/26/17 at 4:25 p.m. with the Maintenance Supervisor confirmed that the call lights in 214-A, 214-B and 206-B were not lighting up or alarming when the red call button was pushed. He stated the call lights are checked once on month and is logged in the TELS System. The Maintenance Supervisor provided the Logbook Documentation- Nurse Call System Test from (MONTH) (YEAR) and Feburuary through (MONTH) (YEAR). Review of the Logbook Documentation- Nurse Call System Test revealed: Room 214 (A and B) was tested monthly and documented as passed, with the exception of (MONTH) 2, (YEAR), which documented N/[NAME] (The room was empty during this time and being remodeled) Room 206-B was tested monthly and documented as passed. Interview on 6/26/17 at 4:45 p.m. with the Maintenance Assistant AA revealed he had replaced the call light cords in room 214-A, 214-B and 206-B and that there were now functioning properly. Observation on 6/26/17 at 4:47 p.m. with the Maintenance Assistant revealed the call lights in rooms 214-A, 214-B and 206-B lit up and sounded an alarm when the red call button was pushed. Interview on 6/29/17 at 2:10 p.m. with the Maintenance Supervisor confirmed Logbook Documentation- Nurse Call System Test for room 214-A and 214-B was not tested [DATE] and stated the room was being remodeled at that time. He further stated the room was not occupied with any residents at the time of remolding. During observations on 6/26/17 at 12:15 p.m., all of the resident bed call lights were checked on the A-hall. Further observation revealed that all of the call lights were functional, except for 111-A and 111-B, which did not activate the nurse call system when the button was pressed (the B-bed in room 111 was not occupied by a resident). During observation and interview with resident (R) Q in room 111-A at this time, she demonstrated that she knew how to call the nurse by pressing the call button, and stated that she would punch this thing to summon staff. During further interview, she stated that she had not had a problem with staff responding when she needed assistance. During interview with Licensed Practical Nurse (LPN) FF on 6/26/17 at 3:30 p.m.,she verified that the call lights for beds 111-A and 111-B were not functional, and that she would notify Maintenance.",2020-09-01
610,COMER HEALTH AND REHABILITATION,115289,2430 PAOLI ROAD,COMER,GA,30629,2019-08-08,600,D,0,1,CFQQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to assess cognitively impaired residents related to inappropriate sexual behavior for 3 residents (R) (R#75, R#61, and R#43). The census was 102 residents. Findings Include: Review of the Minimum Data Set Quarterly review dated 7/2/19 for R#75 revealed a Basic Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. Mood with a total severity score of zero indicating no mood disorder. Behavior of wandering daily. Functional Status of limited one-person assistance with bed mobility, transfers, dressing, bathing, and moving off and on the toilet and personal hygiene; Not steady but able to stabilize without human assistance for walking. Frequently incontinent of bowel and bladder. Active [DIAGNOSES REDACTED]. Medications of an antianxiety and antidepressant 7 out of 7 days a week. Review of the Care Plan for R#75 revealed he is at risk for mood/behavior problems, has a history of compulsive disorder with inappropriate sexual behaviors, and rejects care at times. R#75 has a [DIAGNOSES REDACTED]. Interventions include: R#75's behavior will not adversely affect self or others through next review date. Explain procedures/cares prior to beginning. If patient is upset leave and allow time to calm, then approach and offer again later. Notify MD of changes in status as needed. Observe patient for inappropriate behaviors. Provide meds as ordered and observe effectiveness. Psychiatric consult as needed. Redirect patient as needed. The following nurse notes from 7/21/18- 4/13/19 revealed: On 7/21/18, it was reported by staff that R#75 was touching another resident (R#61) inappropriately. Resident was redirected successfully (Completed by LPN AA). On 9/10/18 reads: Another resident (R#43) reported that over weekend R#75 came into her room while she was brushing her teeth and urinated in toilet and shook his penis at her. He wanders into other rooms during day and at night. (Completed by LPN AA). On 10/12/18 nurse note reads: R#75 up walking, nurse took him back to room, she put him on bed, and he grab her between the legs. Nurse instruct R#75 not to do that it was wrong. He told her to go to hell. (Completed by LPN JJ) On 2/15/19 nurse note reads: Found R#75 in R#61's room. R#61 was sitting in her wheel chair and R#75 was standing in front of her with his pants unbuttoned and unzipped. Refused to leave room. Was fighting staff. (Completed by LPN II). On 3/3/19 nurse note reads: R#75 had sexual behaviors during shift. He had another resident (R#61) hand on him and was using it to rub himself. He had other behaviors of this kind during day. R#75 redirected and other resident (R#61) moved to another location. Will continue to monitor R#75 during day. (Completed by LPN AA). On 3/19/19 nurse note reads: Yesterday resident followed CNA around the building and tried to get her to kiss him. Inappropriate actions. Resident difficult to redirect at that time. (Completed by Director of Nursing (DON)). On 3/27/19 nurse note reads: R#75 has been up since 3:30 a.m. walking around and then sitting in dining room. He became frisky with a lady (R#61) from b hall. Asked patient to leave her alone, he stopped, then later a Certified Nursing Assistant (CNA) came to separate him from her. (Completed by LPN JJ) . Review of the medical record for R#75 revealed the 4/13/19 nurse note reads: About 2:55 p.m. R#75 pulled his penis completely out of his pants in front of nursing station beside another resident (R#61). (Completed by LPN AA). During an observation on 8/6/19 at 10:50 a.m. R#75 was observed wandering down the 200 hall. He was observed to try and exit through the door to the outside at the end of the hall. R#75's wander guard locked the door and prevented him from exiting. The maintenance supervisor was observed redirecting R#75 momentarily then he was observed to turn and walked back over to the door and stare out the window on the door but did not attempt to open the door this time. R#75 was observed to stand at the door for a minute then a staff member brought him back down to the nurses station to the bench. During an interview on 8/6/19 at 11:00 a.m. with LPN AA she stated that R#75 has ongoing sexual behaviors and cannot have [MEDICATION NAME] (hormone)because it was tried in the past and he developed a blood clot. She stated that all that is being done at this point is monitoring and redirecting him when he has sexually inappropriate behaviors. Nurse stated that, prior to R#75 and R#61's decline, they liked each other and she, R#61, liked for R#75 to touch her. She stated that R#61 would look around and see if anyone was looking, place a hat or a sweater over her lap while R#75 placed his hand underneath, so they didn't get caught. She stated we try to put them in areas where they aren't so close together. LPN AA stated that R#75 goes in and uses other resident's bathrooms, but she has never saw or heard of him going into a room and then have a sexual abuse complaint made on him. She stated that they have placed STOP signs across some of the doors to prevent Residents who wander from going into rooms that aren't theirs and it has really helped with R#75. She stated in the last few months he has tried kissing staff but does not feel he is a danger or would hurt anyone. LPN AA stated that the incident on 4/13/19 R#75 was at the nurse's station and R#71 was sitting in a wheelchair in front of him. She stated she observed R#75 to have his penis out, his back arched with his hips protruding forward toward R#61's face. She stated she reported this incident to the Resident Care Coordinator (RCC) for the 100 hall and to the RCC for the 200 hall. LPN AA stated that she put in the Nurse Practitioner (NP) book for her to see R#75 when she came in for increased behaviors but did not notify the daughter, call the Medical Doctor (MD), or the NP. During this time the behaviors for R#75 was reviewed on the Electronic Medication Administration Record [REDACTED]. On 3/2/19 LPN AA had documented 4 sexual behaviors but there was no documentation as to what kind of sexual behavior was observed. She stated all that is documented is how many behaviors and if the medication worked or not, but they do not document the type of sexual behavior the resident exhibited. She stated that on 3/3/19 she must not have gone back and documented that R#75 had a behavior that day. LPN AA stated that on 3/15/19 the NP increased R#75's [MEDICATION NAME] (used for depression,obsessive-compulsive behavior) due to increased sexual behaviors. She stated she doesn't remember if she reported the incident on 3/3/19. During an interview on 8/6/19 at 11:49 a.m. with CNA CC she stated that when she sees R#75 having sexually inappropriate behaviors, she will redirect him and tell him he can't do that and ask him to keep his hands to himself. She stated she then will separate him from the person he is touching. She stated she has only been here for 2 months and has not had any in-services regarding sexual behaviors and how to approach that as a care giver. CNA stated that she witnessed R#75 touch a female resident's leg in front of the nurse's station and Medical Records (MR) staff DD quickly redirected him. During an interview on 8/6/19 at 11:50 a.m. with CNA BB she stated if she sees R#75, who wanders and/or has sexually inappropriate behaviors, she will tell him his behavior is not appropriate and try to take him out of the situation. She stated she will report it to the charge nurse. CNA BB stated that R#75 will usually listen to her and might get upset but he will usually come back and apologize. She also stated that they get the Hand in Hand training for abuse and dementia and have on-line courses and town hall meetings where different people will talk to them about abuse and other things. CNA BB stated that R#75 usually has inappropriate behaviors towards other female residents. During an interview on 8/6/19 at 11:53 a.m. with MR DD revealed she had to redirect R#75 a month ago and she cannot remember the resident he was being inappropriate with, but he was blowing kisses and said, I'll get you girl. She stated she told R#75 he can't do that and then stated she took him to the dining room. She stated that she has had in-services on how to intervene and redirect with any resident exhibiting any behaviors from fighting, yelling, and sexual behavior. During an interview on 8/6/19 at 11:55 a.m. with CNA EE revealed if he sees a resident wandering in and out of other resident's rooms he tries to distract them and re-direct them. He stated they have a man here who wanders and has inappropriate behaviors and if he sees the resident doing this, he reports it to the Unit Manager (UM) or the DON. He stated he has been at the facility for five months and did receive the Hand in Hand training when he was hired which talked about dementia and abuse. During an interview on 8/6/19 at 12:30 p.m. with CNA EE, he verified the male resident he was talking about that wanders and has inappropriate behaviors is R#75. During an interview on 8/6/19 at 12:05 p.m. with the Administrator and the DON, they were asked to read the nurse notes dated 4/13/19, 3/27/19, 3/19/19, 3/3/19, 2/15/19, 10/12/18, 9/10/19, and 7/21/19. The DON stated she feels sure that LPN AA told she and the Administrator about the incident on 3/3/19. They stated the documented behavior is a common behavior for R#75. The Administrator stated they have placed STOP signs over the doors of the women he, R#75, likes to assist in stopping him from going into their room. He stated because R#75 wanders, the staff try different things like take him outside, do one on one with him, and stated they placed a bench at the nurse's station because he likes to sit there and it helps staff be able to monitor him more closely. The DON stated she does not know why residents name has not been seen by Psych services since (MONTH) of (YEAR) but added he has an appointment for some time in August. She stated for the incident related to 4/13/19 LPN AA most likely reported this to the RCC for the 100 hall but it was not reported to her. She stated that the families of R#61 and R#43 who have had sexual inappropriate behaviors toward them by R#75 were not notified and the daughter of R#75 was not notified. Administrator stated that the facility would have notified the family for R#75 for any falls or change in condition, things like that, but their policy is to notify the family of both parties and the physician. DON stated that she would expect any out of the ordinary behaviors for R#75 to be documented but, if it is the same sexual behavior as always, she would not expect them to document every single one of those behaviors. She stated that the relationship between R#75 and R#61 was consensual. She stated they knew each other a long time ago when they went to school together and reconnected here. The Administrator stated the staff have had Dementia training, and some of the monthly required training has some abuse and other things that are related to Dementia. He stated they have a monthly Town Hall Meeting where the topic is generalized, and they discuss a little of everything. He stated that they do not mention any names of any resident but sometimes a staff member may mention an incident. He stated he remembers R#75 being mentioned but cannot recall the specifics. The DON stated when R#75 is sexually inappropriate his nurse reports the behavior to the RCC then she in turn reports it at the morning meeting the following morning. She stated she would not expect staff to call the NP but put the incident in the NP book and have her see them on Monday morning. The Administrator stated that he defines the word Frisky, mentioned in the nurse note on 3/27/19 to be flirty. He stated that he began working at this facility in 2011 as a floor tech and R#75 was here at that time and he has always known R#75 to be flirty. He stated that he interprets the separation of the residents on 3/27/19 to mean that staff felt the need to separate the residents so nothing more happened. He stated he does not recall this incident being reported. Administrator stated that the incident on 2/15/19 was typical for R#75 because he will leave his zipper undone after using the restroom. The DON stated there was no background check done on R#75, prior to his admission, because he was admitted (MONTH) 2014 and the current owners took over in (MONTH) 2014 and that is when all new residents began receiving background checks. The DON stated that the facility will protect the other residents from R#75's inappropriate behavior with global education. The Administrator stated that they are using STOP signs and that seems to work for R#75. DON stated that most residents call R#75 by name and tell him to leave right away when he comes into their room. She and Administrator both agree that R#75 coming into other resident's room is more of an aggravation and they have not had any complaints that other residents fear him. Administrator stated that, knowing R#75, he would not consider any of the documented incidents to be abuse except for possibly 3/3/19. The DON stated that there is no specific monitoring in place for R#75. The Administrator stated that none of the incidents have been reported to the State Agency and stated he is the Abuse Coordinator. He stated, by reading from the Facility Abuse Policy, that sexual harassment, sexual coercion, and sexual assault is defined as abuse but stated he would only consider the documented incident on 3/3/19 cause to further investigate but stated, knowing R#75, none of this jumped out at him enough to concern him that further investigation was needed. During an interview on 8/6/19 at 5:00 p.m. with the DON she stated by consensual she means that they had a touchy feely relationship and gave the example that R#61 would cover her lap with a purse or sweater and allow R#75 to continue to do whatever to her that he does. During a telephone interview on 8/6/19 at 1:59 p.m with the CEO of Psych Services revealed they work with the facility for ongoing clinic. She stated R#75 had not been scheduled for Services at the clinic since (MONTH) (YEAR). CEO stated she would like for the facility to notify them and inform them on any behaviors/changes in the resident and stated the facility will set up the clinics by giving the care now services a list of residents to be seen by psych services. She stated if the facility doesn't schedule a clinic for a resident then services aren't provided. CEO stated the initial assessment for R#75 was in (YEAR) and the reason was for inappropriate behaviors. An associate of Psych Services, also on the call, stated she calls the facility every month and the facility have regular clinics as requested per the facility. She stated the process of care now services tele-psych is typically held on Tuesday and Thursday weekly. She stated the facility NP reviews the resident's medical records to include medications, labs, and Medication Administration Record [REDACTED]. Associate stated R#75 has an appointment with the tele-psych on (MONTH) 16, 2019. During a telephone interview on 8/6/19 at 2:22 p.m. with the Daughter of R#75 she stated R#75 has been in the facility for 5 1/2 years and she visits him 2 - 3 times per week. She stated she is very happy with her Father's care thus far and the facility will contact her of any changes or concerns with her father including falls, hospitalization s, infections, changes in medications, or behaviors. She stated to her knowledge her father does not have any infections, pressure sores, or has fallen recently but her father tends to wander around the building and try to get outside. Daughter stated that her father can become very agitated at times and occasionally will get physical. She stated she is invited to the family care plan meetings quarterly and her last meeting was last week, (MONTH) 29th and during the meeting there was no mention of sexual or inappropriate behaviors exhibited by her father. She stated that during the meeting they stated, R#75 is being R#75 and he has not had any changes in status and is doing well. Daughter stated that the people in attendance for her father's care plan meeting was the two social services ladies, dietary, his CNA for the week, and his nurse for the week. She stated if there are any changes in her Father or any incidents that involve him, she would expect to be notified and in fact always stresses to staff, especially his nurses, to contact her if there are any issues because she is always available 24/7. Daughter stated that she had not been contacted in the last 6 months regarding any sexual or inappropriate behaviors that her Father was displaying but stated she was contacted over a year ago regarding her father being fresh with females in the facility but she has not been informed of any of the documented incidents of her father displaying sexual or inappropriate behaviors. She stated that she would expect to have been contacted about them and it mentioned during the care plan meeting. She stated she assumed that her father had not displayed anymore sexual or inappropriate behaviors since she was last notified 1 year ago. Daughter stated she does not want anyone else's rights in the facility to be infringed upon and wants her father to be comfortable as well. She stated that her Father has not received Psych or therapy services since he has been in the facility and stated she has not been contacted about referring her Father to Psych or therapy services but would not be opposed to her father receiving psych services if it meant ensuring the safety of others and himself. Daughter stated she is very involved in her father's care and the medications that he is being prescribed ad stated a few years ago she requested for them to reduce some of his medications for dementia because she felt that he was being over medicated but has not had that problem recently. During an interview on 8/6/19 at 1:57 p.m. with the Administrator and the DON. The Administrator was asked: At what point would you get concerned for your female residents related to the sexual behaviors of R#75? The Administrator stated that if the sexual behaviors got to the point of being more widespread for other female residents that he would be concerned, or if there was a change in the type of behavior R#75 was having he would be concerned. He stated that right now R#75's behaviors were pretty much isolated to R#61, whom he has had a relationship with for quite a while. He stated he would take each incident case by case, and if there was an increase in behaviors or a change in the type of behavior, he would address it. He stated that he felt that they had a pretty good reporting system. When the Administrator was asked if it had to be an increase in behaviors, wouldn't even one sexual behavior be too many? He stated that he was not notified of all the incidents brought to his attention by the survey team, and/or the staff did not give enough details of the incidents for him to be concerned, such as what part of the body the resident was rubbing on 3/3/19. He stated that R#75 was just being R#75. He stated that if he had known all the details of the incident on 3/3/19, that he would have done a self-report to the State. The Administrator further stated that from what he had learned today, that his plan was to re-educate the staff on reporting, and on sexual abuse. He stated that he felt the staff had just gotten used to R#75's sexual behaviors and had become lax at reporting them. He stated that there needed to be more of an evaluation of each incident to know all the details. He stated that a (psych) evaluation would be appropriate, and referral to inpatient psychiatric services would be considered. He stated that R#75's behavior was discussed with the daughter in care plan meetings, and that the daughter wanted to keep her father here. He said that another care plan meeting needed to be held not only with R#75's family, but with R#61's family as well. The Administrator further stated that if R#75's needs could not be met here, that he would have to be sent out to another facility. During an interview on 8/6/19 at 2:16 p.m. with the ADON she verified that she did the psych scheduling, which she stated was done by Tele-Health (remotely) and not directly in the facility. She stated that the Tele-Health was usually done every other month, and that the psych service company would send her a list of residents on their services and when they were last seen. She stated that she thought R#75 was recommended to be seen by the psych service every 1 to 4 months, but that they have had a heavy schedule of other residents that needed to be seen and verified R#75 had not been assessed by psych since (MONTH) (YEAR). She stated that she tried to schedule the psych reviews with the residents with the oldest follow-up reviews to be seen first, and then any residents that were currently having behavioral issues. She stated that psych services had contacted her today to schedule the next group of residents to be seen, and that R#75 was on the list to be seen 8/16/19 at 1:00 p.m. During an interview on 8/6/19 at 2:29 p.m. with the Administrator he stated he has already educated first shift on sexual abuse. He stated he felt that what staff had reported to him was not abuse due to the lack of information given to him but when he processes this in his mind, after getting more of the details, he will probably go ahead and do a thorough investigation and a self-report for the incident on 3/3/19, which stands out most to him. He stated at this point, any sexual behavior would be reported to the physician and stated if he had more information about the incidents brought to his attention today, he would have contacted psych services to see R#75. Administrator stated any physical touching would be considered two types of abuse: physical and sexual. He stated R#75's flirtatious comments would have to be taken on a case by case basis but had staff made him aware that R#75 was showing his penis to another resident, he would have contacted psych, but that no detailed information had been given to him. He stated that staff had become complacent in R#75's behaviors, and that R#75 was being R#75; they were just used to him being like that. During a telephone interview on 8/6/19 at 2:45 p.m. with the Medical Director, and R#75's physician, he stated he was aware of R#75's behavior in (MONTH) 2019 and that his NP saw R#75 and increased his [MEDICATION NAME]. Medical Director further stated he wasn't aware that R#75 had exposed himself to a female resident or took a female resident's hand and rubbed his groin area with it. He stated he was aware that R#75 had been seen by psych services in (MONTH) and he spoke with the facility today and asked them to put him back on the psych schedule. He also stated he had spoken to the Unit Manager today and had ordered a low dose of [MEDICATION NAME] for R#75 as well. During a telephone interview on 8/6/19 at 3:30 p.m. with the NP she stated that if there is a concern she needs to address the nurses put that information in the book and when she comes in on Mondays she reviews the book and see's the residents. She stated the nurses put the name of the resident, their concerns and she then see's the resident. NP stated that staff told her R#75 was exhibiting sexually inappropriate behaviors but stated that she was not aware he was touching residents or pulling out his penis or she would have ordered a Psych consult and check to see if he had a urinary tract infection to see if this was causing his increased behaviors. She stated she would also check the side effects of each of his medications as well as any possible interactions and after she had collected all the information, she would discuss the situation with the Medical Director, and physician for R#75, but would definitely tell the facility to stick to their policies. She stated if R#75's behavior is repetitive it wouldn't be inappropriate to send him out, but she doesn't know what their policy is for that. NP stated if the staff had called her with these concerns about R#75 she would not have objected to sending him out if that is what they wanted to do but stated she honestly would not expect staff to have called her for behaviors documented on 3/3/19 and 4/13/19 but would have expected them to put s note in the book for her to see the resident on her next visit. During an interview on 8/7/19 at 12:32 p.m. with the Administrator, DON, and the Corporate Nurse the Administrator stated that his definition of sexual relationship as it relates to R#75 and R#61 is one of boyfriend and girlfriend, holding hands, kisses on the cheek, putting his arm around her, and stated it has never been any more than that. He stated that they have never been in bed together and no sexual intercourse. The Administrator stated, regarding R#61 pulling a sweater or hat over her lap to hide the hand of R#75, he doesn't recall an incident like that, and he hasn't witnessed that but stated he is sure it was just hands on her clothing underneath the hat or sweater. The DON stated that R#75 did not put his hand down in her (R#61's) clothing but just under the sweater or the hat she pulled over her lap. Administrator stated that the incident on 4/13/19 was inappropriate behavior but couldn't say if it was sexual without doing an investigation, he stated the incident on 3/27/19 was flirting and described the term frisky as nudging, putting his arms around someone, saying things like, Hey pretty lady but he would not consider that being sexually inappropriate, Administrator stated the incident on 3/19/19 he would also consider flirtatious and would not consider that sexual abuse and stated out of all the nurses notes brought to his attention today the only one that stands out to him as a possibility would be 3/3/19. During an observation on 8/7/19 at 1:00 p.m. R#75 was observed to wander into the conference room and stand in the doorway. A staff member immediately came in and redirected him back out to the nurses station. Review of the facility Abuse Policy dated (MONTH) 2019 revealed sexual harassment, sexual coercion, and sexual assault is defined as abuse. Review of the Associate Recognition Programs within the Facility, example of orientation revealed, on hire, employees have (including but not limited to) Patient's Rights, Abuse Reporting, and Elder Justice Act. 2. Review of resident (R) #61's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of a hospital History and Physical dated 8/6/19 revealed that R#61 had severe dementia at baseline. Review of a Monthly Nursing Summary dated 7/19/19 revealed that R#61's cognition varied throughout the day, and she was disoriented to place, situation, and time. Further review of this Summary revealed that she had short term and long term memory problems, had delusions, wandered and intruded on others, and had poor safety awareness. Review of a Social Services Quarterly assessment dated [DATE] revealed very close, supportive, regular interaction with family and friends, but no mention of any type of relationship with R#75. Review of R#61's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicates that the staff conducting the interview was unable to complete one or more questions of the interview. Further review of this MDS revealed that a staff assessment for mental status was done, and they assessed R#61 as having short-term and long-term memory problems, and moderately impaired cognitive skills for daily decision making. Further review of the Cognitive Patterns section of the MDS revealed that R#61 had disorganized thinking, the severity of which fluctuated. Review of R#61's care plans last reviewed on 5/9/19 revealed: (R#61) has severe cognitive impairment related to Alzheimer's dementia. She is noted with confusion, disorientation, and forgetfulness. She has a history of wandering which has declined due to her decline in functional mobility. Her mental status is noted to vary throughout the day. (R#61) has impaired communication skills related to Alzheimer's dementia. She is noted with confusion and disorientation. Her speech rambles and she has difficulty in finding the right words or making sentences. She sometimes understands and is sometimes understood. Interventions to this care plan revealed one to maintain a consistent, relaxed environment and encourage social contact with people. (R#61) has a history of wandering which has declined due to her decline in functional mobility. She is at risk for injury related to impaired safety awareness. Review of the interventions to this care plan revealed to observe for patient's location to ensure safety. (R#61) is a risk for mood/behaviors related to [DIAGNOSES REDACTED]. (R#61) is invited and attends group activities. She attends church, music, Bingo, bean auction, food socials and special events. She also enjoys spending time with her husband who is also a resident in this facility and another male friend who is also a resident in this facility. She interacts well with others and is very friendly. She doesn't play bingo anymore R/T (related to) cognitive deficit. Review of the interventions to this care plan revealed to encourage family/friend involvement and socialization. Review of R#61's electronic health record (EHR) Nurse's Notes from (MONTH) (YEAR) to 8/6/19 revealed no documentation of any physical contact with R#75. Review of R#75's Nurse's Note dated 2/15/19, completed by Licensed Practical Nurse (LPN) II, revealed that he was in R#61's room. Further review of this Nurse's Note revealed that R#61 was sitting in her wheelchair, and R#75 was standing in front of her with his pants unbuttoned and unzipped, he refused to leave room and was fighting staff. During interview with LPN II on 8/7/19 at 8:47 a.m., she stated that R#61 and R#75 stayed together all the time, and that R#75 had sexual behaviors that they had to monitor all the time, including between him, R#61, and the staff. She further stated that to the best of her recollection, she observed R#75 in close proximity to R#61 in her room on 2/15/19 with his pants unzipped, but did not remember any direct physical contact. During interview with the Administrator on 8/6/19 at 1:57 p.m., he stated that he would be concerned if R#75's behaviors changed or were more widespread to other female residents, but that right now his behaviors were pretty much isolated to R#61, for whom he has had a relationship with for quite a while. The Administrator further stated that he was not aware of the details of all the interactions between R#75 and R#61 for him to be concerned, and thought that (R#75) was just being (R#75). The Administrator stated during continued interview that R#75's behavior had been discussed with his responsible party (RP) in care plan meetings, but that another care plan meeting to discuss R#75's behaviors needed to be held not only with R#75's RP, but with R#61's RP as well. During interview with the Assistant Director of Nursing (ADON) on 8/6/19 at 2:16 p.m., she verified that she scheduled the residents to be seen by the facility's TeleHealth (remote) psychiatric services provider, and thought that R#75 was recommended to be assessed by psychiatric services every one to four months. The ADON further stated that they have had a heavy schedule of residents that needed to be seen by psych services, and she was scheduling the residents that were furthest behind in their reviews. She verified that R#75 had not been seen by the psychiatric provider since (MONTH) of (YEAR). During interview with the Social Services Director and Social Worker/Admission Director on 8/7/19 at 9:30 a.m., they stated that R#61's last c (TRUNCATED)",2020-09-01
611,COMER HEALTH AND REHABILITATION,115289,2430 PAOLI ROAD,COMER,GA,30629,2019-08-08,607,D,0,1,CFQQ11,"Based on record review, staff interview, and review of the policy Reporting and Investigating Abuse the facility failed to report documented sexually inappropriate behaviors for one resident (R) (R#75) to the Abuse Coordinator. The census on 8/5/19 was 102 residents. Findings include: Review of the medical record for R#75 revealed the following incidents of inappropriate sexual behavior: On 7/21/18 nurse note reads: It was reported by staff that R#75 was touching another resident (R#61) inappropriately. Resident was redirected successfully (Completed by LPN AA). 9/10/18 nurse note reads: Another resident (R#43) reported that over weekend R#75 came into her room while she was brushing her teeth and urinated in toilet and shook his penis at her. He wanders into other rooms during day and at night. (Completed by LPN AA). 10/12/18 nurse note reads: R#75 up walking, nurse took him back to room, she put him on bed, and he grab her between the legs. Nurse instruct R#75 not to do that it was wrong. He told her to go to hell. (Completed by LPN JJ) 2/15/19 nurse note reads: Found R#75 in R#61's room. R#61 was sitting in her wheel chair and R#75 was standing in front of her with his pants unbuttoned and unzipped. Refused to leave room. Was fighting staff. (Completed by LPN II). 3/3/19 nurse note reads: R#75 had sexual behaviors during shift. He had another resident (R#61) hand on him and was using it to rub himself. He had other behaviors of this kind during day. R#75 redirected and other resident (R#61) moved to another location. Will continue to monitor R#75 during day. (Completed by LPN AA). 3/19/19 nurse note reads: Yesterday resident followed CNA around the building and tried to get her to kiss him. Inappropriate actions. Resident difficult to redirect at that time. (Completed by Director of Nursing (DON)). 3/27/19 nurse note reads: R#75 has been up since 3:30 a.m. walking around and then sitting in dining room. He became frisky with a lady (R#61) from b hall. Asked patient to leave her alone, he stopped, then later a Certified Nursing Assistant (CNA) came to separate him from her. (Completed by LPN JJ) . 4/13/19 nurse note reads: About 2:55 p.m. R#75 pulled his penis completely out of his pants in front of nursing station beside another resident (R#61). (Completed by LPN AA). During an interview on 8/6/19 at 11:00 a.m. with LPN A[NAME] She stated she reported the incident on 4/13/19 to the Resident Care Coordinator (RCC) for the 100 hall and to the RCC for the 200 hall. LPN AA stated that she put in the Nurse Practitioner (NP) book for her to see R#75 when she came in for increased behaviors but did not notify the daughter, call the Medical Doctor (MD), or the NP. She stated she doesn't remember if she reported the incident on 3/3/19. During an interview on 8/6/19 at 11:50 a.m. with CNA BB she stated if she sees R#75, who wanders and/or has sexually inappropriate behaviors, she will tell him his behavior is not appropriate and try to take him out of the situation. She stated she will report it to the charge nurse. CNA BB stated that R#75 will usually listen to her and might get upset but he will usually come back and apologize. She also stated that they get the Hand in Hand training for abuse and dementia and have on-line courses and town hall meetings where different people will talk to them about abuse and other things. CNA BB stated that R#75 usually has inappropriate behaviors towards other female residents. During an interview on 8/6/19 at 11:55 a.m. with CNA EE revealed if he sees a resident wandering in and out of other resident rooms, he tries to distract them and re-direct them. He stated they have a man here who wanders and has inappropriate behaviors and if he sees the resident doing this, he reports it to the Unit Manager (UM) or the DON. He stated he has been at the facility for five months and did receive the Hand in Hand training when he was hired which talked about dementia and abuse. During an interview on 8/6/19 at 12:30 p.m. with CNA EE, he verified the male resident he was talking about that wanders and has inappropriate behaviors is R#75. During an interview on 8/6/19 at 2:29 p.m. with the Administrator he stated at this point, any sexual behavior would be reported to the physician and stated if he had more information about the incidents brought to his attention today, he would have contacted psych services to see R#75. Administrator stated any physical touching would be considered two types of abuse: physical and sexual. He stated R#75's flirtatious comments would have to be taken on a case by case basis but had staff made him aware that R#75 was showing his penis to another resident, he would have contacted psych, but that no detailed information had been given to him. He stated that staff had become complacent in R#75's behaviors, and that R#75 was being R#75; they were just used to him being like that. Upon review of the grievances by the Administrator there had been no grievances filed regarding sexually inappropriate behavior by R#75. Review of the policy Reporting and Investigation Abuse dated (MONTH) (YEAR) revealed it is the intent of this Center to establish standards of practice for investigation and reporting abuse, neglect, mistreatment, exploitation, and misappropriation of property. There was no documentation by the Facility that the sexual inappropriate behaviors of R#75 was reported to the Abuse Coordinator.",2020-09-01
612,COMER HEALTH AND REHABILITATION,115289,2430 PAOLI ROAD,COMER,GA,30629,2019-08-08,657,D,0,1,CFQQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update and revise the person centered comprehensive care plan for 2 Residents (R) (R#75 and R#61) related to sexual behaviors. The sample size was 35 Residents. Findings Include: 1. Minimum Data Set Quarterly review dated 7/2/19 for R#75 revealed a Basic Interview for Mental Status (BIMS) score of 99 indicating severely impaired cognition. Mood with a total severity score of zero indicating no mood disorder. Behavior of wandering daily. Functional Status of limited one-person assistance with bed mobility, transfers, dressing, bathing, and moving off and on the toilet and personal hygiene; Not steady but able to stabilize without human assistance for walking. Frequently incontinent of bowel and bladder. Active [DIAGNOSES REDACTED]. Medications of an antianxiety and antidepressant 7 out of 7 days a week. Review of the Care Plan for R#75 revealed he is at risk for mood/behavior problems, has a history of compulsive disorder with inappropriate sexual behaviors, and rejects care at times. R#75 has a [DIAGNOSES REDACTED]. Interventions include: R#75's behavior will not adversely affect self or others through next review date. Explain procedures/cares prior to beginning. If patient is upset leave and allow time to calm, then approach and offer again later. Notify MD of changes in status as needed. Observe patient for inappropriate behaviors. Provide meds as ordered and observe effectiveness. Psychiatric consult as needed. Redirect patient as needed. During an interview on 8/6/19 at 12:05 p.m. with the Administrator and the DON, the DON stated that if a new intervention was tried with R#75's behaviors his care plan should have been updated but stated there is a care plan in place related to his sexual behaviors. She stated that each intervention is dated according to the time it was implemented but she would not expect each incident with R#75, being sexually inappropriate, to be placed on the care plan. The Administrator stated that there is Patient At Risk (PAR) note on 3/15/19 stating the [MEDICATION NAME] dose for R#75 was increased for increased sexual behaviors toward staff and other residents but there are no recommendations on the PAR. The DON stated that in the PAR meetings the nurse, usually the MDS nurse, would be responsible for updating the care plan. She stated in (MONTH) the intervention that should have been added to R#75's care plan is Review Medications, but upon review of the Care Plan it was not added. During this time the DON verified that the Care Plan has not been updated or revised since (MONTH) (YEAR). Review of the policy Patient's Plan of Care dated (MONTH) (YEAR) revealed it is the intent of this center to develop and maintain an individualized plan of care for each patient. Number 4 states: PAR- the care plan should be updated during the PAR meetings. 2. Review of resident (R) #61's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#61's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99, which indicates that the staff conducting the interview was unable to complete one or more questions of the interview. Further review of this MDS revealed that a staff assessment for mental status was done, and they assessed R#61 as having short-term and long-term memory problems, and moderately impaired cognitive skills for daily decision making. Further review of the Cognitive Patterns section of the MDS revealed that R#61 had disorganized thinking, the severity of which fluctuated. Review of R#61's care plans last reviewed on 5/9/19 revealed that they included severe cognitive impairment; impaired communication skills; wandering and impaired safety awareness; and risk for mood/behaviors related to [DIAGNOSES REDACTED].#61 enjoyed spending time with another male friend who was also a resident in this facility. Further review of all of the care plans revealed that there was no mention of any sexual behaviors between R#75 and R#61. Review of Care Plan Conference meeting notes dated 4/24/19, 11/14/18, 8/29/18, and 6/6/18 revealed that R#61 attended all the meetings except the one on 11/14/18, that the responsible party (RP) was invited but did not attend, and none of the notes mentioned any relationship between R#61 and R#75. During interview with the Social Worker/Admissions Director on 8/8/19 at 12:53 p.m., she verified that she spoke with R#61's RP yesterday, and the conversation included R#61's relationship with R#75. She verified that she did not discuss any sexual interactions or behaviors between the two residents, including R#75 pulling his penis out in front of R#61 (on 4/13/19), or R#75 putting R#61's hand on his pelvic area (on 3/3/19). The Social Worker/Admissions Director stated that she had never discussed the interactions between the two residents in detail with R#61's RP as to include the sexual behaviors. Cross-refer to F 600.",2020-09-01
613,COMER HEALTH AND REHABILITATION,115289,2430 PAOLI ROAD,COMER,GA,30629,2019-08-08,835,D,0,1,CFQQ11,"Based on record review, staff interview, and review of the facility's Abuse policy dated (MONTH) 2019 The Administrator failed to ensure cognitively impaired residents were assessed for appropriateness of sexual relationships and to ensure that relationships were carried out in a private setting for 2 residents (R) (R#75 and R#61). The census on 8/5/19 was 102 residents. Findings Include: Review of the medical record for R#75 revealed : 7/21/18 nurse note reads: It was reported by staff that R#75 was touching another resident (R#61) inappropriately. Resident was redirected successfully (Completed by LPN AA). 9/10/18 nurse note reads: Another resident (R#43) reported that over weekend R#75 came into her room while she was brushing her teeth and urinated in toilet and shook his penis at her. He wanders into other rooms during day and at night. (Completed by LPN AA). 10/12/18 nurse note reads: R#75 up walking, nurse took him back to room, she put him on bed, and he grab her between the legs. Nurse instruct R#75 not to do that it was wrong. He told her to go to hell. (Completed by LPN JJ) 2/15/19 nurse note reads: Found R#75 in R#61's room. R#61 was sitting in her wheel chair and R#75 was standing in front of her with his pants unbuttoned and unzipped. Refused to leave room. Was fighting staff. (Completed by LPN II). 3/03/19 hand on him and was using it to rub himself. He had other behaviors of this kind during day. R#75 redirected and other resident (R#61) moved to another location. Will continue to monitor R#75 during day. (Completed by LPN AA). 3/19/19 nurse note reads: Yesterday resident followed CNA around the building and tried to get her to kiss him. Inappropriate actions. Resident difficult to redirect at that time. (Completed by Director of Nursing (DON)). 3/27/19 nurse note reads: R#75 has been up since 3:30 a.m. walking around and then sitting in dining room. He became frisky with a lady (R#61) from b hall. Asked patient to leave her alone, he stopped, then later a Certified Nursing Assistant (CNA) came to separate him from her. (Completed by LPN JJ) . 4/13/19 nurse note reads: About 2:55 p.m. R#75 pulled his penis completely out of his pants in front of nursing station beside another resident (R#61). (Completed by LPN AA). During an interview on 8/6/19 at 12:05 p.m. with the Administrator and the DON, they were asked to read the nurse notes dated 4/13/19, 3/27/19, 3/19/19, 3/3/19, 2/15/19, 10/12/18, 9/10/19, and 7/21/19. Administrator stated the documented behavior is a common behavior for R#75. He stated they have placed STOP signs over the doors of the women he, R#75, likes to assist in stopping him from going into their room. He stated because R#75 wanders, the staff try different things like take him outside, do one on one with him, and stated they placed a bench at the nurse's station because he likes to sit there, and it helps staff be able to monitor him more closely. DON stated they, R#75 and R#61, knew each other a long time ago when they went to school together and reconnected here. Administrator stated that he defines the word Frisky, mentioned in the nurse note on 3/27/19 to be flirty. He stated that he began working at this facility in 2011 as a floor tech and R#75 was here at that time and he has always known R#75 to be flirty. He stated that he interprets the separation of the residents on 3/27/19 to mean that staff felt the need to separate the residents so nothing more happened. Administrator stated that the incident on 2/15/19 was typical for R#75 because he will leave his zipper undone after using the restroom. The DON stated that the facility will protect the other residents from R#75's inappropriate behavior with global education. She stated that most residents call R#75 by name and tell him to leave right away when he comes into their room. She and Administrator both agree that R#75 coming into other resident's room is more of an aggravation and they have not had any complaints that other residents fear him. Administrator stated that, knowing R#75, he would not consider any of the documented incidents to be abuse except for possibly 3/3/19. The DON stated that there is no specific monitoring in place for R#75. The Administrator stated that none of the incidents have been reported to the State Agency and stated he is the Abuse Coordinator. He stated, by reading from the Facility Abuse Policy, that sexual harassment, sexual coercion, and sexual assault is defined as abuse but stated he would only consider the documented incident on 3/3/19 cause to further investigate but stated, knowing R#75, none of this jumped out at him enough to concern him that further investigation was needed. During an interview on 8/6/19 at 1:57 p.m. with the Administrator and the DON. The Administrator was asked: At what point would you get concerned for your female residents related to the sexual behaviors of R#75? The Administrator stated that if the sexual behaviors got to the point of being more widespread for other female residents that he would be concerned, or if there was a change in the type of behavior R#75 was having he would be concerned. He stated that right now R#75's behaviors were pretty much isolated to R#61, whom he has had a relationship with for quite a while. He stated he would take each incident case by case, and if there was an increase in behaviors or a change in the type of behavior, he would address it. He stated that he felt that they had a pretty good reporting system. When the Administrator was asked if it had to be an increase in behaviors, wouldn't even one sexual behavior be too many? He stated that he was not notified of all the incidents brought to his attention by the survey team, and/or the staff did not give enough details of the incidents for him to be concerned, such as what part of the body the resident was rubbing on 3/3/19. He stated that R#75 was just being R#75. He stated that if he had known all the details of the incident on 3/3/19, that he would have done a self-report to the State. The Administrator further stated that from what he had learned today, that his plan was to re-educate the staff on reporting, and on sexual abuse. He stated that he felt the staff had just gotten used to R#75's sexual behaviors and had become lax at reporting them. He stated that there needed to be more of an evaluation of each incident to know all the details. He stated that a (psych) evaluation would be appropriate, and referral to inpatient psychiatric services would be considered. He stated that R#75's behavior was discussed with the daughter in care plan meetings, and that the daughter wanted to keep her father here. He said that another care plan meeting needed to be held not only with R#75's family, but with R#61's family as well. The Administrator further stated that if R#75's needs could not be met here, that he would have to be sent out to another facility. During an interview on 8/6/19 at 2:29 p.m. with the Administrator he stated he has already educated first shift on sexual abuse. He stated he felt that what staff had reported to him was not abuse due to the lack of information given to him but when he processes this in his mind, after getting more of the details, he will probably go ahead and do a thorough investigation and a self-report for the incident on 3/3/19, which stands out most to him. He stated at this point, any sexual behavior would be reported to the physician and stated if he had more information about the incidents brought to his attention today, he would have contacted psych services to see R#75. Administrator stated any physical touching would be considered two types of abuse: physical and sexual. He stated R#75's flirtatious comments would have to be taken on a case by case basis but had staff made him aware that R#75 was showing his penis to another resident, he would have contacted psych, but that no detailed information had been given to him. He stated that staff had become complacent in R#75's behaviors, and that R#75 was being R#75; they were just used to him being like that. Review of the Job Title : Administrator, revised 10/14, revealed the Administrator Job Description reads: Directs the day to day functions of the Nursing Center in accordance with current federal, state, and local regulations that govern long term care centers, and as may be directed by the Regional Vice President, to provide appropriate care for our patients. Under Essential Demonstration of Facility Core Values, the Administrator assumes responsibility for and honors patients' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints and, assumes responsibility for procedural guidelines relative to the prevention and reporting of patient abuse. Essential Managerial Functions of the Administrator include, but is not limited to, makes routine inspections of the Center to assure that established policies and procedures are being implemented and followed. Cross Reference F600",2020-09-01
614,"PLACE AT DEANS BRIDGE, THE",115290,3235 DEANS BRIDGE ROAD,AUGUSTA,GA,30906,2018-07-12,656,D,1,1,8DCC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and record review the facility failed to develop a Comprehensive Care Plan related to the use of a [MEDICAL CONDITION]/hypnotic (Ambien) medication for one resident (R) (R#65). The sample size was 18. Findings include: Record review revealed that R#65 was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of R#65 physician's orders [REDACTED]. Review of the Admission Care Plan dated 5/31/2018 revealed that the resident receives a hypnotic as needed. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident received a hypnotic all seven days of the assessment period. However, review of the Comprehensive Interdisciplinary Care Plan dated 6/6/18 revealed that there was not a care plan to address the residents use [MEDICATION NAME] interventions to monitor for possible complications.",2020-09-01
615,"PLACE AT DEANS BRIDGE, THE",115290,3235 DEANS BRIDGE ROAD,AUGUSTA,GA,30906,2018-07-12,758,D,1,1,8DCC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, and record review the facility failed to provide a rational for the continued use of a PRN (as needed) [MEDICAL CONDITION]/hypnotic (Ambien) past 14 days for one resident (R) (R#65). In addition, the facility failed to respond to a recommendation made by the Consultant Pharmacist to consider adding a rational and duration of the PRN order for the Ambien. The sample size was 18 residents. Findings include: Review of the facility policy Administering Medications (not dated) line 25. If a resident uses PRN medications frequently, the Attending Physician and Interdisciplinary Care Team (IDT) with support from the Consultant Pharmacist as needed, shall reevaluate the situation, examine the individual as needed, determine if there is a clinical reason for the frequent PRN use, a standing dose of medication is clinically indicated. Review of R#65 medical record revealed that the resident had a [DIAGNOSES REDACTED]. Review of her Physician's Orders revealed an order for [REDACTED]. Review of her Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident had received a hypnotic all seven days of the assessment period. Review of her baseline care plan dated 5/31/2018 revealed she received a hypnotic as needed for sleep. Review of her Comprehensive Interdisciplinary Care Plans, dated 6/6/18, revealed there was no care plan developed for the use of a hypnotic for sleep. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the document titled Consultant Pharmacist Communication to Physician dated 7/5/18 revealed the pharmacist recommended that the PRN order for [MEDICAL CONDITION] drugs are to be limited to 14 days. The physician's response on 7/9/2018 was to add a rational of chronic anxiety, [MEDICATION NAME] chronic [MEDICAL CONDITION] with a duration of six months. The resident continued with a PRN hypnotic order for 41 days. Interview on 07/11/2018 at 3:07 p.m. with the Director of Nursing (DON) confirmed that the document titled Consultant Pharmacist Communication to Physician dated 7/5/2018 was in the resident's medical record but a corresponding clarification order was not written to reflect the Physicians Order. Interview on 07/11/2018 at 3:48 p.m. with the Pharmacy Consultant revealed his expectations are that when he makes a recommendation, the Physician will either agree or disagree with his recommendation. A telephone interview on 07/11/2018 at 5:30 p.m. with the Owner and Pharmacist for the dispensing pharmacy revealed he verified that the resident was admitted on the [MEDICATION NAME] mg one tablet at HS PRN for sleep. He revealed according to the dispensing pharmacy policy titled Medication Orders Stop Orders that all PRN non-antipsychotic [MEDICAL CONDITION] will be automatically stopped at 14 days.",2020-09-01
616,"PLACE AT DEANS BRIDGE, THE",115290,3235 DEANS BRIDGE ROAD,AUGUSTA,GA,30906,2017-08-10,252,E,0,1,MZNF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the policy titled Serving Meals and staff interviews, the facility failed to ensure a homelike environment during dining. Specifically, the facility failed to remove the meal trays after delivering meals to 35 residents in the Main Dining room, in an effort to de-emphasize an institutional setting. The facility census was 73 residents. Findings include: Observation in the Main Dining room on 8/7/17 beginning at 11:55 a.m. revealed 32 residents seated at tables for lunch. At 12:05 p.m. the facility staff began serving the residents their meals on meal trays. The staff did not remove the meal trays when the meals were delivered to all 32 residents until the residents completed their meal. Further, the staff was not observed asking any of the 32 residents if they wanted the meal tray to remain in place. Observation in the Main Dining room on 8/8/17 at 12:00 p.m. revealed 31 residents seated at tables for lunch. All 31 residents were served their meals on a serving tray. The serving trays were not removed when the meals were delivered to all 31 residents and the staff was not observed asking any of the 31 residents if they wanted the meal tray to remain in place. The meals trays remained in place until they were picked up after the residents completed their meals. Observation in the Main Dining room on 8/10/17 at 12:11 p.m. revealed 35 residents seated at tables for lunch. All 35 residents had been served their meals on meal trays that were not removed. Interview on 8/10/17 at 12:15 p.m. with resident Y in the main dining room revealed he eats most all of his meals in the Main Dining room. The resident stated that the staff brings the meals on a serving tray and the tray is not removed. Resident Y stated the trays are not picked up until they are finished eating. Interview on 8/10/17 at 12:18 p.m. with the Activities Staff DD revealed she assist in the dining room almost every day. She stated that they serve the residents' meals on the meal trays and they do not remove the trays. Activities Staff DD further stated she did not know why they don't remove the trays, it has always been that way. Interview on 8/10/17 at 12:24 p.m. with Certified Nursing Assistant/Restorative Aide (CNA AA) revealed she has worked in the facility since (MONTH) (YEAR). CNA AA revealed that they do not remove the meals trays after serving the residents' their meals and it has been that way since she started working in the facility. CNA AA further stated that it had never been explained to her to remove the trays but that having the trays in place makes it easier to pick everything up at once rather than in separate pieces. Interview on 8/10/17 at 12:26 p.m. with the Dietary Manager (DM) revealed they have never removed the food items from the trays because it helps keep everything in place for the residents. The DM further stated that they have never gone to fine dining in which all the items on the tray would be removed. Interview on 8/2/17 at 12:32 p.m. with the Administrator revealed that for the past [AGE] years, they had never removed the meal trays when serving meals to the residents. The Administrator stated that it helps keep everything in place. She stated the meal cards remain on the tray and whichever staff member picks up a tray, they observe how much a resident ate and write it on the meal ticket. The meal tickets are then collected for the North and South Halls and the CNAs document the intakes of the residents in a book. Further interview with the Administrator, on the same day, at 1:39 p.m. revealed she reviewed the facility's policy for dining and it does not indicate to remove the food items from the meal trays. She stated a tray would be removed if something spilled on the tray and replaced with a clean tray. She stated they had never implemented fine dining in this facility which meant they would use table clothes, center pieces and remove all of the food items, plates, glasses, condiments and utensil from the tray. She stated fine dining would be more of a five star dining experience and they have never done that in this facility. The Administrator stated that they have not asked the residents in the past if they would like their food and items removed from the trays. The Administrator further stated that they have a policy for the dining room but the policy does not address the removal of meal trays. Review of the policy titled Serving Meals revised (MONTH) 2001 addresses Preparation, Equipment, Supplies, and Resident Rights. There is no documentation in the policy that addressed a homelike environment or ways to de-emphasize an institutional environment during dining. There is no documentation in the policy that addressed removal of meal trays once a meal had been served.",2020-09-01
617,"PLACE AT DEANS BRIDGE, THE",115290,3235 DEANS BRIDGE ROAD,AUGUSTA,GA,30906,2017-08-10,441,E,0,1,MZNF11,"Based on observation, staff interview and facility policy review. The facility failed to ensure that staff follow proper infection control guidelines when passing ice to residents on one (South) of two hallways. The facility census was 73. Findings include: Review of facility's Infection Control Prevention Manual for Long Term Care for Ice chests and Ice Machines (revised 2009) revealed: Policy: The following policy should be followed to reduce the likelihood of contamination of ice chest (ice-storage compartments) and ice machines. II. Ice scoops used should be smooth and impervious and should be kept on an uncovered stainless steel, impervious plastic or fiberglass tray on tope of the chest or in a mounted holder when not in use. Observation on 08/07/2017 11:45 am. Certified Nursing Assistant (CNA) BB passing ice on the south hall. Observed each time she filled a resident's cup with ice she would place ice scoop back into the ice chest on top of the ice to be given. Also noted CNA BB going from one room to the next with no indication of her rubbing her hands together to indicate that she had washed her hands or used sanitizer. Interview 08/07/2017 12:12 pm. with CNA BB when she returned ice chest to nurses' station revealed, when the ice chest was opened, the ice scoop lying on top of ice that was remaining in ice chest. Further interview with CNA BB stated that I'm supposed to place the ice scoop within the bag in the drawer underneath the ice chest. CNA BB further stated when she passes ice to just a few rooms that she just puts the scoop back into the ice chest between rooms then reported that she should have replaced scoop into bag between each resident. Interview 08/10/2017 4:57 p.m. with the Infection control nurse revealed that the staff are expected to wash their hands after each residents' cup is filled with ice and ice scoop is to be replaced within the plastic bag underneath ice chest between each use not inside ice chest. Interview 08/10/2017 5:09 pm. Director of Nursing (DON) Surveyor ask what her expectations are of her staff when passing ice. She stated that she expects them to wash their hands after filling each resident's cup with ice and use good infection control practice by placing the ice scoop within a plastic bag in the drawer underneath the ice chest between each use. She was unaware that CNA BB was not following this practice.",2020-09-01
618,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,580,D,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to notify the Physician of one newly admitted resident (R) Q until six days after the admission, of 47 sampled residents. Findings Include: Review of the clinical record for R Q revealed the resident was admitted to the facility on [DATE] with end stage [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITIONS] (CAD), pneumonia and history of [MEDICAL CONDITION]. Observation during initial rounds on 1/29/18 at 12:33 p.m., R Q complained to surveyor that she was having pain in her left big toe and foot. She stated she had pressed her call light for pain medicine, but she hasn't received anything yet. Further observation on the same day at 12:40 p.m., surveyor notified Licensed Practical Nurse (LPN) QQ of residents' request for pain medicine. Interview on 2/1/18 at 4:20 p.m., with primary Physician, stated that he was not aware that R Q was his resident at the facility, until the nurse notified him on 1/30/18, about the pain and discoloration of left big toe. He ordered a Doppler study to be done for R Q left lower extremity, and stated that given the information from facility staff about R Q's condition, he did not feel that R Q was in any harm by the delay in notification about her admission to the facility. He stated that this was the first time that staff had not notified him of a new admission. Phone interview on 2/1/18 at 7:25 p.m., with LPN NN, stated that the 7:00 a.m. to 3:00 p.m. nurse accepted report from the hospital about R Q. She was given a report on a new admission going to her assigned room. She stated that the orders usually arrive to the facility before the resident does. She stated as best she could remember the resident arrived around 5:45 p.m. She stated that the admitting nurse completes the head to toe assessment and documents in their electronic medical record (EMR). She stated the Unit Managers (UM) contact the Physician about new admissions and transcribes the Physician orders. She has on occasion been asked to notify the Physician about new admissions and to verify orders, but was not ask to do so for R Q. Interview on 2/1/18 at 7:30 p.m., with primary Physician, stated that he examined R Q's left foot and he felt like she may have an arterial compromise and that he was going to consult a Vascular Physician. He further stated that he did not feel R Q had any adverse outcome related to him not being being notified of her admission.",2020-09-01
619,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,644,D,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely obtain a Pre -Admission Screening and Review (PASRR) Level ll assessment and coordinate services for two residents, R #22 and R# 95, of 10 residents in a sample with [DIAGNOSES REDACTED]. Findings include: 1. R#22 was admitted on [DATE] with [DIAGNOSES REDACTED]. On 1/29/18 at 10:37 a.m. during record review, the surveyor was unable to locate PASRR ll information in the medical record of R#22. An interview with, Social Services Assistant (SSA)(AA), presented evidence of a PASRR level I dated 12/21/15. This document did not list any serious mental illness disorders. Further review of R#22 record revealed the resident was diagnosed with [REDACTED]. On 1/31/18 at 1:38 p.m. when asked what is the process for providing PASRR level ll assessments and/or services for a resident who initially was not admitted with a pertinent PASRR diagnosis, but now has one, the SSA was unable to provide a response. Further interview with SSA revealed R#22 was seen twice by psychiatric services on 8/31/17 and 9/28 17 for resistance to activities of daily living (ADLs). On 8/31/17 Resident was diagnosed with [REDACTED]. When asked why a level II had not been completed, especially since the resident has [DIAGNOSES REDACTED]. The Corporate Nurse was present during this interview and validated the resident should have had a level ll assessment completed. Review of resident's Brief Interview for Mental Status (BIMS) revealed his score has remained consistent with a score of 14 from the time of the Minimum Data Set (MDS) admission assessment dated [DATE] through his most recent annual MDS assessment dated [DATE]. Further review of resident record revealed resident #22 is receiving antipsychotic medications. R#22 is being monitored for behaviors. Per Medication Administration Records (MARs), resident has exhibited behaviors for 3 months. Facility policy titled Pre-admission Screening and Resident Review (PASRR) dated (MONTH) (YEAR) revealed that a resident currently diagnosed or with newly evident or possible mental disorder, intellectual disability, or a related condition are referred for level ll PASRR review upon significant change in status assessment. The document also stated that it's purpose is to ensure that individuals with mental disorder and intellectual disabilities receive the care and services they need in the most appropriate setting. Specialized Services are services that the State is required to arrange or provide to meet the needs of individuals who have been diagnosed with [REDACTED]. Specialized services are an add-on to nursing facility services. They are of higher intensity and frequency than specialized rehabilitation services. R#22 is not receiving these services. 2. On 1/31/18 review of the clinical record for R#95 reveals she was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Review of the current (MONTH) (YEAR) Medication Administration Record [REDACTED]. Review of R#95's care plan dated 1/7/17 and revised on 1/23/18 related to receiving medications for anxiety, depression, sleeplessness and antipsychotic drug use for [MEDICAL CONDITION]. Review of the Preadmission Screening/Resident Review (PASRR) Level 1 Assessment for R#95 dated 11/30/16, revealed the level one documentation pages three and four were left blank. There was no Level 2 PASRR in the clinical record for R#95. Interview on 1/31/18 at 12:30 p.m., with Director of Nursing (DON), stated she reviews all PASRR prior to admission to the facility. She further stated she does not do a reconciliation with admitting [DIAGNOSES REDACTED]. She stated it has not been something the facility has been doing. Interview on 1/31/18 at 12:30 p.m., with Corporate Director of Clinical Services JJ verified that facility was not assessing PASRR Level 1 residents for PASRR Level 2 services.",2020-09-01
620,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,656,D,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to individualize and implement a resident-centered care plan related to activities for one resident (R) (#5), and failed to follow the care plan related to the preferred television (TV) programming for one resident (R #48). In addition, the facility failed to follow the care plan related to the application of a soft splint for one resident (#5), and to assess for medication side effects related to the routine use of a laxative for one resident (#46). The sample size was 47 residents. Findings include: 1. Review of R #48's Preferences for Routine and Activities section of her Annual Minimum Data Set ((MDS) dated [DATE], which noted the primary respondent for the questions was the family or significant other, revealed that it was important, but can't do or no choice for the activities of having books, newspapers, and magazines to read; listen to music you like; be around animals such as pets; keep up with the news; do things with groups of people; do your favorite activities; go outside to get fresh air when the weather is good; and participate in religious services or practices. Review of R #48's care plans revealed a revision dated 12/14/17 which noted that she was independent/dependent (sic) for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and [MEDICAL CONDITION]. Review of the interventions for this care plan included that past television programming interests included Catholic and spiritual programming, family programming, and special events that required music. On 1/29/18 at 9:14 a.m., 11:34 a.m., and 1:33 p.m., 1/30/18 at 8:51 a.m. and 5:08 p.m.; 1/31/18 at 8:07 a.m. and 1:34 p.m.; and 2/1/18 at 7:37 a.m. revealed that R#48 was observed in bed, and at none of these times was the resident's TV observed to be tuned to the facility's closed circuit system, which could be individualized for each resident, nor tuned to a station for spiritual programming. During interview with the Activity Director on 2/1/18 at 9:00 a.m., she stated that the facility had a closed-circuit television system (on channel 2) that was available on resident televisions. The Activity Director further stated that she did not know why R#48's TV would not have been turned on to channel 2, as this would provide auditory stimulation for her. On 2/1/18 at 10:20 a.m., Activity Assistant BB was observed to have turned R#48's TV to channel 2, and observation of R#48 at this time revealed that she appeared to look at and be engaged with the gospel singers that were on the channel 2 programming. During interview with Certified Nursing Assistant (CNA) CC on 2/1/18 at 10:32 a.m., she stated that she had seen channel 2 turned on for R#48 maybe once in the past week. 2. Review of the Preferences for Routine and Activities section of R#5's Annual MDS dated [DATE] revealed that it was important, but can't do or no choice for the activities of having books, newspapers, and magazines to read; listen to music you like; keep up with the news; do things with groups of people; do your favorite activities; go outside to get fresh air when the weather is good; and participate in religious services or practices. Review of R#5's care plans revealed one initiated on 1/24/18 which noted that he continued to have little or no activity involvement related to physical limitations, resident receives during individual and group settings (sic) and has been observed over annual period. Resident appears to prefer support visitation as socialization through facial gestures/eye movement. Review of the interventions for this care plan revealed that he preferred the following TV channels: variety for auditory stimulation. Observations on 1/29/18 at 8:53 a.m., 9:54 a.m., 1:18 p.m., and 4:58 p.m.; 1/30/18 at 8:01 a.m. and 4:52 p.m.; 1/31/18 at 7:50 a.m., 10:21 a.m., and 1:27 p.m.; and 2/1/18 at 7:37 a.m. and 1:36 p.m. revealed that R #5 was in the bed with his TV off. During interview with the Activity Director on 2/1/18 at 9:00 a.m., she stated that she did not know why R#5's TV was off, and that the programming on channel 2 would be appropriate for him for auditory stimulation. During interview with CNA CC on 2/1/18 at 10:32 a.m., she stated that she had never seen R#5's TV on, and didn't know if it even worked. Review of a Social Progress Note dated 1/24/18 revealed that R#5 was non-ambulatory, and needed staff assist with all activities of daily living. Further review of this Progress Note revealed that R#5 had his TV on in his room for stimulation. During interview with the Activity Director on 2/2/18 at 12:38 p.m., she stated that she checked R#5's TV earlier today, and found it to be unplugged, but that it worked when she plugged it in. During interview with Registered Nurse MDS Coordinator DD on 2/2/18 at 4:34 p.m., she stated that the Activity Director was responsible for developing and revising the activity care plans for all residents. Cross-refer to F 679. 3. Review of R#5's Annual MDS dated [DATE] revealed that he had functional limitation in Range of Motion (ROM) on one side of the upper and lower extremities, and did not receive skilled therapy services nor restorative services. Review of his ADL (activity of daily living) self-care performance deficit related to dementia, [MEDICAL CONDITION], limited mobility, stroke, and left elbow, hand and knee contractures care plan, initiated 1/30/17 and revised 7/25/17, revealed an intervention for a left soft elbow splint as ordered. On 1/30/18 at 9:14 a.m., R#5 was observed to not be able to completely extend his arms or right leg. No splint or orthotic device was observed on him at this time, as well as observation on 1/30/18 at 4:52 p.m. During interview with restorative CNA HH on 2/2/18 at 1:52 p.m., she stated that information such as splinting and range of motion (ROM) was in the Kardex in the CNA's computerized point-of-care (P[NAME]) system. Observation at this time revealed that restorative CNA HH was not able to locate any restorative services information in the P[NAME] system for R#5. During interview with District Director of Clinical Services JJ on 2/2/18 at 2:15 p.m. she verified that there was no documentation of restorative services provided for R#5. Cross-refer to F 688. 4. Review of R#46's Brief Interview for Mental Status (BIMS) on his Quarterly MDS dated [DATE] revealed that he had a score of 15 (a score of 13 to 15 indicates that a resident is cognitively intact). Review of his care plans revealed a care plan for [MEDICATION NAME] use related to osteo[DIAGNOSES REDACTED] dated 9/2/17 and 12/14/17, and interventions included to observe side effects of antibiotic use. Review of a adverse reaction related to polypharmacy care plan with an initiated date of 2/11/17 revealed interventions that included to observe for possible signs and symptoms of adverse drug reaction, and to review the resident's medications with the physician and consultant pharmacist for adverse reactions. During interview with R #46 on 1/29/18 at 4:53 p.m., he stated that most of his stools for months had been diarrhea. Review of R#46's Physician order [REDACTED]. Further review of the physician's orders [REDACTED]. Review of Documentation Survey Reports that recorded bowel elimination for R#46 revealed that loose/diarrhea stools were documented 12 times and putty-like stools six times in (MONTH) (2017), and 15 loose/diarrhea stools and two putty-like stools in (MONTH) (2018). Cross-refer to F 757.",2020-09-01
621,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,658,D,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, interview and Rule 410-10-.02 Standards of Practice for Licensed Practical Nurses, the facility failed to maintain professional nursing standards of quality as evidenced by failing to notify physician of admission status for one newly admitted resident (R) Q. The sample size was 47 residents. Findings include: Review of the Georgia Rule 410-10-.02 - Standards of Practice for Licensed Practical Nurses revealed that: (1) The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations; (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. Review of the clinical record for R Q revealed the resident was admitted to the facility on [DATE] with end stage [MEDICAL CONDITIONS], hypertension (HTN), [MEDICAL CONDITIONS] (CAD), pneumonia and history of [MEDICAL CONDITION]. Review of the policy titled Admission to the Facility, revised (MONTH) (YEAR), revealed the procedure for admission: The nursing staff obtains and verifies the physician's admitting orders. If not already initiated, the admitting nurse creates the resident's electronic health record (EHR). The licensed nurse notifies the attending physician of the resident's admission and completes an initial assessment of the resident using the Nursing Admission Data Collection. The licensed nurse responsible for the care of the resident obtains the physician orders. Interview on 2/1/18 at 4:20 p.m., with primary Physician, stated he has not seen R Q at all. He stated he did not know the resident was under his care until the facility notified him on 1/30/18, about a change change in condition related to pain and discoloration left big toe and foot. He stated that when the facility notifies him of new admissions, he visits them within 48 hours of admission to the facility. He stated facility never notified him of residents admission to the facility. Interview by phone on 2/1/18 at 6:05 p.m., with primary Physician, stated he would continue hospital recommended orders that residents are admitted with, as he does not know the residents. Interview by phone on 2/1/18 at 7:25 p.m., with Licenced Practical Nurse (LPN) NN, stated as best she could remember the resident arrived around 5:45 p.m. She stated that the orders usually arrive to the facility before resident does. She was given report on a new admission from the 7-3 nurse. She stated the procedure is to complete the head to toe assessment and documents in their EHR. She stated the Unit Managers (UM) contact the physician about new admissions and transcribes the physicians orders. She has on occasion been asked to notify the physician about new admissions and verify orders, but not for this resident. Interview on 2/1/18 at 7:30 p.m., with residents primary Physician, stated that this was the first time that staff had not notified him of a new admission.",2020-09-01
622,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,679,D,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide an ongoing program of activities based on resident representative input and/or activity preference assessments for four residents (R) reviewed for the provision of activities (R#48, R#5, R#10, R#52). The sample size was 47 residents. Findings include: 1. Review of R#48's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had short- and long-term memory problems, and severely impaired decision making, and transfers and locomotion on and off the unit did not occur during the assessment period. Review of the Preferences for Routine and Activities section of her Annual MDS dated [DATE], which noted the primary respondent for the questions was the family or significant other, revealed the following: it was important, but can't do or no choice for the activities of having books, newspapers, and magazines to read; listen to music you like; be around animals such as pets; keep up with the news; do things with groups of people; do your favorite activities; go outside to get fresh air when the weather is good; and participate in religious services or practices Review of R#48's care plans revealed that she had one revised on 12/14/17 noting that she was independent/dependent (sic) for meeting emotional, intellectual, physical, and social needs related to cognitive deficits and [MEDICAL CONDITION]. Review of the interventions for this care plan included that past television (TV) programming interests included Catholic and spiritual programming, family programming, and special events that required music. Further review of the interventions on this care plan revealed that socialization was through family, church volunteers, and staff interaction. Review of all care plans revealed that no interventions were found to remain in her room at all times. On 1/29/18 at 9:14 a.m., R#48 was observed in bed. On 1/29/18 at 11:34 and 1:33 p.m., and 1/30/18 at 8:51 a.m., she was observed in bed, alert but non-verbal, with the TV turned on to a network channel, but she did not appear to be looking at the screen. R #48 was further observed to track anyone in her field of vision with her eyes at each observation. On 1/30/18 at 5:08 p.m., 1/31/18 at 8:07 a.m., 1/31/18 at 1:34 p.m., and 2/1/18 at 7:37 a.m., R#48 was observed in bed with her eyes closed. At none of these times was the resident's TV observed to be tuned to the facility's closed circuit system that could be individualized for each resident. During interview with the Activity Director on 2/1/18 at 9:00 a.m., she stated that she had two activity assistants who assisted with providing one-on-one activities, as well as three church group volunteers that came on specific Tuesdays and Saturdays. She further stated that the facility had closed-circuit TV programming (on channel 2) that was available for residents who had televisions that could receive the signal, and that any staff member could turn a TV to channel 2. She stated during further interview that this programming, as well as a CD (compact disc) to play music, would be appropriate activities for R#48. The Activity Director further stated that she did not know why R#48's TV would not have been turned on to channel 2, as this would provide auditory stimulation for her. On 2/1/18 at 10:20 a.m., Activity Assistant BB was observed to have turned R#48's TV to channel 2. During interview with her at this time, she stated that she personally had not provided any activities for R#48 this week, and did not know if anyone else had. Observation of R#48 at this time revealed that her eyes appeared to track the surveyor and Activity Assistant, and when moved out of her field of vision she appeared to look at and be engaged with the gospel singers that were on the channel 2 programming. During interview with Certified Nursing Assistant (CNA) CC on 2/1/18 at 10:32 a.m., she stated that R#48 would smile at certain people, and was always in the bed in her room. She further stated that she had seen a singing group stop by and sing for her at least once per month, and had seen a CD player in her room playing music maybe once in the past month. CNA CC further stated that the Activity Director announced on the intercom system when channel 2 was active, and that the activity staff or CNAs could turn the TV on for the bedbound residents, but had seen channel 2 turned on for R#48 maybe once in the past week. During interview with the Activity Director on 2/2/18 at 12:38 p.m., she stated that she just put Important, but can't do or no choice for all of the activity preference questions on the MDS, and that she could not provide all activities important to R#48. She further stated that R#48 would look at you and follow you with her eyes, and sometimes move her arm toward her face to music. During continued interview, she stated that church groups came on the weekend, but there was no documentation of who they visited. She further stated that the closed circuit channel 2 ran at various times during the day, and it depended on the make and model of the TV as to whether it could receive this channel, and that the channel 2 programming may or may not be on the activity calendar. She further stated they did have books on tape, but she was not sure if it was utilized for R#48. The Activity Director stated during continued interview that Relaxation on the Individual Activity Participation Record meant that this was a time when the resident was in bed, a quiet time when they may have their eyes closed and comfortable. She verified that she considered this to be an activity for R#48, who was in the bed almost constantly. She further stated that the L for listening on this Participation Record was documented daily as received, as she assumed a resident was listening to the TVor radio, but had no documentation that music was played or the TV was on. Review of Individual Activity Participation Records for R#48 revealed: November (YEAR): documented as passive seven times and listened 21 times for TV/Radio/Movies; passive visits with family or friends 28 times, independent with relaxation 28 times; and volunteer once and TV once for spiritual/religious activities. December (YEAR): documented as listened to TV/Radio/Movies daily; passive visits with family or friends 30 times and listened one time, a volunteer for spiritual/religious activities once; and independent with relaxation every day. January (YEAR): documented as listened to TV/Radio/Movies daily; independent with relaxation daily; and TV on 1/13/18, 1/14/18, 1/21/18, and 1/28/18. Review of Activity Department-Visit/Stimulation/1:1 records since (MONTH) (YEAR) revealed the only ones for R#48 were the following: 9/17/17: devotional reading 10/16/17: daily devotion 1/29/18: light conversation; resident made eye contact Review of the facility's One-to-One Activities policy with a release date of (MONTH) 2007 revealed the following: Any activity that can be presented in a group setting can be provided in a one-to-one activity with adaptation or modifications. Ensure that the frequency and types of activity services provided are reflected in the resident's care plan. Use the comprehensive assessment, the interest and the physical, mental and psychosocial needs of the resident as the basis for formatting One-to-One activities. Complete and maintain a master One to One Activity list of residents. The Activity Director schedules specific days and providers for certain residents on the list to be visited. 2. Review of R#5's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of his Annual MDS dated [DATE] revealed that he had short-term and long-term memory problems, and severely impaired decision making; transfers occurred only one or twice during the assessment period; and locomotion on and off the unit did not occur. Review of his Preferences for Routine and Activities on this MDS revealed that the resident was the primary respondent for Daily and Activity Preferences, and noted the following: it was important, but can't do or no choice for the activities of having books, newspapers, and magazines to read; listen to music you like; keep up with the news; do things with groups of people; do your favorite activities; go outside to get fresh air when the weather is good; and participate in religious services or practices. Review of R#5's care plans revealed one initiated on 1/24/18 which noted that he continued to have little or no activity involvement related to physical limitations, resident receives during individual and group settings (sic) and has been observed over annual period. Resident appears to prefer support visitation as socialization through facial gestures/eye movement. Review of the interventions for this care plan revealed that he preferred the following TV (television) channels: variety for auditory stimulation, and that he receives socialize (sic) with: support group/friends/family/volunteers. Review of all care plans revealed that no interventions were found to remain in his room at all times. Review of R#5's Physician order [REDACTED]. Observations on 1/29/18 at 8:53 a.m., and 2/1/18 at 7:37 a.m. revealed that R#5 was in the bed with his eyes closed and his TV off. Observations on 1/29/18 at 9:54 a.m., 1:18 p.m., and 4:58 p.m.; and 1/30/18 at 8:01 a.m. revealed that R #5 was in the bed with his eyes open, alert, but non-verbal. Observations over the five days of the survey revealed the only time that R#5 was observed to be out of his bed was on 1/30/18 at 9:20 a.m., when he was taken to the shower room via a stretcher for his bath. On 1/30/18 at 4:52 p.m., R#5's TV was observed to be off, his roommate's TV was on, but it was located where R#5 would not be able to see it as he was positioned on the opposite side in his bed. On 1/31/18 at 7:50 a.m., R#5 was observed in his bed and was alert, nodded his head yes when asked a question, and his TV was observed to be off. On 1/31/18 at 10:21 a.m., R#5 was observed to be alert and in bed; his TV was off but his roommate's TV, located across from the end of the roommate's bed, was on. During interview with R#5 at this time, he was asked if he could see and was watching his roommate's TV, and he shook his head yes and said uh-huh. On 1/31/18 at 1:27 p.m., and 2/1/18 at 1:36 p.m., R#5 was observed in bed on his back, alert, and his TV located across from the foot of his bed, was off. During interview with the Activity Director on 2/1/18 at 9:00 a.m., she stated that R#5 would not engage with you, and had only come out of his room for one activity. She further stated that she did not know why his TV was off, and that the programming on channel 2 and a CD player in his room for music would be appropriate for him for auditory stimulation. She stated during further interview that when music was provided via a CD player, that this was not necessarily documented. During interview with CNA CC on 2/1/18 at 10:32 a.m., she stated that R#5 never left his room except on his shower days, and she had never seen him out of his room for a group activity. She further stated that he was able to communicate his needs by nodding his head yes or no. CNA CC further stated that she had seen a church group stop at his room about once a month to sing, but she had never seen his TV on and didn't know if it even worked. She stated that she had seen R #5's roommate's TV tuned to channel 2 programming before, but did not recall if R#5 looked at it. CNA CC added that she had never seen a CD in his room playing music. Review of a Social Progress Note dated 1/24/18 revealed that R#5 was non-ambulatory, and needed staff assist with all activities of daily living. Further review of this Progress Note revealed that R#5 had his TV on in his room for stimulation, napped off and on in his room, and that his wife called on a regular basis to check on him. Review of R#5's Individual Activity Participation Record for (MONTH) of (YEAR) revealed that he listened to TV/Radio/Movies daily; was a passive participant 28 days in visits with family or friends; and independent with relaxation 28 days. Review of the (MONTH) (YEAR) Individual Activity Participation Record revealed that he listened to TV/Radio/Movies daily; was passive participant for visits with family or friends daily; and was independent for relaxation daily. Review of the (MONTH) (YEAR) Individual Activity Participation Record revealed that the TV was used four times for Spiritual/Religious activities; listened daily for TV/Radio/Movies; and was independent for relaxation. Review of Activity Department-Visit/Stimulation/1:1 documentation records since (MONTH) (YEAR) revealed that the only documented activity on these forms for R#5 was conversation with him and his roommate on 1/9/18. During interview with the Activity Director on 2/2/18 at 12:38 p.m., she verified that she conducted the activity preferences section on the 1/23/18 Annual MDS as a resident interview and answered everything as important, but can't do or no choice, but that she should have done it under Staff Assessment of Daily and Activity Preferences, as the resident was not able to answer the activity questions. She stated during further interview that R#5's wife called the facility at times, but that she had never talked to the wife to get input on the resident's activity preferences. She further stated that she could not provide all activities marked as important to him on the MDS, and that church groups came on the weekend but she had no documentation of who they visited. The Activity Director stated during further interview that she was asked by a staff member earlier today if R#5's TV worked, and when she checked it she found it to be unplugged, but that it worked when she plugged it in. She further stated that after this she checked all the TVs on the 400-hall and all but two were unplugged and she did not know why. She verified that she considered Relaxation on the Individual Activity Participation Record as an activity for R #5, which indicated this was a time when he was in bed and quiet. The Activity Director stated that they had books on tape, but did not know if this was utilized for R#5.",2020-09-01
623,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,688,D,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide evidence that restorative services for splinting and range of motion (ROM) were consistently provided for one resident (R) (R#5). The sample size was 47 residents. Findings include: Review of R#5's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of his Annual Minimum Data Set ((MDS) dated [DATE] revealed that he had short- and long-term memory problems, and severely impaired decision making; and this Annual MDS as well as a Quarterly MDS dated [DATE] revealed that he had had functional limitation in ROM on one side of the upper and lower extremities; and did not receive skilled therapy services nor restorative services. Review of his ADL (activity of daily living) self-care performance deficit related to dementia, [MEDICAL CONDITION], limited mobility, stroke, and left elbow, hand and knee contractures care plan, initiated 1/30/17 and revised 7/25/17, revealed an intervention for a left soft elbow splint as ordered. Review of a hospital Consultation dated 10/4/17 revealed that R#5 was in a bed-bound state, with bilateral upper and lower extremity contractures. Review of his physician's orders [REDACTED]. On 1/30/18 at 9:14 a.m., R#5 was observed to not be able to completely extend his arms or right leg. No splint or orthotic device was observed on him at this time, as well as observation on 1/30/18 at 4:52 p.m. During interview with Occupational Therapy Assistant (OTA) FF on 2/1/18 at 12:07 p.m., she stated that R#5 received skilled Occupational Therapy (OT) from 4/24/17 until 6/6/17, OT was addressing his left upper extremity contracture with a soft elbow splint, and discharged him to restorative services last June. She stated during further interview that they assumed that unless the OT heard otherwise, the splint was being worn and there were no problems. Review of an OT-Therapist Progress & Discharge Summary dated 6/6/17 revealed that R#5 made significant progress with skilled OT, and was referred to the nursing restorative program to maintain progress gained from therapy. Review of a Nursing Department Rehab Nursing Program referral to restorative dated 6/17 revealed: Goals: 1. Nursing to perform PROM (passive range of motion) to left elbow through all planes as tolerated. 2. Patient will tolerate left soft elbow splint for 6-8 hours a day as tolerated. Approaches: 1. Nursing will apply splint 6-7 days a week as tolerated to prevent contracture. 2. Nursing will perform PROM to left elbow 6-7 days a week as tolerated. During interview with Licensed Practical Nurse (LPN) Unit Manager GG on 2/1/18 at 3:08 p.m., she stated that her only responsibility with restorative services was to write the order when recommended by therapy, but that she was not sure who oversaw the restorative program. During interview with the Director of Nursing (DON) on 2/1/18 at 4:30 p.m., she stated that they had not had a nurse to oversee the restorative program since last October. During interview with restorative CNA HH on 2/2/18 at 1:52 p.m., she stated she knew which residents needed restorative services as either the DON, Unit Manager, and/or therapy would tell her. She further stated that information such as splinting and ROM was in the Kardex in the CNA's computerized point-of-care (P[NAME]) system. Observation at this time revealed that restorative CNA HH was not able to locate any restorative services information in the P[NAME] system for R#5. Observation of R#5 with the restorative CNA at this time revealed that she was not able to fully extend the fingers of his left hand, and the resident had a soft splint on the left elbow, which the CNA denied applying. During interview with CNA II on 2/2/18 at 2:09 p.m., she stated that she was trained to do both showers and restorative, and did not know who applied R#5's splint that day. Observation with her at this time revealed that she was not able to demonstrate how to document restorative services provided in the P[NAME] system. Review of Restorative Program Notes in the computerized interdisciplinary documentation system revealed the only notation from (MONTH) (YEAR) to the present time related to restorative was on 8/30/17, which noted a splint to the left elbow and ROM was provided. Interview on 2/2/18 at 2:15 p.m. with District Director of Clinical Services JJ revealed that she had developed an Orthotics and Contracture Audit on 1/16/18 and completed the audit for R#5 on 1/31/18 (after the survey entrance), and discovered that there was not a current order for an orthotic for him, and a referral was made to therapy for his left hand, elbow, and knee contractures. She verified during further interview that there was no documentation of restorative services provided for R#5, and updated the CNA's P[NAME] Kardex so that the restorative CNAs could document what they did. During interview with OT KK on 2/2/18 at 2:42 p.m., she stated that she screened R#5 for possible skilled services earlier that day, and recommended that he be referred back to restorative on the same program recommended last June. During further interview, she stated that she had never worked with R#5 prior to today, but could not determine any decline in his ROM after she reviewed the (MONTH) OT Discharge Summary. During interview with restorative CNA HH on 2/2/18 at 2:59 p.m., she stated that she had applied the splint to R#5 on 1/30/18, but that there was no place in the Kardex to document this. She further stated that she told the nurse who was previously over restorative services (who left in October), that there was no place to document restorative in the Kardex, but had not told anybody else since she left, as that nurse was her go to person. Review of the facility's Restorative Care Program Overview, Key Components of Learning module (undated) revealed: As caregivers, we must identify and document, in a written plan of care, the interventions aimed at improving their (the residents) ability to function. Once identified, the members of the Interdisciplinary Team systematically implement these interventions or services. The Director of Nursing is responsible for ensuring the daily provision of Restorative Care services. The Restorative Nursing Aides provide Restorative Care program services as identified in the resident's plan of care, and documents objective information regarding services provided, the amount of time the service was provided, and the resident's response. Restorative Care is provided to maintain, improve, or prevent decline in the resident's ability to function and to perform self-care activities as independently as possible.",2020-09-01
624,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,756,D,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, consultant Pharmacist, and Nurse Practitioner interview, the facility failed to address the continued use of a PRN (as needed) hypnotic (sleep-inducing) [MEDICATION NAME] 14 days for one resident (R) (R#30) of 47 sampled residents. Findings include: Review of R#30's physician's orders [REDACTED]. Review of a Consultant Pharmacist Recommendation to the Medical Director dated 12/18/17 revealed a suggestion [MEDICATION NAME] mg or [MEDICATION NAME] (a hypnotic drug) 7.5 mg at HS PRN sleep. Further review of the pharmacist recommendations revealed that none were found to address the continued [MEDICATION NAME]. During interview with the facility's consultant Pharmacist MM on 2/2/18 at 9:55 a.m., he stated that he made a recommendation on 12/11/17 to consider [MEDICATION NAME], and that he let the Physician know if a PRN [MEDICAL CONDITION] drug order was over 14 days old so that a re-order could be obtained. He further stated that he could not determine if a Physician addressed his recommendations by looking in his pharmacy system, and that if he saw the Physician did not address the recommendation when he visited the facility the following month, he would make another recommendation. During interview with the Director of Nursing on 2/2/18 at 10:12 a.m., she stated that when they received a pharmacist recommendation, that they placed it in the Physician's box, or faxed it to him, and that the Unit Managers ensured that the recommendation got addressed. During interview with Nurse Practitioner LL on 2/2/18 at 11:26 a.m., she stated that she thought she had discontinued [MEDICATION NAME] after the recommendation was made by the pharmacist. Review of the Monthly Drug Regimen Review policy with a release date of (MONTH) (YEAR) noted: The pharmacist reviews resident charts monthly and submits a written report of irregularities to the resident's attending Physician, the Director of Nursing and the facility Medical Director. The attending Physician reviews the report and documents the review and his or her response in the resident's medical record. The Physician must document his or her rationale if no change is made to the resident's medications.",2020-09-01
625,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,757,D,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, staff and Nurse Practitioner interview, the facility failed to evaluate for the continued need for a routine laxative ([MEDICATION NAME]) for one resident (R) (#46), who was experiencing loose bowel movements (BMs). The sample size was 47 residents. Findings include: Review of R#46's clinical record revealed [DIAGNOSES REDACTED]. Review of the Brief Interview for Mental Status (BIMS) on his Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a score of 15 (a score of 13 to 15 indicates that a resident is cognitively intact). Further review of his MDS revealed that he was always incontinent of bowel. Review of his care plans revealed a care plan for [MEDICATION NAME] (an antibiotic with a common side effect of mild diarrhea) use related to osteo[DIAGNOSES REDACTED] dated 9/2/17 and 12/14/17, and interventions included to observe side effects of antibiotic use. During interview with R#46 on 1/29/18 at 4:53 p.m., he stated that most of his stools were diarrhea, and that this had been occuring for months. Review of R#46's Physician order [REDACTED]. Further review of the physician's orders [REDACTED]. During interview with Certified Nursing Assistant (CNA) CC on 1/31/18 at 1:32 p.m., she stated that R#46 had loose stools usually twice on her shift, and that she told the nurse about it. Observation of a stool that R#46 had on 2/1/18 at 1:44 p.m. revealed that it appeared soft, non-formed, and putty-like. Review of Documentation Survey Reports that recorded bowel elimination for R#46 revealed that loose/diarrhea stools were documented 12 times and putty-like stools six times in (MONTH) (2017), and 15 loose/diarrhea stools and two putty-like stools in (MONTH) (2018). During interview with the Director of Nursing (DON) on 2/2/18 at 9:02 a.m., she stated that the Unit Managers and charge nurses were supposed to look at the BM reports at the end of the shift, to ensure that residents were having BMs at least every 72 hours. The DON further stated that the nurses should also be checking for the consistency of the stools, and investigate why a resident may be having loose stools and contact the Physician for any additional orders. During interview with Nurse Practitioner LL on 2/2/18 at 11:26 a.m., she stated that she was not aware that R#46 was having loose stools, and that the [MEDICATION NAME] could be given on an as needed instead basis rather than routinely.",2020-09-01
626,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-02-02,842,E,0,1,UL9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure the Medication Administration Record [REDACTED]. Findings include: 1. R#15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, which indicated no cognitive impairment. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Continued review of clinical record revealed no evidence of the Physician being notified of missed opportunities. 2. R#90 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as five, which indicated mild cognitive impairment. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Continued review of clinical record revealed no evidence of the Physician being notified of missed opportunities. 3. R#21 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as three, which indicated cognitive impairment. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Continued review of clinical record revealed no evidence of the Physician being notified of missed opportunities. Interview on 1/31/18 at 2:10 p.m., with Unit Manager (UM) GG, stated it is her expectation that nurses sign off the medications and care once they have been given. She further stated she doesn't have an explanation why the medications and care are not being documented as given. Interview on 1/31/18 at 3:19 p.m., with Director of Nursing (DON) stated that UM's are the checks and balance system for making sure the Medication Administration Record's (MAR's) are completed by the medication nurses. As far as the MAR indicated [REDACTED]. She further stated that the consultant pharmacist visits monthly and he looks at the MAR's for inaccuracy. Interview on 1/31/18 at 4:56 p.m., with Licensed Practical Nurse (LPN) NN states that she checks after her medication pass to verify that she has given everything. If medication are not given, she documents on the MAR, and the computer system will pop up a progress note to document reason for not administering a medication. She stated that she knows she needs to do a better job with her self audits. Interview on 2/1/18 at 9:06 a.m., with consultant pharmacist MM, stated that he visits facilty monthly and he reviews medications and the medical record on all residents in the building. He stated he mainly looks for drug interactions or contraindications and that medications have proper [DIAGNOSES REDACTED]. He sends the DON a Consultant Pharmacy Review Summary each month with identifying concerns. He stated he does not recall any concerns with documentation on the MAR's. Review of the 11/14/2017, 12/11/2017 and 1/8/2018 Consultant Pharmacy Review Summary's did indicate that he had identified MAR indicated [REDACTED]",2020-09-01
627,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-04-30,694,D,1,0,UHMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to ensure that the enteral nutrition being administered to one resident (R) #2, had been labeled by the administering staff member. The sample size was three. Finding include: Observation of resident (R)#2 on 4/30/18 at 5:40 p.m. revealed the resident in his bed, supine, and sleeping. The resident was receiving enteral nutrition through a gastrostomy tube ([DEVICE]). Continued observation revealed an intravenous (IV) pole located to the left of the resident's bed with an unidentified brown liquid being administered to the resident from a Kangaroo bag using an enteral feeding pump. Observation of the Kangaroo bag revealed there was no label or other type of identification on the bag. Observation and interview on 4/30/18 at 5:43 p.m. revealed that the resident's enteral feeding set was observed by Licensed Practical Nurse (LPN) EE and Registered Nurse (RN) FF who both agreed that the Kangaroo bag was not labeled and that a label stating the contents, the rate, the date and the name of the nurse who starts the feeding set should have been placed on the Kangaroo bag. RN FF discontinued the feeding and removed and discarded the feeding set. Review of the facility policy Enteral Nutrition, revised 2/2017, revealed the documentation requirements for enteral feeding on page four of the policy, under 'Documentation', item 2. the policy states that key documentation elements include type, amount and rate of feeding formula. Under item 3. it states to add Additional documentation required by Lippincott's Nursing Procedures (as required). Interview with the Administrator and the Director of Nursing (DON) on 4/30/18 at 6:45 p.m. who confirm that enteral feeding sets must be labeled by the nurse who starts the feeding with their name, the date the feeding was started, and the type, amount and rate of feeding formula.",2020-09-01
628,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2018-04-30,880,D,1,0,UHMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews, the facility failed to ensure that Hoyer lifts were routinely cleaned as evidenced by observation of significant dirt, debris, dried adhered materials and dried fluid residue on the base and lower support column for four of four of the facility's Hoyer lifts. Findings include: Observation on 4/30/18 at 2:05 p.m. of Hoyer lift East 3 parked outside of resident's rooms [ROOM NUMBERS] with visible debris, dirt, and dried materials, including fluid splatters on the base and support column. Observation on 4/30/18 at 2:07 p.m. of the facility's Hoyer lifts West 4 and East 2 in the designated parking area for the lifts revealed that both lifts had visible debris, dirt, and dried materials, including fluid splatters on the base and on the support columns. Observation on 4/30/18 at 2:35 p.m. of the Hoyer lift parking area empty and one Hoyer lift, East 3, parked outside of resident rooms [ROOM NUMBERS] which revealed continued with the same visible debris, dirt, and dried materials, including fluid splatters on the base and support column. Observation on 4/30/18 at 3:18 p.m. of Hoyer lifts East 2, East 3 and West 3 in the parking area with no changes in the previously observed level of contamination and splatter on the base and support columns of the Hoyer lifts. Observation and interview on 4/30/18 at 5:50 p.m. of East 2, East 3 and West 1 Hoyer lifts in the designated parking area with the Director of Nursing (DON) who agreed that the lifts had substantial dirt, dried debris and fluid residue and concurred that they needed cleaning. The DON stated she thought the lifts were on a scheduled cleaning rotation with the maintenance department. Interview with the Administrator and the DON on 4/30/18 at 6:45 p.m. who confirmed that the Maintenance Director is responsible for cleaning and maintaining the Hoyer lifts. The Administrator also confirmed that the Maintenance Director, DD, had not developed a schedule for cleaning and could not confirm the last time the Hoyer lifts were cleaned. Review of pages 28 and 29 of the Lift and Transfer Manual, published 2010, under the paragraph heading 'Director of Maintenance', revealed that the Director of Maintenance has oversight responsibility for keeping all lifting devices clean and functioning.",2020-09-01
629,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2017-07-27,282,D,0,1,N68F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow the care plan related to doing mouth inspections for one resident (R) #52. The sample size was 29 residents. Findings include: Review of R #52's care plans revealed an undated focus statement that the resident had thrush, and interventions included that the resident required mouth inspections (unspecified frequency), and to report changes to the nurse. During observations on 7/24/17 at 1:26 p.m., 7/25/17 at 8:01 a.m. and 2:57 p.m., and 7/26/17 at 9:33 a.m., a thick, bright white coating was noted covering R #52's tongue. During observation and interview with Certified Nursing Assistant (CNA) HH on 7/26/17 at 9:57 a.m., she verified the white coating on R #52's tongue, and stated that the white stuff had been there ever since she had been a resident at the facility, and that the nurse knew about it. During interview with Licensed Practical Nurse (LPN) GG on 7/26/17 at 10:20 a.m., she stated that R #52 had received [MEDICATION NAME] and [MEDICATION NAME] (antifungal medications) about a month and a half ago, that she was not currently aware of any problems with the resident's tongue, and that the CNAs had not mentioned anything to her. During observation at this time, LPN GG verified the thick white coating on R #52's tongue, and stated that the resident's tongue did not look that bad the last time she was being treated for [REDACTED]. During interview with LPN GG on 7/27/17 at 11:29 a.m., she stated that there was no treatment or other orders to check R #52's mouth on a routine basis, so this was not being done. Cross-refer to F 411.",2020-09-01
630,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2017-07-27,322,D,0,1,N68F11,"Based on observation, record review, and staff interview, the facility failed to give medications and water flushes by gravity drainage through a gastrostomy tube (GT) for one of two residents (R) (#43) observed during medication administration. The sample size was 29 residents. Findings include: During medication pass on 7/26/17 at 8:15 a.m., Licensed Practical Nurse (LPN) AA was observed to give R #43 his morning medications via his GT. Further observation revealed that after LPN AA checked the resident's GT for residual stomach contents by pulling back on the plunger of a 60-mL (milliliter) syringe, she removed the plunger, added the medication that had been dissolved in 30 mL of water, and pushed the medicines in one at a time with the plunger. She was then observed to flush the GT with 60 mL of water by pushing the water in through the syringe with the plunger, instead of allowing the water to flow in the GT by gravity. During interview with LPN AA on 7/26/17 at 1:03 p.m., she stated that R #43's GT would not allow medications and water to flow by gravity, and that was why she pushed them in the GT with the syringe. During further interview, she stated that she did not even try to allow it to flow by gravity anymore. During interview with LPN BB on 7/27/17 at 8:11 a.m., she stated that she usually did not have any problems with R #43's GT, and that she was able to give his medicines and flushes through his GT by gravity, and didn't have to push them in with the syringe. During interview with the Director of Clinical Education on 7/26/17 at 1:34 p.m., she stated that her expectation was for staff to allow flushes and medicines to flow into a GT via gravity drainage, and not be pushed in with a syringe. Review of a facility policy Enteral Tube Medication Administration with a revised date of (MONTH) 2011 revealed: Remove plunger from the 60 mL catheter-tipped syringe and connect syringe to clamped tubing. Put 30 mL of water in syringe and flush tubing using gravity flow. Pour dissolved/dilute medication in syringe and unclamp tubing, allowing medication to flow by gravity.",2020-09-01
631,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2017-07-27,406,D,0,1,N68F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of records and staff interview, it was determined that the facility failed to ensure that one resident (#113) from a sample of twenty-nine (29) resident received the specialized services recommended by the resident's Preadmission Screening and Resident Review (PASRR) Level II authorization document dated 1/6/17. Findings include: Review of the clinical records revealed Resident (R) #113 was admitted on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. [MEDICAL CONDITION] and dementia with behavioral disturbance; observe for behaviors such as yelling/screaming. Review of the plan of care for R#113 last updated 6/12/17 revealed the resident had behaviors of yelling out, singing loudly, and refusing medications and care. Review of the nurses' notes since (MONTH) (YEAR) revealed the resident exhibited behaviors such as refusing medications on some shifts, yelling and screaming continually while resisting redirection, and attempting to exit the front doors of the facility. The nurses' notes for that period also revealed the resident attempted to remove the Wander Guard device that was put in place by biting through it with her teeth. Review of the PASRR Level II document dated 1/6/17, which accompanied the resident at admission, revealed R#113 was approved for Skilled Nursing Facility level of care, and specialized services for Severe Mental Illness, and recommended that the resident receive a behavioral health assessment and diagnostic and ongoing psychiatric care. Review of the clinical records revealed no documentation that the resident had received the recommended behavioral health assessment or diagnostic and ongoing psychiatric care recommended by the PASRR Level II authorization document of 1/6/17. Interview on 07/26/17 at 3:27 p.m. with the Social Service Manager (SSM) revealed the resident was admitted after receiving in-patient care from the Geriatric Psychiatric Services of Trinity Hospital of Augusta in (MONTH) of (YEAR). Since that time, her family has taken her for follow-up visits to her private physician approximately every three to six months. During this time, the SSM believed the resident's [MEDICAL CONDITION] medications were evaluated (although she could not confirm this). However, the facility had never provided the specialized services recommended on the resident's PASRR Level II document, nor had they referred the resident to another entity to receive such services. Interview on 7/26/17 4:22 p.m. with Licensed Practical Nurse (LPN) JJ revealed the family of R#113 takes her for a visit to her personal physician every three months. However, the facility has never initiated any psychiatric services for this resident. LPN JJ stated that for residents who are already receiving psychiatric services in the community, the facility normally ensures that those services continue by assisting with transportation to and from those services. However, the facility does not initiate/procure psychiatric services for residents even when this is recommended by a PASRR Level II authorization. Interview on 0/27/17 at 12:22 p.m. with the Director of Nursing (DON) revealed his expectations are that when a resident is admitted with a PASRR Level II authorization with recommendations for specialized services, the resident is care-planned for those services, and every attempt is made to provide those services in-house or through referral. If the facility is not able to provide the specialized services in-house or through referral, the facility's physician is consulted as to whether the resident can be accommodated in the facility without those services. If the unit Medical Director says the resident must have these services, the facility will consider transferring the resident to a facility that can better meet his/her needs. The DON stated there were no current facility protocol/policy to address the facility's response to residents admitted with PASRR Level II recommendations for specialized behavioral health services.",2020-09-01
632,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2017-07-27,411,D,0,1,N68F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to perform regular oral inspections for one resident (R) #52, who was not allowed to have anything by mouth, and who had a recent history of candidal stomatitis (oral thrush, a fungal infection). The sample size was 29 residents. Findings include: Review of R #52's clinical record revealed that she was originally admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of her physician's orders [REDACTED]. Review of R #52's Medication Administration Record [REDACTED]. Review of her Admission Minimum Data Set ((MDS) dated [DATE] revealed that she needed extensive assistance for personal hygiene. Review of an undated care plan with a focus statement that the resident had thrush, revealed interventions that included the resident required mouth inspections (unspecified frequency), and to report changes to the nurse. During observations on 7/24/17 at 1:26 p.m., 7/25/17 at 8:01 a.m. and 2:57 p.m., and 7/26/17 at 9:33 a.m., a thick, bright white coating was noted covering R #52's tongue. During interview with Certified Nursing Assistant (CNA) HH on 7/26/17 at 9:57 a.m., she verified the white coating on R #52's tongue, and stated that the white stuff had been there ever since she had been a resident at the facility, and that the nurse knew about it. During observation at this time, CNA HH used an foam oral swab to do mouth care for R #52, but was not able to remove any of the white coating from the resident's tongue. During interview with Licensed Practical Nurse (LPN) GG on 7/26/17 at 10:20 a.m., she stated that R #52 had received [MEDICATION NAME] and [MEDICATION NAME] (antifungal medications) about a month and a half ago, that she was not currently aware of any problems with the resident's tongue, and that the CNAs had not mentioned anything to her. During observation at this time, LPN GG verified the thick white coating on R #52's tongue, and stated that the resident's tongue did not look that bad the last time she was being treated for [REDACTED]. During interview with the interim Director of Nursing (DON) on 7/27/17 at 8:47 a.m., he stated that his expectations were for staff to do oral care at least daily if not more often, and that it would depend on the condition of each individual resident's mouth. During interview with Registered Nurse MDS staff I I on 7/27/17 at 11:13 a.m., she stated that she had just completed an oral assessment on R #52, and verified that the resident's tongue had a heavy white coating on it. During interview with LPN GG on 7/27/17 at 11:29 a.m., she stated that there was no treatment or other orders to check R #52's mouth on a routine basis, so this was not being done. Review of a Physician order [REDACTED]. Review of the facility's Oral Care policy with a revised date of 5/12/17 noted: Oral care, which typically involves the nurse or the patient brushing and flossing the patient's teeth and inspecting the mouth, is commonly performed in the morning, at bedtime, and after meals. Implementation: Assess the oropharyngeal cavity. Inspect the oral cavity using a penlight, as needed.",2020-09-01
633,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2017-07-27,431,E,0,1,N68F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that the Central Supply room that contained stock medications was locked when not attended on one of one observation. There were 19 cognitively impaired, independently mobile residents in the facility, and the facility census was 96 residents. Findings include: During interview with Licensed Practical Nurse (LPN) BB on 7/26/17 at 2:42 p.m., she stated that some floor stock medications were kept in the Central Supply room. On the short hallway off the 500-hall where the Central Supply room was located, R #46 was observed at this time to attempt to turn the doorknob of a locked Clean Utility room, which was located approximately eight feet away from the Central Supply room. Further observation at this time revealed that R #46 was able to self-propel her wheelchair without any assistance from staff. Continued observation revealed that the door to the Central Supply room was closed, but not locked. This was verified during interview with LPN BB at this time, who stated that the Central Supply clerk usually kept the door locked when she was not in it. On 7/26/17 at 2:45 p.m. (three minutes after entering the unlocked Central Supply room), Central Supply Tech CC was observed to enter the Central Supply room, and stated that she always kept the door locked to this room whenever she left the room. During further interview, she stated that she had to take care of a problem with a resident's oxygen on the 400-hall, but that she had been gone out of the Central Supply room for only a few seconds. Observation in the Central Supply room at this time revealed that it contained a large cabinet accessed by three unlocked doors. Observation inside this cabinet revealed several shelves containing numerous containers of floor stock medications, including shelves of medications that would be low enough to be accessible by a resident in a wheelchair. During interview with LPN DD on 7/26/17 at 2:54 p.m., she stated that R #46 was a resident on the 100-hall, and that she was able to roll herself around the facility. Review of R #46's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a BIMS (Brief Interview for Mental Status) score of 00 (a score of 0 to 7 indicated severe cognitive impairment), wandering occurred daily, and that she required minimal assist by one person for locomotion off the unit. Review of her care plans revealed that she had safety risks related to exit-seeking behavior and wandering. During interview with the interim Director of Nursing (DON) on 7/26/17 at 5:50 p.m., he stated that the door to the Central Supply room should be locked at all times. Review of a list provided by MDS Coordinator EE on 7/26/17 at 6:26 p.m. revealed that there were 19 residents in the facility who were cognitively-impaired (who had BIMS scores of less than 8), and who were independently mobile. Review of the policy Medication Storage in the Facility-Storage of Medications with a revised date of (MONTH) 2011 revealed: Medication rooms, carts, and medication supplies are locked when not attended by persons with authorized access.",2020-09-01
634,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2017-07-27,441,D,0,1,N68F11,"Based on observation, record review, and staff interview, the facility failed to clean a glucometer in a manner to ensure that it was disinfected between each resident (R) use by one of two nurses observed. Three residents on the 500-hall received a fingerstick blood sugar (FSBS) on the evening shift on 7/25/17. Findings include: On 7/25/17 at 5:13 p.m., Licensed Practical Nurse (LPN) PP was observed cleaning the glucometer with an only an alcohol wipe after performing a FSBS for R #87. During interview at this time, LPN PP stated that she only used alcohol to clean the glucometer as she was allergic to the bleach wipes, and would break out in hives if she used the bleach. During interview with the Director of Clinical Education on 7/26/17 at 1:34 p.m., she stated that the facility staff were expected to use Clorox wipes to disinfect the glucometer, and that alcohol alone would not be sufficient. Review of the facility's Glucometer Decontamination policy revised 9/2015 revealed: Since glucometers may be contaminated with blood and body fluids as well as other pathogens, such as would be encountered in contact precautions, this facility has chosen a disinfectant wipe that is EPA (Environmental Protection Agency) registered as tuberculocidal, therefore it is effective against HIV (human immunodeficiency virus), HBV (hepatitis B virus), and a broad spectrum of bacteria. Should there be an occasion that the disinfectant wipe is not available, a 1:10 bleach solution may be substituted.",2020-09-01
635,WINDERMERE HEALTH AND REHABILITATION CENTER,115291,3618 J DEWEY GRAY CIRCLE,AUGUSTA,GA,30909,2019-10-09,600,G,1,0,1SQO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the facility Abuse and Neglect Prohibition Policy (revised 7/2018) and resident and staff interview, the facility failed to ensure that two (2) residents (R) (R#1 and R#2) were protected from abuse by a Resident Care Specialist (RCS/Certified Nursing Assistant (CNA). Furthermore, another RCS/CNA failed to notify supervisory staff immediately of an observation of the physical abuse, resulting in actual harm, of two residents (R) (R)#1 and R#2, on 9/25/19, by the RCS/CNA perpetrator. This failure to immediately report an observation of the physical abuse and harm of R#1 resulted in the subsequent physical abuse and harm of R#2, on 9/25/19, by the same RCS/CNA perpetrator. The sample size was 21 residents. Findings include: Review of the facility Abuse and Neglect Prohibition Policy (revised 7/2018) revealed that each resident has the right to be free from abuse .and mistreatment .Any observations or allegations of abuse, neglect or mistreatment must be immediately reported to the Administrator. 1. R#1 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that R#1 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment. Continued review revealed that he had no behaviors in the look back period. Further review revealed that he required extensive assistance of staff for activities of daily living (ADLS) and was frequently incontinent of bladder and always incontinent of bowel. Review of the resident's care plan dated 11/12/18 revealed that staff developed appropriate interventions to address his self-care deficit. Continued review revealed that staff addressed his behaviors of pulling his clothing, jerking and using curse words at times. Review of the Facility Incident Report Form for R#1 dated 9/25/19 revealed that on 9/25/19 at 9:30 p.m., RCS/CNA AA had pulled on resident #1's upper body and the resident hit his head on the dresser next to his bed, three times. He sustained a cut on the inside of his mouth. Continued review revealed that RCS/CNA AA also hit R#1 on his upper arm. Review of the care plan for R#1 revealed that it was revised on 10/7/19 to address his behaviors of jerking and pulling with an intervention for staff to explain all procedures to him before initiating care and allow him time to adjust to changes. If his behavior continues, STOP and come back later. When he has behaviors of pulling and jerking, he will stop if you ask him to. Observation and interview on 10/1/19 at 2:21 p.m. with R#1 (roommate of R#2) revealed the resident was lying in his bed. R#1 had no bruising/injuries on his face, neck or arms. He stated at that time that while a RCS/CNA was changing his brief, she grabbed him by his arm and pulled him out of the bed causing him to hit his head on the nightstand next to his bed. Continued interview with R#1 revealed that after providing care for him, the RCS/CNA went to his roommate (R#2) and was speaking loud to him. Further interview revealed that he heard R#2 yell out prior to observing the RCS/CNA leave his room. R#1 stated at that time that he did not know the name of the RCS/CNA who hurt him. R#1 stated that no one else at the facility had abused him and that he felt safe in facility. 2. R#2 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that R#2 had a BIMS score of 5, indicating severe cognitive impairment. Continued review revealed that he had no behaviors in the look back period. Further review revealed that he required extensive assistance from staff for ADLs and was always incontinent of bladder and bowel. Review of the resident's care plan dated 8/28/19 revealed that staff developed appropriate interventions to address his self-care deficit. Continued review revealed that R#2 was resistant to care with an intervention for staff to leave him alone for 5 to 10 minutes and come back to attempt care again. Review of the Facility Incident Report Form for R#2 dated 9/25/19 revealed that on 9/25/19 at 9:45 p.m., RCS/CNA AA was observed by another RCS/CNA to grab the genitals of R#2 causing him to scream and cry. Continued review of both Incident Reports revealed that RCS/CNA AA was suspended and immediately walked out of the building. Both residents were assessed for injuries. Local Law Enforcement and the State Survey Agency (SSA) were notified of the abuse within the mandated two hours. The Responsible Parties (RP) and Physician were notified. Review of the care plan for R#2 revealed that it was revised on 10/7/19 to address his behavior of rejecting care with an intervention to allow him to make decisions about his treatment regime to provide him with a sense of control. An observation and interview on 10/1/19 at 2:16 p.m., revealed that R#2 (roommate of R#1) was lying in his bed. He did not have any obvious bruising/injuries on his face, neck or arms. R#2 did not appear afraid. R#2 had difficulty answering more than yes and no questions due to his [MEDICAL CONDITION]. When asked if anyone had hurt him, R#2 said yes. When asked if anyone currently in facility had hurt him, he said no. When asked if he felt safe in the facility, R#2 said yes, sir, yes sir, yes sir. Review of the Sheriff's Office investigation dated 9/26/19 revealed the incident occurred on 9/25/19 which was related to R#2 being grabbed by genitals by RCS/CNA AA, three times, causing the resident to cry out in pain. R#2 confirmed to the investigator that this occurred at the hands of RCS/CNA A[NAME] Further review revealed an arrest warrant was issued for RCS/CNA AA on 9/30/19, for both R#1 and R#2, by the County District Attorney's office for the offense of: Exploitation and Intimidation of an Elderly/Disabled Adult. A post survey interview on 10/22/19 at 9:41 a.m. with the District Attorney Investigator confirmed that RCS/CNA AA was arrested on 10/1/19 for charges of abuse for R#1 and R#2. Record review revealed that on 10/1/19 the facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting with department heads which included the Administrator, Director of Nursing (DON) and Medical Director. Review of the meeting minutes revealed that interventions were developed and implemented to prevent further abuse of residents. Record review in-service sign-in sheets dated 9/25/19 and 9/26/19 revealed that all staff were in-serviced on Abuse and Neglect. Review of the medical records for R#1 and R#2 revealed that the Social Service Director (SSD) provided psychosocial wellness visits for both residents 72 hours after the abuse to assess for any post-abuse distress. Interview with RCS/CNA BB on 10/1/19 at 3:36 p.m. revealed that she was in orientation at the time of the incident and was assisting RCS/CNA AA in the provision of care for R#1 on 9/25/19 on the 3:00 p.m. to 11:00 p.m. shift. Continued interview revealed that RCS/CNA AA was rough with R#1 and pulling on him during care. R#1 then became combative and RCS/CNA AA punched the resident (R#1) in the arm and chest, three to four times and then grabbed his arm and pulled him off the bed. RCS/CNA BB stated that R#1's mouth was bleeding. RCS/CNA BB then told CNA/RCS AA to obtain clean linens. Further interview with RCS/CNA BB revealed that she finished the care for R#1 and asked him if he was O.K. and he said he was. Continued interview with RCS/CNA BB revealed that R#2, R#1's roommate, was covered in feces so she began providing care for him. RCS/CNA BB stated that RCS/CNA AA came back into the room with clean linens and before RCS/CNA BB could place a clean brief on R#2, RCS/CNA AA grabbed his genitals and squeezed them. Further interview revealed that R#2 cried out in pain. RCS/CNA BB stated that she left the residents' room and notified her preceptor at that time of RCS/CNA AA's abuse. Continued interview revealed that she attempted to notify the Charge Nurse but, the nurse was on the phone. RCS/CNA BB stated that she then went to another hall to assist another RCS/CNA with resident care. When asked why she did not notify supervisory staff immediately after RCS/CNA AA abused R#1 and prior to providing care for R#2, RCS/CNA BB stated, I was in shock and just wanted to finish and get out of there. RCS/CNA BB stated that she was taught in CNA school to immediately notify supervisory staff of any incident of abuse. Interview with the Director of Nursing (DON) on 10/2/19 at 1:39 p.m. revealed that RCS/CNA AA abused R#1 around 9:20 p.m. and abused R#2 around 9:30 p.m. Continued interview revealed that the Charge Nurse was notified by RCS/CNA BB of the events around 9:40 p.m. Further interview with the DON revealed that she had arrived at the facility at around 9:45 p.m. to provide in-services to second shift staff when the Charge Nurse informed her of the incidences. The DON stated, at that time, that RCS/CNA AA was taken to the conference room and a statement was obtained prior to the DON walking her out of the building at around 9:50 p.m. Continued interview revealed that the Administrator arrived shortly after. Review of the in-services provided by the facility on Abuse Prevention revealed that RCS/CNA AA had received in-service on 7/16/19, date of hire, and RCS/CNA BB had received in-service on 9/1/19. Interviews with RCS/CNAs CC on10/1/19 at 4:06 p.m., RCS/CNA DD on 10/1/19 at 4:09 p.m., RCS/CNA EE on 10/1/19 at 4:11 p.m., RCS/CNA FF on 10/1/19 at 4:15 p.m., RCS/CNA GG on 10/1/19 at 4:20 p.m., RCS/CNA JJ on 10/2/19 at 3:37 p.m., RCS/CNA KK on 10/2/19 at 3:34 p.m. revealed that they were not aware of any resident's being abused by staff, before the incident with R#1 and R#2, but if they became aware they would immediately report to the charge nurse and the Administrator. They all confirmed having participated in Abuse in-services at the facility on (MONTH) 25 and 26, 2019. Interviews with Registered Nurses (RN) and Licensed Practical Nurses (LPN) revealed: RN HH on 10/2/19 at 3:20 p.m., RN II on 10/2/19 at 3:22 p.m., and LPN LL on 10/2/19 at 3:37 p.m. were not aware of any incidents of abuse until after the incident with RCS/CNA A[NAME] The were aware to notify their supervisor and the Administrator should they become aware of abuse to a resident. Interviews with cognitively intact residents (Brief Interview for Mental Status (BIMS) of 13-15 indicates cognitively intact and 8-12 indicates moderately cognitvely intact) , R#7 on 10/2/19 at 10:35 a.m. with a BIMS on the Annual MDS dated [DATE] of 15, indicating the resident was cognitively intact, R#5 on 10/2/19 at 10:38 a.m. with a BIMS of 11 on the Quarterly MDS dated [DATE], R#8 with a BIMS of 12 on the Quarterly MDS dated [DATE], R#9 on 10/2/19 at 10:44 a.m. with a BIMS of 11 on the Quarterly MDS dated [DATE], R#10 on 10/2/19 at 10:46 a.m. with a BIMS of 12 on the Admission MDS dated [DATE], R#11 on 10/2/19 at 10:50 a.m. with a BIMS of 14 on the Quarterly MDS dated [DATE], R#13 on 10/2/19 at 11:00 a.m. with a BIMS of 13 on the Quarterly MDS dated [DATE], R#14 on 10/2/19 at 11:06 a.m. with a BIMS of 15 on the Quarterly MDS of 9/25/19, R#15 on 10/2/19 at 11:08 a.m. with a BIMS of 14 on the Quarter MDS dated [DATE], R#16 on 10/2/19 at 11:15 a.m. with a BIMS of 12 on the Admission MDS dated [DATE], R#17 on 10/2/19 at 11:42 a.m. with a BIMS of 15 on the Quarterly MDS dated [DATE], R#18 on 10/7/19 at 12:12 p.m. with a BIMS of 14 on the Admission MDS dated [DATE], R#19 on 10/7/19 at 12:16 p.m. with a BIMS of 13 on the Quarterly MDS dated [DATE], R#20 on 10/7/19 at 12:20 p.m. with a BIMS of 13 on the Annual MDS dated [DATE], and R#21 on 10/7/19 at 12:26 p.m. with a BIMS of 14 on the Quarterly MDS dated [DATE] revealed that they had not been abused or seen any other residents abused. Continued interview revealed that they knew to whom to report any incidences of abuse. An interview with the Administrator, who was the Abuse Prevention Coordinator, on 10/9/19 at 11:01 a.m. revealed that she expected RCS/CNA BB to make sure R#1 was safe first, then get help and notify supervisory staff of the abuse prior to providing care for R#2. The facility failed to ensure that R#1 and R#2 were protected from abuse by RCS/CNA A[NAME] Furthermore, the facility failed to ensure that RCS/CNA BB immediately notified supervisory nursing staff of the abuse of R#1 by RCS/CNA A[NAME] This failure resulted in the subsequent abuse of R#2.",2020-09-01
636,RESORTS AT POOLER INC,115293,508 SOUTH ROGERS STREET,POOLER,GA,31322,2019-02-07,645,D,0,1,8Z4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews the facility failed to ensure a Preadmission Screening/Resident Review (PASRR) Level I Application was reviewed for the need of a Level II PASRR for one (1) resident, Resident #53 (R#53). The PASRR form is completed to ensure a resident in a nursing facility is evaluated when a major mental disorder [DIAGNOSES REDACTED]. The facility census was 75 residents. Finding include: Resident #53 was admitted to the facility on (MONTH) 10, (YEAR) with [DIAGNOSES REDACTED]. During review of the medical record it was noted that R#53 presented with behaviors of refusing care from the staff, agitation and the need for behavior monitoring by the staff. Her medical co-morbidities have caused multiple hospitalization s as well as a psychiatric hospitalization for stabilization of her behaviors. A new [DIAGNOSES REDACTED]. The medical record contains a PASRR Level I form that was presented upon admission to the facility but her status had not been reviewed for the need of a PASRR Level II which may have included recommendations for possible specialized services. During an interview on (MONTH) 7, 2019 at 9:04 a.m., with the Social Service Director (SSD) stated she only reviews the PASRR Levels when a resident admits to the facility or when there are behavior changes that warrant a change in PASRR level. She stated the only thing that would prompt her to look at the PASSR information after admission would be those behavior changes. She also stated that she would not review the PASRR level for a new diagnosis. The SSD also stated this resident has never been offered specialized services before or after her [DIAGNOSES REDACTED]. During an interview with the Administrator on (MONTH) 7, 2019 at 1:42 p.m. she stated her expectations of the staff were to ensure the PASRR forms were reviewed when needed, accurate and meet the needs of the residents ensuring that needed care and services were provided",2020-09-01
637,RESORTS AT POOLER INC,115293,508 SOUTH ROGERS STREET,POOLER,GA,31322,2019-02-07,656,D,0,1,8Z4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the plan of care related to pain management for one resident (R#65). The sample size was 24 residents. Findings include: Review of the clinical records for resident (R)#65 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment of 1/22/19 revealed the resident was on as needed (PRN) pain medications, and experienced occasional pain. Further review of the clinical records revealed an order valid since 11/16/18 for the resident to be assessed for pain every shift. A review of the care plan records for R#65 revealed a plan of care for pain management last updated 1/23/19. Interventions included directives for staff to administer pain medications as ordered, to observe for signs and symptoms of pain, and to notify the physician if pain is not relieved within 45 minutes of receiving pain medications. A review of the (MONTH) 2019 Medication Administration Record [REDACTED]. During an interview on 2/7/19 at 9:29 a.m. with Licensed Practical Nurse (LPN) BB, it was revealed that she assesses R#65 for pain only if he verbalizes pain and/or asks for pain medication. Under those circumstances, the nurse documents the resident's pain number on a scale between 1 and10 before administering pain medication and then assesses his pain level again 45 minutes after the medication is administered. R#65 is not routinely assessed for pain every shift. LPN BB also verified that the resident had not been documented as being assessed for pain each shift, nor had he received an PRN pain medications thus far during the month of (MONTH) 2019. During an interview on 2/7/19 at 11:36 a.m. with the Director of Nursing (DON), it was revealed that, since (MONTH) (YEAR), the facility had experienced issues with the pharmacy not printing some of the orders on the MARS. She had asked repeatedly for the problem to be fixed to no avail. Since that time, staff members who were assigned to check the accuracy of the MARS had identified orders each month that were not preprinted. The orders so identified were manually added to the relevant MARS. Unfortunately, the staff members who were assigned to that task had left the facility, and the staff who were subsequently assigned did not catch the missing orders for (MONTH) 2019. The DON said she was aware that some of the orders were still missing from the MARs, including the order for R#65 to be assessed for pain each shift. Cross-refer to F697",2020-09-01
638,RESORTS AT POOLER INC,115293,508 SOUTH ROGERS STREET,POOLER,GA,31322,2019-02-07,697,D,0,1,8Z4511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and review of the record, the facility failed to complete a pain assessment every shift for one resident (R#65) from a sample of 24 residents. Findings include: Review of the clinical records for resident (R)#65 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set assessment of 1/22/19 revealed the resident was on as needed (PRN) pain medications, and experienced occasional pain. Further review of the clinical records revealed an order valid since 11/16/18 for the resident to be assessed for pain every shift. A review of Medication Administrative Records (MARs) for (MONTH) (YEAR) through (MONTH) 2019 revealed the order for the resident's pain to be assessed every shift was added to the record in pen and had not been printed like the other orders on the record. However, the nurses had documented that the order was followed as written. A review of the MAR for (MONTH) 2019 revealed there was no order, printed or handwritten on that record for the resident to be assessed for pain each shift, no indication that the resident was assessed for pain, nor was it documented that pain medication was administered. During an interview on 2/7/19 at 9:29 a.m. with Licensed Practical Nurse (LPN) BB, it was revealed that she assesses R#65 for pain only if he verbalizes pain and/or asks for pain medication. Under those circumstances, the nurse documents the resident's pain number on a scale between 1 and10 before administering pain medication and then assesses his pain level again 45 minutes after the medication is administered. R#65 is not routinely assessed for pain every shift. LPN BB also verified that the resident had not been documented as being assessed for pain each shift, nor had he received any PRN pain medications thus far during the month of (MONTH) 2019. During an interview on 2/7/19 at 11:36 a.m. with the Director of Nursing (DON), it was revealed that, since (MONTH) (YEAR), the facility had experienced issues with the pharmacy not printing some of the orders on the MARS. She had asked repeatedly for the problem to be fixed to no avail. Since that time, staff members who were assigned to check the accuracy of the MARS had identified orders each month that were not preprinted. The orders so identified were manually added to the relevant MARS. Unfortunately, the staff members who were assigned to that task had left the facility, and the staff who were subsequently assigned did not catch the missing orders for February. The DON said she was aware that some of the orders were still missing from the MARs, including the order for R#65 to be assessed for pain each shift. She planned to update his MAR indicated [REDACTED].",2020-09-01
639,RESORTS AT POOLER INC,115293,508 SOUTH ROGERS STREET,POOLER,GA,31322,2019-02-07,880,E,0,1,8Z4511,"Based on observation, interview, and review of the facility policy titled, Handling Soiled Laundry the facility failed to assure the cross contamination of laundry. This deficient practice affected all residents. The facility census was 75 residents. Findings include: Review of facility policy titled, Handling Soiled Linen Handling Soiled Linen 1. All used linen should be handled using standard precautions (i.e. gloves) and treated as potentially contaminated: a. Linen should not be allowed to touch the uniform or floor and should be handled as little as possible, with minimum agitation to avoid contamination of air, surfaces, and persons. During laundry tour on 2/6/19 at 12:44 p.m. Laundry Aide EE was observed sorting soiled laundry outside of the laundry room. Once the soiled items were sorted the container was then taken into the laundry room for items to be washed. Laundry Aide EE was noted to lean over the container (uniform touching the container) when removing items to put into the washer. While pulling some of the items out of the container they were noted to touch the front of Laundry Aide EE's uniform. It is noted that there was no barrier between resident's clothing and the soiled laundry. On 2/6/19 at 12:55 p.m. Laundry Aide EE was observed pulling a sheet out of the clean linen container and two wash cloths fell to the floor. Laundry Aide EE picked up the two wash cloths and placed them back in the container with the other clean linens. Laundry Aide EE then began to fold a sheet. However, while folding the sheet it was observed to be touching the floor. Laundry Aide EE continued to fold two more sheets with each touching the front of her uniform and touching the floor while folding. In total there were three sheets that touched the floor while Laundry Aide EE was folding and only one was placed in the soiled linen container to be rewashed. During an interview with Laundry Aide EE on 2/6/19 at 1 p.m. it was reported that if clean items fall on the floor they would have to be placed in the soiled laundry container and then rewashed. Laundry Aide EE then acknowledged that the wash cloths were picked up off the floor and placed back into the clean linen container but should have been placed in the container to be rewashed. When questioned about items touching the floor while folding Laundry Aide EE reported that items are going to always touch the floor because he/she is short. During an interview on 2/6/19 at 1:31 p.m. with the Environmental Coordinator it was reported that staff should be using the white jumper with goggles when sorting dirty laundry. It was further reported that if items touch the floor they should be rewashed. Environmental Coordinator also reported that the goggles and jumper were placed in the laundry room yesterday (2/5/19).",2020-09-01
640,RESORTS AT POOLER INC,115293,508 SOUTH ROGERS STREET,POOLER,GA,31322,2017-06-08,253,E,0,1,BUF711,"Based on observations and staff interviews, the facility failed to maintain housekeeping and maintenance services necessary to provide a sanitary, and comfortable interior. This was evidence by unclean floors and baseboards, missing paint, furniture with scuff marks, and holes in the walls on three of three halls. Findings include: Observation on 6/5/17 at 11:45 a.m. revealed the following environmental concerns: 1. Rooms A-4, A-9, B-10, C-10, and C-17 had a buildup of dirt debris in corners as well as near the air conditioners and under the built in desks. 2. Rooms A-1, A-2, A-4, A-10, A-13, B-10, B-11, C-5, C-8, and C-17 had chipped paint on the walls, broken covers on electrical outlets and night stands/tables had scuff marks on the bottom. 3. Rooms A-1, B-3, B-9, B-11, C-3, C-5, C-8, and C-17 had holes in walls and brown stained ceiling tiles. 4. Rooms B-3 and B-10 had baseboards peeling away from the wall. Interview on 6/7/17 at 8:25 a.m. with Housekeeper CC revealed that they clean the residents bathrooms first, check windows and blinds, empty trash cans and clean any dirty areas. Interview on 6/7/17 at 8:30 a.m. with the Housekeeping Supervisor revealed that they are following a cleaning schedule calendar which included a schedule for resident rooms to be deep cleaned. He stated that the housekeepers are to clean 'anything that's actually dirty'. He stated that they have a schedule for the facility floors which includes stripping and waxing, cleaning the baseboards, cleaning the vents in hallways and cleaning the air conditioner vents and frame. Environmental observation rounds and interview were completed on 6/8/17 at 9:00 a.m. with the Maintenance Director which revealed the following: 1. A Hall - Room 11, the middle privacy curtain track was coming off from the ceiling; Room 6, the privacy curtain was stuck on the track. 2. C Hall - Room 2, had brown stained ceiling tiles. An interview with the Maintenance Director during the environmental rounds revealed that the last time the furniture had been redone (re-stained or replaced) was in (YEAR).",2020-09-01
641,RESORTS AT POOLER INC,115293,508 SOUTH ROGERS STREET,POOLER,GA,31322,2017-06-08,460,E,0,1,BUF711,"Based on observations and staff interviews, the facility failed to assure full visual privacy for bed A residents in 16 (A hall - 6 rooms and C hall - 10 rooms) of 33 semi-private rooms on two of three halls. Findings include: Observation on 6/7/17 at 1:00 p.m. of each hall (A, B, and C) revealed 16 of 33 beds near the doorway on the A hall and B hall, the privacy curtain does not provide full privacy due to gaps/openings as well as curtain tracks needing repair. Interview on 6/8/17 at 7:50 a.m. with Housekeeping Supervisor revealed he was not aware that the privacy curtains did not fit. He stated that the Maintenance Director made him aware this morning of the privacy curtains. Interview on 6/8/17 at 8:00 a.m. with Certified Nursing Assistant (CNA) AA revealed that to ensure the resident's privacy, she would make sure the resident was covered and then notify housekeeping or maintenance of the short privacy curtain. Interview on 6/8/17 at 8:05 a.m. with Licensed Practical Nurse (LPN) BB revealed that to ensure the resident's privacy, she would close the door or get a sheet to use to hold up when roommate enters. Environmental observation rounds and interview on 6/8/17 at 9:00 a.m. with Maintenance Director revealed: A Hall - Room 11, the middle curtain track was coming off from the ceiling; Room 6 the privacy curtain was stuck on the curtain track and had a 4 foot opening between the curtains. C Hall - Room 4, the privacy curtain near the doorway had a 4 foot opening between the curtains; Room 5 and 6, curtain track was coming off from the ceiling; Room 7, privacy curtain had a 6 foot opening between curtains; Room 18, the privacy curtain had a 2 foot opening between the curtains.",2020-09-01
642,RESORTS AT POOLER INC,115293,508 SOUTH ROGERS STREET,POOLER,GA,31322,2018-06-12,584,E,1,0,Z2U811,"> Based on observation, interview, and record review the facility failed to provide the necessary housekeeping services to maintain a clean, sanitary and comfortable environment in seven resident rooms (A16 and A17, B7, B11, and B12, C3 and C15) on three halls (A, B, and C), and failed to clean two Hoyer lifts used for resident transfers and failed to clean rolling and stationary walkers, and the facility failed to address that a bathroom wall was separating from the floor tile on the left side of the sink leaving a gap approximately one-inch wide gap and running the length of the wall, and the base of the toilet was rusted and rotting with an oval shaped hole in the floor behind the toilet approximately one inch wide and four inches long for one bathroom. The facility census was 75 residents. Findings include: Observation on 6/11/18 at 1:05 p.m. revealed two Hoyer lifts in the hallway, one with a chrome base that had smeared, greasy residue, dried splatters and debris covering the chrome base and the central support beam. The other Hoyer lift has an off-white molded plastic base and central support beam, both areas were heavily covered with splatters, stuck on debris and dirt. Observation of room B12 on 6/11/18 at 1:10 p.m. revealed dirt and debris behind her bedroom door. Dirt and debris are visible under both the A and B beds and the base of the bed table has dried debris and food matter on it. Interview with the Housekeeping Supervisor on 6/11/18 at 1:50 p.m. who revealed that he wasn't sure who was responsible for cleaning the Hoyer lifts and there was no schedule or record of them being cleaned in his department. Observation of room B11 on 6/11/18 at 1:35 p.m. revealed cobwebs behind the entry door in addition to a layer of built-up dirt and debris. Dirt and debris were visible under both the A and B beds, both beds and tray tables had dirt and food splatters on the bases. A bumper pad on the B bed between the bed and the wall had a thick, visible layer of dust, the wood window blinds were coated with dust and the right wall of the entryway to the resident's room had multiple dried orange-red splatters on it. In the bathroom, there was one loose tile separated from the wall beside the toilet and decayed grout at the base of the toilet leaving a separation between the floor and the toilet base. Observation of room B7 on 6/11/18 at 1:40 p.m. revealed dirt and debris visible under both the A and B beds, both tray tables had dirt and food splatters on the bases. Resident A uses a rolling walker and stated that it has never been cleaned. Resident B's wheelchair was dirty and she states she doesn't know if it has ever been cleaned. All four corners of the bathroom and the area behind the toilet had a layer of built-up and loose dirt and debris and the sink was loose from the wall mounting. All four corners of the bedroom had a layer of built-up and loose dirt and debris. Interview on 6/11/18 at 1:55 p.m. with the Housekeeping Supervisor and housekeeping staff DD who stated that housekeeping did not clean the Hoyer lifts. Interview on 6/11/18 at 2:25 p.m. with the Housekeeping Supervisor who stated he didn't know if housekeeping had ever cleaned the resident's walkers and he was unaware that they needed to be cleaned. Interview on 6/11/18 at 2:30 p.m. with the Housekeeping Supervisor and housekeeping staff DD who confirmed that housekeeping had never cleaned the resident's walkers. Observation of room C3 on 6/11/18 at 2:35 p.m. revealed a layer of dirt and debris in all corners of the room and behind the door, and dust and debris under both beds. The bathroom walls had holes in them that had been spackled but not sanded or painted and splatter from the spackle was on the sides and base of the toilet. The emergency call cord was stiff and crusted with yellow deposits. Observation of room C15 on 6/11/18 at 2:40 p.m. revealed a large counter-top dressing area with a mirror next to the closets. Underneath the counter were large pieces of debris and dirt with visible build-up and a blackish film of dirt in the corners. The area behind the entry door had a thick layer of built-up and loose dirt and debris, as well as all corners of the room. The bathroom smelled of urine, the bathroom wall was separating from the floor tile on the left side of the sink leaving a gap approximately one-inch wide gap and running the length of the wall, and the base of the toilet was rusted and rotting with an oval shaped hole in the floor behind the toilet approximately one inch wide and four inches long. The emergency call cord was stiff and crusted with yellow deposits. Interview on 6/11/18 at 2:50 p.m. with Staff Development Coordinator BB who confirmed that nursing staff wipe down the Hoyer lifts between each resident and it is housekeeping's responsibility to clean the rest of the lift. Observation of room A16 on 6/11/18 at 2:55 p.m. revealed a layer of dirt and debris behind the entry door and in the corners of the room, dirt and debris under the dressing counter, dirt and debris under both beds, and in the closet for side [NAME] The window blinds were covered in a sticky film the entire height of the window. Observation of room A17 on 6/11/18 at 3:00 p.m. revealed reddish brown splatters on the back of the entry door, layers of dirt and debris in all corners of the room and dirt and debris under the beds. The tray table for bed A had a thick layer of residue on the base and both resident walkers had deposits of black greasy residue and splatter on them. A tour of the same rooms (B7, B11, B12, C3, C7, A16 and A17) the following day on 6/12/18 beginning at 1:25 p.m. with the Administrator and the Housekeeping Supervisor FF revealed no changes in the findings. The rolling walker in room B7 and two rolling walkers in room A17 were also observed during the tour. The Administrator and the Housekeeping Supervisor observed and agreed with all findings. The Housekeeping Supervisor agreed that findings were the responsibility of the housekeeping staff and that housekeeping staff were responsible for observing and reporting maintenance concerns to him or the Maintenance Director for repairs. Interview on 6/12/18 at 1:35 p.m. with the Administrator who stated that she was unaware of any of the issues with the resident's rooms or the walkers and Hoyer lifts. None of these items had been brought up in staff meetings and maintenance issues were never reported or they would have been addressed. Cleaning of all resident used equipment, including Hoyer lifts, walkers and wheelchairs has always been the responsibility of the housekeeping staff.",2020-09-01
643,RESORTS AT POOLER INC,115293,508 SOUTH ROGERS STREET,POOLER,GA,31322,2018-06-12,658,D,1,0,Z2U811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, the facility failed to follow Physician orders [REDACTED].#1) by failing to ensure that the resident received her Bydureon 2mg/0.65 ml (milliliter) pen injector every seven days as ordered. The facility census was 75. Findings include: Interview with the family of R#1 on 6/12/18 at 9:30 a.m. revealed she is the resident's sister and gives the resident her Bydureon injections. She confirmed that R#1 received her weekly Bydureon injection at home on 4/30/18. Resident broke her right elbow and was hosptalized on [DATE] and discharged to this facility on 5/3/18. Continuing interview with the complainant revealed that she told the facility on 5/23/18 that the resident's next injection should have been due on 5/7/18 but the facility told her she could not get the medication until she had been in the facility for seven days. The resident did receive her injection on 5/10/18, making the next injection due 5/17/18. Record review revealed that the resident did not receive her injection until 5/21/18. During an interview on 6/12/18 at 10:55 a.m. with the Director of Nursing (DON) revealed that she was the admitting nurse for R#1 and she received report from the hospital via telephone as part of the R#1's admission process, verbally receiving and confirming the resident's list of medications, dosing strengths and times while reading them off the faxed copy of the 'Current Discharge Medication List' from the hospital. The DON revealed that she confirmed the resident's weekly subcutaneous injection of two milligrams (mg) Bydureon (an anti-diabetic medication) but did not ask the hospital when the last injection had been administered or when the next injection was due. Further interview with the DON revealed that R#1's first injection was scheduled to be given seven days (one week) after admission and that facility practice was to schedule a weekly medication for administration seven days after admission. However further interview and review of the Medication Administration Records revealed that one off the medication nurses received a discontinuation order for the R#1's [MEDICATION NAME] 80 milligrams daily on 5/9/18 and incorrectly discontinued R#1's Bydureon injections in addition to the [MEDICATION NAME] and R#1 received her second Bydureon injection on 5/21/18, four days after the scheduled date of 5/17/18. Interview with the DON on 6/12/18 at 5:00 p.m. revealed that the facility does not have a policy that specifies how to conduct a medication reconciliation for new admissions. It is a generally understood process that is verbally provided to the nurses during training. The DON states that they have not experienced an issue like this previously and revealed that residents receiving weekly injections prior to admission have always been scheduled to receive their first injection seven days after admission unless the previous provider tells them otherwise.",2020-09-01
644,STEVENS PARK HEALTH AND REHABILITATION,115294,820 STEVENS CREEK ROAD,AUGUSTA,GA,30907,2018-07-26,803,E,0,1,AD1W11,"Based on observation, staff interview, four week cycle menu review and policy review, the facility failed to serve the proper portion size of three (3) ounce Swiss Steak with gravy per the cycle menu for one lunch meal. This deficient practice affected 16 of 38 residents who received the Swiss Steak with gravy meal choice. Findings include: Review of the weekly menu cycle week four day two for lunch on 7/24/18 revealed resident's receiving a regular diet were to receive three ounces of Swiss Steak with gravy. Review of the facility policy titled Menus updated (MONTH) (YEAR), states it is the intent of this center to provide meals based on a menu following established national guidelines. Under procedural guidelines number five: Menu items will be nutritionally adequate, attractively served, palatable and at a safe and appetizing temperature, and within cost or budget projections. On 7/24/18 at 12:54 p.m., observation of Dietary Aide CC, plating trays for residents eating lunch in the dining room, revealed she placed a small single beef patty, which were the size of a small sausage patty, on the plates and sent them out for residents eating lunch in the dining room. She was asked to weigh the single beef patty. Using the facilities digital scale, the cooked single patty weighed 1.93 ounces. Interview on 7/24/18 at 12:54 p.m., with Regional Dietician (RD), stated the beef patties used for this meal service were four ounce frozen patties. Interview on 7/24/18 at 1:50 p.m., with RD, stated she verified with food vendor that the four ounce frozen beef patties should be cooked down to three ounces. Review of product label revealed Beef Steaks were four ounce frozen patties. Observation on 7/24/18 at 2:04 p.m., of the RD obtaining a frozen beef patty from freezer. Using facilities calibrated digital scale, she weighed the frozen patty and it weighed 4.8 ounces; she then weighted the same patty thawed and it weighed 4.25 ounces. She placed the thawed patty on the grill and cooked it. The cooked weight of the patty was 1.88 ounces; she then placed one ounce of gravy on top of the cooked patty, and the weight was 2.17 ounces.",2020-09-01
645,STEVENS PARK HEALTH AND REHABILITATION,115294,820 STEVENS CREEK ROAD,AUGUSTA,GA,30907,2018-07-26,804,E,0,1,AD1W11,"Based on observation, record review, policy review and staff interviews, the facility failed to maintain the holding temperature of three hot foods on the steam table above 135 degrees, to prevent the potential for food-borne illnesses. There were 38 residents who received an oral diet. The sample size was 20. Findings include: Observation on 7/24/18 at 11:30 a.m., revealed sterno canisters and steam trays sitting on top of steam table. Dietary Manager (DM) stated the steam table wasn't heating on the right and left steam wells. She stated the middle well is the only one working at the moment. She further stated that it quit working yesterday afternoon. During observation of steam table temps on 7/24/18 at 12:54 p.m., obtained by Regional Dietary Manager (RDM) with the facility's calibrated thermometer, temperatures were below 135 degrees Fahrenheit (F) for broccoli, which was 110 degrees Fahrenheit (F). The chopped beef patty temperature at 12:56 p.m. was 110 degrees F and the single beef patty temperature was 110 degrees F at 12:56 p.m. The food item temperatures were verified with the RDM. The RDM removed the three food items from the tray line and placed them in oven to reheat to 165 degrees F. Observation on 7/24/18 at 1:16 p.m., steam table temperatures were rechecked for the three items by the RDM. The broccoli temperature rechecked to be at 195 degrees F, the chopped beef patty temperature rechecked to be at 181 degrees F and the single beef patty temperature rechecked to be at 191 degrees F. Review of the Hot/Cold Temperature Log dated 7/24/18 for lunch service, revealed out of oven temperature for the Swiss Steak patty was recorded as 192 degrees F; Initial temperature at meal service was recorded as 165 degrees F; Mid meal service temperature was recorded as 165 degrees F; and End of meal service temperature was recorded as 168 degrees F. The out of oven temperature for the broccoli was recorded as 174 degrees; the Initial temperature at meal service was recorded as 151 degrees F; Mid meal service temperature was recorded as 150 degrees F; and the End meal service temperature was recorded as 150 degrees F. The out of the oven temperature for the chopped steak was recorded as 163 degrees; the Initial temperature at meal service was recorded as 158 degrees F; the Mid meal temperature was recorded as 159 degrees F; the End meal service temperature was recorded as 152 degree F. There was no time documented on the log as to what time any of these temperature readings were recorded. Review of the facility policy titled Food Preparation and Distribution reviewed and updated (MONTH) (YEAR), revealed it is the intent of the facility to prepare and distribute food in a manner that minimizes the risk of food-borne illness and promotes safe food handling practices. Item number five Distribution letter b. Tray line indicates that foods will be held at or > 135 degrees F. Interview on 7/24/18 at 12:54 p.m., with RDM, stated that he expects staff to monitor the foods throughout the meal service and document on the Hot/Cold Temperature Log. If the foods drop below 135 degrees F, they are to remove the items from the tray line and reheat to 165 degrees. Once the 165 degrees has been maintained for 15 seconds, the food items are placed back on the tray line, and staff are to continue to monitor the temperatures until the completion of the meal service.",2020-09-01
646,STEVENS PARK HEALTH AND REHABILITATION,115294,820 STEVENS CREEK ROAD,AUGUSTA,GA,30907,2018-07-26,812,D,0,1,AD1W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview, the facility failed to ensure opened food items in the dry storage area were discarded according to the labeled use by date. In addition, the facility failed to maintain operating equipment in a sanitary condition. The census was 42 and the sample size was 20. Findings include: 1. During initial tour observation of the kitchen on [DATE] from 10:06 a.m. to 10:31 a.m., revealed the following items located in the dry storage area: one half used 12 ounce package of instant potatoes with a labeled use by date of [DATE]; and a opened 16 ounce bottle of chocolate syrup with a labeled us by date of [DATE]. Interview on [DATE] at 10:31 a.m., with Dietary Manager (DM) verified the two expired food products and discarded them. She stated that the staff check for dates every day and must have overlooked these two items. Review of the policy titled Storage Areas, reviewed and updated (MONTH) (YEAR), indicated the intent of this center is to store food that maintains quality and safety. Procedural guidelines number one letter a. Items will be covered, sealed, labeled and dated appropriately. 2. During initial tour observation of the kitchen on [DATE] from 10:06 a.m. to 10:31 a.m., revealed the microwave oven had dried food particles on the interior top roof and both sides. Also, the toaster glider had collected bread crumbs in the far right and left corners of the pan. These items were verified by the DM during the initial tour. Interview on [DATE] at 10:31 a.m., with DM, stated staff are to clean equipment as they use it. She stated the toaster was used this morning for breakfast, but did not know when the microwave oven was last used.",2020-09-01
647,STEVENS PARK HEALTH AND REHABILITATION,115294,820 STEVENS CREEK ROAD,AUGUSTA,GA,30907,2018-07-26,880,D,0,1,AD1W11,"Based on observation, staff interview and review of facility policy, the facility failed to wash or sanitize hands prior to obtaining a fingerstick blood sugar for one resident (R#24) out of a sample size of 20. Findings include: Observation on 7/25/18 at 4:02 p.m. of a finger-stick blood sugar with Licensed Practical Nurse (LPN) FF revealed that she pushed R#24 down the hall in his wheelchair to his room while she pulled her medicine cart behind her down the hallway. After parking the resident in his room and parking the medicine cart in front of the resident's doorway, she donned her gloves without washing or sanitizing her hands and placed the glucose monitor on a tray along with an alcohol wipe, cotton ball and blood sugar strips. Without removing her gloves, she carried the tray in the room and sat it on the resident's bedside table, pricked the resident's finger and obtained his blood sugar. With the same gloves on she then carried the tray out of the room and sat the tray on the medicine cart. She then removed disposable items from the tray, removed her gloves and sanitized the glucose monitor and then her hands. Interview on 7/25/18 at 4:07 p.m. with LPN FF confirmed that she did not sanitize her hands prior to donning gloves and after handling the resident's wheelchair. Interview on 7/25/18 at 4:28 p.m. with the Director of Nursing revealed that she would expect the nurse to sanitize her hands prior to donning gloves to obtain a fingerstick blood sugar and after handling other items.",2020-09-01
648,STEVENS PARK HEALTH AND REHABILITATION,115294,820 STEVENS CREEK ROAD,AUGUSTA,GA,30907,2019-09-12,880,D,0,1,OM1511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure that one resident (R#33) of three residents with a urinary catheter was handled in a sanitary manner to prevent the spread of infection. Findings include: Observation on 9/9/19 at 2:22 p.m. revealed that resident (R) #33 was out of bed in a wheelchair and the catheter tubing was lying on the floor. The urine in the tubing was observed to be cloudy. Record reveiw for R#33 revealed the following Diagnoses: [REDACTED]. A review of the Physician order [REDACTED]. A review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] documented that the resident had a catheter in the seven-day look-back period. The Quarterly MDS also documented that the resident had a urinary tract infection in the 30-day look back period. A review of the care plan revealed that R#33 had a urinary catheter related to an indwelling/suprapubic catheter. An observation on 9/11/19 at 7:41 a.m. revealed that the resident was lying in bed and the catheter tubing was lying on the floor. The urine in the tubing was very cloudy. An observation on 9/12/19 at 10:19 a.m. of the resident revealed that the resident was in bed and the catheter tubing was lying on the floor. An observation and interview on 9/12/19 at 11:46 a.m. with the Director of Nursing confirmed that the tubing for the catheter was on the floor and that this was an infection control issue.",2020-09-01
649,ZEBULON PARK HEALTH AND REHABILITATION,115295,343 PLANTATION WAY,MACON,GA,31210,2018-07-19,582,B,0,1,855W11,"Based on record review and staff interview, the facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) to the resident or responsible party upon discharge from Medicare Part A services to indicate that they understood the contents of the form for two of three residents (R) reviewed (#9 and #45). Findings include: Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #9 was discharged off Medicare Part A skilled services on 5/25/18 and remained in the facility afterwards with benefit days remaining. Further review of this form revealed that R #45 was discharged off skilled services on 6/25/18, and remained in the facility with benefit days remaining. There was no evidence provided that the SNFABN was provided to either R#9 or R#45. During interview on 7/18/18 at 3:01 p.m. with Case Manager it was reported that if she notifies the family member via telephone she does not typically send a letter. Case Manager further reported that the SNFABN is typically provided to residents who discharge to home in the event they decide to stay an extra day in the facility. However, the SNFABN has not been provided to residents remaining in the facility that were going to be long term. Case Manager confirmed that she did not provide SNFABN forms for R#9 and R#45.",2020-09-01
650,ZEBULON PARK HEALTH AND REHABILITATION,115295,343 PLANTATION WAY,MACON,GA,31210,2019-11-15,656,D,0,1,GS7J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to follow the care plan for two of 32 sampled residents (R) (#154 and R#28). Findings include: 1. Review of the electronic medical record (EMR) for R#154 revealed a [DIAGNOSES REDACTED]. Further review of the EMR revealed a care plan for altered nutritional status related to no free-standing water with an onset date of 11/7/19. Interview with Resident Care Coordinator (RCC) CC on 11/15/19 at 11:15 a.m. who confirmed that there were two cups of water in resident's room. RCC CC reported that there should be no cups or water in resident's room due to fluid restriction and this information is listed on resident's care plan. Observation on 11/13/19 at 8:14 a.m. revealed R#154 in bed in room with a cup of water on nightstand dated 11/12/19, 11-7. Observation on 11/14/19 at 8:20 a.m. revealed R#154 in bed in room with a cup of water noted on her over bed table. Observation on 11/15/19 at 9:25 a.m. revealed a cup of coffee 1/4 full and a full cup of water in R#154's room. Interview on 11/15/19 at 11:23 a.m. with Licensed Practical Nurse (LPN) DD who reported that she was aware that the water cup and coffee was in resident's room. LPN DD was not aware that the care plan indicated no water at the bedside. Cross Refer to F684. 2. A review of the medical record for R#28 revealed resident was admitted to the facility with [DIAGNOSES REDACTED]. Review of the care plan, revised on 9/26/19, revealed that R#28 is at fall risk related to history of falls, with a fall risk score of 12. Continued review revealed that the resident has a scoot chair, and balance concerns, along with impaired memory. Review of the Interventions include, but not limited to the following: non-skid socks/non-skid shoes; place resident in an open area for maximum observation opportunities; anticipate resident's needs; check on resident frequently; and have a fall mat on both sides of bed. Observation on 11/12/19 at 12:07 p.m., R#28 was observed seated in a scoot chair, leaning forward in the day room, without nonskid sole socks and/or shoes. Observation on 11/13/19 at 8:51 a.m., resident was observed sitting in scoot chair in day room alone, leaning forward with eyes closed, without non-skid sole socks and/or shoes. Another observation at 1:23 p.m., revealed that R#28 was lying in bed awake, with a fall mat on left side only of bed and another fall mat leaning on wall. At 3:14 p.m., R#28 was lying in bed with eyes closed, fall mat on left side of bed, and another fall mat leaning on wall. Observation on 11/14/19 at 10:58 a.m., R#28 observed in day room sitting in scoot chair, awake without non-skid socks and/or shoes. Interview on 11/15/19 at 12:31 p.m. with the Director of Nursing (DON), says she expects her staff to review and implement residents Activities of Daily Living (ADL) plan of care/care plans daily at the start of their shift in order to provide the care needed for the residents. Interview on 11/15/19 at 1:50 p.m. with Licensed Practical Nurse (LPN) CC stated that she as well as other staff, are responsible for completing plan of care/care plans for residents, so that the Certified Nursing Assistants (CNA) may review. She confirmed that non-skid socks were on both the ADL plan of care and care plans.",2020-09-01
651,ZEBULON PARK HEALTH AND REHABILITATION,115295,343 PLANTATION WAY,MACON,GA,31210,2019-11-15,684,D,0,1,GS7J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews, the facility failed to follow Physician's Orders for one of five [MEDICAL TREATMENT] residents (R) (#154) with fluid restrictions. Findings include: Observation on 11/13/19 at 8:14 a.m. revealed R#154 in bed in room with a cup of water on nightstand dated 11/12/19, 11-7. Observation on 11/14/19 at 8:20 a.m. revealed R#154 in bed in room with a cup of water noted on her over bed table. Observation on 11/15/19 at 9:25 a.m. revealed a cup of coffee 1/4 full and a full cup of water in room. Review of the electronic medical record (EMR) for R#154 revealed a [DIAGNOSES REDACTED]. Further review of the EMR revealed a Precautions Order for no free water or water at bedside beginning on 11/7/19. Interview with Resident Care Coordinator (RCC) CC on 11/15/19 at 11:15 a.m. who confirmed that there were two cups of water in resident's room. RCC CC reported that there should be no cups or water in resident's room due to fluid restriction. Interview on 11/15/19 at 11:23 a.m. with Licensed Practical Nurse (LPN) DD who reported that she was aware that the water cup and coffee were in resident's room. R#154 had both a cup of coffee and a cup of water in the room. However, she instructed the CNA to move the water cup from the over bed table but not out of the room. LPN DD confirmed the order for no water at the bedside and acknowledged that she was not aware of the order for no water at bedside.",2020-09-01
652,ZEBULON PARK HEALTH AND REHABILITATION,115295,343 PLANTATION WAY,MACON,GA,31210,2019-11-15,880,D,0,1,GS7J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and review of the policy titled Routes of Drug Administration, and staff interviews, the facility failed to administer eye drops in a sanitary manner for one resident (R) (#6); failed to ensure that the urinary catheter bag and tubing were kept off the floor for one resident (#21); and failed to keep personal items off clean linen in the laundry room. Findings include: 1. A review of the policy titled Routes of Drug Administration revealed that when eye drops were administered the first step was to wash hands, the cap to the bottle was to be sat on a clean dry surface, and after eye drops were administered, the hands were to be washed again. An observation on 11/14/19 at 8:43 a.m. of Licensed Practical Nurse (LPN) AA administering eye drops to R#6 revealed that she donned gloves and didn't sanitize her hands or wash with soap/water prior to donning her gloves. She touched multiple objects with her gloves on. She sat the eye drops on a napkin that was already on the table. She took a cup that the resident handed her with her gloved hand and did not remove the gloves, sanitize, and don a clean pair of gloves. She then touched the bedside table with her gloved hands and then administered eye drops without washing her hands, sanitizing or changing gloves. The LPN confirmed that she donned gloves on entering the resident's room, touched multiple surfaces without washing her hands, sanitizing or donning clean gloves. She stated that the purpose of wearing gloves when administering eye drops was to keep the rate of infection down. An interview on 11/14/19 at 9:54 a.m. with the Director of Nursing (DON) revealed that she expected the nurses to verify and follow the physician order [REDACTED]. During a follow-up interview on 11/14/19 at 10:33 a.m. the DON confirmed that not sanitizing hands and touching other surfaces was an infection control issue. She stated that she did not know why the nurse did not sanitize or change gloves after touching multiple objects in the room. Further interview at 11:58 a.m. with the DON revealed that the Infection Control Nurse had not done any audits related to administration of eye drops because no issues had been identified during tracking and trending of infections. She stated that they have a corporate nurse that comes in periodically and watches medication administration with no issues or concerns identified. 2. Review of electronic medical record (EMR) for R#21 revealed an unhealed pressure ulcer on the sacrum. R#21 also had [DIAGNOSES REDACTED]. Observation on 11/12/19 at 11:36 a.m. revealed R#21 in a low bed in room with the catheter in dignity bag and the dignity bag touching the floor. Observation on 11/12/19 at 3:17 p.m. revealed R#21 in a low bed with the catheter tubing touching the floor. Observation on 11/13/19 at 1:24 p.m. revealed the catheter bag and tubing for R#21 was on the floor on the right side of the bed. Observation on 11/13/19 at 3:00 p.m. revealed the catheter bag and tubing for R#21 was on the floor. Observation on 11/14/19 at 10:59 a.m. revealed the catheter bag cover touching the floor for R#21. During an interview on 11/15/19 at 11:17 a.m., Resident Care Coordinator (RCC) CC confirmed that the dignity bag for R#21 was on the floor and should be kept off the floor. Interview on 11/15/19 at 1:28 p.m. with the Assistant Director of Nursing (ADON) revealed that neither the catheter or the tubing should be on the floor at any time. 3. During tour of the laundry room on 11/15/19 at 9:29 a.m., Laundry Aide GG was observed folding clean towels. It was noted that a cell phone was sitting on a towel that had been folded on one end of the table and at the other end of the table there was a purse and a [NAME]et. Laundry Aide GG confirmed that the cell phone, purse, and [NAME]et belonged to her. It was further reported that the items were kept there because she did not have any other place for them. Once the green [NAME]et was moved there was a stack of table cloths under the [NAME]et. Laundry Aide GG reported that the towel and table cloths would have to be rewashed. During an interview with the Environmental Services Supervisor on 11/15/19 at 9:53 a.m. she confirmed that staff's personal items should be kept in either a locker or a closet. The Environmental Supervisor acknowledged the personal items for Laundry Aide GG on the table and further reported the items would have to be rewashed.",2020-09-01
653,LENBROOK,115296,"3747 PEACHTREE ROAD, NE",ATLANTA,GA,30319,2019-08-27,609,D,1,0,785211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews, and review of facility policy titled Abuse, Neglect, and Exploitation, revision date 10/1/18, the facility failed to ensure an allegation of abuse was reported to the State Survey Office (SSO) for one resident (R) R#5. The sample of six residents were reviewed for abuse. The facility census was 55 residents. Findings include: Review of facility policy titled Abuse, Neglect, and Exploitation, revision date 10/1/18, revealed the facility is to report allegations of abuse or suspected abuse immediately. The facility should ensure that all alleged violations involving abuse neglect exploitation or mistreatment including injuries of unknown source and misappropriation of resident property are reported immediately but not later than 2 hours after allegation is made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the advents{sic} that cause the allegation do not involve abuse and do not result in serious bodily injury, to the Administrator of the facility and to other official {sic}(including the State Survey Agency and adult protected services where state law provides for jurisdiction in long term care facilities) in accordance with State law. When suspicion of abuse, neglect, exploitation, or misappropriation of resident property occur, and investigation is immediately warranted. Once the resident is cared for initial reporting has occurred, and {sic} investigation should be conducted. The Administrator should follow up with government agencies, during business hours to confirm the report was received . Review of Facility Reported Incidents from 5/1/19 through 8/8/19 revealed there were no allegations of abuse reported to the SSO. Review of the clinical record revealed R#5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Discharge Minimum Data Set ((MDS) dated [DATE] revealed R#5 had a Brief Interview for Mental Status (BIMS) score of 6, indicating severe cognitive impairment at the time of her discharge. Review of the care plan for R#5 revealed she was care planned on 12/1/18 for confusion, delusions and being physically aggressive. A review of Social Service Care Plan notes for R#5 revealed a Care Plan Conference was conducted on 2/28/19. R#5 did not attend. R#5's family did not attend. The Care Plan Conference notes revealed R#5 had behaviors at times but did not specify what behaviors. Social Service Progress Notes revealed on 6/20/19 R#5 threw her coffee on a Certified Nursing Assistant (CNA). There were no further explanations of the incident. On 8/14/19 at 9:00 a.m. during an interview with the Administrator she revealed that allegations of abuse were very rare in this facility, and she could not think of any allegations that had not been reported. The Administrator revealed she would look through grievances and incidents and copy them for the surveyor if they could be considered abuse allegations. The Administrator revealed the Compliance Officer receives any allegations of abuse and investigates and reports the allegation to the SSO and keeps the Administrator informed. Interviews were conducted on 8/14/19 at 12:48 p.m. with Licensed Practical Nurse (LPN) AA, on 8/14/19 at 1:20 p.m. with Certified Nursing Assistant (CNA) BB, on 8/14/19 at 1:47 p.m. with CNA CC and on 8/14/19 at 2:22 p.m. with LPN DD. They revealed they did not know of any residents that had alleged abuse in the last six months. An interview was conducted on 8/14/19 at 2:10 p.m. with the Assistant Director of Nursing (ADON) and she revealed she was certain that the Compliance Officer reported all allegations of abuse to the SSO. The ADON revealed that allegations of abuse were very rare in this facility and she could not recall any recent allegation of abuse. An interview on 8/14/19 at 4:20 p.m. with Registered Nurse (RN) EE revealed that sometime in (MONTH) a resident made an allegation of abuse while in the Bistro on the first floor. The resident had told a Security Officer that her Outside Personal Provider (OPP) had hit her in the head. RN EE was unable to recall the residents name or the date. RN EE had not heard any more about the allegation of abuse. During an interview conducted on 8/14/19 at 5:30 p.m. the Administrator revealed she had searched and been unable to find any concerns that could be considered allegations of abuse. On 8/15/19 at 9:05 a.m. the Compliance Officer called the surveyor and was interviewed. The Compliance Officer revealed she was familiar with reporting requirements and reported allegations of abuse to the SSO. The Compliance Officer revealed she was able to remember an issue that took place between a resident and her OPP in the Bistro last (MONTH) that she had not reported because it was just an argument on the part of a resident with dementia and the OPP had not responded to the resident arguing. She revealed there was no allegation of abuse to report and there was no investigation. On 8/21/19 at 9:06 a.m. the Compliance Officer called back and asked for clarification related to who could report abuse and what was considered timely reporting to the SSO. An interview was conducted on 8/27/19 at 8:35 a.m. with the Human Resources (HR) Director. The HR Director revealed the former Administrator/Vice President of Healthcare Services had been suspended on 8/15/19 and the current Administrator was the former Manager of Rehabilitation and Education. The former ADON was now the Vice President of Healthcare Services. The HR Director also revealed the Compliance Officer had been suspended on 8/15/19 and resigned on 8/25/19 without notice. Information related to the allegation of abuse that occurred in (MONTH) by a resident in the Bistro was submitted by the facility on request and reviewed as follows: Review of an Incident/Accident Report dated 6/21/19 at 1:15 p.m. revealed LPN DD had received a call from a security officer stating that R#5 had accused her care giver of hitting her on the back of her head. A full body assessment was completed. LPN DD also documented on 6/21/19 that R#5 and her caregiver had signed out to leave the unit for lunch. An hour later the care giver had returned to the unit and said R#5 had fired her and explained the resident had accused her of hitting R#5 in the back of the head. The care giver said she was going to call the son of R#5 and left. A few minutes later a security officer called and said R#5 was at the front desk and gave details of the allegation. The ADON and the Social Service Director (SSD) for Independent Living and Rehabilitation residents came to the floor to speak with the resident. Another care giver was in the main lobby on 6/21/19 at approximately 12:30 p.m. with R#5 and her OPP and was interviewed by the SSD for Independent Living and Rehabilitation and did not see the OPP hit R#5. The care giver did reveal to the SSD that she had witnessed R#5 shout profanity at the OPP. The ADON documented on 6/21/19 that at approximately 1:45 p.m. Security stated that R#5 had accused her care giver of hitting her on the head. When the ADON interviewed R#5 she said she did not have any problem with her caregiver except personality differences. The ADON documented that she had notified the Manager of Rehabilitation and Education, the SSD for the Nursing Home, and the Administrator on 6/21/19. According to the documentation the Administrator had instructed the ADON to place the packet under the Compliance Officers office door and the Administrator would finish the investigation the next day. The SSD for the Independent and Rehabilitation residents documented on 6/21/19 that at 1:45 p.m. the accused OPP was seen leaving the floor. The SSD revealed LPN DD had told her R#5 had a history of [REDACTED]. R#5 told the SSD that she was happy now that she fired her caregiver and that she just didn't like her, that the OPP had not physically done anything to her. A document dated 6/21/19 and signed by the SSD for the Nursing Home revealed she had interviewed R#5 and the resident told her nothing bad happened that day and she had not been hit by her OPP. A Social Progress Note dated 6/24/19 and signed by the SSD for the Nursing Home revealed R#5 was interviewed and said she was happy with the OPP she had alleged hit her in the head three days prior, and that the OPP was her ray of sunshine. Fax confirmations of the cover sheets for this facility reported incident to the State Office were reviewed as follows: 8/23/19 at 12:19 p.m.- five pages with result OK 8/22/19 at 8:47 a.m. three pages- no response 8/22/19 at 8:37 a.m. four pages- no response On 8/27/19 at 12:02 p.m., the SSD for the Nursing Home was interviewed. She revealed the R#5 had told her she did not remember making the statement that she had been hit by her OPP. The resident had issues in the past related to rejecting care giver suggestions and encouragement. On 8/27/19 at 12:30 p.m. the current Administrator revealed he thought this allegation of abuse was not reported to the SSO because the resident denied her allegation when she was interviewed by the Social Worker. The Administrator acknowledged he was aware that reporting to the SSO was to come first according to the policy and according to the regulation and that no allegation of abuse was to be screened to determine if the allegation was credible until after it was reported to the State. During an interview on 8/27/19 at 2:36 p.m. in the conference room with the Chief Executive Officer (CEO) he revealed he expected the Compliance Officer to report any allegations of abuse to the SSO in a timely manner and to be familiar and compliant with regulatory reporting requirements.",2020-09-01
654,LENBROOK,115296,"3747 PEACHTREE ROAD, NE",ATLANTA,GA,30319,2019-08-27,727,F,1,0,785211,"> Based on record review and staff interview the facility failed to ensure a Registered Nurse (RN) was designated as the Director of Nurses (DON) from 3/8/19 through 8/12/19. This resulted in no actual harm but had the potential for more than minimal harm for the 55 residents in the facility. Findings include: An interview with the facility Administrator on 8/14/19 at 10:30 a.m. revealed she had appointed the Assistant Director of Nurses (ADON) to be Director of Nurses (DON) on 3/15/19. Review of a letter dated 3/15/19, addressed to the State Survey Office (SSO) revealed the facility had named the ADON to serve in the role as DON, and had all the requirements to hold the position. A review of the SSO electronic record of Administrators and DONs revealed there had been no change in DON recorded for the facility since (YEAR). An interview was conducted with the Medical Director on 8/14/19 at 12:25 p.m. The Medical Director revealed he did not know who the DON was after the last DON resigned in March. He was not notified of who the DON was. He had not experienced any problems that the ADON and Rehabilitation Manager could not address. An interview was conducted on 8/15/19 at 9:05 a.m. with the Compliance Officer. The Compliance Officer revealed she was not aware of who had been appointed to the DON position last (MONTH) after the former DON resigned. She had not been notified that anyone was taking over the DON position after the former DON resigned. During and interview on 8/14/19 at 4:20 p.m. RN EE revealed the Administrator had said she was going to be the DON until a new DON was hired. The Administrator had said since the facility had 60 beds or less that she could be the Administrator and DON at the same time. Interviews were conducted with LPN AA on 8/14/19 at 12:48 p.m., CNA BB on 8/14/19 at 1:20 p.m., CNA CC on 8/14/19 at 1:47 p.m. and LPN DD on 8/14/19 at 2:22 p.m. They revealed no notice had been sent out to announce who the DON was after the former DON had resigned. They had continued to follow the chain of command and there had not been any problems from 3/8/19 through 8/12/19. On 8/27/19 at 2:50 p.m. the ADON, who had been promoted to Vice President of Healthcare Services on 8/15/19, revealed she had never been appointed to be the DON last (MONTH) after the former DON resigned. She revealed an agency nurse who is no longer with the facility had taken over some of the DON duties such as training and troubleshooting, but the ADON had not performed any of the DON duties and had continued to work as the ADON in the clinic and assistant to the Administrator. The ADON/ Vice President of Healthcare Services reviewed the letter the Administrator had given to the surveyor on 8/14/19, designating the ADON as DON on 3/15/19 and said she had never seen this letter before and that it was not correct, she was not the DON. An interview was conducted on 8/27/19 at 3:00 p.m. with the Human Resources (HR) Director. The HR Director revealed after the former DON resigned, he had heard the Administrator say she was the DON until a new DON could be hired. The HR Director reviewed the letter the former Administrator had given the surveyor on 8/14/19 that was dated 3/15/19 and addressed to the SSO revealing the facility had named the ADON to be the DON. The HR Director revealed he sends out the changes in Administrator and DON notices to the SSO. The HR Director revealed he had not sent this letter and had never seen it before.",2020-09-01
655,LENBROOK,115296,"3747 PEACHTREE ROAD, NE",ATLANTA,GA,30319,2016-10-13,371,E,0,1,4R0I11,"Based on observation, review of policy and procedure and staff interviews, the facility failed to maintain appropriate concentration levels of the Ecolab Quaternary sanitizing solution in the three (3) compartment sink; failed to label and date opened food items before storing in the walk-in freezer and dry storage; failed to ensure food items were discarded past the use by date for one (1) of six (6) resident nourishment refrigerators. This deficient practice had the potential to effect fifty one (51) residents consuming an oral diet. Findings include: Review of policy titled Food and Supply Storage Procedures (Issued 05/1995, revised 01/2012) revealed that the use-by date is the last date food can be consumed, foods past the use-by date should be discarded, and open/unused packages are to be covered, labeled, and dated. Observation and interview with Head Chef and Dietary Manager on 10/11/2016 at 11:20 a.m. revealed that the sanitizer in the three (3) compartment sink was not registering on the indicator strip. The Head Chef confirmed that the indicator strip did not change colors to indicate the presence of quaternary sanitizing solution in the three (3) compartment sink. He retested the water with a new test strip, the test strip did not change color to indicate the presence of quaternary sanitizing solution in the three (3) compartment sink. He emptied the sink and added fresh water and sanitizer and retested with a fresh indicator strip, the strip did not change colors. The Head Chef instructed the dishwasher to empty the sink and obtain water and sanitizer from the mop closet sink and transfer it into the sanitizer sink in the three (3) compartment sink. The Head Chef tested the water obtained from the sink in the mop closet and the strip turned green, corresponding with 200 ppm (parts per million) concentration. Observation and interview with Dietary Manager on 10/11/2016 at 11:24 a.m. in the walk-in freezer revealed an open, unsecured, unlabeled, undated brown paper bag, and an open, unlabeled, undated, chocolate cake. The Dietary Manager confirmed that the open bag was French fries and per his expectations both the French fries and cake should have been secured, dated, and labeled. Observation and interview with Head Chef and Dietary Manager on 10/11/2016 at 11:30 a.m. in dry storage room revealed an undated, open bag of pasta (secured with plastic wrap) and an unlabeled 1-gallon Ziploc bag with a white grain- like substance. The Head Chef identified the grain-like substance as quinoa. The Dietary Manager confirmed that he expected staff to date, label, and secure open dry goods prior to placing them in the storage area. Observation on 10/13/2016 at 10:11 a.m. of the fourth (4th) floor nourishment refrigerator revealed 2 milk cartons with expiration dates of 10/11/2016. Observation and interview with Dietary Manager on 10/13/2016 at 10:30 a.m. of the fourth (4th) floor nourishment refrigerator the Dietary Manager confirmed the 2 cartons of milk were expired and immediately discarded the cartons.",2020-09-01
656,LENBROOK,115296,"3747 PEACHTREE ROAD, NE",ATLANTA,GA,30319,2016-10-13,466,E,0,1,4R0I11,"Based on observation, review of policy and procedure and staff interview, the facility failed to maintain the required amount of emergency water on site for a maximum bed capacity of sixty (60) residents. The current facility census was fifty-three (53) residents. Findings include: A review of the policy titled Emergency Preparedness (dated 05/95, revised 09/14) revealed a minimum allotment of one (1) gallon of water per day per person, including patients and staff. Review of the Disaster Contingency Plan Statement of Understanding for Emergency Services dated 10/01/2016 revealed a contingency plan that Sysco would provide the facility bottled water, as available, during an actual disaster situation. An observation and interview on 10/11/2016 at 11:45 a.m. with the Dietary Manager, revealed a total of thirty (30) gallons of water stored for emergency use. The Dietary Manager confirmed that thirty (30) gallons of water did not meet the facility emergency water requirement and explained that he would order 200 gallons of water and have it delivered the following day (10/12/2016). Observation with the Dietary Manager on 10/13/2016 at 1:45 p.m. revealed 200 gallons of water designated for emergency use.",2020-09-01
657,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2019-03-13,686,D,1,0,2IED11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and interviews and a policy titled Prevention of Pressure Ulcers, the facility failed to provide evidence of treatment as ordered for a pressure ulcer for one resident of 6 sampled residents (R#1 was a closed record). Findings include: A review of Prevention of Pressure Ulcers policy of the facility revealed in item #6 under General Guidelines the facility should have a system/procedure to assure assessments are timely and appropriate and changes in condition are recognized, evaluated, reported to the practitioner, physician, and family and addressed. Item #11 under Interventions indicated the care process should include efforts to stabilize, reduce or remove underlying risk factors; to monitor the impact of interventions; and to modify the interventions as appropriate. A review of the Resident Face Sheet document for resident (R) #1 revealed the following Diagnoses: [REDACTED]. A review of the Hospice Visit Note Report document for resident #1, dated 12/31/18, revealed the assessment of a Mid-coccyx pressure ulcer stage II, measurements show length 1.5cm x width 1cm x depth 0.01cm, the surface area (SQ CM) 1.5cm. The visit included the wound care dressing change on the stage II coccyx wound. A review of the Admission Checklist/Notification document for resident #1, dated Friday 1/11/19, revealed the report from the Hospice Nurse to a staff member at the receiving Center, which reported a stage II on the coccyx. A review of the Admission - Nursing Admission Assessment document for resident #1, dated Friday 1/11/19, revealed the skin assessment area is blank. A review of the Active Orders for resident #1, dated 1/12/19, revealed the following wound care order: [MEDICATION NAME] dressing (OTC) bandage; 4 x 4; 1 bandage; topical special instructions: Clean coccyx with NS, allow to dry then apply [MEDICATION NAME] dressing (OTC) bandage 4 x 4 amt: 1 dressing topical PRN, Once A Day-PRN. A review of the Baseline Care Plan for resident #1, dated 1/13/19, revealed the skin concerns were assessed as small excoriated area on coccyx, with skin break interventions as: Turn and reposition: Q 2-3 hours & PRN, specialty mattress: pressure redistribution, cushions or wedges: pressure redistribution, Other: Hydroc. Drsg with cleaning T/TH/Sat & prn. A review of the Wound Management - wound information document for resident #1, dated Monday 1/16/19, revealed the assessment of the resident's wounds as: Coccyx, stage III, measuring 1.5cm length and 1cm width. And another document repeated for a Left Heel wound stage I assessment. An interview with the wound care nurse on 3/13/19 at 3:25 p.m. revealed she did not remember the resident and she does not have any documents related to treatment of [REDACTED]. An interview with the Director of Nursing (DON) and the Regional Nurse Consultant on 3/13/19 at 3:30 p.m. revealed the DON developed the baseline care plan for the resident on Monday, 1/11/19. She reported the coccyx region had excoriation. She agreed no skin assessment was performed until 1/16/18 by the wound care nurse. The DON and the Regional Nurse Consultant reported resident #1 should have been seen by the wound care nurse on Monday following the resident's admission. The DON and the Regional Nurse Consultant reported they are unable to provide evidence of the provision of treatment for [REDACTED].#1.",2020-09-01
658,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2019-05-07,655,D,1,0,RBFG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record review and policy titled Care Plan-Baseline, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. This failure included two of two residents (R) #1 and R# 4 reviewed for baseline care plans. Sample size was 6. Findings include; 1. On 3/15/19 R#1 was admitted to the facility for respite care, the residents [DIAGNOSES REDACTED]. No medication orders documented. Review of R#1 medical record reveals R#1 fell on [DATE]. He sustained a small laceration to his forehead. First aid provided. Skull series ordered. This was an unwitnessed fall. Review of baseline care plan, in the electronic medical record (EMR), dated 3/18/19, three days after admission, indicated R#1 is at risk for falls. Further review of the baseline care plan did not include any goals or interventions to address falls. During an interview on 5/7/19 at 2:15 p.m. with the Director of Nursing (DON) regarding the baseline care plan dated 3/15/19 for R#1 which identified the resident as a falls risk. There were no goals or interventions in the Resident's electronic medical record or on the baseline care plan. The DON stated that she writes a summary of what the resident needs and then passes it on to the nurses on the unit. 2. On 3/18/19 R#4 was admitted to the facility for respite care. The residents [DIAGNOSES REDACTED]. No medication orders documented. Review of R#4 EMR baseline care plan dated 3/18/19 identified resident as a falls risk. The EMR, baseline care plan did not provide goals and interventions for R#4's risk of falls. R#4 experienced a fall on 3/19/19 at 7:45 a.m, on 3/19/19 at 5:10 p.m. the resident had a second fall and on 3/19/19 Per nurse's notes, resident noted on floor, of his room, at 11:23 p.m. During an interview on 5/7/19 at 2:15 p.m. with Director of Nursing (DON) a document titled baseline care plan, was provided for R#4 dated 3/18/19. This document also identified resident as falls risk. DON stated that as she was preparing this document, she was speaking to the family via phone, as is her habit. It was at this time she was made aware the resident was a fall risk and that he could not speak English. R#4's inability to communicate in English was not addressed on the EMR or on the baseline care plan, nor were there any interventions in place in the EMR care plan identifying resident's risks for falls. During an interview on 5/7/19 at 11:20 am with Registered Nurse (RN) Supervisor AA she was unable to provide evidence of where interventions are located on the EMR. She further could not reference anywhere else in the resident record where interventions may be located. RN AA continued to state the goals and information should be written in the summary area of the EMR baseline care plan. She than said the nurses should be doing that. During an interview on 5/7/19 at 3:30 p.m. with Certified Nursing Assistants (CNA)s BB and CC, both stated they are not provided information on the care of the residents assigned to them. They mostly have to guess what they have to do. Both stated there was no documentation provided to them to let them know if a resident has concerns with falls or any other aspect of the resident's care. During an interview on 5/7/19 at 3:40 p.m. with Licensed Practical Nurses (LPN)s DD and EE, they both stated they give verbal reports to the CNA staff informing them of a new admission. Neither LPN was able to state they provided specifics of a resident's care to CNA nor was there anything in writing to evidence they informed CNA staff of resident's needs. Review of facility policy titled, Care Plans- Baseline, with a revision date of (MONTH) (YEAR), states, a baseline care plan will be developed within forty eight (48) hours of resident's admission. The care plan will meet the resident's immediate care needs including but not limited to; initial goals based on admission.",2020-09-01
659,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2019-05-07,689,D,1,0,RBFG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record reviews and policies titled Admission Assessment and Follow up: Role of the Nurse and Assisting the Nurse in examining and assessing the resident, the facility failed to properly assess and provide supervision to prevent accidents in the area of falls for two of two residents (R), R#1 and R#4 reviewed .Sample size was 6. Findings include; 1. On 3/15/19 R#1 was admitted to the facility for respite care. [DIAGNOSES REDACTED]. Review of the baseline care plan in the electronic medical record (EMR) dated 3/18/19 indicated R#1 was at risk for falls. The careplan did not provide goals and interventions focused towards R#1's risk for falls. Continued review of R#1's medical record revealed resident fell [DATE]. He sustained a small laceration to his forehead. First aid provided. This was an unwitnessed fall. Review of the incident investigation dated 3/16/19 indicated resident was noted on the floor laying on his right side. Observed blood on the floor from his head. The investigation provided for review does not indicate what further interventions would be put into place and/or how the staff will continue to monitor R#1 to prevent falls. During an interview on 5/7/19 at 2:15 p.m. with the Director of Nursing (DON), a handwritten document titled, baseline care plan, was provided for R#1 dated 3/15/19. This document also identified the resident as a falls risk. There were no goals or interventions noted to address falls on this document. The DON stated when the resident is a fall risk we monitor them more closely. The DON was unable to qualify monitoring more closely. 2. On 3/18/19 R#4 was admitted to the facility for respite care. [DIAGNOSES REDACTED]. Review of R#4's admission assessment date 3/18/19, Section N, identifies the resident as having a falls risk/ Further review of R#4 EMR baseline, dated 3/18/19, identified resident as a falls risk. The EMR, baseline care plan did not provide goals and interventions to addresses R#4's risk of falls. R#4 experienced a fall on 3/19/19 at 7:45 a.m. R#4 sustained an injury to his head. X-ray ordered. This was a witnessed fall. On 3/19/19 at 11:45 a.m. resident fell while in the hall. No injuries noted. This was a witnessed fall. On 3/19/19 at 5:10 p.m. resident fell while in his room. This was an unwitnessed fall. No injuries noted. Per nurse's notes, resident's facial expression evidenced pain to his head. On 3/19/19, resident noted on floor, of his room, at 11:23 p.m. No injuries noted. Continues to express pain, when head is touched. On 3/21/19, R#4 noted on floor, of his room at 10:50 a.m. No injuries noted. Fall was unwitnessed. During an interview on 5/7/19 at 11:20 am with the Registered Nurse (RN) Supervisor, AA, she was unable to provide evidence of where interventions are located on the EMR. She further could not reference anywhere else in the resident record where interventions may be located. Stated the care plan is how staff is directed to provide resident care. During an interview on 5/7/19 at 3:30 p.m. with Certified Nursing Assistants (CNA)s BB and CC, both stated they are not provided information on the care of the residents assigned to them. They mostly have to guess what they have to do. Both stated there was no documentation provided to them to let them know if a resident has concerns with falls or any other aspect of the resident's care. During an interview on 5/7/19 at 3:40 p.m. with Licensed Practical Nurses (LPN)s DD and EE, both stated they give verbal reports to the CNA staff informing them of a new admission. Neither LPN was able to state they provided specifics of a resident's care to CNA nor was there anything in writing to evidence they informed CNA staff of resident's needs. During an interview with the DON on 5/7/19 at 4:00 p.m., corporate nurse present, indicated a baseline care plan is completed upon admission; she typically completes it. The information is then shared with the nurses on the unit who should share the information with the CNAs. Review of the policy titled Admission Assessment and Follow Up: Role of the Nurse, with a revision dated (MONTH) 2012, revealed the purpose of this procedure is to gather information about the resident's physical, emotional, cognitive and psychosocial condition upon admission for the purpose of managing the resident, initiating the care plan and completing required assessment instruments, including the Minimum Data Set (MDS). Review of the policy titled Assisting the Nurse in Examining and Assessing the Resident with a revision date (MONTH) 2010, revealed, the primary purpose of assessing the resident is to gather detailed information that will help to develop a plan of care that is appropriate for the resident. The assessment process is continuous.",2020-09-01
660,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2018-05-24,655,D,0,1,KZWN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, and staff interview, medical record review, and review of facility policy, the facility failed to complete the baseline care plan and provide a copy of the summary to the resident and resident representative for one of three sampled residents (Resident (R)#57) who were new admissions to the facility. The findings include: Review of the medical record for R#57 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The medical record revealed the resident had a brief interview for mental status (BIMS)score of 15, which indicated intact cognition. The medical record contained a form titled Baseline Care Plan dated 3/31/18. The baseline care plan did not contain any information for physician orders, medications, dietary needs, or activities of daily living (ADL). There was also no information for hospice services, or interventions to prevent falls. The baseline care plan did not contain a signature from nursing personnel, R#57, or R#57 representative. The medical record did not contain any documentation that care planning had been discussed with the resident or any resident representative. Interview with R#57 on 5/24/18 at 10:25 a.m. in his room revealed he did not remember talking about care planning with anybody when he was admitted , and further revealed he did not receive a copy of a care plan. R#57 representative was not available for interview on 5/24/18. Interview with the Assistant Director of Nursing (ADON) on 5/24/18 at 10:10 a.m. in the office, revealed the baseline care plans are to be started by the admission nurse but ultimately the ADON is responsible for seeing that they are completed. The ADON reviewed the baseline care plan for R#57 and stated No, this is not complete, and the staff did not even sign it. I wasn't the nurse responsible on that date. Review of the policy titled Baseline Care Plan dated (YEAR) revealed the following: 1. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. b. Include the minimum healthcare information necessary to properly care for a resident including, but not limited to: i. Initial goals based on admission orders [REDACTED] ii. Physician orders. iii. Dietary orders. iv. Therapy services. v. Social services vi. PASARR recommendation, if applicable. 4. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. The summary shall include at a minimum, the following: a. The initial goals of the resident. b. A summary of the resident's medications and dietary instructions. c. Any services and treatments to be administered by the facility and personnel acting on behalf of the facility.",2020-09-01
661,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2018-05-24,880,D,0,1,KZWN11,"Based on observation, interview, and facility policy review, the facility failed to ensure infection control practices were maintained to prevent the potential for infection and cross contamination for one resident (R)(R#26) when a nurse placed medication in her bare hand prior to administering it to the resident. The findings include: Medication administration observation was conducted on 5/22/18 at 9:20 a.m. with Licensed Practical Nurse (LPN) AA on the 300 Hall. During the observation, LPN AA dropped several pills on the medication cart and picked them up with her unwashed bare hands, put them in the medication cup, and proceeded to administer the pills to the resident. When the medication administration was completed, the LPN stated I shouldn't have done that. I probably should have put gloves on before picking up those pills. Interview with the Director of Nursing (DON) on 5/23/18 at 1:50 p.m. in her office revealed Medications should never be handled bare handed. Gloves should be worn to handle pills or a gauze 4x4 could be used to break pills. The DON confirmed it is an infection control issue. Review of the facility polity titled Handwashing/Hand Hygiene dated 2001 and revised in (MONTH) (YEAR) revealed the following procedure: Step 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap and water for the following situations: c. Before preparing or handling medications.",2020-09-01
662,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2017-07-20,282,G,0,1,JOE811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interview, it was determined that the facility failed to turn and reposition as care planned for the prevention of pressure ulcers for one resident (R) (R#92) which resulted in actual harm to this resident who developed a facility acquired pressure ulcer. The sample size was 20 residents. Findings include: Review of the clinical record for R#92 revealed an admission date of [DATE] to the facility with the following [DIAGNOSES REDACTED]. Nursing Admission assessment dated [DATE] documented R#92 alert and oriented to person and place. The resident was admitted to the facility with one stage 3 pressure ulcer to coccyx. Review of the interim care plan dated 7/13/17 documented R#92 has impaired skin integrity or at risk for impaired skin: unstageable to the sacrum. Interventions included to perform body audit upon admission and as needed; and reposition/assist with turning every 2-3 hours and as needed. Observations, by the surveyor, on 7/19/17 at 8:30 a.m., 9:32 a.m., 10:15 a.m., and 12:10 p.m. revealed R#92 laying directly on his back with the head of bed elevated. Observation on 7/19/17 at 1:15 p.m. revealed R#92 laying directly on his back with the head of bed elevated. During an interview at this time, resident stated that no one has turned him today. Observation on 7/19/17 at 2:15 p.m., R#92 laying directly on his back with head of bed elevated. Resident's lunch tray was untouched on the bedside table. During an interview at this time with R#92 revealed that the resident was pretty hungry and that no one has turned him since the last interview with the resident. Continuous observation, by the surveyor, on 7/19/17 from 2:40 p.m. to 3:35 p.m., revealed that R#92 remained laying directly on his back with head of bed elevated in addition to observation from 2:40 p.m. to 2:53 p.m. of CNA FF feeding the resident and reports that he ate 100%. Observation of Licensed Practical Nurse (LPN) CC entered R#92's room on 7/19/17 at 3:15 p.m. stating to the resident that she is checking on him. R#92 responded that his butt hurts. LPN CC administered [MEDICATION NAME] 50 milligrams by mouth for pain without changing the resident's position or checking for the cause of the resident's pain. Observation on 7/19/17 at 3:20 p.m., Assistant Director of Nursing (ADON) observed going into resident's room although the resident remained in the same position. Observation on 7/19/17 from 3:25 p.m. to 3:35 p.m., revealed multiple other staff members going into R#92's room without repositioning the resident. Observation on 7/20/17 at 7:40 a.m. revealed R#92 laying directly on his back with head of bed elevated. Wedge pillow laying on the empty bed next to the resident's bed. When asked how he was doing, resident requested the foam pad be placed behind his back. LPN AA entered the resident's room at this time. Interview with the Director of Nursing (DON) on 7/20/17 at 3:50 p.m., revealed that her expectation is for staff to turn and reposition residents with pressure ulcers in order to keep them off the wound area. Specifically, she revealed that staff should know to turn R#92 alternating right and left side every two hours. Cross-refer to F314.",2020-09-01
663,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2017-07-20,314,G,0,1,JOE811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of one clinically avoidable pressure ulcers for one residents (R) R#92 of 20 sampled residents and failed to provide necessary treatment and services to promote the healing of the pressure ulcers. Specifically, the facility failed to assist the resident to turn and reposition and failed to use appropriate infection control technique during treatment to promote healing of the pressure ulcers. This resulted in actual harm for R#92. Findings include: Review of the Dressing Changes and Wound Care Policy revised in (MONTH) 2013 revealed that the guideline of this facility is to provide dressing changes as needed using clean technique which includes guideline number 9: clean wound using circular motion from center of wound outward using only one gauze per wipe. The Skin Integrity Protocol dated (MONTH) (YEAR) documented that it is the policy of this facility to accurately assess each resident's condition for prompt recognition of the risk of pressure injuries, to prevent occurrence and to appropriately treat any pressure injury which the resident may experience. Component [NAME] of the Skin Integrity Program indicated the treatment of [REDACTED]. Review of the clinical record revealed R#92 was admitted to the facility on [DATE] and had active [DIAGNOSES REDACTED]. Review of the Nursing Admission assessment dated [DATE] documented R#92 alert and oriented to person and place. The resident was admitted with one stage 3 pressure ulcer to coccyx and incontinent of bowel and bladder. Review of the admission Braden Scale-For Predicting Pressure Sore Risk dated 7/13/17 revealed that R#92 was At Risk for development of pressure sores with a score of 15 (Total score of 15-18 represents AT RISK). The risk assessment reflected that R#92 requires moderate to maximum assistance with moving. Review of the interim care plan dated 7/13/17 documented that R#92 has impaired skin integrity or at risk for impaired skin: unstageable to the sacrum. Interventions included to perform body audit upon admission and as needed; and reposition/assist with turning every 2-3 hours and as needed. Physical Therapy (PT) Treatment Encounter Notes dated 7/14/17 documented that PT educated Certified Nursing Assistant (CNA), unknown, on purpose and placement of wedge pillow. Observations on 7/19/17 at 8:30 a.m., 9:32 a.m., 10:15 a.m., and 12:10 p.m. revealed R#92 lying directly on his back with the head of bed elevated. Observation on 7/19/17 at 1:15 p.m. revealed R#92 laying directly on his back with the head of bed elevated. During an interview, at this time, R#92 revealed that no one has turned him today. Observation on 7/19/17 at 2:15 p.m., revealed R#92 lying directly on his back with head of bed elevated and the resident's lunch tray, which was untouched, on the bedside table. During an interview at this time, R#92 stated that he was pretty hungry and that no one has turned him since 1:15 p.m. interview. Continuous observation, by the surveyor, on 7/19/17 from 2:40 p.m. to 3:35 p.m., revealed that R#92 remained lying directly on his back with head of bed elevated and the following: 1. Observation on 7/19/17 from 2:40 p.m. to 2:53 p.m., revealed that CNA FF was observed feeding the resident and reports that he ate 100% although the resident's position was not changed. 2. Observation on 7/19/17 at 3:15 p.m., that Licensed Practical Nurse (LPN) CC entered R#92's room and stated to the resident that she is checking on him. R#92 responded that his butt hurts. LPN CC administered [MEDICATION NAME] 50 mg by mouth for pain without repositioning the resident or investigating the cause of the pain. 3. Observation at 3:20 p.m., revealed that the Assistant Director of Nursing (ADON) going into resident's room and the resident's position remains the same. 4. Observation from 3:25 p.m. to 3:35 p.m., revealed multiple other staff members going into R#92's room although the resident's position remains the same. Review of the Wound Management Note completed by the ADON on 7/18/17 at 8:22 a.m. revealed that R#92 had one stage 3 pressure ulcer identified on admission measuring 2.5 cm x 2.5 cm. No documentation of any other pressure ulcers were noted. Review of a Progress Note dated 7/19/17 at 9:25 p.m. documented that a new area to the left lower buttocks was noted. The Nurse Practitioner was notified and a new order was given to apply barrier cream each shift. No measurements or staging were documented. Observation on 7/20/17 at 7:40 a.m. revealed R#92 laying directly on his back with head of bed elevated. The Wedge pillow was observed laying on the empty bed next to the resident's bed. When asked how he was doing, resident requested the foam pad be placed behind his back. Review of a Progress Note dated 7/20/17 at 7:45 a.m. documented that bright red blood was noted to the open area to the coccyx. The Nurse Practitioner was notified and orders received to discontinue [MEDICATION NAME] Tuesday, Thursday, and Saturday. Clean open area to coccyx with normal saline, pat dry with clean gauze, apply Saf-gel, cover with 4 x 4 and secure in place with [MEDICATION NAME] tape daily and as needed. (Note edited at 9:45 a.m. to include the left ischium). Record review revealed a Physician order [REDACTED]. Cleanse open area to left ischium with normal saline, pat dry with clean gauze, apply Saf-gel, cover with 4 x 4 and secure in place with [MEDICATION NAME] tape. During observation of wound care on 7/20/17 at 11:45 a.m., LPN AA removed the dressing from the sacral area. Two wounds were noted: one to the sacrum and one to the left gluteal fold; both with a red, bloody wound bed. LPN AA dipped a 4 x 4 gauze in normal saline and cleaned both wounds with a back and forth wiping motion over each wound with the same 4 x 4 gauze. LPN AA repeated that action with a second 4 x 4 gauze. LPN AA then used a third 4 x 4 gauze with normal saline and wiped all over the resident's entire buttocks including both wounds with the same 4 x 4 gauze. LPN AA then applied the ordered Saf-gel with 4 x 4 gauze and covered with [MEDICATION NAME] tape. When asked about the measurements, LPN AA stated that measurements are done on Tuesday. During an interview on 7/20/17 at 2:15 p.m., LPN AA revealed she normally does the treatment for [REDACTED]. LPN stated that the resident is turned every 2-3 hours by the CNA's. LPN AA further revealed that she would normally clean the wounds separately and could not explain why she did them at the same time. During an interview on 7/20/17 at 2:40 p.m., CNA BB revealed that she did reposition R#92 on 7/19/17 every two hours. She stated that she placed the wedge pillow rotating under each side every two hours although she did not document that in the clinical record. Observation of repositioning technique by CNA BB, at 7/20/17 at 3:00 p.m., revealed that R#92 was in bed with the wedge pillow under his right side. CNA BB removed the wedge pillow, turned the resident more to the left side replaced the wedge to the right side with head of bed elevated. At this time the R#92 complained of pain and requested the head be let down. At this time LPN AA entered the resident's room and instructed CNA BB to turn the resident to the right side and place the wedge pillow under his left side. Further interview with CNA BB on 7/20/17 at 3:15 p.m. revealed that she has been employed at the facility for one year and yesterday was the first time that she had worked with R#92. CNA BB confirmed that she was not aware of any facility policy related to turning the residents. She stated that she usually raises the resident a little bit to the left, comes back in two hours and repositions even more to the left, then comes back two hours later and repositions to the right, and then comes back two hours later and reposition even more to the right. CNA BB denied receiving any in-service related to turning residents. Interview on 7/20/17 at 3:50 p.m., the DON revealed that the nursing staff should know the correct way to clean a pressure ulcer which would be to clean each wound separately and that each wound should be cleaned in a circular outward motion from the center of the wound. The DON confirmed that the resident was not admitted to the facility with the pressure ulcer to the left ischium and the wound was acquired in house. The DON also revealed that training had been provided to the CNA's on perineal care, Foley catheter care, and hand hygiene but they had not received training on turning and repositioning the residents.",2020-09-01
664,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2019-08-08,583,D,0,1,LMN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, the facility failed to maintain privacy during a discussion of financial matters related to the health, occupancy, and financial coverage of one resident (R)#52 from a sample of 33 residents. Findings include: R#52 was a [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 8/7/19, documented a Brief Interview for Mental Status (BIMS) score of 14, which indicated she was cognitively intact. During an interview with R#52 on 8/6/19 at 1:13 p.m., she stated last week she had to speak with the Social Worker (SW) and business office staff who came to her room while her new roommate was present. She stated they came to discuss financial matters related to coverage and billing. She stated she was embarrassed to have these business matters discussed in the presence of her roommate. She stated she felt there were privacy laws against that. During an interview on 8/8/19 at 11:20 a.m. the SW stated they did not talk about anything that would violate Health Insurance Portability and Accountability Act (HIPPA) guidelines. She stated she recalled the resident in-question and they were speaking about her finances. She stated she did not feel like they violated any HIPPA guidelines because they were talking about finances. She stated she was there only as a witness for the Business Office. She stated R#52 did not voice any concerns about the conversation, but later learned the resident complained to nursing services about having the conversation with her roommate present. She stated after she learned about the resident's concern she did not follow up with R#52 to offer a resolution for future conversations requiring privacy. During an interview on 8/8/19 at 11:30 a.m. with the Business Office Manager (BOM), she stated usually when conversations take place in resident rooms, they are by themselves. She stated when there is another person in the room, they try to lower their voices. She stated when she and the SW entered the room, R#52 stated she did not want to talk at that time, but they engaged her in the discussion anyway. The BOM stated she later found out R#52 voiced concerns to the Director of Nursing (DON). The BOM stated she did apologize to R#52 and went in later to speak with her with the roommate present, but the BOM pulled the curtains and spoke in softer tones. She stated R#52 did not complain. She stated she did not discuss a resolution with R#52 for future private conversations.",2020-09-01
665,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2019-08-08,656,D,0,1,LMN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interviews, and review of the facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to develop and implement a Comprehensive Care Plan that included the appropriate goals and interventions for one of one Resident (R) R#46 reviewed with a NPO (nothing per mouth) nutritional status; and failed to follow the care plan for one of one Resident #83 related to the application of bilateral compression leg wraps. The facility census was 88, the sample size was 33. Findings Include: 1. An observation was conducted on 8/7/19 at 8:30 a.m. where the resident was observed quietly lying on her left side, the head of her bed elevated. A tube feeding was in process of infusing via a pump without issues. [MEDICAL CONDITIONS] with humidified oxygen was in place, [MEDICAL CONDITION] was clean, ties secure with clean and dry gauze. Review of the clinical record for R#46 revealed that the resident was admitted with multiple diagnoses; [MEDICAL CONDITIONS], gastrostomy tube, hypertension, diabetes, cerebral infarction, [MEDICAL CONDITION] and [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. In addition, resident was admitted with a Stage 4 sacral wound and a Stage 3 wound to right heel. A review was conducted of the resident's active orders dated 8/8/19. The orders included an initial order date of 6/17/19 for the following: NPO (nothing by mouth); to have oxygen at 5L/min via a [MEDICAL CONDITION] type with a FIO2 at 28% (humidified oxygen); to receive tube feedings of Nepro with Carb Steady at 40ml/hour for 20 hours via pump, with a down time at 10 a.m. and an uptime of 2 p.m., water flushes of 325ml every six (6) hours, one time a day for supplement. To elevate the head of the bed 30-45 degrees during feedings and for 30-45 mins after. Check tube for proper placement prior to each feeding, flush, or medication administration. Review of the Minimum Data Set (MDS) assessment dated [DATE] reflects in Section C. that a Brief Interview for Mental Status (BIMS) was not conducted related to the resident rarely or never understands. Functional, Section [NAME] documents resident is totally dependent, every day during a 7-day period, needing a two-person physical assist for bed mobility and transfers. Section K. indicates that resident has a feeding tube and receives 51% or more of her calories for a feeding tube, and at least 501 ml of her fluids per day by a feeding tube. In Special Programs/Treatments, Section O., resident receives oxygen, suctioning and [MEDICAL CONDITION] care. Review of the Comprehensive Care Plan, initiated 6/18/19, revised 6/19/19 documented under section titled, Focus-Nutrition- the resident is at risk for alteration in nutrition/hydration secondary to terminal diagnosis. Under the section titled, Goal- documented that the resident will consume greater than 50% of meals, snacks and supplements through the review date. Under section titled, Interventions- documented to assist and encourage at meals as needed, encourage the resident to consume all fluids provided within parameters of ordered diet, food preferences provided as available. Observe for signs and symptoms of difficulty swallowing, pocketing, choking, coughing, holding food in mouth and refusing to eat. Observe skin for signs of dehydration/fluid overload (tenting, [MEDICAL CONDITION]). The Registered Dietitian (RD) to make diet change recommendations as necessary (PRN). In care plan section Focus-Feeding Tube, initiated 7/29/19- documents resident is at risk for aspiration related to feeding tube. Under section titled Goal- the resident will be free of any signs and symptoms of complications of tube feeding through review date. An interview was conducted on 8/8/19 at 12:58 p.m. with the DON and the Regional Corporate Nurse, where the DON explained the process for obtaining information for the care plan. The DON confirmed that nurses evaluate the resident initially, then if needed, the therapy department, Physical Therapy and or Occupational Therapy will do their evaluation, then give information to the MDS Coordinator with recommendations. A confirmation of the physician's orders that the resident had a NPO status and review of the resident's Comprehensive Care Plan with the Regional Corporate Nurse was conducted. The nurse confirmed that the goals for nutrition and interventions were not specific or appropriate to the resident that does not eat orally. She stated she would have a teaching review with the MDS coordinator and correct it. A review was conducted of the health note, dated 8/8/19, documenting Nepro with Carb Steady @ 40mLs/hour x 20 hours, via pump. Downtime at 10 a.m. and uptime at 2 p.m. Water flush of 325 ml. every 6 hours via pump, one time a day for supplement. Resident left to the Emergency Department for evaluation of the peg tube. A confirmation of the physician's orders that the resident had a NPO status and a review of the resident's Comprehensive Care Plan with the Regional Corporate Nurse was conducted. The nurse confirmed that the goals for nutrition and interventions were not specific or appropriate to the resident that does not eat orally. She stated she would have a teaching review with the MDS coordinator and correct it. A review was conducted of the facility policy, titled Care Plans, Comprehensive Person-Centered, last revised (MONTH) (YEAR). Under the section titled Policy Interpretation and Implementation at No.2- documentation reflects that the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. Section No. 9 documents that areas of concern that are identified during the resident assessment will be evaluated before interventions are added to the care plan. Section No. 11 documents care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes and relevant clinical decision making. Section No. 13 documents assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes.The care plan nutritional goals and interventions for meal consumption is inappropriate related to the physician's order that the resident is to be NPO. 2. Review of the clinical record revealed R#83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) in Section C coded as 15, indicating no cognitive impairment. Section G functional Status documented that the resident required limited assistance with dressing including donning, prosthesis and removing compression wrap. Review Care Plan dated 7/9/19 revealed that intervention was initiated on 7/23/19, to apply compression wraps on R#83's lower legs by nurses every day and remove at night. Review of the Physician order for [REDACTED]. Observation on 8/5/19 at 11:40 a.m. revealed R#83 laying on bed with compression wraps on. During an interview with R#83, she stated that Certified Nursing Assistance (CNA'S) wrapped her legs every day but sometimes they forget to remove it. On 8/7/19 at 12:00 p.m., an interview was conducted with Licensed Practical Nurse (LPN) AA, she stated that resident (R) R#83 returned to the facility via non-emergency transportation on wheel chair. R#83 returned with tennis shoes on and compression wear on to bilateral legs to knees. R#83 was discharged from Lymph clinic, with referral Physical Therapy (PT), Occupation Therapy (OT) and Nursing service and to wear long term compression thigh wraps high best to knee high at minimum including foot with Velcro pieces. R#83 was alert and oriented to time, person, place and things. LPN AA, also stated she thought that CNA's could wrap R#83 legs with compression wraps. On 8/7/19 at 12:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) BB, stated that R#83 asked her to wrap her legs with compression wrap and she did. CNA BB, also stated that all CNA'S did wrap R#83 legs with compression wraps in the morning and they removed it sometimes before the end of their shift or at the next shift. On 8/7/19 at 12:35 p.m., an interview was conducted with Director of Nursing (DON), related to compression legs wraps. DON stated the CNAS' were not trained to wrap any resident's legs with compression wraps. That was a nurse's duty. Besides that, R#83 was diagnosed with [REDACTED]. DON stated that she was going to do in-service to all CNAS and Nurses immediately. DON stated that it was care plan that nurses should wrap R#83 legs with compression wrap. On 8/8/19 at 7:45 a.m., an interview was conducted with CNA CC, stated that she wrapped R#83 legs after morning care because resident asked her to do it. CNA CC, also stated that R#83 was alert and oriented to time, person, place and things. On 8/8/19 at 8:00 a.m., an interview was conducted with CNA DD, he denied the allegation of compression wrap of R#83 legs; but R#83 insisted that CNA DD, had wrapped her legs more than five times. Reference to F684.",2020-09-01
666,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2019-08-08,684,D,0,1,LMN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to follow Physician's order for one resident of one of one Resident (R) R#83 related to compression wrapping for both legs. Sample size was 33 residents. Findings include: Review of the clinical record revealed R#83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) coded as 15, indicating no cognitive impairment. Section G - Functional Status documented that the resident required limited assistance with dressing including donning, prosthesis and removing compression wrap. Review of the Physician order for [REDACTED]. Observation on 8/5/19 at 11:40 a.m. revealed R#83 laying on bed with compression wraps on. During an interview with R#83, stated that Certified Nursing Assistance (CNA'S) wrapped her legs everyday but sometimes they forget to remove it. On 8/7/19 at 12:00 p.m., an interview was conducted with Licensed Practical Nurse (LPN) AA, stated that resident (R) R#83 returned to the facility via non-emergency transportation on wheel chair. R#83 returned with tennis shoes on and compression wear on to bilateral legs to knees. R#83 was discharged from Lymph clinic, with referral Physical Therapy (PT), Occupation Therapy (OT) and Nursing service and to wear long term compression thigh wraps high best to knee high at minimum including foot with Velcro pieces. R#83 was alert and oriented to time, person, place and things. LPN AA, also stated she thought that CNA's could wrap R#83 legs with compression wraps. On 8/7/19 at 12:30 p.m., an interview was conducted with Certified Nursing Assistant (CNA) BB, stated that R#83 asked her to wrap her legs with compression wrap and she did. CNA BB, also stated that all CNA'S did wrap R#83 legs with compression wraps in the morning, and they removed it sometimes before the end of their shift or removed it at the next shift. On 8/8/19 at 7:45 a.m., an interview was conducted with CNA CC, stated that she wrapped R#83 legs after morning care because resident asked her to do it. CNA CC, also stated that R#83 was alert and oriented to time, person, place and things. On 8/8/19 at 8:00 a.m., an interview was conducted with CNA DD; he denied the allegation of compression wrap on R#83 legs, but R#83 insisted that CNA DD, wrapped her legs more than five times. On 8/7/19 at 12:35 p.m., an interview was conducted with Director of Nursing (DON) related to compression legs wraps. DON stated that the CNAS' were not trained to wrap any resident's legs with compression wraps; that was a nurse's duty. Besides that R#83 was diagnosed with [REDACTED]. DON stated that she was going to do in-service to all CNAS and Nurses immediately. DON stated that it was care plan that nurses should rap R#83 legs with compression wrap.",2020-09-01
667,FAIRBURN HEALTH CARE CENTER,115298,178 WEST CAMPBELLTON STREET,FAIRBURN,GA,30213,2019-08-08,842,D,0,1,LMN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to document Activities of Daily Living (ADLs) for two of two residents (R) R#83 and R#1 related to bowel and bladder incontinence. The sample size was 33 residents. Findings include: 1. Review of the clinical record revealed R#83 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Minimum Data Set (MDS), assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS), Section C, coded as 15, indicating no cognitive impairment. Section G - Functional Status documented the resident required extensive assistance with toileting and incontinent care. Review of the incontinent care papers revealed that the Certified Nursing Assistants (CNA'S) failed to document daily bowel and bladder for R#83. Blank spaces for bowel and bladder in (MONTH) 2019, were for nine days (6/1/19, 6/10, 6/13, 6/16, 6/18, 6/20, 6/22, 6/23, and 6/24). In (MONTH) 2019, signatures in blank spaces were missing for 12 days (7/12, 7/13, 7/14, 7/15, 7/16, 7/17, 7/20, 7/21, 7/22, 7/26, 7/27 and 7/31/19). In (MONTH) 2019, missing signatures appeared for three days (8/1/19, 8/5 and 8/7/19. On 8/5/19 at 11:40 a.m., during an interview with R#83, she stated the Certified Nursing Assistants (CNAs) have left her wet in bed with feces for long periods before they changed her. On 8/8/19 at 7:45 a.m., an interview was conducted with CNA CC, stated that she toileted and changed R#83 as needed, and never saw her laying in feces or wet bed. On 8/8/19 at 8:00 a.m., an interview was conducted with CNA DD, assigned to care for R#83. CNA DD, stated that R#83 was alert and oriented to time, person, place and things; she called them whenever she needed to be changed. CNA DD, denied leaving R#83 on wet bed. On 8/7/19 at 12:35 p.m., an interview was conducted with Director of Nursing (DON) relating to blank spaces in bowel and bladder incontinent papers. DON stated that the CNAS were responsible to sign the incontinent papers after care was done, and it was nurses' duty to monitor that the care was done and CNA's document and sign the bowel and bladder papers. R#83 was care plan for potential alteration in skin integrity and they must provide a good skin care after each incontinent episode. 2. R#1 was a [AGE] year-old male, admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent quarterly Minimum Data Set (MDS) assessment, dated 4/12/19, documented a BIMS score of 12, which indicated moderate cognitive impairment. The MDS assessment further documented R#1 rejected care one to three days of the assessment period; required extensive/one-person assistance for bed mobility, eating, toilet use, and personal hygiene; total dependence with one-person assistance for transfers, locomotion off unit, and dressing. Continued assessment revealed R#1 was always incontinent of bladder and bowel, was at risk for pressure ulcers but no unhealed pressure ulcers at the time of assessment. During an interview with R#1 in his room on 8/6/19 at 11:46 a.m., he stated he has waited up to 19 hours for toileting and diaper change. He stated staff usually changed him three times per day which is not enough because his genital area is often irritated with some skin breakdown. He stated he often uses a cream for the genital area due to irritation. During an interview with R#1 on 8/7/19 at 10:48 a.m., he stated he was toileted only once yesterday morning and remained in a wet, feces-filled diaper for approximately 12 hours. He stated he did not call for help but no one made rounds either to see if he needed a diaper change or anything else. Perineal care observation was conducted on 8/7/19 at 11:15 a.m. with Certified Nursing Assistant (CNA) EE for peri-care for R#1. CNA EE washed the peri-area with soap and water and rinsed with water; used good technique. During peri-care the R#1 complained that his testicles were on fire. Peri-area and scrotal sac were reddish in color and skin appeared inflamed. Writer asked for assigned Licensed Practical Nurse (LPN) FF and the Treatment Nurse (TN) to observe skin integrity. The TN confirmed skin redness and stated she would contact the attending Nurse Practitioner for further instructions. LPN FF confirmed R#1 had been on antibiotic Bactrim for a urinary tract infection [MEDICAL CONDITION] and had a history of [REDACTED]. Review of the policy titled, Activities of Daily Living revealed under Policy and Implementation, item #1, Residents will be provided with care, treatment and services to ensure that their activities of daily living (ADLs) do not diminish unless the circumstances of their clinical condition demonstrate that diminishing ADLs was unavoidable. Item #2 stated, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with a. hygiene (bathing, dressing, grooming, and oral care), and c. elimination (toileting). Review of the Activities of Daily Living (ADL) documentation revealed on 8/5/19, staff documented ADL/incontinence care was performed at 12:16 a.m., 1:49 p.m., and 9:43 p.m. On 8/6/19, staff documented ADL/incontinence care at 10:48 a.m. and 7:47 p.m. On 8/7/19, staff documented care at 4:17 a.m., 9:33 a.m. and 10:02 a.m. On 8/8/19, staff documented care on 1:19 p.m. before the close of this survey. During an interview with the Director of Nursing (DON) on 8/7/19 at 11:00 a.m. in her office, she stated the electronic medical record (EMR) screen for charting ADLs allowed for charting incontinent care once a shift but acknowledged there was a mechanism in place to input additional times of care that perhaps all staff were not aware of. She stated staff are probably assisting residents more often than they were charting because they did not realize they could add more. She stated she expected her staff to make resident rounds at least every two hours for toileting and other needs. During an interview with the corporate MDS Director on 8/7/19 at 11:10 a.m., she stated she would compose an educational tool for the DON to inservice staff to chart each ADL care event to more accurately determine the quality and quantity of care. During an interview with CNA GG on 8/7/19 at 1:55 p.m., she stated staff provide ADL care as needed but round at least every two hours. She denied ever leaving any resident for long periods of time without incontinence care. During an interview with CNA HH on 8/8/19 at 2:15 p.m., he stated when he attended to R#1 earlier at approximately 1:00 p.m., R#1 was wet but not soaked which indicated to him R#1 had been attended to in a reasonable amount of time. CNA HH stated he made efforts to round on all his residents every two hours and believed the facility staffed well enough to accomplish that.",2020-09-01
668,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2019-01-17,584,E,1,1,VPJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in 13 rooms on two of three halls (A2A/C, A6C, A8C, A12C, A16A/C, A18, B1A, B5, B7, B10C, B11, B12A/B/C, B13A/B); warped and broken window blinds in dining room. The facility census was 85. Findings Include: Observation on 1/14/19 at 12:02 p.m., revealed in room A8-C, privacy curtain with two (2) dime sized light brown stains. Observation on 1/14/19 at 12:09 p.m., revealed in room A2-A, privacy curtain with multiple pink colored stains at bottom of curtain. Observation on 1/14/19 at 12:10 p.m., revealed in room A2-C, stained ceiling tile in left upper corner, approximately 12 inches by six inches; chipping paint off bathroom wall; bathroom vent with thick layer of dust buildup on the louvers. Observation on 1/14/19 at 12:29 p.m., revealed in room A6-C, multiple bare patches down to dry wall, around sink in bathroom and left of the sink close to door. Observation on 1/14/19 at 12:40 p.m., revealed in room A12-C, multiple patches of chipped and peeling paint in bathroom; ripped ceiling tile in bathroom; vent in bathroom with heavy layer of dust on louvers and vent loosely hanging from ceiling. Observation on 1/15/19 at 8:32 a.m., revealed in room A16-C, privacy curtain with multiple brown stains in various spots. Observation on 1/15/19 at 9:44 a.m., revealed in room B1-A, two ceiling tiles with light brown stains. Observation on 1/15/19 at 11:19 a.m., revealed in room A16-A, vent in bathroom ceiling dusty and loosely hanging from ceiling; brown dried material on toilet handle; five ceiling tiles ripped and peeling. Observation on 1/15/19 at 11:59 a.m., revealed in room A18-A a cracked ceiling tiles in bathroom around the vent; chipped and peeling paint at the sink and at the toilet paper holder; scuffed wall at entrance, for the length of the wall; missing electrical face plate at socket close to television; broken/missing board at baseboard for head of bed [NAME] Observation on 1/15/19 at 4:48 p.m., revealed in main dining room, blinds on both windows, warped to degree that blinds can't be opened. Broken strings on both sets of blinds. Interview on 1/17/19 at 11:30 a.m. with Housekeeper DD, stated she sweeps and mops each room daily, dusts windows and furniture in room, wipes down bed rails, cleans mattresses, cleans bathroom, toilet, sink and walls. She dusts the light fixtures and vents in bathrooms. She further stated that she inspects the privacy curtains and if needed laundry, will ask maintenance to take down and replace. Interview on 1/17/19 at 2:07 p.m. with Maintenance Supervisor, verified the concerns identified during the survey this week. He stated that staff submit work orders in the maintenance work book that is kept at nurses station. He further stated he has been working on repairs in the facility for awhile, and stated its easier to do when the rooms are empty. He stated he is the only person and he tries to prioritize based on severity. Interview on 1/17/19 at 2:30 p.m. with Housekeeping Supervisor, verified the concerns identified during the survey. stated that he has three housekeeping staff and one floor tech on day shift. He further stated that they are to look at the privacy curtain daily and also supposed to dust the vents in the bathrooms daily. He stated that he does spot checks on the housekeeping staff daily. He also checks behind them on the deep clean days. Observation on 1/15/19 at 8:39 a.m. of room B13 revealed holes and damaged dry wall and peeling paint behind the head of the beds for both A&B. The wall across the length of the room opposite of the beds was heavily scuffed with black marks and damaged dry wall. There were four ceiling tiles that were chipped and one ceiling tile that was heavily stained. Observation on 1/15/19 at 9:00 a.m. of room B12 behind Bed A, the lower wall drywall was damaged and the rubber baseboard is falling away from the wall. Behind Bed B and C, the wall plaster and paint was cracked, peeling and had spackling on it that has not been [MEDICATION NAME] out or painted. The wall near the bathroom was heavily scuffed with black marks, cracked dry wall and spackling that had not been [MEDICATION NAME] out or painted. The rubber baseboard near the air conditioner is coming off the wall and hanging on the floor. The bathroom walls were chipped and damaged down to the dry wall. Observation on 1/15/19 at 9:10 a.m. of room B11 revealed the wall near the bathroom is heavily scuffed and the drywall is damaged and pushed inward. Observation on 1/15/19 at 9:22 a.m. of room B10 revealed the ceiling tile above Bed C was water stained. The wall near the bathroom was heavily scuffed and dirty. The drywall near the entrance door was heavily damaged and chipped.",2020-09-01
669,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2019-01-17,656,D,1,1,VPJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review and staff interviews, the facility failed to implement the care plan related to nail care for one resident R#44; and failed to develop a care plan for smoking for one resident R#27. The sample size was 42. Findings include: Review of the policy titled Care Plans with a review date of 10/25/2018, revealed the comprehensive person-centered care plan is developed to include measurable goals and timeframe's to meet a patient/resident's medical, nursing and psychosocial needs, the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan should describe the following: the services to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. 1. Review of the clinical record for R #44 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Review of the care plan initiated on 11/21/18 revealed R#44 has plan to be long-term resident. Approaches to care include encourage/invite resident to participate in activities of her choice, observe for changes in physical status, encourage socialization with residents/staff, assist with activities of daily living (ADL)'s routinely and as needed (PRN), restorative program as needed, notify Physician/family as needed. Observation on 1/14/19 at 12:37 p.m., 1/16/19 at 8:15 a.m. and 1/17/19 at 8:05 a.m. revealed resident with brown material underneath fingernails on both hands. Interview on 1/16/19 at 2:53 p.m., with Certified Nursing Assistant (CNA) BB stated that activities of daily living (ADL) care consists of getting residents out of bed, dressed, brush teeth, brush hair, shave, feeding, setting up meal trays, transferring and ambulating. She stated that she checks residents nails daily, but shower team and activities usually do the nails most of the time. She further stated that she will cut and clean them if she notices that they need it. She stated she did not notice that R#44 nails were dirty this week. Interview on 1/17/19 at 10:45 a.m. with Director of Nursing (DON) stated that his expectation is that CNA's look at resident's nails daily and clean and cut them when needed. Cross refer to F677 Review of the policy titled Smoke free policy with a review date of 11/5/2018, revealed each patient/resident will be assessed, utilizing the Smoking Observation Form, or electronically, by a licensed nurse upon admission, re-admission, and/or with a significant change. An admission Smoking Care Plan shall be developed by the Licensed Nurse on the Admission Interim Care Plan Form, or electronically. An assessment, utilizing the Smoking Observation Form, or electronic documentation, is completed at least quarterly thereafter only if the answer to either of the first two questions indicated the resident either smokes or has a history of smoking. After completion of the assessment, the care planning team shall review and utilize the assessment when developing the resident's care plan. 2. Review of the clinical record for R #27 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] reflux disease (GERD), [MEDICAL CONDITION], depression, heart failure and history of [MEDICAL CONDITION]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 7, which indicated moderate cognitive impairment. Section J revealed resident was not a smoker. Review of facilities Smoker Worksheet, revealed R#27 name was not on the list of identified smokers in the facility. Based on review of R#27's baseline care plan and current comprehensive care plan provided, no documentation was found for smoking; subsequently no care interventions or goals were found. Interview on 1/15/19 at 10:06 a.m., with Certified Nursing Assistant (CNA) CC, stated smoking materials are kept at nurses station. Smoking list is provided by administrative team. She stated smoke breaks are every two hours, for 15 minutes and limit is two cigarettes per smoking break. She further stated resident #27 transferred from another facility and did not smoke for first week of being here. She then asked for permission to go out to smoke, second week of being here. Interview on 1/15/19 at 10:31 a.m. with Licensed Practical Nurse (LPN) Unit Manager JJ stated that smoking assessments are done on admission and with each quarterly assessment. Unit manager was able to locate admission smoking assessment in residents file, dated 10/24/18, which indicated that resident is not a smoker. Interview on 1/15/19 at 10:38 a.m., with Minimum Data Set (MDS) Registered Nurse (RN) II, stated the care plans are generated from the MDS assessments. She stated that sometimes their computer system freezes up and will not allow login. She further stated when that happens, they use pre-printed paper care plans. She further stated she cannot remember whether she did a paper care plan for resident #27 and was unable to locate care plan in medical record. Interview on 1/16/19 at 2:47 p.m. with Administrator, stated that if residents are admitted and have a desire to smoke, he puts them on the smoking list and the nursing staff alert the smoking supervisors of who has been added to the list, after a smoking evaluation is completed by the nursing staff. He stated that his expectation is that if the smoking supervisors recognize a resident out in the smoking area, smoking, and they are not on the smoking list, they are to inform the Nursing staff. He further stated that he was not Cross Refer F689",2020-09-01
670,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2019-01-17,677,D,1,1,VPJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent resident (R) R#44 related to nail care. The sample size was 42. Findings include: Review of the clinical record for R #44 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Observation on 1/14/19 at 12:37 p.m., 1/16/19 at 8:15 a.m. and 1/17/19 at 8:05 a.m. revealed resident with brown material underneath fingernails on both hands. Interview on 1/16/19 at 2:53 p.m., with Certified Nursing Assistant (CNA) BB stated that she finds out what her assignment is from the Nursing Supervisor. She stated the Kiosk on the wall lists what care each resident is to receive. She stated that activities of daily living (ADL) care consists of getting residents out of bed, dressed, brush teeth, brush hair, shave, feeding, setting up meal trays, transferring and ambulating. She stated that she checks residents nails daily, but shower team and activities usually do the nails most of the time. She further stated that she will cut and clean them if she notices that they need it. She stated she did not notice that R#44 nails were dirty this week. Interview on 1/17/19 at 10:45 a.m. with Director of Nursing (DON) stated that his expectation is that CNA's look at resident's nails daily and clean and cut them when needed. He stated that the floor CNA's as well as the bath team can clean and cut nails. He further stated that the CNA's are not allowed to cut fingernails for residents that are diabetic, but they can clean them at any time. If the nails need to be trimmed, the CNA's are to inform any licensed nurse to cut/trim them. He verified that resident #44 nails were dirty with thick brown substance underneath them. He stated the facility does not have a policy on providing nail care.",2020-09-01
671,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2019-01-17,678,D,1,1,VPJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to ensure that the code status was correctly reflected for one resident (R) #44: specifically documentation in Advanced Directive/Physician order [REDACTED].#44 code status as Allow Natural Death AND Do Not Resuscitate (DNR). The sample size was 42. Findings include: Review of the clinical record for R #44 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Section G revealed resident requires extensive assistance with dressing, toileting and personal hygiene. Review of R#44 Physician order [REDACTED]. Review of the medical record for R#44 revealed that there was a red heart sticker on the spine of the medical record, which reflected the resident to be a Do Not Resuscitate (DNR) status, according to Licensed Practical Nurse (LPN) A[NAME] Further review of the medical record for R#44 revealed the (MONTH) Physician order [REDACTED]. The Medication Administration Record [REDACTED]. Review of the care plan initiated on [DATE] revealed R#44 has an advanced Directive: Do Not Resuscitate. Approaches to care include No CPR in the event of a [MEDICAL CONDITION] or respiratory arrest, review directives with patient/family quarterly, Notify Physician and significant others of any changes. Interview on [DATE] at 1:42 p.m. with Licensed Practical Nurse (LPN) AA, stated that she would look at the physician orders, the chart for a red heart (which means DNR) or the advance directive to see what the residents code status is. She further stated that she has been here so long that she knows what the code status is for each of her residents. Interview on [DATE] at 2:47 p.m. with Licensed Practical Nurse (LPN) EE, stated that finds out residents code status based on whether or not there is a red heart on the chart or she will look at the advance directive tab in the chart. She stated that R#44 is a Full Code, according to physician orders. Interview on [DATE] at 3:59 p.m., with Director of Nursing, stated that the leadership team checks the physician orders [REDACTED]. He further stated that two nurses must check before placing on the charts. Interview on [DATE] at 4:12 p.m. with the DON, stated he corrected the Medication Administration Record [REDACTED]. He further stated that he wrote a physician order [REDACTED].>",2020-09-01
672,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2019-01-17,689,D,1,1,VPJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy review and interviews, the facility failed to ensure safe smoking was for one resident (R#27) of 13 residents reviewed for smoking. The sample size was 42. Findings include: Review of the facility policy titled Smoke Free Policy with a revised date of 11/5/18, revealed the policy statement to be as of (MONTH) 1, (YEAR), smoking is not allowed on the Healthcare center premises by visitors, partners or patients/residents. Smoking will only be allowed in outdoor designated areas for those residents grandfathered in prior to (MONTH) 1, (YEAR). Assessment and Care Planning section, bullet 2. Each patient/resident will be assessed, utilizing the Smoking Observation Form, by a licensed nurse upon admission, re-admission, and/or with a Significant Change. An Admission Smoking Care Plan shall be developed by the Licensed Nurse on the Admission Interim Care Plan Form. Bullet 3. An assessment is completed at least quarterly thereafter only if the answer to either of the first two (2) questions indicate the resident either smokes or has a history of smoking. After completion of the assessment, the care planning team shall review and utilized the assessment when developing the resident's care plan. Bullet 8. Patients/residents will be assessed for risk/hazards prior to smoking in designated area and shall be supervised as necessary based on the Smoking Observation Form. Bullet 9. When the patient/resident is identified as an unsupervised smoker, the Administrator must be notified immediately. Review of the clinical record for R #27 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., [MEDICAL CONDITION] reflux disease (GERD), [MEDICAL CONDITION], depression, heart failure and history of [MEDICAL CONDITION]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 7, which indicated moderate cognitive impairment. Section J revealed resident was not a smoker. Review of Safe Smoking Form documented that residents were to be assessed for safe smoking on admission, quarterly, annually or with a significant change. Review of Smoking Observation Form for R#27, dated 10/24/18, revealed question one: Does the resident smoke? No column is checked. Question two: Does the resident have a past history of smoking? Yes column is checked. Review of facilities Smoker Worksheet, revealed R#27 name was not on the list of identified smokers in the facility. Based on review of R#27's baseline care plan and current comprehensive care plan provided, no documentation was found for smoking; subsequently no care interventions or goals were found. Observation on 1/14/19 at 12:00 p.m., resident was observed smoking in the designated smoking area, along with twelve other residents. She was wearing a smoking apron and appeared to be smoking safely. There were two staff members present during the smoking period. Further review of medical record revealed that R#27 was not assessed for safe smoking until 1/15/19, after surveyor initiated investigation. Interview on 1/15/19 at 10:06 a.m., with Certified Nursing Assistant (CNA) CC, stated the smoking materials are kept at nurses station. A list is provided by administration team, of which residents are allowed to smoke. She stated smoke breaks are every every (2) hours, for 15 minutes and the limit is two (2) cigarettes per smoking break. She further stated R#27 transferred from another facility and did not smoke for the first week of being here. She then asked for permission to go out to smoke, second week of being here. Interview on 1/15/19 at 10:31 am with Unit Manager JJ, stated that smoking assessments are done on admission and with each quarterly assessment. Unit manager was able to locate smoking assessment in residents file, dated 10/24/18, which indicated that resident is not a smoker. Interview on 1/15/19 at 10:38 a.m., with Minimum Data Set (MDS) RN II, stated they keep a paper record of when assessments are due. She stated the care plans are generated from the MDS assessments. She stated that sometimes their computer system freezes up and will not allow login. She further stated when that happens, they use pre-printed paper care plans. She further stated she cannot remember whether she did a paper care plan for resident #27 and was unable to locate care plan in medical record. Interview on 1/15/19 at 10:54 a.m., with Senior Nurse Consultant HH, stated that resident started smoking 1 month ago. They would do an assessment and create care plan for smoking. Interview on 1/16/19 at 1/16/19 with Administrator, stated that if residents are admitted and have a desire to smoke, he puts them on the smoking list and the nursing staff alert the smoking supervisors of who has been added to the list, after a smoking evaluation is completed by the nursing staff. He stated that his expectation is that if the smoking supervisors recognize a resident out in the smoking area, smoking, and they are not on the smoking list, they are to inform the Nursing staff. He further stated that he was not aware that R#27 had been smoking.",2020-09-01
673,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2019-01-17,695,D,1,1,VPJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review and staff interviews the facility failed to ensure humidification was provided for one (1) resident (R# 42) receiving five (5) liters of Oxygen therapy. The sample size was 42. Findings Include: Review of the clinical record for R#42 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 14, which indicated no cognitive impairment. Review of R#42 Physician order [REDACTED]. Review of care plan initiated 8/24/18 and updated 11/23/18, revealed resident is diagnosed with [REDACTED]. She requires supplemental oxygen routinely. Approaches to care include, assess respiratory function as needed (PRN), assess respiratory status: rate/rhythm/depth/type PRN, auscultate lungs sounds for Rales, Rhonchi, Rubs, PRN, Oxygen as ordered, notify Physician of any respiratory complications, medication as ordered, Humidifier/tubing changed per policy as indicated, head of bed elevated as needed to facilitate ease of breathing, monitor for weight gain, observe for signs/symptoms of fluid overload: [MEDICAL CONDITION] of lower extremities, hands, abdomen, periorbital, shortness of breath (SOB), crackles, jugular vein distention (JVD), vital signs and [MEDICAL CONDITION] as ordered. Observation on 1/15/19 at 1:24 p.m. revealed Oxygen concentrator set on five (5) liters being delivered via Nasal Cannula (N/C). Water humidification bottle on concentrator was empty and without date on bottle. Observation on 1/15/19 at 4:50 p.m. revealed Oxygen in use at five (5) liters via concentrator. No date on tubing and water humidification bottle is dry. Resident complains that her nose is sore. Observation on 1/16/19 at 08:04 a.m. revealed Oxygen in use at five (5) liters via N/C. Water humidification bottle remains dry and no date on tubing. Observation on 1/16/19 at 12:55 p.m. revealed Oxygen continues to be used at five liters via N/C, with humidification bottle dry and no date on Oxygen tubing. Resident complains of her nose hurting at times. Observation on 1/16/19 at 2:47 p.m. revealed Oxygen continues to be used at five (5) liters via N/C, with humidification bottle dry. Interview on 1/17/19 at 9:49 a.m. with Licensed Practical Nurse (LPN) AA stated that the nurses check Oxygen saturation levels every shift and it is documented on Medication Administration Record [REDACTED]. She further stated that the night shift nurses change the Oxygen tubing and nebulizer masks. Interview on 1/17/19 at 10:30 a.m. with Director of Nursing, stated that the night shift nurses are responsible for changing out the respiratory supplies and they document it on the MAR. He further stated it is not the policy to date the tubing because they document it on the MAR. The floor nurses are to check the humidification bottles every shift (12 hour shifts) along with the flow rate and Oxygen concentration level.",2020-09-01
674,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2019-01-17,812,F,1,1,VPJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of the Cleaning Schedule Form-Weekly and interviews, the facility failed to maintain the kitchen in a clean and sanitary manner. Additionally, the facility failed to discard expired foods stored for disasters and/or emergencies. 81 of 85 residents in the facility received an oral diet. Findings include: Review of the Cleaning Schedule Form-Weekly that the facility uses as the equipment cleaning schedule in the kitchen, with an effective date [DATE] and revised [DATE] documented the following: Floors-Scrub and deck brush all floors areas including under shelves, along baseboard, and in corners. Fans-Clean-remove all dust and debris Large Equipment- Range and drip pans, oven, steamer, fryer, steam kettle, hot box/bread warmer. (**Detail clean and sanitize) Dish Dollies/ Cart/ Rack: Clean and sanitize. Further review of the Cleaning Schedule Forms-Weekly revealed an area for the Date, Assigned to and Initials. The form did not include a cleaning schedule for the ice machine, air vents, reach in cooler, condiment bins or sugar/flour/cornmeal bins. Kitchen observation on [DATE] beginning at 11:20 a.m. and ending at 11:55 a.m. with the Dietary Manager revealed the following observed concerns: * The air vent on the ceiling in the dishwasher area was coated in black moisture marks. There was plates, utensils and plate lids stored on utility carts underneath the air vent. * The drop ceiling tracks in the dishwasher area were coated in rust. * The gray plastic cart holding clean plate lids was dirty with food debris, brownish black substances and dried liquid stains. * The backside of the food prep table next to the steam table had two stacks of small plates on it. There was food debris on the prep table around the plates and dried liquid running down the back of the prep table. The bottom of the food prep table and leg, steam table and steam table pipe were dirty with heavy black substance, food particles and other buildup. The floor in this area was also covered in heavy buildup. * The metal coffee station was dirty with dried liquid substances. There were three gray, plastic bins, with coffee bags and other condiments that were dirty with dried food debris and dried liquids stains all over the bins and in the inside of the bins. * There were two gray plastic bins containing plastic utensils. The bins and lids were dirty with dust, food debris and dried liquid stains. * The Ice Machine next to the coffee station was dirty on the top, front and sides with dust and other build up. The door/lid was dry on the outside and there was brown build up underneath in the corner joints. There was ice to the right front corner of the bin that was brownish in color and had brown unknown particles on it. * There were two reach in coolers that were dirty on the outside with smudges, and dried liquid stains. The lower air vent of one reach in cooler was dirty and dusty. The top air vent on the second reach in cooler was coated heavily with dust. * There were four large return air vents over the two reach in coolers that were covered in dust. Behind the vents there was black substance surrounding the air ducts. * There were large cornmeal, sugar and flour bins that were dirty with smudges and dried liquid substances on the outside of the bins and on the clear lids. * There was one large return air vent over the three compartment sink that was dusty, had black spots and a section that was stained in a dark yellow/orange substance. * The pipes behind the stove and oven were dirty and had spider webs on them. * The air conditioner vent over a food prep table by the stove that was not properly fitted in the ceiling and heavily coated in dust and corrosion. There was a ceiling tile over the food prep table that was not properly fitted around a pipe. The opening had dust hanging from it. * There was a metal cart at the end of the food prep area that contained various spices and cooking materials. There was a large tub of baking powder that was covered in dust, dirt and other build up. There were three large handled, clear containers of Rubbed, Bay Leaves, and Parsley Flakes that were dirty with smudges, dust and sticky substance all over the outside of the containers. * Near the three compartment sink there was a plastic cart low to the floor that had a container of pink liquid soap, a metal container with a plastic clear pitcher with a blue substance in it. The cart was dirty with pink liquid, black spots and other buildup. There was a large opening in the middle of the cart and in which the floor underneath was covered in buildup and debris. * The pipe underneath the three compartment sink had a rag around it that was soaked, had thick yellow substance on it and had a foul odor. The floor underneath the length of the of the three compartment sink and near the PVC pipe was dirty with heavy buildup and debris. * There was a two compartment sink that had a plate lid underneath it and the floor. The floor and sink pipes were dirty with heavy buildup. There was a spider web across the pipes with four spider egg sacs. * There was a speaker on the ceiling that was coated with dust. * The side of the fryer was heavily coated with grease build up streaks all the way down to the bottom. The floor on the side of the fryer had drippings and buildup of grease in puddles. * There was buildup of grease, food debris and dried liquid stains of the front and bottom of the stove. Observation on [DATE] at 12:15 p.m. of the three-day food supply for emergencies revealed the following expired foods: * Two cases of six #10 cans of Beef Stew with a facility received date of [DATE]. * One case of 12, 33.8 Fluid Ounces boxes of Orange Juice with an expiration date of [DATE]. * One case of 12, 33.8 Fluid Ounces of Apple Juice with an expiration date of [DATE]. * Three cases of 12, 3-pound 1-ounce cans of Chicken Noodle Soup with a facility received date of [DATE]. * One case of 12, 15-ounce containers of Pureed Beef with an expiration date of [DATE]. * One case of 12, 15-ounce containers of Pureed Chicken with an expiration date of [DATE]. * One case of 12, 15-ounce containers of Pureed Pork with an expiration date of [DATE]. * Three, five-pound tubs of Peanut Butter with an expiration date of [DATE]. Interview on [DATE] at 11:55 a.m. with the Dietary Manager (DM) confirmed all concerns observed. The DM confirmed that the grease build up running down the side of the fryer had not been cleaned in a while. She stated the Dietary Cook is responsible for cleaning the fryer, stove and oven. The DM stated that the Dietary Aide is responsible for wiping down all the carts, bins and food prep areas. She stated that the air vents are to be cleaned by the Maintenance Supervisor and she had been verbally reporting to him about the heavy dust build up on the air vents and the Reach-in cooler vents. She stated that the Maintenance Director told her that he was going to order new air vents for the ceilings. The DM stated that the ice machine is supposed to wiped down by the dietary staff daily and the Maintenance Director is responsible for deep cleaning every two weeks. The DM stated that the dietary staff mop the floors but the housekeeping department is supposed to scrub the floor every Tuesday and they had not been doing that lately. Interview on [DATE] at 11:40 a.m. with the Dietary Cook FF confirmed that the grease dripping down the side of the fryer had not been cleaned and was unable to state when the last time it was cleaned. Additionally, the Dietary Cook FF was unable to state when the stove was last cleaned. Interview on [DATE] at 11:48 a.m. with the Dietary Aide GG revealed she is supposed to wipe the food prep areas, bins and carts but it had not been done. She stated they just have not had time. During a follow-up interview on [DATE] at 1:20 p.m. with the DM, she stated that they do have a weekly cleaning schedule but they had not been using them for about six weeks. She stated that she does not keep record of the cleaning schedules with the initials indicating the task had been completed. Further the DM confirmed that the three-day emergency food was expired and she stated that it was just an oversight. The food is kept out in the shed and the dates were not checked. She stated the hand-written dates on the cases is the date that the food was received. She stated that the food is good for one year from the received date or manufacturer's expiration date. The DM stated that the dietary staff, Maintenance and Housekeeping is supposed to work as a team with cleaning the kitchen but they have been overwhelmed. She further stated they were extremely busy over the holidays. DM stated she has one cook and two dietary aides from 5:00 a.m. - 1:00 p.m. and one cook and two dietary aides from 1:00 p.m. -7:00 p.m. Interview on [DATE] at 9:38 a.m. with the Housekeeping Supervisor revealed his responsibility in the kitchen is putting food away from deliveries and his department is responsible for deep cleaning and scrubbing the kitchen floors. He stated they used to scrub the floors under and around all the equipment every two weeks but that had not been consistent in the last six months. He stated last Tuesday they only conducted a basic mop. He stated it had been several weeks since the floors had a deep clean and scrub. He further stated it is a team effort between Dietary, Maintenance and Housekeeping. Interview on [DATE] at 9:55 a.m. with the Maintenance Director revealed he is not responsible for cleaning and dusting the air return vents in the kitchen and stated housekeeping is responsible for that. He stated he is only responsible for repairing broken equipment in the kitchen. He stated he deep cleans and descales the ice machine quarterly. The Maintenance Director stated that he has no assistant and is the only person in the Maintenance Department. He stated he ordered new grids for the air flow vents in the kitchen but the cleaning of the existing vents is not his responsibility. Interview on [DATE] at 10:50 a.m. with the Administrator revealed he was not aware of the expired emergency food and stated he figured the Dietary Manager was taking care of that and no one had reported that as an issue. The Administrator reviewed the photos taken in the kitchen and confirmed the concerns. He stated he was not aware that the kitchen was dirty to that degree.",2020-09-01
675,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2017-02-02,242,D,0,1,P2OR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review of the resident's clinical records, review of the resident's bathing schedule and resident and staff interviews, the facility failed to allow one of 31 sampled residents (R) #92 to choose the time the resident wanted to get up in the mornings. Findings include Resident #92 was admitted to the facility on 8//8/2015. [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) annual assessment dated [DATE] and the most recent quarterly assessment 12/30/16 revealed a Brief Interview for Mental Status (BIMS) of 10 and 13, respectively. According to the annual assessment dated [DATE] indicated under Section F, Preferences for Customary Routine and Activities, the resident had no problem with completing the interview questions which revealed it was very important for R #92 to choose between a tub bath, shower, bed bath, or sponge bath and to choose his own bedtime. The most recent quarterly assessment dated [DATE] had no opportunity to complete Section F and note activity preferences for the resident. Section G, Functional Status for the 7/1/16 and the 12/30/16 assessments revealed the resident was independent in Activities of Daily Living (ADLs) in self-performance and needed no setup of physical help. The resident was noted ambulatory with a steady gait. The most recent care plan reviewed 12/31/16 revealed for self-care deficit needs assist with bathing, he is highly active in his care has the goal for the resident to continue to be independent with ADL's thru next review. An approach was for bath/shower as scheduled with no indication as to showering time preference. Observations through the days of the survey on the Unit B revealed a whirlpool tub that was being used for storage. The only bathing opportunity was the community shower on Unit C. Interview with the resident on 1/30/17 at 1:25 p.m. in the resident's room revealed the resident was on a schedule for showers for 5 a.m. The resident stated he does not want to take a shower that early but that's what the Certified Nursing Assistants (CNAs) have him scheduled for. The resident further stated that usually when he came back from the shower the bed was stripped of the linens. That's, OK; however, the CNAs don't have time to put the linens back on the bed until later in the afternoon. He enjoyed watching his television from the comfort of his bed; however, it was not comfortable with no linens on the mattress. He felt the CNAs didn't have the time to complete all of their duties. Interview with the resident on 2/1/17 8:31 a.m. in the resident's room, the resident stated he had to get up at 20 minutes til 5 this a.m. to take a shower and that is too early. He further stated his linens were changed for the first time in a long time this a.m. Interview with LPN BB on the B wing on 2/1/17 at approximately 10:15 a.m. revealed that residents have their linens changed every other day during their bath time. A review of the bathing schedule for 2/1/2017, revealed R #92 received his shower today. Interview with CNA NN 2/1/17 11:02 a.m. outside the resident's room, the CNA stated the resident like to get up between 4:30 a.m. and 5 a.m. to take a shower. Further interview with R #92 at 2/1/17 11:29 a.m., the resident stated again that he did not want to get up early in the morning - for example 5 a.m. He restated that today after his shower he returned to his bed being made-up. That hasn't happened in a long time.",2020-09-01
676,PRUITTHEALTH - LAFAYETTE,115304,205 ROADRUNNER BOULEVARD,LAFAYETTE,GA,30728,2017-02-02,252,E,0,1,P2OR11,"Based on observations and interviews, the facility failed to ensure the facility was free of urine odors resulting in the facility having a strong urine odor at the facility's entrance and different areas of the building causing an institutional like environment. Findings include: On 1/29/17 at 8:47 a.m. during initial tour of the facility, there were approximately five residents who were seated near the entrance of the building, lined up along the front window. The area smelled of a strong urine odor. On A-hall, room A-2, upon entry into the room there was a strong urine odor. The shared bathroom in this room smelled of urine, and a tied clear plastic bag with a soiled incontinent brief was observed on the floor. On 2/01/17 at 8:25 a.m. and 2/02/17 at 8:30 a.m. upon entry into the facility there was a strong urine odor present. Approximately five to six residents were seated in their wheel chairs near the entrance to the building. On 2/2/17 at 8:51 a.m., the Director of Nursing (DON) was taken to the entrance of the building where the smell of urine was present. When asked if he smelled the urine odor, the DON replied maybe I've become desensitized to the smell. We have been trying to work on that. DON asked the Housekeeping Supervisor to come to the entranced of the building were the urine odor was present. When asked if he smelled the urine odor and did he know where it was coming from, the Housekeeping Supervisor replied We have a couple of urine odor eliminators and use them when cleaning this area. Further interview with the Housekeeping Supervisor stated We have a monthly wheelchair cleaning schedule and as needed. On 2/2/17 at 10:57 a.m. A-Hall was toured with Administrator and Maintenance Supervisor. Upon entry to Room A-2, there was a strong urine odor present. Administrator stated One of the residents in this room will not allow us throw away her dirty incontinent pads. We have tried going through her things but she only allows us to throw away certain things. Observation at this time of the shared bathroom of room A-2, there was a gray bedpan on the floor next to the toilet and the bathroom had a urine odor. Administrator observed uncovered bedpan on floor in bathroom and stated that should not be stored there, and placed on a pair of gloves and disposed of the bedpan.",2020-09-01
677,"PLACE AT MARTINEZ, THE",115308,409 PLEASANT HOME ROAD,AUGUSTA,GA,30907,2019-08-29,640,D,0,1,0XFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the RAI (Resident Assessment Instrument) Version 3.0 Manual and staff interviews, the facility failed to transmit Minimum Data Set (MDS) Assessments timely for three residents (R) (#1, #2, and #3) of 29 sampled residents. Findings include: Review of the RAI Version 3.0 Manual dated (MONTH) (YEAR) documented under Chapter 5: Submission and Correction of the MDS Assessments, Transmitting Data - Assessment Transmission: comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date. All other MDS assessments must be submitted within 14 days of the MDS Completion date. R#1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The discharge MDS for this resident had an Assessment Reference Date (ARD) of 3/18/19. This discharge MDS was not transmitted until 8/28/19 making this assessment 138 days overdue. R#2 was admitted on [DATE] with [DIAGNOSES REDACTED]. The ARD for the discharge MDS for this was 3/31/19. This discharge MDS was not transmitted until 8/28/19 making this assessment 132 days overdue. R#3 was admitted on [DATE] with [DIAGNOSES REDACTED]. The ARD for the Annual MDS assessment was 7/30/19. This annual MDS was not transmitted until 8/28/19 making this assessment one day overdue. During an interview on 8/28/19 at 1:23 P.M., MDS Coordinator AA stated that R#1 and R#2's MDS assessments were not completed therefore did not go into her batch list to be transmitted. She also stated that R#3's MDS was transmitted late by one day. She stated that she transmits MDS's once or twice per week and then runs a validation report to compare those assessments transmitted to her schedule of MDS's due to ensure they were all accepted. She indicated these MDS assessments fell between the cracks. During an interview with the Director of Nursing (DON) on 8/29/19 at 9:00 a.m., she stated that she expects for the MDS staff to complete the MDS assessments by the transmission due date indicated per the system and the RAI Manual.",2020-09-01
678,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2018-02-08,582,B,0,1,7TEM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to provide the Advanced Beneficiary Notice (ABN) to one, Resident (R)#253, of three records reviewed for those residents who were discharged from Medicare services with Medicare days remaining. Findings include: Review of the admission Minimum Data Set (MDS), section A1600, dated 8/16/17, for R#253 revealed he was admitted to the facility on [DATE]. Review of facility records reveal R#253 was provided with a Notice of Medicare Non- Coverage (NOMNC) on 8/28/17. This allowed him to an expedited review of a service termination if chose to appeal the termination. This does not fulfill the facility's obligation to advise the resident of potential liability for payment. He remained in the facility for long term care services. He was not provided with the ABN to inform him of the ending of skilled services that may not be paid for by Medicare so that he could assume financial responsibility if he wanted to continue those services. On 2/6/18 at 1:30 p.m. during an interview with R#253, he stated his family member told him his therapy ended because Medicare would no longer pay for it. He reported he was not given the option to continue his therapy and pay for it himself and had not been told how much it would cost if he chose to continue therapy. On 2/6/18 at 2:15 p.m., interview with the Administrator and the Business Office Manager (BOM) in the Administrator's office, they both confirmed R#253 was not provided with the ABN. The BOM stated she was not aware she was required to issue both the NOMNC and the ABN when a resident remained in the facility. On 2/7/18 review of facility policy Advance Beneficiary Notices (ABNs), effective (MONTH) 2009 and most recently revised 7/19/16, in section titled Procedure Number 3 states, A copy of the Advance Beneficiary Notice will be provided to the patient/resident for his/her records and a copy will be maintained in the patient/resident's record. The facility did not provide R#253 with the ABN when he was discharged from Medicare services with Medicare coverage days remaining and chose to stay in the facility.",2020-09-01
679,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2018-02-08,842,D,0,1,7TEM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to maintain complete and accurately documented medical records for one, Resident (R)#77, of eight resident records reviewed for signed orders related to the code status of that resident. There were 32 residents in the total sample. Findings include: Review of records for R#77 revealed she was admitted to the facility on [DATE] as noted on the face sheet. Review of the medical record revealed a document title State of Georgia Physician's Do Not Resuscitate (DNR) Order for Adult Patient/Resident Without Decision Making Capacity With Authorized Person issued (MONTH) 2006 and most recently revised (MONTH) 2007. This document was signed by the Durable Power of Attorney (DPOA) for Healthcare for R#77 and two physicians on (MONTH) 29, 2013. Review of the monthly physician's orders [REDACTED]. Further review of the face sheet lists dates R#77 was sent to the hospital on [DATE] and readmitted to the facility on [DATE]. R#77 was on bed hold while she was in the hospital per the facility census in the electronic record for census history in the business office. Review of the hospital discharge summary does not indicate a code status for R#77. Further review of the medical record for R#77 reveals a care plan dated 10/19/17 and identifies the advance directive status as DNR. Goals and interventions are listed to honor and carry out resident wishes within the legal guidelines of the advance directive. Review of the re-admission physician's orders [REDACTED]. These orders are dated 10/28/16. The code status on these orders is marked as full code and also include orders for medications, diagnoses, diet, allergies and other miscellaneous orders. The orders received from the physician on return to the facility do not have the orders for DNR carried forward. Review of the monthly Physician order [REDACTED]. The orders received from the physician upon return to the facility are not signed by the nurse who obtained the orders from the physician nor are they signed by the physician. The monthly physician's orders [REDACTED]. The orders received from the physician upon return to the facility are not in the active medical record but are being stored in the thinned record in the medical records department. The nurses caring for R#77 do not have access to the most current physician's orders [REDACTED]. The facility employs an inhouse physician however, the physician responsible for signing the orders dated 10/28/16 is no longer employed by the facility. Review of facility policy, titled Physician Orders, effective 4/1/98 and most recently revised 9/15/17 stated in the section titled Verbal and Telephone Orders 1. All verbal and telephone orders will be immediately transcribed in the medical record by the licensed professional taking the order. 2. The licensed professional will verify the verbal or telephone order by reading the order back to the practitioner issuing the order. 3. The licensed professional will sign and date the order, will indicate the name of the physician giving the order and will document read back as proof of verification of orders. 4. The order will be countersigned by the responsible physician within 30 days for all patients/residents. In the section titled Readmission orders [REDACTED]. Orders to renew all previous medications are not accepted. Review of a second facility policy titled, Do Not Resuscitate Policy: Georgia effective 2/10/15 and with a revision date of 2/10/15 also, the section titled Procedure III C states Healthcare center/agency will indicate a DNR order on the Medication Administration Record [REDACTED]. The Social Worker will be responsible for keeping this list updated. Review of the current MAR for (MONTH) (YEAR) for R#77 revealed there is no code status identified. Review of the facility list of residents who have DNR orders and is kept in the front of the MAR book revealed R#77 is identified on this list as having a current DNR order. On 2/8/18 at 9:20 a.m. an interview with the Family of R#77, who is the DPOA for healthcare for R#77, confirmed he wanted his mother to have a physician order [REDACTED]. On 2/7/18 at 10:15 a.m. during an interview with the Regional Nurse Consultant (RNC) she confirmed the orders dated 10/28/16 were not signed by the physician or the nurse. She stated since R#77 was on bed hold while she was in the hospital, she was not officially discharged from the facility. She stated since she was not discharged , readmission orders [REDACTED]. She acknowledged differences in the handwritten orders dated 10/28/16 and the orders which were in effect when R#77 was sent to the hospital 3 days earlier which include the most recent order of the code status-full code. The RNC verbalized the facility policy when a resident is readmitted to the facility is to obtain orders from the physician and document readback and for the licensed professional receiving the orders to document them and provided from the physician and confirmed the physician should sign all orders within 30 from the time he provided them either as a verbal or telephone order. The RNC stated the orders had not been signed per policy. The facility did not follow their policy for Physician order [REDACTED]. The facility further failed to follow their policy by not identifying an accurate code status on the monthly MAR for R#77. The facility also listed R#77 on the list of residents who have current DNR orders in the front of the MAR book even though the most current physician order [REDACTED].#77 indicates she is to be a full code. The facility failed to honor an accurate advanced directive for R#77 by failing to verify the code status.",2020-09-01
680,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2018-09-13,725,E,1,1,5WYK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of records, and resident, family and staff interview, the facility failed to provide staff in sufficient numbers to care for the needs of its residents as determined through resident assessment instruments and the Facility Assessment of (MONTH) (YEAR). The facility census was 146. Findings include: Review of the resident council minutes recorded between (MONTH) (YEAR) and (MONTH) (YEAR) revealed there were complaints from the resident council related to staffing shortage. The minutes also reflect that, starting in (MONTH) (YEAR), the administration began to meet weekly with the residents in response to these concerns. The minutes recorded for 6/19/18 document that the resident council stated that more assistance was needed during meals in the evenings during the week and during lunch and supper on the weekends. During a follow-up meeting on 6/27/18, the resident council said the weekend and evening meal services had improved, but indicated that this was due to the administrative staff helping out. During this meeting, it was documented that the facility planned to hire some Life Enrichment Aides whose job it would be to provide non-clinical assistance to the residents - making beds, passing ice, answering call lights. During another follow-up meeting held on 7/18/18, the facility informed the residents that they were continuing to hire new certified nursing assistants, and that the Life Enrichment Aides were due to start on 7/19/18. During weekly follow-up meetings between 7/26/18 and 9/6/18, the recorded resident council minutes documented that residents were pleased that there was some improvement in the timeliness of meals and call light responses due to increased staff participation and the addition of the hospitality aides. However, the facility made it clear to the residents in these minutes that the addition of these aides was a temporary measure. During an interview on 9/10/18 at 2:12 p.m. with Resident (R) A, it was revealed that the resident believed the facility did not have enough staff to care for the needs of its residents. RA said the existing staff often work extra hours to cover the gaps in staff, and by the end of their shifts, in the evenings, many of them appear not to care anymore because they are so burned out. The staff shortage is mainly apparent in the evenings and all day on the weekends. When the administrative staff is available during regular business hours, they assist with meals in the dining room. However, in the evenings, when only the nursing staff are working, residents must wait until the nurse and Certified Nursing Assistants (CNAs) are available to come to the dining room to assist with dinner. It is not unusual for residents to wait a long time before they can have their dinner. Even the residents who do not need assistance must wait for a nurse to be present in the dining room before dinner can be served. Because of the long wait time, the dinner is usually cold by the time it is served. The staff are willing to reheat a resident's meal if asked, but that just takes additional time and RA said the reheated food is even more unpalatable than before. Recently, the facility employed three young ladies who are responsible for answering call lights and providing minimal assistance with simple requests from the residents such as ice or water. These additional employees are helpful, but they are not allowed to provide care such as bathroom assistance. Therefore, if the residents need to go to the bathroom, they are still required to wait a long time for assistance. R A said that the residents who require more assistance suffer more hardship by having to rely on staff who are not available. R A described venturing into the hallway at night and seeing residents' call lights ablaze up and down the hall like a Christmas tree. During an interview on 9/10/18 at 2:45 p.m., R B revealed that it often takes staff 30 minutes to an hour to respond when she presses her call button for assistance. Sometimes, she said, they do not respond at all. A review of the Minimum Data Set (MDS) records for R B revealed the resident required the assistance of at least one person for activities such as bed mobility, eating, and toilet use, and required the assistance of at least two persons for transfers. During observation on 9/10/18 at 5:43 p.m., four members of staff were observed in dining room assisting about 30 residents with the dinner meal. These staff included the maintenance director, the environmental services director, one CNA, and a Registered Nurse. During an interview on 9/11/18 at 2:28 p.m. a family member of R C said he did not believe the facility has enough staff to provide for the needs of his family member and the other residents. The family member of R C said when he calls the facility via telephone to check on the status of R C, the phone rings and rings and no one answers. The staff usually puts the resident's tray on the bedside table during mealtimes and leave without feeding her. He has observed that they do the same thing with other residents on the different hallways of the facility during his visits. When he complains, the staff tell him that they place all the trays in the residents' rooms and later return to help the individuals that need assistance with eating. However, the facility rarely has enough staff to assist all the residents with eating, even in the dining room. During the week, there is usually only two staff members assisting residents with eating in the dining room. A review of the MDS records for R C revealed the resident needs the assistance of at least one person for eating and toilet use, and at least 2 persons for bed mobility and transfers. During a group interview with active members of the resident council on 9/12/18 at 11:10 p.m., several residents concurred that the facility did not have enough staff to care for their needs: R D said her unit is not consistently staffed with CNAs and this situation is frustrating to her. The facility often pulls the regular CNAs from her unit to cover the rehabilitation unit. When this happens, her unit goes without help or they are given a part-time CNA, and this makes her feel unsettled. R [NAME] said she had lived at the facility for more than [AGE] years and there had never been such a staff shortage as was currently evident. R A said there were no aides to help the residents with needed items in the dining room in the evening. We wait a long time for someone to help us with drinks, bread, etc. Weekends are the worst. On Thursdays, we think: the weekend is coming; we are going to have to wait 'til breakfast for dinner! She reported having to wait for at least one hour when she requested some ice be brought to her in her room the night before. She kept checking the hallway, and there were no aides in sight during the entire time she waited. The members of the resident council said they had attended several meetings with the administration in previous months in which they had received updates on efforts on the part of the facility to hire more staff. The council said they had informed the administration that more help was needed, and said that the facility had responded that they were hiring more staff. The council said that some staff were hired, but these quit soon after they were hired. During observation of the staff on the South hall on 7/12/18 between 7:15 p.m. and 9:00 p.m., it was revealed that there were three CNAs present and assisting residents. During an interview on 9/13/18 at 12:56 p.m., with R D, it was revealed the regular CNA on her hallway was pulled to work on another unit the previous evening, just as she had claimed in the resident council interview. This CNA was replaced with a CNA with whom the resident was not familiar and this made her extremely uncomfortable. During observation of the lunch meal on 9/13/18 at 1:06 p.m., it was revealed that residents were being assisted by one Registered Nurse, the Registered Dietitian, the maintenance director, and the environmental services director. There were no CNAs available to provide assistance to the residents. During an interview on 9/13/18 at 3:15 p.m. with the CNA/staff scheduler, it was revealed that four CNAs are usually scheduled for the 3:00 p.m. to 11:00 p.m. shift on the South hall and this was the number scheduled for that shift on the evening of 9/12/18. However, two of the scheduled CNAs had not reported for work. Thus, the scheduler (a CNA) had filled in for one of the absent staff. A review of the (MONTH) schedule for the CNAs revealed that, of the 9 available CNA positions on the 7:00 a.m. to 3:00 pm. shift, four were open, and of the 8 available CNA positions on the 3:00 p.m. to 11:00 p.m. shift, 7 remained open. During an interview on 9/13/18 at 3:35 p.m. with the Director of Nursing (DON), it was revealed that the facility's staffing requirements are decided based on acuity - the intensity of care required by the residents - and on the number of residents on any of the units on any given day. If one unit (hallway/wing) in the facility is filled to less that capacity, a CNA might be pulled from that unit to fill in for another unit as needed. A review of the Facility assessment dated (MONTH) (YEAR) revealed that, when compared to the national average, the facility had high to very high acuity levels in the following activities of daily living (ADLs) areas: grooming; bed mobility; transfers; toilet use and eating. 75% of the facility's residents required the assistance of at least one person with their ADLs, and 25% require at least two persons in this area. Overall, the facility judged their acuity level to be high. The facility determined that its staffing to meet the needs of its resident population was sufficient, and this, it said, was determined based on considerations such as staffing and scheduling systems, daily staffing sheets, and how the facility uses its budgeted PPD. During an interview on 9/13/18 at 5:11 p.m. with Licensed Practical Nurse (LPN)AA, it was revealed there are several residents on this nurse's unit who demand much care and attention from the available CNAs. The needs/demands of these residents lead to other residents having to wait a considerable amount of time for service during some of the shifts. It would help if there were more CNAs scheduled on these shifts to ensure that other residents' needs are not ignored. Arnette Murphy ------- On 9/12/18 at 11:00 a. m. during an interview conducted with Licensed Practical Nurse (LPN)EE, she stated they are short staffed Certified Nursing Assistants (CNAs) on the night shift and weekends. She stated it is also the same for the LPNs; that the Unit Managers can't monitor the units and help because they are filling short staff shifts on the medication carts. They also don't have a dedicated shower staff, so the CNAs aides must do that, and be tied up with doing showers so the other residents must wait for help. She confirmed the facility doesn't pay agency staff. She confirmed that the facility is actively hiring, but the aides do not stay. AM -------",2020-09-01
681,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2018-09-13,814,E,1,1,5WYK11,"> Based on observation, staff interviews and policy review, the facility failed to ensure the sanitary handling of garbage and refuse in the facility dumpster area grounds. The facility census was 146. Findings include: Initial observation of the facility dumpster area on 9/13/18 at 11:25 a.m. revealed substantial amounts of trash around the grounds of the two dumpsters and the grease trap. Trash items included plastic bags, aluminum cans, plastic bottles and paper debris which were wet and soggy. During observation of the dumpster area with the Dietary Manager (DM) on 9/13/18 at 11:42 a.m., he confirmed the presence of the trash on the grounds of the dumpster area and stated it was not appropriate to have this area dirty at any time. He stated the responsibility for cleaning the dumpster area belonged to the Maintenance department. During observation of the dumpster area with the Maintenance Director (MD) on 9/13/18 at 11:55 a.m., he confirmed the presence of the trash on the dumpster area grounds and stated he would clean it up right away. He stated the dumpster area should be cleaned up after each trash pickup on Mondays, Wednesdays and Fridays. He stated the trash was picked up as scheduled on the previous day, 9/12/18, and the responsibility for cleaning the dumpster area grounds belonged to the Housekeeping department. During observation of the dumpster area with the Housekeeping Manager (HM) on 9/13/18 at 12:10 p.m., he confirmed the presence of the trash on the dumpster area grounds and stated it should be cleaned up after each trash pickup on Mondays, Wednesdays and Fridays. He stated staff would clean it up right away. During observation of the dumpster area grounds with the Administrator on 9/13/18 at 12:20 p.m., he stated he knew the dumpster area was dirty with large amounts of trash scattered around the two dumpsters and the grease trap. He stated he knew the trash was old and had been there for a while. He stated he would have staff clean the area right away and would ensure there was regular assessment and cleaning of the area. Review of the facility policy titled Waste Disposal revealed the Dietary Department is charged with disposing of waste in an effective manner in order to prevent a breeding place for insects, rodents and the transmission of diseases.",2020-09-01
682,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2019-11-21,584,D,1,1,TQY711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interviews the facility failed to ensure that it was maintained in a safe clean and comfortable homelike environment in seven resident rooms on one of three units with damaged walls, missing chair rails, stained curtains, and personal equipment on the floor in the bathroom. Findings included: Observation on 11/18/19 at 11:50 a.m. during the initial screening process on the South Unit. The following observations were made in the resident rooms: 1. room [ROOM NUMBER]-A two linear holes in the wall were the head of the bed is located the wall also had unpainted dry wall. 2. room [ROOM NUMBER]-B a hole in wall chair rail missing. 3. room [ROOM NUMBER] in the bathroom on the floor was one white measuring hat for urine, one grey fracture bed pan, and one grey basin. 4. room [ROOM NUMBER]-B- hole in wall. 5. room [ROOM NUMBER]- B six linear areas on the wall two of the areas had large holes were the head of the bed close to the window is located. 6. room [ROOM NUMBER]-A missing paint and holes on the long wall. 7. room [ROOM NUMBER]-B missing paint, a hole in wall, red stain on the call light, curtains with brown stains. An observation and interview on 11/21/19 at 3:05 p.m. with the Maintenance Supervisor (MS) and the Assistant Administrator. The MS revealed that the staff alerts the maintenance department via the facility computer based system for repairs broken equipment. He revealed that the system is checked twice a day by the maintenance department. The Maintenance Supervisor also revealed that the Partners are also assigned areas/rooms in the facility to check for compliance. The MS also confirmed that he was the Partner assigned to the South Unit and he had not made compliance rounds in the resident rooms. The MS and Administrator confirmed that the following that the six rooms needed repairs to the damage wall and missing chair rail. A policy was requested but not provided to the surveyor.",2020-09-01
683,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2019-11-21,656,D,1,1,TQY711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, and review of the facility policy titled Care Plans, the facility failed to develop a care plan for contractures and failed to implement a care plan related to maintaining safety during transfers for one resident (R) (R#20), (R#20). In addition, the facility failed to follow the care plan for notifying the dental consultant/Physician of a change in dental status, and did not develop a care plan for a loose bridge for one resident (R#36). The resident sample was 54. Findings Include: Review of the facility policy Care Plans revised 10/5/17 revealed: 3. The comprehensive person-centered care plan is developed to include measurable goals and timeframe to meet a resident's medical, nursing and psychosocial needs, the services that are furnished to attain or maintain the resident's highest practicable physical, mental psychosocial needs that are identified in the comprehensive assessment. Care Plan Review and Update: 4. Care plans will be updated by nurses, Case Mix Directors or any other interdisciplinary team member so that the care plan will reflect the resident's needs at any given moment. 1. Review of R#20's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS of 15 indicates a resident has no cognitive impairment); had functional limitation in ROM on both sides of the upper and lower extremities; and received no restorative services during the assessment period. Review of R#20's care plans revealed that none were found for contractures, nor interventions such as restorative nursing services to address the contractures. Observation on 11/19/19 at 8:48 a.m. revealed that R#20 had a severe extension contracture of the right wrist, and slight flexion contracture of her left hand, and no splint devices were seen. During interview with R#20 at this time, she stated that she had these contractures for a long time, and denied receiving ROM or splint devices to her hands. Review of a PT (Physical Therapy)-Therapist Progress & Discharge Summary dated 6/2/15 revealed: Restorative nursing program created for PROM (passive ROM) of BLE (bilateral lower extremities). Pt (patient) has bilateral wrist extension splints required to maintain tendonesis grip. Pt being discharged to restorative nursing program. Review of computerized restorative records revealed no evidence that restorative services were provided after 9/8/19. Cross-refer to F 688. 2. Review of R#20's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she was totally dependent on two staff for transfers. Review of R#20's risk for falls related to impaired mobility care plan developed 1/11/19 revealed an approach dated 7/1/19 to maintain safety during transfers. During interview with R#20 on 11/19/19 at 8:46 a.m., she stated that she fell off the stretcher used to transport her to the shower about four months ago, and hurt her head. During interview with Certified Nursing Assistant (CNA) HH on 11/21/19 at 11:52 a.m., she stated that CNA II had asked her to help transfer R#20 to the shower stretcher. She stated during continued interview that they used a bed sheet that was underneath the resident to pull her over from the bed to the stretcher instead of using the Hoyer (mechanical) lift, and that CNA II lost her grip on the lower portion of the sheet, and they had to lower R#20 to the floor. Cross-refer to F 689. 3. Record review Admission Minimum Data Set (MDS) assessment dated [DATE] documented R#36 was admitted to the facility on [DATE] with multiply [DIAGNOSES REDACTED]. Review of section L Assessment of Oral/Dental Status R#36 had no dental concerns. Further review of the electronic health record a care plan problem start date: 6/26/19 category: Dental Care Alteration in dentition. Approach: Dental consult as needed. Notify MD (Physician) of any abnormal findings. Review of the dental progress notes dated 5/1/19 revealed resident needs to be careful with the bridge on #11. Care plan was not updated to reflect the dental precautions made by the dentist. An interview with the Medical Director on 11/19/19 at 4:10 p.m., revealed he was not aware of R#36 the exposed root tip. The Medical Director expectations that a Situation, Background, Assessment, Recommendation (SBAR) would be initiated and have R#36 follow up immediately with implant Physician. An interview was conducted on 11/21/19 at 9:34 a.m. with the Unit Manager (UM) MM. The UM revealed that the R#36 exposed root tip was noticed after the resident returned from the hospital on [DATE]. The UM revealed she did not complete an SBAR or document that the physician was notified. Cross Reference F-791",2020-09-01
684,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2019-11-21,688,D,1,1,TQY711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to provide evidence that restorative services including splint application and range of motion (ROM) were provided since 8/30/19 for one of two residents (R) (R#20) reviewed for any concerns with range of motion. Findings include: Review of R#20's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#20's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS of 15 indicates a resident has no cognitive impairment); had functional limitation in ROM on both sides of the upper and lower extremities; and received no restorative services during the assessment period. Review of R#20's care plans revealed that none were found for contractures, nor interventions to address the contractures. Observation on 11/19/19 at 8:48 a.m. revealed that R#20 had a severe extension contracture of the right wrist, and slight flexion contracture of her left hand, and no splint devices were seen. An interview with R#20 on 11/19/19 at 8:48 a.m. the resident revealed that she had these contractures for a long time, and denied receiving ROM or splint devices to her hands. Further observations on 11/20/19 at 8:09 a.m. and 1:04 p.m. revealed that no splint devices were seen to R#20's hands. An interview with Occupational Therapist (OT) FF on 11/21/19 at 1:00 p.m., revealed that R#20 had not been on OT caseload since (YEAR), at which time she had been referred to restorative for hand splints. Review of an Occupational Therapy OT-Therapist Progress & Discharge Summary with start of care of 6/5/15 and end of care of 7/2/15 revealed that R#20 was seen for skilled OT to prevent contractures and appropriate orthotics to decrease risk of contractures. Review of OT Patient Discharge Instructions dated 7/2/15 revealed Patient/Caregiver Training: Donning/doffing orthotics, orthotics schedule. Discharge Plans and Instructions: Continue with RNP (restorative nursing program). Review of PT (Physical Therapy)-Therapist Progress & Discharge Summary dated 6/2/15 revealed: Restorative nursing program created for PROM (passive ROM) of BLE (bilateral lower extremities). Pt (patient) has bilateral wrist extension splints required to maintain tendonesis grip. Pt being discharged to restorative nursing program. Training to restorative nurse and aides in pt's plan of care. Restorative nursing expressed understanding and will don/doff wrist extension splints daily. Restorative plan of care includes donning/doffing B (bilateral) wrist extension splints, as well as PROM of BLE and UE (upper extremity) with emphasis on B (bilateral) ankles and elbows. An interview with Registered Nurse (RN) Corporate Consultant CC on 11/21/19 at 2:39 p.m., she verified that there was no documentation that restorative services were provided for R#20 after 8/30/19, and could not find any reason as to why they would have been discontinued past this date. Review of R#20's Point of Care History records for Restorative Nursing services from 1/7/19 to 9/8/19 (a 245-day time period) revealed the following: Number of days that splint or brace assistance was documented: 116 Number of days that passive range of motion was documented: 114 In addition, there were 74 days between 9/9/19, through the end of the recertification survey on 11/21/19, where no evidence of restorative services was provided. During interview with Restorative Certified Nursing Assistant (RCNA) GG on 11/21/19 at 2:55 p.m., revealed that R#20 was receiving PROM and splint application to both of her hands, that she was not making any progress, and that all restorative documentation was done in the computer. She stated during continued interview that she would let the nurse in charge of the restorative program (the Director of Health Services-DHS) know if a resident was not making progress or was declining, who in turn would send a communication form to therapy. She further stated that the RCNAs met with the DHS weekly on a rotating basis to give her feedback on the residents they provided restorative services for, but she did not know if anyone reported to the DHS that R#20 was not making progress (the current DHS has only been employed at the facility since 11/18/19), nor why R#20 was not currently receiving services. Review of the facility's Restorative Nursing Program procedure reviewed 5/25/18 revealed: It is the policy of this healthcare center to provide restorative nursing which focuses on achieving and maintaining optimal physical, mental and psychological functioning of the patient/resident. Implementation: 1. Patients/residents may be screened/assessed upon admission, re-admission, end of therapy and when a decline is noted in the patient's/resident's ADL (activity of daily living) abilities by observation . 2. Determine appropriate restorative services based on the screening/assessment of the patient/resident needs. The nurse, in collaboration with the patient/resident, therapies, and primary care physician and or physician extender makes this decision. 3. If it is determined that the patient/resident would benefit from a Restorative Nursing Program, the nurse should arrange for such a minimum of six (6) days a week, unless otherwise noted. 4. Develop a Care Plan and address each restorative service. The care plan should include individualized interventions and measurable goals. Note that maintenance goals are appropriate in restorative nursing. Documentation: 1. Utilize one (1) Restorative Flow Sheet for each service that is provided. 2. Initial daily, in the appropriate space on the flow sheet, or the electronic charting system, those restorative services that were provided.",2020-09-01
685,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2019-11-21,689,D,1,1,TQY711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident and staff interview, the facility failed to safely transfer one resident (R) (R#20), resulting in a fall from the bed. A total of four residents were sampled for any concerns related to falls. Findings include: Review of R#20's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#20's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS of 15 indicates a resident has no cognitive impairment), and was totally dependent on two staff for transfers. Review of R#20's risk for falls related to impaired mobility care plan developed 1/11/19 revealed approaches dated 7/9/19 (the date of the fall) to ensure resident was pulled back on the bed when prepping for shower, and to explain to patient regarding the importance of safety transferring when using Hoyer lift to protect her from any danger. Further review of the falls care plan revealed an approach dated 7/1/19 to maintain safety during transfers. Review of a PT (Physical Therapy)-Therapist Progress & Discharge Summary dated 2/1/15 revealed: Precautions: Quadriplegic C4 (fourth cervical vertebra) with improving motor function in BLE (bilateral lower extremities). Pt (patient) requires hoyer and assistance of 2 for safe transfers. Review of R#20's assessment records in the facility's electronic health record (EHR) revealed that an assessment of how to transfer the resident from one surface to another was not found. An interview with R#20 on 11/19/19 at 8:46 a.m., revealed that she fell off the stretcher used to transport her to the shower about four months ago, and hurt her head. She further stated that staff usually used a machine (mechanical lift) to get her out of bed, and that sometimes there was one staff to operate this machine and sometimes two, but could not remember how many staff were in the room during the day of the fall. Review of a facility-provided Falls report from 6/19/19 to 11/19/19 revealed that R#20 had one fall during this time on 7/9/19 at 9:02 a.m. Review of Nurse's Notes revealed that on 7/9/19 at 9:05 a.m., R#20 was in bed being prepped for transfer to shower bed. Further review revealed that R#20 was too close to edge of bed, and slid off onto floor, no injury noted. Review of the facility Event Report for the fall on 7/9/19 revealed: Location of fall: resident room. What was resident doing just prior to fall?: In bed. Pain Observation: No pain. Location of Injury: n/a. The Notes section dated 7/9/19 at 9:05 a.m. revealed: Resident was in bed being prepped for transfer to shower bed. Resident was too close to edge of bed and slid off onto floor. No injury noted. Assisted resident off floor into bed. (Attending Physician) notified, no new orders given. Review of a Post Fall Observation record dated 7/9/19 revealed: Detailed Description of Fall: Resident was being prepped for transport to shower bed and slid off side of bed onto floor. Evaluation: Resident too close to edge of bed. Plan of Care: Move resident closer to center of bed. An interview with Certified Nursing Assistant (CNA) HH on 11/21/19 at 11:52 a.m., revealed that she was working as a Unit Secretary the day of R#20's fall, but that CNA II had asked her to help transfer R#20 to the shower stretcher. She stated during continued interview that they used a bed sheet that was underneath the resident to pull her over in the bed to the stretcher, and that she was holding on to the top portion of the sheet (near the resident's head), and that CNA II was holding on to the bottom portion of the sheet (near R#20's feet), and that during the transfer CNA II lost her grip on the lower portion of the sheet, and they had to lower R#20 to the floor. CNA HH verified that they did not use a mechanical lift to transfer R#20 that day, that R#20 was totally dependent for transfers, and that she referred to the care plan for information such as how to transfer. An interview with CNA II on 11/21/19 at 12:02 p.m., revealed that R#20 did not actually fall from the bed, but that they lowered her down to the floor with a sheet. She further stated that she was familiar with R#20's care, that the resident was totally dependent for care, and had always used a Hoyer (mechanical) lift to transfer in the past. She stated that on 7/9/19, she asked CNA HH to help her slide R#20 from the bed to the shower stretcher, as the resident was not very big and she felt it would be safe to transfer her this way. CNA II stated during continued interview that she was counseled after this event, and told to always use a Hoyer lift whenever transferring any total care resident. An interview with Corporate Registered Nurse (RN) Consultant CC on 11/21/19 at 2:49 p.m. revealed that she was not aware of a facility policy, but that their protocol was to do lift assessments on every resident on admission and then quarterly. She verified that no lift or transfer assessment could be located in the EHR. Review of Lift Observation Forms located in Medical Records revealed that the last one completed for R#20 was dated 8/18/18, and that a mechanical lift with a small sling was required. Review of the facility's Mechanical Lift Use procedure reviewed on 5/25/18 revealed: Using a mechanical lift to raise an immobile patient from the supine to the sitting position allows safe, comfortable transfer from a bed to a chair. It is indicated for an immobile patient for whom manual transfer poses the potential for nurse or patient injury. Skill and care is needed when lifting and transferring patients/residents. Total lifts will be used for patients/residents who are non-weight bearing or those who offer only minimal assistance.",2020-09-01
686,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2019-11-21,791,D,1,1,TQY711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff and family interviews, and the facility policy Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, Mental Health the facility failed to follow up promptly and arrange dental service to repair a damaged dental implant of one resident (R) #36 of one resident reviewed for dental concerns. Findings included: Record review the Admission Minimum Data Set (MDS) assessment dated [DATE] documented R#36 was admitted to the facility on [DATE] with multiply [DIAGNOSES REDACTED]. Review of section L Assessment of Oral/Dental Status R#36 had no dental concerns. Further review of the electronic health record a care plan problem start date: 6/26/19 category: Dental Care Alteration in dentition. Approach: Dental consult as needed. Notify MD of any abnormal findings. Review of note from the facility's Dental Care Service dated 10/21/19 revealed: tooth #11 presents as a partial root tip. The Dentist recommends to refer patient to Oral Surgeon for extractions of #11 due to long root. An observation on 11/18/19 at 11:39 a.m. R#36 has a small abrasion on her left lower lip. An interview was conducted on 11/18/19 at 11:40 a.m. with the family of R#36. The family member revealed that she is having difficulty getting the facility to arrange for R#36 to see a surgeon regarding her exposed upper post tip that is causing an abrasion to her lower lip. The family revealed she notice the exposed post tip around August. She revealed at the time she noticed the exposed root tip she spoke with the Social Service Assistant regarding arranging R#36 to see a dentist. The family reveled In (MONTH) she took pictures of R#36 oral cavity and sent to the facility dental service. The dental service informed the family that resident needs be seen by an oral surgeon. The family of R#36 revealed she informed the social service department and requested that an appointment and transportation arrangements be made and has been unsuccessful. An interview was conducted on 11/19/19 at 3:21 p.m. with Social Service Assistant (SSA) LL. The SSA revealed she is responsible arranging dental appointments for the residents in the facility. She also revealed notes from the dental visits are emailed within 1-2 days after resident is seen by the Dentist or Hygienist. The SSA revealed the notes are reviewed by herself for recommendations and follow up and then a copy is provided to the charge nurse for review. The SSA revealed that R#36 was seen by the service on 6/4/19, 7/9/19, and 10/12/19. The SSA revealed the family spoke with her and informed her the resident was having pain and it was from an exposed post tip and wanted to make sure that a dentist appointment had been arrange. The SSA revealed that she did not document the family concern or notify the nurse of the family concern that R#36 was having pain. The SSA also reveal that R#36 did not have an appointment with an oral surgeon as recommended by the dental service on 10/12/19 notes. Review of the facility policy revise date of 11/21/16 titled Specialty Services: Dental Services, Vision Services, Podiatry Services, Hearing Services, Mental Health revealed Procedure: 2. Nursing partners shall encourage assist the resident in carrying out the specialty service physician recommendations and instruction.",2020-09-01
687,PRUITTHEALTH - BROOKHAVEN,115313,3535 ASHTON WOODS DRIVE NE,ATLANTA,GA,30319,2019-11-21,812,E,1,1,TQY711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, and review of facility policies titled, Labeling, Dating and Storage the facility failed to ensure food to residents were adequately label and date open food items, as well as discarding expired food items in the refrigerator with a received by, open, expiration (exp), or use by date; failed to discard food by the use-by date. This deficient practice had the potential to affect 131 of 154 residents receiving an oral diet. Findings include: During initial tour of the kitchen on [DATE] at 10:15 a.m. revealed the following food items expired of cooler/refrigerator located in the main kitchen revealed the following food items were expired and improperly labeled, opened five-pound bag of shredded coleslaw not dated, two-pound bag of sliced carrots with expiration date of [DATE], one-gallon container of Italian salad dressing with no open or expiration date. All food items were confirmed to be expired or without a visible label and date by the Dietary Cook (EE) at the time of observation. The observation in the walk-in freezer revealed expired food that included a five-pound bag frozen broccoli with use-by date [DATE], confirmed by DM. A large container of breaded squash with no received or open date, best by date read (MONTH) 19, no year, confirmed by DM. Continued initial observation tour on [DATE] at 10:15 a.m. and interview with DM confirmed that items were not appropriately labeled and noted food items were expired. Interview with the DM on [DATE] at 10:35 a.m. about the process of labeling and dating food items revealed that food is to be dated and labeled when it is received after a food item is opened an open and expiration date should be put on an item. There is a rotation of food items when supply is received; the older items are brought forward for use, and newer things are stored behind them. Additional interview with Dietary Manager (DM) on [DATE] at 11:30 a.m. revealed the expectation for proper labeling and discarding of expired foods was that all food items are to label and dated when opened and all expired foods are to be discarded immediately. The policy titled Food ordering, receiving, and storage policy was provided by the Administrator for review.",2020-09-01
688,PRUITTHEALTH - AUSTELL,115314,1700 MULKEY RD,AUSTELL,GA,30106,2018-03-22,641,D,0,1,7J3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the Minimum Data Set (MDS) accurately reflect the resident's (R) status for two (R#110), (R#58) of 23 sampled residents. Findings include: 1. Resident (R) #58 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#58's Annual Minimum Data Set ((MDS) dated [DATE], under Section I, Active Diagnosis, Psychiatric/Mood Disorder revealed the resident was coded as having [MEDICAL CONDITION] ([MEDICAL CONDITION] Disease). This coding triggered the resident for the need of a Level II Preadmission Screening and Resident Review (PASARR). R#58 was tagged in ASPEN as no PASARR with the diagnosis. Review of R#58's Level I PASARR dated 6/12/14 revealed [MEDICAL CONDITION] (other than [MEDICAL CONDITION]) was not a listed diagnosis. Review of R#58's physician's progress notes dated 9/28/15 revealed [MEDICAL CONDITION] (other than [MEDICAL CONDITION]) was not listed as a diagnosis. An interview was conducted in the conference room on 3/22/18 at 4:30 p.m. with the MDS Coordinator. The MDS Coordinator was asked where the [DIAGNOSES REDACTED].? After reviewing R#58's clinical record, the MDS Coordinator stated, it was a coding error and she would correct it. The MDS Coordinator provided a copy of the MDS correction request for a coding error. 2. R#110 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#110's Admission MDS, dated [DATE], under Section I. Active [DIAGNOSES REDACTED]. This coding triggered the resident for the need of a Level II Preadmission Screening and Resident Review (PASARR). R#110 was tagged in ASPEN as no PASARR with the diagnosis. Review of R#110's PASARR Level I dated 1/28/18 revealed [MEDICAL CONDITION] (other than [MEDICAL CONDITION]) was not listed as a diagnosis. Review of R#110's undated face-sheet under active [DIAGNOSES REDACTED]. During an interview in the facility's conference room on 3/22/18 at 2:51 p.m., MDS Coordinator GG said after reviewing R#110's medical file, she found it was a coding error. She also stated R#110 does not have a [MEDICAL CONDITION] diagnosis. The MDS Coordinator further stated, I will submit a correction and reported that the MDS coordinators use the Resident Assessment Instrument (RAI) manual for guidance.",2020-09-01
689,PRUITTHEALTH - AUSTELL,115314,1700 MULKEY RD,AUSTELL,GA,30106,2018-03-22,645,D,0,1,7J3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and interviews, it was determined the facility failed to ensure one resident (R#45) of three sampled residents received a PASAR Level II which could result in preventing the resident from attaining or maintaining his/her highest practicable level or result in a decline in the resident's physical, mental or psychosocial well-being. Findings include: 1. A review of the facility document titled Physician's Recommendation Concerning Nursing Facility Care or Intermediate Care for the Mentally Retarded paragraph 18 documents, I certify that this patient requires level of care provided by a nursing facility or an intermediate care facility for the mentally retarded. This form was signed by the physician and dated 6/14/16. A review of a facility document titled Post-Acute Transfer Summary from the transferring hospital, dated 6/10/16, revealed the following diagnosis, Acute [MEDICAL CONDITION] associated with endocrine, metabolic, or [MEDICAL CONDITION] disorder, and [MEDICAL CONDITION] with delusions. A review of the Nurse Practitioner's documentation dated 1/25/18, Assessment/Plan revealed, [MEDICAL CONDITION], continue [MEDICATION NAME] and monitor for behavior changes. Record review of R#45's Annual Minimum Data Set (MDS), dated [DATE], Section A, Identification Information, paragraph A1500, Preadmission Screening and Resident Review (PASRR) documents, Has the resident been evaluated by PASRR Level II and determined to have a serious mental illness and/or mental [MEDICAL CONDITION] or a related condition? This question was marked as No. The review of Section C, Cognitive, Brief Interview of Mental Status (BIMS) revealed a score of 12. Section I., Active Diagnosis, Psychiatric/Mood Disorder was marked for [MEDICAL CONDITION], other than [MEDICAL CONDITION]. A review of R #45's PASRR Level I Application dated 6/14/16 question 1a was, Does the individual have a primary (Axis I) [DIAGNOSES REDACTED].? This question was answered yes. Paragraph 2. stated, The individual has a primary (Axis I) [DIAGNOSES REDACTED]. Comments: Has [MEDICAL CONDITION] secondary to vascular changes. An interview was conducted on 3/22/18 at 4:30 p.m. with the MDS Coordinator in the conference room. The MDS Coordinator asked about the origin the [DIAGNOSES REDACTED]. She stated, It must be a coding error, and I will correct it. At approximately 5:00 p.m., the MDS Coordinator provided the Nurse Practitioner's documentation dated 1/25/18, page #3 of #4, Assessment/Plan, which revealed [MEDICAL CONDITION], continue [MEDICATION NAME] and Monitor for behavior changes. The MDS Coordinator was asked if an updated PASRR I or a PASRR II was completed, she stated, No.",2020-09-01
690,PRUITTHEALTH - AUSTELL,115314,1700 MULKEY RD,AUSTELL,GA,30106,2018-03-22,655,B,0,1,7J3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide the resident and their representative with a summary of the baseline care plan, which would include goals of the resident, medications, and dietary instructions, services and treatments administered by the facility. In addition, the baseline care plan would include the facility's personnel and updated information based on the details of the comprehensive care plan as necessary for two (Residents (R) #50 and R#175) of six residents who were new admissions and reviewed for compliance with baseline care plan requirements. The total sample was 23 residents. Findings include: 1. Review of the face sheet in the medical record for R#50 revealed the resident was admitted to the facility on [DATE]. A review of the Baseline Care Plan revealed it was not dated when it was initiated. The last page of the baseline care plan contains a section that stated, Post Admission Care Conference/Initial Care Plan Meeting Date: ______________, was blank and contained no date to verify that the post-admission care conference had been completed with the resident and his responsible party. The next area on the Baseline Care Plan had spaces to check what had been completed: Baseline Care Plan and Admission Physician order [REDACTED]. The last area had a section titled Attendees: _____ This area contained the signature of one staff member. R#50 nor his responsible party signed as attended. The Registered Nurse signature at the bottom of the page was dated 2/27/18. During an interview with the Administrator on 3/22/18 at 11:45 a.m. in the conference room, he stated the Nurse Navigator who is responsible for scheduling the post admission care conferences left the facility in January. He stated a new person assumed the position (MONTH) 15, (YEAR). He also stated the Director of Health Services (DHS) was responsible for completing those duties in the time that no one filled the position of Nurse Navigator. He confirmed the DHS was ultimately responsible for ensuring the post admission care conferences were scheduled between the time the former Nurse Navigator left and the new Nurse Navigator took over. An interview with Resident #50 and his wife on 3/22/18 at 1:10 p.m. in his room revealed neither of the two of them received an invitation to the post admission care conference. They stated they had not received a written copy of the baseline care plan but had been wondering when the care plan conference would occur so they would have an idea of how much longer he might be here. They confirmed R#50 nor his wife had not been informed verbally or in writing. An Interview with the DHS in her office on 3/22/18 at 1:40 p.m. revealed a post admission care conference for R#50 had not been done. She confirmed it had been her responsibility to schedule the post admission care conference at the time R#50 was admitted and she had not done that. She stated facility standard is to have a post admission care conference, five to seven days after admission. During the post admission care conference, the resident would be given a written copy of the baseline care plan. She verified the Baseline Care Plan for R#50 was left blank 2. Review of the face sheet in the medical record for R#175 revealed the resident was most recently admitted to the facility on [DATE]. A review of the Baseline Care Plan revealed it was not dated when it was initiated. The last page of the baseline care plan contains a section that stated, Post Admission Care Conference/Initial Care Plan Meeting Date: ______________, was left blank and contained no date the post admission care conference had been completed with the resident and his responsible party. The next area on the Baseline Care Plan had spaces to check what had been completed: Baseline Care Plan and Admission Physician order [REDACTED]. The last area had a section titled Attendees: _____ and contained a note that stated, C/P meeting held 3/20/18 with ortho Atlanta rep. This area had the signature of four staff members. R#175 nor her responsible party signed as attended. The Registered Nurse signature at the bottom of the page was dated 3/15/18. An interview with the DHS in her office on 3/22/18 at 1:40 p.m. revealed a post admission care conference for R#175 had not been done. She confirmed it had been her responsibility to schedule the post admission care conference at the time R#175 was admitted and she had not done that. She stated facility standard is to have a post admission care conference, five to seven days after admission. During this post admission care conference, the resident would be given a written copy of the baseline care plan. She verified the documentation on the Baseline Care Plan for R#175 was left blank. In an interview with the Administrator on 3/22/18 at 5:00 p.m. in his office, he stated the facility had identified baseline care plans as a problem and began education in (MONTH) (YEAR). He stated the facility uses an education program called Care Paths. He noted that this program discusses the new regulation and how the facility should proceed to comply with regulations. The Administrator also stated the facility had developed a Performance Improvement Plan (PIP) regarding the new regulation for baseline care plans and discussed it at the monthly Quality Assurance Performance Improvement (QAPI) meeting. He presented for review a PIP titled Re-hospitalization . In this PIP for Re-hospitalization , it was stated, Failure to follow Care Paths. He stated that would include the baseline care plan. It was explained to him the PIP was for re-hospitalization and not for baseline care plan. He was not able to locate a PIP titled baseline care plans which should include providing a written copy to the resident. He confirmed the facility policy, titled Care Plans, effective 12/31/1996 and most recently revised 10/5/2017, stated in the Section titled Procedure: with subtitle of New Admission Baseline Plan of Care stated the following under 3: Within the first few days of admission, a Post Admission Care Conference will be held for update and review of the baseline care plan. The baseline care plan should be updated to reflect changes since baseline care plan implementation. All meeting attendees will be reflected on the Baseline Care Plan form. A copy of the Baseline Care Plan form and Admission Physician order [REDACTED]. The facility failed to provide a written copy of the baseline care plan to R#50 and R#175.",2020-09-01
691,PRUITTHEALTH - AUSTELL,115314,1700 MULKEY RD,AUSTELL,GA,30106,2018-03-22,842,D,0,1,7J3111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to maintain a complete medical record on each resident that contained the physician progress notes [REDACTED].#47, R#50, R#171 and R#175) of 23 resident records reviewed for physician progress notes [REDACTED].#50) of six skilled residents who were reviewed for nursing progress notes. Findings include: 1. Review of the medical record for R#50 revealed on the face sheet, an admission date of [DATE]. The physician's progress notes for R#50 revealed a handwritten page from the physician as follows: 3/2 Pt seen and examined. Notes will follow. (followed by the physician's signature) 3/10 Pt seen and examined. Notes will follow. (followed by the physician's signature) 3/17 Pt seen and examined. Notes will follow (followed by the physician's signature) There were no additional physician's progress notes in the medical record of R#50. On 3/22/18 at 12:30 p.m. during an interview with the Medical Records Director (MRD), she confirmed that there were no physician's progress notes in the medical record of R#50. At 4:00 p.m., the MRD presented physician's progress notes for review. She stated she contacted the physician's office and had them to fax the missing notes to her at the facility. Further review revealed R #50 was receiving skilled services from the facility from admission through the current date of 3/22/18. As of 3/22/18, there was a combination of hand-written and electronic nursing progress notes. The electronic medical record had nursing progress notes dated 2/22/18, 2/23/18, 2/26/18, 2/27/18, 3/20/18 and 3/22/18. The hand-written nursing progress notes were documented on a form titled Daily Skilled Nurses Notes. The hand-written notes were dated 3/8/18, 3/9/18, 3/10/18 and 3/12/18. There were no additional nursing progress notes in the medical record of R#50. In an Interview on 3/22/18 at 11:00 a.m., the Director of Health Services (DHS) in the conference room, confirmed the dates of the skilled nursing progress notes (electronic and hand-written). The DHS stated the computers might have been down at that time and when the computers are down the nurses are to document on paper Daily Skilled Progress Notes. The DHS stated she would review the record and see if she would be able to locate any additional documentation for skilled nursing progress notes. At 4:00 p.m. the DHS returned to the conference room and stated she had not been able to locate any additional skilled nursing progress notes. The DHS confirmed that out of the 29 days since admission that are required to have daily documentation there were only 10 days of daily skilled progress notes and 19 days that did not have daily skilled progress notes. 2. Review of the Minimum Data Set (MDS), section A1600 in the medical record for R#47 reveals an admission date of [DATE]. Review of the physician's progress notes for R#47 revealed a handwritten page from the physician as follows: 3/5 Pt seen. Note to follow. (followed by the physician's signature) 3/12 Pt seen. Note to follow. (followed by the physician's signature) 3/19 Pt seen. Note to follow (followed by the physician's signature) There were no additional physician's progress notes in the medical record of R#47. On 3/22/18 at 12:30 p.m., during an interview with the Medical Records Director (MRD) in the conference room, she confirmed that there were no physician's progress notes in the medical record of R#47. At 4:00 p.m. the MRD presented physician's progress notes for review. She stated she contacted the physician's office and had them to fax the missing notes to her at the facility. She further stated the progress note for the 3/12/18 physician visit was in the medical records office, but had not been placed in the resident's medical record. She stated she had received the 3/12/18 note on 3/14/18 but had to contact the physician's office to obtain copies of the other physician visits progress notes. 3. Review of the Minimum Data Set (MDS), section A1600 in the medical record for R#171, reveals an admission date of [DATE]. Review of the physician's progress notes for R#171 revealed a handwritten page from the physician on 3/17 Pt seen and examined. Notes will follow. (followed by the physician's signature) There are no additional physician's progress notes in the medical record of R#171. On 3/21/18 at 12:45 p.m., during an interview with the East Wing Unit Manager (EWUM), she confirmed that there were no physician's progress notes in the medical record of R#171. At 3:30 p.m., the EWUM presented physician's progress notes for review. She stated she contacted the physician's office and had them to fax the missing dictated physician progress notes [REDACTED]. 4. Review of the Minimum Data Set (MDS), section A1600 in the medical record for R#175, reveals an admission date of [DATE]. Review of the physician's progress notes for R#175 revealed a handwritten page from the physician as follows: 3/16 Pt seen. Note to follow. (followed by the physician's signature) 3/19 Pt seen. Note to follow (followed by the physician's signature) There are no additional physician's progress notes in the medical record of R#175. On 3/21/18 at 12:45 p.m., during an interview with the East Wing Unit Manager (EWUM), she confirmed that there were no physician's progress notes in the medical record of R#175. At 3:30 p.m., the EWUM presented physician's progress notes for review. She stated she contacted the physician's office and had them to fax the missing notes to her at the facility. The facility failed to maintain complete medical records for R#45, R#50, R#171 and R#175.",2020-09-01
692,FIFTH AVENUE HEALTH CARE,115319,505 NORTH FIFTH  AVENUE,ROME,GA,30165,2017-06-08,431,D,0,1,5XNQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility policy titled Vials and Ampules of Injectable Medications the facility failed to label one vial of Tuberculin Purified Protein Derivative (PPD) with an opened date and dispose of one box of expired suppositories in one of two medication rooms. The facility census was 91. Findings include: Review of facility policy titled Vials and Ampules of Injectable Medications dated (MONTH) 1, (YEAR), revealed opening a vial triggers a shortened expiration date that is unique for that product. The date opened and this triggered expiration date are both important to be recorded on multi dose vials. At a minimum the date opened must be recorded. Observation on [DATE] at 11:15 a.m. of the West Hall medication room refrigerator with Licensed Practical Nurse (LPN) AA revealed one vial of Tuberculin Purified Protein Derivative/ Aplisol 5 TU/ 0.1 milliliters (ml) opened with no date opened on the vial or the box. There were no additional vials of PPD in the Medication refrigerator. LPN AA revealed the PPD vial should be discarded 30 days after opening but there was no way to identify when it was opened. Continued observation revealed one stock box of acetaminophen 650 milligram (mg) suppositories containing 47 suppositories, with a manufacturers expiration date of ,[DATE]. LPN AA confirmed the expiration date and revealed the stock medications are checked by the nurses when administering and by the consultant pharmacist monthly, but the expiration on the acetaminophen suppositories had not been noticed. There were no additional stock boxes of acetaminophen 650 mg suppositories in the medication room. Interview [DATE] at 11:20 a.m. with the West Hall Unit Manager confirmed the PPD vial had not been dated when opened and it was the facility policy to record a date on the vial of any multi-dose medication when opening. The Unit Manager acknowledged the acetaminophen suppositories should have been discarded over five months ago. Interview [DATE] at 4:32 p.m. with the Administrator revealed the policy indicates nurses are to date any multi- dose vial when they open it and the policy had not been followed.",2020-09-01
693,FIFTH AVENUE HEALTH CARE,115319,505 NORTH FIFTH  AVENUE,ROME,GA,30165,2017-06-08,514,D,0,1,5XNQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, review of facility policy titled [MEDICAL CONDITION] Screening and review of manufacturers package insert guidelines titled [MEDICATION NAME] Purified Protein Derivative (Mantoux) [MEDICATION NAME] the facility failed to record administration, lot number and results on the clinical record for one resident (R), (R#125) from a sample of 31 residents. Findings include: Review of facility policy titled [MEDICAL CONDITION] Screening, dated August, 2001, revealed a copy of all documentation pertaining to [MEDICAL CONDITION] testing and the screening process, as well as reports of findings, will be filed in the employee's/resident's medical record. Review of manufacturers package insert guidelines titled [MEDICATION NAME] Purified Protein Derivative (Mantoux) [MEDICATION NAME], dated March, 2013, revealed the permanent medical record of each patient receiving Purified Protein Derivative (PPD) should include the name of the product, date given, dose, manufacturer and lot number, as well as the test result in millimeters (mm) of induration (including 0 mm, if appropriate). Review of the clinical record for R#125 revealed Physician orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the Immunization Report for R#125 for May, (YEAR) and June, (YEAR) revealed there was no data recorded regarding the lot number and test results of the PPD administered. Interview on 6/8/17 4:29 p.m. with the Director of Nursing (DON) revealed there was no documentation for R#125 regarding the lot number or results of PPD administered on 5/19/17 or 6/2/17. The DON confirmed the lot number and results of PPD testing should always be recorded in the residents clinical record according to facility policy and manufacturers guidelines, but the night nurse probably forgot to fill in the Immunization Report on the computer and there is no longer any paper documentation for immunizations or PPD administration.",2020-09-01
694,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2016-11-10,280,D,0,1,HZKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy it was determined the facility failed to revise and implement new care plan interventions to address the ongoing behavior of picking at his skin for 1 resident (R) 23. The sample size was 30. Clinical record review, for R23, revealed the resident has a history of exhibiting ongoing self-injurious behaviors of picking his skin causing injury and bleeding. Documentation review revealed the care plan had been reviewed, by staff quarterly, however there was no evidence that new interventions were put in place to address the behaviors of R23 since the initial development of the care plan. Findings include: Review of the facility policy titled, Care Planning-Interdisciplinary Team, with the revision date documented as 9/13, revealed an individualized comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs and is developed for each resident. Assessments of residents are ongoing and care plans are revised by nursing staff to reflect the needs of the residents. Review of the clinical record for R23 revealed an admitted to the facility of 7/27/12. The residents ' [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) Assessment, for R23, dated 8/22/16, documented the resident's Brief Interview for Mental Status (BIMS) score was two, indicating the cognitive status, for R23, was moderately impaired. The resident was assessed with [REDACTED]. Care Area Assessment (CAA) summary for 8/22/16 documented the resident as having behavioral symptoms and included: R23 exhibited the following changes in mood and behaviors: resists care, verbally abusive towards staff, hallucinations, and delusional episodes. Will proceed to care plan. Review of the care plan, for R23, updated on 8/31/16, with original development date of 8/9/12, revealed the following: 1. Problem Need: Resident exhibits moods/behaviors at times to include: refuses care, medications and meals, throws meal tray and briefs on floor, curses at staff, has hallucinations and delusions, picks at skin causing open areas. The goal of the care plan is for the resident not to injure self and/or others as result of behaviors during the review period of 11/30/16. Care Plan approaches to guide staff in addressing the resident's behaviors included: approach warmly and positively, pull curtains for privacy, keep cool, allow time for resident to express feelings and concerns, if resident refuses care stop and return later, and redirect resident as needed. 2. Problem Need: Resident receives antidepressant and antipsychotic medications. The goals of the care plan resident will be prescribed lowest effective dosage during review period of 11/30/16. Care Plan approaches to address the medications included: observe for signs and symptoms (s/s) of adverse reactions. Consult with pharmacy or MD for medication review. Observe resident's mood/behaviors. If resident endangers self or others intervene. Administer medications as ordered. Review of the clinical record revealed the following: physician progress notes [REDACTED]. Situation Background Assessment Recommendation (SBAR) Communication Form, dated 7/1/16 at 6:15 a.m.: Change in condition for resident, there is observed bleeding second toe left foot. Interdisciplinary Progress Notes, dated 07/02/16, 7/3/16, 7/14/16, and 9/14/16 revealed documentation of the resident continuing to pick at his skin. An observation on 11/7/16 at 12:10 p.m. revealed R23 was sitting in a Geri chair in the dayroom/dining room of the secured unit. Certified Nursing Assistants (CNAs) were present in the room awaiting the lunch meal. R23 was observed picking at an area of skin between his eyes with his fingers until it bled. Staff made no attempt to redirect the resident. An interview with the Social Services Designee (SSD) on 11/10/16 at 9:30 a.m. revealed the SSD was not sure if behavior interventions are addressed with the psychiatrist during the resident's sessions. Interview on 11/10/16 at 9:25 a.m., with LPN CC revealed the residents ' behavior is discussed with the psychiatrist, but no recommendations are made to address the resident's ongoing behavior. The psychiatrist orders medications, but interventions to address behaviors are not discussed. Interview on 11/10/16 at 9:40 a.m., with the Director of Nursing (DON) acknowledged the facility had not developed, or attempted, new interventions to address the resident's ongoing self-injurious behavior of picking his skin. Cross reference to F309",2020-09-01
695,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2016-11-10,309,D,0,1,HZKQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, it was determined the facility failed to provide the necessary care and services to address the persistent self-injurious behaviors of 1 resident (R) 23. The sample size was 30 residents. R23 was assessed to exhibit self-injurious behaviors since admission to the facility on [DATE]. On 11/7/16, during the lunch meal observation, R23 was allowed to continue to pick at his skin until it bled without intervention from the nursing staff. Findings include: Review of facility policy titled, Behavior Assessment and Monitoring, with a revision date documented as (MONTH) (YEAR), revealed, behavior will be identified and managed appropriately. Residents will have minimal complications associated with the management of problematic behavior. The staff will identify and discuss with the practitioner situations where nonpharmacological approaches are indicated and will institute such measures to the extent possible. Review of the clinical records for R23 revealed an admitted to the facility of 7/27/12. The resident's [DIAGNOSES REDACTED]. The Significant Change Minimum Data Set (MDS) Assessment, for R23, dated 08/22/16 documented the resident's Brief Interview for Mental Status (BIMS) score was two, indicating his cognitive status was moderately impaired with decision making poor with cues/supervision required. The resident's behaviors during this assessment period included: physical and verbal behaviors symptoms directed toward others one to three days, other behavior symptoms not directed toward others for one to three days, and rejection of care for one to three days. Functional status of the resident revealed the resident required extensive assistance with bed mobility, transfers, locomotion, dressing eating, personal hygiene, bathing and was incontinent of bowel and bladder. The resident received antipsychotic and antidepressant medications for seven days of the assessment period. Care Area Assessment (CAA) summary for 8/22/16 triggered cognitive loss/dementia, behavioral symptoms and [MEDICAL CONDITION] drug use. Analysis of the findings for the problem area of cognitive loss/dementia stated the resident has short term and long term memory loss, has dementia. Resident will resist care, be combative, takes brief off and throws brief at staff, yells and curses at staff and has hallucinations and delusional episodes, will proceed to care plan for short and long term memory loss with no referrals at this time. The analysis of the findings for the triggered problem of behavioral symptoms was, See CAA summary for cognitive loss/dementia. No referrals at this time. Resident has changes in mood and behaviors, resists care, can be verbally abusive toward staff, has hallucinations and delusional episodes. Will proceed to care plan. Analysis of the findings for [MEDICAL CONDITION] drug use documented the resident receives antipsychotic and antidepressant medications as ordered. The resident has a [DIAGNOSES REDACTED]. No referrals at this time will proceed to care plan. According to the care plan, for R23, reviewed on 8/31/16, with implementation date of 8/9/12, revealed the resident exhibits moods/behaviors at times which included: picking at skin, refusing care, yelling at staff, hallucinations and delusions. The goal of the behavior care plan was for the resident was: not to injure self and/or others. Approaches listed on the care plan to address the residents ' behavior of picking his skin was to redirect the resident as needed. Review of the clinical record revealed the following: 1. physician progress notes [REDACTED]. 2. Situation Background Assessment Recommendation (SBAR) Communication Form, 7/1/16 at 6:15 a.m.: Change in condition for resident, there is observed bleeding second toe left foot. Resident picked at his skin and pulled small piece of skin off second toe left foot. 3. Interdisciplinary Progress Notes dated 7/2/16 at 1:30 a.m., documented the resident continues to pick at skin. 4. Interdisciplinary Progress Notes dated 7/2/16 at 11:15 a.m. documented the resident continues to pick at skin, removing dressing from left second toe. 5. Interdisciplinary Progress Notes dated 7/3/16 at 9:28 a.m. documented the resident continues to pick at skin, removing dressing to left second toe. 7/3/16 at 10:30 a.m. Continues to pick at skin on face and left second toe and at 10:30 p.m. Continues to pick at left second toe. 6. Interdisciplinary Progress notes dated 7/14/16 at 6:30 am documented the resident noted with right hand bleeding, fifth knuckle on right hand with a 0.2 cm (centimeter) opening. 7. physician progress notes [REDACTED]. Pt still yelling out at staff and visitors. 8. Monthly Summary dated 8/10/16 documents Resident picks at skin, in different areas, until it bleeds. 9. Monthly Summary dated 8/21/16 Resident is alert and confused. Will pick at his skin until it bleeds. 10. Situation Background Assessment Recommendation (SBAR) Communication Form and Progress Notes for RNs/LPNs/LVNs dated 9/13/16 at 6:40 a.m., the resident has skin tear inside right ear. Resident picked at skin causing a skin tear to right ear. Resident states he was pulling stingers out of his skin. 11. Monthly Summary dated 9/13/16, documents the resident is alert to name with confusion noted at times. Picks at skin causing it to bleed. 12. Interdisciplinary Progress note dated 9/14/16 at 1:30 a.m., documents the resident continues to pick at skin. 13. Monthly Summary dated 10/14/16, documents the resident is alert to name with confusion noted. Resident will pick at skin and scratch himself. 14. Physician order [REDACTED]. Review of Telepsychiatry Medication Follow-Up form dated 11/3/15 and 5/10/16 revealed the resident refused the visits. A Telepsychiatry Medication Follow-up form of 9/22/16 documented the resident has [MEDICAL CONDITION] a history of resists care, curses, feels something is in his skin and hallucinates. Observation on 11/7/16 at 12:10 p.m. revealed R23 was sitting in a Geri chair in the dayroom/dining room of the secured unit. There were 13 other residents and two certified nursing assistants (CNAs) present in the room awaiting the lunch meal. R23 was observed picking at an area of skin between his eyes with his fingers causing the area to bleed. Staff made no attempt to redirect the resident. The resident continued to pick at the area of skin between his eyes until he was served a lunch tray at 12:20 p.m., at which time the resident stopped picking at his skin picked up a hamburger with blood on his fingers and began eating. When the Director of Nursing (DON) arrived on the unit on 11/7/16 at approximately 11:20 a.m. and was asked about the bloody area of skin between the resident's eyes, the DON replied the resident picks at his skin causing it to bleed and he is care planned for this behavior. A further observation, of R23, on 11/10/16 at 9:00 a.m., revealed the resident was sitting in a Geri chair in the dayroom/dining room of the secured unit. The resident had a circular open area approximately quarter size on the middle chin area. Licensed Practical Nurse (LPN) CC acknowledged, during this observation, that the resident had picked an area of skin off his chin sometime during the night. An interview with LPN BB on 11/8/16 at 3:15 p.m., revealed the staff makes sure the resident's nails are clipped and redirect him. Sometimes redirection works but he still has periods where he picks and digs at his skin. Picking at his skin is an ongoing issue, he does it sometimes more than others. Interview on 11/8/16 at 3:27 p.m., with CNA JJ revealed, if the resident picks at his face she will let the nurse know so the resident does not get a bruise, he digs at his skin a lot. Interview on 11/10/16 at 9:15 a.m. with CNA DD, revealed the resident picks at his skin every day, its routine for him. When he is doing this (picking at his skin) staff will notify the nurse, and tell him to stop, that's what we do for him, but he will keep on doing it. Interview with CNA EE on 11/10/16 at 9:20 a.m. revealed the resident picks his skin all the time. He does it every day. We ask him to stop. He may stop temporarily but when you look at him again he will be picking at his skin again. CNA EE also said she had worked at the facility for three years and the resident had exhibited this behavior since she began working at the facility. Interview on 11/10/16 at 9:25 a.m. with LPN CC revealed the resident picks his skin and makes sores. Nursing staff treat the sores and heal them up and the resident will pick his skin and it starts all over again. Staff keep his fingernails clipped, if he will allows it, and staff treat the sores. The resident has done this for a long time. LPN CC said she has been with the resident when the psychiatrist conducts the tele-conference appointment. LPN CC further stated the residents ' behavior is discussed with the psychiatrist, but no recommendations are made to address the resident's ongoing behavior. The psychiatrist orders medications for residents but does not make any suggestions for interventions in dealing with the residents behaviors. An interview with the Social Services Designee (SSD) on 11/10/16 at 9:30 a.m. revealed he sets up the tele-conference meetings/appointments for residents with a psychiatrist and the nursing staff accompany the residents to the appointment, The Director of Nursing (DON) acknowledged on 11/10/16 at 9:40 a.m. the facility had not attempted new interventions to address the resident's ongoing self-injurious behavior of picking his skin.",2020-09-01
696,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,561,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, interviews and policy review, the facility failed to promote and facilitate resident self-determination and choice for one resident (R) (R# A), who had requested a room change out of a locked memory care unit. The sample size was 44. The findings included: Review of the facility policy titled Resident Rights revised (MONTH) (YEAR), policy statement indicated employees shall treat all residents with kindness, respect and dignity. Policy Interpretation and Implementation 1. e revealed Federal and state laws guarantee certain basic rights to all residents of this facility, including the residents right to self-determination. A review of the clinical record for R A revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Observation on 12/17/18 at 2:46 p.m., resident A sitting in his wheelchair in the Magnolia dining room on the B hall. An interview on 12/17/18 at 2:46 p.m. with the resident revealed that he is in what used to be the locked unit, where he could not go anywhere else in the building. He stated the facility recently unlocked the unit about one week ago, but he is still told he has to eat on the unit. He further stated he would like to eat in the regular dining room. He also stated that he has asked for a room change from the unit, about two months ago, and he hasn't heard anything back from anyone about it. Observation on 12/18/18 at 2:41 p.m., resident sitting in his wheelchair in front lobby, watching television. Observation and interview on 12/19/18 at 8:43 a.m. with the resident revealed he was sitting in his room, on B hall and stated that he still had breakfast in the Magnolia dining room, on the B Hall. Observation on 12/20/18 at 8:10 a.m., revealed resident out of his room and not sitting in dining room. An interview at this time with the Assistant Director of Nursing (ADON) revealed that the resident had a room change last evening, to room [NAME] 307-1. Observation on 12/20/18 at 8:21 a.m. revealed resident lying in bed in the new room on the [NAME] hall with no distress noted. An interview on 12/20/18 at 11:52 a.m., with R #A, stated I got a new room yesterday and I can eat in this dining room now. An interview on 12/20/18 at 12:29 p.m., with Director of Nursing (DON), revealed that she is taking care of room changes, transfers and discharges temporarily until the position of Social Services Director position can be filled. She stated if room changes are requested by resident or family member, the Social Services Director (SSD) would evaluate the request to determine the reason for request. The Interdisciplinary Team (IDT) would meet to discuss the request and determine if room available for transfer. If appropriate and room is available, the resident and family would be notified of the room change. She further stated that she was not aware that R A had requested a room change, until 12/19/18, when resident mentioned it to her. During further interview with DON, she stated that previous SSD resigned early (MONTH) and the facility was unable to locate any documentation for any visits made with R # [NAME] An interview on 12/21/18 at 8:20 a.m., with Assistant Director of Nursing (ADON), revealed that she's been employed here since (MONTH) (YEAR). She stated that R# A was admitted to the facility in (MONTH) (YEAR). She further stated she was not sure why he was admitted to the memory care unit, but she stated he was having some behaviors with taking off his [MEDICAL CONDITION] bag and smearing the feces. During further interview, she sated that resident had mentioned to her that he wanted to change rooms around (MONTH) 3, (YEAR). She stated that the process for room change requests are discussed in morning meeting with the IDT team. She further stated that she did not do any documentation about R # A request for a room change. Cross Refer to F745",2020-09-01
697,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,584,E,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment in nine resident rooms on three of five halls (A 112, B 115, B 118, B 120, B 122, B 123, D 310, D 314, D 315), the end of B hall ceiling tile broken, and dirty dark brown material on shower tiles in three of three shower stalls. The census was 67. Findings include: Observation on 12/17/18 at 10:55 a.m. revealed in room B 118-2, approximately 10 inch by 10 inch circular stained ceiling tile above bed by the window, the window curtain had a torn hem which was hanging loose, and toilet tank had a broken corner off in the bathroom. Observation on 12/17/18 at 10:36 a.m., revealed in Common Shower room [ROOM NUMBER] on C hall, revealed the shower stall had build up of dark brown substance on tiles close to the floor. Observation on 12/17/18 at 10:40 a.m., revealed in Common Shower room [ROOM NUMBER] on C hall, the shower stall had build up of dark brown substance on tiles close to the floor. Observation on 12/17/18 at 10:45 a.m., revealed in Common Shower room [ROOM NUMBER] on [NAME] hall, the shower stall had build up of dark brown substance on tiles close to the floor. Observation on 12/17/18 at 11:03 a.m., revealed in room A 112-2, a light brown oblong shaped stain on ceiling tile above bed by the window, approximately 6 inch by 2 inch. Observation on 12/17/18 at 11:22 a.m., revealed in room B 122-2, the curtain hem ripped and hanging from bottom of curtain. Observation on 12/17/18 at 11:30 a.m., revealed in room B 123, the glove rack in bathroom was loosely attached to wall; the toilet water tank was continuously running; and three moderate sized patched areas of sheet rock in room without paint. Observation on 12/17/18 at 11:31 a.m., revealed in room B 120-2, had a light brownish tan stain on ceiling tile above bed by window, approximately two inch by two inch; the top drawer on dresser was broken and off track; the curtain on window had a torn hem, hanging down. Observation on 12/17/18 at 12:29 p.m., revealed in room D 314, the interior bathroom door had a hole at bottom. Observation on 12/17/18 at 2:53 p.m., revealed in room D 315-2, a brown stained on wall in a spill pattern towards the wall plug; the privacy curtain for bed one had a brown stain near the bottom. Observation on 12/18/18 at 9:46 a.m., revealed in shower room [ROOM NUMBER] on C hall, the shower stall had two slightly loose grab bars. Observation on 12/18/18 at 10:23 a.m., revealed at end of B hall, close to exit door, the ceiling tile around sprinkler head cracked. Observation on 12/18/18 at 10:45 a.m., revealed room B 115, the window curtain hem was torn and hanging from curtain. Observation on 12/18/18 at 11:38 a.m., revealed in room D 310-1, the resident's bedside floor fan had dust build up on face grill and fan blades. An interview on 12/19/18 at 2:24 p.m., with the Housekeeping Aide LL, revealed that her daily duties included sweeping and mopping resident rooms, dusting furniture and headboards and footboards, cleaning the bed rails, cleaning the bathrooms, including toilets and sinks, wiping down the walls in bathroom, restock supplies such as toilet paper, soap, hand sanitizer, wipes windows and window sills and inspects privacy curtains. She stated she has one room to deep clean per day and that consists of wiping down mattress with disinfectant, stripping and waxing floor. She stated that privacy curtains are only washed if noted to be dirty. She stated she does not do anything for window curtains, the maintenance department takes care of the curtains. An interview on 12/21/18 at 2:05 p.m., with the Maintenance Supervisor during walking rounds, verified the concerns identified during the survey. He stated that staff write hand written work orders for maintenance repairs. He further stated that they have routine daily work duties, such as checking water temps, handrails, bed side rails and fire drills. During further interview, he stated the maintenance department has a plan of repainting the resident rooms with patch marks, as the rooms become empty, or another room opens for a temporary room change so the maintenance work can be done. He further stated the window curtains are maintained by housekeeping staff. An interview on 12/21/18 at 2:25 p.m., with the Housekeeping Supervisor, revealed that she has worked at facility for [AGE] years and was just recently (this week) moved into the Housekeeping Supervisor role. She verified during walking rounds the housekeeping concerns identified during the survey. She stated the housekeeping staff have a daily checklist they complete, and she collects them at the end of the day. She stated she reviews them for completeness. She currently does not do any type of spot checks behind housekeeping staff and she further stated that the window curtains are checked and maintained by Maintenance department.",2020-09-01
698,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,609,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide evidence that a required five-day investigation was sent to the State Survey Agency (SSA) after a resident to resident altercation between residents (R) #29 and #71, resulting in a major injury for R#71. The sample size was 43 residents. Findings include: Review of a facility Incident Log revealed that on 10/18/18 at 4:10 p.m., R#71 had a fall with head injury, hematoma, and fracture, and was admitted to the hospital. Review of a Resident Incident Report and Nursing Departmental Notes for R#71 dated 10/18/18 at 5:33 p.m., revealed: At 4:10 p.m. resident (#71) was walking in dining room looking out window when another resident (#29) became agitated and pushed resident down. Resident hit head on floor causing a hematoma to posterior right side of head. Resident complained of 10/10 (described pain as a 10 on a scale of 0 to 10) right hip pain and is unable to bear weight on right leg. Resident also complained of right shoulder pain. Resident able to move LLE (left lower extremity) but unable to move RLE (right lower extremity) due to pain. Doctor notified of findings, order received to send to ER (emergency room ) for evaluation and treatment. EMS (Emergency Medical Services) arrived and resident to ER at 5:00 p.m. Review of Nursing Departmental Notes dated 10/18/18 at 6:07 p.m. for R#29 revealed: At 1610 (4:10 p.m.), it was reported that resident (#29) struck another resident while in the dining room. Statement given by CNA (Certified Nursing Assistant) reported that R#29 was sitting in the chair in the dining hall when another resident (R#71) walked up beside him to look out of the window. (R#29) yelled at the resident and struck her while pushing her to the floor causing her to hit her head. Residents were immediately separated. No injury (R#29). Resident (R#29) calm after event and able to ambulate down the hallway with staff. Stated that he did not remember what happened but asked if she was okay. Will continue to monitor resident behavior and keep residents separated. Review of a Resident Incident Followup dated 11/6/18 revealed: Resident (R#71) Condition after 24 hours: hospitalized 10/25/18 Returned to facility Review of hospital progress notes dated 10/25/18 revealed that R#71 was admitted with an intertrochanteric fracture proximal right femur without significant displacement, with a recent ORIF (open reduction internal fixation) of the right [MEDICAL CONDITION]. Review of the initial investigation e-mailed to the SSA dated 10/18/18 revealed that it was submitted on a Complaint Form by the Social Services Director and revealed: Resident/Patient Information: Name: (Resident #71). Complaint Information: At approximately 4:10 p.m. CNA alerted LPN (Licensed Practical Nurse) to memory unit. Resident experienced a resident to resident altercation resulting in the resident's fall (R#71). Residents were immediately assessed and received orders by MD (Medical Doctor) for the resident to be sent to ER for evaluation. Both residents remain confused at baseline. 5-day report to follow. Review of a Facility Incident Report Form initial investigation e-mailed to the SSA dated 10/19/18 from the Social Services Director revealed: Type of Incident: Abuse, Resident to Resident Resident/Patient Name(s): (Resident #71) Date and Time of Incident: 10/18/18 Details of Incident: At approximately 4:10 p.m. CNA alerted LPN to memory unit. Resident (#71) experienced a resident to resident altercation resulting in the resident's fall. Residents were immediately assessed and received orders by the MD for the resident to be sent to the ER for evaluation. Both residents remain confused at baseline. Injury: No Treatment Required: No Other Resident name: (was left blank) Steps taken by the facility to prevent further incidents: 5-day report to follow. During interview with the Administrator on 12/20/18 at 4:53 p.m., she stated that she could not find any facility investigation of the altercation between R#20 and R#71, and verified that there was no facility-reported incident to the State Agency in their [MEDICATION NAME] notebook. She further stated that the Social Services Director and Administrator at the facility during the time of this incident were no longer employed by the facility. Interview with the SSA Complaint and Investigations Manager on 12/21/18 at 10:40 a.m. revealed that a 5-day investigation report was never received from the facility for this incident. Review of the facility's Abuse Prohibition Policy and Procedures revised (MONTH) (YEAR) revealed: This policy applies to anyone subjecting a resident to abuse including .other residents . Physical abuse includes hitting, slapping, pinching and kicking. Reporting: If the abuse resulted in an injury, the facility will report to appropriate agencies no later than 2 hours after the allegation is made. C. A written report of investigation will be submitted to the administrator and to the Long Term Care Section Complaint Coordinator, within five (5) working days of the incident. 1. This report will contain all of the investigation information: a) Details of the incident and injury; b) Signed statements from pertinent parties; d) Information gathered from the investigation; e) Action taken by facility-safeguarding the resident and preventing a reoccurrence. The final action/conclusion made by the facility. Cross-refer to F 745",2020-09-01
699,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,656,E,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to serving a PO (per os)(by mouth) diet as ordered for one resident (R) (R#36) who had dysphagia (difficulty swallowing); failed to follow the care plan related to enteral feedings as ordered for one resident (R#54 who received all nutrition via a gastrostomy tube (GT)); failed to develop a care plan related to vision for one resident (R#13), who had [MEDICAL CONDITION] and impaired vision; failed to follow the care plan related to obtaining a vision screening as ordered and/or indicated and restorative services for one resident (R#57); failed to implement the care plan related to nail and/or ADL (Activities of Daily Living) care for two residents (R#7 and R#22), and failed to develop an ADL care plan for one resident (R#9) with dirty fingernails; and failed to develop an individualized care plan with measurable goals and interventions related to a PICC line (Peripherally Inserted Central Catheter) for one resident (R#61). The sample size was 43 residents. Findings include: 1. Review of a physician's Monthly Progress Note dated 10/24/18 revealed that R#36 had a past medical history of [REDACTED]. Review of R#36's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he was on a mechanically altered diet and feeding tube. Review of R#36's care plans revealed one for risk for alterations in nutrition and hydration related to receiving feeding per peg (percutaneous endoscopic gastrostomy) tube related to [DIAGNOSES REDACTED]. Review of the interventions for this care plan included to serve PO diet as ordered. Review of R#36's (MONTH) Physician order [REDACTED]. Observation on 12/17/18 at 12:40 p.m. revealed that R#36 was served lunch in his room, and review of the tray ticket revealed that he was on a Mech (mechanical) diet with Chopped Meats. Further observation revealed that the resident was served a piece of regular barbecue chicken which was still on the bone. Observation on 12/18/18 at 12:21 p.m. revealed that R#36 was served a regular hamburger patty on a bun, which staff had cut in half. However, the hamburger patty was not chopped or ground. Observation on 12/18/18 at 5:26 p.m. revealed that R#36 was served supper in bed, which included slices of pork that were not chopped. Cross-refer to F 692. 2. Review of R#54's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of R#54's Quarterly MDS dated [DATE] revealed that he received 51% or more of total calories through a feeding tube. Review of an alteration in skin integrity care plan revealed that it was revised on 9/14/18 to note that R#54 returned from the hospital with a new GT. Review of the approaches to this care plan revealed to give feedings/flushes per MD (Medical Doctor) orders. Review of a risk for alteration in nutrition and hydration related to PEG tube dependency care plan revealed an approach for feedings/flushes per MD orders. Review of R#54's physician's orders [REDACTED]. 10/4/18 Physician's Telephone Orders: [MEDICATION NAME] 1.5 at 55 mL (milliliters) via GT per hour (continuously). 10/15/18 Physician's Telephone Orders: Hold [MEDICATION NAME] 1.5 until it arrives from supplier. Start [MEDICATION NAME] 1.2 at 55 mL per hour until [MEDICATION NAME] 1.5 arrives. 11/21/18 Physician's Telephone Orders: Hold [MEDICATION NAME] 1.5 until it arrives from supplier. Start [MEDICATION NAME] 1.2 until [MEDICATION NAME] 1.5 arrives. 12/18/18 Physician's Telephone Orders: [MEDICATION NAME] 1.2 at 80 mL per hour continuous until [MEDICATION NAME] 1.5 available, then resume 55 mL per hour. Observations of R#54's enteral feeding revealed that he was receiving the following enteral formula via an enteral pump at the following rates: 12/17/18 at 11:42 a.m., 3:57 p.m., and 5:39 p.m., and 12/18/18 at 7:38 a.m., 8:58 a.m., 9:55 a.m., and 12:19 p.m.: [MEDICATION NAME] 1.2 cal at 60 mL per hour observed (the Physician order [REDACTED]. 12/19/18 at 8:21 a.m., 1:00 p.m., and 3:00 p.m., and 12/20/18 at 8:40 a.m. and 9:42 a.m.: [MEDICATION NAME] 1.5 at 60 mL per hour observed (the physician's orders [REDACTED]. During interview with the facility's consultant Registered Dietician (RD) on 12/19/18 at 1:06 p.m., she verified during her observation yesterday (12/18/18) that R#54 received [MEDICATION NAME] 1.2 at 60 mL per hour, instead of the ordered [MEDICATION NAME] 1.5. During interview with the Dietary Manager on 12/20/18 at 9:15 a.m., she stated that it was the nursing staff's responsibility for notifying her when the supply of an enteral formula was low, and that she had a supply of [MEDICATION NAME] 1.5 in her office. During interview with Licensed Practical Nurse (LPN) EE on 12/20/18 at 9:42 a.m., she verified that R#54 was receiving [MEDICATION NAME] 1.5 at 60 mL per hour. She verified during continued interview that the last physician's orders [REDACTED]. Cross-refer to F 692. 3. Review of R#13's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of R#13's History and Physical Record dated 10/15/15 revealed that he had bilateral [MEDICAL CONDITION]. Review of an OD (Doctor of Optometry) provider's exam note dated 11/20/18 revealed an assessment of bilateral age-related nuclear [MEDICAL CONDITION]. Review of R#13's Annual Minimum Data Set ((MDS) dated [DATE] revealed that he had impaired vision with no corrective lenses. Review of the Care Area Assessment (CAA) Summary for this MDS revealed that the Visual Function care area triggered, and that it was to be addressed in the care plan. Review of all of R#13's care plans revealed that a care plan was not developed for vision, nor was it included in any of the other care plans. Review of R#13's Quarterly MDS dated [DATE] revealed that his vision was impaired and he had no corrective lenses. Review of his Brief Interview for Mental Status (BIMS) score revealed a score of 11 (a BIMS score of 8 to 12 indicates moderately impaired cognition). During interview with R#13 on 12/17/18 at 2:41 p.m., he stated that his vision was fair, that he had eyeglasses when admitted to the facility but they went missing at some point, but he did not tell anyone. He further stated that he could see the television in his room, but that it was difficult to read printed material. R#13 stated that he had an eye exam since admission to the facility, and thought that it was to get new glasses, but that this never materialized, and that he would love to get new glasses. During interview on 12/21/18 at 3:26 p.m., the Director of Nursing (DON) verified that Visual Function triggered on R#13's 6/22/18 Annual MDS CAA, the decision was made to care plan for it, but that a vision care plan had not been developed for him. Review of the facility's Care Plans, Comprehensive Person-Centered policy revised (MONTH) (YEAR) revealed: 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. g. Incorporate identified problem areas. 4. A review of the medical record for resident #57 revealed the resident was admitted to the facility 12/12/16 with the following [DIAGNOSES REDACTED]. The face sheet of the chart indicates resident is the responsible party. A review of Annual MDS assessment, dated 11/14/18 revealed the resident has a BIMs of 8. A review of the care plan for R#57 indicates the resident is care-planned for impaired vision with a goal that the resident will not injure self, related to vision status and interventions include vision screening if ordered and as indicated. A review of the progress notes dated 10/24/18 and indicated a late entry revealed a referral to the eye doctor. Review of the facility roster for the contact vision care services, dated 10/30/18, revealed the resident was added for service on 10/30/18 with an appointment date of 11/20/18. The resident's name is hand-written on the page and the word refused is written next to her name. An interview with the resident on 12/19/2018, at 11:20 a.m., revealed the resident does not recall anyone from the eye doctor coming to see her. An interview on 12/19/18 at 12:10 p.m., with the Director of Nursing (DON) revealed that she has talked with the resident and confirmed her desire to have an eye evaluation. The DON is unable to explain the information on the facility roster, whereby, the word refused is next to the resident's name. She agrees the resident should have already received vision services. 4. A review of the clinical record for R#9 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 5, which indicated severe cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Review of updated care plan for R #9, dated 9/12/18, did not have evidence that R #9 had a care plan problem to include assistance needed with Activities of Daily Living (ADL) care. Observation on 12/17/18 at 11:29 a.m., 12/18/18 at 4:23 p.m., 12/19/18 at 9:04 a.m. and 12/20/18 at 4:05 p.m. revealed that fingernails on both hands have dark brown material underneath. Interview on 12/19/18 at 3:20 p.m., with Certified Nursing Assistant (CNA) BB, stated that she checks the bath book, which is kept at nurses station, to see who she has to give bath for. She states she usually has three bathes per day to do. She washes hair if hair looks like it needs to be washed, or if resident asked for it to be washed. She shaves if they need it or resident asks to be shaved. She stated that she does not think that she is allow to do nail care, either cutting or cleaning. She stated she would let the charge nurse know if nails needed to be cleaned or cut. She stated that she has not noticed that R#9 fingernails were dirty. Interview on 12/21/18 at 12:25 p.m., with Licensed Practical Nurse (LPN) GG stated that she gathers information about the residents from face to face assessments, interviews with residents and/or family members and staff members. She also review medical records and the Certified Nursing Assistant (CNA) ADL flow sheet. During further interview, she stated that she does not know how she overlooked R#9 care plan for ADL care. Cross Refer F 677 6. A review of the clinical record for R #7 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for dressing, toilet use and personal hygiene. Review of updated care plan for R #7, dated 2/7/18, revealed resident requires staff assistance with meeting ADL requirements due to physical and cognitive impairments. Approaches to care include assist with ADL's as needed (PRN), call light within reach, verbal cues PRN, praise efforts and accomplishments, observe for signs and symptoms of pain, therapy screen as indicated, wheelchair as indicated, if resident is attempting to participate in ADL care, allow adequate time to do so, offer rest periods PRN, encourage resident to have nails cleaned PRN. Observation on 12/18/18 at 9:53 a.m., 12/19/18 at 2:32 p.m., 12/20/18 at 8:02 a.m. and 12/21/18 at 10:20 a.m. revealed that fingernails on both hands have thick dark brown material underneath. Interview on 12/20/18 at 12:45 p.m., with CNA AA stated that she finds out what her assignment for the day is off the worksheet kept at the A Hall nurses station. She stated she normally works the A Hall and has about 13 residents per day to care for. She further stated that she has 3-4 showers to do each day. For attributives of daily living (ADL) care, she states that she bathes, dresses residents, sets up meals, feeds residents, shaves residents on bath days or as needed, does nail care on bath days and as needed. She stated that R#7 is bathed on Monday/Wednesday/Friday on 7-3 shift and that she has not noticed that her fingernails were dirty. Cross Refer F 677 7. A review of the clinical record for R #22 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated moderate cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for dressing, toilet use and personal hygiene. Review of updated care plan for R #22, dated 7/16/17, revealed resident is at risk for excessive weakness or tiredness related to [DIAGNOSES REDACTED]. Observation on 12/17/18 at 11:02 a.m., 12/18/18 at 3:35 p.m., 12/19/18 at 8:04 a.m. and 12/20/18 at 1:05 p.m. revealed that fingernails on both hands have thick dark brown material underneath and are jagged with varying lengths. Interview on 12/19/18 at 3:20 p.m., with Certified Nursing Assistant (CNA) BB, stated that she checks the bath book, which is kept at nurses station, to see who she has to give bath for. She states she usually has three bathes per day to do. She washes hair if hair looks like it needs to be washed, or if resident asked for it to be washed. She shaves if they need it or resident asks to be shaved. She stated that she does not think that she is allow to do nail care, either cutting or cleaning. She stated she would let the charge nurse know if nails needed to be cleaned or cut. She stated that she has not noticed that R#22 fingernails were dirty. Cross Refer F 677",2020-09-01
700,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,657,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to provide opportunities for one residents (R#47) to participate in care planning. Findings include: A review of the facility undated policy Resident Rights, section one, item 'p', indicates residents will be informed of, and participate in, his or her care planning and treatment. A review of the facility undated policy Care Plans, Comprehensive Person-Centered, item number one indicates the interdisciplinary team, in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. Item number five indicates the resident will be informed of his or her right to participate in his or her treatment. Item number seven indicates the care planning process will facilitate resident and/or representative involvement. 1. Resident 47 (R#47) was admitted [DATE] for rehab following an injury to C5-7 due to an accident. R#47 is immobile in his upper extremities and has limited mobility in his lower extremities. His MDS indicates a BIMs of 14. The face sheet of the chart indicates resident is the responsible party. On 12/19/18 at 2:15 p.m., R#47 reported he has not been invited to any meeting to discuss care and services. He denies receiving any letters or notices or a calendar for him to attend care planning. The facility is unable to provide any evidence of care planning meetings/conferences for/or with this resident. A review of the electronic medical revealed no evidence of care planning meetings/conferences conducted for/or with R#47 this resident. A review of the paper medical record revealed no evidence of care planning meetings/conferences conducted for or with this resident. A review of the Care Plan notebook reveals a document titled Interdisciplinary Care Plan Meeting. The documents are notes from the interdisciplinary team. There are no spaces for a resident or a family member to sign to indicate participation in the meeting. There are no entries/documents for the months of: December November October September August",2020-09-01
701,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,677,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review and staff interviews, the facility failed to ensure that activities of daily living (ADL) was provided for three dependent residents (R) R#9, R#7 and R#22 related to nail care. The sample size was 43. Findings include: Review of the facility policy titled Activities of Daily Living (ADLs) revised (MONTH) (YEAR), revealed it is the policy of the facility for residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy interpretation and implementation number 2 a. Appropriate care and services will be provided for residents who are unable to carry out ADL's independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care). 1. A review of the clinical record for R #9 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 5, which indicated moderate cognitive impairment. Section G revealed that the resident was assessed for total dependence for dressing, toilet use and personal hygiene. Observation on 12/17/18 at 11:29 a.m., 12/18/18 at 4:23 p.m., 12/19/18 at 9:04 a.m. and 12/20/18 at 4:05 p.m. revealed that fingernails on both hands have dark brown material underneath. Interview on 12/19/18 at 3:20 p.m., with Certified Nursing Assistant (CNA) BB, stated that she checks the bath book, which is kept at nurses station, to see who she has to give bath for. She states she usually has three bathes per day to do. She washes hair if hair looks like it needs to be washed, or if resident asked for it to be washed. She shaves if they need it or resident asks to be shaved. She stated that she does not think that she is allow to do nail care, either cutting or cleaning. She stated she would let the charge nurse know if nails needed to be cleaned or cut. She stated that she has not noticed that R#9 fingernails were dirty. 2. A review of the clinical record for R #7 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, which indicated severe cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for dressing, toilet use and personal hygiene. Observation on 12/18/18 at 9:53 a.m., 12/19/18 at 2:32 p.m., 12/20/18 at 8:02 a.m. and 12/21/18 at 10:20 a.m. revealed that fingernails on both hands have thick dark brown material underneath. Interview on 12/20/18 at 12:45 p.m., with CNA AA stated that she finds out what her assignment for the day is off the worksheet kept at the A Hall nurses station. She stated she normally works the A Hall and has about 13 residents per day to care for. She further stated that she has 3-4 showers to do each day. For attributives of daily living (ADL) care, she states that she bathes, dresses residents, sets up meals, feeds residents, shaves residents on bath days or as needed, does nail care on bath days and as needed. She stated that R#7 is bathed on Monday/Wednesday/Friday on 7-3 shift and that she has not noticed that her fingernails were dirty. 3. A review of the clinical record for R #22 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 10, which indicated moderate cognitive impairment. Section G revealed that the resident was assessed for extensive assistance for dressing, toilet use and personal hygiene. Observation on 12/17/18 at 11:02 a.m., 12/18/18 at 3:35 p.m., 12/19/18 at 8:04 a.m. and 12/20/18 at 1:05 p.m. revealed that fingernails on both hands have thick dark brown material underneath and are jagged with varying lengths. Interview on 12/20/18 at 12:45 p.m., with CNA AA stated that she finds out what her assignment for the day is off the worksheet kept at the A Hall nurses station. She stated she normally works the A Hall and has about 13 residents per day to care for. She further stated that she has 3-4 showers to do each day. For attributives of daily living (ADL) care, she states that she bathes, dresses residents, sets up meals, feeds residents, shaves residents on bath days or as needed, does nail care on bath days and as needed. She stated that R#22 is bathed Tuesday/Thursday/Saturday on 3-11 shift and that she has not noticed that her fingernails were dirty or needed trimming. Interview on 12/20/18 at 1:42 p.m., with Director of Nursing (DON) verified the nails on R#9, R#7 and R#22 were dirty with brown material underneath on both hands and also R#22 nails were jagged and needed trimming. She stated that CNA staff are to cut and clean fingernails when they need it. She further stated that it is her expectation that staff follow the care plans for all care as written, including ADL care. She further stated that she would get someone to take care of R#22 fingernails. Interview on 12/21/18 at 1:58 p.m., with DON, notified that R#9 and R#22 fingernails had not been cleaned or trimmed as of 9:39 a.m. this morning. She stated that staff did attempt to cut and clean R#22 nails yesterday, but there is no evidence documented to indicate she refused to have her fingernails cleaned or trimmed. She stated she would check on R#9 nails.",2020-09-01
702,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,685,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide visual services for resident (R) #57. Findings include: A record review for Resident #57 reveals the Resident was admitted to the facility 12/12/16 with admitting [DIAGNOSES REDACTED]. The face sheet of the chart indicates resident is the responsible party. A review of Annual Minimum Data Set (MDS) assessment, dated 11/14/18 revealed the resident has a Brief Interview for Mental Status (BIMS) of 8 indicating cognitive impairment. A review of the facility undated policy, Resident Rights, item f under section 1 indicated residents have a right to communicate with and have access to people and services, both inside and outside the facility. A review of the facility undated policy, Care Plans, Comprehensive Person-Centered, section eight, item b. indicated care plans will describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychsocial well-being. A review of the resident's Initial Social Service History with an admission date of [DATE] revealed the resident has left eye impaired vision. A review of the care plan for R#57 indicates the resident is care-planned for impaired vision with a goal that the resident will not injure self, related to vision status and interventions include vision screening if ordered and as indicated. A review of Departmental Notes for the resident indicated, a late entry, dated 10/15/18 at 10:39 a.m. which reads: Late entry for 10/24/18 at 6p.m. Dr. (doctor) visited; order received; refer to in house eye doctor. Resident aware of order. A review of Contract Vision Serivces Monthly Progress Note dated 10/25/18 revealed an entry reading pt (patient) wants re-eavaluation of her [MEDICAL CONDITION]. A review of Contract Vision Serivces Monthly Progress Note dated 11/17/2018 revealed an entry reading asked for eye evaluation. The facility has a contract with a contract vision doctor for vision services. Review of the facility roster from for the contract vision service company revealed that R#57 was added for service 10/30/18 with an appointment date of 11/20/18. The resident's name is hand-written on the page and the word refused is written next to her name. An interview with the resident on 12/19/2018, at 11:20 a.m., revealed the resident does not recall anyone from the eye doctor coming to see her. An interview on 12/19/18 at 12:10 p.m. with the Director of Nursing (DON) revealed that she is unable to explain the information on the facility roster for the contract vision doctor for vision, whereby, the word refused is next to the resident's name. She agrees the resident should have already received vision services. She reports the social worker is responsible for ensuring vision services are arranged. The social worker left the facility in (MONTH) and the social worker duties were distributed among the Administrator, the DON, and the Assistant DON. The DON revealed that she has talked with the resident and confirmed her desire to have an eye evaluation. The DON reports the eye clinic does not occur at the facility until (MONTH) 2019.",2020-09-01
703,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,688,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to provide restorative services to prevent decrease in functionality for two of two residents (R#57 and R#47) of 43 sampled residents. Findings include: The undated facility policy, Restorative Nursing Program, indicates the restorative program is provided seven days a week and staff are assigned to supervise and assist the residents. Page eight of the Facility assessment dated (YEAR) indicates the facility provides restorative nursing and contracture prevention/care. A review of Assigned Tasks List for restorative therapy revealed R#57 and R#47 are on the task list to receive restorative services. A review of Staff Assignment documents indicate an individual was assigned to perform restorative services 55% of the days in (MONTH) and 30% of the days in November, and 35% of the days, to date, in December. 1. Observation and interview on 12/17/18 at 10:27 a.m. with R#57 observation revealed the resident in a wheelchair, sitting in her room, and was noted that the resident's left arm was flaccid, resting next to her side in the wheelchair. Interview with the resident at this time revealed that a splint was used for her arm was not used. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Status (BIMS) of 8 indicating moderate cognitive impairment although the resident answered screening questions appropriately. Review of Section G indicated the resident had impairment on one side of both the upper and lower extremity. Section O indicated the resident had not received any type of therapy in the last seven days nor any restorative care was assessed. A review of Occupational Therapy Evaluation and Plan of Treatment document, dated 12/5/18, indicates patient and caregivers will be educated on donning/doffing orthotic device with a goal of reducing risk of further contracture of distal LUE (left upper extremity). It is recommended resident wear resting hand splint and finger separators on left hand, on left wrist and on left fingers for 4 hours on and 4 hours off to improve PROM for adequate hygiene, reduce abnormal tone prior to splint application, maintain joint integrity, improve ability to participate w/self-feeding and increase ability to perform self-care tasks. Occupational Therapy note dated 12/7/18 revealed resident has not received her orthotic device. Occupational Therapy note dated 12/14/18 revealed resident has not received her orthotic device. A review of ADL (Activities of Daily Living) revealed that R#57 did not receive restorative services seven days in (MONTH) (YEAR); one day in November; and did not receive restorative services 8 days in (MONTH) up to the 19th of the month (42%). A splint was observed to be on her left hand on (MONTH) 20th. A review of the ADL document reveals CNA II initialed the blocks for the 17th, 18th, 19th indicated the splint was applied. An interview with CNA II on 12/21/18 at 2:00 p.m. revealed she was not the one who entered the initials on the document. She reported she cannot see the spaces to fill them in and her co-workers fill out the form for her. CNA SS reported she wrote CNA II's signature on the document, but she denied filling in the spaces to indicate application of the splint. A review of the care plan for R#57 revealed she requires assistance with meeting ADL requirements with an intervention of assistive devices as needed and splint to left arm as allowed by resident. The care plan indicates restorative nursing with interventions of passive range of motion. Observation on 12/17/18 at 12:56 p.m., R#57 was observed in the dining room for the lunch meal; no splint was on her arm. Observation on 12/17/18 at 2:20 p.m. revealed the resident visiting her next-door neighbor although there was no splint to her arm noted. Observation on 12/17/18 at 4:30 p.m. revealed the resident in her room, sitting in her wheelchair, with no splint to her left arm noted. Observation on 12/18/18 at 7:55 a.m. revealed the resident in her room, in her wheelchair; without the left arm splint in place. Observation on 12/18/18 at 10:50 a.m. revealed the resident without splint to her left arm in use. Observation on 12/18/18 at 2:21 p.m. revealed the resident in the dining room participating in a pizza party without the left arm splint in place. The resident was further observed on 12/18/18 at 4:20 p.m., 12/19/18 at 8:10 a.m., 12/19/18 at 11:10 a.m., and on 12/19/18 at 1:45 p.m. revealed the resident did not have the left arm splint in place. During an interview on 12/19/18 at 1:20 p.m. with CNA HH, she revealed that the resident does have impairment on her left arm although she has not seen a splint in use for the resident. Observation and interview on 12/19/18 at 2:00 p.m. revealed the resident is in her room, sitting in her wheelchair and has a splint on her left arm. The resident reports they came in and put it on me. There are no notes in the medical record indicating the resident refuses care or services for a splint. 2. Observation and interview on 12/17/18 at 10:49 a.m., for R#47 revealed the resident in a wheelchair, sitting in the hallway outside his room. The resident was observed to have no mobility in both his arms. An interview at this time revealed the resident denied that splints were used for his arms. He reported he does have splints, but he does not wear it because the staff do not put them on for him. He reported he does not ask them to help him with the splints, but he knows he should wear them. He reported he does not receive any services/treatment such as stretching or range of motion activities. Review of the Quarterly MDS dated [DATE] revealed the resident has a BIMS of 14 indicating no cognitive impairment. Review of Section G revealed that the resident has impairment of both sides of the upper and lower extremities. Review of Section O revealed that therapy began on 11/24/18 with Physical Therapy for two days and Occupational Therapy for four days during the seven day look back period. No restorative care was assessed. Review of the Physician order [REDACTED]. Review of the care plan with the following identified problems: Restorative Nursing, risk for falls due to impaired mobility, wishes to return to another State upon discharge, at risk for pain R/T (related to) contracture to right elbow and left arm, ADL self-care performance deficit R/T [DIAGNOSES REDACTED]. The care plan indicates splints to be applied to right and left hand and arm daily as tolerated to reduce further contractures and to receive active range of motion to upper extremities for 15 minutes six days each week. A review of ADL documents which are used to record activity of daily living tasks and restorative nursing care revealed splints were applied to the resident's arms. Review of the (MONTH) (YEAR) document indicates the splints were applied on 12/17/18. 12/18/18, 12/19/18. The resident was not observed to have on splints on either of those dates. The document indicates CNA II initialed the blocks for the 12/17/18, 12/18/18 and 12/19/18 indicating the splints were applied. An interview with CNA II on 12/21/18 at 2:00 p.m. revealed she was not the one who entered the initials on the document. She reported she cannot see the spaces to fill them in and her co-workers fill out the form for her. CNA SS reported she wrote CNA II's signature on the document, but she denied filling in the spaces to indicate application of the splint. Observations on 12/17/18 at 12:56 p.m., 12/17/18 at 2:50 p.m., 12/17/18 at 5:00 p.m., 12/18/18 at 7:48 a.m., 12/18/18 at 10:50 a.m., 12/18/18 at 2:21 p.m., 12/18/18 at 4:20 p.m., 12/19/18 at 8:10 a.m., 12/19/18 at 11:10 a.m., 12/19/18 at 1:45 p.m., and 12/19/18 at 5:10 p.m. revealed the resident did not have splints on either arm. An interview on 12/20/2018 at 2:10 p.m. with the Corporate Vice-President, the facility Administrator, and the facility Nurse consultant, revealed that the facility's expectation is that residents should receive splint application as recommended and assistants should not document something that has not been performed. An interview on 12/21/18 at 9:00 a.m., with the Director of Nursing, revealed that the individual who was over the restorative program left the facility around Thanksgiving (YEAR). She reported the duties for the restorative program were to be monitored by the DON and the ADON since the previous person left. The DON reported the charge nurses are supposed to be following up to ensure the splints have been applied. She reported if the resident refuses care it should be documented in the resident's record. In an interview with the R#47 on 12/21/18 at 2:00, he reports he has not had his splints applied any day this week. An interview with the Rehab Director/Certified Occupational Therapist on 12/21/18 at 3:15 p.m. revealed that the recommendation for the hand splints should be for four to six hours daily and the recommendation goes to the restorative program. There are no progress notes in the medical record indicating R#47's refusal of care or services for the splints.",2020-09-01
704,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,692,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to consistently provide a therapeutic mechanically-altered diet as ordered by the physician and as recommended by the SLP (Speech Language Pathologist) to help prevent choking and/or aspiration for one resident (R) (R#36). In addition, the facility failed to administer enteral nutrition via a gastrostomy tube (GT) as ordered for one resident (R#54), who was totally dependent on enteral feedings for all nutrition and hydration. Five residents were reviewed for nutrition, and the sample size was 44 residents. Findings include: 1. Review of R#36's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of a physician's Monthly Progress Note dated 9/15/18 revealed an assessment of dysphagia. Further review revealed that he never suggested oral feeding as this carried unacceptable risk. If with testing is felt to be safe might proceed. Review of a physician's Monthly Progress Note dated 10/24/18 revealed that R#36 had another swallow study done, continues to show aspiration, still Speech Therapy began Honey thick liquids. PM Hx (Past Medical History): Stroke with aphagia (inability or refusal to swallow), dysphagia. Review of R#36's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 3 (a BIMS score of 0 to 7 indicates severe cognitive impairment); needed extensive assistance with eating; and was on a mechanically altered diet and feeding tube. Review of R#36's care plans revealed one for risk for alterations in nutrition and hydration related to receiving feeding per peg (percutaneous endoscopic gastrostomy) tube related to [DIAGNOSES REDACTED]. Review of the interventions for this care plan included to serve PO (per os)(by mouth) diet as ordered, and monitor for signs/symptoms aspiration. Review of a Speech Therapy SLP Evaluation & Plan of Treatment dated 10/8/18 revealed that a MBS (modified [MEDICATION NAME] swallow) performed today-SLP from hospital called and stated that patient can tolerate pureed consistency diet and honey thick liquids-patient is currently on GT (gastrostomy tube) feedings. Staff instructed on basic feeding precautions. Swallow precautions in place. Risk factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for aspiration, dehydration, malnutrition, and weight loss. Review of a Speech Therapy Treatment Encounter Note(s) dated 11/12/18 revealed that the diet consistency was upgraded to mechanical soft and thin liquids. Review of R#36's (MONTH) Physician Orders revealed that he was on a mechanical soft with chopped meats and thin liquids diet. Further review of his Physician Orders revealed that he was receiving enteral formula via a gastrostomy tube between 6:00 p.m. and 6:00 a.m. for nutritional support. Review of a dietary Physician's Orders List report dated 12/20/18 revealed that R#36 was on a mechanical soft with chopped meats and thin liquids diet. Observation on 12/17/18 at 12:40 p.m. revealed that R#36 was served lunch in his room, and review of the tray ticket revealed that he was on a Mech (mechanical) diet with Chopped Meats. Further observation revealed that the resident was served a piece of regular barbecue chicken which was still on the bone. Continued observation revealed that the resident consumed 100% of his food, including all of the chicken, and was not noted to cough or have difficulty swallowing. Review of the Week 1 Day 2 Diet SpreadSheet for Lunch revealed that residents on a regular diet received a 4 ounce portion of BBQ (barbecue) chicken, and residents on a L3 (Level 3)/Advanced diet (L3 diets have food cut in bite-sized pieces) should receive ground BBQ chicken. Observation on 12/18/18 at 12:21 p.m. revealed that R#36 was served lunch in his room, and his tray ticket noted that the diet was to include chopped meats. Further observation revealed that the resident was served a regular hamburger patty on a bun, which staff had cut in half. However, the hamburger patty was not chopped or ground. Continued observation revealed that he was not noted to cough or choke when eating. Review of the Week 1 Day 3 Diet SpreadSheet for Lunch revealed that residents on a L3/Advanced diet should receive a hamburger and bun, ground. Observation on 12/18/18 at 5:26 p.m. revealed that R#36 was served supper in bed, which included slices of pork that were not chopped. Continued observation revealed that he was not noted to cough or choke when eating. Review of the Week 1 Day 3 Diet SpreadSheet for Dinner revealed that residents on a L3/Advanced diet should receive a ground baked pork chop. During interview with SLP RR on 12/21/18 at 1:16 p.m., she stated that R#36 had a swallowing problem, and he had been progressed from tube feedings only to a pureed diet and was currently on a mechanical soft diet. She stated during further interview that R#36 should not have unchopped meats to eat, as there was a potential hazard for him not being able to chew and/or swallow meats that were not chopped, leading to a risk for choking. During interview with the Director of Nursing (DON) on 12/21/18 at 1:34 p.m., she stated that the CNA (Certified Nursing Assistant) should be looking at the tray tickets for the correct diet when serving a resident their meal. She stated during further interview that if the food sent was not correct, that the CNA should not give it to the resident, and should check with dietary. She further stated that R#36 had not choked on food. During interview with Dietary Aide MM on 12/21/18 at 1:41 p.m., she stated that when a resident was on a mechanical soft diet with chopped meats and a hamburger was on the menu, that the dietary staff just cut the hamburger and bun in fourths, but that they did not chop the hamburger meat up. She stated during further interview that the barbecue chicken served on 12/17/18 should have been pulled off the bone and chopped up, and the pork served on 12/18/18 should have been chopped up. During interview with the Dietary Manager (DM) at this time, she stated that the Cook should be monitoring what the tray line staff was serving, to ensure that what was served was correct. The DM further stated that if a resident was sent the wrong diet, the CNA should have brought it back to the kitchen. During interview with CNA SS on 12/21/18 at 1:48 p.m., she stated that she was supposed to, but didn't check the tray ticket before serving a resident their meal. She stated that if she did know that if a resident was supposed to be on a chopped meats diet and it was not sent from the kitchen chopped, that she would chop it up. CNA SS stated during further interview that this happened quite a bit, and that she had told the kitchen staff about it. She added that she had never seen R#36 cough or choke when eating. Review of dietary educational material provided by the consultant Registered Dietician (RD) titled Modified Textures and dated 6/1/18 revealed: Residents with dysphagia may choke on their regular foods and liquids. Residents with dysphagia may swallow food and liquids into their lungs instead of their stomachs. This may lead to pneumonia and death. What's the difference between the textures? Mechanical Soft Diets: Meat is ground, cut up or chopped. Review of the consultant RD's monthly dietary audit and report dated 5/22/18 to 5/23/18, revealed diet orders were either not written by MD (Medical Doctor), or do not match what was served. Review of the facility policy Assisting the Impaired Resident with In-Room Meals revised (MONTH) 2013 revealed: Check the tray before serving it to the resident to be sure that it is the correct diet ordered and that the food consistency is appropriate to the resident's ability to chew and swallow. 2. Review of R#54's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of R#54's Quarterly MDS dated [DATE] revealed that he had short-term and long-term memory problems, and severely-impaired decision making; received 51% or more of total calories through a feeding tube; and had one Stage 3 and one Stage 4 pressure ulcer. Review of an alteration in skin integrity care plan revealed that it was revised on 9/14/18 to note that R#54 returned from the hospital with a new GT. Review of the approaches to this care plan revealed to give feedings/flushes per MD (Medical Doctor) orders. Review of a risk for alteration in nutrition and hydration related to PEG tube dependency revealed an approach for feedings/flushes per MD orders. Review of R#54's weights revealed the following: 9/14/18 (upon return from hospital): 122 pounds 10/3/18: 112 pounds 11/22/18: 111 pounds 12/14/18: 107 pounds (a 12.3% significant weight loss in three months) Review of R#54's Physician's Orders revealed the following: 9/14/18 (readmission from the hospital orders): [MEDICATION NAME] 1.5 one can (bolus) via GT five times a day. 10/4/18 Physician's Telephone Orders: [MEDICATION NAME] 1.5 at 55 mL per hour (continuously). 10/15/18 Physician's Telephone Orders: Hold [MEDICATION NAME] 1.5 until it arrives from supplier. Start [MEDICATION NAME] 1.2 at 55 mL per hour until [MEDICATION NAME] 1.5 arrives ([MEDICATION NAME] 1.5 contains 1.5 calories per mL, and [MEDICATION NAME] 1.2 contains 1.2 calories per mL). 11/21/18 Physician's Telephone Orders: Hold [MEDICATION NAME] 1.5 until it arrives from supplier. Start [MEDICATION NAME] 1.2 until [MEDICATION NAME] 1.5 arrives. 11/22/18 Physician's Telephone Orders: Order Clarification: [MEDICATION NAME] 1.5 continuous at 60 mL per hour. 12/18/18 Physician's Telephone Orders: [MEDICATION NAME] 1.2 at 80 mL per hour continuous until [MEDICATION NAME] 1.5 available, then resume 55 mL per hour. December (YEAR) complete Physician's Orders: [MEDICATION NAME] 1.5 calories via GT at 60 mL per hour continuous (this had an Order Date of 11/22/18). Review of R#54's electronic Medication Records (e-MAR) revealed documentation that he received the following enteral nutrition: September: [MEDICATION NAME] 1.5 calories 1 can via GT (bolus) five times daily from 9/15/18-9/30/18 (correct). October: [MEDICATION NAME] 1.5 via GT (bolus) five times daily from 10/1/18 through 10/4/18 at 10:00 a.m. documented (correct). Documentation on the e-MAR then revealed that he was started on [MEDICATION NAME] 1.5 via GT at 55 mL/hour continuously starting at 6:00 p.m. on 10/4/18 (correct), and he received this through the end of October. (However, there was an order on 10/15/18 to hold the [MEDICATION NAME] 1.5 and give [MEDICATION NAME] 1.2 until the [MEDICATION NAME] 1.5 arrived, but no documentation on the MAR indicated [REDACTED]. November: [MEDICATION NAME] 1.5 via GT at 55 mL per hour documented as given on the e-MAR from 11/1/18 through 11/22/18 at 6:00 a.m. (correct), at which time it was documented that he received [MEDICATION NAME] 1.5 at 60 mL per hour on 11/22/18 through 11/30/18. (However, there was an order on 11/21/18 to start [MEDICATION NAME] 1.2 until [MEDICATION NAME] 1.5 arrived, but no documentation on the e-MAR that he ever received the [MEDICATION NAME] 1.2). December (through 12/20/18): [MEDICATION NAME] 1.5 via GT at 60 mL per hour documented on the e-MAR as given from 12/1/18 through 12/20/18. (However, there was an order written [REDACTED]. Observations of R#54's enteral feeding revealed that he was receiving the following enteral formula via an enteral pump at the following rates: 12/17/18 at 11:42 a.m. (this bag was labeled as hung on 12/16/18 at 7:00 p.m.), 3:57 p.m., and 5:39 p.m., and 12/18/18 at 7:38 a.m., 8:58 a.m., 9:55 a.m., and 12:19 p.m.: [MEDICATION NAME] 1.2 cal at 60 mL per hour observed (the Physician Order was for [MEDICATION NAME] 1.5 at 60 mL per hour). 12/18/18 at 3:02 p.m. and 5:29 p.m.: [MEDICATION NAME] 1.2 at 80 mL per hour observed (this was correct per a Physician order written [REDACTED]. 12/19/18 at 8:21 a.m., 1:00 p.m., and 3:00 p.m., and 12/20/18 at 8:40 a.m. and 9:42 a.m.: [MEDICATION NAME] 1.5 at 60 mL per hour observed (the Physician's Order dated 12/18/18 was to resume [MEDICATION NAME] 1.5 when available at 55 mL per hour). Review of invoices revealed that [MEDICATION NAME] 1.5 enteral formula was ordered from the supplier approximately weekly from 10/4/18 until 12/19/18 with the exception of a two-week period between 10/4/18 and 10/18/18 (there was a Physician's Telephone Order dated 10/15/18 to hold [MEDICATION NAME] 1.5 until it arrived from supplier); a 12-day period between 11/8/18 and 11/20/18 (there was a Physician's Telephone Order dated 11/21/18 to hold [MEDICATION NAME] 1.5 until it arrived from supplier); and a two-week period between 11/29/18 and 12/13/18 (observations on 12/17/18 at 11:42 a.m., 3:57 p.m., and 5:39 p.m., and 12/18/18 at 7:38 a.m., 8:58 a.m., 9:55 a.m., 12:19 p.m., 3:02 p.m. and 5:29 p.m. revealed that R#54 was receiving [MEDICATION NAME] 1.2 instead of the ordered [MEDICATION NAME] 1.5). During interview with the facility's consultant Registered Dietician (RD) on 12/19/18 at 1:06 p.m., she verified during her observation yesterday (12/18/18) that R#54 received [MEDICATION NAME] 1.2 at 60 mL per hour, and that she had told the nursing staff to increase the rate of the enteral formula to 80 mL per hour, since he was receiving fewer calories with the [MEDICATION NAME] 1.2 instead of [MEDICATION NAME] 1.5. She further stated that the nurse told her that [MEDICATION NAME] 1.5 was not available, so that was why they hung the [MEDICATION NAME] 1.2. The RD stated that in a 24-hour period, if the nursing staff continued to give [MEDICATION NAME] 1.2 at 60 mL per hour instead of the [MEDICATION NAME] 1.5, that would mean a difference of 440 calories per day for R#54. She further stated that there was no documentation on the MARs of the staff ever hanging a bottle of [MEDICATION NAME] 1.2, so that she could not verify how many times or for how long R#54 had received it. During continued interview, the RD stated that the Dietary Manager (DM) told her that there was [MEDICATION NAME] 1.5 available in her (the DM's) office, but that the nursing staff was not aware of this. Review of the RD's Departmental Notes revealed the following: 10/23/18: Receiving [MEDICATION NAME] 1.5 at 55 mL per hour continuous drip. No weight since admission. Resident needs to be weighed to assess efficacy of the amount of tube feeding being administered (Review of the Weight Change History report revealed that R#54 had a weight recorded of 112 pounds on 10/3/18, a ten pound 8.2% significant weight loss since readmission from the hospital on [DATE]). 11/19/18: Receiving [MEDICATION NAME] 1.5 at 55 mL/hr continuous drip. Weight 112 pounds, consistent for 30 days, however, a significant weight loss at 90 and 180 days. Recommend increasing [MEDICATION NAME] 1.5 to 60 mL per hour to aid in wound healing and for weight gain. 12/18/18: Order is for [MEDICATION NAME] 1.5 at 60 mL per hour continuous drip. However facility is out of [MEDICATION NAME] 1.5 and is using [MEDICATION NAME] 1.2. Therefore recommend changing tube feeding order to [MEDICATION NAME] 1.2 at 80 mL per hour until the [MEDICATION NAME] 1.5 is available. During interview with the Assistant Director of Nursing (ADON) on 12/20/18 at 9:00 a.m., she stated that when a nurse initialed something on the e-MAR, that meant the resident received that item, and verified that the initials on the e-MAR indicated that R#54 continuously received [MEDICATION NAME] 1.5 and at no time received [MEDICATION NAME] 1.2. The ADON stated during further interview that enteral formula was usually stored in the Central Supply closet, but she found out this week that it had also been stored in the Dietary Manager's (DM) office, but that the nurses did not have a key to get in the DM's office after she left for the day. During interview with Central Supply staff KK on 12/20/18 at 9:10 a.m., she stated that the DM was responsible for ordering enteral formula, as it came out of Dietary's budget. She stated during continued interview that the DM was responsible for stocking the enteral formula in the medication rooms behind each nurse's station, and that the nurses had a key to the medication rooms as well as to Central Supply. During interview with the DM on 12/20/18 at 9:15 a.m., she verified that she was responsible for ordering the enteral formula, and did so weekly. She further stated that the enteral formula was stored behind the nurse's stations in the medication rooms and in the Central Supply room, and that any overflow formula was stored in the DM's office. The DM stated that if the nursing staff ran out of a particular enteral formula after she left for the day, that they could call her and she would come back to the facility and get it out of her office for them. The DM stated during continued interview that it was the nursing staff's responsibility for notifying her when the supply of an enteral formula was low. Observation in the DM's office on 12/20/18 at 9:25 a.m. revealed that there was an unopened case of eight bottles of [MEDICATION NAME] 1.5 inside. During observation at this time, Central Supply staff KK verified that there were no bottles of [MEDICATION NAME] 1.5 in Central Supply, but seven bottles of [MEDICATION NAME] 1.5 were located in a bottom cabinet in the medication room at Nurse's Station 2. During interview with Licensed Practical Nurse (LPN) EE on 12/20/18 at 9:42 a.m., she stated that she looked at the Physician's Orders and the e-MAR to know what tube feeding formula and at what rate to give to a resident. During observation at this time, she verified that R#54 was receiving [MEDICATION NAME] 1.5 at 60 mL per hour. LPN EE further verified that the order on R#54's e-MAR was for [MEDICATION NAME] 1.5 at 60 mL per hour. She verified during continued interview that the last Physician's Order in R#54's paper medical record dated 12/18/18 was for [MEDICATION NAME] 1.2 at 80 mL per hour until the [MEDICATION NAME] 1.5 was available, then resume [MEDICATION NAME] 1.5 at 55 mL per hour. LPN EE stated during continued interview that the order dated 11/22/18 for [MEDICATION NAME] 1.5 at 60 mL per hour had never been discontinued in the computer, so that it continued to display as [MEDICATION NAME] 1.5 at 60 mL per hour on the e-MAR. She further stated that it was the nurse's responsibility who wrote a new order to make the changes in the computer. During interview with the ADON on 12/21/18 at 8:28 a.m., she stated that enteral formula should be stored in the medication room and/or Central Supply. She further stated that she was told that they were out of [MEDICATION NAME] 1.5 this week, and did not know that there was any in the DM's office. She stated during continued interview that when an ordered enteral formula was not available, that the physician was contacted for a new order, and that this should be handwritten on the Physician's Orders form and then entered into the computer. She said that when a new order was typed in the computer, that it automatically updated the e-MAR with the new order. The ADON verified that she did not enter the new order in the computer to use the [MEDICATION NAME] 1.2 on 12/18/18 until the [MEDICATION NAME] 1.5 was available, so that it did not display with the correct order on the electronic MAR. Review of the RD's education material titled Enteral Documentation dated (YEAR) revealed: Observe the formula being administered to ensure the correct formula, rate and time is in accordance with the Pysician's Order.",2020-09-01
705,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,694,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, record reviews and review of the facility's policy (Central Venous Catheter Dressing Changes), the facility failed change the Peripherally Inserted Central Catheter (PICC) dressing per facility protocol for one resident (R#61) The sample size was 43. Findings include: Review of the physician's Discharge Summary dated 11/12/18 for Resident #61 revealed 'the resident was hospitalized [DATE] - 11/12/18 for worsening Stage IV pressure ulcer to the sacrum with infection and a Urinary Tract Infection (UTI )w (with) E-Coli (Escherichia coli) - Foley catheter inserted to promote wound healing of Stage IV pressure ulcer.' Further review of the record revealed the resident had a PICC inserted while in the hospital prior to being transferred back to the facility for intravenous antibiotics. Review of resident #61's physician progress notes [REDACTED]. She was treated for [REDACTED]. She came back with a Foley (Foley catheter), and that is being used to try to avoid contamination in the sore. She has been having diarrhea recently (with no bad smell to suggest [MEDICAL CONDITION] (Closdridium difficile). She has to be on [MEDICATION NAME] IV (intravenous) and [MEDICATION NAME] by mouth.' Further review of the progress note for 'Plan' - '[MEDICATION NAME] and [MEDICATION NAME] IV continued for UTI and sacral wound infection.' Review of the facility's policy entitled 'Central Venous Catheter Dressing Changes' with revision date of (MONTH) (YEAR) revealed under 'Purpose' 'The purpose of this procedure is to prevent catheter-related infections that are associated with contaminated, loosened, soiled or wet dressings. Further review of the policy revealed the following: 1. Apply and maintain sterile dressing on intravenous access devices. Dressings must stay clean, dry and intact. 5. Change transparent semi-permeable membrane (TSM) dressings at least every five to seven days and PRN (as needed) (when wet, soiled, or not intact).' Review of Resident #61's (MONTH) (YEAR) Physician order [REDACTED].>Start Date 12/9/18 'Change PICC line dressing Q (every) week on Sunday. Further review of Resident #61's (MONTH) (YEAR) MAR (Medication Administration Record) revealed: Change PICC line dressing Q week on Monday at 10 a,m. Order date: 11/13/18 Start date: 11/19/18 Discontinue Date: 12/5/18 With last date and time indicating PICC line dressing was changed 12/3/18 at 10 a.m. Change PICC line dressing Q week on Sunday at 10 a.m. Order date: 12/5/18 Start date: 12/9/18' With last dates and times indicating PICC line dressing was changed on 12/9/18 at 10 a.m. and on 12/16/18 at 10 a.m. An interview and observation with CNA (Certified Nursing Assistant) KK on 12/18/18 at 2:35 p.m. where CNA KK was observed assisting Resident #61 to roll from her right side to her back - observed R#61's right upper inner arm - PICC line insertion site - noted transparent dressing with window border intact; however the widow border observed to be light gray in color with date at top of dressing of 12/3/18. CNA KK verified the date was 12/3/18. There was no redness or drainage noted to the PICC insertion site which was noted to be a double lumen line with one red cap and one brown cap on each end. An interview and observation on 12/18/18 at 2:45 p.m. with Licensed Practical Nurse (LPN) EE who confirmed that the PICC line insertion site to right upper inner arm dressing was dated 12/3/18. An interview and observation on 12/18/18 at 4:45 p.m. with the Director of Nursing (DON) revealed PICC line insertion site transparent dressing had been changed on 12/18/18. The DON stated that she had the charge nurse change the dressing today but verified that the previous dressing was dated 12/3/18 and that the Medication Administration Record [REDACTED]. The DON further stated that she expected the dressing to be changed weekly as ordered. She further stated that the Physician was notified and were awaiting a response.",2020-09-01
706,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,745,D,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of Social Services job description, the facility failed to ensure four residents (R# A, R#47, R#71 and R#29) received adequate assistance and support from social services department. Resident R# A requested a room change off the locked memory care unit, R#47 had Physician order [REDACTED]. Findings include: Review of facility job description for the Social Services Director revealed the primary purpose of the job position is to manage the medically related Social Service Program of the facility in accordance with federal, state and local standards, guidelines and regulations and company policies and procedures to ensure the highest possible level of resident physical, mental, and psychosocial well-being by performing the following duties. 1. A review of the clinical record for R A revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 12, which indicated mild cognitive impairment. Interview on 12/17/18 at 2:46 p.m,., resident A stated that he is in what used to be the locked unit, where he could not go anywhere else in the building. He stated the facility recently unlocked the unit about one week ago, but he is still told he has to eat on the unit. He further stated he would like to eat in the regular dining room. He also stated that he has asked for a room change from the unit, about two months ago, and he hasn't heard anything back from anyone about it. Interview on 12/20/18 at 12:29 p.m., with Director of Nursing (DON), stated that she is taking care of room changes, transfers and discharges temporarily until the position of Social Services Director can be filled. She stated if room changes are requested by resident or family member, the Social Services Director (SSD) would evaluate the request to determine the reason for request. The Interdisciplinary Team (IDT) would meet to discuss the request and determine if room available for transfer. She further she was not aware that R A had requested a room change, until 12/19/18, when resident mentioned it to her. During further interview with, DON stated that previous SSD resigned early (MONTH) and the facility was unable to locate any documentation for any visits she made with R # [NAME] Interview on 12/21/18 at 8:20 a.m., with Assistant Director of Nursing (ADON), stated that R# A was admitted to the facility in (MONTH) (YEAR). She further stated she was not sure why he was admitted to the memory care unit. During further interview, she sated that resident had mentioned to her that he wanted to change rooms around (MONTH) 3, (YEAR). She stated that she did not do any documentation about R #'A request for a room change. 2. Review of a Resident Incident Report and Nursing Departmental Notes for R#71 dated 10/18/18 at 5:33 p.m., revealed: At 4:10 p.m. resident (#71) was walking in dining room looking out window when another resident (#29) became agitated and pushed resident down. Resident hit head on floor causing a hematoma to posterior right side of head. EMS (Emergency Medical Services) arrived and resident to ER at 5:00 p.m. Review of Nursing Departmental Notes dated 10/18/18 at 6:07 p.m. for R#29 revealed: At 1610 (4:10 p.m.), it was reported that resident (#29) struck another resident while in the dining room. Statement given by CNA (Certified Nursing Assistant) reported that R#29 was sitting in the chair in the dining hall when another resident (R#71) walked up beside him to look out of the window. (R#29) yelled at the resident and struck her while pushing her to the floor causing her to hit her head. Review of hospital progress notes dated 10/25/18 revealed that R#71 was admitted with an intertrochanteric fracture proximal right femur, and had an ORIF (open reduction internal fixation) of the right [MEDICAL CONDITION]. Review of the initial investigation e-mailed to the SSA (State Survey Agency) revealed that it was submitted on a Complaint Form on 10/18/18 and then again on a a Facility Incident Report Form on 10/19/18 by the Social Services Director. Both forms noted that a 5-day report was to follow. During interview with the Administrator on 12/20/18 at 4:53 p.m., she verified that there was no facility-reported incident to the State Agency in their [MEDICATION NAME] notebook for the incident involving R#29 and R#71. She further stated that the Social Services Director at the facility during the time of this incident was no longer employed by the facility. Interview with the SSA Complaint and Investigations Manager on 12/21/18 at 10:40 a.m. revealed that a 5-day investigation report was never received from the facility for this incident. 3. A record review for Resident #57 reveals the Resident was admitted to the facility 12/12/16 with admitting [DIAGNOSES REDACTED]. The face sheet of the chart indicates resident is the responsible party. A review of MDS, Annual assessment, dated 11/14/18 reveals the resident has a BIMs of 8 indicating severe cognitive impairment A review of the facility undated policy, Resident Rights, item f under section 1 indicated residents have a right to communicate with and have access to people and services, both inside and outside the facility. A review of the facility undated policy, Care Plans, Comprehensive Person-Centered, section eight, item b indicated care plans will describe the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychsocial well-being. A review of R#57's Initial Social Service History with an admission date of [DATE] revealed the resident has left eye impaired vision. The document is incomplete. A review of the care plan for R#57 indicates the resident is care-planned for impaired vision with a goal that the resident will not injure self, related to vision status and interventions include vision screening if ordered and as indicated. A review of Departmental Notes for R#57 indicated a late entry dated 10/15/18 at 10:39 a.m. which reads: Late entry for 10/24/18 at 6p.m. Dr. (doctor) visited; order received; refer to in house eye doctor. Resident aware of order. A review of Contract Vison Doctor's Monthly Progress Note dated 10/25/18 revealed an entry reading pt (patient) wants re-eavaluation of her [MEDICAL CONDITION]. A review of Contract Vison Doctor's Monthly Progress Note dated 11/17/18 revealed an entry reading asked for eye evaluation. The facility has a contract with a Vison Doctor for vision services. Review of the facility roster from contract Vison Doctor revealed the resident was added for service 10/30/18 with an appointment date was 11/20/18. The resident's name is hand-written on the page and the word refused is written next to her name. An interview with the resident on 12/19/2018, at 11:20 a.m., revealed the resident does not recall anyone from the eye doctor coming to see her. On 12/19/18 at 12:10 p.m., The Director of Nursing (DON) is unable to explain the information on the facility roster for the Contract Vision Service doctor with the word refused is next to the resident's name. She agrees the resident should have already received vision services. She reports the social worker is responsible for ensuring vision services are arranged. The social worker left the facility in (MONTH) (YEAR) and the social worker duties were distributed among the Administrator, the DON, and the Assistant DON. The DON reports she has talked with the resident and confirmed her desire to have an eye evaluation. The DON reports the eye clinic does not occur at the facility until (MONTH) 2019. Cross refer to F688",2020-09-01
707,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,801,F,0,1,KL3P11,"Based on record review, Consultant Registered Dietician (RD), Corporate, and staff interview, the facility failed to ensure that the staff designated as director of food and nutrition services was a certified dietary or food service manager, or had a similar food service management certification or degree. There were 66 of 67 residents that received an oral diet. Findings include: During interview with the Dietary Manager (DM) on 12/17/18 at 10:55 a.m., she stated that she had been working as a CNA (Certified Nursing Assistant) at the facility, before recently being appointed as the DM. She stated during continued interview that she had not taken a CDM (Certified Dietary Manager) course, nor was she ServSafe certified. During interview with the consultant RD on 12/18/18 at 2:01 p.m., she stated that the DM was a previous CNA for the facility, and had been in the current position as DM for about two to three months. The RD stated during continued interview that she was looking into getting the DM into a CDM course, and that she was scheduled to take the ServSafe course in January. The RD further stated that the former DM had provided hands-on training for the current DM, and that she (the RD) made monthly two-day visits to the facility. During interview with the DM on 12/19/18 at 12:10 p.m., she stated that her training to be the DM consisted of going to a sister facility from 12/10/18 to 12/14/18 to work with their DM. She further stated that the facility's previous DM was now working as an LPN (Licensed Practical Nurse), that she had shown her how to do some things, but that she had learned most of everything on her own. During interview with the Administrator on 12/20/18 at 8:27 a.m., she verified that the current DM was not certified. Review of an Employee Change Form with an Effective Date of 8/1/18 revealed the current DM had a change in Job Title from CNA to Dietary Manager on this date. Review of a Dietary Manager Job Description in the DM's employee file revealed her date of hire for this position was 8/1/18. Further review of this job description revealed: Education and/or Experience: Bachelor's degree from four-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience. Review of the current DM's Employment Application revealed that the Education section included graduation from high school, but no College/Trade School or Courses and Degrees were noted. This was verified during interview with the Administrator on 12/20/18 at 10:37 a.m., who further verified that the qualifications section of the Dietary Manager job description included Bachelor's degree or one to two years related experience. During interview with the facility's Corporate VP (Vice President) QQ on 12/20/18 at 3:10 p.m., she stated that she had told the previous Administrator not to hire the current DM into that position, but she had done it anyway without her knowledge. Review of the RD's (YEAR) monthly consultant reports and audits revealed the following: August: Additional facility requests: Meet with new dietary manager. November: CDM's Expiration Date: Not ServSafe certified or CDM. December: No one ServSafe certified on staff. Cross-refer to F 812.",2020-09-01
708,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,812,F,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, consultant Registered Dietician (RD), and service technician interview, the facility failed to ensure that foods in one of two reach-in coolers were stored in a manner to prevent potential cross contamination; failed to store scoops outside of bulk containers of two dry goods (sugar and grits) in one of two dry storage rooms; failed to ensure that the dish machine's final rinse temperature was sufficient to sanitize dishes; failed to ensure that canned foods in one of two dry storage rooms were not dented and/or expired; failed to ensure that two items (lima beans and pureed pork) were held at a temperature of at least 135 degrees Fahrenheit (F) on the steam table; and failed to ensure that snacks in one of two resident nourishment refrigerators were labeled. This had the potential to affect 66 of 67 residents in the facility that received an oral diet. Findings include: 1. Initial tour of the kitchen on [DATE] beginning at 10:10 a.m. revealed that on the second shelf inside a reach-in cooler located just outside of the dry storage room contained a plastic bag with cooked sliced turkey, and stored next to the turkey were a box of tomatoes and a box of lettuce. Further observation revealed that below this on the third shelf there was a box of cucumbers with a tray on top of them that contained a plastic bag of cooked ground turkey, a plastic bag of sliced ham, and a plastic bag that contained a partial head of lettuce. Continued observation inside the dry storage room during the initial tour revealed a large bulk storage container of sugar which had a plastic scoop inside of it, with the handle of the scoop flat on top of the sugar. Further observation on the shelving in this dry storage room revealed a plastic storage container containing grits, which had a plastic cup inside used as a scoop which had been placed directly on top of the grits. During interview with the Dietary Manager (DM) on [DATE] at 10:55 a.m., she stated that vegetables were supposed to be stored on the top shelves, cheese on the middle shelf, and meats on the bottom shelves in the coolers, and verified the lettuce and meats stored together on a tray, and an open bag of turkey on the shelf above this. The DM verified during continued interview that a scoop was stored directly on top of the sugar and plastic cup on top of the grits in the dry storage room, and stated that staff were supposed to remove the scoops after use, wash and store them outside of the dry goods containers. During interview with the RD and DM on [DATE] at 10:00 a.m., they stated that they were unable to find any policies in the DM's office related to storing food in the coolers. However, the RD was eventually able to find some education information titled Rules of the Walk In Cooler, undated, which revealed: Ready To Eat (RTE) foods refer to food that do not need cooking or very minimal preparation. Examples are pre-cooked meats, cheese, fruits or vegetables, etc. Produce must be stored ABOVE all cooked and uncooked meat and dairy or stored separately away from all meat and dairy. This can be accomplished by using all shelves in a designated part of the cooler in which only product is stored. Cooked food must be covered/dated/labeled and stored ABOVE all raw meat and dairy and under all produce. Ready to Eat (RTE) food must be covered/dated/labeled and stored ABOVE all raw meat and dairy, and under produce. 2. During interview with the DM on [DATE] at 10:55 a.m., she stated that she had no equipment issues. Observation on [DATE] at 9:26 a.m. revealed that Dietary Aides OO and PP were running breakfast dishes through the dish machine. During interview at this time, neither one knew the type of dish machine the facility used, nor what the final rinse temperature of the water should be. Interview with Dietary Aide NN at this time revealed that they used a high-temp dish machine. Observation of the water temperatures displayed on the front of the machine revealed that the wash temperature got as high as 147 degrees F and rinse temperature as high as 143 degrees F on the first load observed, and the wash temperature got as high as 147 degrees F and the rinse temperature as high as 142 degrees F on the second load run through the machine. After each of these observations, Dietary Aide OO continued to remove the washed items from the dish machine, and store them for future food preparation and resident service use. Review of the High Temp Dish Machine Temp Log for (MONTH) (through [DATE]) revealed that there were three columns to record the Wash and Final Rinse temperature of the machine at each meal, but nothing on the Log to indicate what the temperatures should be. Further review of this Log revealed that each day staff had been circling Y (Yes) in each column, but the actual temperatures obtained on the machine were not recorded. During interview with the Maintenance Director on [DATE] at 9:35 a.m., he stated that the dish machine's (manufacture) service representative had been out to the facility recently to service the dish machine. A third observation of breakfast dishes run through the dish machine by Dietary Aide PP at this time revealed that the highest wash temperature displayed on the machine was 145 degrees F, and the highest rinse temperature was 144 degrees F. During interview with the DM at this time, she stated the wash temperature should be 156 degrees, and the rinse temperature should be 160 degrees or above. The DM verified that the manufacturer's printed directions on the front of dish machine indicated that the rinse temperature should be 180 degrees. A fourth load of breakfast dishes was observed run through by Dietary Aide PP at this time, and the wash temperature was 146 degrees F and the highest rinse temperature was 147 degrees F. During interview with the facility's consultant RD at this time, she stated that this wash temperature was good, because you didn't want it to bake the food on the dish surfaces. When the DM asked the Dietary Aides how long they had been running dishes through the dish machine that morning, Dietary Aide PP replied that they had used it ever since breakfast service was completed. Review of the facility's Meal Times revealed that the last breakfast trays were scheduled to be served on the A-Hall at 8:15 a.m. During interview with the facility's RD on [DATE] at 9:50 a.m., she stated that their policy was for the dish machine final rinse temperature to be 160 degrees. Observation of the final rinse temp at this time revealed that it was 160 degrees F, and the RD instructed the Dietary Aides to continue to use the dish machine as the final rinse temp was adequate. The RD verified that the labeling instructions on the front of the dish machine was for a rinse temperature of 180, and stated that she doubted that they had a policy on the dish machine. During continued interview, the RD stated that she instructed the DM about three months ago to revise the High Temp Dish Machine Temp Log so that it had the required water temperatures on it so staff could refer to it, and verified that this had not been done. During interview with the RD and DM on [DATE] at 10:00 a.m., they stated that they were unable to find any policies in the DM's office related to the dish machine. During interview with the RD on [DATE] at 10:38 a.m., she stated that she was not able to find any policies for the kitchen, and said that her monthly audits contained the only documentation she could find about what the wash and rinse temperatures of the dish machine should be. Review of the Dish Machine section of the Monthly Sanitation Audit revised ,[DATE] revealed that temperatures are recorded three times daily before each use, and that for a high temp machine the wash temperature should be 160 degrees F or greater, and sanitizing (rinse) cycle temperature should be 180 degrees F or greater. The RD verified during interview at this time that the final rinse temperature of the dish machine should be 180 degrees or above, and that they would use paper products to serve the residents until the dish machine could be repaired. Review of the RD's monthly consulting reports since (MONTH) (YEAR) revealed the following: May: Dish machine down for breakfast on (MONTH) 23, (YEAR); used paper. Fixed before lunch. June: The High Temp Sanitizing Cycle temperature recorded was 172 degrees. July: Dish machine: issues with maintaining temperature. Served on paper for breakfast [DATE]. Repaired before lunch and back to full service. Dish Machine ,[DATE] degrees. August: Dish machine sanitizing cycle temperature 159 degrees; needs correcting, call company. Dish Machine log not filled out past (MONTH) 7, (YEAR). September: Dish Machine sanitizing cycle temperature ,[DATE]. Dish machine log inadequate; needs to have a place for wash and rinse temperatures for each meal. Current log is only listing one temp and not indicating which meal. (Review of the Temperature Log from [DATE] to [DATE] attached to the (MONTH) RD report revealed that it had only two columns, one for temperature and one for employee initials, and did not indicate if the temperature was the wash or rinse temperature, and none of the temperatures recorded were above 171 degrees). October: Dish machine out of order as is disposal; used disposable plates, cups, etc. November: The dish machine rinse temperature was recorded as ,[DATE] degrees. December: Dish Machine out of order, not reaching temp. Logs for dish machine need to include wash, rinse temperatures. Review of inservices provided for dietary staff in (YEAR) revealed that the only inservice that possibly may have included proper use of the high temperature dish machine (what exactly was discussed was not documented) was a verbal review of F 812 (the Federal regulation related to food safety requirements). During interview with the DM on [DATE] at 12:44 p.m., she stated that she had no documentation of the kitchen staff receiving inservice training on how to use the dish machine. During interview with manufacture service technician TT on [DATE] at 1:55 p.m., he stated that someone had switched off the hot water booster in the dish room, and that was why the wash and rinse temperatures were not adequate. Observation at this time revealed that the dish machine wash temperature was 167 degrees F, and the rinse temperature was 180 degrees F. During further interview with the service technician, he stated that for the dish machine to work correctly and sanitize, the wash temperature had to be 150 degrees or greater, and the rinse temperature 180 degrees or greater. During interview with the RD on [DATE] at 2:10 p.m., she stated that the dish machine had been out of commission several times, and they have had to use paper products. During interview with Dietary Aide UU on [DATE] at 9:33 a.m., she stated that when she documented on the High Temp Dish Machine Temp Log, that when she circled the Y for Yes, it indicated that the wash and rinse temperatures were in the correct range. When Dietary Aides UU and OO were asked if they received training on the dish machine, they both said yes, and both said the wash temperature should be 160 degrees and the rinse temperature between 170 and 180 degrees. During interview with the Maintenance Director on [DATE] at 9:38 a.m., he stated that the manufacture dish machine was leased, and that there had not been many issues with it not working correctly. He stated that recently there was an issue with the garbage disposal in the dish room not working, and the kitchen staff did not realize they could still use the dish machine when the disposal was broken, and so they used paper plates for about a week until the garbage disposal was fixed. 3. During interview with the RD on [DATE] at 9:45 a.m., she stated that there was no way to know what the use-by date on some of the canned goods in the dry storage/emergency supply room were (located off the dish room). She stated that once canned goods were delivered by the vendor, that they should be discarded after a year. She stated during further interview that any dented cans should be pulled to the side for return to the vendor. She verified that in with the regular canned goods stock was a 6-pound can of Classic Spaghetti Sauce that had a large dent on the side, and one large can of refried beans that was dented. She further verified that the following cans in the general canned goods stock were labeled with the receipt dates of: One large can of Beets dated [DATE]. This can also had an unknown sticky tannish substance on the top. Six large cans Refried Beans dated [DATE]. In the emergency supply, there was: Nine 111-ounce cans of 3-Bean Salad dated [DATE]. Six 6-pound 12-ounce cans of corned beef hash dated [DATE]. During continued interview with the RD at this time, she stated that the kitchen staff must be rotating some of their emergency supply in with the regular stock of dry goods, as some of the emergency supply were not out of date. Review of the RD's monthly consulting report for (MONTH) (YEAR) revealed: Dented cans mixed in with regular cans. Outdated cans removed from storage area. 4. On [DATE] at 12:28 p.m., steam table temperatures were observed taken by Dietary Aide MM using the facility's calibrated thermometer. Observation of the temperature of the lima beans revealed that they were 110 degrees F, and the pan was removed from the steam table to be reheated. Observation of a pre-packaged container of pureed pork revealed that the temperature was 100 degrees F, and all of the packages of pureed meat and vegetables were removed from the steam table and placed in the microwave to reheat. During interview with Dietary Aide MM at this time, she estimated that four residents had already been served the lima beans, and that no residents had yet been served the pureed foods. She further stated that the packages of pureed foods were usually not placed on the steam table until right before they were ready to serve them, because they lost their heat quickly. Review of the only guidance that could be found by the RD related to safe hot food temperatures was titled Meal Service-Delivering Hot Food HOT, dated [DATE], and revealed that the danger zone of foods was 41 degrees F to 135 degrees F, and the danger zone allowed for food to be on the steam table as low as 135 degrees F. 5. Observation in the resident refrigerator located behind Nurse's Station 1 on [DATE] at 4:45 p.m. revealed that there were two black bowls covered with plastic wrap of what appeared to be applesauce on the top shelf, and neither was labeled with the contents, prepared, or use-by dates. This was verified by Central Supply staff KK at this time. Review of dietary guidance provided by the RD titled Rules of the Walk In Cooler (undated) revealed: Do cover, date and label all food once placed in the walk in cooler. All containers must have a date once opened. Review of a dietary Physician order [REDACTED].",2020-09-01
709,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,835,F,0,1,KL3P11,"Based on review of the facility's Administrator Job Description, Corporate and staff interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently, including ensuring that staff hired for the Dietary Manager position had the required certification; and failed to provide oversight for the Social Services Director, to ensure that abuse investigations were completed for two residents (R#71 and R#29), and that assistance with a room change was provided for one resident (R 'A'). This had to potential to affect all of the 67 residents who resided in the facility. Findings include: 1. During interview with the Dietary Manager (DM) on 12/17/18 at 10:55 a.m., she stated that she had been working as a CNA (Certified Nursing Assistant) at the facility, before recently being appointed as the DM. She stated during continued interview that she had not taken a CDM (Certified Dietary Manager) course. Review of an Employee Change Form with an Effective Date of 8/1/18 revealed the current DM had a change in Job Title from CNA to Dietary Manager on this date. During interview with the Administrator on 12/20/18 at 8:27 a.m., she verified that the DM was not certified. During interview with Corporate Vice President QQ on 12/20/18 at 3:10 p.m., she stated that she had told the previous Administrator not to hire the current Dietary Manager, but she did it anyway without her knowledge. Cross-refer to F 801. 2. Review of a Resident Incident Report and Nursing Departmental Notes for R#71 dated 10/18/18 at 5:33 p.m., revealed that R#71 was pushed down by R#29, resulting in a hematoma to her head and a fractured right hip. Review of initial investigations of this resident to resident abuse revealed that they were submitted to the State Survey Agency by the Social Services Director on different forms dated 10/18/18 and 10/19/18, with notations that a 5-day report (of the final investigation) to follow. However, this report was never submitted by the Social Services Director. Cross-refer to F 745. Review of the facility's Administrator Job Description revealed: Summary: Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives by performing the following duties personally or through subordinate supervisors. Supervisory Responsibilities: Manages 5 or more subordinate supervisors who supervise a total of 50 or more employees in the Nursing facility, Social Services, Dietary Department, Environmental Department, Activity, Department, and Administration Department. Is responsible for the overall direction, coordination, and evaluation of these units. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems. Essential Job Functions: Facility Management Functions: Directs and coordinates medical, nursing and administrative staffs and services. Conducts regular rounds to monitor delivery of nursing care. Conducts regular rounds to monitor operation of support departments. Conducts regular rounds to monitor resident needs are being addressed. Directs hiring and training of personnel. Maintain a working knowledge and ensure compliance with all governmental regulations. 3. During initial tour on 12/17/18 at 2:46 p.m. resident (R) A stated he is in what used to be the locked unit, and he could not go anywhere else in the building, but the unit. He stated the facility recently unlocked the unit, about one week ago, but he is still told he has to eat on the unit. He stated he would like to eat in the regular dining room. He also stated that he has asked for a room change off the unit, about two months ago, and he hasn't heard back from anyone about it. Interview on 12/20/18 at 12:29 p.m. with Director of Nursing (DON) stated that she is taking care of room changes and transfers and discharges temporarily until the position of Social Services Director can be filled. She stated if room changes are requested by resident or family member, the Social Services Director would evaluate the request to determine the reason for request. The Interdisciplinary team (IDT) would meet to discuss the request and determine if room available for transfer. She further stated she was not aware that R A had requested a room change, until yesterday (12/19/18), when resident mentioned it to her. She stated that previous Social Services director left early (MONTH) and the facility is unable to locate any documentation of any visits made with resident. Interview on 12/21/18 at 8:20 a.m., with Assistant Director of Nursing (ADON) stated that R A was admitted in (MONTH) (YEAR) and he has been on the memory care unit since he has been here. She stated she was not sure why he was admitted to the memory care unit. During further interview, she sated that R A had mentioned to her that he wanted to change rooms around (MONTH) 3, (YEAR). She stated that the process for room changes is the residents are discussed in morning meeting with the interdisciplinary team (IDT). Phone interview on 12/21/18 at 12:25 p.m., with Licensed Practical Nurse (LPN) GG, stated that the Social Services department is the one who completes the sections D and [NAME] of the Minimum Data Set (MDS) assessment, and she does not know how she gathers that information. Facility currently does not have a Social Services Director, so MDS will begin completing Sections D and E. She stated she does not know why R A was admitted to the memory care/locked unit.",2020-09-01
710,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2018-12-21,880,E,0,1,KL3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to maintain an effective infection control program related to labeling and storage of personal care equipment; also failed to ensure newly hired staff members, four of ten reviewed files, obtained physical examination and for five of ten reviewed files, Purified Protein Derivative (PPD) skin test was completed prior to beginning employment. The facility census was 67 residents. Findings include: Review of facility policy titled Admitting the Resident:Role of the Nursing Assistant revised (MONTH) 2013, revealed the purpose i to assist the resident to his/her room and to help alleviate concerns and answer questions that the resident and family may have. Steps in the procedure 11 and 12 reveal using a indelible ink marker, mark each item of equipment with the residents first and last name and store equipment in appropriate areas (bedside table or bathroom). 1. Observation on 12/17/18 at 10:55 a.m., revealed in room B 118-2 an unlabeled and un-bagged bath basin sitting on the bathroom counter and a used unlabeled bar of hand soap sitting on sink ledge in bathroom shared by two male residents. Observation on 12/17/18 at 11:03 a.m., revealed in room A 112-2 a unlabeled urinal but bagged urinal hanging on side of grab bar. Bag has brown particles in bottom of bag. Bathroom is shared by four female residents. Observation on 12/17/18 at 11:09 a.m., revealed in room B 119-2 soiled towel lying on floor in bathroom and a un-bagged and unlabeled bath basin sitting on countertop in bathroom, shared by three male residents. Observation on 12/17/18 at 11:15 a.m., revealed in room B 120-2 two unbagged and unlabeled bath basins sitting stacked on countertop in bathroom, shared by three female residents. Observation on 12/17/18 at 11:15 a.m., revealed in room B 122-2 an unbagged and unlabeled bath basin sitting on countertop in bathroom shared by three female residents. Observation on 12/17/18 at 3:15 p.m., revealed in room [ROOM NUMBER], unlabeled and unbagged bath basin on the floor next to the commode in bathroom shared by 3 residents. Interview on 12/20/18 at 10:52 a.m., with Assistant Director of Nursing (ADON) verified on walking rounds the infection control issues identified during the survey. She stated that it is her expectation that resident personal care equipment be labeled with their name and placed in plastic bag and stored in bedside stand. Interview on 12/20/18 at 4:28 p.m., with Director of Nursing (DON) stated it is her expectation that all resident personal care equipment be labeled with residents name and be bagged in a clear bag and stored in bathroom. 2. Review of employee files revealed that the facility failed to ensure that newly hired employees received a physical examination upon employment to ensure they were physically and mentally qualified and free from communicable disease for four (4) of ten (10) employee files reviewed; further review revealed that five (5) of the ten (10) newly hired employees did not receive the Purified Protein Derivative (PPD) skin test prior to beginning employment. Interview on 12/21/18 at 9:53 a.m., with Human Resources Director, stated that she did not get any formal training from the previous person who vacated this position. She was handed a folder and said this is what you need to do. During further interview, she stated that she was not aware that the physicals and Purified Protein Derivative (PPD) test needed to be completed before employees began work. She stated that she thought that nursing handled the new hire physicals and PPD skin tests. Interview on 12/21/18 at 4:36 p.m., with the Administrator, stated she has been employed at this facility for three weeks, and is still getting to know everyone and the processes. She stated she was not aware of any concerns with the employee files with background checks, physicals or PPD tests.",2020-09-01
711,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2017-12-22,578,D,0,1,3VI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record and facility policy reviews, the facility failed to implement an ongoing Advance Directive process between residents and their healthcare representatives in order to plan for future healthcare decisions for a time when one is not able to make their own healthcare decisions for three (3) of 18 sampled residents (R#17, R#23, & R#38). R#38 was not provided information regarding advanced directives once the resident was able to receive the information. The findings include: 1. Review of the facility's policy titled Advance Directive Policy undated indicates the following: 2) Informing Resident and or Representative of rights/options a) Procedure for residents who have decision making capacity upon admission. During the pre-admission/admission process, the resident will be asked to provide the facility with a copy of Advance Directive. If the resident has not executed an advance directive, the facility will inform the resident and family of the right to establish an advance directive. Written information will be provided to the resident and a verbal explanation of advance directives will be given. c) Procedure for periodically reviewing resident choices and preferences related to health care decisions after admission: i) The process of advance care planning is ongoing and allows the resident, family and others on the resident's interdisciplinary team an opportunity to reassess the resident's goals and wishes as the resident's medical condition changes . The resident's decision-making capacity will also be periodically assessed, and appropriate legal representative will be involved to make health care decisions once it is determined that the resident does not have decision - making capacity. 2. On 12/20/17 at 4:32 p.m. a review of Resident (R) #17's Advance Directive checklist revealed it was signed by Personal Representative, dated 4/12/16. There were no check marks on the form indicating an advance directive option. On 12/21/17 at 3:00 p.m. R#17 was asked if she was told about and offered an opportunity to complete an advance directive. R #17 replied I think my son has something, but I don't know if he bought it here or not. They never asked me about it or gave me anything since I've been here. Review of R#17's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. The Resident is cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. On 12/21/17 at 3:26 p.m. the Business Office Manager (BMO) was queried as to whether the facility had a copy of R#17's advance directive because the resident spoke about her son having something. BOM reviewed stored documents in her office and in the resident's chart and didn't have any current documentation or documents concerning advance directives for the resident. 3. On 12/20/17 at 5:17 p.m. review of Resident (R) #23's Advance Directives Checklist form revealed it was signed and initialed on 12/8/14 by the Personal Representative indicated the following: (a) I have not executed an Advance Directive and do not wish to discuss Advance Directives further at this time. (b) I have not executed an Advance Directive but would like to obtain additional information about Advance Directive. Information was provided. On 12/21/17 at 3:09 p.m. R#23 was queried concerning a document which specifies what actions should be taken for her health if she is no longer able to make decisions for herself because of illness. R#23 replied no one has ever talked to me about what I wanted to have done for me if I couldn't talk for myself or who I wanted to speak for me (that would be my aunt). I was really sick when I first came in here. Review of R#23's active clinical record revealed the resident was recently readmitted into the facility on [DATE] , with [DIAGNOSES REDACTED]. Resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating cognitively intact. On 12/21/17 at 3:36 p.m. an interview with the BOM concerning R#23's advance directive and if the facility reviewed and provided information to residents concerning their rights to formulate an advance directive. BOM replied If we have anyone's advance directive the documents are stored in the office or in the resident's chart. When asked about Advance Directives for R#23, after looking in the resident's chart and in the business office, she was unable to locate any current documentation or documents concerning advance directives for the resident. 4. On 12/22/17 at 11:04 a.m. Advance Directive checklist and Do Not Resuscitate (DNR) Consent form for R#38 were reviewed. R#38 signed the DNR Consent form on 3/11/13. Advance Directive checklist has resident initials by the following statement: I have executed an Advance Directive and will provide a copy to the facility. I understand that the staff and physicians of this facility will not be able to follow the terms of my Advance Directive until I provide a copy of it to the staff. Review of R#38's active clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Resident is cognitively impaired with a Brief Interview for Mental Status (BIMS) score of three (3). On 12/22/17 at 9.04 a.m. an interview with the BOM concerning R#38's Advance Directive, and whether the facility had attempted to obtain the resident's Advance Directive since the resident indicated upon admission that she had one. BOM stated I was responsible for filing the Advance Directive checklist in resident's chart and if they gave a copy of the Advance Directive or their Power of Attorney (POA), I kept that filed in my office. I am not responsible for following up on any paper work or talking to the resident about advance directives after they are admitted . After looking in the resident's chart and in the business office, she was unable to locate any current documentation or documents concerning advance directives for the resident. On 12/21/17 at 3:40 p.m. the Social Worker (SW) was queried concerning the facility's process for ensuring receipt of information and assistance with advance directive. When asked what type of follow-up occurs when someone indicates they have an advance directive, but the facility does not have a copy of it; and when and how often are advance directives reviewed with the residents. SW replied Advance Directive information is given when someone is admitted . I wasn't aware that I need to follow-up with the resident if they say they have an advance directive in order to get a copy or that advance directives should be reviewed. On 12/22/17 at 10:00 a.m. an interview was conducted with the Director of Nursing (DON) concerning the facility's Advance Directive policy and procedure. DON responded Advance Directive Checklist, means that the advance directive was reviewed and not necessarily is it the directive. Those who completed a code status are not interested in the advance directive that we reviewed. No one is assigned to follow-up with the family to obtain the Advanced Directive that they say they have. We also do not discuss the Advance directives at our Interdisciplinary Team meetings when we meet with residents or their family member(s).",2020-09-01
712,WARRENTON HEALTH AND REHAB,115321,813 ATLANTA HIGHWAY,WARRENTON,GA,30828,2017-12-22,812,F,0,1,3VI611,"Based on observations, interviews and review of temperature logs, it was determined that the facility failed to ensure 55 of 57 residents, who received food prepared in the kitchen, received food prepared, distributed, and served under sanitary conditions as evidenced by: broken or missing thermometers in the refrigerators and freezers, dirty and improperly dated storage bins, uncovered prepped food, a freezer with an out of range temperature and missing temperatures on the temperature record sheet. The findings include: An initial tour of the kitchen was conducted on 12/19/17 at 9:47 a.m. An observation was made of a white two-door reach-in refrigerator known as Fridge 2. There were two thermometers present. The thermometer located in the door registered a temperature of 45 degrees Fahrenheit (F). The thermometer located on the shelf registered 52 degrees Fahrenheit (F). No thermometer was in the freezer section of this refrigerator/freezer. An observation was made of a reach-in freezer known as Freezer 2. The thermometer located on the shelf registered 30 degrees F. The ice cream cups sitting on a tray in the freezer were soft to the touch. The frozen vegetables located in the back of the freezer were solid to the touch. An observation was made of the milk cooler located next to Freezer 2. No thermometer was in the cooler. An observation was made of the white reach-in freezer. The thermometer located in the door of the freezer registered a temperature of 70 degrees. The freezer contained all bread items, which were solid to the touch and cold. An observation was made of the dry storage room. The sugar bin was dated 11/20/17 with no use by date. The bin contained a large Styrofoam cup half buried in the sugar. The flour bin was dated 11/20/17 with no use by date. The corn meal bin was dated 11/20/17 with no use by date. The bin was lined with a black plastic liner that was discolored and had several small tears in it. An observation of the kitchen preparation area revealed two pans of un-cooked rolls on a bottom shelf of a prep table sitting on top of cooking pans. There was no covering over the rolls to protect the rolls from contamination. A second observation was made of the kitchen on 12/20/17 at 3:12 p.m. Fridge 2 had one thermometer which registered 42 degrees. The freezer section had a thermometer, which read 20 degrees. An observation was made of Freezer 2. The thermometer registered 31 degrees. No thermometer was in the milk cooler. An observation was made of the white reach-in freezer. The thermometer registered 70 degrees. The staff was alerted to low temperature readings and the missing thermometers. Kitchen employee AA was asked to provide the temperature logs for the kitchen. The documentation revealed that no temperatures had been taken for Fridge 2 or the white reach-in freezer from 12/1/17 through 12/20/17. The documentation revealed the temperature of Freezer 2 as 0 degrees from 12/1/17 through 12/20/17. The documentation revealed temperatures of 39 degrees on 12/19/17 and 41 degrees on 12/20/17 for the milk cooler. Kitchen employee AA was asked to locate the thermometer in the milk cooler. She could not locate the thermometer used to take the temperature in the milk cooler. Due to the absence of the Dietary Manager, the Maintenance director was interviewed on 12/20/17 at 3:50 p.m. He stated that all the food had been removed from the freezer and they were calling in a repair service to repair the condenser on Freezer 2. He also stated that all the thermometers in the kitchen had been replaced in the refrigerators and freezers.",2020-09-01
713,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2020-02-06,583,D,1,1,8OIS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interview, and review of the policy Resident Rights, dated February 2017, the facility failed to maintain privacy and confidentiality for four resident's (R) (R#71, R#91, R#47, and R#92), of 36 sampled residents, related to posting of signs regarding clinical and personal information in their rooms. Findings include: Review of the facility's policy entitled 'Resident Rights' with revision date: February 2017 revealed the following including but not limited to: The facility protects and promotes the rights of each resident. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. 1. Review of the Quarterly Minimum Data Set (MDS) for R#71 dated 1/1/20 revealed in section C a Basic Interview for Mental Status (BIMS) score of 00 indicating severely impaired cognition. Section D total severity mood score of 99 indicating R#71 was unable to communicate answers. Review of the care plan revised 1/10/2020 for R#71 revealed a focus for self care deficits related to Activities of Daily Living (ADL) for bathing, bed mobility, dressing, eating, and personal hygiene although there was no care plan in place related to maintaining privacy. During an observation on 2/03/2020 at 11:20 a.m. of R#71's room, a sign stating (in part), Reminders: Please & Thanks! Please keep tissues near the resident. Give water or juice, sipping cup or small cup. NO STRAWS. Offer it often. Prop with pillows on her right side, was observed sitting on the night stand next to her bed. During an observation on 2/04/2020 at 9:14 a.m. of R#71's room revealed the sign remains sitting on the night stand next to the bed of R#71. 2. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] for R#91 revealed in section C a Basic Interview for Mental Status (BIMS) score of 9 indicating moderate cognitive impairment. Section G Functional Status indicated R#91 it totally dependent for all Activities of Daily Living (ADL)s. Section H indicated R#91 is always incontinent of bowel and bladder. Review of the care plan dated 1/20/20 revealed no care plan in place related to providing privacy during Activity of Daily Living (ADL) care. During an observation on 2/04/20 at 10:50 a.m. of R#91's room, revealed a sign on the wall near the foot of the bed of R#91 stating, PLEASE DO NOT REMOVE CELL PHONE POWER CORD OR CELL PHONE OF R#91. THANK YOU! During an observation on 2/04/20 at 9:04 a.m. revealed the sign remains on the wall at the foot of the bed of R#91. 3. Review of resident (R) #92 Electronic Health Record (EHR) revealed an admission date of [DATE]. Record review of the Quarterly Minimum Data Set (MDS) assessment, dated 1/2/2020, with a BIMS assessment of 99 resident unable to complete interview. An observation on 2/3/2020 at 9:45 a.m. revealed posted signs in residents' room that include clinical personal care instructions posted on the wall. The sign was on an 8 x 11 piece of white paper typed with black ink and some instructions highlighted in yellow titled Strategies to Help Manage Slow Clearing of the Esophagus with ten bulleted areas. Also, located on the same wall on two 8 x11 piece of white paper typed with black ink and some instructions highlighted in yellow titled How often do you flush a Peg tube and hanging over the head of the resident's bed, one 8 x11 piece of white paper, revealed: 1/3/19 Staff, Resident in room this bed gets cold easily per family, please dress in a LONG sleeve shirt daily. Thanks!. An observation on 2/4/20 at 8:20 a.m. and on 2/5/2020 at 10:20 a.m. revealed the signs were still posted on the walls of the resident's room. An interview on 2/5/20 at 10:25 a.m. with the Unit Manager (UM) AA confirmed that the resident has signs posted on the walls, which are visible to others, with instructions on care of the resident's peg tube, and how to manage the resident's dysphagia. She also, comfirmed that the sign hanging over the resident's bed contained information on how to dress the resident. She revealed the signs should be covered. 4. Review of the Quarterly MDS Assessment, dated 12/19/19, revealed for R#47 had a BIMS assessment of two, indicating severe cognitive impairment. The resident was assessed to have minimal difficulty hearing, clear speech and makes self-understood and understands others. The resident was assessed as requiring extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. The resident was assessed as able to walk with the assistance of staff and requires supervision with eating and is incontinent of bladder with frequent incontinence of bowel. Record review revealed that the resident has the following Diagnoses: [REDACTED]. Review of the care plan with completed date of 12/4/19 revealed the resident had ADL deficits and requires physical assistance with bed mobility, eating meals, personal hygiene, toileting needs and transfers. The resident also had a care plan related to bowel incontinence that included to apply barrier cream to help protect residents skin. Check resident frequently and assist with toileting as needed and to provide perineal care after each incontinent episode. Observation on 2/3/2020 at 10:40 a.m. on the bulletin board above R#47's bed revealed a sign with instructions to each shift for resident's care typed in red letters The sign included: 7 - 3 shift check every two hours and if wet change him, keep water within reach, 'please make sure feces and food are not on the bed rails, floor or air unit, please allow him to walk to the restroom every two to three (2 to 3) hours and allow him to sit three to five (3 to 5) minutes, please bathe and allow him to brush his teeth and please make sure there is a bag in the hamper before placing his dirty clothes. please give him fluids with no ice (water, sweet tea, coffee with three sugars and three creamers or juice throughout the day. Observations on 02/04/2020 at 8:15 a.m., 02/05/2020 at 9:00 a.m. and on 2/5/2020 at 2:00 p.m. revealed the same signage posted on bulletin board above the resident's bed with instructions to each shift for resident's care in red letters. An interview with CNA BB on 2/5/2020 at 8:50 a.m. revealed that she felt it was okay for family members to put up signs in a resident's room that say to keep the resident turned but was unsure of the facility's restrictions about signs in a resident's room. An interview with CNA CC on 2/5/2020 at 8:55 a.m. revealed that he has worked at the facility since 1997 and doesn't see a problem if the family puts signs up in the resident's room letting staff know what to do for the resident. An interview with Charge Nurse DD on 2/5/2020 at 8:55 a.m. revealed that she didn't see anything wrong with signs being posted in a resident's room, letting staff know what they want for the resident. An interview with the Director of Nursing (DON) on 2/5/2020 at 9:00 a.m. revealed that there were signs posted in R#47's room and were placed there at the family's request. The DON further stated they tried to educate the family member regarding placement of the signs, but the family was adamant that the signs stay posted above the resident's bed, so they are visible to staff. The DON also stated the facility only posts the 'Ambassador' signs and the Activity Calendars in the resident's rooms.",2020-09-01
714,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2017-07-24,364,E,1,0,X3QK11,"> Based on resident interviews, family interview, staff interview, and document review the facility failed to serve food palatable for four (4) residents and failed to address the food concerns brought to attention in Resident Council Meetings. The residents were selected from a list of twenty five (18) interviewable residents. Findings include: Observation on 7/24/17 at 12:00 p.m. revealed no concerns for tray line temperatures for all menu items. Observation on 7/24/17 at 12:36 p.m. of West wing lunch meal service reveals no concerns with meal appearance or palatablilty. Residents appeared to enjoy lunch meal. Observaation on 7/24/17 at 1:00 pm with Dietary Manager and District Manager of Dietary Services of test tray. No problems with taste of roasted turkey, bread dressing, green peas, pasta, lima beans, or cranberry sauce. Barbeque pork cutlet appears overcook, pork cutlet is dry, no concerns for taste. Observation on 7/24/17 at 1:32 p.m. of East wing lunch meal service reveals no concerns with meal appearance or palatability. Interview on 7/24/17 at 11:25 a.m. with Dietary Manager (DM) revealed newly hired for position, only employed for a few weeks at this facility. Interview further revealed Bistro is no longer operating due to staffing issues. Interview also revealed facility began contract with a Dietary Service Company for dietary services beginning in (MONTH) (YEAR). Continued interview further revealed the DM has not had opportunity to attend Resident Council meetings to address resident concerns relating to food taste. Interview on 7/24/17 at 11:45 a. m. with the Resident Council president who had a Brief Interview for Mental Status (BIMS) score of fifteen (15) revealed that the Resident Council does meet monthly and the topic of food concerns was always discussed during the meetings. She revealed that the residents state the food has no taste, is not seasoned well and is overcooked. Interview on 7/24/17 at 11:52 a.m. with the Registered Dietician (RD) revealed facility utilizes a four (4) week menu cycle. Further interview revealed she is responsible for calculating caloric intake, weight concerns, and nutritional value. Continued interview revealed the RD was unaware of food complaints. Interview on 7/24/17 at 12:40 p. m. Certified Nursing Assistant (CNA) AA revealed resident's always complain that the food taste bad and has no flavor. Interview on 7/24/17 at 12: 50 p.m. with a family member of R#2, who has cognitive impairment, revealed that the resident often complains of taste of food. The family member revealed that he visits the resident at least five days per week and often comes to facility to feed her. The family member of R#2 revealed turkey and dressing that was served on the day of investigation is a popular well-liked by most residents including R#2, but most meals look horrible. Interview on 7/24/17 at 12:55 p.m. with R#3 who had a BIMS of fifteen (15) revealed lunch meal served the day of complaint investigation was decent, however most meals taste bad, and have no taste. Interview on 7/24/17 at 1:30 p.m. with R#4 who had a BIMS of fifteen (15) revealed turkey and dressing is always good, but most of the other meals taste really bad. Continued interview revealed no problems with food temperature, rather the food is just very bland and has no taste. Interview on 7/24/17 at 2:48 p.m. with the Administrator, who had only started at this facility one week ago, was unaware of the food concerns voiced by residents. Interview on 7/24/17 at 2:53 p.m. with the Director of Nursing (DON) revealed most of the problems with resident complaints regarding food taste started when the current owner took over from the previous owner and began contracting dietary services. The DON confirmed that the facility has done nothing to address the complaints of resident concerning food taste. Review of the resident council minutes for the last four (4) months was completed and revealed a consistent concern for resident complaints about food taste, choices, and food temperature each month. Residents reported food is ofter overcooked or undercooked, cold eggs and coffee, and desires for new food choices such as sweet potatoes and hot dogs. Review of grievance log for past four (4) months revealed grievance filed relating to food on 2/3/17 and 3/5/17. The grievance filed on 2/3/17 revealed it was related to concerns with food choice and selection and diet. The grievance filed on 3/5/17 revealed it was related to the concern that food is always cold.",2020-09-01
715,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2018-08-09,880,D,0,1,V58711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review and review of the facility's policy titled, Infection Prevention Manual for Long Term Care, the facility failed to ensure staff members followed contact isolation precautions in the care of one residents (R) ( R#294) and proper hand hygiene in the care of R#294 out of a sample of 25 residents. Findings include: 1. During observation of the West Wing on 8/8/18 at 10:30 a.m. Certified Nurse Aide (CNA) FF was observed exiting R#294's room carrying a used meal tray without gloves. CNA FF walked from the West Wing to the main hall way and placed the tray onto the dirty tray cart. On the outside of R#294's room there was a sign displayed to the right of the door which noted Please see nurse before entering. There was also a yellow isolation bag hanging on the outside of the door that was stocked with gowns, boxes of gloves, and face masks. 2. At 10:31 a.m. on the same day, after placing the used meal tray of R#294 onto the dirty tray cart, CNA FF was observed walking back onto the West Wing and using hand sanitizer located on the wall. CNA FF then entered another resident's room and closed the door. A review of R#294's lab report from Clinical Laboratory Services, Inc. indicated a stool sample was drawn on 7/29/18 at 11:45 a.m. and a [MEDICAL CONDITION] (C. Diff) panel was done. The results of R#294's stool sample was received on 7/30/18 at 9:36 a.m. The lab report indicated [DIAGNOSES REDACTED] (GDH) AG positive and [DIAGNOSES REDACTED] Toxin A/B positive. An interview was conducted with Licensed Practical Nurse (LPN) DD on 8/8/18 at 11:38 a.m. regarding her understanding of what to do when exiting the room of a resident on contact isolation for [MEDICAL CONDITION]. LPN DD stated, take gown and gloves off and wash hands before leaving the room. Inquired of LPN DD if it was ok to use hand sanitizer instead of washing hands. LPN DD replied, you must wash your hands with soap and water due to there are certain spores that hand sanitizer does not kill. An interview was conducted with CNA FF on 8/8/18 at 11:40 a.m. regarding her understanding of contact precautions in caring for residents who have [MEDICAL CONDITION]. CNA FF stated, she would put on a gown and gloves. She further stated that before she left the room, she would discard any used items into the red bin and wash her hands. CNA FF was asked if she were to enter R#294's room to take out a used meal tray what would she do. CNA FF stated, she would put on gloves to pick up the tray and after returning the tray to the dirty meal cart she would wash her hands. Inquired of the CNA if she could use hand sanitizer instead of washing her hands. CNA FF stated, no that she must wash her hands if she touched anything in the resident's room. CNA FF confirmed that R#294 was on contact precautions for [DIAGNOSES REDACTED]. CNA FF was asked how was she aware of this resident being on contact precautions for [DIAGNOSES REDACTED]. She stated, it was discussed in morning report. She further stated, you also see the yellow isolation bag on the door and the sign that states report to the nurse before entering. Informed CNA FF that she was observed walking to the cart with R#294's tray and after placing the tray onto the cart using hand sanitizer. CNA FF stated, that she was sorry and maybe the call light was ringing and she did not wash her hands. She further stated, she knew that she was supposed to wash her hands. An interview was conducted with the Infection Control Nurse/Assistant Director of Nursing (ADON) on 8/8/18 at 1:43 p.m. regarding education given to staff on infection control in regards to [MEDICAL CONDITION]. ADON stated, an in-service was given on 5/17/18. ADON stated, the in-service was given by her to the nursing and housekeeping staff. ADON stated she discussed personal protective equipment (PPE) and washing hands with soap and water. ADON stated, she emphasized handwashing because [MEDICAL CONDITION] lives on surfaces and that hand sanitizer is not effective in killing the [DIAGNOSES REDACTED] spores. She stated, in regards to nursing staff she discussed exercising contact precautions to include proper PPE of gown and gloves in caring for the resident as well as discarding used items in a red bag. Questioned the ADON regarding her expectations for a staff member who retrieved a used meal tray from the room of a resident on contact precautions for [MEDICAL CONDITION]. ADON stated, if they did not do actual care and did not have contact with the resident then they could use PPE to include gloves. She further stated, after the staff member put the tray on the dirty food cart the staff member should wash their hands with soap and water. An interview was conducted with on 8/8/18 at 2:31 p.m. with Unit Manger (UM) AA regarding her understanding and expectation of staff in regards to residents on contact precautions. She stated, that she expected that whatever precautions it is for that resident for the staff to use proper PPE and if they are unsure of what PPE to use that the staff should see a nurse. Questioned her in regards to residents on contact precautions with [MEDICAL CONDITION] and what expectations are for this type of contact precaution. UM AA stated, gown and gloves for resident contact and if they are not providing any resident care then they may wear gloves only. UM AA further stated, in exiting the room the staff should wash their hands. Inquired of her if staff were removing a meal tray from resident's room what would she expect them to do. She stated, the staff should put on gloves in removing the tray and once the tray is placed on the empty food cart the staff should wash their hands. Asked her if it would be ok for the staff to use hand sanitizer instead of handwashing. She stated, in regards to [MEDICAL CONDITION] we always train staff to do handwashing because sanitizer does not kill the spores. An interview was conducted with the Director of Nursing (DON) on 8/8/18 at 2:38 p.m. in regards to her expectations of staff regarding residents on contact precautions. The DON stated, she expects staff to follow the protocols we set up. The system outside the door should include them knocking before entering and placing on required PPE. Questioned her on if a staff were taking a meal tray into the room of a resident on contact precautions. She stated, put gloves on to take tray in if they are not doing anything to the resident then they do not need a gown. She was asked if a staff were taking a tray out of the resident's room in which the resident had finished her meal, what would she expect. The DON stated in retrieving the tray they should have on gloves. After they put the tray on the dirty cart they should discard their gloves and wash their hands with soap and water. An interview was conducted on 8/8/18 at 5:07 p.m. with the ADON/ Infection Control Nurse regarding training that CNA FF received on infection control in regards to contact precautions. She stated, CNA FF has not been here long. She started on 5/4/18 and went through Facility New Hire Orientation on 6/13/18. She stated, all new hires are educated during orientation on contact precautions. An interview was conducted with CNA FF on 8/9/18 at 10:49 a.m. regarding the training she received on caring for residents on contact precautions. CNA FF stated, she just started and that she has been here about two and a half months. CNA FF further stated, she did get training but she did not remember the date. She stated again, she knew that she did get it. Record review of the facility's policy titled Infection Prevention Manual for Long Term Care with a revision date of 2/18 documented the following: [NAME] Contact Precautions It is the intent of this facility to use contact precautions in addition to standard precautions for residents known or suspected to have serious illnesses easily transmitted by direct resident contact or by contact with items in the resident's environment. Hand hygiene should be completed prior to donning gloves; gloves should be worn when entering the room and while providing care for the resident; gloves should be removed before leaving the resident's room and hand hygiene should be performed immediately; after glove removal and hand hygiene, hands should not touch potentially contaminated environmental surfaces or items. A gown should be donned prior to entering the room or resident's cubicle; the gown should be removed before leaving the resident's room; after removal of the gown, clothing should not contact potentially contaminated environmental surfaces. Contact Precautions will be considered for multi-drug resistant organisms; scabies; [MEDICAL CONDITION] and other infectious causes of diarrhea; uncontained draining wounds. B. [MEDICAL CONDITION] Contact precautions while having diarrhea and until [DIAGNOSES REDACTED] is ruled out; extend contact precautions to 48 hours after diarrhea resolved. Special Considerations-wash hands with soap and water; do not use an alcohol handrub. Alcohol-based hand rubs are not effective in killing [DIAGNOSES REDACTED]icile spores; [DIAGNOSES REDACTED]icile is a spore-forming organism; environmental contamination frequently occurs.",2020-09-01
716,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2018-08-09,908,D,1,1,V58711,"> Based on observation, interview, review of facility data and review of manufacture's manual, the facility failed to perform routine maintenance on air flow mattress pumps that contained an external filter. This failure had potential to negatively affect five (5) of eight (8) residents (R), R#25, R#34, R#46, R#48, and R#59 that were using this type of therapy mattress. The facility census was 89. The resident sample size was 25. Findings include: An observation was conducted on 8/7/18 at 3:15 p. m. of all resident's in the facility with air flow type mattresses after another surveyor noticed a dirty filter on the air mattress pump for R#25. This was observation was confirmed, and eight (8) beds were observed to have this type and/or brand of air mattress that had air flow pumps with external filters. Three (3) of the eight (8) mattress pumps had filters that were observed to be either clean or black in color; five (5) of the filters were light gray in color with a thick amount of gray appearing dust/dirt, with the potential to impede air flow. During an interview on 8/8/18 at 8:00 a. m. with Central Services Clerk HH in the Central Services (CS) office, she confirmed that resident air mattresses are ordered by her. She explained that she receives a call from the Supervisor to obtain an air mattress, then she contacts the bed mattress vendor, confirming that they have a contract with them for mattresses. She confirmed they set up the beds and do repairs on them. When asked, who is responsible for the filters on the air mattress pumps, she stated she would check into it, that her department doesn't do that. She stated that once the bed is set up, the nursing staff will report or call if any air flow problems come up. During an observational tour on 8/8/18 at 9:30 a. m. of resident rooms with the Maintenance Director, he confirmed that there are two types of air mattresses in use. He stated that their contract vendor provides the non-filter type of air flow mattress; but the filter type air flow mattress and pumps are owned by the facility. When asked, who is responsible for cleaning the filters, he confirmed that maintenance was responsible, he confirmed it wasn't housekeeping's responsibility. The Maintenance Director agreed the filters were dirty, he removed five (5) filters and washed them and reapplied them into the pumps during the tour of the rooms. Filters are black in color when clean; all five (5) filters were observed to be light gray in color, with dust/dirt by observation prior to washing. These filters were changed by the Maintenance Director on five (5) resident air mattress pumps; on mattresses for R#25, R#34, R#46, R#48 and R#59. When asked whether maintenance does routine checks, makes rounds, or keeps a maintenance log on these types of air mattress pumps, he confirmed he does not, he stated that he guessed they dropped the ball in checking the filters. A review was conducted of a facility provided maintenance form entitled, Log Book Documentation, dated 7/30/18, under Preventative Maintenance, section #10, inspect beds and other furnishing for proper operation and repair as needed, documentation indicates this was done 7/23/18. Review of the manufacture's manual for the care and maintenance of the air flow mattress with a filtered pump, documents a warning on page two (2) section #4, Warning: to reduce the risk of burns, shock, fire, or personal injury, adhere to the following instructions. Failure to do so could result in personal injury or equipment damage. Section #4 documents Never block the air openings of the product. Do not place the control unit (controls are located on the face of the pump) on a surface, such as a bed or couch, where the air opening and/or filter compartment, located on the back of the control unit may be blocked. Keep the air openings free of lint and hair. On page #12 in the manual, the section titled Filter Cleaning documents to Check the air filter on the rear of the unit regularly for buildup of dust/dirt. If buildup is visible, turn off the control unit and disconnect the power cord from the wall outlet. Remove the filter by grasping the filter pulling outward. Replace with the second supplied filter. Ensure the replaced filter covers the entire filter region. Hand-wash the removed filter in warm soapy water and allow to air dry. When dry, store the filter in a safe place for the next filter maintenance.",2020-09-01
717,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2017-09-21,280,D,0,1,6G1L11,"Based on record review, family and staff interviews, the facility failed to invite the responsible party to one resident's (R) (R Q) care plan meetings. The sample size was 32 residents. Findings include: During interview with a family member of R Q on 9/18/17 at 3:23 p.m., she stated that she had not been invited to attend the resident's care plan meetings since the resident was first admitted , and that this was something that she would like to attend. Review of the only Interdisciplinary Care Plan Meeting Attendance Sheet found in the active clinical record was dated 4/10/15, and noted R Q and her family member/responsible party attended. During interview with the Minimum Data Set (MDS) Coordinator on 9/20/17 at 3:20 p.m., she stated that the Social Services Director (SSD) was responsible for inviting the resident and the family to the care plan meetings. During interview with the Social Services Assistant on 9/21/17 at 9:54 a.m., she stated that the SSD left employment with the facility about five weeks ago. During further interview, she stated that if a resident was due for an MDS assessment, she would talk to the family to set up the care plan meeting either in person or by phone, as well as invite the resident. She further stated that she had worked at the facility for about five months, and didn't recall R Q's family member being invited to attend a care plan meeting. She verified that R Q had MDS assessments done on 5/27/17, 6/5/17, and 6/24/17, and that care plan meetings would have been held for all of them. During interview with the Social Services Assistant on 9/21/17 at 10:18 a.m., she stated that whenever there was a care plan meeting, the attendance was documented on an Interdisciplinary Care Plan Meeting Attendance Sheet, but that she was not able to find any of these forms for the past year for R Q. During interview with the interim Director of Nursing on 9/21/17 at 11:15 a.m., she stated that they were aware of concerns with residents and families not being invited to attend care plan meetings, and that there had been several SSD recently, and the previous SSD was not inviting the resident and/or family to the meetings. Review of MDS transmitted to the State Survey Agency for Resident Q revealed the following MDSs had been completed: Quarterly MDSs on 8/26/16, 11/26/16, 5/27/17, 6/5/17, and 6/24/17; an Annual MDS on 2/24/17; and a Significant Change MDS on 8/1/17. DONE",2020-09-01
718,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2017-09-21,282,D,0,1,6G1L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident and staff interview, the facility failed to follow the plan of care related to pain management for one resident (#51). The sample size was 32. Findings include: Review of the clinical records for Resident (R)#51 revealed a current [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set MDS) assessment, a quarterly, dated 8/14/17 revealed the resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On the quarterly MDS assessment of 8/14/17, R#51 was also assessed as receiving scheduled pain medications, receiving no non-medication interventions for pain, and experiencing severe pain almost constantly that could affect day-to-day activities and/or make it difficult to sleep at night. A review of the R#51's plan of care for chronic pain related to chronic pai[DIAGNOSES REDACTED], last updated 8/24/17 revealed interventions such as: anticipate the resident's need for pain relief and respond immediately to any complaints of pain; evaluate the effectiveness of pain interventions; observe/document for side effects of pain medication; observe/record pain characteristics during rounds and as needed: Quality (e.g. sharp); Severity (1 to 10 scale); observe/record/report to the nurse the resident complaints of pain or requests for pain treatment. A review of the clinical records for R#51 revealed she returned from a leave of absence to visit her family on 9/15/17. A further review of the resident's clinical records revealed that the resident's scheduled pain medication - [MEDICATION NAME] 5-325mg was not dispensed by the remote pharmacy system with the resident's other prescribed medication between 9/15/17 at 9:24 p.m. and 9/17/17 at 3: 53 p.m. due to the unavailability of a current written prescription. During this time, the staff did not: anticipate the resident's need for pain relief by having the resident's scheduled pain medication available; respond immediately to complaints of pain; offer other available pain management interventions such as PRN pain relief, except for one instance on 9/17/17.",2020-09-01
719,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2017-09-21,309,D,0,1,6G1L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and resident, staff, and pharmacy interview, the facility failed to follow orders related to pain medication and failed to effectively manage the pain of one resident (#51) by immediately addressing barriers to having the resident's pain medication available to administer when scheduled and offering as needed pain medication. The sample size was 32. Findings include: Review of the clinical records for Resident (R)#51 revealed a current [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set MDS) assessment, a quarterly, dated [DATE] revealed the resident was assessed as having a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. On the quarterly MDS assessment of [DATE], R#51 was also assessed as receiving scheduled pain medications, receiving no non-medication interventions for pain, and experiencing severe pain almost constantly that could affect day-to-day activities and/or make it difficult to sleep at night. A review of the R#51's plan-of-care for chronic pain related to chronic pai[DIAGNOSES REDACTED], last updated [DATE] revealed interventions such as: administer pain medications prior to treatments and therapy, if indicated; anticipate the resident's need for pain relief and respond immediately to any complaints of pain; evaluate the effectiveness of pain interventions; observe/document for side effects of pain medication; observe/record pain characteristics during rounds and as needed: Quality (e.g. sharp); Severity (1 to 10 scale); observe/record/report to the nurse the resident complaints of pain or requests for pain treatment. A review of the census history for R#51 revealed she was placed on Leave of Absence (LOA) from [DATE] and returned to the facility on [DATE] A review of the nurses' notes of [DATE] documented resident went on LOA on [DATE] at 8:00 p.m. to visit her daughter and that resident had medications to last until 1800 (6:00 p.m.) on [DATE]. A review of orders administration notes from [DATE] through [DATE] revealed the following was documented: [DATE] at 9:24 p.m. - Awaiting pharmacy to release medications. [DATE] 2:55 a.m. - [MEDICATION NAME] Tablet ,[DATE] mg, give 1 tablet by mouth every 6 hours for pain scheduled, medication unavailable, waiting for pharmacy. [DATE] at 7:12 a.m. - [MEDICATION NAME] Tablet ,[DATE] mg, give 1 tablet by mouth every 6 hours for pain scheduled, medication unavailable. A review of the nurses' notes for [DATE] at 6:32 p.m. revealed documentation that the nurse called the on-call nurse practitioner who advised that she was unable to generate a hard script for the medication, and the matter would need to be followed up with the MD's office during business hours on Monday. The note also documented that the resident was notified of this development. A review of orders administration notes from [DATE] revealed the following was documented: [DATE] at 12:09 a.m. - [MEDICATION NAME] Tablet ,[DATE] mg, give 1 tablet by mouth every 6 hours for pain, scheduled, meds not available waiting from pharmacy [DATE] at 6:09 a.m. - [MEDICATION NAME] Tablet ,[DATE] mg, give 1 tablet by mouth every 6 hours for pain, scheduled, not available from pharmacy [DATE] 12:47 p.m. - [MEDICATION NAME] Tablet ,[DATE] mg, give 1 tablet by mouth every 6 hours for pain, scheduled, waiting on pharm [DATE] 1:50 p.m. - Tylenol Tablet 325 mg, give 2 tablets by mouth every 6 hours as needed for mild pain or fever >100.5, PRN Administration was: Effective Interview on [DATE] at 11:15 a.m. with the pharmacist revealed if a resident returned from LOA with a scheduled pain medication such as [MEDICATION NAME] ,[DATE], this medication should be immediately available to the resident upon return. If, for some reason, the medication is not immediately available in the facility, the nurse can receive a stat order from the pharmacy which should arrive at the facility within two hours. The pharmacist was not sure what had occurred in this instance, but would look into the matter. Re-interview on [DATE] at 11:39 a.m. with the pharmacist revealed she had spoken to the pharmacy technician and this is what she believed had occurred: R#51 had a prescription for the [MEDICATION NAME] which expired on [DATE]. The MD- Dr. Frinks sent a PRN order for the [MEDICATION NAME] instead of a scheduled med order on [DATE] and the order was put in as such. When the resident returned from LOA on [DATE], [MEDICATION NAME] was not dispensed from the remote pharmacy system with the resident's routine medications; the nurse called the pharmacy and the pharmacy released the medications again; when the nurse contacted the pharmacy again and again to say the [MEDICATION NAME] had not been dispensed, the technician checked the prescription on file and noted that it was a PRN, not a routine medication order; at that point, the resident's physician was contacted and a prescription for the medication as a scheduled administration was obtained; the pharmacy then released the [MEDICATION NAME]. Interview on [DATE] at 4:00 p.m. with Licensed Practical Nurse (LPN) FF, ,[DATE] p.m. nursing supervisor revealed the resident returned from LOA late on [DATE]. He believes the resident arrived at the facility sometime after 6:00 pm. He was informed by the floor nurse that the resident's medications were not dispensed by the medication system/machine. He immediately called the pharmacy and was informed that the resident was showing as discharged in their system; the pharmacy would put her back into the system, but they needed copies of her orders to do so. LPN FF faxed this information to the pharmacy. When he returned to work on [DATE] on the ,[DATE] shift, he was informed by nursing staff that nursing staff that the resident's other medications were being dispensed by the pharmacy system, but the resident's scheduled pain medication was still not being made available for administration; LPN FF again called the pharmacy and was informed by pharmacy staff the resident needed a written prescription for the [MEDICATION NAME]; LPN FF next called the on-call nurse practitioner who informed him that the she could not obtain a new hard script for the medication until the following Monday. She did not have access to a hard copy of the prescription that needed to be sent to the pharmacy by the physician. The nursing supervisor informed the resident and the R#51's daughter that the pain medication would not be available and that staff would resolve as soon as possible on Monday. He recalls the resident was upset and said she had been on the medication for a while. LPN FF said he was told by the floor nurse that the resident had a PRN order for Tylenol 325 mg every 6 hours. He believes the nurse may have offered this PRN pain medication (Tylenol) to the resident, but is not sure. When the nursing supervisor came in on the 3:00 p.m. to 11:00 p.m. shift on Sunday, [DATE], he learned from staff that the resident's [MEDICATION NAME] medication was still not available. At that time, he called the pharmacy again spoke with the pharmacy personnel who said they could not proceed without a prescription. However, he reminded the pharmacy staff that the resident had been on this scheduled medication for some time, they were able to release three [MEDICATION NAME] pills for the resident on Sunday afternoon and the resident was administered one of these pills. The nursing supervisor, LPN FF said he does not recall whether [MEDICATION NAME] was listed as either a PRN or scheduled medication on the resident's order that he pulled and faxed to the pharmacy on Friday evening - [DATE]. He is not aware of another similar situation on the weekend and is not aware of any protocol for such a situation. He did not call the Medical Director or the Director of Nursing (DON). Review of the (MONTH) Medication Administration Record [REDACTED]. Review of the pharmacy dispense report for [DATE] revealed that three [MEDICATION NAME] ,[DATE] mg were dispensed for the resident at 3:53 p.m. on [DATE]. Interview on [DATE] at 5:00 p.m. with R#51 revealed she returned to the facility late on [DATE] and was informed by the night supervisor, LPN FF, that her pain medication was not available. She did not get her regular pain medication until 4:30 p.m. on Sunday, [DATE]. She said she was hurting all weekend. The resident said she only remembers being offered and having received PRN Tylenol only one time that weekend. She is not sure if this was on Saturday or Sunday. Review of the clinical records for R#51 revealed a pain level of zero was documented on [DATE] at 12:27 p.m.; pain level of 3 was documented on [DATE] at 12:47 p.m., and a pain level of 2 was documented on [DATE] at 5:50 p.m. Interview with the Director of Nursing (DON), CC, on [DATE] at 5:15 p.m. revealed that, if a resident returned from leave or is readmitted in the evenings or on the weekends and medications are not available/dispensed by the remote pharmacy system, nursing staff should contact the pharmacist and provide whatever documentation is required by the pharmacist to have the resident's medications dispensed. If a narcotic is involved, the pharmacist should call the resident's doctor for a written prescription. If a written prescription is not immediately available, the pharmacist can and should get a verbal order from the resident's doctor for a small quantity of those narcotics until a written order is available. If the pharmacist insists on a written prescription and the Physician is not available, the staff can reach out to the Medical Director or call the DON who would reach out to the Medical Director for a written prescription for the resident to receive his/her pain medication. Under no circumstances should the resident have to wait until the weekend is over to receive their pain medications to be released for administration.",2020-09-01
720,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2017-09-21,323,E,0,1,6G1L11,"Based on observation and interview, the facility failed to assure electrical safety in 10 rooms on two of two wings where an electrical power strip was used to provide electricity to multiple medical devices. Extension cords were connected to power strips in two of 10 rooms, supplying electricity to resident's personal equipment. The census was 92 residents. Findings include: 1. Observation on 9/19/17 at 4:32 p.m., on the West Wing, revealed eight resident rooms with power strips affixed to the wall and plugged into an electrical outlet near each hospital bed. Connected to the power strips and supplying electrical current were hospital beds, oxygen concentrators, feeding pumps, and floatation air mattress pumps. 2. Observation on 9/19/17 at 4:32 p.m., on the West Wing, room 1-1, revealed a power strip sitting on the floor at the right side of the bed. The power strip was plugged into electrical outlet on the wall and supplying electricity to multiple electrical items. 3. Observation on 9/19/17 at 4:32 p.m., on the West Wing, revealed rooms 10-1 and 15-2, to have an extension cord in use, plugged into a power strip, draped across the wall and connected to resident's personal televisions. 4. Observation on 9/19/17 at 4:43 p.m., on the East Wing, revealed two resident rooms with power strips affixed to the wall and plugged into an electrical outlet near each hospital bed. Connected to the power strips and supplying electrical current were hospital beds and oxygen concentrators. 5. Observation on 9/19/17 at 4:43 p.m., on the East Wing, room 33-2, revealed an extension cord, plugged into a power strip, draped along baseboard of floor, connected to residents mini-fridge. Interview on 9/20/17 at 5:04 p.m. with Maintenance Supervisor, stated the facility is old and they are making improvements a little at a time. He stated the fire Marshall told him the facility could not use extension cords to plug in electrical equipment, but they could use surge protectors, so the facility will need to purchase extra surge protectors. Interview on 9/21/17 at 7:45 p.m., with facility Administrator, stated the facility did not have a policy on the use of power strips. He further stated there were not any waivers for the use of power strips as extra electric outlets for the facility. He stated the Fire Marshall did not have a problem with the power strips being in use.",2020-09-01
721,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2017-09-21,371,E,0,1,6G1L11,"Based on observation, record review and interview, the facility failed to maintain sanitary conditions in the dietary kitchen with unlabeled/undated powdered product and unidentifiable and unlabeled frozen casserole with use by date of 9/7/17 in the walk-in freezer. Microwave oven had dried food particles on the inside roof and sides of the oven and staff stored personal food items in walk-in cooler. Resident food pantry's on two of two Wings were noted to have multiple opened/unlabeled items along with personal food items stored in refrigerator and non-food items stored on top of refrigerators. The census was 92 residents. Findings include: Observation on 9/18/2017 at 10:40 a.m., in the main kitchen revealed a plastic storage container with white flaky dry product unlabeled and undated. Observation on 9/18/17 at 10:50 a.m., revealed microwave oven in the main kitchen had dry crusty food particles on both sides and on the roof of the oven. Observation on 9/18/2017 at 11:15 a.m., revealed an unidentified and unlabeled frozen casserole in downstairs walk-in kitchen freezer with foil covering peeled off with a use by date on this product was 9/7/17. Observation and interview, with the Food Service Manager (FSM), on 9/18/2017 10:14 a.m., revealed staff members personal pint of coffee creamer in downstairs walk-in cooler unlabeled and undated which was verified at this time by the FSM that the coffee creamer belonged to staff. Observation on 9/19/7 at 10:29 a.m., revealed microwave oven in the main kitchen remained dirty with dry crusty food particles on inside roof and both sides. Observation on 9/20/17 at 9:33 a.m., West Wing resident pantry revealed staff food items (Popeye's chicken) in fridge, multiple unopened/unlabeled bottles of water in bottom storage drawer, top of fridge dusty and brown bag with clothing item on top. Walls in West Wing resident pantry are dirty with dried brown material, around trash can. These observations were verified by DON DD on 9/21/17 at 10:42 a.m. Observation on 9/20/2017 2:31 p.m., East wing resident pantry revealed unidentifiable food baggie in freezer, unlabeled with no date, unlabeled opened bottles of water x's 2, Feel Good nutritional drink in fridge unlabelled, microwave oven, in East wing resident pantry, was dirty with dried food particles and dark stains on inside walls and unlabeled insulated lunchbox on top of fridge. Interview on 9/18/17 at 10:41 a.m., with Food Service Manager (FSM), stated the contents in the plastic storage container was mashed potatoes. He had staff make a label for container. He stated he could not identify the frozen casserole dish and didn't know why it was put in freezer. He immediately discarded the item. He further stated staff are not supposed to place personal items in any of the facility coolers or freezers. He removed the coffee creamer and discarded it. He stated staff just used the microwave oven in the main kitchen, when surveyor pointed out the microwave oven is in exact same condition it was observed to be in the previous day. Interview on 9/20/17 at 9:30 a.m., with FSM stated that microwave has been removed from kitchen. Interview on 9/21/2017 at 10:42 a.m., with DON, DD stated that each shift is to make sure the pantry's are cleaned at the end of each shift. She stated there is not a specific list of cleaning tasks that are to be done, but they are just told to keep it clean. She further stated that the 11-7 shift is the last shift responsible, as there is more of an opportunity for them to clean because it is less busy. The 11-7 shift checks and records the temperatures for the freezer and fridge daily. Review of the facilty Policy titled Food Storage dated (MONTH) 2014, indicated that The Food Services Director insures that all food items are stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of HealthCare Service Group Policy titled Cold Food Storage indicated that foods placed in refrigerator must be used within three days and that all items placed in refrigerators must be labeled and dated. Items not labeled will be thrown out and any food more than three days will be thrown out.",2020-09-01
722,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2017-09-21,511,D,0,1,6G1L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, and radiology employee interview, the facility failed to obtain the results of an ordered chest x-ray (CXR) in a timely manner for one resident (R) (#157), who was complaining of shortness of breath. The sample size was 32 residents. Findings include: Review of R #157's closed clinical record revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital History and Physical dated 7/14/17 revealed the resident developed a pneumothorax that necessitated chest tube placement. Review of her risk for altered respiratory status/difficulty breathing related to a recurrent right pleural effusion, status/post right pneumothorax with chest tube, right [MEDICAL CONDITION], and sleep apnea care plan revealed an intervention to observe for signs and symptoms of respiratory distress and abnormal breathing patterns, and report to the physician as needed. Review of a Medical Attending physician progress notes [REDACTED].#157 had a right pleural effusion, shortness of breath, a loud cardiac murmur, and was on [MEDICAL TREATMENT] due to [MEDICAL CONDITION]. Review of the Plan on this progress note revealed for the resident to have a CXR, and oxygen as needed. Review of physician's orders [REDACTED]. Review of nursing progress notes dated 8/7/17 at 3:43 p.m. revealed the physician visited and R #157 complained of shortness of breath, and a new order was received for a CXR. Review of the portable CXR report results done 8/7/17 noted R #157 had a large right pleural effusion, and possible increased density involving the medial right lung apex as well. Further review of the CXR results revealed a dense consolidation involving right perihilar region and medial right lung apex. Further review of the report revealed the CXR was read by the radiologist at 11:02 p.m. on 8/7/17, with a large notation of ALERT printed across the page. Further review revealed a handwritten notation on the report that the results were reported to the attending physician on 8/8/17, with a new order to send to emergency room (ER). Review of an SBAR (Situation-Background-Assessment-Request) Follow up dated 8/8/17 at 10:15 a.m. revealed that R #157's CXR results were received and reported to the physician, and an order was obtained to send her to the hospital ER. Review of a handwritten entry on a Transfer/Discharge Report dated 8/8/17 revealed that the resident had a CXR done on 8/7/17 due to complaints of shortness of breath, and the results revealed a large right pleural effusion with dense consolidation involving the right perihilar region, and that the physician ordered to send the resident to the ER. During interview with Licensed Practical Nurse (LPN) Unit Manager AA on 9/21/17 at 8:20 a.m., she stated that R #157's CXR was ordered by the physician at 2:00 p.m. on 8/7/17, and that per the printing on the top of the CXR report, the CXR was read by the radiologist at 11:02 p.m., and the results were received by fax from the radiology provider on 8/7/17 at 11:21 p.m. She further stated that she thought that when a radiology report had a notation of ALERT across it, that the radiology provider called the facility and spoke to a nurse to ensure they were aware of the result, but could find no evidence that this was done. She further stated that the physician had not ordered the CXR to be done stat or ASAP (as soon as possible), so it was just requested to be done that day. LPN AA stated that if the resident had appeared to be in distress or extremely short of breath, they would have sent her immediately to the ER. LPN Unit Manager AA stated that she discovered R #157's CXR report when she came on duty the next day on 8/8/17, and immediately reported the result to the ordering physician, who ordered for the resident to be sent to the ER. During continued interview, she stated that when something like a CXR was ordered, that it should be discussed in the shift-to-shift nursing report so that the oncoming shift was aware of the order and could watch for the results. She stated that the charge nurse and/or nursing supervisor was responsible for checking the fax machine for any results, and could provide no evidence that this was done. During interview with customer service representative BB from the facility's mobile radiology provider on 9/21/17 at 9:13 a.m., she stated that the radiology technician did R #157's CXR on 8/7/17 at 5:27 p.m., and verified the CXR was read by the radiologist at 11:02 p.m. and faxed to the facility at 11:21 p.m. that night. During further interview, she was not able to determine if anyone from the radiology provider had called to notify the facility staff of the CXR results. During interview with the interim Director of Nursing (DON) on 9/21/17 at 10:10 a.m., she stated that any pending diagnostic test results should be communicated to the oncoming shift so they could watch for it. She further stated she was not aware of any facility policy that addressed this, but that her expectation was for staff to look for test results and address any abnormal results in a timely manner. The DON further stated that a CXR result of a pleural effusion should definitely have been called to the physician as soon as it was received. DONE",2020-09-01
723,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2018-10-30,600,D,1,0,RWWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff and resident interviews and policy reviews, the facility failed to ensure one Resident, (R)#1, out of three sampled residents was free from verbal abuse by not reporting the resident's allegation of verbal abuse to the State Agency (SA). In addition the facilty continued to assign the alleged perpetrator to provide direct care for R#1 and assigned to the resident's general living area after the allegation was made. Findings include: On 10/29/18 at 12:05 p.m. R#1 was interviewed in her room. She stated she had lived in the facility for five years. She stated about two weeks ago, during the day shift, two Certified Nursing Assistants (CNAs), BB and CC, were assisting her to her wheelchair from her bed, using a Hoyer lift. She stated CNA BB would not listen to her about the placement of the straps on the lift sling. She stated the main thing that caused her pain was the unnecessary transfer of her to the wrong chair. She stated when she complained to CNA BB she said God wouldn't like it hearing you talk that way. R#1 then stated this hurt her feelings and made her angry. She stated CNA BB also got the wrong wheelchair. She stated she had two wheelchairs, one manual, and one electric, and CNA BB got the manual chair. R#1 stated CNA BB blamed her for her complaint of pain. She stated CNA BB had been assigned to her direct care one time since the incident. She stated she told the Activities Director (AD), who told the Administrator. Review of the undated face sheet revealed R#1 was admitted to the facility in 2013. Review of R#1's undated [DIAGNOSES REDACTED]. Review of R#1's Quarterly Minimum Data set (MDS), dated [DATE], section C, revealed a brief interview for mental status (BIMS) score of 15, signifying intact cognition. Review of section [NAME] of this same MDS revealed R#1 had behavioral symptoms every one-to-three days such as threatening, screaming, or cursing. Review of section G of the MDS revealed R#1 required extensive assistance for nearly all of her activities of daily living (ADLs), and was totally dependent on caregivers for toileting, transfers, and bathing, and she was non-ambulatory. Further review of this MDS, section H, revealed R#1 had an indwelling catheter and was always incontinent of bowel. On 10/30/18 at 12:20 p.m. CNA CC was interviewed in the conference room. She stated R#1 was not upset during the transfers. She stated further she shortly afterwards saw R#1 crying in the hallway and the AD was talking to her. On 10/29/18 at 2:10 p.m. the AD was interviewed in the conference room. She stated she had worked for the facility for six years. She stated she knew R#1 well because she was R#1's Ambassador. She stated the Ambassador's role was to advocate for the resident when the resident expressed a concern. She stated she checked her assigned residents for concerns frequently, usually daily. She stated on the day R#1 complained about abuse from the CNA she heard through the grapevine that R#1 complained of pain when she was moved. She stated she went to see R#1 to check out the complaint. She stated she found R#1 in her electric wheelchair outside the door of her room in the hall crying. She stated she comforted R#1. She stated R#1 told her that CNA BB spoke to her disrespectfully and hurt her during the transfer. She stated while she was talking to R#1, BB approached them and said she heard her name and wanted to know what it was about. She stated she stayed with R#1 for a while then went to the Administrator and told him about the allegation. On 10/30/18 at 12:00 p.m. the AD was further interviewed in the conference room. She stated she now recalled CNA BB told her about the incident involving the transfer of R#1 from the bed to the wrong chair. She stated this was early in the morning about two-and-one-half weeks ago. She stated after the morning huddle meeting she and the Administrator discussed the incident. She stated she told the Administrator R#1 told her that CNA BB said you're not appreciated and God would not appreciate what you are saying. She stated she told the Administrator she thought this incident was verbal abuse because R#1 was upset and crying when she (the AD) comforted her. On 10/30/18 at 1:15 p.m. CNA BB was interviewed over the telephone. She stated she had worked in the facility for ten years. She stated on the morning of the incident she, CNA CC, and a nurse transferred R#1 into the wrong chair. She stated R#1 did not cry during the transfer but got very angry about being in the wrong chair and started insulting them and using the F-word. She stated she never spoke to the resident disrespectfully. She stated they put R#1 into her electric wheelchair and they left. She stated the Administrator spoke to her about it later and said he would have to report it to the state. She stated she had cared for R#1 one or two times since the incident. On 10/30/18 at 1:45 p.m. Licensed Practical Nurse (LPN) NN was interviewed over the telephone. She stated she had worked for the facility for one year. She stated she was in the room during the transfer incident involving R#1. She stated CNA BB was in the room and another CNA she could not remember. She stated things were going fine until R#1 started cursing them for putting her in the wrong wheelchair. She stated CNA BB told R#1 be nice to me I am only trying to help you. On 10/30/18 at 2:10 p.m. the Director of Nursing (DON) was interviewed in the conference room. She stated she had worked at the facility for just over a year. She stated she had not heard of this incident until today. She stated she was not at the stand-up huddle meeting that morning. She stated if there was suspected abuse there should have been a formal investigation. She stated the alleged perpetrator should have been suspended or at least removed from the area of the building where the resident resided until the investigation was complete. She stated any abuse, including verbal abuse, should be reported to the state. She stated if BB approached R#1 while the AD was interviewing her about the incident she would think that was intimidation and this was unacceptable. On 10/30/18 at 2:35 p.m. the Administrator was interviewed in the conference room. He stated about three weeks ago the AD brought the R#1 transfer incident to his attention and it was something about putting the resident in the wrong wheelchair in preparation for going to a doctor appointment. He stated the AD did give him the details later. He stated he interviewed R#1. He stated R#1 said she had cursed BB. He stated he interviewed BB and BB told him she told R#1 to be nice to her. He stated the AD had pretty much agreed that this was what had happened. He stated no one mentioned any disrespectful comments from the CNA until the state surveyors were in the building. He stated he did not document this incident in any way because he did not suspect it was abuse, verbal or otherwise. He stated he did not report this to the state for the same reason. He stated that if abuse was suspected, the perpetrator should be removed from caring for the resident, an investigation started, and this should be reported to the State Agency within two hours. He stated anything less than that would be unacceptable. He stated in these cases the involved employee would be suspended. Review of the Resident Rights document, dated (MONTH) (YEAR), revealed policy that facility staff would treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes the maintenance of enhancement of his or her quality of life, recognizing each resident's individuality. Review of the Abuse & Neglect Prohibition document, dated (MONTH) (YEAR), revealed facility policy that defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Further review of this same document revealed mistreatment to be defined as inappropriate treatment or exploitation of a resident. Further review of this document revealed verbal abuse to be defined as the use of language that willfully included disparaging or derogatory terms to residents or to others regarding the residents. Review of this document also revealed the facility was obligated to report all allegations and substantiated occurrences of abuse to the State Agency within 24 hours after management became aware of the allegation if the events that cause the allegation did not result in serious bodily injury. Further review of this same document revealed any employee alleged to be involved in an instance(s) of and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. Review of the Midnight Census Report, dated 10/29/18 revealed R#1 lived in the East Wing of the facility. Review of the daily staffing schedules dated 10/24/18, 10/23/18, 10/22/18, 10/20/18, 10/19/18, 10/18/19, 10/17/18, 10/16/18, 10/14/18, 10/13/18, 10/10/18, 10/9/18, and 10/8/18 revealed CNA BB worked in the East Wing of the facility on those dates. Review of the undated Facility Layout map revealed anyone working in the East Wing of the facility would have easy access to any resident living in the East Wing.",2020-09-01
724,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2018-10-30,607,D,1,0,RWWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff and resident interviews, and facility policy review, the facility failed to implement facility written policies and procedures that prohibited and prevented alleged verbal abuse on one Resident (R)#1 out of three sampled, by not formally investigating R#1's allegation, not reporting the allegation to the State Agency (SA), and by not suspending the alleged perpetrator, resulting in the possibility of continuing abuse. Findings include: On 10/29/18 at 12:05 p.m. R#1 was interviewed in her room. She stated she had lived in the facility for five years. She stated about two weeks ago, during the day shift, two CNAs, BB and CC, were assisting her to her wheelchair from her bed, using a Hoyer lift. She stated CNA BB put her in the wrong chair and she complained to CNA BB. She stated CNA BB said God wouldn't like it hearing you talk that way. R#1 then stated this was disrespect and hurt her feelings and made her angry. She stated she told the Activities Director(AD) shortly after this happened. Review of the undated face sheet revealed R#1 was admitted to the facility in 2013. Review of R#1's undated [DIAGNOSES REDACTED]. Review of R#1's Quarterly Minimum Data Set (MDS) assessement, dated 10/1/18, section C, revealed a brief interview for mental status (BIMS) score of 15 out of 15, signifying intact cognition. Review of section G of the MDS revealed R#1 required extensive assistance for nearly all of her activities of daily living (ADLs), and was totally dependent on caregivers for toileting, transfers, and bathing, and she was non-ambulatory. Further review of this MDS, section H, revealed R#1 had an indwelling catheter and was always incontinent of bowel. On 10/29/18 at 2:10 p.m. the (AD) was interviewed in the conference room. She stated she had worked for the facility for six years. She stated she knew R#1 well because she was R#1's Ambassador. She stated the Ambassador's role was to advocate for the resident when the resident expressed a concern. She stated she checked her assigned residents for concerns frequently, usually daily. She stated on the day of the alleged incident she heard R#1 was upset, so she went to see her. She stated she found R#1 in her electric wheelchair outside the door of her room in the hall crying. She stated she comforted R#1. She stated R#1 told her that CNA BB spoke to her disrespectfully and hurt her during the transfer. She stated while she was talking to R#1,CNA BB approached them and said she heard her name and wanted to know what it was about. She stated she felt that CNA BB was intimidating R#1. She stated she stayed with R#1 for a while then went to the Administrator, the Abuse Coordinator for the facility, and told him about the allegation. On 10/30/18 at 12:00 p.m. the Activities Director was further interviewed in the conference room. She stated she now recalled more about the incident involving R#1's transfer to the chair. She stated she told the Administrator R#1 told her that CNA BB said you're not appreciated and God would not appreciate what you are saying. She stated she did not document anything about this incident. She stated she thought this incident was verbal abuse and she told the Administrator this because R#1 was upset and crying when she (the AD) comforted her. Review of the Abuse & Neglect Prohibition document, dated (MONTH) (YEAR), revealed facility policy that abuse definitions included intimidation or verbal abuse that results in mental anguish, among other results. Further review of this same document revealed mistreatment to be defined as inappropriate treatment of [REDACTED]. Review of this document also revealed the facility was obligated to report all allegations and substantiated occurrences of abuse to the State Agency within 24 hours after management became aware of the allegation if the events that caused the allegation did not result in serious bodily injury. Further review of this same document revealed any employee alleged to be involved in an instance(s) of and/or neglect will be suspended immediately and will not be permitted to return to work unless and until such allegations of abuse/neglect are unsubstantiated. Review of the Midnight Census Report, dated 10/29/18, revealed R#1 lived in the East Wing of the facility. Review of the daily staffing schedules dated 10/24/18, 10/23/18, 10/22/18, 10/20/18, 10/19/18, 10/18/19, 10/17/18, 10/16/18, 10/14/18, 10/13/18, 10/10/18, 10/9/18, and 10/8/18 revealed CNA BB worked in the East Wing of the facility on those dates. On 10/30/18 at 1:15 p.m. CNA BB was interviewed over the telephone. She stated she had worked in the facility for ten years. She stated on the morning of the incident she, CNA CC, and a nurse transferred R#1 into the wrong chair. She stated she never spoke to the resident disrespectfully. She stated they put R#1 into her electric wheelchair and they left. She stated the Administrator spoke to her about it later that day and said he would have to report it to the state. She stated she had been assigned to direct care for R#1 one or two times since the incident. On 10/30/18 at 2:10 p.m. the Director of Nursing (DON) was interviewed in the conference room. She stated she had not heard of this incident until today (10/30/18). She stated if there was suspected abuse the should have been an investigation, per facility policy. She stated the alleged perpetrator should have been suspended or at least removed from the area of the building where the resident resided until the investigation was complete. She stated any abuse, including verbal abuse, even if only suspected, should be reported to the state. She stated anything less was unacceptable. On 10/30/18 at 2:35 p.m. the Administrator was interviewed in the conference room. He stated about three weeks ago the AD told him about the incident involving the transfer of R#1. He stated he interviewed R#1. He stated R#1 said she had cursed BB. He stated he interviewed BB and BB told him she told R#1 to be nice to her. He stated the AD had pretty much agreed that this was what had happened. He stated no one mentioned any disrespectful comments from the CNA at the time he questioned the three staff members about it. He stated he did not document this incident in any way because he did not suspect it was abuse, verbal or otherwise. He stated he did not report this to the state for the same reason. He stated that if abuse was suspected, the perpetrator should be removed from caring for the resident, an investigation started, and this should be reported to the State Agency within two hours. He stated anything less than that would be unacceptable. He stated in these cases the involved employee would be suspended.",2020-09-01
725,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2018-03-22,761,F,0,1,ZKOV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure medications were stored and maintained at the correct temperature in one of one medication storage rooms. The facility census on 3/19/18 was 74 residents. Findings include: Observation On 03/22/18 at 2:30 p.m. to 2:46 p.m. of the medication storage room with Registered Nurse (RN) Charge Nurse (CN) EE (RN EE) revealed two refrigerators' in the mediation room, one for specimen storage and one for medication storage. The medication refrigerator had a thermometer in the bottom drawer in a basket that contained numerous unopened vials of insulin for resident and facility stock insulin. The temperature in the refrigerator was observed to register 28 degrees on the thermometer. At this same time, the temperature of twenty-eight (28) degrees, was confirmed with RN EE. The following medications were observed inside the refrigerator: One (1) vial of [MEDICATION NAME] 100 units/milliliter (ml) One (1) Intravenous piggy back of [MEDICATION NAME] 2 grams (gm) per 100 ml bag (IVPB) Five (5) IVPB's [MEDICATION NAME] 2 gm/50ml IVPB Fifteen (15) 0.5 ml syringes Influenza vaccine Eight (8) vials of Pneumococcal vaccine 0.5 ml Four (4) [MEDICATION NAME] 60 mg/ml Three (3) vial [MEDICATION NAME] 100 unit/ml One (1) vial opened and not dated [MEDICATION NAME] purified protein derivative 0.1 ml Two (2) Toujeo 300 units/ml Seven (7) [MEDICATION NAME] 1 gm/50 ml IVPB Eight (8) vials [MEDICATION NAME] R 100 units/ml Two (2) vials [MEDICATION NAME] R 100 units/ml One (1) vial [MEDICATION NAME] 100 units/ml Two (2) vials [MEDICATION NAME] 2 milligram/ml Review of the manufacture's instructions and back label for all medications stored in the refrigerator revealed that the medications should NOT be frozen and should be stored between 36 and 46 degrees. Interview on 3/22/18 at 3:05 p.m. with RN EE revealed that she checked with the DON and all the medications that were in the refrigerator should be stored between 36-46 degrees and that these medications would be discarded.",2020-09-01
726,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2018-03-22,880,D,0,1,ZKOV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview failed to maintain infection control standard precautions during medication administration for one sampled resident during medication administration observation. The facility census was 74 residents. Findings include: Medication Administration observation on 3/22/18 at 1:30 p.m. with Licensed Practical Nurse (LPN) DD on the 100/200 Hall medication cart revealed the following: Observation on 3/22/18 at 1:36 p.m. revealed that LPN DD walked down to the 300 hall and brought back a blood pressure machine. LPN DD then went into room [ROOM NUMBER] C pulled the privacy curtain with her bare hand, handled the blood pressure cuff and machine. LPN DD was then observed to come out of the room with the blood pressure machine, took the medication cart keys out of her scrub pocket, opened the medication cart, retrieved the residents blood pressure medication and dispensed the pill into her hand and then placed the medication into the medication cup, then LPN DD went back into the room and administered the medication to the resident. Interview on 3/22/18 at 1:40 p.m. with LPN DD revealed that she did not wash or sanitizer her hands after handling the blood pressure machine equipment, that she placed the medication into her hand and then into the medication cup and then she administered it to the resident.",2020-09-01
727,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2019-04-18,812,E,0,1,EAIB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, observation, and review of the facility's policies titled, Food Receiving & Storage - Revised (MONTH) (YEAR) the facility failed to discard expired items and failed to label and date items after opening. This had the potential to affect 81 of 88 residents receiving an oral diet. Findings include: Observations during the brief kitchen tour which began on [DATE] at 11:56 a.m. with the Food Service Director (FSD) revealed the following: Observation in one of the two dried food pantries revealed a bag of powdered milk ,[DATE] full with an open date of [DATE]. The FSD confirmed, at this time, that the food items are good for seven days after opening. An observation on [DATE] at 12:05 p.m. revealed a loaf bag of opened undated Sara[NAME]bread, an undated 5 pound (lb) plastic container of ground pepper. A further observation of a 20 ounce (oz) bottle filled with black pepper had a hand written label with a best by date of [DATE]. An interview with the FSD, at this time revealed there is ,[DATE] of the loaf left and it does not have an open date. She further revealed that the original 20 oz bottle for black pepper was thrown away and they use this bottle as a refill. She was unsure as how they figured the date on the bottle because the dated label is for onion powder. An observation on [DATE] at 12:05 p.m. revealed a 20 oz plastic container of baking soda with a use by date of [DATE]. An interview with the FSD, at this time, revealed it is out of date. During an interview and observation on [DATE] at 5:08 p.m. with the FSD, she revealed that she is responsible for assuring the labeling and dating of items. During an interview on [DATE] at 8:30 a.m. the FSD revealed she has in serviced her staff on all the items that were found to be opened and not dated in the kitchen including items that are outdated and remaining in use. During in an interview on [DATE] at 10:55 a.m. with the Administrator she revealed her expectations were for kitchen items to be labeled and dated. She confirmed the Food Receiving and Storage - Revised (MONTH) (YEAR) is the current policy for the kitchen. During an interview on [DATE] at 11:06 a.m. the Director of Nursing (DON) confirmed that seven residents receive nourishment through tube feedings.",2020-09-01
728,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2017-07-13,371,E,0,1,H0FY11,"Based on observation, staff interviews, and review of the facility's policy titled, Food Receiving and Storage and Resident nutrition services, the facility failed to ensure that expired foods were discarded after the expiration date, dented and rusted cans were returned to the vendor, and failed to ensure that food on the steam table was maintained at safe temperatures throughout the serving process. The facility also failed to maintain food pantry refrigerators that were clean, items labeled and dated in the food pantry refrigerators, failed to label and date food items in the dry food storage and freezer. These practices could affect 66 residents receiving an oral diet. The census was 72. Findings include: Initial kitchen tour on 7/10/17 at 1:12 p.m. with Dietary Manager revealed the following: 1. Observation of the reach in refrigerator revealed a box of prune juice (4 fluid ounce (fl oz.) containers) that dietary manager was unable to tell when the items were placed in the refrigerator or when the juice should be used by. The prune juice was not dated but the dietary manager reported that the box was opened about a week ago. 2. Observation of the stand-up freezer in the kitchen there were five (5) containers of non-dairy whipped topping that did not have a received on date or an expiration date. Interview with Dietary Manager on 7/11/17 at 8:15 a.m. who reported that the prune juice was dumped because she did not have a way to determine when they were placed in refrigerator or when they expire. Documentation provided related to non-dairy whipped topping that was not dated in the freezer to show that it was received on 6/8/17. She further reported that going forward these items would remain in the box until ready to use. Observation on 7/12/17 at 11:59 a.m. with Dietary Manager revealed: 1.There was one (1) container labeled with noodles that had 1 package of drum wheat semolina pasta (elbow macaroni) that was opened but not dated. 2. One opened container of egg noodles in original package that was not labeled or dated. The expiration date on the bag is worn; 3. Disaster supplies of Six #10 cans of fruit with an in date of 9/22/16 noted to have an expiration date rust on rim of cans); 4. Fruit Six #10 cans in date of 2/11/16 no expiration date and rust on rim of cans, 5. Seven - 36 oz. boxes of Uncle Ben's rice no expiration date, 6. Five - 4 gallon waters with no date for in or expiration with dust buildup noted on bottles, 7. Three - 4 pound containers of tuna fish not labeled or date, 8. Three -- 36 oz. potato mix containers not labeled or dated, 3 56.8 oz. containers of mashed potatoes not labeled or dated, 9. Vegetables for stew with an in date of 4/20/17 with no expiration date, 10. One (1) bag of mini marshmallows with no open date. Inteview with the Dietary manager, at this same time, reported that they last had macaroni and cheese on the menu last week. Dietary Manager reported that egg noodles last used on Monday. Dietary Manager also reported that she was not aware of the rusting cans and she is not able to determine the expiration dates of the items. Observation on 7/12/17 at 12:56 p.m. revealed the Roast pork with brown gravy was 92 degrees Fahrenheit (F) on the steam table. The main dining room had been served and one hallway was served at the time of the temperature reading. On 7/12/17 at 1:27 p.m. the roast pork with brown gravy was reheated to 166.5 F. Interview on 7/12/17 at 12:39 p.m. with the Dietary Manager who reported that canned items should have the in date on them so that they know when items come in. It is reported that the tuna and salmon are on the menu for supper and, when ordered, these items are typically used within two weeks. Cans that are not currently labeled have been here maybe three weeks. Dietary Manager reported that she does not know what the codes means on the canned goods that do not have expiration dates. Observation on 7/12/17 at 1:16 p.m. of three (3) plastic containers each with cereal (rice krispies, corn flakes, fruit whirls) and one (1) container of flour but none with open date or use by date. There is also a large yellow container that has saltine crackers in it but it does not have an in date or use by date. Interview on 7/12/17 at 3:05 p.m. with the Dietary Manager who reported that she received expiration dates from her vendor regarding the fruit cocktail and peaches. Dietary Manager further reported that the vendor was not aware that there were no expiration dates on these items. Dietary Manager acknowledged that she did not have a way of knowing the expiration dates of the items that do not have expiration dates already identified. Observation of resident food pantry on 7/13/17 at 9:38 a.m. revealed the following: 1. In the refrigerator there was a 46 oz. container of[NAME]Ready Care thickened orange juice with directions of once opened, store at ambient temperature for up to 8 hours or refrigerate for up to 7 days. the open date was 7/1/17. 2. There was one 6 oz container of great value blueberry yogurt with a used by date of (MONTH) 1, (YEAR). 3. One half used 20 oz. container of ketchup with a best by date of (MONTH) 28, (YEAR). 4. One 24 oz. container of Hunts tomato ketchup with a best by date of (MONTH) 23, (YEAR). 5. There were four (4) 4 fl. oz. containers of Ardmore Apple Juice that did not have a use by date and was not labeled. 6. Microwave was observed to have splattered food on the back and in the top. Interview on 7/13/17 at 9:53 a.m. with the Director of Nursing (DON) revealed that she keeps a log of temperatures of the refrigerators. The DON stated that she checks the food in the resident refrigerator daily to assure items are not outdated. The DON confirmed the outdated yogurt, ketchup, thickened orange juice, and the dirty microwave. The DON revealed that she was not aware that the DON reported that she is not sure of who is responsible for cleaning the microwave. It was further reported that the Apple juice came from the kitchen but that she was unsure of which day and what the expiration date was. Review of the Food Receiving and Storage Policy revealed: 8. All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the Resident nutrition services 4. To minimize risk of food borne illness, the time that potentially hazardous foods remain in the danger zone will be kept to a minimum.",2020-09-01
729,PRUITTHEALTH - WASHINGTON,115325,112 HOSPITAL DRIVE,WASHINGTON,GA,30673,2018-06-27,584,D,0,1,830B11,"Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment including dusty and warped blinds in common areas, dining room and one resident room (A 20); dusty air conditioner (AC) units in three resident rooms (rooms A 16, A 20, A 21) as well as broken face grill on AC unit in room A 16. The sample size was 28. Findings include: Observation on 6/24/18 at 3:20 p.m., revealed the blinds in the common sitting room/media room at the front of the building, were broken, warped and dusty on three of three windows. Observation on 6/24/18 at 3:30 p.m., revealed room A 16 AC unit dusty face grill and face grill had one slat broken off. Observation on 6/24/18 at 3:42 p.m., room A 20 revealed blinds on window were broken and warped to a condition that does not open to allow natural sunlight in; AC unit with dusty face grill. Observation on 6/24/18 at 3:51 p.m., revealed room A 21 AC unit with dusty face grill. Observation on 6/24/18 at 5:18 p.m., revealed the blinds in the dining room (two windows and one door) were dusty with thick layer of dust. An interview on 6/27/18 at 2:30 p.m., with the Maintenance Director revealed that housekeeping staff are supposed to dust the blinds in resident rooms and in the common areas every day. He further stated the AC units are serviced by the maintenance department, but the housekeeping staff are supposed to dust them off daily, when they clean the resident rooms. He stated he has new housekeeping staff, but they have been oriented as to their job responsibilities. He stated there is not a formal checklist for compliance or understanding about what their specific job responsibilities are. An interview on 6/27/18 at 4:03 p.m. with Housekeeping tech DD revealed that she is new and is still getting a feel of what her responsibilities are. She stated she cleans all the resident rooms, sweeping, mopping, emptying trash, cleaning bathroom, wiping walls and countertops. She stated that she wipes the blinds if they look like they need to be cleaned, but she doesn't do it everyday. She stated that she was never told to wipe the air conditioner (AC) units. An interview on 6/27/18 at 7:08 p.m. with the Administrator revealed that she has not been informed of any concerns with the environment, such as broken/warped blinds, dusty blinds in common areas, dusty AC units.",2020-09-01
730,PRUITTHEALTH - WASHINGTON,115325,112 HOSPITAL DRIVE,WASHINGTON,GA,30673,2018-06-27,880,D,0,1,830B11,"Based on observation, staff interview, and policy review, the facility failed to maintain a clean environment in the laundry room by transporting soiled laundry in the clean side of laundry, to prevent contamination; also failed to maintain environment in laundry room in a sanitary manner. The facility census was 39 residents. Findings include: Review of the facility policy titled Infection Control-Linen and Laundry Services revealed that all soiled linen should be bagged or put into carts at the location where used. Dirty linen should be clearly separated from areas where clean linen is handled. During observation of laundry services on 6/26/18 at 10:20 a.m., Laundry Aide CC was observed sorting soiled laundry wearing appropriate personal protective equipment (PPE). During this observation, Floor Tech, opened laundry room door, on the clean side of the laundry. He walked into the clean side of the laundry room carrying in his bare hands, soiled towels, that had been used to clean the meal carts in the kitchen. Laundry Aide CC spoke in a loud voice at him What are you doing? She stated to surveyor I can't believe he just did that. After observation of sorting laundry, surveyor observed Laundry Aide CC removing clean laundry from the dryer into a wire basket with wheels, labeled Clean. The Laundry Aide CC began folding clean linen from the wire basket and stacked them onto the folding table, later to be transported to linen closets on each unit. During continued observation of the laundry room, the area behind the two washing machines had multiple areas of brown, formed substance in clunks, spread over the entire floor area. There was also a darkened, mold colored fabric material wadded up in the left corner of the area. Laundry Aide CC stated she did not know what the brown material was or what the wadded fabric was, however, she stated it looked like a sheet. An interview on 6/26/18 at 7:49 a.m. with the Floor Tech, stated that he did not know that he could not walk through the clean side of the laundry to place dirty laundry items in the barrels. He stated that he does that all the time and no-one told him he couldn't. He further stated that he did not receive any training pertaining to infection control with the laundry service. An interview on 6/27/18 at 2:30 p.m. with the Maintenance Director revealed that the Floor Tech works in the laundry room every other weekend, and has been trained on infection control procedures when working in the laundry. He stated that he knows that he is not supposed to even transport dirty linen in the halls without being bagged. He stated he probably just forgot. An interview on 6/27/18 at 6:38 p.m. with the Director of Health Services (DHS) revealed that she was not aware that the Floor Tech did not know he should not take dirty laundry through the clean side of the laundry facility. She stated that she thought the Maintenance Director was responsible for doing their in-service trainings, and cannot recall if the Floor Tech had attended one of her in-services on infection control. An interview on 6/27/18 at 6:38 p.m. with the Administrator revealed that the Corporate Maintenance Director does the in-service training for the Maintenance and Housekeeping staff. She stated that the Floor Tech knows he should not transport dirty linen in the hallways without being bagged, and entering into the clean side of the laundry room with dirty linen.",2020-09-01
731,PRUITTHEALTH - WASHINGTON,115325,112 HOSPITAL DRIVE,WASHINGTON,GA,30673,2018-06-27,921,D,0,1,830B11,"Based on observation and staff interview, the facility failed to maintain two of two public water fountains in a clean and sanitary manner. The facility census was 39. Findings include: Observation on 6/24/18 at 3:22 p.m., 6/25/18 at 8:18 a.m., 6/25/18 at 4:01 p.m., 6/26/18 at 9:19 a.m., 6/26/28 at 4:33 p.m., 6/27/18 at 7:58 a.m., and 6/27/18 at 2:00 p.m., revealed that the public water fountain in the front lobby to have green slimy residue on the spigot and in the drain area. Observation on 6/24/18 at 4:18 p.m., 6/25/18 at 8:20 a.m., 6/25/18 at 4:04 p.m., 6/26/18 at 9:21 a.m., 6/26/18 at 4: 35 p.m., 6/27/18 at 8:01 a.m., and 6/27/18 at 2:03 p.m., revealed that the public water fountain on A Hall to have green slimy residue on the spigot and in the drain area; also pink material dried over the surface bowl of the fountain. An interview on 6/27/18 at 2:30 p.m. with the Maintenance Director revealed that the housekeeping staff are supposed to clean the public water fountains when they clean the public restrooms. He stated he has new housekeeping staff, but they have been oriented as to their job responsibilities. He stated there is not a formal checklist for compliance or understanding about what their specific job responsibilities are. He verified that the two public water fountains were dirty with green slimy residue on the spigot and in the drain area and the fountain on A Hall had dried pink material on the bowl of the fountain. An interview on 6/27/18 at 4:03 p.m. with Housekeeping tech DD revealed that she is new and is still getting a feel of what her responsibilities are. She stated she was not told that she was supposed to be cleaning the public water fountains every day. An interview on 6/27/18 at 7:08 p.m. with the Administrator revealed that she has not been informed of any concerns with the environment or dirty water fountains. She stated there was not any policies or procedures for cleaning the public water fountains.",2020-09-01
732,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2018-04-05,657,D,0,1,XZ0V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to update the care plan to reflect interventions to prevent falls and code status for one resident (Resident (R) #66) of 22 sampled residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R#66 had two or more falls with no injury or major injury. Review of the care plans for R#66 revealed that the resident had a care plan for being at risk for falls but did not identify that the resident had any actual falls. Further review of the care plans, for R#66, revealed that resident had a care plan and that his code status was reflected to be full code. However, there was a physician's orders [REDACTED]. Further record review revealed that there were incident reports dated 12/14/17, and 12/23/17, in which R#66 fell but did not have any injuries. The care plan was updated on 9/11/17, 12/19/17, and 3/12/18, but there were not any updates to reflect the residents actual falls or updated to reflect the change to the residents code status. Interview on 4/4/18 at 10:54 a.m. with the Director of Health Services (DHS) revealed that if there are falls Hospice and facility care plans would be updated. DHS further reported that care plans are updated as needed. Interview on 4/5/18 at 1:37 p.m. with Licensed Practical Nurse (LPN) FF revealed that an Minium Data Set (MDS) worker updates the care plans. Interview on 4/5/18 at 2 p.m. with Case Mix Director revealed that if a care plan needs updating nursing can do so related to falls. If falls are documented the care plan should reflect actual falls and not potential for falls. The Case Mix Director revealed that she typically goes by what is listed on resident's POLST form when completing code status care plan. Interview and record review on 4/5/18 at 2:10 p.m. with Case Mix Director and LPN FF revealed that she would consider resident #66 a DNR but there is confusion with the forms currently in the residents file. LPN FF revealed that she has never updated the care plan. Case Mix Director revealed that she would provide Cardiopulmonary Resuscitation for Resident #66 because one of the forms in the residents chart indicate that the resident should be a full code. Further interview revealed that the Case Mix Director revealed that she should have updated the residents care plan to reflect the residents actual falls. Interview on 4/5/18 at 2:20 p.m. with the Social Services Director (SSD) GG revealed that the DNR on the chart from hospice is correct. SSD GG reported that she does not typically do the care plans but sometimes puts a generic care plan for DNR on the file if there is a change in code status. Further intervew revealed that the yellow sticker on chart means DNR. SSD GG also reported that a list of residents and their code status are kept in the Medication Administration Record [REDACTED]. SSD GG reported that she would correct the list so the R#66 would be documented on the Code Status list as a DNR. Care Plans policy with revision date of 10/05/17 revealed care plans will be updated by nurses, Case Mix Directors, or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment.",2020-09-01
733,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2018-04-05,677,D,0,1,XZ0V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to ensure that Activities of Daily Living (ADL) care was provided related to showers according to the schedule for one resident (R) #55. The sample size was 23 residents. Findings include: Record review for R#55 revealed a quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment and physical help with bathing and extensive assistance with getting dressed was required. Interview on 4/03/18 at 10:26 a.m. with R # 55 reported that he/she is supposed to get showers on Mondays, Wednesdays, and Fridays but it has been a week since he/she had a shower. Observation on 4/5/18 at 7:39 a.m. of R# 55 sitting in his/her wheelchair near the 500 hall nurse's desk. Licensed practical Nurse (LPN) DD questioned resident if he/she received a shower on yesterday (Wednesday) and R#55 reported no. When LPN DD questioned why the shower was not received R#55 revealed that he/she could not get help to get a shower. LPN DD questioned resident related to which days he/she should receive a shower and R#55 reported Mondays, Wednesdays, and Fridays when he/she can get the help. Review of the bath schedule for 4/4/18 revealed room [ROOM NUMBER]A was on the list for a shower but room was scratched through and another room was put in it's place. Interview on 4/5/18 at 10:14 a.m. with the Director of Health Services (DHS) revealed that company was hacked and ransom requested so all Activities of daily living (ADL) information is not in the computer but that they have the ADL information in a paper format. On 4/5/18 at 10: 25 a.m. DHS provided a copy of the Bath CNA role roster for (MONTH) (YEAR) through (MONTH) (YEAR). January's report revealed showers on the 3rd, 11th, and 15th; February's report revealed showers on 9th, 14th, 19th, 21st, 22nd, 23rd, and the 28th; (MONTH) showers on the 1st, 5th, and the 30th; and (MONTH) with no showers documented, indicating that it had been six days since R#55 had a shower. Interview on 4/5/18 at 1:38 p.m. with Licensed Practical Nurse (LPN) FF who revealed that he/she assures residents have received showers by reviewing the shower forms to see if bath/showers are being signed off on. LPN FF denied that R#55 has voiced concerns about not getting a shower. It was further reported that if care is refused it should be documented but there have been any recent reports of refusals. Interview on 4/5/18 at 2:35 p.m. with Certified Nursing Assistant (CNA) AA, revealed that R#55 will only refuse showers when his/her knee hurts. CNA AA revealed that CNA AA is currently on the evening shift for showers and denied that R#55 has voiced that he is not getting his showers on evening shift and that he wants showers. R#55 is reported as not liking bed baths and prefers showers. CNA AA further reported that the resident does not change clothes until he/she gets shower. Interview on 4/5/18 at 6 p.m. with R#55 revealed that he/she prefers showers in the evenings but he/she cannot get the help from staff in order to get a shower.",2020-09-01
734,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2018-04-05,725,D,0,1,XZ0V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, and the Resident Council interview, the facility failed to ensure that there was enough staff to provide nursing care to resident's in a timely manner from a sample of twenty (22) residents. Findings Include: Interview with Resident Council members and the Resident Council President on 4/4/18 at 10:00 a.m. revealed it takes a long time for CNAs to respond to the call light because they do not have enough staff to provide care in a timely manner. Interview with CNA AA on 4/05/18 at 2:57 p.m. for the five-hundred (500) hall revealed she is the only CNA on the hall, and the CNA floater takes three (3) rooms from the 500 halls and five (5) rooms from the three (300) hall. Interview revealed CNA AA usually has 16 residents a shift that require dependent help, and four (4) residents that are independent. During the interview with CNA AA revealed there are two CNAs for sixty (60) residents; interview revealed there are CNAs that work in the front office that do not assist with resident care. CNA AA does not feel she can go to the DHS to express burnout. CNA AA revealed there is not enough help daily unless there are five CNAs scheduled for the day. CNA AA will sometimes come in and residents are wet from the previous shift, and they have not been changed since four o'clock [NAME]M. Further interview with CNA AA revealed it may take a long time to respond to a call light if she is in another resident's room providing care, and is not able to stop care with that resident at that time to go to another resident. CNA AA revealed once ADL care has been completed with the resident then CNA AA can move on to the next resident to provide care. Interview revealed the nurse will hesitate on answering the call light if the CNAs are in a room providing care, and the nurse is sitting at the desk. Interview with CNA CC on 4/5/18 at 5:35 p.m. revealed working on the Rehab hall which consists of halls 100-400 with a total of 38 residents; there are usually three CNAs scheduled to work; but only two CNAs are covering the halls. When providing care for the resident's CNA CC feels rushed to get done with that resident to get to the next resident, CNA CC the best care has not been provided to the resident. Interview reveals when CNAs are in rooms with other resident's; it takes longer to respond to the call light that is going off in another room or area. Record review for R#55 revealed a quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive impairment and physical help with bathing and extensive assistance with getting dressed. Interview on 4/03/18 at 10:26 a.m. with R # 55 reported that he/she is supposed to get showers on Mondays, Wednesdays, and Fridays but it has been a week since he/she had a shower. Review of the bath schedule for 4/4/18 revealed room [ROOM NUMBER]A was on the list for a shower but room was scratched through and another room was put in it's place. On 4/5/18 at 10: 25 a.m. DHS provided Bath CNA role roster for (MONTH) (YEAR) through (MONTH) (YEAR). January's report revealed showers on the 3rd, 11th, and 15th; February's report revealed showers on 9th, 14th, 19th, 21st, 22nd, 23rd, and the 28th; (MONTH) showers on the 1st, 5th, and the 30th; and (MONTH) with no showers documented revaling that it had been six days since the resident had a shower. Interview on 4/5/18 at 6 p.m. with R#55 who reported that he/she prefers showers in the evenings but he/she cannot get the help from staff in order to get a shower.",2020-09-01
735,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2018-04-05,812,E,0,1,XZ0V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and review of policy titled Labeling, Dating, and Storage and Patient/Residents' Personal Food policy the facility failed to discard expired items, and failed to label and date items in one reach in refrigerator. This included two of two food pantries. The census was 90 residents. Findings include: Observation on [DATE] at 11:35 a.m. during a brief kitchen tour with the Dietary Manager revealed the following: 1. There was 5 pound (lbs) sliced cheese in a container with no open date or anyway to determine the expiration date of the cheese. 2. There were open containers of Lyons Apple Juice (2), Orange Juice (2), Cranberry (2) and there was not way to determine the expiration date of the juices. 3. There was a 5lb container with cottage cheese that had a use by date of [DATE]. DM confirmed that cottage cheese was expired. 4. There was a package of Swiss American Pasteurized cheese but there was no open date and no way to determine the expiration date of the cheese. 5. In the walk-in cooler there was a box of Ready Care Strawberry shakes that were thawed. The directions on the box revealed that once the shakes are thawed they should be discarded after 14 days. Interview on [DATE] at 11:45 a.m. with the Dietary Manager who verified that the items in the reach in refrigerator and walk in cooler were not labeled and dated. The Dietary Manager also revealed that she was not able to identify expiration dates for some items. It was explained that the Ready Care strawberry shakes were currently thawed and arrived in the facility on [DATE]. Dietary Manager further revealed that the shakes are thawed when received and they are kept until all gone. Dietary Manager reported that sometimes the shakes remain frozen and are pulled to be thawed however she could not confirm when the shakes in the cooler were pulled and thawed. Directions on shakes reveal that the shakes should be discarded after 14 days. During kitchen tour on [DATE] at 12:46 p.m. food temperatures on the steamtable were the following: 1. Egg noodles had a temperature of 100 degrees fahrenheit (F). 2. Pureed rice had a temperature of 124 degrees F. 3. Ground meat had a temperature of 120 degrees F. At the time food temperatures taken on the steam table food had been sent to dining rooms on the 100, 500, and 700 halls. Observation on [DATE] at 7:08 a.m. during tour of the nutrition room on the 300 hall (rehab unit) the following was observations were made with Registered Nurse (RN) HH: 1. There was one container of Everfresh Cran Apple juice that did not have a name and there was no way to determine the expiration date. 2. There were two grapefruit cups that did not have a name and there was no way to determine the expiration date. 3. In the freezer there was a chic fil a bag with no name and no date. During tour with the Director of Health Services (DHS) on [DATE] at 4:15 p.m. the following was observed: 1. In the nourishment room on the Rehab unit there was one chic fil a cup with no name or date on it 2. There were two one-pint ice cream containers in the freezer that were not labeled. 3. In the nourishment room on the 500 hall (long term unit) there was one KFC bag that was not labeled or dated. 4. There was one container of juice with no name or date on it. The DHS confirmed that these items should be labeled and dated in the freezer and refrigerator. Policy: Labeling, Dating, and Storage For purchased products, always follow the manufacturer's expiration date or packaging date. Patient/Residents' Personal Food policy: Frozen foods must be labeled and dated and will be discarded after 14 days.",2020-09-01
736,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2018-04-05,880,E,0,1,XZ0V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of the Lippincott procedures the facility failed to bag and label sixteen wash basins and failed to bag and label and bag one urinal and one urine hat. The facility census was 90 residents. Findings include: During observation on 4/3/18 at 8:53 a.m. in the bathroom of room [ROOM NUMBER] there were stacked wash basins sitting on the shower chair in the bathroom. During observation on 4/3/18 at 8:56 a.m. in the bathroom for room [ROOM NUMBER] there was one urinal on grab bar by toilet with black matter in it not labeled two wash basins under sink, one wash basin in shower area, and one urine hat on floor in bathroom not bagged During observations on 4/3/18 at 10:19 a.m. in the bathroom for room [ROOM NUMBER] there was a wash basin not labeled or bagged. During observation on 4/3/18 at 11:39 a.m. in the bathroom of room [ROOM NUMBER] there were three wash basins in the shower stacked but not covered. During observation on 4/2/18 at 3:38 p.m. there was a urinal on the grab bar in the bathroom for room [ROOM NUMBER]. During observation on 4/4/18 at 8 a.m. in the bathroom of room [ROOM NUMBER] there were stacked wash basins that were not labeled or bagged. During observation on 4/4/18 at 8:01 a.m. in the bathroom for room [ROOM NUMBER] there was one basin on floor under sink in bathroom not bagged. During observation on 4/4/18 at 8:04 a.m. in the bathroom of room [ROOM NUMBER] there were three wash basins stacked but not labelled or covered in the bathroom. During observation on 4/4/18 at 2:08 p.m. in the bathroom of room [ROOM NUMBER] there was stacking of wash basins in the bathroom. During observation on 4/4/18 at 2:09 p.m. in the bathroom for room [ROOM NUMBER] there was a wash basin on the floor uncovered under bathroom sink. During tour with Director of Health Services (DHS) on 4/5/18 from 4:15 p.m. to 4:35 p.m. the following was confirmed: 1. In room [ROOM NUMBER] at 4:20 p.m. there were wash basins in the bathroom not labelled or bagged. 2. In room [ROOM NUMBER] at 4:30 p.m. there were four stacked wash basins in the bathroom that were not labelled or bagged. 3. In room [ROOM NUMBER] at 4:35 p.m. there was one wash basin not bagged and not labeled on the floor in the bathroom. During an interview with DHS on 4/5/18 at 4:36 p.m. it was reported that Certified Nursing Assistants (CNA) are responsible for assuring items are bagged and labeled. DHS also reported that items should not be stored on the floor. Review of Lippincott procedures for bedpan and urinal use dated (MONTH) 12, (YEAR) revealed the following: Bedpans and urinals to be issued to individual patient/resident. The bedpan or urinal will be labeled and stored in a plastic bag in the patient/resident's closet, bedside stand, on a shelf in the patient/resident's bathroom or hanging on handrail in the bedroom.",2020-09-01
737,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2017-05-18,278,D,0,1,V93611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) assessments for two residents (#53 and #159). Sample size was 30 residents. Findings include: 1. Resident (R) # 53 was admitted to the facility on [DATE]. A review of the clinical record revealed that a [MEDICAL CONDITION] and [MEDICATION NAME] were identified on the assessment. However, the MDS nurse failed to accurately code the status of bladder function on the admission MDS dated [DATE]. Urinary status was coded as occassionally incontient of urine. The 14-day scheduled assessment with an Assessment Reference Date (ARD) of 2/07/17 coded bladder funtion as being not rated. Discharge assessment with an ARD date of 3/24/17, coded the resident's bladder function as always continent. The OBRA Quarterly Review dated 4/14/17 coded the residents bladder function as frequently incontinent and bowel function as always incontinent. The 30-day scheduled assessment with ARD date of 4/28/17 coded the resident's bladder status as occassionally incontinent and bowel function as occassionally incontinent. Interview with MDS nurse AA on 5/17/17 at 4:05 p.m. revealed that the admission MDS had been coded wrong and changed with coding on the 14 day MDS assessment dated [DATE]. She stated that when the resident went into the hospital, the other MDS nurse completed the discharge assessment and then continued to assess him when he returned. Interview with MDS nurse BB on 5/17/17 at 4:20 pm revealed that the MDS assessments were coded incorrectly and that they would be corrected. 2. Resident (R) #159 was admitted to the facility on [DATE]. A review of the resident's clinical record revealed that the resident received [MEDICAL TREATMENT] three times a week. However, the MDS nurse failed to accurately code the [MEDICAL TREATMENT] in Section O of the MDS. The five-day MDS assessment with an ARD date of 4/14/17 revealed that [MEDICAL TREATMENT] was not coded in Section O. The Discharge MDS Assessment with an ARD date of 4/14/17 revealed that the nurse failed to code the [MEDICAL TREATMENT] service in Section O. Interview with MDS nurse AA on 5/17/17 at 4:05 pm revealed that the admission MDS had not been coded correctly and continued to be coded incorrectly until the resident was discharged .",2020-09-01
738,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2019-06-20,656,D,0,1,1TZL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, and review of the facility policy titled Care Plans, the facility failed to develop a care plan related to respiratory [DIAGNOSES REDACTED].#35) of 25 sampled residents. Findings include: Review of the policy titled Care Plans revealed a policy statement: It is the policy of the health care center for each patient/resident to have a person-centered care plan developed according to the Resident Assessment Instrument (RAI) manual and patient/resident choice. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed R#35 with a Brief Interview of Mental Status (BIMS) score 10, indicating moderate cognitive impairment and active [DIAGNOSES REDACTED]. Section J - Health Conditions documented the resident had shortness of breath or trouble breathing, with and without exertion, and when lying flat. Section O - Special Treatment and Programs revealed oxygen therapy was not documented/marked. MDS Quarterly assessment dated [DATE] revealed R#35 received oxygen therapy while a resident in the facility. Review of current Physician Orders revealed an order dated 8/9/18 for oxygen at 2 LPM (liters per minute) via n/c (nasal cannula) prn (as needed); and change respiratory circuit/supplies weekly on Wed (Wednesday), and prn if soiled. Review of the baseline care plan dated 7/25/18 revealed no documentation of respiratory [DIAGNOSES REDACTED]. On 6/18/19 at 10:02 a.m., R#35 was observed sitting up in bed with oxygen (O2) via n/c running at 2 LPM from a concentrator beside the bed. The resident also had a portable O2 tank in a caddy on the back of her wheelchair. During an interview at this time, R#35 stated she went out of the facility yesterday and used the O2 tank and that is why the O2 tank is on the back of her wheelchair. Resident revealed she needed her O2 all the time and wore it continuously. Additional observations of R#35 on 6/18/19 at 3:50 p.m., 6/19/19 at 8:10 a.m., 06/19/19 at 11:49 a.m., and 6/19/19 at 3:29 p.m., revealed R#35 used O2 via n/c at 2 LPM continuously during the day. During an interview on 6/20/19 at 1:45 p.m., the Director of Nursing (DON) confirmed there was not a care plan for any respiratory diagnoses, or a care plan that included oxygen therapy for R#35. Her expectation was that the resident should have a care plan developed for respiratory concerns that included oxygen therapy because R#35 uses oxygen. The DON did not know why the respiratory care plan had not been developed.",2020-09-01
739,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2019-06-20,801,F,0,1,1TZL11,"Based on record review and staff interview, the facility failed to ensure that the staff designated as Dietary Manager was a certified dietary or food service manager or had a similar food service management certification or degree. There were 85 out of 86 residents that received an oral diet. Findings include: A review of the personnel file for the Dietary Manager revealed that her hire date was 4/23/17. Further record review revealed that the DM was enrolled in a course for the Certified Dietician Manager on 8/14/17. The completion date for the course was 8/14/17. There was no evidence of dietary manager certification. During an interview on 6/17/19 at 11:41 a.m., the Dietary Manager (DM) revealed that she has been employed with the facility for approximate 16 months. She stated she is not certified because she was unable to take the exam for personal reasons. She revealed a completion of the course work for the exam in (MONTH) (YEAR). DM stated per her knowledge the time frame was five years to become certified as dietary manager and she has until 2021 to take the exam. She has not obtained a schedule date to take the exam. During an interview on 6/20/19 at 11:17 a.m., the Administrator confirmed that the Dietary Manager was not certified. The Administrator revealed that his expectation is for the Dietary Manager to be certified. He was under the assumption that the Dietary Manager had until (MONTH) 1, 2019 to become certified. The Administrator revealed that the Registered Dietician (RD) comes at least once per week.",2020-09-01
740,PRUITTHEALTH - MAGNOLIA MANOR,115326,3003 VETERANS PARKWAY S,MOULTRIE,GA,31788,2019-06-20,806,D,1,1,1TZL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and interview, the facility failed to honor food preferences for breakfast food for one resident (R) (#5) of 25 sampled residents. Findings include: Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed R#5 with a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13 to 15 indicates that a resident is cognitively intact). Review of the undated document titled Diet History/Food Preference List, revealed R#5 was able to make needs known, talked about food preferences, preferences noted, and they will encourage intake. Documentation included R#5 did not like eggs, grits, and did like toast, bacon, biscuits, cereal, and grilled cheese. Review of a Nutritional Progress Note dated 5/17/19 revealed the Registered Dietician (RD) visited R#5 related to a need for updated food preferences. The RD documented she informed the kitchen of breakfast preference of grilled cheese with bacon, cranberry juice, milk, disliked grits, eggs, and fried foods; and resident did better with handheld foods, so she could feed herself. During an interview on 6/18/19 at 9:43 a.m., R#5 revealed breakfast was biscuit, sausage, and gravy, and she didn't like the greasy sausage and gravy. R#5 stated she dislikes grits, eggs, fried, and greasy food; and they send her the same thing all the time. She asked for grilled cheese and bacon, and had also asked for cereal, but her food choices and preferences were not honored. Observation on 6/19/19 at 8:34 a.m. revealed R#5 received sausage, eggs, and toast for breakfast. Interview at this time revealed her main preference for breakfast was grilled cheese and bacon, or cereal. She told the certified nursing assistant (CNA) what she wanted, wrote it on the meal ticket/slip and sent it back to the kitchen, but stated they send the same food all the time. She revealed staff told her she could only get what was on the main menu or alternate menu, and they could not cater to everyone. She revealed if she got bacon and grilled cheese, she could feed herself, and wanted to be as independent as possible. Interview also revealed the RD came and talked with her a few weeks ago, and the DM was supposed to come talk to her but had not. Interview on 6/19/19 at 4:55 p.m. with the DM revealed she interviews residents about preferences, likes, and dislikes within five days of admitting. If a resident complained about food, any staff could notify her at any time. She would go talk to the resident, update their food preferences, and try to provide food choices and preferences within reason. During further interview, the DM revealed staff should follow the diet ordered on meal slip when preparing trays and she was not aware of any concerns or complaints related to food preferences.",2020-09-01
741,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2018-09-13,584,D,1,1,7L8V11,"> Based on observation and interviews, the facility failed to ensure that it was maintained in a safe, clean and comfortable home-like environment including unclean bird cage in common area, damaged sheetrock, leaking sink and loose toilet, and bathroom door scraping floor in five of 16 rooms on two of three halls, common sitting area and shower room. Sample size was 41. Findings include: 1. During observation on 9/10/18 at 10:42 a.m. revealed bird aviary in front lobby had dirty cage with feathers and bird feed on floor underneath cage. 2. During observation on 9/10/18 at 11:07 a.m. revealed room C 2-2 missing a chunk of sheetrock from wall on the left side of the bed. 3. During observation on 9/10/18 at 11:28 a.m. revealed room A 12 light over sink in bathroom not working. Also, approximately four inch long semi-circular indentation in the wall just inside the bathroom, across from the sink. 4. During observation on 9/10/18 at 11:31 a.m. revealed room C 6 bathroom door scraped across the floor when opening and closing. 5. During observation on 9/10/18 at 11:52 a.m. revealed room C 7 had patch of torn sheetrock on the wall at the foot of the two beds. 6. During observation on 9/10/18 at 12:22 p.m. revealed shower room on B Hall sink was leaking water and bath basin on floor underneath sink to collect the water. Toilet in the shower room loose. 7. During observation on 9/11/18 at 10:10 a.m. revealed room A 3-2 had brown stain on wall above head of bed. Interview on 9/13/18 at 7:08 p.m. with Maintenance Supervisor verified on walking rounds the above identified environmental concerns. He stated there is a maintenance log kept at the nurses station and staff write work orders for things that need repaired. He stated he checks the log book at least three times per day, and staff also will let him know verbally if things need his attention. He prefers they write it in the book so that he can keep track of the work orders he has completed. He stated that housekeeping cleans the bird cage every week. He stated that he was not aware of any of the environmental issues identified this week.",2020-09-01
742,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2018-09-13,656,D,1,1,7L8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to nail and oral care, showers as scheduled, and splint application for one resident (R) (R 'S'). In addition, the facility failed to implement the care plan related to behavior monitoring for one resident (R#6), and failed to develop a care plan for [MEDICAL CONDITION] drug use for one resident (R#51). The sample size was 41 residents. Findings include: 1. Review of R 'S's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates that a resident has no cognitive impairment); needed limited assistance for personal hygiene; and was totally dependent for bathing. Review of R 'S's care plans revealed one last revised on 8/23/18 for ADL (activity of daily living) self-care performance deficit related to [MEDICAL CONDITIONS], DM (diabetes mellitus), recent episode of illness, lower knee amputation. Review of the interventions on this care plan revealed: Bathing/Showering: check nail length and trim and clean on bath day and as necessary. Showers as scheduled, shave on shower days as desired. Oral Care Routine: set up and assist only as needed to complete, encourage him to complete as much as he can. During interview with R 'S' on 9/11/18 at 10:58 a.m., he stated that he recently went two months without getting a shower until finally getting one on Friday (9/7/18), and he was supposed to get on on Tuesdays and Thursdays. R 'S' stated during further interview that the last time his teeth were brushed was a week ago, and that his fingernails had not been cut for about two weeks. Observation at this time revealed that R 'S's teeth were discolored, and there was a small amount of debris noted between his bottom teeth, and all of his fingernails were moderately long and uneven. Review of all of the Shower Sheets in the shower room going back to 8/8/18 revealed that the only Shower Sheet in the notebook for R 'S' was dated 9/7/18, and it noted that a shower was given but nail care not provided. Review of the A-Hall Shower Schedule in this notebook revealed that R 'S' was scheduled to be showered on the 3-11 (3:00 p.m. to 11:00 p.m.) shift on Mondays and Thursdays. During interview with CNA AA on 9/12/18 at 2:50 p.m., with CNA BB on 9/13/18 at 10:00 a.m., and with the Director of Nursing (DON) on 9/13/18 at 1:06 p.m., they stated that if a resident refused a shower, it should be documented on a Shower Sheet. Cross-refer to F 677. 2. Review of R 'S's Quarterly MDS dated [DATE] revealed that he had functional limitation in range of motion (ROM) on one side of his upper body, and both sides of his lower body, and that he was receiving restorative for passive range of motion (PROM) and splint assistance six days a week. Review of R 'S's care plans revealed one for [MEDICAL CONDITION] to right side related [MEDICAL CONDITION](stroke). Review of the interventions to this care plan included range of motion active or passive with restorative six times a week, with a revision date of 4/27/18. Review of a care plan for arthritis (gout) and muscle weakness noted an intervention for use of supportive devices such as splints as recommended by OT (Occupational Therapy), last revised on 4/27/18. Review of a Restorative Rehabilitation Program Recommendations with date established of 1/11/18 by OT revealed application of a hand splint 6 hours daily or to tolerance, right hand. During interview with R 'S' on 9/11/18 at 11:26 a.m. he stated that nobody had done range of motion (ROM) or applied a splint to his right hand for about two weeks, and no splint was seen on him at this time. Further observations on 9/11/18 at 2:49 p.m., 9/12/18 at 9:10 a.m., and 9/13/18 at 9:46 a.m. and 7:33 p.m. revealed that R 'S' did not have a splint on his right arm. Review of a Restorative Nursing Program Flow Sheet dated 8/18 (August (YEAR)) revealed splint or brace assistance was initialed as done through 8/26/18, with no documentation past then. During interview with restorative CNA DD on 9/13/18 at 10:14 a.m., she stated that all she did was ROM to R 'S's right hand, and verified there was no documentation that any restorative services had been provided since 8/26/18. Cross-refer to F 688. 3. Review of the clinical record for R#6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, indicating severe cognitive impairment. The assessment revealed the resident was not, at the time, experiencing mood symptoms but exhibited physical behavior symptoms directed towards others 1-3 days. The assessment also documented that the resident was receiving antidepressant and [MEDICAL CONDITION] medications. Review of Physician orders [REDACTED]. Review of care plan for R#6, initiated on 6/3/16 and updated on 8/22/18, revealed she has [DIAGNOSES REDACTED]. Care plan interventions indicated to administer medications as ordered, monitor and document for side effects and effectiveness when given, arrange for psych consult and monitor, document and report signs and symptoms of behaviors. Interview on 9/13/18 at 4:53 p.m., with Director of Nursing (DON) stated that her expectation is for the nurses to be doing behavior monitoring and completing the documentation each day. She stated that she does not have a reason for what the previous DON had done prior to her assuming the role. 4. Review of the clinical record for R#51 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, indicating severe cognitive impairment. The assessment revealed the resident was not, at the time, experiencing mood or behavior symptoms. The assessment also documented that the resident was receiving antidepressant medications. Review of Physician orders [REDACTED]. Review of R#51 care plan revealed there was no identified concern addressing resident's history of depression and routine use of antidepressant medication. Interview on 9/13/18 at 3:53 p.m. with Unit Manager, MDS, verified that R#51 was coded on MDS CAA's for [MEDICAL CONDITION] drug use. She stated she does not know why resident did not have a care plan for [MEDICAL CONDITION] drug use.",2020-09-01
743,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2018-09-13,677,D,1,1,7L8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to ensure that showers were given as scheduled, and nail and oral care consistently provided for one resident (R) (R 'S'). The sample size was 41 residents. Findings include: Review of R 'S's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of R 'S's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates that a resident has no cognitive impairment); was totally dependent for bed mobility, transfer, and locomotion; needed limited assistance for personal hygiene; was totally dependent for bathing; and had functional limitation in range of motion (ROM) on one side of his upper body, and both sides of his lower body. Review of R 'S's care plans revealed one last revised on 8/23/18 for ADL (activity of daily living) self-care performance deficit related to [MEDICAL CONDITIONS], DM (diabetes mellitus), recent episode of illness, lower knee amputation. Review of the interventions on this care plan revealed: Bathing/Showering: check nail length and trim and clean on bath day and as necessary. Showers as scheduled, shave on shower days as desired. Oral Care Routine: set up and assist only as needed to complete, encourage him to complete as much as he can. Transfer: requires mechanical lift with two or more staff assistance. Review of a care plan for refuses or resists care in the following areas: hygiene/bathing, dietary orders, and at times medication was revised on 8/23/18, and interventions included: Allow him to pick and choose the days he wants to shower; document when he refuses his showers and respect his rights. During interview with R 'S' on 9/11/18 at 10:58 a.m., he stated that he recently went two months without getting a shower until finally getting one on Friday (9/7/18). He further stated that his shower schedule was supposed to be Tuesdays and Thursdays, and that he had talked to staff about it and they told him they did not have enough help. R 'S' stated during further interview that the last time his teeth were brushed was a week ago, and he would like for them to be brushed after every meal. R 'S' stated during continued interview that his fingernails had not been cut since the restorative CNA (Certified Nursing Assistant) quit about two weeks ago, and he liked his nails shorter than they were. Observation at this time revealed that R 'S' had his own natural teeth which were discolored, and there was a small amount of debris noted between his bottom teeth. Further observation revealed that all of his fingernails were moderately long and uneven. During interview with R 'S' on 9/11/18 at 2:49 p.m., he stated that he had not had his shower yet that day, and staff usually came to get him around 3:00 p.m. Interview with R 'S' on 9/12/18 at 9:10 a.m. revealed that he did not get a shower, oral care or nail care on 9/11/18, and no staff came in to tell him why. During interview with CNA AA on 9/12/18 at 2:50 p.m., she stated the facility used to have a shower team, but around (MONTH) the shower team was disbanded and the CNA assigned to a resident was responsible for giving them a shower on their scheduled days. CNA AA stated during further interview that the ADL book and shower book told them when a resident was scheduled for a shower. She stated during continued interview that the first shift CNAs did the showers for residents in the bed by the door, and the second shift CNAs did the showers for residents in the bed by the window. CNA AA stated that she let the nurse know if a resident refused a shower, and that this was also documented in the ADL book and on the shower sheets. She stated that she did oral care for the residents every morning, and that nail care was done on shower days and as needed. CNA AA added that the ADL book only documented how much assistance was needed to perform personal hygiene, but did not specify the care provided. Review of all of the Shower Sheets in the shower room going back to 8/8/18 revealed that the only Shower Sheet in the notebook for R 'S' was dated 9/7/18, and it noted that a shower was given but nail care not provided. Review of the A-Hall Shower Schedule in this notebook revealed that R 'S' was scheduled to be showered on the 3-11 (3:00 p.m. to 11:00 p.m.) shift on Mondays and Thursdays. Review of R 'S's Resident Status Sheet in the ADL Book revealed that the section for Grooming, including brush teeth and nail care, and the section for Oral Care, were blank. Review of the Bathing section revealed that he was checked for Shower. During interview with R 'S' on 9/13/18 at 9:46 a.m., he stated that he still had not been showered since 9/7/18, nor had nail or mouth care been done. Observation of his teeth at this time revealed that they were discolored, with small amounts of debris along and between upper and lower teeth. Further observation revealed that his fingernails still appeared moderately long and uneven. During interview, R 'S' denied refusing showers, and that he sometimes asked the staff to obtain his toothbrush and paste for him so that he could brush his teeth. During interview with CNA BB on 9/13/18 at 10:00 a.m., she stated that any time a resident was given a shower-or if they refused a shower-this should be documented on a Shower Sheet in the notebook in the shower room. She further stated that she knew that he refused a shower one time because he was dizzy. CNA BB further stated that nail care was done during the showers but could be done anytime, and that she did mouth care every morning. During interview with the Director of Nursing on 9/13/18 at 1:06 p.m., she stated that if a resident received-or refused-a shower, that it should be documented on a Shower Sheet. During interview with the Administrator on 9/13/18 at 3:19 p.m., she stated that the facility did not currently have a policy on ADL care. During interview with R 'S' on 9/13/18 at 7:33 p.m., he stated that he did not get a shower, mouth or nail care that day.",2020-09-01
744,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2018-09-13,684,D,1,1,7L8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to perform a thorough assessment of a burn including measurements on the day of the burn, and failed to provide evidence that treatments to the burn were done daily as ordered for one resident (R) (R#75); facility also failed to obtain psychiatric evaluations on three of three residents (R) R#6, R#56 and R#58. The sample size was 41 residents. Findings include: 1. Review of R#75's [DIAGNOSES REDACTED]. Review of R#75's Minimum Data Set (MDS) revealed that he was admitted to the facility on [DATE]. Review of additional MDS's revealed that he was discharged to the hospital on [DATE], and readmitted to the facility on [DATE]. Review of his Admission MDS dated [DATE] revealed that he was assessed by staff for cognitive skills for daily decision making as modified independence-some difficulty in new situations only, and had no signs of [MEDICAL CONDITION]. He was assessed as needing supervision for eating; had no limitation in functional ROM (range of motion); and had no burns. Review of the facility's Occurrence Action Log revealed that R#75 spilled coffee on himself on 9/7/18 (sic) in the dining room with an injury to the right thigh, and treatment initiated. Review of R#75's Nurse's Notes revealed : 9/3/18 (untimed): Resident was in the dining room with speech therapist when he spilled coffee onto himself. He was then brought to the hall to be changed. When changing the resident CNA (Certified Nursing Assistant) noted burn/blister on right upper thigh. 9/4/18 6:00 a.m.: Resident alert with confusion. No distress. No c/o (complaints of) pain. Right upper thigh redness with tiny blister. Review of the R#75's Incident/Accident Report dated 9/3/18 at 9:00 a.m. revealed: Resident was in dining room with speech therapist when he wasted food and drink on himself. Was notified that he need to be changed. CNA took him in shower room. Reddened area on his right upper thigh, not open. Review of a Witness Statement attached to this Incident/Accident Report from the Licensed Practical Nurse (LPN) Wound Care Coordinator (WCC) noted she was in the dining room feeding another resident, and was not told of the coffee spill until R#75 was in the shower room and the charge nurse came to get her to show her the resident's right upper thigh, which was red. Tx (treatment) in place. Review of Interdisciplinary Care Plans dated 9/3/18 [MEDICAL CONDITION] coffee left post (posterior) thigh and right upper thigh. Resident spilled coffee on his lap when eating breakfast. Review of R#75's Wound Care Report dated 9/7/18 revealed that the resident had a burn from coffee to his right upper thigh facility-acquired on 9/3/18, 21.0 X 4.0 X 0.1 cm (centimeters), and inner left thigh 13.0 X 5.0 X 0.1 cm, with the characteristics of open blisters, and was treated with [MEDICATION NAME] cream. Review of these Nurse's Notes and Incident/Accident Report revealed that there was conflicting information as to whether R#75 had just redness or blisters to his thigh on the date of the incident on 9/3/18, and there was no documentation on the Wound Care Report as to the appearance of the burn on 9/3/18. During interview with the LPN WCC on 9/13/18 at 8:25 a.m., she verified that she did not document a description of the burn on the Wound Care Report when she first saw it on 9/3/18, and stated she thought the charge nurse would have documented the appearance of the burn when it happened. She further stated that when she saw R#75's thigh in the shower room on 9/3/18 that it was just reddened, that she did not see any blisters, and that she applied TAO (Triple Antibiotic Ointment) to it. The WCC stated that the next day the burn looked more extensive, and she started using the [MEDICATION NAME] cream on 9/4/18. She verified the only documentation she had of description of the wound was on the Wound Care Report with a date of 9/7/18. The WCC stated during continued interview that these reports were done on Fridays, and that was why it was dated 9/7/18. She verified there was no actual documentation on this report as to when she did the assessment and measurements, but stated she did it on 9/4/18 when she did her weekly wound assessments. She stated during continued interview that the application of the [MEDICATION NAME] would be documented in the Nurse's Notes. Review of the resident's Medication Administration Record [REDACTED]. However, no physician order for [REDACTED]. On 9/6/18 the area for documentation of the [MEDICATION NAME] on the MAR indicated [REDACTED]. Review of a treatment order on the MAR for [MEDICATION NAME] 1% cream to the left post peri (perineal) area had an order date of 9/5/18, and was documented as done 9/5/18 to 9/6/18, and 9/8/18 to 9/10/18. However, the physician order for [REDACTED]. Review of the Nurse's Notes revealed that the only documentation seen related to a treatment to the burn was on 9/4/18 at 3:00 p.m. that a new order had been obtained for [MEDICATION NAME], and on 9/9/18 at 10:00 a.m. that treatment to the left upper leg was being done by treatment nurse. During interview with LPN GG on 9/13/18 at 8:56 a.m., she stated that she was on duty the day R#75 spilled his coffee, and that the redness was more up under his legs, and she did not see any blisters. She further stated that the WCC would be responsible for putting the [MEDICATION NAME] cream on the burn. 2. During record review of medical record it was discovered psych evaluations were ordered for 3 of 3 records reviewed and the orders were never implemented. Record review reveals a nurse's note dated 7/12/2018 7:45 a.m. , for Resident (R) (R#56) reporting new orders which included a psych eval. A review of physician orders reveals an order written [REDACTED]. 3. Record review for Resident (R) (R#58) reveals an order written [REDACTED]. 9/12/18; 11:05 a.m. - Director of Nursing reports no psych evaluations were ever arranged for R#56 or R#58. 9/13/18; 10:00 a.m. - Director of Nursing reports several orders for psych evals were overlooked because of the change in nursing leadership. She presents a plan to have residents evaluated by a new service. The plan is for 2 weeks with 15 residents being evaluated each week. 4. Review of the clinical record for R#6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, indicating severe cognitive impairment. The assessment revealed the resident was not, at the time, experiencing mood symptoms but exhibited physical behavior symptoms directed towards others 1-3 days. The assessment also documented that the resident was receiving antidepressant and [MEDICAL CONDITION] medications. Review of Physicians Phone order, dated 3/14/18, revealed an order for [REDACTED]. Interview on 9/13/18 at 2:08 p.m., with DON stated that several residents with psych evaluations were missed. She is not sure how they were overlooked, unless it was during the change in staffing. She further stated the facility has contracted with a new provider for psychiatric services, and she has started a list of residents who had orders for psychiatric evaluations, to be seen during the next few weeks.",2020-09-01
745,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2018-09-13,688,D,1,1,7L8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interview, the facility failed to provide evidence that splint application to the right hand had been done as recommended by Occupational Therapy (OT) since 8/26/18 for one resident (R) (R 'S'). The sample size was 41 residents. Findings include: Review of R 'S's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of R 'S's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates that a resident has no cognitive impairment), had functional limitation in range of motion (ROM) on one side of his upper body, and both sides of his lower body, and that he was receiving restorative for passive range of motion (PROM) and splint assistance six days a week. Review of R 'S's care plans revealed one for [MEDICAL CONDITION] to right side related [MEDICAL CONDITION](stroke). Review of the interventions to this care plan included range of motion active or passive with restorative six times a week, with a revision date of 4/27/18. Review of a care plan for arthritis (gout) and muscle weakness noted an intervention for use of supportive devices such as splints as recommended by OT, last revised on 4/27/18. On 9/11/18 at 11:26 a.m., R 'S' was observed to have paralysis on his right side, and he stated during interview that he had a stroke on that side. Further observation revealed that R 'S's right hand was closed, but he demonstrated that he was able to open all of the fingers on his right hand with his left hand. R 'S' stated during interview that he was receiving ROM and splint application to his right hand prior to a restorative CNA (Certified Nursing Assistant) quitting about two weeks ago, but had not received these services since. Further observation at this time revealed that there was a splint on the resident's nightstand. Observation on 9/11/18 at 2:49 p.m. revealed that there was no splint on R 'S's right hand. During interview with R 'S' on 9/12/18 at 9:10 a.m., and 9/13/18 at 9:46 a.m. and 7:33 p.m., he stated that no one had come in to do ROM or apply the splint to his right hand since the surveyor asked him about it on 9/11/18. Review of a Restorative Rehabilitation Program Recommendations for R 'S' with date established of 1/11/18 by OT noted grooming, continue to wash right hand with setup, 6 times per week for 12 weeks. Hand splint 6 hours daily or to tolerance, right hand. During interview with CNA AA on 9/12/18 at 2:50 p.m., she stated that a restorative CNA (RCNA) had quit about two weeks ago, and another RCNA started about a week ago. During interview with Licensed Practical Nurse (LPN) CC on 9/13/18 at 9:50 a.m., she stated that she had taken over the position as the restorative nurse about a month ago, that the previous RCNA was in the process of leaving around that time, and that a new RCNA started about a week ago. LPN CC stated during continued interview that the RCNA knew which residents to provide restorative services for, as they were listed in a restorative notebook. Review of the restorative notebook revealed that there was a list residents that required orthotics, and R 'S' was on the list as needing a right hand orthotic. Review of a page labeled Contractures/Splinting dated (MONTH) (YEAR) revealed that R 'S' was on the list. Review of a Restorative List dated (MONTH) (YEAR) (the most up to date seen in the notebook) revealed that R 'S' was not on the list. Review of a Restorative Nursing Program Flow Sheet dated 8/18 (August (YEAR)) revealed documentation of the provision of splint or brace assistance services for R 'S,' but no documentation of services provided past 8/26/18. Review of Weekly Notes on the Restorative Program Summary in the restorative notebook revealed no entries after 8/7/18. During interview with RCNA DD on 9/13/18 at 10:14 a.m., she stated that she started in the position of RCNA around 9/3/18, and that the restorative notebook told her what restorative services a resident needed. She stated during further interview that she did rotation (when clarified RCNA DD verified she meant ROM) of R 'S's right hand, and verified that she had no documentation of provision of restorative services in September. During interview with OT EE on 9/13/18 at 11:31 a.m., she verified that the latest therapy recommendations to restorative were dated 1/11/18, and that the ADL (activity of daily living) and grooming recommendation was for 12 weeks only, but the recommendation for the hand splint should be ongoing indefinitely, unless there was a problem with the splint. She further stated that ROM was typically recommended to the affected extremity any time there was a recommendation for a splint, but verified that ROM was not on the 1/11/18 OT recommendation. Review of an Occupational Therapy Discharge Summary dated 1/8/18 noted RNP (restorative nursing program) to facilitate patient maintaining current level of performance and in order to prevent decline, development and instruction in the following RNPs has been completed with the IDT (interdisciplinary team): AROM (active range of motion) and splint or brace care. Review of the facility's Rehabilitative Nursing Care policy with a modified date of 3/11/04 noted: Rehabilitative nursing care is performed daily for those residents that require such services.",2020-09-01
746,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2018-09-13,758,D,1,1,7L8V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to document behavior medication side effects for two residents (R) R#6 and R#51, who were receiving [MEDICAL CONDITION] medications. The sample size was 41. Findings include: 1. Review of the clinical record for R#6 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, indicating severe cognitive impairment. The assessment revealed the resident was not, at the time, experiencing mood symptoms but exhibited physical behavior symptoms directed towards others 1-3 days. The assessment also documented that the resident was receiving antidepressant and [MEDICAL CONDITION] medications. Review of Physician orders [REDACTED]. Review of the behavior monitoring records for months (MONTH) through (MONTH) (YEAR) revealed target behaviors had not been identified and behavior monitoring side effects had not been documented. (MONTH) record revealed only documentation completed was night shift on 4/20/18; no documentation of behavior monitoring for month of (MONTH) (YEAR); no documentation of behavior monitoring for month of July; no documentation of behavior monitoring for month of (MONTH) (YEAR); documentation of behavior monitoring for month of (MONTH) was completed for 9/2/18 only. 2. Review of the clinical record for R#51 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 0, indicating severe cognitive impairment. The assessment revealed the resident was not, at the time, experiencing mood or behavior symptoms. The assessment also documented that the resident was receiving antidepressant medications. Review of Physician orders [REDACTED]. Review of R#51 medical record revealed there was no evidence that behavior monitoring had been done since admission to facility. Review of Pharmacy Nurse Consultant report edated 6/13/18 summary of findings revealed charting omissions on Medication Administration Records (MAR) for behaviora monitoring records and behavior records with no target behaviors identified. Interview on 9/12/18 at 2:06 p.m., with Licensed Practical Nurse HH, stated she documents behavior monitoring on the residents receiving [MEDICAL CONDITION] medications at the end of the shift. She stated there is a notebook kept at the nurse's station that has the behavior monitoring sheets for each unit. She further stated that she tries to redirect resident from behaviors, such as toileting, providing 1:1 and offering a snack, before resorting to medication use. On 9/13/18 at 3:39 p.m., Administrator stated the facility does not have a policy for behavior monitoring. Interview on 9/13/18 at 4:53 p.m., with Director of Nursing (DON) stated that she has only been in the position for one month. She stated that her expectation is for the nurses to be doing behavior monitoring and completing the documentation each day. She stated that she does not have a reason for what the previous DON had done prior to her assuming the role. She further stated that she is working on inservicing the nurses about several things, including behavior monitoring.",2020-09-01
747,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2018-09-13,812,F,0,1,7L8V11,"F812 - Kitchen Sanitation. Based on observations, staff interviews, and review of the facility's policies titled Safe Food Handling and Personal Hygiene, the facility failed to assure that the food prep area was free of unsanitary conditions. The sample size was 41 residents. Findings include: On 9/12/18 at 10:55 a.m. an observation was conducted of preparation of pureed foods. The Dietary Manager failed to completely cover her longer-than-shoulder-length hair on both sides of her head. She had a white hair covering on the top and sides of her head to right above her ears and the hair below the ear line was exposed. She proceeded to prepare pureed foods of pot roast, cooked carrots, white potatoes, and bread. She cleaned the blender between each food item and she washed her hands between each food preparation. A review of a facility In-service Record Log dated 7/2/(no year) indicates a staff update was provided regarding Safe Food Handling and Personal Hygiene. The Dietary Manager's signature is on the document as an attendee. The document Personal Hygiene indicates Hair must be kept clean and kept restrained with a hair net or cap covering all hair. On 9/13/18 at 8:45 a.m. the Dietary Manager was observed in the kitchen near the food prep tables with her hair exposed on one side of her head. On 9/13/18 at 8:47 a.m. the Regional Dietary Director was present at the facility and he was interviewed regarding the use of hair coverings while in the kitchen and food-preparation area. He reports the hair should be completely covered. On 9/13/18 at 8:50 a.m. the Regional Dietary Director observed the Dietary Manager with her hair exposed.",2020-09-01
748,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,156,D,0,1,NZ7H11,"Based on interview and review of Advance Beneficiary Notices provided to residents and/or their responsible party revealed the facility failed to provide the appropriate Notice of Medicare Non-Coverage (NOMNC) to 3 of 4 sampled residents (R) (R73, R74 and R77) who received skilled services. The notices that Medicare Part A services would be ending did not provide the residents the information that they could appeal the notice or request an expedited review of their case. Findings include: 1. R73 was issued an Advance Beneficiary Notice of Non-Coverage (ABN) form CMS (Centers for Medicare and Medicaid Services)-R-131. Review of the form revealed it was signed on 6/30/16 by the spouse of R73. The notice stated Occupational Therapy (OT) and Physical Therapy (PT) Medicare Part A would be discontinued on 7/12/16. The form did not include information on how to appeal the facility's decision or to request an expedited review. The form utilized was a single-page form. A photocopy of the addressed and stamped envelope was included with the ABN form. Review of the issued CMS-R-131 revealed it was incomplete. Item C Identification Number was left blank. The section at the top of the page labeled NOTE read If Medicare doesn't pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that your or your health care provider have good reason to think you need. We expect Medicare may not pay for the D.__________ below. This blank was not completed with the service that was ending. 2. The CMS-R-131 was provided to a family member of R77. The family member of R77 signed the form on 5/13/16 with the last billable day for Medicare Part A, PT and ST (speech therapy) services, documented as 5/20/16. The form did not include information on how to appeal or request expedited review of the facility's decision. Review of the issued CMS-R-131 revealed it was incomplete. Item C Identification Number was left blank. The section at the top of the page labeled NOTE read If Medicare doesn't pay for D. below, you may have to pay. Medicare does not pay for everything, even some care that your or your health care provider have good reason to think you need. We expect Medicare may not pay for the D.__________ below. This blank was not completed with the service that was ending. 3. R74 received skilled therapy according to the Medical Record. Interview with the Social Worker (SW) on 10/12/16 at 10:30 a.m. revealed she was unable to find a NOMNC issued to the resident or their responsible party. The SW stated she was not employed here at the time of R74's discharge from therapy. Interview with the SW on 10/12/16 at 1:20 p.m. revealed she was told to use Form CMS-R-131 by the skilled nursing facility (SNF) company. She stated she had never used that form before when issuing notices of non-coverage of Medicare services. Further interview with the SW on 10/12/16 at 2:10 p.m. confirmed she had only completed a few of the CMS-R-131 forms for residents. She stated she was unaware of the difference in Medicare A and Medicare B services notification requirements. She confirmed that she mailed the form via regular mail if the resident was unable to sign for themselves. When asked how she knew if the form was received after being mailed, she stated she did not. She also stated she had never issued one by telephone. She maintained a three-ring binder for CMS-R-131s with a log in front for each month documenting who they were sent to and when. A one-page document was in the front of her ABN book titled ABN/BNI Notices. The form identified 5 forms used to issue notice of Medicare Non-Coverage in different situations and for different billing types. The form contained the explanation and when to use the CMS-R-131. It stated the CMS-R-131 was to be issued when Medicare B services were ending and was to be issued in conjunction with the CMS- Notice of Medicare Non-Coverage. R73 and R77 were not issued a CMS- . Interview at 2:31 p.m. on 10/12/16 with Administrator revealed she issued notices during the gap between the previous social worker and the current social worker starting work. She stated they used the same notice for Medicare A and Medicare B services that were ending. She stated she was unaware that the form being used was specifically for Part B services in a SNF setting. She reviewed the ABN/BNI explanation that was located in front of the ABN Binder in the social services office and read the directions for completing the CMS-R-131 and said oh. She was unaware the notice being used did not include the information that a resident could appeal or request an expedited review of the notice. She was also unaware a resident had the right to appeal or request an expedited appeal. She stated they would obtain the correct forms and educate herself and SW on the completion of them. She was unaware the notices should be sent by certified mail with a return receipt to ensure the ability to identify if a notice was received by the responsible party and was not aware the notice could be verbally issued documented on the form and sent certified mail as well.",2020-09-01
749,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,225,E,0,1,NZ7H11,"Based on record review and staff interviews, the facility failed to ensure all residents were adequately protected from potential abuse as evidenced by lack of appropriate screening of potential employees. Specifically, licensure/certification verification was not completed for three of five nursing staff members whose employee records were reviewed (the Director of Nursing (DON), Certified Nurse Aide (CNA1) and CNA2) and reference checks were not completed for two of five nursing staff members whose employee records were reviewed (Licensed Practical Nurse (LPN) 2 and CNA1). This failure potentially affected the safety of residents residing on two of the three halls in the facility where these employees consistently worked. Findings include: The facility's Policy on Abuse and Neglect read, in pertinent part, Screening: 1. All applicants for employment in the facilities shall, at a minimum, have the following screening checks conducted: a. Reference checks with the current and/or past employer; b. Appropriate licensing board or registry check; c. Fingerprinting as required by state law; and d. Criminal background check pursuant to state law or facility policy. The facility DON was hired by the facility on 5/23/16. According to the DON's Employee Record, verification of his/her Registered Nurse (RN) license was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. CNA1 was hired by the facility on 5/12/16. According to CNA1's Employee Record, verification of his/her CNA certification was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. CNA2 was hired by the facility on 9/28/16. According CNA2's Employee Record, verification of his/her CNA certification was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. LPN2 was hired by the facility on 12/4/15. According to LPN2's Employee Record, verification of his/her references was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. CNA1 was hired by the facility on 5/12/16. According to CNA1's Employee Record, verification of his/her references was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. During an interview, conducted with the Human Resources Manager on 10/14/16 at approximately 11:35 a.m., she stated the usual process was to verify an employee's license/certification right after the employee's application was received and then place the documentation immediately into the employee's file. She stated reference checks were conducted prior to an employee's first day of work in the facility, check marks were placed next to the references that were checked on the Reference Sheet Form, and then the document was placed immediately in the employee's file. The Human Resources Manager stated she had been unable to find the above referenced licensure/certification verifications or reference checks in the employee files, and so had run the licensure/certification checks that morning (10/14/16) after the documentation was requested by the survey team.",2020-09-01
750,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,226,E,0,1,NZ7H11,"Based on record review and staff interviews, the facility failed to follow their own Policy on Abuse and Neglect. Specifically, three of five newly hired nursing staff (the Director of Nursing (DON), CNA1, and CNA2) did not receive proper licensure/certification verification and reference checks were not properly completed for two of five nursing staff (LPN2 and CNA1) prior to hire per policy, creating the potential for residents on the two of three hallways on which these employees worked in the facility to be subjected to abuse or neglect. Findings include: The facility's Policy on Abuse and Neglect read, in pertinent part, Screening: 1. All applicants for employment in the facilities shall, at a minimum, have the following screening checks conducted: a. Reference checks with the current and/or past employer; b. Appropriate licensing board or registry check; c. Fingerprinting as required by state law; and d. Criminal background check pursuant to state law or facility policy. The facility DON was hired by the facility on 5/23/16. According to the DON's Employee Record, verification of his/her Registered Nurse (RN) license was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. CNA1 was hired by the facility on 5/12/16. According to CNA1's Employee Record, verification of his/her CNA certification was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. CNA2 was hired by the facility on 9/28/16. According CNA2's Employee Record, verification of his/her CNA certification was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. LPN2 was hired by the facility on 12/14/15. According to LPN2's Employee Record, verification of his/her references was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. CNA1 was hired by the facility on 5/12/16. According to CNA1's Employee Record, verification of his/her references was not completed until 10/14/16 at 10:00 a.m., after the survey team requested this record. During an interview, conducted with the Human Resources Manager on 10/14/16 at approximately 11:35 a.m., she stated the policy of the facility was to verify licensure/certification for newly hired employees and conduct at least two reference checks, preferably with previous employers, prior to a new staff member beginning work in the facility. She stated she had been unable to find the above referenced licensure/certification verifications or reference checks in the requested employee files, and so had run the licensure/certification checks that morning (10/14/16) after the documentation was requested by the survey team.",2020-09-01
751,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,246,D,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to ensure 1 resident ((R) R113) of 35 sampled residents, received reasonable accommodation of her needs to ensure her call light button was within her reach. This deficient practice had the potential to preclude R113 from calling for help to meet routine and emergency needs. Findings include: The facility's (MONTH) 2010 policy, titled Answering the Call Light, documented, in pertinent part, When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. R113 was admitted to the facility on [DATE] with diagnoses, according to the 9/6/16 Admission Record, of [MEDICAL CONDITIONS], dementia with behavioral disturbance, restlessness and agitation, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The 8/26/16 admission Minimum Data Set (MDS - a comprehensive assessment completed by facility staff), with an Assessment Reference Date of 8/26/16, documented R113 had impaired cognition (section D0500) and was totally dependent on staff for bed mobility, transfers, and all activities of daily living (section G0110). R113's 8/26/16 Interdisciplinary Resident Care Plan documented she was dependent for all activities of daily living, and the approaches included: assist with transfers as indicated .(and) incon(tinence) care as needed The care plan also documented a potential for diminished skin integrity related to incontinence and disease process. The approaches included, Place call light within reach. On 10/10/16 at 11:52 a.m., R113 was observed lying in bed. Her call light button was attached to the privacy curtain, right next to the wall near the call light box, which was approximately 3 feet away from the bed. The resident was unable to reach her call button from her bed. When asked, R113 stated she did not know where her call button was. On 10/11/16 at 10:50 p.m., R113 was observed lying in bed asleep. The call light button was clipped to the privacy curtain, approximately 3 feet away from the head of the bed. On 10/13/16 at 1:25 p.m., R113 was again observed lying in bed with the call light button clipped to the privacy curtain, approximately 3 feet away from the bed. On 10/14/16 at 8:58 a.m., R113 was observed lying in bed with her call light button attached to the privacy curtain, approximately 3 feet away from the bed. The resident was unable to reach her call button from her bed. On 10/14/16 at 9:32 a.m., the ADON was alerted to the above observation. She stated the call light button should be kept within reach of the resident while in bed, and immediately moved the button to the resident's bed. On 10/14/16 at 1:14 p.m., Licensed Practical Nurse (LPN) 1 stated R113 was confused at times, but was usually able to use her call light to summon help without problems. She stated the call light button should always be kept in reach of the resident, and it should be clipped on to the bed. The LPN stated storing the call light button on the privacy curtain was not right.",2020-09-01
752,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,279,D,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure two Residents (R) (R16 and R40) of 39 sampled residents had care plans in place to address their comprehensive clinical needs. Specifically, R16's care plan did not address his dental status and R40 did not have a care plan in place to address her use of a hypnotic medication to help her sleep. Findings include: 1. R16 was admitted to the facility on [DATE] with diagnoses, according to the 7/13/15 Admission Record, of malnutrition, dysphagia, and anxiety. R16's Minimum Data Set (MDS) assessment, an Annual assessment of comprehensive status dated 7/8/16, indicated R16 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of 5 out of 15. He received a mechanically altered diet, and had no natural teeth and required the use of dentures, which were broken and/or loosely fitting according to the assessment. According to the Care Area Assessment (CAA) portion of the assessment, dental care was a triggered care area for R16, which indicated the need for a care plan to address this need. R16's Care Plan, dated 7/22/16, was reviewed. No documentation could be found to indicate a care plan was in place for R16 regarding his impaired dental status (missing teeth) or his broken/ill-fitting dentures. Quarterly/Follow-up Nutrition Progress Notes, dated 10/5/16, indicated the resident was received a mechanical soft diet and that the resident had no teeth at the time of the assessment. A Telephone Order (TO), dated 9/14/16, indicated R16 was to have a dental consult related to broken dentures. 2. R40 was admitted to the facility on [DATE] with diagnoses, according to the most recent 10/1/16 Admission Record, including [MEDICAL CONDITION], depression, anxiety, and [MEDICAL CONDITION]. R40's Minimum Data Set (MDS), a quarterly assessment of comprehensive status dated 6/19/16, indicated R40 had moderately impaired cognition with a BIMS score of 12 out of 15. A dash was entered into the assessment in reference to the administration of a Hypnotic medication for sleep, indicating this portion of the assessment was not completed or the answer to the question was unknown at the time of the assessment. According to the CAA portion of the prior Annual MDS Assessment, dated 3/21/16, [MEDICAL CONDITION] medication administration was triggered for the resident, indicating the need for a care plan addressing the use of [MEDICAL CONDITION] medications, including the resident ' s use of her hypnotic medication. R40's physician's orders [REDACTED]. R40's Care Plan, dated 10/12/16, was reviewed. No documentation could be found to indicate a care plan was in place for the use of [MEDICATION NAME] to induce sleep. During an interview with the Assistant Director of Nursing (ADON), conducted on 10/14/16 at approximately 2:40 p.m., she stated We do not have the care plans. These care plans should be in place. The issue will be addressed.",2020-09-01
753,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,280,E,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan for 1 resident ((R) R95) of 39 sample residents with interventions after each fall to address the root cause of the falls and/or prevent recurrence. Findings include: R95, age 84, was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the 7/22/15 Admission Record, of diabetes, muscle weakness, debility, senile dementia, hypertension, [MEDICAL CONDITIONS], constipation, and prostate atrophy. The quarterly Minimum Data Set (MDS) assessment, with an Assessment Reference Date (ARD) of 8/23/16, documented R95 had minimally impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (section C0500). He had impaired vision (section B1000) and exhibited verbal behaviors toward others at times (section E0200B). R95 required extensive assistance with bed mobility and locomotion and total assistance with transfers (section G0110). He had impaired functional range-of-motion in one lower extremity (section G0900). R95 experienced two or more falls without injury and one fall with injury in the previous quarter (section J1900). He did not use any physical restraints (section P0100). The 8/17/16 Fall Risk Evaluation documented the resident was at moderate risk for falls (score of 9 out of 10) related to 1 to 2 falls in the past 3 months, chair-bound status, a balance problem while standing, use of pre-disposing medications, and predisposing diagnoses. An Interdisciplinary Care Plan, last updated on 9/7/16, documented the resident had a potential for falls related to both internal and external factors, debility, disease process. The care plan indicated R95 had fallen 8 times from (MONTH) (YEAR) to (MONTH) (YEAR) and also had fallen on 5/29/16, 6/3/16, 6/11/16, 7/3/16, 7/25/16, and twice on 9/7/16. The approaches included: Encourage daily exercise .Place call light within reach .Provide a clutter free environment .Encourage use of appropriate footwear - non-skid .Assess for comfort .Re-educate to use call signal to request assistance .Provide assistance devices as ordered .Staff awareness and supervision .Remind to lock brakes on (wheelchair) .Therapy to screen .Encourage to call for assistance . (and) Continue current P[NAME] (Plan of Care). Review of facility records revealed: a. A 5/29/16 Nurse's Note documented R95 dropped out of chair to floor with no injuries, no (complaints of) pain The corresponding 5/29/16 Incident Report documented the resident was sitting on the edge of his bed, tried to stand up and get into his wheelchair independently, and slipped to the floor. The interventions added to the care plan on 5/29/16 were: Therapy to screen. Encourage to call for assistance. Continue Current P[NAME]. b. A 6/3/16 Nurse's Note documented R95 was observed in kneeling position (at) 5:36 a.m. on the floor of his room. The corresponding 6/3/16 Incident Report documented R95 was observed in kneeling position next to his bed. There were no injuries noted. The interventions added to the care plan on 6/3/16 were: Continue current P[NAME] .PT (physical therapy) to eval(uate) .Encourage resident to call for assistance. c. A 6/11/16 Nurse's Note documented R95 was heard yelling for help at 7:55 a.m. and was found on the floor in his bathroom. He had hit his head on the floor and was sent to the hospital for evaluation, but returned without evidence of serious injury. The 6/11/16 Incident Report documented R95 was heard yelling and was discovered on bathroom floor, after having attempted to transfer himself from the wheelchair to the commode. The resident stated his feet slid out from under him. The interventions added to the care plan on 6/11/16 were: Continue current P[NAME]. Therapy to screen. Reeducate (and) encourage to call for assistance. d. A 7/3/16 Nurse's Note documented R95was found on the floor of his bathroom around 7:50 p.m., wedged between the wall and the toilet. He suffered a skin tear to his back. The 7/3/16 Incident Report documented R95 was observed on the bathroom floor between wall and commode; he had attempted to go to the bathroom by himself. The interventions added to the care plan on 7/3/16 were: Continue P[NAME]. 2 Person assist. Re-educate use (sic) call light for assistance. Therapy to screen. e. A 7/25/16 Nurse's Note documented R95 was being repositioned in his wheelchair by staff and he began slipping from the chair. He was assisted to the floor. The interventions added to the care plan on 7/25/16 were: Continue current P[NAME]. Therapy to screen. A 7/26/16 therapy recommendation documented non-slip strips on the floor next to his bed and staff to use the mechanical sit/stand lift for transfers. f. A 9/7/16, 2:00 a.m. Nurse's Note documented R95 was heard yelling and was found on the floor. He stated he stood up from his wheelchair when it was not locked and it rolled away. The 9/7/16, 2:00 a.m. Incident Report documented R95 was heard yelling from his room and was found lying prone on the floor in his room with his wheelchair at his head. The resident stated the wheelchair was not locked. The interventions added to the care plan on 9/7/16 were: Continue current P[NAME]. Therapy to screen. Bed in lowest position. A 9/7/16 therapy Communication Form documented, Since patient is refusing rehab, all recommendations will be environmental. Recommend no slip strips on the floor by bed to give him traction on feet when he is sitting edge (sic) of bed. g. A 9/7/16, 8:00 p.m. Nurse's Note documented R95 was found lying on his back between the bed and wheelchair; the wheelchair was unlocked. The resident suffered three skin tears to his right upper arm. A 9/7/16 Incident Report documented R95 attempted to transfer himself from wheelchair to bed without assistance. The wheelchair brakes were not locked and it rolled away. The resident suffered 3 skin tears to his right forearm. The interventions added to the care plan on 9/7/16 included: Continue current P[NAME]. Therapy to screen. Encourage to use call light. The 9/8/16 therapy Communication Form documented, Pt (patient) needs to be encouraged to not transfer on his own. All transfers need to be with Hoyer lift due to poor joint integrity and extreme weakness. The care plan was not updated with new interventions to address the root cause of each fall; rather, the same interventions were continued. The care plan also was not updated to reflect therapy recommendations, including non-slip strips on the floor and using the Hoyer lift during transfers. On 10/13/16 at 1:27 p.m., the ADON stated, Normally we try new interventions after each fall, but he is just one of those that doesn't (sic) cooperate. On 10/13/16 2:24 p.m., the ADON stated R95 was so non-compliant that the facility was unable to implement any recommended interventions. She stated the resident understood the risks of continued falls related to his refusal to call for help with transfers, refusal to work with therapy, and refusal to use a mechanical lift with transfers, though she was unable to provide documentation of this education with the resident. The care plan did not reflect the resident's refusals to cooperate with therapy and nursing interventions and recommendations.",2020-09-01
754,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,312,E,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interview, the facility failed to ensure 4 residents (R) (R59, R53, R46, and R52) of 39 sample residents received assistance with showers necessary to maintain good hygiene. Findings include: 1. R59 was admitted to the facility on [DATE] with diagnoses, according to the 6/30/15 Admission Record, of diabetes, upper [MEDICAL CONDITIONS], anxiety, [MEDICAL CONDITION], and [MEDICAL CONDITION]. The Minimum Data Set (MDS - a comprehensive assessment completed by facility staff that drives the care planning process), with an assessment reference date (ARD) of 8/5/16 documented R59 had minimally impaired cognition and required total assistance by staff with showers. Review of R59's 8/18/16 Interdisciplinary Resident CarePlan (sic) revealed it did not contain information regarding the resident's preference for frequency of showers or instruction to staff regarding how often to assist the resident to shower. The (MONTH) (YEAR) Shower Schedule documented R59 received only 5 showers during the month, on 9/2/16, 9/5/16, 9/19/16, 9/26/16, and 9/29/16. The (MONTH) (YEAR) shower records revealed R59 had only 1 shower during the month, on 10/13/16. There was no documentation of any refused attempts to provide shower assistance. On 10/11/16 at 1:03 p.m., R59 stated she was supposed to receive a shower at least twice per week, but I haven't (sic) had a bath for two weeks. I don't (sic) know why. Staff hasn't (sic) said anything. This is the second time this has happened. Her hair appeared greasy. 2. R53 was admitted to the facility on [DATE] with diagnoses, according to the 4/11/16 Admission Record, of [MEDICAL CONDITION] and [MEDICAL CONDITION], muscle weakness, malaise, arthropathy, and [MEDICAL CONDITION]. The quarterly MDS assessment, with an ARD of 8/3/16 documented R53 had moderately impaired cognition and required assistance, in part, by staff with showers. R53's 4/8/16 Care Plan documented, Showers per protocol, encourage participation to tolerance. It did not contain information regarding the resident's preference for frequency of showers or instruction to staff regarding how often to assist the resident to shower. The (MONTH) (YEAR) Shower Schedule documented R53 received only 1 shower during the month, on 9/22/16. R53 refused showers on 9/19/16 and 9/26/16. The (MONTH) (YEAR) shower records revealed R53 had only 1 shower during the month, on 10/13/16. On 10/14/16 at 11:02 a.m., bath aide (BA) 1 stated she did not know why only 1 shower was given in (MONTH) (YEAR). BA1 confirmed the BAs were often pulled to work on the floor instead of giving showers. On 10/14/16 at 11:07 a.m., BA2 stated the BAs were pulled to work on the floor instead of provide showers almost every other day. She stated when the BAs were pulled to the floors, the residents were not provided with their scheduled showers because the staff are too busy. When asked if the floor certified nurse aides (CNAs) were expected to provide assistance with showers, BA2 stated yes, but added, There is no way. How are we going to? There's not enough staff to get showers done. We (the BAs) usually work the floor because we don't (sic) have the staff to schedule. If someone calls off, we work short. On 10/14/16 at 1:03 p.m., Registered Nurse (RN) 2 stated she reviewed shower records daily and found that showers were given according to the facility shower schedule. When asked why R59 and R53 had only one record of a shower in (MONTH) (YEAR), RN2 stated the facility recently implemented a new shower record last Friday with a new shower schedule of three times per week for all residents. She stated, the shower books got misplaced and the that's (sic) the only record we have. When asked how she was monitoring to ensure showers were provided per the schedule, RN2 stated, I ask the staff and residents to confirm if they got showers. RN2 stated her expectation was that every shower was documented by the staff. The RN added, If there are times the BAs are pulled (to work on the floor), all CNAs are expected to give showers .It is put on the daily assignment sheets. When asked to provide these daily assignment sheets, RN2 provided the daily staffing schedule. The daily schedules did not include resident-specific information, including who was to receive assistance with showering. The facility's 2006 Bath, Shower policy documented the purpose was To cleanse and refresh the resident To observe the skin .(and) to provide increased circulation. The policy went on to describe the procedure for providing assistance with bathing. The policy did not address the frequency with which showers should be offered. 3. R52 was admitted to the facility on [DATE] with diagnoses, according to the 6/30/15 Admission Record, of [MEDICAL CONDITION], chronic pain, and depression. R52's most recent Minimum Data Set (MDS) a quarterly assessment of overall status dated 7/22/16, documented R52 had intact cognition with a BIMS score of 14 out of 15, and was totally dependent on staff assistance to complete all of her Activities of Daily Living (ADLs) including daily hygiene and bathing. R52's most recent Plan of Care, dated 5/3/16 and revised on 10/14/16, indicated the resident had a self-care deficit related to her [DIAGNOSES REDACTED]. Staff was to assist R52 with showers per her shower schedule. R52's Shower Schedules, dated 7/16, 8/16, 9/16, and 10/16 indicated the resident was to have showers on Mondays and Fridays during the months of (MONTH) and (MONTH) and then on Tuesdays and Saturdays during the months of (MONTH) and October. Review of the records revealed the resident did not receive a shower per schedule on the following dates: 7/25/16, 7/29/16, 8/22/16, 8/26/16, 8/29/16, 8/31/16, 9/6/16, 9/10/16, 10/1/16, 10/8/16, and 10/11/16. During an interview conducted with R52 on 10/13/16 at 11:05 a.m., she stated, The last shower I had was a week ago Wednesday. She stated she often went long periods of time without a shower because shower aides were being pulled to the floor. She stated, I need to move to another facility where I can get better care. The resident was lying in bed during the interview. Her hair was observed to be greasy and matted. 4. R46 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the 7/12/16 Admission Record, of dementia, right femur fracture, and history of falls. R46's most recent Minimum Data Set (MDS) a quarterly assessment of overall status dated 7/18/16, documented R46 had severely impaired cognition with the Staff Assessment for Mental Status indicating the resident had both short and long-term memory impairment. According to the MDS, R46 was totally dependent on staff assistance to complete many of his Activities of Daily Living (ADLs) including daily hygiene and bathing. R46's most recent Plan of Care, dated 4/27/16 and revised on 5/17/16, indicated the resident had a self-care deficit related to his [DIAGNOSES REDACTED]. Staff was to assist R46 with showers per his shower schedule. R46's Shower Schedules, dated 8/16, 9/16, and 10/16 indicated the resident was to have showers on Tuesdays and Fridays. Review of the records revealed the resident did not receive a shower per schedule on the following dates: 8/16/16, 8/23/16, 8/26/16, 8/30/16, 9/6/16, 9/9/16, and 9/27/16. Shower documentation was requested by the survey team, however this documentation was not received prior to survey exit. During an interview with RN1 on 10/11/16 at approximately 10:00 a.m., she stated, Residents have been complaining because they are missing their showers. We don't have enough staff. During an interview with the Assistant Director of Nursing (ADON) on 10/14/16 at approximately 11:10 a.m., she stated, No comment. I know when to keep my mouth closed. There is an issue with the showers.",2020-09-01
755,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,323,E,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for five residents ((R) R95, R40, R46, R90, and R122) out of a total sample of 39 residents. Specifically, the facility failed to: [NAME] Implement a system to ensure side rails fit appropriately on the bed to eliminate the risk for entrapment for R95, R40, R90, and R122. The failure to ensure side rails did not have a large gap between the mattress and the rails put R95, R40, R90, and R122 at risk for potential entrapment within the gap. The side rails were first observed on [DATE] with a large gap between the side rail and the mattress. This was brought to the facility's attention on [DATE]; however, the side rails were again observed on [DATE] with the same large gaps. This was again brought to the facility's attention on the afternoon of [DATE]; however, the beds of R95, R40, R90, and R122 were still observed with the same large gaps on the evening of [DATE]; B. Devise new interventions based on root cause analysis of multiple falls for R95 and R46, placing both residents at risk for serious injury from continued falls; and C. Ensure the treatment cart and sharp objects, such as scissors, were stored securely to prevent accidents for residents with cognitive impairment. Findings include: [NAME] Side Rails Review of the Food and Drug Administration's (FDA) Hospital Bed Safety Workgroup article, Clinical Guidance For the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, and Home Care Settings, dated (MONTH) 2003, indicated, in pertinent part, .Use of bed rails should be based on patients' assessed medical needs and should be documented clearly and approved by the interdisciplinary team Bed rail use for patient ' s mobility and/or transferring, for example turning and positioning within the bed and providing a hand-hold for getting into or out of bed, should be accompanied by a care plan Inspect, evaluate, maintain, and upgrade equipment (beds/mattresses/bed rails) to identify and remove potential fall and entrapment hazards and appropriately match the equipment to patient needs, considering all relevant risk factors If it is determined that bed rails are required The mattress to bed rail interface should prevent an individual from falling between the mattress and bed Maintenance and monitoring of the bed, mattress, and accessories such as patient/caregiver assist items .should be ongoing . According to the FDA's Guidance for Industry and FDA Staff article, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, issued [DATE], For [AGE] years, FDA has received reports in which vulnerable patients have become entrapped in hospital beds while undergoing care and treatment in health care facilities. The term entrapment describes an event in which a patient/resident is caught, trapped, or entangled in the space in or about the bed rails, mattress, or hospital bed frame. Patient entrapments may result in deaths and serious injuries. FDA received approximately 691 entrapment reports over a period of [AGE] years from (MONTH) 1, 1985, to (MONTH) 1, 2006. In these reports, 413 people died , 120 were injured, and 158 were near-miss events with no serious injury as a result of intervention. These entrapment events have occurred in openings within the bed rails, between the bed rails and mattresses, under bed rails, between split rails, and between the bed rails and head or foot boards. The population most vulnerable to entrapment are elderly patients and residents, especially those who are frail, confused, restless, or who have uncontrolled body movement. Entrapments have occurred in a variety of patient care settings .Long-term care facilities reported the majority of the entrapments .Zone 3 - Between the Rail and the Mattress: This area is the space between the inside surface of the rail and the mattress compressed by the weight of a patient ' s head. The space should be small enough to prevent head entrapment when taking into account the mattress compressibility, any lateral shift of the mattress or rail, and degree of play from loosened rails .FDA is recommending a dimensional limit of less than 120 mm (4 3/4 inches) for the area between the inside surface of the rail and the compressed mattress. 1. R95, age 84, was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the [DATE] Admission Record, of diabetes, muscle weakness, debility, senile dementia, hypertension, polyneuropathy, insomnia, constipation, and prostate atrophy. The quarterly Minimum Data Set (MDS), a comprehensive assessment completed by the facility that drives the care planning process, with an Assessment Reference Date (ARD) of [DATE], documented R95 had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) score of 12 out of 15 (section C0500). He had impaired vision (section B1000) and exhibited verbal behaviors toward others at times (section E0200B). R95 required extensive assistance with bed mobility and locomotion and total assistance with transfers (section G0110). He had impaired functional range-of-motion in one lower extremity (section G0900). R95 experienced two or more falls without injury and one fall with injury in the previous quarter (section J1900). He did not use any physical restraints (section P0100). The Assist with ADLs (Activities of Daily Living) Care Plan, revised [DATE], documented, (MONTH) use (right) SR (side rail) as enabler as ordered per physician and (MONTH) use SRs as enabler for bed mobility. A care plan addressing side rail use, revised [DATE], documented, Uses quarter or half rails when in bed for enable turning and repositioning secondary to (decreased) bed mobility. The approaches included: Assess for (side rails) per protocol .Refer to Restorative Nursing as needed for bed mobility .Maintain SRs in good repair .Assess as needed for continued use of SRs . Assess for comfort PRN (as needed) . (and) Remove SRs if not being used for bed mobility. The [DATE] Side Rail Assessment documented R95 desired the use of side rails for bed mobility. He could have fluctuations in his level of consciousness and he had visual deficits, poor balance, a history of falls, and a history of postural hypotension. The resident did not use medications that required safety precautions. The assessment recommended a right side rail be used to promote bed mobility (and) positioning. The [DATE] Fall Risk Evaluation documented the resident was at moderate risk for falls (score of 9 out of 10) related to 1 to 2 falls in the past 3 months, chair-bound status, a balance problem while standing, use of pre-disposing medications, and predisposing diagnoses. Review of R95's medical record on [DATE] revealed no physician's order for the use of side rails. R95's Nurse's Notes documented he experienced a fall from bed on [DATE] at 5:36 a.m., when he was found on his knees on the floor at the side of the bed. On [DATE] at 2:30 p.m., R95's bed was observed with a 1/4 side rail on the right side of his bed. The side rail was not secured in place, and could be easily pulled out to accommodate a wider mattress, leaving a 6.5-inch gap between the inside of the side rail and the right edge of the mattress. On [DATE] at 4:00 p.m., the Maintenance Supervisor (MS) stated he did regular rounds to ensure the side rails were in good working condition, but his rounds did not include checking the bed environment for the fit of the rails on the beds and the potential for entrapment related to gaps between the side rails and the mattress. The MS stated he had never been instructed to do so, nor had he been instructed on the facility's expectations related to the size of the gap between the rails and the mattress. On [DATE] at 4:20 p.m., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were alerted to the survey team's concerns over side rails observed with a gap between the rail and mattress. The Administrator stated there should not be any gaps wider than 2 inches between the side rails and the mattress, as this could pose an entrapment risk to the residents. She stated the facility did not have a policy regarding the fit of side rails on the bed. She also stated the facility did not have a monitoring system to ensure the side rails fit properly on the beds to eliminate any gaps that would pose a risk of entrapment. The ADON stated the residents should have physician orders for the use of side rails, and an assessment for the use of side rails was to be completed quarterly. On [DATE] at 8:07 a.m. and 2:44 p.m., R95's side rail was again observed on the bed and unsecured; it was able to be pulled out to the side to create a 6.5-inch gap between the rail and the mattress. On [DATE] at 2:40 p.m., R95 stated he used his side rail for help with positioning in bed and with standing up from his bed or wheelchair. He stated whenever he pulled on the rail to use it to assist him with standing, it would slide out (to the wide position, which created the large gap between the rail and the mattress). He also stated if he was in bed and rolled over, the rail would slide out to the wide position. On [DATE] at 1:47 p.m., the Administrator provided a [DATE] Side Rails policy, which documented, A side rail screening should be completed on all new submissions. Nursing is responsible for completion of the form; however, assistance from therapy (and) other caregivers is appropriate .When side rail use is determined to be necessary (and) meets the criteria for usage .a physician's order must be obtained .Residents with decreased cognition who demonstrate poor judgment and attempt to climb over side rails are not candidates for side rail use .A Fall Risk Assessment should have been completed on admission and residents in the moderate to high-risk category or with a history of false (sic) are not candidates for side rails. Other interventions should be tried. On [DATE] at 1:47 p.m., the Administrator also provided a newly adopted facility policy, taken from the MED-PASS Nursing Services Policy and Procedure Manual, revised (MONTH) 2007, titled, Bed Safety. The policy documented, The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement .To try to prevent deaths/injuries from the beds and related equipment .the facility shall .review that gaps within the bed system are within the dimension established by the FDA (see above reference) .Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; and .Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment. On [DATE] at 10:50 p.m., R95's right side rail was in the up position. The rail was easily pulled out to the wide position and would not lock in place in the up position. Registered Nurse (RN) 1 and Licensed Practical Nurse (LPN) 2 were alerted, and stated the potential for the rail to be pulled out created a risk for entrapment, and both confirmed they were not alerted to any concern with the gaps between the mattresses and side rails or provided with any education regarding the proper fit/use of side rails. RN1 stated she would contact maintenance to get access to the zip ties, or switch out the beds for the night to ensure residents' safety. On [DATE] at 11:42 p.m., the Administrator was alerted to the continued risk of a large gap on R95's bed. She confirmed that R95's side rail would be tied down to the bed frame and stated the staff would do a facility-wide sweep tomorrow to ensure all bed rails were tied down as needed and fitting properly. On [DATE] at 10:17 a.m., the Administrator, DON, and ADON stated all side rails in the facility would be inspected for fit and would be tied down or secured properly to ensure no gaps larger than 2 inches were present. B. Falls R95, age 84, was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the [DATE] Admission Record, of diabetes, muscle weakness, debility, senile dementia, hypertension, polyneuropathy, insomnia, constipation, and prostate atrophy. The quarterly MDS assessment, with an ARD of [DATE], documented R95 had moderately impaired cognition with a BIMS score of 12 out of 15 (section C0500). He had impaired vision (section B1000) and exhibited verbal behaviors toward others at times (section E0200B). R95 required extensive assistance with bed mobility and locomotion and total assistance with transfers (section G0110). He had impaired functional range-of-motion in one lower extremity (section G0900). R95 experienced two or more falls without injury and one fall with injury in the previous quarter (section J1900). He did not use any physical restraints (section P0100). The [DATE] Fall Risk Evaluation documented the resident was at moderate risk for falls (score of 9 out of 10) related to 1 to 2 falls in the past 3 months, chair-bound status, a balance problem while standing, use of pre-disposing medications, and predisposing diagnoses. An Interdisciplinary Care Plan, last updated on [DATE], documented the resident had a potential for falls related to both internal and external factors, debility, disease process. The care plan indicated R95 had fallen 8 times from (MONTH) (YEAR) to (MONTH) (YEAR) and also had fallen on [DATE], [DATE], [DATE], [DATE], [DATE], and twice on [DATE]. The approaches included: Encourage daily exercise .Place call light within reach .Provide a clutter free environment .Encourage use of appropriate footwear - non-skid .Assess for comfort .Re-educate to use call signal to request assistance .Provide assistance devices as ordered .Staff awareness and supervision .Remind to lock brakes on (wheelchair) .Therapy to screen .Encourage to call for assistance . (and) Continue current P[NAME] (Plan of Care). Review of facility records revealed: a. A [DATE] Nurse's Note documented R95 dropped out of chair to floor with no injuries, no (complaints of) pain The corresponding [DATE] Incident Report documented the resident was sitting on the edge of his bed, tried to stand up and get into his wheelchair independently, and slipped to the floor. The interventions added to the care plan on [DATE] were: Therapy to screen. Encourage to call for assistance. Continue Current P[NAME]. The facility was unable to provide a record of the therapy screen that was added as an intervention in the care plan. b. A [DATE] Nurse's Note documented R95 was observed in kneeling position (at) 5:36 a.m. on the floor of his room. The corresponding [DATE] Incident Report documented R95 was observed in kneeling position next to his bed. There were no injuries noted. The interventions added to the care plan on [DATE] were: Continue current P[NAME] .PT (physical therapy) to eval(uate) .Encourage resident to call for assistance. The facility was unable to provide a record of the therapy screen that was added as an intervention in the care plan. c. A [DATE] Nurse's Note documented R95 was heard yelling for help at 7:55 a.m. and was found on the floor in his bathroom. He had hit his head on the floor and was sent to the hospital for evaluation, but returned without evidence of serious injury. The [DATE] Incident Report documented R95 was heard yelling and was discovered on bathroom floor, after having attempted to transfer himself from the wheelchair to the commode. The resident stated his feet slid out from under him. The interventions added to the care plan on [DATE] were: Continue current P[NAME]. Therapy to screen. Reeducate (and) encourage to call for assistance. The facility was unable to provide a record of the therapy screen that was added as an intervention in the care plan. d. A [DATE] Nurse's Note documented R95was found on the floor of his bathroom around 7:50 p.m., wedged between the wall and the toilet. He suffered a skin tear to his back. The [DATE] Incident Report documented R95 was observed on the bathroom floor between wall and commode; he had attempted to go to the bathroom by himself. The interventions added to the care plan on [DATE] were: Continue P[NAME]. 2 Person assist. Re-educate use (sic) call light for assistance. Therapy to screen. The facility was unable to provide a record of the therapy screen that was added as an intervention in the care plan. e. A [DATE] Nurse's Note documented R95 was being repositioned in his wheelchair by staff and he began slipping from the chair. He was assisted to the floor. The interventions added to the care plan on [DATE] were: Continue current P[NAME]. Therapy to screen. A [DATE] therapy recommendation documented non-slip strips on the floor next to his bed and staff to use the mechanical sit/stand lift for transfers. f. A [DATE], 2:00 a.m. Nurse's Note documented R95 was heard yelling and was found on the floor. He stated he stood up from his wheelchair when it was not locked and it rolled away. The [DATE], 2:00 a.m. Incident Report documented R95 was heard yelling from his room and was found lying prone on the floor in his room with his wheelchair at his head. The resident stated the wheelchair was not locked. The interventions added to the care plan on [DATE] were: Continue current P[NAME]. Therapy to screen. Bed in lowest position. A [DATE] therapy Communication Form documented, Since patient is refusing rehab, all recommendations will be environmental. Recommend no slip strips on the floor by bed to give him traction on feet when he is sitting edge (sic) of bed. g. A [DATE], 8:00 p.m. Nurse's Note documented R95 was found lying on his back between the bed and wheelchair; the wheelchair was unlocked. The resident suffered three skin tears to his right upper arm. A [DATE] Incident Report documented R95 attempted to transfer himself from wheelchair to bed without assistance. The wheelchair brakes were not locked and it rolled away. The resident suffered 3 skin tears to his right forearm. The interventions added to the care plan on [DATE] included: Continue current P[NAME]. Therapy to screen. Encourage to use call light. The [DATE] therapy Communication Form documented, Pt (patient) needs to be encouraged to not transfer on his own. All transfers need to be with Hoyer lift due to poor joint integrity and extreme weakness. Cross-reference F280: Care Plan Revision - The care plan was not updated with new interventions to address the root cause of each fall; rather, the same interventions were continued. The care plan also was not updated to reflect therapy recommendations, including non-slip strips on the floor and using the Hoyer lift during transfers, nor did the care plan did not reflect the resident's refusals to cooperate with therapy and nursing interventions and recommendations. On [DATE] at 1:27 p.m., the ADON stated R95 was physical unable to transfer by himself, but he often attempted to do so. She stated he refused to work with therapy and refused to use a mechanical lift for transfers. The ADON stated, Normally we try new interventions after each fall, but he is just one of those that doesn't (sic) cooperate. On [DATE] at 2:24 p.m., the ADON stated R95 was so non-compliant that the facility was unable to implement any recommended interventions. She stated the resident understood the risks of continued falls related to his refusal to call for help with transfers, refusal to work with therapy, and refusal to use a mechanical lift with transfers, though she was unable to provide documentation of this education with the resident. Side Rails 2. R40 was admitted to the facility on [DATE] with diagnoses, according to the [DATE] Admission Record, including Insomnia, chronic kidney disease, anxiety, and glaucoma. R40's [DATE] Side Rail Assessment indicated R40 expressed a desire to use side rails for bed mobility. She had poor balance per the assessment. The assessment recommended a right side rail be used as an enabler to turn side to side. R40's MDS, a quarterly assessment of comprehensive status dated [DATE], indicated R40 had moderately impaired cognition with a BIMS score of 12 out of 15, had impaired vision, required extensive assistance with bed mobility and was totally dependent upon staff for transfers, had impaired functional range of motion in both lower extremities, and had experienced no falls since admission to the facility. The assessment indicated no restraints were in use for the resident. The [DATE] Fall Risk Evaluation documented the resident was at high risk for falls (score of 10 out of 10) related to chair-bound status, a balance problem while standing, decreased muscular coordination, use of pre-disposing medications, and predisposing diagnoses. The Activities of Daily Living Care Plan, most recently dated [DATE], read, (Resident) is able to assist staff with turning in bed, encourage participation to tolerance. (MONTH) use SR (side rail) as ordered per physician as enabler on right side. Review of R40's medical record revealed no physician's order for the use of side rails. On [DATE] at 12:10 p.m., R40 was observed seated in her wheelchair in her room. Side rails were in place and in the raised position on both sides of the resident's bed. R40 stated, They don't want me to fall. That's why I have the rails on my bed. They come in here and pull out the rail when they make my bed. Sometimes they leave it (the rail) out. I don't sleep with it out, though. R40 then explained to the surveyor how to pull the rail out to accommodate a larger mattress. When the surveyor had the rail pulled approximately ,[DATE] of the way out, the resident stated, You can pull it out further than that. The surveyor then easily pulled the rail out to full extension. The gap between the mattress and the bed rail on the outward facing side of the bed was measured to be 7 inches when the rail was pulled out to full extension. On [DATE] at 10:20 p.m., the rail was checked again for R40. The surveyor was able to easily pull the rail out to bariatric size. After the rail was pulled out, the rail could not be re-locked into a snug position against the side of the resident's mattress, leaving a gap approximately 7 inches wide between the mattress and the rail. The resident was in bed at the time of the observation, and was able to easily push the rail out to full extension away from the bed by simply leaning against the rail. R40 stated, A lot of times, at night, I push up against the rail while I'm sleeping and by the time I wake up the rail is pushed all the way out and my pillow is down in the hole (between the mattress and the side rail). During an interview with CNA8 on [DATE] at approximately 10:30 p.m., she stated she did not know what the rails on the resident's bed were used for. CNA8 accompanied the surveyor into R40's room to check on the rail, and confirmed she was unable to lock the rail into position snuggly against R40's mattress, allowing the rail to very easily slide out to full extension. R40 stated, The rail has always been loose like this. I wake up with pillow down in that hole almost every night. On [DATE] at approximately 10:45 p.m., CNA5, CNA7, and RN1 were observed in R40's room attempting to get the bed rail to lock into place. None of the staff members was able to lock the rail securely into place to prevent a gap from forming between the mattress and the rail. RN1 stated, I will put this issue in the Maintenance Book. On [DATE] at approximately 11:15 p.m., staff replaced R40's bed with another bed and placed a sign on the original bed that indicated the bed was Broken. Falls: The facility's Fall Protocol, undated, read in pertinent part, When a fall occurs, whether witnessed or unwitnessed, the primary goal is to reduce the risk of reoccurrence that may result in a more serious injury; and Assess (the resident), obtain vital signs, and if a head trauma has been sustained, begin neuro-checks in accordance with facility neuro-check policy. The facility's Neuro-check Policy was requested, multiple times, by the survey team, however this policy was not received prior to survey exit. During an interview with the Assistant Director of Nursing (ADON), conducted on [DATE] at approximately 1:00 p.m., however, she stated is was the policy of the facility to conduct neuro-checks with every suspected head injury and every un-witnessed fall. R46 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the [DATE] Admission Record, of dementia, right femur fracture, and history of falls. R46's most recent MDS a quarterly assessment of overall status dated [DATE], documented R46 had severely impaired cognition with the Staff Assessment for Mental Status indicating the resident had both short and long-term memory impairment. According to the MDS, R46 was totally dependent upon staff to complete his Activities of Daily Living (ADLs), including transfers and toileting. The assessment indicated R46 had impaired vision, had a history of [REDACTED]. R46's most recent Activities of Daily Living (ADL) Plan of Care, dated [DATE] and revised on [DATE], indicated the resident had a self-care deficit related to his [DIAGNOSES REDACTED]. The Fall Plan of Care, dated [DATE], indicated R46 was at risk for falls related to impaired cognition, physiological concerns, medications, and history of falls. The care plan indicated staff was to anticipate and meet the resident's needs, keep call light within reach of the resident, use bed and chair alarm, review information on past falls and attempt to determine the root cause, and have therapy evaluate and treat per orders. Several Short Term Fall Care Plans were in place for R46, dated [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. Additional fall related interventions on these care plans included hipsters as tolerated, landing mat, wedge cushion to wheelchair, and anti-tippers to wheelchair. All short term care plans indicated R46 should be screened by therapy. R46's Fall Risk Evaluation, dated [DATE] documented the resident was at high risk for falls (score of 17) related to decreased level of consciousness, history of falls, chair-bound status, a balance problem while standing, use of pre-disposing medications, and predisposing diagnoses. Nurses Notes revealed the resident experienced falls on the following dates: On [DATE], R46 was found on floor in the Green Room after falling from his chair. The fall was un-witnessed. On [DATE], R46 was found on the floor in his room kneeling on his knees next to his bed after trying to transfer from his wheelchair to his bed. The fall was un-witnessed. On [DATE], R46 was found on the floor next to his bed after attempting to transfer himself from his wheelchair to his bed. The fall was witnessed by a staff member. On [DATE], a nurses note documented R46, fell again this shift. Further notation indicated the resident was found sitting on the floor in the facility lobby after attempting to transfer without staff assistance. The fall was un-witnessed. On [DATE], R46 fell from his chair to the floor while attempting to self-transfer. The resident was sent to the emergency room for evaluation after this fall and returned the same day with no documented injuries. The fall was un-witnessed. On [DATE], R46 fell out of bed and onto his floor mat. The fall was un-witnessed. On [DATE], R46 fell on to the floor in his room while attempting to transfer himself. The fall was un-witnessed. On [DATE], R46 fell on to the floor in his room after attempting to transfer himself from his wheelchair to his bed. The fall was un-witnessed. On [DATE], R46 fell from his bed to the floor. The fall was witnessed by a staff member. On [DATE], R46 was found on the floor in his bathroom after transferring himself from his wheelchair to the toilet. The fall was un-witnessed. Neuro-Check documentation was requested for R46 on [DATE], [DATE], and then again on [DATE]. Documentation of neuro-checks could not be found in the resident's clinical record, and was not provided by the facility, for falls on the following dates: [DATE], [DATE], [DATE], and [DATE]. Neuro-check documentation was present for the fall on [DATE], however, the assessment was incomplete. Documentation of all Therapy Screens related to the above referenced falls was requested for R46 on [DATE], and twice on [DATE]. Documentation of the therapy screens could not be found in the resident's clinical record and was not provided by the facility for falls on the following dates: [DATE], [DATE], and [DATE]. During an interview with the ADON on [DATE] at approximately 10:20 a.m., she stated all of the neuro-check reports should have been in the resident's chart. She stated, When we discuss falls we always ask for therapy screens. They should be in the medical record or down in the therapy gym. Side Rails 3. Resident 122 (R122) was admitted on [DATE] with a [DIAGNOSES REDACTED]. He was alert and oriented and able to independently accomplish ADL's. His care plan dated [DATE] documented a bed rail assist bar evaluation reflecting that he requested the bed rail for assistance in bed motility. On [DATE] at 1:30 p.m. R122 was observed in bed. It was determined the distance from the mattress to side rail was approximately 5 inches when the side rail was pulled out. On [DATE] at 2:42 p.m. the Maintenance Supervisor (MS) was observed to measure (using his tape measure) the distance from the mattress to side rail as 5 inches on R122's bed when the side rail was pulled out. On [DATE] at 3:19 p.m. the survey team informed the Administrator, DON, ADON, and MS that R122's bed had side rails that could be pulled out to a distance of 5 inches from the edge of the mattress. On [DATE] at 9:06 a.m. observed R122's bed rail was not fixed and continued to measure approximately 5 inches when the side rail was pulled out. On [DATE] at 10:45 p.m. a tour of the building was conducted to check side rail positions. R122's side rail was not fixed and continued to measure approximately 5 inches when the rail was pulled out. 4. Resident 90 (R90) was admitted on [DATE]. According to the MDS dated [DATE] the resident required assistance with ADL's. Her care plan documented a bed rail assist bar evaluation reflecting that the bed rail was for assistance in bed motility. The MDS dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of 10 out of 15, which indicated moderate cognitive impairment. On [DATE] at 1:00 p.m. R90 was observed in bed in his room. It was determined the distance from the mattress to side rail was approximately 5 inches when the side rail was pulled out. On [DATE] at 2:48 p.m. the MS was observed to measure (using his tape measure) the distance from the mattress to side rail as 5 inches on",2020-09-01
756,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,329,D,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure one (R1) of 39 sampled residents was free from potentially unnecessary medication. Specifically, [MEDICAL CONDITION] medications were being administered to the resident without proper [DIAGNOSES REDACTED]. Findings include: R1 was admitted to the facility on [DATE] with diagnoses, according to the (MONTH) (YEAR) Admission Record, of [MEDICAL CONDITION], anxiety, and Type 2 Diabetes. R1's Minimum Data Set (MDS) assessment, a quarterly assessment of comprehensive status dated 9/6/16, indicated R1 had moderately impaired cognition with a Brief Interview of Mental Status (BIMS) score of 12 out of 15, and did not exhibit behaviors of any kind during the assessment reference period (the seven days prior to the date of the assessment). In addition, the assessment indicated R1 received antipsychotic medication every day during the assessment reference period. R1's Psychosocial Care Plan, dated 10/10/16, indicated the resident had a history of [REDACTED]. The Care Plan indicated the resident took medication as prescribed by the physician, and that staff was to provide the opportunity for positive interaction, explain all procedures to the resident prior to starting and allow the resident 5 to 10 minutes to adjust to changes; explain why certain behaviors were inappropriate to the resident; intervene as necessary to protect the rights and safety of others; and monitor and document behavior episodes and attempt to determine underlying causes. R1's physician's order [REDACTED]. R1's Behavior/Intervention Monthly Flow Record, dated (MONTH) (YEAR), indicated the behaviors monitored for R1 were yelling out and resisting cares. No documentation could be found in the record to indicate R1 was monitored for behaviors associated with aggression or [MEDICAL CONDITION], the two indications documented for the administration of the above referenced drugs. During an interview, conducted with the Assistant Director of Nursing (ADON) on 10/14/16 at approximately 11:00 a.m., she stated R1 was on medication for his [DIAGNOSES REDACTED]. She acknowledged R1 was not being monitored for his aggression toward staff, even though this was an indicator for the administration of the [MEDICATION NAME], and stated she was unaware of the resident exhibiting any psychotic behavior while at the facility, so she would not know what to track for his [DIAGNOSES REDACTED].",2020-09-01
757,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,353,E,0,1,NZ7H11,"Based on record review and resident, family, visitor, and staff interviews, the facility failed to have sufficient nursing staff to provide showers to residents to maintain adequate hygiene. This deficient practice affected 7 residents ((R) R59, R53, R46, R52, R92, R34, and R95) of 39 sample residents. Findings include: Cross-reference F312: Assistance with Activities of Daily Living - the facility failed to ensure 4 residents received assistance with showers necessary to maintain good hygiene. According to facility records, R59, R53, R46, and R52 received only shower the month of (MONTH) (YEAR). The 10/10/16 Resident Census and Conditions of Residents form documented there were currently 86 residents in the facility, none of whom were independent with bathing. There were 54 residents who required assistance by 1 or 2 staff, and 32 residents who were dependent on staff with bathing. On 10/10/16 at 1:10 p.m., family member (F) 2 stated the facility did not have adequate staffing, and this contributed to residents experiencing falls and their needs not being met. On 10/10/16 at 2:48 p.m., R92 stated she did not feel there was enough staff available to make sure she got the care and assistance she needed without having to wait a long time. She stated, Sometimes they run slow and went on to describe how she used a washcloth to clean herself daily as the staff did not have time to assist her to the shower. On 10/10/16 at 4:07 p.m., a frequent visitor to the facility stated numerous complaints had been voiced by residents regarding insufficient staffing to meet their needs. The visitor stated complaints had also been voiced regarding staff not providing showers as scheduled and long wait times to get help when needed. During an interview with RN1 on 10/11/16 at approximately 10:00 a.m., she stated, Residents have been complaining because they are missing their showers. We don ' t (sic) have enough staff. On 10/11/16 at 1:03 p.m., R59 stated she did not feel there was enough staff available to make sure she got the care and assistance she needed without having to wait a long time. She stated, They never have enough staff. We have had to wait for help, sometimes for an hour or two. R59 added she was supposed to receive a shower at least twice per week, but I haven't (sic) had a bath for two weeks. I don't (sic) know why. Staff hasn't (sic) said anything. This is the second time this has happened. Her hair appeared greasy. On 10/11/16 at 1:44 p.m., F1 stated she felt there was not enough staff available in the facility to ensure residents received the care they needed. She stated the staffing level was too low, and often things like showers did not get done because of this. On 10/11/16 at 1:57 p.m., R34 stated she did not feel there was enough staff available to make sure she got the care and assistance she needed without having to wait a long time. She stated, Sometimes we have to wait too long for help. On 10/11/16 at 2:42 p.m., R95 stated he did not feel there was enough staff available to make sure he got the care and assistance he needed without having to wait a long time. He stated, I have to wait such a long time for someone to come, so I usually just do things myself, though they tell me I shouldn't (sic). During an interview conducted with R52 on 10/13/16 at 11:05 a.m., she stated, The last shower I had was a week ago Wednesday. She stated she often went long periods of time without a shower because shower aides were being pulled to the floor. She stated, I need to move to another facility where I can get better care. The resident was lying in bed during the interview. Her hair was observed to be greasy and matted. On 10/14/16 at 11:02 a.m., bath aide (BA) 1 stated she did not know why only 1 shower for R59 and R53 was given in (MONTH) (YEAR). BA1 confirmed the BAs were often pulled to work on the floor instead of giving showers. On 10/14/16 at 11:07 a.m., BA2 stated the BAs were pulled to work on the floor instead of providing showers almost every other day. She stated when the BAs were pulled to the floors, the residents were not provided with their scheduled showers because the staff are too busy. When asked if the floor certified nurse aides (CNAs) were expected to provide assistance with showers, BA2 stated yes, but added, There is no way. How are we going to? There's not enough staff to get showers done. We (the BAs) usually work the floor because we don't (sic) have the staff to schedule. If someone calls off, we work short. During an interview with the Assistant Director of Nursing (ADON) on 10/14/16 at approximately 11:10 a.m., she stated, No comment. I know when to keep my mouth closed. There is an issue with the showers. Review of the facility's (MONTH) (YEAR) Daily Staffing Sheets revealed both BAs were pulled off of showers to work as floor CNAs on 10/1/16, 10/2/16, 10/3/16, 10/4/16, 10/9/16, 10/10/16, 10/11/16, and 10/12/16. Moreover, there were no BAs scheduled to work on 10/6/16 and 10/8/16.",2020-09-01
758,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,412,D,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure one (R16) of 39 sampled residents was provided with appropriate dental services to meet his needs. Specifically, dental services were not provided in a timely manner after the resident's dentures were broken and unable to use. Findings include: R16 was admitted to the facility on [DATE] with diagnoses, according to the 7/13/15 Admission Record, of malnutrition, dysphagia, and anxiety. R16's Minimum Data Set (MDS) assessment, an Annual assessment of comprehensive status dated 7/8/16, indicated R16 had severely impaired cognition with a Brief Interview of Mental Status (BIMS) score of 5out of 15. He was received a mechanically altered diet, had no natural teeth and required the use of dentures, which were broken and/or loosely fitting according to the assessment. R16's Nutrition Care Plan, dated 7/22/16, indicated staff was to follow up with the dentist as needed for concerns related to oral hygiene. R16's Nursing Evaluation Collection Form, dated 7/13/15, indicated the resident did not have his own teeth, but that he was admitted to the facility with complete upper and lower dentures. An undated Resident Status Sheet indicated R16 had dentures at the time of the assessment. Quarterly/Follow-up Nutrition Progress Notes dated 10/5/16, indicated the resident was received a mechanical soft diet and that the resident had no teeth at the time of the assessment. Nurses Notes dated 9/14/16 read, Examined by NP (Nurse Practitioner) with new orders: Dental Consult with house dentist noted and carried out. A Telephone Order (TO), dated 9/14/16 and signed by the NP, read, Broken Dentures. Dental Consult with House Dentist. Review of the comprehensive clinical record for R16 revealed no follow up related to the 9/14/16 TO as of the survey exit date of 10/14/16. Review of the house dental visit records indicated the house dentist had not been in the facility to see residents since 6/10/16, prior to the order written for R16 to see the facility dentist. During an interview with the Assistant Director of Nursing (ADON), conducted on 10/13/16 at approximately 3:00 p.m., she confirmed the facility dentist has not been to building since 6/10/16, and stated, He will not come to the building until 10 residents are on our list to be seen. She stated that, as of the date of the interview, R16 was the only resident on the list to be seen, and so it might be a while before the dentist was scheduled to visit the facility. She stated no attempt had been made to make an appointment for the resident with an outside dentist, but that she would follow up to attempt to make one so that the resident could be seen.",2020-09-01
759,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,431,F,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and staff interviews, the facility failed to ensure medication was appropriately labeled and stored in accordance with accepted professional principles. Specifically, the facility medication storage room was observed unlocked and unattended on the evening/night shift. This failure created the potential for diversion of medication stored in the medication room for 86 of 86 residents residing in the facility and created the potential for confused residents (including R97) to access the medication and/or needles stored in the room. Findings include: The facility's Storage and Expiration of Medications, Biologicals, Syringes, and Needles Policy, most recently revised on 1/1/13, read, in pertinent part, Facility should ensure that medications and biologicals: 9.0 Facility should ensure that resident medication and biological storage areas are locked and do not contain non-medication/biological items and 12.1 Facility should ensure that Schedule II through IV controlled substances are only accessible to licensed nursing, Pharmacy, and medical personnel designated by Facility. 1.Medication Room Observations Observations of the facility medication room were made between 10/11/16 at 11:39 p.m. and 10/12/16 at 12:15 a.m. The medication room door was standing open and unsecured. Two nurses (RN1 and LPN3) were observed coming and going from the nurse ' s station desk located approximately fifteen feet from the medication room door. The following medication was stored on shelves inside the medication room: 12 bottles of Iron Elixir, 2 bottles of Liquid Pain Relief (Acetaminophen), 1 bottle of Milk of Magnesia, 1 bottle of Calcium Carbonate, 3 bottles of Lactulose, 3 boxes of Stool Softener, 4 boxes of Senna Plus, 6 boxes of Allergy Relief Tablets, 5 boxes of Loratadine Allergy Relief Tablets, 2 bottles of Multivitamins with iron, 13 bottles of Multivitamins with minerals, 3 bottles of Melatonin 3 mg tablets, 3 bottles of Aspirin 81 milligram (mg) chewable tablets, 3 bottles of Aspirin 325 mg, 2 bottles of Aspirin Low Dose Enteric Coated 81 mg, 3 bottles of Nephro-Vitamin Tablets, 9 bottles of Buffered Aspirin 325 mg, 1 bottle of Ibuprofen 200 mg Tablets, 3 boxes of Acetaminophen Suppositories, multiple boxes of injection needles of various sizes, and a cardboard box 1/3 full of resident medications waiting for destruction. In addition, an unlocked refrigerator was observed in the medication room containing a facility narcotic box (containing liquid narcotic medication used to control pain and anxiety), 2 vials of Pneumonia Vaccination, multiple vials of regular insulin, 1 vial of [DIAGNOSES REDACTED] Vaccination, and Engerix-B20 mcg/ml injectable. Supplemental Resident (SR) 97, admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the 4/4/16 Admission Record of Chronic Viral Hepatitis C, Cirrhosis of the Liver, and Type 2 Diabetes, was observed seated next to the nurse's station approximately 15 feet from the unlocked medication room between 11:39 p.m. and 12:15 a.m. According to the resident ' s most recent Minimum Data Set (MDS) a Significant Change of Status Assessment, dated 7/11/16, he had moderately impaired cognition (BIMS 11/15), and was able to move about the facility independently in his wheelchair. SR97 was repeatedly requesting pain medication during the observation period, stating It's never enough. when asked, by the surveyor, if he had been given pain medication recently. During an interview, conducted with RN1 on 10/11/16 at approximately 11:55 p.m., she stated SR97 had a history of [REDACTED]. On 10/11/16 at 11:50 p.m., and then again at 12:00 a.m., during the above referenced observations of the unlocked medication room, one nurse (LPN3) was observed walking in and out of the open medication room to place medications delivered from the pharmacy into the medication room. The medication room door was not locked by LPN3 either time she was observed exiting the room after delivering the medication. During an interview with the Administrator on 10/12/16 at approximately 12:10 a.m., she acknowledged the narcotic box in the medication refrigerator and the other medications in the medication room were not safely stored, and that the medication room should be locked at all times. She stated she would speak to the nursing staff regarding proper storage of medication.",2020-09-01
760,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,469,F,0,1,NZ7H11,"Based on observations, record review, and resident and staff interviews, the facility failed to maintain an effective pest control program to keep the building free of roaches and other insects throughout the facility. The deficient practice had the potential to affect all residents of the building. The facility census at the time of entrance was 86. Findings include: 1. On 10/10/16 at 1:10 p.m., family member (F) 2 stated there were roaches and rats crawling all over the facility. 2. On 10/10/16 at 2:31 p.m., resident (R) 92 stated, There are big old roaches and flies in all the rooms. I take my shoes off and at night when I move my shoes, they run out from under the shoes. I don't (sic) report them because they won't (sic) do anything about it. They see the flies though. 3. On 10/11/16 at 9:37 a.m., a frequent visitor to the facility stated the facility had a roach infestation, and roaches were seen in resident rooms throughout the facility. The visitor stated this had been an ongoing concern since (MONTH) (YEAR). 4. On 10/11/16 at 11:01 p.m., room B4 was observed with a large, black, roach-like insect. Housekeeper (H) 1 stated she saw these bugs often, and she added, That's (sic) too bad; the residents shouldn't (sic) have to see that. 5. On 10/11/16 at 12:12 p.m., resident (R) 40 stated, This is an old building. They can't (sic) keep the bugs out. I have seen - you name it - roaches, just about everything but snakes. The last time I saw bugs was over the weekend .on Sunday. They were crawling across the floor in my room. On Sunday it was the daytime, but usually they come at night. 6. On 10/11/16 at 1:05 p.m., R59 stated she has seen bugs in the building including roaches and ants. She stated she saw big cockroaches mostly at night. 7. On 10/11/16 at 1:46 p.m., R98 stated he had seen roaches and rats throughout the facility. 8. The ongoing maintenance Repair/Request Log documented: -12/29/15: Please get rid of the roaches in (A7W) -1/31/16: B12 HAS BUGS - exterminator spray needed -3/14/16: A7 Roaches in in resident's room all over -4/9/16: A17 has roaches - please spray for bugs -4/14/16: A18W .c/o (complained of) roaches -5/25/16: A2/A4 Roaches crawling on wall -7/8/16: A17W room has ants -7/20/16: Roaches seen in room 9 C hall -7/20/16: Roaches seen in Rm 12A -8/3/16: Ants in bed and all over resident's side of room (A3) On 10/14/16 at 9:14 a.m., the maintenance assistant (MA) stated the pest control company came in monthly, but they usually arrived during the night, when there were no maintenance staff available. He stated the facility had just recently made arrangements for the pest control company to come in during the day so the maintenance staff could accompany them on their rounds. The Maintenance Supervisor (MS) stated the pest control company came in for the first time during the day on 9/1/16, but they have not been back since then. The MA stated the exterminators don't usually go in resident rooms, they just focus on the outside perimeter and offices. When asked what was done to address the numerous complaints in the Repair/Request Log, the MA stated, they (the pest control company) just come in monthly. The MA and MS agreed the pest control company had not mentioned seeing roaches in building. The MA provided the undated page 3 of the contract with the pest control company, which documented, (Name of company) will perform services Monthly for the Monitoring and Control of Insects and Rodents. The areas service (sic) will include, dining areas, offices, kitchen, break rooms, dishwashing area, hallways, laundry room, and closets. Locked areas will have to be accessible for treatment. Additionally, I have included 8 exterior rodent bait stations. This is equal to the number currently in use. Patient rooms will only be treated as needed. It is required that the patient be removed from the room during treatment. The MA also provided the pest control invoices from (MONTH) (YEAR) forward, dated 1/21/16, 2/27/16, 3/15/16, 4/4/16, 5/16/16, 6/20/16, 7/24/16, and 9/1/16. All invoices documented only common areas and outside areas were treated; no resident rooms were treated. 9. During an interview, conducted with CNA4 on 10/11/16 at approximately 10:40 p.m., he stated, I see roaches in building, mostly in the hallways, at night. I saw one two days ago in the hallway. CNA4 stated he saw bugs in the building at night about one time per week. 10. During an interview with CNA5 on 10/11/16 at approximately 10:55 p.m., she stated, I see big ole bugs in the halls, in rooms, and up on the walls at night. 11. During an interview, conducted with RN1 on 10/11/16 at approximately 11:20 p.m., she stated she had seen bugs (cockroaches) all over the building. She stated she worked on all three hallways in the building and had seen the bugs on all three hallways while working at night. She stated she had seen the bugs in resident rooms, in window sills, and in all three hallways. 12. An observation on 10/10/16 at 11:27 a.m. at the nurse's station desk revealed an insect approximately one-inch long walking on the nursing desk counter top. Registered nurse (RN) 4 was seated at the desk, on the phone, and did not notice the insect. At 11:30 a.m. on 10/10/16 RN 4 was observed standing at a medication cart in front of the nursing station. At 11:32 a.m. the insect was at the end of the counter walking back and forth across the end. A staff member was observed to walk past the insect, looked down at it and kept walking. At 11:34 a.m. the insect was observed walking down the end of the counter toward the swinging door to the hallway, then walked across the swinging door. Multiple staff were observed in the area and none were observed to notice it or do anything about it. 13. On 10/11/16 at 11:00 p.m. a large black roach-like insect was observed inside resident room B4 outside the bathroom door. A second observation at 11:05 p.m. on 10/11/16 revealed a large black roach-like insect to go into the bathroom under the bottom of the door.",2020-09-01
761,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,490,E,0,1,NZ7H11,"Based on observations, record review, and staff interview, the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to ensure side rails fit appropriately on the beds to eliminate the risk for entrapment for 4 sample residents ((R) R95, R40, R90, and R122) of 39 sample residents. The failure to ensure side rails did not have a large gap between the mattress and the rails put the 4 residents at risk for entrapment within the gap. Findings include: The facility's undated Job Description for the Administrator documented the Administrator Contributes to the physical, mental, emotional, (and) spiritual well being (sic) of the residents by coordination, supervision, (and) directing of all facility personnel .works with all facility departments to provide overall care (and) comfort for each resident ensures the implementation of established resident care policies . Cross-reference F323: Accidents and Supervision - The side rails were first observed on 10/10/16 with a large gap between the side rail and the mattress. This was brought to the facility's attention on 10/10/16; however, the side rails were again observed on 10/11/16 with the same large gaps. This was again brought to the facility's attention on the afternoon of 10/11/16; however, the beds of R95, R40, R90, and R122 were still observed with the same large gaps on the evening of 10/11/16. On 10/10/16 at 4:20 p.m., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were alerted to the survey team's concerns over side rails observed with a gap between the rail and mattress. The Administrator stated there should not be any gaps wider than 2 inches between the side rails and the mattress, as this could pose an entrapment risk to the residents. She stated the facility did not have a policy regarding the fit of side rails on the bed. She also stated the facility did not have a monitoring system to ensure the side rails fit properly on the beds to eliminate any gaps that would pose a risk of entrapment. On 10/11/16 at 1:47 p.m., the Administrator provided a newly adopted facility policy, taken from the MED-PASS Nursing Services Policy and Procedure Manual, revised (MONTH) 2007, titled, Bed Safety. The policy documented, The resident's sleeping environment shall be assessed by the interdisciplinary team, considering the resident's safety, medical conditions, comfort, and freedom of movement .To try to prevent deaths/injuries from the beds and related equipment .the facility shall .review that gaps within the bed system are within the dimension established by the FDA .Ensure that bed side rails are properly installed using the manufacturer's instructions and other pertinent safety guidance to ensure proper fit; and .Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment. On 10/11/16 from 10:30 p.m. to 10:50 p.m., the beds of R95, R40, R90, and R122 were again observed with side rails that were not locked in place to be flush against the mattress and had the ability to be pushed out to create a gap of 6.5 inches between the rail and the mattress. On 10/11/16 at 10:50 p.m., Registered Nurse (RN) 1 and Licensed Practical Nurse (LPN) 2 were alerted to the 4 residents' side rails posing a danger of entrapment related to a potential for large gaps between the side rails and the mattress, and both confirmed they were not alerted to any concern with the gaps between the mattresses and side rails or provided with any education regarding the proper fit/use of side rails. RN1 stated she would take immediate action to ensure the residents' beds were safe for the night. The Administrator failed to implement a system to check all beds with side rails for proper fit of the rails on the bed when the issue was first brought to her attention. The facility failed to communicate identified concerns regarding the fit of the side rails on the beds to the night shift staff, who were responsible for ensuring the safety of the residents while in bed at night.",2020-09-01
762,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,514,E,0,1,NZ7H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident records were complete and accurately documented. Specifically, the facility failed to ensure progress notes by the Medical Doctor (MD) and Nurse Practitioner (NP) were received and signed in a timely manner and placed in the medical record; social services (SS) progress notes were written regarding resident to resident altercations; toileting and eating documentation related to Activities of Daily Living (ADLs) were fully documented; and completion of the Treatment Administration Record (TAR) was documented for 8 of 39 sampled residents (R) (R18, R25, R79, R84, and for R92) MD/NP notes; R100 for SS notes; R121 for the TAR; and R69 for toileting and eating.) Findings include: 1. Review of resident (R)79's medical record revealed MD and NP progress notes were not complete and signed in a timely manner as follows: 12/9/15 by the NP and electronically signed on 12/23/15; 1/5/16 by the NP and electronically signed on 3/30/16; 1/13/16 by the MD and electronically signed 3/30/16; 2/9/16 by the NP and the second page was missing; 3/9/16 by the MD and electronically signed on 3/30/16; 4/20/16 by the NP and electronically signed on 5/6/16; 5/11/16 by the MD and electronically signed on 6/1/16; and 6/27/16 by the NP and the second page of the note was missing. The missing second pages would have contained further information on the assessment and treatment plan for the resident. 2. Review of R84's medical record revealed MD and NP progress notes were not complete and signed in a timely manner as follows: 12/9/15 by the NP and electronically signed on 3/30/16; 1/13/16 by the MD and electronically signed on 3/30/16; 2/9/16 by NP and the second page of note was missing; 5/11/16 by the MD and electronically signed on 6/1/16; and 6/27/16 by the NP and missing the second page of the note. No MD or NP progress notes were available in the medical record after 6/27/16. The missing second pages would have contained further information on the assessment and treatment plan for the resident. 3. Review of R25's medical record revealed MD and NP progress notes were not complete and signed in a timely manner as follows: 11/11/15 by the MD and electronically signed on 1/20/16; 12/9/15 by the NP and electronically signed on 1/20/16; 1/13/16 by the MD and electronically signed on 1/20/16; 2/9/16 note by NP and the second page was missing; 3/9/16 by the MD and electronically signed on 3/24/16; 5/11/16 by the MD and electronically signed on 6/1/16; and 8/8/16 by the MD and the second page was missing. The missing second pages would have contained further information on the assessment and treatment plan for the resident. 4. Review of R100's SS notes revealed that the last note written was dated 3/10/16. For the year of (YEAR) there were only 3 SS notes available. R100 had been involved in 3 altercations that were identified as resident to resident altercations in the nursing notes without any documentation by SS related to the incidents. 5. On 10/14/16 at 11:15 a.m. an interview with the Assistant Director of Nursing (ADON) revealed the physician notes are e-mailed to social services, who then prints them and provides them to medical records for placement in the medical record. She stated they have to ask all the time for the notes and that they have addressed it in the Quality Assurance (QA) program. She could not remember at the time of the interview when the issue was placed into Q[NAME] She stated she did not know why the visit date and electronic signature dates were different. 6. R18 was admitted to the facility on [DATE] with diagnoses, according to the 8/5/15 Admission Record, of diabetes, history of falls, [MEDICAL CONDITION] with depressed mood, obesity, [MEDICAL CONDITION], nuclear [MEDICAL CONDITION], and diabetic retinopathy. Review of R18's medical record on 10/12/16 revealed the most recent physician visit record was dated 4/28/16. On 10/13/16 at 4:27 p.m., the ADON provided subsequent monthly physician visit records that had been faxed over by the physician. The ADON stated the records were not in the facility prior to receiving the fax on 10/13/16. 7. R92 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses, according to the 8/5/15 Admission Record, of [MEDICAL CONDITION], altered mental status, hypertension, [MEDICAL CONDITIONS], and [MEDICAL CONDITION]. Review of R92's medical record on 10/12/16 revealed the most recent physician visit record was dated 4/28/16. On 10/13/16 at 4:27 p.m., the ADON provided subsequent monthly physician visit records that had been faxed over by the physician. The ADON stated the records were not in the facility prior to receiving the fax on 10/13/16. 8. On 10/14/16 at 11:16 a.m., the ADON stated the facility had an ongoing problem with not receiving physician visit documentation in a timely manner. She stated the facility had spoken with the physician repeatedly but the issue had not been resolved. 9. Resident 121 (R121) was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was transferred from an acute care hospital. Hospital records revealed the resident had a Stage II pressure ulcer to coccyx and a Stage IV pressure ulcer to the right hip when he was in the hospital. Record review revealed an nursing admission assessment dated 12/16/15 that documented one Stage II pressure ulcer on the coccyx and one Stage IV pressure ulcer on the right hip. The Skin Assessment Sheet dated 12/17/15 documented one Stage II pressure ulcer on the coccyx which measured 2.2cm (centimeter) x 0.2cm x 0.1cm and one Stage IV pressure ulcer on the right hip which measured 5.0cm x 4.0cm x 0.5cm. An initial care plan documented a plan of care and physician orders [REDACTED]. Wound care physician orders [REDACTED]. The physician's orders [REDACTED]. The physician's orders [REDACTED]. 1/4 strength Dakin's and secure with 4x4 and ABD secure with prolix bid. The Medication Administration Record [REDACTED]. Review of the resident's record revealed no TARs were in the record. The medical record revealed the resident was transferred from the facility to an acute care hospital on [DATE]. On 10/13/16 at 4:05 p.m. interview with the ADON confirmed the record was accurate and that the facility could not find any TARs for R121 for the dates of 12/16/15 through 12/20/15. Therfore, it could not be determined if the treatments were completed as ordered. 10. Resident (R) 69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) (a standardized screening and assessment tool used for long term care residents) dated 6/8/16 documented the resident's Brief Interview for Mental Status (BIMS) score was 3 out of 15, which indicated the resident was severly cognitive impaired. Review of the facility Grievance Log revealed a report for R69 on 8/1/16. The report revealed the staff were instructed to toilet the resident every 2 hours. Review of R69's Activities of Daily Living (ADL) Flow Record for (MONTH) (YEAR) failed to document the resident was toileted 66 of 90 times. Review of R69's medical record reflected the resident was evaluated by speech therapy on 8/30/16 and the resident's diet was changed to mechanical soft with thinned liquids and distant supervision at meals. Review of R69's ADL Flow Record for (MONTH) (YEAR) failed to document monitoring of meals 33 of 60 times. Interview on 10/14/16 at 11:15 a.m. with the Assistant Director of Nurses (ADON) confirmed the order for distance supervision during meals required documentation on R69's ADL Flow Record. She also confirmed the record was accurate for the lack of documentation of R69's toileting.",2020-09-01
763,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2016-10-14,520,E,0,1,NZ7H11,"**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 quality of care related to use of side rails, physician visit documentation, and provision of showers. The facility's failure had the potential to affect 13 sampled residents (R) - 4 sampled residents (R95, R40, R90, and R122) who used side rails with a risk of entrapment, 5 sampled residents (R25, R79, R84, R18, and R92) whose physician progress notes [REDACTED]. Findings include: During the annual recertification survey and complaints investigation from 10/10/16 to 10/14/16, the facility was found out of compliance with regulatory requirements regarding prevention of accidents related to side rail use, obtaining documentation of physician visits, and provision of assistance with showers: [NAME] Cross-reference F323: Accidents and Supervision: The facility failed to implement a system to ensure side rails fit appropriately on the bed to eliminate the risk for entrapment for R95, R40, R90, and R122. The failure to ensure side rails did not have a large gap between the mattress and the rails put R95, R40, R90, and R122 at risk for entrapment within the gap. The side rails were first observed on 10/10/16 with a large gap between the side rail and the mattress. This was brought to the facility's attention on 10/10/16; however, the side rails were again observed on 10/11/16 with the same large gaps. This was again brought to the facility's attention on the afternoon of 10/11/16; however, the beds of R95, R40, R90, and R122 were still observed with the same large gaps on the evening of 10/11/16. B. Cross-reference F514: Clinical Records The facility failed to ensure progress notes by the Medical Doctor (MD) and Nurse Practitioner (NP) were received and signed in a timely manner and placed in the medical record for R25, R79, R84, R18, and R92. C. Cross-reference F312: Assistance with Activities of Daily Living The facility failed to ensure R59, R53, R46, and R52 received assistance with showers necessary to maintain good hygiene. D. On 10/10/16 at 4:20 p.m., the Administrator, Director of Nursing (DON), and Assistant Director of Nursing (ADON) were alerted to the survey team's concerns over side rails observed with a gap between the rail and mattress. The Administrator stated there should not be any gaps wider than 2 inches between the side rails and the mattress, as this could pose an entrapment risk to the residents. She stated the facility did not have a policy regarding the fit of side rails on the bed. She also stated the facility did not have a monitoring system to ensure the side rails fit properly on the beds to eliminate any gaps that would pose a risk of entrapment. On 10/14/16 at 12:50 p.m., the Administrator stated the QA committee met at least quarterly, and was doing pretty well with meeting monthly. She stated the committee had not ever identified the gaps between the side rails and the mattress as a problem to address in the QA committee. E. On 10/14/16 at 12:50 p.m., the Administrator stated the issue of missing physician progress notes [REDACTED]. She stated the issue was first identified in (MONTH) (YEAR). The Administrator stated the facility's plan of action to address the issue was to call and speak with the physicians, letting them know which notes were missing from resident records. The Administrator also stated the Medical Director had spoken to the physicians regarding the importance of providing their progress notes to the facility in a timely manner, but stated it still continues to be an ongoing issue. The Administrator stated the QA committee's ongoing plan was to, keep calling the physicians when we see progress notes missing. There was no evidence the QA committee monitored the effect of implemented changes and made needed revisions to the action plan. F. During an interview with the Assistant Director of Nursing (ADON) on 10/14/16 at approximately 11:10 a.m., she stated, No comment. I know when to keep my mouth closed. There is an issue with the showers. On 10/14/16 at 12:50 p.m., the Administrator stated the QA committee had talked about the showers. She stated, They (the residents) have been getting their baths, they're (the baths) just not being documented. The Administrator stated Registered Nurse (2) reviewed shower paperwork daily, but there had been no plan of action devised in the QA committee to address the missing paperwork and/or provision of assistance with showers.",2020-09-01
764,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,159,E,0,1,GYL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain an accounting system which met generally accepted practices of accounting. Specifically, the facility failed to ensure that six of six trust fund accounts reviewed (R B, R A, R#11, R#31, R#28, and R#45) remained under the $2000.00 limit to maintain eligibility for Medicaid services, failed to provide a quarterly financial statement of a resident trust fund account for one resident (R#28) and failed to ensure that debits from two resident trust fund accounts (R A and R#31) were accounted for. The facility managed 90 resident trust fund accounts. Findings include: Review of the undated policy titled Resident Trust Fund Policy & Reconciliation Requirements documented: A quarterly statement of financial transactions will be available for residents and mailed to the responsible party. Receipts for all transactions shall be kept with Trust Account records. One receipt book will be kept for all deposits made into each Trust Account and one receipt book will be kept for all withdrawals cash/check. Upon discharge or death of a resident, all money shall be surrendered to the resident and/or responsible party, executor or the administrator of the estate within 30 days. All residents and/or responsible party who receive Medicaid benefits will be notified when their trust account balance reaches $1,800.00. Maintain $2000.00 limit for Medicaid eligibility: 1. Review of the trust fund account for R B revealed the following balances over $2000.00: [DATE] in the amount of $16,443.72 [DATE] in the amount of $13,927.23 [DATE] in the amount of $14,828.54 [DATE] in the amount of $2,703.04 [DATE] in the amount of $3,604.08 [DATE] in the amount of $4,505.08 Interview with the Business Office Manager (BOM) on [DATE] at 8:35 a.m. revealed that the R B had expired in (MONTH) of (YEAR) and the Social Security checks kept coming and were directly deposited into the resident's account. The BOM stated that she began this position in (MONTH) of (YEAR) and that the original BOM no longer worked at the facility since (MONTH) (YEAR). She stated that no one was in the office for about a month. She stated that prior to her, there was a BOM for about two months and she no longer worked at the facility either. The BOM stated that the accounting of the resident trust funds were a mess and she has been trying to work on all the accounts. The BOM stated that all debits from the account were reversed, the account was reconciled and they issued a check to Social Security on [DATE] in the amount of $17, 345.29 and on [DATE] in the amount of $628.64. 2. Review of the trust fund account for R A revealed to following balances over $2000.00: [DATE] in the amount of $5,107.09 [DATE] in the amount of $3,134.12 [DATE] in the amount of $4,920.15 3. Review of the trust fund account for R#11 revealed the following balances over $2000.00: [DATE] in the amount of $3,409.60 [DATE] in the amount of $2,847.64 [DATE] in the amount of $3,724.69 [DATE] in the amount of $3,310.75 [DATE] in the amount of $3,498.79 [DATE] in the amount of $2,719.83 [DATE] in the amount of $2,900.83 Interview on [DATE] at 9:20 a.m. with the BOM revealed that since she has started this position in (MONTH) of (YEAR), she has been working with the residents and/or family members and has been conducting Spend downs. The BOM stated that in (MONTH) of (YEAR), with permission of the responsible party, $1000.00 was sent to the funeral home and again in (MONTH) (YEAR) for $890.00 and the funeral home expense is now paid in full. She stated that the resident has clothes and the family does not know where to spend the money. The BOM stated that the family wanted to buy the resident a new bed for the resident. The BOM stated there was nothing wrong with the facility's bed, the family wanted to buy the resident a bed. The family purchased a new bed and the BOM stated that the family understands that the bed does not belong to the facility and when the resident passes, the family will take the bed with them. 4, Review of the trust fund account for R#31 revealed the following balances over $2,000.00: [DATE] in the amount of $5,280.84 [DATE] in the amount of $3,280.86 [DATE] in the amount of $6,172.99 [DATE] in the amount of $5,501.61 [DATE] in the amount of $5,702.72 [DATE] in the amount of $4,959.01 [DATE] in the amount of $4,324.01 [DATE] in the amount of $3,699.10 [DATE] in the amount of $5,572.39 Interview on [DATE] at 9:30 a.m. with the BOM revealed she worked with the resident's family for a spend down and on [DATE] they purchased a new wheel chair and other personal items for R#31. She stated that this is the only spend down so far but she is talking with the family about possibly transferring the overage into the resident's state Qualified Income Trust (QIT) and she waiting for the family's decision on that. 5. Review of the trust fund account for R#28 revealed the following balances over $2,000.00: [DATE] in the amount of $2,665.76 [DATE] in the amount of $3,378.80 Interview on [DATE] at 9:50 a.m. with the BOM revealed she spoke with R#28 about a spend down and the resident requested the purchase of a cremation package which was purchased on [DATE] in the amount of $2,984.00 and this brought the residents balance down to $394.80. The BOM further stated that the resident liability for R#28 is $483.00 monthly and her Social Security check (SSA) is $748.00 monthly. The BOM stated that she has written Medicaid to have the resident liability increased and with that much money left over, it's very easy for the resident's account to accumulate over $2,000.00. 6. Review of the trust fund account for R#45 revealed the following balances over $2,000.00: [DATE] in the amount of $3,614.83 [DATE] in the amount of $3,260.87 [DATE] in the amount of $3,175.92 [DATE] in the amount of $2,625.84 Provision of Quarterly Financial Statement Record review for R#28 revealed an Annual Minimum Data Set (MDS) assessment which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. Interview on [DATE] at 10:38 a.m. with R#28 revealed she does not receive a quarterly financial statement from the facility and she has no idea how much her balance is in her trust fund account. R#28 stated I guess they would tell me if I asked. R#28 further stated that she would like to have a quarterly statement for her records and she would like to know how much money she has in her account. Interview with the BOM on [DATE] at 9:50 a.m. revealed that she had just started this position and she has only issued one quarterly financial statement thus for May, (MONTH) and (MONTH) (YEAR). She stated the next quarterly financial statement is due now but she has not yet printed or dispersed them. The BOM stated the statements are sealed in an envelope and handed out to the cognitive residents and the others are mailed to the responsible party. She stated she does not keep a hard copy of the statements or documentation that a resident or their family member received the statement. The BOM further stated that she does not remember providing R#28 with the quarterly statement ending in July, (YEAR) and has not record that she did. Unaccounted debits from resident trust funds accounts. 1. Review of the trust fund account for R A revealed a debit on [DATE] in the amount of $93.00 and description reading PL ,[DATE]. Interview with the BOM on [DATE] at 9:00 a.m. revealed the prior BOM had made numerous debits from the account for patient liability dating back to 2014 and (YEAR). The BOM stated that the resident expired in (MONTH) of (YEAR). The BOM reviewed the facility's operational account and she could not confirm a debit on the facility's end to explain the debit of $93.00 on [DATE]. The BOM stated that the past patient liability for 2014 and (YEAR) should never have been debited after the resident expired. She stated that she had not worked on this account as it was not an active account and she was under the impression that the third party consultant was working reconciling the inactive accounts. 2. Review of the trust fund account for R#31 revealed a debit on [DATE] in the amount of $4,040.00 and description reading PL ,[DATE]. Interview on [DATE] at 9:30 a.m. with the BOM revealed that resident liability is $2,020.00 each month. The BOM reviewed the facility's operation account and stated that the resident's liability had been paid every single month, including (MONTH) (YEAR) and she had no idea or account of what the withdrawal in the amount of $4,040.00 was for. The BOM stated that according to her records, the resident did not owe liability payment.",2020-09-01
765,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,160,D,0,1,GYL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey resident funds and final accounting to the individual administering the residents estate within 30 days upon the death of two residents (R B and R A). The facility managed 90 resident trust funds accounts. (Refer F159) Findings include: 1. Review of the trust fund account for R B with the Business Office Manager (BOM) on [DATE] at 8:35 a.m. revealed on (MONTH) 7, (YEAR) a balance of $16,443.72. Further review revealed the patient liability in the amount of $901.00 was credited to the account each month through May, (YEAR). Interview with the BOM at this time revealed that the resident had expired in (MONTH) of (YEAR) and the Social Security checks kept coming and were directly deposited into the resident's account. The BOM further stated that she is aware that when a resident passes away, they have 30 days to reconcile the resident's trust fund account and convey the remaining balance of that account to the resident's estate. The BOM stated that she began this position in (MONTH) of (YEAR) and that the original BOM no longer worked at the facility since (MONTH) (YEAR). She stated that prior to her, there was a BOM for about two months and she no longer worked at the facility either. The BOM stated that the accounting of the resident trust funds were a mess and she has been trying to work on all the accounts. She stated that she was told by the corporation not to close any accounts with an active balance. The BOM stated that all debits from the account were reversed, the account was reconciled and they issued a check to Social Security on [DATE] in the amount of $17,345.29 and on [DATE] in the amount of 628.64. The BOM stated the account was finally closed in (MONTH) of (YEAR). The BOM was able to show record of the checks issued to Social Security. 2. Review of the trust fund account for R A with the BOM on [DATE] at 9:00 a.m. revealed a balance of $5,107.09 on [DATE] and a closing balance of $1,300.39 on [DATE]. Interview with the BOM at this time revealed that the resident expired in (MONTH) (YEAR). The BOM stated that this account is still active and that the remaining balance had never been disbursed to the executor of the resident's estate because she was told not to close any accounts and the third party consultant was supposed to be handling the reconciliation of inactive accounts.",2020-09-01
766,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,242,D,0,1,GYL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and facility data, the facility failed to ensure that choices and preferences were considered for bathing and/or showers for three residents (R#74, R#12 and R#60). The resident sample size was 42. Findings include: 1. Review of the clinical record of Resident (R) #74 reflects the resident was admitted to the facility on [DATE] with a history of diabetes mellitus II (DM), hypertension, [MEDICAL CONDITION] arthritis, urinary tract infection and dementia. An Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status(BIMS) with a summary score of 11 indicating the resident has moderate cognitive impairment. During an interview during the initial tour on 11/7/17 at 11:41 a.m. resident (R) #74 stated the Certified Nurse Aides (CNAs) hurry her and give her attitude when they must help with bathroom visits and showers. She stated they can't come all the time; stated on weekends they don't have enough people to help. The resident stated her shower days are Tuesdays and Fridays and stated, sometimes they are short of help and I don't get it then, they don't have time. On 11/9/17 at 7:55 a.m. during an observation and brief interview R#74 was observed in room sitting in wheelchair, the resident confirmed that she does not get showers when she wants them, she stated she did get one Tuesday. On 11/9/17 at 8:00 a.m., during an interview with CNA AA , she stated that there is two on the shower team and sometimes two or three on the evening shift. She stated that staff get assigned residents to help shower when there isn't a 3-11 p.m. shower aide. On 11/9/17 at 11:00 a.m. during an interview with a day shift Shower Team Aide, she stated that there is just her and another aide on the shower team, she confirmed that there is no one right now on 3-11 p.m. shift to give baths. She provided two months of R#74's shower schedule. She stated that no showers are given on Sunday and on Saturday the hall aides give showers. She stated she did not know their schedule or how many baths they do. Review of the bath schedule for R#74 reflects in month of 9/17 the resident received 6 showers, in 10/17 the resident received 9 showers and in 11/17 she has received one shower to date. The 9/17 initialed shower schedule reflects the resident did not receive her scheduled two showers a week. The facility failed to provide choices and preferences regarding her bathing schedule. Review of the resident's Comprehensive Care Plan reflects an incomplete care plan that does not address the resident's choices of when and how many showers she would prefer to take. 2. Record review for R#12 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. The resident was assessed as totally dependent for bathing and required extensive assistance with bed mobility and transfers. The resident did not exhibit the behavior of rejection of care. Section F- Preferences for Customary Routine and Activities assessed that it is somewhat important to choose between a tub bath, bed bath or shower. Interview on 11/7/17 at 9:18 a.m. with R#12 revealed he is not happy with receiving a shower only two times a week. R#12 stated he talked to them (staff) about it but they didn't really say anything other than he gets a shower on Mondays and Thursdays. R#12 stated he never received his scheduled shower last Thursday (11/2/17). Review of the Shower Sheet for R#12 indicated on 11/2/17 Shower, Shampoo, Shave, Nail Care. 3. Record review for R#60 revealed an Admission MDS dated [DATE] which documented a BIMS of 14, indicating no cognitive impairment. The resident did not exhibit the behavior related to rejection of care. The resident was assessed for total dependence with bed mobility, transfers and bathing. Section F- Preferences for Customary Routine and Activities coded that it is very important to choose between tub bath, bed bath or shower. Review of the Quarterly MDS assessment dated [DATE] indicated a BIMS of 14 and that the resident required total assistance with bed mobility, transfers and bathing. Review of the Care Plan for R#60 dated 12/1/16 identified the resident has an ADL self-care performance deficit related to [MEDICAL CONDITIONS], Diabetes Mellitus (DM), and recent episode of illness. An intervention listed indicates: showers per schedule, shave on shower day. Interview on 11/6/17 at 2:07 p.m. with R#60 revealed he is only scheduled for a shower twice a week but stated that sometimes they miss those mostly on Thursdays. R#60 stated he is scheduled for showers on Mondays and Thursdays. The resident stated that he got his shower this morning but he did not get his shower last Thursday (11/2/17). R#60 stated he did not complain when he did not get his shower last Thursday because it doesn't do any good, they don't listen. R#60 further stated that they (staff) don't bring a washcloth or towel in between his shower days to assist with getting cleaned up up in his room. Observation on 11/9/17 at 1:15 p.m. revealed the R#60 sitting in the day room (Green Room) at a table with another resident. R#60 waved, he was alert and dressed, and his hair was a slightly greasy in appearance. The resident stated he is supposed to get his shower today but he has not gotten one yet. R#60 stated there is no specific time when he gets his shower and that he gets his shower whenever they come and get him at all different times of the day. Review of the Shower Schedule Sheet for (MONTH) and (MONTH) of (YEAR) revealed no documentation of receiving a shower four times on 9/4/17, 10/5/17, 10/12/17, and 10/26/17. On 11/2/17 the Shower Schedule Sheet indicated: Shower, Shampoo, Shave, Nail Care. Interview on 11/9/17 at 4:48 p.m. with the Assistant Director of Nursing (ADON) revealed showers are given twice a week on each floor. They are given on the dayshift by the Bath Team consisting of two Certified Nursing Assistants (CNA) Monday through Friday. Showers or baths on Saturday is assigned to the CNAs on the hall. The ADON stated there is no Bath Team on the 3:00 p.m. - 11:00 p.m. but if a resident does not get their scheduled shower on the dayshift, it is to be assigned to the evening shift. The ADON stated that R#12, R#2 and R#60 has never personally told her that they are not happy with showers only two days a week. Review of the policy titled Shower/Tub Bath revised (MONTH) 2010 documented: The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The policy is procedural in nature and does not address resident preferences.",2020-09-01
767,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,279,E,0,1,GYL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the policy titled Administrative Policies & Procedures- Care Plans Policy and staff interviews, the facility failed to develop individualized comprehensive care plans to include appropriate goals and interventions of identified concerns for 9 residents (R#40, R#74, R#114, R#12, R#123, R#58, R#97, R#8, and R#81. The resident sample was 42. Findings include: Review of facility policy titled, Administrative Policies & Procedures-Care Plans Policy revised 3/11/04 revealed, It is the policy of this facility that the care plan/interdisciplinary team develop a comprehensive assessment and care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs. A comprehensive assessment (Minimum Data Set (MDS) is completed within 14 days of the resident's admission to the facility. A Comprehensive Care Plan is developed within seven days of completion of the Minimum Data Set (MDS) assessment. An interdisciplinary team, in coordination with the resident and his/her family or sponsor, develops and maintains the care plan for each resident. The assessment and care plan is developed by an interdisciplinary team. Care plans are revised as changes in the resident's condition dictate. Reviews are made quarterly. During the interview on 11/9/17 at 8:50 a.m. with the MDS Coordinator/RN, the surveyor had asked for copies of the care plans for residents (R#40, R#74, R#114) as they were not found in the nurses Care Plan Book or in the resident records. She confirmed she had not completed them, but printed copies for the surveyor on 11/9/17. Review of the Comprehensive Care Plans for reflects no resident preferences are documented. Interview conducted on 11/8/17 at 6:10 p.m. with the Assistant Director of Nursing (ADON) while reviewing a closed record for R#40, she confirmed that there was no Comprehensive Care Plan nor a facility form entitled, Instant Care Plan in the record. The ADON confirmed that the Comprehensive Care Plan should have been retained in the closed record. Review of the closed clinical record for R#40 revealed resident was admitted on [DATE] with completion of the MDS Assessment on 5/30/17; Cognitive=BIMS (11), Mood=00, Behavior=00, Functional= total dependence, 2 people assist; Active Diagnosis: [REDACTED].= ht.=64 inches, wt.=120 lbs. therapeutic diet, Dental= no natural teeth. date of death was 6/21/17, 22 days after the MDS assessment was completed. Review of resident record R#40 included review of physician orders, dietitian's order/recommendations, weight logs, nursing notes and medications. No evidence of facility form Instant Care Plan or a Comprehensive Care Plan was found in the record. The facility failed to develop a timely and specific plan of care in areas of concern or monitoring, treatment goals and interventions. Interview conducted on 11/8/17 at 11:45 a.m. During a resident interview, R#114 stated the food quality is sad some days. He stated he is diabetic and they serve him pie and ice cream on his trays. Stated he got ham casserole last night and he is sure that what he is getting regularly is not for diabetics. The resident confirmed he has not seen a dietitian. He also confirmed he has not told anyone or complained about the food. He stated he has been there a month and is planning on a short stay. Interview conducted on 11/9/17 at 8:15 a.m. During an interview regarding the resident's nutrition with LPN (BB), the LPN stated R#114 likes to stay in his room, eats his meals in his room. She stated that he likes to eat snacks all day long including requesting sweet items such as juices and cool-aid drinks. Interview conducted on 11/9/17 at 8:00 a.m. Interview with the direct care CNA (AA), regarding the resident's eating habits, she stated she knows R#114 well. She confirmed the resident prefers to eat alone and is eating good however, he likes to eat snacks all day long. She confirmed that snacks are offered to residents at 10:00 a.m. ,2:00 p.m., 8:00 p.m. and consist of peanut butter and jelly sandwiches, oatmeal cakes, milk and juice. Review of the clinical record for R#114 revealed the resident was admitted [DATE], MDS Assessment done 8/18/17 Cognitive=BIMS 11, Mood=little interest (02), Behavior=00, Function= unsteady balance, limited assistance, wheelchair/walker; Medication=antidepressant, Dental= obvious cavity, broken natural teeth, Nutrition= ht. 69 inches, wt.=187 lbs., mechanical altered diet. The record revealed that resident had a 11-lb. weight loss within two months of admission. Further review of the clinical record for R#114 revealed no Comprehensive Care Plan was found in the record or in the nurses Care Plan Book. An Instant Care Plan form was found in the record; however, it was blank. A printed copy of the Comprehensive Care Plan was printed by the MDS Coordinator upon surveyor's request on 11/9/17. The care plan copy revealed it was initiated on 10/13/17, 67 days after the MDS was completed 8/18/17. The resident was care planned for diabetes, activities of daily living (ADL) deficits related to confusion; interventions for eating-tray set up; care planned for congested heart failure; care planned for weight loss-RD to make diet changes and recommendations as needed prn; risk for impaired skin due to incontinent episodes; and fall risk due to muscle weakness. Although care planned for weight loss, no resident specific nutrition interventions were found initiated in the record. The facility failed to have the Comprehensive Care Plan completed timely and available to nursing staff. An interview was conducted on 11/9/17 at 8:50 a.m. with the MDS/RN Coordinator. During the interview with the RN, she stated she is the MDS Coordinator, the Care Plan Coordinator and does Medicaid adjustments and works in admissions when needed. She confirmed she knows she is required to do the Comprehensive Care Plan within 14 days of the resident's admission. She confirmed that the Point.Click Care electronic system for care plans is accessible only to her, not the nurses. When asked, she confirmed she puts completed care plans into the Care Plan Book for the nurses. She stated If the nurses are aware of any resident changes or updates they need to let her know to input them it. She confirmed she is behind and doesn't have time to keep up with updates and revisions. She confirmed that the nurses can use the Instant Care Plan when there isn't one yet completed by her. She stated that the Instant Care Plan is initiated by the admitting nurse mainly for after hours and weekends. She confirmed she gets information from morning rounds on who was admitted and discharged . Review of clinical record for R#74 revealed the resident was admitted [DATE], with a history of Diabetes Mellitus II, hypertension, [MEDICAL CONDITION] arthritis, urinary tract infection, Dementia, acute knee injury (AKI). The MDS dated [DATE] revealed Cognitive=BIMS 11 which indicates moderate cognitive impairment. Review of the Comprehensive Care Plan for R#74 is incomplete; the resident was admitted on [DATE]. The care plan that was initiated by the Care Plan Coordinator is dated 11/9/17. Care plan goals and interventions were either incomplete and/or blank, and did not include self-care and ADL goals and interventions. An Admission Interim Care Plan facility form was dated initiated 8/22/17 for R#74 was initially care planned for migraines, pain screening, catheter care, hypertension and [MEDICAL CONDITION] related to a recent knee replacement. A Comprehensive Care Plan was not found in the record or in the nurses Care Plan Book. A printed copy of the care plan was requested by the surveyor during an interview with the MDS/RN Coordinator on 11/9/17. The provided printed Comprehensive Care Plan documents it was initiated 11/9/17, the day of interview with the MDS Coordinator, 78 days after the MDS assessment was completed on 8/22/17. The care plan was reviewed, and documented the following: care planned for Diabetes Mellitus; at risk for potential nutritional problems (unspecified), (interventions blank); deficits in ADLs self-care r/t (blank) (blank goal dates) (interventions not specified/blank). Resident #74 Comprehensive Care Plan was not timely, unavailable to nursing staff, was determined incomplete for interventions and was not resident specific. No evidence of resident choices and/or preferences was found. Additionally, during the interview with the MDS Coordinator, the surveyor asked for a copy of the CP as it was not found in the Care Plan Book or in the resident's record. She confirmed she had not completed it. A printed copy of the Comprehensive Care Plan, submitted to the surveyor for R#74, reflects it is incomplete and not specific to the resident. Review of the clinical record of R#74 reflects on 8/22/17 an Admission Interim Care Plan/Instant Care Plan was done by the admitting nurse. The resident was care planned for migraine pain screening, catheter care, hypertension, [MEDICAL CONDITION] and for a recent knee replacement. Review of the Comprehensive Care Plan (CP) printed off by the MDS/RN Coordinator during an interview reflects it was initiated 78 days after admission on 11/9/17 and was noted to be incomplete. The CP was incomplete for interventions, the resident was care planned for DM, at risk for potential nutritional problems (unspecified), (interventions blank); deficits in activities of daily living (ADL) self-care related to (form blank) (blank goal dates) (interventions not specified and/or blank). 4. Record review for R#12 revealed [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment for R#12 dated 7/21/17 revealed a Brief Interview for Mental Status (BIMS) summary score of 14, indicating no cognitive impairment. Section H- Bowel and Bladder assessed the resident as having an indwelling urinary catheter. Section K- Swallowing/Nutrition assessed weight loss or gain was unknown and the resident received a therapeutic diet. Section N- Medications assessed that the resident received insulin injections, antianxiety, antidepressant and diuretic medications seven out of seven days reviewed. Section V- Care Area Assessment (CAA) triggered Urinary Incontinence/Indwelling Catheter, Nutritional Status and [MEDICAL CONDITION] Drug Use with the decision to be care planned. Triggered Indwelling Catheter to be care planned. Review of the most recent Quarterly MDS assessment dated [DATE] assessed the resident to have a indwelling urinary catheter, no weight loss or gain and received insulin injection, antianxiety, antidepressant and opioid medications seven out of seven days reviewed. Review of the care plans for R#12 revealed the following: F[NAME]US- The resident has (Specify: Condom/intermittent/Indwelling/Suprapubic) catheter. Date initiated 8/3/17. GOAL: The resident will show no signs or symptoms of urinary infection through review date. The resident will be/remain from catheter-related trauma through review date. The Focus did not specify the type of catheter. There was no documented review date. The care plan did not include any interventions for this identified concern. F[NAME]US- The resident is on pain medication therapy (Specify medication) related to. Date initiated 8/3/17. GOAL: The resident will be free of any discomfort or adverse side effects from pain medication through the review date. The Focus did not specify the pain medication. There was no documented review date. The care plan did not include any interventions for this identified concern. F[NAME]US- The resident has a mood problem related to. Date initiated 8/3/17. GOAL: The resident will have improved mood state (Specify happier, calmer appearance, no signs and symptoms of depression, anxiety or sadness) through the review date. The Focus did not specify what the mood problem was related to, the Goal did not specify the improved mood state and there was no documented review date. The care plan did not include any interventions for this identified concern. F[NAME]US- The resident has depression related to. Date initiated 8/3/17. GOAL: The resident will exhibit indicators of depression, anxiety or sad mood less than daily by review date. The resident will remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood by/through review date. There was no documented review date and the care plan did not include any interventions for this identified concern. F[NAME]US- The resident has bowel incontinence related to. Date initiated 8/3/17. GOAL: The resident will have less than two episodes of incontinence per day through the review date. The Focus did not specify what the resident's bowel incontinence was related to. There was no documented review date and this care plan did not include any interventions for this identified concern. Interview on 11/9/17 at 4:10 p.m. with the Care Plan Coordinator revealed she is not sure why there are no interventions in place for the identified concerns for mood and depression, pain medication therapy, nutrition, indwelling catheter or bowel incontinence. She stated the resident has been in the facility for a while and the initiation date of 8/3/17 is not correct. She stated there were previous care plans and she does not know what happened to them. The Care Plan Coordinator stated that somehow the interventions have gotten deleted. She stated she knows she would have completed the interventions. The Care Plan Coordinator further stated that she alone is responsible for all resident care plans and all residents' assessments in this facility and stated it is just too much. 5. Record Review (RR) revealed R#123 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident is to receive [MEDICAL TREATMENT] treatments on Monday, Wednesday, and Friday. Admission Interim Care Plan is not available for review. Interview with the ADON on 11/09/2017 at 3:32 p.m. confirmed an initial admission interim care plan was not done for the resident on admission. It is expected for the charge nurse on duty at the time of admission to complete an Admission Interim Care Plan for the resident. The facility failed to complete an Admission Interim Care Plan and follow-up with a comprehensive care plan for the resident who is receiving [MEDICAL TREATMENT] treatments via a right chest port access for [MEDICAL TREATMENT] treatments. 6. Resident #58 was admitted to facility on 2/27/17 with [DIAGNOSES REDACTED]. Review of Physician orders [REDACTED]. A review of Significant Change Minimum Data Set ((MDS) dated [DATE] revealed a Care Area Assessment for tube feedings. A review of Administrative Policies and Procedures titled Care Plans with a modified date of 3/11/14, revealed that it is the policy of this facility that the care plan team develop a comprehensive assessment and care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychosocial needs. A review of the clinical record revealed that there was no comprehensive care plan related to tube feedings. Interview on 11/9/2017 at 6:09 p.m., with Minimum Data Set (MDS) Coordinator stated that the resident's tube feedings had been discontinued on (MONTH) 1, so she discontinued it from the residents care plan. She further stated that her protocol for updating care plans is to delete the issues once they have been resolved, and because the residents tube feedings had been discontinued, she deleted tube feedings from her care plan. The resident continued to have a gastric tube for medication and water flushes. 7. Resident #97 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Comprehensive Assessment Minimum Data Set ((MDS) dated [DATE] revealed a Care Area Assessment for Pressure Ulcer. A review of the clinical record revealed that there was no comprehensive care plan related to pressure ulcer. Interview on 11/9/2017 at 5:28 p.m., with MDS Coordinator stated that she knew resident was admitted with a pressure ulcer, and she states she is pretty sure that she did a care plan for wound care, but doesn't know why it's not showing on the screen in the electronic record. She then added it to care plan with date of 11/9/17. 8. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Comprehensive Assessment Minimum Data Set ((MDS) dated [DATE] revealed a Care Area Assessment for [MEDICAL CONDITION] drug use. A review of the clinical record revealed that there was no comprehensive care plan related to depression. Additionally, her initial care plan was revised on 10/12/16, with no quarterly updates until 11/9/17. Interview on 11/9/2017 at 5:18 p.m., with MDS Coordinator stated that she does not know how the [DIAGNOSES REDACTED]. She stated she would add it to the care plan today, with date initiated of 11/9/17. 9. Resident #81 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Comprehensive Assessment Minimum Data Set ((MDS) dated [DATE] revealed a Care Area Assessment for falls. A review of the clinical record revealed that resident is at risk for falls related to internal and external factors with a history of falls. There were no interventions added to care plan following a fall with injury on 10/26/17. Additionally, her initial care plan dated 12/11/15 had no quarterly updates, until 11/9/17. Interview on 11/9/17 at 3:53 p.m., with the MDS Coordinator, stated that she has in her notes where the resident was discussed in morning meeting after her fall on 10/26/17, and she has notes to update her care plan, but she stated she just hasn't had time to do that, since she has so many other responsibilities. She was asked how staff are to know what interventions are to be done, and she says its the floor nurse's responsibility to inform the other staff members.",2020-09-01
768,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,280,D,0,1,GYL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and facility policy; the facility failed to revise the care plan for one (1) resident (R) (#82) of 42 sample residents with interventions after each fall to address the root cause of the falls and/or prevent recurrence. The census sample size was 90. Findings include: Record Review (RR) revealed R82 was admitted to the facility on [DATE] with a readmission date of [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] section C- cognitive patterns; revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11 out of 15 indicating he has adequate cognition. Resident #82 has impaired vision but able to read large print. Review of section G- functional status; R #82 required total dependence with transfer from surfaces with two person physical assistance from staff. Further review of the annual MDS care area assessment (CAA) revealed R #82 triggered for falls; these concerns to be addressed on the care plan. Review of an Interdisciplinary Care plan initiated 6/6/16 with a last revision date of 10/17/16 revealed R#82 has had actual falls and has potential for injury related to falls. The care plan did not indicate the resident had an unwitnessed fall on 10/14/17 while trying to self-transfer to his wheelchair resulting in an injury of an abrasion to his mid-back. Goals and approaches were not updated on the care plan to reflect new interventions for the resident to participate in restorative care program for safe transfers. An interview with the Interim Director of Nursing (DON) on 11/09/2017 at 9:51 a.m. revealed the interdisciplinary care plan is to be updated as changes or accidents occur. During the interview the interim DON stated she does not have time to update resident care plans and MDS information as changes or accidents occur. An interview with the Assistant Director of Nursing ADON on 11/09/2017 at 10:05 a.m. revealed, resident falls and accidents are discussed in the interdisciplinary morning meetings, the information is given to and received by the MDS coordinator/Interim DON to be placed on the resident's care plan for updates. Expectations are to follow the facility's Administrative Policies and Procedures. Review of Administrative Policies and Procedures titled Care Plans revealed Care plans are revised as changes in the resident's condition dictate, and reviews are made quarterly. The facility failed to update the care plan to reflect updated interventions and care services for R#82 who had a fall on 10/14/17 resulting in an injury to his mid-back.",2020-09-01
769,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,282,D,0,1,GYL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to follow the care plan related to weight loss for Resident (R) #58 who was receiving enteral tube feedings who had a significant weight loss. The sample size was 42. Findings include: A review of the clinical record for R#58 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the care plan dated 3/29/17, which was 31 days past her admitted , revealed that R#58 was at risk for weight loss related to disease process. It further noted the following interventions: Administer medications as ordered, obtain and monitor lab and report results to Medical Doctor, provide and serve diet as ordered and Registered Dietician (RD) to evaluate and make diet changes as recommended. Review of a hand written note on a document labeled Nutrition Services Progress Note, dated 4/27/17 tilled RD Monthly Wt Note signed by the RD, for triggered weight gain of 6.95%, in 30 days. RD indicates will continue to follow, but no other RD notes located on file. Review of facility policy titled Nutrition/Unplanned Weight Loss with a revised date of (MONTH) 2011, revealed that the Dietician will estimate calorie, nutrient and fluid needs and, with the physician, will identify whether the current intake is adequate to meet his or her nutritional needs. Review of Policy on Enteral Feeding revised (MONTH) 2011, indicates the Dietician will monitor residents who are receiving enteral feedings, and will make appropriate recommendations for interventions to enhance the tolerance and nutritional adequacy of enteral feedings. During an interview on 11/9/17 at 4:14 p.m., with the Dietary Manager (DM), stated that he attends the Patients at Risk (PAR) meetings, but he does not do any of the documentation in the resident files. He stated the RD did the documentation, and that he took care of things such as food choices for the residents. During an interview with the Regional RD on 11/9/17 at 5:25 p.m., Regional RD stated that the (DM) was responsible for doing quarterly assessments/notes on residents that are not being followed by the registered dietician for other issues, such as weight loss, [MEDICAL TREATMENT], wounds, tube feedings, etc. The Regional RD was unable to locate documentation in the residents file pertaining to tube feedings or a weight loss of 15 pounds in one month. Cross refer to 325",2020-09-01
770,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,325,D,0,1,GYL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow the the care plan for weight loss for Resident (R) #58 who had greater than 10 percent significant weight loss in one month. Resident was currently receiving enteral nutrition. The sample size was 42, Findings include: A review of R#58's clinical record revealed that she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Significant Minimum Data Set ((MDS) dated [DATE] revealed that nutritional status and tube feeding triggered as an area of concern. Review of the at risk for weight loss related to disease process care plan dated 3/29/17 revealed interventions for Administer medications as ordered, obtain and monitor lab and report results to Medical Doctor, provide and serve diet as ordered and Registered Dietician (RD) to evaluate and make diet changes as recommended. Review of an [MEDICATION NAME] laboratory result dated 9/7/17 revealed a level of 3.1 (3.5-5.7). During an interview with the Regional RD on 11/9/17 at 5:25 p.m., the Regional RD stated that the RD followed residents who present with weight loss, residents on [MEDICAL TREATMENT], residents with wounds and residents on tube feedings. The Regional RD was unable to locate Nutritional documentation in the residents file pertaining to R#58 being on enteral nutrition or having a significant weight loss greater than 10 pounds in one month.",2020-09-01
771,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,431,E,0,1,GYL511,"Based on observation, interviews with facility staff and policy review, the facility failed to ensure nine bottles of liquid tears, one bottle of ear drops, and one vial of insulin were dated appropriately when opened to determine the discard date, in three of three medication carts. Also, the facility failed to discard expired biological's prior to expiration date. The sample size was 42. Findings include: 1. During observation on 11/8/17 at 5:01 p.m., on Cypress Hall medication cart, Licensed Practical Nurse (LPN) DD, revealed two opened and used bottles of liquid tears eye solution for two residents with with open dates of 8/29/17. Interview on 11/8/17 at 5:01 p.m., LPN DD stated she believes that the policy for eye drops for expiration is 30 days after opening. She is not sure why they have not been replaced. 2. During observation on 11/8/17 at 5:15 p.m., on Briarwood Hall medication cart, LPN EE, revealed one bottle of ear drops with expiration date of 10/2013; liquid tears eye drop bottles with open dates of 9/19/17, 10/1/17 and two bottles opened on 10/3/17; one bottle of Lantoprost with open date of 8/30/17. Furthermore, a half of 1000 milliliter bottle of Eldertonic had expired 9/2017. Interview on 11/8/17 at 5:15 p.m., LPN EE stated she was not aware of expiration dates for eye drops or ophthalmic solutions, other than what the bottle lists as expiration dates. She was unable to locate a policy for dating medications after opening. 3. During observation on 11/8/17 at 5:31 p.m., on Autumnwood Hall medication cart, Assistant Director of Nursing (ADON) revealed one Novolog vial of insulin without an open date. Interview on 11/8/17 at 5:31 p.m., the Assistant Director of Nursing (ADON ) stated that insulin should be labeled once opened, because it has to be replaced after 28 days. she is not sure when the vial was opened. She stated that she was not aware of a policy pertaining to when medications are to be replaced after being opened. Observation of medication room on 11/8/17 at 5:45 p.m with ADON, revealed 27 cans of Nephro oral supplement on wooden shelving with expiration date of (MONTH) 27, (YEAR); two opened bottles of B-Complex vitamins, with open dates of 10/6/16 and 6/6/15, on storage shelf with un-opened bottles; 6 dulcolax suppositories in a box with expiration date 9/2017; gray rubber storage box in corner with numerous pill sleeves; 15 vials of Hepatitis B vaccine in fridge with expiration date 9/2017; eight 250 milliliter bags of Ampicillin 1500 mg intravenous antibiotic expired 11/5/2017. Review of Policy from MED-PASS revised 2007, titled Labeling of Medication Containers, indicates that individual medications should be labeled with expiration dates when applicable. Review of policy from MED-PASS revised 2007 indicates that the facility shall not use discontinued , outdated, or deteriorated drugs or biological's. All such drugs shall be returned to the dispensing pharmacy or destroyed. Interview on 11/8/17 at 6:25 p.m., with the ADON stated that the nursing staff on night shift are responsible for doing cart audits, in which they clean the carts, check for expired drugs, restocking supplies, including stock med's and checking for open dates on med's. She stated that all med nurses on all three shifts are responsible for keeping the medication room cleaned, checking for expired over the counter med's, checking refrigerator temperature and keeping it cleared of expired or discontinued med's. She stated there is no checklist for who is checking what or whether anyone is checking it at all. She states that she tries to check it two times weekly herself, but admits she hasn't been consistent with checking it.",2020-09-01
772,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,441,F,0,1,GYL511,"Based on observations, interviews, and review of the facility policies and procedures data, the facility failed to demonstrate ongoing recognition, investigation and surveillance of infections and maintain an effective infection control program. The resident sample size is 42. The facility census is 90. Findings include: Interview on 11/9/17 at 1:55 p.m. During an interview with the Assistant Director of Nursing (ADON)/ Infection Control Nurse (ICN) and the RN/Corporate Nurse, copies of the facility's Infection control policy was given to the surveyor. During an interview with the ADON she stated she has only been the ICN since 11/5/17, that the previous ICN left at that time, but stated she previously was the ICN in the month of 1/17. She further explained the facility's process to track infections. A unit nurse logs in all new orders for antibiotics needed for new infections and the ICN maintains a color-coded grid for all rooms each month to monitor 15 areas of infections they track, such as urinary tract infections, upper respiratory infections etc. or any newly identified types. A Line Listing form is used to track the specific infection, outcome, labs, specific resident, and whether the infection was hospital or community acquired. Trends are to be shared in the monthly Quality Assurance Process Improvement (QAPI ) meetings. Blank facility forms are attached for examples; form entitled Infections by Device Days revised 2009, the form entitled Infection Control Grid dated 5/16 and facility form entitled Line Listing of Resident Infections revised 2009. Additionally, the facility's Infection Control Log book was reviewed with the surveyor during the interview with both facility nurses. The ADON/ICN confirmed the surveyor's findings that no information or reports had been logged in the IC book or tracked for the months of 3/17, 6/17, 7/17, 8/17, 9/17, 10/17 nor for the month of 11/17 to date. The ADON and corporate nurse confirmed that they could not find any IC tracking or trending information for those missing months. A review of the facility policy entitled Administrative Policies & Procedures-Infection Control revised 3/11/04 was conducted. The policy statement documents that It is the policy of the facility to maintain a safe, sanitary and comfortable environment to prevent the development and transmission of disease and infections. The facility shall establish an infection control program which investigates, controls and prevents infections; establish procedures as to when isolation should be applied; maintain record of incidents and corrective actions related to infections and prevent the spread of infections in the resident population and staff personnel.",2020-09-01
773,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,466,F,0,1,GYL511,Based on observation and staff interview it was determined the facility failed to ensure an adequate three day supply of drinking water was available on-site for emergencies. This deficient practice had the potential to effect all residents. The census sample was 90. Observation by the surveyor of the emergency supply of water stored in the maintinence area on 11/8/17 at 8:10 a.m. revealed the Maintinence Director (MD) has eight (8) cases of twenty-four (24) ounce bottles of drinking water available for the facility. Interview with the MD at this time confirms this is all of the emergency water supply that he has stored in case of an emergency or disaster. Interview with the MD on 11/09/2017 at 6:33 p.m. revealed he expects for there to be at least 3 days' worth of emergency water supply for residents totaling 300 gallons to provide one gallon of water per day per resident. During the interview the MD revealed he will communicate better with the DM to ensure there is enough water supply for residents in the event of an emergency. Further interview revealed he is now aware of the requirement for emergency water supply in the event of an emergency or disaster. Review of[NAME]Healthcare Inc. policy titled Georgia- Loss of Primary Water Supply revealed when there is a short term loss of water; an alternate source of drinking water will be necessary. The Maintinence Director is to check the disaster plan as to source for this and update the water supply as necessary for time and delivery of water to equal two (2) liters per resident per day.,2020-09-01
774,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,469,E,0,1,GYL511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to maintain an effective pest control program that would ensure the facility remained free of pests and rodents. The resident sample was 42. The facility census was 90. Findings include: 1. Observation during a resident interview on 11/6/17 at 5:12 p.m. A pest glue strip was noted in the resident's room on the floor under the window, near the corner. Three dead roaches and one dead fly noted on the pest strip. Resident (R) #95 stated he had a mouse in his room last week and maintenance put down the strip, but stated he has not seen the mouse since then. Review of Minimum Data Set (MDS) quarterly review 10/5/17 cognitive score= BIM 08 with indicates the resident has moderate cognitive impairment. 2. During interview with resident (R) #43 on 11/7/17 at 10:55 a.m. the resident stated that the nursing home has a problem with bugs. The resident stated she killed three roaches in the bathroom and one in her shared room this morning. Review of resident's MDS annual assessment reveals cognitive scoring= BIMS 12 which indicates moderate cognitive impairment. 3. Interview on 11/8/17 at 8:50 a.m. with the Laundry Manager during a tour of the laundry, the manager stated they have a problem with 2-3 rodents that routinely come in under the door to the drying room. She stated that there is a gap from the bottom of the door to the floor and believe they are getting in that way. She confirmed she has notified maintenance and confirmed she has not seen any rodent traps. The drying room door was observed to have approximately a one inch gap from door to concrete. 4. Interview conducted on 11/8/17 at 2:00 p.m. with the Maintenance Director and review of the pest control contract and service invoices was conducted. During the interview, the director stated they fired the last pest control vendor after their last recertification process and have used another pest control service since 11/16. He confirmed he often makes rounds with them. He stated they are seeing much less roaches and rodents this year, although admitted it an ongoing concern. He stated ants were coming in from around air conditioners and now housekeeping cleans around air conditions with bleach and maintenance caulks around the units. He stated they now have (10) rodent bait stations around the perimeter of the facility, and use very few rodent strips or traps. He confirmed that one resident's room does have a strip trap due to the resident seeing a rodent last week on C-Hall, he stated it was confirmed by the night nurse. No rodent has been caught. When asked to explain his duties and process for managing pests, the Maintenance Director stated the nurses have a maintenance log where they log in concerns or they will call him on day shift, he stated he checks the log each morning during his rounds. He further stated that should a grievance come in regarding pests the social worker will notify him and he will interview the resident or family and check out the problem. Additionally, the director stated the current pest service has asked him to call if there are problems and not to put out rodent traps in resident's rooms due to infection control issues or safety issues. He stated that the vendor comes monthly and always focuses on areas of recent complaints, the kitchen and outside drains. On 11/9/17 at 9:30 a.m. Interview with the Maintenance Director when asked what the facility is doing to improve pest issues besides what the pest control company is doing monthly he stated that he did want to call them more often, but stated that if the service is due out within a few days he will wait until they are coming. He stated he did not have any record of extra service calls. He confirmed he has not gotten any recommendations from the current pest control service in what the facility's maintenance should do extra. He confirms he has let his Administrator know there is still problems but restated that things are so much better. He stated he has focused on air-conditioning units, that the roof is good and that he does look for nests and gaps when he makes his rounds. He stated his plans to improve the program is to talk to his administrator; he was unable to voice any solutions to decrease pests any further or elaborate. 5. Review of facility maintenance book kept at the nurse's station, entitled Repair Request Log, reveals the following pest requests for maintenance from nursing staff: 1. 8/19/17 large roaches on A-hall, room A-6 and right side of B-hall 2. 8/29/17 roaches room A-10 3. 9/1/17 roach room A-8 4. 9/6/17 roaches/water bugs room A-10 5. 10/1/17 roach in room B-2 6. 10/29/17 multiple insects A-3 7. 10/30/17 family requests bug spray A-3 8. 11/7/17 ants in room- the wall A-2 Review of the facility's pest service agreement dated 10/25/16 reveals after initial service the facility agrees to one trip per month, 12 months of service. The agreement is for the control of roaches, ants, silverfish, mice, rats, fleas, ticks, spiders and fly control. The initial service trip was to treat all rooms. The monthly service treats all break rooms, kitchen, shower room and other rooms that are on the site log; exterior PPS and rodent control includes the maintenance shop. Review of the monthly invoices for pest treatments from the current pest control service revealed areas of treatment, and type of pests targeted. No recommendations for the facility was found. 6. Interview on 11/7/17 at 9:00 a.m. with the state Ombudsman revealed that the concerns/complaints that she receives from the residents on a regular basis is related to roaches in the facility and that they even have seen mice and rats in the building. 7. Record review for R#64 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 12, indicating moderate cognitive impairment. Interview on 11/7/17 at 10:03 a.m. with R#64 revealed she has seen big roaches crawling on her walls and in her closet several times a week. R#64 stated she sees them during the day and at night. 8. Record review for R#28 revealed an Annual MDS assessment dated [DATE] which documented a BIMS summary score of 14, indicating no cognitive impairment. Interview on 11/7/17 at 10:30 a.m. with R#28 revealed she has heard other residents complaining about rats and mice but she has not seen them herself. R#28 stated she has seen Big ole black roaches on the walls and they even get in the bed. R#28 further stated You know how women get together and talk, yesterday as a matter of fact, women were talking about bugs in their room and little mice in their room. 9. Record review for R#12 revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 14, indicating no cognitive impairment. Interview on 11/8/17 at 8:10 a.m. with R#12 revealed they need to get rid of the roaches and he's been telling them for a long time. He has had two roaches in his bed and they come out at night. They are big and long. R#12 stated the roaches get on his bedside table. He has also seen a little tiny mouse running around his room. R#12 stated he is not afraid of them but they need to get rid of them. 10. During interview in the Business Office Manager (BOM) on 11/8/17 at 9:00 a.m., a slim, medium size cockroach came crawling out of the printer and continued to crawl on the walls, files cabinet and flooring in the office. Interview with the BOM at this time revealed she has seen roaches before in the facility but not in here office 11. On 11/6/17 at 10:00 a.m., during observation of morning smoke break, several residents were voicing concerns to surveyor about the bugs and rats inside the facility. Findings include: 1. R#99 stated he has seen roaches in his room almost everyday. 2. R#116 stated he has seen roaches in his room almost daily. 3. R#107 stated he has seen a mouse running in the hallway on Autumnwood hall, at least 2 times in the past week. 4. R#121 stated that she has seen the mouse also. She stated she has named it[NAME]Mouse. 5. R#106 stated she has seen roaches in her room daily and in her closet. She stated she has seen the mouse also. On 11/6/17 at 11:37 a.m., surveyor was standing at med cart at Nurses Station and spotted a roach crawling on the counter top across a newspaper sitting on the top ledge of the desk.",2020-09-01
775,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,517,F,0,1,GYL511,"Based on observation and staff interview it was determined the facility failed to ensure an adequate three day food supply of items was available on-site for emergencies. This deficient practice had the potential to effect all residents receiving an oral diet. The census sample was 90. Findings include: Observation by the surveyor on 11/6/17 at 11:23 a.m. during the initial kitchen tour with the Dietary Manager (DM) revealed the facility's emergency three day food supply was low. Interview with the DM at 11:30 a.m. on 11/6/17 revealed the emergency food supply was low at this time, and there is only one day's worth available. The interview revealed there are only two (2) cases of 16.9 ounce bottles of drinking water available for residents. Interview with the District Dietary Manager on 11/08/2017 at 11:07 a.m. revealed, he expects for the DM to maintain a three day par level of emergency food supply at all times. The interview also confirmed the emergency drinking water supply is not at a three day par level for. Interview with the DM on 11/08/2017 at 11:37 a.m., confirmed the emergency food supply remains under a three day par level due to some foods were to expire soon and were discarded. Interview revealed there was a lack of replacing emergency food supply, and water after use for facility parties or other dining events. Review of the Healthcare Services Group policy titled Emergency Preparedness revealed the Food Services Director will ensure that the emergency plans and supplies are readily accessible to staff, and emergency supplies will be stored in accordance with applicable State and local requirements. Review of Emergency Menu Guide Quantity per 100 water quantity should equal 300 gallons; one (1) gallon per person per day. Food item quantities vary per item.",2020-09-01
776,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-11-09,520,E,0,1,GYL511,"Based on record review, review of the policy titled Quality Assessment and Assurance Plan and staff interviews, the facility failed to maintain an effective Quality Assurance (QA) program that systematically reviewed an identified concerns. Specifically, the facility identified quality concerns related to resident trust fund accounts in (MONTH) (YEAR) but never implemented an action plan to resolve the concerns. Six of six resident trust fund accounts reviewed (R B, R A, R#11, R#31, R#28, and R#45) revealed the facility failed to ensure that generally accepted accounting principles were applied related to funds balance limitation of $2,000.00, conveyance of funds/final accounting within 30 days after the death of a resident and unexplained/unaccounted debits from resident trust fund accounts. (Refer F159 and F160) Findings include: Review of the policy titled Quality Assessment and Assurance Plan created on 01/94 and modified on 3/11/14 documented: It is the policy of this facility to develop, implement, and maintain an ongoing program designed to monitor and evaluate the quality of resident care, purse methods to improve quality of care; and to resolve identified problems. PURPOSE: To establish and provide a system whereby a specific process, and the documentation relative to it, is maintained to support evidence of an ongoing QA program, encompassing all aspects of resident care including safety, infection control, and quality of life applicable to nursing home residents. To develop plans of correction and evaluate corrective action taken to obtain the desired results. To provide a centralized, coordinated approach to quality assessment and assurance activities so as to bring about a comprehensive program of quality assessment and assurance to meet the needs of the facility. COMMITTEE ACTIONS: The committee will develop and implement plans of action to correct identified negative care outcomes. Review of resident trust fund accounts on 11/8/17 beginning at 8:35 a.m. with the current Business Office Manager (BOM) revealed the following concerns: 1. Trust fund balances over the $2,000.00 limit to ensure Medicaid eligibility for six residents. (R B, R A, R#11, R#31, R#28, and R#45) 2. Upon the death of two residents (R B and R A) the trust fund balance was not dispersed to the resident estate within 30 days. 3. R#28, a cognitive resident, had not received quarterly financial statements of her trust fund account. 4. Debits from two resident rust fund accounts (R A, R#31) were not documented, could not be explained or accounted for. Interview on 11/8/17 beginning at 8:35 a.m. with the current Business Office Manager (BOM) revealed she began this position in (MONTH) of (YEAR) and that the original BOM 1 no longer worked at the facility since (MONTH) (YEAR). She stated there was no one in the business office for about one month. She stated that prior to her, there was another BOM 2 for about two months and she no longer worked at the facility either. The BOM stated that the accounting of the resident trust funds were a mess and she has been trying to work on all the accounts. The current BOM further stated that she was asked by the corporation not to close any accounts. She stated there was a third party consultant that did training and she was under the impression that the consultant would be handling the inactive accounts. The current BOM stated that she has not reconciled all the accounts and confirmed the above identified quality concerns. She further stated that there are still many trust fund accounts that need to be reviewed. The BOM stated that trust fund accounts were never formally placed in QA but that she is actively addressing the concerns. Interview on 11/8/17 at 2:20 p.m. with the Administrator revealed she has been the Administrator in this facility for about three months and was actively trying to identify the facility concerns and address them. The Administrator stated that she has already identified staffing as a concern and it was placed into QA/QAPI (Quality Assurance/Quality Assurance Performance Improvement). She stated they are advertising in the local paper as well as internet jobsites. She stated they have increased the pay scales for employees, have put measures in place to improve staff morale/recognition and they are currently looking into improved benefits plans. The Administrator stated she was not aware that the resident trust funds accounts had any concerns related to conveyance of funds upon death within 30 days, trust fund accounts with balances in excess of $2,000.00 or that accepted accounting principles were not being applied in the management of the 90 resident trust fund accounts. The Administrator stated that resident trust fund accounts have not been a topic of discussion in the QA meetings since she began three months ago. Interview on 11/8/17 at 2:40 p.m. with the Vice President (VP) and the Regional Director (RD) for the facility revealed that the prior Business Office Manager 1 had worked in the facility for several years. The VP stated that in (MONTH) (YEAR), she picked up her paycheck and never returned to the facility. The VP stated that they were aware that they did not physically have a BOM in the facility but that they had hired a third party consultant to review and audit the resident trust fund accounts. The VP stated that they hired a BOM 2 but she was terminated after two months of employment in (MONTH) (YEAR). The VP stated the current BOM began in (MONTH) of (YEAR). The VP stated he had just recently taken over this region. The VP stated that although they did consult a third party financial consultant, they did not place resident trust fund accounts in QA with a course of action to handle the funds while they did not have a BOM or a plan for when all the accounts would be reconciled. The VP stated the third party consultant was mainly for training staff and helped with some accounts. The VP stated that resident trust fund accounts should have been placed in QA back in (MONTH) (YEAR) when the prior BOM 1 quit and when the current BOM identified numerous concerns when she arrived in (MONTH) (YEAR). During QA&A (Quality Assessments & Assurance) interviews, the Administrator was not available due to a family emergency. The Assistant Director of Nursing (ADON) and the Corporate Regional Director (RD) was present at time of interview. Interview on 11/9/17 at 9:37 p.m. with the Corporate Regional Director (RD) revealed she has only been in this position for about two weeks and this was her first time in the facility. The RD stated that the prior BOM 1 left the facility in (MONTH) (YEAR) and the business office was empty for about a month. They hired another BOM 2 but she was terminated in (MONTH) (YEAR). The current BOM was hired in (MONTH) (YEAR). The facility was aware that the resident trust funds were not properly accounted. She stated that someone should have made the New Administrator aware and trust fund accounts should have been placed in QA a long time ago, with record kept of what had been done so far. The RD stated they did involve a third party biller and for training. The RD stated this third party biller came in (MONTH) to do an audit but they have no documentation of what type of audit was completed and they have nothing to give the facility. The RD stated she does not understand how they could conduct an audit and not have record of the audit for the facility. She stated the third party biller is currently searching for results of that audit. The RD further stated they flew in an Independent Financial Consultant and she is here to help the current BOM with the resident trust funds account until every account has been audited and reconciled.",2020-09-01
777,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-12-21,550,D,1,0,19JF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, resident and staff interviews, record review and review of the facility policy titled Quality of Life-Dignity, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect for two of four sampled Residents (R) #2 and (R) #3. Specifically, R#2 stated that she was told to toilet in her brief because it was easier to clean her up than assist her to the toilet. R#3 stated she was left wet in bed with no assistance from facility staff for six hours. The facility census was 79 residents. Findings include: Review of the facility policy titled Quality of Life- Dignity Policy revised (MONTH) 2009 documented: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Demeaning practices and standard of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: Promptly responding to the resident's request for toileting assistance. 1. Record review for R#2 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate cognitive impairment. The resident required extensive, one person, physical assistance with toileting. Further record review for R#2's care plan initiated 11/27/17 indicated R#2 is incontinent at times and at risk for skin breakdowns. Interventions included; check every two hours and as required for incontinence. Resident is able to assist with toileting the amount of assistance may vary from day to day, have her assist to tolerance and provide peri-care for incontinent episodes. Interview on 12/21/17 at 10:40 a.m. with R#2 revealed she was told to go in her brief at nighttime because it would be easier to clean her up than take her to the restroom. The resident did not recall the name of the employee and could not recall the exact day it happened but did recall that she was wet for a long time and it made her feel stupid. R#2 further added, she could not remember everything about all the other times but she did know it happened more than one time. Interview on 12/21/17 at 10:49 a.m. with a Family friend of R#2's revealed she was in the room with R#2 on a night when a CNA told the resident to just go ahead and pee in her pull-up and it will be easier for a CNA to just come in afterward and change her. Family friend added, she was also sitting with R#2 a second time when a CNA came in at night to answer R#2's call light and told R#2 that she was not going to get her up because the resident was un-steady on her feet and then told her to just go in her pull-up a CNA would change her later. Interview on 12/21/17 at 11:41 a.m. with Certified Nursing Assistant CNA (AA) revealed R#2 cannot toilet herself and requires one person assistance for toileting. CNA AA further revealed the he tries to care for residents in order of priority and he does not address resident call lights if he cannot get to the resident right away. CNA AA added, he has had to tell a resident not to hold it, go ahead and go in their brief and he would come back in change them as soon as he could. 2. Record review for R#3 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 12, indicating moderate cognitive impairment. The resident required full, one person, physical assistance with toileting. Further record review of a care plan for R#3 and initiated 3/29/17 revealed, R#3 has incontinence and is at risk for skin breakdown. Interventions include; check and change every two hours and as needed while awake and during sleeping hours as needed. Check frequently for incontinence, was rinse and dry perineum. Interview on 12/21/17 10:18 a.m. with R#3 revealed, staff have left her in bed without checking on her or changing her from 6:00 a.m. until 12:00 p.m. several times. R#3 revealed she knows how long it she has been left because staff get her up at 6:00 a.m. for breakfast in her room and they will return at lunchtime to change her. She further revealed that she does not recall if she used the call light or not to ask for help, but she believes she told them she needed help because it's not comfortable sitting in a bucket of water, it felt nasty, it burns, it made her feel lousy. R#3 added, it has happened maybe one time in the past few weeks, but she could not recall the specific day. Interview on 12/21/17 at 12:10 p.m. with Certified Nursing Assistant CNA (BB) revealed, the lack of staffing has caused staff not to be able to do their jobs and due to staffing, people have been left wet, left soiled, had accidents and had to use their briefs because staff could not get to them to change them or take them to the toilet. Interview on 12/21/17 at 5:00 p.m. with the Administrator revealed she believes the residents are being cared for and staff have been re-educated on toileting, changing and repositioning. The Administrator further revealed the facility discussed the issue of residents being told to toilet in their briefs and she is certain the issue has been addressed however; the issue will be discussed again in an upcoming Quality Assurance Performance Improvement Meeting (QAPI) scheduled (MONTH) 27, (YEAR).",2020-09-01
778,WILLOWWOOD HEALTHCARE AND REHABILITATION,115327,4595 CANTRELL ROAD,FLOWERY BRANCH,GA,30542,2017-12-21,656,D,1,0,19JF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Administrative Policies and Procedures and resident and staff interviews, the facility failed to follow the care plan for two of four sampled Residents (R) #2 and #3 related to incontinence care and toileting assistance. The facility census was 79 residents. Review of the facility policy titled Administrative Policies and Procedures revised 3/11/14 documented: This facility will provide the necessary care and services for the residents to attain or maintain the highest mental, physical, and psychological well being, in accordance with the comprehensive assessment and plan of care. Finding include: Refer to F550 1. Record review for R#2 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 10, indicating moderate cognitive impairment. The resident required extensive, one person, physical assistance with toileting. She was admitted to the facility on [DATE] with the following diagnoses; altered mental status, muscle weakness, dysphagia, abnormalities of gait and mobility, lack of coordination, repeated falls, cognitive communication deficit, dementia with Lewy bodies, [MEDICAL CONDITION], [DIAGNOSES REDACTED] of intestine, major [MEDICAL CONDITION], progressive supranuclear ophthalmoplegia, diaphragmatic hernia without obstruction or gangrene,[MEDICAL CONDITION] acquired absence of cervix and uterus. Further record review for R#2 of a care plan initiated 11/27/17 indicated R#2 is incontinent at times and at risk for skin breakdowns. Interventions included; check every two hours and as required for incontinence. Resident is able to assist with toileting the amount of assistance may vary from day to day, have her assist to tolerance and provide peri-care for incontinent episodes. Interview on 12/21/17 at 11:41 a.m. with Certified Nursing Assistant CNA (AA) revealed R#2 cannot toilet herself and requires one person assistance for toileting. CNA AA further revealed the he tries to care for residents in order of priority and he does not address resident call lights if he cannot get to the resident right away. CNA AA added, he has had had to tell a resident not to hold it, go ahead and go in their brief and he would come back in change them as soon as he could. 2. Record review for R#3 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 12, indicating moderate cognitive impairment. The resident required full, one person, physical assistance with toileting. She was admitted to the facility on [DATE] with the following diagnoses; Type II DM, nonrheumatic mitral insufficiency, [MEDICAL CONDITION], depression, DM, polyarthritis, asthma, [MEDICAL CONDITIONS], HTN, allergic rhinitis and age-related [MEDICAL CONDITION]. Further record review of a care plan for R#3 and initiated 3/29/17 revealed, R#3 has incontinence and is at risk for skin breakdown. Interventions include; check and change every two hours and as needed while awake and during sleeping hours as needed. Check frequently for incontinence, was rinse and dry perineum. Interview on 12/21/17 at 12:10 p.m. with Certified Nursing Assistant CNA (BB) revealed, the lack of staffing has caused staff not to be able to do their jobs and due to staffing, people have been left wet, left soiled, had accidents and had to use their briefs because staff could not get to them to change them or take them to the toilet. CNA BB futher revealed staff has care plans available for all resident's in the care plan book. Interview on 12/21/17 at 5:00 p.m. with Administrator revealed her expectation if for staff to follow the resident's care plan and she believes the residents are being cared for and staff have been re-educated on toileting, changing and repositioning. The Administrator further revealed the facility discussed the issue of residents being told to toilet in their briefs and she is certain the issue has been addressed",2020-09-01
779,HARBORVIEW HEALTH SYSTEMS THOMASTON,115329,310 AVENUE F,THOMASTON,GA,30286,2019-01-02,656,E,1,0,T89211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to follow the care plan related to securing the urinary catheter tubing for two residents (R) (#2 and #3) out of three sampled residents with indwelling catheters. Findings include: 1. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R#2 had a Brief Interview for Mental Status (BIMS) score of 6 (a BIMS score of 0 to 7 indicates severe cognitive impairment), [DIAGNOSES REDACTED]. Review of the care plan for R#2 dated 12/28/18 revealed an alteration in elimination of bowel/bladder related to history of constipation and Foley catheter in place. Interventions included to anchor catheter and avoid excessive tugging on the catheter during transfer and delivery of care. On 12/31/18 at 1:55 p.m. Certified Nursing Assistant (CNA) BB was observed performing catheter care for R#2 and no catheter strap was seen securing the catheter when covers were pulled back and brief removed. A catheter strap was not placed on the resident at any point during or after catheter care. Further observation and interview with Licensed Practical Nurse (LPN) CC on 1/2/18 at 11:00 a.m. revealed R#2 did not have a catheter strap or anchoring device securing the tubing of the catheter. 2. Review of the Quarterly MDS assessment dated [DATE] revealed that R#3 had a BIMS score of 1, [DIAGNOSES REDACTED]. Review of the care plan for R#3 dated 12/31/18 revealed an alteration in elimination of bowel/bladder related to Foley catheter. Interventions included to anchor catheter and avoid excessive tugging on the catheter during transfer and delivery of care. On 12/31/18 at 2:20 p.m. CNA AA was observed using the mechanical lift to transfer R#3 from the Geri-chair to the bed. CNA AA then performing catheter care and no catheter strap was seen securing the catheter when the covers were pulled back and brief removed. The resident was repositioned during and after care. Catheter strap was not placed on the resident at any point during or after catheter care. Further observation on 1/2/19 at 8:24 a.m. revealed resident in bed. R#3 pulled the covers back and revealed no catheter strap or anchoring device used. Interview with the Director of Nursing (DON) on 1/2/18 at 11:15 a.m. revealed that she expects residents with Foley catheters to have legs straps or to be secured in some way. The facility did not have a care plan policy. Cross Refer F690",2020-09-01
780,HARBORVIEW HEALTH SYSTEMS THOMASTON,115329,310 AVENUE F,THOMASTON,GA,30286,2019-01-02,690,E,1,0,T89211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the facility policy titled Order for Foley/ Suprapubic Catheter, and staff interview, the facility failed to secure the urinary catheter tubing to prevent tension on the urethra for two residents (R) (#2 and #3) out of three sampled residents with indwelling catheters. Findings include: 1. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that R#2 had a Brief Interview for Mental Status (BIMS) score of 6 (a BIMS score of 0 to 7 indicates severe cognitive impairment), [DIAGNOSES REDACTED]. Review of the current Physician order for [REDACTED]. On 12/31/18 at 1:55 p.m. Certified Nursing Assistant (CNA) BB was observed performing catheter care for R#2 and no catheter strap was seen securing the catheter when covers were pulled back and brief removed. A catheter strap was not placed on the resident at any point during or after catheter care. Further observation and interview with Licensed Practical Nurse (LPN) CC on 1/2/18 at 11:00 a.m. revealed R#2 did not have a catheter strap or anchoring device securing the tubing of the catheter. 2. Review of the Quarterly MDS assessment dated [DATE] revealed that R#3 had a BIMS score of 1, [DIAGNOSES REDACTED]. Review of the current Physician order for [REDACTED]. On 12/31/18 at 2:20 p.m. CNA AA was observed using the mechanical lift to transfer R#3 from the Geri-chair to the bed. CNA AA then performing catheter care and no catheter strap was seen securing the catheter when the covers were pulled back and brief removed. The resident was repositioned during and after care. Catheter strap was not placed on the resident at any point during or after catheter care. Further observation on 1/2/19 at 8:24 a.m. revealed resident in bed. R#3 pulled the covers back and revealed no catheter strap or anchoring device used. During an interview on 1/2/18 at 11:05 a.m., CNA BB revealed that the nurse usually puts something on the tubing of the Foley catheter to secure it into place. Interview with the Director of Nursing (DON) on 1/2/18 at 11:15 a.m. revealed that she expects residents with Foley catheters to have legs straps or tubing to be secured in some way. Review of the undated policy titled Order for Foley/ Suprapubic Catheter revealed: 2. Put in order. (c) description, iv. Leg strap checked per shift and as needed.",2020-09-01
781,HARBORVIEW HEALTH SYSTEMS THOMASTON,115329,310 AVENUE F,THOMASTON,GA,30286,2019-04-26,812,F,0,1,ZS6U11,"Based on observation, interviews, and review of policies titled Thawing. Storing Prepared Foods, and Foods Brought by Family/Visitors the facility failed to assure that items were labeled and dated, used by expiration date, failed to use step to open trash can, failed to keep can opener free of buildup, failed to assure dishwasher was functioning at appropriate temperatures, failed to assure the cleanliness of the ice machine in the kitchen, and failed to follow the recipe when preparing puree meals. The facility also failed to assure the cleanliness of 1 of 2 resident food pantries and to assure that items in the resident refrigerator were stored appropriately. This practice affected 100 residents that received an oral diet. The facility census was 102. Findings include: During the initial kitchen tour with the Dietary Manager (DM) on 4/23/19 at 11:55 a.m. the following was observed: 1. In the reach in cooler there were five 32 fluid ounce (fl. oz.) containers of concentrated orange juices that were thawed and did not have an open date or expiration date. The package said to keep frozen. 2. In the dry storage area there was a bag of hamburger buns with a use by date of 2/12/19 and there was also a bag of hot dog buns that did not have an open date or an expiration date. 3. There was no step to open trashcan noted by either of the hand washing sinks. 4. The containers containing flour, sugar, rice, corn meal, and thickener were not labeled or dated. The thickener container noted to not have a tight-fitting lid and the thickener was in a white trash bag in the container. 5. The lip of ice machine had black buildup when the DM wiped it with a paper napkin. During interview with the DM on 4/23/19 at 12 p.m. she confirmed that she was not able to tell when the juice items in the refrigerator would expire due to not having a thaw date. DM reported that the bread was kept in the freezer and had been thawed for use although, the bread did not contain an open or use by date as a result of the freezing. DM further reported that everything should be labeled and dated. DM reported that the ice machine is cleaned monthly and Maintenance is scheduled to clean on this Thursday. During the follow up kitchen tour on 4/25/19 at 12:14 p.m. with the DM the following was observed: 1. In the dry storage area there was a 12-pack container of hotdog buns that were not labeled or dated with expiration date. The DM reported that the hot dog buns were taken out of the freezer today and they have seven days to use them. DM acknowledge that no one would be able to tell when the hotdog buns were thawed or when they should be used by without labeling. 2. In the dry storage area there were four 12 pack hamburger buns and 1 case of eight 12 pack hamburger buns that did not indicate a thaw date. Dm reported that hamburger buns had been in walk in cooler since last Thursday. 3. In the dry storage area there was one package of fettuccine open 1/27/19 and use by 2/27/19. DM reported all staff responsible for labeling and dating. has had in-services in the past but none recently. 4. There were no step to open trash cans by either of the two hand washing sinks. 5. The containers with flour, sugar, rice, corn meal, and thickener were not labeled or dated. 6. The canned items in the dry food storage area were not dated and DM unable to read codes on cans to determine expiration dates. During observation of dishwasher usage on 4/25/19 at 12:47 p.m. it was reported that the dishwasher was a high temp dishwasher. The wash temperature was 164 degrees Fahrenheit (F) and the rinse temperature was 153 degrees F. The Dietary Manager reported that whenever the rinse temperature is not 180 degrees F maintenance is notified and adjustments are made. On 4/25/19 at 12:58 p.m. the Director of Maintenance reported that he made adjustments to the dishwasher and it is now rinsing at 190 degrees F. He reported that whenever the temperature on the dishwasher needed adjusting dietary staff typically call him and he is able to make the necessary adjustments. The DM reported that a sanitizing solution is used in the dishwasher, but they are not checking it daily. DM reported that the dishwasher was a high temperature dishwasher and the range for water temperatures was noted on the dishwasher. The sign on the dishwasher revealed a wash temperature of 150 degrees F and a rinse temperature of 180 degrees F. Review of the dishwasher temperature log for (MONTH) 2019 revealed that the dishwasher did not wash at 150 degrees F on 4/1/19 through 4/6/19 and the rinse was not 180 degrees F on 4/1/19 through 4/11/19, 4/15/19 through 4/17/19, and 4/18/19 through 4/24/19. During the evening meal the dishwasher rinse temperature was recorded but it was never documented as being 180 degrees F for the month of (MONTH) 2019. Observation of the front resident pantry tour conducted on 4/26/19 at 9:00 a.m. revealed the following: 1. One container of Med Pass was open and sitting on the table. However, there was no open date noted. Instructions revealed once opened four days to use if refrigerated or four hours usage if not refrigerated. 2. There was build up on the floor near the refrigerator and on baseboards and two glasses were on the floor between the cabinet and the table holding the microwave. 3. In the refrigerator there was a bag with a resident's name dated 4/6/19 that contained two boxes, one containing a chicken sandwich and one box containing a cheeseburger. All had keep frozen on the package. Interview on 3/26/19 at 9:15 a.m. with Unit Manager BB who reported that housekeeping is responsible for cleaning of the pantry. She also reported that the Med Pass should be thrown away at the end of every shift. She confirmed that the MedPass did not have an open date on it. Unit Manager BB reported that she does not typically look into residents' bags to see what they have or check for expiration dates when the items are placed in the resident refrigerator and said she could not speak for anyone else. Unit Manager BB further reported that the items in the refrigerator are not kept longer than a week and the sandwiches should have been thrown away. An interview with the DM on 4/26/19 at 9:33 a.m. who reported that there has not been a system in place related to labeling and dating canned items to identify first in first out per the policy. When viewing the containers with flour, sugar, rice, and cornmeal she confirmed that there were no labels or dates on the containers. She also reported that a new shipment comes in each week. She reported that the old product is removed so that the new product can be placed in the container. Once the new product is in the container the old product is then poured on top of it. Observation of food puree process began on 4/26/19 at 9:43 a.m. with Cook CC who was preparing the puree and the DM who observed the process. Cook CC reported 12 residents would receive the puree meal and she would be using 9 fish patties for the 12 residents. The DM then directed Cook JJ to get 3 more patties so that there would be a serving for each resident. When preparing the puree fish Cook JJ used four cups of water and 3/4 cup of thicker to the fish and did not follow the recipe. When questioned if the recipe recommended using water Cook JJ reviewed the recipe and said yes. Interview with the DM on 4/26/19 at 10:15 a.m. revealed that the Registered Dietitian was contacted about the preparation of the fish puree who informed her that water should not be used to thin foods when preparing the puree. DM then reported that Cook CC has been given instructions to redo the puree. DM reported that she assumed that staff were using broth instead of water because she used broth when she had to prepare the puree. Recipe for Pureed fish week 4, day 6 lunch read as follows: 2. Measure desired # of servings into food processor. Blend until smooth. Add broth or gravy if product needs thinning. Add commercial thickener if product needs thickening. Thawing Policy, dated 2011 Acceptable thawing method: Identify food with date placed in refrigerator for thawing and a use by date. Foods Brought by Family/Visitors, revised (MONTH) 2014 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. Storing Prepared Foods, dated 2001 Labeling: For dry goods such as flour or sugar, identify the item by its name and date and place in appropriate container for dry good items.",2020-09-01
782,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2018-04-12,565,E,0,1,T1XP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and review of facility policy, the facility failed to ensure residents' call lights were answered in a timely manner to include three residents present for the group interview (Residents (R) #11, #21, and #91). The sample size was 25. The census was 108. The findings included: Review of the facility's policy titled Grievance Procedure (not dated) noted the following: 1) Any resident, or resident's representative who wishes to submit a grievance in regard to treatment, conditions, or violations of rights while under the care of the facility, are welcome to submit a written account a written account of the details of the grievance to the Administrator. In the event the resident is unable to do so in writing, he/she may select someone to write the report for him/her or state the complaint orally to the Administrator. 2) The Administrator of each facility is considered the Grievance Official and will oversee the grievance process, receive and track grievances through to their conclusions; lead any necessary investigations by the facility; maintain the confidentiality of all information associated with grievances, for example, identity of the resident for those grievances submitted anonymously, issue written grievance decisions to the resident; and coordinate with state and federal agencies as necessary in light of specific allegations. 3. No later than 3 days after the submission of the grievance, the Administrator or designees will respond with a resolution to the complainant and the aggrieved party; if someone other than the complainant. 4. In the event the Administrator is unable to resolve a resident grievance under the procedure outlined above, she will refer the concern to the Home Office staff for further investigation. Review of Resident Council Meeting minutes from 10/2017 - 3/2018 revealed residents had the following complaints/grievances: 10/10/17 - Residents complained CNAs (Certified Nursing Assistant) will walk pass call lights at times. Call lights aren't answered timely especially on the 11:00 p.m. - 7:00 a.m. shift and weekends but has improved slightly during meal times. On Sundays 3-11 or 11-7 it still continues to be the same. 11/12/17 - Residents complained CNAs will walk pass call lights at times but has improved slightly during meal times. 12/12/17 - Residents complained CNAs will walk pass call lights at times but has improved slightly during meal times. Call lights aren't answered timely especially on the 11:00 p.m. - 7:00 a.m. shift and weekends. 1/9/18 - Residents complained staff would walk pass a (resident's) light instead of addressing his concern .Call lights aren't answered timely. 2/13/18 - Residents complained they are always short staff and need more help, and that staff would see a call light on and walk pass her room instead of addressing the issue. One resident stated on Friday 3-11 shift she turned her light on and a CNA, who was not assigned to her, stopped in her room to turn the light off and said, She would be back. After minutes went by the resident went to the door and asked for assistance and the CNA wasn't very pleasant and responded negatively. Call lights aren't answered timely. 3/13/18 - Residents complained that the issue of being short of staff has not been resolved; and staff seeing call lights on and walking pass the room instead of addressing the issue has not been resolved. Call lights are not answered timely. Review of the facility's In-service Education Records revealed the following: 1/22/18 - In-service for CNAs - Place Call light within reach. Do not wrap on bedside. 3/5/18 - In-service for CNAs - Introduce yourself every time you enter a room. Answer all call lights. There were no in-service training records regarding answering call lights provided for the months of (MONTH) (YEAR), (MONTH) (YEAR), or (MONTH) (YEAR). Review of Staff Reminders for 3/2018 noted Call lights, please do not turn them off unless you assist, please do not tell residents 'I am not your nurse assistant.' The group interview was conducted on 4/10/18 at 10:11 a.m. in the facility's main dining room. The seven residents that attended the meeting stated there was an ongoing problem with the staff either not answering call lights in a timely manner, and/or the staff turning off the call lights. Staff would say that they are coming back but never return to attend to the needs of the resident. 1. During the group meeting, R #11 stated when he was first admitted into the facility, he turned on his call light and had to wait 44 minutes before staff answered the call light. He said he needed assistance with toileting; however, he did not have a toileting accident, because of having to wait for staff to answer the call light. Review of Resident #11's Admission Minimum Data Set (MDS) assessment dated [DATE] noted the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R #11 was assessed to be cognitively intact scoring 13/15 on the Brief Interview for Mental Status (BIMS) assessment. The resident required the extensive assistance of one staff person for bed mobility, transfers, walking in room, dressing and toileting. R #11 had no impairment of upper and lower extremities, and he utilized a walker and wheelchair for mobility. 2. During the resident's group meeting, R #21 (Resident Council President) said on the weekends there were two times when she had to wait 60 minutes before her call light was answered. R #21 said during the timeframe in which she had to wait, her brief was soiled with urine. The resident stated staff sometimes turned her call light off and say I'll be back; however, it takes a long time for anyone to return. R #21 indicated the call light issue was an on-going problem. Review of Resident #21's Quarterly MDS assessment dated [DATE] noted the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R #21 was assessed to be cognitively intact scoring 13/15 on the BIMS assessment. The resident required the extensive assistance of one staff person for bed mobility, transfers, dressing and toileting. R #21 had impairment on one side of her lower extremities, and she utilized a walker and wheelchair for mobility. 3. During the resident's group meeting, R #91 stated that call lights going unanswered mostly happens on the weekends. R #91 said she had a situation where she had to have a suppository, and when she needed to relieve herself, she engaged the call light. It took 15 minutes for staff to answer the call light, and as a result, R #91 had a toileting accident (a bowel movement). Review of Resident #91's Quarterly MDS assessment dated [DATE] noted the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R #91 was assessed to be moderately cognitively impaired scoring 11/15 on the BIMS assessment. The resident required the extensive assistance of two staff persons for bed mobility. She required the extensive assistance of one staff person for transfers, dressing and toileting. R #91 had impairment on one side of her upper and lower extremities, and she utilized a wheelchair for mobility. Interview on 4/12/18 at 10:00 a.m. with the Social Services Director (SSD) FF in her office revealed resident council issues were reported to her and she was aware of the residents' concerns regarding call lights not being answered in a timely manner. The SSD said when she became aware of their complaints, she reported the information to the Director of Nursing (DON), Administrator, and/or Staff Development Nurse (SDN). She said in-services are done to address the staff answering call lights. The SSD was not aware if any audits of the call light system had been done to address the on-going problem. Interview on 4/11/18 at 10:10 a.m. with the SDN II, in her office, revealed she was aware there was an ongoing call light issue with the residents. SDN II said she completed in-services regarding answering call lights at least monthly, and the problem seems to continue. The nurse said she thinks it could be because when resident go to the council meetings that's they opportunity to bring up the same issue over again even if it has been addressed. SDN II said she is regularly talking with staff about answering call lights; informing them that anyone can answer call lights, even housekeeping (and then get nurse). SDN II stated the facility did not have a call light system that tracked the amount of time it took staff to answer a call light. Interview on 4/12/18 at 10:24 a.m. with CNA BB in the 200 Hallway revealed it typically took about three to four minutes to answer call lights. The aide said there were times when it could take between five to six minutes to answer a call light if there were two aides on the hall and both were working with a resident who required assistance. The aide stated the staff received in-services regarding call lights at least monthly. Interview on 4/12/18 at 11:15 a.m. with the facility's Administrator in her office revealed during each monthly council meeting old concerns are addressed and information provided as to what interventions were put into place to address the concern. The Administrator said there was a Response Form the facility could use to document any interventions they have done to address the call light issue; however, the facility had not been using the form to document interventions they had made. During a follow-up interview on 4/12/18 at 12:50 p.m. with the Administrator in her office, the Administrator confirmed that she was made aware of the on-going resident complaints about the untimely response to the call lights. The Administrator revealed she did consider the residents' complaints about the call lights to be a grievance and said the facility has not gone back to the residents to let them know how they are working on resolving the on-going issue.",2020-09-01
783,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2018-04-12,578,E,0,1,T1XP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and document review, it was determined the facility did not have a process in place to ensure Resident's Advance Directives were complete, accurate, and communicated to the facility staff the resident's wishes for four (4) of 25 sampled residents (Resident (R) #64, #101, #228, #230) of a total census of 108. Findings include: 1. Review of R#64's clinical record revealed an admission date of [DATE]. R#64 had [DIAGNOSES REDACTED]. R#64's Admission Minimum Data Set ((MDS) dated [DATE], noted the resident scored a 14/15 on the Brief Interview of Mental Status (BIMS), indicating the resident was cognitively intact. Review of the resident's Quarterly MDS dated [DATE] noted the resident's BIMS was now a 12/15. Review of R#64's clinical record, Advance Directives section, there is a document titled Do Not Resuscitate Order, the residents name was written in the blank section marked for resident's name. The form indicted The above-named resident does not have decision making capacity at this time. Based on a reasonable degree of medical certainty the above-mentioned resident is a candidate for nonresusitation(sic) due to a medical condition which can reasonably be expected to result in the imminent death of the resident. The form was dated and signed on 9/21/17 by the attending physician. A second document was located behind the Do Not Resuscitate Order that indicates in bold type Do Not Resuscitate. Review of R#64's Physician order [REDACTED]. Observations conducted on 4/9/18, 4/10/18, and 4/11/18 of R#64 and the resident's room failed to provide any indication of the resident's code status. An interview was conducted on 4/11/18 at 10:45 a.m. with Licensed Practical Nurse (LPN) JJ at the main nursing station. LPN JJ was asked what R#64's code status was? LPN JJ stated, I will have to look at the resident's record to find out. LPN JJ was asked how she would know R#64's code status if she had found the resident unresponsive in her room? LPN JJ responded, I would have to go to the nursing station and look in the resident's record or send someone to find out. An interview was conducted on 4/11/18 at 11:00 a.m. with the Director of Nursing (DON) and the Administrator in the DON's office. They were asked where the resident's code status could be located if the resident was found unresponsive? They responded, it can be found on the Medication Administration Record [REDACTED].e. MAR. Both the DON and Administrator verified the DNR order had been signed and dated by the physician, but had not been placed into the regular physician's orders [REDACTED]. But understood the gravity of the situation and would address it today. A review the facility Policy & Procedure Regarding Advance Directives, Georgia (no dates). Policy Statement, each resident will be provided information regarding federal and state laws concerning advance directives and that the facility will protect the rights of all residents with regards to making their own treatment and/or decisions. 2. Review of R #101s Significant Change MDS dated [DATE] noted an admitted d of 2/23/18 with admission [DIAGNOSES REDACTED]. Section C of the assessment noted the resident was severely cognitively impaired having scored 5/15 on the BIMS assessment. R #101 had a prognosis of less than six months of life expectancy and during the assessment period received hospice services while a resident at the facility. Review of R #101's recapitulated (recap) physician's orders [REDACTED]. According to the orders, R #101's resuscitation status was a full code (2/23/18). Record review of R #101's Allow Natural Death Request dated 3/13/18 signed by the physician on 3/15/18, R #101's status was do not resuscitate (DNR). R #101's hospice care plan dated 3/27/18 revealed R #101 requires hospice r/t end of life care and [DIAGNOSES REDACTED]. The approaches to address this area were: administer pain medications as ordered; coordinate plan of care with hospice agency reflecting the hospice philosophy; ensure the facility and the hospice agency are aware of the other's responsibilities in implementing the plan of care; involve resident in care and decision making to maximal potential; medication and medical supplies to be provided by hospice as needed for palliation and management of the terminal illness and related conditions; notify hospice when there is any change in the resident's condition; provide basic comfort measure; respect resident's spiritual and cultural needs; and respond to inquiries honestly. During an interview at the nurses' station on 4/10/18 at 3:23 p.m. with Licensed Practical Nurse (LPN) EE, when asked the status of the resident's resuscitation orders, LPN EE was unsure of R #101's status. The nurse stated R #101 should have a notification at the tab marked Advance Directive to indicate if the resident was full code or DNR status. LPN EE stated the resident should be a DNR because he is a hospice patient. After looking at the resident's recap physician's orders [REDACTED]. LPN EE said she would ask the social worker for clarification. Interview on 4/10/18 at 3:31 p.m. with Social Service Director (SSD) FF in her office revealed the Allow Natural Death form was initiated by hospice, and confirmed the form indicated R #101 was of DNR status. SSD FF said upon admission, residents and/or family complete a DNR if that is what is desired. SSD FF said the process is that the DNR form is completed along with a telephone order generated by the SSD FF. According to the SSD FF, that documentation goes to medical records, and the information is then changed on the resident's Medication Administration Record [REDACTED]. SSD FF confirmed R #101 did not have the form to indicate the resident's resuscitation status and stated the information in the resident's clinical record made it unclear as to his resuscitation status. 3. Review of R #228's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. R #228's Admission MDS was not completed (still within 14-days of admission); and therefore, was not available for review. Review of the resident's Advanced Directive (AD) Checklist dated 3/28/18 noted the document was not signed to indicate whether the resident 1) had an executed AD and would later provide it to the facility; 2) did not have an AD; or 3) did not have an executed AD but wanted additional information. 4. Review of R #230's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS dated [DATE] revealed R #230 was cognitively intact, scoring 15/15 on the BIMS assessment. The resident was not prognosed to have a life expectancy of less than six months and did not receive hospice services prior to being admitted to facility, or while a resident at the facility. Review of R #230's Advanced Directive Checklist dated 3/7/18 noted the document was not signed to indicate whether the resident 1) had an executed AD and would later provide it to the facility; 2) did not have an AD; or 3) did not have an executed AD but wanted additional information. Review of R #230's recap orders for 4/2018 revealed the resident was a full code. Additional review of the clinical record revealed there was not a care plan that addressed AD. Interview on 4/12/18 at 10:34 a.m. with the Admissions Coordinator (AC) HH, revealed she reviewed the AD checklist with the resident and/or family upon admission. She confirmed the section indicating: Please check one(1) of the following statements was not completed, and should have been. The AC HH stated it was something she must have overlooked for R #228 and R #230. The AC HH said she would be more diligent about ensuring the form was completed in its entirety, and in ensuring the information regarding residents' ADs be obtained during the admission process, when needed.",2020-09-01
784,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2018-04-12,655,E,0,1,T1XP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident, family, and staff interview, and medical record review, the facility failed to complete the baseline care plan and provide a summary to the resident and resident representative for seven of seven sampled residents (Residents (R)#76, R#101, R#225, R#228, R#230, R#325, R#328) who were new admissions to the facility. The facility reported a census of 108. The findings include: 1. Review of the medical record for R#76 revealed an admission date of [DATE] and a re-admission date of [DATE] after a hospitalization . [DIAGNOSES REDACTED]. R#76 had a Brief Interview for Mental Status (BIMS) score of 13 indicating intact cognition. The medical record contained a form titled Admission Nursing Care Plan dated 1/19/18. The care plan contained information entered for mobility, pain, falls, and discharge. The areas for activities of daily living (ADL's) and nutrition were blank. There was no summary and no documentation that the care plan had been reviewed with the resident or resident representative. The medical record contained a second form titled Admission Nursing Care Plan dated 2/5/18. The care plan contained information entered for mobility, pain, falls, ADL's, and discharge. The area for nutrition was blank. There was no summary and no documentation that the care plan had been reviewed with the resident or resident representative. Interview with R#76 on 4/11/18 at 10:30 a.m. at her bedside revealed I don't remember talking about a care plan or getting a copy of one when I was admitted . I came in once and then had to go back to the hospital because of a blood clot in my lung so I have had two admissions. R#76 telephoned her family, who was present on admission, and confirmed no copy of the base line care plan was given. 2. Review of R #101s Significant Change MDS dated [DATE] noted an admitted d of 2/23/18 with admission [DIAGNOSES REDACTED]. Section C of the assessment noted the resident was severely cognitively impaired having scored 5/15 on the BIMS assessment. R #101 required the extensive assistance of one staff person for bed mobility, transfers, locomotion on the unit and personal hygiene. The resident required the total assistance of one staff person for dressing and toileting. R #101 had no impairment of upper and lower extremities and utilized a wheelchair for mobility. R #101 was always incontinent of bowel and bladder; received a therapeutic diet; was at risk for the development of pressure ulcers; and was administered an antidepressant for seven days during the assessment period. R #101 had a prognosis of less than six months of life expectancy and during the assessment period received hospice services while a resident at the facility. Review of R #101's clinical record revealed there was no evidence a written summary of the resident's baseline care plan was provided to the resident and/or his family. 3. Review of R #225's clinical record on 4/10/18 revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive Admission MDS was not available for review (still within 14-day period to develop the assessment). Review of R #225's Admission Nursing Care Plan dated 4/2/18 revealed the plan addressed mobility, pain, safety risk/falls, [MEDICAL CONDITION], and discharge. Nutrition was not addressed in the care plan. Continued review revealed there was no evidence a written summary of the resident's baseline care plan (admission nursing care plan) was provided to the resident and/or his family. Review of R #225's physician's orders [REDACTED]. Review of R #225's Initial Nutritional assessment dated [DATE] noted the resident was 5'4 and 211 pounds, and received a mechanical soft NAS, NCS diet. Comments: Tolerating current diet, await labs, monitor by po (by mouth) intake and outs. Review of R #225's Diet Order form dated 4/2/18 noted the resident was to receive a mechanical soft NCS, NAS diet - give small portions per family request. During an interview in the facility's conference room on 4/11/18 at 4:00 p.m. with the facility's Director of Nursing (DON), the DON stated the Admission Nursing Care Plan was the baseline care plan implemented within 48 hours of admission. The DON confirmed the resident's baseline care plan was not complete, and should include more information detailing the care required for the resident. Interview on 4/11/18 at 9:50 a.m. with MDS Coordinator GG in her office, revealed the nurse was fairly new to the position having been in the position for 6 weeks. MDS Coordinator GG stated she had not been involved with developing the baseline care plan, however, moving forward she will be involved in its development. The nurse stated she recognized that the check marks on the admission care plan did not provide adequate direction as to the care the resident required. 4. Review of R #228's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. A comprehensive Admission MDS was not available for review (still within 14-day period to develop the assessment). Review of R #228's clinical record revealed there was no evidence a written summary of the resident's baseline care plan was provided to the resident and/or her family. 5. Review of R #230's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS dated [DATE] revealed R #230 was cognitively intact, scoring 15/15 on the BIMS assessment. R #230 required the supervision of one staff for bed mobility, transfers, walking in room and/or corridor, locomotion on the unit, dressing and eating. The resident required the limited assistance of one staff person for toileting and personal hygiene. R #230 required the extensive assistance of one staff person for bathing. R #230 had no impairment of upper and lower extremities and utilized a walker and/or wheelchair for mobility. R #230 was always continent of bowel and bladder, received a therapeutic diet, was administered an anticoagulant and a diuretic for seven days during the assessment period, and received occupational and physical therapy serviced. Review of R #230's clinical record revealed there was no evidence a written summary of the resident's baseline care plan was provided to the resident and/or her family. 6. Review of the medical record for R#325 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The medical record contained a form titled Admission Nursing Care Plan dated 4/3/18. The care plan contained check marks for ADL's, mobility, pain, tube feeding, and falls. No specific interventions were listed and it was not signed by a nurse. There was no documentation of the care plan being reviewed with the resident or resident representative. Family of R#325 was interviewed at the bedside on 4/9/18 at 3:18 p.m. Family of R#325 stated My dad is very weak and has difficulty talking. We haven't had a care plan meeting yet. I think they hold those after a week or two in the facility. I don't have a copy of the care plan, but I can get one after our meeting if I want one. 7. Review of the medical record for R#328 revealed an admission date of [DATE]. [DIAGNOSES REDACTED]. The medical record contained a form titled Admission Nursing Care Plan dated 3/22/18. The care plan contained information for ADL's, activities, mobility, nutrition, pain, urinary incontinence, cognitive impairment, falls, and elopement. There was no information related to respiratory care and the need for oxygen. The admission orders [REDACTED]. There was no documentation of the care plan being reviewed with the resident representative. R#328 was not interviewable and the family was not available. Interview with licensed practical nurse (LPN) AA on 4/10/18 at 9:33 a.m. at the medication cart in the hall revealed the admitting nurse completes an initial care plan. LPN AA stated I complete the initial care plan based on my assessment and the physician orders. It's usually completed with the resident, but the family isn't usually present. LPN AA denied giving a copy of the care plan to the resident or resident representative. LPN AA stated The Director of Nursing (DON) and the others who attend morning meeting will go over any new information and then they will hold a care plan meeting with the family, but I don't know what the time frame is. Interview with the DON on 4/10/18 at 11:40 a.m. revealed the facility does not have a policy or procedure for the new baseline care plan regulation. The DON stated The facility has been completing an initial care plan, but we have not been having the resident or family sign it and give them a copy. We have been reviewing the process in QAPI (Quality Assurance Performance Improvement) since the new regulations went into effect in November. We weren't sure how best to have the documentation of the resident and family involvement. The DON confirmed the facility was not in compliance.",2020-09-01
785,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2018-04-12,656,D,0,1,T1XP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews and interviews, the facility failed to ensure a comprehensive care plan was developed for one of nine residents reviewed for new admission status (Resident (R) #230). The sample size was 25. The census was 108. The findings included: Review of R #230's clinical record revealed the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Admission MDS dated [DATE] revealed R #230 was cognitively intact, scoring 15/15 on the BIMS assessment. R #230 required the supervision of one staff for bed mobility, transfers, walking in room and/or corridor, locomotion on the unit, dressing and eating. The resident required the limited assistance of one staff person for toileting and personal hygiene. R #230 required the extensive assistance of one staff person for bathing. R #230 had no impairment of upper and lower extremities and utilized a walker and/or wheelchair for mobility. R #230 was always continent of bowel and bladder, received a therapeutic diet, was administered an anticoagulant and a diuretic for seven days during the assessment period, and received occupational and physical therapy serviced. Review of R #230's clinical record revealed there was not a comprehensive care plan filed in the resident's chart. Interview on 4/12/18 at 2:37 p.m. with Registered Nurse (RN) LL at the nurses' station confirmed there was not a comprehensive care plan in the resident's chart. RN LL stated the MDS Coordinator was responsible for completing the comprehensive care plan. During an interview with the facility's Director of Nursing (DON) on 4/11/18 at 2:40 p.m. at the nurses' station, the DON stated the care plan had been done. She stated the care plan coordinator (MDS Coordinator) may still be working on it, or someone may have taken it out of the book and did not put it back. During a follow-up interview on 4/11/18 at 3:57 p.m. with the DON in the facility's conference room, the DON revealed the MDS Coordinator had been in the position just since (MONTH) (YEAR) so there may be a gap in completing some of the care plans. Interview on 4/12/18 at 9:50 a.m. with the MDS Coordinator GG revealed the nurse was fairly new to the position having been in the position for six weeks. She confirmed R #230's comprehensive care plan had not been completed until 4/11/18, after the surveyor intervened. MDS Coordinator GG also stated the usual process was to develop the comprehensive care plan from the information provided in the Care Area Assessment of their Admission MDS. She stated that somehow R #230's comprehensive care plan was over looked and was not completed until 4/11/18.",2020-09-01
786,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2018-04-12,812,F,0,1,T1XP11,"Based on observations, interviews and review of facility policy, the facility failed to store and prepare food in accordance with professional standards for food service safety. This practice affected all resident receiving food from the kitchen. The census was 108. The findings included: 1. Review of the facility's policy and procedure manual for Family Dining Services 2014 edition noted: - General storage guidelines to be followed: All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded .wrap food properly. Never leave any food item uncovered and not labeled. - Date marking for freezer storage items: Once a package is opened, it will be re-dated with the date the item was opened and shall be used by the safe food storage guidelines or by the manufacturer's expiration date. - Date marking for refrigerated storage food items: Once a case is opened, the individual, refrigerated food items are dated with the date the item was received into the facility and placed in/on the proper storage location utilizing the first-in - first-out method of rotation. Once opened, all ready to eat, potentially hazardous food will be re-dated with a use by date according to safe food storage guidelines or by the manufacturer's expiration date. - Date marking for dry storage food items: Once a case is opened, the individual food items are dated with the date the item was received into the facility and placed in/on the proper storage unit utilizing the first-in - first-out method of rotation Continued review of the policy noted prepared food or opened food items should be discarded when the food item does not have specific manufacturer expiration date and has been refrigerated for more than 7 days; when the food item is leftover for more than 72 hours; and when the food item is older than the expiration date. 2. Observations in the facility's walk-in freezer on 4/9/18 at 8:50 a.m., accompanied by the Lead Cook (LC) CC revealed on the freezer shelves were four previously opened bags of unlabeled and undated food items that LC CC identified as being chicken liver, chicken breast, chicken nuggets, and egg plant. The chicken was not stored improperly above other food items. The bags were not in their original packaging and did not contain a manufacturer's expiration date on the packaging. Continued observation revealed there were six opened bags of unlabeled and undated food items that LC CC identified as being chicken tenders, breaded fish, buffalo chicken breast, sweet potato fries, diced chicken and hamburger patties. The bags were not in their original packaging and did not contain a manufacturer's expiration date on the packaging. Interview with LC CC at this time revealed the facility was in the process of bringing on a new Dietary Manager. LC CC also said there was new kitchen staff and not all staff had been trained regarding labeling, dating and sealing food items. LC CC confirmed the food items should be sealed, label and dated with the date the food item was opened. 3. Observations in the facility's walk-in refrigerator on 4/9/18 at 8:54 a.m., accompanied by LC CC revealed on the shelves were two bags of unopened carrots with use thru dates of 3/27/18 and 4/2/18. Interview at this time with LC CC revealed the facility had just received the two bags of carrots from the vendor on Thursday, 4/5/18. LC CC stated there may be a problem with what the vendor is sending. 4. Observations on 4/9/18 at 8:59 p.m., accompanied by LC CC in the dry storage area revealed an opened bag of elbow macaroni and a bag of spaghetti pasta (both food items identified by LC CC). Both bags were unlabeled and undated. 5. Observation of the reach-in freezer I on 4/9/18 at 9:02 a.m. revealed an opened box of partially served angel food cake. The container did not indicate the date the box was opened. Continued observation of reach-in freezer II, at this time, revealed an opened bag of biscuits that contained no label or date (the food item was identified by LC CC). The biscuits were not in their original packaging and did not contain a manufacturer's expiration date on the packaging. 6. Observations in the dry storage area on 4/11/18 at 11:40 a.m., accompanied by LC CC, revealed an opened bag of tortilla strips that were not labeled or dated; and in the walk-in freezer were two previously opened bags of chicken tenders and cauliflower that were not labeled or dated. The chicken was not stored improperly above other food items. The food items were identified by LC CC. The bags were not in their original packaging and did not contain a manufacturer's expiration date on the packaging. Interview at this time with LC CC revealed the new dietary manager was to start soon. LC CC said after the walk-thru on 4/9/18 with the surveyor, LC CC spoke with dietary staff about appropriately sealing, labeling and dating foods. LC CC stated dietary staff saw her as their equal and did not follow through with her instructions. LC CC stated she reported directly to the facility's Administrator until the new Dietary Manager officially starts his position. LC CC said she did not speak with the Administrator about the storage issues in the kitchen. Interview on 4/11/18 at 1:50 p.m. with the facility's Administrator revealed the facility had been without a dietary manager since the beginning of the year. She said LC CC was currently acting as the Dietary Manager and was advised to come to her if there were any problems. The Administrator was not aware of the food storage issues identified in the kitchen on 4/9/18. 7. Review of the facility's policy and procedure manual for Family Dining Services 2014 edition noted potential hazards include biological, chemical and physical - are typically the cause for food contamination. One of the common factors identified as responsible for foodborne illness was noted to be contaminated equipment. Observations in the facility's kitchen on 4/09/18 at 8:46 a.m. revealed Prep Cook (PC) DD held two oven mitts in her hands and dropped one of the mitts onto the floor. PC DD picked the oven mitt up from the floor and then used the contaminated mitt to remove a baked cake from the oven. Interview at this time with PC DD confirmed she used the contaminated oven mitt to remove the cake from the oven. PC DD stated she has received training regarding cross contamination in the kitchen. She said she should have obtained a clean oven mitt to remove the cake from the oven.",2020-09-01
787,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2019-05-23,684,D,1,1,BM2N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to follow the Physician's Order to apply [NAME] hose (compression stockings) daily for one resident (R) (#67) from a sample of 40 residents. Findings include: A review of the clinical records for R#67 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A further review of the clinical records revealed a Nurse's Note of 4/26/19 which documented 1+ [MEDICAL CONDITION] observed to the resident's bilateral lower extremities. A review of the Physician's Orders revealed an order written [REDACTED]. During an observation on 5/21/19 at 11:51 a.m. R#67 was noted to have significant [MEDICAL CONDITION] in the bilateral lower extremities. However, the resident was not wearing [NAME] hose. During an observation on 5/22/19 at 11:50 a.m., R#67 was observed sitting near the nurses' station and was again not wearing the ordered [NAME] hose. During an interview on 5/22/19 at 2:45 p.m. with Licensed Practical Nurse (LPN) AA, it was revealed that there was an order documented in the EHR since 4/30/19 for R#67 to have [NAME] hose applied during the day and removed at night. After checking the resident, LPN AA verified that the resident was not wearing [NAME] hose on either leg. She said the aides were responsible for applying this item during the day and removing it at night per the order. However, after rechecking the order in the EHR, LPN AA said the order was not correctly added to the electronic records to trigger the task to be completed by the aides. During an observation on 5/23/19 at 11:16 a.m., R#67 was observed to be wearing [NAME] hose while engaged in activities in the dining area. During an interview on 5/23/19 at 12:57 p.m. with the Director of Nursing (DON), it was revealed that orders for items such as [NAME] hose, which are the responsibility of the CNAs, are put into the system by the charge nurse and triggered in the care system so that the CNAs are aware to follow those orders. If such an order is not appropriately added in the EHR, however, then it does not trigger for the CNAs to follow in their care system. The DON further said that orders meant to be completed by the CNAs are not routinely added to the Medication Administration Records or in any similar areas to alert the nurse to check that they are followed, and that this oversight was a glitch in the current process. Going forward, however, she planned to make changes wherein such orders are required to be activated in both the care system used by the CNAs and the treatment administration record used by the nurse.",2020-09-01
788,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,166,D,0,1,FEJH11,"Based on interviews and record review, the facility failed to resolve grievances in a timely manner related to incompatibility of roommates for one resident (R) (R#57) from a sample of 38 residents. Findings included: On 6/13/17 at 11:39 a.m. R#57 stated that he did not like his roommate and that he told staff that he would like another room. On 6/16/17 at 7:37 p.m. an interview was conducted with the Social Service Director. She stated that she was made aware a couple weeks ago by R#57 and his family that he did not get along with his roommate. When asked if she wrote up a grievance she stated that she had not. She confirmed that there were beds available for a room change when the resident complained about not being compatible with his roommate. When asked why a room change was not conducted, she stated that she just did not do a room change. She did not provide further explanation as to why she did not file a grievance or make the room change. During an interview with the Administrator on 6/16/17 at 7:56 p.m. she stated that there ate twenty-seven dually certified. She stated that it is her expectation that if a resident or a residents family complains of having a problem with a roommate, that the Social Services Director write up a grievance and try to accommodate the resident with a room change at the next available room that they could go to. If the resident was in a Long Term Care bed and there was a Rehab bed available that would be an accomodation. Social worker will discuss in the morning meeting or come to her one on one to discuss the resident's needs. She stated that this information would be discussed in the next morning meeting. The Administrator said that she was not aware that R#57 requested a room change or that he had a problem with his roommate. On 6/16/17 at 8:29 p.m. an interview with the Administrator and the Social Services Director was conducted. The Social Services Director stated that she did complete a formal grievance related to the incompatibility of R#57 and his roommate on 5/26/17. The Administered provided a copy of that grievance dated 5/16/17 which noted that R#57 was not pleased with new roommate. If further noted that R#57 stated that the roommate was a rude and nasty man and that the roommate was not nice to his guest and told them to leave. The resolution was that the Social Services Director spoke to roommate about being polite and respectful and told R#57 to try through the weekend and if things did not improve then he would be moved. It noted that R#57 and family did not complain about roommate over the weekend. The Social Services Director stated that she did not follow up with the resident or the family because the nurse did not relay any concerns from the family or resident over the weekend after the grievance was wrote up. The Administrator stated that it is the expectation that the facility follow up with the resident and family related to the concerns. On 6/16/17 at 8:39 p.m. the Administrator and the Social Services Director came into the conference room and informed the team that they had just went to speak with R#57 that he still wanted to move. The Administrator stated that the room change will be conducted in the morning. A review of the grievance policy dated (MONTH) (YEAR) noted that residents and resident representative(s) are always encourages to visit with administration at any time they have input or concerns. In the majority of instances, the concern will be resolved. No later than 3 days after the submission of the grievance, the Administrator or designee will issue a decision with a resolution to the complainant and the aggrieved party.",2020-09-01
789,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,167,C,0,1,FEJH11,"Based on observation, resident and staff interview the facility failed to post results of the last survey conducted by State Surveyors were available to read without asking, and failed to inform the current and former resident council presidents of the location of survey results. The resident census was 104. Findings include: Observation on 6/13/17 at 7:50 a.m. a framed sign on the front desk nurses station as follows: Survey results are available at the front Nurses Station. The nurse will be happy to assist you if you wish to review those results. The survey results were observed in a note book behind the nurses station in a green binder. Interview on 6/15/2017 at 5:54 p.m. with the Administrator confirmed survey results have been behind the nurses desk for at least a year, as long as she has been Administrator here. The Administrator indicated she thought if the survey results were behind the nurses desk anyone who wanted them would ask. During an interview on 06/15/2017 at 5:22 p.m., Resident (R) #99 stated she was aware of a small sign posted at the nurse's station advising residents they can ask for the state survey results. However, R #99 did not know where the results were located. The most recent quarterly Minimum Data Set (MDS) assessment completed for the resident on 3/14/17 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 14, indicating the resident is cognitively intact. During an interview on 06/16/2017 12:42 p.m., R#45 revealed she has been at the facility for more than nine years, but was not aware that the state survey results were available for residents to review. Had she been aware the results were available to be reviewed by residents, she would have asked to see them herself or ask that they be shared with the residents present during resident council meetings. The most recent quarterly MDS assessment completed for R#45 on 3/30/17 revealed in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) score of 11, indicating the resident has a moderate cognitive impairment.",2020-09-01
790,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,176,D,0,1,FEJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of facility policy titled Medications, Self-Administration of, the facility failed to monitor and re-assess one resident (R), (R#51) for cognitive ability and safety of self-administration of medication. The Stage Two sample was Findings include: Review of facility policy titled Medications, Self-Administration of, dated 12/2009, revealed a re-assessment will be repeated quarterly unless there is a significant change in condition affecting cognitive abilities and safety regarding self-administration. The resident will be monitored as to the usage and effectiveness of as needed (PRN) medications daily to insure that there are no problems that need to be addressed in terms of increased symptoms, need for changes or further diagnostic work up that could indicate a need for medication change. The Charge Nurse is to initial the Medication Administration Record (MAR) after questioning the resident during medication pass if they have taken their prescribed medication. The assessment form is to be filed under the assessment tab in the resident's medical record. Review of the clinical record for R#51 revealed admission to the facility on [DATE], with the most current re-admission on 9/1/14. [DIAGNOSES REDACTED]. Review of physician orders [REDACTED]. 1. Start date 9/1/14- open ended, [MEDICATION NAME] tablets; 1/150; amt;1/150; sublingual Special Instructions: Give sublingual times five minutes as need if chest pain persists call MD (patient may self administer one tablet of [MEDICATION NAME] as needed) (send one tablet in appropriately labeled container for patient administration and second bottle for nurses administer) (total of three tablets) ([DIAGNOSES REDACTED]. 2. Start date 9/1/14- open ended, Patient should be allowed to carry his own sublingual 1/150 to use on as needed. Basis (sic) one sublingual every five (sic) as needed for chest pain Continued review of the physician orders [REDACTED]. The renewal orders had been signed by the resident's physician each month. Review of the Medication Administration Records for R#51 revealed the above order was renewed monthly for March, (YEAR), April, (YEAR), May, (YEAR) and June, (YEAR). No administrations or monitoring of self-administrations of [MEDICATION NAME] were recorded during these four months. Assessments in the current clinical record were reviewed. One assessment form titled Self Administration of Medication Assessment was found in the clinical record. This indicated the last assessment of R#51's ability to self-administer medication had been completed by a charge nurse on 4/17/2014. The Interdisciplinary Team had last approved self-administration of medication on 10/20/14. No additional assessments of self-administration of medication were in the current clinical record filed under any tab. The thinned clinical record for R#51 was requested from medical records and was retrieved from the Director of Nurses (DON) office. The physician order [REDACTED]. No self-administrations or facility administrations were initialed. No monitoring of self-administrations were initialed. No Self Administration of Medication Assessments were in the thinned record. During an interview conducted on 6/14/17 at 9:10 a.m., R#51 revealed he did not know where his bottle of [MEDICATION NAME] was, it used to be in his pants pocket, and he could not remember any one asking him anything about the [MEDICATION NAME]. R#51 indicated he had not needed the [MEDICATION NAME] for years and would ask the nurse for one if he did need it. An interview conducted on 6/14/17 at 9:13 a.m. with the charge nurse Licensed Practical Nurse (LPN) AA for R#51 revealed she could not remember how long it had been since she had asked the resident about his usage of [MEDICATION NAME], or assessed him for self-administration of medication. LPN AA also revealed she thought he kept it in the top drawer of his night stand, but had not seen it for a long time. LPN AA confirmed any resident who administers medication themselves should be asked about this by their charge nurse at least with the morning medication pass and the assessment form completed quarterly but she could not remember completing the assessment form and did not know when she had last asked him if he had used his [MEDICATION NAME]. On 6/14/17 at 9:20 a.m. an interview with the DON revealed she expected the charge nurses to ask the residents who self-administered any medications about this every day and re-assess their cognition and safety with medications every three months and with any change in cognition. The DON was unsure of how the charge nurses would know it was time for the re-assessment to be completed. The DON acknowledged she had searched the thinned record for R#51 and he had not been re-assessed since 4/17/2014 for safety to self-administer medication or indications of daily monitoring of self -administrations, and the policy had not been followed. Cross refer F281",2020-09-01
791,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,248,D,0,1,FEJH11,"Based on observation, record review, and staff interview, the facility failed to provide activities to meet the assessed needs of one resident (R#67) of 38 sampled residents. Findings include: Review of the Annual Minimum Data Set (MDS) with reference date of 12/2/16 revealed in Section F - Preferences for Customary Routines and Activities - that Resident (R) #67 preferred activities involving music and animals in a group setting, and that it was very important to the resident to participate in her favorite activities. Review of the resident's plan of care for the risk for social isolation last updated 6/3/17 revealed a goal for the resident to be escorted to activities. Associated interventions directed staff to: emphasize independent actions; escort the resident to events within the facility; and provide diversional activities, as appropriate, for functional ability. Review of quarterly activity progress notes of 9/2/16 and 12/2/16 revealed the resident enjoyed watching television, and participating in socials, music therapy, Happy Hour group, Bingo, and special events. She required reminders to attend activities of interest. The plan was for staff to continue to invite the resident to activities and to remind her to attend. Review of the most recent activity progress quarterly note dated 6/9/17 documented the resident's needs remained the same. The plan was for staff to continue to invite and assist her to activities of interest. Review of the facility's activity calendar for the month of (MONTH) (YEAR) revealed several activities were scheduled for (MONTH) 13 between 9:00 a.m. and 4:00 p.m., including Hand Massage and Music at 10:35 a.m., a welcome social at 3:00 p.m., and Flashback TV Show at 4:00 p.m. During observations conducted on 6/13/17 at 11:00 a.m. and again at 1:00 p.m., R#67 was seen in her room sitting between the outer wall and bed facing the bedside table upon which a television sat. The television was turned off. Review of the facility's activity calendar of events for 6/14/17 revealed activities scheduled between 10:15 a.m. and 6:00 p.m. During observations conducted on 6/14/17 at 10:15 a.m., 11:30 a.m., and 3:00 p.m., the resident was observed asleep in bed. Review of the activity calendar for 6/15/17 revealed several events scheduled between 9:00 a.m. and 4:00 p.m., including a make-up session at 9:00 a.m., exercise at 10:15, Adaptive Sports at 10:35 a.m., and Bingo at 3;00 p.m. During observation conducted on 6/15/17 at 9:45 a.m., the resident was noted sitting in her room facing a television on her side table which was turned to the off position. During observation conducted on 6/15/17 at 10:05 a.m. activity staff was noted on the resident's hallway inviting residents to attend activities. Staff did not stop at the resident's room, nor invite to the resident to activities. During observation conducted on 6/15/17 at 10:23 a.m., the resident was seen sitting in her in room between the bed and the wall facing her television which was still turned off. During observations conducted on 6/15/17 between 11:45 a.m. and 3:00 p.m., the resident was noted to be in bed. Interview on 6/15/17 at 3:25 p.m. with Certified Nursing Assistant (CNA) FF revealed she works the 3:00 p.m. to 11:00 p.m. shift and knows the resident sometimes wheels herself to activities in the evenings and seems interested in many different activities. Interview on 6/15/17 at 3:40 p.m. with CNA GG revealed she works the 7:00 a.m. to 3:00 p.m. shift and knew the resident to be interested in many activities to which she would propel herself in her wheelchair in times past. Recently, however, the resident seems to have less interest in these activities, and rarely leaves her room to attend them. Interview on 6/15/17 at 3:50 p.m. with Licensed Practical Nurse (LPN) HH, the evening nurse on the resident's hallway, revealed the resident likes to attend activities such as Bingo in the evenings. The evening staff or activities staff usually escorts the resident to these activities. The evening staff gets the resident up to attend activities or to have dinner. Interview on 6/16/17 at 11:00 a.m. with the Activities Director (AD) revealed that R#67 participates in various group activities of her choice and abilities. She sometimes attends activities such as sensory groups on Mondays through Thursdays, but usually attends Happy Hour (a music based group) on Friday afternoons. The resident has shown a decline in her ability to participate since her admission and so she now participates in lower level activities. She can participate on her own, but needs staff assistance with some hands-on activities. Her participation is not consistent, but fluctuates from week-to week. The activity staff has no record of the resident's level of participation. The activity staff knows each resident well, and if they notice a resident is present at few of the activities available to them, this will trigger activity staff to add that resident to the list of residents that receive one-on-one activities. This resident is not currently receiving one-on-one activities so this suggests that she participates to some extent in group activities. The AD also stated that the resident does not seem interested in watching television, but needs staff to turn it on. Interview on 6/16/17 at 11:20 a.m. with LPN, II, revealed that the resident likes to attend activities such as Bingo and Music/Happy hour. She does not always participate in the group such as Bingo, but will observe and will become very vocal about wanting to leave when she has had enough. The staff will try to encourage her when activities are available, but can be physically aggressive with staff if she does not wish to be bothered. It is the unit nurses' responsibility to ensure that the resident is ready and that a staff member is available to escort her if/when she wishes to attend activities.",2020-09-01
792,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,279,D,0,1,FEJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident interviews, family interview and staff interviews, the facility failed to develop a comprehensive care plan for one resident (R) that had natural teeth with likely cavity/broken teeth (R#35) and failed to develop a care plan to ensure the coordination of care for one resident that was admitted to Hospice services (R#105). The sample was 38 residents. Findings include: 1. R#35 was admitted to the facility on [DATE] and admitted to Hospice care on 8/8/15 for [MEDICAL CONDITIONS]. Additional [DIAGNOSES REDACTED]. Record review for R#35 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 01, indicating severe cognitive impairment. Section G- Functional Status indicated the resident required total assistance with personal hygiene. Section L- Oral/Dental Status assessed the resident had natural teeth with likely cavity/broken teeth. Section V- Care Area Assessment (CAA) triggered Dental Status with the decision to be care planned. Review of the care plans for R#35 revealed no evidence of a care plan related to the resident's dental status. Observation on 6/13/17 at 11:30 a.m. revealed the R#35 in her room sitting in a broda chair. Observation of the resident's teeth revealed she had several broken front teeth on both the top and bottom. The resident's teeth were dark in color, no buildup or food debris noted. Observation on 6/16/17 at 8:54 a.m. revealed the R#35 in the dining room being assisted with eating her breakfast by a CN[NAME] The resident had a puree diet. No complications with eating noted. Interview on 6/16/17 at 3:10 p.m. with the Social Service Director (SSD) revealed when R#35 was admitted to the facility she had an admission consent to be seen by the dentist. R#35 was admitted to hospice care in (MONTH) (YEAR). The SSD stated that she spoke with the LPN AA and she reported that she spoke with the resident's daughter and was told she did not want dental work anymore for R#35. The SSD stated the dental program is not a monthly program, the dentist visits every four months and provides a cleaning and general exam. The Dentist is provided the list of residents to be examined and he calls the Responsible Party (RP) or cognitive resident for consent before each service. The resident and/or RP is billed directly from the dentist. Interview on 6/16/17 at 3:30 p.m. with the family of R#35 revealed that she did stop the dental service. She stated she cancelled it not because she doesn't care about her mother's teeth, she just felt that the risk of cleanings was greater than the need. She stated if she was in any pain or needed immediate dental work she would get it for her R#35. Interview on 6/16/17 at 4:58 p.m. with the MDS/Registered Nurse (RN) QQ confirmed that R#35 did not have a care plan for dental status. She stated that she does not know what happened or why a dental triggered in the CAA with the decision to care plan and it was not developed. She stated that once the assessment is completed, the care plan should have been developed right then and there. 2. R#105 was admitted to the facility on [DATE] and admitted to (name) Hospice on 1/17/17 with a primary [DIAGNOSES REDACTED]. Record review for R#105 revealed a Significant Change MDS dated [DATE] which assessed the resident in Section O- Special Treatments and Programs for Hospice Care. Review of the facility care plans for R#105 revealed no evidence of a care plan related to the coordination of care with Hospice services. Review of the (name) Hospice Initial Assessment and Initial Plan of Care dated 1/20/17 indicated RN frequency once weekly, Certified Nursing Assistant (CNA) frequency three times weekly, Social Worker once to assess and a Chaplain once to assess. Review of the (name) Hospice Aide Plan of Care (P[NAME]) assignment sheet dated 5/25/17 indicated the visit frequency three times weekly to include: Bath type (shower x 2, bed bath x 1), hair (shampoo/style), nail care, skin care, oral care, assist with dressing, reposition the patient, peri care, safety devices and emotional support/socialization. Other: apply barrier cream to buttocks with brief change. Review of the facility care plan for R#105 dated 10/29/16 and updated 3/30/17 identified Activities of Daily Living (ADL) Functional/Rehabilitation Potential. Goal: resident will be able to participate in personal hygiene and basic ADLs x 90 days. Interventions include, but not limited to; encourage participation, anticipate residents needs daily. Assist of one with ADLs. Review of the assigned Discipline for all interventions did not include Hospice. Review of the (name) Hospice Service Records from 5/16/17 through 6/16/17 revealed that the RN and CNA visited the resident at the frequency indicated in the Hospice agreement and P[NAME]. Interview on 6/16/17 at 4:50 p.m. with the MDS/RN QQ revealed the resident had a Significant Change MDS assessment on 12/22/16 due to admission into Hospice care. She confirmed that there was no facility care plan related to the coordination of care with Hospice. She stated she must have missed it and that typically she will develop a care plan immediately after the assessment is completed. Interview on 6/16/17 at 5:05 p.m. with the Executive Director revealed the Hospice CNA follows the custom Plan of Care and follows it as stated. The P[NAME] is determined by the resident's preference in a meeting with the facility, family and the Hospice Case manager. Refer F312",2020-09-01
793,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,281,D,0,1,FEJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident, staff, Nurse Practitioner and Consultant Pharmacist interviews, review of the National Council of State Boards of Nursing, Chapter ,[DATE].02, and the State of Georgia Standards of Practice for Licensed Practical Nurses, review of facility Job Description Charge Nurse and facility list of ,[DATE] Charge Nurse Duties the facility failed to maintain professional standards of quality by failing to provide a medication ordered for self-administration for one resident (R) (R#51) of 38 sampled residents. Findings include: Review of the National Council of State Boards of Nursing, Chapter ,[DATE]-.02 Standards of Practice for Licensed Practical Nurses, Authority: O.C.[NAME][NAME] [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] documented that Licensed Practical Nurses (LPNs) may participate in the assessment, planning, implementation and evaluation of the delivery of health care services and other specialized tasks when appropriately trained and consistent with board rules and regulations. Such care shall relate to the promotion of health, the prevention of illness and injury, and the restoration and maintenance of physical and mental health through acts authorized by the board, which shall include, but not be limited to the following: (a) Participating in patient assessment activities and the planning, implementation, and evaluation of the delivery of health care services and other specialized tasks when appropriately educated and consistent with board rules and regulations. (b) Providing direct personal patient observation, care, and assistance in hospitals, clinics, nursing homes, or emergency treatment facilities, or other health care facilities in areas of practice including, but not limited to: coronary care, intensive care, emergency treatment, surgical care and recovery, obstetrics, pediatrics, outpatient services, [MEDICAL TREATMENT], specialty labs, home health care, or other such areas of practice. The facility list titled ,[DATE] Charge Nurse Duties, not dated, revealed the night Charge Nurse is to check medications delivered from Pharmacy and put them in the med cart for each resident. Review of facility Job Description Charge Nurse no date, revealed Charge Nurses' are responsible for seeing all the physician's orders [REDACTED]. The medication carts are to be re-stocked with all supplies at the end of the shift and medications are to be re-ordered as needed. Review of the clinical record for R#51 revealed readmission to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE], revealed R#51 had a Brief Interview for Mental Status score of 12, indicating moderate cognitive impairment. Review of the care plan for R#51 revealed a care plan dated [DATE] and updated on [DATE] and [DATE] as follows: Category: Cardiovascular Resident has Pacemaker Resident to keep one [MEDICATION NAME] for self administration as needed. Interventions regarding the self administration of [MEDICATION NAME] included the following: Approach Start Date: [DATE] Instruct resident to inform nurse whenever he self administers [MEDICATION NAME]. Approach Start Date: [DATE] Nurse to monitor for self administration of medication Review of physician progress notes [REDACTED].>[MEDICAL CONDITION] Pectoris, unspecified treatment plan: [REDACTED]. Review of physician's orders [REDACTED]. [MEDICATION NAME] tablets, ,[DATE] sublingual- special instructions, give sublingual times 5 minutes as need (sic) if chest pain persists call MD (Patient may self administer one tablet of [MEDICATION NAME] as needed) (send one tablet in appropriately labeled container for patient administration and second bottle for nurses administer(sic) total of three tablets). During an interview conducted on [DATE] at 9:10 a.m., R#51 indicated his bottle of [MEDICATION NAME] was empty and had been empty for a long time. He did not know where the bottle was, had not seen it in a long time, and thought it might be in his pants pocket in the closet. R#51 confirmed none of the nurses had asked him if he had used the medication, or where the bottle was and he did not think about asking for the medication because he had not needed it. R#51 revealed he would have asked one of the nurses for a [MEDICATION NAME] if he had chest pain. An interview conducted on [DATE] at 9:13 a.m. with the charge nurse AA Licensed Practical Nurse (LPN) for R#51 revealed she could not remember how long it had been since she had checked with R#51 regarding the location of the bottle containing one [MEDICATION NAME] he had ordered to be kept on his person, if the bottle actually contained anything or the expiration date. LPN AA also revealed the last time she had seen it was in his top nightstand drawer but could not recall checking to see if it contained a [MEDICATION NAME]. LPN AA confirmed the nurses are supposed to check with the resident every day to confirm the medication is accessible to the resident and if the medication had been self-administered. LPN AA revealed there was no [MEDICATION NAME] in the medication cart labeled with this residents name, but it was always available in the Emergency Medication Box where there is a bottle containing 100 sublingual [MEDICATION NAME] ,[DATE] milligrams (mg). An observation on [DATE] at 9:17 a.m. in the room of R#51 with LPN AA, revealed the bottle of [MEDICATION NAME] could not be located in the night stand or any pants or shirts in the closet. During an interview conducted on [DATE] at 10:00 a.m. the Director of Nurses (DON) revealed she had called pharmacy and there was no record of [MEDICATION NAME] being sent to the facility for R#51 self-administration or facility administration since [DATE]. The DON revealed the Charge Nurses are responsible for making sure the residents have their medications to self-administer and the medications are not expired. This should be checked every day with medication pass as specified in the policy. The DON revealed the pharmacy is supposed to review all medications every month for usage and this medication had not been administered since it appeared on the signed renewal order on [DATE]. The DON revealed the re-admission orders [REDACTED]. Interview [DATE] at 11:05 a.m. with R#51's Nurse Practitioner revealed he was aware of the order for R#51 to have one [MEDICATION NAME] on his person and since it was signed every month by the physician he expected the facility to follow the order. The Nurse Practitioner revealed the original order had been given at the residents request because he was accustomed to having the medication on his person and it gave him a sense of security after admission to the facility. Interview [DATE] at 4:12 p.m. with the Consultant Pharmacist revealed she would never recommend [MEDICATION NAME] be discontinued for any resident with a [DIAGNOSES REDACTED]. She acknowledged if a resident has an order to self-administer [MEDICATION NAME] they should have the medication as ordered. The Consultant Pharmacist revealed it is the facility's responsibility to ensure medications ordered by the physician are in the medication cart, but [MEDICATION NAME] is always available in the Emergency Medication Box. The Consultant Pharmacist confirmed she does not reconcile what is ordered by the Physician with what is sent by the pharmacy or available in the medication cart. The facility is responsible for this. Cross refer to F176 /",2020-09-01
794,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,282,D,0,1,FEJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to follow the care plan interventions to administer oxygen as ordered for four (R#35, R#124, R#105 and R#16) of five sampled residents of 17 residents receiving oxygen therapy. Findings include: 1. Record review for R#35 revealed a Respiratory care plan with a Problem Start Date of 9/6/16. The Long Term Goal documented the resident will not exhibit signs of increased activity intolerance (e.g. fatigue, shortness of breath, pallor or cyanosis, [MEDICAL CONDITION], weakness). The Approach documented the following interventions: Assess for signs and symptoms of respiratory distress (e.g. fatigue, shortness of breath, pallor or cyanosis, [MEDICAL CONDITION], weakness), Medication/oxygen as ordered, Provide rest periods between activities. Review of the Physician orders [REDACTED]. Order date 8/27/17, check oxygen saturation (SaO2) for shortness of breath as needed. Order date 5/25/16, may increase oxygen per nasal cannula at six liters per minute (6 LPM) for shortness of breath. Order date 5/25/16 (Open ended), oxygen per nasal cannula at 4 LPM continuously every shift. Observation on 6/13/17 at 11:29 a.m. revealed R#35 in sitting in her room with nasal cannula in her nose that was connected to a portable oxygen (O2) tank. Observation of the O2 tank revealed it was set on 4 LPM, however, the gauge needle was in the red zone, indicating that the tank was empty. There was no oxygen flow coming from the outlet port. Licensed Practical Nurse LPN AA checked the O2 tank and confirmed that the gauge needle was in the red zone and that no oxygen was being delivered to R#35. Observation on 6/15/17 at 7:39 a.m. revealed R#35 sitting in the dining room with a nasal cannula that was barely in one nostril. The nasal cannula was connected to a portable O2 tank attached to the back of her chair. The tank was half full and set at 1.5 LPM. LPN AA confirmed the nasal cannula was barely in the resident's nose and that the liter flow of oxygen was set at 1.5 LPM. Interview with LPN AA at the time of the observation revealed that the resident is supposed to be on 4 LPM. 2. Record review for R#124 revealed a Cardiovascular care with a Problem Start Date of 5/16/17 and an Approach to administer oxygen as ordered. Review of the Physician orders [REDACTED]. Observation on 6/13/17 at 1:03 p.m. in the Rose Dining room revealed R#124 sitting at a table with a nasal cannula in her nose that was connected to a portable O2 tank, attached to the back of her wheel chair. Observation of the O2 tank revealed the gauge needle was in the red zone, indicating the tank was empty. Further observation revealed the liter flow was set at zero (0). Interview on 6/13/17 at 1:05 p.m. with CNA KK revealed she had brought R#124 to the dining room for lunch about five minutes earlier. CNA KK stated that she told LPN LL that the resident needed a new O2 tank prior to bringing her to the dining room. CNA KK stated that she did not think to leave the resident on her oxygen concentrator in her room until LPN LL could change the O2 tank, but that she should have. Interview on 6/13/17 at 1:08 p.m. with LPN LL revealed that CNA KK may have asked her to change the portable O2 tank, but that she really did not remember. Interview on 6/13/17 at 1:12 p.m. with the LPN MM in care of R#124 revealed that nobody had alerted her that the portable O2 tank for R#124 needed to be changed. She stated that she does not typically check the resident's tanks once they arrive to the dining room because she had already checked them in the morning. 3. Record review for R#105 revealed a Cardiovascular care plan with a Problem Start Date of 10/29/16. The Goal documented Resident will not exhibit signs of activity intolerance (fatigue, shortness of breath, pallor or cyanosis, [MEDICAL CONDITION] weakness etc.) and an Approach to administer medications and monitor SaO2 as ordered. The Approach documented administer medications and monitor SaO2 as ordered. Monitor for tolerance to activities/self-care (fatigue, shortness of breath, pallor or cyanosis, [MEDICAL CONDITION], weakness etc.) Review of the Physician orders [REDACTED]. Observation on 6/15/17 at 7:36 a.m. revealed R#105 sitting in the dining room waiting for her breakfast. The resident had a nasal cannula in use that was connected to a portable O2 tank attached to the back of her wheel chair. The O2 liter flow was set at 1 LPM. Observation on 6/15/17 at 7:42 a.m. with LPN AA confirmed that the oxygen liter flow on the portable tank for R#105 was set at 1 LPM. During an interview at the time of the observation with LPN AA, she stated that the oxygen liter flow for R#105 should have been set at 2 LPM. 4. Record review for R#16 revealed a Respiratory care plan with a Problem Onset Date of 4/28/17 with an Approach to administer oxygen as ordered. Review of the Physician orders [REDACTED]. Observation on 6/16/17 at 8:35 a.m. revealed the R#16 in her bed with a nasal cannula in use that was connected to the O2 concentrator at 6 LPM. Observation on 6/16/17 at 8:45 a.m. with LPN AA confirmed that the oxygen liter flow for R#16 was set on 6 LPM and stated that the O2 liter flow should be set at 5 LPM. Interview on 6/16/17 at 12:05 p.m. with the Director of Nursing (DON) revealed ultimately the nurse are responsible for making sure the resident is on their oxygen and that it is on prescribed liter flow. She stated the nurses should be checking daily to make sure the concentrators are on the correct liter flow and that the tanks are on correctly once a CNA gets the resident up. Cross refer to F328",2020-09-01
795,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,309,D,0,1,FEJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of facility policies titled [MEDICAL TREATMENT] dated January, (YEAR) and [MEDICAL TREATMENT] (Bruit/Thrill) AV Shunt dated January, (YEAR) the facility failed to provide coordination of care with the [MEDICAL TREATMENT] center and failed to document bruit/thrill, weight and vital signs on the treatment administration record (TAR) for one (1) resident (R#7) of two (2) residents who receive [MEDICAL TREATMENT] treatment. Findings include: Record review for R#7 revealed the resident was admitted to the facility on [DATE] and re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Record review of the care plan dated 3/30/17 for R#7 revealed a problem of R#7 is at risk for fluid volume excess r/t (related to) end stage [MEDICAL CONDITION]. Resident on [MEDICAL TREATMENT]. It also revealed an approach of [MEDICAL TREATMENT] as ordered, monitor shunt site for bleeding, palpate for thrill, auscultate for bruit and weights as ordered. Record review of the physician's orders for R#7 revealed an order for [REDACTED]. Record review of the April, (MONTH) and (MONTH) (YEAR) TAR revealed no documentation of bruit/thrill check, pre and post [MEDICAL TREATMENT] weight or pre and post vital signs. Record review of the facility policy titled [MEDICAL TREATMENT] with effective date of January, (YEAR) revealed Policy: To ensure effective communication between the community and the resident's [MEDICAL TREATMENT] center Equipment: Dedicated [MEDICAL TREATMENT] notebook for each resident Procedure: Nursing staff must obtain and document the resident's pre-[MEDICAL TREATMENT] weight on the [MEDICAL TREATMENT] book and the treatment administration record (TAR) on scheduled [MEDICAL TREATMENT] day or as ordered by the practitioner. Nursing staff must obtain and document resident's pre-[MEDICAL TREATMENT] vital signs on [MEDICAL TREATMENT] book and TAR on scheduled [MEDICAL TREATMENT] day. Community to provide resident with a pack lunch to take to [MEDICAL TREATMENT] center unless contraindicated. Upon return from [MEDICAL TREATMENT], nursing staff to obtain post [MEDICAL TREATMENT] weight and VS and document in [MEDICAL TREATMENT] book and treatment administration record (TAR) Nurse to assess and document the bruit (by listening with a stethoscope over the fistula) and the thrill (by palpating with fingers over the fistula) of the AV shunt on the treatment administration record (TAR). This should be completed daily. Report any signs and symptoms of occlusion or infection to the practitioner. Record review of facility policy titled [MEDICAL TREATMENT] (Bruit/Thrill) AV shunt revealed Policy: To ensure patency of the arteriovenous shunt (AV) of the [MEDICAL TREATMENT] resident. Equipment: Stethoscope Procedure: 1. Introduce self and explain procedure to the resident 2. Provide privacy by pulling curtains 3. Wash hands and apply gloves 4. Place stethoscope over the shunt and auscultate the bruit. You should be able to hear the gushing continuous blood flow through the access. Once heard, remove stethoscope. 5. Gently place first two to three fingers over the shunt and palpate for the thrill. You Should feel a pulsating sensation over the access site. 6. Observe for signs and symptoms of infection at the access site (i.e. increased warmth, pain, tenderness, swelling, drainage or redness). 7. Remove gloves and wash hands. 8. Position the resident for comfort. 9. Place call light within reach. 10. Document on the treatment administration record (TAR) 11. Notify physician if the access site shows signs of infection or unable to hear the bruit or palpate the thrill Observation of R#7 on 6/15/17 at 9:39 a.m. revealed resident being transferred from his wheelchair to the stretcher by 2 EMT's. One EMT asked LPN BB, if there was paperwork for the [MEDICAL TREATMENT] center and the LPN said no. The resident was wheeled out of the facility with his blue bag containing two blankets and his lunch. Observation on 6/15/17 at 2:58 p.m. revealed R#7 returning from the [MEDICAL TREATMENT] center via stretcher with two EMTs pushing the stretcher down to the resident's room. The resident told the EMT's that his bed was the one by the window. The EMT removed the wheelchair from the room and then wheeled the stretcher into the resident's room and placed the resident on his bed with the sheet from the stretcher under the resident. Observation of R#7's room on 6/15/17 from 3:06 p.m. to 4:20 p.m. revealed resident in bed and no nurse entering the room to assess the resident. Observation at 3:04 p.m. CNA EE, entered the resident's room and removed the resident's leg immobilizer and shoes per his request. Observation at 3:30 p.m. CNA CC, passed ice water to the resident. Observation at 3:50 p.m. an unnamed CNA observed leaving resident's room with a brief in a plastic bag. Observation at 4:00 p.m. resident observed in bed sleeping. During an interview with LPN BB on 6/15/17 at 2:52 p.m. she stated before the resident leaves for [MEDICAL TREATMENT] she makes sure that the resident eats breakfast, she administers medications, provides supplement and obtains the resident's lunch. She also stated when the resident returns from [MEDICAL TREATMENT] transportation brings a return form to the nurse to sign stating she received the patient back in the facility. She also state she documents in the resident's chart in the nurse's notes form that the resident left for [MEDICAL TREATMENT] and return from [MEDICAL TREATMENT]. She stated she had not charted for today yet. During an interview with LPN DD on 6/15/17 at 5:26 p.m. she stated when the resident returns from [MEDICAL TREATMENT] the nurse is expected to assess the site for bleeding or trauma and remove the bandage after 4 hours and document in the nurse's notes in resident's chart. The resident is to be assessed immediately upon return. There is a communication sheet in the resident's chart that is to be completed by the facility nurse before the resident goes to [MEDICAL TREATMENT], sent to the [MEDICAL TREATMENT] center and returned to the facility. During an interview with the Director of Nursing on 6/15/17 at 5:41 p.m. she stated the nurse is to assess the resident and record vital signs including weight in the nurse's notes pre and post [MEDICAL TREATMENT]. The nurse is to check the bruit and thrill as well and record on the TAR. She confirmed there were no vital signs documented in nurse's notes or on the TAR for the months of April, (MONTH) and (MONTH) of (YEAR). She also confirmed that the resident does not have a [MEDICAL TREATMENT] notebook per the facility policy. She also stated the policy is just a guideline and it does not have to be followed specifically. She stated she expects the receiving nurse to perform an assessment of the resident within 30-60 minutes of resident returning to the facility. During an interview with the Administrator on 6/16/17 at 9:22 a.m. she stated she expects the staff to follow the policy as written. It is the responsibility of the management staff to educate staff on the policy. She expects new and revised policies to be reviewed and staff to be educated within 30-60 days of receipt of policy. She confirmed the [MEDICAL TREATMENT] policy was not followed for this resident and the resident does not have a [MEDICAL TREATMENT] notebook. During a telephone interview with the [MEDICAL TREATMENT] facility Administrator on 6/16/17 at 9:49 a.m. she stated the [MEDICAL TREATMENT] center prefers to use communication sheets to communicate with the facility; however, if the resident has excessive bleeding the facility will be notified via telephone. The site is bandaged and the [MEDICAL TREATMENT] center nurse makes sure the bleeding has stopped and the bandage is clean.",2020-09-01
796,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,312,D,0,1,FEJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the policy titled Oral Hygiene, resident and staff interviews, the failed to consistently provide oral care for one resident (R) who required extensive assistance with personal hygiene (R#105). The sample was 38 residents. Findings include: Review of the policy titled Oral Hygiene revised January, (YEAR) documented Purpose- to ensure cleanliness, prevent odor, improve appetite, prevent cavities/tartar buildup and gum disease and stimulate circulation of blood to the gums. Frequency- every morning and bedtime. R#105 was admitted to the facility on [DATE] and admitted to Hospice services on 1/17/17 with an admitting [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment for R#105 dated 12/22/16 revealed a Brief Interview for Mental Status (BIMS) summary score of seven, indicating severe cognitive impairment. Section B- Hearing, Speech and Vision assessed in B0700 Makes self understood that the resident sometimes understands, responds adequately to simple, direct communication only. In B0800 Ability to understand others, the resident sometimes understands , responds adequately to simple, direct communication only. Section G- Functional Status indicated the resident required extensive assistance with personal hygiene. Section O- Special Treatments and Programs indicated the resident receive Hospice care while a resident in the facility. Review of the Quarterly MDS assessment dated [DATE] revealed a BIMS summary score of 7. Section G indicated the resident required extensive assistance with personal hygiene, Section O indicated the resident received Hospice care. Although R#105 had a BIMS summary score of 07, the resident was alert, oriented and able to engage in conversation appropriately. Review of the care plan for R#105 dated 10/29/16 and updated 3/30/17 identified Activities of Daily Living (ADL) Functional/Rehabilitation Potential. Goal: resident will be able to participate in personal hygiene and basic ADLs x 90 days. Interventions include, but not limited to; encourage participation, anticipate residents needs daily. Assist of one with ADLs. Despite a BIMS score of 7, R#105 was able to consistently engage in sensible conversation and answer questions appropriately. Interview on 6/13/17 at 12:02 p.m. with R#105 revealed the staff do not take her to the sink, or set up her tooth brush to brush her teeth. She stated she could use a little help and that it would be nice to at least brush her teeth once a day, especially in the evening. R#105 further stated you give up a lot of things when something like this happens to you. The resident stated she has her own natural teeth. An observation of R#105's teeth at the time of the interview revealed a heavy thick white substance on both the top and bottom teeth. Observation on 6/14/17 at 10: 18 a.m. revealed R#105 in her room in her bed. Observation of the resident's teeth revealed a white thick substance, food particles and food debris trapped between her teeth. The resident stated in interview at the time of the observation that no one assisted her with brushing her teeth last night or this morning. During an interview on 6/15/17 at 7:36 a.m. with R#105 in the dining, she stated no one had helped her brush her teeth the night before and her teeth were not brushed this morning when she got up and dressed for breakfast. Observation of the resident's teeth at the time of the interview revealed a white thick substance trapped between the resident's teeth and across her front top teeth. Observation on 6/15/17 at 12:22 a.m. revealed the resident in her room in bed, just waking up. Interview with the resident at the time of the observation revealed she did not get her teeth brushed after breakfast and she had not yet been to lunch. Observation of the resident's teeth revealed a heavy, thick white substance across her front teeth and in between her teeth. Observation on 6/15/17 at 5:25 p.m. revealed R#105 in the dining room waiting for dinner. The resident had not yet received her dinner. Interview with R#105 at the time of the observation revealed no one had brushed her teeth today. Observation of the resident's front teeth revealed the top front teeth were covered with a thick, white film, food particles and debris trapped between her teeth. Observation on 6/16/17 at 7:20 a.m. revealed the resident sitting in her wheel chair in the hall outside of her room. The resident was dressed. Interview with the resident at the time of the observation revealed she had not gotten her teeth brushed the night before and did not get her teeth brushed this morning. Observation of the resident's teeth revealed a thick, white film over her front teeth, food debris and buildup trapped in between her teeth. Interview on 6/16/17 at 8:45 a.m. with the Certified Nursing Assistant (CNA) NN, who was in care R#105, revealed that she does know the resident a little bit but she does not usually work on this hall. She stated the resident was already up and dressed in her wheel chair when she came on her shift this morning. CNA NN stated that her routine when she provides a.m. care is to get the resident up, washed up with a cloth, dressed and in their wheel chair. She stated she does assist a resident with oral care if they can't do it themselves or she will brush their teeth with a.m. care but the resident was already up when she came on her shift. Observation on 6/16/17 at 10:45 a.m. revealed the R#105 in her wheel chair in the hallway in front of the nurse's station. Interview with R#105 at the time of the observation revealed she had gotten her hair done today in beauty shop. The resident further stated that she still had not gotten her teeth brushed. Observation of R#105's teeth revealed a thick white film/substance on both the top and bottom teeth with food debris trapped in between her teeth. At 10:47 a.m. CNA OO arrived to take R#105 back to her room to lie down before lunch. Interview on 6/16/17 at 10:50 a.m. with the CNA OO revealed that when she came to work this morning, R#105 was already dressed and out of bed by the Hospice CN[NAME] She stated that she had not brushed her teeth yet today because the resident was already up and had a.m. ADL care. She stated that ADL care includes washing the resident up, brushing their teeth and hair and getting the resident dressed. CNA OO looked in the resident's night stand and was not able to locate a toothbrush. She looked in all three drawers thoroughly and there was no tooth brush present. The CNA OO stated that that she found the oral basin and a small tube of tooth paste but no tooth brush anywhere. Interview on 6/16/17 at 12:05 p.m. with the Director of Nursing (DON) revealed that oral care is expected to be provided with a.m. care and can be done in the evening too. If a resident is on Hospice, the Hospice CNA does provide oral care with their visit but the facility staff is still responsible for oral care too. The DON further stated that the CNAs should be helping the residents set up for brushing their teeth and encourage them to be as independent as possible and of course brush a resident's teeth that cannot do it themselves. Observation on 6/16/17 at 1:33 p.m. of the supply closet with the Medical Records staff PP, who also assist with ordering medical supplies revealed that she and one other supply staff and the charge nurse on nights have a key to the supply closet. When a CNA gets supplies from the closet they sign the Central Supply Requisition with the resident's name, the product removed from the closet, the amount and which shift. Medical Records staff PP then transfers it to the Ancillary Charge Sheet which is turned into the business office each month. Review of the Central Supply Requisition form revealed R#105's name, dated 6/16/17, products: mouth swab, tooth paste and tooth brush, one of each. Interview on 6/16/17 at 1:45 p.m. with the Receptionist/Business Office staff revealed that she receives the Ancillary Charge Sheet and keys it into the computer. She stated that she could print a Billing Journal that would show any ancillary charges the R#105 has had. The Receptionist provided copies of the Billing Journal from (MONTH) (YEAR) through mid-May, (YEAR). She stated that the Ancillary Charge Sheet goes from the 20th of the month through the 19th of the next month, therefore, she has not received (MONTH) 20th through (MONTH) 19th, (YEAR) yet. She stated if the resident received a toothbrush from the facility, it would reflect on the billing journal. Review of the Billing Journal from (MONTH) (YEAR) through (MONTH) (YEAR) revealed no evidence of tooth brushes. Observation on 6/16/17 at 4:00 p.m. revealed the R#105 in her bed. Interview with the resident at the time of the observation revealed that CNA OO did brush her teeth today and her mouth feels much better! R#105 stated it might take a few times to get all the stuff off the front of her teeth. Observation of the resident's teeth revealed there was no more food debris in between her teeth, the thick white substance was no longer present but there was a whitish/clear film buildup that remained on her front teeth. Interview with on 6/16/17 at 5:05 p.m. with the Executive Director Hospice revealed that most of the personal supplies for residents under hospice care in the nursing facility is typically supplied by the facility. They do have personal supplies in case they need them, but typically the Hospice CNA does not bring a tooth brush, it is supplied by the facility.",2020-09-01
797,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,328,D,0,1,FEJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of the Policy titled Oxygen Administration, resident and staff interviews, the facility failed to ensure that four of five sampled residents (R) were administered oxygen therapy in accordance with the physician orders [REDACTED].#124, R#105 and R#16). The census for residents receiving oxygen therapy was 17. Findings include: Review of the policy titled Oxygen Administration revised (MONTH) 2008 documented: Purpose- to provide higher concentration of oxygen than is available in room air. Administration of Cannula- apply nasal cannula and position so that soft flexible nose tips are inserted at nares. Adjust flow to ordered rate. 1. R#35 was admitted to the facility on [DATE]. The resident was admitted to Hospice care on 8/18/15 for [MEDICAL CONDITION]. Additional [DIAGNOSES REDACTED]. Record review for R#35 revealed an Annual Minimum Data Set ((MDS) dated [DATE] which assessed in Section C- Cognitive Patterns a Brief Interview for Mental Status (BIMS) summary score of 02, indicating severe cognitive impairment. Section B- Hearing, Speech and Vision (B0700) makes self understood assessed that R#35 sometimes understands and responds adequately to simple, direct communication. (B0800) Ability to understand others assessed that R#35 sometimes understands and responds adequately to simple, direct communication. Section O- Special Treatments and Programs indicated the resident received oxygen while a resident in the facility. Review of the Quarterly MDS dated [DATE] assessed a BIMS summary score of 01, indicating severe cognitive impairment. Assessment for [MEDICAL CONDITION] indicated that behaviors related to inattention, disorganized thinking or altered level of consciousness was not present. Section O indicated the resident received oxygen while a resident in the facility. Further record review for R#35 revealed a Respiratory care plan with a Problem Start Date of 9/6/16 and an Approach to administer oxygen as ordered. Review of the Physician orders [REDACTED]. Order date 8/27/17, check oxygen saturation (SaO2) for shortness of breath as needed. Order date 5/25/16, may increase oxygen per nasal cannula at six liters per minute (6 LPM) for shortness of breath. Order date 5/25/16 (Open ended), oxygen per nasal cannula at 4 LPM continuously every shift. Observation on 6/13/17 at 11:29 a.m. revealed R#35 in her room sitting in a broda chair with her legs extended. The resident's respirations were mildly labored with accessory muscle use noted. R#35 had a nasal cannula in her nose that was connected to a portable oxygen (O2) tank. Observation of the O2 tank revealed it was set on 4 LPM, however, the gauge needle was in the red zone, indicating that the tank was empty. There was no oxygen flow coming from the outlet port. Despite a BIMs score of 01, indicating sever cognitive impairment, R#35 was able to engage in a sensible conversation, answer questions appropriately and make her needs known. During an interview with the resident at the time of the observation, she was able to voice that it is hard to breath. The Licensed Practical Nurse (LPN) AA was called to check on R#35. LPN AA came to the resident's room and assessed the resident's SaO2 which read 91% (normal range is 90% - 100%). LPN AA then checked the O2 tank and confirmed that the gauge needle was in the red zone and that no oxygen was being delivered to R#35. LPN AA removed an oxygen key from her pocket and turned the top valve which opens the tank. The gauge needle moved into the green zone and oxygen began flowing from the outlet port. LPN AA stated at this time that the tank is not empty but confirmed the tank valve had not been opened. She stated that she changed the resident's tank before R#35 attended an activity and she thought she had opened the valve. LN AA further stated that only the LPNs have a tank key and that the LPNS are responsible for changing the O2 tanks. LPM AA stated that it had only been about 30 minutes since she went to activity. LPN AA re-assessed the resident's SaO2 on 4 LPM and it read 98%. Interview on 6/13/17 at 11:38 p.m. with the Activities Assistant (JJ) revealed she took the resident to group activity of relaxation and music. She stated that she took R#35 to the activity at 10:30 a.m. and she was returned to her room at 11:15 a.m. The Activity Assistant JJ stated that the nurses change the tanks and when she returns a resident to their room, she will disconnect the nasal cannula from the potable O2 tank and re-connect the cannula tubing to the oxygen concentrator in the resident's room. She stated that she does not touch the oxygen concentrators and they are already set to the number the resident is supposed to be on. The Activity Assistant JJ stated that she did not re-connect the resident's nasal cannula to the oxygen concentrator in her room because she had about five other residents to take back to their rooms. She further stated that she does not typically let anyone know when a resident had been returned to their rooms after an activity. The Activities Assistant JJ stated that she had never received training on portable O2 tanks and she did not know how long an O2 tank last when in use. Interview conducted on 6/14/17 at 11:30 a.m. with the family of R#35 revealed that the resident is on Hospice care and her cognition had actually improved. The family stated she did not know if it had to with increasing her oxygen, but that she was actually able to visit with R#35 and have sensible conversations with the resident. Observation on 6/15/17 at 7:39 a.m. revealed R#35 in the dining room in a broda chair, waiting for breakfast. The resident had a nasal cannula that was barely in one nostril. The nasal cannula was connected to a portable O2 tank attached to the back of her chair. The tank was half full and set at 1.5 LPM. The resident was observed to be mildly labored with accessory muscle use noted. LPN AA was asked to check R#35 and at 7:44 a.m., she confirmed the nasal cannula was barely in the resident's nose and that the liter flow of oxygen was set at 1.5 LPM. Interview with LPN AA at the time of the observation revealed that the resident is supposed to be on 4 LPM. LPN AA assessed the resident's SaO2 which read 91%. LPN AA increased the liter flow to 4 LPM. The LPN AA stated that she believed the night shift Certified Nursing Assistant (CNA) got R#35 up, dressed and into her wheel chair. She stated that the CAN would have placed the resident on the portable O2 tank. Observation on 6/15/17 at 12:26 p.m. revealed the R#35 in her room sitting is her broda chair. The resident had a nasal cannula in use that was attached to the O2 concentrator set at 4 LPM. The resident stated she is doing well. The resident's respirations were observed to be mildly labored with accessory muscle use noted. 2. R#124 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for R#124 revealed an Admission MDS dated [DATE] which assessed a BIMS summary score of 11, indicating moderate cognitive impairment. Section O- Special Treatments and Programs indicated the resident received oxygen while not a resident in the facility and while a resident in the facility. Further record review for R#124 revealed a Cardiovascular care with a Problem Start Date of 5/16/17 and an Approach to administer oxygen as ordered. Review of the Physician orders [REDACTED]. Observation on 6/13/17 at 1:03 p.m. in the Rose Dining room revealed R#124 sitting at a table with a nasal cannula in her nose that was connected to a portable O2 tank, attached to the back of her wheel chair. Observation of the O2 tank revealed the gauge needle was in the red zone, indicating the tank was empty. Further observation revealed the liter flow was set at zero (0). The resident did not have labored breathing and there was no cyanosis observed. Interview with R#124 at the time of the observation revealed she was not short of breath. Interview on 6/13/17 at 1:05 p.m. with CNA KK revealed she had brought R#124 to the dining room for lunch about five minutes earlier. CNA KK stated that she told LPN LL that the resident needed a new O2 tank prior to bringing her to the dining room. CNA KK stated that she did not think to leave the resident on her oxygen concentrator in her room until LPN LL could change the O2 tank, but that she should have. CNA KK then removed R#124 from the dining room and returned her to her room. Interview on 6/13/17 at 1:08 p.m. with LPN LL revealed that CNA KK may have asked her to change the portable O2 tank, but that she really did not remember. She stated that she does not normally work on this hall and she was just helping out today. LPN LL further stated that she did not have an oxygen key to change the O2 tank for R#124. Observation on 6/13/17 at 1:10 p.m. of R#124 revealed the resident in her room with CNA KK. Interview with CNA KK at the time of the observation revealed the maintenance staff had come and changed the resident's O2 tank already and she was about to return the resident to the dining room. Interview on 6/13/17 at 1:12 p.m. with the LPN MM in care of R#124 revealed that nobody had alerted her that the portable O2 tank for R#124 needed to be changed. She stated that she does not typically check the resident's tanks once they arrive to the dining room because she had already checked them in the morning. LPN MM stated that she knows a portable tank will last about 3-4 hours on 2 LPM, which is the resident's prescribed liter flow. LPN MM further stated that the resident's SaO2 is checked every shift and it was 95% this morning with O2 in use at 2 LPM. 3. R#105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for R#105 revealed a Significant Change MDS dated [DATE] which assessed a BIMS summary score of 07, indicating severe cognitive impairment. Section O- Special Treatments and Programs indicated the resident received oxygen while a resident in the facility. Review of the Quarterly MDS assessment dated [DATE] assessed a BIM summary score of 07, indicating severe cognitive impairment. Section O indicated the resident received oxygen while a resident in the facility. Further record review for R#105 revealed a Cardiovascular care plan with a Problem Start Date of 10/29/16 and an Approach to administer medications and monitor SaO2 as ordered. Review of the Physician orders [REDACTED]. Observation on 6/15/17 at 7:36 a.m. revealed R#105 sitting in the dining room waiting for her breakfast. The resident had a nasal cannula in use that was connected to a portable O2 tank attached to the back of her wheel chair. The O2 tank was nearly full and set at 1 LPM. No signs or symptoms of shortness of breath or cyanosis noted. Interview with the R#105 at this time revealed she was not having any difficulty breathing. Observation on 6/15/17 at 7:42 a.m. with LPN AA confirmed that the oxygen liter flow on the portable tank for R#105 was set at 1 LPM. During an interview at the time of the observation with LPN AA, she stated that the oxygen liter flow for R#105 should have been set at 2LPM. LPN AA assessed the SaO2 for R#105 which read 94%. LPN AA further stated that she believed the night shift CNAs got R#105 up, dressed and into her wheel chair. She stated that the CNA would have placed the resident on the portable O2 tank. 4. R#16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Record review for R#16 revealed an Annual MDS assessment which assessed and BIMS summary score of 01, indicating severe cognitive impairment. Section O- Special Treatments and Programs indicated the resident received oxygen while a resident in the facility. Further record review for R#16 revealed a Respiratory care plan with a Problem Onset Date of 4/28/17 with an Approach to administer oxygen as ordered. Review of the Physician orders [REDACTED]. Observation on 6/16/17 at 8:35 a.m. revealed the R#16 in her bed with a nasal cannula in use that was connected to the O2 concentrator at 6 LPM. Observation on 6/16/17 at 8:45 a.m. with LPN AA confirmed that the oxygen liter flow for R#16 was set on 6 LPM. Interview with LPN AA at the time of the observation revealed the oxygen is supposed to be set on 5LPM and she does not know why the liter flow is set to 6 LPM. Interview on 6/16/17 at 12:05 p.m. with the Director of Nursing (DON) revealed ultimately the nurse are responsible for making sure the resident is on their oxygen and that it is on prescribed liter flow. She stated that there is no specific policy related to how they check the resident's tanks once the resident is up but that the nurses should be checking daily to make sure the concentrators are on the correct liter flow and that the tanks are on correctly once a CNA gets the resident up. She stated that the CNAs can look at the concentrator and see what it is set to know what liter flow should be or they can verify the liter flow with the nurse. The DON stated that every nurse has a key to the O2 tanks and some CNA's do. The DON stated that she would have to check to see if she has any in-services or competencies related to oxygen concentrators and portable tanks, however, the DON never produced evidence of training related to oxygen, concentrator or portable O2 tanks. The DON stated it was shocking to her that some of the tanks were found empty, not opened up or on the wrong liter flow and that she does not know what happened.",2020-09-01
798,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,372,F,0,1,FEJH11,"Based on observations, review of the job description titled Maintenance Supervisor and Maintenance Assistant and staff interviews, the facility failed to ensure that two of two garbage dumpsters (#1 and #2) were in good repair as evidenced by one garbage dumpster (#1) that was leaking a liquid substance unto the concrete area attracting flies, the top lid was damaged and did not close properly and a second garbage dumpster (#2) that did not have a plug in the drainage outlet exposing the garbage inside. The facility census was 104 residents. Findings include: Observation on 6/13/17 at 8: 37 a.m. revealed two medium sized garbage dumpsters at the back of the facility. Garbage disposal #1 revealed the top lid/cover was warped and damaged, did not close and fit properly at the top right corner, leaving a large opening into the dumpster. Disposal #1 also had a steady leak of black, greenish substance coming from the front bottom of the disposal that was spilling onto the concrete area. There were numerous flies buzzing around the leaked substance. Disposal #2 revealed a missing drainage plug. A white garbage bag could be seen through the drain opening. Observation on 6/13/17 at 8:40 a.m. of dumpster #1 with the Maintenance Director confirmed the top lid/covering was damaged and did not close properly, leaving the top of the dumpster open. Interview with the Maintenance Director at this time revealed he just started this position two weeks ago and was trying to get everything in order. He stated that he complained to Disposal Company about the damaged lid but that he had not addressed the leaking from the dumpster. He stated that he did not know how long the dumpster had been leaking but that it had been evident the two weeks since he had been in the position. Observation on dumpster #2 at 8:42 a.m. with the Maintenance Director confirmed that the drainage opening did not have a plug. He stated in interview at this time that he was going to have to call Disposal Company about both garbage containers and have them replaced. Interview on 6/14/17 at 10:27 a.m. with the Maintenance Director revealed that they had pressure washed the concrete where the dumpster container was leaking. He further stated that both garbage dumpsters had just been replaced this morning. He further stated that he would have to look for a facility policy related to maintaining the dumpster area. The Maintenance Director further stated the maintenance of the dumpsters is the responsibility of the sanitation company. Interview on 6/14/17 at 3:04 p.m. with the Administrator revealed that there is no specific policy related to the dumpsters or the maintenance of the area around the dumpster. She stated that the Maintenance Department is responsible for the facility grounds. The Administrator stated that she has job descriptions for the Maintenance Supervisor and Maintenance Assistant. The Administrator provided copies of the job descriptions at the time of the interview. Review of the undated job description titled Maintenance Supervisor documented Purpose- to plan, organize, develop and direct overall operations of the Maintenance Department in accordance with current federal, state and local standards, guidelines and regulations governing this facility, and as may directed by the Administrator, to assure that our facility is maintained in a clean, safe, and comfortable manner. Review of the undated job description titled Maintenance Assistant documented duties that include but were not limited to; Maintain general plant and facility in good repair, ensuring a safe, clean and orderly environment.",2020-09-01
799,DELMAR GARDENS OF SMYRNA,115330,404 KING SPRINGS VILLAGE PKWY,SMYRNA,GA,30082,2017-06-16,441,E,0,1,FEJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the policy titled Bedpan or Urinal, Administration of, and staff interviews, the facility failed to store and label personal care equipment (bed pans, urinals and wash basins) in a sanitary manner to prevent cross contamination on five of five halls (A Annex, B Hall, C Hall, C Annex and A Hall). The facility census was 104 residents. Findings include: Review of the undated policy titled Bedpan or Urinal, Administration of documented Procedure- equipment: bedpan and or urinal with resident's name. Observations on 6/13/17 of personal care equipment in resident bathrooms on the A Annex revealed the following: At 11:20 a.m. in room [ROOM NUMBER], for which two residents share, revealed two bed pans that were bagged in clear plastic bags sitting on the floor to the left of the toilet. The two bedpans were not labeled. There was one graduated cylinder sitting on top of the toilet tank. At 11:26 a.m. in room [ROOM NUMBER], for which two residents share, revealed two bed pans that were bagged in clear plastic bags sitting on the floor on the right side of the toilet. The two bedpans were not labeled. At 11:29 a.m. in room [ROOM NUMBER], for which two residents share, revealed one unbagged, unlabeled wash basin sitting on top of the toilet tank. At 11:31 a.m. in room [ROOM NUMBER], for which two residents share, revealed two unbagged, unlabeled bed pans on the floor to the left of the toilet. Observations on 6/13/17 of personal care equipment in resident bathrooms on B Hall revealed the following: At 1:34 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unbagged, unlabeled wash basin sitting in the bath tub. At 1:35 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unbagged, unlabeled wash basin on the bathroom floor. At 1:38 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unbagged, unlabeled wash basin and one unbagged, unlabeled bedpan sitting on top of the toilet tank. At 1:40 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unbagged, unlabeled urinal hat sitting on the floor on the left side of the toilet. Observations on 6/13/17 of personal care equipment in resident bathrooms on the C Hall and C Annex revealed the following: At 1:38 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unlabeled bed pan in a clear plastic bag sitting on top of two unbagged urinal hats sitting on the floor to the left of the toilet. At 1:40 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unlabeled bed pan in a clear plastic bag sitting on top of the toilet tank. At 1:41 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unlabeled bed pan in a clear plastic bag balanced on top of the hand rail to the right side of the toilet and one unlabled bed pan in a clear plastic bag balanced on top of the hand rail on the left side of the toilet. At 1:42 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unbagged, unlabeled bed pan sitting inside one bagged, unlabeled bedpan in the bath tub of the resident bathroom. At 1:43 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unbagged, unlabeled bed pan sitting on top of the toilet tank. Observation on 6/13/17 of personal care equipment in resident bathrooms on the A Hall revealed the following: At 1:45 p.m. in room [ROOM NUMBER], for which two residents shared, revealed one unbagged, unlabeled wash basin sitting in the bathtub. At 1:47 p.m. in room [ROOM NUMBER], for which two residents share, revealed one bagged, unlabeled bedpan and one bagged, unlabeled urinal on the floor on the left side of the toilet. At 1:50 p.m. in room [ROOM NUMBER], for which two residents share, revealed one unbagged, unlabeled urinal hat sitting in the bath tub. Observations on 6/13/17 of personal care equipment on the C Hall and C Annex with the Director of Nursing (DON), beginning at 2:01 p.m. and ending at 2:11 p.m., confirmed the personal care equipment in rooms 144, 218, 215, 211 and 210 were not properly stored, had no identifying labels and/or properly bagged. Observations on 6/13/17 of personal care equipment on the A Annex with the DON, beginning at 2:11 p.m. and ending at 2:20 p.m., confirmed the personal care equipment in rooms 232, 231, 230 and 227 were not properly stored, had no identifying labels and/or properly bagged. Observations on 6/13/17 of personal care equipment on the B Hall with the DON, beginning at 2:20 p.m. and ending at 2:30 p.m., confirmed the personal care equipment in rooms 120, 122, 128 and 130 were not properly stored, had no identifying labels and/or properly bagged. Observation on 6/13/17 of personal care equipment on the A Hall with the DON, beginning at 2:30 p.m. and ending at 2:37 p.m., confirmed the personal care equipment in rooms 108, 109 and 110 were not properly stored, bagged and/or labeled. Interview on 6/13/17 at 2:40 p.m. with the DON revealed that all personal care equipment is expected to be properly labeled with the resident's name, bagged and should never be on the floor. The personal care equipment should hang from the rails. The DON further stated that the residents do not use the bath tubs in the resident rooms for bathing, they all go to the shower room. The DON stated that she had provided in-services recently to the staff about properly bagging, labeling and storing personal care equipment but It's not working. Review of the In-Service education Record dated 4/10/17 documented Brief Description/Objectives: all patient toiletries are to be labelled, bagged and placed in the bedside table or closet after use. Also bag and label bed pans, urinals, nurse hats, wash basins. Do not leave on the floor in the bathroom. There were 27 nurse and CNA signatures on the sign in sheet indicating being in attendance of the in-service. Interview on 6/14/17 at 4:02 p.m. with the DON stated they do not have a specific policy related to infection control practices for personal care equipment. She stated the CNAs receive education during orientation and in-services with instructions on how to properly care for personal care equipment such as labeling with the resident's name and room number, washing out the bedpan, ensuring that it's dry, place in a bag, the bag should also be labeled and be hung up on the rails not on the floor. If the equipment is soiled and unable to be cleaned, it is thrown out and changed as needed.",2020-09-01
800,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2019-02-22,812,E,0,1,14FP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the kitchen dry storage room floor was clean and in good repair, that the walk-in freezer was free of dripping water that froze on boxes of food, and that the walls in the dishwashing area were clean and in good repair. This deficient practice had the potential to effect 73 of the 77 residents receiving an oral diet. Findings include: The initial kitchen inspection was conducted with the Dietary Manager (DM) on 2/19/19 from 8:30 a.m. until 8:55 a.m. The following concerns were observed: The linoleum tile floor in the dry storeroom was is in poor condition; seven tiles were broken creating an uneven surface that could not be completely cleaned. There was black grime in the areas of the flooring where the tile was missing. The missing pieces of tiles ranged from several inches in size to approximately 12 inches by three inches in size. The walk-in freezer had a large icicle that had dripped from a pipe near the ceiling onto a cardboard box of turkey roasts that was partially open (the roasts were individually sealed in plastic). The icicle was cone shaped and approximately two feet long and six inches in diameter at the bottom where it was attached to the box of turkey roasts. The DM broke the icicle, removed it, and disposed of it in a sink in the kitchen. The DM stated the freezer had been doing that for a while and she needed to call to get it fixed again. She stated maintenance staff was aware of it. The temperature of the freezer was 0 degrees Fahrenheit (F). The corner seam, where the two walls in the dishwashing area were adjoined (near where trays of dishes entered the dish-machine) was observed with a black speckled substance underneath the clear caulking and on the wall. The black speckled substance was under all the caulking from the ceiling half-way down the seam of the two walls. The bottom halves of the walls were buckled with the walls coming apart from each other where they should have joined in the corner; there was no caulking in this area. The area visible behind the buckled walls was black. Observations in the kitchen were made on 2/21/19 from 1:35 p.m. through 2:01 p.m. with the DM with the following concerns observed: The linoleum floor was in the same condition with seven tiles with missing pieces with black grime caked in the areas of missing tile. In the freezer, there were large chunks of ice (up to six inches in size) formed in a drip pattern and adhered to the top of the card board boxes of turkey roasts, hash brown potatoes, and pizza. A small drip hanging from the pipe of approximately three inches in length was observed. The DM stated she had informed maintenance about the ice build-up on 2/19/19; however, nothing had been done to fix it yet. The DM stated large amounts of ice had been forming in the freezer for a month or two. The temperature was 0 degrees F. The corner seam, where the two walls in the dirty side of the dishwashing area were adjoined, and wall were in the same condition with black speckled substance under the caulking and on the wall. The bottom half of the walls continued to be buckled. The area visible behind the buckled walls was black. A dietary staff was spraying off dishes prior to pushing them into the dish machine. The walls and corner seam were wet, and the area was steamy. An interview on 2/22/19 at 9:48 a.m. the Maintenance Director stated staff notified him of the need for repairs by documenting issues in the computer system and on Maintenance Request forms on clip boards located at the nurses' stations. The Maintenance Director stated the facility was built in the 1960s which required a lot of maintenance. When asked about the ice accumulation in the freezer, the Maintenance Director stated he had repaired the freezer door a few months ago and the ice build-up was a result of the door not staying closed which created condensation and then ice. The Maintenance Director stated warm air circulated with the cold resulting in the [MEDICATION NAME] pipe sweating, dripping, and then freezing. The Maintenance Director stated the DM had informed him of the ice build-up on 2/19/19 following the surveyor's initial kitchen inspection and stated that he was not aware prior to 2/19/19 that the freezer door continued to be problematic after his previous repair. The Maintenance Director stated he had looked at the freezer door on 2/19/19 and was going to tighten the closure to ensure the door would stay closed. The Maintenance Director stated he was aware of the broken tiles in the kitchen dry food store room, adding he could replace them. The Maintenance Director stated he had not noticed the black substance in the dish room in the corner seam under the caulking and on the wall. The Maintenance Director stated he would look for any documentation related to notification or repair of the freezer, dish room walls, and tile floor. Observation and interview in the kitchen with the Maintenance Director on 2/22/19 at 9:53 a.m. revealed that when walking into the walk-in freezer from the walk-in refrigerator, the freezer door was observed to be open approximately a foot and a half (into the walk-in refrigerator). The walk-in freezer was accessed by going through the walk-in refrigerator. The Maintenance Director stated the door being open was the problem and said he would tighten it, so it would close more easily. There were no dietary staff in the immediate area. The freezer temperature was zero. There were ice chunks up to six inches in size on the boxes of turkey, pizza, and hash browns. The Maintenance Director and surveyor went into the dish room. The Maintenance Director stated the wall with black speckled substance in the dish room had been recently painted. The Maintenance Director stated the wall that was buckling in corner and coming apart was a false wall and there was nothing he could do about it. He stated there were quotes to have the wall replaced and Corporate was aware of the problem. The Maintenance Director and surveyor went into the dry store room and he confirmed the seven linoleum tiles that were broken. A follow up interview on 2/22/19 at 11:46 a.m. with the Maintenance Director revealed that the last time the freezer door was repaired was on 11/16/18. The Maintenance Request form dated 11/16/18 indicated freezer door not working. Under the heading of Follow Up/ Resolution, the Maintenance Request form indicated it was fixed. The Maintenance Director verified he did not have any additional documentation to show the issues of the dry store room floor or dish room buckling walls were identified or repaired. The Maintenance Director stated the black speckled substance under the caulking and on the wall in the dish room was mold and stated corporate would send a vendor out to look at it. The Maintenance Director stated any repairs over $500 were out of his hands and required Administrator and Corporate approval to repair. The Maintenance Director stated the buckling wall had been brought up several months ago; however, his emails were deleted after 30 days so he did not have any documentation of this. The Maintenance Director stated replacement of the false wall in the dish room would cost more than $500. He stated, in the mean-time, he would remove the caulking from the corner, spray the wall with a bleach solution and re-caulk it. An interview on 2/22/19 at 12:11 p.m. with the Administrator revealed that the building was old. The Administrator stated she was aware of the problem with the freezer door, the buckling wall in the dish room, and the floor in the store room having broken tiles. The Administrator stated the process to get approval for large projects was to complete a Capital Expenditure Request (CER) form. She stated Corporate would review the form, a vendor from the approved list would provide a quote for the repair, and then it went through the corporate approval process. A follow up interview on 2/22/19 at 1:24 p.m. with the Administrator revealed that the dish room wall needed to be replaced and she put in the CER request for the dish room wall in (MONTH) (YEAR). The Administrator stated the buckling wall was not replaced; however, a repair to the wall was made between (MONTH) (YEAR) and (MONTH) (YEAR). She stated she did not have approval for any additional the repairs at this time.",2020-09-01
801,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2017-02-23,252,D,0,1,45OZ11,"Based on observation and interview, the facility failed to ensure that one room (#18) of 15 rooms on the Unit Two hall remained free of odors thus maintaining a comfortable and pleasant environment for residents in the facility. The facility census was 84. Observation on 02/21/17 at 11:08 a.m. revealed a strong odor of urine in Room 18 that could be detected even in the hallway. Observation of Room 18 on 2/23/17 at 3:25 p.m. revealed a strong odor of urine continued to emanate from the room, especially in the area of the bathroom. Closer observation revealed no signs of soiled bed linens, urinals, or other items in the room/bathroom that might have contributed to the odor. Interview on 2/23/17 at 3:30 p.m. with the unit Licensed Practical Nurse (LPN) (LPN AA) revealed that staff has complained to the Administration for at least two months about the unpleasant odor of urine in Room 18. Despite several deep cleaning efforts by housekeeping in the room and bathroom, the smell persisted and staff advised the Administrator that the smell might be due to urine having settled under the tilework in the bathroom. Despite these complaints from staff, no further action was taken to eliminate the odor in that room. Interview on 2/23/17 at 3:40 p.m. with the Administrator revealed that he had not been made aware of the odor problem in the bathroom of Room 18 since his arrival in the facility the week before. However, he planned to immediately issue a work order to have the bathroom thoroughly cleaned and/or the tiles replaced if necessary.",2020-09-01
802,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2017-02-23,282,D,0,1,45OZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to follow the plan of care related to nail care for one resident (R) (R#3) from a sample of 30 residents. Refer F312 Findings include: Record review for R#3 revealed a Significant Change Minimum Data Set (MDS) assessment dated [DATE] which documented in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) could not be obtained due to severe cognitive deficits; in Section [NAME] - Behavior - the resident was assessed as having no behaviors such as rejection of care; in Section G - Functional Status - the resident needed extensive assistance with personal hygiene, eating, dressing, and bed mobility, had functional limitation in ROM on one side in the upper extremities and on both sides in the lower extremities; and in Section I - Active [DIAGNOSES REDACTED]. In Section V - the Care Area Assessment summary, Activities of Daily Living (ADLs) Functional/Rehabilitation potential triggered with the intent to complete a care plan for those areas. Review of the care plan for R#3 updated 12/22/16 identified self-care deficit in ADLs related to poor cognitive and physical status requiring total assistance with ADLs, a history of cardio-vascular accidents with left side weakness, and a history of head injury revealed a goal to have ADL needs met with dignity for 90 days. Accompanying interventions included: bath/shower as scheduled; daily grooming; oral/hair/skin care; nail care/shampoo as needed; and incontinent care after each episode with a reminder to staff that the resident has the right to refuse care. Observation on 2/21/17 at 11:13 a.m. of R#3 revealed that some of the nails on both hands were broken/jagged, and all of the fingers on the left hand showed black substance under the nails. Observation on 2/22/17 at 12:15 p.m. revealed R#3 sitting in her room in a Broda chair with a clean face and fresh clothing. The nails on both hands were noted to project about 1/3 of an inch beyond the nail bed and were jagged with black material under those on left hand. The right arm and hand remained immobile while the resident raised the left arm, slightly. Interview on 2/22/17 at 12:20 p.m. with unit nurse, Licensed Practical Nurse (LPN BB), revealed R#3 needs total care for all activities of daily living. She receives a bath three times a week - Mondays, Wednesdays, and Fridays. The Certified Nursing Assistants (CNAs) usually check daily and provides nail care for residents, as needed. However, R#3 has a [DIAGNOSES REDACTED]. In between the podiatrist visits, the unit nurse is responsible for doing nail care for the resident. The nurse checks daily to see if the resident needs nail care and will complete this task at least weekly, or as needed. LPN BB further stated if she sees the nails on the hands are too long, especially since the resident can use her nails on her left hand to scratch at her skin, she always asks the resident's permission before cutting her nails. LPN BB stated that R#3 has never refused nail care. Observation on 2/22/17 at 3:15 p.m. revealed resident lying in bed with the nails on both hands freshly cleaned and trimmed.",2020-09-01
803,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2017-02-23,312,D,0,1,45OZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide nail care for one of 30 sampled Residents (R) (R#3), that was totally dependent on staff for personal hygiene. Findings include: Review of the records revealed that R#3 is an [AGE] year-old admitted to the facility on [DATE]. Current [DIAGNOSES REDACTED]. Review of the Significant Change Minimum Data Set (MDS) assessment for R#3 dated 11/18/16 documented in Section C - Cognitive Patterns - a Brief Interview for Mental Status (BIMS) could not be obtained for the resident due to severe cognitive deficits; in Section [NAME] - Behavior - the resident was assessed as having no behaviors such as rejection of care; in Section G - Functional Status - the resident needed extensive assistance with personal hygiene, eating, dressing, and bed mobility, had functional limitation in ROM on one side in the upper extremities and on both sides in the lower extremities; and in Section I - Active [DIAGNOSES REDACTED]. In Section V - the Care Area Assessment summary, Activities of Daily Living (ADLs) Functional/Rehabilitation potential triggered with the intent to complete a care plan for those areas. Review of the care plan for R#3 updated 12/22/16 identified self-care deficit in ADLs related to poor cognitive and physical status requiring total assistance with ADLs, a history of cardio-vascular accidents with left side weakness, and a history of head injury revealed a goal to have ADL needs met with dignity for 90 days. Accompanying interventions included: bath/shower as scheduled; daily grooming; oral/hair/skin care; nail care/shampoo as needed; and incontinent care after each episode with a reminder to staff that the resident has the right to refuse care. Review of the Occupational Therapy (O/T) progress and discharge summary completed for R#3) on 12/13/16 revealed the resident was assessed as having a [DIAGNOSES REDACTED]. The resident was further assessed as needing total assistance with ADL self-care for upper body dressing, lower body dressing, grooming, and bathing. The resident was discharged from occupational therapy services with effect from 12/8/16 due to a decline following multiple hospitalization s which left her an inappropriate candidate for therapy services. Review of the Completed Care Tasks for R#3 from the facility kiosk records revealed the resident received ADL care at least one shift each day during the period from 2/9/17 to 2/23/17. Observation on 2/21/17 at 11:13 a.m. of R#3 revealed that some of the nails on both hands were broken/jagged, and all of the fingers on the left hand showed black material substance under the nails. Observation on 2/22/17 at 12:15 p.m. revealed resident sitting in her room in a Broda chair with a clean face and fresh clothing. The nails on both hands were noted to project about 1/3 of an inch beyond the nail bed and were jagged with black material under those on left hand. The right arm and hand remained immobile while the resident raised the left arm, slightly. Interview on 2/22/17 at 12:20 p.m. with unit nurse, Licensed Practical Nurse (LPN) (LPN BB), revealed R#3 needs total care for all activities of daily living. She receives a bath three times a week - Mondays, Wednesdays, and Fridays. The Certified Nursing Assistants (CNAs) usually check daily and does nail care for residents, as needed. However, R#3 has a [DIAGNOSES REDACTED]. In between the podiatrist visits, the unit nurse is responsible for doing nail care for the resident. The nurse checks daily to see if the resident needs nail care and will complete this task at least weekly, or PRN if she sees the nails on the hands are too long, especially since the resident can use her nails on her left hand to scratch at her skin. LPN BB further stated that she always ask the resident's permission before cutting her nails and that R#3 has never refused nail care. Observation on 2/22/17 at 3:15 p.m. revealed resident lying in bed with the nails on both hands freshly cleaned and trimmed.",2020-09-01
804,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2017-02-23,371,F,0,1,45OZ11,"Based on observation, staff interviews, and review of policy and procedure, the facility failed to ensure that staff thawed meat in a manner to prevent contamination of ready-to-eat food items in the walk-in refrigerator, and failed to discard expired food items in the dry food storage area of the kitchen. This deficient practice had the potential to affect 76 residents receiving an oral diet. The facility census was 84 residents. Findings include: Review of policy last revised on 6/14/16 titled Labeling, Dating, and Storage revealed food items are to be properly labeled with the name of the item, and an open and a discard by date. Foods are to be stored in original containers or wrapped tightly with film, foil, etc. and clearly labeled with the name of the item and a discard date. Prepared food items will be discarded within 48 hours of prep. Items that require refrigeration will be labeled with the date once opened and discarded based on the type of food item. Observation of the walk-in refrigerator on 2/21/17 at 8:25 a.m. during the initial tour of the kitchen revealed one plastic crate containing five pound (5 lb) packages of ground beef and one metal basin containing 5 lb packages of ground beef thawing on an open storage shelf above a 12x18 metal pan of Jell-O in the walk-in refrigerator. Observation of the dry food storage area on 2/21/17 at 8:35 a.m. during the initial tour of the kitchen revealed two 5 lb white paper bags containing gingerbread baking mix with expiration/discard by dates of 1/11/17 sitting on a multi-shelf metal storage cart. A closer look at the underside of each bag revealed rust stains where the bags rested against the metal shelf. Interview with the dietary manager on 2/21/17 at 8:40 a.m. during the initial tour of the kitchen revealed that she expects dry food items are to be discarded by the manufacturer's use-by/discard-by date and meat should not to be thawed on the shelf above other food items, but on the bottom shelf of the refrigerator.",2020-09-01
805,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2018-03-01,695,D,0,1,4EX411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to provide proper [MEDICAL CONDITION] care for one (1) resident (R) #43. This deficient practice had the potential to cause increased respiratory infections for residents with tracheostomies. The sample size was 24. Findings Include: Record Review revealed R#43 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the admission Minimal Data Set (MDS) section C- cognitive patterns dated 3/9/17 revealed the resident has a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident is rarely/or never understood. Review of section G- functional status revealed R#43 is total dependent on staff for all ADL care; with two persons, physical assist. Further review revealed in section O- special treatments, procedures, and programs; R#43 receives oxygen therapy; suctioning, and [MEDICAL CONDITION] care. Review of physician's orders [REDACTED]. Resident observed on 02/28/18 at 10:07 a.m. while in his room lying in bed eyes closed Trach-Collar on with Oxygen (O2) bled in at two (2) Liters Per Minute (LPM) with 28% Air compressor to provide cool mist humidity. Respiratory status is non-labored with no signs of distress noted. During further observation, a portable suction machine is noted at the bedside with a previously used disposable suction catheter still attached to the suction canister tubing lying on top of a dresser. [MEDICAL CONDITION] care is observed now by Licensed Practical Nurse (LPN NN a ). LPN NN provided [MEDICAL CONDITION] (trach) care to R#43 with non-sterile gloves, and by cleaning around R#43s [MEDICAL CONDITION] stoma site with skin integrity wound cleanser, a chemical agent used to clean pressure ulcer wounds. Interview with LPN NN at this time revealed she uses the wound cleanser to clean around the residents' tracheal stoma site when providing trach-care to R#43. Interview with the Unit two (2) Nurse Manager on 03/01/18 at 10:44 a.m. revealed staff are to [MEDICAL CONDITION] for R#43 using [MEDICAL CONDITION] kit which contains normal saline, sterile gloves, and sterile disposable suction catheter. Staff are to clean around R#43s tracheal stoma site with gauze and normal saline.[MEDICAL CONDITION] is done each shift or as needed. During the interview the Unit 2 Nurse Manager revealed that it is her expectation for NN to use normal saline around the resident's tracheal stoma site, and not skin integrity wound cleanser. Review of facility policy titled [MEDICAL CONDITION] cannula and stoma care revised (MONTH) 17, (YEAR) revealed the following: Perform hand hygiene, put on clean gloves, use a sterile guaze pad with normal saline solution, squeeze out the excess liquid to prevent accidental aspiration. Then wipe the patient's neck under the [MEDICAL CONDITION] flages and [MEDICAL CONDITION] ties.",2020-09-01
806,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2018-03-01,812,F,0,1,4EX411,"Based on observation, staff interview, and facility policy title, Food Temperature the facility failed to maintain food temperature above 135 degrees Fahrenheit (F). This had the potential to effect 75 residents out of a census of 79. Findings include: Observation of one steam table on 3/1/19 at 1:14 p.m. revealed the following: Pureed meat 80 degree F and removed from steam table to reheat, pureed squash 120 degrees F and removed from steam table, chopped meat at 130 degrees F then removed from steam table. A second observation was conducted on 3/1/18 at 1:37 p.m. revealed the following temperature after re-heating: pureed rice was 130 degrees F, pureed meat was 140 degrees F, pureed squash was 158 degrees F, puree squash was 158 degrees F, chopped meat was 142 degrees F. Interview on 3/1/18 at 1:55 p.m. with Dietary Manager revealed that her expectations are for the steam table temperature to held above 135 degrees F and not sure if re-heating temperature should be 150 degrees F or 165 degrees Farenheit. Policy Food Temperature title Food Temperature revealed the following all hot foods served from the steam table must be held at or above 135 degrees. If the food item is not at an acceptable temperature , the food item must be removed and heated/cooled to an appropriate temperature prior to serving. Food items must be reheated to a temperature of 165 degrees for 15 seconds. Leftover must be reheated to 165 degrees for 15 seconds to prevent /kill bacteria growth.",2020-09-01
807,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2018-03-01,880,D,0,1,4EX411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of Lippincott Procedures: Contact Precautions utilized by the facility, and staff interview, the facility failed to ensure that a Certified Nursing Assistant (CNA) donned gloves and a gown and washed her hands with soap and water during meal service for one (1) resident (R) (R#74) of three (3) residents reviewed for transmission-based precautions. Findings include: Review of Lippincott Procedures: Contact Precautions (revised 5/12/2017) provided by the facility revealed that contact precautions help prevent the transfer of microorganisms that spread through direct or indirect contact with a patient or the patient's environment. Effective contact precautions require a single room, if possible, and the use of gloves and a gown by anyone who has contact with the patient, the patient's support equipment, or items that have come in contact with the patient or the patient's environment. Glove use is important for preventing the spread of [MEDICAL CONDITION] spores via the hands of health care workers. Because alcohol does not kill [DIAGNOSES REDACTED]icile spores, the use of soap and water for hand hygiene is more effective at removing spores than the use of alcohol-based hand rubs. R#74 was admitted on [DATE] with a [DIAGNOSES REDACTED]. diff), a bacterium that can cause symptoms ranging from diarrhea to inflammation of the colon. Review of her medical record revealed that she was treated with [MEDICATION NAME] (an antibiotic) for ten (10) days and had been placed on isolation/contact precautions. On 2/26/18 at 1:15 p.m., Certified Nursing Assistant (CNA) DD was observed sitting in a chair in the hall outside the resident's room door providing 1:1 supervision for the resident who had attempted to leave her room. A cart with Personal Protection Equipment (PPE), i.e., gowns, gloves and masks, was observed in the hall outside the resident's room door. On 2/26/18 at 1:20 p.m., CNA DD obtained a meal tray from the meal cart in the hall. Without donning a gown or gloves, CNA DD entered the resident's room and placed the tray on the resident's overbed table. CNA DD set up the tray for the resident, pushed the resident in her wheelchair closer to her bed, pushed the overbed table closer to the resident so that she could feed herself and placed a napkin around the resident's neck and over her chest. Without washing her hands with soap and water, CNA DD left the resident's room and sat in the chair outside the door. Interview with CNA DD on 3/01/18 at 12:05 p.m. revealed that she did know what type of PPE should be donned when providing care for a resident on contact isolation. When asked why she did not don gloves or a gown when setting up the lunch tray for R#74 on 2/26/18 at 1:20 p.m., CNA DD stated I thought I put gloves on. Interview with Licensed Practical Nurse (LPN)/Unit Manager AA on 3/1/18 at 1:05 p.m. who was responsible for Infection Control surveillance revealed that staff were supposed to don clean gloves and a gown when entering the room of a resident who had been placed on contact precautions. Continued interview revealed that staff were also supposed to wash their hands with soap and water prior to leaving the room of a resident who had [MEDICAL CONDITION]. Review of the facility in-service titled: Infection Control and Contact Precautions dated 2/9/18 revealed that CNA DD had attended the in-service.",2020-09-01
808,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2018-03-01,914,D,0,1,4EX411,"Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of four of 100 beds on two of six halls. The facility census was 79 residents. Findings include: On 2/28/18 at 12:40 p.m., during walking tour with Housekeeping Supervisor, observation revealed privacy curtains in rooms 223C, 225A, 331B and 331D were short approximately four feet from end of the curtain to the wall, which did not ensure full visual privacy for the resident during patient care. Interview on 2/28/18 at 12:40 p.m., with Housekeeping Supervisor, stated that housekeeping staff are given assignments for which rooms which need privacy curtains need to be laundered. He stated that when the original curtain is taken down, the housekeeping staff put up a temporary curtain to provide privacy during care. He stated that he was not aware that the temporary curtains were not long enough to provide full privacy for the residents receiving care. Interview on 3/1/18 at 8:49 a.m., with Housekeeping Supervisor, stated he changed the privacy curtains out in rooms 223C, 225A, and 331B and 331D yesterday. Surveyor informed him that the curtains were checked early this morning at 7:45 am, and curtains did not provide full privacy for residents. He stated that he misunderstood the rooms that were shown to him the previous day. He stated curtains with 42 hooks are the longest that he could order, but he had some 18 hook curtains that he will hang along with the others to make sure residents are provided full privacy.",2020-09-01
809,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2018-03-01,919,D,0,1,4EX411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, the facility failed to ensure that the call light communication system was functioning adequately to allow residents to call for staff assistance in five rooms (334A, 335A, 336A & 336B, 339A, and 117A) on two of three halls (100 hall and 300 hall). The facility census was 79 residents. Findings include: Observations on 2/26/18 at 10:15 a.m., during intial tour of resident rooms revealed the following: 1. On the 300 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 2. On the 300 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 3. On the 300 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 4. On the 300 Hall, room [ROOM NUMBER] bed B, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 5. On the 300 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. 6. On the 100 Hall, room [ROOM NUMBER] bed A, the call light was tested by pushing the red button. The light above the door did not light up and no sound was heard. There was no resident currently residing in bed- A however, it was available for new admission. Review of the quarterly Preventative Maintenance provided by Corporate Environmental Services Director, revealed that the call light maintenance for the fourth quarter was completed on 11/3/2017, which would have cycled to be checked the next quarter on (MONTH) 3, (YEAR), according to the Coporate Environmental Services Director. The report showed that rooms 1-4 and 29-40, had not been checked during the month of Febuary, which should have cycled to be checked (MONTH) 3. (YEAR). Walking rounds on 2/26/18 at 12:15 p.m., with Interim Director of Health Services (DHS) verified rooms 17 bed A, 34 bed A and 39 bed A had non-functioning call lights. Rooms 35 bed A and 36 bed A and bed B were already replaced by Maintenance Supervisor earlier today. Interview on 2/26/18 at 10:40 a.m., R#32 stated that his call light has not worked for the past week. He stated he told the maintenance man about it, but he could not recall what his name was. Interview on 2/26/18 at 1:13 p.m., with the Maintenance Supervisor stated that the facility uses a software program called Building Engineering Data, which tracks quarterly when call lights are scheduled to be checked. He stated that he has not noticed any call lights in the building that were not functioning properly. When asked about the observed rooms with non-functioning call lights on today's tour, he stated they were working on his last quarterly check. Interview on 3/1/18 at 8:15 a.m., with Maintenance Director, stated that he did not have an explanation as to why the call lights in rooms 34A, 35A, 36A and 36B on the 300 hall were not checked in (MONTH) when they were due for this quarter monitoring. He was able to pull up on his computer system Building Engineers that those rooms were due for inspection on 2/5/18. He was asked about the frequency of checking the call lights every three months, and he stated that's what the program is set up to do, so that's what he does.",2020-09-01
810,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2017-06-16,246,D,1,0,TF3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff and resident interview, the facility failed to assist one resident with showers as requested by the resident (R#1) out of three residents sampled. The facility census was 83. Findings include: Resident #1 (R#1) admitted [DATE] with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. Review of R#1's Minimum Data Set (MDS) 'Entry Tracking Record' dated 6/9/2017 reveals no assessment data. Interview with R#1 and a family member (FM) AA on 6/16/2017 at 5:45 p.m. revealed that R#1 requested assistance to receive a shower from staff beginning on the day after admission on and was told by different certified nursing assistants (CNAs) that he could only receive showers on his scheduled shower days and they explained the shower schedule to him. R#1 states he asked two different staff members for showers and finally received a shower three days ago. R#1 states they offered him bed baths instead of a shower. Interview and review of 'Shower Schedule on 6/16/2017 at 6:30 p.m. with the Unit Manager BB reveals showers should be accommodated when the resident requests. Resident is on a shower schedule to receive showers Tuesdays, Thursdays, and Saturdays. Resident received a shower on Tuesday, 6/13/2017 and on 6/15/2017. BB states that R#1 is alert and oriented and would estimate a he has a cognitive score of 14 or 15, indicating the resident is cognitively intact. R#1 is in a motorized wheelchair but can bear some weight when transferring, and requires one person assistance because of his size. Review of 'Nutrition Screening and Assessment Form dated 6/14/2017 reveals that R#1's weight is 386 pounds. Interview with the Director of Nursing (DON) on 6/16/2017 at 7:12 p.m. who states that resident's requests for bathing assistance should be accommodated when the resident requests. The shower schedule is used as a guide.",2020-09-01
811,PRUITTHEALTH - AUGUSTA,115334,2541 MILLEDGEVILLE ROAD,AUGUSTA,GA,30904,2017-06-16,309,D,1,0,TF3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interview and record review, the facility failed to assure that one resident, Resident #1 (R#1) of the three sampled residents recieved physican ordered pain medications until five days after admission to the facility. Facility census was 83. Findings include: Resident #1 (R#1) admitted [DATE] with a primary [DIAGNOSES REDACTED]. Additional [DIAGNOSES REDACTED]. A Pain Observation Form was completed on 6/12/2017 listing arthritis, [MEDICAL CONDITION], perineal and scrotal [MEDICAL CONDITION], shooting pain in legs, especially at night, discomfort to lower extremities, knees, and discomfort to buttocks. [MEDICATION NAME] 10/325 miligrams (mg) 1 by mouth every six hours as needed for pain. Review of the 'Admission Interim Care Plans Form' dated 6/12/2017 for R#1 revealed to 'administer pain medications per physician's orders [REDACTED]. Review of the out-patient medication orders, dated 6/9/2017 listed 23 active medications, including [MEDICATION NAME]-[MEDICATION NAME] 10 mg/[MEDICATION NAME] 325 mg to be taken one tablet by mouth every six hours as needed for pain. Review of the 'physician's orders [REDACTED]. Review of the 'Medication Record' dated 6/9/2017 reveals that resident did not receive any [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME] until 6/14/2017. Review of the 'Skilled Daily Nurses Note' dated 6/11/2017 at 5:00 a.m. reveals R#1 complained of lower limb pain and was given 650 mgs of Tylenol. Review of the 'Skilled Daily Nurses Note' dated 6/9/2017 reveals that [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME] had not been brought by the pharmacy yet. R#1 had some relief. Intensity of the pain was rated a '10' on a scale of 0-10, with 0 being no pain and ten being the highest pain. R#1 was complaining of shooting pain at night in both legs. Review of the 'Skilled Daily Nurses Note' dated 6/14/2017 at 5:30 p.m. reveal complaint of right lower extremity pain, no intensity documented. [MEDICATION NAME] administered for pain. Review of faxed requests to R#1's facility physician reveals physician was not contacted until 6/12/2017 (no time available) with a request to send renewal forms for R#1's [MEDICATION NAME] 10/325mg 1 tablet by mouth every six hours. An 'Approved Prescription' was received on 6/13/2017 at 4:57 p.m. that reads '[MEDICATION NAME]-[MEDICATION NAME] 10mg-325mg, Take 1 tablet(s) every 6 hours by oral route as directed for 30 days. Interview with the Director of Nursing (DON) on 6/16/2017 at 7:12 p.m. who states that the facility's physician was out of town at the time the resident was admitted and that the VAMC should have sent a written prescription with the resident for the [MEDICATION NAME]-[MEDICATION NAME] 10mg/325mg [MEDICATION NAME]. DON admits that no attempt was made to contact the on-call physician or call the VAMC for a prescription. Interview with the DON on 6/16/2017 at 9:05 p.m. who reveals that the on-call physician could have been contacted for a prescription and that there is no policy requirement that residents receiving narcotics must have a written prescription when admitted in order to receive narcotics. The DON futher reveals that the facility's physician will only write prescriptions for narcotics on Tuesdays and Fridays. Interview with R#1 on 6/16/2017 at 4:25 p.m. who reveals that he always has pain, but pain medications make the pain bearable. He requested pain medication the night he arrived but was told he did not have any yet. He asked again the following day when lunch was served and again that night. He was told by one of the nurses that he would not have a prescription until Tuesday because that's when the doctor wrote them. R#1 stated that he takes [MEDICATION NAME] for [MEDICAL CONDITION], and that staff gave him some Tylenol, but that was like drinking water, it didn't help. R#1 further states that he complained about pain every day. Interview with R#1 and FM AA on 6/16/2017 at 5:45 p.m. who reveal that resident always experiences some pain. AA reveals that she went to the nurse's station and asked for pain medication from staff and was told that resident needed a prescription from the doctor and they were attempting to get it. FM AA states that resident complained of pain everyday but all he received was Tylenol.",2020-09-01
812,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2018-03-23,640,B,0,1,YGXR11,"Based on record review and staff interview, the facility failed to ensure that Minimum Data Set (MDS) assessments were transmitted within 14 days of completion to CMS's (Centers for Medicare and Medicaid Services) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two residents (R) (R#2 and R#3). The sample size was 39 residents. Findings include: 1. Review of a listing of R#2's completed and transmitted MDS revealed that a Quarterly MDS with an Assessment Reference Date (ARD) of 10/8/17 was the last MDS transmitted for her. Review of the MDS Transmission Results Summary provided by the Regional MDS Coordinator revealed Target Date 1/7/18 and the assessment was rejected. 2. Review of a listing of R#3's completed and transmitted MDS revealed that a Quarterly MDS with an Assessment Reference Date (ARD) of 10/16/17 was the last MDS transmitted for her. Review of the MDS Transmission Results Summary revealed Target Date 1/15/18 and the assessment was rejected. Interview on 3/21/18 at 3:15 p.m. with the Regional MDS Coordinator revealed the Quarterly Assessments for R#2 and R#3 were completed and submitted timely, however, they were rejected and required correction. She stated that they were never re-submitted and she does not know why. The Regional MDS Coordinator stated that the person that submitted the assessments no longer works in the facility and she is not aware of any reports or programs in the facility to monitor missing or late assessments. She stated when they receive notice that an assessment was rejected they typically make the correction right then and re-submit the assessment.",2020-09-01
813,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2018-03-23,655,D,0,1,YGXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to follow an Admission Care Plan Approach to prevent tension on the urinary meatus for one resident (R) (#235) that was admitted to the facility with a urinary catheter. The sample size was 39 residents. Findings include: Record review for R#235 revealed he was readmitted to the facility after a hospital stay on 3/16/18 with [DIAGNOSES REDACTED]. R#235 was admitted with a urinary catheter. Review of the General Admission Information form dated 3/16/18 documented an Admission Care Plan- Resident admitted with a urinary catheter related to [MEDICAL CONDITIONS] with bladder obstruction. Goal- Resident will not develop any complications associated with catheter usage within the next 30 days. Approach- Provide catheter care per policy, keep catheter tubing free of kinks, keep drainage bag below level of bladder, prevent tension on the urinary meatus from catheter. Observations on 3/20/18 at 11:29 a.m., 3/21/18 at 5:30 p.m., and with the Director of Nursing (DON) on 3/22/18 at 10:20 a.m. revealed the resident had a urinary catheter and there was no catheter strap in place. Interview on 3/22/18 at 10:20 a.m. with the DON revealed the nurses are responsible for ensuring the catheter strap is in place each shift and document placement on the Quick MAR. Interview on 3/22/18 at 10:30 a.m. with the Licensed Practical Nurse (LPN) BB in care of R#235 revealed the resident was just admitted last Friday (3/16/18) and she did not work Friday or the weekend but had been on duty since Monday 3/19/18. LPN BB further stated that she had not checked R#235 to ensure that a catheter strap was in place. Review of the Treatment Administration Record (TAR) revealed documentation for assessing placement of the catheter strap for R#235, was noted as completed per shift, and began on the evening shift (3:30 p.m. to 11:59 p.m.) on 3/19/18. Cross Refer F690",2020-09-01
814,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2018-03-23,656,E,0,1,YGXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to assistance with baths or showers for two residents (R) (R Q and X), and for assistance with grooming for three residents (R #11, R #85, and R #112). The sample size was 39 residents. Findings include: 1. Review of R #11's care plan for required daily assistance with ADLs (activities of daily living) due to [MEDICAL CONDITION], with a reviewed date of 3/16/18, revealed a goal that she would be clean and well-groomed daily through the next review. Review of an approach in this care plan revealed to assist with grooming daily and as needed. Further review of her care plans revealed that none were seen for refusal of care. Observation on 3/20/18 at 11:10 a.m. and 3/21/18 at 9:07 a.m. revealed that R #11's chin was extensively covered with hair, and her fingernails were untrimmed and some appeared jagged. Observation on 3/21/18 at 3:25 p.m. and 3/22/18 at 8:37 a.m. revealed that R #11's chin hairs had been removed, but all of her fingernails remained long, and the nail polish had chipped away. 2. Review of R #85's care plan for received assistance daily with ADLs, reviewed on 2/19/18, revealed an approach to assist the resident with daily hygiene and grooming. Further review of the care plans revealed that none were seen for refusal of care. Observation of R #85's fingernails on 3/20/18 at 3:55 p.m. and 3/21/18 at 9:13 a.m. revealed that the nails on the fifth fingers of both hands were long, and the second and third fingernails of the left hand appeared to have broken off and had rough edges. Observation on 3/22/18 at 8:41 a.m. revealed that the fifth fingernails on both hands remained long, as well as the thumbnail of the left hand. Continued observation revealed that the other fingernails of the left hand were shorter, but had rough edges. 3. Review of R #112's care plan for required extensive assistance with ADLs, last reviewed on 3/6/18, revealed a goal that she would be clean and well groomed daily through the next review. Review of the approaches for this care plan revealed to provide grooming care support daily. Further review of her care plans revealed that none were seen for refusal of care. Observation on 3/20/18 at 12:26 p.m., 3/21/18 at 3:18 p.m., and 3/22/18 at 8:47 a.m. revealed that all fingernails of R #112's right hand, except the fourth finger, were long, especially her thumb. Observation of the resident's left hand at this time revealed that all of her nails were short. During interview with the Director of Nursing (DON) on 3/23/18 at 11:35 a.m., she verified that R #11, R #85, and R #112's fingernails needed to be cut. 4. Review of R Q's Admission MDS dated [DATE] revealed that she had a BIMS score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment). Review of R Q's self care deficit care plan due to inability to perform ADLs and mobility independently, dated 12/27/17, revealed a goal that all daily care needs would be met. Review of the approaches for this care plan revealed an approach to assist with bathing/showering as scheduled and prn (as needed). Further review of her care plans revealed that none were seen for refusal of care. During interview with R Q on 3/20/18 at 2:52 p.m., she stated that she got a shower once a week, and would like one twice a week. She further stated that she did not get a bed bath on the days she did not get a shower. During interview with R Q on 3/21/18 at 3:22 p.m., she stated that she did not get a shower that day, and could not remember the last time she had gotten a bed bath. Interview with a family member of R Q at this time revealed that the last time she had a bath was about a week ago. Cross-refer to F 677. 5. Review of the Admission Minimum Data Set (MDS) Assessment for R X dated 1/19/18 revealed a BIMS summary score of 13, indicating no cognitive impairment. During an interview on 3/20/18 at 9:57 a.m. with R X, she stated she does not receive her showers three days a week as scheduled on Tuesday, Thursday and Saturday. Review of the ADL care plan for R X dated 1/12/18 identified the resident requires assistance with ADLs related to limited mobility secondary to left [MEDICAL CONDITION] from recent right sided [MEDICAL CONDITIONS]. Review of the goal documented All daily care needs will be met. Review of an Approach documented Bathing- 1- staff members to assist with bathing/showering needs. Transfers: 1 staff members to assist with transfers. Review of the ADL Flow Record and the Skilled Daily Nurses Note revealed no evidence that R X received her scheduled showers on 1/13/18, 1/16/18, 1/20/18, 1/23/18, 1/25/18, 1/28/18, 1/30/18, 2/1/18, 2/3/18, 2/6/18, 2/8/18, 2/10/18, 2/13/18, 2/17/18, 2/20/18, 2/22/18, 2/24/18, 2/27/18, 3/6/18, 3/8/18, 3/10/18, 3/13/18 and 3/15/18. Interview on 3/22/18 at 4:45 p.m. with the Rehab Unit Manager LPN AA revealed if there is no documentation on the CNA ADL Flow Record it means they either did not document that a shower was given or they did not provide a shower that day. Cross Refer F677",2020-09-01
815,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2018-03-23,677,E,0,1,YGXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to provide activity of daily living (ADL) care related to showers as scheduled for two residents (R) (R Q and X), and nail care for three residents (R #11, R #85, and R #112). The sample size was 39 residents. Findings include: 1. Review of R#11's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#11's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 6 (a BIMS score between 0 and 7 indicates severe cognitive impairment); she did not reject care; and she needed extensive assistance for personal hygiene. Review of R#11's care plan for daily assistance with ADLs included an approach to assist with grooming daily and as needed. Further review of her care plans revealed that none were seen for refusal of care. Observation on 3/20/18 at 11:10 a.m. and 3/21/18 at 9:07 a.m. revealed that R#11's chin was extensively covered with hair, and her fingernails were untrimmed and some appeared jagged. Observation on 3/21/18 at 3:25 p.m. and 3/22/18 at 8:37 a.m. revealed that R#11's chin hairs had been removed, but all of her fingernails remained long, and the nail polish had chipped away. An interview with the resident during these observations revealed that she liked her fingernails shorter than they were. During interview with Certified Nursing Assistant (CNA) GG on 3/22/18 at 2:45 p.m., she stated that her resident assignment was on the CNA's assignment sheet, which also told her what each resident's care needs were. She stated during continued interview that showers were given three times a week, and the schedule was listed on the CNA assignment sheet and in the shower book. CNA GG further stated that on shower days, she bathed the resident, washed their hair, cut their nails, brushed their teeth, and shaved them. During an interview with the Director of Nursing (DON) on 3/23/18 at 11:35 a.m., she stated that facial hair was typically removed on shower days and as needed, and that nail care was done on the shower day and prn (as needed). She further stated that the CNA's usually did the ADL care, but that the nurses could, too. She stated during continued interview that showers, nail care, and shaving were documented on the CNA's Bath Schedule form, and/or the CNA's ADL Flow Record. The DON verified that the fingernails of both of R#11's hands were long during interview at this time. Review of a CNA schedule dated 3/22/18 revealed that R#11's bath days were Monday, Wednesday, and Friday. Review of Bath Schedule forms dated 3/12/18, 3/14/18, and 3/19/18 revealed that the column for fingernails trimmed and shaved was not documented at all for R#11. Review of a Bath Schedule form dated 3/16/18 revealed that n (no) was circled in the column for fingernails trimmed and shaved for R #11. 2. Review of R#85's Quarterly MDS dated [DATE] revealed that she had a BIMS score of 5, did not reject care, and she needed extensive assistance for personal hygiene. Review of a care plan for R #85 revealed that she received assistance daily with ADLs, and an approach to assist with daily hygiene and grooming. Further review of the care plans revealed that none were seen for refusal of care. Observation of R#85's fingernails on 3/20/18 at 3:55 p.m. and 3/21/18 at 9:13 a.m. revealed that the nails on the fifth fingers of both hands were long, and the second and third fingernails of the left hand appeared to have broken off and had rough edges. During interview with the resident at this time, she stated that she liked her fingernails shorter than this. Observation on 3/22/18 at 8:41 a.m. revealed that the fifth fingernails on both hands remained long, as well as the thumbnail of the left hand. Continued observation revealed that the other fingernails of the left hand were shorter, but had rough edges. Interview with R#85 at this time revealed that she liked her fingernails shorter, but that she could not clip them herself. Review of the inside cover of the Station 2 Shower Sheets notebook revealed a notation that nails were to be inspected and trimmed during the shower or bed bath. During interview with the DON on 3/23/18 at 11:35 a.m., she verified that the fingernails of R#85's left hand were jagged and rough, and that the fifth fingernail of the right hand was long. During interview with R#85 at this time, she stated that someone could trim them for her. Review of a CNA schedule dated 3/23/18 revealed that R#85's bath days were Tuesday, Thursday, and Saturday. Review of Bath Schedule forms dated 3/13/18, 3/15/18, 3/17/18, and 3/22/18 revealed that there was no documentation recorded for the column fingernails trimmed for R#85, and on 3/20/18 this column was circled as n (no). 3. Review of R#112's clinical record revealed that she had [MEDICAL CONDITION] (paralysis on one side of the body); [MEDICAL CONDITION] (loss of ability to understand or express speech); and dementia. Review of R#112's Quarterly MDS dated [DATE] revealed that a BIMS assessment could not be conducted because the resident was rarely or never understood, had short-term and long-term memory problems, and severely impaired cognitive skills for daily decision making. Further review of this MDS revealed that she was totally dependent for personal hygiene. Review of R#112's ADL care plan revealed that she required extensive assistance with ADLs, and approaches included to provide grooming care support daily. Further review of her care plans revealed that none were seen for refusal of care. Observation on 3/20/18 at 12:26 p.m., 3/21/18 at 3:18 p.m., and 3/22/18 at 8:47 a.m. revealed that all fingernails of R#112's right hand were long, especially her thumb, except for her right fourth finger was shorter. Observation of the resident's left hand at this time revealed that all of her nails were short. During interview with the DON on 3/23/18 at 11:35 a.m., she verified that the fingernails of R#112's right hand were long except for the fourth fingernail, and did not know why the right hand had short fingernails when the left hand fingernails were long. Review of a CNA schedule dated 3/22/18 revealed that R#112's bath days were Tuesday, Thursday, and Saturday. Review of Bath Schedule forms dated 3/15/18 and 3/20/18 revealed that the column for fingernails trimmed was blank, and this column was documented as n (no) on 3/13/18, 3/17/18, and 3/22/18 for R #112. 4. Review of R Q's Admission MDS dated [DATE] revealed that she had a BIMS score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment). Review of her Preferences for Customary Routine section of the MDS revealed that it was very important for her to choose the type of bath she wanted. Further review of the MDS revealed that she needed physical help in part of bathing activity, the activity of walking did not occur, and she needed extensive assistance for transfers and locomotion on and off the unit. Review of R Q's care plan for self care deficit due to inability to independently perform ADLs and mobility revealed an approach to assist with bathing/showering as scheduled and prn (as needed). Further review of her care plans revealed that none were seen for refusal of care. During interview with R Q on 3/20/18 at 2:52 p.m., she stated that she got a shower once a week, and would like one twice a week. She further stated that she did not get a bed bath on the days she did not get a shower. During interview with R Q on 3/21/18 at 3:22 p.m., she stated that she did not get a shower that day, and could not remember the last time she had gotten a bed bath. Interview with a family member of R Q at this time revealed that the last time she had a bed bath was about a week ago. During interview with the DON on 3/23/18 at 11:35 a.m., she stated that R Q's scheduled shower days were Monday, Wednesday, and Friday on the 3:00 p.m. to 11:00 p.m. shift, and verified that R Q's name was not consistently included on the Bath Schedule form. She stated during further interview that a part-time employee was supposed to update the Bath Schedule to ensure that it reflected the residents currently in each room, but that it appeared staff were copying an old Bath Schedule that did not have R Q's name on it. The DON further stated that the only places a shower would be documented was on either the ADL Flow Sheet or the Bath Schedule form. Review of a CNA schedule dated 3/23/18 revealed that R Q's bath days were Monday, Wednesday, and Friday. Review of Station 2 Shower Sheets from 3/12/18 through 3/23/18 revealed that there was no documentation of R Q receiving a shower. Review of R Q's ADL Flow Records from 1/1/18 through 3/22/18 revealed that there were either blanks or an 8-8 written in for bathing for the entire 81-day time period, except nine times there was documentation that she received a bath or a shower, and that she refused a bath or shower twice. During interview with the Regional MDS Registered Nurse (RN) HH on 3/23/18 at 1:50 p.m., she stated that any documentation of an 8-8 meant that the activity did not occur. 5. Record review for R X revealed re-admission to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 13, indicating no cognitive impairment. Section G- Functional Status assessed that R X required extensive assistance with transfers, personal hygiene and physical help in part of bathing. The Care Area Assessment (CAA) triggered Activities of Daily Living (ADL) Function/Rehabilitation Potential with the decision to be care planned. During an interview on 3/20/18 at 9:57 a.m. with R X, she stated she is okay with her shower schedule if I would get my showers. R X stated she does not receive her showers three days a week as written on her dry erase board. Observation of the dry erase board hanging on the resident's wall in her room read Showers Tuesday, Thursday, and Saturday 3-11. She stated a certain Certified Nursing Assistant (CNA) on the 3:00 p.m. to 11:00 p.m. shift does not give her showers. R X stated a dayshift CNA tries to give her a bed bath when she can. R X stated her daughter made complaints about the evening CNA and she heard the CNA was suspended. Observation of the resident's room at the time of the interview revealed a large private shower with a shower chair. R X stated the staff doesn't want to use the shower chair in her shower because they want the one that has wheels. R X stated it's easier to transfer her to the shower with the chair that has wheels but they don't want to take the time to go and get that chair. Review of the Shower Record for R X documented SR x 2 shower chair, Assist x 1, Tuesday, Thursday, Saturday. Review of the CNA ADL Flow Record for R X revealed no documentation that the resident received a shower on the following days: Sat-3/3/18, Tues-3/6/18, Thurs-3/8/18, Sat-3/10/18, Tues-3/13/18, Thurs-3/15/18. (MONTH) (YEAR) documented Code #8 (Activity did not occur) on Thurs- 2/1/18, Sat- 2/3/18, and Sat 2/10/18. There was no documentation on Tues- 2/6/18, Thurs-2/8/18, Tues- 2/13/18, Sat- 2/17/18, Tues-2/20/18, Thurs- 2/22/18, Sat- 2/24/18 and Tues- 2/27/18. There was no ADL Flow Record for (MONTH) (YEAR). Interview on 3/22/18 at 4:45 p.m. with the Rehab Unit Manager LPN AA revealed they have not been able to locate the ADL Flow Record for (MONTH) (YEAR). She stated that if there is no documentation on the CNA ADL Flow Record it means they either did not document that a shower was given or they did not provide a shower that day. She stated there is no way of knowing. Interview on 3/23/18 at 1:40 p.m. with the MDS Regional Coordinator revealed they were unable to locate the ADL Flow Record for the R X in (MONTH) but that the nurse's also document in the Skilled Daily Nurses Note under Functional Status and Activity of ADLS. Review of the Skilled Daily Nurse's Notes revealed the following documentation for bathing: On 3/3/18: D (dayshift) #8 (Activity did not occur), [NAME] (Evening shift) no documentation, N (Night shift) #8 On 3/6/18: D- #3 (Extensive assistance), E- #3, N- #8 On 3/8/18: D- #3, E- #3, N- #8 On 3/10/18: D- #3, E- no documentation, N- #8 On 3/13/18: D- #2 (Limited assistance), E- #2, N- #8 On 3/15/18: D- #2, E- #3, N- #8 On 2/1/18: D- #3, E- no documentation, E- #8 On 2/3/18: D- #8, E- no documentation, E- #8 On 2/6/18: D- #3, E- #3, N- #8 On 2/8/18: D- #3, E- #3, N- #8 On 2/10/18: D- #8, E- no documentation, N- #8 On 2/13/18: D- #8, E- #3, N- #8 On 2/17/18: D- #8, E- no documentation, N- #8 On 2/20/18: D- #3, E- #3, N- #8 On 2/22/18: D- #3, E- #3, N- #8 On 2/24/18: D- #8, E- no documentation, N- #8 On 2/27/18: D- #2, E- #2, N- #8 On 1/13/18: D- #8, E- no documentation, N- no documentation On 1/16/18: D- #3, E- no documentation, N-no documentation On 1/20/18: D- #0 (Independent), E- no documentation, N- no documentation On 1/23/18: D- #8, E- no documentation, N- no documentation On 1/25/18: D- #8, E- #8, N- #3 On 1/28/18: D- #8, E- no documentation, N- #8 On 1/30/18: D- #8, E- no documentation, N- no documentation",2020-09-01
816,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2018-03-23,690,D,0,1,YGXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the policy titled Catheter (Indwelling) Insertion and Removal of (Female and Male), family and staff interviews, the facility failed to obtain Physician orders related to catheter care and failed to ensure placement of a catheter strap in accordance with facility policy and the General Admisssion Information form for one resident (R) (#235) that was admitted to the facility with a urinary catheter. The sample size was 39 residents. Findings include: Review of the facility policy titled Catheter (Indwelling) Insertion and Removal of (Female and Male) documented in Insertion of Indwelling Catheter- Equipment which included Catheter Strap. Documented under Procedure #12 Tug gently on catheter until you fell resistance. Secure to leg with catheter strap. Allow sufficient slack for adequate movement. Record review for R#235 revealed he was readmitted to the facility after a hospital stay on 3/16/18 with [DIAGNOSES REDACTED]. Review of the hospital records dated 3/14/18 revealed a Cystoscopy showed bleeding from the prostate and that the resident was stable with no intervention needed at this time, continue Foley for now. Review of a listing of R#235's completed and transmitted Minimum Data Set (MDS) revealed a Discharge Assessment- Return not anticipated dated 2/12/18 and an Entry Tracking Record dated 3/16/18. An Admission MDS assessment had not yet been completed and transmitted. Review of the General Admission Information form dated 3/16/18 documented in section Continence Assessment that the resident had an indwelling catheter for a [DIAGNOSES REDACTED]. This section specified Verify the following orders for indwelling catheter care are written: Order written for catheter (must include the bulb size), Leg strap placement check q (every) shift, Change catheter q month, Date of month to be changed. There were boxes with Yes to verify that the orders had been written, however, these boxes indicating Yes had not been checked. Observation on 3/20/18 at 11:29 at a.m. revealed the R#235 lying in bed with a urinary catheter in place. There was blood tinged urine in the collection bag and the catheter connective tubing. There was no catheter strap in place and the resident was wearing a brief. Observation on 3/21/18 at 5:30 p.m. revealed R#235 lying in bed with three family members at the bedside. There was blood tinged urine in the collection bag and in the catheter connective tubing. There was no catheter strap in place to secure the urinary catheter. An interview with the family at the time of the observation revealed R#235 had bleeding in his urine at the hospital and they were not sure what the bleeding was from. They stated that the bleeding had gotten a little better prior to being admitted to the facility. The family stated he had a scope and they found that his prostate was very large and blocking urine from coming out. The family of R#235 further stated that when the resident was in the hospital he had a tape device that held his catheter on his leg. During observation on 3/22/18 at 10:20 a.m. with the Director of Nursing (DON), she pulled the bedding back from the resident and confirmed there was no leg strap in place to secure the urinary catheter. The DON stated that a leg strap is to be kept in place to ensure that the catheter does not pull on the meatus. She stated that the nurses are responsible for ensuring the leg strap is in place each shift. The DON stated catheter care is performed by the CNAs and they report any concerns to the nurse. She stated the nurse charts that catheter care was conducted in the Quick MAR and that catheter care consist of washing the penis and catheter, patency, urine, and signs and symptoms of infection. Interview on 3/22/18 at 10:30 a.m. with the Licensed Practical Nurse (LPN BB) in care of R#235 revealed a leg strap is to be in place and that she is responsible for ensuring the leg strap is in place. LPN BB stated the R#235 was just admitted last Friday and she did not work Friday or the weekend but had been on duty since Monday 3/19/18. LPN BB further stated that she had not checked R#235 to ensure that a catheter strap was in place. LPN BB showed the leg strap that they use for catheters, called Cath Secure Multi Purpose Tube Holder and stated she was going to place the leg strap on R#235 right now. Review of the Physician's Orders revealed the following orders were not obtained until 3/19/18: 1. Perform Foley catheter care Q shift (every shift) and PRN (as needed). Ensure placement of Foley catheter strap, Schedule: Daily 00:00 to 07:29, Daily 07:30 to 15:29, Daily 15:30 to 23:59 2. Change Foley catheter every month on the 17th and PRN Interview on 3/22/18 at 1:35 p.m. with the Certified Nursing Assistant (CNA CC) revealed she provides catheter care for R#235 with every brief change. CNA CC stated she had only worked yesterday (3/21/18) and today. CNA CC stated that she did notice yesterday (3/21/18) that there was no catheter strap in place and that the nurses are responsible for the catheter straps. She stated she did see LPN BB place one on the resident today. Review of the Treatment Administration Record (TAR) revealed documentation for catheter care and assessment for placement of the catheter strap began on the evening shift (3:30 p.m. to 11:59 p.m.) on 3/19/18. Interview on 03/22/18 at 2:47 p.m. with the Rehab Unit Manger LPN AA revealed she entered orders for R#235 when he was admitted . She stated that she does not personally assess the resident and was not aware he had a catheter. She stated that when they had a clinical meeting on 3/19/18 and became aware of that R#235 had a urinary catheter and entered orders for catheter at that time on 3/19/18. Interview on 3/22/18 at 4:03 p.m. with the Registered Nurse (RN DD) who admitted the resident on 3/16/18 revealed she is not responsible for putting in orders. RN DD stated the Unit Manager receives the orders prior to admission and puts the orders in. RN DD stated she assessed R#235 and she did notice the resident had a urinary catheter. RN DD stated she should have obtained orders for catheter care when she noticed there were no orders on the Quick MAR but she did not. Interview on 3/22/18 at 4:45 p.m. with the DON revealed the facility has a library set of orders for catheter care and any nurse on any of the shifts from 3/16/18 to 3/19/18 could have and should have entered the orders.",2020-09-01
817,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2018-03-23,925,E,0,1,YGXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to follow pest control company recommendations to help reduce the potential for rodents and other pests. The facility census was 141 residents (R), and the sample size was 39. Findings include: During interview with R#129 on 3/19/18 at 7:17 p.m., he stated that in the past month they had caught two mice in his room. Observation at this time revealed sticky traps positioned under his air conditioner unit, and behind his nightstand. Review of R#129's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment). Review of his clinical record revealed that he was admitted to the facility on [DATE]. During interview with R#40 on 3/20/18 at 12:00 p.m., she stated that there had been a problem with rodents and bugs about six months ago, but that she had not seen any recently. Review of R#40's Annual MDS dated [DATE] revealed that she had a BIMS score of 15. During interview with R#129 on 3/20/18 at 2:59 p.m., he stated that the last time he had seen a mouse in a trap was about ten days ago. He further stated that his roommate (R#31) had a package of sugar in her nightstand, and a visitor noted that there were rat pellets in the nightstand drawer, and the sugar packages had been torn into and eaten. R#129 further stated that he had seen a total of four mice in his room since admission, each about four inches long. During interview with R #31 on 3/20/18 at 3:05 p.m., she stated that she had seen three mice since she was admitted to the facility. Review of R#31's clinical record revealed that she was admitted on [DATE], and the BIMS score on her Admission MDS dated [DATE] was 15. Review of Pest Prevention Service Reports from the facility's contracted pest control company revealed that the last visit was on 3/14/18, and included a critical recommendation to pull pine straw away from building approximately 12-inches to prevent pest harborage. Further review of Pest Prevention Service Reports revealed that this recommendation was also made on 2/20/18, 2/6/18, 1/23/18, 1/9/18, 11/28/17, 11/7/17, 10/26/17, 10/18/17, 10/2/17, 9/13/17, 8/17/17, 7/25/17, 7/6/17, 6/21/17, 6/12/17, and 6/1/17. Further review of Pest Prevention Service Reports revealed the following: On 10/26/17, light mouse activity was noted in two resident rooms on the 200-hall, and the exterior. On 7/6/17, light activity for mice was noted. On 6/8/17, commented that several glueboards were inspected throughout the facility, and one field mouse was removed. During interview with the Maintenance Director on 3/23/18 at 8:10 a.m., he stated that there had been recent problems with mice in three rooms on the 300-hall, two rooms on the 200-hall, and one room on the 400-hall. He further stated that the mice were gone for awhile around Thanksgiving and had spotty activity after that, but got worse again this past month. The Maintenance Director stated during further interview that the last mouse caught was in February, and there had been a few roaches caught in the sticky traps he put out. He verified during further interview the repeat critical recommendations made by the pest control company to pull the pine straw away from the building approximately 12-inches to prevent pest harborage and to make the traps more effective, and stated the pest company workers usually pulled the straw away when they were there. He further stated that when the lawn service company came weekly, their workers pushed the pine straw back against the building, despite him telling them not to. During observation of the exterior wall of the 200-hall at this time, the Maintenance Director verified that there was several inches of pine straw pushed against the foundation walls.",2020-09-01
818,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2017-04-28,278,D,0,1,8CRI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure that the annual Minimum Data Set (MDS) assessment accurately reflected the dental status for one resident (#186) and failed to ensure that a comprehensive MDS assessment was accurately identified as an annual assessment for one resident (#157). The sample size was 28. Findings include: 1. During an observation conducted on 4/25/17 at 3:15 p.m., the upper front teeth of Resident (R) #186 were noted to be broken and blackened. Review of the annual MDS assessment for R#186 with a reference date of 2/21/17 revealed the resident was assessed on Section L - Oral/Dental Status - as having no dental issues. Interview on 4/28/17 at 4:50 p.m. with the MDS Coordinator, CC, revealed the dental status of R#186 was coded incorrectly on the annual MDS dated [DATE]. The MDS coordinator's assessment of the resident after examination of his teeth was that he has bad teeth which are broken, missing, and brown on the top. The MDS nurse responsible for completing the MDS is expected to examine the resident's teeth prior to completing the dental section of the MDS to ensure accuracy. This examination may not have been done in this instance. The resident should have been coded as D - obvious or likely cavity or broken teeth - and not Z - none of the above. DONE 2. A review of the clinical record for R#157 revealed that registered nursing staff had completed a comprehensive MDS assessment with an Assessment Reference Date (ARD) of 1/12/17. However, the assessment was inaccurately coded as an Admission assessment, instead of an Annual assessment. During an interview on 4/28/17 at 2:55 p.m., MDS Coordinator AA confirmed that the 1/21/17 comprehensive MDS assessment should have been an Annual MDS, not an Admission MDS.",2020-09-01
819,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2017-04-28,282,D,0,1,8CRI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document the amount of enteral nutrition received every shift, as care planned, for one resident (#67) from at total sample of 28 residents. Findings include: Resident (R) #67 had a care plan, since 8/13/15, for receiving enteral tube feedings related to a [DIAGNOSES REDACTED]. However, a review of the clinical record revealed no evidence that licensed nursing staff were documenting the amount of enteral nutrition the resident received through her gastrostomy tube, as care planned. During an interview on 4/28/17 at 10:20 a.m., the Director of Nursing (DON) confirmed that licensed nursing staff had not documented the resident's daily intake of enteral nutrition. Cross refer to F325",2020-09-01
820,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2017-04-28,325,D,0,1,8CRI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to accurately determine the nutritional intake for one resident with a gastrostomy tube (#67) from at total sample of 28 residents. Findings include: Resident (R) #67 received all nutritional and fluid intake through a gastrostomy tube. There was a care plan in place, since 8/13/15, for receiving enteral tube feedings related to a [DIAGNOSES REDACTED]. However, a review of the clinical record revealed no evidence that licensed nursing staff were documenting the amount of enteral nutrition the resident received through her gastrostomy tube, as care planned. There was a physician's orders [REDACTED]. During an interview on 4/28/17 at 10:12 a.m., Licensed Practical Nurse (LPN) BB stated that the resident's gastrostomy tube pump was placed on hold when staff provided Activities of Daily Living (ADL) care. When care was completed, the pump was restarted for the nutritional feeding to continue. However, when the Registered Dietician (RD) assessed the resident's nutritional intake on 3/3/17 and 3/23/17, she failed to factor in the time the nutritional feeding would be placed on hold during care, and not infusing, when determining if the nutritional order met the resident's nutritional needs. During an interview on 4/28/17 at 10 a.m., the RD stated she assumed the gastrostomy tube pump would be kept running (from 7 p.m. to 10 a.m.), even while staff provided care and that the nutritional order was being executed as written. A review of the resident's weights revealed that the weight had increased from 111.6 pounds on 2/27/17 (hospital return date) to 114.4 pounds on 4/17/17. During an interview on 4/28/17 at 10:20 a.m., the Director of Nursing (DON) confirmed that licensed nursing staff had not documented the resident's daily intake of enteral nutrition.",2020-09-01
821,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2019-05-02,550,D,0,1,DXIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and the facility policy titled Dignity and Quality of Life Policy, the facility failed to maintain dignity to one resident (R), R#126, who has a biliary bag of 44 sampled residents. Findings include: Record review of policy titled Dignity and Quality of Life Policy stated the following: To promote care of residents in a manner and in an environment, that maintains or enhance each resident 's dignity and respect and full recognition of his or hers individuality. The resident has the right to -be treated with dignity, respect and consideration at all times; privacy in the treatment and care of your personal needs. Record review of the resident's medical record revealed [REDACTED]. Review of the Admission Nursing Assessment, dated 4/16/19, revealed that resident was assessed as being cognitve and oriented times three. and that the resident was admitted for rehabilitation purposes only. Review of Nurse's note dated 4/26/19 at 7:15 a.m. stated that resident was seen at a local hospital for a special procedure and returned to the facility on the same day at 12:00 p.m. with biliary drainage tube. An observation on 4/30/19 at 10:22 a.m. revealed the resident sitting in his wheelchair in the rehab therapy room with six other residents. The resident's catheter bag, that included a cholecystectomy tube (biliary drainage tube), was not covered exposing dark yellow bile and urine in the catheter bag. An interview with the resident on 4/30/19 at 4:01 p.m. revealed that he was unaware and received no education from staff that his catheter and biliary bag should be covered. The resident stated that he would had like for staff to provide covering so no one will see his business. An interview on 5/2/19 at 11:55 a.m. with Licensed Practical Nurse (LPN) HH revealed her expectations are for residents to always have attached bags covered to ensure privacy. She further stated that at one time staff used a pillow case for the resident's biliary bag. An interview with on the Director of Nursing (DON) on 5/1/19 at 2:58 p.m. revealed that she expects the biliary tube bag to be covered. She further stated that she was not sure if her staff had received any in-service training on ensuring dignity care for residents who have a catheter/ biliary bag.",2020-09-01
822,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2019-05-02,580,D,0,1,DXIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and review of the facility policy titled To Provide Direction /Guidance in Reference to Change of Conditions and the Hospice contract agreement policy titled Nursing Facility Agreement dated 1/2/19 the facility failed to provide notification to the Physician and Hospice staff about one Resident (R) W draping a call light around his neck and across his shoulders of 44 sampled residents. Findings include: Review of policy titled To provide direction/guidance in reference to changes of conditions revealed, It is the policy of the facility to notify the MD/NO/PA (Medical Director/Nurse Practitioner/Physician Assistant) of any change of condition regarding the patient. When a change of condition or change from baseline is observed and reported, the licensed nurse is responsible to evaluate the resident 's condition. The nursing supervisor on duty is also notified regarding the change in condition. The SBAR (Situation Background Assessment Recommendation) is then completed and sent to the provider for review. Record review of R W revealed an admission date of [DATE] with a [DIAGNOSES REDACTED]. Review of Physician Orders (POF) and the Medication Administration Record [REDACTED]. The resident was receiving [MEDICATION NAME] 100 milligrams (mg) in the morning and 200 mg at HS (hour of sleep). Review of the Quarterly Minimum Data Set (MDS) assessment that was completed on 10/23/18 revealed a Brief Interview Mental Status (BIMS) score of two, with no behaviors assessed. Review of the Quarterly MDS completed on 1/17/19 indicates a BIMS score of four, with no behaviors assessed. A BIMS score of two or four out of 15 indicates severe cognitive impairment. Record review of Hospice record revealed that R W was admitted to Hospice on 1/13/18. The Hospice primary admitting [DIAGNOSES REDACTED]. Record review of Nurse Notes dated 9/16/18 (no specific time given), 10/7/18 at 2:00 a.m., 10/7/18 at 4:00 p.m., 10/7/18 at 8:00 p.m., and 10/15/18 at 11:00 p.m. revealed separate incidents of RW wrapping call light around his neck. There was no documentation evidence, in the record, to indicate that Hospice and/ or the Physician were notified of the incidents. An observation on 4/29/19 at 1:10 p.m. and on 4/30/19 at 4:52 p.m., revealed R W lying in bed, with his eyes closed with the call light attached and within reach. An observation on 5/1/19 at 10:40 a.m., revealed R W to be alert and lying in bed with the call light attached to the bed and within reach. Family was present in room visiting at that time. An observation on 5/2/19 at 8:10 a.m., revealed R W to be alert, call light removed and bell within reach. Also, observed R W lying in bed, HOB (head of bed) elevated with a Certified Nursing Assistant (CNA) WW, feeding the resident his breakfast. CNA WW reported that he is providing monitoring (as a sitter) and has been authorized by the Administrator to sit with resident for eight hours. After the incident was identified during the survey and brought to the Director of Nursing (DON) attention on 5/1/19 at 2:00 p.m., the DON reported that she was unaware of the incidents. She further stated that the licensed nursing staff who wrote the nurse notes were no longer employed with the facility. Further interview with the DON on 5/1/19 at 2:27 p.m. revealed that R W was only draping the call light around his neck and shoulders. The call light was never observed by staff to encircle his neck. DON reported that information was provided by a Certified Nursing Staff (CNA) UU. She further stated that this was a known habit of this resident. The DON described R W as having periods of confusion. The DON revealed that R W was described as being nonsuicidal and has no history displaying behaviors of trying to hurt himself. During an interview on 5/1/19 at 4:15 p.m., the Family Member of R W revealed that the facility contacted the family today about sending RW out for a psych eval (psychological evaluation) earlier today. The family did not want a psych evaluation and were aware of an incident of R W wrapping call light around his neck and did not view the incident as R W trying to harm himself. The Family Member described the resident's behavior of wrapping the call light around his neck as being scared and fear that he would lose it (meaning the call light) and not wanting his room door closed. She stated that R W would never harm himself and that the resident denied trying to harm himself when she asked him. She was not sure the exact date the incident occurred and felt that it happened in (MONTH) or (MONTH) of (YEAR). An interview with the DON and the Administrator on 5/1/19 at 5:40 p.m. R W draping the call light around his neck on at least three occasions revealed that the Administrator was not aware of these incidents. The Administrator revealed the facility approach to ensure R W safety is to evaluate the resident to see if he could use a hand-held bell to call for assistance, and if so, would remove the call light. The DON revealed there was no evidence that the Physician was notified of the incidents. An interview with CNA UU on 5/1/19 at 5:40 p.m. revealed that she found the resident in his room about four or five months ago, with his call light draped around his neck. She reported that the positioning of the call light did not place the resident at risk/ jeopardy of choking himself although she informed the resident not to drape the call light cord around his neck. She revealed that the resident had been instructed to use his call light if there was an emergency or he needed something. CNA UU revealed that the cord was removed from R W's neck, placed at his bedside and the Licensed Practical Nurse (LPN) was notified. The CNA was unable to remember which LPN was notified and was not aware that the resident had ever done this before. An interview with the Physician on 5/1/19 at 6;00 p.m. revealed that he had not been notified about the incident until 5/1/19. He stated that due to resident 's [DIAGNOSES REDACTED]. He further stated that the resident was wrapping the call light around his neck for placement purpose and to use so he will be able to reach it and have contact with others. He further stated that the call light was never in a loop (a loop would had been a concern). When asked if he would had put any intervention in place of the time of the incident occurrence providing he received notifications? He stated no, because R W has medications to calm him ([MEDICATION NAME]) When asked if he felt the increase in [MEDICATION NAME] made a difference in R W's behavior? He stated no. An interview with the Administrator on 5/1/19 at 7:10 p.m. revealed that she was putting in place the following: a staff( to serve as a sitter) to provide 1:1 throughout the night and ongoing until her team decide on how to ensure safety. Staff will log information on the staff who will be sitting starting tonight She stated that the call light has been removed and R W was given a bell to use. An interview on 5/2/19 at 12:46 p.m., with the Hospice Register Nurse (RN) revealed that notifications in regard to the incidents of R W draping call light around his neck and shoulder was not provided to Hospice until yesterday afternoon by the DON. She stated that the Hospice policy clearly states that certain incidents are mandatory reporting. This incident would had been categorized as critical- and entered in the Triage system. She reported that she has researched the triage and there were no calls recorded from the facility. She further reported that she does not feel that R W is suicidal or want to harm himself. She stated that the resident has a fear of being left alone, want the door be open, becomes afraid at night and use to sleep with his finger on the call light. She stated that his fine motor skills are gone and he view the call light as a safety blanket. On 5/2/19 at 11:00 a.m., the DON presented a physician progress notes [REDACTED]. Record review of physician progress notes [REDACTED]. Patient has always been comfortable.",2020-09-01
823,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2019-05-02,583,D,0,1,DXIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain full visual privacy for one resident (R) (R#47) by not totally encircling the bed with the privacy curtains during a dressing change. In addition, the facility failed to provide personal privacy by not posting a sign in the resident room which was visible to others that included clinical information for one resident (R#74). The sample size was 44 residents. Findings include: Review of the facility Dignity and Quality of Life Policy, effective 12/2018 revealed: Purpose: To provide dignity, respect, and quality of life to all residents in the healthcare center. Procedure: To promote care of residents in a manner and in an environment that maintains or enhances each resident's dignity and respect and full recognition of his or hers individuality. The resident has a right to privacy in the treatment and care of your personal needs. Review of a Hospital Discharge Summary with an admission date of [DATE] and a discharge date of [DATE] revealed that R#47 had discharge [DIAGNOSES REDACTED]. Review of R#47's Physician order [REDACTED]. On 5/1/19 at 1:59 p.m., Licensed Practical Nurse (LPN) MM was observed changing the dressing over R#47's biliary drainage tube, which was located in the right upper quadrant of her abdomen. The LPN was observed to pull the privacy curtain between the two beds in the room, and then she pulled R#47's shirt up to her breasts to reveal the abdominal dressing. Also observed at this time was a female visitor for R#47's roommate, who was sitting in the corner of the room at the foot of the roommate's bed and next to the window, and the visitor was sitting at an angle such that she would be able to see past the privacy curtain between the two beds. At this time when R#47's shirt was pulled up but the dressing not yet removed, there was a knock on the hallway door and staff opened the door to ask LPN MM a question, before closing the door back. LPN MM had not pulled the privacy curtain on the hallway side of the room, so that R#47 could potentially be seen by anyone walking past the room in the hallway. After R#47's abdominal dressing was removed, there was a second knock on the hallway door, and LPN MM told them to come in, without covering the resident up or pulling the privacy curtain. Staff were observed to open the door to R#47's room about a quarter of the way, before closing the door back. After cleansing around the biliary tube site, LPN MM stated that she had forgotten a drain sponge, and left R#47 uncovered while she opened the hallway door to exit and re-enter the room with the drain sponge. After completing the dressing change, LPN MM pushed the privacy curtain completely back between the two beds before pulling R#47's shirt back down over her abdomen, and the visitor was still in the room as well as R#47's roommate, who was awake. During interview with LPN MM on 5/2/19 at 2:50 p.m., she verified that she did not pull the privacy curtains all the way around R#47's bed during the dressing change on 5/1/19, and said she must have forgotten. She verified during continued interview that the resident was potentially visible from the hall when the hallway door was opened, as well as potentially visible by the visitor in the room. LPN MM further stated that there were usually no visitors in the room when she did the dressing change, and guessed she could have asked them to step out. During interview with the Director of Nursing (DON) on 5/2/19 at 2:57 p.m., she stated that staff should pull the curtains around the bed when providing care for the resident, and ask a visitor to step out unless the resident requested for the visitor to be there. 2. Review of R#74's Annual Minimum (MDS) data set [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 2 (a BIMS score between 0 and 7 indicates severe cognitive impairment), and was always incontinent of bowel and bladder. During observations on 4/29/19 at 11:13 a.m., 4/30/19 at 8:12 a.m., and 5/1/19 at 7:58 a.m., a sign with large print was seen posted over the head of R#74's bed, and plainly visible by anyone in the room, which read: APPLY Z-GUARD REMEDY PASTE TO SACRUM AND BUTT[NAME]KS WITH EVERY BRIEF CHANGE! -WOUND CARE TEAM During interview with the DON on 5/2/19 at 10:15 a.m., she verified the sign above R#74's bed, and verified that it was a dignity concern. She stated during continued interview that she had told staff to take all of these types of signs down, and that it was the manager's responsibility to ensure that it was done.",2020-09-01
824,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2019-05-02,656,D,0,1,DXIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of policy titled Elopement Policy the facility failed to ensure that care plan interventions were followed for four of 44 Residents (R#25, R#64, and R#(W) related to care plan implementation of use of a contractive prevention device for R#25, and care plan development for wandering/elopement for R#64 and behaviors for R#(W). Findings include: 1. Review of the Elopement Policy, dated 12/2017 revealed: The elopement care plan is implemented once a patient has been identified as being at risk for elopement. Review of medical record for R#64 revealed that on 12/9/18 R#64 was displaying exit seeking behaviors as evidenced by pushing against exit doors and eventually exiting a door on 300 Hall before being redirected back inside of the facility. Exit seeking /wandering behaviors were also documented on 12/10/18, 12/18/18, and 12/26/18. An elopement assessment was completed for R#64 on 12/20/18 and indicated that resident was high risk for elopement. Further review of the record did not reveal a care plan for wandering/elopement. Interview on 4/30/19 at 5:16 p.m.with Registered Nurse (RN), MDS Coordinator EE and LL, who reported that MDS is responsible for creating the elopement care plan for residents at risk for elopement. RN MDS LL reported that she was unable to find an elopement care plan for R#64. Review of R#64's chart on 4/30/19 at 5:24 p.m. with Registered Nurse (RN) MDS PP revealed no wander or elopement care plan. Cross refer to F689 2. Record review of R#(W)'s medical record revealed a [DIAGNOSES REDACTED]. Record review of nurses notes from the time period of (MONTH) (YEAR) through (MONTH) (YEAR) revealed several incidents of R#(W) exhibting behaviors of draping the call light around his neck and shoulders due to periods of increase anxiety and agitations. Record review of R#(W)'s Minimum Data Set(MDS ) dated 10/23/18 that was assessed near the time frame the incidents were occurring revealed a Brief Interview Mental Status (BIMS) score of 2 (two). The most recent Annual MDS dated [DATE] reveals a BIMS score of 4 (four). A BIMS score of 2 or 4 out of a total score of 15 indicates cognitive severly impaired. During review of R#(W) 's plan of care dated 1/17/19, there was no notations/documentations that a care plan with interventions was developed to address the behaviors. During an interview on 5/1/19 at 5:30 p.m. with Administrator and the Director on Nurse (DON), the Administrator revealed that a new care plan will be developed to address R#(W)'s behaviors. The Administrator stated that the MDS Coordinator and licensed nursing staff are responsible for implementing and revising a resident's care plan to address any changes or concerns. The Administrator and the DON stated that they were unaware of R W's behaviors. The Administrator futher stated that her expectations are for the care plan to be developed as incidents/concerns occur. On 5/2/19 at 11:36 a.m., the DON presented a new care plan dated 5/1/19 with interventions to address R W 's behaviors thataddressed safety measures put in place. Interview on 5/2/19 at 1:00 p.m. with MDS Coordinator LL revealed that she was unaware of the behaviors/incidents of R#(W) draping the call light around his neck and shoulders.The MDS office staff should have been made aware of the situation so the care plan could have been developed in a timely manner She revealed that the care plan process requires a 7 (seven) day look back period of assessments services pertain to a resident care needs. The care plan development/revision process is based on the look back period. She further stated that all incidents/behaviors are discussed during the morning clinical meeting. Record review of the care plan policy titled Care Plan Policy read [NAME] It is the policy of the facility to have a patient centered care plan developed following the completion of the MDS assessment. [NAME] schedule for care plans will be developed and distributed to IDT and made available to the resident and or responsible party. Care plan revision will be updated to the care plan to reflect ongoing changes in the patient's condition or needs. Cross refer to 580 3. A record review revealed that R#25's admitting [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) of 12 indicating the resident was cognitively intact, special treatment of [REDACTED]. Review of the care plan revealed the resident had a contracture to the left hand with Restorative Nursing for range of motion (ROM)/splint application although it did not include the resident refusing to wear the splint. A review of the 'Restorative Care Flow Report' dated (MONTH) (YEAR) revealed the restorative activity of the splint is: left hand ROM bilateral upper extremity (BUE), wash and dry, apply carrot splint - wear for six-eight hours, remove at bedtime. Watch for redness or changes in skin and notify nurse. Review of the Physician order [REDACTED]. Review of the monthly nursing summary dated 9/8/18 revealed that the resident refuses to wear the carrot in her hand for contractures to the fingers; that staff place the carrot splint and the resident quickly removes it. Review of Restorative Nursing Notes from 11/7/18 to 3/21/19 revealed that the resident participates well with restorative and is maintaining function. An observation on 4/29/19 at 10:55 a.m. revealed the resident sitting up in a reclining chair with her feet elevated in her room, and with no carrot splint in her left-hand which was contracted. An observation on 4/29/19 at 12:16 p.m. revealed the resident in her room and a Certified Nursing Assistant (CNA) placed the carrot splint in her left hand. After a minute, the resident removed the carrot splint and stated that she did not like it. An observation on 4/30/19 at 3:44 p.m revealed the resident in bed with no carrot splint in her left hand. The resident agreed to allow observation of her hand and a slight odor was noted; she can only open her thumb and 1st finger (per resident demonstration) and long nails observed on the other three contracted fingers. The resident denied any pain related to the palm area. An observation on 5/1/19 at 9:53 a.m. revealed the resident in her bed with her eyes open and with no carrot splint in place. She stated that she does not like to use it and will tell them no when they ask. Review of Restorative flow record documentation for the resident revealed for (MONTH) 2019 of numerous refusals related to the carrot splint wearing, other days reveal two to five hours of wearing the splint. An interview on 5/2/19 at 8:22 a.m. with MDS Coordinator Registered Nurse (RN) EE (who oversees the restorative program), stated that she had referred the resident to therapy on 4/29/18 due to refusals for wearing the carrot splint during the month of April. She stated that they do not get Physician order [REDACTED]. She stated that therapy had changed the recommendation from eight hours to four to six hours back in (MONTH) 2019. An interview on 5/2/19 at 1:50 p.m. with an agency CNA FF, who stated that the CNAs apply the splints and if the resident refuses, they will tell the charge nurse and then document the information in the activity of daily living (ADL) book on the restorative form. She stated that the CNAs do the restorative for their own residents.",2020-09-01
825,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2019-05-02,689,D,0,1,DXIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of policy titled Elopement Policy the facility failed to assure that quarterly elopement risk assessments were completed, and the elopement book was updated for one Resident (R#64) of 44 sampled residents. Findings included: Review of the Elopement Policy, dated 12/2017 revealed: Elopement Definition: When a resident leaves the premises or a safe area without authorization and/or any necessary supervision to do so. Assessment/Reassessment are completed at the following time intervals: Admission, re-admission, post elopement even, and quarterly. Once the patient is identified to be at risk for elopement, a photograph of the patient is taken and placed in the elopement book. Review of medical record for R#64 revealed that on 12/9/18 the resident was displaying exit seeking behaviors as evidenced by pushing against exit doors and eventually exiting a door on 300 Hall before being redirected back inside of the facility. Exit seeking /wandering behaviors were also documented on 12/10/18, 12/18/18, and 12/26/18. An elopement assessment was completed for the resident on 12/20/18 and indicated that resident was high risk for elopement. Based on the elopement assessment dated [DATE] a resident is considered high risk for elopement if a score of eight or greater is obtained. Once a resident is identified as high-risk photo of the resident was to be obtained and placed in the elopement book. Review of the elopement books at each of the nurse stations (three total) did not reveal any information of R#64 being identified. Interview on 4/30/19 at 10:25 a.m. with Unit Manager QQ who reported that elopement assessments are completed quarterly. However, upon review of R#64's medical record there was no evidence of a quarterly assessment being done since 12/20/18. Review of elopement book did not reveal that R#64 was identified in the elopement book. Interview on 4/30/19 at 4:49 p.m. with Licensed Practical Nurse (LPN) OO who reported that elopement assessments are completed monthly by the nurse. LPN OO was not aware of what code to call in the event of an elopement and further reported that he/she was not sure of the elopement process since he/she was not accustomed to being on the Alzheimer's unit. During interview on 4/30/19 at 5:24 p.m. with Registered Nurse (RN) MDS PP it was reported that risk meetings are conducted weekly and residents at risk for elopement are discussed at that time. During interview with Unit Manager QQ on 4/30/19 at 5:41 p.m. it was reported that the clinical team is responsible for updating the elopement book when a resident trigger being at risk for elopement. During an interview with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) on 4/30/19 at 5:50 p.m. clarification received on who the was included on clinical team. The DON reported that in addition to herself the clinical team included the ADON and the clinical managers. DON explained that the clinical team is responsible for obtaining residents' pictures and then updating the elopement book if high risk for elopement. The DON revealed that clinical meetings and department head meetings are discussed daily Monday through Friday and if a resident has triggered high risk for elopement it is discussed during the meeting. DON reported that the elopement books are assessed quarterly but was unable to provide a date for when this was last done. DON further reported that she or the ADON are responsible for checking the elopement books to assure that they are up to date. DON described elopement as when a resident leaves the premises. DON reviewed elopement book and did not find information for R#64. During interview with DON on 5/1/19 at 11:08 a.m. she revealed that it is her responsibility to put the resident's picture in the elopement book. She further reported that the weekend supervisor conducts an audit of monthly and quarterly assessments that includes but not limited to elopement assessments. It was reported that if assessments are found to be missing they are followed up on Monday's by a clinical manager. During interview on 5/2/19 at 9:59 a.m. with LPN RR it was reported that R#64 displays exit seeking behaviors that consist of pushing on doors. It was reported that this behavior is not all the time but is more likely to happen after spouse has visited the resident. It was further reported that once a resident is triggered as being at risk for elopement staff are notified. An interview was conducted with Certified Nursing Assistant (CNA) SS on 5/2/19 at 3:53 p.m. revealed that she is not aware of an elopement book and would have to ask someone about that. She revealed that R#64 is assessed as being at risk for elopement due to pushing on doors trying to get out at times. CNA SS reported that when this behavior is observed for the resident, then the resident is redirected.",2020-09-01
826,UNIVERSITY EXTENDED CARE/WESTW,115336,561 UNIVERSITY DRIVE,EVANS,GA,30809,2019-05-02,812,F,0,1,DXIW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on observation, interview, and the facility policies titled Food and Supply Storage Procedures and Cleaning Vents the facility failed to store, label, date, discard of expired food items, and to prepare food in a sanitary manner to prevent food contamination by ensuring that one ceiling vent over a preparation counter was clean. This had the potential to effect 136 oral fed residents of a total of 139 residents. Findings include: 1. Record review of policy titled Food and Supply Storage Procedures read Foods past the use by, sell by best-by, or enjoy by date should be discarded. Foods that are stored on ladder/speed racks must be fully covered to prevent contamination from airborne contaminants as well as from dripping condensation. Either use a bag that covers the entire cart, or cover each tray individually An observation with the Dietary Manager (DM) on [DATE] at 10:46 a.m. of one of two Reach in Refrigerators designated for dairy items labeled as the milk cooler revealed three, one quart containers of half and half with an expiration date of [DATE]. An observation with the DM on [DATE] at 10:47 a.m. revealed the following food items: one box of mushroom not completely sealed or covered with no open date, An observation with the DM on [DATE] at 10:49 a.m. of the pantry revealed an open bag of rice in a large plastic bag with no open date and no expiration date. Interview with DM on [DATE] at 10:35 a.m. reported that her expectations are for staff to label, date, discard of expired food, and store food properly to prevent contamination. 2. Record review of policy titled Cleaning of Vent the policy stated that the Maintenance Department is responsible for cleaning the vent, An observation with the DM on [DATE] at 10:58 p.m. of one of three ceiling vents revealed one ceiling vent covered with thick dark brown and dark greyish substances located directly above one preparation counter that contained a toaster. The DM confirmed at the time of the observation that the substance was dust mixed with dirt and debris. She further stated the counter is used to prepare toast and sandwiches. The DM stated that the Maintenance Supervisor is responsible for cleaning the vents in the kitchen. An interview on [DATE] at 1:25 p.m. with the DM and the Maintenance Director (MD) revealed that it is the MD duty to clean the vent. He last cleaned the vent last year and could not recall the exact date. The Maintenance Director was asked to provide a copy of the cleaning log although it was not provided during the survey. An interview with the Administrator on [DATE] at 8:56 a.m. revealed that the DM had made her aware of the problems in the kitchen and her expectations are for the dietary staff to clean the vents in the kitchen. She further stated that her expectations are for all food items to be labeled, dated, and expired food items to be discarded.",2020-09-01
827,MIONA GERIATRIC & DEMENTIA CENTER,115338,201 POPLAR STREET,IDEAL,GA,31041,2018-02-22,656,G,1,0,O1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of clinical records and staff interviews, it was determined that the facility failed to follow the care plan to ensure that a two person assist was provided for one resident (R) (R#1) during a transfer after the resident fell out of the bed. The sample size was six residents. Findings include: Review of the most recent Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed that R#1 was totally dependent on staff for bed mobility and required two person assistance, was totally dependent on staff for bathing and required one person assist for bathing, and this quarterly assessment also documented that R#1 was totally dependent on staff for transfers and required two person assistance for transfers. Review of the care plan dated 4/6/17, last updated 1/2/18, revealed that R#1 has thin fragile skin. She bruises easily and requires assistance with Activities of Daily Living (ADL's) with an approach that required two people for transfer. During a phone interview with Certified Nursing Assistant (CNA) AA on 2/21/18 at 2:00 p.m., revealed that on 2/9/18 she was giving the resident a bed bath, turned around to get the resident's clothes out of the closet and the resident fell out of the bed onto the floor. She then picked the resident up off the floor by herself and put her back in the bed. She further stated that she knew the resident was a two person transfer according to the sign that was posted over the resident's bed. Interview on 2/21/18 at 12:55 p.m. with Licensed Practical Nurse (LPN) BB revealed that R#1 required a two person assist transfer. Interview on 2/21/18 at 1:45 p.m. with the Registered Nurse (RN) MDS Coordinator revealed that R#1 was coded to have one person assist for bathing. Further interview revealed that R#1 was care planned as requiring two person assist for transfers. Post survey telephone interview with the Director of Nursing (DON) on 3/6/18 at 10:52 a.m. revealed that if a resident has a care plan for a two person transfer then two people should transfer that resident. Further interview revealed that the DON confirmed that R#1 resident required two people when transferring. Cross refer F689",2020-09-01
828,MIONA GERIATRIC & DEMENTIA CENTER,115338,201 POPLAR STREET,IDEAL,GA,31041,2018-02-22,689,G,1,0,O1UN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of clinical records, the Incident/Accident Policy, and staff interviews, it was determined that the facility failed to provide adequate supervision during a bed bath to prevent an avoidable fall. Actual harm was identified when Resident (R) #1 fell from her bed during a bed bath on 2/9/18, and suffered a left femur fracture and a closed nondisplaced fracture of left frontal skull. The sample size was six residents. Findings include: Record review revealed that R#1 was admitted to the facility and had the following Diagnoses: [REDACTED]. The resident was assessed on the 1/2/18 Quarterly Minimum Data Set (MDS) as having severely impaired cognition, required a two person assist for bed mobility and two person assist for transfers and required one person assist for dressing, hygiene and bathing. During a phone interview with Certified Nursing Assistant (CNA) AA on 2/21/18 at 2:00 p.m., she revealed that on 2/9/18 she was giving the resident a bed bath, turned around to get the resident's clothes out of the closet and the resident fell out of the bed onto the floor. She then picked the resident up off the floor by herself and put her back in the bed. She stated that she did not report the fall because she was scared. She stated that she did not tell the truth until about two or three days later to the Administrator and the owner. She further stated that she knew the resident was a two person transfer according to the sign that was posted over the resident's bed. During an interview with the Director of Nursing (DON) on 2/21/18 at 3:40 p.m., revealed that on 2/9/18 one of the night nurses called him to report a bruise on the resident's left elbow which they thought was caused by staff trying to remove a [NAME]et from the resident's arm. The next morning on 2/10/18, he conducted a full head to toe assessment on the resident and noted swelling to the left hip and thigh without bruising, a bruise to the left elbow and a bruise to the left forehead at the hairline. He stated that during their investigation, they interviewed CNA AA again (meaning they interviewed the CNA two times) who admitted the resident fell out of the bed when she turned to get clothes out of the closet. The DON indicated that the distance from the bed to the closet was approximately 10 feet. The DON further revealed that the expectation would be for staff to have all of the supplies before starting a bath. He further added, if staff must get something while bathing a resident they should first lower the bed and position the resident in the center of the bed. During an interview with the Administrator on 2/22/18 at 9:45 a.m., revealed that CNA AA did not report the resident's fall until a couple of days later. She stated she would expect the staff to immediately report a fall. She stated that CNA AA was terminated. She further stated the facility did not have a policy and procedure addressing bed baths. Observation on 2/22/18 at 10:50 a.m. revealed that the distance from the bed to the closet was approximately 10 to 15 feet. Record review revealed Nurse's Notes dated 2/10/18 at 10:30 a.m., that documented the following: Reported on 2/9/18 at 7:30 p.m. by CNA during routine care bruising noted. Initial investigation indicated previous shift had difficulty with dressing resident. There was also a bath performed for resident on prior shift. Further assessment revealed purple discoloration to left side of head in hairline and tenderness to left hip. Doctor notified of findings. New orders noted. New Physician order, for R#1, dated 2/10/18 documented the following: Send to E.R. (emergency room ) for Eval (evaluation). Record review of the Nurses Notes dated 2/10/18 at 11:00 a.m. revealed that a report was called in to the emergency room . Review of the 2/10/18 History and Physical from the hospital documented that the resident had a left femur fracture and a closed nondisplaced fracture of left frontal skull. The plan noted the physician would perform left hip open reduction internal fixation (ORIF). Post survey telephone interview with the Director of Nursing (DON) on 3/6/18 at 10:52 a.m. revealed that if a resident has a care plan for a two person transfer then two people should transfer that resident. The DON further revealed that there is card over the resident's bed that specifies how many people should be used for transfers, and that if a resident has a fall, that the CNA should not move the resident. The CNA should immediately call for a Licensed Practical Nurse (LPN) or a Registered Nurse (RN) to come and complete a head to toe assessment and perform Range of Motion (ROM) before moving a resident. Further interview revealed that the DON confirmed that R#1 required two people when transferring. Review of an undated policy titled Policy on Incident/Accident revealed any staff member observing an incident should immediately contact or have someone contact a charge nurse. The charge nurse will be in charge of determining whether or not a resident should be moved. A resident should not be moved at all until a charge nurse arrives.",2020-09-01
829,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2018-02-08,655,D,0,1,STYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a baseline care plan for one resident, Resident (R) #424, of 23 sampled residents. The baseline care plan did not include the minimum healthcare information necessary to properly care for the resident including services for elopement. Findings include: Record review revealed R #424 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the Elopement Risk Observation Form dated 1/26/18 revealed that R #424 upon admission was evaluated by the nursing home staff to be at moderate risk for elopement and required interventions including but not limited to three day monitoring, four weeks behavior management program to determine appropriate interventions after the three day evaluations and / or quarterly assessments. Review of the three day Behavior Management Log Form reveals an incomplete form providing the residents name, dates including 1/26/18, 1/27/18 and 1/28/18 and instructions that the resident is to be monitored for behavioral symptoms, interventions and outcomes of the findings. Review of the undated Baseline Care Plan revealed there was no care plan to address the resident's moderate risk for elopement and the ongoing verbal statements by the resident of wanting to leave the facility. Interview with R#424 on 2/6/18 at 11:13 a.m. reveals he needs to leave as stated by him because he has two apartments he needs to get back to, he continues by saying, I've got to take care of my business. Interview with Certified Nursing Assistant (CNA) CC on 2/8/18 at 8:30 a.m. reveals that R #424 says he must go to a different facility, he has asked if there is any transportation to get there. Interview with the Licensed Practical Nurse (LPN) BB on 2/8/18 at 9:00 a.m. confirmed the facility's three day Behavior Management Log Form were incomplete. Interview on 2/8/18 at 9:27 a.m. with the Social Service Director (SSD) revealed the four weeks Behavior Management Program was not started on this resident, and that during morning meetings there was not any discussion of this resident attempting to wander. Interview with the of Director Nursing (DON) on 2/8/18 at 10:07 a.m. confirmed the resident's three day Behavior Management Log Form for elopement were incomplete. The DON continued by saying the Elopement Observation Risk Form on new admissions are to be completed, we find out the risks, if any, put in place the interventions that would have been done by completing the three day Behavior Management Log Form and depending on those results the 4-week behavior program would have been completed.",2020-09-01
830,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2018-02-08,690,D,0,1,STYF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews the facility failed to provide services including physician ordered interventions for one resident (R#114) to maintain or restore normal bowel function as possible. The sample size was 23 residents. Findings incude: R#114 is an [AGE] year old female admitted to the facility following a right [MEDICAL CONDITION] repair. She was readmitted to acute care hospital on [DATE] and returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. She was also diagnosed with [REDACTED].#114 had a fecal impaction. A fecal impaction is a large lump of dry, hard stool that stays stuck in the rectum. It is most often seen in people who are constipated for a long time. (U.S. National Library of Medicine) A review of the Skilled nursing admission orders [REDACTED]. The orders indicate this medication was to be continued at the nursing facility. A review of the facility admitting orders dated 1/3/18 include the following medications to be given for the [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment tool ((MDS) dated [DATE] (assessment reference date) reveals Section H0600 answered as a No to the question was constipation present. Review of the (MONTH) (YEAR) Medication Administration Records (MARs) reveal routine [MEDICATION NAME] is signed off for all dates/times twice daily; milk of magnesia is signed off for all dates/times except 1/15/18 and 1/30/18; the as needed [MEDICATION NAME] and Fleets enema are not signed off indicating they were not utilized during the month of (MONTH) (YEAR). Review of a Skilled Daily Nurses Note dated 1/17/18 at 4:00 a.m. notes R#114 was impacted. Digital impaction removal until rectal vault emptied. During an interview conducted on 2/08/18 at 1:52 p.m. with Licensed Practical Nurse (LPN) EE, she confirmed the skilled daily nurses note documenting the fecal impaction.",2020-09-01
831,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-02-28,625,D,0,1,HSV811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews, and review of the facility policy titled, Bed Hold Acknowledgement Form, the facility failed to ensure that two of 34 Residents (R#63 and R#105) that were transferred out of the facility to an acute care hospital received notice of the facility's bed hold policy prior to being transferred. Findings Include: Review of the facility a facility policy titled, Bed Hold Acknowledgement Form: Georgia, Policy: Bed Holds revealed the following: Two notices related to the healthcare center's bed hold policy will be issued. The first notice of bed hold policies is given during this admission . The second notice, which specifies the duration of the bed hold policy, will be issued at the time of any transfer. In case of emergency transfer, notice at the time of transfer means that the family and/or undersigned parties, not to include the healthcare center, is provided with written notification within 24 hours of the transfer. This facility policy was revised 12/19/2014. During a record review for R63 revealed that he was initially admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further record review revealed that R63 was transferred out of the facility to an acute care hospital on the following dates: 12/1/18, 12/8/18, and on 12/30/18 Interview on 2/26/2019 at 8:01 a.m., with R#63 revealed that he had been sent out to the hospital several times lately and he stated that he was not told or given any information by the facility regarding returning to his bed in the facility. During an interview with the Social Service Director (SSD), AA on 2/26/19 at 2:42 p.m., SSD AA revealed that they have never sent bed-hold information out with the resident. She stated that she was not aware of the regulation where they (the facility) have to provide the bed hold policy information to the resident and responsible party (RP) with each transfer. Interview on 2/26/19 at 2:44 p.m. with the Director of Nursing (DON) revealed that when a resident transfers/discharges out the facility they send the face sheet, a transfer form and current medication list for the resident. She stated they have never sent out bed-hold forms/policy information before. She also stated she was unaware that they needed to provide a copy of the bed-hold information and policy to the resident or RP upon transfer. Interview with Financial Officer BB, on 2/26/19 at 3:16 p.m. revealed that she doesn't know what the resident gets when they are leaving the facility because sometimes she isn't here, and the nurses do that portion. Financial Officer BB revealed that she finds out when she comes in on the next business day and that she calls the family to see if they want to pay for a bed hold. She stated she has never documented this communication that she has with the responsible party. Interview with the Administrator on 2/26/19 at 3:24 p.m. revealed that that the bed hold information is supposed to be provided to the resident and the responsible party on every transfer/discharge. The Administrator revealed that she is aware that the information must contain duration of the Medicaid bed-hold, the reason for transfer/discharge and the amount to be charged if the resident wishes to continue the bed hold past the Medicaid seven (7) day bed-hold. 2. Record review of a closed record for R105 revealed the resident was initially admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed that the resident was transferred to the hospital on [DATE] and that there was no evidence in the resident's medical record that a bed-hold notice had been given to the resident or the residents Responsible party. Interview on 2/26/2019 at 2:44 p.m. with the Director of Nursing (DON) revealed that she does not send a bed hold policy with the resident when discharged to the hospital. She stated she has never sent them out.",2020-09-01
832,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-02-28,640,D,0,1,HSV811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled MDS Assessment Accuracy the facility failed to complete a discharge Minimum Data Set (MDS) assessment for one of 34 residents (R#1). Findings include: Review of the policy titled, MDS Assessment Accuracy effective 5/1/2006, reviewed 10/24/2018, revised 6/24/2015 revealed: The Policy Statement: It is the policy of this healthcare center that each MDS reflect the acuity and the medical status of each patient/resident in accordance with acceptable professional standards and practices. All MDS Assessments must be completed following the guidance set forth in the Resident Assessment Instrument (RAI) Manual as directed by the Centers for Medicare and Medicaid Services (CMS). Record review for R#1 revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 11/1/2018. Review of the completed MDS's for R#1 revealed a discharge MDS was not completed in a timely manner. An interview on 2/27/2019 at 4:01 p.m. with Registered Nurse MDS LL stated a discharge MDS should have been completed upon discharge. She verified that a discharge care plan was not completed but should have been completed when the resident was discharged . MDS LL stated during that admissions and discharges are discussed in morning meetings and The MDS department also gets e-mails from the Social Worker and the Therapy Department indicting discharges that are coming up. MDS LL also revealed that the MDS department is responsible for completing them (MDS Assessments) in a timely manner.",2020-09-01
833,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-02-28,655,D,0,1,HSV811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and review of the facility policy titled, Care Plans the facility failed to ensure a copy of the Baseline Care Plan was provided to one of 34 residents (R86), and her responsible party after the resident was admitted to the facility. Findings include: Review of the facility policy titled, Care Plans, Policy Statement: Procedure: New Admission Baseline Plan of Care, Number three (3), Within the first few days of admission, a Post Admission Care Conference will be held for update and reviews of the baseline care plan. Bullet number three (3), . A copy of the Baseline Care Plan form and Admission Physician Order from will be given to the patient and representative. This policy was revised 10/10/2017. Review of a closed record revealed that R86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with the Nurse Navigator, CC, on 2/27/2019 at 10:58 a.m., revealed that neither R86 nor the residents responsible party signed the Baseline Care Plan form. Further interview with Nurse Navigator CC revealed that this indicated that neither the resident nor the residents responsible party received a copy of the baseline care plan. During an interview with the Director of Nursing (DON) on 2/27/2019 at 11:00 a.m., revealed that the DON confirmed that this resident and the responsible party did not receive a copy of the Baseline care plan as evidenced by no signatures present on the Baseline Care Plan form. The DON stated she expected the staff to follow the regulations with regard to the Baseline Care Plan information being given to the resident and the residents responsible party.",2020-09-01
834,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-02-28,657,D,0,1,HSV811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record reviews and review of a facility policy titled Care Plans the facility failed to revise the person-centered plan of care for two of 34 residents (R53 and R81). The facility failed to update/revise the care plan for R53 to reflect hospice services and code status, and the facility failed to update or revise the care plan for R81 related to the resident being noncompliant with care including not following recommended fluid restriction and not wearing life vest as ordered and or removing battery from life vest. Findings include: 1. R53 was admitted [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed a form titled Pruitt Health Hospice Notification of Admission to Hospice with an admission date of [DATE]. There is also a Do Not Resuscitate (DNR) form signed by the responsible party and the physician dated 1/3/19. A review of the medical record revealed a physician's orders [REDACTED]. The order was signed by the physician on 1/8/19. A review of the Minimum Data Set (MDS), a Resident Assessment Instrument (RAI) revealed a Significant Change of Condition MDS completed with an Assessment Reference Date (ARD) of 1/10/19 with Section J1400 indicating a prognosis of life expectancy of less than six (6) months. A review of the comprehensive care plan revealed no updates or revisions related to the end stage prognosis and no updates or revisions related to the change in code status from full code to do not resuscitate. A review of a facility policy titled Care Plans with a date of 10/25/18 reveals the procedure for care plan review and update included 1. Comprehensive care plans should be reviewed not less than quarterly according to the OBRA MDS schedule, following the completion of the assessment. Care plan updates/reviews will be performed within 7 days of each quarterly assessment, each acute change in condition, and as needed following each hospital stay. 2. Discontinued problems, goals or approaches should be indicated directly on the care plan. A line should be drawn through the discontinued item. Updates to the care plans should be made with any changes in condition at the time the change in condition occurred. 3. All updates to care plans are to be dated and signed. The Master Care Plan will be electronically updated and printed following the completion of Comprehensive OBRA assessments. 4. Care plans will be updated by nurses, Case Mix Directors (CMD), or any other interdisciplinary team member so that the care plan will reflect the patient/resident's needs at any given moment. An interview was conducted on 2/27/19 at 1:06 p.m. with a Registered Nurse (RN), Minimum Data Set (MDS) Coordinator KK. She confirmed that any time a resident is admitted to hospice services a Significant Change MDS is completed. She also confirmed that it is the policy of the facility to update and revise the comprehensive plan of care to include the resident's change in condition including the reason they were admitted to hospice. 2. Record review revealed that R#81 was admitted to the facility with the following [DIAGNOSES REDACTED]. Review of Minimum Data Set ((MDS) dated [DATE] revealed Section C -Brief Interview Mental Status (BIMS) score of 15 indicating that the resident is cognitively intact. Review of Physician order [REDACTED]. R#81 record review revealed that Resident (R) R#81 had a history of [REDACTED]. Review of Care Plans for R81 dated 2/5/19 revealed a care plan that addressed the resident's therapeutic diet and a second care plan that addressed the resident's diuretic use. Further review of the care plans revealed that that the care plans did not address or capture the problem that the resident was refusing to follow his diet fluid restriction. Review of a nurses note dated 2/8/19 time 2:40 p.m. documented Resident in bed, alert, able to make needs know, continues to be noncompliant with fluid restriction. Resp (respirations) even and unlabored. Skin warm and dry. No noted pain or distress. Will continue to observe. Review of a nurse note dated 2/7/19 documented: Sitting up in bed. Resident noncompliant with fluid restriction. Education provided and resident states I really don't drink that much, Noted 20 ounces (oz) soda, two -eight oz cups and 16 oz cup on bedside table. Lungs clear. Life Vest in place. Resp even and unlabored. No noted distress. Will continue to observe for needs. Review nurse of nurse note dated 2/12/19 at 11:30 pm read Resident alt x 3 pizza and 2 L soda daily-noncompliance with restriction. Nurse writer noted resident taking battery out of cardiac vest. Nurse put fully charged battery in device and encourage resident to keep battery in. Review of nurse note dated 2/13/19 documents in pertinent part . Resident non-compliant with fluid restriction. Has ordered pizza and 2 L (liter) soda, nurse writing observed resident took out battery to life vest stated-It's too noisy. Interview on 2/26/19 at 11:00 a.m., R#81 revealed that he wears he wears life vest daily and verified removing life vest maybe once or twice. R#81 verified ordering food out from various restaurants that include beverages at least twice or more during the week. R#81 admitted not following his fluid restriction diet and also obtaining soda from the facility vending machine. During an interview on 2/27/19 at 1:25 p.m., the Director of Nursing (DON), revealed that Register Nurse (RN) CC obtained a diet refusal form from resident, after the surveyor inquiry. The DON provided a copy of the signed form titled Refusal of Care Against Medical Advice Form. The statement on the form documented I understand that if I refuse the offered services. I am doing so against medical advice. I understand that my refusal may result in a worsening of my condition and could pose a threat to my life, health, and safety. Interview on 1/27/19 at 1:29 p.m., with Certified Nursing Assistant (CNA) DD revealed that she has never witnessed the resident taking off his life vest, however other CNA's have informed her that the resident has removed his vest on other shifts. CNA DD also stated that she has witnessed R#81 ordering food from the outside that consists of large soda beverages. Stated that resident uses his own personal credit card. Resident is known to order pizza more than once during the week. R#81 will also consumes food on his tray and beverages and eat the food from the restaurant as well. When asked how she monitors resident intake of fluids, CNA DD reported that it is hard to monitor the resident's fluid intake throughout the day because resident is independent and drinks whenever he chooses. Interview on 2/27/19 at 1:31 p.m., Licensed Practical Nurse (LPN) FF revealed that Reported that resident has a history of removing his life vest and battery in the past; however, she has never witnessed this. LPN FF revealed that R81 has a history of consuming as many beverages as he likes and ordering and receiving food from restaurants. Interview on 2/27/19 at 1:41 p.m. with Register Dietician (RD) revealed that she has not had a chance to assess R82 and stated that she came on aboard this month (MONTH) 2019. However, the RD stated that she feels fluid restriction POF orders is important and should be communicated in the resident plan of care. Interview on 2/27/19 at 2:00 p.m., the DON revealed that her expectations are for staff to revise the care plan per R#81 's care needs. She stated that the Life Vest and new physician orders [REDACTED]. Interview on 2/28/19 at 2:13 p.m., the Case Mix Coordinator/MDS Coordinator (KK) revealed that usually the nurses can update the care plan. MDS KK further revealed that she was not aware that the resident was refusing to wear the Life Vest and was not following his fluid restriction. MDS KK revealed that if she was made aware of R#81 's behavior not being compliant, she would had notified the MD and updated the care plan in both areas.",2020-09-01
835,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-02-28,660,D,0,1,HSV811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and the facility policy titled Discharge Planning, the facility failed to develop a discharge plan of care for one of 34 residents (R107). Findings include: Review of a facility policy titled Discharge Planning revised 10/29/18 documents the following: Discharge planning will begin with each patient /resident and patient/resident 's representative upon admission. The process is coordinated by Social Services/Nurse Navigator or designees. The patient/resident, patient /resident representatives and Interdisciplinary Team (IDT) are involved in the planning process. The post-discharge plan of care is developed with the participation of the patient/resident and/or the patient/resident 's representative with the patient/resident's consent. The discharge plan will be monitored and revised as necessary throughout the patient/resident stay. 1. Discharge and care plans goals will be established with the IDT, patient/resident and patient/resident representative at the time of admission based on the patient /resident discharge goals and treatment preferences in conjunctions with needs as identified by the IDT. 2. Discharge care plans will be updated after the Post Admission Care Conference, reviewed quarterly, prior to the anticipated discharge date and as needed. Record review of the closed medical record for R107 revealed an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the closed record revealed that there was a discharge document titled Discharge Recapitulation of Stay Form dated 12/4/18 for R107 that documented a brief synopsis of the resident's admission to the facility; however, further record review revealed that there was no evidence that the facility had initiated or completed Discharge planning for R107. Further record review of a facility form titled, Social Services Assessment Form dated 10/30/18 read discharge is anticipated. Further review of Social Service Notes from the time (MONTH) (YEAR) through (MONTH) (YEAR) revealed that there were not any other social services notes addressing the residents discharge. Further record review revealed a Physician order [REDACTED]. Interview with the Director of Nursing (DON) on 2/28/19 at 1:06 p.m. revealed that there was not any discharge planning or care plan for R107. The DON confirmed that she was not aware of the omission of the discharge care plan until it was identified during the survey. Further interview with the DON revealed that Social Service is responsible for completing the discharge process, and the nurse provides medications/education to the patient and the family. This process includes identify the resident discharge potential and goals. Interview with Case Mix Coordinator/Minimum Data Set (MDS) Coordinator (KK) revealed that the social worker usually enters the discharge care plan it in the system after she has met with the Interdisciplinary Team (IDT) team and the patient's family. This is a 72 hours meeting after the resident has been admitted .",2020-09-01
836,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-02-28,773,D,0,1,HSV811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident, family, and staff interviews, and review of the facility policy titled, Diagnostic and Laboratory Services: Procedure for Processing the facility failed to communicate a final urine culture report for one of 34 residents (R358). Findings include: Review of the facility policy titled Diagnostic and Laboratory Services: Procedure for Processing effective 3/1/12, reviewed 10/24/18, revised 11/21/16 revealed: The Unit Manager or charge nurse obtains the resident diagnostic test results from the contracted provider. The licensed nurse is responsible for communication resident diagnostic results to the provider upon receipt. The nurse will document the notification in the clinical record. Record review revealed that R358 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the admission Minimum Data Set ((MDS) dated [DATE] indicates poor cognition, needs extensive assistance with bed mobility, transfers, dressing, locomotion, toileting, and personal hygiene. He is total dependent with bathing. The assessment indicated the resident was occasionally incontinent of bladder and frequently incontinent of bowel. Review of the medical record for R358 revealed that he complained of burning on urination on 2/14/2019. The physician was notified, and an order was received to collect a urine specimen for a urinalysis and urine culture and to [MEDICATION NAME](an antibiotic) 500 milligram (MG) one tablet two times a day for ten days for a urinary tract infection [MEDICAL CONDITION]. Review of the Clinical Laboratory Services (CLS) for a urinalysis and urine culture revealed the urine specimen for R358 was collected on 2/15/2019, received on 2/15/2019 and reported on 2/15/2019. The results were printed on 2/15/2019. The results indicated a completed urinalysis, but the urine culture was pending. The paper copy was signed (initialed) by the physician on 2/18/2019. On 2/27/2019 the Director of Nursing (DON) printed a copy of the urinalysis and urine culture collected on 2/15/2019 and the urine culture indicated a growth of [MEDICATION NAME] faecalis and it was resistant to the [MEDICATION NAME](meaning that the bacteria would not respond to the ordered Cipro). There was no indication in the medical record that the physician was notified of the result of the urine culture. An interview with the DON on 2/27/2019 at 2:43 p.m. revealed she reviewed the residents medical record and verified a copy of the resident's urine culture was not in the paper medical record or electronic medical record. Further interview with the DON on 2/27/2019 at 2:56 p.m. revealed resident's lab results are printed daily and dispersed to the different units. She then stated the unit managers call the physician with the results and then puts the lab results in the physician's box. Her expectations are if the lab result needs immediate attention she expects them to be called to the doctor with in a day or two. She agreed the urine culture for R358 showed it was resistant [MEDICATION NAME] the antibiotic should have been changed to something else. The DON stated she cannot find a copy of the urine culture signed by the physician or verify the physician was aware of the urine culture results. An interview held on 2/28/2019 at 9:49 a.m. with Licensed Practical Nurse (LPN) Unit Manager (UM) (MM) for the 300 and 400 halls revealed she receives the resident's lab results daily from the printer or from the DON. She and the other Unit Managers divide the labs between themselves and take them to their unit. LPN MM stated an abnormal urine culture would have been called to the physician for a change in the resident's therapy.",2020-09-01
837,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-02-28,812,E,0,1,HSV811,"Based on observation, staff interview, and the facility policy titled Patient s/Resident 's Personal Food, the facility failed to properly store, discard, label and date food for 2 of 2 Unit Refrigerators. Findings include: Review of the facility policy titled Patients/Residents' Personal Food revealed the following: It is the policy of[NAME]Health to allow the patient /resident 's family to provide personal food items for patient/resident consumption. The patient /resident 's personal food items will be maintained in a clean, healthy environment to help prevent foodborne illness. This applies to all nursing and dietary partners employed by[NAME]Health: 4. Foods requiring refrigeration must be stored in the nursing unit refrigerator or the patient/resident 's personal refrigerators. Those items stored in the nursing unit refrigerator must be kept to a minimum due to limited space. Food requiring refrigeration must be labeled and dated and will be discarded after 48 hours. 5. Frozen food items must be stored in the nursing unit freezer or the patient/resident's personal freezer. Those items stored in the nursing unit freezer must be kept to a minimum due to limited space. Frozen foods must be labeled and dated and will be discarded after 14 days. 7. Nursing personnel will be responsible for the disposal of outdated foods maintained in the patient/resident 's room and those stored in the nursing unit refrigerators. Refrigerator /Freezer temperatures must be recorded daily on the Food Refrigerator /Freezer Temperature Log. 8. The healthcare center reserves the right to dispose of any food that is deemed unsafe for consumption. Observation of Unit Refrigerator #1 (designated for Hall 300 and 400 residents) on 2/26/19 at 1:16 p.m. with Licensed Practical Nurse (LPN) II of the nutrient refrigerator for Hall 300 and 400 revealed the following concerns with the food items listed below: 1 (one) 16 oz (ounce) soda bottle unlabeled 1 open 32 oz Fiji bottle water-contents were 1/2 frozen unlabeled 1 large plastic bag dated 2/25/19 that contained multiple sandwiches with no used by or expiration date 1 small container of yogurt with the name of Social Worker listed on the container Package of 5 bottles of Dannon yogurt with the expiration date of 2/24/19 1 cup of orange juice with a plastic saran wrap paper covering unlabeled 1 small container of food unlabeled Observation of the Unit Refrigerator #2 (designated for Hall 100 and Hall 200) on 2/26/19 at 1:28 p.m. with Certified Nursing Assistant (CNA) JJ and the Director of Nursing (DON) revealed concerns with the following food items listed below: 1 open 16 oz bottle of water that was 1/2 filled - unlabeled 1 bottle 16 oz of water unlabeled 1 frozen dinner with staff name listed on the container. Observation of Unit Refrigerator #1 (designated for Hall 300 and 400) on 2/28/19 at 8:44 a.m. with the DON revealed the followings concerns with one of the same food items observed on 2/26/19 and one new food item: a small container of yogurt with the name of the Social Worker on the container remaining in the refrigerator and a plate of partially eaten salad unlabeled Interview on 2/26/19 at 1:20 p.m., with LPN II revealed that the 16-ounce (oz) soda located in the Nutrient Refrigerator #1 for Hall 300 and 400 belonged to her. LPN II further stated that she was aware of the policy about staff storing their personal items in the refrigerator with residents' foods. She verified that the refrigerator was for resident use only. She identified the name on the small container of yogurt as belonging to the Social Worker. Interview on 2/26/19 at 1:21 p.m., the Administrator who also was present at the time of the interview with LPN II revealed that the unit refrigerator was designated for residents use only. The Administrator stated that her expectations are for staff not to store their food items in the unit refrigerator. The Dietary Manager (DM) is responsible for monitoring the refrigerator daily and that nursing staff also share the responsibility as well ensuring that food items are dated. Interview on 2/26/19 at 1:26 p.m., with the Dietary Manager (DM) revealed that she is solely responsible for checking the unit refrigerators each morning. DM stated that the last time she checked Unit Refrigerator #1 was yesterday morning and she removed all refrigerator items that were not in compliance with their food expiration, label, and date policy. She further stated that both dietary and the nursing staff are responsible for monitoring the items in the refrigerators. The DM also stated that the unit refrigerators are designated for resident use only. Interview on 2/26/19 at 1:30 p.m. with CNA JJ and the DON revealed that the frozen meal with a staff name marked on the package belonged to a CNA, who works a different shift. The DON also stated that staff has a separate refrigerator in the lounge/break room and are required to keep their food items in the refrigerator up front.",2020-09-01
838,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2018-04-06,550,D,1,0,BJ4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff and resident interviews, the facility failed to provide incontinent care for three (3) resident (R#2, R #3, R#4). The sample size was four residents. Findings include: 1. Review of the clinical record for R#3 revealed the following [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15. Further review of this MDS revealed the resident needed extensive assistance by one staff for toileting, and was always incontinent of bladder. An observation on 3/27/18 at 2:40 p.m. revealed R#3 sitting in her wheelchair near her bed. R#3 revealed that she was waiting to have her diaper change. Surveyor remained in the room with R#3. At 3:22 p.m. a Certified Nurse Aide (CNA) BB entered the room and turned off the call light and informed R#3 that she will get her assigned CNA and left the room. BB returned to R#3 room with a Hoyer lift, she repositioned the bed, position R#3 wheelchair to face the foot of the bed and took the Hoyer pad straps and draped over R#3 legs and again left the room. At 3:40 p.m. CNA BB and CNA CC were observed to enterthe room, and CC removed the first Hoyer lift and brought in a 2nd Hoyer lift. At 3:50 p.m. the two (2) CNA BB and CC transferred R#3 to her bed. R#3 wheelchair pad, the Hoyer pad, and resident's pants are wet. Further observation revealed that the adult brief was observed to be heavily y saturated with urine and had a moderate amount of fecal matter. During this observation, R#3 revealed that she has been in her wheelchair since 10:30 a.m. wet and wanting to go back to bed. An interview on 3/27/18 at 3:50 p.m. CNA CC revealed that R#3 is always soaking wet, and nothing has been done about day shift leaving residents wet. An observation of R#3 on 3/28/18 at 11:15 a.m. revealed that the residents adult brief is heavilyy saturated with urine and the resident was observed to have a slight odor; the sheets including the bedsheet and the draw-sheet were observed to be wet. The bed pad was observed to have a large wet urine area with a brown outer ring. Furhter observation revealed taht there is moderate amount of bowel movement (BM) is the adult brief. An interview on 3/28/18 at 9:30 a.m. R#3 revealed that CNA AA came into her room, but she had not been changed since 4:30 a.m. The resident continued to state that she felt very uncomfortable and felt embarrassed that she had soaked through her diaper. R#3 revealed that the morning shift is the worst in having long wait time and that this is daily occurrence. 2. Review of the clinical records revealed R#4 had the following [DIAGNOSES REDACTED]. R#4 BIMS score is 13 During an observation on 3/28/18 at 1:37 p.m. R#4 revealed that she laid in her bed for over three (3) hours in her bowel movement. Continued to say that this made her feel terrible and that her bottom was burning from the stool. 3. Review of the clinical records revealed that R#2 was admitted with the following but not limited to anxiety, rhabdomyolysis, [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. An interview on 3/27/18 at 3:06 p.m. CNA DD revealed that R#2 did sit in her feces and the family was upset but could not remember the details. An interview on 3/28/18 at 3:55 p.m. the Administrator revealed that the facility does not have a call light policy and that an acceptable wait time is about 20 minutes",2020-09-01
839,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2018-04-06,725,D,1,0,BJ4811,"> Based on observation, resident, family, and staff interview, the facility failed to provide sufficient nursing staff to address activity of daily living (ADL) needs and call light response for four (4) of four (4) Residents (R#2, R3# R#4 R#5). The facility census was 111 residents and the sample size was four residents. Findings include: An observation on 3/27/18 at 2:40 p.m. to 3:55 p.m. revealed R#3 waiting for assistance to have her soiled adult brief change and to be transferred to her bed. Review of the staffing hours revealed a staff ratio of 2.93. However, residents needs were not met. An interview on 3/27/18 at 3:08 p.m. R#3 revealed that she has not been change since 10:30 a.m. and that Certified Nurse Aide (CNA) AA has been in the room at least six times to attend to her roommate. R#3 continued to state that this is a daily occurrence of not getting assistance. An interview on 3/27/18 at 3:50 p.m. CNA CC revealed that R#3 is always soaking wet, and nothing has been done about day shift leaving residents wet. An observation on 3/27/18 at 3:55 p.m. observed a Registered Nurse (RN) JJ and a Licensed Pratical Nurse (LPN) II assisting a resident off the floor in the lounge area of 200 Hall. An interview on 3/28/18 at 11:00 a.m. CNA AA revealed that she did not have R#3 on her assignment, and was not aware that she was to be observed for peri-care. A subsequently interview revealed that from 7:30 a.m. to 11:15 a.m. R#3 did not have an assigned CNA due to shortage of CNAs' and the assignment was adjusted after she was pulled from her duties. An observation on 3/28/18 at 11:15 a.m. revealed R#3 adult brief is heavy saturated with urine and a slight odor; the sheets (bedsheet and draw-sheet) are wet. The bed pad has a large wet urine area with a brown outer ring. There is moderate amount of bowel movement (BM) is the adult brief. An interview on 3/28/18 at 2:02 p.m. CNA EE revealed that she did not have R#3 on her assignment and that at 7:00 a.m. she had check to see if R#3 was dry by asking her. But she was not assigned to provide care for R#3. She continued to say that 7:00 a.m. was the only time she had entered R#3 room. An interview on 3/28/18 at 1:37 p.m. R#4 revealed that she lain in her bed for over three (3) hours in her bowel movement. Continued to state that a CNA came into her room at 10:25 p.m. and informed her that another CNA would be the person to change her. R#4 revealed it was 1:30 a.m. before another CNA came into her room to change her. An interview on 3/28 at 3:06 p.m. CNA DD revealed that since mid-January (YEAR) there has been a shortage of CNAs'. When the facility hire people, they do not stay long due to the heavy workload. An interview on 3/28 at 3:20 p.m. CNA FF revealed that every day that she works she is alone covering two (2) halls for about 48 residents until another CNA comes on duty. Continue to say that she tries her best to assist the residents but the residents have a longer wait time for services. CNA FF stated that her workload is too much for her and is contemplating about quitting or working as needed. An interview on 3/28/18 at 3:25 p.m. with Licensed Practical Nurse (LPN) GG revealed that the nurses are working as CNA's and having to pass medications, and they try to put safety of resident first. Continue to revealed that the facility has had three Administrators, and that the CNAs' assigned to restorative, activity and central supply are getting pulled to help the CNA's working on the unit. An interview on 3/28/18 at 3:51 p.m. the Administrator revealed that she is aware of the staffing problem. The facility has a shortage of certified nurse aides. And that she has pulled licensed personnel from offices to help during the shortage of CNAs.",2020-09-01
840,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2018-04-06,880,D,1,0,BJ4811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff/resident interviews, the facility failed to provide incontinet care in a manner to prevent a potential urinary tract infection [MEDICAL CONDITION], due to fecal contamination, for one Resident (R) (R#3). Three residents were reviewed for concerns with urinary incontinence, or urinary tract infections [MEDICAL CONDITION], and the sample size was four residents. Findings include: Review of the Infection Control Tracking and Trending Log revealed that in (MONTH) (YEAR) there were no residents with a UTI; in January2018 a total of five (5) residents had an UTI and in (MONTH) there were two (2) residents with UTI. 1. Review of R#3 clinical record revealed that she was admitted with, but not limited to, the following Diagnoses: [REDACTED]. Review of her Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15. Further review of this MDS revealed the resident needed extensive assistance by one staff for toileting, and was always incontinent of bladder. An observation on 3/28/18 at 11:15 a.m. Certified Nurse Aide (CNA) AA is observed with a wash basin and soapy water on the bedside table in order to provide peri-care for R#3. Observation revealed that the adult brief, for R#3, is heavily saturated with urine and had a slight odor; the sheets (bedsheet and draw-sheet) are wet. The bed pad was observed to have a large wet urine area with a brown outer ring. There is moderate amount of bowel movement (BM) is the adult brief. CNA AA is observed using a wash cloth to remove the fecal material from the residents genital area. CNA AA was observed to then take the wash cloth and rinse the fecal material in the wash basin. Further observation revealed that CNA then, using the same wash cloth, CNA AA was observed to separates the residents labia and wipes downward over the urethral area. CNA AA was observed to dip the same cloth into the fecal contaminated water and return to remove fecal material near the rectum. CNA AA was then observed to place a fresh adult brief under R#3, when she is stopped to check R#3 for thoroughness in cleaning. Observation, at that time, revealed that on there was dried fecal material on the the residents inner bilateral thighs, in the crease of the residents legs near the genital area is fecal; and after R#3 is turned, there is fecal material at the residents rectum area. At this time, CNA AA was observed to take the same wash cloth dip it in the fecal contaminated wash basin and remove the remaining fecal material. During interview with Certified Nursing Assistant (CNA) AA on 3/28/18 at 2:06 p.m. revealed that she did not see the fecal material left on R#3 because the fecal material was in her blind spot. She continued to reveal that she had attended an in-service on peri-care in (MONTH) (YEAR) but had not done a hands-on demonstration. Record review of a local hospital history and physical dated 1/19/18 revealed that R#3 was admitted to a local hospital on [DATE] [MEDICAL CONDITION] due to gram-negative bacteria infection with urinary tract infection. This met the definition of [MEDICAL CONDITION] because of acute kidney injury and toxic-metabolic [MEDICAL CONDITION]. Review of the Skills Checklist Assignment Detail revealed CNA AA had completed the annual CNA training on 12/13/17.",2020-09-01
841,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-05-24,689,E,1,0,WK1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff and resident interviews and record review, the facility failed to ensure that the handicapped accessible feature for the double doors at the main entry of the building were functioning properly. This failure resulted in two of three residents (R)#4 and R#6, who were unable to physically open the doors, from being able to re-enter the facility through the main entry way without assistance without a call system in place to request assistance. Findings include: Review of the Minimum Data Set (MDS) Admission assessment for R#4 revealed that he was admitted on [DATE]. Under Section C of the assessment, titled Cognitive Patterns, R#4 scored a 15 on the Brief Interview of Mental Status (BIMS). This score indicates that R#4 was cognitively intact. Under section G of this same assessment, titled Functional Status, R#4 was assessed as unable to walk and required supervision for locomotion in a wheelchair on and off the facility unit. Review of the MDS Admission assessment for R#5 revealed that he was admitted on [DATE]. Under Section C of the assessment, titled Cognitive Patterns, R#4 scored a 15 on the Brief BIMS. This score indicates that R#5 was cognitively intact. Under section G of this same assessment, entitled Functional Status, R#5 was assessed as requiring limited assistance for locomotion in a wheelchair on and off the facility unit. Review of the MDS Admission assessment for R#6 revealed that he was admitted on [DATE]. Under Section C of the assessment, titled Cognitive Patterns, R#4 scored a 15 on the Brief BIMS. This score indicates that R#5 was cognitively intact. Under section G of this same assessment, entitled Functional Status, R#6 was assessed as unable to walk, requiring limited assistance for locomotion in a wheelchair on and off the facility unit. On 5/21/19 at 10:30 a.m., three residents in wheelchairs were observed outside of the building's main entry in a shaded area designed for seating. Surveyor attempted to enter the facility through the main entry and depressed the handicapped access pad (pad) located on the right column at the entrance. The doors failed to open, and the access pad was depressed again. One of the residents advised the surveyor that the handicapped entrance was not working. Interview with resident (R)#4, at this time, revealed that the pad had not worked reliably since he arrived in April. Interview with R#6, at this time, revealed that the door had not been working properly for at least a year. R#6 stated that the doors worked intermittently and were repaired about a month ago. The repair only lasted a few days, then the doors went back to the way they worked before. If you pressed the pad a certain way, sometimes the doors would open. Further interview with R#5 revealed that he was physically able to open the doors by himself by wedging his wheelchair between the doors and that he would then hold doors open for other residents who needed assistance. R#6, agreed that the doors had not been handicapped accessible for a long time, but he had never been stuck outside, someone always came and took him back inside the building. He stated that he was not able to open the doors without assistance. Observation of the entry revealed that there were not any out of order signs or other documentation advising residents that the handicapped access doors were not working. Interview on 5/21/19 at 10:50 a.m. with the Courtesy Desk clerk (CD), revealed that he was aware that the pad to open the front doors was not working properly but that he had not reported it to maintenance. CD AA said that he watched residents who were outdoors and opened the doors if they needed help to enter the building. CD AA confirmed there was no sign-out process for residents going outdoors and that residents could go out and return at will. He also confirmed that the interior pad used to exit the building worked but that the pad used to enter the facility had not worked reliably for a long time. When asked, CD AA admitted that he was not always at the courtesy desk and agreed that it wasn't safe for residents to be outside if they could not get back in. When asked if there was call bell or alarm system outside of the front entry for resident use when they needed assistance, CD AA took the surveyor to the front entry. Located inside of the building, between two sets of double doors, was a call button. CD AA explained that residents and visitors used this call button after 8:00 p.m. when the second set of double doors was locked. Further interview revealed that residents or visitors could not access this call button if they were disabled and were not physically able to open the first set of double doors and confirmed that there was no call button located on the outside of the front entry. Interview with the Maintenance Director (MD) BB, on 5/21/19 at 11:15 a.m. revealed that he did not know that the handicapped entry pad was not working. MD BB said that the pad was repaired about a month ago and had been working fine. No one had told him or reported any problems with it since then. Interview with R#4 on 5/22/19 at 10:20 a.m. in his room revealed that he was admitted about two weeks ago for rehabilitation. He went out just about every day and had been stuck outside several times. There was no bell to ring for assistance. Sometimes someone at the courtesy desk would see him and open the doors. R#4 estimated that he had previously had to wait for assistance at least 30 minutes before and stated that other residents, or other people going in or out of the building, or other staff would open the doors for him. He also stated that he spoke to someone in maintenance about the doors and that they had said they knew the doors weren't working properly. Interview with Occupational Therapist (OT) HH on 5/22/19 at 10:40 a.m. in the therapy room revealed that resident families had complained to her about the handicapped doors not working properly. OT HH confirmed that she had not reported the problem because everyone knew the doors weren't working. Interview on 5/22/19 at 2:40 p.m. on the front porch with resident R#5 revealed that he frequents the front porch almost daily. He observed the handicapped entrance doors work once in the last three weeks and that he has helped residents get back in several times. He also stated that facility nurses and transport personnel knew that the doors don't open because they have helped residents through the doors themselves. Interview with Maintenance Director (MD) BB on 5/23/19 at 3:10 p.m. who provided invoices for repair work done on the handicapped access doors on 4/18/19. MD BB confirms that the doors were tested and were working fine after the repairs. MD BB stated that he made daily safety rounds throughout the facility, including a check on all the points of entry into and out of the building. He confirmed that he did not check the working condition of the handicapped access pads and stated that multiple attempts have been made to repair handicapped access to the front doors without success and have been unable to determine what the problem is. MD BB admits that the functionality of the handicapped doors should have been monitored daily to ensure that they were working properly. Interview on 5/23/19 at 3:40 p.m. with the Administrator and the Director of Nursing (DON) who were unaware of any problems with the handicapped access doors at the front entry. They were aware of the repairs made in (MONTH) and stated that the doors were working correctly after the repairs. They agreed that all staff are responsible for reporting equipment malfunctions and the failure of the handicapped access doors to open should have been reported. The Administrator confirmed that the front courtesy desk staff were expected to observe residents who are on the front porch and provide assistance where needed but did not monitor them or sign them in or out and there was no process for doing that except after 8:00 p.m. when the doors are locked. The DON confirmed there had been no complaints filed or staff reports of residents being outside for extended periods of time or being treated for [REDACTED].",2020-09-01
842,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-05-24,908,E,1,0,WK1Z11,"> Based on observation and staff interviews, the facility failed to maintain the handicapped access doors located at the facility's main entry which resulted in the failure of the automatic doors to open. This had the potential to affect all handicapped residents who were not physically able to open the doors manually to enter/re-enter the building. Findings include: On 5/21/19 at 10:30 a.m. three residents in wheelchairs were observed outside of the facility's main entrance way. Surveyor attempted to enter the facility using the handicapped entrance and depressed the access pad located on the right column of the main entry to the facility. The doors failed to open, and the access pad was depressed again. Resident (R) #4 advised the surveyor that the handicapped access pad was not working. Continued interview with R#4. at this time, revealed that the pad had not been working properly since the first time he came here about a year ago. Interview with an additional resident located outside the building, R#6, revealed that the doors had not been working properly for at least a year. They worked intermittently and were finally repaired about a month ago. That repair lasted a few days, then the doors went back to the way they worked before. If you pressed the pad a certain way, sometimes the doors would open. R#5 agreed that the doors had not been since he was admitted , and he had waited for staff to assistance to get back in. The residents stated that maintenance and other staff were already aware that there was a problem. Interview on 5/21/19 at 10:50 a.m. at the courtesy desk with Staff Member AA who revealed that he worked at the courtesy desk all day Monday through Friday and was aware that the pad used to open the double doors was not fully functional. Interview with Occupational Therapist (OT) HH on 5/22/19 at 10:40 a.m. in the therapy room who revealed that resident families had complained about the handicapped doors not working frequently but she had not reported the problem because everyone knew they weren't working. Interview with member of the Transport Staff LL on 5/22/19 at 2:55 p.m. who confirmed that the handicapped access doors have not been working properly since (MONTH) of this year. They work sporadically, one day they will work and the next day they won't. Interview of 5/23/19 at 2:40 p.m. with Transport Services JJ who stated that the handicapped access doors have not worked properly for months. They have assisted residents and guests to enter the building who were unable to open the doors manually by themselves. Interview with Maintenance Director (MD) BB on 5/23/19 at 3:10 p.m. in the conference room who provided invoices for repair work done on the handicapped access doors on 4/18/19. MD BB confirmed that the doors were tested and were working fine after the repairs. MD BB stated that he made daily safety rounds throughout the facility, including a check on all of the points of entry into and out of the building. He confirmed that he did not test the functionality of the handicapped access pads and that the functionality of the handicapped doors should have been monitored daily to ensure that they were working properly. Cross refer F689",2020-09-01
843,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2017-06-30,281,D,1,0,SPY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, review of facility policy titled Physician Orders, and review of the National Council of State Boards of Nursing Model Nursing Practice Act, the facility failed to provide safe and effective nursing care by writing an order to withhold medication without receiving physician's approval for one resident (R#1) of eleven resident records reviewed who receive the same medication. The census sample was 111. Review of R#1's History and Physical (H and P) dated 4/26/2017 reveals resident has multiple other comorbidities including [MEDICAL CONDITION]. Review of R#1's 'Physician's Orders' dated 6/2/2017 through 6/30/2017 reveals R#1 is prescribed multiple medications, including [MEDICATION NAME] 100 micrograms (mcg) by mouth once daily. Review of R#1's Medication Administration Record' (MAR) reveals that [MEDICATION NAME] 100 mcg by mouth once daily was not dispensed to the resident on 6/9/2017, 6/10/2017, 6/11/2017 or 6/12/2017. Resident did receive [MEDICATION NAME] 100 mcg by mouth daily on 6/13/2017. New physician's orders were received on 6/14/2017 and [MEDICATION NAME] 112 mcg by mouth was orderd to be given on 6/14/2017. Review of R#1's laboratory results reported on 6/9/2017 reveal a handwritten note dated 6/9/2017 stating 'Hold [MEDICATION NAME] X 2 day. Recheck on Monday, signed by the Director of Nursing (DON). The results of the R#1's TSH ([MEDICAL CONDITION] stimulating hormone) was 31.9. Normal ranges for TSH are 0.45 -5.33. The results were circled in pen. A 'Physician's Interim Orders' dated 6/9/2017 written and signed by the DON reads Hold [MEDICATION NAME] x 2 days, recheck TSH on Monday. The 'Physician's Interim Orders' is not signed by the physician. The physician made rounds in the facility on Tuesday, 6/13/2017 and reviewed R#1's lab results from 6/9/2017. Under the note written by the DON, the physician wrote DO NOT HOLD, resume [MEDICATION NAME], what is the dose?? She needs to be on a higher strength signed and dated 6/13/2017. Review of 'Physician's Interim Orders' reveals an order written [REDACTED].? Fax results to my office. Do not hold [MEDICATION NAME]. An additional 'Physician's Interim Orders' was written and signed by the physician on 6/14/2017 that reads Increase [MEDICATION NAME] to 112 mcg. Repeat TSH in four weeks. A phone interview wuth the physician for R#1 on 6/29/2017 at 1:56 p.m. reveals that he was unaware that R#1's [MEDICATION NAME] was placed on hold and he did not authorize the order. The physician reveals he only became aware of the order when he came in for his regular rounds on Tuesday, 6/13/2017 and reviewed R#1's lab results. He immediately contacted the Administrator and discussed the unauthorized order, questioned why he was not notified, and explained the medical context of the error. Continuing interview with the physician reveals he has reviewed his personal phone records, the office phone records, the answering service and his colleagues phone record with no record obtained of the DON attempting to contact them for authorization of the order. The physician also said it is not uncommon for nurses to misunderstand TSH lab results because a high result indicates the resident requires more [MEDICATION NAME], not less. The physician was asked if the four-day omission of the resident's [MEDICATION NAME] could have caused harm to the resident. He replied no, because [MEDICATION NAME] is a slow acting medication and dose adjustments typically take four weeks to see results. He also stated that he had not experienced this problem previously. Interview with the Administrator on 6/29/2017 at 2:20 p.m. reveals that the DON misinterpreted the lab results, wrote the order to hold the [MEDICATION NAME], and attempted to call the physician for approval. Interview with the DON on 6/30/2017 at 2:40 p.m. with the Administrator present reveals that the DON misinterpreted the lab results, wrote the order to hold the [MEDICATION NAME], and attempted to contact the on-call physician for approval. She made one attempt to reach the on-call physician at 7:11 p.m. and states she has a phone record indicating the call and it was two minutes long, but cannot recall if she left a message. The DON stated that she made no additional calls or attempts to reach the other physician, the physician's office or the answering service. Both the DON and the Administrator stated that the order should not have been written without the physician's consent. Review of the facility policy on 6/29/2017 at 2:10 p.m. entitled 'Physician Orders', revised on 10/25/2016 under 'Scope' reveals the policy applies to all nursing staff serviced by PruittHealth pharmacy. Under 'Procedures' item 2, it states that 'the order must be signed by the physician'. The section entitled 'Verbal and Telephone Orders' under item 2., states that 'The licensed professional will verify the verbal or telephone order by reading the order back to the practitioner issuing the order, and item 3. States the licensed professional will sign and date the order, will indicate the name of the physician giving the order and will document 'read back' as proof of verification of orders. Interview with the Administrator on 6/29/2017 at 2:20 p.m. who confirms that the policy 'Physician Orders' applies to nurses who write orders on behalf of the physician. The orders are invalid without a physician's approval and should not be followed or entered into the resident's medical record.",2020-09-01
844,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-12-12,600,D,1,0,FNPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property and staff/resident interviews, the facility failed to ensure that two of 10 residents (R) (#1 and #2) reviewed were free from physical abuse and neglect. Findings include: Review of the policy, Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised [DATE] revealed: It is the policy of (the facility) and its affiliated entities to actively preserve each patient's right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, neglect .Definitions: Neglect is the failure of the facility, its employees or service providers to provide goods and services to a patient that are necessary to avoid physical harm, mental anguish, or emotional distress. 1. R#1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) Assessment document R#1 with a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact. The resident expired on [DATE] due to an unrelated medical condition. Review of the facility investigation documentation revealed an incident on [DATE]. R#1 was being assisted by CNA J[NAME] R#1 had been waiting for a while for care with toileting and during this wait, she had soiled herself. CNA JJ took the resident into her room to be cleaned. CNA JJ poured a basin of water over the resident's body to wash her off. During this incident R#1's bilateral leg dressings were left wet with this unsanitary water drainage and the resident was not positioned in a manner that she could rest or breath well. LPN KK entered R#1's room and finished cleaning the water from the floor, changed the bandages on her bilateral lower legs and positioned her to a comfortable position. During an interview with the Director of Nursing (DON) on [DATE] at 3:43 p.m., she stated that she did believe this incident was abuse. The state agency and police were notified. CNA JJ was suspended during the investigation and then terminated from employment at the facility. During an interview on [DATE] at 3:46 p.m., LPN KK stated that on the night of the event, CNA JJ was being rude to everyone including staff and residents. 2. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS Assessment for R#2 dated [DATE] revealed a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment. The Incident Note dated [DATE] documented that yelling and screaming was heard and upon entering the room, R#2 was being attacked by the resident in the next room. R#2 was assessed and found to have no injuries and no complaints of pain. Review of the clinical record revealed R#7 had a history of [REDACTED].#8) with a gait belt on [DATE]. R#8 had no injuries. The Admission MDS assessment dated [DATE] documented a BIMS score of 00 indicating severe cognitive impairment. The staff use an application and have a translator because the resident speaks Spanish. A urinalysis and labs were drawn after the first incident. The resident is redirected as needed and medications are administered as ordered. Behaviors are monitored. The resident was scheduled for a psychiatric evaluation after the second incident. During an interview with the DON on [DATE] at 9:38 a.m., she stated that the Interdisciplinary Team, at this time, did discuss that if R#7's behaviors continued they would try to find a more appropriate place for her. During an interview with R#7 on [DATE] at 10:29 a.m., which was translated by the Nurse Practitioner due to the resident speaking Spanish, revealed that she remembers hitting others to protect herself.",2020-09-01
845,PRUITTHEALTH - SAVANNAH,115339,12825 WHITE BLUFF ROAD,SAVANNAH,GA,31419,2019-12-12,609,D,1,0,FNPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property, the facility failed to notify the State Agency (SA) within the required two hours of an incident involving resident to resident physical abuse of one resident (R) (#2) of 10 sampled residents. Findings include: Review of the facility policy titled Prevention of Patient Abuse, Neglect, Exploitation, Mistreatment and Misappropriation of Property revised on 11/21/16 revealed: the regulations require that occurrences of abuse and mistreatment be reported, including injuries of unknown origin, in accordance with established State procedures. Resident #2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual MDS Assessment for R#2 dated 11/29/19 revealed a Brief Interview of Mental Status score of 5 indicating severe cognitive impairment. The Incident Note dated 9/15/19 documented that yelling and screaming was heard and upon entering the room, R#2 was being attacked by the resident in the next room (R#7). R#2 was assessed and found to have no injuries and no complaints of pain. During an interview with the Administrator, Director of Nursing (DON) and the Social Service Director on 12/10/19 at 2:23 p.m., all three stated they believed this behavior was abuse and should have been reported within two hours. The DON and the Administrator stated they did not believe this incident was reportable because it was a resident to resident incident and both residents were severely cognitively impaired. No reporting was provided to the State and the incident was not reported to the Police. During an interview on 12/11/19 at 12:05 p.m. Licensed Practical Nurse (LPN) LL stated that she went into R#2's room and removed R#7 from the area. She did report the incident to the DON.",2020-09-01
846,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2016-02-18,161,D,0,1,1FTP11,"Based on review of the Surety Bond Continuation Certificate and staff interviews, the facility failed to ensure that the amount of the surety bond covered the ending balance in the resident trust fund account for three (3) out of twelve (12) months reviewed. The facility managed a total of forty eight (48) resident trust fund accounts. Findings include: Review of the Surety Bond Continuation Certificate in effect from 8/6/2015 - 8/6/2016 revealed the bond coverage was in the amount of $30,000. Review of the Resident Trust Account bank statements revealed the ending balances exceeded the bond coverage amount for the following months: February 28, (YEAR) through (MONTH) 31, (YEAR): $34,827.64 April 1, (YEAR) through (MONTH) 30, (YEAR): $34,628.77 December 1, (YEAR) through (MONTH) 31, (YEAR): $40,186.36 Initial review the resident trust bank statements was referenced from (MONTH) (YEAR) through (MONTH) (YEAR). It was noted that the ending balance on the (MONTH) (YEAR) statement exceeded the amount of the surety bond coverage. An interview at the time of review with the Administrator on 02/18/16 at 1:12 p.m. confirmed that the ending balance of the (MONTH) (YEAR) bank statement was $40,186.36. Further review of the resident trust bank statements referenced from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the bank statement in (MONTH) (YEAR) and (MONTH) (YEAR) exceeded the amount of the surety bond. Interview with the Corporate Book Keeper on 02/18/16 at 1:33 p.m. revealed that two (2) social security checks had been deposited in (MONTH) (YEAR) due to the holiday season, and this was why the ending balance was high. The Book Keeper and the Administrator confirmed at 1:50 p.m. that the bank statement that ended on (MONTH) 31, (YEAR) was $34,827.64 and the statement that ended on (MONTH) 30, (YEAR) was $34,628.77, exceeding the surety bond coverage. They did not have an explanation as to why.",2020-09-01
847,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-06-11,684,D,1,0,YEWV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to administer one medication to one resident (R), R#2, in accordance with Physician orders. The sample size was three residents. Findings include: Review of the clinical record for R#2 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. R#2 was diagnosed with [REDACTED]. An additional order was given for [MEDICATION NAME] 250 mg by mouth daily indefinitely after the antibiotic was completed. The [MEDICATION NAME] ordered to be administered daily should have started on 3/29/18. Review of the Medication Administration Record [REDACTED]. Review of Physician orders [REDACTED]. those months. Review of Nursing Notes revealed R#2 had not had any problems with gastrointestinal illness. During an interview conducted on 6/11/18 at 3:55 p.m. the Director of Nursing (DON) revealed the pharmacy had missed the order for [MEDICATION NAME] 250 mg by mouth once a day indefinitely that should have started on 3/29/18. The DON revealed that she checked R#2's MAR for (MONTH) (YEAR) before (MONTH) 1, (YEAR) and compared the MAR indicated [REDACTED]. The DON confirmed R#2 should have been administered [MEDICATION NAME] 250 mg daily since 3/29/18.",2020-09-01
848,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-08-16,604,D,1,1,3J9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, record review, and review of the Policy titled Use of Restraints, the facility failed to ensure that one resident (R) (#9) was free from restraints and provide ongoing monitoring and evaluation for the continued use of a physical restraint related to bed rails out of 41 sampled residents. Findings include: Review of the Minimum Data Set ((MDS) dated [DATE] documented R#9 with a Brief Interview for Mental Status (BIMS) score of 99 indicating the resident was cognitively impaired; required two-person extensive assistance with transfers and no restraints used. The clinical record for R#9 revealed a [DIAGNOSES REDACTED]. Observation on 8/13/18 at 10:55 a.m. revealed R#9 in bed with 1/2 side rails up on each side of the bed. Bed rails were observed to be located mid-way on either side of the bed. Resident was observed toward the end of the bed and attempting to get up. Residents brief was noted to be wet. Review of the care plan last revised on 6/25/18 revealed R#9 has an alteration in communication and is unable to make her needs known. Self-care deficit related to impulsiveness, no safety awareness, and cognition and has 1/2 assist rail in use on right and left side to assist with turning, repositioning, Activities of Daily Living (ADL) care and to define bed parameters. Resident at risk for falls related to no safety awareness, history of falls, and use of [MEDICAL CONDITION] medications and is impulsive, resistant to care, and unable to redirect. Review of the Physician order [REDACTED]. 1/2 upper right and left assist rails to assist with turning and positioning, bed mobility, and to help define the parameters of the bed. [DIAGNOSES REDACTED]. On 8/14/18 at 8:55 a.m. R#9 was observed sitting in a scoot chair in the day room located between the 300 and 400 hall. Resident was observed attempting to scoot up to the edge of the seat and put her feet onto the floor. The seat of the scoot chair was observed to be tilted back and the back of the chair was reclined. Resident attempted numerous times to move forward in the chair and put her feet on the floor but was unable to do so. The resident was not observed to move around in her scoot chair. Observation on 08/14/18 at 9:30 a.m. of Certified Nursing Assistant (CNA) DD assisting R#9 back to room. Observation on 8/14/18 at 9:45 a.m. of resident in bed. Left side rail was up and the right-side rail was raised to the top of the bed and locked in position as an assist rail. Observation on 8/15/18 at 9:10 a.m. of resident in bed with side rails up on either side of the bed. Position of the rails were noted to be in the middle on either side of the bed. During an interview on 8/15/18 at 10:07 a.m. outside of R#9's room with Licensed Practical Nurse (LPN) AA revealed that the resident prefers to be in bed. Stated when attempting to get R#9 up into the scoot chair the resident will say, No! No! No! LPN AA stated resident is combative when trying to give peri care and stated it takes 2 people to give incontinent care. LPN AA stated the side rails that were up on the resident bed at this time are 1/2 assist rails and located in the middle portion of the bed on either side. During an interview on 8/15/18 at 12:23 p.m. with MDS Coordinator BB, in the MDS office, revealed that the staff know to leave the bed rails locked in the raised position to the top of the bed to be used as assist rails. Stated the staff has been told numerous times not to leave the rails up on either side of the bed because it can be considered a restraint. MDS Coordinator BB stated that no pre-restraining assessment and review to determine the need for restraints was done. During an interview on 8/15/18 at 1:00 p.m. with CNA DD, in the R#9's room, revealed that in the morning hours R#9 will try getting up out of bed by working her way down to the foot of the bed. Stated that R#9 has not actually made it out of the bed but does try to get up in the mornings. CNA DD stated that with the side rails down to either side of the bed she doesn't believe the resident could get out of the bed and stated R#9 cannot put the rails down as they were put up. Reviewed, with CNA DD, the side rail assessment and physician order [REDACTED].#9 uses 1/2 upper right and left assist rails. CNA DD stated when the rails are lowered down, they are located in the middle of the bed on either side but when they are raised they are located to the upper portion of the bed. CNA DD stated that, at this time, the rails are located in the middle portion of the bed and are up on both sides. CNA DD stated to her knowledge, the resident has not had a fall. During an interview on 8/15/18 at 2:00 p.m. with the DON revealed there is no monitoring documentation by nursing in the resident's medical record while side rails were up on either side of the bed. Review of the Use of Restraints Policy revised 2007 revealed, including but not limited to, that Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint. Practices that inappropriately utilize equipment to prevent resident mobility are considered restrains and are not permitted, including: a. Using bedrails to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility while in bed. b. Tucking sheets so tightly that a bed-bound resident cannot move; c. Placing a resident in a chair that prevents the resident from rising; and d. Placing a resident who uses a wheelchair so close to a wall that the wall prevents the resident from rising. Prior to placing a resident in restrains there shall be a pre-restraining assessment and review to determine the need for restrains. The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms. The following safety guidelines shall be implemented and documented while a resident is in restraints: a. Restrains shall be used in such a way as not to cause physical injury to the resident and to insure the least possible discomfort to the resident. b. Physical restraints shall be applied in such a manner that they can be speedily removed in case of fire or other emergency. Restraints with locking devices shall not be used. c. A resident placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel and an account of the resident's condition shall be recorded in the resident's medical record. d. The opportunity for motion and exercise is provided for a period of not less than ten (10) minutes during each two (2) hours in which restraints are employed. e. Restrained residents must be repositioned at least every two (2) hours on all shifts.",2020-09-01
849,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-08-16,625,D,1,1,3J9O11,"> Based on record review, family and staff interview, the facility failed to notify the responsible party (RP) of the bed hold policy at the time of a therapeutic leave extending past midnight for one resident (R) (R#39). The sample size was 41 residents. Findings include: During interview with a family member on 8/14/18 at 10:30 a.m., she stated that she was the RP and Power of Attorney for R#39, and that she was present when he was admitted to the facility in 2008. She further stated that there had been several deaths in the family in (YEAR), and she took R#39 home for a few days at a time each time. She stated that she had received a bill from the facility for $166, and that she was told by the Bookkeeper that she kept R#39 out one day too many during the last therapeutic leave in (MONTH) of (YEAR), and was told that he was allowed only six or seven days out of the facility per year. She stated during continued interview that R#39's payor source was Medicaid, and that she did not recall receiving any information related to bed holds when the resident was admitted to the facility in 2008. Review of a Resident Statement for R#39 dated 1/5/18 revealed a charge for a therapeutic bed hold room charge from 12/25/17 to 12/25/17 for $166.00. Review of R#39's quarterly Resident Trust Fund Statement with a Statement Date of 4/10/18 revealed withdrawals from his account for resident liability on 1/8/18 for $133.00, on 2/2/18 for $30.00, and on 3/5/18 for $3.00 (total of $166.00). Review of the facility's Admission Packet revealed that it contained the following: Bed Hold Policy (dated 11/2016): Policy: At the time .when the resident goes on therapeutic leave extending past midnight, the facility will provide information to the resident and/or the resident representative regarding the duration of the bed hold policy. Procedure: 1. The facility Bed Hold policy will be reviewed with the resident and/or the resident representative by the facility Bookkeeper or designee during the admission process, .or when the resident goes on therapeutic leave extending past midnight. 2. A signature attesting to this review during the admission process will be requested and stored in the resident financial file. 3. The facility Bookkeeper will call the resident and/or resident representative in a timely manner whenever the resident census indicates the Bed Hold Policy is initiated. The Bed Hold Policy will be verbally reviewed with the resident and/or resident representative and a hard copy of the policy will be mailed with return signature requested. 4. The Bookkeeper will record the notification conversation in the EHR (electronic health record) census notes. The information listed below will be reviewed: Medicaid Bed Hold: Therapeutic Leave: 2. The Medicaid program will continue to provide payment if the resident spends two (2) days away from the facility, provided the resident's attending physician documents in the plan of care that such visits are therapeutic in nature. The resident is not permitted to exceed (4) such visits for a total of eight (8) days of therapeutic leave in any calendar year. 3. HOSPITAL STAY OR THERAPEUTIC LEAVE BEYOND THE TIME MEDICAID WILL MAKE PAYMENT. Arrangements may be made for holding a bed for a resident for days exceeding the established limit of Medicaid payment. This must be arranged with the Business Office and the resident will be responsible for payment of the posted basic daily room rate that is in effect at the time of the resident's absence from the facility. Review of a facility Bed Hold Agreement letter revealed that it was to remind you (resident or RP) of the Bed Hold policy. Review of the Medicaid Residents section of this letter revealed: Therapeutic Leave: The Medicaid program will continue to provide payment if the resident spends time away from the facility on a therapeutic leave, provided the resident's attending physician documents in the plan of care that such visits are therapeutic in nature. The resident is not permitted to exceed eight (8) days in any calendar year. Further review of this form revealed that there was a section for the RP to sign and date, and the contact information of the Business Office Manager and facility phone number. During interview with the Bookkeeper on 8/15/18 at 3:59 p.m., she stated that Medicaid paid for eight days per year of overnight therapeutic leave, and that this information was included in the admission paperwork. She further stated that these eight days do not need to be consecutive, and on the ninth day of leave the room charge became private pay status for Medicaid residents. The Bookkeeper further stated that she was not going to recognize when a resident went on an extended therapeutic leave until Medicaid denied payment for it. She further stated that they had probably 20 residents a day go out on therapeutic leave per day, but most did not stay after midnight. She stated that families were good about letting her know if they would be taking a resident out for several days, so that she could let them know if they had enough bed hold days available. She stated during continued interview that she remembered that R#39 was the only one that exceeded his eight day bed hold limit, and she had called and told the RP that she went one day over the allotted number of days and that it would be private pay, and that the $166.00 charge would be taken out of R#39's trust fund account. The Bookkeeper further stated that when R#39 was out on therapeutic leave past midnight on 12/25/17, that this night put him over the eighth day. She stated that a copy of the admission packet was given to family at the time of admission, and they sign that they received it. She further stated that she did not think that it was realistic to expect her to review the bed hold policy with family every time someone went out on a therapeutic leave. The Bookkeeper provided an acknowledgment signed by R#39's RP on 6/6/08 that the RP had received a written copy of several documents, including the Policy on Bed Holds. She stated during continued interview that she printed the facility Census every day to know who was there and who was on bed hold, but the report did not tell her the total number of days a resident had accumulated on a bed hold status. During continued interview she said that she relied on the family or staff tell her when a resident was out on therapeutic leave after midnight. During interview with R#39's RP on 8/16/18 at 10:53 a.m., she stated that when she had talked to the Bookkeeper about the bed hold concern, that the Bookkeeper told her that she should have told you but I didn't think about it. During interview with the Administrator on 8/16/18 at 1:25 p.m., she stated that the Business Office Manager was responsible to notify the family about the bed hold policy whenever a resident went on a therapeutic leave.",2020-09-01
850,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-08-16,644,D,1,1,3J9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, and review of policy, Admission Criteria, the facility failed to refer one resident (#32) for a pre-admission screening and resident review (PASARR) Level II resident review when the resident experienced a change in his emotional and behavioral status which increasingly impacted his day-to-day functioning. The sample size was 42. Findings include: Review of the policy titled Admission Criteria last revised (MONTH) (YEAR) revealed that the nursing and medical needs of individuals with mental disorders will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review program. Review of the clinical records for Resident (R) #32 revealed the resident was admitted on [DATE] with no psychiatric diagnoses. A Level I PASSARR document of 10/20/14 documented that the resident did not have a suspected mental illness or developmental disability and the admission Minimum Data Set (MDS) assessment of 10/28/14 also documented that the resident had no psychiatric diagnoses. A further review of the clinical records for R#32 revealed current [DIAGNOSES REDACTED]. A review of the Annual MDS assessment of 3/15/18 revealed that the resident was not referred for Level II evaluation, but had active [DIAGNOSES REDACTED]. The most recent MDS assessment, a quarterly MDS dated [DATE] revealed the resident was experiencing hallucinations had active [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the nurses' notes for R#32 since (MONTH) of (YEAR) revealed the resident showed evidence of increasing mental health difficulties and was finally referred for behavioral health services on 5/24/18: 1.The nurses' note of 2/10/18 documented that the resident was weepy during the shift and voiced thoughts of wanting to die; 2.A review of the nurses' note of 2/14/18 revealed the behavioral health service used by the facility was notified that the resident was voicing thoughts of self-harm; 3.A review of the nurses' notes of 5/2/18 and 5/4/18 revealed the resident was again voicing thoughts of wanting to die; A review of a psychological evaluation completed by the behavioral health service on 5/24/18 revealed that the resident was referred for services due to combative behaviors and depression. The recommendation was for the resident to receive individual therapy 1-3 times per month to decrease symptoms of depression. During an interview on 8/15/18 at 2:57 p.m. with the Social Service Director, it was revealed R#32 had experienced a change in his behaviors, and these included hallucinations. She had referred him and he had received psychological services from a behavioral health service. However, the resident had not been referred for a PASARR Level II evaluation. The facility did not routinely refer residents for a level II assessment when they experienced changes in their behavioral/emotional health. She is working with the current administrator to see what needs to be done to refer residents for a Level II screening when they have a behavioral change. During an interview on 8/16/18 10:36 a.m. with Licensed Practical Nurse (LPN) EE, it was revealed that the resident's mood often fluctuated. He had expressed wanting to die in the past and was referred for psychological services. However, when she began to work with him on a steady basis in (MONTH) (YEAR), his expressions of wanting to die became more frequent and he was again referred for psychological service.",2020-09-01
851,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-08-16,656,D,1,1,3J9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to implement the care plan related to use of a securement device to anchor a Foley catheter for one resident (R) (R#25). In addition the facility failed to follow the care plan related to treatment of [REDACTED].#228). The sample size was 41. Findings include: Observation on 8/13/18 at 11:14 a.m.; 8/14/18 at 8:54 a.m. and 4:43 p.m.; and on 8/15/18 at 9:58 a.m. and 1:21 p.m., revealed that R#25 was in bed, and he had a Foley catheter draining urine to a bedside bag (BSB). Review of R#25's Physician order [REDACTED]. Review of R#25's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had an indwelling catheter. Review of R#25's Indwelling Catheter care plan with a start date of 5/24/13 revealed that he was at risk for complications due to a [DIAGNOSES REDACTED]. Review of the approaches for this care plan revealed one dated 6/26/18 for securement device as ordered, and one dated 5/24/13 to avoid pulling on the tubing, and to use leg strap as tolerated and as he will allow. During observation on 8/14/18 at 9:47 a.m. with Licensed Practical Nurse (LPN) FF, R#25's Foley catheter was observed to not be secured to his thigh in any way. Further observation revealed that when the LPN pulled his gown back, the catheter tubing moved and R#25 said ow. During observation on 8/15/18 at 6:23 p.m. with LPN GG, no catheter strap or other device was seen securing R#25's catheter tubing to his leg. During an observation with Certified Nursing Assistant (CNA) HH on 8/16/18 at 9:21 a.m., she verified that there was no cath holder for R#25's catheter tubing. During interview with CNA HH after this observation, she stated that she did not know if the facility had any catheter straps, as she had never seen one on R#25. During interview with the Director of Nursing on 8/16/18 at 1:33 p.m., she stated that a resident with a catheter should have a leg strap or a [MEDICATION NAME] used to secure the catheter. Record Review revealed that Resident #228 had a care plan for verbal and physical abusive behaviors with [DIAGNOSES REDACTED]. Review of her care plan dated 12/30/11 revealed an approach of if the resident becomes aggressive, walk away calmly and re-approach her later. During an interview with Certified Nursing Assistant (CNA) JJ on 8/16/18 at 6:20 a.m., the CNA stated that while changing the resident's brief on 6/27/18 around 2:00a.m., R#228 became agitated and started swinging her arms and legs trying to hit and kick the CN[NAME] The CNA then stated that she walked away from the resident for a few minutes and came back and the resident was still agitated, swinging her arms and legs, and resisting getting her brief changed. The CNA then proceeded to change R#228s brief. The CNA stated that R#228 hit her head against the wall beside the bed and hit her arms against the siderails on the bed causing skin tears and bleeding on both of her forearms and left leg. The CNA stated she mashed the call bell and CNA KK came into the room. She stated CNA KK then left the room to go get the Licensed Practical Nurse PP. When PP came into the room, CNA JJ left the room to continue making rounds on the other residents. Cross ref: F689 and F690",2020-09-01
852,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-08-16,657,D,1,1,3J9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and policy, Care Plans, Comprehensive Person-Centered, the facility failed to revise the plan of care for one resident (#32) related to mood state/behaviors associated with a [DIAGNOSES REDACTED]. The sample size was 42. Findings include: A review of the policy titled Care Plans, Comprehensive Person-Centered last revised (MONTH) (YEAR), the interdisciplinary team must review and update the care plan at least quarterly, in conjunction with the required quarterly MDS assessment. A review of the Annual MDS assessment dated [DATE] for Resident (R)#32 revealed that the resident had active [DIAGNOSES REDACTED]. Under the Care Area Assessment Summary, mood state triggered and the decision was made to create a plan of care for that area. A review of the plan of care for R#32 related to alteration in mood state/behaviors associated with the [DIAGNOSES REDACTED]. A review of the most recent MDS assessment, a quarterly MDS dated [DATE], revealed the resident continued to experience hallucinations, had active [DIAGNOSES REDACTED]. During an interview on 8/16/18 at 8:14 a.m. with MDS coordinator CC, it was revealed that the interdisciplinary team last met to have a care plan meeting for R#32 on 6/20/18. She had intended to update his care plan related to mood state at that time, but had simply forgotten to do so.",2020-09-01
853,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-08-16,689,D,1,1,3J9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of clinical records and staff interviews, it was determined that the facility failed to provide adequate care during activities of daily living (ADL) care, brief change to prevent an avoidable injury to Resident (R) #228. Actual harm was identified from hospital records dated . Findings include: Record review revealed that R#228 was admitted to the facility with the following Diagnoses: [REDACTED]. The resident was assessed on 5/11/18 Annual Minimum Data Set (MDS) as having impaired cognition, and exhibiting physical and verbal behaviors towards others, such as hitting, grabbing, and cursing. She required the extensive physical assistance of one staff member for most ADLs. R#228 required physical assistance of one to two staff members for most transfers. During an interview with JJ, Certified Nursing Assistant (CNA) on 8/16/18 at 6:20 a.m., the CNA stated that while changing the resident's brief on 6/27/18 around 2:00a.m., R#228 became agitated and started swinging her arms and legs trying to hit and kick the CN[NAME] The CNA then stated that she walked away from the resident for a few minutes and came back and the resident was still agitated, swinging her arms and legs, and resisting getting her brief changed. The CNA then proceeded to change R#228s brief. The CNA stated that R#228 hit her head against the wall beside the bed and hit her arms against the siderails on the bed causing skin tears and bleeding on both of her forearms and left leg. The CNA stated she mashed the call bell and KK, CNA came into the room. She stated KK then left the room to go get the PP, Licensed Practical Nurse. When PP came into the room, JJ stated that she and KK left the room to continue making rounds on the other residents. During an interview with CNA, KK on 8/16/18 at 6:54 a.m., she stated that she knew the resident very well. She stated she went into the room to help JJ, CNA change the resident's brief. She stated that they normally do this together because the resident frequently will resist care. She stated when she walked into the room, she noticed that the resident was bleeding from her left forearm, so she told JJ to stop working with the resident & she went out of the room to get the charge nurse. The nurse came in and started working with the resident, so KK went out of the room with JJ and continued making rounds on other residents. KK stated that she had received training related to dementia care residents about a month before this incident. She stated that she had learned if a resident is upset or resisting care, CNAs should leave the resident alone for a few minutes to calm down because frequently the resident why they are upset. KKs also stated that she needs to always notify the nurse if a resident becomes upset or resist care.",2020-09-01
854,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-08-16,690,D,1,1,3J9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to anchor a Foley catheter strap to one resident's (R) leg (R#25), to prevent excessive tension on the catheter. The sample size was 41 residents. Findings include: Review of a physician's History and Physical dated 5/8/13 revealed that R#25 had a recent hospitalization with [MEDICAL CONDITIONS] ([MEDICAL CONDITION]) and had a Foley catheter, and hemorrhagic [MEDICATION NAME]. Review of R#25's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status score of 99, indicating that he was unable to complete one or more questions of the interview, and staff assessed him as having short- and long-term memory problems and moderately impaired decision making. Further review of this MDS revealed that he had an indwelling catheter. Review of R#25's Indwelling Catheter care plan with a start date of 5/24/13 revealed that he was at risk for complications due to a [DIAGNOSES REDACTED]. Review of the approaches for this care plan revealed one dated 6/26/18 for securement device as ordered, and one dated 5/24/13 to avoid pulling on the tubing, and to use leg strap as tolerated and as he will allow. Review of R#25's Physician order [REDACTED]. Review of the urologist's Encounters and Procedures report dated 7/10/18 and 8/7/18 revealed that R#25 was at his office for [MEDICAL CONDITION] with an indwelling Foley catheter secondary to [MEDICAL CONDITION] bladder, and required cystoscopy to be able to place a Foley catheter. Further review of this report revealed that there was ventral erosion of the urethra. Observation on 8/13/18 at 11:14 a.m.; 8/14/18 at 8:54 a.m. and 4:43 p.m.; and on 8/15/18 at 9:58 a.m. and 1:21 p.m., revealed that R#25 was in bed, and he had a Foley catheter draining urine to a bedside bag (BSB), which was placed inside a privacy bag hooked to the bedframe below the level of the resident's bladder. During observation on 8/14/18 at 9:47 a.m. with Licensed Practical Nurse (LPN) FF, R#25's Foley catheter was observed to not be secured to his thigh in any way. Further observation revealed that when the LPN pulled his gown back, the catheter tubing moved and R#25 said ow. During observation on 8/15/18 at 6:23 p.m. with LPN GG, no catheter strap or other device was seen securing R#25's catheter tubing to his leg. During an observation of ADL (activity of daily living) care by Certified Nursing Assistant (CNA) HH on 8/16/18 at 9:21 a.m., R#25 was observed to refuse his bath. Further observation revealed that when CNA HH pulled his covers back to change them, she verified that there was no cath holder for R#25's catheter tubing. CNA HH was then observed to remove his BSB from the privacy bag, and pulled the drainage spout down so that it was uncovered, and then placed the BSB directly on the floor. The CNA was then observed to empty the urine from the BSB before placing it back inside the privacy bag. During interview with CNA HH after this observation, she stated that she did not know if the facility had any catheter straps, as she had never seen one on R#25. During interview with the Director of Nursing on 8/16/18 at 1:33 p.m., she stated that a resident with a catheter should have a leg strap or a [MEDICATION NAME] used to secure the catheter. Review of the facility's policy Catheter Care, Urinary, with a revised date of (MONTH) 2014 revealed: The purpose of this procedure is to prevent catheter-associated urinary tract infections. Be sure the catheter tubing and drainage bag are kept off the floor. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site (Note: Catheter tubing should be strapped to the resident's inner thigh.) Secure catheter utilizing a leg band.",2020-09-01
855,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2018-08-16,880,D,1,1,3J9O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to perform hand hygiene when indicated during two of two meal observations on two of five halls. The facility census was 77 residents, and the sample size was 41. Findings include: 1. During observations at breakfast on 8/16/18 at 7:45 a.m. for residents served in their rooms on the 300-hall, Certified Nursing Assistant (CNA) II was observed to obtain a tray off the food delivery cart, opened the linen closet door to obtain a towel, and took the tray to a resident in room [ROOM NUMBER]. Further observation revealed that the CNA moved a pillow on the bed, raised the head of the bed, and began to prepare the foods which included picking up and splitting open a biscuit with her bare hands. CNA II was then observed to move the overbed table, then picked up a sausage patty with her bare hands and placed it alongside the plate on top of the serving tray. Continued observation revealed that after CNA II left room [ROOM NUMBER], she never washed her hands or used hand sanitizer, and she obtained another tray off the food cart, knocked on the door of room [ROOM NUMBER], entered and placed the tray on a resident's overbed table. She was then observed to put her hair behind her left ear with her hand, raised the resident's head of the bed, moved and raised the overbed table. CNA II was then observed to pick up a glass of orange juice near the rim after removing the lid, and the resident was observed to drink from this glass. During continued observation the CNA opened the paper napkin holding the silverware, removed the spoon and placed it in the yogurt. She was then observed to pick up and split open the resident's biscuit with her bare hands, then picked up the sausage patty with her bare hands and put it inside of the biscuit. Further observation revealed that the resident then picked up and began to eat this sausage biscuit. CNA II was then observed to leave the room, opened the linen closet door to get a towel, knocked on the door of room [ROOM NUMBER] to re-enter it, placed the towel over the resident's chest, and pulled up the siderail on one side of the bed. CNA II was asked to assist with another resident, and she was observed to use some hand sanitizer from a dispenser on the wall before entering room [ROOM NUMBER]. Review of the facility policy Assisting the Impaired Resident with In-Room Meals, revised (MONTH) 2013, revealed: Employees must wash their hands before serving food to residents. It is not necessary to wash hands between each resident tray; however, if there is contact with soiled dishes, clothing or the resident's personal effects, the employee must wash their hands before serving food to the next resident. Review of the facility policy Handwashing/Hand Hygiene revised (MONTH) (YEAR) revealed: Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: Before and after direct contact with residents; After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; Before and after assisting a resident with meals. During dining observation on 8/13/18 at 12:15 p.m., on 400 hall, MDS Coordinator CC was not observed to sanitize or wash her hands before taking a tray off of the cart and taking it in to room [ROOM NUMBER] bed A, set up the tray, take the utensils from the tray and cut up the ham as requested by the resident. MDS Coordinator CC was then observed leaving the room and took another tray from the cart, took it into room [ROOM NUMBER] bed B and set it on the bedside table, pick up the bed remote and raised the head of the bed up, set up the resident's tray, and fed the resident a bite of food. MDS Coordinator CC walked out of the room and went to the med cart on the 300 hall, got a straw, brought it back into room [ROOM NUMBER] bed B, opened it, placed it in the resident's milk carton and held the straw while the resident drank. After setting down the milk carton MDS Coordinator CC took a metal chair leaned against the head of the resident's bed, unfold the chair, set down and began to use the utensils on the tray to feed the resident. At no time was MDS Coordinator CC observed to wash or sanitize her hands. Observation of dining on 8/15/18 at 5:45 p.m. on the 400 hall revealed staff using hand sanitizer between serving resident trays, setting up trays, after touching other items in the rooms or in the hall. No breaks in infection control were observed. During an interview on 8/16/18 at 10:31 a.m. with the DON revealed that she expects staff, when delivering meal trays, to sanitize their hands between residents and stated if staff touch something in the room she would expect them to sanitize their hands prior to assisting with the meal tray any further. DON stated if staff is feeding a resident she expects them to sanitize their hands prior to setting up the tray and at any time, in between, that they touch something other than what is on the meal tray. DON gave the example that if staff begin feeding a resident and stop to raise or lower the bed with the control, or touch something else in the room, they should sanitize their hands before continuing to assist the resident with eating. DON stated that hand sanitation was discussed recently, and the decision was made that after three uses of hand sanitizer staff should wash their hands. During dining observation on 8/13/18 at 12:15 p.m., on 400 hall, MDS Coordinator CC was not observed to sanitize or wash her hands before taking a tray off of the cart and taking it in to room [ROOM NUMBER] bed A, set up the tray, take the utensils from the tray and cut up the ham as requested by the resident. MDS Coordinator CC was then observed leaving the room and took another tray from the cart, took it into room [ROOM NUMBER] bed B and set it on the bedside table, pick up the bed remote and raised the head of the bed up, set up the resident's tray, and fed the resident a bite of food. MDS Coordinator CC walked out of the room and went to the med cart on the 300 hall, got a straw, brought it back into room [ROOM NUMBER] bed B, opened it, placed it in the resident's milk carton and held the straw while the resident drank. After setting down the milk carton MDS Coordinator CC took a metal chair leaned against the head of the resident's bed, unfold the chair, set down and began to use the utensils on the tray to feed the resident. At no time was MDS Coordinator CC observed to wash or sanitize her hands. Observation of dining on 8/15/18 at 5:45 p.m. on the 400 hall revealed staff using hand sanitizer between serving resident trays, setting up trays, after touching other items in the rooms or in the hall. No breaks in infection control were observed. During an interview on 8/16/18 at 10:31 a.m. with the DON revealed that she expects staff, when delivering meal trays, to sanitize their hands between residents and stated if staff touch something in the room she would expect them to sanitize their hands prior to assisting with the meal tray any further. DON stated if staff is feeding a resident she expects them to sanitize their hands prior to setting up the tray and at any time, in between, that they touch something other than what is on the meal tray. DON gave the example that if staff begin feeding a resident and stop to raise or lower the bed with the control, or touch something else in the room, they should sanitize their hands before continuing to assist the resident with eating. DON stated that hand sanitation was discussed recently, and the decision was made that after three uses of hand sanitizer staff should wash their hands.",2020-09-01
856,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2017-08-31,156,D,0,1,KULD11,"Based on observation, staff interview, clinical record review and review of the facility's policy titled, Advance Beneficiary Notices dated (MONTH) (YEAR) revealed two of three residents (R#12 and R#17) notices were incorrectly issued denying the resident the ability to request an appeal or expedited appeal review. The sample was 27. Findings include: 1. R#12 was on a Medicare Part A stay when the facility issued the form Centers for Medicare and Medicaid Services (CMS) R-131. The form CMS-R-131 was used to indicate Part B therapy services were ending. R#12 was issued the notice indicating her physical therapy (PT) and occupational therapy (OT) were ending on 8/16/17. R#12 had reached the max (maximum) rehab potential met for the time frame. The notice was issued on 8/16/17 and signed on 8/16/17 by the responsible party. The form CMS R-131 did not provide the information and number needed to appeal to the Quality Improvement Organization (QIO) or request an expedited appeal review of the facility's decision. 2. R#17 was issued a Notice of Medicare Non-Coverage (NOMNC) form CMS- on 4/21/17. The NOMNC indicated PT/OT would end on 4/21/17. The form was signed by the responsible party on 4/21/17. The NOMNC should have been issued and signed 4/19/17. A Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) was issued to R#17 as well and did not indicate when it was given, the estimated cost of continued therapy and the information and number of the QIO was not given to request a demand bill. The SNFABN form was signed on 4/21/17 by the responsible party. Interview with the social worker on 8/30/17 at 10:12 a.m., revealed she had only been in the position about two months. She had issued the notice to R#12 and was unaware there was a separate form to notify Medicare Part A recipients. R#17 was issued a notice by the former social worker. Review of the facility's policy titled, Advance Beneficiary Notice dated (MONTH) (YEAR), revealed .4. A Notice of Medicare Non-Coverage (NOMNC) shall be issued to the resident/representative when Medicare covered service(s) are ending. This informs the resident on how to request an appeal or expedited determination from their Quality Improvement Organization (QIO). It also specified in .5. To ensure that the resident, or representative, has enough time to make a decision whether or not to receive the services in question, the notice shall be provided within two days of the last anticipated covered day.",2020-09-01
857,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2017-08-31,244,E,0,1,KULD11,"Based on observations, resident interview, and review of monthly Resident Council Meeting Minutes, the facility failed to act promptly upon the grievances and recommendations of resident council members regarding cold food served to residents, potentially affecting 77 residents receiving oral alimentation in the facility. Findings include: A dining observation on 8/28/17 on Hall D revealed a food cart arrived at 12:22 p.m. The food cart had open shelves holding the trays with no means to preserve temperature. It was noted one staff member was passing trays to residents dining in their rooms. The last tray was delivered on Hall D at 12:38 p.m. In an interview with a resident council representative, Resident (R#90) on 8/29/17 at 3: 23 p.m., when asked if the facility listened to and addressed the groups concerns and recommendations, he stated no, they had voiced concerns about food temperatures at the monthly meetings over and over and they have not fixed the problem. By the time the cart gets to the end of the hall the food is cold. He continued indicating only one staff person delivered meals most of the time while doing other tasks. He further indicated the facility had assured the group they were working on solutions but thus far there had been no resolution. Review of Resident Counsel Meeting Minutes dated (MONTH) (YEAR) through (MONTH) (YEAR) revealed the residents had voiced concerns about food temperature. The following information was obtained from the meeting minutes: 1. On 1/11/17 one resident complained that her food was always cold on Hall D when she got her tray. A response from the administrator dated 1/11/17 stated that concerns had been forwarded to the department director for further investigation. 2. On 2/9/17 a resident on Hall D complained of breakfast food being cold when getting the tray and staff had not offered to heat the food up. A response from the Administrator dated 2/11/17 stated the department director would be meeting with residents individually to discuss in further detail. 3. On 3/8/17 one resident complained breakfast trays were not being passed out in a timely manner after coming to the hall on the tray carts, resulting in cold food. Another resident stated the food was cold on Hall C. On 3/9/17 a response from the Administrator stated they were diligently working on the continued concern voiced from the 500 (a resident hall) representatives concerning food temperatures at breakfast. We are working on a new process for getting trays out more quickly hopefully reducing the likelihood of cold foods being served. 4. On 4/12/17 one resident complained the meatloaf was raw when served. A response from the Administrator on 4/17/17 stated if grievances were voiced they had been forwarded to the appropriate department for investigation. 5. On 6/13/17 four residents complained of cold food. A response from the Administrator on 6/13/17 stated, It appears there are still many issues with food temperatures and satisfaction of food being served. We are constantly striving to improve delivery time of your meals to ensure a hot meal each time. Dietary is planning to meet with the residents to cover these food specific issues more in-depth within the next few days. 6. On 8/8/17 one resident complained he got his food last and it was cold and another resident complained that staff were still leaving the food in the halls too long and her ice was melted in her tea. On 8/9/17 a response from the Administrator stated there were still a couple residents who had expressed a continued issue with the timeliness of meals served, thus causing cold food and melted ice. A test tray was completed on 8/30/17 during the lunch meal in Hall A with the dietary manager. The surveyor verified the hot food was no longer hot and the milk was no longer cold. Temperatures were taken and it was noted the potatoes were 129 degrees Fahrenheit (F), pot roast 120.5 degrees F, carrots 112 degrees F, cold bean salad 66 degrees F, pear parfait 54 degrees F, cold macaroni salad 67 degrees F, and the milk 51.8 degrees F Cross Reference F364",2020-09-01
858,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2017-08-31,329,D,0,1,KULD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview the facility failed to ensure a gradual dose reduction was attempted for the use of an antipsychotic medication regarding one Resident (R#44) of 27 sampled residents. Findings include: Review of R#44's clinical record revealed she had [DIAGNOSES REDACTED]. The Physicians Orders (PO) revealed [MEDICATION NAME] (an anti-psychotic medication) 100 milligrams (mg) twice a day and 300 mg half a tablet at night was ordered on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] in sections D and [NAME] revealed the resident had physical and verbal behavior, wandering, poor appetite and a short temper. A review of the Mood and Behavior Monitoring Sheet in the resident's clinical record revealed in (MONTH) (YEAR) the resident had not exhibited any moods or behaviors The MDS quarterly assessment dated [DATE] in sections D and [NAME] revealed R#44 had a short temper, a poor appetite and physical behavior symptoms. The Mood and Behavior Monitoring Sheets for (MONTH) (YEAR) and (MONTH) (YEAR) revealed the resident had not exhibited any moods or behaviors. An interview with the Director of Nursing (DON) on 08/30/17 at 4:30 p.m., verified the Mood and Behavior grids indicated the resident had no issues with mood and behaviors for (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). She confirmed the [MEDICATION NAME] (an anti-psychotic medication) had not been reduced since (MONTH) (YEAR). She further confirmed the resident had not been exhibiting any mood or behaviors.",2020-09-01
859,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2017-08-31,364,F,0,1,KULD11,"Based on observation, monitoring review and staff interview the facility failed to ensure the residents had foods that were appropriate temperatures to ensure the food was palatable. There were 77 of 78 residents who received food from the kitchen. Findings include: Review of the Resident Council Minutes from (MONTH) (YEAR) to (MONTH) (YEAR) revealed the residents had consistently complained about cold food. The Communication Record regarding the resident council minutes dated 3/8/17 revealed meal trays were not being handed out in a timely manner after being pushed out of the dining room on the food cart, resulting in cold food. The intervention to address the complaint of cold food was to monitor the delivery of the breakfast trays for timeliness. The documentation of monitoring of hall trays by the facility revealed the breakfast trays were only checked on 3/10/17, 3/13/17, 3/14/17 and 3/17/17. No other meal trays were checked. On 8/30/17 at 11:20 a.m. the kitchen staff prepared the food for tray line. The temperatures were taken of the foods prior to delivery. The pot roast temperature was 162 degrees Fahrenheit (F), the stewed potatoes were 160 degrees F, the carrots were 170 degrees F, pureed pot roast was 160 degrees F, pureed potatoes were 160 degrees F, pureed carrots 170 degrees F, gravy 165 degrees F and milk was 32 degrees F. The A Hall food cart was delivered on 8/30/17 at 11:59 a.m. and was placed in a corner of the hall by the kitchen staff. The Certified Nurse Aide (CNA) began delivering the lunch trays at 12:00 p.m. At 12:02 p.m. the Dietary Manager (DM) paged staff to come to the A Hall. Another CNA arrived and began delivering lunch trays at 12:03 p.m. The DM stated, usually one CNA passes trays. The trays were all delivered by 12:18 p.m. There were 19 trays delivered. The test tray was completed at 12:18 p.m. with the DM. The pot roast temperature was 120 degrees F, the potatoes were 120 degrees F, the carrots were 112 degrees F, the cold bean salad was 66 degrees F, the milk was 51.8 degrees F, the cold pear parfait was 54 degrees F and the cold macaroni salad was 67 degrees F. The temperatures were checked and the food tasted. The hot foods were not hot to taste and the cold foods were not cold. The DM verified the temperature test results and the taste test. An interview with the Dietary Manager (DM) on 8/30/17 at 12:30 p.m., verified there were consistent complaints regarding the cold food and they were documented in the resident council minutes. An interview with the Administrator on 8/30/17 at 3:15 p.m., verified residents had consistently complained of cold food. She indicated the problem was the facility did not have enough staff to deliver meals in a timely manner. She further indicated there were no new interventions initiated to address the identified problem and the cold foods were not addressed by the Quality Assurance (QA) committee.",2020-09-01
860,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2017-08-31,371,F,0,1,KULD11,"Based on observation and staff interview the facility failed to ensure the kitchen was maintained in a sanitary manner. There were 77 of 78 residents who received food from the kitchen. Findings include: The initial kitchen tour on 8/28/17 began at 9:20 a.m., with the Dietary Manager (DM) revealed an observation of the stock room containing dried foods and cans revealed stacked boxes with six boxes flushed to the floor. The DM indicated they were short staffed and the boxes had been delivered yesterday. The metal grate over the two lights over the stove had a large amount of built up dust. Further observation revealed there were five boxes on the floor outside of the walk-in cooler. Each box contained bottles of Ecolab chemicals. There were four large drum containers near the walk-in cooler that contained Ecolab chemicals. The DM indicated chemicals for the kitchen were usually kept in a secured cabinet, but the staff had not found a place to store these chemicals. There were five empty cardboard boxes near the back door on the floor and the DM stated the boxes should have been taken to the dumpster. Observation with the DM on 8/30/17 at 10:30 a.m., revealed the air conditioner in the stock room had a large amount of dirt build up on the grids. The unit air conditioner in the window near where the food was being prepared and cooked had a large amount of build up dirt. The fan on the floor near the reach in cooler had a large amount of dust build up. The air conditioner unit in the window near the area of food preparation had dirt build up. The floor fan next to the reach in cooler had a large amount of dust build up.",2020-09-01
861,CALHOUN HEALTH CARE CENTER,115340,1387 HIGHWAY 41 NORTH,CALHOUN,GA,30701,2017-08-31,372,F,0,1,KULD11,"Based on observation and staff interview the facility failed to ensure the dumpsters were maintained in a manner that confined the waste and garbage material in a proper manner. This had the potential to effect 78 residents who resided in the facility. Findings include: Observation on 8/28/17 at 9:50 a.m., revealed a bin of garbage out in the courtyard, not far from the dumpsters. The first dumpster had a side door open. The second dumpster had one of the lids open. The Dietary Manager (DM) verified these observations and stated the dumpsters were supposed to be closed. She stated the laundry bin should not be open in the courtyard filled with garbage.",2020-09-01
862,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2019-01-15,602,D,1,0,XLLQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview and review of facility policy, the facility failed to ensure that controlled medications were free from misappropriation for two (2) residents (R), (R#1 and R#2) from a sample of three (3) residents. The facility census was ninety-six (96) residents. Findings include: Review of facility policy titled Grievances, Abuse Prohibition, Intent, Reviewed and Updated for Release (MONTH) (YEAR), revealed the following: It is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse, or misappropriation of patient's property . Misappropriation of patient property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a patients belongings or money without the patient's consent. 1. Review of the clinical record for R#1 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the latest Minimum Data Set (MDS) completed on 10/25/18, revealed R#1 had been unable to complete Brief Interview for Mental Status (BIMS) scoring. Continued review revealed R#1 received opioid pain medication, had mild pain and received scheduled and as needed (PRN) medications for pain. Review of physician's orders [REDACTED]. Review of Controlled Drug Records revealed R#1 had documentation of five (5) PRN [MEDICATION NAME] administrations from 10/1/18 through 10/31/18. Continued review of Controlled Drug Records revealed R#1 had administrations of PRN [MEDICATION NAME] documented thirty-three (33) times from 11/1/18 through 11/30/18. The Controlled Drug Record from 11/29/18 through 12/6/18 was missing and the facility provided a faxed copy, used to reorder [MEDICATION NAME] from the pharmacy. A review of the pharmacy manifest of dates [MEDICATION NAME] orders were filled for R#1 revealed this [MEDICATION NAME] order for thirty (30) tablets was filled on 11/26/18. The documentation was completed on the faxed copy from 11/29/18 through 12/4/18. The [MEDICATION NAME] was reordered according to the fax date stamp on 12/4/18 and there were fifteen (15) remaining [MEDICATION NAME] on 12/4/18. Five (5) lines were blank on the faxed copy. R#1 also had Physician orders [REDACTED]. There were four (4) PRN documentations on the MAR for R#1, from 12/4/18 through 12/6/18 and these were subtracted from the missing [MEDICATION NAME] documentations. Six (6) [MEDICATION NAME] tablets, prescribed for R#1, were not accounted for on Controlled Drug Records or Medication Administration Records from 12/4/18 through 12/6/18. The next available Controlled Drug Record for [MEDICATION NAME] for R#1 was also a copy of the record faxed to the pharmacy to reorder on 12/13/18. A review of the date of this reorder revealed this order for 30 [MEDICATION NAME] was filled on 12/4/18. Documentations were recorded from 12/7/18 at 12:00 a.m. through 12/14/18 at 12:00 a.m. and there were seven (7) [MEDICATION NAME] that could not be accounted for when compared with the MAR. [MEDICATION NAME] was documented as administered on this copy of the Controlled Drug Record with seven [MEDICATION NAME] remaining. The next Controlled Drug Record was also a faxed copy with documentations from 12/14/18 through 12/20/18. This order for 30 [MEDICATION NAME] was filled on 12/14/18. [MEDICATION NAME] was also documented administered on this Controlled Drug Record for the second time on 12/14/18 at 12:00 a.m. There were seven (7) [MEDICATION NAME] that could not be accounted for. No documentations of the MAR indicated [REDACTED]. The faxed date stamp revealed [MEDICATION NAME] was reordered with eleven (11) tablets remaining on 12/20/18 at 12:00 p.m. Between 12/20/18 at 12:00 p.m. and the next Controlled Drug Records first documentation on 12/21/18 at 12:00 a.m. a comparison with the MAR indicated [REDACTED] The next Controlled Drug Record was an original, with documentations of administration beginning 12/21/18 at 12:00 a.m. and ending on 1/1/19 at 12:00 a.m. was reviewed and did not reveal any [MEDICATION NAME] was not accounted for. The Controlled Drug Record for 1/1/19 through 1/9/19 was also reviewed and there were no [MEDICATION NAME] tablets not accounted for. A narcotic count for R#1 was conducted on 1/9/19 at 12:20 p.m. and the count of controlled drugs was correct. Packaging of the controlled medication was observed and intact without evidence of tampering. There were no PRN [MEDICATION NAME] administrations documented on the Controlled Drug Records or (MONTH) (YEAR) and (MONTH) 2019 MAR's from 12/26/18 through 1/9/19 at 12:00 a.m. Observations of R#1 were conducted on 1/9/19 at 11:50 a.m., 1/9/19 at 12:40 p.m., 1/15/19 at 10:50 a.m., and 5:15 p.m. revealed R#1 was comfortable and no signs of discomfort were observed. Record review of Nurse's Medication Notes dated 11/3/18 at 12:00 a.m. revealed R#1 had requested her scheduled [MEDICATION NAME] at 12:00 a.m. Continued review revealed R#1 had told the nurse she was supposed to get her pain pill on 11/4/18 at 12:00 a.m. Record review of Nurse's Progress notes from 10/1/18 through 1/8/19 did not reveal any notes regarding unrelieved or continued pain. References in summaries were reviewed revealing R#1 was administered scheduled and PRN pain medication but there were no specific notes regarding dates and times of administrations to account for the missing [MEDICATION NAME]. An interview conducted with R#1 regarding pain medications on 1/9/19 at 11:50 a.m. revealed she was aware she was administered pain medication and it was effective. R#1 was unsure and could not remember if she requested pain medication. R#1 revealed she was not currently experiencing pain or discomfort. 2. Review of the clinical record for R#2 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the MDS for R#2 completed on 10/24/18 revealed a BIMS of 12, indicating moderate cognitive impairment. Review of physician's orders [REDACTED]. Review of the Pharmacy manifest listing dates filled for 30 [MEDICATION NAME] 5-325 mg every 8 hours PRN order for R#2 revealed a missing Controlled Drug Record faxed to the Pharmacy for refill on 11/23/18. The next available Controlled Drug Record had been retrieved from copies of Controlled Drug Records that had been faxed to the pharmacy for refill. The copy of the reorder was reviewed and documentation of administrations started on 11/29/18 and stopped on 12/10/18 at 8:00 p.m. with twelve (12) [MEDICATION NAME] left. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) MAR's for R#2 revealed from 12/10/18 at 8:00 p.m. when the faxed copy of the Controlled Drug report ended, and the first [MEDICATION NAME] administered from the next Controlled Drug Record started on 12/13/18 at 8:00 p.m., there were documentations of two (2) administrations. Ten (10) [MEDICATION NAME] 5-325 prescribed for R#2 were not accounted for. Observations of R#2 on 1/9/19 at 12:54 p.m., 1/15/19 at 4:30 p.m. and 1/15/19 at 5:20 p.m. revealed no indications of pain or discomfort. Record reviews of the Nurse's Progress Notes and Physician's Progress Notes from 10/1/18 through 1/8/19 did not include any complaints of unrelieved pain. An interview was conducted with R#2 regarding pain medication on 1/9/19 at 12:46 p.m R#2 revealed she experiences pain from arthritis in her back, neck, shoulders arms and legs. R#2 revealed she asks for pain medication usually once or twice a day and receives it when she asks. R#2 revealed the pain medication is effective. She is able to go to meals in the dining room and activities and visit with her spouse after being administered the pain medications. An interview was conducted with the Director of Nursing (DON) on 1/9/19 at 9:10 a.m. regarding missing controlled drugs. The DON revealed the Assistant Director of Nurses (ADON) had texted a message to her on 11/7/18, that LPN AA administered more narcotics than other nurses. The DON revealed she had compared administrations documented on the Controlled Drug Reports with the corresponding Physician orders [REDACTED]. The DON revealed she was called by Unit Manager DD on the morning of 11/30/18 and was informed that the 7:00 a.m. change of shift count was incorrect. The DON revealed when she arrived at the facility Unit Manager DD showed her a blister pack of [MEDICATION NAME] belonging to R#1 that had been tampered with. LPN AA had worked the day before and administered medication to R#1. The DON revealed the package was [MEDICATION NAME] 10-325 mg and the there were opened foil seals that had been taped in the middle of the blister pack. The pills looked the same to the DON. When she checked the numbers on the substituted pills on the internet they were [MEDICATION NAME] 5-325. The DON and Administrator then made the decision to conduct drug screening for the nurses that had access to the Station 2 short hall medication cart, where R#1 resided. LPN AA had no opiates reported on her drug screen. The Consultant Pharmacist had been called, and came to the facility and destroyed the [MEDICATION NAME] 5-325 that had been substituted for 10 mg [MEDICATION NAME]. The DON revealed she and Unit Manager DD had counted and looked at packaging for all the other narcotics on Station 2 and had not found anything else tampered with, including [MEDICATION NAME] 5-325. The DON revealed she and Unit Manager DD continued to watch LPN AA and in general the controlled drug administrations on Station 2. On 12/26/18 Unit Manager DD and Staff Development Coordinator (SDC) GG had counted narcotics after 9:00 a.m. medication pass on Station 2 short hall cart was completed because LPN AA had gone in and out of the bathroom [ROOM NUMBER] or 4 times carrying her purse. They found the narcotic count was incorrect. The DON revealed the time of this unscheduled count was approximately 10:30 a.m. The Charge Nurses with access to the Station 2 short hall cart, including LPN AA who was administering medications from this cart on 11/30/18, were drug screened. LPN AA was suspended pending investigation and called a few hours later and resigned. The DON acknowledged she had not audited for missing narcotics at any time while watching LPN AA or the administration of controlled drugs on Station 2, by comparing MAR's to Controlled Drug Reports and then comparing pharmacy shipment manifests to determine if medication was being misappropriated.",2020-09-01
863,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2019-01-15,606,D,1,0,XLLQ11,"> Based on record review, review of facility policy, Administrator interview, and an interview of Georgia Crime Information Center Help Desk staff, the facility failed to ensure a Georgia Crime Information Center background check was completed for one (1) of six (6) licensed nurses hired during (MONTH) (YEAR) and (MONTH) (YEAR). The facility census was ninety-six (96) residents. Findings include: During a record review of employees files for licensed nurses, a failure to provide a Georgia Crime Information Center ( GCIC) background check was identified, related to a Licensed Practical Nurse (LPN) (LPN AA), hired on 10/2/18. The employee file for LPN AA included federal and Tennessee background screening. A review of facility policy titled Abuse Prohibition- Screening and Hiring Practices reviewed and updated for release (MONTH) (YEAR), revealed prior to hiring an employment applicant, the center shall request a criminal record check from GCIC to determine whether the applicant has a criminal record. Review of background checks for the six licensed nurses hired by the facility from 10/1/18 through 1/8/19 revealed an incomplete background check, missing the GCIC screening, for LPN A[NAME] A review of Grievances, Entity Reported Incidents and Resident Council Minutes for 10/1/18 through 1/9/19 revealed the name of LPN AA was not mentioned. Further review of the employee file for LPN AA revealed she was suspended on 12/26/18, when the narcotic count on her medication cart was incorrect. Review of the separation notice for LPN AA revealed she left the facility after suspension pending further investigation and called back and resigned without notice on 12/26/18. An interview with the Administrator regarding pre-employment screening on 1/9/19 at 3:25 p.m. revealed he had called the third-party provider of background checks for the former corporation and they had told him LPN AA did not have a GCIC because she did not have a Georgia drivers license or address. A review of an email, provided by the Administrator on 1/9/19 at 5:05 p.m., addressed to the Administrator and sent on 1/9/19 at 4:59 p.m., from the former corporations third party background check provider, revealed the facility entered the request for a background check for LPN AA on 9/19/18 and did not request a statewide criminal search for Georgia. On 1/15/19 at 12:13 p.m. the GCIC Help Desk was contacted. The employee who answered the call would not provide her last name but explained that GCIC background checks include accessing the data bases of smaller municipalities and county court records that sometimes have a delay in reporting to the main GCIC database. These reports would also be delayed in reaching the federal and out of state criminal information systems. The GCIC employee revealed a Georgia address and drivers license were not a requirement for an employer to receive a GCIC background check because people from other states do commit crimes in Georgia.",2020-09-01
864,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2019-01-15,609,D,1,0,XLLQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, Administrator and staff interview, and review of facility policy, the facility failed to report a situation involving misappropriation of a controlled drug ([MEDICATION NAME]) to the State Complaint Investigation Intake and Referral Unit or the local Police Department, for one (1) resident (R) (R#1) from a sample of three (3) residents. The facility census was ninety-six (96) residents. Findings include: A review of facility policy titled Reporting and Investigating Abuse Reviewed and Updated for Release (MONTH) (YEAR), revealed once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of patient property the incident will be immediately reported .The Administrator or designee will immediately notify the Complaint Investigation Intake and Referral Unit .of the incident and the pending investigation . Contact the local Police Department if there is reasonable cause to believe abuse or suspicion of a crime has occurred, to begin and investigation . Even if the police are called, the center will call the Complaint Investigation Unit as soon as possible. An interview conducted on 1/9/19 at 9:05 a.m. with the Administrator regarding an allegation of controlled medication misappropriation, revealed the Director of Nurses (DON) had been notified by the Assistant Director of Nurses (ADON) that on Station 2, a bottle of liquid [MEDICATION NAME] looked like it had been punctured from the top. The DON then joined the interview at 9:10 a.m. and revealed she had immediately examined the bottle and there was no sign of a puncture. The DON revealed she was not sure of the date this occurred and did not document the incident. The DON revealed the liquid was all the same in appearance and counted correctly when compared with the Controlled Drug Record, and there was no action to be taken. The Administrator revealed he had been made aware by the DON of an allegation made by the ADON on 11/7/18 that a Licensed Practical Nurse (LPN), (LPN AA) was administering more controlled medications than the other charge nurses. The DON revealed she and the Station 2 Unit Manager RN DD immediately counted narcotics and checked the resident's orders and could not find any controlled drugs being administered outside of the time frame allowed by the physician's orders [REDACTED]. The Administrator then revealed he had called the corporation and spoke to a Regional Vice President regarding possible drug testing. The Administrator revealed he was told that without more evidence than giving more narcotics than other nurses that drug screens on the nurses could not be conducted. The DON revealed she was informed by Unit Manager DD that the count was incorrect on Station 2 on 11/30/18 at 7:00 a.m. The DON revealed the Unit Manager had told her that five (5) or six (6) [MEDICATION NAME] 5 milligram (mg) had been substituted for 10 mg [MEDICATION NAME] on one resident's blister pack. The blister pack had been opened from the back and the pills substituted and then the foil on the back of the package had been taped. The DON revealed she and the Administrator had then instructed the ADON to conduct drug screens on the nurses on Station 2, and LPN AA had not tested positive for [MEDICATION NAME]. The DON revealed the count was incorrect again on the medication cart used by LPN AA on 12/26/18 and LPN AA was then suspended and she called back to resign without notice about 2 hours later. The Administrator revealed he had called the Consultant Pharmacist and discussed the above events on 11/30/18 and discussed the issue at the Quality Assurance meeting with the former interim Medical Director on 12/20/18. The Administrator revealed no one could think of anything else to do than what had already been done. Review of Medication Discrepancy Reports for R#1 from 10/1/18 through 1/8/18 revealed a Medication Discrepancy Report was completed on 11/30/18 as follows: Resident had orders for 10 mg [MEDICATION NAME], Three tablets were punched out and replaced with 5 mg tablets. Reported to Pharmacist - (3) 5 mg [MEDICATION NAME] were destroyed by DON/Pharmacist. This report was signed by the DON and Pharmacist on 11/30/18. A second discrepancy report dated 12/26/18 was reviewed as follows: Medication not given or signed out with doses missing- Hydro(sic) 10/325 mg X 3 missing. No harm to resident(s). Signed by LPN GG and on 12/30/18 the Consultant Pharmacist.Physician response was noted. An interview was conducted on 1/15/18 at 6:15 p.m. with the Administrator, related to reporting abuse. The Administrator revealed he had not considered missing medication as misappropriation of resident property and had not considered the evidence concrete enough to report to the police or the State Complaint Investigation Intake and Referral Unit.",2020-09-01
865,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2019-01-15,756,D,1,0,XLLQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff, Administrator and Consultant Pharmacist interviews, review of facility policy and review of Consultant Pharmacist Monthly reports, the Consultant Pharmacist failed to audit Medication Administration Records (MAR's) and Controlled Drug Records when conducting monthly medication regimen reviews to address documentation irregularities related to the administration of an opiate, [MEDICATION NAME], for two residents (R) (R#1 and R#2) from a sample of three (3) residents. The facility census was ninety-six (96) residents. Findings include: Review of facility policy titled Controlled Medication Administration reviewed and updated (MONTH) 20, 2009, revealed the following procedural guideline: When a PRN (as needed) controlled medication is administered, the order of documentation is : 1st MAR, 2nd Nurses Medication (Med) notes, 3rd Controlled Drug Record Sheet. Review of Monthly Consultant Pharmacist Report Indicators for Appropriate Use of Medication revealed the following: [NAME] Medications are used in the presence of acurate(sic) documentation, transcription and policy adherence pertaining to the use of any prescribed medication or treatment. 1. Review of the clinical record for R#1 revealed a physician's orders [REDACTED]. Review of the (MONTH) (YEAR) MAR for R#1 revealed two (2) PRN administrations were documented on the front of the MAR as follows: on 10/22/18 and on 10/29/18. Review of the (MONTH) (YEAR) Nurse's Med Notes on the back of the MAR revealed four (4) PRN administrations were documented. The (MONTH) (YEAR) Controlled Drug Record for R#1, revealed PRN [MEDICATION NAME] 10/325 mg was documented to have been administered five (5) times. The (MONTH) (YEAR) MAR for R#1 was reviewed and PRN [MEDICATION NAME] administrations were documented on the front of the [DATE] times. The Nurse's Med Notes on the back of the (MONTH) (YEAR) MAR revealed PRN [MEDICATION NAME] administrations were documented thirteen (13) times. The (MONTH) (YEAR) Controlled Drug Record for R#1 was then reviewed and compared to the (MONTH) (YEAR) MAR documentation. PRN [MEDICATION NAME] was documented as administered thirty-three (33) times. A review of the (MONTH) (YEAR) MAR for R#1 revealed PRN [MEDICATION NAME] administrations were documented twenty-three (23) times. A review of the (MONTH) (YEAR) Nurse's Med Notes for R#1's PRN [MEDICATION NAME] revealed twenty-two (22) documentation's. The Controlled Drug Record for R#1's PRN [MEDICATION NAME] documented administrations for (MONTH) (YEAR) was compared to the documented administrations on the (MONTH) (YEAR) MAR. Three completed original Controlled Drug Records were missing as follows: from 11/29/18 through 12/7/128, from 12/7/18 through 12/14/18 and from 12/14/18 through 12/21/18. Unit Manager DD revealed on 1/9/19 at 5:10 p.m. had searched for the missing Controlled Drug Records and they could not be found. An interview with the Unit Manager DD was conducted on 1/15/19 at 9:15 a.m. regarding missing Controlled Drug Records. She revealed she had been able to retrieve the Controlled Drug Records that had been faxed to the pharmacy and had been used to reorder [MEDICATION NAME] for R#1. Unit Manager DD revealed she was aware missing Controlled Drug Records could indicate narcotics were being misappropriated. Review of the Controlled Drug Records for R#1 for (MONTH) (YEAR) continued using the copies of faxed records and revealed PRN [MEDICATION NAME]/APAP 10/325 was documented removed from R#1's medications twenty-three (23) times. Review of the (MONTH) 2019 MAR and corresponding Controlled Drug Record for R#1 for 1/1/19 through 1/8/19 revealed no PRN [MEDICATION NAME] had been documented as administered or removed from the blister pack. 2. Review of the clinical record for R#2 revealed a physician's orders [REDACTED]. Review of the front of the (MONTH) (YEAR) MAR for R#2 revealed [MEDICATION NAME] 5/325 mg PRN for pain was documented as administered thirty-six (36) times. Review of the Nurse's Med Notes on the back of the (MONTH) (YEAR) MAR revealed administrations of PRN [MEDICATION NAME] 5/325 mg were documented twenty-eight (28) times. Review of Controlled Drug Record Sheets from 10/1/18 through 10/31/18 revealed [MEDICATION NAME] 5/325 mg PRN had been documented as administered forty-two (42) times. The (MONTH) (YEAR) MAR for R#2 was reviewed and documentation indicated [MEDICATION NAME] 5/325 mg PRN was administered twenty-six (26) times. Review of the Nurse's Med Notes on the back of the MAR for (MONTH) (YEAR) revealed documentation for thirty-three (33) administrations of PRN [MEDICATION NAME]. A review of R#2's Controlled Drug Record for 11/1/19 through 11/30/19 revealed forty-nine (49) documented administrations of PRN [MEDICATION NAME] 5/325. Review of the (MONTH) (YEAR) MAR for R#2 revealed documentation for the administration of PRN [MEDICATION NAME] twenty-eight (28) times. The Nurse's Med Notes on the back of the (MONTH) (YEAR) MAR for [MEDICATION NAME] PRN documented administrations twenty-two (22) times. From 12/1/18 through 12/10/18 the original Controlled Drug record was missing and a copy of the faxed Controlled Drug record, used to reorder from the Pharmacy on 12/10/18 with twelve (12) remaining, was the only document available. Review of the available (MONTH) (YEAR) Controlled Drug Record documentation revealed there were forty-four (44) documented administrations of [MEDICATION NAME] PRN for R#2. The (MONTH) 2019 MAR was reviewed and from 1/1/19 through 1/8/19 PRN [MEDICATION NAME] was documented administered five (5) times. The corresponding Nurse's Med Notes were reviewed and six (6) PRN administrations were documented. The Controlled Drug Record for R#2 from 1/1/19 through 1/8/19 was reviewed and PRN [MEDICATION NAME] was documented administered eleven (11) times. Review of the Monthly Consultant Pharmacist Report of consultant pharmacist activities from 10/1/18 through 11/1/18, 11/1/18 through 12/1/18 and 12/1/18 through 1/1/19, revealed the medication regimen for R#1 and R#2 was reviewed and there were no recommendations related to [MEDICATION NAME] or lack of documentation. One hundred percent (100%) of the residents reviewed met the indicator related to accurate documentation, transcription and policy adherence pertaining to the use of any prescribed medication or treatment. An interview on 1/15/19 at 2:05 p.m. with the Consultant Pharmacist regarding missing documentation and missing controlled medication revealed he had been told by the Director of Nurses (DON) that [MEDICATION NAME] 10 mg had been removed from a package and someone had substituted 5 mg [MEDICATION NAME] in its place. He was unsure of the number of [MEDICATION NAME] that had been tampered with. He had advised the DON to watch the narcotics and the suspected nurse. The second time this was discussed with him by the facility he was told the suspected nurse had quit, and he advised the DON to audit all narcotics to find what was missing. The Consultant Pharmacist revealed he considered a complete audit the comparison of the pharmacy shipment records with the Controlled Drug Records, and then a comparison with the MAR for each individual resident. He revealed that in his experience the way nurses misappropriate narcotics is to take the Controlled Drug Record when they take the medication. The Consultant Pharmacist revealed he had not been aware of any missing Controlled Drug Records. The consultant pharmacist revealed he had been in the building on 11/30/18 to destroy the [MEDICATION NAME] 5 mg that had been substituted for the 10 mg, and had also been in the building on 12/26/18 for monthly reviews and had not done any of the auditing of Controlled Drug Records and MAR's to look for misappropriated controlled drugs himself, but had expected to hear from the DON the next time he came, which will be this week, the results of the facility audits and have the documentation available to do some audits himself if there were any problems. He had told the DON that she needed to have available the exact medications missing and numbers of medications with dates that were missing if there was going to be any report to the Secretary of State or police. The Consultant Pharmacist revealed he had not checked the narcotic MAR documentation against the Controlled Drug Records or delivery records, but would have planned on doing that if the nurse was still here, he just wanted to make sure the nursing home would have all the documents available before he did any audits. An interview was conducted with the Administrator on 1/15/19 at 5:05 p.m. regarding job descriptions and contracts and revealed he had called the former management corporation on 1/9/19 and requested a job description and contract for the Consultant Pharmacist and as yet he had not received them. Continued interview on 1/15/19 at 6:00 p.m. regarding his expectations of the Consultant Pharmacist revealed he was aware of the monthly indicators for appropriate use of medications specifies the resident clinical records are to be reviewed for accurate and complete documentation of the administration of all medications and would have expected him to audit the narcotic records to ensure there were no administration or documentation irregularities and notify the Administrator in the monthly report if there were any concerns. The Consultant Pharmacist had not notified him of any concerns for R#1 or R#2.",2020-09-01
866,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2019-01-15,842,D,1,0,XLLQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and Administrator interview and review of facility policy, the facility failed to provide complete and accurate documentation on Medication Administration Records (MAR's) related to administration of [MEDICATION NAME], an opioid, for two (2) residents (R), (R#1 and R#2) from a sample of three (3) residents. The facility census was ninety-six (96) residents. Findings include: The facility policy titled Controlled Medication Administration Reviewed and Updated (MONTH) 20, 2009, was reviewed related to as needed (PRN) controlled medications as follows: Procedural Guidelines D. When a PRN controlled medication is administered, the order of documentation is : 1st: Medication Administration Record (MAR), 2nd: Nurses Medication (Med) notes, 3rd: Controlled Drug Record Sheet (count sheet). Accountability for correct drug count is determined from the medical records (i.e. MAR, nurses med notes), NOT the Controlled Drug Record Sheet. 1. Review of the clinical record for R#1 revealed an ongoing order, dated 10/15/17, for [MEDICATION NAME]-APAP 10-325 take one (1) tablet by mouth every six (6) hours as needed for pain. Review of the (MONTH) (YEAR) Controlled Drug Record Sheets for R#1, for PRN documentations of [MEDICATION NAME] 10-325 milligrams (mg) compared with documentations of PRN administrations on the (MONTH) (YEAR) MAR revealed there were no administrations documented on the MAR to account for administrations documented on the Controlled Drug Record twice as follows: on 10/8/18 at 3:20 a.m. and 10/26/18 at 8:00 a.m. Review of the (MONTH) (YEAR) Controlled Drug Records for R#1, for PRN documentations of [MEDICATION NAME] 10-325 mg were compared with documentations of PRN administrations on the (MONTH) (YEAR) MAR and revealed there were sixteen (16) missing documentations on the MAR as follows: 11/2/18 at 9:00 a.m., 11/5/18 at 4:00 p.m., 11/8/18 at 9:00 a.m., 11/9/18 at 9:00 a.m., 11/9/18 at 4:00 p.m., 11/12/18 at 5:00 p.m., 11/13/18 at 9:00 a.m., 11/13/18 at 6:00 p.m., 11/15/18 at 6:00 p.m., 11/21/18 at 6:00 p.m., 11/27/18 at 7:00 a.m., 11/27/18 at 6:00 p.m., 11/29/18 at 6:00 p.m. and 11/30/18 at 7:00 a.m. An interview regarding missing Controlled Drug Records with Unit Manager DD on 1/9/19 at 5:10 pm revealed she had been unable to find three Controlled Drug Records for R#1 for [MEDICATION NAME] 10-325 mg, from 11/29/18 through 12/7/18, from 12/27/18 through 12/14/18 and from 12/14/18 through 12/21/18. Continued interview related to missing Controlled Drug Reports with the Unit Manager on 1/15/19 at 9:15 p.m. revealed she had been able to retrieve missing partial Controlled Drug Records that had been faxed to the pharmacy to reorder [MEDICATION NAME] for R#1. The faxed copies did not include that last medications that had been administered after the [MEDICATION NAME] had been reordered. Reconciliation of the (MONTH) (YEAR) MAR and (MONTH) (YEAR) PRN [MEDICATION NAME] documented administrations was partial due to the missing dates and times on the faxed copies and revealed on the Controlled Drug Record that an administration was documented on 12/3/18 at 6:00 p.m. twice. Documentations on the available (MONTH) (YEAR) Controlled Drug Records, but missing on the (MONTH) (YEAR) MAR include 12/21/18 at 7:00 am, 12/21/18 at 6:00 pm, 12/22/18 at 7:00 a.m., and 12/22/18 at 6:00 p.m There were no further documentations of PRN [MEDICATION NAME] administrations for R#1 on the (MONTH) (YEAR) and (MONTH) 2019 MAR's or Controlled Drug Records after 12/26/19. The Nurse's Progress Notes for R#1 were reviewed from 10/1/18 through 1/8/19 and indicated on the summaries that [MEDICATION NAME] was administered PRN for pain but did not include any of the specific dates and times missing from the (MONTH) (YEAR), (MONTH) (YEAR) or (MONTH) (YEAR) MAR's. 2. Review of the clinical record for R#2 revealed an ongoing order, dated 2/19/18, for [MEDICATION NAME]-APAP 5-325 take one tablet by mouth every eight (8) hours as needed for pain. The (MONTH) (YEAR) MAR was compared with the (MONTH) (YEAR) Controlled Drug record for documentation of administration of PRN [MEDICATION NAME] administration for R#2. Nine (9) documentations of administration were included on the Controlled Drug record but not documented on the MAR as follows: 10/1/18 at 8:00 p.m., 10/2/18 at 4:00 p.m., 10/5/18 at 8:00 p.m., 10/16/18 at 1:00 p.m., 10/19/18 at 8:00 a.m., 10/19/18 at 8:00 p.m., 10/25/18 at 8:00 p.m., 10/28/18 at 7:20 p.m., and 10/29/18 at 8:00 p.m. Review of (MONTH) (YEAR) MAR for [MEDICATION NAME] PRN for R#2 compared with the (MONTH) (YEAR) Controlled Drug records revealed the following fifteen (15) [MEDICATION NAME] administrations were documented on Controlled Drug Records and not documented on the MAR: 11/18/18 at 8:00 p.m., 11/5/18 at 12:00 p.m., 11/8/18 at 8:00 a.m., 11/9/18 at 7:00 a.m., 11/16/18 at 7:00 a.m., 11/16/18 at 8:00 p.m., 11/18/18 at 8:00 p.m., 11/20/18 at 8:00 p.m., 11/21/18 at 9:00 p.m., 11/23/18 at 8:00 p.m., 11/25/18 at 8:00 p.m., 11/26/18 at 8:00 p.m., 11/27/18 at 8:00 a.m., 11/28/18 at 8:00 p.m., and 11/30/18 at 8:00 p.m. The Controlled Drug Record for R#2 from 11/29/18 through 12/13/18 was missing and a copy of the faxed Controlled Drug Record was used to reconcile with the (MONTH) (YEAR) MAR. Only dates and times on the faxed copy were used for reconciliation. The following thirteen (13) administrations were documented on the available (MONTH) (YEAR) Controlled Drug Record but not documented on the (MONTH) (YEAR) MAR: 12/1/18 at 8:00 p.m., 12/2/18 at 8:00 p.m., 12/7/18 at 8:00 p.m., 12/8/18 at 8:00 p.m., 12/9/18 at 8:00 p.m., 12/14/18 at 8:00 p.m., 12/15/18 at 8:00 p.m., 12/16/18 at 8:00 p.m., 12/21/18 at 8:00 p.m., 12/23/18 at 8:00 p.m., 12/28/18 at 5:00 a.m., 12/30/18 at 8:00 p.m., and 12/31/18 at 8:00 p.m. Review of R#2's (MONTH) 2019 MAR from 1/1/19 through 1/8/19 compared with Controlled Drug Records from 1/1/19 through 1/8/19 for PRN [MEDICATION NAME] revealed documentation of administration on the Controlled Drug Record was not documented on the MAR four (4) times as follows: 1/2/19 at 8:00 p.m., 1/4/19 at 8:00 p.m., 1/5/19 at 8:00 p.m. and 1/6/19 at 8:00 p.m. The Nurse's Progress Notes for R#2 were reviewed from 10/1/18 through 1/8/19 and none of the missing documentation of administrations on the (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) 2019 MAR's was included in the notes. An interview conducted on 1/9/19 at 4:00 p.m. with Unit Manager DD regarding missing PRN medication documentation revealed she checks the Station 2 Controlled Drug Records about once a week by comparing them with Physician orders [REDACTED]. Unit Manager DD revealed she tries to compare the Controlled Drug Records to the corresponding MAR's and thought the Station 2 MAR's adequately reflected the PRN controlled drugs administered, but acknowledged the missing documentation listed above for R#1 and R#2 from 10/1/18 through 1/8/19 and revealed she now understands there are many missing documentations on the MAR's. Unit Manager DD revealed she is aware of the policy for documenting PRN controlled medications requires the documentation on the front of the MAR is completed, then the Nurse's Med Notes on the back of the MAR, then the Controlled Drug Record. Unit Manager DD revealed the Station 2 Nurses had been documenting administrations on the Controlled Drug Records, but sometimes had not documented on the front or back of the MAR's.",2020-09-01
867,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2016-03-17,279,D,0,1,DOUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a comprehensive care plan related to dental status for one (1) of twenty six (26) sampled residents (Resident #86). Findings include: Record review for resident (#86) revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Further review revealed an Minimum Data Set (MDS) assessment dated [DATE] which assessed the resident as having only top dentures and no natural teeth. The Care Area Assessment (CAA) Summary identified dental status/care as a concern, with the decision to be care planned. Review of the Care Plans for Resident #86 revealed no evidence that a care plan for dental status had been developed. Interview conducted on 3/16/2016 at 10:00 a.m. with the MDS Nurse/Care Plan Coordinator AA confirmed that there was no care plan addressing dental status/care for this Resident #86.",2020-09-01
868,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2016-03-17,312,D,0,1,DOUE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure consistent oral/dental care was provided for one (1) resident (#85) who was non-verbal and totally dependent on staff for personal hygiene. The sample was twenty six (26) residents. Findings include: Record review for Resident #85 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) was not attempted due to the resident was rarely/never understood. Section G- Functional Status assessed the resident as being totally dependent with Personal Hygiene. Review of the Care Plans for Resident #85 revealed no evidence that a care plan related to oral/dental status had been developed. Observations on 03/16/2016 at 9:08 a.m. of Resident #85's mouth revealed visible build up and debris on the teeth and tongue. Observation on 3/16/16 at 12:05 p.m. of Resident #85's mouth revealed redness around the gums, particles of food in the teeth and a white substance around the gum line. Observation on 03/17/2016 at 10:08 a.m. of Resident #85's mouth revealed visible build up and debris on teeth and tongue. Observation on 03/17/2016 10:10:12 AM-in the room of Resident #85 revealed the Hospice Certified Nursing Assistant (CNA) brushing the resident's teeth using a toothbrush and safe to swallow toothpaste provided by the family. Interview with the Hospice CNA at the time of the observation revealed Resident #85 enjoys the tooth brush and attempts to assist in oral care with tongue and mouth movements. The Hospice CNA further stated the resident receives hospice care two (2) times weekly on Tuesday and Thursday. Record review for Resident #85 revealed no evidence of documentation related to oral/dental care. Interview on 3/16/16 at 10:19 a.m. with the CNA YY revealed she is familiar with care for Resident #85. CNA YY stated the staff CNA's and Hospice provide oral care but she uses a sponge because the resident will chew objects placed in her mouth. CNA YY stated the resident does have a toothbrush but it's too difficult to use. CNA YY further stated she had not been trained or instructed to document oral care. Observation on 3/16/16 at 11:00 a.m. of the Shower Sheets with the Charge Nurse ZZ revealed an area in which oral care could be documented. There was no documentation of oral care on the Shower Sheets for Resident #85 from 1/14/16-3/16/16. During an interview on 3/16/16 at 12:05 p.m. with the Responsible Party (RP) for Resident #85 revealed the resident cringes when biting down. The RP further sated they were concerned that resident has dingy teeth and inflamed gums caused by lack of oral care by facility staff. Interview on 3/16/16 at 1:55 p.m. with the facility Corporate Nurse XX and Unit Manager WW revealed the facility does not have a policy on for Activities of Daily Living (ADL) or a policy for Oral/Dental. The Corporate Nurse XX and Unit Manager WW further stated such policies are not required because it is considered a standard of care. The CNA's are trained on ADL care. The Corporate Nurse XX stated the CNA's receive verbal training on Oral and ADL care however, she was unable to provide documentation of the training.",2020-09-01
869,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2017-10-19,282,D,0,1,ZVHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow the care plan related to administration of insulin and Finger Stick Blood Sugar (FSBS) monitoring for one residents (#65) and failed to follow the plan of care related to behavior monitoring for one resident (#103) with behavioral symptoms that received an anti-psychotic medication. The sample size was 30 residents. Findings include: 1. Review of clinical record revealed R#65 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15. Review of the care plan last updated 8/24/17 revealed that R#65 has a [DIAGNOSES REDACTED]. Interventions include FSBS as ordered and medications as ordered. Review of the physician's orders [REDACTED].#65 revealed the following: FSBS three (3) times a day and Humalog Insulin 100 Units per milliliters (U/ML) 10 units (0.10 ML) subcutaneous (Sub-Q) AC with breakfast, lunch and supper. Review of the Medication Administration Record [REDACTED]. During an interview with the RN, FF on 10/19/17 at 12:10 a. m., she revealed that the nurse responsible for recording FSBS and Humalog administration no longer works at the facility. She also stated nurses are expected to document FSBS and administration of Humalog; however, she doesn't know what happened that caused the lack of documentation. 2. Review of the clinical record for Resident (R) #103 revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed a current physician's orders [REDACTED]. Review of the resident's records revealed a plan of care, last updated 9/6/17, for [MEDICAL CONDITION] medication use related to [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. However, the behavior monitoring sheets revealed that the licensed nursing staff did not consistently monitor the resident for the targeted behaviors. There were at least 23 shifts in (MONTH) (YEAR) during which behaviors were not documented as being monitored and seven days during the first 18 days for (MONTH) (YEAR) in which there was no documentation that behaviors were monitored;",2020-09-01
870,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2017-10-19,309,D,0,1,ZVHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow the Physician's order to document observation of [MEDICAL TREATMENT] port every shift for one (1) resident (R#65) of one resident who receives [MEDICAL TREATMENT] treatment of [REDACTED]. Findings include: Review of clinical record revealed R#65 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15. Review of the Physician's orders dated (MONTH) (YEAR) and (MONTH) (YEAR) for R#65 revealed to observe [MEDICAL TREATMENT] port to right (rt) upper chest every shift for signs or symptoms (s/s) of bleeding. Review of the Medication Administration Record (MAR) dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed no documentation of observation of [MEDICAL TREATMENT] port on 10/4/17 (11-7) shift, 9/16/17, 9/22/17, 9/26/17 (11-7) shift and 9/30/17 (7-3) shift. During an interview with Registered Nurse (RN) RCC, FF on 10/19/17 at 11:00 a.m., revealed the [MEDICAL TREATMENT] port should be checked every shift and documentation of the check should be recorded on the MAR and it was not.",2020-09-01
871,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2017-10-19,329,D,0,1,ZVHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor targeted behaviors for one residents (#103) with behavioral symptoms and failed to monitor for side effects for two residents (#103, and #30) that received anti-psychotic medications from a sample of thirty (30) residents. Findings include: 1. Review of the clinical record for Resident (R) #103 revealed [DIAGNOSES REDACTED]. Further review of the medical record revealed a current physician's orders [REDACTED]. Review of policy titled: Monitoring of Antipsychotics last updated (MONTH) (YEAR) documented: when antipsychotic therapy is initiated, the resident is to be monitored for behaviors on each shift every day. Side effects are also to be monitored on each shift, every day, and staff are to indicate whether side effects are noted or not noted. If side effects are observed and noted, then an explanation must be documented in the nurses' notes. Review of clinical records for R#103 revealed a Behavior Monitoring Record: [MEDICAL CONDITION] Medications sheet which indicated that the resident was to be monitored for two targeted behaviors: striking out at staff/other residents and crying. The sheet contained areas for the number of episodes per targeted area to be monitored each shift, the type of intervention to be initiated if the behaviors were observed, and the outcome of that intervention. The back of this sheet contained an area for side effects of the resident's [MEDICAL CONDITION] medications to be documented each shift; if no side effects were documented for the month, a box was available to check that no side effects noted this month. Review of the Medication Administration Record [REDACTED]. However, the behavior monitoring sheets revealed that the licensed nursing staff did not consistently monitor the resident for the targeted behaviors. There were at least 23 shifts in (MONTH) (YEAR) during which behaviors were not documented as being monitored and seven during the first 18 days of (MONTH) (YEAR) during which there was no documentation that behaviors were monitored; There was no documentation on the Behavior Monitoring Record: [MEDICAL CONDITION] Medications that side effects were monitored or documented for (MONTH) (YEAR) or (MONTH) (YEAR)and the box indicating that there were no side effects during the month of (MONTH) was unchecked. 2. Review of the clinical record for Resident (R) #30 revealed a [DIAGNOSES REDACTED]. Further review of the medical record revealed a current physician's orders [REDACTED]. Review of the MAR for (MONTH) (YEAR) and (MONTH) (YEAR) staff administered antipsychotic medication, quetiapine, as ordered. However, side effects (or no side effects) were not documented on the sheets titled: Behavior Monitoring Record: [MEDICAL CONDITION] Medications. During an interview on 10/19/17 at 3:18 p.m., with the Director of Nursing (DON) it was revealed that staff are expected to document behaviors and side effects on every shift for residents placed on [MEDICAL CONDITION] medications. If there are no side effects, this too is documented on the back of the behavior monitoring sheet indicating that there were no side effects; if there are side effects then action is taken, including notifying the physician and other necessary actions. The facility initiated a new behavior monitoring sheet in (MONTH) on which behaviors are monitored on the front, and side effects on the back.",2020-09-01
872,RIDGEWOOD MANOR HEALTH AND REHABILITATION,115341,1110 BURLEYSON DRIVE,DALTON,GA,30720,2017-10-19,514,D,0,1,ZVHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document administration of [MEDICATION NAME] and failed to document Physician notification of fingerstick blood sugars (FSBS) outside of parameters for one resident (R#83) from a sample of 30 residents. Findings include: 1. Review of the clinical record for R#77 revealed Physician orders [REDACTED]. The original order date was 3/10/17. Review of the Medication Administration Record (MAR) for R#77 for September, (YEAR) and October, (YEAR) revealed no documentation that nursing staff administered [MEDICATION NAME] as ordered at bedtime on 9/1/17, 9/2/17, 9/3/17 and 9/4/17. Continued review revealed no documentation for the administration of [MEDICATION NAME] Sprinkles from 9/8/17 through 9/13/17, 9/15/27 through 9/20/17, and 9/23/17 through 10/17/17. Continued review of the medical record revealed that the resident was in the facility on the dates that the above medications were to be administered. During an interview conducted on 10/17/17 at 4:40 p.m. the 100 hall Unit Manager revealed there was no regular evening charge nurse for the long hall for the first three weeks of September. Charge nurses from other areas and other shifts covered until the current full-time evening charge nurse was hired and trained. The Unit Manager confirmed the [MEDICATION NAME] ordered for R#77 to be administered at bedtime had only been documented as administered six times since 9/1/17. During and interview conducted on 10/17/17 at 4:50 p.m., Licensed Practical Nurse (LPN) AA revealed she had administered bedtime medications to R#77 since the last week of (MONTH) and remembers that she gave the [MEDICATION NAME] every evening but indicated she missed signing for administering the routine medication because it was listed with the as needed (PRN) medications. LPN AA confirmed she usually compares the medications listed on the packaging with the medications listed on the MAR but must have missed doing this. An interview conducted on 10/18/17 at 9:20 a.m. with the Director of Nurses (DON) revealed she expects the Unit Managers to review every residents' previous months MAR at the beginning of the next month. The DON confirmed the missing documentation of administration for R#77 had been missed by the Unit Manager when she reviewed the MAR for (MONTH) because the pharmacy had changed the area where [MEDICATION NAME] was listed from the routine medication listings to the PRN medication area of the MAR. The DON revealed she had identified this as a possible source for documentation omissions on another residents MAR and had contacted the pharmacy in (MONTH) and (MONTH) to correct the location of [MEDICATION NAME] on the MARS. The DON indicated she had checked other residents MARs that received [MEDICATION NAME] but had not checked the MAR for R#77. There were no documentation omissions on any other residents MARS. 2. Review of Physician orders [REDACTED]. Review of the MARS for R#83, including (MONTH) through October, (YEAR) revealed FSBS results less than 60 and over 400 as follows: 10/3/17 at 11:30 a.m. - 403 10/5/17 at 8:00 a.m. - 438 10/9/17 at 8:00 a.m. - 422 10/10/17 at 11:30 a.m. - 458 10/11/17 at 11:30 a.m. - 428 9/4/17 at 8:00 a.m. - 58 9/25/17 at 8:00 a.m. - 426 8/9/17 at 11:30 a.m. - 429 8/10/17 at 8:00 a.m. - 54 8/11/17 at 11:30 a.m. - 478 7/21/17- 11:30 a.m. - 408 Review of Nurse's Progress Notes for R#83 for (MONTH) through (MONTH) (YEAR) revealed no documentation of Physician or Nurse Practitioner notification of the above FSBS results. Patient at Risk (PAR) review notes dated 9/26/17 revealed R#83 is a brittle diabetic with blood sugars that range from very low to very high. During an interview, Licensed Practical Nurse (LPN) BB on 10/18/17 at 12:50 p.m. confirmed she initialed FSBS results on the MAR for R#83 on 10/3/17 at 11:30 a.m., 10/5/17 at 8:00 a.m., 10/9/17 at 8:00 a.m., 10/10/17 at 11:30 a.m., 10/11/17 at 11:30 a.m., 9/4/17 at 8:00 a.m., 9/25/17 at 8:00 a.m., 8:10/17 at 8:00 a.m. and 7/21/17 at 11:30 a.m. LPN BB revealed R#83 is a brittle diabetic and has FSBS results over 400 or less than 60 several times each month. LPN BB acknowledged there were no nurses progress note entries documenting Physician or Nurse Practitioner notification of the above FSBS results but she is certain she called. LPN BB indicated she was aware she is expected to document Physician and Nurse Practitioner notifications but had missed these documentations. An interview conducted on 10/18/17 at 2:40 p.m. with the Nurse Practitioner confirmed she is sure she is notified of FSBS results less than 60 and greater than 400 for R#83 because she checks this residents' blood sugar results when she visits the facility and is aware of being called each time. An interview on 10/18/17 at 4:10 p.m. with the Regional Nurse confirmed the charge nurses should document when a Physician or Nurse Practitioner is notified of FSBS results less than 60 or greater than 400. The Regional Nurse revealed she had reviewed the Nurses Progress Notes and was unable to find documentation of notification for the above blood sugar results.",2020-09-01
873,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2018-08-21,812,F,1,0,8LQ611,"> Based on observation, records, staff interviews and facility policy Date Marking for Food Safety, the facility failed to ensure open food items were properly marked/dated as opened and dated for discard; failed to maintain the kitchen ice machine in a sanitary manner. The facility's Form CMS-672, Resident Census and Conditions of Residents, documented that only one (1) resident received nutrition by tube feeding indicating that the facility's remaining 92 residents received food prepared in the kitchen thereby had the potential to be affected by this deficient practice and sanitary condition which could cause or likely to cause food borne illness. Findings include: Review of the policy Date Marking for Food Safety reads Policy Explanation and Compliance Guidelines for Staffing: 2. The food shall be clearly marked to indicate the date or day by which the food shall be consumed or discarded. 3. The individual opening or preparing a food shall be responsible for date marking the food at the time the food is opened or prepared. 4. The marking system shall consist of the day/date of opening, and the day/date the item must be consumed or discarded During an observation on 8/7/18 at 11:35 a.m. with the Dietary Manager in the cooler located on the right side of the kitchen as standing with the stove and counters on your left, the following food items revealed: An observation on 8/7/18 at 11:35 a.m. on the top shelf is plastic opened container of Daisy sour cream without an opened date. An observation on 8/7/18 at 11:39 a.m. on the second shelf of the cooler, is slice cheese wrapped in a clear plastic that is not completely sealed without an open date. An observation on 8/7/18 at 11:40 a.m. on the second shelf of the cooler, is a package of sliced Swiss cheese wrapped in clear plastic without an open date. An observation on 8/718 at 11:41 a.m. on the top shelf, is large plastic an opened container of salsa without an open date. An observation on 8/7/18 at 11:42 a.m. on the top shelf, is plastic opened container of del destino capers without an open date. An observation on 8/7/18 at 11:43 a.m. in a crate full with carton of whole milk, there is one opened quart size carton of Daisy fresh buttermilk without an opened date. An observation on 8/7/18 at 11:44 a.m. on the top shelf is a large opened plastic container of Ventura heavy duty mayonnaise without an opened date. An observation on 8/7/18 at 11:45 a.m. on the top shelf is a large opened container of LaChoy sweet & sour sauce without an opened date. An observation on 8/7/18 at 11:46 a.m. on the top shelf is an opened jar of sweet relish revealed an opened date of 6/21/18, (17 days past discard date). An observation on 8/7/18 at 11:47 a.m. on the top shelf is another opened plastic container of daisy sour cream without an opened date. An observation on 8/7/18 at 11:48 a.m. on the top shelf is a large opened container of Kikkoman soy sauce that has been open without an opened date. An observation on 8/7/18 at 11:49 a.m. on the top shelf is a large opened container of banquet style ranch dressing that does not have an open date. An observation on 8/7/18 at 11:50 a.m. on the top shelf is a large opened container of chunky salsa revealed an opened date of 6/21/18, (17 days past discard date). An observation on 8/7/18 at 11:51 a.m. on the 2nd shelf is a large opened bottle of Italian dressing without an opened date. In the refrigerator in the rear of the kitchen, the following food items: An observation on 8/7/18 at 11:55 a.m. on the left side of refrigerator are two bowl of fruit cocktail in a Styrofoam bowl cover with clear plastic without a date. An observation on 8/7/18 at 11:56 a.m. on the left side of the refrigerator are several baked brownies in a container without a date. An observation on 8/7/18 at 11:57 a.m. on the left side of the refrigerator is an open bag of marshmallow with an opened date. An observation on 8/7/18 at 11:58 a.m. on the left side of the refrigerator is a large opened jar of grape jelly without an open date. During these observations on 8/7/18 at 12:00 p.m. the Dietary Manager revealed that the food items should have been dated by the person who opened them and opened food items are to be discarded after 30 days. And that she did not know when the food items had been opened and would throw all open food items away. Continued to state that she was overall responsible for the kitchen. And that a shortage of kitchen aides was the cause of this problem. An interview on 8/8/18 at 1:24 p.m. the Administrator revealed that the food policy will be re-evaluated and he will enforce the policy.",2020-09-01
874,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2018-08-21,880,F,1,0,8LQ611,"> Based on observation, records, staff interviews and facility policy Ice Chests and Ice Machines, the facility failed to ensure that the kitchen ice machine was kept in a sanitary manner. In addition, the facility failed to ensure that the ice scoop was placed on a tray or protective container. The facility's Form CMS-672, Resident Census and Conditions of Residents, documented that only one (1) resident received nutrition by tube feeding indicating that the facility's remaining 92 residents received food prepared in the kitchen thereby had the potential to be affected by this deficient practice and sanitary condition which could cause or likely to cause food borne illness. Findings include: Review of the facility policy Ice Chests and Ice Machines reads III. Ice scoops should be smooth and imperious and should be kept on an uncovered stainless steel, imperious plastic, or fiberglass tray on top of the chest or in a mounted holder when not in use. The tray and the scoop should be run through a dishwasher daily. IV. Clean, disinfect, and maintain ice-storage chests on a regular basis. Review of a typed form on the right side of the ice machine as standing facing the ice bin, that reads Ice Machine Task Sign Off Sheet, Ice Machine is to be Cleaned by PM Diet Clerk every Friday & You Are To Have Supervisor Check It. The date signed off is 5/4/17 as being cleaned. Review of a (YEAR) Maintenance Schedule for Ice Machine Cleaning revealed the last deep cleaning by maintenance was 4/17/18. During an observation on 8/7/18 at 12:01 p.m. with the Dietary Manager, the ice machine located in the kitchen was noted with heavy growth of a black substance on the plastic white ice chute and on the ice deflector. The Dietary Manager is observed using a clean white cloth to wipe the ice chute easily removing some of the black substance. Sitting on top of the ice machine is a silver ice scoop without a cover or in a protective container. An interview on 8/7/18 at 12:03 p.m. the Dietary Manager revealed that the last documented cleaning was 5/4/17. Continued to state that the ice scoop sitting on top of the ice machine was not stored in a sanitary manner. Dietary Manager also revealed that some staff are not doing their job and that she is overall responsible for the kitchen. An observation on 8/7/18 at 12:53 p.m. cook aide is cleaning the outer portion of the ice machine with the ice bin open exposing the ice remaining in the bin. An observation on 8/8/18 at 9:54 a.m. the Maintenance Director in the kitchen removed the top panel of the Koolaire ice machine to expose the ice chute had been cleaned revealed that the ice deflector also has black substance that is easily removed with a white cloth and needed cleaning. An interview on 8/8/18 at 10:00 a.m. the Maintenance Director revealed that he does a deep cleaning every quarter on the ice machines and that the kitchen staff is responsible for the daily cleaning. Continued to state that the ice machine has an ice chute, a water deflector cover, drip pan and ice deflector. And that in the ice machine had a moderate amount of mold on the ice deflector and heavy amount of mold on the ice chute. An interview on 8/8/18 at 10:17 a.m. Dietary Manager revealed that she is overall responsible for cleanliness in the kitchen. And that the lack of cleaning of the ice machine was a result of a shortage of staff in the kitchen. Continued to state that dietary cooks were not doing their job. The facility has one person who receives tube feeding formula. An interview on 8/8/18 at 1:24 p.m. the Administrator revealed that the ice machine needs cleaning, and that he will purchase ice for the residents until the ice machine is properly cleaned.",2020-09-01
875,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2018-11-29,655,D,0,1,4DH611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the policy titled, Baseline Care Plan the facility failed to complete and date a baseline care plan within 48 hours of admission and failed to provide the resident and representative a copy of a written summary of the baseline care plan for three residents (R) (R#338, R#65, and R#88). The Sample size of 45 residents. Findings include: Review of the policy titled Baseline Care Plan Policy effective date 11/28/2017 revealed the following: Be developed within 48 hours of a residents admission. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. Review of the medical record for R#338 revealed that the resident was admitted to the facility from aa acute care facility with diganoses that included: [MEDICAL CONDITION] without loss of consciousness, history of falls, unspecified convulsions, [MEDICAL CONDITION], [MEDICAL CONDITIONS], hypertension, [MEDICAL CONDITION], chronic pain, cardiac pacemaker and coronary angioplasty implant and graft. Review of the physician's orders [REDACTED]. A hard copy of the resident's Interim Plan of Care was reviewed, documentation reflects problem areas circled: the resident was at risk for fluid imbalance; resident/family has expressed desire to be discharged home; The Interim Plan of Care was found to be undated, giving no indication of timeliness of the care plan, no signature to indicate the author of the assessment, no evidence or documentation was found that the resident was provided a copy within 48 hours of admission. The care plan did not include resident specific initial goals with interventions to address each of the resident's care areas. Interview with Social Worker SW AA on 11/28/2018 at 1:00 p.m. revealed the nurses on the floor are responsible for completing the Interim Care Plans when a resident is admitted to the facility. She would expect the Interim Care Plan to be dated when completed. SW AA verified that the care plan was not dated or signed by the resident or family. She is unsure or unaware if the resident or family received a copy of the interim care plan or comprehensive care plan. She also stated she did not know to give a copy of the interim care plan to the resident or family member. Interview with SW BB on 11/28/2018 at 1:15 p.m. revealed the nurses on the floor are responsible for completing the Interim Care Plans when a resident is admitted to the facility. She would expect the Interim Care Plan to be dated when completed. SW BB verified that the care plan was not dated or signed by the resident or family. She is unsure or unaware if the resident or family received a copy of the interim care plan or comprehensive care plan. SW BB also stated she did not know to give a copy of the interim care plan to the resident or family member. Interview with RN MDS Coordinator FF on 11/28/2018 at 1:25 p.m. revealed the nurses complete the Interim Care Plans on admission and is unaware if the nurses give a copy to the resident or family member. She verified the Interim Care Plan was not dated or signed by the resident or family. She stated they have an admission meeting within a few days after admission to discuss discharge plans and therapy plans. She stated they do not go over the care plans or give them a copy of the care plan. She states she tries to get the Comprehensive Admission MDS, and Care Plans done within eight days after admission. Interview with the Director of Nursing (DON) on 11/28/2018 at 1:50 p.m. revealed the nurse who admits the resident is responsible for completing all the admission paperwork including the Interim Care Plan that his expectations are to have it completed within the first 24 hours. The DON verified resident had a Interim Care Plan completed but it was not dated or signed by the resident or family member. 2. A review of the closed electronic and hard copy record for Resident (R) R#88 documents that resident was admitted from an acute hospital and discharged to the communinty. The resident was admitted with [DIAGNOSES REDACTED]. A review of R#88's Minimum Data Set (MDS) assessment dated [DATE] was conducted. The assessment documents the following: cognitive- a Brief Interview for Mental Status (BIMS) score of 14, functional- extensive assistance, 2-person assistance; medications- antibiotic; special treatments- intravenous (IV) antibiotics, oxygen, Section Q300- expects to be discharged to community; Section Q400 discharge plan actively occurring, Section Q600- no referrals. Review of the physician's orders [REDACTED]. Review of admission treatment orders reflect documentation for the following: cleanse skin tear to right lower leg and apply steri-strips; monitor steri-strips daily until area heals; do not resuscitate (DNR); cleanse skin tear to right forearm with normal saline and apply steri-strips; change oxygen tubing, humidifier bottle, and nebulizer tubing every Saturday night; Registered Dietitian consult as indicated; 8/12 chest X-Ray- PA and lateral; oxygen at 2 liters via nasal cannula; regular diet- pureed texture, regular consistency; assess pain prior to treatments; assess pain every shift. A hard copy of the resident's Interim Plan of Care was reviewed, documentation reflects problem areas circled: the resident was at risk for fluid imbalance; at risk for urinary complications; had a potential alteration of skin integrity; resident/family has expressed desire to be discharged home; at risk for falls, and an alteration in comfort/pain. The Interim Plan of Care was found to be undated, giving no indication of timeliness of the care plan, no signature to indicate the author of the assessment, no evidence or documentation was found that the resident was provided a copy within 48 hours of admission. The care plan did not include resident specific initial goals with interventions to address each of the resident's care areas. Review of the nursing note dated 8/3/18 documents: resident arrived to facility via stretcher, alert and oriented to person, place, and most of situation. Able to voice wants and needs. 02 @2l/min NC continuous. Continues ABT for PN[NAME] DOE. Lung sounds diminished in bilateral lower lobes. Two person assist with bed mobility, transfers, and toileting. Continent of b/b. Uses bedside commode. Abd. soft, non-tender, non-distended. No complaints of pain now. oriented resident to surroundings. Call light in reach. The nursing note dated 8/12/18 documents: let M.D. (Physician) be aware of resident having occ. (occasional) non-productive cough with congestion, wheezing in lung fields, and coarseness noted with anterior and posterior lung fields. Let M.D. be aware of resident feeling SOB (shorness of breath) even with SPO2-97% with O2 (oxygen) applied at 2LPM (2 liters per minute) via nasal cannula and of nebulizer txs. (treatments) not being effective. New orders received from M.D. and noted. Note Text: The order you have entered [MEDICATION NAME] Tablet 20 MG Give 1 tablet by mouth one time a day for SOB; difficulty breathing for 4 days. The 8/30/18 nurse note documents: discharge instructions reviewed with daughter. Medication list faxed to pharmacy per patient's choice. All patient's meds from facility given to patient's daughter to carry home. patient left facility via w/c with daughter and grandson to private vehicle. Review of the physician's Discharge Summary, dated 8/30/18 reflects, short term resident 02 dependent, visually impaired, strong support from son, wheelchair for transportation, all orders completed as directed; home health to follow, condition improved. A review of the facility form titled Discharge Instructions and dated 8/30/18 conducted. Written medications and instructions were given to family and signed by resident 8/30/18, 02 at 2L via nasal cannula continuous was ordered. The record reflects that R#88 was planning to return to the community after medication and treatment for [REDACTED]. 3. Review of the medical record revealed that R #65 was admitted to the facility and had the following Diagnoses: [REDACTED]. degeneration lumbar region; [MEDICAL CONDITION] unspecified; personal history of other diseases of the digestive system; other specified postprocedural states; gastro-[MEDICAL CONDITION] reflux disease (GERD) without esophagitis; essential primary hypertension; [MEDICAL CONDITION] disorder current episode depressed severe without psychotic features; [MEDICAL CONDITIONS] unspecified; [MEDICAL CONDITION] unspecified. Further review revealed R #65 had a Interim Plan of Care in the care plan section of the physical/hard chart. There was no other baseline or admission care plan found in the physical/hard chart or in the electronic record. The Interim Plan of Care was not dated, no indication or documentation when it was done, no evidence or documentation that the resident was provided a copy within 48 hours of admission, and it did not have specific goals with interventions to address each of the residents person-centered care areas. On 11/29/18 at 11:00 a.m. the DON (Director of Nursing) reported that the facility does not have a policy related to baseline care plans or for updating and revising the resident care plans.",2020-09-01
876,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2018-11-29,656,D,0,1,4DH611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and review of the policy titled Comprehensive Care Plan Policy and policy titled Fall Management and staff interview revealed the facility failed to follow the fall care plan for one resident (R)(R#14) and the facility failed to update the care plan with new interventions related to falls for one residents(R) (R#82). The Sample size was 45 residents. Findings include: Review of the policy titled Comprehensive Care Plan Policy effective date 11/28/2017 revealed the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. The comprehensive care plan will include measurable objectives and timeframe's to meet the residents needs. Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made. Review of the policy titled Fall Management revised date 3/12/2015 revealed in part to identify appropriate interventions to reduce the likelihood of the resident falling and to try to minimize complications from falling. Appropriate interventions will be put in place as indicated by evaluations. Develop and revise care plan. Monitor compliance and response. 1. Observation made on 11/27/2018 at 2:02 p.m. revealed R#14 was out of bed in a wheel chair, in the small activity room on west wing. She has on soled shoes. No sensor alarm attached to the wheelchair. Observation made on 11/27/2018 at 3:46 p.m. revealed R#14 out of bed in a wheel chair, no sensor alarm attached to the wheelchair. Observation made on 11/28/2018 at 11:28 a.m. revealed R#14 sitting in dining room ready for lunch. No sensor alarm attached to the wheelchair. Observation made on 11/29/2018 at 8:00 a.m. revealed R#14 up in her wheelchair, in the dining room eating breakfast. No sensor alarm noted on wheelchair. Review of the medical record for R#14 revealed she was admitted to the facility with the following Diagnoses: [REDACTED]., malignant neoplasm of unspecified site of female breast, [MEDICAL CONDITION] arthritis. A review of R#14's Minimum Data Set (MDS) assessment dated [DATE] was conducted. The assessment documents the following: C-Cognitive: a Brief Interview for Mental Status (BIMS) score of six, D-Mood: score of six, E-Behavior: Zero, G-Functional Status: bed mobility extensive assistance one person assist, transfer extensive assistance one person assist, walking in room extensive assistance one person assist, locomotion in room extensive assistance one person assist, locomotion off unit total dependence one person assist, dressing extensive assistance one person assist, eating supervision set up only, toileting extensive assistance one person assist, personal hygiene supervision one person assist, bathing total dependence one person assist, H-Bowel and Bladder: frequently incontinent of both bowel and bladder, I-Diagnosis: [REDACTED]. Review of R#14's care plan revealed a care plan for the potentials for falls due to a history of falls, weakness, impaired mobility, impaired decision making skills, poor safety awareness, poor endurance, not calling for assistance before transferring, ambulating, or toileting herself, and a history of a left [MEDICAL CONDITION]. Interventions include keeping the bed against the wall, slip resistant footwear, locking wheel chair prior to transfer, bed in low position, clutter free room, call light in reach, fall matt, scheduled toileting, sensor alarm to bed and wheelchair, and a winged mattress Review of Patient at Risk (PAR) Note dated 8/7/2018 at 9:55 a.m. revealed the Interdisciplinary Team (IDT) met to review fall of 7/24/2018; bed is now against wall; now has sensor alarm in bed and wheelchair; referred for therapy which she declined to participate with; also has fall mat beside bed; continue plan of care. Review of Nursing Assistant Care Sheet for R#14 dated 9/19/018 revealed: Safety: Fall risk; call light in reach; bed in low position; bed against wall; fall matt; alarm to bed and chair; winged mattress. Interview with RN DD on 11/29/2018 at 8:44 a.m. revealed resident is supposed to have a bed and wheelchair sensor alarm. She verified the residents bed alarm was in place and functioning well. She verified the resident was in the correct wheelchair and it did not have an alarm on it. Interview with the DON on 11/29/2018 at 9:35 a.m. revealed he was unaware of resident not having the sensor alarm on her wheelchair. He stated the Certified Nursing Assistants (CNA's) are to look at the residents Kardex to know the patients needs. The nurses are to look at the residents care plans and are to follow the care plans. He is not sure if there is a policy for use of bed and wheelchair alarms. 2. Review of the resident's Admission Record for R#82 revealed that she was admitted to facility on 5-30-18 with the [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Assessment Set dated 11-10-18 revealed that the resident had a Brief Interview Mental Status (BIMS) of 11 which indicates that she is cognitively intact, requires extensive assistance of one staff person with transfers. Section J - Health Conditions documented resident to have had two or more falls with no injury. Review of the care plan for R#82 which was initiated on 6-7-18 revealed resident had thirty falls from 8-29-18 through 11-19-18 with no new interventions implemented. During an interview on 11-29-18 at 11:00 a.m. with the Director of Nursing (DON) revealed that the facility does not have a policy for updating and revising the resident care plans. Cross Reference F689",2020-09-01
877,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2018-11-29,689,E,0,1,4DH611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, review of facility records, and facility policy titled safe water temperatures,' it was determined the facility failed to ensure safe hot water temperatures, in seven resident rooms (room [ROOM NUMBER], 112, 113, 124, 127, 133, 150) and two common shower rooms, were maintained at less than 110 degrees Fahrenheit, to prevent the potential [MEDICAL CONDITION] the facility failed to conduct a root cause analysis to determine the cause of falls or evaluate the effectiveness of care planned interventions to evaluate if they were effective for one resident (R#82). The sample size was 45 residents. Findings include: Review of the facility policy Safe Water Temperatures, with an original date of 11/28/17, revealed The facility would maintain appropriate water temperatures in resident care areas. Policy explanation and compliance guidelines: 1. Direct care staff will monitor residents during prolonged exposure to warm or hot water for any signs or symptoms [MEDICAL CONDITION] will respond appropriately. 2. Staff will be educated on safe water temperatures upon employment and on a regular basis. 3. Thermometers will be available as needed for use by all staff. 4. Staff will report abnormal findings, such as complaints of water too cold or hot,[MEDICAL CONDITION] redness, or any problems with water temperatures to the supervisor and/or maintenance staff. 5. Water temperature will be set to a temperature of no more than 110 degrees Fahrenheit, or the state's allowable maximum water temperature. 6. Maintenance staff will check water heater temperature controls and the temperatures of tap water in all hot water circuits weekly and as needed. 7. Documentation of testing will be kept in the maintenance office. 1. Observations on 11/26/18 between 11:00 a.m. and 12:17 p.m., during the initial screening of residents, revealed water from the sink in resident rooms felt very hot to the touch, this surveyor could not hold her hand under the running water for more than a few seconds. The temperature(s) (temp) of the water was checked with the surveyor's thermometer in the following rooms, and obtained the following temps: room [ROOM NUMBER]- 114 degrees Fahrenheit (F) room [ROOM NUMBER]- 118 degrees F room [ROOM NUMBER]- 122 degrees F room [ROOM NUMBER]- 118 degrees F room [ROOM NUMBER]- 123 degrees F room [ROOM NUMBER]- 116 degrees F room [ROOM NUMBER]- 116 degrees F On 11/26/17 at 12:20 p.m. the Maintenance Supervisor (MS) HH was asked to check the water, to verify temps and interview at that time revealed he was not aware of any unsafe hot water temps. Interview with HH revealed maintenance staff did ten random water checks every week, four from each wing, and both shower rooms, and they were scheduled to be done that day. HH further revealed the facility had three (3) hot water heaters, one controlled East wing, one controlled West wing and one controlled the kitchen and laundry. East wing consisted of rooms 101 to 126, West wing consisted of rooms 127 to 160. MS HH confirmed the following unsafe water temps, using the facility's digital thermometer, assisted by maintenance staff (II): room [ROOM NUMBER]- 121.0 degrees F at 12:30 p.m. room [ROOM NUMBER]- 122.0 degrees F at 12:34 p.m. room [ROOM NUMBER]- 112.0 degrees F at 12:38 p.m. East wing whirlpool shower- 138.0 degrees F at 12:42 p.m. room [ROOM NUMBER]- 123.4 degrees F at 12:45 p.m. West Wing Shower- 113.3 degrees F at 12:50 p.m. after running the water for 60 seconds. room [ROOM NUMBER]- 112.0 degrees F at 12:52 p.m. after running the water for one minute. room [ROOM NUMBER]- 113.0 degrees F at 12:55 p.m. after running the water for one minute. room [ROOM NUMBER]- 126.5 degrees F at 1:00 p.m. after running the water for one minute. At 1:05 p.m. MS HH confirmed the temps were too hot and revealed the hot water heater had a thermostat that needed to be adjusted, and immediately told (II) to go turn it down now. Maintenance worker (II) left to go adjust the thermostat on the hot water heater. MS HH revealed they check water temps weekly and they normally range between 110 to 115 degrees and if they found water above range, they adjusted the thermostat. The surveyor requested a copy of their weekly temp checks, and documentation to verify what they did if they found unsafe water temps. Interview on 11/26/18 from 1:25-1:45 p.m. with the Administrator revealed he was not aware of any unsafe water temps prior to today and further revealed they utilize an app called Gen-Core (GN-X care/maintenance care software) that integrates with the Point Click Care (PCC) to report, check and document issues, and receive alerts. All staff had access, could report issues from the kiosk and it went directly to maintenance staff, no complaints of hot water temps had been reported. they had stopped bathes in the shower and were checking the water temps every two hours. Interview on 11/26/18 at 4:41 p.m. with the Administrator confirmed they continued to have two elevated temps. room [ROOM NUMBER] tested between 111 to 113 degrees F and room [ROOM NUMBER] tested 114.5 degrees F. The Administrator, DON, and maintenance supervisor assured the survey team that they had put a plan of action in place, monitoring of temps were ongoing, they would provide documentation, and baths in the shower rooms had been stopped. A copy of the hot water temp policy was provided. Observation on 11/27/18 at 8:15 a.m. revealed the water in the East wing whirlpool shower was still very hot to the touch. MS HH was asked to check the water and interview at that time revealed they had some unsafe hot water temps overnight. Using the facility thermometer, MS HH confirmed water from the sink in the East wing whirlpool shower tested between 117 and 120 degrees F. MS HH provided the following temperature checks from overnight, using the facility thermometer: (MONTH) 26, starting at 1:00 p.m., thru (MONTH) 27 at 7:00 a.m., water temps ranged from 101.5 to 131. He confirmed they still had hot water issues. Interview on 11/27/18 at 9:45 a.m. with the Administrator revealed Central Plumbing out of Tifton had come and checked the hot water heaters and the mixer valve was bad. The parts needed for repair were in another state but had been ordered. Interview on 11/28/18 at 8:15 a.m. with HH revealed water temperature checks for (MONTH) 27 at 7:00 a.m. thru (MONTH) 28 at 5:00 a.m., using the facility thermometer, ranged from 67 degrees to 113.6 degrees F. Interview on 11/29/18 at 9:15 a.m. with HH revealed Central Plumbing was in the building for repairs to the hot water heater on East and West wing. At that time he provided documentation of temp checks from (MONTH) 28 at 7:00 a.m. thru (MONTH) 29 at 7:00 a.m., the temp range was from 60 degrees F to 115 degrees F 2. Review of the facility Falls Management policy date revised 3-12-15, revealed that the intent of the facility is to provide an environment which remains as free of incident hazard a is possible .the facility utilizes previous evaluation and current data to assist staff in identification of resident's specific risks and causes in an effort to identify appropriate intervention to reduce the likelihood of the resident falling and to try to minimize complications from falling .implement action plan based on root cause analysis set a re-evaluation timeline to determine how the plan is working .if falling recurs despite initial interventions, stall will implement additional or different interventions, or indicate why the current approach remains relevant. Review of the resident's Admission Record revealed that she had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Brief Interview for Mental Health Status (BIMS) of 11, indicating that she was cognitively intact; required limited assistance from one staff person for transfer; used a wheelchair for mobility; required extensive assistance from two staff members for toilet use; was frequently incontinent of bladder and bowel, was on a toileting program; and had two or more falls since the last assessment (Quarterly MDS dated [DATE]). Review of the Quarterly MDS dated [DATE] revealed that the resident had a BIMS of 9, indicating that she had some confusion; required limited assistance from one staff member for transfers; required extensive assistance from one staff member for toilet use; was frequently incontinent of bladder and bowel; and was on a toileting program. Review of the resident's care plan initiated 6-7-18 revealed that the resident had falls on 8-29, 8-31, 9-3, 9-11, 9-12, 9-13, 9-16, 9-20, 9-23 ,9-24, 9-27, 9-28, 9-29, 10-6, 10-7, 10-12, 10-13, 10-18, 10-24,10-29, 11-2, 11-3,11-9, 11-11, 11-15, and 11-19 without injuries. Continued review revealed interventions for staff to assess the resident's wheelchair for appropriate size and assess the need for footrests, keep the bed in low position, keep call light in reach, observe gait; assist with equipment as needed, orientation to new room and roommate, remind to use call light for needed assistance, scheduled toileting program, and for therapy to evaluate and treat as indicated. Review of the resident's records revealed that a root cause analysis for the falls had not been completed. During an interview on 11/28/18 at 11:00 a.m. with RN Resident Care Liaison (RCL) revealed that falls are discussed during the morning clinical meeting the day after the fall. The fall is then discussed weekly in an interdisciplinary team (IDT) meeting for the four weeks after the fall. During an interview on 11/28/18 at 1:00 p.m. with the Director of Nursing (DON) revealed that when a resident has a fall, the fall is discussed in the morning meeting the next day after the fall. Continued interview revealed that the facility was unable to provide documentation that a root cause analysis had been completed for any of the falls. Further interview revealed that the DON stated that the resident has the right to fall.",2020-09-01
878,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2018-11-29,812,E,0,1,4DH611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and review of policy titled Cleaning Procedures the facility failed to ensure that the floor in the dry goods area of the kitchen was kept clean, failed to ensure that sanitary sink drains were used and failed to ensure that a fan and a kitchen shelf were kept clean and sanitary. The facility census was 91 residents. Findings include: Review of the policy titled Cleaning Procedures and dated 7/2/17 revealed that floors were to be wet mopped daily with detergent/sanitizer and water and then rinsed. Review of the cleaning schedule revealed that walls and fans were to be cleaned by everyone on Wednesday. Observation and interview on 11/28/18 at 8:26 a.m. with the Dietary Manager (DM) revealed that the floor in the dry good area was very sticky. The DM stated that she kept a cleaning schedule posted and that the dry good area was to be mopped routinely on Monday and Thursday when supplies were delivered and as needed. The DM confirmed that the floor was very sticky in the dry goods area. Observation on 11/28/18 at 8:59 a.m. of the three-compartment sink with the DM revealed that paper towels were being used in place of the sink drain [MEDICATION NAME]. The DM confirmed that paper towels were being used in place of the sink drain [MEDICATION NAME] and stated that the drain [MEDICATION NAME] break easily. She stated that she needed to order new drain [MEDICATION NAME]. Observation on 11/28/18 at 9:04 a.m. of two fans in the kitchen revealed a build-up of dust on one fan that was located over the covered chest that contained the plate warmers and facing the steam table. There was a heavy build-up of dust on the shelf below the second fan that was at the entrance from the dining room into the kitchen. The shelf held the pitchers used to serve beverages. Interview with the Dietary Manager confirmed that there was a build-up of dust on the one fan and on the shelf below the other fan. Interview on 11/29/18 at 12:36 p.m. with the Regulatory Compliance Nurse revealed that the expectation was that there would be no accumulation of dust on fans or shelves that house dishes or food items.",2020-09-01
879,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2018-11-29,814,E,0,1,4DH611,"Based on observation, interview, the facility failed to ensure the sanitary handling of garbage and refuse at the dumpster site. The facility census was 91 residents. Findings include: Observation of the dumpster area on 11/28/18 at 8:43 a.m. with the Dietary Manager ( DM) revealed several pieces of trash including disposable gloves, Styrofoam plates, and plastic bags lying on the ground and other pieces of trash that had blown off further on the edge of the facility grounds. The sliding door to the trash bin was observed to be open. Interview with the DM on 11/28/18 at 8:45 a.m. confirmed that there was trash on the ground and revealed that the trash lady did not care whether trash was left on the ground or not. She also stated that this had been an ongoing problem. She stated that she had her staff go out and clean it up when she found it like this. When asked if she had done anything else to correct the problem, she stated that she mentioned it in the morning meeting. Interview on 11/28/18 at 1:20 p.m. with the DM revealed that the trash lady was the lady that drove the city trash truck. The DM reported that the on-going problem with this driver had been reported multiple times by the Head of Maintenance to the city authorities. Interview on 11/29/18 at 9:00 a.m. with the DM revealed that they have no policy for keeping the area around the dumpster clean. Interview on 11/29/18 at 12:36 p.m. with the Regulatory Compliance Nurse revealed that the expectation was that there would be no trash on the ground around the dumpster.",2020-09-01
880,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2017-03-30,226,D,0,1,K22H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to implement their policy and investigate injuries of unknown origin for a resident who had acquired abrasion and bruises to the left side of their neck, blisters on the chest and a skin tear on the right side of their neck for one resident from a sampled 35 residents in Stage II. (Resident (R) #251) Findings include: Policy titled Occurrences revised date 5/4/16 revealed .In an effort to prevent occurrences, each .resident will be observed and assessed for risks . Definition: Any event .incident .which results in an injury .Unexplained injury . such as a bruise or skin tear .reported to the Charge Nurse immediately .3. If occurrence is noted without direct staff observation, the incident entry must be completed in the software system on the shift the occurrence was reported. Occurrence Documentation: 1 .Nurse will be responsible for completing the following occurrence documentation requirements prior to the end of the shift .This . will be noted in the .resident's clinical record AND in the occurrence reporting software program.2. Clinical record occurrence documentation will include .Investigation and follow up: 1. Occurrence investigation and follow-up .4. The licensed nurse will be responsible for notifying the Director of Health Services (DHS) .6. DHS will be responsible to review each occurrence for thorough investigation . Policy titled Reporting Patient Abuse, Neglect, . revised date 2/24/17, stated It is the policy of Pruitt-Health .to comply with all applicable federal and state requirements regarding the reporting of patient abuse, neglect, .1 .including injuries of an unknown source, should be immediately reported to the Administrator .2.the Administrator .should be notify the appropriate state agency .within 2 hours after .result of bodily injury . The following Body Audit forms revealed: 8/6/16, revealed abrasion, bruise left abdomen/chest area. 8/13/16, revealed scab to chest/abdomen. 8/21/16, revealed scabs left abdomen/chest area. 8/27/16, revealed scab and discoloration to chest/abdomen area. 9/3/16 revealed bruise left abdomen/chest area. Review of Wound Observation and Assessment forms revealed the following: 8/4/16, Tx (treatment) initiated per charge nurse to area to (L) left side of neck-abrasion . 8/8/16, revealed, Several small blisters to RUE (Right Upper Extremity) . 8/16/16, .Tx cont. to abrasion L side of neck .abrasion to RUE healing . 8/20/16, .Skin (ST) to R (right) neck tx initiated . 8/27/16, Tx dc'd (discontinued) to R neck . 8/30/16, Tx dc'd .RUE-area resolved. The Nurse's note dated 8/4/16, revealed Certified Nursing Assistant (CNA) CC (with) hospice reports area to left side of neck and left chest area. Treatment nurse notified CNA CC new order received (sic). Discoloration to left chest area. The clinical record lacked documentation of the origin of the abrasion/bruise to the left side of R#251's neck, nor the blisters to RUE. The clinical record also lacked documentation explaining the skin tear to R#251's right side of neck. Physician's Document of Patient Capable to Manage Benefits form dated 3/18/16 revealed R#251 .Condition is progressing & permanent. He is declining and near death. Review of the physician's orders [REDACTED]. 8/4/16, Apply no sting to area to left side of neck every other day (QOD) and prn (as needed). 8/8/16, Apply no sting to Blister to RUE QOD & (and) prn. 8/30/16, D/C (discontinue) tx to area to L side of neck-Resolved, D/C tx to RUE-Resolved, D/C Tx to R neck-effective 8/27/16-Resolved. The clinical record lacked documentation the physician ordered new medications in (MONTH) of (YEAR). Review of Behavior Symptom Screening form dated 12/11/15, revealed Patient putting self in floor, crawls around floor . Review of the plan of care updated 8/4/16, revealed, skin breakdown related to limited mobility .Has end stage liver failure with impaired cognition. Requires assistance with bed mobility and major position changes updated 8/4/16, has red area to L side of neck. Tx (treatment) as ordered to L side neck 8/8/16 Blister to right upper extremity (RUE) . Review of the plan of care updated 2/29/16, revealed, .episodes to get down on all fours and crawl in floor .Approaches: .Monitor patient behavior and report .Place on behavior management, placed on behavior maintenance. Review of the plan of care with review date 8/8/16, revealed, Potential for injury from falls reviewed date 8/8/16, Goals: Will have no fall related injury .Approaches .Maintain safety with transfers, Monitor for changes in Resident's condition that may warrant increased supervision/assistance or adverse side effects of medications .Mattress to floor, Mat to floor beside bed, . Review of the plan of care dated 8/17/16, revealed, . Self care deficit activity of daily living (ADL) .Goal: ADL needs are met .Approaches: .Assist with transfer as needed . Transfer c (with) total lift. Review of the plan of care review date 8/8/16, revealed, Hospice program R/T end stage liver disease reviewed 8/8/16 .Approaches: .Monitor for skin issues and promote comfort . Review of the following treatment records revealed: 8/4/16 through 8/30/16, stated Apply no sting to area to left side of neck every other day and prn (as needed). 8/8/16 through 8/30/16, Apply no sting to blister to RUE (right upper extremity) QOD (every other day) and prn. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section G revealed R#251 was totally dependent on two staff person for bed mobility and transfer. Section O revealed hospice care. Review of the Admission MDS dated [DATE] Section J revealed life expectancy less than six months history of falls with injury 3/29/17 2:56 p.m., an interview with the Director of Health Services (DHS) in the Administrators office with the Interim Administrator, Nurse Consultant JJ, Assistant Director of Health Services (ADHS), and Surveyor present stated We try to make sure they understand they have a 2 hour window with the stated. The Certified Nursing Assistant (CNA's) know to notify me immediately. The first thing I do is call my Administrator. The DHS stated that this was according to the facility policy. I am aware that he (R#251) had those marks. We have a daily meeting. We talked about him being a picker (scratching). 3/29/17 3:11 p.m., an interview with the Interim Administrator in her office stated the occurrence reporting system was an incident report. The Interim Administrator stated there was no incident report for (MONTH) or (MONTH) for R#251. 3/29/17 3:17 p.m., the DHS stated a bruise of unknown origin is definitely a reportable incident. We would not report to the state if it was not of unknown origin. The DHS stated she can't remember if the Charge Nurse notified her when the injury was identified. 3/29/17 5:14 p.m., an interview with Charge Nurse / Licensed Practical Nurse (CN/LPN) DD in the Human Resource Building stated, I remember an area on his chest stated reported to the supervisor. I thought I just report it to the treatment nurse. CN/LPN DD stated, injuries of unknown origin should be reported and she did not report the incident to the DHS nor the Administrator. 3/30/17 8:26 a.m., an interview with Magnolia Hall Unit Manager AA stated she didn't remember any skin conditions on R#251. If I were aware I would have put it on the 24 hour report sheet and discussed in morning meeting at 9:00 a.m. I would have reported immediately to the Administrator. Not ten minutes but immediately. 3/30/17 at 9:23 a.m., an interview with the DHS revealed that she was not informed about R#251's areas of unknown origin, but it was common knowledge R#251 was a picker/scratcher. 3/30/17 9:33 a.m., an interview with the DHS stated the previous Administrator would have been aware of the injury of unknown origin for R#251. She would have known it was a reportable. The 24 hour nurse report charting and morning meeting notes for 8/4/16 was requested but not provided. Review of the Reportable log for (MONTH) (YEAR) lacked documentation of State incident reporting. The clinical record lacked documentation of the CN/LPN DD notifying the DHS of R#251's injury of unknown origin. The clinical record lacked documentation of the DHS conducting an investigation surrounding R#251's injury of unknown origin as indicated by the facility policy. The clinical record lacked documentation stating investigation was initiated and completed surrounding R#251's injuries of unknown origin. The clinical record lacked documentation related to the origin of the left neck bruise and abrasion , RUE injury and right neck skin tear. The facility failed to investigate injuries of unknown origin for R#251 who had abrasions and bruises to the left side of neck, skin tear to the right side of neck and blisters to the chest as indicated by the policy nor report this occurrence to the State Survey Agency.",2020-09-01
881,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2017-03-30,465,B,0,1,K22H11,"Based on observation, interview, and review of facility policy, it was determined the facility failed to develop a system to ensure the smoking aprons for eight smokers were properly sanitized. The facility stored the residents' smoking aprons in the soiled utility room, and was unable to identify a system to ensure the common use smoking aprons were thoroughly cleaned after daily use. Findings include: Observation on 3/29/17 at 9:03 a.m. revealed six residents in the outside smoking area supervised by an activities staff member. Four of the six residents were wearing a smoking apron. Further observation revealed 12 smoking aprons stored in the facility soiled utility room next to the nursing station between the Blue and Magnolia Units. The smoking aprons were gray in color with stains and the neck and waist straps were white in color but dirty. One smoking apron was missing the neck straps; another smoking apron was missing the waist straps; and another smoking apron was completely frayed around the edges of the neck collar. Two smoking aprons were on the floor by the mop bucket. Interview with the Licensed Practical Nurse (LPN) Supervisor AA on Magnolia Unit at 3/29/17 at 11:30 a.m. revealed the smoking aprons were stored at one time in the medication and room folded up. It was decided this was not good since the folding would cause the aprons to crease and crack. Storage was then switched to the dirty utility room so the aprons could be hung up. Aprons are not assigned to the smoking residents. She had no idea why it was decided to store the apron in the soiled utility room. Supervisor AA further stated she did not know how often or when the smoking aprons were cleaned. On 3/29/17 at 11:50 a.m. interview with the Assistant Director of Health Services (ADHS) at the nurses' station between the Blue Unit and Magnolia Unit revealed she has worked at the facility for seven months and did not know anything about cleaning the aprons or why they are stored in the soiled utility room. The ADHS stated she would find out. Interview on 3/29/17 at 2:10 p.m. with the Activity Staff KK in the smoking area revealed the smoking aprons have always been stored in the soiled utility room since she started working at the facility less than a year ago. Activity staff KK was unaware if there was a policy for cleaning the smoking aprons. According to the facility policy the resident is to wear a smoking apron while smoking. However the smoking aprons are not individually assigned to the residents. The staff member could not identify who was responsible for cleaning the smoking aprons or the frequency. On 3/29/17 at 4:00 p.m. interview with the Director of Health Services (DHS) in front of the soiled utility room revealed she was unaware of where the staff stored the smoking aprons for the facility smokers. The DHS was shown the smoking aprons were stored in the soiled utility room and she expressed surprise at the location of the storage area. The DHS was asked to examine the smoking aprons and she acknowledged the aprons were dirty and grimy. The DHS was unaware if there was a policy or procedure for the storage and cleaning of the smoking aprons. The DHS also stated the Activities Department was responsible for monitoring the smokers and storage of the smoking materials. On 3/30/17 at 8:30 a.m. interview with the Activity Director HH by the soiled utility room revealed the activities staff supervises the smokers at break time and assist with distributing the residents' cigarettes. Housekeeping is responsible for cleaning the smoking areas in the evening. The Activity Director was not sure who was responsible for cleaning the aprons; and did not know if there was a policy, procedure or record maintained for cleaning the smoking apron. The Activity Director acknowledged the apron straps looked grimy and dirty. States the residents are not assigned their own aprons. But stated it would be a good idea for each smoker to have their own individual apron to avoid the transmission of germs/organisms. The Activity Director believes the central supply staff is responsible for ordering new aprons. Interview on 3/30/17 at 9:03 a.m. in the soiled utility room with the central supply staff (Staff member II) who is responsible for ordering facility supplies including the smoking aprons. Central Supply Staff II states the staff informs her when new smoking aprons are needed, and does not remember exactly when the smoking aprons were ordered but believes they were ordered sometime this year. Surveyor requested that she pull the order forms to determine when the smoking aprons were last ordered. Staff member II also states she doesn't know if the aprons comes with care instructions but will call her distributor to see if he can send that information. An additional interview with Central supply staff II 20 minutes later revealed the aprons have a label that documents the following: Do not launder but wiped down with a spray type cleaner and damp cloth. But the staff member does not know how often this is done or by whom. The interviewee also acknowledged the aprons did look dirty. Review of the facility's policy titled Smoke Free Policy with a revision date on 1/10/17 revealed the policy does not address the use and care of the residents' smoking aprons. The facility failed to have an effective sanitary system in place for the storage and cleanliness of residents smoking aprons.",2020-09-01
882,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2019-07-19,578,D,0,1,E3U111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain a concurring physician's signature on a DNR (Do Not Resuscitate) order form for two residents (R)(R#72 and R#118). A total of 41 residents' advance directives information was reviewed. Findings include: Review of the facility's Do Not Resuscitate Policy: Georgia revised 2/4/19 revealed: II: Requesting a DNR Order: [NAME]the Social Worker/professional nurse shall be responsible for completing the process. C. If a patient/resident does NOT have decision making capacity: 1. A Durable Power of Attorney for Healthcare (DPOAHC) or Healthcare Agent, may consent orally or in writing to a DNR order along with the signature of the patient/resident's Attending Physician. 2. An Authorized Person who is not the patient/resident's DPOAHC or Healthcare Agent may consent orally or in writing to a DNR order. The patient/resident's DNR becomes effective upon the signature of the patient/resident's attending physician along with the signature of a concurring physician. 1. Review of an Advance Directives Checklist for R#118 revealed a section was checked for: I have not executed an advance directive, and do not wish to discuss advance directives further at this time. This checklist was signed on 10/1/18 by a resident representative listed as the responsible party on the resident's face sheet. Review of a Durable Power of Attorney for Healthcare Decisions signed by R#118 on 7/18/07 revealed that she listed a family member as her healthcare agent, and another family member as an alternate agent. Review of the resident's face sheet revealed that these two agents were listed as the second and third emergency contacts. Review of R#118's State of Georgia Physician's Do Not Resuscitate (DNR) Order for Adult Patient/Resident Without Decision Making Capacity With Authorized Person revealed that the form was signed by the same person listed as the resident representative on the Advance Directives Checklist, who was neither the healthcare agent nor alternate agent listed on the DPOAHC. In addition, this DNR order form was signed on 10/4/18 by the attending physician only. Review of R#118's Physician order [REDACTED]. 2. Review of a Physician's DNR Order Form for Adult Hospice Patient/Resident Without Decision-Making Capacity With Authorized Person Other Than Durable Power of Attorney for Healthcare (GA)(Georgia) for R#72 revealed that an authorized person signed the DNR form on 2/7/17, and the attending physician only signed the form on 2/8/17. Review of R#72's Physician order [REDACTED]. Further review of the physician's orders [REDACTED]. Review of R#72's Annual Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score between 13 and 15 indicates no cognitive impairment). Further review of this MDS revealed that R#72 was not receiving hospice services. During interview with the Social Services Director (SSD) on 7/19/19 at 10:07 a.m., she stated that for a resident with decision-making capacity that desired a DNR, only one physician signature was needed on the DNR order form. She further stated that if the resident did not have decision-making capacity, two physicians needed to sign the form. The SSD stated during continued interview that if a resident had a DPOAHC, that the designated healthcare agent could sign the DNR form, and in that case only one physician signature was needed. She stated that when a DNR form was printed out of the facility's computerized system, that the form had only one line for the attending physician's signature, and no place designated for a concurring physician signature. She further stated that because of this, she used a pre-printed DNR form that had signature lines for both the attending and the concurring physicians. The SSD stated during continued interview at this time that R#72 was not able to sign her DNR form when she was first admitted and was on hospice, so a DNR order form for a hospice resident without decision-making capacity was used. She verified that R#72 was no longer on hospice services, but stated that because the information on the DNR form was the same whether or not a resident was on hospice, another DNR order had not been obtained when the resident was removed from hospice services. The SSD verified that there was only one physician signature on both R#72's and R#118's DNR order forms, and that the facility policy was for the attending and a concurring physician sign the DNR if the resident did not have decision-making capacity, and the responsible party signing the form was not the DPOAHC agent.",2020-09-01
883,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2019-07-19,656,D,1,1,E3U111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, the facility failed to implement the care plan related to nail care prn (as needed) for one totally-dependent resident (R) (R#52). The sample size was 68 residents. Findings include: Review of R#52's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#52's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she was totally dependent for personal hygiene. Review of R#52's self care deficit related to progressive MS-functional [MEDICAL CONDITION] care plan revealed an approach dated 6/5/19 to provide daily grooming, including nail care prn. Observation on 7/15/19 at 11:34 a.m. and 7/16/19 at 8:57 a.m. revealed that R#52's fingers were contracted into her palms, and the fingernails that could be seen were very long. Continued observation revealed that there was an unpleasant odor to the right hand. Observation on 7/16/19 at 9:26 a.m. revealed that Licensed Practical Nurse (LPN) MDS Coordinator GG was cutting and filing R#52's fingernails. During interview at this time, LPN GG stated that while she was in R#52's room, she noted the resident's fingernails were long and in need of cutting. Cross-refer to F 677.",2020-09-01
884,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2019-07-19,677,D,0,1,E3U111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to perform nail care for one totally-dependent resident (R) (R#52), who had bilateral hand contractures. The sample size was 68 residents. Findings include: Review of R#52's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of R#52's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 3 (a BIMS score between 0 and 7 indicates severe cognitive impairment); was totally dependent for personal hygiene; and had functional limitation in range of motion (ROM) of the upper and lower extremities. Review of R#52's self care deficit related to progressive MS-functional [MEDICAL CONDITION] care plan revealed an approach dated 6/5/19 to provide daily grooming, including nail care prn (as needed). Review of an OT (Occupational Therapist)-Therapist Progress & Discharge Summary with start of care of 8/24/18 and end of care of 8/31/18 revealed: Start of Goal Status: The patient exhibits flexion of digits on both hands into palms due to joint stiffness and contractures putting patient at high risk for skin breakdown in palms. Educated RNP (restorative nursing program) and CNA/nursing staff regarding recommendations for positioning and hand splinting program. ROM (range of motion) should be performed daily, as well as hand hygiene and nail trimming as needed. Observation on 7/15/19 at 11:34 a.m. and 7/16/19 at 8:57 a.m. revealed that R#52's fingers were contracted into her palms, and the fingernails that could be seen were very long. Continued observation revealed that there was an unpleasant odor to the right hand. Observation on 7/16/19 at 9:26 a.m. revealed that Licensed Practical Nurse (LPN) MDS Coordinator GG was cutting and filing R#52's fingernails. During interview at this time, LPN GG stated that while she was in the room assessing R#52 for a Significant Change MDS, that she noted the resident's fingernails were long and in need of cutting. Continued observation at this time as the nurse straightened the resident's fingers as much as she could to cut them, that the left middle fingernail was especially long, and had dark debris underneath. Continued observation revealed that R#52 did not exhibit any discomfort as her nails were cut and filed, and no skin breakdown was seen in her palms. Further interview with LPN GG revealed that either the CNAs (Certified Nursing Assistants) or Activity staff typically performed the nail care, but may not have been doing it because it caused the resident discomfort. During continued interview with LPN GG, she stated the resident's right palm was moist, and verified that this hand had an odor. During interview with CNA HH on 7/17/19 at 2:33 p.m., she stated that R#52 was totally dependent for care, and that the CNAs were responsible for cutting fingernails as needed.",2020-09-01
885,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2019-07-19,684,D,0,1,E3U111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow the physician's order [REDACTED].#62), who was reviewed for adaptation devices for eating. Findings include: Review of the electronic current physician order [REDACTED]. Review of meal ticket dated 7/17/19 (Dinner) revealed Resident # 62 was to receive a divided plate. Review of the Quarterly Minimum Data Set (MDS) MDS dated [DATE] revealed a Brief Interview in Mental Status (BIMS) of 15 (a BIMS score between 13 - 15 reveals intact cognitive) and a functional status including independent for eating via section G of the quarterly MDS dated [DATE]. Review of the electronic medical record revealed Resident R #62 had a [DIAGNOSES REDACTED]. Interview with R# 62 on 7/16/19 at 8:37 a.m. during breakfast stated her food is always cold because the plate she receives can ' t go into the insulated plate. She stated she had spoken with staff about getting a different type of plate which would provide her food with insulation and not be cold. Interview with Dietary Manager DM on 7/17/19 at 10:37 a.m. regarding the adaptive device (divided plate) for R #62. The DM stated she thought she placed on the meal ticket for the resident to receive a regular plate. The DM verified the changes to the meal ticket had not been made and the meal ticket indicated divided plate. The DM verified she had spoken with R # 62 about the divided plate. Interview with Licensed Practical Nurse LPN/Unit Manager for the 200 hall on 7/17/19 at 11:20 a.m. verified R # 62 has a current physician's order [REDACTED].",2020-09-01
886,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2019-07-19,690,D,0,1,E3U111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that a urinary catheter was secured to the leg to prevent urethral traction for one resident (R) (R#52). A total of three residents were reviewed for urinary catheter use. Findings include: Review of R#52's clinical record revealed that she had a history of [REDACTED]. Review of R#52's Physician order [REDACTED]. Catheter: [DIAGNOSES REDACTED]. [MEDICATION NAME] (an antibiotic) solution; 40 mg (milligrams)/mL (milliliter; amount: 2 ml; injection Special Instructions: Mix 1 vial [MEDICATION NAME] in 500 cc (cubic centimeters) normal saline, place 100-150 cc in bladder and clamp for 30 minutes and release. Repeat qmwf (every Monday, Wednesday, and Friday) Once A Day. [MEDICATION NAME] (an antibiotic for preventing and treating UTIs) [MEDICATION NAME] capsule; - Crushed; 50 mg; amount: One; oral Once A Day. Catheter: Catheter care every shift. Catheter: Change PRN (as needed) per facility protocol for leakage, dislodgement, obstruction. Review of R#52's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 3 (a BIMS score between 0 and 7 indicates severe cognitive impairment); was totally dependent for toilet use, personal hygiene, and bathing; had an indwelling catheter; and a [MEDICAL CONDITION] bladder. Review of R#52's indwelling urinary catheter care plan dated 4/3/18 revealed the catheter was related to [MEDICAL CONDITION] bladder, with [MEDICAL CONDITION] and recurrent UTIs. Review of R#52's laboratory results revealed that a urinalysis and urine culture were done on 5/13/19, indicating 2+ bacteria that was treated [MEDICATION NAME]([MEDICATION NAME]-an antibiotic). During an observation of R#52's skin with Licensed Practical Nurse (LPN) MDS Coordinator GG on 7/16/19 at 9:26 a.m., the resident's catheter was observed to not be secured to her leg in any way. This was verified by LPN GG, who stated that she would get a catheter strap for the resident. During observation of pressure ulcer wound care performed by LPN Treatment Nurse II and assisted by Certified Nursing Assistant (CNA) HH on 7/17/19 at 2:06 p.m., R#52's catheter tubing was observed to not be secured to her leg, and the tubing was pulling to the right side of the bed where the drainage bag was located. This was verified by LPN II, who stated that she would obtain a catheter strap after the treatment was completed. During interview with CNA HH on 7/17/19 at 2:33 p.m., she stated that she thought R#52 had a catheter strap earlier that day, and that she would apply a leg strap if she noticed that a resident did not have one. During interview with LPN MDS Coordinator GG on 7/17/19 at 3:03 p.m., she stated that R#52 had been taken to the shower shortly after the skin observation the morning of 7/16/19, and that she got busy and forgot to get a catheter strap for her after her shower. During interview with the Assistant Director of Health Services (ADHS) on 7/19/19 at 10:28 a.m., she stated that the usual nursing practice was for any resident with a catheter to have a catheter strap or Cath Secure device, and that a physician's orders [REDACTED]. The ADHS further stated that all residents with a catheter should have a leg strap unless they refused it, and this would be care planned. Review of the facility's Indwelling Urinary Catheter (Foley) Care and Management procedure revised 11/11/16 revealed: Make sure that the catheter is properly secured. Assess the securement device daily and change it when clinically indicated and as recommended by the manufacturer. Clinical alert: Provide enough slack before securing the catheter to prevent tension on the tubing, which could injure the urethral lumen and bladder wall. Complications: Complications associated with indwelling urinary catheter use include CAUTI (catheter-associated urinary tract infection), [MEDICAL CONDITION] trauma, epididymitis (in men), retained balloon fragments, bladder fistula (with prolonged use), bladder stone formation, and incontinence.",2020-09-01
887,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2019-07-19,698,D,0,1,E3U111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to communicate with the [MEDICAL TREATMENT] center for one resident (R) R #76. According to the facilities Resident Census and Conditions of Residents (CMS Form 672) there are two [MEDICAL TREATMENT] residents. The census is 147. Findings are as followed: Resident #76 [DIAGNOSES REDACTED]. Medications including but not limited to: [MEDICATION NAME] (antidepressant) tablet 20mg x1 tab daily, [MEDICATION NAME] (gastric-reflux) tablet 20mg x1 twice daily, [MEDICATION NAME]-[MEDICATION NAME] (pain) tablet; 5-325mg x1 tab PRN, [MEDICATION NAME]( [MEDICATION NAME] binder) tablet 800mg x1 tab daily, [MEDICATION NAME] table (ulcers) 1gm x 1 tab twice daily. Review of the Quarterly Minimum Data Det (MDS) assessment dated [DATE] revealed Section C: Brief Interview for Mental Status (BIMS) score of 15/15 ( indicating no cognitive impairment), Section G: 0110-bed mobility 3/3, dressing 3/3, eating 1/1, toilet use 3/2. Section H: 0300 frequently incontinent, 0400 always incontinent, Section J: 1700 Fall history/ none Section K: 0100 swallowing/nutritional status/ none Section M: 0100 Pressure ulcer/injury risk- YES Section N: 0410 Medications 7 antidepressant-7 anticoagulant. Section O: none concerns. Review of Physician order [REDACTED]. Record review dated 10/6/99 of [MEDICAL TREATMENT] Agreement signed between by both parties the facilities' and [MEDICAL TREATMENT] representative. Titled: [MEDICAL TREATMENT] Agreement by and between [MEDICAL TREATMENT] Center and the Nursing Center revealed no communication agreement. Review of record dated 2/26/19 of Care Plan for R#76 revealed problems/needs: History of Falls [MEDICAL CONDITION] with [MEDICAL TREATMENT] and complications with the port. Self-care deficit- incontinent B&B - antidepressant medication use - risk for change in cognition personality changes Evaluation/Goals: No further fails -has left femoral permcath for [MEDICAL TREATMENT] three times a week Xarelto was added on 1/23/19 for clot access prevention. Prefers to stay in bed on days he is not at [MEDICAL TREATMENT] he can use bed controls to raise and lower his head to watch TV or for meals-has occ pain generalized per pt with [MEDICATION NAME] 5/325mg every 6 hours as needed has urinal with frequent incontinence of bowel still scratches at rectum getting feces on self -mood state states difficulty sleeping but napping during day 9.3 on [MEDICATION NAME] 20mg daily wife does not visit as often no rash observed during assessment has dry, scaly skin on feet. A record review of (MONTH) 2019 and (MONTH) 2019 Nurse's Notes (NM) from R#76 revealed no shared communication between the nursing home and the [MEDICAL TREATMENT] facility. No documentation of [MEDICAL TREATMENT] treatment provided and resident's response, including declines in functional status, falls, the identification of symptoms such as anxiety, depression, confusion, and/or behavioral symptoms that interfere with treatments were found in R#76's medical record. An interview with R#76 on 7/15/19 at 12:20 p.m. revealed his [MEDICAL TREATMENT] days are on Tuesday, Thursday, Saturday. He states the facility provides the transportation. Reports no issues with [MEDICAL TREATMENT] services. Stated [MEDICAL TREATMENT] access was in his left groin. R#76 state he's unable to tell me what type of access he has. An interview with Certified Nursing Assistant (CNA) KK on 7/16/19 at 2:24 p.m. she has never received [MEDICAL TREATMENT] training since employment. States if there's an emergency or equipment failure it's reported to a Unit Manager or the Director of Nursing (DON). States she isn't aware of any type of [MEDICAL TREATMENT] communication report, and if she had any concerns about R#76, she would immediately notify the nurse. An interview with Licensed Practical Nursing (LPN) BB on 7/16/19 2:55 p.m. revealed she received [MEDICAL TREATMENT] training with the health university in (MONTH) of 2019. Reports when R#76 returns from the [MEDICAL TREATMENT] center, she will check his bruits/thrill and remove the dressing to ensure no bleeding. States if there's are any concerns with R#76 at the [MEDICAL TREATMENT] center, they will typically call the facility. States if R#76 leaves the facility with concerns, they will contact the [MEDICAL TREATMENT] center to inform the staff. Reports the facility doesn't have a communication form, but they typically call if they have concerns. An interview with Administrator on 7/16/19 at 4:30 p.m. revealed that the facility reviews the current orders, ancillary orders, diagnosis, and services provided according to the plan of care for the [MEDICAL TREATMENT] R#76. States all communication between the [MEDICAL TREATMENT] center is verbal, and they receive a monthly report from [MEDICAL TREATMENT] on the [MEDICAL TREATMENT] treatment. The Administrator submitted a faxed report dated 7/16/19 of the [MEDICAL TREATMENT] treatments for R#76 for the month of (MONTH) 2019. States the facility doesn't have a [MEDICAL TREATMENT] communication form. When asked for the monthly communication report for the past year the facilty was unable to provide the reports. An interview with DON on 7/17/19 at 3:14 p.m. revealed that the facility communicates with the [MEDICAL TREATMENT] center verbally. States if any concerns arise, the [MEDICAL TREATMENT] center will call the facility. States after resident returns from treatment, her staff will obtain vital signs and monitor for shortness of breath and [MEDICAL CONDITION]. Reports the [MEDICAL TREATMENT] center sends a monthly report for the attending physician to review, however the DON could not provide evidence of the monthly reports.",2020-09-01
888,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2019-07-19,801,F,0,1,E3U111,"Based on record review, Registered Dietician (RD), and staff interview, the facility failed to ensure that the staff designated as Director of food and nutrition services was a certified dietary or food service manager or had a similar food service management certification or degree. Findings include: During interview with the Dietary Manager (DM) on 7/15/19 at 11:00 a.m., she stated that she had been working as an Assistant Dietary Manager at the facility, before recently being appointed as the DM. During the interview she will complete the Certified Dietary Manager course at the end of the (MONTH) 2019. During interview with the administrator on 7/16/19 at 9:57 a.m., he stated the DM was hired into the dietary manager position on 9/22/18. During interview with the RD on 7/18/19 at 10:15 a.m., she stated that the DM was hired for the facility in (MONTH) (YEAR). The RD stated she comes into the facility two or three times a month. She said when she enters the facility, she reviews the weight report, wound report, census and completes updates with nurses on residents. The RD stated she does monthly inspection in the kitchen and will assist the DM with menu changes and sign off on the changes as needed to the menu. She said she does not help daily in the kitchen. During interview with DM on 7/19/19 11:55 a.m. verified her hire date as the Assistant Dietary Manager was 3/3/13 and she was hired into the Dietary Manager position (MONTH) (YEAR), she confirmed she does not have an Associates or Bachelor's degree in any nutrition related areas, however she is completing the final for the Certified Dietary Manager course at the end of (MONTH) 2019. Review of the email from the desk of the DM dated 7/15/19 revealed the she began taking the Nutrition and Food service Professional training course on 2/2/19. The course will end 7/31/19.",2020-09-01
889,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2019-07-19,880,E,0,1,E3U111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure proper sanitization/cleaning of monitors for testing of blood glucose during 9 observations of 6 resident's (R) (R#36, R#136, R#18, R#117, R#139, and R#58) on 3 of 6 halls out of a total of 36 residents who receive glucose testing. One out of two nurses observed reforming finger sticks failed to clean the blood glucose monitoring equipment. Review of the Healthcare Professional Operator's Manual for the G3 Blood Glucose Monitoring System revealed on page 11 that the G3 Meter should be cleaned and disinfected between each patient. The meter is validated to withstand a cleaning and disinfection cycle of ten times per day for an average period of three years. Clorox Healthcare Bleach Germicidal and Disinfectant Wipes have been approved for cleaning and disinfecting the G3 Meter. Step 1. Wash hands with soap and water. Step 2. Put on single-use medical protective gloves. Step 3. Inspect for blood, debris, dust, or lint anywhere on the meter. Blood and bodily fluids must be thoroughly cleaned from the surface of the meter. Step 4. To clean the meter, use a moist (not wet) lint-free cloth dampened with a mild detergent. Wipe all external areas of the meter including both the front and back surfaces until visibly clean. Avoid wetting the meter test strip port. Step 5. To disinfect your meter, clean the meter surface with one of the approved disinfecting wipes. Step 6. Remove gloves. Disposal of infectious material: Blood, body fluids and cleaning materials should be disposed of according to federal, state, and local regulations for infectious waste disposal. Review of the Policy Diabetes Monitoring: Blood Glucose Equipment and Supplies dated 9/2012 revealed standardized cleaning and disinfecting procedures will be utilized to promote compliance to manufacturer and CDC guidelines. Glucometer Cleaning and Disinfecting Procedure: 1. Wash hands. 2. Put on clean gloves. 3. Clean the outside of the glucometer with [MEDICATION NAME] alcohol wipe (70%-85%) or lint free cloth dampened with soapy water. 4. Disinfect the meter with a bleach solution wipe (>0.5% sodium [MEDICATION NAME]) or spray 1:10 bleach solution on a paper towel. 5. Remove gloves and wash hands after cleaning glucometer. An observation on 7/16/19 at 11:31 a.m. of Registered Nurse (RN) AA, on Red hall, while performing a bedside blood glucose check revealed she failed to clean the blood glucose collection device prior to the procedure or after the procedure for two residents. She did not wash her hands or sanitize her hands between residents. Prior to entering the room for R#36, RN AA collected her equipment: gauze, lancet, gloves, paper towels, blood glucose collection device. She did not wash her hands prior to starting the procedure. She did put on gloves. She entered the room and laid the blood glucose device on the over-the-bed table. she cleaned the resident's finger, performed the finger stick and collected the blood onto the blood glucose strip. RN AA removed her gloves, wrapping the lancet inside one of the gloves; she did not wash her hands before leaving the room and returning to her medication cart. Upon returning to her medication cart, RN AA laid the glucose monitor on the medication cart; obtained lancets, gauze, gloves and paper towels from a stack on the cart - she went into room for resident R#136 carrying the supplies to check his blood glucose. RN AA did not clean the glucometer and she did not wash or sanitize her hands prior to the procedure; she put on gloves, cleansed the resident's finger while holding the glucometer in her gloved hands, she collected the drop of blood onto the blood glucose strip. RN AA left the room without washing her hands; she removed her gloves and proceeds to the medication cart. She did not sanitize her hands after the procedure. During an observation on 7/16/19 at 4:05 p.m. with RN AA performing a glucose check on R#36 she was observed to open the top drawer of the medication cart and take out one of two glucometers and lay it on the top of the cart. She took a test strip for the glucometer and placed it in the meter and lay it back down on the top of the medication cart. RN AA then took two 2x2 gauze, an alcohol prep wipe, gloves, lancet, and glucometer and brought them into the room of R#36. She lay the glucometer, 2x2 gauze, lancet, and alcohol prep wipe down on the bed, put the gloves on, opened the alcohol prep wipe and cleaned the resident's finger. She allowed it to dry for a second then pricked the finger with the lancet, picked the glucometer up and collected the blood sample in the test strip. When finished she lay the glucometer down on the bed and placed the 2x2 gauze on the resident's finger. The nurse gathered all the used supplies, except the lancet, removed her gloves while folding the used items inside the gloves and tossed them into the trash can in the resident's room. She took the lancet to the sharp container, located on the side of the medication cart, and placed it inside then lay the glucometer on top of the medication cart and repeated the same process for the next resident receiving a glucose test. At no time was RN AA observed to clean the top of the medication cart, clean the glucometer before or after use on the resident, or to wash or sanitize her hands before or after the procedure prior to moving on to the next resident. During an observation on 7/16/19 at 4:15 p.m. with RN AA performing a glucose check on R#139 she was observed to take a test strip for the glucometer and place it in the meter laying on the medication cart that she had just used for resident R#36 and lay it back down on the top of the medication cart. RN AA then took two 2x2 gauze, an alcohol prep wipe, gloves, lancet, and glucometer and brought them into the room of R#139. She lay the glucometer, 2x2 gauze, lancet, and alcohol prep wipe down on the bedside table, put the gloves on, opened the alcohol prep wipe and cleaned the resident's finger. She allowed it to dry for a second then pricked the finger with the lancet, picked the glucometer up and collected the blood sample in the test strip. When finished she lay the glucometer back down on the bedside table and placed the 2x2 gauze on the resident's finger. The nurse gathered all the used supplies, except the lancet, removed her gloves while folding the used items inside the gloves, and tossed them into the trash can in the resident's room. She took the lancet to the sharp container, located on the side of the medication cart, and placed it inside then lay the glucometer on top of the medication cart and repeated the same process for the next resident receiving a glucose test. At no time was RN AA observed to clean the top of the medication cart, clean the glucometer before or after use on the resident, clean the bedside table prior to laying the glucometer down on it, or to wash or sanitize her hands before or after the procedure prior to moving on to the next resident. During an observation on 7/16/19 at 4:20 p.m. with RN AA performing a glucose check on R#58 she was observed to take a test strip for the glucometer and place it in the meter laying on the medication cart that she had just used for R#139 and lay it back down on the top of the medication cart. RN AA then took two 2x2 gauze, an alcohol prep wipe, gloves, lancet, and glucometer and brought them into the room of R# 58. She lay the glucometer, 2x2 gauze, lancet, and alcohol prep wipe down on the bed, put the gloves on, opened the alcohol prep wipe and cleaned the resident's finger. She allowed it to dry for a second then pricked the finger with the lancet, picked the glucometer up and collected the blood sample in the test strip. When finished she lay the glucometer down on the bed and placed the 2x2 gauze on the resident's finger. The nurse gathered all the used supplies, except the lancet, removed her gloves while folding the used items inside the gloves and tossed them into the trash can in the resident's room. She took the lancet to the sharp container located on the side of the medication cart, placed it inside, then lay the glucometer on top of the medication cart and repeated the same process for the next resident receiving a glucose test. At no time was RN AA observed to clean the top of the medication cart, clean the glucometer before or after use on the resident, or to wash or sanitize her hands before or after the procedure prior to moving on to the next resident. During an observation on 7/16/19 at 4:25 p.m. with RN AA performing a glucose check on R#136 she was observed to take a test strip for the glucometer and place it in the meter laying on the medication cart that she had just used for R#58 and lay it back down on the top of the medication cart. RN AA then took two 2x2 gauze, an alcohol prep wipe, gloves, lancet, and glucometer and brought them into the room of R#136. She lay the glucometer, 2x2 gauze, lancet, and alcohol prep wipe down on the bed, put the gloves on, opened the alcohol prep wipe and cleaned the resident's finger. She allowed it to dry for a second then pricked the finger with the lancet, picked the glucometer up and collected the blood sample in the test strip. When finished she lay the glucometer down on the bed and placed the 2x2 gauze on the resident's finger. The nurse gathered all the used supplies, except the lancet, removed her gloves while folding the used items inside the gloves and tossed them into the trash can in the resident's room. She took the lancet to the sharp container, located on the side of the medication cart, and placed it inside, then placed the glucometer back in the top drawer of the medication cart. At no time was RN AA observed to clean the top of the medication cart, clean the glucometer before or after use on the resident, or to wash or sanitize her hands before or after the procedure. During an interview on 7/16/19 at 5:20 p.m. with RN AA she stated that she has worked in the facility for one and a half years and received training on the proper procedure for performing a glucose test when she was hired and that the training is provided yearly. She stated that the glucometer should be cleaned with Clorox Bleach Germicidal Wipes that is kept in the bottom drawer of all medication carts, before use, allow to air dry, and then clean it again after use with each resident. During this time RN AA opened the green hall medication cart and there was no Clorox Bleach Germicidal Wipes observed to be in the medication cart. She then opened the medication cart on the red hall and there was a container of Clorox Bleach Germicidal Wipes observed in the drawer. RN AA stated that she should wash or sanitize her hands before and after a glucose on each resident, but stated she was in a hurry and did not sanitize or wash her hands, or clean the glucometer, between residents on the red hall. On 7/16/19 at 5:25 p.m. The facility's Administrator, Director of Health Services (DHS) CC, Corporate Consultant Nurse, Area Vice President for the company, and DHS DD were informed of the concern involving glucose testing after nine observations on seven residents. During this time an interview was conducted with DHS CC and she stated that it is her expectation that all nurses, performing a glucose test, wipe the glucometer with a Clorox Bleach Germicidal Wipe and allow it to air dry prior to use then wipe the glucometer again after use and allow it to air dry prior to using on the next resident. She stated the bleach wipes should also be used on any surfaces the glucometer may be laid and she expects handwashing or hand sanitizer to be used before and after performing a glucose test. DHS CC stated that there should be a container of Clorox Bleach Germicidal Wipes in the bottom drawer of each medication cart. During an interview on 7/16/19 at 5:38 p.m. with the Area Vice President for the company she stated that RN AA had been removed from the floor and is being retrained on the proper way to do glucose testing. She stated that all nursing staff will be retrained and in-serviced immediately. During an interview on 7/16/19 at 5:50 p.m. the Area Vice President for the company she stated there was Clorox Germicidal Bleach Wipes on the green hall medication cart in a side drawer. She stated they are checking all the medication carts to ensure they all have bleach wipes. During an interview on 7/17/19 at 8:50 a.m. with the Administrator, he stated that the facility has put together an action plan. He stated that RN AA was pulled from the floor yesterday evening, re-educated on the proper procedure for glucose testing, written up, and suspended. Administrator stated that the medical [DIAGNOSES REDACTED]. He stated he was not certain if any of these residents were receiving an antibiotic, but he would look at that and advise of any antibiotic use and the reason for use. He stated that RN AA works primarily on the red and green halls. Administrator stated that all medication carts were checked to ensure that there were Clorox Bleach Germicidal Wipes in each cart and all nurses were educated when to replace with a new container and ensure there is always one on the cart. He stated that all nurses are being re-educated on the proper procedure for glucose testing and are being given a competency check off. Administrator stated that this will continue until all nursing staff is re-educated and they will not be allowed to work on the floor until receiving the education and successfully complete the competency check off. Administrator stated that the Education Nurse EE, DHS CC, and Assistant Director of Health Services (ADHS) will be ensuring the re-education and competency check off for all nursing staff. He stated there will be a daily audit done of three random nurses performing glucose testing. He stated that cleaning of barriers and ensuring hands were gloved prior to touching sharp containers was not included in the action plan but will be added and implemented immediately. During an interview on 7/17/19 at 12:05p.m. with the Administrator, he stated that all residents on glucose testing have been identified and their information including the times they receive a glucose test is documented. He stated that the [DIAGNOSES REDACTED]. Review of the Residents with Blood Sugar Checks log revealed a total of 36 resident who receive glucose testing, none have bloodborne pathogens, and two are currently on antibiotics, one for a Urinary Tract Infection, and one for an Upper Respiratory Infection. There are no Residents on transmission-based precautions currently. Review of the in-service sign-in sheet dated 8/21/18 with a program titled All Staff Meeting revealed RN AA attended. Topic of discussion included, but was not limited to, Infection Control Issues. Review of the in-service sign in sheet dated 9/17/18 through 9/18/19 with a program titled Skills Fair (YEAR) revealed RN AA attended. Topic of discussion included, but was not limited to, [MEDICAL TREATMENT] patient care for the nurse/Certified Nursing Assistant (CNA), glucometer care, tube feeding management station, life vest, skin care and appropriate identification and treatment of [REDACTED]. Review of transcripts for University for RN AA revealed on 5/31/18 infection control was completed, and a skills competency checklist was met on 9/18/18. Review of the Manager Evaluation dated 7/16/19 revealed RN AA admitted to knowing the correct policies and procedures related to infection control, however chose not to follow those policies and procedures. During two observations on 7/16/19, between 4:00 p.m. and 4:05 p.m., revealed RN AA did not wash, or sanitize her hands, before she performed a finger stick glucose check on R#18, and R#117. Interview at that time, RN AA revealed that today, she had all rooms on green, and red hall. An observation at 4:00 p.m., revealed RN AA opened the top drawer of the medication cart, took out one glucometer, two blood test strips, two lancets, two alcohol swabs, and several 2x2 gauze, and laid them out on the top of the medication cart, then took one of the test strips and placed it in the glucometer. She then laid the glucometer back on the medication cart and placed the additional supplies in the top drawer of the med cart. RN AA got gloves from a box on the med cart, picked up the supplies that remained on the medication cart, and went to room of R#18, and R#117. RN AA explained to R#18 what she was going to do, laid the supplies down on the over-the-bed table, donned gloves, cleaned the resident's finger with an alcohol prep, and waited a second for it to dry. RN AA pricked the finger of R#18 with the lancet, picked the glucometer, up and collected a drop of blood on the test strip. She then laid the glucometer on the table, and dried blood from the finger of R#18 with the 2x2 gauze. RN AA gathered the used supplies in her gloved hand, removed gloves, and placed them in the trash, and then placed the used lancet in the sharp's container on the medication cart. RN AA laid the glucometer on top of the medication cart, used hand sanitizer to clean her hands, and allowed to air dry. RN AA then repeated the same process for resident #117. An observation at 4:03 p.m., revealed RN AA performed a glucose check on R#117. RN AA used hand sanitizer and allowed her hands to dry, she removed supplies from the top drawer, placed them on top of the medication cart, placed the blood test strip in the glucometer, picked up gloves and supplies, and went into the room of R#117. RN AA explained what she was going to do, laid supplies down on the bed, donned gloves, and cleaned the finger of R#117 with an alcohol prep. She then performed a stick with the lancet, got a drop of blood on test the strip, dried blood from finger with the 2x2 gauze, gathered the used supplies in her gloved hand, removed gloves, and placed them in the trash. RN AA went back to the medication cart, put away the glucometer, and used hand sanitizer. RN AA did not clean the glucometer before, after, or between use, of R#18, or R#117. RN AA was not observed to clean the top of the medication cart, or the over-the-bed table, or to put a drape/covering down to provide a barrier to lay supplies on. RN AA was not observed to wash or sanitize her hands prior to gathering and laying out supplies, or to wash or sanitize her hands before performing test on R#18, or performing test on R#117 after she gathered supplies and touched the med cart. RN AA was not observed to clean the glucometer before or after use on either resident.",2020-09-01
890,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2018-07-24,656,E,1,0,H8KB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to revise the care plans to reflect suspicion of scabies, treatment of [REDACTED].#1 and R#2) that received treatment for [REDACTED]. (Refer F684) Findings include: 1. Record review for R#1 revealed a Physician's Interim Order's form dated 12/3/17 for [MEDICATION NAME] 5% Cream, apply as directed at night, shower off in AM, repeat in one week and a Physician's Interim Orders form dated 3/13/18 to Apply [MEDICATION NAME] 5% from head to soles of feet. Wash cream off after 8-14 hours, then repeat treatment in one week. Further record review for R#1 revealed a Quarterly Minimum Data Set ((MDS) dated [DATE] revealed in Section M- Skin Conditions M1040- Other Problems (open [MEDICAL CONDITION] other than ulcers, rashes, cuts etc.) the conditions were assessed as not being present. Application of ointment/medications other than to feet was not coded. Review of the Quarterly MDS dated [DATE]/18 revealed in Section M- Skin Conditions: M1040- Other Problems (open [MEDICAL CONDITION] other than ulcers, rashes, cuts etc.) the conditions were assessed as not being present. The resident received application of ointment/medication other than feet. Review of the Review of the Care Plan for R#1 with an Onset date of 8/2/17 identified a potential for alteration in skin integrity. The Goal and Target Date documented Will be free from skin breakdown x 90 days. The Approaches documented: Encourage and/or assist resident/patient to change positions per turning schedule, Incontinent care after each incontinent episode, Report any s/s of skin alteration to charge nurse or supervisor, Provide WC cushion and pressure redistribution mattress, Routine skin assessments, Moisturizers to feet for dry scaly feet, Podiatry care as needed. An update on 8/11/17 documented Rash- back and torso. The Goal and Target Date documented Rash will improve with tx x 30 days and the Approach documented Hibaclenze and shower x 10 days, Follow with Gold Bond powder to keep dry, monitor rash- notify MD if no improvement. The care plan was not updated in (MONTH) (YEAR) or (MONTH) (YEAR) to reflect a rash or that the resident received orders for [MEDICATION NAME] 5% Cream for the treatment of [REDACTED]. Interview on 7/18/18 at 3:25 p.m. with Case Mix Director/LPN (CMD/LPN) GG revealed R#1 was treated for [REDACTED]. She confirmed that the skin care plan was not updated to reflect the resident had a rash in (MONTH) (YEAR) or in (MONTH) (YEAR) and was treated for [REDACTED]. The CMD/LPN GG stated that when they treated all residents on the Yellow and Green Halls, she thought that she had updated everyone's care plan and she must have just missed his. 2. Record review for R#2 revealed a Physician's Interim Orders form dated 12/3/17 at 11:00 a.m. for [MEDICATION NAME] 5% Cream, apply as directed at night, shower off in the AM. Repeat in one week and a Physician's Interim Orders form dated 3/13/18 to Apply [MEDICATION NAME] 5% Cream from head to soles of feet. Wash cream off after 8-14 hours then repeat treatment in one week. Further record review for R#2 revealed a Quarterly MDS dated [DATE] which documented in Section M- Skin Conditions: M1040- Other Problems (open [MEDICAL CONDITION] other than ulcers, rashes, cuts etc.) none of the above were present. Application of ointment/medications other than to feet was not coded. Review of a Significant Change MDS dated [DATE] revealed in Section M- Skin Conditions: M1040- Other Problems (open [MEDICAL CONDITION] other than ulcers, rashes, cuts etc.) none of the above were present. Application of ointment/medications other than to feet was not coded. Review of the Care Plan for R#2 revealed Problem Onset date 4/6/17- Resident has a heat rash, GOAL: resident's rash will be resolved with treatment x 90 days. APPROACHES: Keep resident's area clean and dry, Resident needs topical ointment as ordered, Evaluate resident for source of rash, Monitor resident for signs of infection or spreading, Resident needs daily observation of skin with routine care, Resident needs a full skin evaluation weekly with bath/shower, Resident needs to avoid hot showers/baths to reduce itching. Updated 7/24/17- Rash Back. Spots drying upper thighs, Back, Left arm. Updated 8/21/17- Diagnosis: [REDACTED]. Ivermectin as ordered. Infection Control Protocol. Updated 8/31/17- Continue treatment as ordered for scabies. Rash improving. Resolved 9/25/17. Approach update on 4/29/17- [MEDICATION NAME] cream as ordered. Approach update on 5/5/17- [MEDICATION NAME] BID x 10 days as ordered. Treatment to left groin as ordered. Approach update on 7/20/[MEDICATION NAME] 25 MG TID x 15 days. Approach update 7/25/17- Change treatment to use [MEDICATION NAME] cream PRN. Approach update 8/5/17- Schedule [MEDICATION NAME] QD and PRN. Approach update 8/5/17- Family to set up follow up with Dr.[NAME] Dermatologist. The care plan was not updated in (MONTH) (YEAR) to reflect a rash or that the resident received orders for [MEDICATION NAME] 5% Cream for the treatment of [REDACTED].",2020-09-01
891,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2018-07-24,684,E,1,0,H8KB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, review of the Georgia DPH Scabies Handbook (YEAR) and staff interviews, the facility failed to follow the physician's orders [REDACTED]. Findings include: Review of the Georgia DPH (Department of Public Health) Scabies Handbook (YEAR) documented that scabies is a common communicable skin infestation cause by a mite. The severity of scabies infestations is directly related to the number of mites residing on the skin and the length of time between the initial infestation and subsequent [DIAGNOSES REDACTED]. If [DIAGNOSES REDACTED]. Topical steroid creams should not be used during treatment as this may cause the treatment to fail. The earliest and most common symptom of scabies is intense itching over most of the body, especially at night. Another obvious sign of scabies infestation is a rash of the skin that can appear as red bumps, burrows (short wavy thread-like lines in the skin) or pimple-like irritations. The [DIAGNOSES REDACTED]. Their skin is generally dry and scaly and there may be preexisting, chronic dermatological conditions for which oral or topical steroids have been prescribed. Even if a skin scraping is or biopsy is negative, it is possible a person is still infested. 1. R#1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of six, indicating severe cognitive impairment. Quarterly MDS dated [DATE]/18 documented a BIMS summary score of six. Other skin conditions were assessed as not being present. The resident received application of ointment/medication other than feet. Review of the Quarterly MDS dated [DATE] documented a BIMS of six. Other skin problems (open [MEDICAL CONDITION] other than ulcers, rashes, cuts etc.) was assessed as none of the above were present. Application of ointment/medications other than to feet was not coded. Further record review for R#1 revealed a Physician's Interim Order's form dated 12/3/17 for [MEDICATION NAME] 5% Cream, apply as directed at night, shower off in AM, repeat in one week and a Physician's Interim Orders form dated 3/13/18 to Apply [MEDICATION NAME] 5% from head to soles of feet. Wash cream off after 8-14 hours, then repeat treatment in one week. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed the order for [MEDICATION NAME] Cream 5% was transferred by hand. The first dose was initialed as administered on 12/10/17, seven days after it was ordered. The follow up dose was marked on the MAR to be administered on 12/19/17, nine days after the first dose was administered. There were no nurse initials on 12/19/17 to indicate that the follow up dose in one week was administered. Review of the Nurse's Notes and the Skilled Daily Nurses Notes in (MONTH) (YEAR) revealed no evidence or documentation that the [MEDICATION NAME] 5% Cream had been administered. There was no evidence or documentation of follow up assessments for signs and symptoms of the rash or the effectiveness of [MEDICATION NAME] 5% cream when first administered on 12/10/17. Review of the weekly Body Audit Forms revealed the following: * 12/3/17 Rash was documented in the Chest/Abdomen section, in the Shoulders/Back section and in the Legs/Inner Thighs section of the form. The word Rash was documented on the body diagram pointing to the chest, back, arms and legs. The form did not document that [MEDICATION NAME] 5% Cream had been administered for a rash and/or suspected scabies. * 12/10/17 documented Rash in the Legs/Inner Thighs section of the form. The word Rash was documented on the body diagram pointing to the chest, back, arms and legs. The form did not document that [MEDICATION NAME] 5% Cream had been administered for a rash and/or suspected scabies. * 12/17/17 documented Rash in the Chest/Abdomen and in the Shoulders/Back section of the form. There was no documentation on the body diagram. The form did not document that [MEDICATION NAME] 5% Cream had been administered for a rash and/or suspected scabies. * 12/30/17 documented in Chest/Abdomen section, in the Shoulders/Back section and in the Legs/Inner Thighs section of the form. Review of the body diagram documented the word Rash pointing to the abdomen, back and legs. The form did not document that [MEDICATION NAME] 5% Cream had been administered for a rash and/or suspected scabies. * 1/6/18 revealed no documentation of rash and checked normal in the Chest/Abdomen section, in the Shoulder/Back section and in the Legs/Inner Thighs section of the form. Review of the Pharmacy Copy- Physician's Interim Orders provided by the[NAME]Health Pharmacy Manager OO on 7/19/18 at 11:30 a.m. revealed a physician order [REDACTED]. Review of the pharmacy Delivery Manifest forms revealed the following: Status for [MEDICATION NAME] 5% cream was delivered and the form was signed by a facility nurse on 12/4/17 at 9:02 p.m. Status for [MEDICATION NAME] 5% cream was delivered and the form was signed by a facility nurse on 12/11/17 at 9:04 p.m. Status for [MEDICATION NAME] 5% Cream was delivered and the form was signed by a facility nurse on 12/19/17 at 8:17 p.m. Review of the (MONTH) (YEAR) MAR revealed the order for [MEDICATION NAME] 5% Cream was not transferred to the MAR and there was no evidence that it had been administered. Review of the Nurse's Notes for (MONTH) (YEAR) revealed no evidence or documentation that the [MEDICATION NAME] 5% Cream was administered and there was no documentation for follow up of signs and symptoms of a rash or the effectiveness of the treatment. There was no evidence of weekly Body Audit Forms during (MONTH) (YEAR). There were three blank, undated, Body Audit Forms in R#1's clinical record prior to the Body Audit Forms completed in (MONTH) (YEAR). Review of the weekly Body Audit Form dated 4/2/18 revealed no documentation of a rash. Interview on 7/17/18 at 1:54 p.m. with the Director of Health Services (DHS) confirmed that (MONTH) (YEAR) MAR for R#1 documented that the first dose of [MEDICATION NAME] 5% Cream was not administered until seven days after it was ordered and there was no evidence that the follow up dose in one week was administered either on the MAR or in the Nurse's Notes. The DHS confirmed that the order for [MEDICATION NAME] 5% Cream on 3/13/18 was not transcribed to the (MONTH) (YEAR) MAR. The DHS stated that when the Yellow and Green Halls were treated for scabies, they had to stagger the treatment in groups because there was no way they could treat all residents at the same time. She stated they do not have record of which groups were treated and without proper documentation, there is no way determine when the treatment was administered. Interview on 7/19/19 at 10:47 a.m. with the Dispensing Pharmacist (DP) MM revealed when they receive and order for the [MEDICATION NAME] 5% Cream and repeat in one week, they only dispense the first dose. They do not automatically send the second dose in one week, the facility must request it. She stated when the first dose is dispensed, it includes a refill sticker. The facility has a refill form and they would attach the refill sticker to the form and fax it to the pharmacy when the refill is needed. DP MM stated that the definition of one week is seven days. When surveyor asked about specific residents, she transferred me to the Assistant Pharmacy Manager. Interview on 7/19/18 at 10:47 p.m. with the Assistant Pharmacy Manager (APM) NN revealed the nursing facility requested and order for [MEDICATION NAME] 5% Cream and repeat treatment in one week for R#1 on 12/4/17 and it was dispensed on 12//4/17. She stated on 12/11/17 the facility requested the medication and it was dispensed on 12/11/19. She stated a repeat request for the medication was received by the facility on 12/19/17 and it was dispensed on 12/19/17. She stated on 3/13/18 the facility requested [MEDICATION NAME] 5% Cream and repeat treatment in one week and it was dispensed on 3/13/18. She stated the refill was requested by the facility on 3/21/18 and was dispensed on 3/21/18. The APM NN stated she would make copies of their records. Surveyor drove to the pharmacy to retrieve records on 7/19/18 at 11:30 a.m. Interview on 7/19/18 at 11:10 a.m. with Registered Nurse/Unit Manager (RN/UN) FF revealed when they need a refill on a medication, they use the pharmacy medication refill form. She stated they receive a refill sticker with the first dose of [MEDICATION NAME] 5% Cream and there is a refill sticker attached. She stated they put that sticker on the refill form and fax it to pharmacy. She stated that the definition of one week is seven days. Review of the Pharmacy Copy- Physician's Interim Orders revealed a fax was received by the nursing facility on 3/13/18 at 2:11 p.m. for an order for [REDACTED]. Review of the Pharmacy Packing Slip revealed [MEDICATION NAME] 5% Cream for R#1 was received on 3/13/18 and signed off by a facility nurse on 3/13/18. Review of the pharmacy Medication Reorders form revealed the pharmacy received the refill for the [MEDICATION NAME] 5% Cream for R#1 by fax from the nursing facility on 3/21/18 at 7:40 a.m., eight days after the original order on 3/13/18. Review of the pharmacy Packing Slip revealed [MEDICATION NAME] 5% Cream for R#1 was delivered to the facility on [DATE] and was signed and dated as received by a facility nurse on 3/21/18 (no time indicated). Observation on 7/19/18 at 2:12 p.m. revealed the R#1 actively participating in group activity. There were no apparent rashes noted on the resident at the time of observation. The resident was not observed scratching or itching. 2. R#2 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the [DIAGNOSES REDACTED]. Review of a Significant Change MDS dated [DATE] documented a BIMS summary score of nine, indicating moderate cognitive impairment. Other skin problems (open [MEDICAL CONDITION] other than ulcers, rashes, cuts etc.) was assessed as none of the above were present. Application of ointment/medications other than to feet was not coded. Review of the Quarterly MDS dated [DATE] documented a BIMS summary score of 14, indicating no cognitive impairment. Other skin problems (open [MEDICAL CONDITION] other than ulcer(s), rashes, cuts etc.) assessed that none of the above was present. Application of ointment/medication other than to feet was not coded. Review of the Care Plan for R#2 with Problem Onset date of 3/13/18- Resident has a recurrent rash- patient has scattered rash over entire body and reports sometimes itches. GOAL: Resident's rash will be resolved with treatment x 30 days. APPROACHES: Keep resident's area clean and dry, Monitor resident for signs of infection or spreading, Resident needs daily observation of skin with routine care, Resident needs to avoid hot showers/baths to reduce itching, [MEDICATION NAME] treatment as ordered, repeat in one week, Observe skin with bath/shower, WC cushion- pressure redistribution mattress, Routine skin assessments, Use draw sheet to assist with pulling up in bed. Further record review for R#2 revealed a Physician's Interim Orders form dated 12/3/17 at 11:00 a.m. for [MEDICATION NAME] 5% Cream, apply as directed at night, shower off in the AM. Repeat in one week. Review of the (MONTH) (YEAR) MAR for R#2 revealed the order for [MEDICATION NAME] 5% Cream was transcribed by hand on the MAR, however, there was no nurse initials documented to indicate that the treatment had been administered. Review of the Nurse's Notes for (MONTH) (YEAR) revealed no evidence or documentation that either the first dose of [MEDICATION NAME] 5% Cream or the follow up dose in one week was administered. There was no documentation of a rash or suspected scabies or follow up of signs and symptoms or effectiveness of treatment once administered. Review of the Body Audit Forms revealed a skin assessment was conducted on 12/7/17, 12/14/17, 12/21/17 and 12/28/17. None of the skin assessments documented R#2 with a rash or suspected scabies. Review of the Pharmacy Copy- Physician's Interim Orders provided by the[NAME]Health Pharmacy Manager OO on 7/19/17 at 11:30 a.m. revealed order for R#1 was received by fax from the nursing facility on 12/3/18 at 10:54 a.m. for [MEDICATION NAME] 5% Cream, apply as directed at night, shower off AM. Repeat in one week. Review of the Profile Scan by NDS[NAME]Health Pharmacy Toccoa (a list of all residents and dates when [MEDICATION NAME] 5% Cream was dispensed to the facility by the pharmacy) revealed the first dose of [MEDICATION NAME] 5% Cream was dispensed on 12/4/17. Further review of the Profile Scan by NDS[NAME]Health Pharmacy Toccoa revealed the follow up dose in one week for Premethrine 5% Cream was not dispensed in (MONTH) (YEAR) or (MONTH) (YEAR). Review of the pharmacy Delivery Manifest revealed the Status for [MEDICATION NAME] 5% cream for R#2 was delivered and the form was signed by a facility nurse on 12/4/17 at 9:02 p.m. Interview on 7/19/18 at 11:30 a.m. with the Pharmacy Manger OO revealed the pharmacy did not have record of a refill request for the second administration of [MEDICATION NAME] 5% Cream after the first dose was dispensed on 12/4/18. Review of the Physician's Interim Orders form dated 3/13/18 to Apply [MEDICATION NAME] 5% Cream from head to soles of feet. Wash cream off after 8-14 hours then repeat treatment in one week. Review of the (MONTH) (YEAR) MAR revealed the order dated 3/13/18 for [MEDICATION NAME] 5% Cream, repeat treatment in one week was never transcribed to the (MONTH) (YEAR) MAR. There is no evidence or documentation that the first or follow up dose in one week was administered. Review of the Documentation of Wound Observation and Assessment form dated 3/11/18 documented Body Audit revealed scattered red rash to chest, ABD, flanks and back. Review of the Body Audit Form dated 3/11/18 documented in the Chest/Abdomen section- scattered red rash. Documented in the Shoulders/Back section- scattered red rash. There were no other Body Audit forms in the clinical record for R#2 in the (MONTH) (YEAR). Review of the Nurse's Notes and Skilled Daily Nurse's Notes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed one note written by the Infection Control Nurse on 3/15/18 at 11:30 a.m. which documented Skin; Overall condition is dry, some flakey areas noted at elbow, feet and lower extremities. Has scattered rash over his entire body that sometimes itches. He states it's been like this for several weeks. Unable to roll over to assess his back. There was no mention of suspicion of scabies or scabies treatment in this documented note. There were no further nurse's notes during this time frame with documentation of a rash and/or scabies or that R#2 was treated for scabies in (MONTH) (YEAR) or follow up assessments once Premethrine 5 % Cream was administered. A nurse's note on 7/11/18 documented rash still present, remains on [MEDICATION NAME]/[MEDICATION NAME]. On 7/12/18 [MEDICATION NAME] and [MEDICATION NAME] continue for treatment of rash. On 7/7/18 rash till present on torso and extremities, lucerin cream applied, [MEDICATION NAME] and [MEDICATION NAME] continues. Review of the Profile Scan by NDS[NAME]Health Pharmacy Toccoa revealed the first dose of [MEDICATION NAME] 5% Cream for R#2 was dispensed on 3/13/18 and the second dose was dispensed on 3/24/18, eleven days after the first dose was dispensed. Review of the pharmacy Packing Slip dated 3/13/18 revealed [MEDICATION NAME] 5% Cream was delivered to the facility and the form was signed by a facility nurse (no time indicated). Review of the pharmacy Delivery Manifest revealed the Status of [MEDICATION NAME] 5% Cream for R#2 as delivered. The form was signed and dated by a facility nurse as received on 3/24/18 at 4:51 p.m. Review of the Physician's Progress Notes dated 7/6/18 documented Diffuse [MEDICAL CONDITION] > [MEDICAL CONDITION], consider meds vs. scabies. Continue treatment of [MEDICATION NAME] but family does not want [MEDICATION NAME], Ivermectin or Benedryl. Review of the Physician's Progress Notes dated 7/15/18 documented Diffuse [MEDICAL CONDITION]/Puritis/[MEDICAL CONDITION]. On steroids. Interview on 7/16/18 at 11:15 a.m. with the Infection Control Nurse (ICN) revealed R#2 has had a rash off and on for over a year. She stated R#2 has been treated a total of eight times with [MEDICATION NAME] ([MEDICATION NAME] 5% Cream). She stated that the resident has also had a [MEDICAL CONDITION] type rashes and is being treated with other steroid type ointments. The IFN nurse stated that the family reported that the resident has had rashes at home and when he went to the Dermatologist, the skin scraping for scabies was negative. Interview on 7/17/18 at 12:10 p.m. with Dr. (Name) revealed R#2 has had [DIAGNOSES REDACTED]. He stated that the resident also has a long history of other [MEDICAL CONDITION] type rashes. The Physician stated that the resident has declined over the past several months and was placed in hospice. He stated he has consider additional scabies treatments as R#2 continues with a rash even though he is being treated with a steroid cream. He stated he discussed additional scabies treatment with the family of R#2 but because of the resident's condition, they do not want any further treatment. The Physician stated he just recently assessed the resident and he does not feel like the rash the resident currently has is scabies. Telephone interview with the Medical Director in the Administrators office on 7/19/18 at 2:41 p.m. revealed she had received a call from the wound care nurse about the rash observed on R#2. She stated that wound care nurse reported to her that the resident's rash had worsened. Dr.[NAME]tated that she was going to assess the resident's rash tomorrow in the meantime, she was going to order a steroid cream. She stated that she did not think that the rash is scabies at this time. Interview on 7/17/18 at 1:54 p.m. with the Director of Health Services (DHS) confirmed that the order for [MEDICATION NAME] 5% Cream was transcribed by hand on the (MONTH) (YEAR) MAR for R#2. The DHS confirmed that the MAR revealed no nurse initials to indicate that either the first does or the follow up dose in one week was administered. The DHS further confirmed that there was no documentation in the Nurse's Notes that the medication was administered. The DHS stated that the [MEDICATION NAME] 5% Cream should have been documented as administered on the (MONTH) MAR as well as in the Nurse's Notes and she did not know why it was not. The DHS further confirmed the order for [MEDICATION NAME] 5% Cream and repreat in one week on 3/13/18 was never transcribed to the (MONTH) (YEAR) MAR and revealed no evidence in the MAR or the Nurse's Notes that the medication was administered. Further interview on 7/17/18 at 3:25 p.m. with Dr. (Name) revealed he was not aware that when he ordered the Premethrine 5% Cream in (MONTH) (YEAR) and (MONTH) (YEAR) for R#2, that it was not documented in the resident's clinical record that it was administered. He was not aware that the follow up dose was never refilled in (MONTH) (YEAR). The Physician stated that he writes the orders and he expects that the facility takes care of the rest and administers the medication as ordered. The Physician stated there is no way to know for sure if the medication was administered and that the resident was appropriately treated for scabies. Interview on 7/19/18 at 10:47 p.m. with the Assistant Pharmacy Manager (APM) NN revealed the nursing facility requested and order for [MEDICATION NAME] 5% Cream and repeat treatment in one week for R#2. She stated the medication was dispensed on 12/4/18. She stated there was no request made by the facility for the second dose. APM NN stated that on 3/13/18, the facility requested [MEDICATION NAME] 5% Cream, repeat treatment in one week and it was dispensed on 3/13/18. She stated they received a repeat request or refill for the second dose on 3/24/18. Observation on 7/19/18 at 1:50 p.m. revealed the R#2 in his bed asleep. The resident had his sheet down around knee level, was wearing a t-shirt and adult brief. There was obvious older healing rash with scabbing all over the resident's stomach area and some on the resident's arms. There were red bumps, some with pustules sporadically spread on the resident's lower abdomen, upper thighs on the sides near the adult brief and down the side and back of the thighs. Observation and interview with the Skin Integrity Nurse/ Licensed Practical Nurse (SIC/LPN) HH on 7/19/18 at 1:55 p.m. confirmed the red bump on the lower abdomen area, upper side and back thighs, some with pustules. The SIC/LPN HH stated that yesterday the resident's rash was not that bad and it had flared up since yesterday. She stated she had not yet applied the resident treatment for his rash. The wound care nurse stated some of the bumps did have pustules but she did not think it appeared to be scabies. The wound care nurse stated she was going to call the physician to let them know the resident's rash had worsened since yesterday. Telephone interview with the Medical Director in the Administrators office on 7/19/18 at 2:41 p.m. revealed she had received a call from the wound care nurse about the rash observed on R#2. She stated that wound care nurse reported to her that the resident's rash had worsened. Dr.[NAME]tated that she was going to assess the resident's rash tomorrow in the meantime, she was going to order a steroid cream. She stated that she did not think that the rash is scabies at this time.",2020-09-01
892,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2018-07-24,756,E,1,0,H8KB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the policy titled Consultant Pharmacist Services Provider Requirements and staff interview, the Consultant Pharmacist failed to report findings from the medication regimen reviews to address the lack of documentation in the Medication Administration Record (MAR) related to the administration of [MEDICATION NAME] 5% Cream (a scabicide) for two residents (R) (R#1 and R#2). The sample was four residents. (Refer F842) Findings include: Review of the facility policy titled Consultant Pharmacist Services Provider Requirements dated 4/1/1998, revised 1/23/15, reviewed 1/3/18 documented in PR[NAME]EDURE- #3: The Consultant Pharmacist, or his designee, provides consultant pharmacist services, including but not limited to: Submitting a written report of findings from the medication regimen and nursing documentation records to the attending physician and Director of Health Services, respectively. 1. Record review for R#1 revealed a physician order dated 12/3/17 for [MEDICATION NAME] 5% Cream, apply as directed at night, shower off in AM, repeat in one week. Review of the (MONTH) (YEAR) MAR revealed order had been transcribed by hand on the MAR. The first dose was initialed as administered on 12/10/17. There was no evidence that the following dose in one week was administered as ordered. Further record review for R#1 revealed a physician's order dated 3/13/18 to Apply [MEDICATION NAME] 5% from head to soles of feet. Wash cream off after 8-14 hours, then repeat treatment in one week. Review of the (MONTH) (YEAR) MAR revealed the order was not transcribed to the MAR and there was no evidence that either the first dose or the following dose in one week was administered as ordered. Review of the Record of Medication Regimen and Chart Review form indicated the Consultant Pharmacist (CP LL) conducted a drug regimen review for R#1 on 3/28/18, 4/27/18, 5/24/18, and 6/28/18. 2. Record review for R#2 revealed a physician order dated 12/3/17 for [MEDICATION NAME] 5% Cream, apply as directed at night, shower off in the AM. Repeat in one week. Review of the (MONTH) (YEAR) MAR revealed the order for [MEDICATION NAME] 5% Cream was transcribed by hand on the MAR. There was no evidence that either the first dose or the following dose in one week was administered as ordered. Further record review for R#2 revealed a physician order dated 3/13/18 to Apply [MEDICATION NAME] 5% Cream from head to soles of feet. Wash cream off after 8-14 hours then repeat treatment in one week. Review of the (MONTH) (YEAR) MAR revealed the order was not transcribed to the MAR and there was no evidence that either the first dose or the following dose in one week was administered as ordered. Review of the Record of Medication Regimen and Chart Review form indicated the Consultant Pharmacist (CP LL) conducted a drug regimen review for R#2 on 3/10/18, 4/27/18, 5/25/18 and 6/28/18. Interview on 7/19/18 at 10:38 a.m. with the Consulting Pharmacist (CP LL) revealed when he conducts a monthly drug regimen review it includes reviewing every medication, reviewing MAR documentation, review of vital signs, review of weekly weights, review of labs and timeliness of lab collection, medication pass and medication storage review. He stated that during his review, it should have been caught that the [MEDICATION NAME] 5% Cream was not documented on the MAR for R#1 in (MONTH) (YEAR) and (MONTH) (YEAR) and or on the MAR for R#2 in (MONTH) (YEAR) and (MONTH) (YEAR). CP LL stated that he does not remember having a conversation with the Administrator about a lack of documentation on the MAR for [MEDICATION NAME] 5% Cream for R#1 or R#2. He stated it would not be recommendation he would just mention it to the Administer upon exit.",2020-09-01
893,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2018-07-24,842,E,1,0,H8KB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Georgia DPH Scabies Handbook (YEAR) and staff interviews, the facility failed to ensure complete and accurate documentation in the clinical record related to the administration of [MEDICATION NAME] 5% Cream (a scabcide) and follow up assessments once administered for two residents (R) (R#1 and R#2), and failed to document administration of [MEDICATION NAME] 0.025% Cream for one resident (R#4). The sample was 4 residents. Findings include: Review of the Georgia DPH Scabies Handbook (YEAR) documented: As soon as a possible case of scabies is identified, the nursing staff or infection control practitioner should develop a contact identification list. This list should identify every resident, health care worker, visitor and volunteer who may have had direct physical contact with the case within the previous month. Information to be collected should include: nursing unit, name, date of onset symptoms, result of skin scrapings, date of initial treatment, date of follow up treatment, results of treatment (e.g. condition resolved or not resolved) and the date of repeat skin scrapings if performed. 1. Record review for R#1 revealed a Physician's Interim Order's form dated 12/3/17: 11:00 a.m. [MEDICATION NAME] 5% Cream, apply as directed at night, shower off in AM, repeat in one week. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed the order had been transcribed by hand on the MAR. The first dose was initialed as administered on 12/10/17. There was no evidence that the following dose in one week was administered as ordered. The [MEDICATION NAME] 5% Cream was not transcribed on the Treatment Administration Record (TAR) for (MONTH) (YEAR). Review of the Nurse's Notes and the Skilled Daily Nurses Notes revealed no evidence or documentation that the [MEDICATION NAME] 5% Cream had been administered. There was no evidence or documentation of follow up for signs and symptoms of the rash or the effectiveness of [MEDICATION NAME] 5% cream after the first dose was administered on 12/10/17. Further record review for R#1 revealed a Physician's Interim Orders form dated 3/13/18 to Apply [MEDICATION NAME] 5% from head to soles of feet. Wash cream off after 8-14 hours, then repeat treatment in one week. Review of the (MONTH) (YEAR) MAR revealed the order was not transcribed to the MAR and there was no evidence that either the first dose or the following dose in one week was administered as ordered. The [MEDICATION NAME] 5% Cream was not transcribed on the TAR for (MONTH) (YEAR). Review of the Nurse's Notes revealed no documented notes between 1/29/18 through 4/21/18. There was no evidence or documentation that the [MEDICATION NAME] 5% Cream had been administered and no documentation for follow up of signs and symptoms of a rash or the effectiveness of the treatment. (Refer F684) 2. Record review for R#2 revealed a Physician's Interim Orders form dated 12/3/17 at 11:00 a.m. for [MEDICATION NAME] 5% Cream, apply as directed at night, shower off in the AM. Repeat in one week. Review of the (MONTH) (YEAR) MAR revealed the order for [MEDICATION NAME] 5% Cream was transcribed by hand on the MAR. There was no evidence that either the first dose or the following dose in one week was administered as ordered. The [MEDICATION NAME] 5% Cream was not transcribed on the TAR for (MONTH) (YEAR). Review of the Nurse's Notes revealed no evidence or documentation that the [MEDICATION NAME] 5% Cream had been administered. There was no evidence or documentation of follow up for signs and symptoms of the rash or the effectiveness of [MEDICATION NAME] 5% Cream treatment. Review of the Physician's Interim Orders form dated 3/13/18 to Apply [MEDICATION NAME] 5% Cream from head to soles of feet. Wash cream off after 8-14 hours then repeat treatment in one week. Review of the (MONTH) (YEAR) MAR revealed the order for [MEDICATION NAME] 5% Cream was not transcribed to the MAR and there was no evidence that either the first dose or the following dose in one week was administered as ordered. The [MEDICATION NAME] 5% Cream was not transcribed on the TAR for (MONTH) (YEAR). Review of the Nurse's Notes and Skilled Daily Nurse's Notes from (MONTH) (YEAR) through (MONTH) (YEAR) revealed one note written by the Infection Control Nurse on 3/15/18 at 11:30 a.m. which documented Skin; Overall condition is dry, some flakey areas noted at elbow, feet and lower extremities. Has scattered rash over his entire body that sometimes itches. He states it's been like this for several weeks. Unable to roll over to assess his back. There was no mention of scabies or scabies treatment in the note. There were no further nurse's notes during this time frame with documentation of a rash and/or scabies, treatment of [REDACTED]. Interview with the Registered Nurse/Unit Manager (RN/UM) FF on 7/18/18 at 1:10 p.m. revealed that all orders for [MEDICATION NAME] 5% Cream should have been documented in both the MAR and the Nurse's Notes. She stated they received no instructions by the DHS or the ICN to document follow up after the treatment for [REDACTED]. Interview on 7/18/18 at 1:37 p.m. with the Skin Integrity Coordinator/Licensed Practical Nurse (SIC/LPN) HH revealed the staff would report a resident with a rash and she or the other wound care nurses would assess the rash. She would call the Physician and describe the rash and they would go ahead and order [MEDICATION NAME]. She stated that the wound care nurses were never instructed to follow up with the rash once the treatment had been administered. Interview on 7/18/18 at 1:55 p.m. with LPN/Treatment Nurse (LPN II) revealed at the time of the (MONTH) (YEAR) scabies outbreak, she was a Unit Manger. She stated she did not conduct any follow up assessments once scabies treatment had been administered to residents, or to ensure the nurses were documenting. She stated there should have been ongoing documentation until both treatments were completed. Interview on 7/17/18 at 1:54 p.m. with the Director of Health Services (DHS) confirmed that the treatment orders for [MEDICATION NAME] 5% Cream for both R#1 and R#2 in (MONTH) (YEAR) and (MONTH) (YEAR) were not completely and/or adequately documented as administered and confirmed there was no evidence in the Nurse's Notes for follow up assessments to the treatments. She stated that the medication administration should have been documented in both the MAR and the Nurse's Notes and she did not know why it was not. Interview on 7/19/18 at 11:10 a.m. with Registered Nurse/Unit Manager, RN/UM FF revealed that they had gone through the charts of the residents that received treatment for [REDACTED]. (Refer F684) 3. Record review for R#4 revealed an admission order for [MEDICATION NAME] 0.025% Cream, Apply topically daily for treatment of [REDACTED]. Review of the (MONTH) (YEAR) TAR for R#4 revealed the order for [MEDICATION NAME] 0.025% Cream, Apply topically daily was transcribed to the TAR. There was no evidence of administration all six days the resident resided on the facility. Review of the pharmacy copies of admission medication orders for R#4 revealed the order for [MEDICATION NAME] 0.025% Cream, Apply topically daily was received by fax from the nursing home facility on 4/26/18 at 3:13 p.m. Review of the pharmacy Delivery Manifest dated 4/26/18 revealed the order for [MEDICATION NAME] Cream 0.025% was delivered and signed by a facility nurse on 4/26/18 at 8:28 p.m.",2020-09-01
894,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2018-07-24,865,F,1,0,H8KB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the policy titled Quality Assurance and Performance Improvement Policy (SNF) and staff interviews, the facility failed to maintain an effective Quality Assurance (QA) program which systematically identified, reviewed, developed, and implemented plans to correct quality deficiencies. Specifically, the facility identified a concern related to suspicion of scabies outbreak and failed to make a good faith attempt to treat, contain and prevent future contamination or re-contamination. 27 symptomatic and non-symptomatic residents on the Yellow Hall, Green Hall and MSU were treated with a scabicide in (MONTH) (YEAR). Eleven more residents were treated for [REDACTED]. This failure had the potential to affect all 156 residents in the facility. (Refer F656, F684, F756, F842 and F880) Findings include: Review of the facility policy titled Quality Assurance and Performance Improvement Policy (SNF) dated 7/1/16, reviewed 11/30/17, revised 12/1/17 documented: Review of the facility policy titled Quality Assurance and Performance Improvement Policy (SNF) dated 7/1/16, reviewed 11/30/17, revised 12/1/17 documented: The purpose of the Quality Assurance and Performance Improvement (QAPI) Program at Pruitt Health is to continually take a proactive approach to assure and improve the way we provide care and engage with our patients, partners, and other stakeholders so that we may fully realize our vision, mission and commitment to caring pledge. PR[NAME]ESS: All Pruitt Health partners and contracted staff are responsible for the quality of care and services within their respective departments and are expected to participate in the Pruitt Health QAPI Program. Each Center must develop, implement, and maintain an effective, comprehensive, data-driven QAPI program that focuses on indicators of the outcomes of care, quality of life, and resident choice. It is the expectation of the Pruitt Health Skilled Nursing Facility and Rehabilitation Center (SNRC) QAPI Program that each location will follow the established QAPI process in order to guide and direct the operations of that location. The executive leadership of Pruitt Health sets the expectation and provides resources for implementation. Each SNRC establishes a QAPI committee (steering committee), which has the overall responsibility to develop and modify their respective QAPI plan, review information, and set priorities for performance improvement projects (PIPs). Center Level Quality Assurance and Assessment (QAA) Committee: Each Pruitt Health SNRC will have a QAA Committee that charters teams to work on particular problems and/or implementation of new programs, initiatives and/or projects. Design and Scope: The Pruitt Health SNRC QAA Committee should be an ongoing, comprehensive program that addresses the full range of care and services provided by the center. When improvement opportunities are identified through quality assessment activities, the center takes action to improve performance, including education, modification of systems and processes, or formal performance improvement projects. PERFORMANCE IMPROVEMENT PROJECTS (PIPs): The facility must conduct distinct performance improvement projects. The number and frequency of improvement projects conducted by the center must reflect the scope and complexity of the facility's services and available resources. Performance Improvement projects must include at least annually a project that focuses on high risks, high volume or problem prone areas for improvement through the data collection and analysis. The center must set priorities for its performance improvement projects based on the results of quality monitoring that consider the incidence, prevalence and severity of problems in those areas; and affect health outcomes, resident safety, resident autonomy, resident choice, and quality of care. The center's QAA Committee will charter a team of subcommittee members for each Performance Improvement Project (PIP). The subcommittee should include members of appropriate departments, disciplines and programs in planning, implementation and evaluation of selected performance improvement activities and projects. Documentation of the Pruitt Health QAPI Program includes: All performance improvement projects being conducted, The reasons for conducting these projects, Measurable progress achieved during performance improvement projects, Evidence that demonstrates the operation of the centers QAPI Program. The results of its performance improvement activities, Pruitt Health takes action aimed at performance improvement and measures and monitors improved performance to ensure that improvements are sustained. Progress and improvement measured through selected performance improvement activities and projects are evaluated as long as deemed necessary by the Pruitt Health QAA Committee. Review of the Ivermectin Tabs and [MEDICATION NAME] Cream tracking log provided by the Infection Control Nurse (ICN) on 7/16/18 at 11:30 a.m. revealed the facility had been treating residents for suspected scabies since (MONTH) (YEAR). Specifically, 19 residents received Ivermectin in (MONTH) (YEAR), three residents in (MONTH) (YEAR), three residents in (MONTH) (YEAR), one resident (R#2) in (MONTH) (YEAR), one resident in (MONTH) (YEAR), one resident in (MONTH) (YEAR) and one resident in (MONTH) (YEAR). Seven residents received [MEDICATION NAME] Cream in (MONTH) (YEAR), three residents in (MONTH) (YEAR), four residents in (MONTH) (YEAR), four residents in (MONTH) (YEAR), four residents in (MONTH) (YEAR), three residents (including R#2) in (MONTH) (YEAR), one resident in (MONTH) (YEAR), five residents in (MONTH) (YEAR), eight residents (including R#1 and R#2) in (MONTH) (YEAR), three residents in (MONTH) (YEAR), eight residents in (MONTH) (YEAR), 27 residents in (MONTH) (YEAR), one resident in (MONTH) (YEAR), nine residents in (MONTH) (YEAR) and two residents in (MONTH) (YEAR). Review of the facility infection mapping for (MONTH) (YEAR) revealed the entire Yellow Hall, Green Hall and one room on MSU was treated for [REDACTED]. Suspicion of scabies was not mapped in January, February, (MONTH) or (MONTH) of (YEAR), although residents received treatment during those months. The ICN did not have record of residents that had a suspicious rash or residents that were treated [MEDICATION NAME]. A sample of four residents with a rash or suspicious rash were selected for review. Two of the four residents (R) (R#1 and R#2) had physician orders in (MONTH) (YEAR) and (MONTH) (YEAR) for [MEDICATION NAME] 5% Cream (a scabacide) and repeat treatment in one week. Record review for R#1 and R#2 revealed the physician's orders were not followed as ordered in (MONTH) (YEAR) and (MONTH) (YEAR). The Medication Administration Record (MAR) for R#1 and R#2 did not indicate scabies treatment had been administered in (MONTH) (YEAR) and (MONTH) (YEAR) as ordered. The Nurse's Notes did not document onset of rash, treatment for [REDACTED]. There was no record of isolation implemented during treatment of [REDACTED]. Interview on 7/17/18 at 12:20 p.m. with the Director of Health Services (DHS), Assistant Director of Health Services (ADHS) and the Infection Control Nurse (ICN) revealed they had to stagger the [MEDICATION NAME] treatments because there was no way they could treat 25 residents and disinfect the rooms all at once. They stated the unit managers had a list of 4-6 residents to be treated at a time based on rooms and adjoining rooms. The DHS stated the rooms being treated at the staggered times were in isolation until the first treatment had been completed but stated there is no documentation for isolation or type of isolation used. The DHS stated the nightshift administered the [MEDICATION NAME] and they had a flowsheet for which residents needed to be washed off the following day on dayshift. The DHS stated they did not keep record of the flowsheets or when the 'wash off was completed. The DHS, ADSH And the ICN stated they discussed in the morning meetings which residents were treated but did not keep record of the morning meetings. Further interview with the DHS and ICN on 7/17/18 at 3:39 p.m., revealed they had check list for the room cleaning and treatment. Review of the Checklist for Care of Residents with Scabies form provided by the DHS revealed the following: At the bottom of the form was a place for the Infection Control Nurse, Charge Nurse and Housekeeper to sign and date when completed. 14 of the 25 forms were incomplete, not all check off task were initialed as task completed. 11 forms were completely blank. None of the 25 forms were signed and dated by the Infection Control Nurse, Charge Nurse or Housekeeper. The DHS confirmed that all 25 forms were not signed off and dated on the bottom as indicated by the Infection Control Nurse, The Charge Nurse and the Housekeeper. The ICN stated the room cleaning check list forms were given to her and she put them in a folder. The DHS stated that she was not sure if the scabies outbreak was placed in QAPI, she would have to ask the Administrator. The DHS stated that there was no formal action plan in which members of the QA committee were delegated a task for ensuring the [MEDICATION NAME] cream was ordered, received by pharmacy, administered by staff and documented in the MAR, documentation following the treatment for [REDACTED]. Nobody on the QA Committee was assigned to ensure that documentation of the Checklist for Care of Residents with Scabies was completed, dated and signed. The DHS stated they discussed in 'morning meetings what needed to be done but no one was given any task to follow up and ensure that the measures taken had been conducted and appropriately documented. During the interview, the ICN confirmed that she did have a copy of the Georgia DPH Scabies Handbook (YEAR). Interview on 7/18/18 at 1:10 p.m. with the Registered Nurse/Unit Manager (RN/UM) FF revealed she is a member of the QA Committee. She stated that the scabies outbreak was not, to her knowledge, placed in formal Q[NAME] She stated she was not delegated with any specific task. She stated she attended 'morning meetings and would report to the ICN which group of residents were treated for [REDACTED]. The RN/UM FF stated she did not review the resident's MAR to confirm the administration of the [MEDICATION NAME]. She stated the Charge Nurses would write it down on the 24 hour report and that is how she knew it was administered. She stated the 24 hour report form is a form used by the nurses to communicate anything they feel needs to be aware of or changes in a residents condition. The Charge Nurse would write [MEDICATION NAME] applied on the form. She stated they do not have record of these forms and stated they were just boxed up and picked up for record storage. The RN/UM FF stated that relying on the 24 hour report forms and not the resident's MAR was not the best practice for ensuring that the [MEDICATION NAME] treatment had been administered. She stated that it should have been documented in both the MAR and the Nurse's Notes. She stated they received no instructions by the DHS or the ICN to document follow up after the treatment for [REDACTED]. Interview on 7/18/18 at 1:37 p.m. with the Skin Integrity Coordinator/Licensed Practical Nurse (SIC/LPN) HH) revealed she is member of the QA Committee. She stated that she is not aware that the scabies outbreak was placed in formal QA with a plan of action. She stated she does not remember any type of meeting with department heads about the scabies. She stated it was discussed in morning meetings. The SIC stated that staff would report a resident with a rash and she or the other wound care nurses would assess the rash. She would call the Physician and describe the rash and they would go ahead and order [MEDICATION NAME]. She stated that the wound care nurses were never instructed to follow up with the rash once the treatment had been administered. Interview on 7/18/18 at 1:55 p.m. with LPN/Wound Nurse II revealed at the time of the (MONTH) (YEAR) scabies treatment she was a Unit Manger. She stated she was a member of the QA Committee and never received any specific instructions or delegated task during the (MONTH) (YEAR) scabies treatment. She stated they did discuss in 'morning meeting an initial plan to quarantine the Yellow Hall and have the rooms deep cleaned. She stated they added the Green Hall because of a cluster of rashes in one of the rooms on that hall. She stated she used the 24 hour report form to communicate that [MEDICATION NAME] treatment was administered to a resident. She stated she did not conduct any follow up once the treatment had been administered or to ensure the nurses were documenting. She stated there should have been ongoing documentation until both treatments were completed. Interview on 7/18/18 at 2:20 p.m. with LPN/UM EE revealed she is on the QAPI Committee. She stated she did not receive any specific task or duties during the (MONTH) (YEAR) scabies treatment. She stated she volunteered to help obtain orders for the [MEDICATION NAME]. She stated she was never part of a team discussion for who would be responsible for what and further stated she did not work on the Yellow and Green Hall and it had been a long time since anyone had a rash on her hall. Interview on 7/18/18 at 2:30 p.m. with the Medical Director revealed the facility kept having outbreaks of scabies and she finally told the facility they had to treat everyone on the Yellow Hall. The Medical Director stated without a doubt, we had patients with scabies. The Medical Director stated that to her knowledge, scabies had not been placed formally in QAPI but they had discussions about scabies in the QA meetings. She stated that if after the treatment in (MONTH) (YEAR) of Yellow Hall did not improve, she told them that everyone in the building, including staff was going to have to be treated but the rashes had quieted down and they have not had to treat anyone in a while. The Medical director further stated that she made it very clear that any staff with symptoms of a rash could come to her and she would prescribe treatment for [REDACTED]. Interview on 7/18/18 at 2:52 p.m. with the Director of Environmental Services (DES) revealed he is a member of the QA Committee and was not aware of any official QA Meeting or PIP during the scabies treatment in (MONTH) (YEAR). He stated he was not assigned or delegated any specific task and he did not follow up to ensure the room cleaning checklist was completed or signed off and dated by the housekeeper. He stated they just had discussion in the morning meetings. Interview on 7/18/18 at 3:25 p.m. with Case Mix Director/LPN (CMD/LPN) GG revealed she is a member of the QA Committee and stated as far as she knew, the scabies outbreak in (MONTH) (YEAR) was never formally placed in Q[NAME] She stated she was never assigned a specific task or duty during the scabies outbreak. Interview on 7/18/18 at 5:40 p.m. with the Administrator revealed the facility has had scabies off and on for the past year. She stated when Medical Director decided to treat all the residents on the Yellow and Green Halls for scabies, it was not placed and QAPI and they did not formally discuss a plan of action, delegate specific responsibilities or who would follow up to ensure everything was completed and properly documented. The Administrator stated I don't know why. She stated when the Medical Director said to treat all the residents on those halls we just jumped in there and starting doing it. The Administrator stated that they gave it a good effort but can see where they could have improved. She stated there was so much going on and they had discussions every day in the morning meetings. Interview on 7/19/18 at 9:55 a.m. with the Dietary Manager (DM) and the Assistant Dietary Manager (ADM) revealed they are members of the QA Committee. They stated they did not remember the scabies outbreak being placed in formal QA and they were not assigned any specific duties. She stated she attended morning meetings where they had discussions about who was being treated that day. Interview on 7/19/18 at 2:26 p.m. with the Administrator revealed the QA Committee consist of herself, DHS, ADHS, Treatment Nurses and all department heads. She stated they identify concerns through morning meetings, staff, resident and family complaints, grievances and resident council and quality measures. She stated they look for trends and if a trend is identified, the concern is placed in formal QA and PIP. She stated that once a concern is placed in QA the Committee will determine the root cause, ask the 5 whys and tasks are assigned to the appropriate department heads depending what the concern is and they report back to QAPI. She stated they monitor the concern, perform audits using audit tools, depending on what the concern is. She stated that typically the goal is to reach resolution in 60-90 days. The Administrator stated that if a concern has not been resolved, they start over form the beginning and come up with a new action plan. The Administrator confirmed that the scabies and rashes was a trend and should have been formally placed in QAPI. The Administrator further stated that the Yellow Hall and Green Hall was never closed down. The Administrator further revealed that the facility does not currently have a Scabies Protocol to follow.",2020-09-01
895,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2018-07-24,880,F,1,0,H8KB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, review of the policy titled Infection Prevention and Control Program, review of the Georgia DPH Scabies Handbook (YEAR) and staff interviews, the facility failed to: 1. place signage in a conspicuous place outside the resident's room to clearly identify the type of precautions per CDC category of transmission based precautions (contact, droplet or airborne), communicate the appropriate PPE to be used and/or instructions to see the nurse before entering, for three of three residents in transmission based precautions. 2. track and trend infections and communicable disease, perform analysis of infection control surveillance data and document follow-up measures in response to the data for six of six months of (YEAR) infection control data reviewed (January (YEAR) through (MONTH) (YEAR)). 3. follow the Georgia DPH scabies recommendations, implement appropriate precautions and prevent further transmission of scabies or document follow-up activity in response to scabies treatemnt. 4. comply with local public health authority requirements for identification, reporting and containing communicable diseases and outbreaks. This failure had the potential to affect all residents in the facility. The facility census was 156 residents. Findings include: 1. Review of the facility policy titled Infection Prevention and Control Program dated 2/1/08, revised 1/15/16 and reviewed 4/30/17 documented It is the policy of this facility to establish and maintain an Infection Control Program that includes detection, prevention and control of the transmission of disease and infection among patients/residents and partners. Observation on 7/16/18 at 10:17 a.m. revealed an isolation cart on the hallway wall between rooms [ROOM NUMBERS]. There was no signage or conspicuous posting on either door identifying which room was in transmission based precautions, the type of isolation (contact, droplet or airborne) or the required PPE (Personal Protection Equipment). During observations on 7/16/18 at 10:54 a.m. with the Registered Nurse (RN) AA, she showed a nightstand looking furniture piece on the hallway wall between rooms [ROOM NUMBERS] and stated it was an isolation cart for the resident in room [ROOM NUMBER]-B [MEDICAL CONDITIONS] in the sputum. There was no signage or conspicuous posting on either door identifying which room was in precautions, the type of isolation or required PPE. Surveyor entered room [ROOM NUMBER] earlier to observe the resident in 128-B with no knowledge of transmission based precautions. RN AA stated that they do not post signs on the door when a resident is on isolation. She stated it is[NAME]Health policy that no signs are to be posted on a resident's door. RN AA stated that the staff know what residents are in transmission based precautions because they know the residents and they relay that information in shift report to each other. RN AA stated that visitors would not know when a resident was in transmission based precautions but they would stop a visitor before entering a room in isolation. if they saw someone going in an isolation room. When asked, What if you did not see a visitor going in the room how would they know, RN AA shrugged her shoulders and did not have an explanation. Observation on 7/16/18 at 11:03 a.m. with RN AA revealed an isolation cart on the hallway wall outside of room [ROOM NUMBER]. There was no signage or conspicuous posting on the door to identify the type of isolation or required PPE. RN AA stated she was unsure but thought the resident in 125-B was in transmission based precautions for ESBL (Extended Spectrum Beta-Lactamase) in the urine. Interview on 7/16/18 at 11:15 a.m. with the Infection Control Nurse (ICN) revealed there was a total of three residents in house currently on isolation. The ICN stated that[NAME]Health does not allow for any signs posted on the resident's door or anything indicating isolation because of resident's rights. She stated they educate the family of residents in isolation. The ICN further stated the staff know the residents and provide shift report when a resident in isolation. Interview on 7/16/18 at 2:15 p.m. with Certified Nursing Assistant (CNA) CC revealed he knows when a resident is in isolation by seeing a cart outside of a resident's room. He stated if he is not sure which resident is in isolation, he asks the Charge Nurse. CNA CC stated there are no signs posted on or near the resident's door. Interview on 7/16/18 at 2:20 p.m. with Licensed Practical Nurse (LPN) DD revealed she knows when a resident is in isolation because she receives it in shift report or she would check the resident's chart. She stated there are no signs on the resident's door and nothing that specifies what PPE to wear. LPN DD stated I just use what's in the cart. Interview on 7/16/18 at 2:55 p.m. with the Director of Health Services (DHS) revealed it is the company's policy that they cannot place any signs on a resident's door. She stated it is against a resident's rights. The DHS stated that the staff know the residents and know who is in isolation. She stated they discuss the residents that are in isolation in morning meeting. She stated the staff also participate in isolation training in[NAME]University and should know which PPE to use. The DHS opened the top drawer of the nightstand looking isolation cart between room [ROOM NUMBER] and 128 and pulled out a folded care plan that indicated the type of isolation and required PPE. The DHS further stated they keep the isolation care plan in the top drawer. When asked how do visitors know when someone is in isolation, the DHS stated that visitors are supposed to stop at the receptionist desk and they would find out there. When asked if the receptionist attends morning meeting or if she has a list of resident's in isolation, the DHS stated No, she doesn't but the staff would stop a visitor from going in a room that is in isolation. Interview on 7/16/18 at 4:40 p.m. with RN Unit Manager (RN/UM) FF revealed she had worked in the facility for 19 months. She stated there are no signs posted on a resident's door or in a conspicuous place when they are in isolation and in the 19 months she has worked in the facility, she has never seen an isolation care plan in the top drawers of the isolation carts. RN/UM FF stated the visitors have no clear way of knowing if a resident is in isolation unless a staff member stopped them before entering the room and told what PPE to wear. Interview on 7/16/18 at 4:47 p.m. with the Case Mix Director (CDM) GG revealed that prior to today, she had never printed an isolation care plan to be placed in the top drawer of the isolation carts. She stated that earlier today, the DHS asked her to print the isolation care plan and put it in the top drawers of the isolation carts for the residents currently in isolation. 2. Review of the facility policy titled Infection Prevention and Control Program dated 2/1/08, revised 1/15/16 and reviewed 4/30/17 documented The IP (Infection Preventionist) is responsible for collecting, analyzing and providing infection data and trends to staff. PR[NAME]EDURE: 1. Patient/resident infection cases are monitored and documented by the IP. The IP reviews cases of infections, including tracking and analysis of the findings and develops an action plan to resolve identified concerns. 2. A report of resident infections, Epidemiology Report and monthly [MEDICAL CONDITION] (TB) reports are submitted monthly to the Administrator and Director of Health Services (DHS), quarterly to the Infection Control Committee. Review of the Infection Control binder provided by the Infection Control Nurse (ICN) on 7/16/18 at 11:15 a.m. revealed no line listing of infections (to include but not limited to; signs and symptoms exhibited, diagnosis, antibiotic dose and duration), no calculation of the monthly infection rates and no listing of antibiotics. The binder included resident face sheets, lab results and facility location mapping. The ICN provided a separate binder for UTI (Urinary Tract Infection) that did not include a line listing of infections, listing of antibiotics and no evidence of minimal criteria, such as McGreers, for identifying active infection. The ICN printed an Infection Log from the computer. Review of the Infection log revealed a list of resident names, room numbers, nosocomial or community acquired, symptom onset date, infection category, pathogen, related diagnosis, antibiotic, disposition, and status. The list did not document the signs and symptoms exhibited and only answered yes or no for the antibiotic. In Pathogens, 192 infections out 194 documented no culture done or no results. In Related Diagnosis, 193 infections out of 194 were not documented or identified. The ICN provided a weekly list, that she receives from the pharmacy, of residents on antibiotics. The list did include the antibiotic, dosage and duration; however, the list did not include the signs and symptoms exhibited or any documentation related to antibiotic follow up or antibiotic time out (ATO). Review of the Ivermectin Tabs and [MEDICATION NAME] Cream tracking log provided by ICN on 7/16/18 at 11:30 a.m. revealed the following: * 19 residents received Ivermectin in (MONTH) (YEAR), three residents in (MONTH) (YEAR), three residents in (MONTH) (YEAR), one resident in (MONTH) (YEAR), one resident in (MONTH) (YEAR), one resident in (MONTH) (YEAR) and one resident in (MONTH) (YEAR). * Seven residents received [MEDICATION NAME] Cream in (MONTH) (YEAR), three residents in (MONTH) (YEAR), four residents in (MONTH) (YEAR), four residents in (MONTH) (YEAR), four residents in (MONTH) (YEAR), three residents in (MONTH) (YEAR), one resident in (MONTH) (YEAR), five residents in (MONTH) (YEAR), eight residents in (MONTH) (YEAR), three residents in (MONTH) (YEAR), eight residents in (MONTH) (YEAR), 27 residents in (MONTH) (YEAR), one resident in (MONTH) (YEAR), nine residents in (MONTH) (YEAR) and two residents in (MONTH) (YEAR). Review of the facility infection mapping revealed residents that were treated with [MEDICATION NAME] ([MEDICATION NAME] 5% Cream- a scabicide). No rooms were mapped in January, February, May, or (MONTH) (YEAR). (MONTH) (YEAR) mapping revealed a hand-written note Scabies scare, zero confirmed scraping and zero BIT testing but Dr. (Name) and Dr. (Name) blanketed Yellow Hall, Green Hall and MSU with treatments from 3/9/18 until 3/13/18. The color code for the mapping was [MEDICATION NAME] and drawn around the Yellow Hall, Green Hall and room [ROOM NUMBER] on MSU. Interview on 7/16/18 at 11:15 a.m. with the Infection Control Nurse (ICN) revealed she did not know what a line listing was. The ICN further stated she did not report monthly infection rates and was not sure what that was or how to calculate the rate. She stated she maps UTI (Urinary Tract Infection, MDRO (Multi Drug Resistant Organisms) and [MEDICAL CONDITIONS] but does not map other infections such as rashes, URI (Upper Respiratory Infection) or wound infections. The ICN stated she uses the Infection Log in the computer to track infections. The ICN stated she does not use McGreers (Criteria for Surveillance Definitions for Infection) or any type of algorithm to determine active infection and further stated she did not know what that was. Interview on 7/17/18 at 8:25 a.m. with the DHS revealed they found a Line Listing form and a form for calculating and reporting monthly infection rates. The DHS stated she realized they had not been tracking and trending infections and infection rates appropriately. The DHS further revealed they had obtained the[NAME]Health- Revised McGreers criteria to determine active infection and they were going to implement its use immediately. The DHS stated that she and the ICN had started employment with the facility around the same time and she was unsure how Infection Control had been conducted prior. The DHS stated they had not been doing a good job tracking infections or collecting hard data. She stated they had just been discussing infections and antibiotic use in morning meetings and huddles. During a further interview with the DHS on 7/17/18 at 12:20 p.m., she stated they had not been following the facility's Infection Control Policy. The DHS confirmed the Infection Control program had not included signs and symptoms, the antibiotic dosage and duration, Antibiotic Time Out, calculating monthly infection rates or tracking and trending infections. 3. Review of the Georgia DPH (Department of Public Health) Scabies Handbook (YEAR) documented the most common means of scabies transmission is by direct contact between individuals when mites are crawling on the skin surface. Scabies is more usually passed from person to person in settings where people live in close quarters, including hospitals, nursing homes, prisons, child care facilities and institutions. Scabies transmission can also can also occur via prolonged contact with bed linen, clothing and other fabrics. The [DIAGNOSES REDACTED]. Their skin is generally dry and scaly and there may be preexisting, chronic dermatological conditions for which oral or topical steroids have been prescribed. Even if a skin scraping or biopsy is negative, it is possible a person is still infested. Once diagnosed , it is essential that scabies treatment is properly completed. Long Term Care facilities should have a scabies prevention program. As soon as a possible case of scabies is identified, the nursing staff or infection control practitioner should develop a contact identification list. This list should identify every resident, health care worker, visitor and volunteer who may have had direct physical contact with the case within the previous month. Initially, the contact identification list should be limited to the nursing unit where the suspect or confirmed case resides. Information to be collected should include: nursing unit, name, date of onset symptoms, result of skin scrapings, date of initial treatment, date of follow up treatment, results of treatment (e.g. condition resolved or not resolved) and the date of repeat skin scrapings if performed. Resident, healthcare worker, visitor and volunteer contacts determined to be symptomatic should be treated as soon as possible, preferably within 24-48-hour treatment period. The following precautions should be used to prevent further infestation: Place symptomatic resident(s) on isolation to their room(s) for the duration of the first treatment period (8-12 hours). Following bathing to remove the first application of scabicide, discontinue isolation precautions. In nursing homes and other institutional settings, symptomatic healthcare workers, volunteers and visitors and their contacts should be treated during the same treatment period of the as the symptomatic residents are treated. Contact with a symptomatic case is substantial such as bed making, physical assessment or turning a resident. Asymptomatic and symptomatic persons should be treated with one application of [MEDICATION NAME]. Interview on 7/16/18 at 11:15 a.m. with the Infection Control Nurse (ICN) revealed in (MONTH) (YEAR), the Yellow Hall, Green Hall and one room with three residents on MSU were closed to treat for suspected scabies and treat other residents [MEDICATION NAME]. She stated that not all the rashes were suspicion of scabies, some were contact [MEDICAL CONDITION] related to sensitivities such as laundry detergent. The ICN stated she had a list of the residents treated in (MONTH) (YEAR) but the list did not identify which residents were symptomatic, date of onset symptoms, results of skin scrapings (if performed), date of initial treatment, date of follow up treatment, results of treatment, or identify which residents were treated [MEDICATION NAME]. She stated when she started in (MONTH) (YEAR), she started a tracking tool for residents that had received [MEDICATION NAME] ([MEDICATION NAME] Cream). She stated it was discussed verbally in morning meeting any residents with a rash and any new rashes. Reports of new rashes were forwarded to the Wound Care Nurse for assessment. If the rash was significant, they would conduct a BIT (Burrow Ink Test). If the BIT revealed any tracking or stippling, they did not send the resident to the Dermatologist for skin scraping, they would just go ahead and treat the resident for scabies and the roommate of that resident as a precaution. The ICN stated Dr. (name) just treated any resident with a suspicious rash to error on the side of caution. Interview on 7/16/18 at 2:05 p.m. with CNA BB revealed she was instructed to look over a resident's skin during ADL (Activity of Daily Living) care and if she noticed skin rashes or resident complaints of itching, to report it to the charge nurse. CNA BB stated This has been going on for a long time. Residents are treated and it keeps coming back. Interview on 7/16/18 at 2:10 p.m. with the Registered Nurse (RN) AA revealed that any suspicious rashes were reported to the wound care nurses for evaluation. RN AA stated this has been going on since she started employment in (MONTH) (YEAR). RN AA stated the Yellow Hall was quarantined and the residents were treated. She stated the rooms were cleaned, the linens and resident clothing was washed. RN AA further stated that she had developed a rash with intense itching for about two weeks. She stated she reported it to her Unit Manager and she got an order from one of the facility physician's for [MEDICATION NAME] treatment. RN AA stated after treatment with [MEDICATION NAME], her rash went away. Interview with Dr. (Name) on 7/17/18 at 12:10 p.m. revealed he is partners with Dr. (Name), the Medical Director of the nursing home facility. He stated they had been treating isolated cases off and on for scabies. He stated they had a cluster of residents around winter of last year. He stated a couple of residents did have skin scrapings that were negative but skin scrapings are not always accurate. He stated you must get a good sample. He stated that by having a negative skin scraping does not always mean they don't have scabies. He stated residents with typical presentation of scabies or rash that did not get better with other medications, such as topical steroids, he felt it was probably scabies and they went ahead and treated for [REDACTED]. He stated there was distribution of rashes on the torso, thighs and hands with intense itching (Puritis). He stated some residents had to be treated with Ivermectin an oral treatment and they also treated any roommates of the infected resident. He stated the rashes generally improved with treatment but they kept having issues mainly on the Yellow Hall. He stated the peak was in (MONTH) of (YEAR) when several residents at the same time were having rashes. He stated he did not think isolation precautions were specifically ordered but would expect that staff would need to gown, wear gloves and conduct good hand washing. He stated the residents were basically kept in their rooms, the rooms were deep cleaned and thoroughly wiped down. Dr. (Name) stated he was an ER Physician for [AGE] years and he is very familiar with the presentation of scabies. He stated that in his opinion, the residents definitely had scabies. He said there were a few residents that had a contact [MEDICAL CONDITION] or other rash. Interview on 7/17/18 at 9:22 a.m. with the[NAME]County Public Health Epidemiologist revealed she was notified by the Preventionist from[NAME]County Hospital in late (MONTH) (YEAR) that a patient and her husband had both been residents at PruittHealth Toccoa nursing facility and had to be treated for [REDACTED]. The Epidemiologist stated that she had also received a call on (MONTH) 2, (YEAR) from[NAME]County Environmental Health Department that a home health nurse had reported to them that she had been seeing a lot of residents being discharged from PH Toccoa Nursing facility with rashes and had concerns about scabies. The Epidemiologist stated the day after, she called the nursing facility and spoke with the Infection Control Nurse and asked her if they were having any issues with scabies. She stated the Infection Control Nurse told her they had residents with rashes in (MONTH) (YEAR) and did have a couple of skin scrapings that were negative. The Infection Control Nurse told her they had no confirmed cases of scabies and had not treated any residents for scabies since (MONTH) (YEAR) and had no more rashes in the facility. The Epidemiologist stated she was concerned about the infection control practices and measures being taken and sent the nursing facility Infection Control Nurse a copy of the DPH Scabies Handbook. She stated when treating for suspicion of scabies, it is the same as treating for actual scabies and all precautions should be taken. She stated that if they had multiple residents and/or staff with rashes, she would have preferred a skin scraping had been conducted on everyone. She further stated the facility should have followed full isolation including treating everything in the room. All linens and clothing washed on high heat, all other items and mattress to be bagged for at least 72 hours. She stated the entire facility should be treated, staff, residents and their family members. She stated had this been reported to her, this would have been her recommendation. During an interview on 7/17/18 at 12:20 p.m. with the DHS, ICN and the Assistant Director of Health Services (ADHS), they stated they blocked off the Yellow and Green Halls by closing the hall doors for 5-6 days and treated all residents on the halls. They stated they had to stagger the [MEDICATION NAME] treatments because there was no way they could treat 25 residents and disinfect the rooms at once. They stated the unit managers had a list of 4-6 residents to be treated at a time based on rooms and adjoining rooms. The DHS stated she did not have a list of which resident groups were treated or when they were treated. The DHS stated the rooms being treated at the staggered times were in isolation until the first treatment had been completed but stated there is no documentation for isolation or type of isolation used. The DHS stated the nightshift administered the [MEDICATION NAME] and they had a flowsheet for which residents needed to be washed off the following day on dayshift. The DHS stated they did not keep record of the flowsheets or when the wash off was completed. The ICN stated she did not have documentation given to her for when a resident received the medication, it was reported to her verbally in morning meeting and she entered it into the [MEDICATION NAME] Tracking Log. The DHS, ADHS and ICN stated when the residents were treated and went to the shower to have the [MEDICATION NAME] washed off, the housekeeping staff stripped the rooms bare. They bagged up all clothing and linens to be washed and all personal items that could not be washed were bagged and stored for 72 hours. They stated everything was thoroughly cleaned and wiped down. They stated that dietary delivered disposables and paper for meals. They stated all staff were gowned and gloved and they kept the same employees assigned to the Yellow and Green Hall. The DHS stated they kept record of room cleanings in a folder. Review of the Resident Record of Scabies Treatments Month of (MONTH) form provided by the Infection Control Nurse revealed 25 resident names. R#2 was not on the list (Refer F684). Review of the Checklist for Care of Residents with Scabies form provided by the DHS revealed the following: A place for the resident name, room number and date. The checklist had a designated spot to initial each instruction as follows: * Charge Nurse will obtain order for treatment for [REDACTED].>* Charge Nurse will report infestation to the Infection Control Nurse * Charge nurse will explain the procedure to resident and family * Charge nurse will be sure that the resident has clean clothing to put on after application of lotion/cream * Charge nurse will have CNA bathe resident with soap and water. After bath, allow the skin to dry before applying treatment * Charge nurse will apply the medication in a thin layer and rub thoroughly. Cover the entire body from neck to toes. Pay special attention to folds, creases, fingernails and inter-digital spaces * Charge nurse will ensure that the resident is bathed 10-12 hours after treatment applied and that clean clothing is put on after bath * Charge nurse will ensure that staff wear gloves, gowns before, during the 12-24 hours after treatment * Housekeeping/CNA staff will bag all clothing, bedding etc. in plastic bags and seal for 72 hours (3 days). Clothing and bedding may be washed in hot soapy water and dried in HOT cycle of dryer * Housekeeping/CNA staff will place articles that are not washable in a plastic bag & seal for 72 hours. This may or may not include, curtains, stuffed animals, pillows etc. * Housekeeping will wipe down beds, mattresses, furniture, etc. with germicidal solution. The mattress will be removed from the room, taken to the garage and replaced with another mattress. At the bottom of the form was a place for the Infection Control Nurse, Charge Nurse and Housekeeper to sign and date when completed. 14 of the 25 forms were incomplete, not all check off task were initialed as task completed. 11 forms were completely blank. None of the 25 forms were signed and dated by the Infection Control Nurse, Charge Nurse or Housekeeper. Specifically, for R#1, the form was not or completed. Missing components include: Charge nurse will apply the medication in a thin layer and rub thoroughly. Cover the entire body from neck to toes. Pay special attention to folds, creases, fingernails, and inter-digital spaces. The form was not signed off and dated by the Infection Control Nurse, the Charge Nurse or the Housekeeper (Refer F684). There was no form for R#2 (Refer F684). Further interview with the DHS and the ICN on 7/17/18 at 3:39 p.m. confirmed out of the 25 Checklist for Care of Residents with Scabies forms, only 14 were partially completed and 11 were not documented on at all. The DHS confirmed that all 25 forms were not signed off and dated on the bottom as indicated by the Infection Control Nurse, The Charge Nurse and the Housekeeper. The ICN stated the room cleaning check list forms were given to her and she put them in a folder. She stated the housekeeping staff cleaned the rooms but obviously didn't document on the forms. The ICN stated she did not sign off on the forms where indicated for the Infection Control Nurse and stated I didn't see that. She stated the Unit Managers said they were going to use those forms and that's what they did. The Infection Control Nurse stated that a few staff members came to her with a rash and stated one of the staff members just looked like a pimple on her hand. She stated she did the BIT test on some employees and others went to theER on their own. She stated they did not [MEDICATION NAME] treat the staff and there was only three to her knowledge that had complaints of a rash and/or itching. The ICN stated she did not keep record of staff rashes or itching. ICN stated they discussed in the morning meetings with the Unit Managers when a resident completed treatment and stated and no, I did not document that. The ICN stated that the purpose of the infection control mapping is to note each occurrence and any clusters or trends. When asked why the scabies rash was not documented on the infection control mapping for January, February, (MONTH) or (MONTH) of (YEAR) when residents were treated for [REDACTED]. The ICN further stated at 4:24 p.m. that the BIT test was performed with a black sharpie ran across a highly-affected area at least three by three inch square, then wiped off and observe for any tracking, tunneling or stippling. The ICN stated she did not personally document this but maybe the wound care nurses did. She stated I don't know, if I would have been the wound care nurse, I would have. Interview on 7/18/18 at 9:00 a.m. at[NAME]County Hospital with the Infection Control Preventionist (HOSP ICN PP) revealed they had admitted several residents with rashes over the past several months. She stated the worse was a husband and wife that recently required scabies treatment. She stated the husband and wife were admitted to the hospital from home but were previously residents in the nursing facility in (MONTH) (YEAR) when they were discharged from the hospital for rehabilitation. She stated although the wife had been being treated by her physician with a topical steroid cream for a rash that he thought was a reaction to medications, when she was readmitted to the hospital on [DATE] for [MEDICAL CONDITION], the rash was really bad. The HOSP ICN PP stated when her husband was admitted several days later on 4/23/18, he also had a rash with puritis that presented as scabies. She stated although they admitted from home, they both were residents and roommates at the nursing facility. She stated after caring for the husband and wife, 13 hospital staff members had developed a rash and had to be treated for [REDACTED]. She stated that prior to admission of the husband and wife, the staff did not have any rashes. She stated that after treatment for [REDACTED]. The HOSP ICN PP stated that she had spoken with the nursing facility Infection Control Nurse (ICN) and was told they had done some skin scrapings on residents that resulted negative. She stated the nursing home ICN told her they would treat the rashes for scabies and they would go away and eventually come back. She stated she asked the nursing facility ICN if they had treated their staff and was told they were not having any problems with the staff in the nursing facility. The HOSP ICN PP stated that she told the nursing facility ICN that the hospital had to treat hospital staff after the husband and wife were admitted and even if her staff did not have symptoms, if they had contact with any residents with suspected rash, the staff should be treated. The HOSP ICN PP stated she is so concerned about scabies and residents coming from the nursing facility that she instructed her staff and ER (emergency room ) that any resident coming from the nursing facility is to receive a complete skin assessment and report any rashes to her. She stated she is concerned what the nursing facility is doing and they are trying to stop the scabies at their own hospital door. Interview on 7/18/18 at 1:37 p.m. with the Skin Integrity Coordinator (SIC/LPN) HH revealed she and the ICN did not perform very many BIT test on residents. She stated they basically did it as a trial to see if it worked but it didn't show anything. She stated she did not rely on that test and did not document it. She stated it was just a trial and they watched a you-tube video how to do it. The SIC/LPN HH further stated that staff would report a resident with a rash and she or the other wound care nurses would assess the rash. She would call the Physician and describe the rash and they would go ahead and order [MEDICATION NAME]. She stated that the wound care nurses were never instructed to follow up with the rash once the treatment had been administered. She stated that they have not treated anyone for scabies for several weeks and she is currently treating three residents with a steroid cream and [MEDICATION NAME] lotion for residual effects of the [MEDICATION NAME] treatment or [MEDICAL CONDITION] type rashes including R#2. She stated the scabies rash has been a problem off and on since last year. Interview on 7/18/18 at 1:55 p.m. with LPN/wound nurse (LPN II) revealed at the time of the (MONTH) (YEAR) scabies treatment she was a Unit Manger. She stated they discussed in 'morning meeting an initial plan to quarantine the Yellow Hall and have the rooms deep cleaned. She stated they added the Green Hall because of a cluster of rashes in one of the rooms on that hall. She stated she used the 24 hour report form to communicate that [MEDICATION NAME] treatment was administered to a resident. She stated she did not conduct any follow up once the treatment had been admin",2020-09-01
896,PRUITTHEALTH - TOCCOA,115345,633 FALLS ROAD,TOCCOA,GA,30577,2018-07-24,881,F,1,0,H8KB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the policy titled Antibiotic Stewardship Program and staff interviews, the facility failed to perform analysis of antibiotic surveillance data and document follow-up measures in response to the data for six of six months of (YEAR) infection control data reviewed (January (YEAR) through (MONTH) (YEAR)). (Refer F880) Findings include: Review of the facility policy titled Antibiotic Stewardship Program dated 11/28/17, revised 6/13/18 documented As part of the Infection Prevention and Control Program,[NAME]Health will implement and maintain and Antibiotic Stewardship Program (ASP). The goal of ASP is to promote appropriate use of antibiotics to treat infections and reduce possible adverse events associated with antibiotic use. Antibiotic Time Out- Reassessment of the continuing need and choice of antibiotics when the clinical picture is clearer and more diagnostic information is available. The antibiotic time out should be performed within 2-3 days after antibiotics are initiated. Indication- a valid sign, symptom, or [DIAGNOSES REDACTED]. The ASP Team will be established to be accountable for promoting and overseeing antibiotic stewardship activities. The ASP Team will monitor and review the following data: Infections and antibiotic usage patterns on a regular basis, Antibiogram reports for trends of antibiotic resistance, Antibiotic resistance patterns for multidrug resistant organisms (e.g.[MEDICAL CONDITION], VRE, ESBL, CRE, etc.), Number of antibiotics prescribed (e.g. days of therapy) and the number of residents treated each month, include a separate report for the number of residents on antibiotics that did not meet criteria for active infection. ACTION: a) All[NAME]Health facilities will implement evidence-based ASP protocols to help guide optimal decisions for therapy and to ensure appropriate antibiotic selection. b) An antibiotic time-out (ATO) will be performed after the initiation of all antibiotics prescribed in the facility. c) During the ATO, the Prescribing Provider will imitate the review and document the following information in the medical chart: (i.) Whether the resident has an infection that will respond to the antibiotic ordered (e.g. Do the clinical symptoms and diagnostic test results support the [DIAGNOSES REDACTED].) If so, whether the patient is on the appropriate antibiotic (s), dosage, duration, indication and route of administration. (iii.) Whether a more targeted antibiotic be used to treat the infection (i.e. also known as de-escalation). (iv.) Whether the duration of the antibiotic is necessary. (V.) What is the clinical justification for the use of an antibiotic beyond the initial duration ordered. (VI.) Document the resulting clinical decision of the ATO. TRACKING: a) The IP will be responsible for infection surveillance and multi-drug resistance organism (MDRO) tracking. b) The IP, along with the DHS, will collect and review the following data such as: I. Documentation of completion of antibiotic choice, dosage, duration, indication and route of administration. II. Whether appropriate tests, such as labs and/or cultures were obtained before ordering antibiotic. III. Whether the antibiotic was changed during the course of treatment. c) Each month the Antibiotic Stewardship Pharmacist will provide assessment, monitoring and written communication of antibiotic usage data including the number of antibiotics prescribed (e.g. days of therapy), numbers of resident/resident days, antibiotic rates and utilization to the ASP team. d) Each month the Antibiotic Stewardship Pharmacist will monitor, document and provide each facility the following antibiotic use of information on the Monthly Healthcare Associated Infection Summary Report: * Percent of residents receiving antibiotics *Percent of new admissions receiving antibiotics * New antibiotic starts * Rate of Antibiotic Days of Therapy (DOT). e) Each month the Consultant Pharmacist will ensure appropriate antibiotic use and provide a written monthly medication regimen review to the DHS and prescribing provider (s) which will include: *Review of the medical record for each patient/resident * Identifying irregularities including unnecessary drugs * Documenting significant findings in the medical record, * Communicating potential or actual or actual problems detected relating to medication therapy orders to the prescribing physician. Review of the Infection Control binder provided by the Infection Control Nurse (ICN) on 7/16/18 at 11:15 a.m. revealed no evidence of antibiotic surveillance data, analysis, documentation of follow up in response to the data or monthly antibiotic reporting. The ICN provided a weekly list, that she receives from the pharmacy, of residents on antibiotics. The list did include the antibiotic, dosage and duration; however, the list did not include the signs and symptoms exhibited or any documentation related to antibiotic follow up or antibiotic time out (ATO). Interview on 7/16/18 at 11:15 a.m. with the Infection Control Nurse (ICN) revealed she does not use infection assessment tools or management algorithms for infections to assess the minimum criteria for initiation of antibiotics and stated she did not know what that was. She confirmed that her infection log did not specify signs or symptoms or the type of antibiotic dosage or duration. She stated she receives a list from the pharmacy each week that list residents on antibiotics with the dosage and duration. The ICN stated that she personally does not review lab results to ensure the appropriate antibiotic dosage and duration was ordered for the specific organism identified and she is not sure who does. She stated that possibly the DHS monitors that. She stated they are in the process of developing the Antibiotic Stewardship Program and they are supposed to be getting new computer programs for this. She stated that she does not personally follow up or conduct antibiotic time out (ATO) after an antibiotic has been started to collect data and document the effectiveness or if signs and symptoms persist. She stated they discuss in the morning meeting when an antibiotic was completed and the nurses should be documenting every shift the antibiotic, vital signs and signs and symptoms but she does not compile this information or track it. She further stated that the Consultant Pharmacist is responsible for monitoring antibiotics. Interview on 7/17/18 at 8:25 a.m. with the DHS revealed they had been focused on moving into the antibiotic stewardship but had not yet implemented all components of the program. She stated they had just been discussing infections and antibiotic use in 'morning meetings and huddles. During further interview with the DHS and ICN at 12:10 p.m., the DHS stated yes she was aware that the effective date for regulations related to antibiotic stewardship was 11/28/17 and the ICN stated I guess. The DHS stated they had not been conducting antibiogram reports for trends of antibiotic resistance, number of antibiotics prescribed and days of therapy or the number of residents treated each month up until about two months ago with the Pharmacy. The DHS stated the program had not been fully implemented and stated they were not sure what they were going to do with the information at this point in time. The DHS stated they have basically been reporting to the Physician based on the lab results and culture sensitivities and the Physician ordered the appropriate antibiotics based on the information they were given. Post exit telephone interview on 7/24/18 at 11:16 a.m. with the Consultant Pharmacist CP LL (Wesley McConnell) revealed they use a computer program called Framework that prints a report of all residents on antibiotics and antibiogram reports that is sent to each facility monthly. He stated he does not personally review the signs and symptoms and appropriate antibiotics prescribed. He stated they just started using this program and began providing these reports to the facility about 2-3 months ago as part of the infection control program.",2020-09-01
897,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,578,D,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy titled Skilled Inpatient Services Advanced Directive, and staff interviews, the facility failed to update the code status on one resident (R) (#30) of 41 sampled residents. Findings include: A review of a Physician order [REDACTED]. Further review of the clinical record revealed a Physicians Orders for Life Sustaining Treatment (POLST) document signed and dated by the resident on [DATE] indicating the resident wants to allow a natural death, comfort measures, and no artificial nutrition by tube. A review of R#3's care plan dated [DATE] revealed resident is a Full Code with the following goal: Advanced Directive decisions will be honored as applicable during the review period and interventions of follow advanced directives as written. The care plan further revealed under Care Area/Problem dated [DATE]: has POLST. In an interview on [DATE] at 3:39 p.m., the Social Services Director (SSD) revealed she changed his code status on [DATE] from full code to allow natural death. She reported she had forgotten to change his status back in (MONTH) (2019) when he signed the POLST. During an interview on [DATE] at 3:49 p.m., the Minimum Data Set (MDS) Coordinator MM verified R#3's last care plan meeting was held [DATE] which he did not attend. Following notification that R#3's POLST was signed on [DATE], the MDS Coordinator agreed that if the resident had experienced an event in this past month, the facility would have considered him a full code. During an interview on [DATE] at 11:58 a.m., the Director of Nursing (DON) reported that she expects the orders to be updated once the POLST in signed. DON stated the nurses check the POLST book at the nurse's station prior to starting Cardiopulmonary Resuscitation (CPR). In an interview on [DATE] at 1:12 p.m., the Administrator reported the ribbon (header of the electronic health care record) and care plan were not updated, and most likely CPR would have been done. A review of the policy titled Skilled Inpatient Services Advance Directives updated for release (MONTH) 2019 revealed on page five under C. Procedures for periodically reviewing patient choices and preferences related to health care decisions after admission: 6. During Advanced Care Planning (ACP) conversations, education may be provided to patients on the Georgia Physicians Orders for Life Sustaining Treatment (POLST). The POLST is a physician's orders [REDACTED]. 7. A POLST that has been appropriately completed will be accepted and followed by the center.",2020-09-01
898,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,584,D,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, the facility failed to ensure a clean, comfortable and homelike environment as evidenced by torn and unpainted sheetrock and scraped walls; uneven legs on an elevated commode seat; unsecured cove base; missing night light cover; scraped doorframes; hole in wall; and soiled enteral feeding pump stand. These concerns were observed in seven resident rooms and three resident bathrooms on two of five halls. Findings include: 1. During observations of the environment on the 500-hall, the following concerns were noted: room [ROOM NUMBER]: 1/6/2020 at 2:55 p.m.: A section of cove base was observed pulled away from the wall approximately ten inches starting just outside the bathroom door. During interview with R#40 at this time (review of his Quarterly Minimum (MDS) data set [DATE] revealed that he was assessed as having no cognitive deficits), he stated that staff had painted the walls in his room about three weeks ago and he thought they would have secured the cove base then, but they did not. He further stated the cove base had appeared this way for about three months. An earlier random observation on 1/6/2020 at 2:30 p.m. revealed that Maintenance staff was in R#40's room mounting a hat rack to his wall on the opposite side of the bathroom door in room [ROOM NUMBER], but he did not secure the cove base while in the room. Bathroom for rooms [ROOM NUMBERS] (shared by three residents): 1/7/2020 at 8:19 a.m.: The sheetrock to the left of the sink in the bathroom had been torn away and was unpainted. Bathroom for rooms [ROOM NUMBERS] (shared by three residents): 1/7/2020 at 9:44 a.m.: The legs of the elevated commode seat in the bathroom were of different lengths, resulting in the commode seat being uneven and wobbly. This was verified during interview with Licensed Practical Nurse (LPN) GG on 1/7/2020 at 9:52 a.m., who stated that all three residents that shared this bathroom needed staff assistance to use the bathroom. She further stated that she would notify Maintenance to fix the legs on the elevated commode seat. On 1/9/2020 at 9:15 a.m., a walk-through of the above environmental concerns was done with the Maintenance Supervisor. He verified that the elevated commode seat for rooms [ROOM NUMBERS] was unsteady and adjusted the legs at this time so that they were all the same length. The Maintenance Supervisor stated that the nursing staff had verbally told him earlier this week that the commode tank in that bathroom was not level, not that the elevated commode seat was not level. The Maintenance Supervisor verified that the sheetrock in the bathroom for rooms [ROOM NUMBERS] above the soap dispenser and to the left of the sink had been torn and was unpainted. He stated during interview that it appeared another soap dispenser had been removed from that area and was relocated to its present position by his Assistant, but he was not told that the wall needed to be patched and painted. The Maintenance Supervisor verified during observation that the cove base above the floor outside the bathroom door in room [ROOM NUMBER] was not attached to the wall. 2. During observations of the environment on 400 and 500 halls the following concerns were noted: room [ROOM NUMBER]: 1/8/2020 at 9:12 a.m. revealed a tube feeding pump pole base next to the A bed heavily soiled with a tan dried substance. room [ROOM NUMBER]: 1/6/2020 at 11:08 a.m. the night light bulb was exposed with no cover over the bulb. room [ROOM NUMBER]: 1/6/2020 at 11:10 a.m. the A bed wall was scraped with sheetrock exposed and the bathroom doorframe with denting, scuffing and chipping paint. room [ROOM NUMBER]: 1/6/2020 at 11:25 a.m. left lower corner of wall at heating and air conditioning unit, the wall is damaged with a hole. Behind the A bed the cove base had pulled away from wall exposing sheetrock and debris. room [ROOM NUMBER]: 1/6/2020 at 11:30 a.m. bathroom cove base next to the commode has pulled away from the wall. room [ROOM NUMBER]: 1/6/2020 at 11:40 a.m. the corner wall with sheetrock exposed. room [ROOM NUMBER]: 1/6/2020 at 11:45 a.m. next to the B bed the wall scraped and exposing sheetrock. Apart from room [ROOM NUMBER], the above concerns were noted during rounds on 1/7/2020 at 2:13 p.m., 1/8/2020 at 8:40 a.m., and 1/9/2020 at 8:00 a.m. On 1/09/2020 at 9:30 a.m., a walk-through of the above environmental concerns was done with the Maintenance Supervisor. He reported during the interview they utilize the TELS system for maintenance issues. He indicated that work orders are placed in the system, which he prints out each morning and assigns between his assistant and himself. He further indicated they add to the list throughout the day any additional concerns they find or fix then enter it into the system at the end of each day. During our walk through the Maintenance Supervisor verified the night light bulb was exposed in room [ROOM NUMBER] with no cover, the scraped walls and exposed sheetrock in rooms 403, 500, 502 and 503, and the cove base pulling away from the walls in room [ROOM NUMBER] and the bathroom of room [ROOM NUMBER]. During our tour he further reported he is working on a solution for the condition of the walls. In an interview on 1/9/2020 at 10:00 a.m. with the Central Supply Clerk, she reported she is responsible for cleaning the tube feeding poles. She indicated all equipment is cleaned once per week, indicating she had cleaned the tube feeding pole pump in 400A yesterday (1/8/2020). She further indicated the equipment is not scheduled for cleaning, and there is no written accounting of the equipment she cleans. In an interview on 1/09/2020 at 12:56 p.m. with the Administrator he reported he expects maintenance to do a daily visual inspection and identify what needs to be corrected and to follow the TELS routine. He further indicated they have a corporate painter who has been at the facility and stated that painting is a constant task in the building.",2020-09-01
899,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,607,D,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Reporting and Investigation Abuse, and interviews, the facility failed to implement its abuse policy related to reporting verbal abuse for one of two residents (R) (Z) reviewed for abuse. Findings include: Record Review of facility policy titled, Reporting and Investigating Abuse revised (MONTH) 2019 revealed it is the Intent of the center to establish standards of practice for investigation and reporting of abuse, neglect, mistreatment, exploitation and misappropriation of property. Procedural Guidelines: 1. Reporting: [NAME] Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of patient property the incident will be immediately reported (within 2 hours). Interview with R Z on 1/6/2020 at 12:45 p.m. revealed she has concerns with several of the CNA's that work at the facility. R Z stated that many of them are lazy and rude. R Z stated this past Saturday (1/4/2020), Certified Nursing Assistant (CNA) CC called her a fat ass [***] . R Z stated she told CNA CC you're a black [***] . R Z stated the verbal exchange was so loud and that Registered Nurse (RN) AA walked into her room to see what was going on and R Z stated she told RN AA what happened and that CNA CC called her a fat ass [***] . Interview with RN AA on 1/6/2020 at 1:40 p.m. revealed she was made aware of the allegation of verbal abuse by R Z on Saturday 1/4/2020 around 1 p.m. RN AA stated she could hear a verbal argument coming from R Z's room and she walked down there to see what was going on. RN AA stated as she walked down to R Z's room because she heard R Z say black [***] to CNA CC who was standing at R Z's door but she did not hear CNA CC say anything to the R Z. RN AA stated that R Z reported to her that CNA CC called her a fat ass [***] . RN AA stated that she did not report the incident to anyone on Saturday 1/4/2020 when the incident occurred but RN AA stated she reported it to the Director of Nursing (DON) on 1/6/2020. RN AA stated per the facility's policy any allegation of abuse is to be reported to Administration immediately. RN AA stated she did not follow facility policy when she chose not to report the allegation to anyone. Record Review of Facilities email confirmation revealed the Administrator reported the allegation of verbal abuse on 01/06/2020 at 2:03 p.mm over 48 hours after the incident was first reported to RN A[NAME] Interview with DON on 01/08/2020 at 2:45 p.m. revealed she and the administrator became aware of the allegation of abuse on Monday 1/6/2020 at 9 a.m. prior to the morning meeting. DON stated that RN AA told her about the allegation of verbal abuse and provided the two statements written by two staff members. DON stated that RN AA did not report it within the 2-hour required reporting timeframe, but RN AA did start the investigation. Interview with CNA EE on 01/09/2020 at 11:30 a.m. revealed she worked Saturday 1/4/2020 and she assisted R Z with making her bed after there was a dispute with two other staff. CNA EE stated R Z reported to her that CNA CC called her a fat ass [***] and that she called CNA CC a black [***] . CNA EE stated she immediately reported the allegation to her nurse supervisor, RN A[NAME]",2020-09-01
900,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,656,D,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident/staff interview, the facility failed to follow the care plan for three residents (R) (R, #73, and #16) related to nail care; and failed to follow the care plan related to placing a splint on the left hand of one resident (#16). In addition, the facility failed to implement the care plan related to use of fall mats, use of an insulated cup with cover to [MEDICAL CONDITION] hot liquids, keeping frequently used personal items within reach/reacher, reclining wheel chair back, and providing assistance with self-care as needed for one resident (R). The facility also failed to use a sliding board for transfer as care planned for one resident (#100). The sample size was 41 residents. Findings include: 1. Review of R R's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score between 13 and 15 indicates no cognitive impairment); needed extensive assistance for dressing and personal hygiene; was totally dependent for bathing; needed extensive assistance for transfers and walking in room; and supervision for eating. Review of R R's self-care deficit due to ADL (activities of daily living) decline due to [MEDICAL CONDITION] care plan revised 11/15/19 revealed an intervention to provide assistance with self-care as needed. Observation on 1/6/2020 at 4:25 p.m. revealed that R R was in his bed, and there were five dark brown spots on the fitted bed sheet on his left side, and he had dried food debris on the left side of his mouth. Observation on 1/7/2020 at 7:47 a.m. revealed that the brown spots noted on R R's fitted bed sheet were still there, and he was wearing the same shirt that he had on the previous day which had several stains on the front of it. During interview with R R at this time, he stated that he was supposed to get showers every Monday, Wednesday, and Friday, but had not gotten a shower for one week and could not remember when his bed linens were last changed. Observation at 1/7/2020 at 10:33 a.m. and 1:40 p.m., and 1/8/20 at 3:31 p.m. revealed that R R had dark debris under the fingernails of the third and fourth fingers of his left hand. Review of the 500-Hall Bath Schedule kept at the nurse's station revealed that R R's shower days were Monday, Wednesday, and Friday on the 3:00 p.m. to 11:00 p.m. shift. Review of 30 days of printed ADL documentation (from 12/9/19 to 1/8/20) revealed that showers were only documented for R R on 12/11/19; 12/13/19; 12/16/19; 12/18/19; and 1/8/20 (no documentation of showers provided on 12/20/19; 12/23/19; 12/25/19; 12/27/19; 12/30/19; 1/3/20; and 1/6/20). Cross refer to F677. 2. Review of R R's care plans for fall risk, and for fall or near fall last updated 1/7/2020 revealed they were updated to reflect the falls he sustained. Review of the interventions to these care plans revealed that they included to place a fall mat to right and left side of the bed (added 11/19/19); needed and desired items in reach/easy access (added 12/23/19); use of a reacher (added 12/23/19); and a reclining wheelchair back (added 12/8/19). Review of R R's care plan for burn/risk for burn developed 11/20/19 revealed that he spilled coffee onto his inner thighs and his abdomen was reddened. Review of the interventions for this care plan revealed for staff to pour coffee/liquids in teal insulated cup with cover and handle at bedside with straw in opening (added 12/6/19). Review of R R's neuromuscular disease care plan related to [MEDICAL CONDITION] revealed that it was updated on 12/6/19 for special feeding devices as required. Review of a Nursing Progress Note dated 11/20/19 at 2:47 p.m. revealed that R R spilled his hot coffee this morning from the table top and it spilled on his lower abdominal area and his anterior thigh. The skin from the spilled coffee looks pinkish colored, no blisters noted, consistent with 1st degree burns, 5% of body surface area. Review of an Occupational Therapy Discharge Summary dated 12/13/19 revealed: (R R) has been provided with a double walled cup with lid and small knob that can be opened or closed to sip one's drink. It has a handle. He is able to handle the cup safely and effectively, no spillage noted and he prefers to use a straw to drink from it. Observation on 1/7/2020 at 10:45 a.m. and 1:20 p.m.; 1/8/20 at 7:40 a.m. and 3:31 p.m.; and 1/9/20 at 7:59 a.m. and 10:44 a.m. revealed that there were no fall mats on the floor on either side of R R's bed. Observation on 1/8/2020 at 7:40 a.m. revealed that R R had been served breakfast in bed, and an uncovered regular coffee mug with two straws in it was on his tray, half consumed, and the outside of the mug felt warm to the touch. During observation on 1/9/2020 at 7:59 a.m., R R was observed in bed feeding himself breakfast. Further observation revealed that Certified Nursing Assistant (CNA) HH entered the room at this time and brought R R a cup of coffee in a regular coffee mug with a straw in it and handed the mug to him. R R's grip was unsteady and when holding the mug, he did not keep it level so that the coffee would come up to the edge of the rim, and a small amount of the coffee spilled on the towel covering his torso. During interview with CNA HH at this time, she stated that R R was supposed to have a special mug for his coffee, but the kitchen staff was supposed to put this mug on his meal tray. During continued interview, CNA HH verified there were no fall mats in his room. Observation on 1/9/20 at 10:44 a.m. revealed that R R's reacher (used to grab items not in easy reach) was observed on the floor out of his reach. During interview with Registered Nurse (RN) Resident Care Coordinator (RCC) AA on 1/9/20 at 11:05 a.m., she stated that if R R's wheelchair seat back was able to be reclined, she did not know how to do it. She verified that R R's reacher was on the floor where he could not reach it, and that all of his commonly-used items should be in his reach. RCC AA further verified there were no fall mats in R R's room and did not know where they were. She stated that the Kitchen staff sent the special cups on R R's tray for his hot liquids, and that the CNAs were responsible for pouring coffee from the regular coffee mug into this special mug when he was served. Cross refer to F689. 3. Review of R#73's Admission MDS dated [DATE] revealed that she had short- and long-term memory problems and severely impaired decision making and was totally dependent for personal hygiene. Review of R#73's care plan for self-care deficit updated 12/4/19 revealed an intervention to assist with ADLs as needed. During observation on 1/9/20 at 10:49 a.m., R#73's fingernails were observed to have varying lengths but all of them were long, and several fingernails had straight sharp corners and dark debris was noted under most of her fingernails. During interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) AA on 1/9/20 at 11:05 a.m., she verified that R#73's fingernails were long and had sharp edges and stated she would have staff cut them. Cross refer to F677. 4. R#16 was admitted to the facility on [DATE]. The Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. Section G - Functional Status revealed that the resident was assessed for total dependent for personal hygiene. Functional limitation in Range of Motion: upper extremity impairment on both sides. Section O - Special Treatment and Programs: Restorative nursing AROM (active range of motion) and splint brace assistance. Review of the care plan updated 11/11/19 identified the resident has: Self-care deficit related to [MEDICAL CONDITION], amputation to right and left lower legs at knee level. Needs assistance with hygiene. Goals: Patient will accept assistance with ADL's and needs will be met during the review period. This patient is identified as requiring assistance for self-care areas on the comprehensive care plan. Observations on 1/6/2020 at 11:40 a.m., 1/7/2020 at 12:57 p.m., and 1/8/2020 at 8:18 a.m. revealed R#16 with long nails on both hands with thick dark brown debris under the nails. During further observation and interview on 1/8/2020 at 8:22 a.m., R#16 stated his nails need to be cut and he placed a napkin in the palm of his hand to keep his nails from digging in his skin. During an interview and observation on 1/8/2020 at 12:00 p.m., Resident Care Coordinator (RCC) LL revealed that on bath days a resident should have their nails cleaned and clipped. R#16's bath days are on the 3 p.m. to 11 p.m. shift on Tuesday-Thursday-Saturday. RCC LL confirmed that R#16 nails were dirty and long on both hands and do not appear to have been cleaned or clipped on 1/7/2020 during his bath. Cross refer to F677. 5. Review of the care plan updated 7/29/18 identified the resident has: Range of motion limited - at risk for/actual contractures. Related to decreased range of motion (ROM) fingers. Limited joint mobility interferes with hygiene. Goals: Patient will maintain or improve ROM through the review period. Restorative program for ROM as indicated. Use devises, appliances, splints, or positioning pillows as indicated. Observations on 1/6/2020 at 11:40 a.m., 1/7/2020 at 12:57 p.m., 1/8/2020 at 8:18 a.m., and 1/9/2020 at 9:49 a.m. revealed R#16 with left hand fingers in a bent position touching the palm. The resident was unable to straighten fingers on left hand. There was no splint on left hand. An interview and observation was conducted on 1/8/2020 at 12:10 p.m. with Occupational Therapist (OT) II. OT II revealed that R#16 is on restorative services and uses a splint to his left hand due to fingers are contracted. OT confirmed that he did not have on his splint and he should have the splint on his left hand. Cross refer to F688. 6. A review of R#100's Annual MDS Assessments revealed a BIMS score of 15 and the resident required two plus extensive assistance with transfers. A review of R#100's care plan revealed she is at risk for falls or near fall related to sliding board transfer as evidenced by fall on 7/11/19 - and reviewed and continued on 11/7/19. The goal identified is patient will be free from complications related to falling or near fall. Interventions included two person assist with sliding board transfers. A review of R#100's Activities of Daily Living (ADL) Plan of Care dated 11/28/19 revealed transfers: extensive assistance with two person assist, and special equipment of wheelchair and sliding board. A review of the Nurses Notes for R#100 revealed the following note related to the injury on her nose: 1/06/2020 Resident was being assisted in her chair with a lift and the cross bar on the lift bumped her nose causing a small skin tear. During an interview on 1/6/2020 at 11:08 a.m. R#100 reported one staff member, Certified Nursing Assistant (CNA) QQ used the lift to transfer her from the bed to the chair. During further interview on 1/07/2020 at 2:30 p.m., R#100 reported she hasn't been using the slide board the way she should have because CNA QQ prefers to use the lift more than the slide board. She further reported she has no objections to using the slide board and stated some staff will pick her up and she will pivot (stand pivot), or they will use the lift or the slide board. She does not recall the last time she used the slide board and she allows the staff to make the decision on how to transfer her, stating it really doesn't matter to her which method is used as long as they get her up. During an interview on 1/08/2020 at 3:11 p.m. with CNA PP, she reported she transfers R#100 with a Hoyer lift. When asked how she knows how to transfer R#100 she reported she knows this because she has been here four years and has been assigned to R#100 and is familiar with her. She further reported she ensures someone is with her when using the Hoyer lift. During an interview on 1/09/2020 at 8:47 a.m. with CNA QQ she reported R#100 used the sliding board in the past, but now they get her up with the Viking lift because she can't use the sliding board or stand pivot. During an interview on 1/9/2020 at 12:06 p.m. with the DON she reported resident transfer status is determined on admission with an assessment tool to determine the best way to transfer a resident, verifying their ability level and assistance devices used. The DON verified the day R#100 was injured, the CNA utilized a Hoyer lift. Cross refer to F689.",2020-09-01
901,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,677,D,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff/resident interviews, and policy review, the facility failed to ensure that activities of daily living (ADL) was provided for three dependent residents (R) (#16, #106, and #73) related to nail care; and failed to consistently provide clean linen, clothing and showers as scheduled for one resident (R) of 41 sampled residents. Findings Include: Review of the facility policy titled Skilled Inpatient Inservices Care of Fingernails/Toenails dated 2/2019 indicated the following: Intent - it is the intent of this center to provide appropriate nail care to all patients. Procedural Guidelines: 10. Gently, clean under each nail with an orange stick. You may have to soak hand before cleaning. 11. Trim fingernails. 12. Smooth with nail file or emery board if needed. 1. Review of the Electronic Health Record (EHR) revealed R#16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. Section G - Functional Status documented the resident as totally dependent for personal hygiene. Observations on 1/6/2020 at 11:40 a.m., 1/7/2020 at 12:57 p.m., and 1/8/2020 at 8:18 a.m. revealed R#16 with long nails on both hands with thick dark brown debris under the nails. During further observation and interview on 1/8/2020 at 8:22 a.m., R#16 stated his nails need to be cut and he placed a napkin in the palm of his hand to keep his nails from digging in his skin. During an interview and observation on 1/8/2020 at 12:00 p.m., Resident Care Coordinator (RCC) LL revealed that on bath days a resident should have their nails cleaned and clipped. R#16's bath days are on the 3 p.m. to 11 p.m. shift on Tuesday-Thursday-Saturday. RCC LL confirmed that R#16 nails were dirty and long on both hands and do not appear to have been cleaned or clipped on 1/7/2020 during his bath. 2. Review of the EHR revealed R#106 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE] revealed a BIMS score of 99 which indicates R#106 was unable to complete the assessment. Section G - Functional Status revealed that the resident was assessed for extensive assistance for personal hygiene. An observation on 1/6/2020 at 11:55 a.m. revealed R#106 with long nails on both hands with dark brown debris under nails. During an observation and interview on 1/9/2020 at 2:05 p.m., family of R#106 revealed that the resident's nails were dirty and long. During an observation and interview on 1/9/2020 at 2:30 p.m., the Administrator in Training (AIT) confirmed that R#106 had long nails with a brown debris under the nails. An interview was conducted on 1/9/2020 at 10:00 a.m. with the Director of Nursing (DON). The DON revealed her expectations are all residents' nails should be cut and trimmed on bath days and as needed. 3. Review of R#73's Admission MDS dated [DATE] revealed that she had short- and long-term memory problems and severely impaired decision making and was totally dependent for personal hygiene. Review of R#73's care plan for self-care deficit updated 12/4/19 revealed an intervention to assist with ADLs as needed. During observation on 1/9/2020 at 10:49 a.m., R#73 was observed in a wheelchair in her room, and she was alert but non-verbal. Further observation revealed that her fingernails were of varying lengths but all of them were long, and several fingernails had straight sharp corners and dark debris was noted under most of her fingernails. During interview with the Registered Nurse (RN) RCC AA on 1/9/2020 at 11:05 a.m., she stated that the CNAs (Certified Nursing Assistants) were responsible for doing nail care on bath days, and that R#73 was totally dependent for ADLs. During observation at this time, RCC AA verified that R#73's fingernails were long and had sharp edges and stated she would have staff cut them. 4. Review of clinical record for R R revealed that he had [DIAGNOSES REDACTED]. Review of the Quarterly MDS for R R dated 10/15/19 revealed that he had a BIMS score of 15, needed extensive assistance for dressing and personal hygiene, and was totally dependent for bathing. Review of R R's self-care deficit due to ADL decline due to [MEDICAL CONDITION] care plan revised 11/15/19 revealed an intervention to provide assistance with self-care as needed. Observation on 1/6/2020 at 4:25 p.m. revealed that R R was in his bed, and there were five dark brown spots on the fitted bed sheet on his left side, and he had dried food debris on the left side of his mouth. Observation on 1/7/2020 at 7:47 a.m. revealed that the brown spots noted on R R's fitted bed sheet were still there, and he was wearing the same shirt that he had on the previous day which had several stains on the front of it. During interview with R R at this time, he stated that he was supposed to get showers every Monday, Wednesday, and Friday, but had not gotten a shower for one week and could not remember when his bed linens were last changed. Observation at 1/7/2020 at 10:33 a.m. and 1:40 p.m., and 1/8/20 at 3:31 p.m. revealed that R R had dark debris under the fingernails of the third and fourth fingers of his left hand. During interview with R R on 1/9/2020 at 7:59 a.m., he stated that staff had changed his bed sheets, but he did not get a shower yesterday (Wednesday) as scheduled. Interview with R R on 1/9/2020 at 10:44 a.m. revealed that staff had showered him that morning. Review of the 500-Hall Bath Schedule kept at the nurse's station revealed that R R's shower days were Monday, Wednesday, and Friday on the 3:00 p.m. to 11:00 p.m. shift. Review of 30 days of printed ADL documentation (from 12/9/19 to 1/8/20) revealed that showers were only documented for R R on 12/11/19, 12/13/19, 12/16/19, 12/18/19, and 1/8/20. No documentation of showers provided on 12/20/19, 12/23/19, 12/25/19, 12/27/19, 12/30/19, 1/3/20, and 1/6/20. Review of the facility's Reports of Resident Grievance/Compliments revealed a grievance filed by a family member of R R on 12/4/19, that when she visited on 12/1/19 she had to get R R bathed, shaved, and had to change his bed linens. Further review of the grievance revealed that R R's urinal had been full which caused him to spill it on himself when he needed to use it. Review of the Actions Taken section of this grievance revealed that the DON developed a calendar for shower days which incorporated a signature agreement between the aide and the resident when a shower was provided; provided education with staff regarding how to care for a resident with [MEDICAL CONDITION]; and that bed sheets would be changed on scheduled shower days and as needed in addition to the urinal being emptied as needed.",2020-09-01
902,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,688,D,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to provide evidence that restorative services for splinting and range of motion (ROM) were consistently provided for one resident (R) (#16) of 41 sampled residents. Findings include: Observations on 1/6/2020 at 11:40 a.m., 1/7/2020 at 12:57 p.m., 1/8/2020 at 8:18 a.m., and 1/9/2020 at 9:49 a.m. revealed R#16 with left hand fingers in a bent position touching the palm. The resident was unable to straighten fingers on left hand. There was no splint on left hand. Review of the Electronic Health Record revealed R#16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated cognition intact. Section G - Functional Status revealed that the resident was assessed for total dependent for personal hygiene. Functional limitation in Range of Motion: upper extremity impairment on both sides. Section O - Special Treatment and Programs: Restorative nursing AROM (active range of motion) and splint brace assistance. Review of the care plan updated 7/29/18 identified the resident has: Range of motion limited - at risk for/actual contractures related to decreased ROM fingers. Limited joint mobility interferes with hygiene. Goals: Patient will maintain or improve ROM through the review period. Restorative program for ROM as indicated. Use devises, appliances, splints, or positioning pillows as indicated. Review of the Physician Progress History dated 12/2/19 revealed R#16 Musculoskeletal: finger contractions. Review of the Nursing Restorative Care Program revealed: Date plan developed 10/23/18. Date Program initiated 8/16/19. Duration of program: Continuous. Goal 1. Patient will tolerate wearing resting hand splint on left hand for six hours in the a.m. per day. 2. Patient will maintain/improve adequate range of motion in affected extremity/joint of splint application as evidence by splint continuing to fit appropriately. 3. Patient will maintain skin integrity in affected extremity/joint of splint application. Review of the Flow Sheet for October-December 2019 and (MONTH) 2020 revealed no documentation for the following days: October 2019: 10/23-10/31. November 2019: 11/1, 11/2, 11/3, 11/4, 11/5, 11/6, 11/7, 11/8, 11/9, 11/10, 11/11, 11/12, 11/13, 11/14, 11/15, 11/18, 11/19, 11/20, 11/21, 11/22, 11/23, 11/24, and 11/29. December 2019: 12/1, 12/4, 12/5, 12/7, 12/10, 12/15, 12/16, 12/19, 12/20, 12/21, 12/22, 12/23, 12/25,12/26, 12/30, and 12/31. January 2020: 1/1, 1/2, 1/3, 1/4, 1/5, 1/6, 1/7, 1/8, and 1/9. An interview and observation was conducted on 1/8/2020 at 12:10 p.m. with Occupational Therapist (OT) II. OT II revealed that R#16 is on restorative services and uses a splint to his left hand due to fingers are contracted. OT confirmed that he did not have on his splint and he should have the splint on his left hand. The OT revealed all CNA's are trained to apply/remove splints. The OT revealed there is a nurse that is responsible for overseeing the restorative program. An interview was conducted on 1/9/2020 at 9:00 a.m. with the Director of Rehab. The Director revealed R#16 was on therapy service 9/5/18- 10/24/2018. R#16 was discharge to restorative with AROM and splinting. An interview was conducted on 1/9/2020 at 12:49 p.m. with the Director of Nursing (DON) and the Resident Assessment Instrument Director (RAI). The DON revealed that the RAI Director is responsible for overseeing the restorative program. The RAI Director confirmed restorative services for splinting and range of motion (ROM) were not consistently provided for R#16.",2020-09-01
903,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,689,D,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to provide fall mats on the floor beside the bed, place a frequently-used item in reach (a reacher), and provide a wheelchair with a reclining back for one resident (R) (R) who had a history of [REDACTED]. In addition, the facility failed to safely transfer one resident (R#100) resulting in a skin tear to the nose. The sample size was 41 residents. Findings include: 1. Review of R R's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of R R's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score between 13 and 15 indicates no cognitive impairment); needed extensive assistance for transfers and walking in room; and supervision for eating. Review of R R's care plans for fall risk, and for fall or near fall last updated 1/7/2020 revealed they were updated to reflect the falls he sustained. Review of the interventions to these care plans revealed that they included to place a fall mat to right and left side of the bed (added 11/19/19); needed and desired items in reach/easy access (added 12/23/19); use of a reacher (added 12/23/19); and a reclining wheelchair back (added 12/8/19). Review of R R's care plan for burn/risk for burn developed 11/20/19 revealed that he spilled coffee onto his inner thighs and his abdomen was reddened. Review of the interventions for this care plan revealed for staff to pour coffee/liquids in teal insulated cup with cover and handle at bedside with straw in opening (added 12/6/19). Review of R R's neuromuscular disease care plan related to [MEDICAL CONDITION] revealed that it was updated on 12/6/19 for special feeding devices as required. Review of R R's Fall Risk assessment dated [DATE] revealed a score of 7 (a score between 7 and 18 indicates a resident is at high risk for falls). During interview with R R on 1/7/2020 at 10:45 a.m., he stated that he had rolled out of bed yesterday, but did not hurt himself, and that he has had multiple falls in the past several months. Observation on 1/7/2020 at 10:45 a.m. and 1:20 p.m.; 1/8/2020 at 7:40 a.m. and 3:31 p.m.; and 1/9/2020 at 7:59 a.m. and 10:44 a.m. revealed that there were no fall mats on the floor on either side of R R's bed. Review of R R's Nurse's Progress Notes revealed that falls or accidents included the following: 10/24/19 at 4:12 p.m.: Resident noted lying on his bedroom floor between his w/c (wheelchair) and his bed with loose stool on the floor. Resident said he stood up to get in the bed, then he slid in the loose BM (bowel movement), causing his fall. 11/20/19 at 4:45 a.m.: Resident noted trying to crawl out of bed with w/c in front of bed and bed in lowest position to floor with two fall mats to both sides of bed for fall safety. resident sustained [REDACTED]. 11/20/19 at 2:47 p.m.: Resident spilled his hot coffee this morning from the table top and it spilled on his lower abdominal area and his anterior thigh. The skin from the spilled coffee looks pinkish colored, no blisters noted, consistent with 1st degree burns, 5% of body surface area. 12/4/19 at 5:12 p.m.: Resident up in w/c after breakfast waiting for CNA (Certified Nursing Assistant) to change his bed linens. When CNA walked out of the room to get a set of sheets, resident got out of w/c walked one step and fell to the floor landing on floor mat. 12/5/19 at 7:46 p.m.: Resident out of bed in w/c most of morning to activities, resident then noted trying to get back in bed unassisted. Staff transfer resident back to bed call bell in reach. No c/o (complaints of) pain or discomfort from fall to the floor. 12/8/19 at 10:50 a.m.: Resident propelling self down hallway towards (sic) when tilted forward in wheelchair and fell to the floor. Laceration to nose and skin tears to first and second digits of right hand. Review of the facility's Incident Report log from 6/1/19 to 1/6/20 for R R that was not found in the Nurse's Progress Notes revealed these additional falls: 9/24/19 at 9:55 a.m.: Fall/near fall in room from bed, no apparent injury. 1/5/2020 at 11:45 a.m.: Fall/near fall with laceration in room-bed. Review of electronic Event-Initial Notes for R R included: 11/20/19 at 7:50 a.m.: Resident in bed with breakfast tray in front of him. While drinking coffee resident spilled the coffee onto self causing redness to abdomen and inner thighs. Unsteady, impaired judgement, [MEDICAL CONDITION], impaired safety awareness. New intervention added after the event: supervision with hot beverages to prevent further injury. 1/5/20 at 11:45 a.m.: Resident attempting to plug in charger for electric shaver and fell out of bed. Laceration right eyebrow. New intervention added after the event: Bed in low position, call light in reach, Therapy referral. (the clinical record documentation did not note whether or not fall mats were in place at the time of the fall). Observation on 1/8/2020 at 7:40 a.m. revealed that R R had been served breakfast in bed, and an uncovered regular coffee mug with two straws in it was on his tray, half consumed, and the outside of the mug felt warm to the touch. Observation on 1/8/2020 at 1:01 p.m. revealed that R R was feeding himself lunch in his room, and his coffee had been served in a metal mug with a lid on it with a straw inserted in the opening of the lid. R R stated during interview that the drink was warm, and that he had spilled and burned himself with coffee before. During interview with the Dietary Manager on 1/8/2020 at 3:41 p.m., she stated that the tray line staff was responsible for putting any adaptive eating equipment on the meal trays. She further stated that R R was supposed to get a Provale cup for his coffee and hot liquids, which looked like a short metal mug with a lid on it, and an Easy Flow cup for cold liquids, because he had spilled liquids when drinking in the past. The Dietary Manager further stated that if the Provale cup did not come back to the kitchen on R R's tray after a meal, that they did not have another one to be used for his hot liquids. During observation on 1/9/2020 at 7:59 a.m., R R was observed in bed feeding himself breakfast. Further observation revealed that there was no coffee on his tray, and R R stated that he had not received any and had asked the staff to bring him some. CNA HH entered the room at this time and brought R R a cup of coffee in a regular coffee mug with a straw in it, and handed the mug to him. R R's grip was unsteady and when holding the mug he did not keep it level so that the coffee would come up to the edge of the rim, and a small amount of the coffee spilled on the towel covering his torso. During interview with CNA HH at this time, she stated that R R was supposed to have a special mug for his coffee, but the kitchen staff was supposed to put this mug on his meal tray. CNA HH located the lidded metal insulated mug with R R's name on it on the nightstand behind and to the side of his bed, that had been left from the previous day and not removed for cleaning. During continued interview, CNA HH stated that she knew that R R was supposed to have fall mats on both sides of his bed and thought that housekeeping staff may have removed them to clean them as he sometimes spilled his urinal on them, but was not sure the last time she had seen the fall mats in his room. During interview with R R after CNA HH left the room, he stated that he has had several falls, and that he liked for the fall mats to be on the floor. He stated during further interview that he thought the mats were removed around Wednesday of the previous week but did not know why they were removed. Review of the facility's Reports of Resident Grievance/Compliments revealed a grievance filed by a family member of R R on 12/4/19, who requested that R R be given fall mats at bedside to help prevent him from falling. Review of the Actions Taken section of this grievance revealed that fall mats were in place on both sides of the bed. During interview with the Physical Therapist Director of Rehab on 1/9/2020 at 9:26 a.m., she stated that R R was not able to ambulate safely as his gait was unsteady and he scissored his legs. She further stated that fall mats must have been a nursing intervention, as rehab did not recommend them. The Rehab Director further stated that R R's vision was impaired as he had a tendency to gaze away. She further stated that the Speech Therapist (ST) recommended the use of a Provale cup to control the flow when drinking hot liquids. During interview with Occupational Therapist (OT) II on 1/9/2020 at 9:56 a.m., she stated that OT had worked with R R in part for a cup to [MEDICAL CONDITION] hot liquids, because the resident did not like the one that the ST had recommended. OT II further stated that R R told her that he liked his coffee very hot, and that he had tremors because of his [MEDICAL CONDITION]. She stated during continued interview that they tried a teal-colored metal mug with a lid on it for hot drinks, and that it seemed to work well for him. OT II further stated that the recommendation for staff was to transfer coffee from a regular mug into this insulated metal mug and put a straw through the opening on the lid, and that nursing and not Therapy obtained and provided this mug. She stated during continued interview that Therapy had not provided a wheelchair with a reclining back for R R. Review of a Speech/Language Pathology Discharge Summary dated 12/2/19 revealed: The pt (R R) was seen for an evaluation to determine the most appropriate drinking utensil to allow for decreased bolus presentation, particularly when drinking coffee. ST has recommended that the pt use a 10 cc (cubic centimeter) Provale cup to drink coffee. The pt recently spilled coffee on himself and suffered a 1st degree burn. The Provale cup allows for 10 ccs of thin liquid to be released at a time. Pt was able to drink thin consistency liquid from Provale without demonstrating of overt difficulty with swallowing. Cup has been labeled and issued to the pt. with dietary staff. Review of an Occupational Therapy Certification dated 11/26/19 revealed he (R R) was noted to be able to manipulate the spoon but has noted to have tremors all throughout the task. Spillage noted but increase shaking noted during reaching for the cup to hydrate. Review of an Occupational Therapy Discharge Summary dated 12/13/19 revealed: (R R) has been seen in skilled OT services and discharge today with FMP (Functional Maintenance Program) with staff education, staff demo good follow through of setting up the tray prior to meals. Coffee needs to be poured into the double walled cup and no ice on his tea, straws are readily available because he prefers to take his drink that way. Minimal tremors noted and no spillage noted with meals. (R R) has been provided with a double walled cup with lid and small knob that can be opened or closed to sip one's drink. It has a handle. He is able to handle the cup safely and effectively, no spillage noted, and he prefers to use a straw to drink from it. Observation on 1/9/2020 at 10:44 a.m. revealed that R R's reacher (used to grab items not in easy reach) was observed on the floor out of his reach. During interview with Registered Nurse (RN) Resident Care Coordinator (RCC) AA on 1/9/2020 at 11:05 a.m., she stated that if R R's wheelchair seat back was able to be reclined, she did not know how to do it. She verified that R R's reacher was on the floor where he could not reach it, and that all of his commonly-used items should be in his reach. RCC AA further stated that the nurses put fall interventions such as fall mats into place, and that the CNAs and all staff were responsible for ensuring that they were followed. She stated during continued interview that Housekeeping may take up fall mats to clean them and verified there were none in R R's room and did not know where they were. She stated that the Kitchen staff sent the special cups on R R's tray for his hot liquids, and that the CNAs were responsible for pouring coffee from the regular coffee mug into this special mug when he was served. Review of the Fall Management policy dated (MONTH) 2019 revealed: Fall Event: 3. Implement interventions to prevent recurrence and maintain patient safety. 2. An observation on 1/6/2020 at 11:08 a.m. revealed R#100 with an injury across her nose. R#100 was observed with a horizontal laceration approximately 3/4 inch in length and no dressing in place. R#100 reported the injury occurred when one staff member, CNA QQ used the lift to transfer her from the bed to the chair. She reported something slipped and the bar of the lift struck her nose. She further reported CNA QQ notified the nurse, but no cleansing of the wound or dressing was applied. R# 100 was sniffling throughout the interview and complained of breathing becoming more difficult. Resident blew her nose and there was blood on the tissue. R#100 was observed again at 3:00 p.m. with a dressing on her nose. During an interview on 1/07/2020 at 2:30 p.m. with R#100, she reported she hasn't been using the slide board the way she should have because CNA QQ prefers to use the lift more than the slide board. She further reported she has no objections to using the slide board and stated some staff will pick her up and she will pivot (stand pivot), or they will use the lift or the slide board. She did not recall the last time she used the slide board and she allows the staff to make the decision on how to transfer her, stating it really doesn't matter to her which method is used as long as they get her up. During an interview and observation on 1/08/2020 at 11:15 a.m. with R#100, she reported this morning that Nurse Aide Trainee (NAT) OO transferred her from the bed to the chair using the sliding board. She reported it worked out very well, and she had no difficulty using the sliding board. An observation of the area on her nose revealed it continued to be covered with a thin mesh over her nose where the injury is located. A review of R#100's medical record revealed the following Diagnoses: [REDACTED]. A review of R#100's Physician order [REDACTED]. *Eliquis 2.5 mg tablet (APIXABAN) 1 tablet by mouth 2 times per day per pharmacy recommendation Dx : DEEP VEIN [MEDICAL CONDITION] 11/04/2019 *ETH: Silicone-based Contact Layer Monday, Wednesday and Friday Day Shift Cleanse skin tear on the nasal area with Normal Saline, blot dry. Apply skin protective wipes around the wound. Cover with Versatel mesh, then secure with a band aid. Leave the Versatel mesh in place during dressing change. MWF and PRN. Dx : SKIN TEAR 01/06/2020 A review of R#100's care plan revealed she is at risk for falls or near fall; related to sliding board transfer; evidenced by fall on 7/11/19 - and reviewed and continued on 11/7/19. The goal identified is patient will be free from complications related to falling or near fall. Interventions included two person assist with sliding board transfers. A review of R#100's Activities of Daily Living (ADL) PLAN OF CARE dated 11/28/19 revealed Transfers: extensive assistance with two person assist, and Special equipment of wheelchair and sliding board. A review of R#100's Annual MDS Assessments revealed a BIMS score of 15 and the resident required two plus extensive assistance with transfers. A review of the nurses notes for R#100 revealed the following note related to the injury on her nose: 1/06/2020 - Resident was being assisted in her chair with a lift and the cross bar on the lift bumped her nose causing a small skin tear at 10:45 a.m., RCC notified, Message left for MD at 10:50 a.m., notified her son; (name) at 10:55 a.m. Resident has no c/o pain/discomfort noted, Vitals 136/74, 18, 98.1, 78, 02 sat 98% on RA (room air). A review of the clinical record shows evidence of a therapy screen being completed on 7/18/19 for a noted change of condition, indicated R#100 is being referred for sliding board transfer to decrease burden of care. A review of R#100's Occupational Therapy discharged Summary dated 9/13/19 indicated R#100 demonstrated improved strength, confidence, and decreased anxiety with sliding board transfers with different staff. She was discharged on [DATE] to restorative nursing for a functional maintenance program of exercise and positioning, which included a sliding board for equipment. A review of R#100's Physical Therapy Discharge Summary dated 9/13/19 indicated R#100 was discharged to restorative nursing for a functional maintenance program to include exercise and sliding board transfers. This document recommended sliding board transfers and exercise to bilateral lower extremities. During an interview on 1/08/2020 at 9:06 a.m. with NAT OO she reported before she transfers a resident, she will look to see how she gets up and which lift to use. She further reported she transferred R#100 using a sliding board, and indicating the resident let her know to use the sliding board. She indicated another aide assisted her with the transfer. She further reported she raised the head of her bed so she could sit up in the bed and had her place her feet on the floor. She placed the sliding board between the bed and the chair, then helped guide the resident while she slid. During an interview on 1/08/2020 at 3:11 p.m. with CNA PP, she reported she transfers R#100 with a Hoyer lift. When asked how she knows how to transfer R#100, she reported she knows this because she has been here four years and has been assigned to R#100 and is familiar with her. She further reported she ensures someone is with her when using the Hoyer lift. During an interview on 1/09/2020 at 8:47 a.m. with CNA QQ she reported R#100 used the sliding board in the past, but now they get her up with the Viking lift because she can't use the sliding board or stand pivot. She further reported therapy, the nurses and Resident Care Coordinator (RCC) are aware of her transfer status using the lift. During an interview on 1/09/2020 at 8:58 a.m. with RCC AA, she reported on admission all residents are evaluated by therapy for transfer status and this is entered into the orders under the admission order set. If they see a decline or an area they need to target, therapy will re-evaluate the resident. CNAs are aware via their Plan of Care (P[NAME]). She further reported in the weekly Utilization Review (UR) meeting they are notified of resident progression or decline, new changes, etc. RCC AA validated R#100's current P[NAME] and Care Plan. She reported she is unable to answer why CNA QQ used the Viking lift without assistance to transfer R#100 on 1/6/2020, adding that it is difficult to monitor implementation of care plan interventions. During an interview on 1/09/2020 at 9:55 a.m. with the Director of Rehab (DOR) NN, she reported they will screen residents when the nursing staff give them a referral to screen. They do not do screenings per a resident's assessment schedule. A review of the therapy referral log for R#100 revealed she was recently picked up on therapy case load (1/6/2020). She indicated R#100 received transfer training from 7/19/19 to 9/13/19, and the recommendation was for resident to transfer using the sliding board with touch or supervision assist. She further reported they notify the CNAs and Nurses during UR meeting and update the care plan. She indicated the therapy staff will go with the resident and the aide and train them on how to transfer per their recommendations. During an interview on 1/9/2020 at 12:06 p.m. with the DON she reported resident transfer status is determined on admission with an assessment tool and verifying the resident's ability level and assistance devices used. They consider a resident's Activities of Daily Living (ADL) abilities and will notify therapy and request an evaluation of the resident. The DON indicated generally they will re-assess the resident at their quarterly assessment, or if a change is noticed. She indicated staff are notified of changes to a resident's plan of care via the ADL care plan and the CNAs can pull the resident up in their plan of care (P[NAME]) to determine a resident's care needs. The nurse educator will provide training on transfers and they have involved therapy to provide training if there is a device involved. She further reported that she expects the CNAs to implement the plan of care as written. The DON verified the CNA utilized a Hoyer lift the day R#100 was injured.",2020-09-01
904,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,732,B,0,1,TXH811,"Based on observation and staff interview, the facility failed to post the nurse staffing information daily for two of four days. The facility census was 107. Findings include: During an observation on 1/6/2020 at 10:16 a.m., the posted nurse staffing information displayed in a glass at the front of the first floor of the facility carried the date of 1/2/2020. During random observations of the posted nurse staffing information on 1/6/2020 between 11:26 a.m. and 3:30 p.m., the information displayed was from 1/2/2020, which was the past weekend numbers. During an observation on 1/7/2020 at 11:11 a.m., the posted nurse staffing information displayed in a glass at the front of the first floor of the facility carried the date of 1/6/2020. During an interview on 1/7/2020 at 11:48 a.m., the administrator in training revealed that the posting of the daily staffing is the responsibility of the staffing coordinator. She stated she's aware the information posted is reflective of the previous day. The administrator said that the staffing coordinator did not come into work on 1/6/2020. Thus, the staffing for 1/6/2020 was completed but not posted. He reported the facility does not have a policy to support the expectations related to daily staffing post. During an interview on 1/9/2020 at 9:10 a.m. the Staffing Coordinator revealed he's responsible for posting the nurse staffing on a daily basis. He confirmed that the information displayed on 1/6/2020 reflected staffing for 1/2/2020 because he was out of the office on vacation.",2020-09-01
905,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,759,E,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure that the medication error rate was less than 5%. A total of 27 opportunities were observed with 10 errors for two of five residents for an error rate of 37.04%. Findings include: 1. On 1/8/2020 at 7:49 a.m., Licensed Practical Nurse (LPN) JJ was observed giving R#78 her 8:00 a.m. medications via the resident's gastrostomy tube (GT). LPN JJ counted the number of medications that he had prepared and verified that was all that the resident got for that time of day. The nurse crushed seven of the medications and put them all into one 30-cc (cubic centimeter) medication cup. After flushing R#78's GT with 30 cc of tap water, all of the crushed medications were diluted with a small amount of water in the medication cup they had been placed in, and the nurse poured the mixture with the appearance of a thick slurry with clumps into the syringe connected to the GT. Further observation revealed that this mixture was too thick to flow into the GT, and LPN JJ poured the mixture into a plastic drinking cup and added some water to the syringe and milked the GT tubing in an attempt to get it to flow again. Once the flow was restored, the LPN added more water to the remaining medications in the 30-cc medication cup and the plastic cup he had emptied the undissolved medications in, and poured them into the syringe connected to the GT, but the pill mixture would not flow into the GT and LPN JJ had to again empty the GT syringe into the plastic drinking cup while he added more water to the syringe and restored the flow into the GT. LPN JJ then added more water to the remaining medications that had been emptied from the GT syringe and poured them into the syringe, and he was able to get the medications to flow into the GT at this time. The nurse was observed to flush the GT with 30 cc of water after he said he was finished giving the medications, but a small amount of pill residue was observed in the plastic drinking cup he had emptied the partially dissolved crushed medications in. During interview with LPN JJ on 1/8/2020 at 8:13 a.m., he verified that he combined all of the crushed medications together in one cup. Review of R#78's Consolidated (Physician) Orders and eMAR (electronic Medication Administration Record) revealed that calcitonin nasal spray was ordered to be given daily, and scheduled at 8:00 a.m., the same scheduled time of the other medications observed given at 7:49 a.m. However, the calcitonin was not observed given by LPN J[NAME] Further review of the Physician order [REDACTED]. Further review of R#78's Physician order [REDACTED]. During interview with LPN JJ on 1/8/20 at 10:35 a.m., he verified that he had omitted the calcitonin in error during the 8:00 a.m. med pass for R#78. He further verified that he gave 5 mL of [MEDICATION NAME] instead of the ordered 10 mL. LPN JJ stated during continued interview that he was taught to either crush each med separately and dilute each with water when giving medications via a GT but had also been taught he could crush and place all meds into a single cup and give it all at one time. He verified that during the observed medication pass today that he crushed and combined all the medications given via the GT for R#78. Review of the facility's Feeding Systems policy dated (MONTH) 2019 revealed: Medication Administration Via Tube: H. Prepare medications for administration: 1. Crush tablets and dissolve in water or other appropriate liquid. 4. Dilute liquids with water, using up to 60 ml of water for highly concentrated solutions. [NAME] Administer medications separately as outlined per pharmacy guidelines. Review of the Pharmacy Services Enternal (sic) Tube Medication Administration policy (undated) revealed: Guideline: 1. It is recommended that crushed medications not be combined and given all at once via feeding tube in order to avoid obstructing the tube and to ensure the complete delivery of each medication. 9. Prepare medication for administration: -Crush tablets(s) and dissolve in water or other appropriate liquid. -Flushing should occur between each crushed or liquid medication administered per tube. The Director of Nursing (DON) verified during interview on 1/8/2020 at 9:54 a.m. that the facility's policy was to give each medication separately when given via a GT. 2. On 1/8/2020 at 8:26 a.m., LPN KK was observed giving R#85 her 8:00 a.m. medications. One of the medications prepared and given was [MEDICATION NAME] DM ([MEDICATION NAME]) 600 mg/30 mg (600 mg of [MEDICATION NAME] and 30 mg of [MEDICATION NAME]), one tablet. Review of R#85's Consolidated (Physician) Orders revealed an order for [REDACTED]. During interview with LPN KK on 1/8/2020 at 10:41 a.m., he verified the Physician order [REDACTED].#85 revealed that he gave [MEDICATION NAME] DM. LPN KK stated that the [MEDICATION NAME] was a stock drug and not labeled for individual resident use, and he found a box of plain [MEDICATION NAME] in the medication cart and verified that this was what he should have given to R#85.",2020-09-01
906,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,761,D,0,1,TXH811,"Based on observation, review of the facility policy titled Medication Storage in the Care Center, and staff interviews, the facility failed to ensure that one of four medication carts was locked and medications secured when not in use. Findings include: On 1/8/2020 at 7:49 a.m., Licensed Practical Nurse (LPN) JJ was observed preparing and giving medications to resident (R) #78. As he entered the resident's room to administer the medications, it was observed that he left a bottle of Certravite (multivitamins) unsecured on top of the cart, and the bottle of pills felt full when lifted. Further observation revealed that LPN JJ did not lock the medication cart when leaving it to give R#78's medications, which took approximately 15 minutes to administer via her gastrostomy tube. One observation in the hallway outside R#78's room on the 400-hall after entering her room revealed that two randomly-observed residents self-propelled their wheelchairs past the unlocked medication cart. During interview with LPN JJ on 1/8/2020 at 8:13 a.m. after the completion of R#78's medication administration, he verified that he had left the medication cart unlocked and the vitamins left on top of the cart while he was giving R#78's medications, and that he usually puts all medications away and locked the cart when it was unattended. Review of the facility's policy Medication Storage in the Care Center (undated) revealed: Intent: Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. Guideline: 2. Only licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. During interview on 1/8/2020 at 9:54 a.m., the Director of Nursing (DON) verified that the facility's policy was to lock the medication cart when unattended, and that all medications should be locked inside the cart when not attended.",2020-09-01
907,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2020-01-09,880,D,0,1,TXH811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and review of facility policies, the facility failed to store a urinary catheter bedside drainage bag and leg bag in a sanitary manner for one resident (R) (#100) reviewed of four residents with indwelling urinary catheters. Findings include: A review of R100's Annual Minimum Data Set (MDS) Assessments dated 12/16/19 revealed she has no cognitive deficits and under bowel and bladder appliances, indwelling catheter is indicated, including indwelling suprapubic and nephrostomy tube. A review of R#100's clinical record revealed the following Diagnoses: [REDACTED]. A review of R#100's physician orders dated 11/26/19 revealed the following: Catheter Suprapubic Cather Size= 16 French balloon size= 10cc to bedside drainage. A review of R#100's Care Plan revealed the following: Problem: urinary catheter (11/7/19) related to neuromuscular dysfunction of bladder. Interventions: maintain closed, sterile system, and tubing free of kinks. Observation of R#100 on 1/06/2020 at 11:26 a.m. revealed a catheter drainage bag sitting in the privacy bag hanging from the bed and a catheter leg bag strapped to her left leg/shin, secured with an elastic band. She reported they switch from the catheter drainage bag to the catheter leg bag when she transfers from the bed to the wheelchair. In an interview on 1/8/2020 at 1:16 p.m. with Nurse Assistant Trainee (NAT) OO, she reported her process for this resident's catheter storage as disconnecting the catheter tubing from the bag, then connecting the tubing to her leg bag. She first places the leg bag on the resident's leg and secures it with an elastic band that has buttons on it. She reported she will empty the drainage bag then place it back into the privacy bag. During an observation, NAT OO removed the catheter drainage bag from the privacy bag below R#100's bed. The catheter drainage bag had not yet been emptied, and the end of the catheter tubing that connects to the bag (white tip) was not covered. She further reported that she obtained the leg bag from the bathroom grab bar. An observation of the resident's bathroom at this time, revealed a discolored leg drainage bag hanging over the grab bar in the resident bathroom, adjacent to the commode. In an interview on 1/08/2020 at 3:13 p.m. with Certified Nursing Assistant (CNA) PP, she reported she provides catheter care when getting R#100 up and putting her to bed. She reported after care is provided, she then rinses the leg bag, places it in a clear trash bag and leaves it in the bag in the bathroom with the bed number on it. She reported the bed drainage bag is reused and placed back into the privacy bag. She further reported she would clean/wash/sanitize the white tip prior to placing the bag into storage. In an interview on 1/09/2020 at 12:19 p.m. with the Director of Nursing (DON) she reported they should empty the drainage bag prior to disconnecting it. Once disconnected the CNA will cap off the ends and place it in a plastic bag and stored it in her bedside table. DON read the policy, which included a diluted bleach solution for rinsing and cover drainage bag tip with protective cap. She further reported her expectation is for staff to follow this policy and for CNAs to drain the leg bag prior to removing it, then rinse the leg bag with tap water, then drained or discarded and a new one obtained. DON confirmed upon review of the picture taken of the catheter drainage bag that the white tip of the drainage bag was not in a protective cap or secured per the bag style. She further confirmed upon review of a picture taken of the leg bag that, the leg bag was stored in the resident bathroom and hanging over the grab bar, not in a sanitary manner. The Nurse Consultant, at this time, confirmed the leg bag was not stored per best practices. A review a policy titled Skilled Inpatient Services Foley Catheter Care updated for release (MONTH) 2019, did not provide guidance related to sanitary storage of catheter bags (leg and drainage) when not in use. Review of the facility policy titled Skilled Inpatient Services Catheter Leg Bag Decontamination, updated for release (MONTH) 2019, revealed to provide decontamination of an indwelling catheter leg bag decreasing the risk of UTI from connecting/disconnecting leg bag and cleaning the bag. This policy did not provide guidance related to sanitary storage of catheter leg bags when not in use.",2020-09-01
908,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2018-08-02,584,E,0,1,6T5N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to maintain clean resident's care equipment by assuring there was no dirt or debris buildup on lifts and one scale. The census was 105 residents. Findings include: Observation on 7/30/18 at 1:16 p.m. of lift on hallway outside of room [ROOM NUMBER] observed to have missing paint and have a black buildup of dirt at base of lift. Observation on 8/2/18 at 11:29 a.m. on 100 Hall revealed lift near room [ROOM NUMBER] with black dirt and build up on base. Observation on 8/2/18 at 11:33 a.m. on 400 hall revealed a lift (7-6-18) #8 with black dirt and buildup on base of the lift. Observation on 8/2/18 at 11:37 a.m. on 500 hall revealed a Lift with black dirt and buildup on base of the lift. Observation on 8/2/18 at 11:40 a.m. on 200 hall revealed a lift noted with black dirt and buildup on base. Environmental tour with Maintenance Supervisor began on 8/2/18 at 11:43 a.m. and confirmed the following: 1. Observation of the lift on 200 hall black dirt and build up on base of lift. 2. Observation of the lift on 100 hall found to have black build up on the base of the lift. There were 2 standup lifts and a 1 swing lift all noted to have black build up on the base and connecter of the lifts. 3. Observation of #8 lift on 500 hall with black dirt build up and missing paint on base. Interview on 8/2/18 at 11:45 a.m. with Central Supply who reported that it was her understanding that Certified Nursing Assistants (CNA) are responsible for the cleaning of lifts after usage. Interview and observation on 8/02/18 at 12:32 p.m. with the Director of Nursing (DON ) who reported that lifts are to be cleaned by housekeeping staff. Upon observation of lift in hallway on 100 hall DON confirmed the buildup of dirt and debris and reported again that housekeeping staff are responsible for the dusting and cleaning of the lifts and the CNAs are to wipe down if they are soiled. DON further reported that Maintenance is responsible for paintings and functioning upkeep of the lifts. Interview on 8/2/18 at 12:38 p.m. with the Environmental/Laundry Supervisor who reported that wheelchairs are cleaned on Fridays and lifts are typically cleaned at that time. Documentation of the cleaning of the lifts was requested but not received. Interview on 8/2/18 at 12:55 p.m. with the Administrator who reported that Guardian Angel rounding is done daily and results are discussed in morning meeting. Surveyor requested guardian angel round reports for the month of July. Interview on 8/2/18 at 1:39 p.m. with the Administrator reported that wheelchairs and lifts are to be cleaned on Fridays. He provided a copy of a wheelchair cleaning schedule that staff were to use as a guide for cleaning but did not have an actual schedule of cleaning for the lifts. He further reported that his documentation of the Guardian Angel program rounds is not available due to a computer issue. When a picture of lifts were shown to the Administrator he reported that the lift looked like it had not been cleaned for at least two Fridays. Interview on 8/2/18 at 2:47 p.m. with Housekeeper DD who reported that housekeeping does not clean the lifts and Central Supply is responsible for this task. Interview and observation on 8/2/18 at 3:30 p.m. with Environmental/Laundry Supervisor reported that the scale is responsibility of nursing to clean. It was confirmed that the scale had dust, dirt, and buildup on the base. Interview on 8/2/18 at 3:33 p.m. with the Assistant Director of Nursing (ADON) who reported that she is unsure of who should clean the scale but confirmed the scale was dirty. The scale was noted to have dust and dirt build up at the base of the scale. Environment/Laundry Supervisor reported that she would clean the scale as soon as residents were no longer being weighed. Wheelchair Cleaning schedule: It is the responsibility of the nursing staff that the chairs and lifts are spot cleaned daily.",2020-09-01
909,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2018-08-02,644,D,0,1,6T5N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to refer Level II PASRR (Preadmission Screening and Resident Review) to the appropriate state-designated authority for evaluation and determination of specialized services for one of one resident (R) #50 reviewed that was later identified with mental illness. Sample size was 24. Findings Included: Review of R#50 clinical record revealed the resident was admitted on [DATE]. R#50 current [DIAGNOSES REDACTED]. Current medications: [REDACTED] 1/2 tab at bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 20mg one tab by mouth every morning for depression. Review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Section D D0200 Resident Mood Interview symptom presence B. Feeling down depressed, or hopeless. C. Trouble falling asleep, or staying asleep, or sleeping too much D. Feeling tired or having little energy. Section N N0410 Medication Received [NAME] Antipsychotic 4 out of 7 days. C. Antidepressant 7 out of 7days. An interview on 8/2/18 at 3:45 p.m. with R#50 revealed that when she was admitted to the facility she was having uncontrolled crying spells. Review of the physician progress notes [REDACTED]. An interview was conducted on 8/2/18 at 4:45 p.m. with the Social Service Director (SSD) regarding the facility policy on PASRR level II screening. The Social Service Director revealed the facility has no policy on PASRR screening and the facility strictly follow the state and federal guidelines. The Social Service Director confirmed R#50 had a significant change in behavior after admission and there was no Resident Review (PASRR) II screening for the newly identified mental illness. An interview was conducted on 8/2/18 at 5:03 p.m. with the Director of Nursing (DON) regarding her expectations of resident review for PASRR level I and II screening and determination of specialized services for resident that are identified with mental illness. The DON stated she is not familiar with the PASRR process and it is the responsibility of the SSD.",2020-09-01
910,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2018-08-02,656,D,0,1,6T5N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to develop comprehensive care plans for one of one resident (R) #50 reviewed related to [MEDICAL CONDITION] drug use. Sample size was 24. Findings Included: Review of R#50 clinical record revealed the resident was admitted on [DATE]. R#50 had the following current [DIAGNOSES REDACTED]. Current medications: [REDACTED] 1/2 tab at bedtime for [MEDICAL CONDITION], [MEDICATION NAME] 20mg one tab by mouth every morning for depression. Review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed was assessed with [REDACTED]. Feeling down depressed, or hopeless. C. Trouble falling asleep, or staying asleep, or sleeping too much D. Feeling tired or having little energy. Section N N0410 Medication Received [NAME] Antipsychotic 4 out of 7 days. C. Antidepressant 7 out of 7days. Section V. Care Area Assessment (CAA) Summary decision. V0200. CAA and Care Planning, care area 17. [MEDICAL CONDITION] drug use triggered with the decision to care plan. Review of the current comprehensive care plan revealed there was no care plan for [MEDICAL CONDITION] drug use. No documentation in the medical records on the facility's rational for deciding not to proceed with care planning for the triggered area of [MEDICAL CONDITION] drug use. An interview was conducted on 8/2/18 at 5:32 p.m. with the Care Plan Coordinator regarding R#50 comprehensive care plan. The Care Plan Coordinator confirmed that R#50 did not have a care plan for [MEDICAL CONDITION] drug use in the electronic medical records. Revealed that it should be a care plan on the chart reflecting [MEDICAL CONDITION] drug use.",2020-09-01
911,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2017-09-28,242,D,0,1,GWKO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, it was determined the facility failed to assist one resident (R) #111 who desired to spend time outside on the facility's porch. This effected one of 21 residents reviewed for self-determination. Findings include: Policy review of the facility's Developing an Interdisciplinary Care Plan - At a Glance document, no date listed on the document, revealed it is the policy of Bolingreen Health & Rehabilitation to develop individualized programs that assist residents to maintain their highest level of function. The individualized program should consider the resident's desires as part of the development process. Interview conducted on 9/27/17 at 9:11 a.m. with R#111 in her room revealed that she had previously informed facility managerial staff of her desire to go outside of the facility for fresh air and sunshine. The resident stated she was informed by facility staff members she needed to have either a family member or a staff member accompany her outside for safety. R#111 was instructed to request to be accompanied by a staff member each time she desired to exit the facility. R#111 voiced frustration that when she asked individual facility staff members to accompany her outside, she was often told they were too busy at the time to take her. The resident reported had complained to the facility administrator, social worker and Assistant Director of Nursing (ADON) about the unavailability of staff to accompany her outside when she requested. All interviewed staff subsequently denied R#111 had ever asked them specifically to accompany her outside of the facility No observations were made of staff asking the resident to accompany her outside at any time before 9/27/17 of the survey. On 9/27/17 at 2:30 p.m. following staff interviews regarding R#111's choice to be outside of the facility, the resident was observed seated on the facility's porch with a staff member present. Record review of R#111's medical record revealed the resident was admitted to the facility on [DATE] with primary medical [DIAGNOSES REDACTED]. The use of a walker was required to assist with ambulation and was without any cognitive deficits. On 5/15/17 R#111 sustained a compression fracture to her lumbar spine after another resident fell into her causing the fall. No other falls were documented for the resident during her admission to the facility. Record review of the R#111's Significant Change assessment dated [DATE] indicated that the assessment was conducted as a result of a fall on 5/15/17 in the facility's shower room that resulted in an injury to R#111's lumbar spine. Further review of the 5/30/17 MDS assessment revealed the resident was not a flight risk and going outside was somewhat important to her. Review of R#111's written Plan of Care developed falling the 5/15/17 fall with fracture and the 5/30/17 Significant Change Assessment, failed to reveal any safety interventions requiring the resident to being accompanied by a family member or staff member when she requested to go outside of the facility. Further review of the written Plan of Care did reveal evidence of approaches to address R#111 activity preferences, fall prevention measures and other safety concerns. Interview conducted on 9/27/17 at 10:26 a.m. with the facility's social worker (SW) in the Social Work Office revealed R#111 had voice frustration to her of not being able to go outside when she wanted. SW#AA stated the resident had been informed she needs to have someone with her when she goes outside. There was no written plan or set schedule for staff to take the resident outside. It is to up to her to ask someone when she desires to go outside for her safety. The social worker was unable to recall the date when R#111 voiced her frustration and denied the existence of any documentation of the encounter. Interview conducted on 9/27/17 at 10:43 a.m. with the facility's ADON the Transitional Care Unit (TCU) Nurses Station revealed R#111 has voice her desire to go outside of the facility and yes, she has voiced concerned that staff were not available to take her outside when she asks. The ADON acknowledged there are no schedule or assigned staff member to take the resident outside. The ADON denied the existence of any documentation related R#111 desire to go onto the facility's porch or that the issue was discussed in subsequent interdisciplinary care conferences. Interview conducted 9/27/17 at 11:07 a.m. at the TCU nurses station with the Director of Nursing (DON) revealed Resident # 111 is restricted from going outside unaccompanied by either a family or staff member. The DON acknowledged the restriction was due to the resident having an unsteady gait related to a fall on 5/15/217 with a compression fraction to her lumbar spine. We have told her she must either have a family member or staff member with her when she goes outside. The DON also stated she can go outside anytime she wants, as long as someone is with her. The DON acknowledged it was the resident's responsibility to find someone to accompany her outside the facility. Interview conducted 9/27/2017 at 11:37 a.m. with the facility Administrator revealed he was not aware R #111 was not being accommodated by staff when she had requested to go outside. The Administrator revealed he was aware R#111 had an unsteady gait and required to have someone with her when she is outside. The Administrator stated if he had been aware R#111 was frustrated that staff were not taking her outside he would have designated someone to take accompany her outside.",2020-09-01
912,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2017-09-28,279,D,0,1,GWKO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and review of facility policies, it was determined the facility failed to develop comprehensive care plans for one resident (R) # 111 from a sample of 21 residents reviewed for self-determination (Resident #111) Findings include: Review of an undated policy titled Developing an Interdisciplinary Care Plan - At a Glance revealed resident care plans must include consultation recommendations from identified disciplines that constitute the interdisciplinary team, such as Therapy. Interview conducted on 9/27/17 at 9:11 a.m. with R#111 in her room revealed she had previously informed facility managerial staff of her desire to go outside of the facility for short periods of time for fresh air and sunshine. The resident stated she was informed by facility staff members she needed to have either a family member or a staff member accompany her outside for safety due to an unsteady gait Record review of the resident's 5/30/17 Minimum Data Set (MDS), Significant Change revealed R#111 sustained a compression fracture of her lumbar spine following a fall in the facility's shower room on 5/15/17. Review of the assessment revealed R#111 was admitted to the facility on [DATE] with primary medical [DIAGNOSES REDACTED]. The assessment findings determined R#111 had no cognitive deficits, had no mood or behavioral issues, was not prone to wandering and was somewhat found of spending time outside. Review of R#111's written Plan of Care, developed based on the 5/30/17 MDS assessment, failed to reveal any safety interventions requiring the resident to being accompanied by a family or staff member when she desired to go outside of the facility. The plan of care was developed to address the resident's safety, fall risk and activity preferences. A walker devices was documented as required for ambulation assistance. Interview conducted on 9/27/17 at 10:55 a.m. in the MDS Office with MDS Coordinator CC revealed a written plan of care had not been developed to address R#111's needs to go outside of the facility. MDS Coordinator CC acknowledged she was aware R#111 required either a family or staff member to accompany the resident outside due to her unsteady gait. MDS Coordinator CC's understood it was the resident's responsibility to find someone to take her outside. MDS Coordinator CC acknowledged a plan of care should have been developed to address the resident's safety needs. Interview conducted on 9/28/17at 8:44 a.m. in the Rehabilitation Office with the facility's Rehabilitation Director revealed R#111 had received therapy following a fall with a fracture on 5/15/17. The Director stated the Physical Therapist (PT), who is no longer employed at the facility, had imposed the safety measure requiring someone being with the resident when outside of the facility. The Rehabilitation Director also revealed the safety measure was not documented in the PT's notes, and no individual was identified as being responsible for accompanying Resident # 111 outside of the facility. The Director revealed the safety precaution was passed on verbally to the facility's nursing service, who was expected to provide staff for the safety precaution. Record review of Physical Therapy Daily Notes, 5/26/17, 6/20/17 and 6/26/17 failed to reveal any recommendation by the Physical Therapist of the safety need for R#111 to be accompanied by either a family or staff member when on the facility's porch. Interviews conducted on 09/28/2017 9:47:57 at the TCU nurses station with CNA HH, CNA II and CNA JJ resulted in each CNA denying R#111 had ever approached them requesting assistance to exit to the facility's porch.",2020-09-01
913,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2018-03-29,690,E,0,1,JQP411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review and review of a written policy titled Daily Cath Care Policy, the facility failed to provide adequate catheter care for two residents (R)#8 and (R )#49 of three residents with catheters. In addition the facility failed to follow their policy for catheter care. Finding include; 1. Resident #49 was admitted to the facility on [DATE]. The residents [DIAGNOSES REDACTED]. Review of R#49's Annual Minimum Data Set (MDS) assessment dated [DATE], the Brief Interview for Mental Status (BIMS) score of 12 out of 15 indicating the resident has moderate cognitive impairment. During an interview on 3/27/2018 at 9:58 a.m. with R#49 she stated she has had a catheter since (MONTH) 23, (YEAR). R#49 stated it has not been changed since being put in while in the hospital. She stated she doesn't know why she still has the catheter unless its because she can't walk and she wears a brief for a bowel movement . R#49 continued saying she has not had any kind of bladder training to attempt removal of the catheter. States the physician comes every Saturday and she has asked him at different times since being admitted here when she can get the catheter out and she states he told her that when she gets to walking better but not until. Stated she is having pelvic area pain now like she has a UTI and that she has asked about getting an order from the doctor to get her urine checked. On 3/27/2018 at 10:17 a.m. durning an Interview with R#49 revealed she has had 2 UTI's since being admitted to the facility and that she had to go to the hospital one time since being admitted here and they found out she had a urinary tract infections [MEDICAL CONDITION] when she got to the hospital. States her daughter said she was a little out of her mind when they got her to the hospital. She states she wears a brief and when she needs to have a bowel movement she goes in her brief and the CNA's will come change her when they get a chance. Also states that her catheter leaks a lot and she has told the physician every Saturday when he comes that she wants the catheter out and states he told her that when she gets to walking better it can come out. Record Review revealed on 2/17/2018 a History and Physical form from a local Medical Center reads: Patient at a SNF (Skilled Nursing Facility) brought into the emergency department because she called for an ambulance in the room. She said she needed an ambulance because felt as though she might fall. While in the emergency department the patient began to have hallucinations seeing her son in the room, believing that she was in a jungle. Urine Analysis suggestive of UTI and hospital service called for acute [MEDICAL CONDITION] due to suspected UTI. Diagnosis, Assessment and Plan reads: 1. Acute [MEDICAL CONDITION] due to suspected UTI: On 3/28/2018 10:20 a.m. the Assisted Director of Nursing (ADON)the was in the room, with the residents permission the surveyor observed the ADON to confirm the size of the catheter and balloon by looking at the catheter. She confirmed the catheter is a 16 FR with a 10cc Balloon. During observation R#49 stated to the ADON that she has told the physician that her catheter is leaking and that she wants the catheter out. The ADON advised the resident that she will call the physician. On 3/28/2018 10:25 a.m. Interview with LPN FF revealed that upon reviewing the residents Medication Administration Record [REDACTED]. 3/28/18 10:30 a.m. Interview with the ADON revealed that they do not typically do intake. 3/28/18 10:35 a.m. Interview with LPN CC revealed that upon looking in the resident's chart there is no intake and output documented in the record. 3/28/18 10:36 a.m. Interview with LPN FF revealed that upon looking in the resident's chart there is not intake and output documented in the record. 3/28/18 10:40 a.m. Interview with the Director of Nursing (DON) revealed that if a resident with an indwelling Foley catheter complains of burning, discomfort, leaking she would check the balloon and placement. States she would expect staff to change out the Foley catheter if the catheter continues to leak after checking placement and balloon. On 3/28/2018 at 10:45 a.m. during interview with the DON revealed, upon review of Electronic Medical Record (EMR) with the surveyor, there is no intake and output flow sheet on the EMR and there is no documentation in the nurses notes of intake and output, or documentation of daily catheter care per the policy, DON states that she isn't going to waste the surveyors time because upon review of the EMR the intake and output and catheter care is not being documented. States she will begin re-education and in-services with staff immediately. Review of an undated Daily Catheter Care Policy reveals staff should maintain accurate records of the resident's daily fluid intake and output and that the collection bag should be emptied every night, eight (8) hours or more often if necessary. Reporting Procedures reads: Upon completion of giving catheter care, the nurse assistance should report the following to the staff/charge nurse: 1. That the catheter care had been given. 2. The time the care was given. 3. How the resident tolerated the procedure. 4. Any complaints the resident may have of burning, tenderness, pain in the urethral area, or changes in the appearance of the urine. If the resident refused the treatment, the reason(s) why. 6. Your observations of anything unusual. Documentation: As a minimum, the following information must be recorded the resident's clinical record: Nurses's Notes, Medication Administration Record [REDACTED]. b. The date and time it was performed. c. Amount of urine drained. If sent to the lab, note laboratory tests requested. d. Summary of what was done and why it was necessary. e. Observations relating to the initial procedure, e.g., obstruction, discomfort, refusal, urine clear, or evidence of blood or pus. f. Other information as needed or that may be requested. g. Signature and title of the person recording the data. 2. Resident #8 was admitted to the facility on [DATE], her [DIAGNOSES REDACTED]. R#8 has a urinary catheter related to (r/t) stage 3 or 4 pressure ulcer in sacral area affected by incontinence. Review of the Admission MDS dated [DATE] R#8 BIMS is coded 15 out of 15 which indicates the little to no cognitive impairment. On 3/27/2018 at 11:34 a.m. R#8 was observed in bed with a indwelling catheter in place the tubing was noted to be cloudy and full of sediment that was thick, milky white in appearance. On 3/28/2018 at 11:00 a.m. observation of the catheter tubing with Licensed Practical Nurse (LPN) EE, stated the resident's catheter may require changing. Nurse stated she needed to check to see when the catheter was last changed. LPN EE referred to the Wound Care Nurse, for information as to when catheter should be changed. Further conversation with wound care nurse revealed that R#8's catheter had not been changed in January, (MONTH) and thus far in (MONTH) of (YEAR). On 3/28/2018 at 11:23 a.m. during a parallel observation with the Director of Nursing (DON) when she observed the catheter tubing. The DON stated that based on what she observed she would have encouraged staff to change the catheter tubing. On 3/28/2018 at 12:00 p.m. Review of an undated policy titled Daily Catheter Care stated change tubing immediately should it become contaminated. DON was asked to clarify the phrase from the policy from this policy. At that time she stated she could not be would seek clarification. On 3/28/2018 at 12:30 p.m. DON explained that contamination meant staff should change the tubing immediately should it touch a dirty surface while being inserted. On 3/28/2018 at 1:00 p.m. review of R#8's care plan identifies a problem stating; Resident has a urinary catheter relating to (r/t) stage 3 or 4 pressure ulcer in sacral area affected by incontinence. Resident is at risk for infection. Goal for the problem states resident will have no signs or symptoms of urinary tract infection [MEDICAL CONDITION] through next review. Interventions include but not limited to change catheter per policy, change drainage bag per policy, keep catheter tubing free of kinks. Keep drainage bag below level of bladder and provide catheter care. The facility was unable to provide evidence that catheter care was being done,",2020-09-01
914,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2018-03-29,693,D,0,1,JQP411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, facility failed to follow physician's orders to check residual for one Resident (R)#8 of seven residents receiving tube feedings. Findings include: On 3/28/2018 at 12:15 p.m. during medication administration observation, it was noted Licensed Practical Nurse(LPN) EE did not accurately measure R#8's abdominal contents for residual. After listening for proper placement of the gastrostomy tube ([DEVICE]), LPN EE began to aspirate the contents. After viewing the contents, nurse returned them to R#8's stomach. Surveyor asked nurse how much did she get for residual, nurse stated more than 60 cubic centimeters (cc) but the syringe she used was a 60 cc syringe. On 3/28/2018 at 1:00 p.m. review of R#8's physician orders state, check residual every shift, if greater than or equal to 100cc, hold tube feeding for 1 hour and recheck. If residual still over 100cc notify MD. On 3/29/2018 at 10:00 a.m. an interview with Director of Nursing (DON) revealed that staff should be using a 100cc syringe. If there was not one available then staff should have 2 60cc syringes. On 3/29/2018 at 1:00 p.m. an interview with LPN EE revealed that she felt she followed procedure and was correct in her process.",2020-09-01
915,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2018-03-29,761,D,0,1,JQP411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to follow the policy titled Storage of Medications and Biological's. They failed to ensure disposal of expired medications in two of ten medication carts. Findings Include: On 3/28/2018 at 11:42 a.m. it was identified by the Director of Nursing (DON) that the facility has ten medication carts. Five medication carts were observed, with four expired medications in two carts of the five carts: 1. On 3/28/2018 at 11:42 a.m. observation with Licensed Practical Nurse (LPN) EE found expired medications in cart number five of the Rehabilitation Unit. The medications were: One box of [MEDICATION NAME] Powder 25 calories per serving found in cart number five, expired on 5/9/2017 Lot number 6069T176A0. One box of [MEDICATION NAME] 10 milligrams tablets expired on 10/17. Lot number Y . 2. On 3/28/2018 at 11:59 a.m. observation with Licensed Practical Nurse (LPN) FF found expired medications in cart number four. The following expired medications were found: One bottle of [MEDICATION NAME] Sodium 50 milligrams capsules, lot number A , expired on 2/2018. One bottle of Calcium 600 milligrams with vitamin D, lot number 747F01, expired on 2/2018. A record review of the facility's Storage of Medications and Biologicals, Medication Administration policy with an issue date of (MONTH) 1st, 2007 and a review/revision date of (MONTH) 1st, 2010/ (MONTH) 1st, 2013, revealed the facility will ensure medications and biologicals are stored, labeled, and disposed of properly by expiration date. An interview on 3/28/2018 at 11:42 a.m. with the Licensed Practical Nurse (LPN) EE revealed staff are expected to date/label all medications when opened and check for expired medications in the medication carts on a daily basis before the administration of medication to all residents. An interview on 3/28/2018 at 11:59 a.m. with Licensed Practical Nurse (LPN) FF revealed staff are expected to date all medications when opened and check for expiration date. An interview on 3/28/2018 at 12:10 p.m. with the Director of Nursing (DON) revealed staff are in-serviced on medication storage, medication administration, medication expiration date, DON initiates in-services to all Licensed Nurses.",2020-09-01
916,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2017-04-13,241,D,0,1,O5WC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure one of 29 sampled residents (R) (R#149) was provided care and services in a manner enhancing their dignity and respect. Signage with personal information related to bowel movements was placed on the wall in two separate places in full view of staff or visitors entering the resident's room. Findings include: Observation on 4/10/17 at 12:05 p.m., in R#149's room revealed a sign posted in two places on the wall which read, Please put (resident's full name) in bed after lunch so she can make (sic) her bowel movement (BM), it is easier for her when she is in bed than when she is sitting up. Interview with the Staff Development Coordinator (SDC) on 4/12/17 at 1:15 p.m., regarding the signage posted in the resident's room, the SDC stated that residents' personal information should not be posted in the residents' rooms. The surveyor accompanied the SDC to R#129's room. The SDC acknowledged both signs should be covered. On 4/12/17 at 3:04 p.m., during a follow-up interview with SDC, she stated that the social service director was going to try and contact the family about the signs. The SDC stated she felt it was probably the family that posted the signs in R#149's room, but nursing should have removed the signs or put a cover sheet over them. Review of R#149 annual Minimum Date Set ((MDS) dated [DATE] and most recent quarterly assessment dated [DATE], indicated the resident had a Brief Interview for Mental Status (BIMS) score of 0/15 which indicated severe cognitive impairment. During an interview on 4/13/17 at 8:32 a.m., Certified Nursing Assistant (CNA) FF stated that she takes care of R#149 on a regular basis. CNA FF stated R#149 only speaks Spanish, was dependent on staff for all care needs and does not talk much. When asked about the signs on the wall, CNA FF stated that she did not post the signs. CNA FF stated, It was probably the family, the signs have been up for a while.",2020-09-01
917,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2017-04-13,274,D,0,1,O5WC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, and record review the facility failed to assure that a Significant Change Assessment was completed for one of 29 sampled residents. Facility staff failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) after Resident (R) (R#147) had a change in cognition and activities of daily living. Findings include: Resident #147 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. The discharge to the hospital was unplanned and a readmission was anticipated. Residnet #147 was readmitted from the hospital on [DATE]. Review of the 14-day admission MDS with an Assessment Reference Date (ARD) of 11/25/16 and compared to the Quarterly MDS with an ARD date of 2/18/17 showed R#147's Brief Interview for Mental Status (BIMS) score improved from 5 (severe impairment) to 13 (cognitively intact). His bed mobility, transfers, locomotion on unit, eating, personal hygiene all showed a decrease by two or more points and were documented as total dependence changed Review of the MDS Care Area Assessments (CAA's) dated 11/25/16 showed R#147 triggered for Activities of Daily Living (ADL's). The Quarterly MDS review dated 2/18/17, under Discharge Q300: Residents Overall Expectation was not completed. (This includes discharge). During an interview on 4/13/17 at 9:32 a.m., MDS staff EE, stated a Continuation of Therapy (COT) MDS had been completed on 12/2/17 and this would replace a need for a SCS[NAME] Review of the COT MDS dated [DATE] showed a BIMS score was not completed and for ADL's the only areas reviewed were: Bed mobility, Transfer, Eating and Toilet use. When a policy for SCSA was requested the facility provided pages 2-22 to 2-28 of the CMS Resident Assessment Instrument (RAI) 3.0 Manual. Review of the RAI manual on page 2-22; 03. SCS[NAME] Documentation shows: A significant change is a decline or improvement of a resident's status that: 2. Impacts more than one area of the resident's health status. During an interview on 4/13/17 at 10:07 a.m., MDS staff EE, stated a SCSA had been opened up for R#147 and the facility would reassess and monitor.",2020-09-01
918,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2017-04-13,281,D,0,1,O5WC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and review of the facility's policy on Administration of Medication, the facility staff failed to assure that one of 29 sampled residents (R) (R#237), blood pressure (BP) was taken to determine whether a medication to control the resident's hypertension (high BP) should be administered in accordance with the BP parameters ordered by the physician. Licensed staff administered medication without assessing the resident's blood pressure. Findings include: According to R#237's Face Sheet the facility admitted the resident on 12/16/16. Her [DIAGNOSES REDACTED]. Review of R#237's admission screening and assessment tool Minimum (MDS) data set [DATE] revealed that she was totally dependent on staff for all activities of daily living except eating. She had a BIMS (Brief Interview for Mental Status) score of 5 out of a possible 15 indicating she had severe cognitive impairment. Resident #237 had a physician's orders [REDACTED]. Hold if blood pressure is less than 120. Review of R#237's Care Plan dated 12/28/16 revealed Resident has potential for complications related to [DIAGNOSES REDACTED].#237 included, Administer medications as ordered and monitor for side effects and effectiveness (see current physician's orders [REDACTED]. Observation on 4/12/17 at 10:10 a.m., revealed facility licensed practical nurse (LPN) GG did not obtain R#237's blood pressure as ordered by the physician prior to administering the medication [MEDICATION NAME] 50 milligrams. During interview with LPN GG at 10:14 a.m., she stated, I took blood pressures before I started {medication administration}. Upon further inquiry she was unable to provide the resident's current blood pressure or show documentation of a blood pressure obtained prior to the administration of medication. Review of R#237's clinical record revealed no documentation on the MAR (Medication Administration Record) that blood pressures were taken prior to administering [MEDICATION NAME] 50 milligrams as ordered by the physician since February. Review of the facility's policy on Administration of Medication revealed a Standard, that All medications are administered safely and appropriately to help residents overcome illness, relive/prevent symptoms and help in diagnosis. Procedure # 20 of the policy indicated Medication that requires blood pressure (BP) parameters is charted in the MAR (Medication Administration Record). The LPN did not implement the procedure. She failed to meet professional standards of clinical practice as determined by the facility's own policy through failure to obtain and document R#237's blood pressure in the MAR prior to administering medication. In addition, the LPN failed to meet professional standards of quality by providing R#237 with care and services as written in the plan of care through failure to administer the medication as ordered by the physician.",2020-09-01
919,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2019-04-26,637,D,1,1,YLUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident and staff interview, the facility failed to complete a Significant Change Minimum Data Set (MDS) assessment after declines in cognition, five areas of ADL (Activities of Daily Living), and in bladder and bowel continence between the Quarterly MDS assessments of 1/9/19 and 4/11/19 for one resident (R) (#94). In addition, the facility failed to do a Significant Change MDS for one resident (R#65) who had been placed under Hospice services. The sample size was 38 residents. Findings include: Review of the facility's Resident Assessment Instrument & Care Plan policy last revised 11/28/16 revealed the following: The MDS uses assessment, patient observation, staff, family and patient interviews to form the foundation of the comprehensive assessment. MDS assessments are completed at a minimum upon admission, quarterly, annually, and with a significant change in patient status. The Care Area Assessment provides a systematic method to further assess the patient and determine if the Care Area that triggered requires interventions and care planning. The information identified using the MDS and Care Area Assessment process is used to develop an individualized person-centered Care Plan that includes the patient's voice, the patient's goals while residing in the facility and for discharge that assist the patient to attain and/or maintain their highest practicable level of well-being. 1. Review of R#94's Quarterly MDS dated [DATE] revealed that she had a BIMS (Brief Interview for Mental Status) score of 12 (a BIMS score between 8 and 12 indicates moderate cognitive impairment); needed limited assistance by two persons for transfers; needed extensive assistance by one person for dressing, toilet use, and personal hygiene; needed supervision only for eating; and was frequently incontinent of bowel and bladder. Review of R#94's Quarterly MDS dated [DATE] revealed that she had a BIMS score of 00 (a BIMS between 0 and 7 indicates severe cognitive impairment); was totally dependent by two persons physical assist for transfers; was totally dependent by one person physical assist for dressing, toilet use, and bathing; needed extensive physical assistance by one person for the ADL of eating; and was always incontinent of bowel and bladder. During interview with the Director of Rehabilitation Services on 4/25/19 at 1:28 p.m., she stated that R#94 had been on rehab caseload in the past for functional intervention, but was not currently. She further stated that if a resident had a decline in their ADL, therapy would want to know this so that they could screen them for skilled services, but had not gotten a referral from nursing for R#94. During interview with Licensed Practical Nurse (LPN) MDS Coordinator KK on 4/25/19 at 1:36 p.m., a Significant Change MDS would be done if a resident had two or more significant events, such as going on hospice services, a new wound, weight loss, or decline in ADL. She verified that R#94 had areas of decline from the (MONTH) and (MONTH) MDS in areas of cognition, transfers, dressing, toilet use, bathing, eating, and continence, and that a Significant Change assessment would have been appropriate after the (MONTH) MDS. During interview with R#94 on 4/26/19 at 2:24 p.m., she stated that she did not feel that physical or occupational therapy would be beneficial for her. 2. Review of the clinical records for R#65 revealed she was admitted to the facility on [DATE] and, after a hospital stay beginning on 10/3/18, was readmitted on hospice services with [DIAGNOSES REDACTED]. A review of the MDS assessments revealed the last comprehensive assessment completed for the resident was an admission MDS of 9/19/18. After her admission to hospice services on 10/9/18, two quarterly assessments were completed on 12/20/18 and 3/22/19, respectively. However, there was no evidence that a comprehensive assessment had been completed to reflect the significant change the resident experienced at the time of her admission to hospice services. Interview on 4/19/19 at 10:45 a.m. with LPN MDS Coordinator NN revealed that a significant change assessment should be completed when a resident has significant changes in at least two areas of functioning. A significant change assessment should have been completed for R#65 after she was admitted to hospice which signaled that she had a significant decline in several areas. That such an assessment was not completed for the resident was an oversight and one would be completed immediately.",2020-09-01
920,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2019-04-26,640,B,1,1,YLUP11,"> Based on record review and staff interview, the facility failed to ensure that discharge Minimum Data Set (MDS) assessments were transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for three of six discharged residents (R) (#1, #100, #101) reviewed. Findings include: Review of a CASPER (Certification and Survey Provider Enhanced Reports) Report (GA) MDS 3.0 Missing OBRA (Omnibus Budget Reconciliation Act) Assessment report with a run date of 4/26/19 revealed that R#1, R#100, and R#101 had missing MDS assessments. Review of R#1 MDS listing in the facility's computerized MDS system revealed that she had an Entry Tracking Record dated 11/16/18, an OBRA Admission/5-day assessment on 11/23/18, a 14-day assessment on 11/29/18, a 30-day assessment on 12/17/18, and a Discharge/Return Anticipated MDS on 12/19/18. Review of R#1's computerized Nurse's Notes dated 12/19/18 at 1:36 p.m. revealed that she was discharged to the hospital. During interview with Licensed Practical Nurse (LPN) MDS Coordinator KK on 4/25/19 at 2:35 p.m., she stated that all of R#1's MDS in their computerized system had a Status of Completed, except for the Entry and Admission MDS, which had a Status of Accepted. MDS LPN KK stated during continued interview that R#1's Discharge MDS was completed on 12/27/18, and verified that her Discharge MDS did not have a Status of Accepted. During interview with LPN MDS Coordinator NN at this time, she stated the facility transitioned from one computerized software system to another one in (MONTH) of (YEAR), and during this time they had to manually select which MDS to transmit to CMS. LPN MDS NN stated during continued interview that they chose not to submit R#1's Discharge MDS in error, and would do so that day. During interview with LPN MDS Coordinator NN on 4/26/19 at 10:04 a.m., she stated that R#101 was discharged from the facility on 1/24/19, and that they had completed a Discharge MDS with Return Not Anticipated MDS on 1/30/19. She further stated that R#100 was discharged from the facility on 2/23/19, and his Discharge MDS with Return Not Anticipated MDS was completed on 2/26/19. She verified during further interview that neither of these Discharge MDS had been transmitted to CMS, and should have been.",2020-09-01
921,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2019-04-26,684,D,1,1,YLUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interviews, the facility failed to follow Physician order [REDACTED].#67 and R#42) related to wearing TED hose (compression stockings) of 38 sampled residents. Findings include: 1. Review of the clinical record revealed R#67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) coded as 10, indicating moderate cognitive impairment. Section G - Functional Status documented that the resident requires extensive assistance with dressing including donning and removing TED hose. Review of the Physician order [REDACTED]. Observation on 4/23/19 at 11:40 a.m. revealed R#67 sitting in the wheelchair with no TED hose on. The resident wore regular red socks. The Medication Administration Record [REDACTED]. During an interview on 4/24/19 at 3:06 p.m., Certified Nursing Assistant (CNA) DD stated that she was not aware that R67 has an order to wear TED hose and has never put TED hose on the resident. During an interview on 4/24/19 at 3:30 p.m., CNA FF stated that R#67 wore regular socks and the charge nurse never gave them report for R#67 to wear TED hose. 2. Review of the clinical record revealed R#42 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Annual MDS assessment dated [DATE] revealed a BIMS coded as 03, indicating severe cognitive impairment. Section G - Functional Status documented that the resident requires extensive assistance with dressing including donning and removing TED hose. Review of the POF dated 3/20/19 revealed an order for [REDACTED]. Observation on 4/23/19 at 1:15 p.m. revealed R#42 sitting in the wheelchair. The resident was not wearing TED hose. Review of the MAR for (MONTH) 2019 and (MONTH) 2019 revealed that the order was not transcribed. During an interview on 4/24/19 at 4:00 p.m., Licensed Practical Nurse (LPN) GG stated that she received the orders for the TED hose and forgot to enter them on the MARs.",2020-09-01
922,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2019-04-26,689,G,1,1,YLUP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interviews, record review, review of the facility policies titled Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages and Feeding a Resident, the facility failed to provide adequate supervision when offering hot beverages for three residents (R) (#85, #99, and #33) of 38 sampled residents. The three residents [MEDICAL CONDITION] their body which resulted in actual harm. Findings include: Review of the undated facility policy titled Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages revealed: [MEDICAL CONDITION] result from hot liquids that are 120 degrees F (Fahrenheit) or above, supervision is required to provide a safe environment in which our residents can enjoy a good-tasting cup of coffee or other hot beverages. Hot beverages should be available to residents only in areas that are supervised at all times. Evaluate each resident's ability to manage hot beverages and provide needed assistance. Develop a process to ensure that all associates involved with dining, activities, etc., are aware of who needs this special supervision. Review of the facility policy titled Feeding a Resident effective 11/26/18 revealed that it was the responsibility of all nursing staff to provide assistance to residents who are unable to feed themselves or need assistance with meals and snacks. This facility will ensure that properly trained personnel supervised by nursing assist residents as needed with meals and snacks and feed residents who are unable to feed themselves. 1. R#85 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Assessment for R#85 dated 4/9/19 revealed a Brief Interview for Mental Status (BIMS) score of 8 (a BIMS score of 8 to 12 indicates moderately-impaired cognition). Section G - Functional Status documented the resident requires one-person extensive assistance with eating. Resident #85's baseline care plan dated 4/2/19 notes resident skin was intact and states resident requires assistance with activities of daily living (ADL) and mobility. During an interview on 4/23/19 at 10:33 a.m., R#85 stated he wanted to go home but the burn wound on his thigh was keeping him from going home. During wound care observation on 4/24/19 at 10:34 a.m., Licensed Practical Nurse (LPN) II and LPN Wound Care Nurse HH provided the dressing change to R#85's right thigh. LPN II stated the wound was a healing burn and that the resident fell asleep and spilled hot coffee on his leg. A review of Nurse's Note for 4/5/19 offered an event note timed 23:45 (military time) which stated Resident observed with lesion on his right upper thigh. Resident stated, The coffee spilled on me and burned me. Physician (MD) notified, resident's family notified. New order for [MEDICATION NAME] ointment applied to area. Resident is stable. No acute distress noted. The Weekly Skin Integrity Data Collection forms for R#85 documented the following: On 4/5/29, resident has lesion from burn to right front thigh. On 4/6/19, resident has a burn to right front inner thigh, skin blistering. On 4/9/19, burn to the right front thigh continues with decreased scarring. No signs and symptoms of infection. On 4/12/19, right front thigh blister intact. On 4/17/19, right front thigh burn noted with layer of yellow tissue at wound surface. R#85 was seen by Wound Physicians starting 4/9/19 and review of the latest Wound Evaluation and Management Summary dated 4/23/19 revealed a wound 8.3 centimeters (cm) in length (L), 12.5 cm in width (W) and 0.1 cm in depth (D) to the right thigh caused by a coffee burn was unchanged with 50% necrotic tissue. Resident received excisional debridement. During an interview on 4/24/19 at 3:33 p.m., the Administrator stated the burn incident occurred around 5:30 p.m. on 4/5/19. He completed an investigation which revealed Certified Nursing Assistant (CNA) MM served hot coffee to R#85. R#85 was lying in bed and the coffee spilled, burning his leg. After completion of the investigation, CNA MM was terminated due to failure to follow facility policy on serving hot beverages. Administrator stated facility policy is that temperature checks are completed on all hot liquids leaving the kitchen. He further stated that the coffee company came to the facility to lower the coffee machine temperatures to less than 165 degrees. An interview on 4/24/19 at 3:47 p.m. with Assistant Director of Nursing (ADON) revealed R#85 requested a cup of coffee. CNA MM went to the kitchen, requested a cup of coffee and was told by dietary staff to serve herself. CNA MM obtained the coffee and provided it to the resident. ADON further stated that after the incident, all coffee pots were removed from the pantries and thermoses are now in their place. An interview on 4/25/19 at 4:00 p.m. with DON revealed there have been two other burn incidents in the facility. On 10/1/18, R#33 was burned after CNA heated soup, upon request, on the night shift. At that time all staff were educated and banned from heating any beverages for residents. DON further stated CNA violated policy when she retrieved coffee without the knowledge of dietary staff. Since this incident, the kitchen is now locked. Any staff requesting entrance must be let in by the dietary staff. An interview on 4/25/19 at 4:24 p.m. with Food Service Director (FSD) revealed there were three employees on duty the evening of the incident. All employees denied allowing access to the kitchen. FSD stated the kitchen usually closes around 8:30 - 9:00 p.m. The coffee had not yet been sent out in thermoses to the floor pantries. FSD further stated it is the facility's policy to check the temperature on all hot beverages before they leave the kitchen. The temperatures are taken and then logged. If the temperatures are greater than 150 they are cooled down with water; and that only dietary staff should be in the kitchen. No beverages were logged in that evening. During further interview on 4/26/19 at 1:21 p.m., R#85 stated he could recall the incident where he was burned. He stated he requested a cup of coffee from the CN[NAME] She brought it in and placed it on the table next to the bed. When he attempted to bring the table closer, the coffee turned over on his lap. An interview with Wound Care Physician on 4/26/19 at 3:28 p.m. revealed he was unable to assign a degree of burn to R#85's wound due to the amount of necrotic tissue present and the wound has some full to partial thickness involvement. The wound is healing as expected and requires some debridement. The wound is superficial in nature. He further stated that if the wound was a third degree burn, the resident would have been sent to a wound clinic. 2. Review of a [DIAGNOSES REDACTED].#99 had [DIAGNOSES REDACTED]. Review of R#99's completed MDS revealed that she had Entry Tracking Records on 12/7/18, 12/18/18, 3/1/19, and 3/15/19. Further review of her MDS revealed Discharge Assessment-Return Anticipated completed on 12/9/18, 1/26/19, 3/9/19, and 3/26/19. Review of R#99's Admission MDS dated [DATE] revealed that she had a BIMS score of 9, needed extensive one-person assist for eating, and had no burns. Review of her Medicare 5-day MDS dated [DATE] revealed these items were coded the same as on the Admission MDS, except her BIMS score was 8. Review of a care plan initiated 12/7/18 revealed that R#99 needed ADL assistance and therapy services to maintain or attain highest level of function. Review of the Interventions/Tasks of this care plan included assist with ADLs as needed. Review of a care plan developed 3/24/19 revealed R#99 sustained a burn to the right breast and right flank. Interventions/Tasks to this care plan included to refer to therapy for assistive device for hot beverage. Review of a Speech Therapy SLP (Speech Language Pathologist) Evaluation and Plan of Treatment dated 3/19/19 revealed R#99 was referred to ST (Speech Therapy) services for dysphagia due to decline in ability to respond to cues/instruction, ability to use compensatory strategies, signs/symptoms of dysphagia, pneumonia, oral/pharyngeal function, need for assistance from others and safety awareness. Clinical Impressions: Based on the evaluation only, patient is at risk for aspiration pneumonia and a diet downgrade. Patient exhibits increased confusion, limited verbal output, lack of mastication, and poor tongue strength. Patient also exhibits similar s/s (signs and symptoms) of a stroke or TIA, but hospital tests came back negative. Patient not appropriate for ST services due to recent medical decline and increased inability to participate. Review of Nursing Progress Notes revealed the following: 3/17/19 10:33 p.m. Health Status Note: Resident weak and non-verbal. 3/19/19 8:38 a.m. Health Status Note: Resident unable to swallow. Will not open mouth or speak at this time. 3/24/19 10:18 a.m. Event Note: Pt. (patient) found in bed by nurse with coffee spilled on bedside table, gown and bed. Skin noted to be red on abdomen, right breast area and right flank. [MEDICATION NAME] 1% cream to be applied to right abdomen, right flank daily until healed. Treatment carried out by wound care nurse. Pain assessment rendered. OT (Occupational Therapy) screen ordered for device needed for hot beverages. New order for wound MD to evaluate and treat if appropriate. 3/24/19 2:19 p.m. Health Status Note: Skin assessed, red area on abdomen and right breast. No blisters noted. No complaints of pain but upon assessment and palpation around the area, resident begin to frown. 3/24/19 3:22 p.m. Skin/Wound Note: Reported new skin issue, area assessed. Patient has newly burn site to right upper quadrant of abdomen extended to right flank, redness to the area noted no drainage, new order for [MEDICATION NAME] cream to apply daily and prn (as needed) until resolved. 3/26/19 1:00 p.m. Event Note: Skin to abdomen is intact with slight redness noted. No blistering or open areas. (R#99) denies pain. Review of a Weekly Skin Integrity Data Collection dated 3/24/19 revealed a new finding of burn to abdomen and right rear iliac crest, treated per wound care. Review of an incident report dated 3/24/19 revealed: Writer went to resident's room and saw coffee spilled on the bedside table and on resident's gown and on resident, skin red on right breast area around to right flank. Therapy to screen for device for hot beverages, wound care MD to evaluate. Mental status oriented to person and place. Predisposing Physiological Factors: recent illness. No witnesses. Review of a physician phone order dated 3/24/19 revealed to cleanse right abdomen and flank burn site with normal saline, apply [MEDICATION NAME] cream and leave area open to air daily. Review of a Wound Evaluation & Management Summary dated 3/26/19 revealed: Patient presents with a wound on her right, anterior flank. There is no exudate. There is no indication of pain associated with this condition. Burn wound of the right, anterior flank. Wound size: 3.0 x 12.0 x not measurable (centimeters). Primary dressing: Silver [MEDICATION NAME] apply once daily for 30 days. During interview with the DON on 4/25/19 at 5:32 p.m., she stated that CNA LL was the staff member who had served R#99 the coffee the day the resident was burned. She stated during further interview that the CNA had made coffee from the single-serve coffee maker in the pantry but did not know what the temperature of the coffee maker was set to. During interview with CNA LL on 4/25/19 at 7:05 p.m., she stated that when she was passing breakfast trays on the unit on 3/24/19, she offered R#99 a cup of coffee, which was stored on top of the breakfast carts. She stated during further interview that she added some cold milk to the coffee cup, placed a straw in the cup, remained with the resident as she took her first sip, and then placed the cup on the overbed table. The CNA further stated that the resident had no difficulty drinking the coffee, so she left the room and continued passing breakfast trays to other residents on the unit. CNA LL stated during continued interview that when she had reached the end of the hall, she was told that R#99 had spilled the coffee on herself. She stated that she had received education several times, both before and after this incident, about the handling of hot beverages, and that staff were not allowed to heat up a resident's coffee. CNA LL added that when working with a resident she was not familiar with, she asked the nurse about what the resident's care needs and level of assistance were. During interview with the DON on 4/26/19 at 9:22 a.m., she stated that when she interviewed CNA LL after R#99 was burned, the CNA said that R#99 was alert when served the coffee. The DON further stated that the CNA told her that she supervised R#99 when she took her first sip with a straw, and then left the room to continue to pass the breakfast trays. The DON stated during continued interview that R#99 had been in and out of the hospital several times and could not remember what her physical status was at the time of the burn. During interview with LPN MDS Coordinator NN on 4/26/19 at 10:08 a.m., she stated that if a resident was coded as needing extensive assistance for eating with one-person physical assist, that staff should be present when the resident was eating or drinking. During interview with the Director of Rehabilitation Services on 4/26/19 at 10:12 a.m., she stated that they did not have an assistive device for hot beverages (as per intervention in R#99's burn care plan), but rather looked more at a supervision and positioning aspect for drinking hot beverages. Continued interview revealed that the last time R#99 was on therapy caseload was from 3/15/19 to 3/26/19 for general strengthening and mobility, as the resident had a decline with physical mobility and weakness after a hospitalization for pneumonitis. The Rehabilitation Director further stated that ST assessed R#99 as supervision for self-feeding, and that the ST evaluation dated 3/19/19 had a recommendation for upright position during feeding with an emphasis more on swallowing than ability to feed herself safely. She further stated that on the OT evaluation dated 3/16/19, R#99 was assessed as independent for eating. During interview with SLP OO on 4/26/19 at 10:56 a.m., she stated that she screened R#99 for skilled ST services after a hospital readmission. She further stated that there was a change in the resident's medical status and cognition, and she was not as aware of her surroundings. She stated during continued interview that when she evaluated R#99 on 3/19/19, she recommended that the resident required supervision with eating due to changes in cognition and medical status. SLP OO further stated that she did not feel that R#99 was safe to feed herself after 3/19/19 because of this decline and periods of varying awareness and needed to be supervised when eating and drinking. During interview with LPN Wound Care Nurse HH on 4/26/19 at 1:25 p.m., she stated that she recalled R#99's burn, and that the resident's skin was intact and just reddened, but not blistered. Review of a Quality Assurance and Performance Improvement Plan for Hot Beverage (undated but with the first goals dated 3/24/19) revealed that a resident (R#99) sustained a burn to right breast and flank area. Actions included wound care MD to evaluate and treat; therapy screen for device and self-feeding of hot liquids; one cup coffee maker immediately taken out of use and removed from nutrition room. Staff to be educated on pouring and set-up of hot beverages with post-test on reducing the risk [MEDICAL CONDITION] hot beverages. Establish times that coffee tea and cocoa will be available to residents with supervision. Coffee will be made from equipment located inside the food service department only and transferred to carafes to be served on unit. Hot liquids will be checked and recorded on the food temp log to ensure guidelines are met before leaving the department. 3. Review of the clinical records revealed R#33 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the MDS assessments revealed a Quarterly MDS of 8/3/18 which revealed R#33 had BIMS score of 15, indicating that the resident was cognitively intact. The assessment also documented that the resident needed extensive assistance with bed mobility and one-person limited assistance with eating (an assessment that a resident needs limited assistance in this area means that, while the resident is able to eat by herself/himself, staff must set up the tray and assist with needed items such as cutting meat, opening containers, and handing utensils. At times, such as when the resident is tired, staff may also need to guide the resident's hand so she/he will get the utensils to his/her mouth). During an interview with R#33 on 4/26/19 at 12:28 p.m., it was revealed that she sustained a burn in (MONTH) or (MONTH) of (YEAR) during the 11:00 p.m. to the 7:00 a.m. shift. This occurred after she asked a CNA to heat up some soup she could have as a late snack. The resident said she placed the soup in a Styrofoam cup and gave it to the CNA to be heated in the microwave. When the CNA returned with the heated soup, she cautioned the resident to be careful because the soup was hot. The resident said she was very hungry so she immediately put the soup to her mouth, but when it burned her lips, she must have squeezed the cup, reflexively, causing the hot soup to spill on her chest. The CNA came in immediately when she called and placed some cold, wet towels on the burned area. The resident said she later learned that the CNA had been reprimanded and that the staff were advised that they were no longer able to heat/reheat food items on her behalf. Review of an incident report dated 9/30/18 at 1:00 a.m. revealed the resident had sustained a burn to her breast during the night shift. The nurse was called to the room by the resident (R#33) who stated that she had wasted her soup cup on her chest that the CNA had just warmed up for her. The resident was listed as being in bed and alert and oriented to her surroundings when the incident occurred. The physician was notified and gave orders to monitor the resident's chest for signs and symptoms of infection every shift related to a thermal burn allegedly caused by food to chest area. The incident report also documented that the resident's care plan was reviewed and updated and that the resident and staff were educated on handling hot objects. Review of a physician's telephone order form of 9/30/18 revealed that the staff received orders to cleanse the resident's sternum with normal saline, pat dry, apply [MEDICATION NAME] cream, and cover with a protective dressing daily and as needed. Review of an Initial Wound Evaluation and Management Summary of 10/2/18 revealed that the resident was referred by the physician for assessment and evaluation of a burn wound of the anterior chest of at least three days duration. The area was described as having a light serous exudate with a partial thickness wound related to the resident spilling hot noodles on the chest. The wound size was described as being 22 cm L x 21 cm W x 0.1 cm D with 60% dermis/40% skin affected. The recommended treatment was for silver [MEDICATION NAME] to be applied once daily for 30 days. The Rehab Services Screen of 10/5/18 documented that R#33 sustained a burn to the chest over the previous weekend while eating hot soup in bed. The screen also documented that nursing staff had reported that the resident frequently ate in bed with the head of the bed at a 35-degree elevation. The resident was assessed as having no changes in the areas of self-feeding, swallowing, cognition, communication, and range of motion/strength. The therapy staff recommended that it was appropriate for the resident to continue to eat as before but, because she normally ate in bed, it was recommended that the head of the bed be positioned at 60 degrees to prevent future burn injury, spillage, etc. Review of the care plans for R#33 revealed a plan of care for ADLs initiated 2/22/18 and updated on 9/30/18 for noncompliance with upright positioning while eating. A review of staff education documents of 10/2/18 revealed more than 100 members of staff were provided education related to Reducing the Risk [MEDICAL CONDITION] Residents from Hot Beverages. Post-tests elicited responses that: hot beverages were to be served at 145 to 155 Fahrenheit; staff should never warm up liquids if they were not part of the dietary staff; and all hot beverages should be served in a mug. However, residents were still [MEDICAL CONDITION] to hot liquids despite the facility staff education of (MONTH) (YEAR). A review of the pantry areas on the resident hallways revealed copies of posted signs which read: Liquids shouldn't be warmed up by staff. Any Liquids to be warm should be taken to dietary to be warmed by Dietary Staff ONLY. An interview on 4/19/19 at 2:46 p.m. with the DON revealed that R#33 sustained a burn to her chest after she asked a CNA to warm some soup on her behalf and, subsequently, dropped said soup on her person when she discovered it was too hot. The DON said that the facility immediately educated all staff that non-dietary staff are not to heat/reheat liquids for residents. If residents need liquids heated/reheated, dietary staff must perform this action and must take the temperature of the heated food item before it is served to the resident. The DON said the management team determined that only dietary staff had the training and equipment needed to reheat food items on behalf of residents because these food items must be a certain temperature before being presented to the resident. A therapy screen determined that R#33 was appropriate to have hot liquids/items without supervision if she was sitting upright during its consumption. The CNA involved in the incident also received the relevant training.",2020-09-01
923,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2019-08-09,656,D,1,0,S67E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident, staff interview, facility training Indwelling urinary catheter (foley) care and management the facility failed to develop and implement the care plan related to caring for a urinary catheter as appropriated of one resident (R) R#1; of three (3) residents with indwelling urinary catheter. Finding include: Review of R #1's Admission Minim Data Set (MDS) assessement dated 2/14/19 revealed that she had an indwelling catheter, and indwelling catheter triggered as an area of concern on the Care Area Assessment Summary. Review of her MDS dated [DATE] revealed that she still had an indwelling catheter. Comprehensive care plan developed on 2/7/19 and revised on 4/2/19 did not address resident indwelling catheter. The care plan did not address the resident ' s foley catheter and interventions included to care for the catheter as appropriate. During observation of catheter care by CNA AA on 8/8/19 at 9:55 a.m. revealed continuous use of the wet cloth use to provide care was soiled with feces in which she continuous introduction of feces into the resident periurethral and meatal area while providing care. Further observation revealed the catheter tubing was not inspected or cleaned during the care. Interview with Certified Nursing Assistant (CNA) AA on during the catheter care observation 8/8/18 she stated that she been a CNA for 8 years and attended training for catheter care x 1 month ago. She stated that she was trained to perform the catheter care always first before attending to resident soiled brief to prevent feces contamination. According to the facility skills checklist- Indwelling urinary catheter (foley) care and management state: Develop an individual care plan based on assessment findings and revise as needed and identify approaches to minimize the risk of infection by providing catheter/tubing/bag care. Review of hospital discharge summaries revealed that on 5/27/19 resident was admitted to the hospital with [REDACTED]. The second admission to the same hospital on [DATE] final [DIAGNOSES REDACTED]. Her most recent hospitalization on [DATE] states resident again had a [DIAGNOSES REDACTED]. A urine culture pending upon discharge from hospital following a broad-spectrum antibiotics therapy. Cross-reference F690",2020-09-01
924,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2019-08-09,690,D,1,0,S67E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, and staff interview, the facility failed to perform catheter care in a manner to prevent a potential urinary tract infection [MEDICAL CONDITION] due to fecal contamination. For one of three Residents (R) #1 resident reviewed for with history urinary tract infections [MEDICAL CONDITION], or urinary catheter use, and the sample size three (3) residents. Findings include: Review of R #1 clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly Minimum Data Set (MDS) dated Quarterly 5/17/19 revealed that she had a Brief Interview for Mental Status (BIMS) score a 1 indicates severely-impaired cognition; however, the resident had a recent decline in physical and mental status and was not able to answer screening questions. Further review of this MDS revealed the resident needed extensive assistance by two staff for bed mobility and transfers. MDS assessment on 2/14/19 and 7/19/19 section H bowel and bladder revealed R#1 was assessed as having an indwelling catheter. According to hospital discharge summaries revealed that on 5/27/19 resident was admitted to the hospital with [REDACTED]. The second admission to the same hospital on [DATE] final [DIAGNOSES REDACTED]. Her most recent hospitalization on [DATE] states resident again had a [DIAGNOSES REDACTED]. A urine culture pending upon discharge from hospital following a broad-spectrum antibiotics therapy. Observation of R #1 catheter care conducted on 8/8/19 revealed that R#1 had a bowel movement and the CNA AA repeatedly introduce feces into the resident periurethral and meatal area. Further observation revealed that AA failed to inspect and clean the catheter tubing during care. During an interview with Certified Nursing Assistant (CNA) AA on during the catheter care observation 8/8/18 she stated that she been a CNA for 8 years and attended training for catheter care x 1 month ago. She stated that she was trained to perform the catheter care always first before attending to resident soiled brief to prevent feces contamination. During an interview with the Director of Nursing (DON) on 8/9/19, revealed that the facility use Lippincott 2019 Skills check list procedure to train staff catheter care and AA was taken off direct care temporarily until she was properly trained for peri care and catheter care. She also revealed that the facility had recently hired Staff developer and was unable to locate training record for AA and other staff. She further revealed that AA should have stopped catheter care and performed incontinent care for the resident's bowel first and resumed the catheter care. Review of the facility Lippincott procedure 2019 Skill checklist Indwelling urinary catheter and management which instruct to cleanse the periurethral and meatal area using soap and water OR perineal cleanser, cleansing front to back.",2020-09-01
925,LIFE CARE CENTER OF GWINNETT,115347,3850 SAFEHAVEN DRIVE,LAWRENCEVILLE,GA,30044,2017-10-12,425,D,1,0,GRKE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, staff interviews, record review, review of the facility Physician order [REDACTED].#1) of three (3) sampled residents. Findings include: An interview with the Complainant and the Resident's (R1's) Responsible party on 10/12/17 at 12:05 p.m. revealed R1's family believes the facility abruptly stopped administering Zoloft to R1 as prescribed, causing her mental health to decline and her dementia worsen and caused her recent fall and subsequent injury because it made her dizzy. Review of the clinical record for Resident (R#1) revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Record Review revealed the resident had experienced a fall on 9/9/17 attempting to go to the toilet without assistance. The resident had sustained a laceration to her head requiring four staples to close to the wound. Review of the Physician order [REDACTED]. clarify and include in new order discontinuation of the existing order. Review of Physician orders [REDACTED]. Review of the Hospital discharge medicine list also revealed two orders for Sertraline 25mg 1 tablet by mouth daily. Further review of the physician's orders [REDACTED]. The order did not indicate that the order to discontinue was only for the duplicate order. An additional order dated 9/16/17 for Sertraline 25 mg tablet daily indicating the medication was resumed on 9/17/17. Review of the Medication Administration Record [REDACTED]. The order for Sertraline 25 mg one daily was not transcribed to the (MONTH) (YEAR) MAR until (MONTH) 17, (YEAR) indicating (R#1) did not receive medication as ordered by the Physician from (MONTH) 1, (YEAR)-September 16, (YEAR). Interview on 10/12/17 with Registered Nurse (RN)/Unit Manager HH revealed that R#1 was admitted to the facility with a prescription for Zoloft/Sertraline and another antidepressant medication. However, the hospital orders were duplicated in transcription, for Sertraline 25 mg one daily. The facility nurse reviewed the orders and intended to discontinue one of the orders because it was a duplicate. When we faxed it to the pharmacy, it was automatically discontinued and R#1 did not receive the Zoloft/Sertraline until the error was discovered. However, the resident did receive the Zoloft /Sertraline on 8/31/17.The order for Sertraline 25 mg tab by mouth at 9 a.m. for depression happened on time on 8/31/17 and resumed on 9/16/17 when the family asked if she was getting the medication. After this incident, the staff development nurse gave Licensed Practical Nurse LPN (II) training on how to transcribe when you have duplicate orders. I would expect my nurses to write that an order is duplicate on the orders if she was discontinuing a duplicate order. Interview on 10/12/17 at 5:21 p.m. with R#1's Physician revealed, the same way you can change one antidepressant to another, there is no detrimental effect for discontinuing Zoloft/Sertraline. It would not cause dizziness or disorientation. This is not a huge medical impact on the patient's quality of life causing major side effects. Interview on 10/12/17 at 5:51 p.m. with facility pharmacy consultant KK revealed if it's a high dose you would taper down over a few weeks to avoid side effects. R#1 was already a low dose and so it's hard to say it would contribute to a fall. I don't believe stopping a dose that low would be a factor. Interview on 10/12/17 at 6:35 p.m.-with Administrator-QA is monthly, and as needed and the medical director is there each meeting. We review all departments and we have a report from pharmacy. We have not had a QA meeting since this incident, if the nurses find an incident with a med error, the nurse's immediately educate. If there is a pattern, it's brought up in Q[NAME] I believe this incident was isolated. Things happen. We feel there is a process in place to make sure this does not happen again. We are going to put it in QA and address it in the next meeting. The nurses have monthly in-service meetings-this is not a pattern it was just a fluke but it is something we are keeping an eye on. We will be putting this in the QAPI. Interview 10/13/17 at 9:07 a.m. with the Dispensing Pharmacy General Manager revealed if the pharmacy receives an order to discontinue Zoloft/Sertraline, it will be discontinued off the profile. The system would have caught any duplication of the original orders and left only one (1) prescription if a duplicate order was submitted. The dispensing pharmacy encourages the facility to read through hospital orders and transcribe them before sending them to the dispensing pharmacy. On the dispensing pharmacy side, we would catch the duplicate and only fill it once. The facility should have just marked through the duplicate or discontinued the original order. It could be considered a documentation issue. The key is for the facility to review and transcribe orders and convert them to the dispensing pharmacy order sheet prior to submission, this is strongly encouraged, but not mandated. There is no way the pharmacist would question a discontinued order on the pharmacy side. We get a thousand discontinued orders a day. Sertraline is a common drug and it was ordered at a low dose, I can't see any pharmacy questioning the discharge of such a low dose of Sertraline.",2020-09-01
926,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2019-02-21,656,D,1,0,ELJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, and record reviews, the facility failed to follow the plan of care related to elopement risk and the level of supervision required for one resident (#2) of three residents sampled for wandering behaviors/accidents. Findings include: Review of the clinical records for Resident (R)#2 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment records for the resident revealed a 5-day PPS assessment of 1/31/19 in which he was assessed as having wandering behaviors which occurred 1-3 days during the assessment period. A further review of the MDS records revealed a 14-day assessment of 2/7/19 which documented the same behaviors were occurring 4-6 days during that assessment period. A review of the plan of care records for R#2 revealed a plan of care last revised 2/4/19 related to the resident being an elopement risk and wandering aimlessly. Interventions included the use of a wander alert bracelet, and one to one supervision as ordered. A review of the nurses' notes revealed that, immediately after R#2 was admitted on [DATE], he began to exhibit behaviors of ambulating into other residents' rooms, including the rooms of female residents, touching and getting into the belongings of those residents, and repeatedly going to the exit doors. Review of the nurses' notes for the next week revealed these behaviors continued and did not respond well to interventions such as redirection. A nurses' note of 2/3/19 documented that the resident exited through an unlocked door at the rear and climbed over the locked fence that surrounded the area immediately outside. The resident was placed on one-on-one staff supervision after that time requiring one member of staff to be dedicated to keep a close eye over him to the exclusion of any other duties. During a continuous period of observation on 2/21/19 beginning at 1:44 p.m., R#2 was seen sitting in the dining room with his back to the wall. Four other residents were also observed in the dining room at that time. However, no staff members were observed in the vicinity. During continued observation on 2/21/19 at 1:58 p.m., one of the two nurses on the unit entered the dining room and removed one of the other residents from the room wheeling that resident down the hallway. R#2 was observed to exit the dining room immediately after the nurse left. He hovered, briefly, in the hallway outside before wandering down the hallway leading to the courtyard in the back where he was reported to have eloped a few weeks before. A housekeeper standing in the hallway outside the dining room gestured to a CNA appearing in the hallway and pointed in the direction in which R#2 had wandered. The CNA went down the same hallway and was observed in the courtyard outside the exit door. She approached R#2 who was pacing a few feet from the door and was overheard encouraging him to follow her inside. He allowed her to gently lead him inside after a few seconds. During an interview on 2/21/19 at 2:08 p.m. with Certified Nursing Assistant (CNA) AA it was revealed that R#2 wanders throughout the facility; he has even wandered out the same door from which he exited earlier. On one such occasion, he climbed the fence which enclosed the area outside of the same exit on the Meadows unit through which he had wandered unsupervised earlier. The staff are expected to watch him all the time, even when he is asleep. They are not to take a break without being relieved by another member of staff. The staff scheduler was responsible for watching him in her office in the building next door during the current shift. However, that staff member could not bring him to the dining room where he was overseen by the speech therapist during lunch. One of the other CNAs escorted him to the dining room from next door, and someone should have escorted him back to that area after lunch. This CNA said she was not sure why he was left unattended in the dining room. She remembered he was still sitting with the speech therapist when she left the dining room. R#2 was not supposed to be wandering off by himself. During an interview on 2/21/19 at 6:55 p.m. with the Director of Nursing (DON), it was revealed that residents are placed on one-to-one staff supervision if there are safety concerns regarding that resident. R#2 was placed on one-on-one supervision after he went over the fence (although he had not travelled far beyond the fence) enclosing a courtyard reserved for the residents in the back of the facility. He was removed from one-to-one supervision after a few days because he was not making any further attempts to exit. The same day, however, he was on line-of-sight, when staff saw him exiting the door leading to the same courtyard with the fence beyond. By the time staff approached him, he was again at the fence. He did not have the chance to get over the fence at that time, but his actions prompted the interdisciplinary team to put him back on one-on-one supervision. This level of supervision means that staff should always be with him. Wherever he goes, there should be a member of staff with him. When the staff member assigned to supervise R#2 goes on break, that person is to notify the nurse and have someone, even the nurse, step in before the first staff member can go on break. All department heads are to educate their staff that this resident is to receive a one-to-one level of supervision.",2020-09-01
927,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2019-02-21,689,D,1,0,ELJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, and record reviews, the facility failed to ensure that one resident (#2) on one-to-one supervision of three residents reviewed received consistent supervision to prevent him wandering into an area from which he had previously eloped. The sample size was three residents reviewed for wandering behaviors/accidents. Findings include: Review of an undated policy titled Safety and Supervision of Residents revealed that facility staff will use various sources such as assessments, medical history, and observation to identify accident hazards or risks for their residents and to target interventions necessary for their safety. Implementing these interventions include: communicating specific interventions to staff; assigning responsibility for carrying out those interventions; providing training, as necessary; and ensuring that interventions are implemented. Review of the clinical records for Resident (R)#2 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment records for the resident revealed a 5-day PPS assessment of 1/31/19 which documented a Brief Interview for Mental Status score of 6 which indicated a severe cognitive impairment. The same assessment documented wandering behaviors which occurred 1-3 days during the assessment period. A further review of the MDS records revealed a 14-day assessment of 2/7/19 which documented a BIMS score of 4 with increased wandering behaviors that were now occurring 4-6 days during that assessment period. Review of the nursing progress notes for R#2 revealed the following: 1/24/19 at 2:30 p.m., the day on which the resident was admitted , the nurse documented that he was observed wandering around the unit, going from door-to-door, exhibiting signs of delusionary thinking, and that a Wander-Guard bracelet was applied. 1/24/19 at 10:30 p.m., the nurse documented that the resident was confused, ambulating into other residents' rooms, including the rooms of female residents, touching and getting into the belongings of those residents, and repeatedly going to the exit doors. The nurse noted that the Wander-Guard bracelet was in place. 1/25/19 at 11:24 p.m., the nurse documented that R#2 was confused, wandering into other residents' rooms. He was constantly being redirected, but was not responding well to that redirection. 1/27/19 at 11:47 a.m., the nurse documented that the resident goes into other resident's room and takes items, has to watched by staff, redirected frequently to room and surroundings, resident has a very short-term memory with redirection unsuccessful most of the time. 1/28/19 at 7:51 p.m., the nurse documented that the resident was wandering throughout the unit, in and out of the other residents' rooms. 1/31/19 at 11:14 p.m. documented that the resident was wandering throughout facility for most of the day, was wearing a Wander Guard bracelet, and was redirected at times. 2/2/19 3:54 p.m. the nurse documented: Resident very confused, wandering into other resident's rooms, caught with other resident's personal belongings many times and placed back where and whom items belonged to. Redirected to room and surroundings numerous times without success. Does not show any interest in anything except getting out of facility. Family here visiting with resident attempting to explain situation, resident shows no interest (understanding) in cooperating with staff/facility rules. 2/3/2019 12:15 at p.m. documented: Nurse notified per another resident that she witnessed this resident jump over the fence in the courtyard. Resident was found just a few feet away from the outside fence. No apparent injury noted. Denies pain or discomfort. Skin assessment completed. One on one with staff started. A further review of the progress notes and a review of the associated incident reports/ Change in Condition Evaluation forms revealed that the resident was continued on one-on-one observation by staff. On 2/5/19, he was removed from that level of observation. However, he was again placed on a one-on-one level of supervision later that same day when a Certified Nursing Assistant (CNA) reported to the nurse that she observed the resident attempting to get over the fence at the back of the courtyard. Review of the current orders for R#2 revealed an order for [REDACTED]. During an observation conducted on 2/21/19 2/21/19 at 12:35 p.m., R#2 was observed sitting at a table in the dining room on the Meadows unit eating lunch. The speech therapist was observed sitting at same table encouraging him to eat. During observation on 2/21/19 at 1:44 p.m., R#2 was seen sitting in the dining room in the same area with his back to the wall. Four other residents were also observed in the dining room at that time. However, no staff members were observed in the vicinity. During an observation on 2/21/19 at 1:58 p.m., one of the two nurses on the unit entered the dining room and removed one of the other residents from the room, wheeling that resident down the hallway. R#2 was observed to exit the dining room immediately after the nurse left. He hovered, briefly, in the hallway outside before wandering down another hallway leading to the courtyard in the back where he was reported to have eloped a few weeks before. A housekeeper standing in the hallway outside the dining room gestured to a CNA appearing in the hallway and pointed in the direction in which R#2 had wandered. The CNA went down the same hallway and was observed in the courtyard outside the exit door. She approached R#2 who was pacing a few feet from the door and was overheard encouraging him to follow her inside. He allowed her to gently lead him inside after a few seconds. She then led him down another hallway where they both exited before entering an outbuilding. The same CNA returned minus the resident a few minutes later. During an interview on 2/21/19 at 2:08 p.m. with Certified Nursing Assistant (CNA) AA it was revealed that R#2 wanders throughout the facility; he has even wandered out the same door from which he exited earlier. On one occasion, he was able to climb over the fence which encloses the courtyard outside of the same exit on the Meadows unit. R#2 had been placed under the supervision of sitters for the previous three weeks. The sitters are CNAs that volunteer to work a shift on their days off. The staff/sitters are expected to watch him all the time, even when he is asleep. They are not to take a break without being relieved by another member of staff. Everyone pitches in, the CNA went on to say. For instance, the staff scheduler was responsible for watching him in her office in the building next door during the current shift. However, that staff member could not bring him to the dining room where he was overseen by the speech therapist during lunch. One of the other CNAs escorted him to the dining room from next door, and someone should have escorted him back after lunch. This CNA said she is not sure why he was left unattended in the dining room. She remembers he was still sitting with the speech therapist when she left the dining room. R#2 was not supposed to be wandering off by himself. During an interview on 2/21/18 at 2:30 p.m. with Speech and Language Therapist (SLT) DD it was revealed that she is aware that R#2 has issues with wandering. For safety/and so he cannot leave the building, he has a wander alert bracelet in place. She believed that he was mostly on one-to-one level of supervision. She said that she was not sure of the exact definition of one-to-one supervision for R#2 but believed that staff should be in the same room, close by, sitting near him. Staff are not to leave him alone. Staff are to hand-off his care/supervision to another staff before leaving him. She believed the nursing staff signed a roster of some sort. Before leaving R@2 in the dining room earlier that afternoon, she told one of the CNAs assigned to dining room duties during lunch that R#2 was finished with her for the day. During an interview on 2/21/19 at 3:12 p.m. with CNA EE it was revealed that she is responsible for scheduling staff to supervise R#2 on a one-to-one basis. The resident had attempted to get over the fence in the courtyard before and was placed on one-on-one immediately. The director of nursing (DON) made the decision to remove him from one-on-one after a couple of days. However, he attempted to go out the door again to the same fence, and he was placed on one-on-one supervision again. The door to the courtyard is the only door he can use to get out without the bracelet that he wears automatically locking the door. However, management said that door cannot be locked because the other residents have a right to go in and out to the courtyard. That's the whole reason he's on one-to-one, she said because they won't lock that door CNA EE said she can usually find a CNA who is not scheduled each day to provide one-on-one on supervision for R#2 on an 8-hour shift similar to what they would normally work. If, however, she is not able to find a CNA who is a scheduled off day, then she has to pull a CNA from the floor to provide him supervision. She tries not to pull someone from the floor because she knows how difficult it is to work with one less CNA on the hallway. She could not find a CNA to supervise the resident on the first shift that day, so she decided she would watch him in [MEDICATION NAME] with social services, the business office manager, and the MDS coordinator. At lunch, the CNA assigned to provide him with routine care came to take him to lunch. during lunch, the CNA in the dining room was supposed to watch him along with the speech therapist. His CNA was supposed to return him to her after lunch. However, when he returned from lunch he did not, at first, return to her care and supervision. He was brought to her by the business office manager and she was not aware that he had been left unattended after lunch. One-on-one supervision means staff should always remain within arms-length of the resident. The person responsible for watching the resident, should ask someone to watch him when he/she wishes to go leave the room/go on a break. During an interview on 2/21/19 at 3:45 p.m. with the maintenance director it was revealed that three of the six exit doors in the building are locked and require a code to get out. The other three exit doors are not kept locked between 8A and 5P. Two of these unlocked doors have Wander Guard alarm systems that alert staff when a resident wearing a bracelet comes within a few feet of one of these exits. The third door that is kept unlocked during the day does not have a Wander Guard system in place. That door leads to the patio at the back where residents can go out to sit or walk. After a fence was put up around the courtyard, that door ceased to be locked during the day. The maintenance director said the fence around that courtyard is locked at all times and residents should not be able to get out. However, he said that anything was possible if someone was determined to get over the fence. Observation of the exit doors during this interview revealed 6 exit doors - three with locks and codes to enter/exit and two unlocked doors with wander guard systems. A third door leading to the back courtyard; (the door through which R#2 was reported to leave the premises and the door through which he was observed exiting earlier in the day) did have a key pad on which a code could be entered to lock that exit. However, the door was observed to be unlocked. At the back of the courtyard was a wooden fence about 6 feet tall. The fence consisted of fence slats closely fitted together and nailed to three planks across the top, middle, and bottom which could be used as steps to climb over to the other side. During an interview on 2/21/19 at 4:06 p.m. with the Director of Social Services (SDD) it was revealed that R#2 had jumped the fence in the back. The care team had decided that they could not keep him safe in their facility; even with the Wander Guard bracelet he wears. There is a wander guard system on all the doors, except the door leading to the fenced/enclosed area in the back; That area is supposed to be a safe place for their residents to go out, enjoy the sunshine. However, that was the door through which R#2 exited unsupervised on the day went out and went over the fence. The SSDs said she believed there were several episodes where he attempted to elope. However, the first time was the only time he got over the fence. He was put on one-on-one supervision since the last time he attempted to elope over the courtyard fence. The SSD also said that one-on-one supervision means that the resident should always remain within eyesight of one of the staff and, instead of six residents, for example, that staff member would be responsible for watching only one - R#2. When the CNAs and nurses are not available to watch him, then the department heads such as the business office manager - provides one-on-one supervision. If the person supervising him needs to go on break, then that member of staff should turn supervision of the resident over to another member of staff. During an interview on 2/21/19 at 6:55 p.m. with the Director of Nursing (DON), it was revealed that residents are placed on one-to-one staff supervision if there are safety concerns regarding that resident. R#2 was placed on one-on-one supervision after he went over the fence (although he had not travelled far beyond the fence) enclosing a courtyard reserved for the residents in the back of the facility. He was removed from one-to-one supervision after a few days because he was not making any further attempts to exit. The same day, however, he was on line-of-sight, when staff saw him exiting the door leading to the same courtyard with the fence beyond. By the time staff approached him, he was again at the fence. He did not have the chance to get over the fence at that time, but his actions prompted the interdisciplinary team to put him back on one-on-one supervision. This level of supervision means that staff should always be with him. Wherever he goes, there should be a member of staff with him. The CNA responsible for scheduling the nursing staff is supposed to assign him someone to watch him, 24/7. When the staff member assigned to supervise R#2 goes on break, that person is to notify the nurse and have another member of staff tale over the supervision before that person can go on break. R#2 eats in dining room for all meals (unless he does not wish to go to the dining room). He has lunch in the dining room with the speech therapist for lunch. When he is with the speech therapist, she is responsible for being his one-on-one supervisor. All department heads are to educate their staff that this resident is to receive one to one supervision. When she interviewed her earlier, the speech therapist said she had notified one of the CNAs in the dining room that she was through working with R#2 and was leaving the dining room. She could not verify if the CNA had acknowledged this notification. However, the DON acknowledged that it was still not appropriate for the speech therapist to have left the resident unattended in the dining room even if the CNA was aware of her departure since the CNAs in the dining room during lunch are responsible for other residents and thus cannot be expected to provide the one-on-one supervision required by R#2.",2020-09-01
928,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2019-02-21,741,D,1,0,ELJQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interview, record review, and review of the Facility Assessment Tool last revised on 2/18/19, the facility failed to provide staff in sufficient numbers to care for the behavioral health needs of its residents. The facility census was 85. Findings include: Review of the Facility Assessment Tool last revised on 2/19/19 revealed that the facility has an average daily census of 88 and routinely cares for residents with psychiatric/mood disorders defined as disorders including [MEDICAL CONDITION], impaired cognition, depression, and [MEDICAL CONDITION] disorder. The assessment tool also documented that the facility uses an Acuity Assessment Quarterly Report based on Minimum Data Set (MDS) information to assist in adjusting the scheduled staffing. Staffing is also adjusted based on the daily report of managers of the changing needs of residents. The facility assessment tool also documented that the average daily number of residents identified with behavioral health needs was 45 and that the calculated PPD based on the needs of the average number of residents served was 3.151 for all nursing staff and 2.082 for Certified Nursing Assistants (CNAs). A review of the staffing schedules for (MONTH) and (MONTH) 2019 revealed there were two vacant CNA positions on the first shift, one on the second, and two on the third. A further review of the staffing schedules for that time frame revealed that, on average, four CNAs were scheduled on each of the two units/wings on the first shift, and three each on the second shift. A review of the staffing average for the two weeks prior to the survey showed an average PPD of 2.84. The two-week staffing average showed that the facility did not meet its forecasted PPD average on any of the 14 days listed. Review of the facility's Form CMS-672, Resident Census and Conditions of Residents of 2/21/19, revealed that the facility census was 85 and the facility was caring for 38 residents with documented psychiatric diagnoses, 44 residents with dementia, and 16 residents with behavioral health needs. A review of the clinical records document that the facility admitted at least one resident in the month of (MONTH) 2019 for whom the facility implemented behavioral interventions which called for the addition of 24 hours of CNA time above the daily care duties of the staff. That resident was identified as resident (R)#2. A review of the nurses' notes revealed that R#2 was admitted on [DATE] and immediately exhibited behaviors of ambulating into other residents' rooms, including the rooms of female residents, touching and getting into the belongings of those residents, and repeatedly going to the exit doors. Review of the nurses' notes for the following week revealed these behaviors continued and did not respond well to interventions such as redirection. The nurses' note of 2/3/19 documented that the resident exited through an unlocked door at the rear and climbed over the locked fence that surrounded the area immediately outside. The resident was placed on one-on-one staff supervision after that time requiring one member of staff to be dedicated to keep a close eye over him to the exclusion of any other duties. During continuous observation on 2/21/19 between 1:44 p.m. and 1:58 p.m., R#2 was seen sitting in dining room on the Meadows unit. Four other residents were also observed in the dining room at that time. However, no staff members were observed in the vicinity. During continued observation on 2/21/19 at 1:58 p.m., one of the two nurses on the unit entered dining room and removed one of the other residents from the room wheeling that resident down the hallway. R#2 was observed to exit the dining room immediately after the nurse left. He hovered, briefly, in the hallway outside before wandering down the hallway leading to the courtyard in the back where he was reported to have eloped a few weeks before. A housekeeper standing in the hallway outside the dining room gestured to a CNA appearing in the hallway and pointed in the direction in which R#2 had wandered. The CNA went down the same hallway and was observed in the courtyard outside the exit door. She approached R#2 who was pacing a few feet from the door and was overheard encouraging him to follow her inside. He allowed her to gently lead him inside after a few seconds. She then led him down another hallway where they both exited before entering an outbuilding. The same CNA returned minus the resident a few minutes later. During an interview on 2/21/19 at 2:08 p.m. with CNA AA it was revealed that there are usually not enough CNAs scheduled to care for the residents on each of the two wings. Five CNAs is the number expected to be scheduled on each hall during the 7:00 a.m. to 3:00 p.m. shift. However, only three are usually scheduled during the week and on weekends. That leaves each CNA with an average of 15 to 18 residents to care for and makes it difficult to provide care to the other residents and watch R#2. CNA AA also said that the facility admitted a couple of residents with needs/behaviors similar to those of R#2 in the previous months. However, this CNA said the facility found other facilities where there is a special area for people like that - wanderers. to which these residents were transferred. During an interview on2/21/19 at 3:12 p.m. with CNA EE who was responsible for scheduling the nursing staff, it was revealed that staff, especially CNAs are scheduled each day based on the number of residents in the facility. For example, the facility has estimated that five CNAs are needed for each of the two wings - Springs and Meadows - on the 7:00 a.m. to 3:00 p.m. shift. However, they have two vacant positions on that shift, so they have had to schedule four CNAs on each of those wings during the previous month or two. On the 3:00 p.m. to 11:00 p.m. they have estimated a need for seven CNAs. However, they were currently scheduling six because this was the number available. A similar situation existed on the 11:00 p.m. to 7:00 a.m. shift where five CNAs are forecasted, but only four are routinely scheduled. During the previous two weeks or so, the staff on that shift have worked with three CNAs until a fourth came in at 3:00 a.m. to assist in getting residents up in the morning. The call outs kill us, the scheduler said. In addition, she said that the need for a staff member dedicated to supervising R#2 on a 24-hour basis had placed a strain on staffing needs that were already strained. The facility was asking CNAs to come in on their scheduled days off to provide one-to-one supervision for R#2. She can usually persuade a CNA who is not scheduled each day to provide one-on-one supervision to R#2 on an 8-hour shift similar to what they would normally work. If, however, she is not able to find a CNA who is scheduled off on any given day, then she is compelled to pull a CNA from the floor. She tries not to pull someone from the floor because she knows how difficult it is to work with one less CNA on the hallway. No one was able to come in on the first shift that day to supervise R#2, so she decided she would watch him in [MEDICATION NAME] with social services, the business office manager, and the MDS Coordinator. At lunch, the CNA assigned to provide him with routine care came to take him to lunch. During lunch, the CNA in the dining room was expected to watch him along with the speech therapist. A member of staff should have returned him to her care after lunch However, when he returned from lunch he did not, at first, return to her care and supervision. He was brought to her by the business office manager and she was not aware that he had been left unattended after lunch. During an interview on 2/21/19 at 4:06 p.m. with the Social Service Director (SSD) it was revealed that the facility's interdisciplinary team (IDT) decided that they could not assure the safety of R#2 in their facility, even with his being equipped with a Wander-Guard bracelet and, therefore, they were actively seeking another facility to which he could be transferred. The SSD went on to say that the other residents in the facility who wear a Wander Guard System were easier to keep track of than was R#2. She said they had several wanders in their building. However, the other residents that wander generally wander only in the facility; they do not try to go out of the doors. Most of our residents can't get over the fence. He's a special case; an escape artist, she said. The SSD said the IDT met and came to an agreement that they could not have him on one-on-one forever. She felt he would be easy to care for if he did not have the wandering issue. Interview on 2/21/19 at 7:21 p.m. with CNA BB revealed that sometimes they do have four CNAs working on the Meadows hall during the evening shift. However, they sometimes have only three. This CNA said the workload is more manageable when there are four. Interview on 2/21/19 at 7:23 p.m. with CNA CC revealed that there were three CNAs on working on Meadows during that evening shift. There should be four and sometimes there are four. When there are only three CNAs, the staff simply does their best by pitching in and helping each other out.",2020-09-01
929,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-04-05,550,E,0,1,CX7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations record review, review of the policy titled Quality of Life- Dignity, Review of the policy titled Meal Distribution, resident and staff interviews, the facility failed to promote care in a manner that maintained or enhanced each resident's dignity and respect. Specifically, two of 33 sampled residents (R) (B and E) wore the same shirts that were visibly dirty for three days and failed to ensure staff provided assistance with toileting and incontinent care in a timely manner for R E. Additionally, the facility failed to promote an environment that maintained dignity by not ensuring that all residents eating meals at the same table in the Springs dining room were served together in a timely manner. Findings include: Review of the facility policy titled Quality of Life- Dignity revised (MONTH) 2009 documented: Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Residents shall be treated with respect at all times. 1. R B was admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 15 indicating no cognitive impairment. R B was assessed as requiring extensive assistance with dressing. Observation of R B on 4/2/18 at 11:20 a.m. revealed the resident had heavy dandruff and flaking of his scalp and dry flaking skin around the edges of his hairline, cheeks, chin and forehead. The resident was wearing a black, short sleeved shirt that had several dry liquid stains on it and his shirt was covered in food crumbs, dandruff and skin flakes. At 3:12 p.m. the resident was observed with the same shirt on and it remained dirty with dry liquid stains, food crumbs, dandruff and skin flakes. The resident stated in an interview at the time of the observation that he felt dirty. Additional observations on 4/3/18 at 8:40 a.m. and 12:05 p.m., 4/4/18 at 9;20 a.m., 10:55 a.m., 1:30 p.m. and at 1:55 p.m. with the Director of Nursing (DON) revealed the resident wearing the same black short sleeved t-shirt that had food crumbs, dry liquid stains, dandruff and skin flakes on it. (Cross Refer F677) 2. R [NAME] was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE] documented a BIMS summary score of 15, indicating no cognitive impairment. R [NAME] was assessed as requiring extensive assistance with dressing. The resident was assessed of being frequently incontinent of bladder and bowel. During an interview with R [NAME] on 4/2/18 at 12:05 p.m., she stated it takes a long time for staff to come and assist her and it often takes one to two hours before they come and by that time she has already wet or soiled her brief. R [NAME] stated It is so embarrassing to use the bathroom on yourself!. R [NAME] stated she can use the bed pan or the bedside commode. R [NAME] stated I just can't hold it if it takes the staff a long time to help. Observation of the resident at the time of the interview revealed she was wearing a bright pink t-shirt that had several dry liquid stains across the front of it. Interview on 4/3/18 at 12:40 p.m. with R [NAME] revealed she was upset and stated when her regular CNA KK was busy with another resident, she pushed her call light for assistance and another CNA on light duty told her she would go get her assigned CN[NAME] R [NAME] told the CNA that she could not wait that long and the CNA turned around and walked out of her room. R [NAME] stated that by the time her regular CNA KK could get to her about 15 -20 minutes later, she had already had a bowel movement. R [NAME] stated she had diarrhea that went all the way down her legs to her feet. R [NAME] stated I tried to hold it as long as I could but it just started coming out. Observation on 4/4/18 at 9:15 a.m. revealed R [NAME] in her bed on her right side and the resident was crying. R [NAME] stated she had been soaking wet since she woke up around 7:00 a.m. She stated that she called for assistance twice and two different staff members came to her room to answer her call but no one had come back to assist her. Observation of R [NAME] at the time of the interview revealed the gel in her brief was wet and swollen, her bed pad was wet and a section of her top sheet was damp. The resident was still wearing the same bright pink, short sleeved t-shirt with several dry liquid stains across her chest. Incontinent care observation conducted by Registered Nurse Surveyor (RN) # on 4/4/18 at 9:52 a.m. with CNA LL and CNA MM confirmed the adult brief on R [NAME] was saturated with urine, the gel was swollen up and urine had spilled over onto the bed pad and the resident's top sheet. The adult brief was lifted and observed to be very heavy. The CNA's changed the top sheet but did not change the resident's bed pad or shirt. Interview on 4/5/18 at 9:30 a.m. with the CNA KK revealed on Tuesday 4/3/18, she was told that R [NAME] needed assistance and she was getting another resident out of bed. She stated when she got to the resident's room she had a diarrhea spilling out of her diaper and in her bed. She stated the R [NAME] was very upset and reported to her that she had pushed her call light and the CNA on light duty told her she would get her CN[NAME] CNA KK stated the resident was extremely apologetic and kept telling her she tried to hold it but could not. CNA KK stated the resident is continent, knows when she needs to use the bathroom and all she needs is her bedpan. She stated R [NAME] does not like to use the bathroom on herself. (Cross Refer to F677) 3. Review of the facility policy titled Meal Distribution revised (MONTH) (YEAR) documented: Meals are transported to the dining locations in a manner that ensures proper temperature maintenance, protects against contamination and are delivered in a timely and accurate manner. #4- The nursing staff will be responsible for verifying meal accuracy and the timely delivery of meals to residents/patients. Dining Observation of the Springs dining room on 4/2/18 beginning at 12:25 p.m. revealed 12 total residents at four tables. At 12:30 p.m. the meal cart was delivered to the dining room. Table#1 had four seated residents and only two residents were served their lunch. Table #2 had two seated residents and only one resident was served their lunch. Table #3 had three seated residents and only one resident was served their lunch. Table #4 had three seated residents and only two residents were served their lunch. At 12:40 p.m. a staff member took the meal cart with numerous meal trays on it, down the hall. There was a total of six residents that sat and watched the other residents eat. One resident pointed at the table in front of him and asked where is mine? One demented resident kept getting out of his chair and staff had to keep re-directing him to sit back down and telling him his lunch was coming. At 12:46 p.m. one lunch meal was delivered to a resident at Table #3 leaving one resident at the table without his meal. A second meal cart was delivered to the Springs dining room at 12:56 p.m. (26 minutes later). Five of the six residents served their lunch at 12:30 p.m. had finished their meals and were leaving the dining room and one continued with assisted eating. Five residents served had already finished their meals, one remain eating and one was being assisted by staff. The remaining five residents were served their lunch at 12:57 p.m. During an interview with R A on 4/3/18 at 3:40 p.m., he was asked about his dining experience during lunch on 4/2/18 and how did it make him feel when he did not receive his lunch at the same time as other residents. R A stated it happens all the time that they serve other residents at the table but not all at once. The resident stated It's not right, I'm hungry too you know! R A stated he eats in the dining room most of the time. Interview on 4/5/18 at 5:55 p.m. with the Dietary Manager revealed she is not sure what happened in the Springs dining room during lunch on 4/2/18. She stated that usually the residents are served at one time. She stated the staff is supposed to let the dietary staff know who is eating in the dining room and she said some of the tickets got messed up so the was confusion with the trays that came out. She stated that when she came out she noticed that some of the residents did not have their lunch in Springs dining room on 4/2/18, she asked the staff why they didn't tell her. The Dietary Manager stated no one told her that some of the residents did not have their meals. She stated they should have told her immediately and she would have made sure they got their meals. Further she stated that each table is to be served together and the staff should not have served different residents at different tables.",2020-09-01
930,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-04-05,584,D,0,1,CX7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to clean and repair four bathrooms on two of five hallways and three of six rooms on one of five hallways. Findings include: Observation of the bathroom shared by rooms [ROOM NUMBERS] on 4/2/18 at 12:11 p.m. revealed a dark ring around the base of toilet emanating outwards about 6 inches. The door jambs around the two doors leading from the rooms to the bathroom showed severe rust between 6-12 inches on the bottom. Observation of the paint on the walls behind the three beds in the room [ROOM NUMBER] on 4/2/18 at 12:14 p.m. revealed they were scuffed/gouged to the extent that the natural color of underlying bricks was revealed in a two-foot swathe directly behind and above the headboards. Observation of the bathroom between rooms [ROOM NUMBERS] on 4/2/18 at 3:32 p.m. revealed the floor tiles around the bottom of the toilet were raising away from the underlying floor and was stained a rusty brown. Observation of the bathroom shared by rooms [ROOM NUMBERS] on 4/2/18 at 4:07 p.m. revealed the baseboard had been removed and the stone floor around the toilet was stained a rusty brown color. Observation of the sink in the bathroom shared by rooms [ROOM NUMBERS] on 4/5/18 at 2:20 p.m. revealed a rusty ring around the drainage trap. Observation of the walls in room [ROOM NUMBER] on 4/5/18 at 2:22 p.m. revealed the paint was were completely rubbed off in a four-foot swathe the floor to the top of the headboards behind each of three beds and also on the wall to the left of the door. Observation of room [ROOM NUMBER]on 4/5/18 at 2:25 p.m. revealed the paint on the wall to the right of the doorway, beginning at the floor and moving up the wall in a four- foot swathe, was scuffed and flaked to the extent that the natural color of the underlying bricks showed through. Interview with the maintenance director revealed he was engaged in the painting and repair of the rooms and bathrooms of the hallway of rooms 31 to 35 when the facility changed ownership in (MONTH) of (YEAR). He was advised by management to halt the painting since the company planned to repaint the entire building with a different color scheme. The plan is to also repair the bathrooms by replacing the tiled floors in all the bathrooms and replace the fixtures and door jambs. However, he had no timetable for when this work would be initiated or complete",2020-09-01
931,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-04-05,656,D,0,1,CX7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the policy titled Care Planning- Interdisciplinary Team and staff interviews, the facility failed to follow care plan goals and approaches for Activities of Daily Living (ADL) for one resident (R) (R B) that required extensive assistance with dressing and failed to develop a care plan for one resident (R E) that required extensive assistance with dressing and toileting and was frequently incontinent of bowel and bladder. The sample size was 33 residents. Cross Refer to F677 Findings include: Review of the facility policy titled Care Planning- Interdisciplinary Team revised (MONTH) 2013 documented A comprehensive care plan for each resident is developed within seven (7) days of completion of the resident assessment (MDS). A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status summary score of 15, indicating no cognitive impairment. R B was assessed as requiring extensive assistance with dressing. The Care Area Assessment (CAA) triggered ADL Function to be care planned. Review of the ADL care plan for R B with an onset date of 4/26/17 identified the resident required extensive to dependent assistance for ADL care in bathing, grooming, personal hygiene, dressing, bed mobility, transfer and toileting. The GOAL documented the resident's ADL care needs will be anticipated and met throughout the next review period. An Approach included, but not limited to; Staff to assist with ADL needs daily. Observations of R B on 4/2/18 at 11:20 a.m. and 3:12 p.m., 4/3/18 at 8:40 a.m. and 12:05 p.m., 4/4/18 at 9;20 a.m., 10:55 a.m., 1:30 p.m. and at 1:55 p.m. with the Director of Nursing (DON) revealed the resident wearing the same black short sleeved t-shirt that had food crumbs, dry liquid stains, dandruff and skin flakes on it. Interview on 4/4/18 at 1:55 p.m. with the Director of Nursing (DON) revealed it is her expectation that residents clothing is to be clean and changed every single day. Interview on 4/4/18 at 3:30 p.m. with CNA JJ revealed R B did have on the same shirt black, short sleeved t-shirt yesterday and today and she had not change his shirt. She stated she did not care for R B on Monday. CNA JJ stated she was going to wait until his shower to change his clothes but he did not get his shower 2. Record review for R [NAME] an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 15, indicating no cognitive impairment. R [NAME] was assessed as requiring extensive assistance with dressing and toileting. The resident was assessed of being frequently incontinent of bladder and bowel. The CAA triggered ADL Function and Urinary Incontinence to be care planned. Review of the care plans for R [NAME] revealed no evidence of a care plan for ALDs or Bowel and Bladder Incontinence. Observations of R [NAME] on 4/2/18 at 12:05 p.m., 4/3/18 at 12:40 p.m. and 4/4/ at 9:15 a.m. revealed the resident was wearing the same short sleeved, bright pink t-shirt with several dry liquid stains across the chest. Interview on 4/5/17 at 2:14 p.m. with the MDS Coordinator confirmed the Admission MDS was completed on 3/12/18 and that the CAA triggered ADL Function and Urinary Incontinence to be care planned. The MDS Coordinator stated there should be care plans for the triggered areas but they have been having problems with the new electronic computer system they are now",2020-09-01
932,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-04-05,657,E,0,1,CX7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident, and staff interviews, the facility failed to provide evidence that resident (R) R A, R B, R C, R D, R F and, R G was invited or attended care plan meeting for 6 out 6 reviewed. The sample size was 32 residents. Findings include: Review of the policy Care plans, comprehensive person-centered revised (MONTH) (YEAR) revealed the resident has a right to participate in the development and implementation of his or her plan of care. 1. Record review R F 3/29/18 annual Minimum Data Set (MDS) assessment revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Brief Interview for Mental Status (BIMS) summary score of 13 which indicates the resident is cognitively intact. An interview was conducted on 04/03/18 at 09:13 a.m. with R F. The Resident stated that she is never invited to care plan meetings. The resident stated that she would like to attend the care plan meetings. Review of the facility Interdisciplinary attendance log for R F revealed no evidence or documentation that the resident was invited or attended the care plan meeting on 3/7/17, 6/6/17, and 2/6/18. 2. Record review R G 12/22/17 annual Minimum Data Set (MDS) assessment revealed the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Brief Interview for Mental Status (BIMS) summary score of 14 which indicates the resident is cognitively intact. An interview was conducted on 04/03/18 at 8:47 a.m. with R [NAME] Resident stated that she is never invited or attended a care plan meeting. The resident stated that she would like to attend her care plan meeting. Review of the facility Interdisciplinary attendance log for R G revealed no evidence or documentation that the resident was invited or attended the care plan meeting on 1/10/17, 4/18/17, 7/7/17, 10/2/17. During interview with the Social Worker (SW) on 4/4/17 at 3:3p p.m., she stated that the previous social worker left employment with the facility a few weeks ago. SW revealed she started this position last week and has not been orientated on the procedure on inviting residents to care plan meetings. During interview with the Minimum Data Set (MDS) Coordinator on 4/5/18 at 9:05 a.m., she stated that the Social Services Director (SSD) was responsible for inviting the resident and the family to the care plan meetings. The MDS Coordinator stated she could that she could not find any documentation that residents were invited or attended their care plan meeting. 3. Record review for R B revealed an Annual MDS assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, indicating no cognitive impairment. Interview on 4/2/18 at 3:01 p.m. with R B revealed he had attended care plan meetings when he first was admitted but it has been a very long time since he has been invited or attended one. R#81 stated he wants to be a part of the meetings to discuss his care. Review of the Interdisciplinary Attendance Log for R B revealed no evidence or documentation that the resident was invited or attended the care plan meeting on 6/13/17, 9/12/17, 12/12/17 or 3/13/18. 4. Record review for R D revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 15, indicating no cognitive impairment. Interview on 4/3/18 at 9:24 a.m. with R D revealed he had never been to care plan meeting and he has only been invited once or twice. Review of the Interdisciplinary Attendance Log for R D revealed no evidence or documentation that the resident was invited or attended the care plan meeting on 6/13/17, 9/2/17, 11/7/17 or 2/6/17. 5. Record review for R C revealed a Quarterly MDS assessment dated [DATE] which documented a BIMS summary score of 15, indicating no cognitive impairment. Interview on 4/3/18 at 9:57 a.m. with R C revealed in 3 years he has been to one meeting and he is his own responsible party. He stated they do not invite him. He stated it is important to him to discuss his care and concerns. Review of the Interdisciplinary Attendance Log for R Crevealed no evidence or documentation that the resident was invited or attended the care plan meeting on 10/31/17 or 1/23/18, 7/2/178/1/17 6. Record review for R A revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of seven, indicating severe cognitive impairment. Despite an admission BIMS score of seven, the resident was alert and oriented times three (people, place and time) and could answer screening questions appropriately. Interview on 4/2/18 at 3:54 p.m. with R A revealed he has never been invited to the care plan meeting. R#77 stated he has seen his family come in but he wants to go to the care plan meetings too. Review of the Interdisciplinary Attendance Log for R A revealed no evidence or documentation that the resident was invited or attended the care plan meeting on 1/2/18 or 2/2/18. The Responsible Party was in attendance on 1/2/18 and via phone on 2/2/",2020-09-01
933,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-04-05,677,D,0,1,CX7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to provide Activities of Daily Living (ADL) care for two residents (R) that required extensive assistance with dressing (R B and R E). Specifically, R B wore the same shirt for three days that was covered in food crumbs, dry liquid stains, dandruff and skin flakes from facial scaling and R [NAME] wore the same shirt for three days that had several dry liquid stains on it. In addition, the facility failed to ensure that staff provided incontinent care in a timely manner for R E. The sample size was 33 residents. Findings include: 1. R B was admitted to the facility with multiple [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 15 indicating no cognitive impairment. R B was assessed as requiring extensive assistance with dressing. The Care Area Assessment (CAA) triggered Activities of Daily Living (ADL) Function to be care planned. Review of the ADL care plan for R B with an Onset date of 4/26/17 identified that the resident requires extensive to dependent assistance with ADLs due to weakness and [DIAGNOSES REDACTED]. Observation on 4/2/18 at 11:20 a.m. revealed R B in his bed with a black, short sleeved t-shirt that was covered in food crumbs, dry liquid stains, dandruff and skin flakes from facial scaling. An observation at 3:12 p.m. revealed the resident had the same black, short sleeved t-shirt that remained covered in food crumbs, dry liquid stains, dandruff and skin flakes. Observation on 4/3/18 at 8:40 a.m. revealed R B in bed with the same black t-shirt, short sleeved t-shirt on. The resident's shirt had copious food crumbs all over the front, dry liquid stains, dandruff and skin flakes from facial scaling. Observation at 12:05 p.m. revealed the resident in his bed with the same black, short sleeved t-shirt that was covered with food crumbs, dry liquid stains, dandruff and skin flakes. R B stated he is scheduled for a shower today but he has not yet received his shower. Observation on 4/4/18 at 9:20 a.m. revealed R B in his bed sleeping with the same black, short sleeved t-shirt on that remained covered in food crumbs, dry liquid stains, dandruff and skin flakes from facial scaling. At 10:55 a.m. the resident was observed in the bed with the same black, short sleeved t-shirt that remained covered in food crumbs, dry liquid stains, dandruff and skin flakes. At 1:30 p.m. the resident was observed in his bed with the same black, short sleeved t-shirt on that remained covered in food crumbs, dry liquid stained, dandruff and skin flakes. Observation on 4/4/18 at 1:55 p.m. with the Director of Nursing (DON) revealed R B in his bed in the same black, short sleeved t-shirt on that was covered in food crumbs, dry liquid stains, dandruff and skin flakes. The DON confirmed that R B's shirt was dirty and covered with food crumbs, dry liquid stains, dandruff and skin flakes. The DON stated it is her expectation that regardless of a resident's shower days, their clothing is to be clean and changed every single day. Interview on 4/4/18 at 3:30 p.m. with CNA JJ revealed she was caring for R B yesterday 4/3/18 and today 4/4/18. CNA JJ stated the resident did have on the same shirt black, short sleeved t-shirt yesterday and today and she had not change his shirt. She stated yesterday was his shower day so she was going to wait until his shower to change his clothes but he did not get his shower. CNA JJ stated R B's shower was rescheduled for today so she just figured his clothes would be changed today. CNA JJ stated that she doesn't really know why the ball was dropped she just got busy in the chaos. CNA JJ further stated that a residents clothing should be clean and changed every day and stated that typically they do. 2. R [NAME] was admitted to the facility with [DIAGNOSES REDACTED]. Review of the Admission MDS assessment dated [DATE] documented a BIMS summary score of 15, indicating no cognitive impairment. R [NAME] was assessed as requiring extensive assistance with dressing. The resident was assessed of being frequently incontinent of bladder and bowel. The CAA triggered ADL Function and Urinary Incontinence to be care planned. Review of the care plans for R [NAME] revealed no evidence of an ADL care plan or a care plan for Bowel and Bladder Incontinence in the resident's clinical record. Observation on 4/2/18 at 12:05 p.m. revealed R [NAME] in her bed. The resident was wearing a short sleeved, bright pink t-shirt that had several liquid stains across the chest area. During an interview with R [NAME] at the time of the observation, she stated it takes a long time for staff to come and assist her with toileting. She stated it often takes up to one-two hours and by that time she has already wet or soiled her brief. R [NAME] stated that she was continent at home and is still continent. She stated she knows when she needs to use the bathroom and is able to use both the bedpan and a commode, she just can't hold it if it takes the staff a long time to help her. Interview on 4/3/18 at 12:40 p.m. with R [NAME] revealed her regular CNA KK was busy with another resident and a different CNA answered her call light. R [NAME] did not know the CNA's name but stated she told the CNA she needed her bed pan. The CNA said I'll go find your CN[NAME] R [NAME] stated she told the CNA she couldn't wait and by that time it would be too late. R [NAME] stated the CNA turned around and walked out of her room. R [NAME] stated she thought the CNA that answered her call light was on light duty and further stated that when CNA KK came to her room, she stated I don't know why she didn't just help you while she was in here. She can still put a bedpan under you since you can roll yourself. R [NAME] stated it was about 15 - 20 minutes before CNA KK she got there and she tried to hold it as long as she could but it just started coming out. R [NAME] stated she had diarrhea and it was all the way down to her feet in the bed. She stated that CNA KK had to change her bedding. Observation of R [NAME] revealed she was wearing the same bright pink t-shirt on with several dry liquid stains across the chest. R [NAME] stated she had worn this t-shirt for several days. The resident stated that she has other clothes but the staff told her they are waiting until they get labels placed in her clothing. Observation on 4/4/18 at 9:15 a.m. revealed R [NAME] in her bed on her right side. The resident was wearing the same short sleeved, bright pink t-shirt with several dry liquid stains across the chest. The resident was crying and stated she has been soaking wet since she woke up around 7:00 a.m. R [NAME] stated she had pushed her call light for assistance twice and two different times staff told her they would be there soon. R [NAME] stated her bed pad and top sheet was wet. The resident showed her brief which is notably wet and a section of her top sheet was damp. Interview conducted on 4/4/18 at 9:37 a.m. by Registered Nurse (RN) Surveyor # with R [NAME] revealed the last time her adult brief was changed was at 5:00 a.m. The resident stated prior to breakfast she asked to use the bed pan and the Housekeeping Supervisor answered the light. R [NAME] informed the Housekeeping Supervisor that she needed to use the bedpan and he told her that he would let someone know. R [NAME] stated no one came to assist her and she put the light on again. She stated it was answered by someone else and no one came to assist her. R [NAME] stated she ate her breakfast with a wet brief. Interview on 4/4/18 at 9:45 a.m. with CNA LL revealed R [NAME] did call after breakfast to have her brief changed but it was at the same she was on her way to assist another CNA with a shower. CNA LL stated she could not remember the exact time. She stated she did not change the resident's brief before going to the shower room and she did not ask another staff member to assist the resident. Incontinent care was observed by the RN Surveyor # on 4/4/18 at 9:52 a.m. with CNA LL and CNA MM. No care no issues were observed during incontinent care however, the resident's adult brief was observed to be saturated with urine, the gel was swollen up and urine had spilled over onto the bed pad and the resident's top sheet. The adult brief was lifted and observed to be very heavy. R [NAME] was provided a clean top sheet and pillow case. The bed pad underneath R [NAME] was not changed but remained wet under the resident. Observation on 4/4/18 at 10:05 a.m. after R [NAME] received incontinent care revealed the resident lying in her bed on her back. The resident was wearing the same short sleeved, bright pink t-shirt with several dry liquid stains on it. R [NAME] was upset and crying and stated the pad under her was wet and the back of her t-shirt was damp and the CNA did not change it. Observation on 4/4/18 at 10:15 a.m. with the Treatment Licensed Practical Nurse (LPN) DD confirmed that the cloth pad under R [NAME] was wet and it should have been replaced when the CNA provided incontinent care. The Treatment nurse stated that it was not acceptable. R [NAME] then stated that the back of her t-shirt was damp as well and the CNA did not change her shirt either. Interview on 4/4/18 at 10:25 a.m. with the DON revealed that it is expected if a residents bedding and clothing is wet, everything should be changed out as part of incontinent care. The DON stated that CNA LL is a good CNA and she does not understand why she did not change the residents wet bed pad after incontinent care. The DON further stated that if a CNA is busy and a resident is soaked and needs a brief change, they should ask someone else to attend to the resident. If a staff member answers a call light and the assigned CNA is busy, they should attend to the resident. The DON stated that any staff CNA or nurse should be addressing the resident's needs. Interview on 4/5/18 at 9:30 a.m. with the CNA KK revealed on Tuesday 4/3/18, she was told that R [NAME] needed assistance and she was getting another resident out of bed. She stated when she got to the resident's room she had a diarrhea spilling out of her diaper and in her bed. She stated the R [NAME] was very upset and reported to her that she had pushed her call light and the CNA on light duty told her she would get her CN[NAME] CNA KK stated the resident was extremely apologetic and kept telling her she tried to hold it but could not. CNA KK stated R [NAME] can turn herself and all the other CNA had to do was slide a bed pan under her and she does not understand why she did not. She stated the R [NAME] did not know the CNAs name but she does know of one CNA on light duty. CNA KK stated the resident is continent, knows when she needs to use the bathroom and all she needs is her bedpan. She stated R [NAME] does not like to use the bathroom on herself. The facility was unable to provide a policy related to ADL Care.",2020-09-01
934,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-04-05,684,D,0,1,CX7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews, the facility failed to follow the physician orders [REDACTED]. The sample size was 33 residents. Findings include: Record review for R B revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status summary score of 15, indicating no cognitive impairment. The resident was not assessed as having any non-pressure related skin conditions (open [MEDICAL CONDITION], rashes, cuts) at the time of the assessment. Review of the Quarterly assessment dated [DATE] documented a BIMS summary score of 15. The resident was not coded as having any non-pressure skin conditions. Further record review revealed a physician order [REDACTED]. Further review revealed a physician order [REDACTED]. Review of the care plans for R B revealed no care plan related to the resident's skin condition diagnosed as Tinea Versicolor (defined as a fungal infection of the skin). Observation 4/2/18 at 11:20 a.m. and 3:12 p.m. of R B revealed the skin around the edges of his hairline, cheeks, ears and forehead was very dry, flaking with red splotchy patches. The resident also had heavy dandruff and flaking skin on his scalp. The resident's shirt was covered in skin flakes and dandruff. Interview with R B at the time of the observation revealed the staff do not apply any cream or lotion to his face. Observation on 4/3/18 at 8:40 a.m. and 12:05 p.m. or R B revealed dry flaky skin around the edges of his hairline, cheeks, ears and forehead. The resident had heavy dandruff/flaking in his scalp. The resident's shirt was covered in skin flakes/dandruff. Observation on 4/4/18 at 9:20 a.m., 10:55 a.m. and with the Director of Nursing (DON) at 1:55 p.m. revealed R B had dry flaky skin around the edges of his hairline, ears, cheeks and forehead and had heavy dandruff/flaking on his scalp. The resident's shirt was covered in skin flakes. Interview on 4/4/18 at 2:15 p.m. with Certified Nursing Assistant (CNA) GG revealed she has not seen a prescription shampoo for R B and she uses a multipurpose body wash/shampoo on the resident's hair. Interview on 4/4/18 at 2:25 p.m. with the Treatment Licensed Practical Nurse (LPN) DD revealed that he does not apply the [MEDICATION NAME] 2.5% cream on the resident's face stating the charge nurses should be doing that. He stated he only provides treatment of [REDACTED]. He further stated that he does not know anything about an order for [REDACTED]. He stated the charge nurse should have it on her cart. Observation on 4/4/18 at 2:30p.m. with LPN FF of her assigned medication cart revealed a tube [MEDICATION NAME] cream 2.5%. The prescription dispense date was 1/8/18 and the tube was less than one quarter (1/4) empty. LPN FF stated that if the cream was being applied to the residents face daily as prescribe, the tube would not have lasted three months. She stated that she applies the cream to the resident's face and documents on the Medication Administration Record [REDACTED]. LPN FF stated she was not aware of an order for [REDACTED]. LPN FF checked her medication cart and stated there was no [MEDICATION NAME] 2% Shampoo on her cart for R B. LPN FF stated that the MARs are signed off as administered because it is assumed that since it is ordered with his showers, the Bath Aide is applying it. LPN FF stated there is no process in place for dispensing the [MEDICATION NAME] 2% Shampoo to the Bath Aide, monitoring or communicating with the Bath Aide that it was administered. LPN FF stated that it is ultimately the nurse's responsibility to ensure that the medicated shampoo is being administered as ordered. Observation on 4/4/18 at 2:40 p.m. revealed the Treatment LPN DD checking the locked cabinet in the Springs Shower room for the [MEDICATION NAME] 2% Shampoo. LPN DD stated that there wasn't any in the locked cabinet in the Springs Shower room. At 2:45 p.m. LPN DD stated that he found another tube of [MEDICATION NAME] cream 2.5%. The dispense date on the box was 2/8/18. LPN DD stated he was not able to locate any other tubes of the cream. Telephone interview on 4/4/18 at 3:16 p.m. with Senior Triage Pharmacy Technician HH revealed the order For R B for [MEDICATION NAME] 2% Shampoo, apply topically to scalp every day shift two times weekly as directed on Tuesdays and Thursdays for Tinea Versicolor did not match the order in the pharmacy system. She stated the active order in the pharmacy system was dated 5/4/17 for [MEDICATION NAME] 2% Shampoo three times a week. She stated she does not have a discontinue order for three times a week or a new order for twice weekly with showers. The Pharmacy Technician stated that the facility faxes the orders to them and they are entered in the computer at that time. She stated that this shampoo is not a cycle prescription and they do not send the refill automatically. She stated the facility must request a refill when needed. The Pharmacy Technician stated the [MEDICATION NAME] 2% Shampoo has only been dispensed once in (MONTH) (YEAR) and they have not received any requests for refills. She further stated that the [MEDICATION NAME] 2.5% cream is not refilled automatically and the prescription is still active. She stated that the cream was only filled on 1/8/18 and 2/7/18 and there has been no other refill request for this medication. The Pharmacy Technician stated she would fax the order they received for the [MEDICATION NAME] 2% shampoo. Review of the physician order [REDACTED]. [MEDICATION NAME] cream 2.5% to scaly areas on the face. Review of the MARs for R B on (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed [MEDICATION NAME] 2% Shampoo, apply topically to scalp every day shift two times weekly as directed on Tuesdays and Thursdays for Tinea Versicolor was signed off as administered every Tuesday and Thursday as ordered. [MEDICATION NAME] cream 2.5% was signed off as administered daily as ordered. Review of the MARs for R B with the DON revealed the [MEDICATION NAME] 2% shampoo on Monday, Wednesday, and Friday was discontinued on 9/12/17 and a new order [MEDICATION NAME] 2% Shampoo, apply topically to scalp every day shift two times weekly as directed on Tuesdays and Thursdays for Tinea Versicolor began on 9/14/17. Interview at the time of the observation with the DON revealed the initials on the MAR indicated [REDACTED]. Interview on 4/5/18 at 2:50 p.m. with the DON revealed that she has only worked in the facility for a few weeks but stated the ball was dropped somewhere along the line for ensuring the new order for [MEDICATION NAME] 2% Shampoo, apply topically to scalp every day shift two times weekly as directed on Tuesdays and Thursdays for Tinea Versicolor was faxed to the pharmacy and ensuring that the medicated shampoo was re-ordered. The DON further confirmed the tubes of [MEDICATION NAME] cream 2.5% with dispense dates of 1/8/18 and 2/7/18 were both less than 1/4 used. She stated if the cream was applied as directed daily to all the affected areas of the R B's face, the (MONTH) tube would be empty and the (MONTH) tube would be close to empty.",2020-09-01
935,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-04-05,725,D,0,1,CX7O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interview, it was determined that the facility failed to provide sufficient nursing staff to provide the assistance residents needed with activities of daily living (ADLs). The facility's census was 93. Findings include: 1. During an interview on 4/2/18 at 3:02 p.m., R#44 said she usually had to wait more than 15-20 minutes when she presses the call light to summon staff assistance. Quite often, this is when she needs to use the bedside commode and this means she must hold it until staff shows up. Sometimes the techs come in after a few minutes, but simply turns off the call light, advising her that your tech will come in a few minutes, but often no one comes to her assistance until she summons them again. A review of the clinical records of R#44 revealed [DIAGNOSES REDACTED]. A review of the quarterly minimum data set (MDS) assessment of 1/24/18 revealed R#44 had a brief interview for mental status score of 15, documenting that the resident was cognitively intact. This assessment also documented that the resident needed extensive assistance with bed mobility, transfer, tilt use, and personal hygiene, was frequently incontinent of bladder/occasionally incontinent of bowel. Review of the resident's plan of care initiated 2/12/18 for restorative nursing program: toileting revealed staff were to provide verbal/physical prompts and assist/cue the resident with toileting. Review of the plan of care for R#44 initiated 5/14/15 for limited to extensive assistance needed with ADLs, including toileting related to weakness/impaired lower extremities revealed staff were to assist with transfers and encourage participation. 2. During interview on 4/3/18 at 3:49 p.m. with six members of the resident council, it was revealed that there is not enough staff to provide the care and assistance they need and the available staff are overworked trying to keep up with the demands of the residents. Interview on 4/5/18 at 9:44 a.m. with certified nursing assistant (CNA) KK revealed R#44 is able to use the bedside commode for bowel and bladder needs, but does not always do so on schedule. When staff asks, she often says she is not ready but will call on staff when she needs to. The resident does call staff for assistance when she needs to use the toilet because she is not able to do son on her own due to weakness in her lower extremities. The CNA also believes the resident is fearful of transferring to/from the commode on her own for fear of falling. Review of the grievances for the past year revealed several, especially in the past three months regarding lack of care and services related to staffing. On 1/9/18, R#40 reported that his call light was on for 45 minutes before staff responded. On 3/22/18, the members of the resident council complained of call lights not being answered in a timely manner or being answered, but staff turning the lights off and never returning to assist. On 4/13/18, one resident filed a grievance stating she had noted R#245 sitting covered in urine since approximately 11:30 a.m. that day; the facility's investigation validated that the resident was indeed found in the common area covered in urine. 3. During an interview with R [NAME] on 4/2/18 at 12:05 p.m. she stated it takes a long time for staff to come and assist her, often one to two hours and by that time she has already wet or soiled her brief. R [NAME] stated they do not have enough staff to help her especially in the evenings and nights. During an interview with R [NAME] on 4/3/18 at 12:40 p.m., she stated she pushed her call light because she had to use the bathroom. She stated her regular CNA KK was busy with another resident and when a different CNA answered her call light, that CNA told her she would get her assigned CN[NAME] R [NAME] stated by the time her regular CNA KK could get to her about 15-20 minutes later, she had already had a bowel movement. She stated she had diarrhea and it was on her bed and down her legs. During an interview with R [NAME] on 4/04/18 at 9:15 a.m. the resident was observed crying and stated she had been soaking wet for since she woke up around 7:00 a.m. She stated she has pushed her call light for assistance twice and two different staff members told her they would be there soon. Observation at the time of the interview revealed her brief was notably wet and a section of her top sheet was damp. Incontinent care observation conducted by Registered Nurse Surveyor (RN) on 4/4/18 at 9:52 a.m. with CNA LL and CNA MM revealed the adult brief on R [NAME] was saturated with urine, the gel was swollen up and urine had spilled over onto the bed pad and the resident's top sheet. The adult brief was lifted and observed to be very heavy. Interview on 4/4/18 at 10:10 a.m. with CNA LL revealed that they are short staffed at times and it is hard to get all her work done but she does get it done. She stated that they could use more help. Observations of R [NAME] on 4/2/18 at 12:05 p.m., 4/3/18 at 12:40 p.m. and 4/4/ at 9:15 a.m. revealed the resident was wearing the same short sleeved, bright pink t-shirt with several dry liquid stains across the chest. Interview on 4/4/18 at 10:25 a.m. with the Director of Nursing (DON) revealed she has been back in the DON position since (MONTH) 6, (YEAR). She stated that they have been short staffed of nurse's and CNAs. She stated they are interviewing and often once a CNA is hired, they don't show up for work. She stated she has even worked on the medication carts herself to do whatever it takes to get the done. She stated that even though the facility is short staffed, that is an internal problem and she expects that the staff work as a team and get the care done. Interview on 4/4/18 at 2:15 p.m. with the Bath CNA GG revealed the facility is short staffed at times. She stated it is a lot to do and its hard but she does get it done most of the time. She stated that she does occasionally get pulled to the floor and the floor CNAs are responsible for bathing their residents but this has only happened a few times. Interview on 4/4/18 at 3:30 p.m. with the CNA JJ revealed staffing has been an issue and it makes it difficult to provide all the care to the residents. She stated there have been occasions when they only had two CNAs and sometimes they have to pull the Bath Aid to the floor. CNA JJ stated when that happens they are responsible for their own showers and must get at least two showers completed each. She stated that often on the 3rd shift there is only two CNAs in the facility, one on[NAME]nd one on Springs. She stated that she does hear complaints from residents that on the evening shift and night shift it takes a long time to answer call lights and that it takes a long time to get brief changes. She stated the residents also complain that the CNAs don't get to spend as much time with them due to the staffing. Interview on 4/5/18 at 9:30 a.m. with CNA KK revealed it is common to come in on her morning shift to a lot of her residents with wet or soiled briefs. She stated that most of the night CNAs leave and do not do conduct walking rounds but some do. She stated that she often hears the residents complain that nobody changed their brief or took a long time to answer call lights. She stated she has heard residents say there was only one CNA on the unit at night. CNA KK stated staff will answer a call light and tell the residents I'll tell your CNA' and never tell them. CNA KK stated staffing has been a problem for a long time and there is not enough staff. She stated patient care does suffer but she works very hard to get her care done. She stated there is usually three CNAs on the Springs Unit but often there are only two CNAs and they are told to do your best. (Cross refer F677) 4. During interview on 4/2/18 at 2:59 p.m. with R B, he stated he pushes the call light and the staff will say they will be back and not come back for 30 minutes to an hour for brief changes when wet or had a bowel movement. R B stated he wears a brief and does not use the toilet. Observations of R B on 4/2/18 at 11:20 a.m. and 3:12 p.m., 4/3/18 at 8:40 a.m. and 12:05 p.m., 4/4/18 at 9;20 a.m., 10:55 a.m., 1:30 p.m. and at 1:55 p.m. with the DON revealed the resident wearing the same black short sleeved t-shirt that had food crumbs, dry liquid stains, dandruff and skin flakes on it. (Cross refer F677) 5. During an interview on 4/2/18 at 3:51 p.m. with R A, he stated there is often only two CNAs on the floor. He stated you can wait up to a couple hours to get help when you call for assistance. 6. During an interview on 4/3/18 at 9:22 a.m. with R D, he stated they only have two CNAs and it takes a long time for them to help you. R A stated Like today, I am supposed to get his shower today so I will have to stay in bed until they can come to give me a shower. R D stated he requires assistant to get out of bed. 7. During an interview on 4/3/18 at 9:51 a.m. with R C, he stated there is not enough staff. He stated sometimes most of the hall will be lit up with call lights and there is only two CNAs on the floor. R C stated on nights there is often only one CN[NAME] The resident stated he watches and see's what's going on. R C stated things sure are different while the surveyors are here. He stated they are running around like crazy doing things that they never do and he has noticed a lot more staff here. Interview on 4/3/18 at 10:28 a.m. with the Ombudsman revealed she has been at this facility for a little over a year. She stated staff turnover has been a problem. She stated there has been four Administrators, new Social Worker and new DON. The Ombudsman stated she had received complaints about not having enough staff especially on evenings and weekends. Review of the resident council minutes dated 1/4/18 documented under Discussion of old/finished business: CNA's take 45 minutes to answer call lights. CNA's come in, cut the lights off and nobody never comes back. CNA's still saying I'm not your aide. CNA's are short staffed. CNA (name) wouldn't put (resident name) to bed. (resident name) having problem getting put to bed. Laundry- need a second shift person, clothes are missing. Documented under Discussion of New Business- Patient/Resident Request/Concerns- CNA's has bad attitudes, lights still not being answered in a timely manner. Review of the Resident Council Minutes dated 2/1/18 documented under Discussion of Old/Unfinished Business- CNAs no improvements, still cutting off lights and not coming back, still have attitudes. Review of the Resident Council Minutes dated 3/8/18 documented under Discussion of Old/Unfinished Business- Last Month Meeting CNAs no improvements still cutting lights off not coming back, still have attitudes. Resident Request/Concerns: Residents complain that other residents are holding the CNAs to long that they cannot get to them in time to do what they need for them. Review of the Resident Council Minutes dated 12/1/17 documented under Discussion of Old/Unfinished Business- CNAs coming in with an attitude, still not answering call lights. Documented under Patient/Resident Request/Concerns: CNAs talking on cell phones and not doing patient care. Taking too long to answer call lights, taking their problems out on the residents. Coming in cutting off the lights saying I am not your CNA but I will get your CNA and nobody comes. Review of the Resident Council Minutes dated 11/2/17 documented under Discussion of Old/Unfinished Business: Resident complaint when they ask for a nurse it takes 30 minutes to respond. Too many residents per CNA on 2nd and 3rd shift, slow about answering lights. Takes all day for the 1st shift to make beds. Call lights is still an issue. Under Discussion of New Business: CNA's call lights no better CNAs come in cut lights off and never come back. waiting 2 hours to get diapers changed. Resident Council minutes dated 10/1/17 documented under Discussion of Old/Unfinished business: Nursing- time management CNAs not answering call lights in a timely manner. Resident complaint when they ask for a nurse it takes them 30 minutes to respond. Resident Council Minutes dated 9/3/17 documented complaints about call lights. Resident Council Minutes dated 8/3/17 documented complaints about call lights. Resident Council Minutes dated 7/6/17 documented under Discussion of New Business: Staff sitting behind desk and not being passing out. Second shift leaves residents wet until third shift. Resident Council minutes dated 6/1/17 documented under Discussion of New Business: Call lights are still an issue.",2020-09-01
936,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-04-05,732,C,0,1,CX7O11,"Based on observations, the facility failed to post the daily nurse staffing on two days - 3/31/18 and 4/1/18. The facility's census was 93. Findings include: Observation on 4/2/18 at 10:35 a.m. of the daily staffing information posted near the front entrance revealed a documented date of 3/30/18 indicating that staffing information had not been posted for the weekend days of 3/31/18 and 4/1/18. Observation on 4/2/18 at 3:00 p.m. of the daily staffing information posted near the front entrance revealed it had been updated with a documented date of 4/2/18.",2020-09-01
937,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2019-04-29,658,J,1,0,TR5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and Ombudsman interviews, review of facility policy titled Enteral Nutrition revised (MONTH) 2014, and review of the Georgia Nurse Practice Act (chapter ,[DATE]) the facility failed to provide care and services in accordance with facility policies and that met professional standards related to providing a dinner tray to one resident (R) (R#1) with a Physician order to have nothing by mouth (NPO). Failure to provide services according to professional standards resulted in R#1 choking on food, aspirating, then a cardiopulmonary arrest and an eleven (11) day admission to an Intensive Care Unit, where he was maintained on life support, with an endo tracheal tube, then a [MEDICAL CONDITION], and remained unresponsive due to suspected [MEDICAL CONDITIONS]. R#1 was transferred to a Long Term Acute Care Unit (LTAC) where he expired twenty-seven (27) days later. The sample included ten (10) residents. On (MONTH) 25, 2019 a determination was made that a situation in which the 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. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on (MONTH) 25, 2019 at 10:44 a.m. The noncompliance related to the Immediate Jeopardy identified to have existed on (MONTH) 22, 2019 when staff failed to follow the Physician's orders for nothing by mouth (NPO) for resident (R) (R#1) who was newly admitted to the facility and was served a dinner tray which resulted in R#1 choking on a food item and R#1 went into [MEDICAL CONDITION]. The facilty had not provided a Removal Plan at the time of the exit on (MONTH) 29, 2019 therefore the IJ is ongoing. The immediate jeopardy is outlined as follows: Resident #1 was admitted to the facilty on (MONTH) 22, 2019 with a feeding tube and written Physician's orders to have nothing by mouth (NPO). Nursing failed to follow the physicians orders and served the resident a tray from the kitchen. Shortly after the tray was delivered R#1 was found to be in severe respiratory distress choking on a food item. The incident resulted in R#1 going into [MEDICAL CONDITION] and Cardiopulmonary Resuscitation (CPR) was started Emergency Medical Service (EMS) arrived and transported R#1 to the emergency room (ER) where R#1 was intubated and admitted to Intensive Care Unit (ICU) and later transferred to a Long Term Acute Care (LTAC) facilty where R#1 expired on (MONTH) 2, 2019. The immediate jeopardy was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.21 Services Provided Meet Professional Standards (F 658 Scope and Severity: J) C.F.R. 483.25 Quality of Care (F 684 Scope and Severity: J) C.F.R. 483.70(d)(1)-(3) Governing Body ( F 837 Governing Body Scope and Severity:J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25 Quality of Care (F 684 Scope and Severity :J). Findings include: Review of the Georgia Nurse Practice Act, chapter ,[DATE], revealed that licensed and registered nurses are required to: assess their patients in a systematic, organized manner; initiate nursing actions to assist the patient to maximize his/her health capabilities; evaluate with the patient the status of any goals as a basis for reassessment and reordering of priorities; function within the legal boundaries of nursing practice; and determine that care performed is based on the orders/directions of a licensed physician or other similarly licensed professional. Review of the facility policy titled Enteral Nutrition revised (MONTH) 2014 revealed on page 8 in part, #11. The Nurse will confirm that there are appropriate orders for oral (PO) intake or restrictions for nothing by mouth (NPO), as appropriate. Review of the clinical record for R#1 revealed he was admitted to the facility on (MONTH) 22, 2019 after being transferred from a local hospital with [DIAGNOSES REDACTED]. A nurse's report sheet dated (MONTH) 22, 2019 and timed 12:20 p.m. revealed the hospital nurse had reported that R#1 also had a [DIAGNOSES REDACTED]. Review of the printed transfer orders that were sent with R#1, from the transferring hospital revealed an order for [REDACTED].>Review of the facility Physician orders dated (MONTH) 22, 2019 revealed an order for [REDACTED]. Review of the Progress Notes for R#1 revealed on (MONTH) 22, 2019, LPN DD began to document medication order notes in the Electronic Medical Record (EMR) for R#1 at 2:49 p.m. At 4:15 p.m. LPN DD documented an admission note revealing R#1 was jaundiced and alert to person and place. LPN DD also documented that R#1's PEG tube was intact. Continued review of the Progress Notes for R#1 revealed on (MONTH) 22, 2019 at 6:00 p.m. R#1 was in bed, had no pulse and no respirations. Cardiopulmonary Resuscitation (CPR) was initiated and 911 was called. At 6:05 p.m. Emergency Medical Technicians (EMT) arrived, CPR continued and R#1 was transferred to the local hospital Emergency Department (ED). Review of the Hospital Record for R#1 revealed on (MONTH) 22, 2019 an ED Physician documented in History of Present Illness that according to (EMS) R#1 was found choking on food at the nursing home, had a [MEDICAL CONDITION] at that time. Patient did receive CPR at nursing home staff . patient was reportedly eating a biscuit, his room mate reportedly stated that the patient put the entire biscuit in his mouth. On Reexamination and Reevaluation the ED Physician documented he had seen and reexamined R#1 several times . the patient's brother does express concern over the fact that the patient is supposed to be nothing by mouth and receiving everything via PEG tube and yet he choked on a biscuit. (sic) The ED Physician's final [DIAGNOSES REDACTED]. After admission to the Intensive Care Unit (ICU) the care of R#1 was transferred to a Physician Hospitalist service. The Hospitalist History and Physical dated (MONTH) 23, 2019, revealed R#1 had been brought to the hospital after apparently choking on a food item with subsequent CPR . The Hospitalist documented on the Discharge Summary dated (MONTH) 6, 2019 that R#1 had apparently gone into [MEDICAL CONDITION] after choking on a biscuit. According to EMS, patient was choking on food at the nursing home, had a [MEDICAL CONDITION] at that time. Review of the Expiration Summary from the Long Term Acute Care (LTAC) unit where R#1 was a patient from (MONTH) 6, 2019 until his death on (MONTH) 2, 2019, revealed that R#1 had a prolonged ventilator course and required [MEDICAL CONDITION] and PEG tube placement at the hospital and was transferred to the LTAC unit for ongoing management of [MEDICAL CONDITION]. He was suspected to have [MEDICAL CONDITIONS]. During his hospitalization he remained dependent on the ventilator and his mentation did not improve. [MEDICAL CONDITION] medicine recommended that the chances of weaning R#1 from mechanical ventilation were almost nil. The hospital Ethics Committee was consulted due to R#1 suffering with prolonged ventilator support and requiring Vasopressor support (medication to maintain blood pressure) as well. Infectious Disease was following the patient. On the date of expiration patient continued to require increased amount of vasopressors, full ventilator support and in spite of that he passed away on (MONTH) 2, 2019 at 3:12 a.m. An interview with Unit Manager II was conducted on (MONTH) 29,2019 at 11:09 a.m. She revealed she had never been told that R#1 had been given food. The Unit Manager stated she had been at home at approximately 6:15 p.m. on Friday (MONTH) 22, 2019 when she received a call from LPN DD. LPN DD told the Unit Manager that R#1, who had just been admitted that after noon, had a cardiopulmonary arrest and had been transferred to a hospital with CPR in progress. LPN DD also told her that food was in the room and R#1 may have eaten something. Unit Manager II stated she called the former Director of Nurses (DON) and was told the DON would report this to the Corporate Regional Vice President, and the former Administrator, and would complete an incident report and initiate an investigation. Continued interview with Unit Manager II on (MONTH) 29, 2019 at 1:40 p.m. revealed that she was told by the former DON on (MONTH) 1, 2019 to give LPN DD a disciplinary write up related to not following Physicians orders on (MONTH) 22, 2019. She stated she was never told what order LPN DD did not follow and she had not asked what the write up was related to specifically. The Unit Manager revealed she assumed it was for LPN DD allowing R#1 to possibly get into food that was left in his room. Unit Manager DD confirmed she had never discussed anything related to the disciplinary write up with the former DON or the former Administrator who did not start an incident report and had never asked the staff to provide written statements or questioned them regarding R#1 eating food that was in the room because she was not told to do any of this. The Unit Manager confirmed that there is no incident report or investigation because no one initiated an incident report or investigation. The Unit Manager acknowledged that R#1 was bed bound so food in the room would not be a concern unless the food that was in the room was directly in front of him. The Unit manager also confirmed that disciplinary write ups are not given to employees for the possibility of Physician orders not being followed. She stated she had no knowledge of this. An interview was conducted on (MONTH) 29, 2019 at 4:37 p.m. with LPN DD related to R#1's brief stay at the facility. LPN DD stated she remembered R#1 and the events that had occurred prior to his cardiopulmonary arrest. LPN DD revealed she had received report from a hospital nurse for R#1 shortly after noon on (MONTH) 22, 2019. She stated she had been informed that R#1 had a history of [REDACTED]. LPN DD revealed that one of the Certified Nursing Assistants (CNAs) had told her when dinner trays came that R#1 said he was hungry, and she had made a terrible mistake. She stated she did not check Physician orders but had gone to the kitchen and told the staff that a resident on the unit with a regular diet had dropped his tray and she needed a replacement. They gave her a regular diet tray and she had taken it back to the[NAME]wing and given it to the CN[NAME] She stated she saw the CNA take it into the room. She stated she had said the tray was for someone else because she had not confirmed all the Physician orders yet, the dietary department had not received any information for R#1 and it would just be faster to say it was for someone that already had a diet order for. LPN DD revealed she did not remember what the CNA's name was, and did not actually see R#1 set up with the dinner tray, but she knows he did receive the food. LPN DD would not say how she knows that but repeated she just knows. LPN DD stated she was called to the room because R#1 had been found with no pulse or respirations. LPN DD stated she does not remember much more about the code, but she did not see the dinner tray near R#1, the CNA's had started CPR, and she did not notice if any food had been consumed from the tray or if there was food in his mouth. Interview with the former DON on (MONTH) 29, 2019 at 5:04 p.m. related to any investigation of the circumstances surrounding the admission and transfer of R#1 and the disciplinary write up of LPN DD. The DON revealed she had given the corporation her thirty day notice at the end of (MONTH) and her last day was to be (MONTH) 22, 2019. The former DON revealed she continued to come to the facility to help out but was not functioning as DON. She stated she was called by Unit Manager II on the night of (MONTH) 22, 2019 and told that R#1 had required CPR and transfer to the hospital and that there had been food in the room. The DON acknowledged that R#1 was immobile and that she was not sure why food in the room would be a concern unless it had been served to him. The DON stated she had told Unit Manager II to initiate an incident report, begin collecting statements from staff involved. The former DON revealed she had informed the former Administrator, the new DON, the new Administrator. The DON revealed she could not remember if she had informed the Corporate Regional Vice President, but if she had not the former Administrator should have done this. The DON stated she had no knowledge of LPN DD not following Physician orders on (MONTH) 22, 2019 and had never told the unit Manager to give LPN DD a disciplinary write up on (MONTH) 1,2019 or any other date. The former DON revealed she had not started any kind of investigation, but she had requested hospital record from the hospital R#1 was admitted to after he required CPR at the facility. She stated she did not remember the date she requested the hospital record. The DON revealed she had reviewed the hospital records and determined there were no concerns for R#1 choking on food. Interviews on (MONTH) 29, 2019 with the current DON at 10:50 a.m., the current Administrator at 11:00 a.m., the former Administrator at 1:24 p.m., the Corporate Regional Vice President at 12:43 p.m. and Corporate Co-Owner/Vice President KK at 5:22 p.m. revealed they were not informed by anyone that R#1 had been admitted to the facility on (MONTH) 22, 2019 and had a cardiopulmonary arrest at 6:00 p.m., or any situation related to a nurse not following Physician orders on Feburary 22, 2019 and providing a dinner tray to R#1 who was NPO. They all stated there was no incident report or investigation and they had had no knowledge of this situation until a State Surveyor began to investigate at the facility on (MONTH) 23, 2019. Cross Refer to F 837 and F 684",2020-09-01
938,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2019-04-29,684,J,1,0,TR5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff interviews, and facility policy review entitled Interdepartmental Notification of Diet (Including Changes and Reports), the facility failed to ensure that one (1) out of 10 sampled residents were protected from not following physician orders. Resident (R) R#1, was a new admission, who was ordered nothing by mouth (NPO), and was given a dinner tray after admission. After R#1 received his dinner tray, he choked on a piece of bread, requiring Cardiopulmonary resuscitation (CPR) to be performed due to [MEDICAL CONDITION], and transportation to the hospital emergency room (ER) and then Intensive Care Unit (ICU ) requiring mechanical ventilation and tracheotomy. On (MONTH) 25, 2019 a determination was made that a situation in which the 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. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on (MONTH) 25, 2019 at 10:44 a.m. The noncompliance related to the Immediate Jeopardy identified to have existed on (MONTH) 22, 2019 when staff failed to follow the physician's orders [REDACTED].#1) who was newly admitted to the facility and was served a dinner tray which resulted in R#1 choking on a food item and R#1 went into [MEDICAL CONDITION]. The facilty had not provided a Removal Plan at the time of the exit on (MONTH) 29, 2019 therefore the IJ is ongoing. The immediate jeopardy is outlined as follows: Resident #1 was admitted to the facilty on (MONTH) 22, 2019 with a feeding tube and written physician's orders [REDACTED]. Nursing failed to follow the physicians orders and served the resident a tray from the kitchen. Shortly after the tray was delivered R#1 was found to be in severe respiratory distress choking on a food item. The incident resulted in R#1 going into [MEDICAL CONDITION] and Cardiopulmonary Resuscitation (CPR) was started Emergency Medical Service (EMS) arrived and transported R#1 to the emergency room (ER) where R#1 was intubated and admitted to Intensive Care Unit (ICU) and later transferred to a Long Term Acute Care (LTAC) facilty where R#1 expired on (MONTH) 2, 2019. The immediate jeopardy was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.21 Services Provided Meet Professional Standards (F 658 Scope and Severity: J) C.F.R. 483.25 Quality of Care (F 684 Scope and Severity: J) C.F.R. 483.70(d)(1)-(3) Governing Body ( F 837 Governing Body Scope and Severity:J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25 Quality of Care (F 684 Scope and Severity :J). Findings include: R#1 was admitted to the facility on (MONTH) 22, 2019 at 2:16 p.m. with a [DIAGNOSES REDACTED]. The resident was later transferred out of the facility to a local hospital by Emergency Medical Services( EMS) on (MONTH) 22, 2019 at 6:23 p.m. Review of the Admissions Report dated (MONTH) 22, 2019 at 12:20 p.m., revealed that R#1 had a [DIAGNOSES REDACTED]. Review of the Nursing Admission Screening/History dated (MONTH) 22, 1019 at 12:59 p.m., revealed that the resident was alert to person, place, time and situation at time of admission. Continued review revealed that he has some short term memory problems, looked thin and anxious, and appeared jaundice in color. Review of continuing assessment revealed that his throat was clear, and pink; his mouth was pink, moist and lips were pink with tongue being moist and pink. All extremities were within normal limits (WNL) for range of motion (ROM). Review of the Progress Note dated (MONTH) 22, 2019 at 6:00 p.m., revealed R#1 in bed without a pulse, and/or respirations. Continued review revealed that CPR was started along with 911 being called. Further review indicated that at 6:05 p.m., Emergency Medical Services (EMS) arrived with CPR being continued and R#1 was transferred to the ER at a local hospital. Review of the Transfer Form V 4.1 dated Feburary 22, 2019 revealed that resident was transferred to a local hospital on (MONTH) 22, 2019 at 6:23 p.m., related to respiratory arrest. Continued review revealed that R#1 was NPO, had trouble swallowing and was receiving [MEDICATION NAME] (fiber-fortified tube feeding formula) 1.5 at 55 milliliters (ml)/20 hours (hr). Review of the Admitting Physician order [REDACTED]. Review of the Diet Order and Communication Form dated (MONTH) 22. 2019 with an unknown time, revealed that the resident was NPO with peg feeding. Review of the History and Physical from the local Medical Center dated (MONTH) 6, 2019 revealed that the resident was recently sent back from a Skilled Nursing Facility (SNF) today for respiratory distress. The patient was recently admitted to the hospital and was discharged earlier today for further rehab as he had a non-ST elevation [MEDICAL CONDITION] infarction (MI) with right lower lobe pneumonia and [MEDICAL CONDITION]. The patient was found to be in severe respiratory distress at the nursing facility with low oxygen saturations and subsequently sent back to the hospital. The patient came to theER on a nonrebreather and was placed on a Bi-level positive airway pressure ([MEDICAL CONDITION]). Subsequently, the patient is being admitted for further management to intensive care unit (ICU). Review of the Local Medical Center EMS report dated (MONTH) 22, 2019 revealed that EMS responded to a [AGE] year old male, [MEDICAL CONDITION], on arrival EMS supervisor was on scene and had already intubated (process of inserting a tube through the mouth and into the airway). Staff states that they were unsure how long patient had been unresponsive, but had checked on the patient a few minutes before and he was conscious alert and now, patient is pulseless. Patient was administered [MEDICATION NAME] (medication used to treat life-threatening allergic reactions) three times. Though CPR was being continued, R#1 had no change during rhythm check. R#1 had to be ventilated (having an opening to allow air to pass out) at a rate of 8 to 10 breaths per minute. During further review, R#1's systems were not assessed, such as mental status, skin, HEENT (head/face, eyes, and/or neck/airway), chest, abdomen, back, pelvis, neurological, and/or extremities. Review of the Final Report Emergency Department (ED) note-Physician from a local Medical Center dated Feburary 22, 2019 revealed that resident was brought into the ED due to choking on food at the nursing home, according to EMS. Patient did receive CPR by nursing home staff and he cannot be assessed secondary to patient's clinical status, but R#1 does have a peg tube. Patient was reportedly eating a biscuit, his roommate reportedly stated that the patient put the entire biscuit in his mouth. He had weak and thread peripheral pulses, with no spontaneous respiratory activity. Diffuse inspiratory crackles bilaterally when receiving bagged ventilations, slightly worse on the right. Patient seen and reexamined several times, and stabilized on a treatment course. Discussed findings and prognosis with patient's brother, who was at R#1's bedside, he voices understanding, and appreciative of care. Review of the Impression and Plan (page 6 of 7) revealed a [DIAGNOSES REDACTED]. R#1 was admitted to the hospital. Review of the local Medical Center Discharge Summary dated (MONTH) 6, 2019 revealed that the resident had presented to theER on (MONTH) 23, 2019 from the nursing home after patient had apparently gone into [MEDICAL CONDITION] after choking on a biscuit. According to EMS, patient was found choking on food at the nursing home, and had a [MEDICAL CONDITION] at that time. Patient did receive CPR by nursing home staff and was brought to the ER. In the ER, patient was emergently intubated and admitted to ICU for [REDACTED]. He remained unresponsive and neurology determined he had suffered [MEDICAL CONDITIONS] (occurs when the brain is deprived of oxygen) from the [MEDICAL CONDITION]. Eventually, had a [MEDICAL CONDITION] placed on (MONTH) 4, 2019 and subsequently accepted for transfer to a local Long Term Acute Care (LTAC) for further care. Review of the LTAC Discharge Summary dated (MONTH) 24, 2019 revealed that resident was admitted on (MONTH) 6, 2019 and expired on (MONTH) 2, 2019. admitted from a Medical Center after coming to the ER suffering [MEDICAL CONDITION]. He was intubated, and kept on a ventilator. R#1 was suspected to have [MEDICAL CONDITIONS]. Due to his prolonged vent course, trach, and peg tube and he was transferred to a LTAC center in hopes to vent weaning (remove the ventilator); however, no improvement, resident had poor prognosis. Depict increased amounts of vasopressors (medication given for septic shock), and full ventilation support, the resident passed on (MONTH) 2, 2019 at 3:12 a.m. Interview with Licensed Practical Nurse (LPN)/Treatment Nurse AA on (MONTH) 24,2019 between 10:32 a.m.-10:40 a.m., revealed that he was the manager on duty for this particular weekend. Continued interview revealed that when he was told about the resident's condition, he entered the room and CPR was being completed. There was two nurses and two Certified Nursing Assistants (CNA) in the room. He took over chest compressions, which he continued until EMS arrived, and one of the other nurses DD was giving report to EMS. He took the lead once he entered the room. Stated an ambo bag was applied , lifted head, and resident's chest raised and fell without any problems. The incident did occur during supper time; however, he did not recall seeing a dinner tray for this resident, but for other residents in the room. When EMS arrived, they took over and resident was transported. He did the initial skin/wound assessment earlier that day, and said that the resident was a pale yellow, indicating that the R#1 looked very sick. Continue to say that R#1 had to be vented at a local Medical Center and just got extubated (removed) a few days prior to being admitted to the facility. Interview with LPN, DD, over the phone, on (MONTH) 24, 2019 at 1:50 p.m., revealed that she found the resident non-response with no pulse, and called a code blue while she went to get the crash cart. Continued interview revealed that another nurse called 911, and EMS arrived within minutes of being called. She started doing chest compressions, and when EMS arrived they took over, and placed a devise for [MEDICAL CONDITION] with continuous mechanical chest compressions on R#1. EMS did Intubate resident and transported him to a local hospital. She confirmed that R#1 was NPO, so stated that there was no dinner tray delivered to him. Interview with ER admitting physician CC, on (MONTH) 24, 2019 at 4:16 p.m. via the phone, revealed that he is fairly sure that he saw some biscuit that particular evening because he stated that he is newly divorced and is learning to cook, which he had made some biscuits and brought for dinner that evening, which he gave away. He continued to state that if the resident had not gotten over the pneumonia that too could have caused the [MEDICAL CONDITION] because of the shock to his body. Stated that EMS would still have been able to Intubate even if there was a foreign object in the throat which would just push the object down further. Confirms that he should do a better job of documenting of what the foreign object was, which he usually does, but does not remember documenting in this particular case. Interview with the Registered Dietitian (RD) BB on (MONTH) 24, 2019 at 3:25 p.m., revealed that with every meal usually, there is a roll, and/or slice of bread that is served to the residents. Could not confirm if a biscuit was served that evening (February 22, 2019) of the particular incident. Stated that when a new resident comes to the facility, the nurse after taking off the orders, will fill out a diet slip for dietary with the appropriate diet. During another interview at 4:03 p.m., confirmed that there was no dietary slip received in dietary that particular day, and if there is no slip, then a new admit resident would not receive a tray without a slip from nursing. Interview with CNA EE, on (MONTH) 24,2019 between 5:00 p.m.-5:10 p.m., revealed that this particular resident came in around dinner time, when she was in his room showing him the call light, he stated that he was hungry, so she left the room and told the nurse DD, who went to the kitchen and obtained him a tray. Continued interview revealed that when she returned to the room to check on him, his head was flat on the bed, and he was reaching for the tray, which was on the nightstand and did contain a roll. Stated that she put his head up, moved the tray to an over bed table, which she had to go get, and R#1 grabbed the roll off the tray; however, could not confirm if he ate anything prior to this. Said that when she left the room, R#1 was doing well, and a few minutes later she heard the code blue for that resident. Confirmed that she was unaware of his NPO status and said that the nurses give information on newly admitted residents, including diet orders. Confirmed that upon getting to the facility and starting her shift, rounds were completed, as they are everyday, but this resident had not been admitted as of that time, stating he came in around dinner time. Interview with cook FF, on (MONTH) 25, 2019 at 7:40 a.m., that she has been at the facility for the past [AGE] years, and normally works 5:30 a.m.-1:30 p.m.; however, on (MONTH) 22, 2019, worked over due to call out until about 7:30 p.m. Continued interview revealed that nurse DD came back to the kitchen requested a dinner tray for another resident, who was on a regular diet, stating that this resident dropped his tray. Stated that on the tray that evening would have been a piece of meat, vegetables, and bread, mostly likely a dinner roll. She confirmed that the nurse DD never mentioned that the tray was for R#1, and the kitchen never received a diet communication sheet. She stated that she knew he was NPO, so he would have not received a tray. Stated that if staff come back to the kitchen and request a tray for a resident that is newly admitted , then the kitchen staff asks about a diet communication sheet prior to giving that tray. If staff come back to the kitchen and request another tray for an existing resident, then the kitchen staff fixes that particular residents tray again per their diet order. Interview with CNA GG on (MONTH) 25,2019 between 8:00 a.m.-8:15 a.m. over the telephone, revealed that she has been working on the ,[DATE] shift for about six to seven months. Continued interview revealed that she was here that particular evening; however, did not see R#1 receive a dinner tray, but knows he received a tray. Said that the resident came in around dinner time. Confirmed that she knew that he received a tray was because of what happened, code blue being called. She was the one that gathered all other CNA's to his room, while another CNA called the code blue. She confirmed that she was the one that dug a piece of roll out of his throat during the code blue. Went on to state that nurse DD, while performing CPR, R#1's chest was not rising, so CPR was stopped. This is when he was turned to his side and she dug a piece of roll out of his mouth, and CPR was continued. Stated that the ambulance came within minutes, and took over and the resident was transported out of the facility. Confirmed that nurse DD got tired while performing CPR, and she took over CPR, while LPN/Treatment Nurse was in the room, but all he did was holler for the crash cart. Stated that there has been no roommate changes, and confirmed that nurse DD got all the CNA's together that evening to let them know that this particular resident was NPO after he arrived on the unit. Confirmed that upon admission of a new resident, it is the nurses who let them know of the orders, including diet orders. Interview with LPN HH, on (MONTH) 25, 2019 at 8:38 a.m., revealed that when a newly admitted resident comes to the facility, after orders are taken off, a diet communication slip is filled out, and sent to the kitchen. Continued interview revealed that a copy is made and put into the resident's chart, along with being put into the computer. Interview with LPN/Unit Manager (UM) on (MONTH) 25, 2019 at 8:40 a.m., revealed that after the orders are taken off, then a diet communication slip is filled out, sent to the kitchen, and placed into the medical records box, which then is scanned into the computer. The facility has been electronic charting since around (MONTH) (YEAR). During another interview on (MONTH) 25, 2019 at 9:30 a.m., revealed that she has been the UM for the past five years and confirmed that the information on the SBAR and transfer form was obtained from nursing notes. Confirmed that she was not here at the time of this particular incident. However, received a call from nurse DD who said that there was food in the resident's room, but unsure if resident ate anything. Went on to state that R#1 coded, CPR was started, EMS was called and R#1 was transported out of the facility. Confirmed that she notified the previous DON about this incident. Confirmed that she made sure the paperwork was completed. She recalls that she was here at the time R#1 was admitted ; however, was not here at this particular incident. Said that she normally works 8:00 a.m.-4:30 p.m., but has to be flexible in her hours due to what is going on the unit. Since this incident, there has been no further incidents of this kind and she is unaware of the time that she left that particular day. Said that is the nurses responsibility to inform the CNA and dietary of any diet orders upon admit. Interview with the DON on (MONTH) 25, 2019 between 8:42 a.m.-8:48 a.m., revealed that both her and the Administrator has only been in the facility since (MONTH) 26 2019, and she does not know of anything that happened that particular evening (February 22, 2019). Confirmed that since she has arrived, there has been no other incidents of this kind. Review of facility policy Interdepartmental Notification of Diet (Including Changes and Reports) with revised dated of (MONTH) 2008, revealed that when a new resident is admitted , or a diet has been changed, the Nurse Supervisor shall ensure that the Food Services Department receives a written notice of the diet order. Continued review revealed that the Food Services Department will also be notified verbally if the diet change or report occurs one hour or less before a scheduled meal, or if circumstances indicate that the written procedures will not be adequate to ensure service at the next meal. Refer to F658 and F837",2020-09-01
939,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2019-04-29,837,J,1,0,TR5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, Ombudsman, staff, Administrator, and Corporate co-owner/Vice President interview it was determined that the of the facility's Governing Body failed to ensure a process was in place to identify risk and exposures and effective communication between the Governing body, the facility Administrator and the staff. This failure resulted in regulatory risk to include Standards of Professional Practice related to following MD orders and Quality of Care, when one resident (R), R#1 choked on food from a dinner tray that was delivered to him shortly after admission. R#1 had hospital transfer orders, dated (MONTH) 22, 2019 and admission orders [REDACTED]. R#1 became pulseless and apneic (without respirations) after choking and subsequently required intubation, mechanical compressions and administration of code medications. He was transferred to a local Emergency Department and admitted to the local hospital's Intensive Care Unit. These failures resulted in Immediate Jeopardy. The sample size was ten residents. On (MONTH) 25, 2019 a determination was made that a situation in which the 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. The Administrator and the Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on (MONTH) 25, 2019 at 10:44 a.m. The noncompliance related to the Immediate Jeopardy identified to have existed on (MONTH) 22, 2019 when staff failed to follow the physician's orders [REDACTED].#1) who was newly admitted to the facility and was served a dinner tray which resulted in R#1 choking on a food item and R#1 went into [MEDICAL CONDITION]. The facilty had not provided a Removal Plan at the time of the exit on (MONTH) 29, 2019 therefore the IJ is ongoing. The immediate jeopardy is outlined as follows: Resident #1 was admitted to the facilty on (MONTH) 22, 2019 with a feeding tube and written physician's orders [REDACTED]. Nursing failed to follow the physicians orders and served the resident a tray from the kitchen. Shortly after the tray was delivered R#1 was found to be in severe respiratory distress choking on a food item. The incident resulted in R#1 going into [MEDICAL CONDITION] and Cardiopulmonary Resuscitation (CPR) was started Emergency Medical Service (EMS) arrived and transported R#1 to the emergency room (ER) where R#1 was intubated and admitted to Intensive Care Unit (ICU) and later transferred to a Long Term Acute Care (LTAC) facilty where R#1 expired on (MONTH) 2, 2019. The immediate jeopardy was related to the facility's noncompliance with the program requirements as follows: C.F.R. 483.21 Services Provided Meet Professional Standards (F 658 Scope and Severity: J) C.F.R. 483.25 Quality of Care (F 684 Scope and Severity: J) C.F.R. 483.70(d)(1)-(3) Governing Body ( F 837 Governing Body Scope and Severity:J) Additionally, Substandard Quality of Care was identified with the requirements at C.F.R. 483.25 Quality of Care (F 684 Scope and Severity :J). Finding include: Review of the undated face sheet for R#1 revealed he was admitted to the facility on (MONTH) 22, 2019. The [DIAGNOSES REDACTED]. Review of the clinical record for R#1 revealed on (MONTH) 22, 2019 at 12:20 p.m. a nurse received report for R#1. The nursing report included a [DIAGNOSES REDACTED]. An admission assessment dated (MONTH) 22, 2019 revealed R#1 was alert and oriented and unable to ambulate. Review of the electronic medical record Progress Notes for R#1 revealed Licensed Practical Nurse (LPN) DD had first documented admission medication orders at 2:49 p.m. and documented that the medications were to be given by PEG tube. Further review revealed an admission note documented at 4:15 p.m. that R#1 had no signs of distress and his PEG tube was intact. The following day on (MONTH) 23, 2019 at 2:44 p.m. LPN DD documented that on (MONTH) 22, 2019 at 6:00 p.m. R#1 was in bed, had no pulse, no respirations, 911 was called and at 6:05 p.m. the Emergency Medical Technicians had arrived and R#1 was transferred to an emergency room . Review of the transfer record Physician orders [REDACTED].#1 was transferred from revealed R#1 was to have nothing by mouth. The facility Physician orders [REDACTED].>A review of the eInteract transfer form dated (MONTH) 22, 2019 time 6:23 p.m. by Unit Manager LPN II revealed R#1 was not ambulatory. On (MONTH) 29, 2019 at 10:50 a.m. an interview was conducted with the current Director of Nurses (DON). She revealed that she entered the facility for orientation with the current Administrator on (MONTH) 26, 2019. The DON revealed the former DON was in the building to orient her for that week. She stated no one told her anything about a resident that choked on food with an order to be NPO and was transferred to the hospital the day he was admitted . The DON revealed she had not heard about this concern until a surveyor began to investigate last week. The DON revealed she would have expected the former DON to give her this information and to have an incident report and an investigation. The DON revealed there is no incident report on paper or in the Electronic Medical Record (EMR) system. She stated she was not told of any outstanding issues by anyone at the facility. The DON stated she started her own investigation on (MONTH) 23, 2019 and has interviewed staff and has written statements. Copies were requested, and the DON agreed to provide them. The DON revealed she was told by LPN DD, the admitting nurse for R#1 that LPN DD had gone to the kitchen to get a tray for R#1 because he said he was hungry and had told the dietary staff she had dropped a dinner tray and she just needed another one. She stated that LPN DD has a Performance Improvement Plan initiated by the Unit Manager, for not following orders on (MONTH) 22,2019. A copy of the personnel file for LPN DD was requested and the DON agreed to provide this. The DON revealed she had suspended LPN DD. On (MONTH) 29,2019 at 11:00 a.m. the Administrator joined the interview and revealed she had also started employment for the facility on (MONTH) 26, 2019 and was not given any information about any resident who had required CPR a few hours of admission, went to the hospital and expired. The Administrator revealed she had not been given any information about outstanding issues and learned of this concern with the DON, when the State Surveyor began to investigate last week. A review of the Payroll Detail Report for the former DON revealed she was in the building on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] for eight (8) hours each day. An interview was conducted with Unit Manager II on (MONTH) 29, 2019 at 11:09 a.m. related to her knowledge of R#1's admission to and brief stay at the facility. The Unit Manager confirmed she is responsible for the Meadows Wing where R#1 was a resident. The Unit Manager stated she was not in the building when dinner trays were being served on Friday, (MONTH) 22, 2019 and had left at approximately 4:30 p.m. that day after entering orders into the computer that she had received from the Admissions Department prior to R#1's arrival. The Unit Manager revealed that the orders are not accepted into the EMR until the charge nurse receives a paper copy when the resident arrives and confirms all the orders on the EMR. Then the orders are considered complete and final. She stated that she was at home on the evening of (MONTH) 22, 2019 and received a call from LPN DD saying that R#1 had been observed with no pulse or respirations at approximately 6:00 p.m. and that he might have gotten into some food that was in the room. The Unit Manager revealed she was not given any other details , but had assumed since R#1 had a [DIAGNOSES REDACTED]. The Unit Manager acknowledged that R#1 was not ambulatory and not able to transfer himself out of the bed, get to food out of the reach of his bed, then return to the bed and eat the food. She acknowledged the only food he could access would be food that was placed directly in front of him. Unit Manager II stated she called the former DON after the call from LPN DD and was told by her that the former DON was going to initiate an investigation and that the former DON would complete an incident report, call the former Administrator, and call the Regional Vice President. The Unit Manager revealed she had not heard anything more about this incident until she was told by the former DON on (MONTH) 1, 2019 to give LPN DD a written disciplinary action related to not following Physicians orders on (MONTH) 22, 2019. The Unit Manager revealed she had never been given any information by the former DON related to what order was not followed and the write up did not include any additional information. The former DON was called by the Unit Manager last week when the State Surveyor was here investigating the concern. The former DON told her she was initiating a request. The Unit Manager revealed she was told by the former DON that it was in her office in a manila envelope. She stated she gave this information to the DON and Administrator and they had searched the former DON's office multiple times from top to bottom and the investigation could not be found. They had searched for an incident report as well and that could not be found. An interview was conducted on (MONTH) 29, 2019 at 12:43 p.m. with the Corporate Regional Vice President, related to notification of a resident who was admitted to the facility on (MONTH) 22, 2019 and was transferred to the local hospital a few hours later with CPR in progress. The Corporate Regional Vice President confirmed that is her position, but she is also Administrator at another facility. She stated that she should have been notified of this but does not consider herself responsible for this facility because she is Administrator somewhere else. The Corporate Regional Vice President revealed she was never notified of this situation until the surveyor arrive last week. She denied being notified by the former DON of this issue and indicated she will discuss any problems with the facility management but is not part of the Governing Body or chain of command. She revealed she was not sure who the Governing Body is, because the Administrator does have final responsibility for anything that happens in the facility, but the two owners of the corporation can be called for any problems. An interview was conducted with the former Administrator on (MONTH) 29, 2019 at 1:24 p.m. related to his knowledge of the admission of R#1 on (MONTH) 22, 2019 and his transfer to the hospital with CPR in progress a few hours later. The former Administrator revealed he had not been informed of any information surrounding this incident until the State Surveyor began to investigate last week. The former Administrator revealed he had attended the morning clinical stand up meeting on (MONTH) 25, 2019 and the former DON was there, and this was his last day as Interim Administrator, and her last day as DON. He revealed the new DON and Administrator were not there because they did not start until the next day. He revealed the former DON had never called him regarding this incident and there was no mention of this from her or the Unit Manager in the clinical stand up meeting or by telephone. The former Administrator revealed he should have been notified of this incident by the DON or it should have been brought to everyone's attention in the clinical stand up meeting by Unit Manager II. The former Administrator revealed he has reviewed his notes and his email history from (MONTH) 22, 2019 through (MONTH) 1, 2019 and has no indication that anyone informed him of this. He stated this should have been reported to the state and an investigation should have been initiated. A review of morning meeting attendance sheets revealed the former DON signed in (MONTH) 21, 2019 and (MONTH) 22, 2019, and signed into morning meeting on (MONTH) 27, 2019 and (MONTH) 28, 2019 . There were no further signatures on the roster by the former DON from (MONTH) 22, 2019 through (MONTH) 5,2019. The former Administrator signed the roster for morning meeting on (MONTH) 25, 2019 as a consultant, and on (MONTH) 5, 2019 as a consultant. There were no additional signatures on morning meeting rosters from (MONTH) 22, 2019 through (MONTH) 5, 2019 by the former Administrator. An interview with LPN Unit Manager II was conducted on (MONTH) 29, 2019 at 1:40 p.m. related to reporting of the events of R#1's admission and stay at the facility. The Unit Manager revealed she does not remember being told that LPN DD did not follow Physicians orders, and confirmed that is what is documented on the Performance Improvement Plan dated (MONTH) 1, 2019, with her signature and the signature of LPN DD. She stated the DON may have found something with her investigation. The Unit Manager revealed she had assumed the order that was not followed was related to R#1 possible getting into some food that was in the room and choking on it. The Unit Manager acknowledged that R#1 was not capable of getting into any food that was not directly in front of him, and that disciplinary write ups are not given for possibly not following Physician orders. The Unit Manager confirmed her signature was present on the disciplinary write up dated (MONTH) 1, 2019 and that she was told that day by the DON to present the write up to LPN DD. The Unit Manager confirmed that LPN DD had been given a disciplinary write up in (MONTH) for administering [MEDICATION NAME] to a resident when the order had been discontinued over two weeks before the last administration. The Unit Manager revealed she did not question anyone about the cardiorespiratory arrest of R#1 or file an incident report, or mention this in morning meeting, or tell the new DON and Administrator about it because the former DON had told her she would take care of all that. The Unit Manager confirmed that LPN DD was disciplined for not following Physician orders [REDACTED]. The Unit Manager revealed she does not remember if the former DON was in the morning meeting on (MONTH) 25, 2019, but the former Administrator was there and she assumed he was still the Administrator on that day because the new Administrator and DON were not in the building yet. A review of disciplinary Individual Performance Improvement Plans in the personnel file of LPN DD revealed on [DATE] at 9:00 a.m. and 5:00 p.m., [DATE] at 10:00 a.m., [DATE] at 2:00 p.m., [DATE] at 12:00 p.m., [DATE] at 10:00 a.m., [DATE] at 10:00 a.m., [DATE] at 12:00 p.m. and [DATE] at 6:00 p.m. [MEDICATION NAME] was given to a resident without an order, [MEDICATION NAME] order had been discontinued on [DATE]. There were no signatures or date on the Performance Improvement Plan. The Performance Gap was documented to be a Medication Error, the Expected Result was staff will pay closer attention to Medication Administration Records/ Treatment Administration Records (MARs/TARs) when administering medication. The Developmental Process was documented to be education via DON. The Measurement of Expected Results was documented Unit Manager (UM) will monitor Narcotic Boxes for discontinued medications, with a Target date of Immediately. Hand written on the Performance Improvement Plan was a note to please sign education attached. An education roster dated [DATE] was included. The topic was detailed as follows: Always make sure you check the MARs/TARs before giving a medication to ensure there is an active order for the medication. There is no signature on the education roster. It is blank. An additional Individual Performance Plan for LPN DD was reviewed dated (MONTH) 22, 2019. The description of event was documented as follows: No (sic) following MD orders. The date of the meeting on the Plan was (MONTH) 22, 2019. The Performance Gap was documented as Unsatisfactory Performance. The Expected Result was all MD orders will be followed. The Developmental Process was education by UM's. The Measurement of Expected Results was to spot check as needed, with a Target Date of Immediately. This was signed by Unit Manager II and LPN DD as acknowledged and completed. There was no documentation of suspension in the personnel file, or any statements by LPN DD related to R#1. The Ombudsman arrived and was interviewed on (MONTH) 29, 2019 at 2:45 p.m. The Ombudsman revealed she was called by a family and named the family of R#1. She stated the family had told her that they received a call from an anonymous staff person on (MONTH) 20, 2019 that R#1 had choked on food he had been given at the nursing home. They were aware of this already but felt the issue was being covered up because the call from the nursing home they received on (MONTH) 22, 2019 after R#1 had coded revealed he had respiratory distress and staff initiated CPR and he was on his way to the hospital. The Corporate Regional Vice President called at (MONTH) 29, 2019 at 4:09 p.m. and asked if she could send the disclosure of owner ship instead of information about the Governing Body because there was no Governing Body. She stated the facility is owned by a Limited Liability Company (LLC) and the Administrator answers to owners if there are any problems. The Corporate Regional Vice President revealed she calls the two owners on a daily basis. An interview was conducted on (MONTH) 29, 2019 at 4:37 p.m. with LPN DD related to her recollection of the admission and transfer of R#1 on (MONTH) 22, 2019. LPN DD revealed she had just been terminated that day and would admit to me that she made a horrible mistake. She stated she had told the Unit Manager (UM) when she called her after R#1 left for the hospital with CPR in progress that there had been food in the room and R#1 may have eaten some of it. LPN DD revealed she had taken report for R#1 and the report included the information that he had previously had aspiration pneumonia, was NPO and had a new PEG tube with orders for feedings to be provided through the tube, but had forgotten this information. LPN DD then stated she had been told by a Certified Nursing Assistant (CNA) that R#1 said he was hungry and without remembering R#1 was NPO, or checking his orders had walked to the kitchen and requested a tray for another resident who received a regular diet and told them that that other resident had dropped his tray. LPN DD revealed she had done this because she had not yet confirmed the orders for R#1 and it would be easier for her to just get a tray for another resident and give it to R#1. She had returned to the floor and had given the tray, still with the plate covered to the CNA that had told her that R#1 was hungry, she stated she could not remember the CNA's name, and observed the CNA go to R#1's room with the tray. When she was called to the room because R#1 needed CPR she did not observe the tray near him and did not notice if any food was missing or if there was food in his mouth. LPN DD revealed she knows the resident did get the tray and would not reveal how she knows this. An interview was conducted on (MONTH) 29, 2019 at 5:04 p.m. with the former DON related to being told R#1 had been transferred to the hospital on (MONTH) 22, 2019 with CPR in progress a few hours after he was admitted . The former DON revealed she had written her notice at the end of (MONTH) due to personal issues and it was effective on (MONTH) 22, 2019. She stated that she was no longer DON after that day when she left, but she had stayed to help out. The former DON stated she was not in the building at all on (MONTH) 1, 2019 and did not remember if she was in the building to attend morning meeting on (MONTH) 25, 2019. She stated Unit Manager II had called her the evening of (MONTH) 22, 2019 and said a new patient had to go to the hospital soon after admission. She stated she was told LPN DD had started CPR and the wound care nurse LPN AA had assisted with CPR. She stated she was aware R#1 came in with a recent insertion of a PEG tube, was NPO and was completely dependent on the staff for mobility and transfers. The former DON stated she was told R#1 had a tray in his room . The former DON revealed she was told the tray was untouched. The former DON denied doing any form of investigation and then confirmed she had requested the record from the hospital R#1 was transported to after he had a cardiopulmonary arrest on (MONTH) 22, 2019. The former DON acknowledged she had reviewed this record and did not find any reference to choking on food and determined that he must not have choked on food. The former DON denied any knowledge of a CNA clearing food from the mouth of R#1 during ventilations with an Ambu bag because of inadequate chest rise and said she had not investigated the incident at all because she had told the Unit Manager II to investigate the incident, get staff interviews, and make an incident report. The former DON confirmed that if there was food in the room the resident would not be able to get to the food because he was immobile and if there was any food obstructing his airway it would have had to be placed right in front of him. The former DON revealed she had notified the former Administrator of the cardiopulmonary arrest of R#1, and does not remember if she called the Corporate Regional Vice President. She stated she does remember telling the new DON and the new Administrator. The former DON denied any interviews, denied any investigation, denies telling anyone that investigative results related to R#1's cardiopulmonary arrest being placed in a manila envelope that was lost, denied completing any incident report, and denied ever telling the Unit Manager II to complete a disciplinary write up for LPN DD for not following physician orders [REDACTED]. The former DON revealed she had instructed Unit Manager II to complete and incident report and begin collecting statements of staff on duty on (MONTH) 22, 2019 related to the incident with R#1. Record review of the hospital record for R#1 revealed the following references to him choking on food: February 22, 2019 a hospital Emergency Department (ED) Physician's note documented under the heading of Impression and Plan with a [DIAGNOSES REDACTED]. The Reexamination and Evaluation documented the concern of the brother of R#1 related to the resident choking on food when he was supposed to receive only tube feedings and nothing by mouth. The ED Physician's Final Report dated (MONTH) 22, 2019 was reviewed and under History of Present Illness the ED Physician documented that according to EMS the patient was found choking on food at the nursing home and that patient was reportedly eating a biscuit and his room mate told EMS that the patient put the entire biscuit in his mouth. The Hospitalist documented on the discharge summary dated (MONTH) 6, 2019 that R#1 had apparently gone into [MEDICAL CONDITION] at the nursing home after choking on a biscuit and eventually had a [MEDICAL CONDITION] placed by Pulmonology on (MONTH) 4, 2019. A History and Physical dated Feburary 23, 2019 by the hospitalist revealed that R#1 was brought to ED after apparently choking on a food item with subsequent CPR being done as well as interventions by EMS with a subsequent return rhythm. A review of the resignation dated (MONTH) 23, 2019 of the former DON revealed the effective date was (MONTH) 22, 2019. A call was placed to the Corporate Co- owner of the facility KK on (MONTH) 29, 2019 at 5:22 p.m. and an interview was conducted. He revealed he was not informed about any resident admitted on (MONTH) 22, 2019 that choked on food, had a cardiopulmonary arrest and was transferred to the hospital with CPR in progress the same day he was admitted , until a State Surveyor came to investigate on (MONTH) 23, 2019. The Corporate Co -Owner revealed the former Administrator and the Corporate Regional Vice President who is Administrator at another facility should have been notified right away and he also should have been notified immediately. The Corporate Co -Owner revealed he thinks the notifications, investigations and reports were missed because the situation occurred while the facility was in the midst of changing the DON and Administrator. Corporate Co -Owner KK revealed that there is no Governing Body Policy, but the chain of command should be Administrator, Regional Vice President then the owners. He stated that he has an organizational chart and he will send that and a disclosure of ownership. He revealed that every one with responsibility, including the owners, the Regional Vice President and the former Administrator would take their responsibility. Review of the disclosure of ownership of the facility sent by Co -Owner KK revealed the facility is at the bottom of the chart with one of two Managers listed as Co-Owner KK. Next up on the chart is the name of the Corporation identifying the corporation as an LLC. Next there are four names listed at the top of the algorithm with 25% after each name. One of the names is Co-Owner KK. On (MONTH) 29, 2019 at 5:10 p.m. the current DON was again requested to provide a copy of her investigation and she revealed she would copy it now and give it to the surveyor. A job description for the Corporate Regional Vice President was requested and the DON revealed she and the Administrator were both told they are to report anything of any concern or out of the ordinary or any adverse out comes to her, but they do not have a job description for the Corporate Regional Vice President and were in the process of obtaining a job description from her. An interview was conducted with LPN AA on (MONTH) 29, 2019 at 5:33 p.m. related to his recollection of providing CPR for R#1. LPN AA wound care nurse revealed he remembered that he was in facility on (MONTH) 22, 2019 and was providing wound care in another room when a CNA came to get him and said there was a code. He remembered providing a skin assessment for the resident who was coding, R#1. He went to the room and 2 CNA's were providing CPR and LPN DD was standing in the doorway. He revealed she was a seasoned nurse who had been involved in codes multiple times in the facility but she looked very upset. The crash cart was in the room and he asked how long they had been giving CPR and was told ,[DATE] minutes, an ambulance was in parking lot from just dropping off another resident and they came right in. LPN AA had observed a CNA having trouble giving ventilations with the ambu bag and had taken it from her and given two breaths with the ambu bag when he heard LPN DD tell the female paramedic the resident might have gotten some food. He revealed he was shocked that LPN DD had not given him this information before he gave the two breaths with the ambu bag because if he had known that he would have checked the residents mouth for food. He looked in residents' mouth when the paramedic opened R#1's mouth to intubate and did not see food. R#1 had looked jaundiced when the skin assessment was done, and as he was receiving CPR R#1 looked white around his mouth and eyes. He remembers the former DON asking him for a written statement possibly on (MONTH) 26, 2019 and he provided one to her. LPN AA revealed any time there is a significant change in a residents condition or they go to the hospital he understands the Unit Manager is told, she tells the DON who tells the Administrator, and he tells whoever is next in command. He revealed the statement he had written for the DON had also been provided to the Unit Manager on (MONTH) 22, 2019 when she asked for a written statement and it had disappeared. He revealed he had made a copy of the statement and left it in his office on (MONTH) 26, 2019 and that too had disappeared. He revealed he had save the second copy on his computer and had hand written from the saved copy a statement for the current DON and had given that to her and he did not remember the date but it was after the State Surveyor began investigating last week. Requested he provide me the statement he prepared for the DON. He agreed to do this. A review of the above mentioned undated statement, on plain paper, no letterhead, and no date of the event provided to the surveyor from LPN AA revealed a description of the occurrences he explained during his interview above. A post survey telephone call was made on (MONTH) 1, 2019 at 9:56 a.m. to the current Administrator related to the request for the Corporate Regional Vice President's job description. The current Administrator revealed she had found out yesterday that there is no one in that position and there is no job description for that position. The current Administrator and Current DON revealed they had been told to report any concerns or adverse or unusual events to the Corporate Regional Vice President by the former Administrator, and gave her name, but that must have been incorrect because now they have been told there is no one with that position. The current Administrator stated she would have the Corporate Co-Owner call me when he gets to the facility today. A post survey conference call was received from the former Administrator and the Corporate Co-Owner KK, who were both at the facility on (MONTH) 1, 2019 at 12:08 p.m. The Corporate Co-Owner and the former Administrator revealed there is no one in the position of Corporate Vice President and there never has been. The former Administrator revealed he was never notified of what happened to R#1, but if he had been notified he would have notified the owners because there was no Regional Vice President, and there is no job description for the position, they are developing one now and are going to hire someone soon for the position. Co-Owner KK revealed the former Administrator would oversee the two facilities that are owned by the corporation for now. Co -Owner KK revealed he did not think there was any system failure that caused the former Administrator and the owners to not be notified of the admission and transfer of R#1 with CPR in progress, and did not think any system failure would account for there being no incident report, investigation or education of the staff involved. He stated that it was just one nurse who had acted without regards for Physician orders [REDACTED]. He stated he had read a written statement from the nurse and she had confessed in the written statement to getting R#1 a tray when he was NPO and that she had knowledge that he received the tray, choked on the food and had a cardio [MEDICAL CONDITION] arrest. Corporate Co-Owner KK revealed that none of that is a system failure.",2020-09-01
940,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2017-05-04,159,D,1,1,CNII11,"> Based on interviews and record review, the facility failed to ensure that three (Resident (R) #37, 30, and 95) of 31 sampled residents out of 84 residents with trust accounts had reasonable access to funds after hours and on weekends. The census was 91. Findings included: During an interview with R#37 on 5/01/17 at 11:40 a.m. revealed that he has a personal funds account with the facility but that money from that account is not available on the weekends. During an interview with R#30 on 5/01/17 at 1:30 p.m. revealed that he has a personal funds account with the facility but that money from that account is not available on the weekends. During an interview with R#95 on 5/01/17 1:30 p.m. revealed that he has a personal funds account with the facility but that money from that account is not available on the weekends. During an interview with the Business Office Manager on 5/4/17 at 10:09 a.m. she stated that the process is that residents with trust accounts, managed by the facility, have access to their funds through the receptionist who's hours are Monday through Friday 8:00 AM-4:30 PM. She revealed that she was not sure of the process related to evening or weekend funds being available. She further revealed that residents have to get the money prior to the receptionist leaving in the evening or on Friday to carry them over until the next day or until Monday. She stated, It is like banking hours. She revealed that the residents are informed of this process when they are admitted . On 5/04/17 at 10:20 a.m. Receptionist AA revealed that she has been working in the facility, as the receptionist, since (MONTH) (YEAR) and is responsible for disbursing funds to residents from their trust accounts and that her hours are Monday through Friday 8:30 a.m. until 4:30 p.m. She further revealed that a the end of the day she balances the money and provides the receipts and balance documents to the Business Office Manager and locks up the money box in the receptionist desk. She revealed that when she leaves at 4:30 PM another receptionist is in the building until 7:00 PM and has a key to the box for emergency purposes only although the other receptionist does not disburse any money to residents. She stated that no one disburses money in the evenings or on the weekends. She stated, If (residents) want money on the weekend, they have to get the money out on Friday. During an interview with the Admission Director on 5/04/17 at 10:27 a.m. she revealed that the admission packet only has information related to opening a trust account but not when the money is available. She stated that there use to be a petty cash box for after hours but that process stopped for some reason. On 5/04/17 at 10:33 a.m. with the Administrator revealed that before the receptionist leaves on Friday's she is expected she is expected to leave $50.00 in the nursing cart for residents with a facility account who want money on the weekends. She further revealed that typically, the residents have to catch the receptionist before 4:30 p.m. Monday through Friday to get any money they want before she leaves. She was not aware that the receptionist was not following this process and that the Director of Nursing is responsible for ensuring that this was done. On 5/04/17 at 10:39 a.m. the Director of Nursing stated that on Fridays, the receptionist is responsible for giving the money bag with $100.00 to the nurse before she leaves for the day. She stated that she was not aware that this process had changed and thought it was still ongoing. A review of the Trial Balance Log dated 5/3/17 revealed that R#37, R#30 and R#95 all had a current active trust account managed by the facility. A review of the facility policy related to Resident Trust Funds with revision date of 11/28/16 revealed that the facility will provide for temporary safekeeping of a residents personal funds only upon the expressed request of the resident or responsible party. It was documented in the policy that the facility will ensure that residents have ready and reasonable access to their personal funds. Each service location will maintain a resident petty cash box for after hour disbursement of funds. The policy states that after hours cash box recommended amounts as: More than 25 accounts $50.00. The after hour cash box will be locked in the medicine room (or locked location designated by the Administrator/ED) after hours.",2020-09-01
941,ETOWAH LANDING,115348,809 SOUTH BROAD STREET,ROME,GA,30161,2018-11-13,584,E,1,0,ZDGK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff and family interview, the facility failed to maintain a clean, comfortable, homelike environment on five of five halls. Observations included unsanitary and rusted over bed tables, rusted bathroom door jambs, unsanitary standing lifts, rusted tube feeding poles, a broken toilet paper holder and towel rack, stained bathroom thresholds, unsanitary geri-chairs, a leaking toilet flush handle, and a cold water faucet that would not turn off. The facility census was ninety-three (93). Findings include: An interview was conducted with the family member of Resident (R) R#6 regarding the cleanliness and general condition of the building on 10/31/18 at 10:00 a.m. The family member revealed when their father was admitted to the facility they were concerned about the presence of rust on almost anything metal in the resident's room. There was chipped paint and rust on the doorways and the metal on the tables was rusted, and there were stains and debris on the tiles and flooring in the corners. The family member additionally revealed he had noticed dust and debris and stains from spills on the furnishings and equipment. An interview was conducted on 10/31/18 at 11:00 a.m. with the Administrator related to housekeeping and maintenance. The Administrator revealed the facility is looking forward to renovation of the shower rooms. The Administrator revealed he had considered the condition of the shower rooms, with chipped, broken, discolored, and missing tiles unacceptable since he had become Administrator at the facility. The Administrator confirmed the replacement tile was to be replaced and the shower rooms painted, and the work was to be started within the next two to three weeks. The Administrator also confirmed the renovation had been approved by corporate. Observations of the environment were conducted as follows: An observation was conducted during wound care in room [ROOM NUMBER]A on 11/13/18 at 8:50 a.m. There were 2 rolling poles in the room, one on each side of head of bed to hold bags of tube feeding. Both metal rolling poles had rusted bases. The over bed table for bed 28A has a rusted base and was coated with dust on the bottom. On 11/13/18 at 10:30 a.m. during observation of wound care in room [ROOM NUMBER] A with the wound nurse, the bed was moved away from the wall. The wound nurse revealed the family wants it there. There were four dried brown liquid drips on wall from the level of the top of the mattress to the floor. The wound nurse revealed he would prefer the bed to be away from the wall to facilitate care for the resident, but the family wants it where it is. He had not seen the drips and he was in the room for wound care yesterday but does not always have to pull the bed away from the wall. Environment observations were conducted with the Maintenance Director on 11/13/18 at 2:35 p.m. On 11/13/18 at 3:00 p.m. the Housekeeping Manager joined the tour and revealed the housekeepers should be wiping down the overbed tables every day as part of cleaning each room, and the brown stains on the marble thresholds could be wax or wax stripper and confirmed they were quite unsightly. Observations were made as follows: At 2:35 p.m. room [ROOM NUMBER]/3- shared by 6 females. The over bed table for room [ROOM NUMBER]B was rusted on the base and leg, and had crumbs and dried liquid residue stains. The over bed table for room [ROOM NUMBER]C was rusted on the leg and base. The threshold in the entry from room [ROOM NUMBER] into the bathroom was stained with a brown substance. The toilet flushing handle was dripping water and in room [ROOM NUMBER] the cold water would not turn off at the sink. At 2:40 p.m. in room [ROOM NUMBER]A the over bed table base was rusted and had dried liquid residue, crumbs and dust. The bathroom, shared by 4 females, had brown stained thresholds and the door jambs had two inches of rust extending from the floor. . At 2:45 p.m. in room [ROOM NUMBER], the overbed tables for A and B beds were rusted on the bases and legs and had drops of dried liquids and dust and food crumbs on the bases. At 2:48 p.m. in room [ROOM NUMBER]/7 the over bed table for 5B was rusted on the base and leg and had crumbs and dried liquid drops on the base. The bathroom, shared by 6 females, had brown stained thresholds. At 2:50 p.m. in room [ROOM NUMBER]B the overbed table was rusted and had dried liquid drops and crumbs and dust on the leg and base. At 2:51 p.m. the Maintenance Director revealed the corporation had told him to purchase ten overbed table a month to replace the rusted overbed tables. The Maintenance Director revealed there has not been a cleaning schedule, other than the once a month deep clean schedule, to clean the overbed tables and even though the facility was replacing ten (10) a month the rusted tables and the new tables all need to be cleaned every day when the rooms are cleaned. At 2:52 p.m. in room [ROOM NUMBER]/11, the bathroom doorway jambs were rusted extending to 3 inches above the floor in room [ROOM NUMBER]. This was measured by the Maintenance Director with his tape measure. The bathroom is shared by 6 males. The over bed table for room [ROOM NUMBER], beds A, B and C were rusted on the bases and legs and had food and liquid residue dried on the bases. At 2:55 p.m. in room [ROOM NUMBER] B, the over bed table base was rusted and had food and dried liquid residue were noted. The bathroom, shared by 3 female residents from room [ROOM NUMBER] and 3 female residents from room [ROOM NUMBER], had rusted door jambs extending 4 inches up from the floor from room [ROOM NUMBER]. This was measured by the Maintenance Director with his tape measure. The threshold from room [ROOM NUMBER] bathroom doorway was stained brown. At 2:58 p.m. in room [ROOM NUMBER] A and B the overbed tables were rusted and had food and dried liquid residue on the bases and legs. The bathroom between room [ROOM NUMBER] and room [ROOM NUMBER] was shared by 6 males. The doorway into the bathroom from room [ROOM NUMBER] was missing 5 inches of the bottom of the jamb on the left side. It had completely deteriorated with rust and had sharp and jagged edges. Three inches of the right side of the doorway into room [ROOM NUMBER] from the bathroom was rusted extending from the floor, and the paint was chipped around the doorway. These measurements were provided by the Maintenance Director using his tape measure. In room [ROOM NUMBER] at 2:59 p.m. the overbed tables for beds A and B were rusted and had food and liquid residue and dust on the bases and legs. At 3:00 p.m. in room [ROOM NUMBER] A and B the overbed tables were rusted and had food and liquid residue on the bases and legs. The bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] was shared by 4 males . The thresholds in the bathroom doorways were both stained with brown liquid splatters. Three inches of the bathroom doorway from room [ROOM NUMBER] was rusted extending from the floor on the right side. This was measured by the Maintenance Director with his tape measure. At 3:03 p.m. in room [ROOM NUMBER] B the overbed table was rusted and soiled with crumbs, dust and liquid residue. At 3:05 p.m. outside room [ROOM NUMBER] in the hallway were 2 geri-chairs and a standing lift. The standing lift had dust and debris on the foot rest. The geri-chairs had dried drips and spills of tan, red, pink and orange and clear liquids on the sides, arm rests, pads and leg rests. At 3:07 p.m. the Maintenance Director revealed there was no cleaning schedule for the geri-chairs and standing lifts but they should be wiped off every time they are used, and on the same monthly cleaning schedule with the wheelchairs. The Maintenance Director and the Housekeeping manager acknowledged the standing lift and geri-chairs must not be getting cleaned. At 3:10 p.m. in room [ROOM NUMBER]B the overbed table had dust, rust, food and dried liquid residue on the base and leg. At 3:20 p.m. in the bathroom of room [ROOM NUMBER] and 25 shared by 4 males the door jamb was rusted away extending one (1) inch from the floor with sharp and jagged edges on the right side of the doorway to room [ROOM NUMBER]. This was measured by the Maintenance Director with his tape measure. The overbed table for 23B was rusted, dusty, and soiled with food and dries liquid residue on the base and leg. At 3:23 p.m. the overbed tables for room [ROOM NUMBER]A and 27 B were rusted, soiled with dried liquid residue, crumbs and dust on the bases and legs. In the bathroom shared by 2 females, the toilet paper holder and the towel rack were both broken and nonfunctional. At 3:25 p.m. in room [ROOM NUMBER]A and 28C the overbed tables were rusted and soiled with dried liquids and food residue. The bathroom, shared by 5 males, had 4 rusted door jambs extending 1 inch from the floor. This was measured by the Maintenance Director with his tape measure. At 3:28 p.m. the over bed table in room [ROOM NUMBER]B was rusted and soiled with dried liquids and food residue on the metal base and leg. At 3:30 p.m. in the hallway between room [ROOM NUMBER] and room [ROOM NUMBER] a standing lift was observed to have crumbs, white flakes, dust and a cracker wrapper on the foot stand. At 3:31 p.m. in room [ROOM NUMBER]B the overbed table was rusted and had dried liquids and food residue on the base and leg. At 3:32 p.m. in room [ROOM NUMBER]A and 33B the overbed tables were rusted and had dried liquids and food residue on the bases and legs. At 3:35 p.m. in room [ROOM NUMBER]A and 36B the overbed tables were rusted and had dried liquids and food residue on the bases and legs. At 3:40 p.m. In room [ROOM NUMBER] and 40, the bathroom, shared by 4 males had rust on the door jamb in the doorway to room [ROOM NUMBER] on the left side extending 2 inches from the floor. This was measured by the Maintenance Director with his tape measure. The over bed tables for bed 39 B and room [ROOM NUMBER] A were rusted and soiled with dust, dried liquids and food residue on the bases and legs. A list of residents that go in and out of BR independently was requested and provided by the unit managers. There were 29 residents names on the list. The incident log from 8/1/18 through 10/31/18 was checked for lacerations and abrasions. Then nurses notes of the residents with lacerations, skin tears and were reviewed for any type of wound occurring in or near the bathrooms of rooms with rusted out doorway molding and there were none. A blank Deep Clean Check Off List was submitted by the Housekeeping Manager. Review of the list included the following were to be included in the monthly deep cleaning of each room: This room must be sanitized, dusted, and dirt free when you are done. Clean and wipe down all walls Clean and wipe down closets and shelves inside and outside Clean and wipe down all tables, night stands, and rolling tables. Clean and wipe down all chairs Maps of facility were submitted to the surveyor by the Housekeeping Manager and reviewed as follows: January to (MONTH) 27,2018- deep clean schedule maintained monthly- rooms were marked with X- they were rooms that were stripped and waxed. Nothing designated as deep clean, no other schedule was produced by the Housekeeping Manager March 28,2018 - July- no mention of deep clean- designated 14 rooms that were stripped and waxed. 10/10/18- scrub and re-wax, noted on the facility map: could not wait any longer for the remodel to start- Kitchen Hall and Lobby 10/10, 10/11, 10/12 Main middle Hall top scrub and wax 10/17/18, 10/18, 10/19 Back Hall top scrub and wax back hall 10/24, 10/25 11/1/18- received word that showers will not be remodeled as soon as expected. Will start back scrubbing and waxing. 11/13, 11/14, 11/15- room [ROOM NUMBER]-13 11/21, 11/22 top scrub and wax circled rooms 30 to 37 5/1/18 Bathrooms completed 33/35, 32/34, 26/28, 23/25 5/2/18- Bathroom assessment- done 33/35, rust and tile cleaning 36/37, 32/34 done, rust, paint 38, rust tile 41/42, rust tile 39/40, rust tile 5/7, 9/11, and 12/13, ring and rust 1/3, rust tile 2/4, 6/8, 10, tile loose and missing and rust 20/21, rust 19, rust 18, rust and tile 16/17, hole, rust and tile 15/16, 22/24, paint and rust 24/32, tile 31, paint and rust 27/19. An interview was conducted with the Housekeeping Manager related to cleaning of the facility, on 11/13/18 at 4:30 p.m. The Housekeeping Manager revealed there had been no rooms deep cleaned in the facility for a month because there were 2 new Housekeepers who had not yet been trained to do the deep cleaning. He revealed he had no documentation to indicate any resident rooms had been deep cleaned for 3 months. He has 4 Housekeepers and 3 work Monday, Wednesday, Thursday and Friday. On Saturday, Sunday and Tuesday there are 2 Housekeepers. The Housekeeping Manager revealed he would like to hire another Housekeeper but had to be careful of the number of hours his employees work.",2020-09-01
942,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2017-07-07,371,E,0,1,W9LD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility policy, the facility failed to date opened food in the walk-in refrigerator, failed to label and date opened food in the walk-in freezer, failed to date opened food in the dry good storage area, failed to discard food opened for greater than thirty days in the walk-in refrigerator, failed to ensure kitchen staff wore hair nets and beard guards, and failed to ensure kitchen equipment remained free of debris. This deficient practice had the potential to effect fifty-four (54) residents receiving an oral diet. Findings Include: Observation on 7/5/17 at 10:38 a.m. of the ice machine, in the kitchen, revealed a pink substance inside the machine on the right side of the ice guard one inch long and two inches long on the left side of the ice guard. Observation on 7/5/17 at 10:40 a.m. of the meat slicer revealed white and pink particles on the blade. Observation on 7/5/17 at 10:50 a.m. of the walk-in refrigerator revealed one opened and undated 4 pound (lbs) jar of maraschino cherries, two opened and undated jars of 24 ounce (oz) Grey Poupon mustard, one container of mint jelly with a prepared date of 6/4 and one 3lbs jar of mustard with an opened date of 4/4/16. Observation on 7/5/17 at 11:11 a.m. of the walk-in freezer revealed a package of unlabeled and undated crepe shells wrapped in plastic. Observation on 7/5/17 at 11:21 a.m. of the dry storage area revealed an opened and undated 25lbs bag of long grain brown rice. Observation on 7/6/17 from 11:00 a.m. to 11: 50 a.m. of the kitchen revealed that cook HH, was not wearing a hair net while mixing flour in the mixing bowl, that dietary staff member EE was not wearing a beard guard or fully covering his hair with the hair net while preparing cheeseburgers and kitchen staff person AA was not wearing a beard guard while washing dishes at the three compartment sink. The hair on the cook HH's head was one inch long, the hair on dietary staff member EE's face and head was one inch long and the beard and [MEDICAL CONDITION] kitchen staff person AA's face was two to three inches long. During the tour of the kitchen with the Food Service Manager (FSM) on 7/5/17 from 10:30 a.m. until 11:30 a.m. the above observations were made and confirmed by the Food Service Manager. He stated that he expects all opened food to be labeled, dated and discarded 30 days after being opened. He also stated he expects the meat slicer to be cleaned after each use and that the slicer had not been used for food preparation on 7/5/17. During an interview with Dining Room Superviors FF on 7/6/17 at 11:40 a.m. she confirmed that the cook HH was not wearing a hair net while mixing cornbread in the standup mixer and dietary staff member EE's hair was not completely covered by the hair net. During an interview with the FSM on 7/6/17 at 11:52 a.m. he confirmed that neither dietary staff members EE or AA were wearing beard guards while working in the kitchen while food was being prepared. He stated that the facility did not have any beard guards and the staff does not have to wear a beard guard unless the facial hair was longer than a quarter (1/4) inch. Review of the policy titled Hair Restraints dated (MONTH) 2014 revealed hair restraints shall be worn by all Dining Services staff when in food production, dishwashing areas or when serving food from the steam table. Hair restraints, hats, and/or beard guards shall be used to prevent hair from contacting exposed food. Facial hair is discouraged. Any facial hair that is longer than the eyebrow shall require coverage with a beard guard in the production and dishwashing area. Review of the policy titled Cleaning Instructions: Food Preparation Appliances dated (MONTH) 2014 revealed small food preparation appliances, such as blenders, food processors, and mixers, will be cleaned and sanitized following each use. Review of the policy titled Food Storage (Dry/Refrigerated/Frozen) dated (MONTH) 2014 revealed all food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. Discard food that has passed the expiration date, and discard food that has been prepared in the facility after seven days of storing under proper refrigeration.",2020-09-01
943,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2017-07-07,431,F,0,1,W9LD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to ensure that two of two medication carts and one of one treatment cart was locked and secured when not in use. Findings included: On 7/5/17 at 11:05 a.m. the Medication Cart for Hall A, Hall B, and Hall C was observed parked on Hall B and was unlocked and unattended. The Activities Director was observed walking by at 11:09 a.m. and confirmed that the cart was unlocked. She stated that it was Licensed Practice Nurse (LPN) BB's cart. She was observed to lock the cart. There were no residents observed around the cart at this time but the cart was within access of all residents and visitors. On 7/5/17 at 11:55 a.m. the Medication Cart for Hall D, Hall E, and Hall F was observed parked on Hall F in front of room [ROOM NUMBER] with the resident ' s room door closed. The medication cart was unlocked and unattended. Registered Nurse (RN) CC exited the room at 11:56 a.m. and stated that she was responsible for the medication cart. She was observed to lock the cart. There were no residents observed around the cart at this time but the cart was within access of all residents and visitors. During an interview with LPN BB on 7/5/17 at 12:00 p.m. she confirmed that she was responsible for the Medication Cart for Hall A, Hall B, and Hall C Hall and stated that she is aware that the cart should be locked when she is not using it. The Facility Treatment Cart was observed unattended and unlocked on 7/5/17 at 12:50 p.m. There were no residents observed around the cart at this time but the cart was within access of all residents and visitors. The Director of Nursing came over to the cart at 12:51 p.m. and stated that she was using the treatment cart and did not realize that she had left it unlocked. She stated that the expectation is that the medication and treatment carts are locked when unattended and not in use. On 7/07/17 at 3:35 p.m. LPN BB confirmed that there are only two med carts and one treatment cart for the facility. On 7/7/17 at 3:56 p.m. the Assistant Director of Nursing (ADON) stated that the facility does not have a policy related to locking the medication carts. She stated that it is just common practice to lock the carts when not in use. She was asked to provide the Medication Storage Policy. The ADON brought in the Dispensing LTC Facility Pharmacy Services and Procedures Manual with last revision date of 1/1/13 noting that Facility should ensure that all medication and biologicals, including treatment items, are securely stored in a locked cabinet/cart or locked medication room that is inaccessible by resident and visitors.",2020-09-01
944,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2018-07-26,582,B,0,1,OG2711,"Based on record review and staff interview, the facility failed to ensure that two of three residents (R) (#4 and #37) received the CMS- Form: Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN). The total census was 59. Findings include: 1.) Review of R4's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed that Medicare Part A Skilled Services Episode Start Date was 12/26/17 and Last covered day of Part A Service was 1/26/18. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Continued review revealed that the resident remained in the facility and a CMS- Form: Notice of Medicare Provider Non-Coverage (NOMNC) was given on 1/23/18; however, no evidence that the CMS- was provided to the resident and/or the resident's representative. The explanation was that it was not effective until 4/30/18. 2.) Review of R37's Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review revealed that Medicare Part A Skilled Services Episode Start Date was 1/5/18 and Last covered day of Part A Service was 2/1/18. The facility/provider initiated the discharge from Medicare Part A Services when benefit days were not exhausted. Continued review revealed that the resident remained in the facility and a CMS- Form: Notice of Medicare Provider Non-Coverage (NOMNC) was given on 1/30/17; however, no evidence that the CMS- was provided to the resident and/or the resident's representative. The explanation was that it was not effective until 4/30/18. Interview with the Administrator Assistant AA, on 7/24/18 at 11:45 a.m., she stated that Corporate stated that the SNF ABN did not need to be given out and said that they were not effective until (MONTH) 30, (YEAR). However, she confirmed that the SNF ABN were not given for these two residents. Review of the email dated 4/27/18 from the Regional Nurse Specialist revealed that effective 4/30/18, there is a new requirement to use a revised SNF ABN form that will replace the SNF Denial Letters and SNF notice of Exclusion from Medicare Benefits (NEMB).",2020-09-01
945,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2018-07-26,656,D,0,1,OG2711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to follow the care plan for two residents (R) (R#31 and #52) related to monitoring vital signs. The sample size was 17 residents. Findings include: 1.) Resident #31 was admitted to the facility with [DIAGNOSES REDACTED]. Review of resident's care plan dated 6/10/18 revealed that resident has a pacemaker related to a history of cardiac arrhythmias and hypertension. Continued review revealed that the resident is status [REDACTED]. Review of the Vitals Report dated 4/1/18-7/26/18 revealed no evidence for daily BP and/or pulse for the following dates: 6/6, 6/7, 6/8, 6/9, 6/10, 6/11, 6/12, 6/13, 6/14, 6/15, 6/16, 6/17, 6/18, 6/19, 6/20, 6/21, 6/22, 6/23, 6/24, 6/26, 6/27, 6/28, 6/29, 6/30, 7/2, 7/3, 7/4, 7/5, 7/6, 7/7, 7/8, 7/9, 7/10, 7/11, 7/13, 7/14, 7/15, 7/16, 7/17, 7/18, 7/19, 7/20, 7/21, 7/22, 7/24, and 7/25. Interview with the Assistant Director of Nursing (ADON) on 7/26/18 at 10:45 a.m., revealed that she was able to find the following BP and/or P for the following weeks: 5/20-5/26, 5/27-6/2, 6/17-6/23; however, confirmed that there were none for weeks of 6/10-6/16 and 7/15-7/21. Continued interview revealed that she confirmed that the care plan was not being followed per MD order's for daily BP and/or P except on dates of 7/24 and 7/25, but said that was a miss type because we only put resident's that are on antibiotics on daily vital signs and then follow up. She said that once an order is written it is then placed into the computer system, and carried over into the Certified Nursing Assistant (CNA's) care assist where they can see each resident. This is where each CNA goes under resident task for vital signs and that determines when the CNA's take the resident's vital signs. Also, the staff get report from the off going nurse. If the system should crash, then there is no backup for the staff to look at the care plan, it is only on the computer system. The CNA's can look at the care plan on their system under the individual resident. Interview with CNA, BB on 7/26/18 at 12:35 p.m., revealed that they get report from the off-going nurse on how to take care of each resident including vital signs and then they can also look into the computer system to see who needs vital signs even if they are daily. 2.) R#52 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 7/15/18 revealed that the resident is at risk for abnormal blood pressure and cardiac related to [DIAGNOSES REDACTED]. Further review revealed under interventions, that the blood pressure is to monitored per physician's orders [REDACTED]. Review of the physician's orders [REDACTED]. Review of the Vitals Report dated 3/1/18-7/26/18 revealed no evidence for the following dates that blood pressure and/or pulse were taken: 4/9, 4/16, 5/28, 6/4, 6/11, 6/25, 7/2, 7/9 and 7/16. Interview with the ADON on 7/26/18 at 10:45 a.m., revealed that she was able to find the following blood pressure and/or pulse for the following dates 4/9, 4/16, 5/28, 6/11, 6/25, 7/2; however, confirmed that the dates of 6/4, 7/9, and 7/16 she could not find and that the care plan was not being followed per MD order's.",2020-09-01
946,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2018-07-26,684,D,0,1,OG2711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician orders [REDACTED].#31 and #52) from a total sample of 17 residents. Findings include: 1.) Resident #31 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Vitals Report dated 4/1/18-7/26/18 revealed no evidence for weekly BP and/or pulse 5/20-5/26 (BP/P), 5/27-6/2 (P), 6/10-6/16 (BP/P), 6/17-6/23 (BP/P), and 7/15-7/21 (BP/P). Interview with the Assistant Director of Nursing (ADON) on 7/26/18 at 10:45 a.m., revealed that she was able to find the following BP and/or P for the following weeks: 5/20-5/26, 5/27-6/2, 6/17-6/23; however, confirmed that there were none for weeks of 6/10-6/16 and 7/15-7/21. 2.) R#52 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the Vitals Report dated 3/1/18-7/26/18 revealed no evidence for the following dates that blood pressure and/or pulse were taken: 4/9, 4/16, 5/28, 6/4, 6/11, 6/25, 7/2, 7/9 and 7/16. Interview with the ADON on 7/26/18 at 10:45 a.m., revealed that she was able to find the following blood pressure and/or pulse for the following dates 4/9, 4/16, 5/28, 6/11, 6/25, 7/2; however, confirmed that the dates of 6/4, 7/9, and 7/16 she could not find.",2020-09-01
947,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2018-07-26,758,D,0,1,OG2711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the behavior management policy, and staff interview, the facility failed to monitor behaviors and side effect for one resident (#165) receiving [MEDICAL CONDITION] medications from a sample of seventeen (17) residents. Findings include: A review of the clinical records for Resident (R) #164 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission Minimum Data Set (MDS) assessment of 7/16/18 documented active [DIAGNOSES REDACTED]. The assessment also documented that the resident was being administered antianxiety and antidepressant medications. A review of the physician's orders [REDACTED].#165 to receive [MEDICATION NAME] (an antianxiety agent)1 mg at bedtime and duloxetine (an antidepressant) 60 mg daily. A review of the Medication Administration Record (MAR) for (MONTH) (YEAR) revealed the antianxiety and antidepressant medications were being administered to R#165 as prescribed. A further review of the clinical records for R#165 revealed there were no behavior or side effects monitoring records related to the use of [MEDICAL CONDITION] medications. Review of facility policy titled, Accommodating Behaviors using Person-Centered Care dated (MONTH) 2013 revealed the staff are required to chart targeted harmful behaviors which are first defined. These behaviors must be documented quantitatively each shift on the flow sheet. The occurrence of any side effects must also be charted quantitatively, every shift, on the flow sheet. During an interview on 7/25/18 at 1:03 p.m. with the Assistant Director of Nursing (ADON) it was revealed that behaviors and side effects are no longer monitored on the flow sheet, but on the MAR since the facility went to an electronic health record (EHR) system. Under the current system, the staff responsible for transcribing the residents' [MEDICAL CONDITION] medications into the EHR are also responsible for adding the instructions for behavior and side effects monitoring so that these are generated on the MAR. The nurses then document the frequency of targeted behaviors and the presence of side effects on the MAR as per the ordered schedule (e.g. every shift). This process was not followed for R#165. As a result, the resident was not being monitored for behaviors or side effects. The ADON planned to immediately add behavior and side effect monitoring to the resident's records. Further review of the MAR on 7/26/18 at 8:00 a.m. revealed that behavior and side effects monitoring had been added for R#165 with effect from 7/25/18 and that observations were being documented on the MAR from that date. During an interview on 7/26/18 at 9:02 a.m. with Licensed Practical Nurse (LPN) CC revealed that R#165 did not have many signs of depression or anxiety but sometimes seemed sad and enquires of staff how soon before she can return to her home. DONE",2020-09-01
948,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2019-10-03,656,D,0,1,4LSF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to develop a person-centered care plan for one dependent resident (R) (#52) related to nail care of 32 sampled residents. Findings include: The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed R#52 was unable to complete the Brief Interview for Mental Status (BIMS) as resident is rarely/ never understood. Section G - Functional Status documented resident requires total assistance with bathing and personal hygiene. The resident has [DIAGNOSES REDACTED]. Review of the care plan revised 9/30/19 revealed that R#52 is dependent on staff for entire bathing and dressing with two-person assistance. The care plan does not indicate the need for nail care. Observation on 10/2/19 at 7:58 a.m., 10/2/19 at 2:58 p.m. and 10/3/19 at 8:46 a.m. revealed resident with brown substance underneath fingernails on both hands. Interview on 10/3/19 at 9:20 a.m. with Certified Nursing Assistant (CNA) AA stated that each resident has a Resident Care Assignment sheet taped to the inside of their closet door. She stated that is how she knows what to do for each resident. She stated that nails are done on Sundays, and she will do them as needed, if they are dirty. Cross Refer F677",2020-09-01
949,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2019-10-03,657,D,0,1,4LSF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Care Plan Conference, Interdisciplinary and staff interviews, the facility failed to ensure that a quarterly care plan conference was held for one resident (R) (#8) for two consecutive quarters of 32 sampled residents. Findings include: Review of the undated facility policy titled Care Plan Conference, Interdisciplinary, the standard purpose revealed documentation is done on the Interdisciplinary Resident Care Conference form. Purpose number 2. Conferences are held within 21 days of admission and every 90 days thereafter. Procedures number 1. The Care Plan Coordinator prepares a list of residents to be reviewed to all disciplines one week in advance of the conference. Number 5. Documentation is made on the Interdisciplinary Care Conference Summary form at the time of the Interdisciplinary Conference by the individual representing each discipline. The form must be dated and signed. Number 14. c. The resident care plan is reviewed/revised within 21 days, and every 90 days thereafter. A review of the clinical record for R#8 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Care Conference Information sheet dated 2/21/19 revealed one nurse, social services, activities and resident's sister in law attended the meeting. During further review, there was no evidence that the quarterly Care Plan Conference meetings were held for the second quarter (April, May, June) 2019 or third quarter (July, August, September) 2019. During an interview on 10/3/19 at 9:50 a.m., Minimum Data Set Registered Nurse BB stated she gets information for the quarterly assessments from staff and face to face visits with the residents, along with medical record review. She stated that the Social Worker sets up the quarterly care plan meetings after she completes the assessments. She stated that residents are invited verbally, and the family members are sent an invitation card one week before the meeting. She stated Social Services Director sends out the invites for the families. During an interview on 10/3/19 at 10:35 a.m., Social Services Director stated she sends the care plan meeting invitations to the families. She stated there is not any response required from the family to indicate if they will attend the meeting or not. She further stated that the interdisciplinary team (IDT) meets and discusses the resident's current status and any future plans for care. She stated that activities, nursing and dietary members attend, and she documents on the care conference in the electronic medical record, those in attendance. She stated if family members attend the meeting, she will document their names on the attendance section. She further stated if the family is not able to attend, she doesn't have a care conference meeting and does not document anything in the electronic medical record (EMR). Interview on 10/3/19 at 10:40 a.m. with Assistant Director of Nursing revealed the facility does have quarterly care plan meetings for the residents, even if family members and/or residents don't attend the meeting. She confirmed that resident EMR did not reflect any type of documentation that quarterly care plan meeting was held with IDT for 2nd or 3rd quarters of this year, 2019.",2020-09-01
950,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2019-10-03,677,D,0,1,4LSF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews and policy review, the facility failed to ensure that activities of daily living (ADL) was provided for one dependent resident (R) (#52) related to nail care of 32 sampled residents. Findings include: Review of the undated facility policy titled[NAME]Gardens Nursing Policy and Procedure Manual Bed Bath revealed: procedure: 18. clean resident's fingernails. A review of the clinical record for R#52 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's Quarterly Minimum Data Set (MDS) 9/16/19 revealed R#52 was unable to complete the Brief Interview for Mental Status (BIMS) as resident is rarely/ never understood. Section G - Functional Status revealed resident requires total assistance with personal hygiene. Observation on 10/2/19 at 7:58 a.m., 10/2/19 at 2:58 p.m. and 10/3/19 at 8:46 a.m. revealed resident with brown substance underneath fingernails on both hands. Interview on 10/3/19 at 9:20 a.m. with Certified Nursing Assistant (CNA) AA revealed that each resident has a Resident Care Assignment sheet taped to the inside of their closet door indicating what to do for that resident. She stated that she gives every resident a bed bath when they get up, even if they are scheduled for a shower. She stated that nails are done on Sundays, and she will do them as needed, if they are dirty. During an interview on 10/3/19 at 12:54 p.m., the Assistant Director of Nursing (ADON) stated that it is her expectation for staff to keep the residents well-groomed and fingernails clipped and clean. They should do it as needed, not just on Sundays.",2020-09-01
951,DELMAR GARDENS OF GWINNETT,115350,3100 CLUB DRIVE,LAWRENCEVILLE,GA,30044,2019-10-03,689,D,0,1,4LSF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of the facility policy, the facility failed to implement new measures to prevent additional falls for one of three residents (R) (#11) reviewed for falls. Findings include: Review of the facility policy titled Post-Fall Assessment with effective date of 8/1/15, revealed the purpose is all falls are investigated to determine the reasons for the fall and to develop interventions to minimize or eliminate future falls. Residents at risk for falls are identified based on the Fall Risk/Prevention Program. Procedure number 5. The charge nurse will review the resident's plan of care and make any additions to the care plan that are needed. Be sure to note the date of the fall, any injuries and any new/revised interventions. Number 7. The Interdisciplinary Fall Review Team will meet weekly and formally address each resident that has fallen during the previous week. Discussion will focus on interventions that have been implemented and other interventions that may be required to reduce falls and meet the resident's needs. A review of the clinical record for R#11 revealed resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 7, which indicated severe cognitive impairment. Section G revealed resident requires extensive assistance with bed mobility and transfers and limited assistance locomotion on and off unit. Section V revealed resident at risk for falls. Review of the care plan revised 8/1/19 revealed that R#11 is able to ambulate with assistance of staff. Approaches include provide frequent reminder to not get up without help, apply dycem to wheelchair, offer night time snack, give resident verbal reminders not to ambulate/transfer without assistance, occupy resident with meaningful distractions, anticipate resident's needs, walk with restorative nursing, keep resident in common area while awake, staff to provide frequent rounding of resident, and floor mats at bedside. Review of document titled Delmar Gardens of Gwinnett-Falls for Facility revealed R#11 experienced eight falls in the past six months: On 9/5/19 at 10:27 p.m., called to dining room. Resident observed on floor. Per many witnesses in dining room resident got up and legs gave out. Resident sustain an abrasion to left knee otherwise resident is stable and continue to be pleasantly confused. Family and MD (medical doctor) notified. Interventions put in place: Provide frequent reminders to resident not to get up without help. On 8/21/19 at 9:57 p.m.-Resident observed getting up from chair in front of nursing station, before staff could get to her, she pushed against her wheelchair and slid to the floor. No apparent injury. Remain alert and pleasantly confused. Interventions put in place: Apply Dycem to wheel chair, offer resident night time snack. On 8/1/19 at 9:30 p.m. Resident observed on floor in hallway in front of nurse's desk. Resident was in wheelchair in front of nurse's desk for monitoring. Resident got up from wheelchair and fell . Fall witness by staff at the desk but staff was unable to get to resident before the fall occur. Resident fell on buttocks and no apparent injury noted. Family and MD (medical doctor) notified, and resident brought closer to staff within hand reach. Interventions put in place: Give resident reminders not to ambulate/transfer without assistance. Occupy resident with meaningful distractions (music, companion, crafts). On 6/24/19 at 8:57 p.m. Resident observed on right side of bed sitting on bed side floor pad. No apparent injury noted, and resident was alert but was only said sorry. Two-person assist to bed and bed in lowest position. The clinical record did not reflect any new interventions added at the time of the fall. On 6/24/19 at 3:01 p.m. Staff observe resident sitting on floor mat on buttocks resident states I got out a slip. The clinical record did not reflect any new interventions added at the time of the fall. On 6/15/19 at 7:30 a.m. Housekeeping notified Skilled Nurse (SN) this resident walking in hallway and went to her room. SN noted resident sitting on floor in front of bathroom door, upon asking resident states she fell , passive range of motion (PROM) done to all extremities without pain, staff notified and was assisted back to bed. The clinical record did not reflect any new interventions added at the time of the fall. On 5/12/19 at 2:48 p.m., observed resident on the floor on right side in hallway by her door. The clinical record did not reflect any new interventions added at the time of the fall. On 4/3/19 at 7:05 p.m., observed sitting on buttocks on the floor in hallway nearby nurse's station. The clinical record did not reflect any new interventions added at the time of the fall. Interview on 10/3/19 at 9:20 a.m. with Certified Nursing Assistant (CNA) AA stated that she walks R#11 back and forth to the bathroom, but Restorative Aide walks her in the hallways. She stated that resident falls when she tries to get up and walk, or to go to the bathroom, or sometimes she says that she is looking for her husband. She stated that resident has had many falls but has not really hurt herself. She further stated that if she saw a resident on the floor, she would stay with them and call for the nurse. During an interview on 10/3/19 at 9:25 a.m., the Assistant Director of Nursing (ADON) stated they discuss all falls in their morning meeting and discuss interventions that are currently in place and discuss what further interventions can be used to try to alleviate falls. She further stated there is no paper copy kept of the meeting discussions. She stated R#11 wants to get up and walk all the time, so that is what restorative does for her daily. During further interview, she confirmed that the falls for 6/24/19 (two falls), 6/15/19, 5/12/19 and 4/3/19 had no interventions put into place for these falls. She stated she is pretty sure they discussed them but does not know why interventions were not put in place. Interview on 10/3/19 at 10:50 a.m. with Minimum Data Set (MDS) Registered Nurse BB revealed she does the MDS assessments for the long-term care residents. She stated that it was her responsibility to update the care plans for the falls, and she does not remember what was discussed specifically for those five falls, so she has no reason to explain why there were no interventions put in place.",2020-09-01
952,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2016-05-26,363,D,0,1,QAG711,"Based on observation and staff interview the facility failed to have a recipe system in place for pureed food items to establish consistency and appropriate nutrient content. This deficent pratice had the potential to effect twenty one (21) residents receiving a puree consistency diet. Findings include: Observation on 05/25/16 at 10: 25 a.m. of AA , Dietary Cook revealed that she was going to be pureeing cooked green peas and rice pilaf. Continued observation revealed the cook placed the green peas in the food processor bowl and poured in water from a pitcher. The cooked then turned on the machine, stopped the machine, scrapped down the sides of the bowl and added more water. She placed the pureed peas in an aluminum pan and washed the food processor bowl, blade, and lid to puree the rice pilaf. Further observation revealed AA pureed the rice pilaf in a similar manner as the green peas, placed the food item in the bowl, added water from the pitcher, turned the machine on, turned the machine off, scrapped down the sides, added more water, turned the machine back on to finish the puree process. Interview on 05/25/16 at 10:28 a.m. with BB, Lead Dietary Cook, revealed the only recipes in the recipe book were for regular food items. BB revealed she was not sure if the facility had recipes for pureed food items and needed to ask the Dietary Supervisor. Interview on 05/25/16 at 10:40 a.m. with the Dietary Supervisor revealed that the facility does not have any recipes for pureed foods and does not have any documentation for staff to use as a guideline for pureed food items. He revealed that dietary staff eyeball how much water/fluid or thickening agent to add when pureeing food. Review of the Diet Listing by Resident revealed that 21 residents were receiving a pureed diet in the facility.",2020-09-01
953,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2016-05-26,371,E,0,1,QAG711,"Based on observation, staff interview, and record review the facility failed to label and date opened food items before storage in the walk-in refrigerator, walk-in freezer, and dry storage; failed to discard leftover foods by discard dated indicated on food label; failed to use the three (3) compartment sink correctly to prevent food borne illness; and failed to clean a fan in the dish room to prevent cross contamination. This deficient practice had the potential to effect one hundred twenty six (126) residents receiving an oral diet. Findings include: Observation on 05/23/16 at 10:35 a. m. of a single door reach in refrigerator revealed an aluminum pan, twenty (20) inches in length, twelve (12) inches in width, and two (2) inches in depth that contained orange gelatin with pineapple rings. The pan of gelatin was wrapped and the labeled indicated that it was made on 05/18/16 and date to discard was 05/21/16. Observation on 05/23/16 at 10:40 a. m. of the walk-in refrigerator revealed a one hundred fourteen (114) ounce container of Heinz Ketchup with a label indicating that the container contained Barbecue (BBQ) Sauce. The label revealed that it was made on 05/07/16 and to be discarded by 05/09/16. Observation on 05/23/16 at 10:45 a. m. of the walk-in freezer revealed a foiled wrapped food item that was eight (8) inches in length, five (5) inches in width, and three (3) inches in thickness in a clear plastic resealable bag. The foil wrapped food item did not have a label identifying the food item or the date it was placed in the freezer. Observation on 05/23/16 at 11:00 a. m. of the dry storage area revealed a one pound bag of light brown sugar that was opened, wrapped with plastic wrap and did not have label or date. Interview on 05/23/16 at 11:15 a. m. with the Dietary Manager (DM) revealed that he confirmed the label on the pan of orange gelatin with pineapple rings indicated the discard dated was 05/21/16. The DM revealed he expects staff to discard food by the discard food dates that is placed on the labels. He revealed that dietary staff record the temperature and check the contents of the refrigerator daily and confirmed that dietary staff had checked the refrigerator already for the day. He revealed that staff should have seen the date and discarded the gelatin. Continued interview with the DM revealed the Heinz Ketchup container contained homemade BBQ Sauce in the walk-in refrigerator and was made on 05/07/16 and label indicated to discard 05/09/16. He expects staff to review dates of all food items and discard by the date on the label. The DM confirmed the foiled wrapped food item in the walk-in freezer did not have a label or date on the foil wrapping or on the clear plastic bag. The DM revealed that he expects staff to label and date the food items before placing in the freezer. Further interview with the DM confirmed the bag of light brown sugar was opened with no label or date. He expects staff to label and date opened food items. Observation on 05/25/16 at 10:35 a. m. of AA , dietary cook wash the food process bowl, blade, and lid in the 3 compartment sink revealed that she rinsed the items with a spray hose. The dietary cook then washed the items in soapy water, rinsed with water, then she placed them in the sanitizing solution for thirty (30) seconds. Continued observation revealed a poster that hung above the sink which stated Pot and Pan Cleaning & Sanitizing Procedures, the poster revealed to submerge items in sanitizer sink for one to two (1-2) minutes, then air dry. Interview on 05/25/16 10:35 a. m. with AA , dietary cook revealed she had been told items only needed to be in the sanitizing solution for 30 seconds. Continued interview with the dietary cook revealed that she had been in-serviced on the usage of the 3 compartment sink. Interview on 05/25/16 at 10:45 a. m. with the Dietary Supervisor revealed that the facility uses EcoLab Quaternary Sanitizer in the 3 compartment sink. He revealed that items need to be in the sanitizing solution for 30 seconds. He confirmed when shown the label on the container of sanitizing solution that it stated immerse all items for at least 1 minute. He expects staff to follow the manufactures recommendations for using the sanitizing solution. He revealed that he has not conducted any in-services regarding the 3 compartment sink since he had been at the facility which was (MONTH) (YEAR). Observation on 05/25/16 at 12:50 p. m. and 05/26/16 at 9:20 a. m. of the dish room area revealed a twenty four (24) inch fan mounted to the wall pointed to the side of the dish machine where the clean dishes exit. Continued observation revealed that there was black lint on the fan blade as well as the metal housing surrounding the blade. Interview on 05/26/16 at 9:20 a. m. with Dietary Supervisor revealed he confirmed the fan was covered with black lint. He revealed that he is not sure how often the fan is cleaned. He revealed he is not aware if the cleaning of the fan is on the cleaning schedule for the dietary staff. Review of the facilities Food Service Policy and Procedure for Food Preparation, Receiving Product, and Personal Hygiene revealed leftovers will be properly handled, when making labels they must have the following information, (a) what the items is, (b) the current date, (c) the use by date and who labeled the item. Review of the policy for Sanitation revealed the dietary department will follow strict guidelines set by the State of Georgia, the local health department, and the National Restaurant Association. The policy also revealed equipment will be cleaned and sanitized daily. The policy revealed that when properly using the three compartment sink soak items in sanitizer solution for 1 to 2 minutes, air dry items placing them upside down so they will drain. Review of the policy for Using Dietary Equipment revealed in ordered to accomplish the departments daily mission, equipment must be used properly and maintained. The policy also revealed that equipment will be cleaned, returned and secured at the designated location. Review of the policy for Dietary Cleaning Schedule revealed that the Dish Machine, dietary staff is required to ensure each work station is properly cleaned and sanitized at the end of each shift. Review of the EcoLab Quaternary Sanitizer label revealed to immerse all items for at least 1 minute and air dry. Review of the documentation provided by the facility regarding the 3 compartment sink revealed immerse washed and rinsed utensils in sanitizer for one minute. Review of the dietary department in-services revealed that meetings were conducted on 02/12/16 regarding Basic Information and updates, Sanitation and also on 03/11/16 regarding Basic Information and updates. Review of the Main Kitchen Cleaning Schedule sheets revealed no assignment for the dish room area and fan.",2020-09-01
954,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2016-05-26,372,C,0,1,QAG711,"Based on observation and staff interview the facility failed to ensure the dumpster area was free from debris to prevent insects and pests. This deficient practice had the potential to effect all one hundred thirty six (136) residents in the facility. Findings include: Observation on 05/23/16 at 11:05 a. m. of the dumpster area revealed the facility had a large compacting dumpster located behind the building. Continued observation revealed that the dumpster was full with no more room to place trash. Further observation revealed on the ground to the right of the dumpster in the grass area was at least one hundred (100) clear plastic trash bags containing various items such as soiled briefs and six (6) black trash bags. Observation of the ground two (2) feet from the dumpster was one (1) white plastic knife, 2 plastic individual cereal bowls, 2, four (4) ounce white plastic juice cups, 1, 4 ounce Styrofoam ice cream cup, 1, eight (8) ounce empty milk carton. Continued observation of the ground revealed tan and off white food debris 2 feet from the dumpster which was mixed with in the debris on the ground. Further observation revealed that there were at least twelve (12) flies landing on the food debris that was on the ground. Interview on 05/23/16 at 11:10 a. m. with the Dietary Manager revealed that maintenance is responsible for the dumpster. He revealed that when he parks his car in the back he looks at the dumpster area to see if there is any debris or if the door is open. The DM confirmed that there were trash bags on the grass area near the dumpster. He confirmed that the dumpster was full. He confirmed that there was food debris on the ground near the dumpster and confirmed there were flies on the food debris. Interview on 05/23/16 at 11:15 a. m. with CC , Maintenance revealed that the waste management company did not come and empty the dumpster over the weekend. He revealed that the facility is scheduled to have the dumpster's hauled away once a week. He confirmed that there were trash bags on the ground and he confirmed that there were flies on the trash. He revealed that his supervisor had called the waste management company regarding the dumpster and the need to have it emptied. Interview on 05/26/16 at 11:30 a. m. with the Director of Maintenance revealed that he contacted the waste management company that the facility has a contract with and notified them that the dumpster was almost full and needed to be emptied on Friday 05/20/16. He revealed that the waste management company told him that the dumpster would not be emptied until Monday. He revealed that staff at the facility were aware that the dumpster would not be emptied until Monday. He was not notified on over the weekend that trash and garbage bags were being stored on the grass area near the dumpster. He revealed that when he came to the facility Monday morning he noticed all of the trash bags on the ground and called waste management company again notifying them that they need the dumpster emptied out as soon as possible. He revealed that his staff loaded all of the trash bags that were on the ground into the facilities trucks and took the trash to a sister facility to be disposed. He revealed that the area surrounding the dumpster is a team effort to keep clean. He revealed that his staff observe the dumpster daily and often, whenever they are outside doing other tasks. He revealed that they do not have a scheduled day that the dumpster is emptied, the facility calls the waste management company when the dumpster is full.",2020-09-01
955,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2016-05-26,456,E,0,1,QAG711,"Based on observation and staff interview the facility failed to ensure the walk-in freezer was in proper working condition. This deficient practice had the potential to effect one hundred twenty six (126) residents receiving an oral diet. Findings include: Observation on 05/23/16 at 10:45 a. m. of the walk-in freezer revealed a significant ice buildup coming from behind the air condenser located on the back wall of the freezer. The Freon pipe, located towards the left side of the air condenser, had two (2) sections of covered with ice. One of the ice buildup areas was towards the top were it connects to the air condenser, this ice was 2 inches in length, 2 inches in width, and one half (1/2) in depth. The second ice buildup on the Freon pipe was located six (6) inches from the first ice buildup and was 4 inches in length, 2 inches in width and 1/2 inch in depth with ice icicles that were 6 inches in length and one fourth (1/4) inch in diameter extend down over a case of Premium Cheese Pizza. The case of cheese pizzas were open with the top lid flips folded into the sides on the box. Continued observation of the case of cheese pizza ' s revealed the entire inside was filled with ice, covering the food items in the box. Further observation of the walk-in freezer revealed a four (4) tiered metal storage rack on the left side of the freezer which icicles had formed on each shelf corner that was under the air condenser and Freon pipe. Each icicle was extended down towards the floor and were eight to ten inches in length. The back quarter of the freezer floor was covered with a 1/4 inch ice. Interview on 05/23/16 at 10:50 a. m. with the Dietary Manager (DM) revealed he noticed the issue with ice build-up in the freezer this past Friday. When asked if he completed and submitted a work order for maintenance to look at the freezer the DM revealed that he did complete a work order. Continued interview with the DM revealed he confirmed that the inside of the case of cheese pizzas was ice that covered all of the food product. The DM confirmed that there was icicles on the metal storage rack, on the Freon pipe, and on the freezer floor. Interview on 05/23/16 at 10:52 a. m. with CC , maintenance revealed that he did not receive a formal written work order from the DM for the ice in the walk-in freezer in the kitchen. He revealed that the DM did speak with him Friday regarding the freezer and the ice build-up but no written form was completed. When BB was asked if an issue such as ice build-up in the freezer would and should require a work order to be completed he stated yes a work order should have been completed. Interview on 05/26/16 at 11:45 a. m. with the Director of Maintenance revealed that he was notified by his staff on Monday that there was an ice issue in the walk-in freezer in the kitchen. He revealed that he is in the process of addressing work orders and how to complete with the facility staff. He revealed areas such as the kitchen a verbal work order were fine to give to any maintenance worker. Interview on 05/26/15 at 11:50 a. m. with CC revealed that he was not able to get into the kitchen last Friday after the DM told him about the ice to look at the walk-in freezer. CC revealed that Heating, Ventilation, and Air Conditioning (HVAC) company was called on Monday after surveyor identified issue of ice in the walk-in freezer. He revealed the ice was caused by a clog in the drainage tube when the freezer goes into the defrost cycle.",2020-09-01
956,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2019-06-12,656,G,1,0,C4Z111,"> Based on staff interview, record review, and review of the facility policy titled, Pressure Ulcer Management the facility failed to conduct routine skin assessments as care planned for one of three residents (R#1) at risk for pressure ulcers. Actual Harm was identified to have occurred on 5/28/19, when a wrist watch was removed from R#1's left arm and revealed three unstageable pressure ulcers. Findings include: The facility had a Pressure Ulcer Management policy that included a section for Prevention of Pressure Ulcers. Along with several other interventions, the list included weekly body audits and daily skin inspections. Resident (R) #1 had a care plan, dated 2/25/19, for the presence of a stage four pressure ulcer to the right hip. The care plan problem also included that R#1 was non-ambulatory, incontinent, required total assistance with bed mobility and transfers. The care plan was updated on 5/9/19 to include a Deep Tissue Injury (DTI) of the right heel and again on 5/20/19 to include that the stage four pressure ulcer to the right hip had healed. The care plan included an intervention for skin assessments to be completed by nursing staff per protocol. However, a review of the clinical record revealed that the skin assessments had not been completed weekly per protocol, as care planned. A review of the Weekly Skin Integrity Review forms revealed that weekly skin assessments had not been completed after 5/1/19, until 5/31/19. Further record review revealed that on 5/28/19, while preparing R#1 for transport to the hospital for evaluation, three unstageable, eschar covered pressure ulcers were identified to the left wrist, after a watch was removed from her arm. During an interview on 6/11/19 at 12:25 p.m., with the Licensed Practical Nurse (LPN) Treatment Nurse revealed that the head to toe skin assessments are to be completed weekly by the nurses assigned to the residents. Cross refer to F686",2020-09-01
957,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2019-06-12,686,G,1,0,C4Z111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews, record review and review of the facility policy titled, Pressure Ulcer Management the facility failed to identify a pressure ulcer timely for one of three residents (R#1) reviewed and failed to complete routine skin assessments for one of three residents (R#2). Actual Harm was identified to have occurred on 5/28/19, when a wrist watch was removed from R#1's left arm and revealed three unstageable pressure ulcers were found. Findings include: 1. Review of the facility policy titled, Pressure Ulcer Management revealed a section for the Prevention of Pressure Ulcers. Along with several other interventions, the list included weekly body audits and daily skin inspections. The facility also had a Weekly Skin Assessment procedure. The procedure documented that as an integral part of the pressure ulcer prevention program, a skin assessment would be completed at a minimum of every week. Resident (R) #1 had [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] documented that R#1 had a Brief Interview Score of three indicating severe cognitive impairment. This MDS assessment also documented that the resident was totally dependent on staff for bed mobility, eating, dressing, and personal hygiene, and the resident had impairment to bilateral upper and lower extremities, with one stage four facility acquired pressure ulcer. Review of a Braden Scale dated 5/14/19 documented that documented R#1 scored a 13 which indicated that the resident was at a moderate risk for developing pressure ulcers. Record review revealed that R#1 had a history of [REDACTED]. There was a care plan in place, dated 2/25/19, for pressure ulcers that included R#1 was non-ambulatory, incontinent, required total assistance with bed mobility and transfers with an intervention for skin assessments to be completed by nursing staff per protocol. A review of the Treatment Administration Record (TAR) book revealed a Weekly Skin Integrity Review schedule at the front of the book. R#1 was scheduled to have skin assessments completed weekly, on Thursdays on the 11:00 p.m. to 7:00 a.m. shift. However, a review of the clinical record revealed that even though the Skin Integrity form for 5/1/19 was dated and signed, it was blank. In addition, further review of the Weekly Skin Integrity Review forms dated: 5/8/19, 5/15/19, and 5/22/19 revealed that these forms were not signed or dated, and review also revealed that these forms were blank without any evidence of documentation that weekly skin assessments had been completed for R#1. Record review revealed a Nurses note dated 5/28/19, when R#1 was received back to the facility from the hospital, that documented the following: Resident back to the facility via stretcher. While preparing resident for transport (to the hospital) Certified Nursing Assistant (CNA) removed a watch from the resident's left arm. The residents arm began to bleed. An imprint of the watch was imbedded in the resident's arm. Review of a Physician's order dated 5/28/19 revealed the following wound care orders: Clean left wrist (posterior and anterior wound) with wound cleanser or normal saline. Apply moist gauze to eschar part/area. Apply 4 x 4 gauze, apply roll gauze. Change daily and prn (as needed) for 14 days. Record review revealed a Wound Assessment Departmental Note dated 6/1/19 that documented the following: On 5/28/19 new area to left posterior wrist unstageable pressure with measurements of 1.5 centimeters (cm) x 5.0 cm x 0.1 cm soft eschar 100%, small red exudate peri wound (tissue surrounding the wound) and foul odor. Interview on 6/11/19 at 11:27 a.m. with Licensed Practical Nurse (LPN) BB revealed that she used to be the Unit Manager but stepped down but is training the new Unit Manager. LPN BB pulled the shower schedule and reviewed it with surveyor. The shower schedule revealed that Resident #1 was not included on the schedule. Per LPN BB, R#1 came over from the East wing and they are incorporating her into the bath schedule. However, review of the schedule revealed that neither R#1, nor her roommate, were on the list. LPN BB then stated that R#1 gets daily bed baths and that jewelry should be removed during a bed bath. Further interview with LPN BB revealed that she is unsure who put the watch on R#1. The daily assignment sheets were reviewed with LPN BB for (MONTH) 2019 and revealed that LPN BB did not see R#1's name included on the list for a shower or for a bedbath. During an interview on 6/11/19 at 12:25 p.m., with the Treatment Nurse, revealed that after nursing staff removed a watch from the resident's wrist staff notified her to assess R#1's wrist. The Treatment Nurse stated the ulcers were dark eschar with bleeding around them and odor. She also stated, that due to the odor, that she felt that the watch had been on the resident's arm for a while. The Physician was notified, and treatment orders were obtained. Interview on 6/11/19 at 2:50 p.m. with the Director of Nursing (DON) and review of the Weekly Skin Integrity forms and Daily Skin Check forms with the DON revealed that the Daily Skin Check Report forms (completed by the CNA's) are to be completed any time they (the CNAs) change or bathe a resident and that the head to toe assessments are to be completed by the nurses daily. Further review with the DON revealed that the form dated 5/1/19 was signed, but blank, and the forms dated 5/8, 5/15 and 5/22/19 were blank as well. During an interview on 6/12/19 at 12:07 p.m. with Emergency Medical Technician (EMT) AA, who assisted in transporting the resident to the hospital on [DATE], revealed that when the nurse removed a piece of jewelry from the resident's left arm, the area he saw under it was black and necrotic and bleeding around the wound. Phone interview on 6/12/19 at 12:25 p.m. with LPN AA, the LPN on duty on 5/28/19, and the nurse assigned to R#1. Per LPN AA, she, and a CNA, were getting R#1 ready for transport and she saw some blood on the resident's arm and removed the watch. LPN AA stated she could tell it (the watch) had been there for a while because she kind of had to peel it (the watch) off. 2. Record review revealed that R#2 had [DIAGNOSES REDACTED]. She had a care plan problem in place since 6/25/18 for having the potential for skin breakdown related to requiring assistance with bed mobility and bowel and bladder incontinence. A further review of the care plan and clinical record revealed that the resident had a history of [REDACTED]. A review of the Treatment Administration Record (TAR) book revealed a Weekly Skin Integrity Review schedule at the front of the book. R#2 was scheduled to have a skin assessment completed weekly, on Saturdays on the 11:00 p.m. to 7:00 a.m. shift. However, a review of the Weekly Skin Integrity Review forms revealed that the skin assessments had not been completed weekly since 2/2/19, the skin assessments had only been completed, for R#2, on the following dates: 2/24/19, 3/9/19, 4/20/19, 5/18/19, and 6/8/19. During an interview on 6/11/19 at 12:25 p.m., the licensed practical nurse (LPN) Treatment Nurse stated that the head to toe skin assessments are to be completed weekly by the nurses assigned to the residents. During an interview on 6/12/19 at 2:56 p.m., the Physician stated he expected the nurses to routinely assess the resident's skin.",2020-09-01
958,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2017-07-12,157,D,1,0,Z0R511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to consult with an oncologist in regards to continuation of [MEDICAL CONDITION] medications after an intuit thirty (30) day administration of this medication for one resident (#1). Sample size was two residents [MEDICAL CONDITION] medications in the facility. Findings include: Resident #1 had a [DIAGNOSES REDACTED]. She had an appointment with her oncologist on 2-28-2017, at which time the oncologist gave the resident a prescription for Letrazole 2.5 milligrams (mg.) daily for thirty (30) days. Review of this prescription for the Letrazole 2.5 mgs revealed that there were additional orders for five (5) refills of this medication. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. daily for thirty (30) days. However, review of the (MONTH) (YEAR) MAR indicated [REDACTED]. for that month. The review of the (MONTH) (YEAR) MAR indicated [REDACTED]. from 5-1-2017 to 5-23-2017. Interview with Unit Manager (UM) Registered Nurse (RN) AA on 6-30-17 at 4:00 PM revealed that the facility had obtained this prescription of 2-28-2017 for the Letrazole 2.5 mg. daily for thirty (30) days with five refills. She stated that she had called the nurse at the oncologist's office to clarify the order for the Letrazole 2.5 mg. daily, in regards to the five (5) refills. Further interview with UM RN AA at that time revealed that the oncologist's nurse had told her that within the first three (3) weeks of this medication administration, that the oncologist would review the medication for possible side effects/increased risks. The UM RN AA stated that the oncologist's nurse had told her that she (oncologist's nurse) would contact her in three (3) weeks in order clarify if the oncologist wanted the resident to continue the Letrazole 2.5 mg. daily after the initial thirty days of administration. This was not documented in the clinical record. UM RN AA stated during this interview that the oncologist's nurse had never called her back in regards to the status of the five (5) refills of this medication. She also confirmed that she had failed to notify/ consult with the oncologist after the first thirty (30) day dosage of the Letrazole 2.5 mg. daily, in regards to whether or not continue the Letrazole 2.5 mg. daily past the initial thirty days. She further stated that, during a follow-up visit to the oncologist on 5-24.2017, the physician had discovered that the resident had not been given this medication past the initial thirty (30) day administration (from (MONTH) 1 (YEAR) to (MONTH) 24, (YEAR). On 5-24-2017, the oncologist wrote another order for Letrazole 2.5 mg. daily indefinitely. Telephone interview with the attending physician for this resident on 7-12-17 at 11:30 AM revealed that the resident had not suffered any harm in regards to the facility's failure to administration the Letrazole 2.5 mg. daily from 4-1-17 to 5-23-17.",2020-09-01
959,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2017-07-12,514,D,1,0,Z0R511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews and staff interviews, it was determined that the facility had filed to ensure an accurate clinical record for one resident (#1) [MEDICAL CONDITION] medications from a total sample of two (2) residents [MEDICAL CONDITION] medications. Findings include: Resident #1 had a [DIAGNOSES REDACTED]. She had an appointment with her oncologist on 2-28-2017, at which time the oncologist gave the resident a prescription for Letrazole 2.5 milligrams (mg.) daily for thirty (30) days. Review of this prescription for the Letrazole 2.5 mgs revealed that there were additional orders for five (5) refills of this medication. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. daily for thirty (30) days. However, review of the (MONTH) (YEAR) MAR indicated [REDACTED]. for that month. The review of the (MONTH) (YEAR) MAR indicated [REDACTED]. from 5-1-2017 to 5-23-2017. Review of an oncologist's note for 5-23-2017 revealed that she had documented that the facility had failed to administer this medication for the month of (MONTH) (YEAR) and from 5-1-2017 until 5-23-2017. Interview with Unit Manager (UM) Registered Nurse (RN) AA on 6-30-17 at 4:00 PM revealed that the facility had obtained this prescription of 2-28-2017 for the Letrazole 2.5 mg. daily for thirty (30) days with five refills. She stated that she had called the nurse at the oncologist's office to clarify the order for the Letrazole 2.5 mg. daily, in regards to the five (5) refills. Further interview with UM RN AA at that time revealed that the oncologist's nurse had told her that within the first three (3) weeks of this medication administration, that the oncologist reviewed the medication for possible side effects/increased risks. The UM RN AA stated that the oncologist's nurse had told her that she (oncologist's nurse) would contact her in three (3) weeks in order clarify if the oncologist wanted the resident to continue the Letrazole 2.5 mg. daily after the initial thirty days of administration. Review of the Nursing Notes (NN) and Skilled Nurses' Notes with UM RN AA on 6-30-2017 at 4:15 PM revealed that she had failed to document in the clinical record the conversation she had with the oncologist's nurse on 2-28-2017 in regards to the continuation of the Letrazole 2.5 mg. daily. after the initial thirty (30) day administration. UM RN AA confirmed this failure to document during this interview.",2020-09-01
960,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2017-08-17,280,D,0,1,57JI11,"Based on observation, interview, record review, and review of facility policies, it was determined the facility failed to develop comprehensive care plans for one resident from a sampled 32 residents reviewed for range (Resident #22) Findings include: Policy review of the facility's policy titled Care Planning dated 11/15/16 revealed it is the responsibility of the Care Plan Coordinator to ensure concerns/changes for a resident is updated in the care plan. The policy continues, it is the responsibility of the Director of Nursing (DON), Registered Nurse (RN) Supervisor and Licensed Charge Nurses to assure provisions of care are delivered in accordance with the care plan. Policy review of the facility's document titled Nurse Aide Maintenance Program dated 8/19/13 revealed Range of Motion (ROM) to extremities is provided during the delivery of care by the Certified Nursing Assistant (CNA) assigned to the residents that shift. Interview conducted 8/14/17 3:40 p.m. with Unit Manager (UM) BB at South Wing Nurses' Station revealed Resident (R)#22 had a contracture of her bilateral knees. Observations made on 8/16/17 at 10:43 a.m. revealed R#22 was in the facility's Main Dining Room. R# 22 was seated in a geri -chair. The resident was positioned on her left side with both of her knees bent at a 90-degree angle. No splints were observed in place on the resident's bilateral knees. When an attempt was made to ask R#22 about her contracted knees, the resident was only able to speak a few words. The resident stated my back is hurting. R#22 was not able to respond to any further interview questions. Interview conducted on 8/17/17 at 10:26 a.m. with CNA DD next to the South Wing Nurses' Station revealed the CNA was assigned to R#22 for the current shift. CNA DD stated she was familiar with R#22's care needs and that she had assisted the resident with her bed bath earlier in the shift. The CNA also stated R#22 does not wear splints and that passive range of motion (PROM) is provided to R#22's knees by her assigned CNA when they assist the resident with dressing. CNA DD stated she had performed PROM on R#22's bilateral knees earlier during her shift while assisting with her bed bath. Observations made on 08/17/17 at 11:13 a.m. in R#22's assigned room, of CNA II performing PROM on the resident's bilateral knees revealed the resident could not tolerate the movement of her knees. R#22 was observed with a noticeable change in her facial expression from calmness to tense grimacing when CNA II attempted the PROM intervention on left knee. CNA II was not able to move the resident's left knee. CNA II then attempted to perform PROM on the resident's right knee. Again, R#22 grimaced, shook her head back and forth while reaching for CNA II's hands as she attempted to perform PROM on the resident's left knee. CNA II was not able to move R#22's right knee. Record review of R#22's Restorative Nursing Program document revealed the resident had been receiving Range of Motion assistance by Restorative Aides since 2/12/15. Review of R#22's Resident Assessment - Activities of daily living - Functional Rehabilitation Potential form dated 3/1/17 revealed the resident had been receiving PROM assistance by the facility's Restorative Technicians. On 3/1/17 PROM assistance for R#22 was transferred to the CNA Maintenance Program. Further review of the document revealed R#22 was being transferred to the CNA Maintenance Program due to no longer being a candidate for licensed therapy services or the Restorative Program. Review of R#22's Care Plan revealed a plan of care was developed on 12/5/16 to address the resident's contractures to her bilateral lower legs. The established goal of the plan of care was that the resident would have no worsening of contractures for the next 90 days. The identified approaches for the plan of care included requiring nursing staff to report any worsening of contractures to R#22's physician and for CNA staff to provide gentle ROM exercises to comfort level of resident as ordered/tolerated. The written plan of care to address R#22's contractures had not updated since it was established on 12/5/16. Review of R#22's Aide Assignment Record from 6/1/17 through 8/17/17 revealed no documentation entries were made to indicate ROM assistance had been provided to R#22. Interview conducted on 8/17/17 at 2:25 p.m. with Minimum Data Set (MDS) Coordinator HH and the Director of Nursing (DON) revealed once a resident is discontinued from the Restorative Program and are still in need of assistance, they are transitioned to the CNA Maintenance Program. The care plans should have been updated to state ROM with AM care or CNA Maintenance Program.",2020-09-01
961,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2017-08-17,318,D,0,1,57JI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, - record review, facility policy review, it was determined the facility failed to provide range of motion services for two residents (Resident (R) #22 and #30 from a sampled, 32 residents reviewed for range of motion. Findings include: 1. Policy review of the facility's Nurse Aide Maintenance Program document dated 8/19/13 revealed it is the policy of Muscogee Manor to provide range of motion (ROM) for residents on a maintenance program by the Certified Nursing Assistant (CNA) assigned to direct care of the resident. Observation on 08/17/17 at 11:13 a.m. revealed R#22 in her assigned room receiving passive range of motion (PROM). CNA II was performing PROM to the resident's bilateral knees. R#22 could not tolerate the movement of her knees. R#22 was observed with a noticeable change in her facial expression from calmness to tense grimacing when CNA II attempted the PROM intervention on left knee. CNA II was not able to move the resident's left knee. CNA II then attempted to perform PROM on the resident's right knee. Again, R#22 grimaced, shook her head back and forth while reaching for CNA II's hands as she attempted to perform PROM on the resident's left knee. CNA II was not able to move R#22's right knee. Review of R#22's Resident Assessment - Activities of daily living - Functional Rehabilitation Potential form dated 3/1/17 revealed the resident had been receiving PROM assistance by the facility's Restorative Technicians. On 3/1/17 PROM assistance for R#22 was transferred to the CNA Maintenance Program. Further review of the document revealed since R#22 was no longer a candidate for licensed therapy services or Restorative Program the resident was transferred to the CNA Maintenance Program. Record review of R#22's Aide Assignment Record from 6/1/17 through 8/171/17 failed to reveal any documentation to indicate ROM assistance had been provided to R#22. Interview conducted 8/14/17 3:40 p.m. with Unit Manager (UM) BB at South Wing Nurses Station revealed it was the UM's understanding the CNAs assigned to her unit were to only to document that they assisted with the care of the residents. UM BB also stated CNAs on her unit do not perform PROM, Restorative Technician perform PROM if the resident is in the facility's Restorative Program. Interview conducted 8/17/17 at 2:25 p.m. with the facility's Minimum Data Set (MDS) Coordinator HH and the facility's Director of Nursing revealed once a resident is discharged from the Restorative Program, and are still in need of ROM assistance, they are transferred to the CNA Maintenance Program. The assigned CNAs are then expected to perform ROM exercises with the assigned resident sometime during their shift. 2. Interview on 8/14/17 at 4:00 p.m. with UM BB in the South Wing Nurses Station reported Resident (R)#30 does have a contracture of his left upper extremity from an old [MEDICAL CONDITIONS]. R#30 was reported to receive PROM exercises to his left arm by a Restorative Technician six to seven days per week. R#30 was reported to not have a splint ordered for his contracture. Observation made on 8/14/17 at 4:20 pm. near the South Wing Nurse's Station revealed R#30 was seated in a wheelchair. The resident was observed to have a contracture of his left hand. The fingers of the left hand were curled into the thumb, and all were pressed against the palm of the left hand. The individual fingers of the left hand were contracted and resting on the thumb of the left hand. The left hand was without odor or skin breakdown and the nails of the fingers were trimmed. No splint of the left upper extremity was observed to have been placed on the resident. Attempts to interview R#30 during the observation were unsuccessful due to the resident being extremely hard of hearing. Interview conducted on 8/16/17 at 3:15 p.m. with Restorative Technician (RT) AA revealed his current work (?) schedule is Monday through Friday with an occasional scheduled Saturday. RT AA stated he provides R#30's PROM every morning he is scheduled to work. Observations made on 8/16/17 at 3:28 pm. revealed R#30 in his room receiving ROM care. RT BB was performing PROM of R#30's left upper extremity and appeared familiar with the ROM care. Good interaction, knowledge of the resident's needs and competence in technique were observed during the PROM session. Record review of R#30's Restorative Nursing Program record revealed on 8/27/15 the resident was transitioned from skilled therapy to the facility's Restorative Program. Further review of the document revealed the facility's Director of Therapy services ordered PROM at a frequency of six to seven days per week. Record review of R#30's Restorative Nursing Program - Documentation Record from 5/1/17 - 8/17/17 revealed RT's had documented completion of PROM sessions with the resident five days per week for 10 of the 13 weeks reviewed. Interview on 8/17/17 at 9:24 a.m. in the Therapy Department with the Director of Physical Therapy (PT) EE revealed he had ordered Restorative Nursing services to be conducted six to seven days a week following discharge from skilled therapy on 8/27/15. PT EE also stated it is the UM's responsibility to schedule the RT's assigned to their units to ensure ROM therapies are completed as ordered. Interview conducted on 8/17/17 at 10:04 a.m. South Wing Nurses Station with UM BB revealed she was unaware she was responsible for scheduling RT's on her unit. Interview conducted on 8/17/17 at 2:25 p.m. with MDS Coordinator HH and the facility's DON revealed it is the responsibility of Unit Managers to schedule RT's assigned to their units to ensure residents who are ordered Restorative Nursing are provided those services at a frequency ordered by the Director of Therapy Services.",2020-09-01
962,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2018-08-23,551,D,0,1,DVG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that Resident (R)#53 had a legal surrogate to exercise her resident's rights. The facility was aware that R#53 did not have a family member or responsible party and failed to take steps to obtain a legal surrogate. The sample size was 36 residents. The findings include: R#53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of R#53's most recent Minimum Data Set (MDS), a comprehensive assessment with an Assessment Reference Date (ARD) of 6/6/18 assessed R#53 as scoring three out of a possible 15 on the Brief Interview for Mental Status (BIMS), indicating that R#53 was severely cognitively impaired with decisions regarding daily living. Review of R#53's face sheet documented that the responsible party (RP)/contact person was the name of the facility Social Worker. The face sheet did not include any information about any family members. An advance directive in R#53's clinical record was signed by the resident prior to admission. R#53's cognitive status had significantly declined since admission. Review of R#53's comprehensive care plan dated 6/27/18 did not reveal any documentation regarding an assigned responsible party. Review of R#53's social services notes did not reveal any references to family members and did not document any efforts to obtain a court appointed guardian for the resident or any efforts taken by the facility to declare R#53 as mentally incompetent. An interview conducted with Registered Nurse (RN) CC on 08/22/18 at 10:37 AM revealed that R#53 did not have any family. When asked who acted as resident's RP, RN CC stated that the social worker at the facility acted as R#53's RP. An interview was conducted with the Social Worker on 08/22/18 at 11:04 a.m. in the conference room. When asked who acted as R#53's RP, the Social Worker stated that she had signed on to be R#53's RP. The Social Worker further stated that when a resident did not have any family someone in the facility was assigned to take on the lead role to make sure the resident was comfortable. When asked who made clinical decisions for R#53 the Social Worker stated that the Physician made all the clinical decisions. When asked why R#53 did not have an assigned guardian, the Social Worker did not know anything about that. When asked if steps had been made to obtain a court appointed guardian the Social Worker stated, That's a good question, I don't know the answer. When asked how many residents did not have a responsible party the Social Worker stated that R#53 was the only one. Review of the Social Worker's notes documents the following:6/14/17 (Name of Social Services Director) is now her representative as of 6/14/17. 12/8/17 (name of R #53) and her family (there is no family) were invited to the CPM (care plan meeting, the SSD (Social Services Director) is her guardian and was present for the CPM. An interview was conducted with the Administrator on 8/23/18 at 8:45 a.m. in the conference room. The Administrator was asked to describe what the facility did when a resident did not have family or an RP. The Administrator stated that the facility did not really have any process for a resident without an RP, but any clinical decisions that needed to be made would be made through their ethics committee composed of the facility Medical Director (MD), the Director of Nursing (DON), the RN Unit Managers and the Administrator, and that this committee acted as the resident's RP. When asked if anyone not employed by the facility was invited to be part of the ethics committee such as the Ombudsman, the Administrator stated no, just the people named. When asked if the ethics committee had ever met to discuss R#53's clinical status, the Administrator stated that they had not. When asked if he, or the ethics committee, had taken any steps to obtain a guardian for R#53 the Administrator stated that he has never felt the necessity to seek guardianship. The Administrator was asked to confirm if the facility was making all decisions for R#53, the Administrator stated that was true. When asked if the ethics committee maintained meeting notes the Administrator stated that they did not. The Administrator was asked if the Social Worker was designated as R #53's RP, the Administrator stated that she was not and shouldn't be the designated RP. When asked why the Social Worker described herself as the resident's responsible party the Administrator stated that she had misunderstood and that is not her role. A policy was requested at this time regarding residents who were without an RP. The Administrator stated that there was no such policy. An interview was conducted on 8/23/18 at 1:27 p.m. with the Medical Doctor (MD) in the conference room. When asked who acted as R#53's responsible party, the MD stated that the ethics committee, The nurse, myself, the Administrator, Social Worker and the DON, acts as R#53's responsible party. When asked what the ethics committee decides, the MD stated the course of treatment best for the patient, for example if she needs to go in-hospice or not, we would make that decision. When asked who acted on the patient's behalf for those types of decisions the MD stated, That's where the social worker comes in. When asked if anyone had discussed guardianship for the resident the MD stated that he didn't recall. The MD further stated, The administrator takes care of that. The MD was asked if he was aware of the process to obtain guardianship for a resident, the MD stated that he thought that it was usually started by social worker. A message was left on the Ombudsman's voice mail to discuss R#53's lack of RP but this writer did not receive a call back prior to exit from the survey. A review of the facility document Social Worker Job Description revealed, in part, the following documentation: Assist resident with information concerning resident rights, living will, etc.",2020-09-01
963,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2018-08-23,656,D,0,1,DVG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to develop a complete comprehensive care plan for fluid monitoring for one resident (R#32) diagnosed with [REDACTED].#53 from a sampled 36 residents. The findings include: 1. Review of the undated Admission Face Sheet revealed R#32 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the Quarterly 5/17/18 Minimum Data Set (MDS) assessment revealed the Brief Interview for Mental Status test could not be completed. The resident was documented with short-term and long-term memory impairment as well as severely impaired decision-making. Under functional status, the resident was assessed as being dependent on staff for activities of daily living (ADLs), which included eating. The Clinical Laboratory Services report dated 7/30/18 revealed the resident's sodium level was elevated at 153; the normal range per the lab was 136 - 145 (a sodium blood test measures the amount of sodium in the blood. If sodium blood levels are too high, it may mean kidney problems or dehydration). On 8/6/18, a nephrology (is a specialty of medicine that concerns itself with the kidneys) consultation was completed. Review of the 8/6/18 Reevaluation of Multiple Conditions note, the following was documented by the Nephrologist: female with history of hypertension and diabetes mellitus as well as CKD ([MEDICAL CONDITION]). [DIAGNOSES REDACTED]. chronic [MEDICAL CONDITION] patient has had chronic high NA (sodium), indicating less than adequate hydration. [MEDICAL CONDITION] - [MEDICAL CONDITION] worsened. Adv (advise) to raise PO (by mouth) water intake . consider PEG (percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach) for sustained hydration. Following the nephrology consultation on 8/6/18, Physician's orders were written as follows: On 8/6/18 at 3:00 p.m. - high NA (sodium) 153. Needs more PO (by mouth) water, consider PEG to avoid ARF (acute [MEDICAL CONDITION]), give her 1500 cc of water everyday by mouth at least. Although the resident's sodium level was elevated, fluid intake was documented as being inadequate, and a feeding tube was being considered for the sole purpose of providing additional fluids, the care plan did not include this information. There was nothing on the care plan related to fluid intake or fluid balance; the nutrition care plan dated 5/17/18 did not include any information related to fluids. The Director of Clinical reimbursement was interviewed on 8/23/18 11:05 a.m. in the surveyor conference room. She explained how the interdisciplinary team developed care plans. She stated all residents on the North Unit, where R#32 resided, were reviewed on the same day by the MDS Coordinator, activity staff, dietary staff, the unit manager, restorative staff and Certified Nurse Assistants (CNA)s. The team reviewed the care plan to determine if there were any changes. If there was something new, the team discussed the need for a new care plan. The Director of Clinical Reimbursement stated the MDS Coordinator who was assigned wrote the care plan. She stated she often attended the meetings as well, stating I usually sit in when I am here. When asked about acute issues such as an elevated sodium, she stated if an issue came up in between the scheduled care conferences, it was usually caught in the 24-hour communication log. She stated issues in the 24-hour communication log were brought to the daily meeting with department heads who then talked about interventions. She stated if it was not settled in the daily meetings, it would be settled with the manager. She stated new issues should be documented in the care plan as needed in between scheduled care plan meeting dates. She stated the staff relied on the information being documented in the communication book in order not to miss important issues that came up between scheduled care conferences. A copy of the 24-Hour Report for 8/6/18 was requested. The 24-Hour Report dated 8/6/18 indicated, the resident returned from a nephrology appointment with a new order for 1500 ml of water per day for elevated sodium. 2. R#53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#53 was assessed on her most recent comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/6/18 as being severely cognitively impaired with decisions of daily living. R #53 was also assessed as being totally dependent with all Activities of Daily Living (ADLS), requiring assistance of one to two staff members for care. R#53 was observed on the following dates and times lying in her bed and full-length bilateral side rails in the up position; 8/20/18 at 10:45 a.m., 8/21/18 at 8:51 a.m. and 8/22/18 at 8:42 a.m. Review of R#53's comprehensive care plan dated 6/27/18 did not have any documentation regarding the use of side rails. Review of R#53's physician orders from (MONTH) (YEAR) through (MONTH) (YEAR) did not reveal an order for [REDACTED]. Review of R#53's Nurse Aide's Information Sheet (undated) documented, in part, the following; Siderails at night upper. Review of a facility form titled Side Rail Assessment Tool dated 6/6/18 documented the following: What side rails are available on resident's bed? Top: Right / Left. Are side rails used? Yes. If yes which rails are used? To; Right / Left. When are rails used: At all times in bed - Yes. Does Resident release rails at will? No. Requested by resident? Yes. Reason for request: A) Safety concerns E) Positioning. IDT (interdisciplinary team) recommends side rails? Yes. Reason for request B) Safety concerns, E) Positioning. Do rails impede resident's freedom of movement? No. Do rails preclude resident's access to his/her body? No. Signed by the Director of Clinical Reimbursement. On 8/22/18 at approximately 11:45 a.m. an interview was conducted in the conference room with the Director of Clinical Reimbursement who was also responsible for overseeing the completion of comprehensive care plans and the MDS. When asked to describe the process for creating a care plan the Director of Clinical Reimbursements stated that a care plan was based off the triggered areas on the MDS Care Area Assessments (CAAs), along with areas that the facility knew were to be addressed with the resident's daily care. When asked who ensured that all necessary areas were included on the care plan, the Director of Clinical Reimbursement stated that the Interdisciplinary team (IDT) met every Wednesday and Thursday and that the IDT included representatives from MDS, dietary, restorative nursing, the unit manager, a CNA, activities and social services. Each area was reviewed on the care plan and the team made sure that all relevant care areas were included. When asked if the use of side rails would be something that would be included on the care plan, the Director of Clinical Reimbursement stated that they would. The Director of Clinical Reimbursement was asked to review R#53's comprehensive care plan and state whether or not her bilateral, full length side rails, currently in use, were care planned. The Director of Clinical Reimbursement stated that they were not. When asked if the side rails should have been care planned, the Director of Clinical Reimbursement stated that they should have been included on the care plan. A review of the facility policy titled Care Planning dated 11/15/16 revealed, in part, the following documentation; 7. It is the responsibility of the Care Plan Coordinator to review timely a resident's status and any change in needs following a hospital stay or any other unexpected event as deemed appropriate. 9. The Care Plan Team will include participation by CNAs, Licensed Charge Nurses, Registered Nurse Supervisors (including the Director of Nursing (DON) as deemed appropriate for the conference being held that day. These staff members will be invited to assure a comprehensive review of the resident's status and needs. 10. The CNA ADL record will be updated during the Care Plan Conference to reflect interventions defined on the care plan. 11. The DON, RN (Registered Nurse) Supervisor and Licensed Charge Nurses are responsible for assuring provision of care in accordance with the care plan.",2020-09-01
964,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2018-08-23,692,D,0,1,DVG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the facility failed to ensure one out of four residents (R) reviewed for nutrition/hydration. R#32 was assessed for adequacy of fluid intake and provided with appropriate and coordinated medical care to address [MEDICAL CONDITION] (elevated sodium) and decreased fluid intake. Failures included: -A lack of a system to notify the Dietitian of pertinent lab results; -A lack of assessment of R#32's fluid balance such as fluid intake and output in light of conflicting data (labs and fluid intake records); -A lack of clarifying Physician Orders and subsequently, discontinuing orders without Physician input; and -A lack of coordinated care between Physicians and the interdisciplinary team regarding fluids. Findings include: Review of the facility's undated Admission Face Sheet revealed the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. The resident was 5'5 tall and weighed 198 pounds. Review of Physician's Orders (August (YEAR)) revealed the resident was prescribed 300 mL of water to be administered eight times a day by nursing staff for a daily total of 2400 milliliters (ml) equivalent to 80 ounces or 10 cups daily. This order was initiated on 9/23/16 and was current during the survey as evidenced by nursing staff documenting fluid intake of 300 ml eight times a day (review of Medication Administration Records 6/1/18 - 8/22/18) for a daily total of 2400 ml. The diagnosis/reason for the order of 2400 ml of fluid by nursing was not documented. Review of the Quarterly 5/17/18 Minimum Data Set (MDS) assessment revealed the Brief Interview for Mental Status test could not be completed. The resident was documented with short-term and long-term memory impairment as well as severely impaired decision-making. The resident was assessed as having inattention and an altered level of consciousness. Under functional status, the resident was assessed as being dependent on staff for activities of daily living (ADLs), which included eating. Additional [DIAGNOSES REDACTED]. The resident's weight was 151 pounds and she received a mechanically altered therapeutic diet. The most recent Dietitian Nutrition Flowsheet (Dietitian charting) was completed on 5/25/18. The resident's fluid needs were calculated by the Dietitian as being between 1800 - 2000 milliliters (ml) per day. The resident was on a pureed, no concentrated sweets, renal diet with meal intake of more than 75%. Pertinent lab data indicated the resident's most recent sodium level was normal at 143, her urea nitrogen level was high at 49, and her creatinine level was high at 2.6 on 4/25/18. Although the resident's fluid needs were 2000 ml on the high end, she was prescribed and administered 2400 ml of water by nursing staff in addition to the fluids consumed during meals and in between meals. An evaluation of the resident's fluid intake in comparison to fluid requirements was not completed by the Dietitian. There were no Dietitian/dietary notes in the record after this date. Review of the Weight Chart revealed a steady unplanned weight loss occurred after the last review on 5/25/18 by the Dietitian: -5/1/18 152 pounds (lbs) -6/1/18 150.8 lbs -7/1/18 147 lbs -8/1/18 143 lbs The resident experienced a 5.9% (non-significant) weight loss from 5/1/18 - 8/1/18. The Clinical Laboratory Services report dated 7/30/18 revealed the resident's sodium level was elevated at 153; the normal range per the lab was 136 - 145 (a sodium blood test measures the amount of sodium in the blood. If sodium blood levels are too high, it may mean kidney problems or dehydration). The resident's urea nitrogen level was elevated at 53; the normal range per the lab was 7 -25 (a high blood urea nitrogen level generally means kidney function is impaired). The resident's creatinine was elevated at 3.5; the normal range per the lab was .6 - 1.2 (creatinine is a waste product produced by muscles and is filtered from the blood by the kidneys and released into the urine; blood levels are usually a good indicator of how well the kidneys are working). These laboratory values showed a deterioration in the resident's renal (kidney) status and/or hydration status compared to the labs on 4/25/18 that were evaluated by the Dietitian. On 8/6/18 nephrology (is a specialty of medicine that concerns itself with the kidneys) consultation was completed. Review of the 8/6/18 Reevaluation of Multiple Conditions note, the following was documented by the Nephrologist: female with history of hypertension and diabetes mellitus as well as CKD ([MEDICAL CONDITION]). She is referred due to elevated creatinine and abnormal electrolytes .[DIAGNOSES REDACTED]. Acute [MEDICAL CONDITION] - creatinine has increased significantly . chronic [MEDICAL CONDITION] patient has had chronic high NA (sodium), indicating less than adequate hydration. Adv (advise) to consider PEG (percutaneous endoscopic gastrostomy, a procedure in which a flexible feeding tube is placed through the abdominal wall and into the stomach) . [MEDICAL CONDITION] - [MEDICAL CONDITION] worsened. Adv to raise PO (by mouth) water intake . consider PEG for sustained hydration. Following the nephrology consultation on 8/6/18, Physician's orders were written as follows: -On 8/6/18 at 3:00 p.m. - high NA (sodium) 153. Needs more PO (by mouth) water, consider PEG to avoid ARF (acute [MEDICAL CONDITION]), give her 1500 cc of water everyday by mouth at least. -On 8/6/18 at 6:30 p.m. a follow up appointment with the Nephrologist was made for 11/19/18 at 3:00 p.m. There was no evidence the Nephrologist was aware of the existing order for 2400 cc of fluids already being administered by nursing. With an order for [REDACTED]. requirements of 1800 - 2000 cc per day calculated by the Dietitian. Review of the resident's Medication Administration Record (MAR) for (MONTH) (YEAR) revealed 300 ml of water was administered by nursing at 7:00 a.m., 9:00 a.m., 11:00 a.m., 1:00 p.m., 3:00 p.m., 5:00 p.m., 7:00 p.m., and 9:00 p.m. totaling 2400 ml per day. The MAR for (MONTH) (YEAR) also included the order for 1500 ml by mouth daily with documentation to occur at 9:00 a.m., 1:00 p.m., and 9:00 p.m. The fluid was administered on 8/6/18 at 9:00 p.m.; however, it was not administered following this one instance. The Physician's Orders for (MONTH) (YEAR) were reviewed and there was no order to discontinue the 1500 ml of fluid that was prescribed on 8/6/18 by the Nephrologist. Meal intake records for (MONTH) (YEAR) and (MONTH) (YEAR) were reviewed. Staff were to document percentages as follows: A=75-100%, B= 50-75%, C=25-50%, D=10-25% and R indicated refusal. Meal and fluids were documented together; there was no separate documentation of fluid intake. There was no way to determine sufficiency of fluid intake at meals from the records. Meal intake records showed the following: -During July, the resident ate between 75-100% for 80% of her meals (73 out of 92 total meal opportunities). -During (MONTH) (through 8/22/18), the resident ate between 75-100% for 85% of her meals (55 out of 65 total meal opportunities). The resident was losing weight during these two months even though her intake records showed good intake. On 8/22/18 at 8:53 a.m. Certified Nursing Assistant (CNA) FF was interviewed in the North hallway by the day room. She stated she just finished feeding the resident breakfast. CNA FF stated the resident ate 100% of her pureed breakfast consisting of pureed eggs, sausage, cereal, applesauce, plus juice and water. CNA FF also stated she had to feed the resident and indicated the resident was blind. CNA FF further stated the resident ate well as long as she was awake. At times, she had to wake her. Licensed Practical Nurse (LPN) GG was interviewed on 8/22/18 at 9:20 a.m. at the North Nurse's station and stated the resident's meal intakes fluctuated. She also stated the resident did not like to eat as much in the morning. LPN GG stated the CNAs had been instructed to feed her last as she liked to sleep later. She further stated the resident ate better if she was awake. LPN GG stated the resident did not receive any nutritional supplements. LPN GG added the resident consumed fluid if staff took the time with her and were patient. She stated the resident's family was considering placement of a feeding tube for provision of fluids. When asked about provision of the 2400 ml of water daily by nursing, she stated she administered water four times on her shift and the resident drank it. When asked about the order for 1500 ml of fluids dated 8/6/18, LPN GG stated she was unsure if this order replaced the previous order for 2400 ml. She reviewed the MAR and stated the 1500 ml order had been discontinued; however, she could not find an order for [REDACTED]. However, after reviewing nurse's notes, she stated there were no nursing notes regarding discontinuing the 1500 ml of fluids. When asked how the Dietitian became aware of abnormal labs such as the elevated sodium level of 153 drawn on 7/30/18, she stated she was not sure how the Dietitian became aware. Registered Nurse (RN) EE was interviewed on 8/23/18 9:49 a.m. at the North Nurse's Station and stated the pharmacy discontinued the 1500 ml order for fluids. RN EE stated she had just called the Physician (Nephrologist) about that. She stated the Nephrologist recommended a PEG tube due to the resident not getting enough water. When asked about the Nephrologist being notified of the order for 2400 ml of fluid at the time the 1500 ml of fluid was prescribed, she stated, We missed that she was already on 2400 ml. I forgot to tell the kidney doctor. When asked if the resident's intake and output were monitored in light of conflicting data showing adequate fluid intake (2400 ml plus fluids at meals and in between meals) and the elevated sodium with Nephrologist's assessment of inadequate fluid intake, she stated the resident's intake and output was not measured. When asked if nursing notified the Dietitian of abnormal labs, she stated the Dietitian was not normally notified of labs. When asked if there was separate fluid intake monitoring for meals, she verified fluids and meal intake were recorded by the CNAs as one total and fluid intake from meals could not be discerned. Interview with the Director of Nursing (DON) and Registered Nurse (RN) EE on 8/23/18 2:58 p.m. in the DON's office revealed staff failed to clarify the order for 1500 ml when it was prescribed by the Nephrologist on 8/6/18. RN EE verified the resident already had an order in place for 300 ml of water to be administered by nursing staff eight times a day, totaling 2400 ml of water, in addition to fluids consumed with meals and in between meals. RN EE stated she clarified the order today and the Nephrologist wanted the 1500 ml discontinued and to keep the order for 2400 ml. RN EE stated the resident's family wanted a feeding tube inserted to provide fluids based on the Nephrologist's recommendations, in addition to the 2400 ml from nursing and fluids provided at and in between meals. RN EE stated an appointment had just been made for insertion of a feeding tube for provision of fluids. The DON and RN EE were asked about the dietitian's estimate of the resident's fluid needs of 1800 - 2000 ml per day and fact that the existing order for 2400 ml exceeded the resident's fluid requirements without any fluids from meals or in between meals being provided. The DON stated a consultation with the Nephrologist, Physician, and Dietitian was needed. RN EE stated the Dietitian came to the facility on ce a month at the beginning of the month. In an interview on 8/23/18 at 2:20 p.m. in the surveyor conference room, the Physician/Medical Director reviewed (MONTH) (YEAR) Physician's Orders and stated he did not see an order to discontinue the 1500 ml of fluid prescribed by the Nephrologist and stated there should be a discontinue order for 1500 ml. The Physician reviewed the Medication Administration Records for (MONTH) and (MONTH) (YEAR) which documented administration of 2400 ml of water per day by nursing. The Physician stated, She might not be getting it (2400 ml of fluid). It doesn't make sense to be getting that much fluid and having a sodium of 153. When asked about the Dietitian being notified of abnormal labs with nutritional implications, he stated it may have fallen through the cracks. He stated it was the nursing department's responsibility to notify the Dietitian of abnormal labs, which included sodium levels. A telephone interview was conducted with the Dietitian on 8/23/18 at 3:40 p.m. He stated he had not been notified of the resident's high sodium level that occurred on 7/30/18 or of the resident's continued weight loss. The Dietitian stated nursing staff should have notified him; he stated he expected to be notified of abnormal labs such as sodium. The Dietitian stated he should have been called on the day the sodium lab was received at the facility. The Dietitian stated he would come and do an assessment which would involve reviewing the resident's diet, her meal and fluid intake, and medications to start with. When asked about the feeding tube for administration of additional fluids, the Dietitian stated the resident could go into fluid overload if too much fluid was given if she was already consuming 2400 from nursing and additional fluids from meals and in between. The Dietitian verified it was his role to determine fluid requirements and that fluid intake should be assessed in relation to fluid requirements. Review of a facility policy titled, Nursing Philosophy policy dated 11/28/16 indicated, Nursing practice is a process that includes assessing the resident's state of being, developing short-term and long-term goals, planning and implementing appropriate nursing measures to help the resident reach those goals and evaluating the effectiveness of the nursing measures. Review of the facility policy titled, Hydration and Nutrition policy dated 11/28/16 indicated, The nutrition and hydration status of each resident is maintained as close to optimal level as possible. Baseline nutrition and hydration information is obtained by a licensed dietitian and/or RN upon admission .Fluid is available to residents at all times .An ongoing assessment of ability to consume and assimilate food by resident is conducted by nursing personnel. Assessments include position needs, environmental and social considerations, ability of resident to feed self, ability of resident to chew and swallow, amount of food lost in spillage, nutrition balance of intake, weight loss of gain, signs of dehydration . Consultation with dietary personnel is performed upon admission, during scheduled team conferences, and as needed. A policy for notification of the Dietitian regarding abnormal laboratory values and weight changes was requested on 8/23/18 at 9:35 a.m. of the Director of Nursing. No policy was provided.",2020-09-01
965,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2018-08-23,700,D,0,1,DVG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility's policy, the facility failed to assess for the risk of entrapment from bed rails, review the risk and benefits of bed rails with resident or resident representative, and to obtain informed consent for three residents (R#23, R#53 and R#89) from a sampled size 36 residents. The failure had the potential to affect all 127 residents placing them at risk for entrapment, not being informed and obtain consent for bed rail use. Findings include: 1. Review of the face sheet in the medical record revealed R#23 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Sheet ((MDS) dated [DATE] and quarterly MDS dated [DATE] revealed the R#23 was assessed as having long and short-term memory problems. R#23 was severely impaired in cognitive skills for daily decision-making on both assessments. R#23 did not have any behaviors which impacted others on both assessments. On both assessments, no wandering behaviors were exhibited. R#23 was coded on both assessments as needing total physical assistance or two or more people for bed mobility, transfers, dressing and toilet use. R#23 needed total physical assistance of one person for locomotion on the unit, eating, personal hygiene, and bathing. R#23 was assessed on both assessments as incontinent of bowel and bladder. On both assessments, no falls, fall history or fracture were indicated. On both assessments, no restraints or alarms were indicated. Review of the Care Area Assessment (CAA) Summary dated 12/12/17 revealed falls were triggered for care planning. The decision was made to care plan. The care plan was revised. Restraints did not trigger for care planning. Observation on 8/20/18 at 10:38 a.m. revealed R#23 lying in bed with bilateral side rails up at the top and bottom of the bed. Blue bolsters were noted on both sides. Observation on 8/20/18 at 1:30 p.m. revealed R#23 lying in bed with bilateral side rails up at the top and bottom of the bed. Blue bolsters were noted on both sides. Observation on 8/21/18 at 10:30 a.m. revealed R#23 lying in bed with bilateral side rails up at the top and bottom of the bed. Blue bolsters were noted on both sides. Observation on 8/22/18 at 8:30 a.m. revealed R#23 lying in bed with bilateral side rails up at the top and bottom of the bed. Blue bolsters were noted on both sides. Record review of Physician's Orders from 3/1/18 to present revealed no order addressing side rails up x (times) four with bolsters to both sides. Record review of the facility's Side Rail Assessment Tool dated 6/7/18 revealed side reals were available on the resident's bed on the top right and left. The side rails were in use. The side rails were always to be used while the resident was in the bed. The side rails were not requested by the resident. The reason for the use of the side rails were for safety concerns and positioning. The rails do not impede on the resident's freedom of movement or preclude access to his/her body. Further review of R#23 medical file revealed no consent for side rail use or review of risk/benefits with the resident or the resident's responsible party. Record review of the care plans revealed: Problem Onset: 3/7/18 - Falls - Resident is at risk for falls r/t (related to)dementia, incontinence, limited mobility. She is totally dependent for ADLs. Goal & target date: Resident will not experience any injuries related to falls thru 6/7/18. Approaches used included: - Mechanical lift with two persons assists for transfers; - Place call light with easy reach; - Low Bed; - Bolster Pads; - document and report any falls circumstances and injuries. Interview with Unit Manager HH in South Nurse's Station on 8/21/18 at 4:15 p.m. revealed the facility uses the side rails and bolsters to prevent the resident from falling from the bed. R#23 is care planned for the use. Unit Manager HH said only the top rails should be used when the resident is in bed not the bottom rails. The Unit Manager said she did not get a consent for the use of the side rails and bolsters. R#23 has a tends to roll up in a ball and by her being so tiny, R#23 can get between the mattress and the side rails. This is the reason for the use of the bolsters and side rails on the bed. When asked if the resident continues to move as much as in the past, the Unit Manager said not as much. The Unit Manager said R#23 had not been reassessed regarding trying a least restrictive intervention. Interview with CNA II in South Nurse's Station on 8/22/18 at 4:25 PM revealed the R#23 should only have the top two side rails up on her bed with bolsters on both sides. CNA II said the resident tends to move in the bed and can get between the mattress and the side rails. CNA II said all four side rails up on a resident is a restraint and should not be done. Review of the facility's Restraint Use/Side Rail Policy dated 11/28/16 revealed Policy: The use of side rails as restraints is prohibited unless are they are necessary to treat a resident's medical symptoms. Side rails add risk to the resident in that they potentially increase the risk of more significant injury from a fall from a bed with raised side rails than from a fall from a bed without side rails. Side rails potentially increase the likelihood that the resident will spend more time in bed and fall when attempting to transfer from the bed. Side rails encourage incontinence as the resident's means of independent toileting is limited. This facility will employ other interventions in care planning to include not limited to: * Provide restorative care to enhance abilities to stand safely and to walk * A trapeze to increase bed mobility * Placing the bed at the lowest possible position Continued review of the facility's policy revealed the following: * Provide frequent staff monitoring at night with periodic assisted toileting for residents attempting to arise to use the bathroom * Furnish visual and verbal reminders to use the call bed for residents who are unable to comprehend this information * As with other restraints, it is expected that the facility will employ process to reduce the use of bed rails. This process is to be clearly systematic and gradual. * Residents are assessed on admission or re-admission, quarterly and if a significant change in condition for the need to utilize side rails. * When side rails are placed the resident, resident representative will be notified. * Bed rails are to be installed according to manufactures recommendation by the maintenance staff. * Bed rails will be inspected to ensure there is no risk to the resident. This is to be done by the nursing staff. 2. R#53 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#53 was assessed on her most recent Minimum Data Set (MDS), a comprehensive assessment with an Assessment Reference Date (ARD) of 6/6/18, as being cognitively severely impaired with decisions regarding daily living, and as totally dependent with Activities of Daily Living (ADLs). R#53 was further assessed as not demonstrating any behaviors during the look back period. Section P, Restraints, documented that R#53 did not have bed rails in place. The following observations were made of R#53: * 8/20/18 at 10:45 a.m. R#53 was observed lying in her bed with the head of bed at approximately 30 degrees and with bilateral full-length side rails were observed in the raised position. * 8/21/18 at 8:51 a.m. R#53 was observed lying in her bed, with the head of the bed at approximately 45 degrees. Bilateral, full length side rails were observed in the raised position. * 8/22/18 at 8:42 a.m. R#53 was observed lying in her bed in a flat position on her back. Bilateral, full length side rails were observed in the raised position. Review of R#53's physician orders between (MONTH) (YEAR) and (MONTH) (YEAR) did not reveal any orders regarding the use of side rails of any type. Review of R#53's comprehensive care plan dated 6/7/18 did not reveal any information about the use of side rails / full body side rails. Review of R#53's clinical record revealed, in part, a facility document titled Side Rail Assessment for 6/6/18 that included the following documentation; What side rails are available on resident's bed? Top, Right, Left. Are side rails used? Yes. If yes which rails are used? Top, Right, Left. When are rails used? At all times in bed - Yes. Requested by resident - Yes. Reason for Request - Safety Concerns; Positioning. IDT recommends side rails? Yes. Reason for request - Safety Concerns, Positioning. Do rails impede resident's freedom of movement? No. Do rails preclude resident's access to his / her body? No. Further review of R#53's clinical record did not reveal any safety assessments for the use of side rails. There was no consent in the clinical record for the use of side rails. On 8/22/18 at 9:57 a.m. an interview was conducted with Certified Nursing Assistant (CNA) AA on the locked dementia unit who worked with R#53. When asked what she used as a reference to determine the needs of the resident, CNA AA stated that she referred to the Nurse Aide's Information Sheet in the ADL (activities of daily living) area book. When asked if she was aware that R#53 had full length side rails up on her bed, CNA AA stated that she wasn't sure. When asked to review the Nurse Aide's Information Sheet CNA AA stated that the instruction was to use the upper rails at night. At this time CNA AA was asked to observe R#53 while she was in her bed, CNA AA confirmed that R#53 had bilateral, full length side rails in the up position. When asked if she was aware that R#53 had the wrong type of side rails per the Nurse Aide's Information Sheet, CNA AA stated that she hadn't even thought about it. An interview was conducted with Licensed Practical Nurse (LPN) BB on 8/22/18 at 10:15 a.m. on the locked dementia unit. When asked who had full length side rails on the unit LPN BB stated, No one, they are considered a restraint, we use the half rails. LPN BB was asked to observe R#53 while lying in her bed. LPN BB stated that she did not know why she had the rails in place. LPN BB further stated, I would say that she attempts to get up on her own, fall history. When asked if R#53 had the ability to get up out of bed unassisted, LPN BB stated, No. When asked again the purpose of the side rails, LPN BB stated that she would have to get back to this writer, she did not know. An interview was conducted with Registered Nurse (RN) CC, the Unit Manager, on 8/22/18 at 10:37 a.m. on the locked dementia unit. RN CC stated, For the most part side rails are to help with positioning / transferring. We try to get rid of the side rails and replace with bolsters and low beds. If they have side rails it is because 1) it is at the request of the resident/RP, or 2) they are used as an aid for positioning / transfers. We use half rails, we do not have any full rails. RN CC was asked to observe R#53 while lying in the bed. RN CC was asked what type of rails she had in place. RN CC stated that she had full rails. When asked why full rails were in place, RN CC stated, She used to crawl out of the bed but doesn't anymore, she used to walk but hasn't for a while, it has been maybe a year. RN CC further stated that R#53 had not tried to get out of the bed for at least a year. When asked the purpose of the side rails for R#53, RN CC stated, Good question. She doesn't try to get out of bed, I don't know why she has them up. I hadn't noticed them before, I usually see her when she is up and dressed. RN CC was unable to provide an assessment for the use of side rails or a consent. A review of the facility policy titled Restraint Use/Side Rails dated 11/28/16, revealed, in part, the following documentation: Standard. (Name of Facility) creates and maintains an environment that fosters minimal use of restraints. Physical restraints include side rails used to keep a resident from voluntarily getting out of bed as opposed to enhancing mobility in bed. Policy. The use of side rails as restraints is prohibited unless they are necessary to treat a resident's medical symptoms. The facility will employ other interventions in care planning to include but not limited to: Placing the bed at the lowest possible position. Residents are assessed on admission or re-admission, quarterly and if a significant change in condition for the need to utilize side rails. Bed rails will be inspected to ensure there is no risk to the resident. This is to be done by nursing staff. 3. R#89 was admitted to the facility on [DATE]; [DIAGNOSES REDACTED]. Review of the falls Care Area Trigger Worksheet dated 7/5/18 revealed the resident required extensive to total assistance with activities of daily living (ADLs). The resident was able to make his needs known. The Care Area Trigger Worksheet indicated the resident fell on [DATE] during an acute illness when he was hallucinating and was being treated for [REDACTED]. A Side Rail Consent form had been signed in (MONTH) (YEAR) by the responsible party. Review of (MONTH) (YEAR) Physician's Orders revealed there was no order for the use of [REDACTED] Review of the Side Rail Assessment Tool dated 7/8/18 revealed the resident utilized upper right and left side rails. The side rails were documented as always being used when the resident was in the bed. The Side Rail Assessment Tool revealed the bed rails were requested by the resident to assist with mobility, transfers, and for positioning. The Side Rail Assessment Tool did not include an evaluation of the fit of the mattress in relation to the bed rails to determine risk of entrapment had been conducted. There were no measurements for gaps between the bed rails and mattress, which could create an accident hazard. Even though the resident recently fell from the bed on 6/23/18 and sustained a fracture, there was no assessment of the safety of the bed rails as a potential hazard if the resident attempted to get out of bed with the rails up. Review of care plan dated 7/9/18 revealed the resident's cognition was impaired related to advanced aging, disease process, and [DIAGNOSES REDACTED]. Review of the care plan dated 7/9/18 revealed the resident recently fell and fractured his ankle due to being hypoxic (decreased oxygen level), hallucinating, and being treated for [REDACTED]. The care plan approaches to address the problem of falls included upper side rails for bed mobility and transfers and maintaining the resident's environment free of safety hazards. Observations revealed the side rails were up when the resident was in bed: -On 8/20/18 at 10:16 a.m. the resident was lying in bed watching television. The head of the bed was elevated; both the right and left side rails were up. The rails ran the length of the top half of the mattress. -On 8/20/18 at 12:13 p.m. the resident was lying in bed watching television. The head of the bed was elevated; both the right and left side rails were up. -On 8/21/18 at 10:52 p.m. the resident was lying in bed watching television. The head of the bed was elevated; both the right and left side rails were up. -On 8/23/18 10:39 a.m. the resident was lying in bed watching television. The head of the bed was elevated; both the right and left side rails were up. The gaps between the mattress and the bed rails was measured by the surveyor. There was a two-inch gap between the bed rail and the mattress on both sides. On 8/23/18 10:39 a.m. the resident was interviewed. He was lying in bed; both top side rails were up. The resident stated he wanted the bed rails and used them for repositioning. When asked about the fall on 6/23/18, he stated he fell out of bed and landed between the bed and the wall. The resident stated he did not remember the details and indicated he was very sick at the time the fall occurred. Certified Nurse Assistant (CNA) FF was interviewed on 8/22/18 10:23 a.m. in a vacant resident's room. CNA FF stated she responded to the resident's fall on 6/23/18. She stated the resident was ill at the time; she reported hearing him holler for help and she ran down to the room. CNA FF stated the resident was lying on the floor between the bed and the wall. She stated the bed rails were up when she found the resident on the floor. CNA FF indicated there had been no problems with the resident falling since this incident. Registered Nurse (RN) EE, who was also the North Unit manager, was interviewed on 8/23/18 at 10:18 a.m. at the North nurse's station. RN EE stated physician's orders were not obtained for side rail use. She stated side rail assessments were completed quarterly. When asked about the resident's fall on 6/23/18, she stated she had not heard that the bed rails were in the up position at the time of the fall. When asked if nursing staff measured the gaps between the mattresses and bed rails, she stated, We don't do the measurements of the bed rails. Licensed Practical Nurse (LPN) GG was interviewed on 8/23/18 at 10:23 a.m. at the North nurse's station. She stated she was working on the day the resident fell (6/23/18) and arrived shortly after the fall occurred. LPN GG stated the resident had been found between the bed and the wall and was on his knees on the floor when he was found. She stated she did not know if the bed rails were up when the fall occurred. LPN GG stated the resident had upper side rails that were to be up whenever he was in bed. The resident's Physician/Medical Director was interviewed on 8/23/18 at 2:05 p.m. in the surveyor conference room. The Medical Director stated he remembered the resident falling and sustaining an ankle fracture. He stated he did not know anything about the side rails in relation to the fall. He stated he did not know the specifics about measuring the gap between rails and the mattress or the facility's assessment process for side rail safety. The Medical Director verified he did not order bed rails; nursing staff implemented bed rails. The Director of Nursing (DON) was interviewed on 8/23/18 at 2:37 p.m. She stated she had not heard anything about the side rails in relation to the resident's fall on 6/23/18. The DON stated bed rails could be a safety hazard. The DON stated staff had been instructed to measure the gaps between the mattresses and bed rails; however, she was not sure who was doing it. She stated she would check with maintenance and nursing to determine who was doing the measurements. The DON did not provide information prior to the survey exit showing the gaps between the rails and mattresses were being measured.",2020-09-01
966,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2018-08-23,756,D,0,1,DVG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and review of the facility's policy, the facility failed to ensure one resident (R)#74 out of six residents reviewed for unnecessary medications had a documented response from the Physician regarding the Pharmacist's recommendation for a gradual dose reduction (GDR) of an antipsychotic medication. Findings include: Resident (R)#74 was admitted to the facility on [DATE] (per the undated Face Sheet). Review of the Nurse Practitioner's Periodic Visit note dated 7/10/18 indicated the resident's current diagnoses in full were: specified symptoms and signs involving digestive system and abdomen, cerebral infarction (stroke), [MEDICAL CONDITIONS], constipation, gastro-[MEDICAL CONDITION] reflux disease, anxiety disorder, and weakness. Review of the (MONTH) (YEAR) monthly physician's orders [REDACTED]. [MEDICATION NAME] was prescribed on 1/10/18 (upon admission), 25 mg tablet, half tablet by mouth at bedtime. No [DIAGNOSES REDACTED]. Behavior monitoring documented on the Medication Administration Records (MAR) was reviewed for the period from 6/1/18 - 8/22/18. The target behaviors nurses were to monitor and document per shift for the medication [MEDICATION NAME] were in full: 1) monitor for excessive talking, and 2) hallucinations/paranoia/delusions. The records showed no episodes of any behaviors having occurred during the period reviewed (all entries were zero). Review of all the Physician's and Nurse Practitioner's Notes from admission through the survey (1/10/18 - 8/22/18) revealed zero incidents of excessive talking, hallucinations, paranoia, and delusions. Review of the Note to Attending Physician dated 6/11/18 revealed the Pharmacist recommended gradual dose reductions of two medications due to There are 0 behaviors noted in the MAR (Medication Administration Record) in the month of (MONTH) or May. The Pharmacist recommended dose reduction for [MEDICATION NAME] (anti-anxiety medication also known as [MEDICATION NAME]) 25 mg every 12 hours administered since 1/31/18, and quetiapine (anti-psychotic medication also known as [MEDICATION NAME]) 12.5 mg administered since 1/10/18. A dose reduction of the [MEDICATION NAME] was initiated by the Physician, however, no dose reduction for the [MEDICATION NAME] was completed. The form indicated if a medication could not be reduced, the Physician was to check the appropriate rationale related to the gradual dose reduction being clinically contraindicated. The choices included 1) No changes. The resident' target symptoms returned or worsened after the most recent attempt at a GDR within the facility, 2) No Changes. An attempted dose reduction at this time would be likely to impair the resident's function or increase distressed behavior, or 3) Changes as follows: None of these boxes were checked and there was no narrative to indicate the rationale for not completing the recommended dose reduction for [MEDICATION NAME]. Under the heading of Physician/Prescriber Response, there were three choices with corresponding boxes for the Physician to check: 1) Agree, please write orders, 2) Disagree, Please document rationale to support your response to this recommendation, and 3) Other. This section of the form was blank; it had not been filled out by the Physician. In an interview on 8/23/18 at 11:42 a.m. on the telephone, the Pharmacist stated he recommended gradual dose reductions (GDR) for antipsychotic medications every quarter to the Physician. The Pharmacist stated if the Physician declined the dose reduction recommendation, he waited another quarter (next three-month period) before requesting it again. The Pharmacist stated he documented the reason for the GDR request, which was a lack of behaviors for R#74. The Pharmacist stated he had talked with the Physician about decreasing medication doses. The Pharmacist stated the Physician should check the pertinent box on the form or write an order for [REDACTED]. The Pharmacist stated the resident was due in (MONTH) for another recommendation to reduce [MEDICATION NAME]. An interview with the Director of Nursing (DON) was conducted on 8/23/18 at 2:17 p.m. in the DON's office. The DON reviewed the Note to Attending Physician dated 6/11/18 and verified no dose reduction had been initiated for the [MEDICATION NAME] and stated she did not see any documentation from the physician addressing the recommendation for a dose reduction. The DON stated the physician should check one of the boxes documenting a response regarding the pharmacist's recommendation. The DON stated the facility wanted to implement gradual dose reductions of antipsychotic medications. In an interview on 8/23/18 at 2:32 p.m. in the DON's office, RN EE stated the physician had missed the recommendation for the [MEDICATION NAME] and did not address it on the Note to Attending Physician dated 6/11/18. She stated the Physician addressed the first recommendation for a dose reduction for the medication [MEDICATION NAME] (anti-anxiety medication), but he had missed the second recommendation for [MEDICATION NAME]. The resident's Physician, who was also the Medical Director, was interviewed on 8/23/18 at 1:36 p.m. in the conference room. When asked about the Pharmacist's recommendation for the dose reduction of [MEDICATION NAME] dated 6/11/18, he stated he implemented a dose reduction for [MEDICATION NAME]; however, had not initiated a dose reduction of the [MEDICATION NAME]. When asked about the lack of documentation on the Note to Attending Physician form regarding the recommendation for the GDR of [MEDICATION NAME], he stated he usually checked on the form whether he agreed or not with the recommendation; however, had not done so in this case. The Medical Director stated he tried to attempt dose reductions every three months. Review of the facility's undated [MEDICAL CONDITION] Medication Policy and Procedure revealed in pertinent part Efforts to reduce dosage or discontinue of psychopharmacological medications will be on going, as appropriate for the clinical situation.",2020-09-01
967,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2018-08-23,758,D,0,1,DVG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to attempt a gradual dose reduction of an antipsychotic medication for two residents of 36 sampled residents. (Residents (R)#53 and R#74). The findings include: 1. R#53 was admitted to the facility on [DATE] with diagnoses that included, traumatic cerebral hemorrhage, aphagia (inability/refusal to swallow) and unspecified dementia with behavioral disturbance. Review of R#53's most recent Minimum Data Set (MDS), a comprehensive assessment with an Assessment Reference Date (ARD) of 6/6/18, assessed R#53 as having a cognitive score of three out of a possible 15, indicating that R#53 was severely cognitively impaired to make daily decisions. R#53 was also assessed as being without behaviors during the look back period. R#53 was also assessed as being totally dependent with all activities of daily living. Review of R#53's comprehensive care plan dated 6/7/18 revealed the following documentation; Cognition - Resident has impaired thought processes r/t (related to) dementia w (with)/behaviors. BIMS score of zero; long and short-term memory problems. APPROACHES: Observe/document any changes in cognitive status/behavior/ sleep pattern/appetite/infections - keep MD (Medical Doctor)/RP (Responsible Party) updated. Anticipate needs call Resident by name, introduce yourself and explain care/ procedures prior to beginning. Keep call light within easy reach. Meds (medications) / Labs (laboratory tests) as ordered by MD. Psychoactive Med use - at risk for adverse side effects r/t use of antidepressant and antipsychotics. No gradual reduction suggested at this time (5/7/18) as it would likely impair her function or increase her distressed behavior. APPROACHES: Document behavior/mood indicators in resident chart q (every) shift and prn (as needed). Report any change in mental status to MD. Give meds as ordered (see MAR (medication administration record)) / Evaluate effectiveness and side effects for possible decrease/elimination as condition/behavior warrants. MD/Pharmacist review per protocol. Review of R#53's physician orders revealed, in part, the following documentation; [MEDICATION NAME] 0.5 mg (milligram) take one tab (tablet) by mouth daily at bedtime. Date of order 8/4/17. Review of R#53's behavior monitoring records since (MONTH) (YEAR) revealed the following information: (MONTH) (YEAR) Behavior Code: Picks and Scratches: Occurred zero times out of 93 assessments (MONTH) (YEAR) Behavior Code: Strikes Out: Occurred one time out of 93 assessments (MONTH) (YEAR) Behavior Code: Refuses Care: Occurred six times out of 93 assessments (MONTH) (YEAR) Behavior Code: Physically Abusive: Occurred zero times out of 93 assessments (MONTH) (YEAR) Behavior Code: Strikes Out: Occurred zero times out of 93 assessments (MONTH) (YEAR) Behavior Code: Refusing Care: Occurred three times out of 93 assessments (MONTH) (YEAR). Behavior Code: Refuses Care: Occurred four times out of 93 assessments (MONTH) (YEAR) Behavior Code: Strikes Out: Occurred zero times out of 93 assessments (MONTH) (YEAR) Behavior Code: Refuses Care: Occurred zero times out of 66 assessments (MONTH) (YEAR) Behavior Code: Strikes Out: Occurred two times out of 66 assessments Review of R#53's pharmacy recommendations revealed the following recommendations for gradual dose reduction (GDR): * 12/7/17 - GDR for [MEDICATION NAME] 0.5 mg. MD checked the box: No changes. An attempted dose reduction at this time would be likely to impair the resident's function or increase distressed behavior. Signed by the physician on 12/18/17 and with the handwritten note: Other per (name of psychiatrist). * 5/7/18 - GDR for use of [MEDICATION NAME] 0.5 mg. MD checked the box: No changes. An attempted dose reduction at this time would be likely to impair the resident's function or increase distressed behavior. Signed by the physician on 5/17/18 and no explanation provided. Review of R#53's psychiatric notes revealed one note dated 8/14/17 with the following documentation: Referral Information / Chief Complaint: [AGE] year-old BFR (black female resident): hx (history) of significant/severe cognitive impairment with multiple medical problems seen for evaluation and management of symptoms r/t cognition and behaviors. History of Present Illness: She reports feeling better, eating, energized. She is barely audible at times, soft spoken, forgetful and dysphoric (being distressed) at times. Recommendations: Decrease Risperadol ([MEDICATION NAME]) to 0.5mg po (by mouth) qhs (at bedtime) to minimize (sentence not completed). Further review of R#53's clinical record did not reveal any other psychiatric notes or evidence that R#53 had followed up with the psychiatrist. A telephone interview was conducted with the Pharmacist on 8/24/18 at 11:45 a.m. The Pharmacist was asked to describe his process for requesting a GDR for antipsychotic medications. The Pharmacist stated that every quarter if an antipsychotic medication was new or changed that a recommendation would be provided to the physician for a GDR each quarter. If the medication was decreased and the change had an undesirable effect, then a GDR would not be requested for a year after that change. The physician, once provided the GDR, could decide whether he agreed / disagreed with the recommendation and would check the corresponding box. The physician is then able to document his reasoning at the bottom of the form and sign. When asked specifically about R#53 the Pharmacist stated that he had made several recommendations for GDRs and all were refused by the physician. When asked the reason for the refusal the Pharmacist stated that the MD indicated that R#53 was not eligible due to her behaviors of striking out and refusal of care. When asked if the Pharmacist reviewed the behavior monitoring documentation the Pharmacist stated that he did and documented the behavior occurrences on the GDR for the MD to review. The Pharmacist further stated, I have talked to the doctor about this resident and that we need to attempt to decrease her medications but he wants to leave her on the current doses. An interview was conducted on 8/23/18 at 01:35 p.m. with the Medical Doctor in the conference room. When asked about his process for GDRs the MD stated that the pharmacist provides a recommendation and then he either agrees or disagrees to the recommendations. When asked about R#53's GDR recommendations and why no GDRs had been attempted for [MEDICATION NAME] since (MONTH) (YEAR), the MD stated that she sees a psychiatrist and that he adjusts her medications. The MD reviewed R#53's GDRs at this time. When asked when R#53 had last seen the psychiatrist the MD stated he did not know but would call him to find out the information. At this time the MD was provided the behavior monitoring sheets and asked if R#53 was demonstrating enough behaviors to warrant the continued used of [MEDICATION NAME]. The MD stated he could not say why R#53 was still taking [MEDICATION NAME] as there was no evidence of continued behaviors. When asked why R#53 was placed on [MEDICATION NAME], the MD stated that she would strike out at nursing staff when they attempted ADL (activities of daily living) care and would refuse care. When asked if those were enough reasons to medicate a resident, the MD stated No. The MD requested time to review R#53's chart to determine when the psychiatrist had last seen her. On 8/23/18 at 2:51 p.m. the MD approached this writer in the hallway and stated that he had called the psychiatrist and he could not remember if he had been in to see her. The psychiatrist was not at a place where he could review his records and would not know for certain for a few more days. The MD stated that he didn't know if the psychiatrist saw R#53 after (MONTH) (YEAR). A review of the facility policy titled [MEDICAL CONDITION] Medication Policy and Procedure (undated) revealed, in part, the following documentation: It is the policy of this facility along with Physicians to sue (sic) [MEDICAL CONDITION] medications appropriately working with the interdisciplinary team to ensure appropriate use, evaluation and monitoring. Procedures: 1. The facility will make every effort to comply with state and federal regulations related to the use of psychopharmacological medications in the facility to include regular review for continued need, appropriate dosage, side effects, risks and / or benefits. 2. The facility supports the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED]. 3. Efforts to reduce dosage or discontinue of psychopharmacological medications will be on going (sic), as appropriate for the clinical situation. 9. Consulting Pharmacist will monitor [MEDICAL CONDITION] drug use in the facility to ensure that medications are not used in excessive doses or for excessive duration. 10. Consulting Pharmacist notifies the physician and the nursing unit if whenever a [MEDICAL CONDITION] medication is past due for review. 11. Medical Director and / or Psychiatrist will monitor the overall use of these medications in the facility and will report to the Nursing staff changes. 12. Interdisciplinary will QAPI (Quality Assurance and Performance Improvement) the usage of psychoactive. (sic). 2. R#74 was admitted to the facility on [DATE] (per the undated Face Sheet). Review of the Nurse Practitioner's Periodic Visit note dated 7/10/18 indicated the resident's current diagnoses in full were: specified symptoms and signs involving digestive system and abdomen, cerebral infarction (stroke), [MEDICAL CONDITIONS], constipation, gastro-[MEDICAL CONDITION] reflux disease, anxiety disorder, and weakness. The resident had been living at home prior to suffering a stroke and was admitted to the facility after hospitalization for the stroke (per the 4/4/18 care plan). The resident was on hospice when she was admitted to the facility due to failure to thrive and the need for nutrition via a feeding tube (per the 1/28/18 care plan). The resident's condition improved, she no longer received tube feeding; hospice was discontinued on 3/19/18 based on review of Medicaid Payor information. Review of the (MONTH) (YEAR) monthly Physician's Orders revealed the resident was prescribed [MEDICATION NAME], an antipsychotic medication. [MEDICATION NAME] was prescribed on 1/10/18 (upon admission), 25 mg tablet, half tablet by mouth at bedtime. No [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed, under the section for Preadmission Screening and Resident Review (PASRR), the resident did not have a serious mental illness. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was unimpaired in cognition with a Brief Interview for Mental Status (BIMS) score of 14 out of a total of 15 (score of 13 - 15 indicates cognition is intact). The resident was documented as taking an antipsychotic medication all seven days of the assessment period. The Mood section revealed the resident exhibited no mood concerns. The Behavior section revealed the resident exhibited no behavioral concerns. Under the Goal Setting section, the resident was identified as wanting to talk to someone about discharge into the community. Review of the CAT (Care Area Trigger) Worksheet for behavioral symptoms dated 4/1/18 read, Resident is alert and responsive. She had [MEDICAL CONDITION](stroke) with left [MEDICAL CONDITION] (paralysis of one side of the body) .She was living at home prior [MEDICAL CONDITION] her son and was ambulatory and cooking She wants to be independent and is frustrated over being dependent . resident on [MEDICATION NAME] d/t (due/to) anxiety and behaviors in the hospital. She has been having behaviors since admission. Cursing out loud, combative with staff, crying, delusions. Review of the CAT (Care Area Trigger) Worksheet for [MEDICAL CONDITION] drug use dated 4/1/18 read, Resident is on [MEDICATION NAME] d/t anxiety and behaviors in the hospital. She has been having behaviors since admission. Cursing out loud, combative with staff, crying, delusuions (sic) 4/1/18 No behaviors noted this last month. She remains on [MEDICATION NAME] at night. Will proceed to care plan. The Quarterly MDS dated [DATE] showed no mood concerns and no behavior concerns. The resident was documented as taking an antipsychotic medication all seven days of the assessment period. Review of the resident's care plan for Multiple falls initiated on 1/26/18 indicated, She is on [MEDICATION NAME] d/t (due to) behaviors of screaming, cursing and combativeness, and cursing. Approaches included, Observe resident for adverse side effects/toxicity of medication. Lethargy, change in mental status. Contact physician with abnormal findings. The care plan for [MEDICATION NAME] and is at risk of side effects initiated on 1/26/18 indicated the goal was no adverse side effects or injuries by next review. Approaches included: document behavior/mood indicators in resident's chart, decrease/elimination of the medication as the resident's condition and behavior warranted per Physician and Pharmacist's protocol, and documenting behaviors and side effects every shift. Review of the resident's behavior monitoring records, documented on the Medication Administration Records (MAR), from 6/1/18 - 8/22/18 were reviewed. The target behaviors nurses were to monitor and document per shift were: 1) monitor for excessive talking, and 2) hallucinations/paranoia/delusions. The records showed all zeros indicating no episodes had occurred for the period reviewed. However, on 8/21/18 at 10:00 p.m. on the second page of the MAR the following was documented excessive talking, Intervention 13. Medication (should not be first intervention). This was the only written comment regarding the target behaviors or evidence of any behaviors. There was no documentation in the nursing notes on 8/21/18 to provide additional information regarding the incident of excessive talking. Review of all the Physician's and Nurse Practitioner's notes from admission through the survey (1/10/18 - 8/22/18) revealed zero incidents of crying, delusions, paranoia, combativeness, hallucinations, screaming, excessive talking, and/or cursing: -Review of the History and Physical dated 1/11/18 revealed under the heading of Psychosocial the resident was alert, oriented and was not exhibiting behavior problems or emotional distress. There were no psychosocial diagnoses listed. -Review of the Physician's Periodic Visit note dated 1/18/18 revealed the only mood/behavior and/or mental illness related [DIAGNOSES REDACTED]. - Review of the Physician's Periodic Visit note dated 2/22/18 revealed the only mood/behavior and/or mental illness related [DIAGNOSES REDACTED]. -Review of the Nurse Practitioner's Periodic Visit note dated 3/24/18 revealed the only mood/behavior and/or mental illness related [DIAGNOSES REDACTED]. -Review of the Physician's Periodic Visit note dated 4/12/18 revealed the only mood/behavior and/or mental illness related [DIAGNOSES REDACTED]. Reporting resident's desire to go home with son. -Review of the Physician's Periodic Visit note dated 4/26/18 revealed the only mood/behavior and/or mental illness related [DIAGNOSES REDACTED]. - Review of the Physician's Periodic Visit note dated 5/10/18 revealed the only mood/behavior and/or mental illness related [DIAGNOSES REDACTED]. - Review of the Nurse Practitioner's Periodic Visit note dated 6/19/18 revealed the only mood/behavior and/or mental illness related [DIAGNOSES REDACTED]. -Review of the Nurse Practitioner's Periodic Visit note dated 7/10/18 revealed the only mood/behavior and/or mental illness related [DIAGNOSES REDACTED]. Review of Nurse Progress Notes from 4/26/18 - 8/22/18 revealed an absence of episodes of crying, delusions, paranoia, combativeness, hallucinations, screaming, excessive talking, and/or cursing. Review of Social Service Progress Notes from (MONTH) (YEAR) - 8/22/18 revealed the only documented behavior and/or mood issues were related to the resident's desire to discharge from the facility to go home or to get an apartment as follows: -6/27/18, reportedly does have days that she crys (sic) when she talks to her sons about going home and she finds out that the time isn't yet. A meeting will be held eventually with she and her family to plan her d/c (discharge). -8/17/18, The topic of (resident's name) staying with one of the children came up and each child stated why this is not possible. The discussion lingered until (resident's name) stormed out of meeting cursing and crying. She expressed that she's tired of being in the NH (nursing home) and she feels like her children would've been working on her apartment arrangement since she's been in the NH (nursing home). SSD (Social Service Director) reassured (resident's name) that her plan to d/c (discharge) to her own apartment in the community is still a possibility SSD reiterated the plan to apply for apartment on her behalf . Review of the Note to Attending Physician dated 6/11/18 revealed the Pharmacist recommended gradual dose reductions of two medications: [MEDICATION NAME] (anti-anxiety also known as [MEDICATION NAME]) 25 mg every 12 hours administered since 1/31/18, and quetiapine (anti-psychotic also known as [MEDICATION NAME]) 12.5 mg administered since 1/10/18. A dose reduction of the [MEDICATION NAME] was initiated but no dose reduction for the [MEDICATION NAME] was initiated. The resident did not exhibit any mood or behavioral concerns during survey observations: -On 8/20/18 at 3:22 p.m. a family member was visiting the resident in her room. She was sitting in a wheelchair speaking softly to the family member. -On 8/21/18 at 8:50 a.m. the resident was in her room. She got up from the wheelchair and walked towards the bed and then sat down. -On 8/22/18 at 9:49 a.m. the resident was sitting in the wheelchair in her room looking out the window. -On 8/22/18 at 10:18 a.m., the resident was sitting in her wheelchair, holding a cell phone, facing the window. -On 08/23/18 at 10:52 a.m. the resident was sitting in her wheelchair facing the window. In an interview on 8/22/18 at 9:49 a.m. in the resident's room, R#74 stated she was not sure what medications she was prescribed. She stated she had a history of [REDACTED]. The resident stated her condition had improved significantly since she suffered her stroke and she could now walk and was again independent with her own care. The resident stated her only concern related to the delay in her discharge from the facility. In an interview on 8/21/18 at 9:42 a.m. at the North Nurse's station, Registered Nurse (RN) EE stated the resident was on hospice when she was admitted to the facility and the [MEDICATION NAME] was initiated by hospice. When asked if the resident had seen the Psychiatrist, or if she had been evaluated for mental illness under the PASRR Level II, she stated the resident had not been seen by a Psychiatrist, no PASRR level II had been completed and the resident was not exhibiting any behaviors. In an interview on 8/22/18 at 10:20 a.m., Certified Nurse Assistant (CNA) FF in a vacant resident room stated she had not seen and was not aware of the resident exhibiting any mood or behavioral issues. She stated the resident needed little staff assistance with activities of daily living and primarily kept to herself. In an interview on 8/22/18 at 11:15 a.m. in the social work office, the Bachelor of Social Work (BSW) stated she was not aware of any behaviors having been exhibited by the resident. The BSW stated initially the resident was not in good shape due to the effects of the stroke when she was admitted to the facility; however, she was now doing much better. The BSW stated she was not aware of any delusions, hallucinations, paranoia, screaming, cursing, or combative behavior on the part of the resident. She stated the resident was quiet and might be experiencing depression related to her situation of being in the facility when she desired discharge to the community. In an interview on 8/23/18 at 11:42 a.m. on the telephone, the Pharmacist stated he generally recommended gradual dose reductions (GDR) for antipsychotic medications every quarter to the Physician. The Pharmacist stated he had talked with the Physician about decreasing medication doses. The Pharmacist stated he documented the reason for the GDR request on 6/11/18, which was a lack of behaviors to support use of the antipsychotic medication for R#74. The Pharmacist stated there were no changes documented by the Physician on the Note to Attending Physician form dated 6/11/18 and verified a dose reduction had not been attempted or initiated following the resident's admission to the facility. When asked about the resident's only mood/behavior [DIAGNOSES REDACTED]. The resident's Physician, who was also the Medical director, was interviewed on 8/23/18 at 1:36 p.m. in the conference room. When asked about the behaviors being monitored on the Medication Administration Records, he stated there should be some documentation of the target behaviors to support the use of the [MEDICATION NAME]. When asked about excessive talking being monitored for [MEDICATION NAME], he stated the target behavior might have come from the hospital. When asked about the resident exhibiting delusions, hallucinations, and/or paranoia, he stated he was not aware of any concerns with delusions, hallucinations or paranoia. When asked what the associated [DIAGNOSES REDACTED]. The Medical Director stated the resident was admitted to the facility from the hospital on [MEDICATION NAME]. The Physician stated he did not initiate a dose reduction for the [MEDICATION NAME] because he had initiated a dose reduction for [MEDICATION NAME] and did not want to make more than one psychoactive medication change at a time. Interview with the Director of Nursing (DON) and Registered Nurse (RN) EE was conducted on 8/23/18 at 2:17 p.m. the DON's office. When asked what kind of behaviors the resident exhibited, the DON stated, I would have to pull the chart to tell you about her behaviors. RN EE stated the resident was admitted to the facility from the hospital with the prescription for [MEDICATION NAME]. RN EE stated the resident was on hospice when she was admitted to the facility following a stroke. RN EE stated the resident exhibited behaviors in the hospital and some behaviors initially when she came into the facility. RN EE stated the resident's behaviors improved and she had not exhibited any behaviors since shortly after admission. When asked what the resident's [DIAGNOSES REDACTED]. When asked about the resident exhibiting delusions, hallucinations, or yelling, RN EE stated she was not aware of the resident exhibiting any of these. The DON stated, after reviewing the resident's record, the resident's documented [DIAGNOSES REDACTED]. Review of the facility's undated [MEDICAL CONDITION] Medication Policy and Procedure revealed in pertinent part the facility supported the goal of determining the underlying cause of behavioral symptoms so the appropriate treatment of [REDACTED]. Efforts to reduce dosage or discontinue of psychopharmacological medications will be on going, as appropriate for the clinical situation . Nursing will monitor for the presence of target behaviors on a daily basis . Medical Director and/or Psychiatrist will monitor the overall use of these medications in the facility and will report to the Nursing staff changes.",2020-09-01
968,MUSCOGEE MANOR & REHABILITATION CTR,115351,7150 MANOR ROAD,COLUMBUS,GA,31906,2018-08-23,761,D,0,1,DVG411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to ensure that drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for one of five medication storage rooms. Findings include: On 8/22/18 at approximately 9:55 a.m., an inspection of the medication storage room on the[NAME]Wing was conducted with Licensed Practice Nurse (LPN) II. While inspecting the contents of the medication refrigerator, three boxes (containing 21 vials) labeled as Influenza Vaccine [MEDICATION NAME] Quadrivalent, Lot number 7754T with an expiration date of 6/30/18 were found. In an interview on 8/22/18 at 3:37 p.m. in the Nurse Manager office, LPN JJ said that all nurses are supposed to check for expired medications. LPN JJ said her night shift nurses have been the main ones that check the medications. The night nurse gives her a list of the expired medications. All expired medications are pulled out and their name are placed on the expired medication list. The expired medications list is checked and signed off with the Assistant Director of Nursing (ADON). The medication is then placed in a bin that is locked and placed in the medication room for pharmacy to pick up. The facility was unable to provide any expired medication lists that had been checked and signed by LPN JJ and the ADON. On 8/22/18 at 3:48 p.m. an interview was conducted with the Director of Nursing (DON) in her office. The DON said the nurses should have seen the expired date and turned it in to the ADON to handle the expired medications.",2020-09-01
969,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-02-13,656,D,1,0,590W11,"> Based on observation, interview and record review, the facility failed to provide assistance with bathing and personal hygiene needs as care planned, for one resident (A), from a total sample of eight residents. Findings include: Record review revealed that resident (R) A had a care plan that included a bathing schedule. The bathing schedule specified the Certified Nursing Assistant (CNA) on the evening shift was to provide the resident with a bath every Monday, Wednesday and Friday. During observations on 2/11/19 at 12:08 p.m., 12:55 p.m. and 2:45 p.m. and again on 2/12/19 at 1:40 p.m., the resident was observed to have oily, unwashed, uncombed hair and several days growth of facial hair. During interviews on 2/12/19 at 4:10 p.m. and 4:42 p.m. the Director of Nursing (DON) stated that the resident was scheduled to receive a bath on Monday, 2/11/19. However, his name was mistakenly omitted from the daily assignment sheet when Licensed Practical Nurse (LPN) AA revised it, therefore he did not receive a bath as scheduled. She stated that it would have been the responsibility of the CNA to wash the resident's hair and shave him during the bath. Cross refer to F677",2020-09-01
970,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-02-13,677,D,1,0,590W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview and record review, the facility failed to provide assistance with bathing and personal hygiene needs for one resident (R A) from a total sample of eight residents. Findings include: Resident (R) A was assessed on the 1/26/19 Minimum Data Set (MDS) assessment as being provided with extensive assistance with personal hygiene and being dependent on nursing staff for bathing. The care plan included a bathing schedule. The bathing schedule specified the Certified Nursing Assistant (CNA) on the evening shift was to provide the resident with a bath every Monday, Wednesday and Friday. RA was recently hospitalized from [DATE] through 2/5/19. A review of the clinical record, including the Bath Roster and Skin Observation forms revealed that since returning from the hospital on [DATE] (a Tuesday), the Resident's bath schedule had not been followed. The forms documented that the resident had received one bath, on 2/7/19 (a Thursday). The Bath Roster form also documented that the resident refused a bath on 2/9/19 (a Saturday). There was no evidence that the resident received a bath as scheduled on 2/11/19 (a Monday). During observations on 2/11/19 at 12:08 p.m., 12:55 p.m. and 2:45 p.m. and again on 2/12/19 at 1:40 p.m., the resident was observed to have oily, unwashed, uncombed hair and several days growth of facial hair. During the observations on 2/11/19 at 12:55 p.m. and 2/12/19 at 1:40 p.m., R A stated he preferred to be clean shaven. During interviews on 2/12/19 at 4:10 p.m. and 4:42 p.m. the Director of Nursing (DON) stated that the resident was scheduled to receive a bath on Monday, 2/11/19. However, his name was mistakenly omitted from the daily assignment sheet when Licensed Practical Nurse AA revised it, therefore he did not receive a bath as scheduled from CNA BB on 2/11/19. LPN AA and CNA BB confirmed via written statements on 2/12/19, that RA had not received a bath on 2/11/19 as scheduled. The DON stated that it would have been the responsibility of the CNA to wash the resident's hair and shave him during the bath.",2020-09-01
971,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2018-05-24,578,D,0,1,1EU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to inform and provide written information needed to formulate an Advance Directive and failed to identify the code status for one of 36 sampled residents, Resident (R) #67. It was determined that R#67 had signed a Do Not Resuscitate directive at the time of admission on [DATE] and this information was not provided to the nursing staff who believed that R#67 was had a full code status. The findings include: R#67 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility Face Sheet for R#67 documented that her niece was her responsible party. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview of Mental Status (BIMS) of 14, indicating the resident was cognitively intact. Review of Section J revealed the resident was assessed as not having a condition or chronic disease that would result in a life expectancy of less than six months. A review of R#67's clinical record did not reveal any documentation that the resident was provided information regarding an Advance Directive and there was no information that provided the resident's code status. A review of the resident's comprehensive care plan, with onset [DATE], revealed no documentation regarding the resident's code status. A review of R#67's nursing notes did not reveal any information regarding code status. Further review of R#67's clinical record did not reveal any information about her code status documented by the physician An interview on [DATE] at 10:55 a.m. with Licensed Practical Nurse (LPN) AA, in the nursing station, when asked to describe what she would do if a resident's code status was not on the chart revealed that the nursing staff would automatically code the resident. She further revealed when asked how she knew a resident's code status that it would be identified on the chart, usually in the very front of the chart. The LPN AA was asked if she knew R#67's code status and she replied the resident was a full code. LPN AA was asked to review R#67's chart and provide information regarding R#67's code status. LPN AA reviewed R #67's chart and stated that there was no information in her chart about her code status therefore she didn't know the resident's code status. An interview on [DATE] at 11:02 a.m. with R#67 in her room, when asked if she knew what her code status, revealed, I don't want to be bothered if that happens. When asked if she knew what she had told the facility about her code status choice, R#67 stated, I don't know. R#67 was asked what she wanted staff to do in the occurrence of code, R#67 stated that she did not know. R#67 was asked if anyone in the facility had talked to her about her code status, R#67 stated that they had not. An interview on [DATE] at 11:16 a.m. with the Administrator, the Licensed Social Worker and the Admissions Director revealed that the Admissions Director stated that the admissions staff were responsible for determining the code status at the time of admission to the facility and then the Licensed Social worker (LSW) stated that she would be responsible. The staff present were asked if a code status was determined for R#67 at the time of admission. The Admissions Director stated that if it was then it would be on the chart. The staff were made aware that the code status was not identified on R#67's chart. The Administrator revealed that the current LSW had been in the facility for only three days and the Admissions Director was not in this position at the time of the resident's admission. The Administrator stated that they would continue to look for information relating to R#67's code status. Observation and interview on [DATE] at 12:00 p.m. with the Admissions Director who provided a Georgia Consent for Do Not Resuscitate Order (DNR) Or No Cardiopulmonary Resuscitation (No Code) (Competent Resident) form that documented the following: I (name of R #67), hereby request that no cardiopulmonary resuscitation (CPR) be used to keep me alive in the event of a cardiac or respiratory arrest. I have discussed my condition and CPR with my attending physician. I understand NO CARDIOPULMONARY RESUSCITATION means that no measures will be used to restore or support cardiac or respiratory function in the event of a cardiac or respiratory arrest. I (the physician) have discussed the condition (s) of the resident with the resident and verify that the resident in my opinion has decision-making capacity in order to make the above decision. The document was signed by R #67 and the physician on [DATE]. When asked where this document was found, the Admissions Director stated that it was found in the old social worker's paperwork. The Admissions Director was asked if the staff were aware of R #67's DNR status which revealed that the staff were not aware, it was not on any paper work in the resident's clinical record. A telephone interview on [DATE] at 9:41 a.m. with R#67's attending Medical Doctor (MD). The MD was asked if she could recall when R#67 was admitted . The MD stated that she couldn't really remember, she had reviewed the resident's chart on [DATE] but could not find any notes for the admission date of [DATE]. The MD further stated, I have a note for [DATE] but don't remember anything prior to that date. The signed DNR was verbally reviewed with the MD and the date signed by R#67 and the MD was verified as [DATE]. When asked if she remembered a conversation with R#67 regarding her code status and the MD stated that she really did not. When asked if R#67 was competent to decide regarding her code status the MD stated that if the resident had signed the document and she had signed the document then she felt that the resident understood the conversation about her code status, thus was competent. A review of the facility policy titled Residents' Rights Regarding Treatment and Advance Directives dated ,[DATE] revealed, in part, the following documentation: Policy: It is the resident's right to formulate an Advance Directive, and to accept or refuse medical or surgical treatment. Policy Explanation and Compliance Guidelines: 1. On admission, the facility will determine if the resident has executed an Advance Directive and if not, determine whether the resident would like to formulate an Advance Directive. A review of the facility policy titled Emergency Procedure - Cardiopulmonary Resuscitation (not dated) revealed, in part, the following documentation: Policy Statement: Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS) including defibrillation for victims of sudden [MEDICAL CONDITION]. General Guidelines: 6. If an individual (resident, visitor, or staff member) is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR unless: a. It is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR and/ or external defibrillation exists for that individual; or b. There are obvious signs of irreversible death. 7. If the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or a physician's order not to administer CPR.",2020-09-01
972,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,166,D,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and family interview, review of the Resident and Family Grievances policy dated 11/24/16, and record review the facility failed to respond to a verbal grievance of loss of personal property for one Resident (R) #24) of 11 grievances reviewed. Findings include: Resident (R) #24 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/18/17 of R#24 showed a Brief Interview of Mental Status (BIMS) of 11. (However, on 6/30/17 at 9:00 a.m. a Brief Interview of Mental Status (BIMS) was completed by a surveyor with a Social Services background with another surveyor present, the resident was able to answer/recall all but 1 item and scored a 14. R#24 did say she was not completely awake when the surveyors met with her and asked the BIMS questions.) During an interview on 6/26/17 at 5:10 p.m. R#24 stated she had some jewelry, necklaces and bracelets, she buys for presents was missing. She stated she had notified the facility but had not heard back from them. During a second interview on 6/30/17 R#24 stated the jewelry, had been missing since 2014. During an interview on 6/28/17 CNA OOO stated if a resident tells me there is something missing I would tell my charge nurse, if it is something of value the nurse will lock it up for the resident. During an interview on 6/28/17 at 9:35 a.m. LPN JJ, stated Social Services (SS) would be notified if a resident if a resident has jewelry or something valuable. On 6/28/17 at 9:42 a.m. the Administrator was interviewed regarding missing resident property. The administrator stated the facility has a procedure for missing property and SS would be notified. Nursing staff will then do a thorough search of the room, laundry would be notified. If the item cannot be located and is determined to be missing the family will be notified. The police would be notified if there is a valid concern. If the item cannot be located the facility will reimburse the resident. The administrator stated she was not aware of any missing jewelry for R#24. A policy was requested for grievances for R24. On 6/28/17 at 10:41 a.m. Social Services Director (SSD) was interviewed and was not aware of any missing jewelry for R#24. On 6/28/17 at 10:50 a.m. the Administrator stated she had found some notes regarding R24 and some missing laundry and socks. On 6/28/17 at 2:52 p.m. the resident family member stated she was not aware of any necklaces or bracelets missing from her mother, however, she stated her mother was missing a diamond engagement ring since (MONTH) of (YEAR). She stated she had notified the Administrator (and identified her by her name) but had not heard back from the facility. The daughter stated she felt the ring was worth approximately $5,000. The daughter stated she knows her mother does some shopping from the television for jewelry because she gets the credit card bills to pay. Review of the Grievance Log for (MONTH) (YEAR) through (MONTH) (YEAR) did not show a grievance for a missing diamond ring. Review of the Departmental Notes from (MONTH) (YEAR) through (MONTH) (YEAR) did not reflect documentation of missing jewelry or diamond ring for R#24. Review of Departmental Notes 6/28/17 by SSD showed I conducted an interview with resident in regards to missing jewelry and resident indicated jewelry was missing since (MONTH) 2014. 6/28/17 SSD contacted daughter and left a voicemail. Daughter returned call stating Um, I know she lost her wedding ring worth at least $5,000 and it has been missing for the last 6 months. And nobody has contacted me about that and I am very concerned. On 06/29/2017 at 10:10 a.m. during an interview the Administrator stated she had not been notified about a missing ring for R#24 but would open an investigation. The Administrator stated the daughter had not told her anything about a missing ring. Review of the Resident and Family Grievances policy dated 11/24/16 showed: . 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. 10. Procedure: a. The staff member receiving the grievance will record the nature of the grievance on a designated grievance form or assist the resident or family member to complete the forms. c. The Grievance Official will take steps to resolve the grievance, and record information about the grievance and those actions, on the grievance form. i. Steps to resolve the grievance may involve forwarding the grievance to the appropriate department manager for follow up. d. The Grievance Official, or designee, will keep the resident appropriately apprised of progress towards resolution of the grievance f. The Grievance Official will issue a written decision on the grievance to the resident or representative at the conclusion of the investigation. The written decision will include at a minimum: i. The date the grievance was received. ii. The steps taken to investigate the grievance. Iii. A summary of the pertinent findings or conclusions regarding the residents' concerns. iv. A statement as to whether the grievance was confirmed or not confirmed. v. Any corrective action taken or to be taken by the facility as a result of the grievance. vi. The date the written decision was issued.",2020-09-01
973,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,223,J,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy titled Facility Abuse Policy, most recently revised on 11/24/16, record review, resident and staff interviews, and observations, the facility failed to ensure four Residents (R) #62, R#105, R#110, and R#170) were free from abuse to include resident to resident abuse and staff abuse of a resident. The sample size was 42 residents. On 6/30/17, 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. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: The Facility Abuse Policy, most recently revised on 11/24/16 read, in pertinent part, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. 1. R#105 was admitted to the facility, per the Face Sheet, on 7/29/15 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), an annual comprehensive assessment of overall health status dated 6/1/17 indicated R#105 was cognitively intact (Score 15/15 on the Brief Interview for Mental Status, (BIM)), and required limited to extensive assistance from staff to compete all of his Activities of Daily Living (ADLs). R#105's Interdisciplinary Notes were reviewed in their entirety from (MONTH) (YEAR) through (MONTH) (YEAR) and indicated that there was not any evidence that the resident had any behaviors. Record review revealed a Departmental Note for R#105, dated 7/9/16, documented by RN BB documented in pertinent part, Resident (R#105) reported that (R#14) was sexually harassing him. Resident stated she hit him in his private, but I was standing in office door and she was noted touching the collar of his shirt in the hall. Upon questioning him he said the incident when he was hit in his private was last week and that he reported it to the lady in the front and would follow up with her on Monday. I (meaning RN BB) spoke with the DON (Director of Nursing) and Administrator. Record review revealed a Departmental Note for R#105, dated 1/19/17 that documents, in pertinent part, Resident (R#105) reported that (R#14) came into his room without permission while he was finishing breakfast. He stated he asked her to get out; however, (R#14) proceeded to roll forward. Once she was within reach of the resident she touched/grabbed him in his private area. (R#105) reported incident to writer (LPN DDD). During an interview with R#105 on 6/29/17 at 6:10 p.m., he was asked if he had any concerns with any other resident in the facility and he stated, I have concerns with (R#14). She put me in the hospital. She can't keep her hands off no man or woman in here. She came up beside me and hit me and bruised my right testicle. My testicle is swollen up big now, and I have to go back to the doctor again. I have a bad bruise and I may have to have surgery. I went to the doctor's office (urologist) after the doctor here got me an appointment. She (R#14) was just over here (near R#105's room) a few minutes ago and she comes in my room. If you are asleep she'll run her hand down your britches and play with you. It happens during the day. She'll fondle me in my (wheel) chair. I went to Administrator the other day (R#105 showed a notebook where he had documented the referred to the meeting with the Administrator on 5/25/17), and talked to her and told her I want to keep (R#14) away from me and that she keeps coming in my room. The Administrator told me she was going to move me to another home. I don't feel safe in my own home .and they want throw me out of here. I like it here. My family is close by and my girlfriend is here. R#105 verbalized that he had reported R#14's behaviors towards him multiple times, however he was unable to recall specific names and dates of the reports. R#105 was observed to be upset during the interview, and indicated that he was distressed due to the lack of follow up regarding his complaints of sexual abuse. Record review revealed Ultrasound Results, dated 9/6/16 documents, in pertinent part, Impression: 6 x 3 x 6 cm (centimeter) fluid collection in the right hemi scrotum. Differential consideration includes a hematoma and complicated epidydimal cyst. Record review revealed an Ultrasound Results report dated 12/26/16 documents, in pertinent part, Impression: 6.4 x 4.6 x 3.6 cm echogenic fluid collection superior to the right testes, probably a hematoma, slightly smaller than the prior. A complicated epidydimal cyst is less likely. Abscess is less likely. Record review revealed a Follow-Up Urology Consult Notes, dated 1/10/17 documents, in pertinent part, The patient seen today to go over recent ultrasound to evaluate scrotal mass. It was initially thought to possibly be hydrocele, however the current reading mentions a possible hematoma. It is getting smaller with time. The patient now seems to remember having trauma to the scrotum at the time of initial growth of the fluid collection. Record review, for R#14 the alleged abuser, revealed that the resident was admitted to the facility on [DATE], according to the Face Sheet printed on 6/29/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) for R#14 was a quarterly assessment of overall health status dated 5/3/17 indicated R#14 was cognitively impaired per Brief Interview for Mental Status (BIMS score 5/15). During an interview, conducted with Licensed Practical Nurse (LPN) AAA on 6/29/17 at 5:55 p.m., she was asked if she was aware of any concerns related to resident abuse or behavior. She stated, I am aware that R#14 touches peoples' privates, and that R#105 has a big issue with her. He has reported this to the Administrator several times. She (R#14) comes in his room at night and she'll touch his privates. He told me directly that he reported it to the Administrator. There have been multiple incidents. The last incident I am aware of is within the last two weeks. R#14 will walk up to R#105 and hit him in the head, hit his leg, grab him in the privates. He has made it clear to everyone that he doesn't like it. He has threatened to leave and everything. During an interview with LPN CCC on 6/29/17 at 6:00 p.m., she stated, she was R#14's nurse for a little while. She likes to touch you in private places. She'll rub your butt when you walk by. I just know that she will take and rub my butt when she passes by. I'm not aware of any complaints from residents about her doing that, just staff. During an interview with Registered Nurse (RN) DD on 6/29/17 at 6:40 p.m., she stated that R#14 wanders over here, the unit R#105 lives, sometimes. R#105 hasn't told me that R#14 touches him inappropriately, but I do know that R#14 touches people like that. She will go by and touch me on the butt. During an interview with Certified Nursing Assistant (CNA) ZZ on 6/30/17 at 9:05 a.m., she stated, R#14 rolls over here on this side where R#105 lives and then she goes in other people's rooms, and some residents might turn the light on to get her out. I hear them (staff and residents) say she rubs on people or pets on them. During an interview with CNA TT on 6/30/17 at 9:10 a.m., she stated, R#14 likes to touch you. If I'm taking care of her she might reach at my breast or pat my hand. Sometimes she will touch other residents like she does us. Its male or female, she doesn't have a preference. I've reported this to the Weekend Supervisor (LPN SS) and the Unit Manager (UM UU). During an interview with the UM LPN UU on 6/30/17 at 8:50 a.m., she stated, I know that R#14 likes to rub on us while we are giving her care. She'll rub on our arms, pat our hand, and kiss our hand. UM LPN UU stated she had not received any reports from staff that R#14 had been inappropriate with other residents. She stated, She has patted me on the butt and kept going. I didn't take it as sexual. I took it as she was hitting me and moving on. During an interview with the former Director of Nursing (DON) on 6/30/17 at 1:15 p.m., she stated she was present during a conversation between R#105 and a male physician. During this conversation R#105 told the physician that he had been hit in his scrotum/testicles by R#14. She stated an appointment was made after that for R#105 to see an Urologist. The former DON stated she did not make out an incident report or do an investigation of R#105's allegation of being hit in the testicles due to the fact that she thought R#105 and his physician were having a Man to Man talk. She stated, (R#14) is touchy feely and likes to be affectionate with everyone. During an interview with R#105's physician on 6/30/17 at 2:05 p.m., he stated, I sent him (R#105) to see the Urologist because he had hydroceles. I don't remember having a conversation with (R#105) him about being hit. The physician stated he had never received the urology or ultrasound reports from the Urologist indicating R#105's injury to his testicles was a hematoma likely caused by trauma. He stated he would follow up with R#105 as soon as possible. During an interview with the Administrator on 6/29/17 at 6:45 p.m., she stated, R#14 is elderly and pleasantly confused. Here recently, in the last two to three months, she has rebounded from a bed bound position and wanders about the facility. She taps on people. It has been reported that she wanders into resident's rooms. It has been reported that she touches people on the leg or arm. (R#105) complained about her several weeks ago, about coming down the hallway and opening the door to his room. He took his foot to the door and closed her out with his foot. The Administrator stated she had no knowledge of R#14 hitting R#105 in his testicle and had no reports of R#14 groping other residents inappropriately. She stated no investigations had been done and nothing had been reported to the state. She stated, I was aware of tapping .but nothing sexual. Observations were made by the surveyor and the Director of Nursing (DON) of R#105's genitalia with his permission on 6/30/17 at 11:20 a.m. The resident's right testicle was observed to be considerably larger than the left testicle. R#105 stated the area remained painful when he moved. He stated the pain was resolved with Tylenol. During an interview with RN BB on 7/1/17 at 10:25 a.m., she stated, I remember reporting to the DON and Administrator regarding the incident reported by (R#105). It was the current Administrator and the former DON. At that time, the former DON said she was aware of the situation and that it had been reported to the resident's physician, and that he (R#105, was being referred to the Urologist. They were going to have an ultrasound for R#105. (R#105) reported it to me (RN BB) and I reported it to Administration like I was supposed to. Incident reports and an investigation regarding R#14 to R#105 were requested, and the facility was unable to locate any documentation related to the alleged incidents. Post survey interview on 7/12/17 at 3:15 p.m. with LPN MDS revealed that during the interview LPN MDS reviewed the resident's medical chart and upon reviewing the residents chart read the following documentation: [NAME] Patient at Risk (PAR) noted dated 5/5/17, in pertinent part, Resident has inappropriate behavior touching male and female residents. B. Social Services Quarterly Note dated 2/17/17 that documented that resident was observed kissing the hands of other residents and wandering down other hall in facility. C. Nurses note dated 8/9/16, in pertinent part, Resident is alert, she has demonstrated sexual behavior toward staff to get in bed with her, resident lowered her top and asked staff to get in bed with her. Continued interview with LPN MDS, at this same time, revealed that she is a new employee and has been the LPN MDS for about one month and that she had not observed R#14 exhibit any inappropriate behaviors, but that she was aware that the resident was severely cognitively impaired and that she had socially inappropriate behavior, such as touching inappropriately, and that she had heard that R#14 had groped a resident. 2. R#110 was admitted the facility on 8/7/15, according to the Face Sheet printed on 6/30/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 5/18/17 indicate R#110 was cognitively intact (BIMS score 15/15), and required supervision to limited assistance from staff to compete all of his Activities of Daily Living (ADLs). R#110's Interdisciplinary Notes were reviewed in their entirety from (MONTH) (YEAR) through (MONTH) (YEAR) and revealed that there was not any evidence of any documentation that the resident had any behaviors. During an interview, conducted with R#110 on 6/29/17 at 6:20 p.m., she was asked if she had ever had any concerns with another resident in the facility and she stated, Yah, I do. R#114 was my roommate when they first moved me over here from 5 (the rehabilitation area). One day she (R#14) was out of the room and I laid down like I usually do. She (R#14) come in and it was about this time of the evening (around 6:30 p.m.), and I was laying on my left side facing the wall, and I began to feel someone coming on up my side, and up my side, and then I turned to look at her and she kissed me on the mouth. I about came up out of my bed and I told her not to do that to me. I called my daughter and I was crying and I was upset. I told her I was leaving and I would sleep on the bridge if I had to. I was afraid to sleep. I was afraid. I said I was leaving. My daughter was really upset and she said (to the staff) you will move her .and they did. That happened after I left the 5 hall. It's been several months ago. I don't want to be harassed like that. R#110 stated she reported the incident to her daughter and to a nurse (she could not recall which nurse). An interview was conducted on 6/30/17 at 1:48 p.m. with R#110's daughter and revealed that there had been an incident in (MONTH) (YEAR). She stated that the resident woke her (R#110) up rubbing her legs and when she turned her head the resident kissed her. She stated this made her mother very uncomfortable. The incident was reported to the previous Social Worker. Record review revealed that there was not any documentation of the alleged incident that could be found in the medical records for either R#110 or R#14. Incident reports and an investigation regarding R#14 to R#110 were requested, and the facility was unable to locate any documentation related to the alleged incident. During an interview with the Administrator on 6/29/17 at 6:45 p.m. she stated she did not recall R#110's daughter reporting an incident of sexual abuse by R#14. She stated no investigation had been completed and no reports had been made to the appropriate entities. 3. R#170 was admitted the facility on 4/26/17, per the Face Sheet dated 6/30/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 5/3/17 indicate R#170 was cognitively intact (BIMS score 14/15), and required extensive assistance from staff to compete all her Activities of Daily Living (ADLs). R#170's Interdisciplinary Notes were reviewed in their entirety for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) and indicated that there was not any evidence of any documentation that the resident had any behaviors. During an interview with CNA PP on 6/28/17 at 3:20 p.m., she stated about three weeks prior to this interview, R#170 was in the lobby by the hallway. R#46 was backing up in her wheelchair and that her roommate was in her way, so the roommate tapped on her to let her know she was backing up and R#46 grabbed her arm (R#170) and twisted it (arm). CNA PP stated, I didn't see it myself, but I was right there and heard it. She stated R#170 was very upset by the incident. CNA PP indicated the survey team should speak with CNA DDD, as she was also present at the time of the incident. During an interview with CNA DDD on 6/29/17 at 1:30 p.m., she stated, she thought R#46 was going in her room one day when R#170 touched her shoulder then someone was hollering. R#170 said she (R#46) twisted her arm. CNA DDD asked R#46,Why did you twist her arm? and (R#46) said because she (R#170) pulled my ear. I didn't see R#170 touch R#46. R#170 is hardly ever in the room with R#46 and I think it's probably because R#170 feels like she's not allowed in there. CNA DDD stated she didn't know if R#170 was afraid of R46, but she stated, I do know that since (R#170) has been in that room (R#46) feels like she can run that room. When R#46 comes around R#170 makes her Oh I hate to see her come face. She have (sic) called R#46 the Devil. CNA DDD stated the Administrator was standing near in the hallway when the incident occurred, so she did not report the incident. She stated, When it (the incident) was going on the Administrator was in the hall. I thought she had seen it. She was standing right there when all of the commotion was going on. Right there at the top of the hallway. Because she was there I didn't tell anyone else. I should have, but I was thinking the Administrator would have charted it. During an interview with R#170 on 6/28/17 at 1:00 p.m., she stated, I don't have nothing to do with her. When asked if she was afraid of R#46, R/#170 nodded her head in the affirmative and stated, She acts all stupid. She don't act right. I don't know why she act like that but she do. Record review for R#46, the alleged abuser, revealed that the resident was admitted the facility, per the Face Sheet printed on 6/29/17, on 5/12/11 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), an annual comprehensive assessment of overall health status dated 5/18/17 indicate R#46 was cognitively intact (BIMS score 15/15). The resident's PHQ-9 (an assessment to identify depression) score was 9, indicating R#46 was moderately depressed, and the assessment indicated R#46 was not displaying any current behaviors. During an interview with the Administrator on 6/28/17 at 3:45 p.m., she stated she could not recall the incident between R#46 and R#170. She stated no incident had been reported to her. During an interview with the Nurse Consultant on 6/28/17 at 3:50 p.m., she stated R#170 was being moved to another room on a different unit away from R#46. 4. Review of the record of the most recent Quarterly Minimum Data Set (MDS), for R#62, dated 4/6/17 indicated R#62 was admitted on [DATE] and has an active [DIAGNOSES REDACTED]. R#62 was assessed as cognitively intact per a Brief Interview of Mental Status (BIMS score 14/15), and required moderate to extensive assistance from staff to complete all his Activities of Daily Living (ADLs). Section G of the MDS indicated R#62 is totally dependent for bathing. An interview was conducted on 6/26/17 at 3:20 p.m. with Resident (R) #62 and revealed that when asked if he had ever been abused, either physically, verbally, or sexually, the resident responded yes. The Surveyor asked R#62 to describe the abuse, R#62 stated a girl on second shift was giving him a shower, pushed him against the wall and hit his head. The Surveyor asked how long ago did this happen? R#62 revealed that it happened three or four weeks ago. When the Surveyor asked R#62 what the name of the girl was he stated her name is - and named the CNA which was identified to be CNA HH. Further interview of R#62 on 6/26/17 at 3:20 p.m. indicated Some staff yell at you and push you around and are sarcastic. R#62 stated this happened a couple days ago, usually on the 3rd shift and that he told the nurse. The resident was not able to identify the nurse or the CNA by name. R#62 stated that yesterday, 6/25/17, that he was not moving fast enough yesterday, and that the CNA was pushing and tugging him about 10:00 a.m. on the way to the shower but he did not tell the nurse. An interview was conducted on 6/26/17 at 4:40 p.m. with LPN AAA revealed that R#62 had complained of staff being rude but has not made any statement of being hit before. A review of the Incident log ran on 6/26/17 at 4:47 p.m. for the dates 3/26/17 to 6/26/17 revealed that there were not any evidence of any documentation that any incidents had been logged R#62. No matching records found. A review of the Departmental Notes dated 6/14/17 at 1:18 p.m. revealed a care plan meeting entry by social services that documented, in pertinent part, R#62 indicated as well that the CNA's are a little rough and would like them to be more gentle while in the sit and stand Hoyer lift. In addition, a hand-written note, dated 6/14/17 at 10:35 a.m., by LPN HH regarding an incident which occurred on 6/13/17 at approximately 10:00 a.m. for R#62. The note documented that LPN HH was invited to attend a care plan meeting for R#62, and that R#62 stated that one time in the shower his head was bumped against the wall of shower. An interview on 6/26/17 at 4:50 p.m. with the Psychiatric Advanced Practice Registered Nurse (APRN) for R#62. The APRN revealed that the resident's mental status is a 26/30, per the Mini Mental Status Exam. A maximum score is 30 points. A score of 26 indicates that the resident is cognitively intact. An interview on 6/26/17 at 5:10 p.m. with the Social Services Director (SSD) revealed that R#62 reported today, 6/26/17, that he has been having issues with three CNA's handling him roughly in the shower. He has requested one CNA not be in the room when he is in the shower. He said the nursing staff is doing a good job, but that CNA HH is rough with him, CNA OOO just stands there and watches and CNA KKK is very pushy when she picks him up and is always in a hurry and never takes her time. He stated he was scared. He named CNA KKK, CNA OOO, CNA HH and a heavy-set African American woman who picks up residents and looks like she could throw the resident in the bed or chair. Further interview with the SSD, at this time, regarding the care plan meeting note, for R#62, documented in the Departmental Notes on 6/14/17, concerning staff handling him roughly, she stated she did recall that meeting and that she wrote a grievance and turned it over to the Director of Nursing (DON). The SSD did not identify the date that she had given to the DON nor could she produce a document to verify the incident was reported. The SSD proceeded to leave her office to find the grievance, when she returned she was accompanied by the Administrator and stated that the Administrator did not complete a grievance or report because she didn't see it as an incident. She felt it was resolved because he stated to her they had roughly washed his hair. The Administrator instructed the SSD to enter a grievance for R#62's care plan meeting complaint as a late entry and another one for today's complaint. The facility did not follow their Abuse Prevention Program Policy with regards to keeping residents free from the alleged physical abuse.",2020-09-01
974,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,225,J,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility policy entitled Facility Abuse Policy most recently revised on 11/24/16, record review and resident and staff interviews, the facility failed to investigate and report allegations of abuse for four Residents (R) (R#62, R#105, R#110, and R#170). The sample size was 42 residents. On 6/30/17, 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. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: The Facility Abuse Policy, most recently revised on 11/24/16 read, in pertinent part, When an alleged incident of abuse, neglect, or misappropriation of resident's personal property is reported, the Administrator will appoint a representative to investigate the incident; and The facility is aware that it must report all alleged violations and substantiated incidents to the state agency promptly per state regulation and to all other agencies as required by state and federal law and this it must take all necessary corrective actions depending on the result of the investigation. 1. Record review revealed that R#105 was admitted the facility, according to the Face Sheet, on 7/29/15 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), an annual comprehensive assessment of overall health status dated 6/1/17 indicate R#105 was cognitively intact (BIMS (brief interview of mental status) score 15/15), and required limited to extensive assistance from staff to compete all of his Activities of Daily Living (ADLs). Record review revealed a Departmental Note, written by RN BB for R#105 dated 7/9/16, was reviewed and read, in pertinent part, Resident reported that (R#14) was sexually harassing him. States she hit him in his private, but I was standing in office door and she was noted touching the collar of his shirt in the hall. Upon questioning him he said the incident where he was hit in his private was last week and he reported it to the lady in the front and would follow up with her on Monday. I (RN BB) spoke with DON (Director of Nursing) and Administrator. Record review revealed a Departmental Note for R#105, dated 1/19/17 documents, in pertinent part, Resident reported that (R#14) came into his room without permission while he was finishing breakfast. He stated he asked her to get out; however, R#14 proceeded to roll forward in her wheelchair. Once she was within reach of resident she touched/grabbed him in his private area. R#105 reported incident to writer, LPN DDD. Record review for R#14, the alleged abuser, revealed the resident was admitted the facility on 9/25/15, according to the Face Sheet dated 6/29/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) for R#14 was a quarterly assessment of overall health status dated 5/3/17 indicate R#14 was cognitively impaired per Brief Interview for Mental Status (BIMS score 5/15), and required supervision from staff for mobility throughout the facility in her wheelchair. Incident reports and an investigation regarding R#14 to R#105 were requested, and the facility was unable to locate any documentation related to the alleged incidents. During an interview with the Director of Nursing (DON) on 6/29/17 at 2:35 p.m., he stated The only thing that is being tracked as an incident at this point is falls .and maybe skin tears. He stated, There is room to grow regarding the recognition, reporting, and investigation of abuse. During an interview with the Administrator on 6/29/17 at 6:45 p.m., she stated she had no knowledge of R#14 hitting R#105 in his testicle. She stated no investigations had been done and nothing had been reported to the State. Cross refer to F223 for specifics related to R#105's allegations of sexual abuse by R#14. 2. R#110 was admitted to the facility on [DATE], according to the Face Sheet dated 6/30/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 5/18/17 indicated R#110 was cognitively intact (BIMS score 15/15), and required supervision to limited assistance from staff to compete all of his Activities of Daily Living (ADLs). No documentation of the alleged incident could be found in either R#110 or R#14's medical records. Incident reports and an investigation regarding R#110's allegation of sexual abuse by R#14 were requested, and the facility was unable to locate any documentation related to the alleged incident. During an interview with the Administrator on 6/29/17 at 6:45 p.m. she stated she did not recall R#110's daughter reporting an incident of sexual abuse by R#14. She stated no investigation had been done and that no reports had been made to the appropriate entities. Cross refer to F223 for specifics related to R#110's reported allegation of sexual abuse by R#14. 3. R#170 was admitted the facility on 4/26/17, according to the Face Sheet dated 6/30/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment of overall health status dated 5/3/17 indicated that R#170 was cognitively intact (BIMS score 14/15), and required extensive assistance from staff to compete all of her Activities of Daily Living (ADLs). Cross refer to F223 for specifics related to R#170's reported allegation of physical/verbal abuse by R#46. During an interview with the Administrator on 6/28/17 at 3:45 p.m., she stated she could not recall the incident between R#46 and R#170. She stated no incident was reported to her. She stated no investigation into the alleged incident had been done and nothing had been reported to the State Agency. She further stated, Off the top of my head I believe we should instantly start investigation (after an allegation of abuse). She stated, We have a two-hour reporting period whether with or without seriously bodily injury. Cross refer to F223 for specifics related to R#170 4. R#62 was admitted to the facility on [DATE], according to the most recent Minimum Data Set (MDS) quarterly assessment dated [DATE] with an active [DIAGNOSES REDACTED]. The resident was assessed as cognitively intact per a brief interview of mental status (BIMS score 14/15), and required moderate to extensive assistance from staff to complete all of his Activities of Daily Living (ADLs). An interview was conducted on 6/26/17 at 3:20 p.m. with Resident (R) #62. When R#62 was asked if he had ever been abused, either physically, verbally, or sexually, the resident responded yes. The Surveyor asked R#62 to describe the abuse, R#62 stated a girl on second shift was giving him a shower, pushed him against the wall and hit his head. The Surveyor asked how long ago did this happen? R#62 responded it happened three or four weeks ago, when the Surveyor asked R#62 what the name of the girl was he stated her name is - (identified by Surveyor as Certified Nurse's Aide (CNA) HH). Cross refer to F223 A review of the Incident log ran on 6/26/17 at 4:47 p.m. for the dates 3/26/17 to 6/26/17 for R#62 revealed no matching records found. During the interview, the SSD was asked about R#62's Departmental Notes on 6/14/17, concerning staff handling him roughly, she stated that . the Administrator stated she did not complete a grievance or report because she didn't see it as an incident. She felt it was resolved because he stated to her they had roughly washed his hair. During an interview conducted on 6/26/17 at 5:10 p.m. the Social Services Director (SSD) stated R#62 reported today that he has been having issues with three CNAs handling him roughly in the shower. He has requested one CNA not be in the room when he is in the shower . CNA HH is rough with him, CNA OOO just stands there and watches and CNA KKK is very pushy when she picks him up and is always in a hurry and never takes her time. He stated he was scared. He named CNA KKK, CNA OOO, CNA HH and a heavy-set African American woman who picks up residents and looks like she could throw the resident in the bed or chair. Post survey interview on 7/7/17 at 10:27 a.m. with the Administrator revealed that she was made aware of the grievances for R#62 dated 6/13/17 and 6/26/17 on 6/26/17. The Administrator stated upon review of the grievances that she considered that when the grievance documented that the resident's head was bumped, or that the resident verbalized that the CNA was pushy, and that he was scared of the CNA that she considered those grievances to be potential abuse and that the grievances had been investigated, but they had not been reported to the State Survey Agency (SSA). Further interview revealed that the Administrator stated that the grievances had not been reported to the SSA because they were late entries and then in further interview the Administrator stated the grievances had not been reported because these grievances had been placed in a file and that it (the grievance being reported) had just been missed. Further interview with the Administrator revealed that as of 6/29/17, the Director of Nursing (DON) had been named the Abuse Coordinator. The Administrator revealed that the DON is the third Abuse Coordinator since (MONTH) (YEAR), and that a previous Social Services Director had been the Abuse Coordinator from 9/21/16 through 3/31/17, and that the next Social Services Director had been the Abuse Coordinator from 3/28/17 through 6/29/17, but that per their facility policy that the Administrator, DON, or designee is the appointed Abuse Coordinator. Post survey interview on 7/7/17 at 11:03 a.m. with the DON revealed that his first day working in the facility was 6/12/17 and that he had been named the Abuse Coordinator on 6/29/17. The DON revealed that he became aware of the grievances for R#62 on 6/26/17 and that he had investigated the grievances and had removed the CNA's, that were named in the grievance, from working on the same unit as R#62, interviewed the resident, notified the physician, notified the responsible party, immediately educated the staff on abuse, but that he had not reported the grievance to the SS[NAME] Post survey interview on 7/7/17 at 11:14 a.m. with the Staff Development Coordinator revealed that prior to the survey the last time she had educated the staff on abuse was 2/23/17 and that at that time she had educated the staff on abuse including the different types of abuse, definitions of abuse, and that abuse should be reported to the Abuse Coordinator. Further interview revealed, that prior to this survey that, per facility policy, she had educated the staff that the Administrator was the Abuse Coordinator and that staff should report all allegations of abuse to the Abuse Coordinator (the Administrator). The facility failed to investigate the alleged physical abuse, failed to file a report with the state agency of the alleged abuse.",2020-09-01
975,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,253,E,0,1,6YM511,"Based on observation and staff interviews, the facility failed to ensure that there was a clean and comfortable environment as evidenced by broken and/or missing bathroom wall tile, broken/missing countertop and/or furniture laminate, stained baseboards/doorframes, stainded floor tile, stained walls and ceilings, gouges in wall and pitted rust around faucets in bathroom sinks. These environmental concerns were observed in seven resident rooms and bathrooms on four of six halls, including the East Wing nursing station. The facility failed to ensure a sanitary and safe environment for residents. Findings Include: During observational rounding on 6/28/17 at 10:00 a.m., there was a foul ammonia smell at the end of the West Wing 400 hall, in the proximity of room 406. An environmental tour was conducted on 6/30/17 at 10:13 a.m., accompanied by the Plant Supervisor (PS). Upon entering room 406 there was a strong ammonia smell, the PS pointed out a large yellowish-brown area on the floor tile at the head of the bed one. When the Surveyor and the PS inspected the stain, it reeked of ammonia and other indescribable smells. The Surveyor asked the PS if maintenance was responsible for removing the tiles and he said no it would up to housekeeping to remove the stain. The surveyor asked to speak to the Housekeeping Supervisor (HS), who explained when asked what the stain was that it was feces and urine. When questioned as to how often housekeeping cleans the floor, he responded housekeeping mops the floor every morning. When asked how long the stain had been there both the PS and HS responded approximately two years. The HS stated they had tried to remove stain unsuccessfully. At that time, the PS took his pocket knife out and proceeded to start scraping the yellowish-brown substance off the floor. An interview with housekeeper (HSK) HH was conducted on 6/30/17 at 10:26 a.m. HSK HH was questioned if she was aware of the stain on the floor at the head of the bed of room 406-1. She stated she was aware of it and had tried to mop and scrape it up. When asked how long she had been employed at the facility she replied about four months. An interview was conducted with Registered Nurse (RN) DD on 6/30/17 at 10:30 a.m. RN DD was questioned if she knew about the stain on the floor in room 406. She stated she was not aware of the floor stain. An interview was conducted with the Administrator at 6/30/17 at 11:20 a.m. The Administrator was asked if she was made aware of the floor tiles being stained with urine and feces in room 406. The Administrator stated she was not aware of the stain but feels if the resident has a problem with smearing feces than staff needs to be toileting him every hour. A review of an undated policy Cleaning and Disinfection of Environment Surfaces, page two, paragraph nine, revealed Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. A review an undated policy Cleaning Spills or Splashes of Blood or Body Fluid, revealed Spills or splashes of blood or other body fluids must be cleaned and the spill or splash area decontaminated as soon as practical. Observations made during the environmental tour accompanied by the Plant Supervisor (PS) on 6/30/17 starting at 9:35 a.m. included: West Wing Main nursing station has broken/missing pieces Formica countertop and edges, exposed to residents in hallway. Observed in room 601 bedside chest veneer coming off, bathroom wall tile missing, stained baseboards/doorframes and pitted rust around faucet in sink. Observed in room 609-bathroom wall tile missing, pitted rust around faucet in sink and gouges in wall outside bathroom door. Observed in room 613 stained baseboards/doorframes, brown stained substance along walls in room and bathroom and pitted rust around faucet in sink. East Wing Observed in room 202 brown stain substance along walls and floor in room and bathroom and pitted rust around faucet in bathroom sink. Observed in rooms 302, 308 and 310 with brown stained substance along the walls and floor in room and bathrooms. Also observed pitted rust around faucet in bathroom sinks of all three rooms. Observed in room 406 stained baseboards/doorframes, brown stained substance along walls and floor tile missing. Also observed pitted rust around faucet in bathroom sink. During an interview with the PS following the environmental tour at approximately 11:00 a.m., the PS was asked how often does maintenance conduct rounds and what do they look for? He responded that he and the maintenance assistant makes rounds every morning and look at exit doors, power strips and anything out of the ordinary. He also will go to each nursing station and pick up work requisitions from the employees. When he was questioned about how many sinks in the facility contained rust as was observed on the tour, he stated all of them. He was asked what was being done to correct this and he stated he had told the Administrator awhile back. An interview was conducted with the Administrator on 6/30/17 at 11:20 a.m., she was asked if she was aware the rusted sinks, she stated she was aware of them. She continued to explain that the facility was waiting on a quote from a plumber to have them all replaced. She was not sure of the timeframe when she would hear back from the plumber.",2020-09-01
976,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,257,D,0,1,6YM511,"Based on review of an undated policy Cleaning and Disinfection of Environment Surfaces, observation, resident interview and staff interviews it was determined that the facility failed to provide comfortable and safe temperature levels for two residents (R#43, R#22). The sample size was 42 residents. Findings include: During the resident interview conducted on 6/27/17 at 3:04 p.m., Resident (R) #43 stated it gets chilly in her room about 3:00 in the afternoon. R#43 further stated I can't stand it cold, it hurts me. During the resident interview conducted on 6/27/17 at 9:08 a.m., R#22 stated sometimes it gets cold during the day in the summer, air conditioning. Review of Resident Council minutes revealed no complaints of the building being to cold. Intevriew of the Council president on 6/29/17 voiced no complaints of the building being cold. An environmental tour was conducted on 6/30/17 at 9:35 a.m. with the Plant Supervisor (PS). The PS was asked to show the surveyor the East Wing thermostat, (where both R#22 and R#43 rooms are located). The East Wing thermostat was set on 72 degrees Fahrenheit (F), the PS showed the surveyor the thermometer located in the hallway which showed it was 70 degrees F in the hallway. The PS and Surveyor proceeded to R#22's room where the Surveyor asked the PS to measure the temperature of the air blowing out of the air conditioning vent. It measured 59 degrees F directly out of the vent, approximately two feet below the vent it measured at 68 to 69 degrees F. When the temperature was measure over the bed closest to the hallway it was 66 degrees. The PS and Surveyor than went to R#43's room at approximately 10:15 a.m. and measured the temperature coming from the air vent and it measured 70.3 degrees F. The Surveyor asked R#43 how the temperature felt to her and she stated she felt cold. The PS proceeded to recommend to R#43 to request a blanket from staff. An interview was conducted with the Administrator on 6/30/17 at 11:20 a.m. The Administrator was asked if residents had expressed any concerns to her about it being too cold in the facility and she stated she was not aware of any problems.",2020-09-01
977,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,282,J,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interviews the facility failed to follow the Behavior Care Plan interventions to assess the need for a psych consult for mood, behavior, or psychosocial wellbeing changes; Social Services involvement if needed; inform physician of behavior for possible medication changes for one resident (R#14). Additionally, the facility failed to follow the care plan titled, [MEDICAL TREATMENT] Access Care related to checking for a thrill and bruit for one of one [MEDICAL TREATMENT] residents (R) (#116). A thrill and bruit need to be assessed after each [MEDICAL TREATMENT] session, listening to the bruit and feeling the thrill help determine if the access site is functional. The sample size was 42 residents. On 6/30/17, 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. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: 1. Record review revealed that R#14 was admitted the facility on 9/25/15, according to the Face Sheet printed on 6/29/17, with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) for R#14 was a quarterly assessment of overall health status dated 5/3/17 indicated R#14 was cognitively impaired per Brief Interview for Mental Status (BIMS score 5/15), and required supervision from staff for mobility throughout the facility in her wheelchair. She had the ability to wheel herself about the facility to where she wanted to go MDS section G Functional Status quarterly dated 2/2/17: section F: Locomotion: resident #14 identified as a level 2 defined as limited assist under self performance locomotion off the unit, self-sufficient once in wheelchair. MDS section G Functional Status quarterly assessment dated [DATE] under Locomotion: assessed at level 1 indicating supervision/oversight only required, self-sufficient once in wheelchair. Review of the Behavior Care Plan, for R#14, dated 9/7/16 and most recently revised on 5/3/17 documented, in pertinent part, I have the potential for mood/behavior and/or psycho-social decline related to dementia and depression. She will wander in and out of other residents' rooms socializing with residents and families. She will at times kiss people on the hand and [MEDICAL CONDITION] at times. She is usually easily directed. Approaches included, in pertinent part: Assess the need for psych consult if mood, behavior, or psycho-social well-being changes; Social Services involvement if needed; Inform physician of behavior for possible medication changes . Record review revealed that The Behavior Care Plan, for R#14, did not include information related to R#14's sexually abusive behavior toward other residents although there was evidence that staff were aware of her behaviors and were aware of R#105's allegations of sexual abuse. There was not any evidence that the staff consulted psych services or that the social worker had reviewed and discussed additional interventions needed to prevent the resident from further sexually inappropriate behavior. The facility policy regarding resident care planning was requested by the survey team on 6/30/17 at approximately 6:30 p.m., however, the Director of Nursing (DON) stated the facility had no specific policy related to care planning. During an interview with the Administrator on 6/29/17 at 6:45 p.m., she indicated that she was not aware that R#14 was behaving in a sexually abusive manner. The DON confirmed on 6/30/17 at 6:39 p.m. the facility had no policy to require completion of a care plan. Post survey interview on 7/12/17 at 3:15 p.m. with LPN MDS revealed that she is a new employee and has been the LPN MDS for about one month and that she had not observed R#14 exhibit any inappropriate behaviors, but that she was aware that the resident was severely cognitively impaired and that she had socially inappropriate behavior such as touching inappropriately and that she had heard that R#14 had groped a resident. LPN MDS revealed that the interventions that have been in place for R#14 have been to redirect the resident. Further interview with LPN MDS revealed that when assessing a resident to determine if the resident needs a psychiatric evaluation you determine if the resident need any medical interventions first such as collecting a urinalysis to determine if a resident had a urinary tract infection, first. LPN MDS reviewed the medical record for R#14 and revealed that prior to this survey that the resident had a urinary tract infection in (MONTH) (YEAR). Continued interview with LPN MDS, at this same time, revealed that MDS normally updates and revises residents care plans for behaviors and that they discuss behaviors during their morning meeting and that the DON brings in a list of incidents that have occurred the day before and that the incidents are discussed and it is decided if a resident's care plan should be updated, revised, or if a new care plan needs to be developed, and that prior to the survey R#14's behaviors had not been discussed, in the morning meeting, since she had been the LPN MDS a little over a month ago. 2. Interview and observation of R#116 on 6/27/17 at 4:15 p.m. revealed he was up in a power scooter at bedside. He stated he went to [MEDICAL TREATMENT] three times a week. He stated when he returned from [MEDICAL TREATMENT] the nurse only looked at the bandage over his [MEDICAL TREATMENT]. He stated the nurses never listened for a bruit or felt the access site for a thrill. A care plan for [MEDICAL TREATMENT] was dated 5/4/17 and indicated the onset of [MEDICAL TREATMENT] was 11/21/14. One approach on the care plan was to check the bruit and thrill in R#116's left forearm. The electronic treatment administration record (E-TAR) only called for checking his left forearm for bleeding on post [MEDICAL TREATMENT] days. Review of the Physician Orders for (MONTH) (YEAR), (MONTH) (YEAR) , (MONTH) (YEAR) , (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR), revealed that there was not an order to check for bruit and thrill. Review of the chart and electronic Medication Administration Record [REDACTED]. During an interview with the West Wing Unit Manager on 6/29/17 at 2:52 p.m. she stated When I'm on the floor I check for it (bruit and thrill) and document. She was unaware the order on the E-MAR was to check for bleeding at the [MEDICAL TREATMENT] site and she was unable to show where she had documented the bruit and thrill in his medical record. During an interview with the Director of Nursing (DON) on 6/29/17 at 2:25 p.m. that he expected the nurses to check the bruit and thrill of a [MEDICAL TREATMENT] resident and document it in the chart. He also stated that there should be orders on the chart for checking for a bruit and thrill for any resident on [MEDICAL TREATMENT]. Review of the facility policy titled [MEDICAL TREATMENT] Access Care with a revision date of (MONTH) 2010 revealed Care of AVFs (arteriovenous fistula artificial created pathway for [MEDICAL TREATMENT]) and AVGs (arteriovenous graft) item H. indicated Check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access.",2020-09-01
978,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,285,D,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure one Resident (R) (#46) of 42 sampled residents had her completed Pre-Admission Screening and Resident Review (PASRR) Level 2 Assessment in her medical record and available for facility reference. Findings include: R#46 was admitted to the facility, per the Face Sheet on 5/12/11 with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), (an annual comprehensive assessment of overall health status) dated 5/18/17 indicate R#46 was cognitively intact per Brief Interview for Mental Status (BIMS score 15/15). The resident's PHQ-9 (an assessment to identify depression) score was 9, indicating R#46 was moderately depressed, and the assessment indicated R#46 was not displaying any current behaviors. R#46's Mood/Behavior Care Plan, initiated on 8/16/13 and most recently revised on 5/2/17 read, in pertinent part, Problem: I have the potential for mood/behavior and/or psychosocial decline r/t (related to) depression, [MEDICAL CONDITION], and dementia. I am non-compliant with diet and will, at times, request food from staff, other residents and visitors. I will refuse care and medications at times. I make non-factual statements to staff, and have manipulative tendencies at times. I also prefer to wear several layers of clothing. Approaches included: Assess the need for psych (psychiatric) consult; Encourage family/friends to visit as often as they are able. Have them bring items from home to create a comfortable, familiar environment; Report any refusals in care or participation and document; Social Services involvement as needed; inform physician of behavior for possible medication changes; and encourage and assist to participate in activities of choice and peer relationships. R#46's Behavior Care Plan, initiated on 8/16/13 and most recently revised on 5/2/17 read, in pertinent part, Problem: I have behaviors of falsely accusing staff of stealing items in her room at times and wanting staff to provide her with a tongue blade to insert cream into vaginal area. Approaches included: Staff will educate resident of findings of investigation; Staff will listen to resident and investigate accusations; keep family informed of resident's behaviors; staff will attempt to redirect resident during obsessive thoughts of staff stealing items from her room; and re-educate resident concerning putting objects into vaginal area. Departmental Notes, dated 5/25/17 read, in pertinent part, R#[AGE] yearly assessment (Social Services) has been completed. (R#46) indicated that she has little interest in attending activities when its BINGO. (R#46) indicates that she feels down and depressed 2-6 days out of the week due to not having pleasurable adult activities. (R#46) was asked if SSD (Social Services Director) could contact relative to purchase items for her and (R#46) stated, No, that is none of her family's business. (R#46) stated that she cannot sleep and that the bed Kills her back daily along with feeling tired daily. (R#46) indicated that she feels bad about herself 3 days out of the week and has trouble staying focused 2-6 days out of the week (it depends on what she is doing at the time.) Departmental Notes, dated 6/25/17 documented, in pertinent part, Resident noted to hide cigarettes and lighters in her room and abuse the smoking policy. She is also having physical altercations with other residents. R#46's PASRR Level 1, dated 5/10/11, was reviewed and indicated a PASRR Level 2 needed to be completed for R#46. R#46's PASRR level 2 was requested by the surveyor on 6/28/17 at approximately 10:00 a.m. The facility was unable to provide a level 2 PASRR to the survey team prior to survey exit on 7/1/17. During an interview with the Director of Nursing (DON) on 6/29/17 at 4:25 p.m., he stated, There is not a copy of the resident's Level 2 anywhere in the record. We requested a copy of the Level 2 from the State Collaborative ASO (the agency responsible for administering the PASRR Assessment), and they don't have a copy, either. A letter from the State Collaborative ASO, dated 6/29/17, was provided to the survey team, and read, in pertinent part, As per our phone conversation, we do not have a copy of the summary of findings for R#46. The letter indicated the original authorization to conduct the Level 2 Assessment was 6/22/10. A reference number to the PASRR Level 2 Assessment was also indicated on the letter.",2020-09-01
979,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,309,D,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to have [MEDICAL TREATMENT] communication available for one of one [MEDICAL TREATMENT] Residents (R) (#16). The stage 2 sample size was 42 residents. Findings include: Review of the medical record for R#116 revealed he is sent out of the facility for [MEDICAL TREATMENT] three times a week. He had [DIAGNOSES REDACTED]. Further review of the medical record revealed the facility failed to locate communication sheets from the [MEDICAL TREATMENT] center after 3/1/17 to the present date of 6/30/17. Communication sheets were only available for the following dates: 1/13/17, 1/16/17, 1/30/17, 2/8/17, 2/20/17, 2/22/17, 2/23/17, 2/24/17 and 3/1/17. The remainder of the visits for (MONTH) (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR) failed to have a communication sheets completed. There was not any evidence of any communication sheets completed for the months of (MONTH) (YEAR), (MONTH) (YEAR) or (MONTH) of (YEAR). During an interview with the Director of Nursing (DON) on 6/29/17 at 2:25 p.m. revealed that he expected there to be communication from the [MEDICAL TREATMENT] center for each treatment visit made by the resident. He was not aware that communication sheets were not being received for R#116's visits. Interview with the West Wing Unit Manager on 6/29/17 at 3:30 p.m. confirmed that there was not any documentation from the [MEDICAL TREATMENT] center for the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR). The facility did not have a policy related to communication from the [MEDICAL TREATMENT] center for review.",2020-09-01
980,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,323,D,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Facility Guidelines for Smoking, undated, record review, and interviews, the facility failed to ensure a safe smoking environment for 1 of 43 sampled Residents (R), #46. The facility failed to ensure coffee temperatures were within safe parameters to prevent burns. This affected one of 42 sampled Residents(R#14). Specifically, smoking assessments were complete, but not accurate, and adequate supervision was not provided for R#46 (who was to be supervised when smoking). Coffee temperatures were not monitored contributing to R#14 being burned (red area no blisters). Findings include: 1. The Facility Guidelines for Smoking, undated, read, in pertinent part, It is the intent of {Facility} to provide Supervised Smoking. Residents will not be allowed to smoke unsupervised; and Residents will not be allowed to keep their own paraphernalia such as lighters, matches, cigarettes, and cigars. All smoking paraphernalia will be secured in a box at the first-floor nursing station; and Proper supervision will be with a designated employee; and Ashtrays of non-combustible material and safe design will be provided in the designated area where smoking is permitted; and Any resident or family members found in violation of the policy can be given a 30-day discharge notice. According to the Face Sheet, printed on 6/29/17, R#46 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to R#46's Minimum Data Set (MDS) an annual assessment of comprehensive health status, dated 5/18/17, R#46 had no cognitive impairment per Brief Interview for Mental Status (BIMS of 15/15), required extensive assistance from staff to complete all of her Activities of Daily Living (ADLs), and had limited movement to one side of her body (left). R#46's Smoking Care Plan, dated 6/17/16 documented, in pertinent part, I am a smoker. Interventions included, Educate resident and family of facility smoking policy; Provide supervision while smoking; Resident to provide own smoking products which are to be kept at nurse's station; Resident is to smoke in designated areas only and with supervision; Provide and ensure resident is wearing a smoking apron; Resident may smoke with family supervision according to policy; and Observe for non-compliance with policy, re-educate as needed. The most recent Safe Smoking Assessment, dated 1/10/17, indicated R#46 was cognitively intact, able to see adequately, able to light and smoke cigarettes while demonstrating safe disposal of ashes, was able to physically hold her own smoking device, and was able to verbalize that she understood smoking materials were for her own personal use and that cigarettes needed to be smoked in the designated smoking area. The assessment referred to the resident's care plan for further details. During an interview, conducted with Certified Nursing Assistant (CNA) OOO on 6/28/17 at 10:35 p.m., she stated R#46 did not consistently follow the smoking rules. She stated, I will come in to work at 7 p.m. and she'll (R#46) be sitting out front smoking, and when she sees someone coming she'll hide the cigarette up under her clothing or down her pants. She has bath and body spray to camouflage the smell. That's dangerous because it can cause a fire. She hides her cigarettes in that purse of hers that she guards with her life. She (R#46) bums (cigarettes) off family members and residents that don't know no better, and gets mad if they don't give them to her. Last time I personally saw her was last week .don't remember specifically the date .I was leaving around seven (p.m.) and she was out front smoking then. I told her she needed to go back inside. She cursed at me. Told me to mind my own damn business. One of the new aides came out the door and took her back in. I don't know what happened after that. It's a big issue with her, though. During an interview, conducted with CNA OO on 6/28/17 at 10:40 a.m., she stated, R#46 is aware of the smoking rules. She doesn't follow the rules. I get off at seven (p.m.) because I work 12 hour shifts. She sits out front (on the front porch) and smokes. Some family members .not hers .or friends of other residents bring her cigarettes. When you see her she says, I ain't smoking, but you see her smoking. She keeps the materials in her purse. She keeps her purse close to her. I report when I see her smoking. I have reported to the supervisor who is on shift and then the next day I report to the Unit Manager. The last time I saw her (out front smoking) was at the end of last month (May). During an interview, conducted with Licensed Practical Nurse (LPN) CCC on 6/28/17 at 3:10 p.m., she stated, I have seen (R#46) smoke on the front porch, on occasion, as I leave the facility for dinner or when I leave late at night. I have seen her sitting out front in her wheelchair smoking with a visitor. I haven't reported it because she was with a visitor. They are not in the designated smoking area. They are on the front porch. The last time I saw her (smoking on the front porch) was a month ago or so. During an interview, conducted with Registered Nurse (RN) BB Evening Supervisor on 6/28/17 at 6:00 p.m., she stated, she had seen R#46 on the facility front porch smoking, and the last incident she observed had been 2 to 3 months prior to the interview. She stated, I saw the smoke (from her cigarette). She flicked it (the cigarette) from her hand and then I saw it in the grass. I asked her if she was smoking and she said Do you see me with a cigarette? She was on the front porch. It was not smoking time. It was on a weekend after breakfast. I also get reports about (R#46) smoking (on the front porch) as the supervisor. Most recently it was reported by one of the girls from the East Wing R#46 was smoking on the front porch about 5 to 6 weeks ago. When I got out there she wasn't doing anything. When she breaks the smoking rules I usually send the text message to the Director of Nursing (DON). During an interview, conducted with LPN UU on 6/28/17 at 10:25 a.m., she stated she had received reports of R#46 smoking on the facility front porch. She stated the most recent report she had received was about a month ago, she stated she had received reports about three times of R#46 smoking on the front porch in the prior six months. During an interview with the DON on 6/28/17 at 10:15 a.m., she stated she had not been able to find any incident reports or grievances related to R#46 smoking in undesignated areas or at undesignated times. She stated, Staff is not generating incident reports regarding (R#46's). The DON stated she was aware of R#46's behaviors related to smoking, but had not had any specific report since the day she began working at the facility (approximately three weeks prior to the survey). 2. Review of the medical record for R#14 revealed a nurses note dated 11/16/16 which indicated Resident was sitting in the dinning (sic) room at her table waiting for breakfast she was given a cup of coffee and she spilt it in her lap. She has a pink area on the lower part of her abdomen and pink area on her upper left thigh. Area was cleaned and calaseptine applied. She denied any pain she was returned to her table for breakfast. The residents physician was notified also left message with (name of family member) to call. Area after breakfast with no noted pink areas. Observation on 6/30/17 at 10:12 a.m. of Dietary Aide DD taking the temperature of the coffee in the kitchen. The temperature of the coffee was 170 degrees Fahrenheit. Interview with the Administrator on 6/30/17 at 10:32 a.m. revealed that she had a resident incident report for R#14 related to the spilling of a cup of coffee in her lap. The incident was reported to the state on 11/16/16. The report stated R#14 had a reddened area on the abdomen and left upper thigh. The report stated the family and doctor were notified, the areas cleaned and cream put on it. Corrective action included that her coffee would be placed in a spill proof cup in the future. R#14's care plan was updated on 11/17/16 and one of the approaches was to use a spill cup proof for hot beverages. Review of the kitchen Prepared Food Temperature Record for (MONTH) (YEAR), (MONTH) to (MONTH) (YEAR) and (MONTH) (YEAR) revealed the temperature of coffee was 203 to 205 degrees Fahrenheit at each meal time daily. Further interview with Dietary Aide DD on 6/30/17 at 10:15 a.m. stated they did not have a log for the month of (MONTH) (YEAR) because the coffee machine was broken and out of service. She remembered R#14 being burned in the fall. The facility did not have a policy related to the serving temperature of hot liquids.",2020-09-01
981,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,329,D,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure one of eight Residents (R), (#4) reviewed for unnecessary medications had appropriate [DIAGNOSES REDACTED]. Findings Include: Record review for R#4, revealed an order entered on 4/27/15 for [MEDICATION NAME] (antipsychotic medication) 0.25 milligram (mg) one tablet by mouth every morning and two tablets at bedtime for the [DIAGNOSES REDACTED]. Review of the last documented Psychiatric evaluation for R#4 dated 2/24/17 revealed Resident current psychiatric medications: [REDACTED]. Past Psychiatric history: Senile Dementia with Delusional features, generalized anxiety disorder. There was not any evidence of any documentation in the record of an acceptable [DIAGNOSES REDACTED]. Record review revealed a Progress note for R#4, Resident observed having a verbal outburst with another male resident in hallway during preliminary work. Staff indicated that resident does this occasionally. No reports of any increase or decrease of behaviors. Resident was seen in front of nurse's station on the East wing. he is pleasant, smiling and denies any problems with sleep, appetite, or anxiety. No medication changes at this time, resident is self, chronic illness. Review of R#4's Electronic Medication Administration Record [REDACTED]. On 5/9/16 the Consultant Pharmacist had recommended to the attending Physician, this resident has been on [MEDICATION NAME] 0.25 mg q (every) a.m. and 0.5 mg q evening (h.s.) since 4/2015, please evaluate the current dose and consider a gradual taper to ensure this resident is on the lowest possible effective/optimal dose. The comments below may assist you in the documentation process. Further review of the documentation revealed the physician checked off the paragraph - Patient has had a good response to treatment and requires this dose for condition stability. Dose reduction is contraindicated because benefits outweigh the risks for this patient and a reduction is likely to impair the residents function and/or cause psychiatric instability. The physician also documented Please continue stable on current med. A review of the last documented Consultant Pharmacist evaluation recommendation dated 9/26/16 recommended the same actions for the residents [MEDICATION NAME] 25 mgs at hours sleep. and received the same response from the physician. Further review of the R#4's E-MAR revealed an area for Behavioral monitoring for target behavior of Psychotic Episodes at 6:00 a.m., 2:00 p.m. and 10:00 p.m. with staff initialing at these times that monitoring had been completed. There were no target behaviors (no descriptions) identified on the E-MAR for staff reference. A review of R#4's care plan dated 5/11/17 revealed the following documentation, I have the potential for behaviors of being verbally and physically abusive when angry or agitated. Plan: Meds as ordered, redirect/reassure and reorient as needed (PRN). Provide and encourage activities for distraction, observe behavior and try to determine cause, provide care in calm unhurried manner, consult my medical doctor (MD) PRN, Document behaviors, during abusive behavior, involve staff that have better success at redirecting. An interview was conducted on 6/29/17 at 2:45 p.m. with Licensed Practical Nurse (LPN) VV. She was asked what target behavioral monitoring was the staff assessing for R#4? She stated he has behavior outburst, he hoards things in his wheelchair, when you attempt to remove them he has an outburst and he tends to smear feces on the wall in his bedroom. When asked if smearing feces on the wall was a behavioral problem? She stated I guess not.",2020-09-01
982,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,334,C,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to minimize the risk of residents acquiring, transmitting or experiencing complications from influenza and pneumococcal pneumonia by assuring that each resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunizations and documenting in each resident's medical record whether the resident received or refused influenza immunizations. The deficient practice impacted all 110 of the 110 residents in the facility. Findings include: 1. Review of resident medical records revealed the lack of documentation that they were provided education regarding the benefits and potential side effects of influenza and pneumococcal immunizations and whether they were administered the flu or pneumococcal vaccines. Interview on 6/29/2017 at 10:12 a.m. with Licensed Practical Nurse (LPN) HH the infection control designee revealed she did not document in each resident's record whether they were provided education regarding the benefits and potential side effects and whether they received the influenza immunization. Instead she maintained a written list on a yellow pad or plain paper of each resident who was administered the influenza vaccine. Documentation that the resident or responsible party was provided education regarding the benefits and potential side effects of influenza immunization was indicated on an Immunization Consent form. The completed form did not become a part of the resident's medical record at any time and the form was maintained in a white binder. Review of the facility's policy and procedures titled Influenza Vaccine revised 2007 revealed: 5. For those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering and the site of vaccination will be documented in the resident's/employee's medical record. 2. During interview with LPN HH the infection control designee on 6/29/2017 at 10:12 a.m. she stated that residents or their responsible party were not provided education regarding the pneumococcal vaccine and the vaccine was not offered or provided to residents. In addition, she stated that there was no policy on pneumococcal vaccine. The Director of Nursing (DON) was interviewed on 06/30/2017 at 10:39 a.m. He stated, There is no reason why we do not educate, offer or administer the pneumococcal vaccine in the facility. The facility's Medical Director was interviewed via telephone on 6/30/2017 at 1:45 pm. She was queried regarding the rationale for not providing education and offering pneumococcal immunization. She stated, I am not sure. I know we offer the flu. Pneumococcal is given in certain cases. We would not give it to everyone. It is not a requirement to give it. Review of facility's physician standing orders revealed, (MONTH) have annual flu vaccine and TB test unless contraindicated. (MONTH) have the [MEDICATION NAME] every 5 years unless contraindicated. Observation of the medication refrigerators on the East Unit with LPN UU and the West unit with LPNs GG and LPN VV revealed that there was no pneumococcal vaccine in the facility.",2020-09-01
983,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,371,E,0,1,6YM511,"Based on observation, staff interview and policy review the facility failed to ensure resident kitchen pantries were used for resident food and that the food items were identified by resident name and dated for 2 of 2 pantries. This has the potential to affect 107 of 110 residents who may have food stored in the kitchen pantries. Finding include: 1. On 6/26/17 at 10:25 a.m. during the initial tour of the West Wing, 600 hall, of the facility the kitchen pantry was observed. The refrigerator/freezer combination had multiple items that were not resident specific or were not labeled and dated. The following items were observed: -one foil wrapped package labeled with a resident name but was not dated. -one plastic Ziploc bag with a hot dog and hot dog bun with no name or date. -one Styrofoam go box with a name on it that was not a resident and no open date. -three 20 oz water bottles that were frozen with no names. -1 1/2 full bottle of[NAME]Fanta that was frozen with no names. During an interview on 6/26/17 at 10:25 a.m., Certified Nursing Assistant (CNA) OOO, stated she did not know who the unmarked items belonged to but the Styrofoam container belonged to a resident. 2. On 6/30/17 at 10:08 a.m. the refrigerator on the 300 hall of the East Wing was observed. There was a large pitcher of brown liquid that was not identified or dated. During an interview at 10:08 a.m. Licensed Practical Nurse (LPN) UU stated she had checked the refrigerator that morning. 3. A tour was conducted on 6/28/17 at 3:40 p.m. of the West Night Kitchen the following objects were located in the refrigerator: -foil wrapped unknown object dripping a yellow substance with a name written on top of it but no date sitting on the second shelf, -one (4) once container of Dannon strawberry banana yogurt dated (MONTH) 13, (YEAR) -two cartons of chocolate milk dated 26 Jun 17 and 10 Jun 17 (which were frozen) located on bottom shelf. -Located in the freezer compartment was two open containers of Mayfield banana Split ice cream that was labeled with a name but was not dated. An interview with Registered Nurse (RN) DD, was conducted on 6/28/17 at 3:50 p.m. RN DD confirmed this refrigerator was for resident food only and that the food observed was either expired or not stored or dated as per policy which was posted on the front of the refrigerator.",2020-09-01
984,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,428,D,0,1,6YM511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the Pharmacist failed to identify concerns with 1 of 5 Residents (R) (#116) that was not administered all of his ordered morning medications on his scheduled dialysis days. The stage 2 sample size was 42 residents. Findings include: Review of R#116's electronic medication administration review (E-MAR) for (MONTH) (YEAR) and (MONTH) (YEAR) revealed he was not given multiple morning medications each month on his dialysis days. R#116's dialysis days were Monday, Wednesday and Friday. The (medications not documented as given were: Nepro carb steady a liquid nutritional supplement, Vitamin C 500 milligrams (mg) for wound healing, gabapentin 300 mg for nerve pain, ferrous sulfate EC 324 mg for anemia, Florastor 250 mg a probiotic, Senna 8.6 mg for constipation, Miralax 17 grams (gm) in 8 ounces of water for constipation, clopidegrel 75 mg a blood thinner, midodrine HCL 10 mg an anti-hypotensive, Renvela 800 mg 2 tabs a phosphorus reducer in dialysis patients, Thera tablet a multivitamin, and Folic Acid 1 mg for anemia. The nurses documented the medication as not given with the reason resident not available on 14 days in (MONTH) and 13 days in June. The majority of the days the medications were not given in the morning were dialysis days. Review of R#116's physician's orders [REDACTED]. Interview with the West Wing Unit Manager on 6/29/17 at 2:52 p.m. confirmed there were no orders to hold his medications on dialysis days or to send them with him to take while out of the facility. She also revealed no one had thought about adjusting his medication times on dialysis days. From (MONTH) (YEAR) through (MONTH) (YEAR) the Consultant Pharmacist performed a monthly review of all medications for R#116 as prescribed. The monthly drug regimen review did not address the missed medications or provide any suggestions or directions that could be implemented to ensure R#116 received all of his prescribed medications including those scheduled in the morning on his dialysis days. A facility policy related to medication administration on dialysis days was not available for review.",2020-09-01
985,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,431,E,0,1,6YM511,"Based on observations, review of the facility's Storage and Expiration of Medications, Biologicals, Syringes, and Needles Policy, most recently revised on 1/1/13, and interviews, the facility failed to ensure all drugs and biologicals stored in the facility were safe for resident use. Specifically, two of two facility drug storage areas were maintained at temperatures that were above safe storage parameters, and multiple drugs and supplies were found in two of two drug storage areas that were expired. Findings include: The facility's Storage and Expiration of Medications, Biologicals, Syringes, and Needles Policy, most recently revised on 1/1/13 read, in pertinent part, Facility should destroy or return all discontinued, outdated/expired, or deteriorated medications or biologicals in accordance with Pharmacy return/destruction guidelines and other applicable law;, and should ensure medications and biologicals have not been retained longer than recommended by the manufacturer (the expiration date);, and Facility should ensure that medications and biologicals are stored at their appropriate temperature according to the United States Pharmacopeia guidelines for temperature ranges (Room Temperature 59 degrees to 77 degrees Fahrenheit). 1. Expired medications: [REDACTED] -One bottle of Aspirin 81 milligram with an expiration date of (MONTH) (YEAR) -One bottle of Aspirin 81 milligram with an expiration date of (MONTH) (YEAR) -One Heparin Flush in a 5 milliliter syringe with an expiration date (MONTH) (YEAR) -Seven Central Line Dressing Kits with expiration dates of (MONTH) (YEAR), four dated (MONTH) (YEAR), (MONTH) (YEAR), and Janury (YEAR). During an interview with Licensed Practical Nurse (LPN) UU on 6/29/17 at 9:30 a.m., she stated, I should be checking expiration dates for supplies (in the medication storage room) and CS (Central Supply) should be checking medications. There has not been a designated person to do these tasks for the last 6 months or so. The person who used to check has been gone for about 6 months. She was doing central supply and she used to check (for expired medication and biologicals). I have kind of taken over. But not officially. The West Unit Medication Storage Area was observed on 6/29/17 at 9:50 a.m. The following medications and biologicals were found: One bottle of Tri-Buffered Aspirin with an expiration date of (MONTH) (YEAR) One bottle of Tri-Buffered Aspirin with an expiration date of (MONTH) (YEAR) One Open Tracheostomy Care Tray (with no expiration date) Four Central Line Kits with expiration dates of (MONTH) (YEAR) One Central Line Kit with an expiration date of (MONTH) (YEAR) One Central Line Kit with an expiration date of (MONTH) (YEAR) During an interview with Registered Nurse (RN) DD on 6/29/17 at 9:55 p.m., she stated, Central Supply stocks the (medication storage) room. It is all of our jobs (licensed nurses) to check the dates for expiration. When Central Supply puts new supplies up (in the medication storage area), they do a check. During an interview with the Central Supply Manager on 6/29/17 at 10:25 a.m., she stated, I stock the (Medication Storage) rooms. I stock both medications and supplies. I check how many medications I have and check the expiration (date) on Mondays, Wednesdays, and Fridays. I check the oxygen tubing, but I think nursing is supposed to check the rest of the supplies. When I find something about to expire, I move it to the front so it gets used and nursing can find it. The Central Supply Manager stated that she was not aware that expired medications and biologicals were in the Medication Storage Areas. 2. The East Medication Storage Area was observed on 6/29/17 at 10:15 a.m. The temperature in the room was taken by the Maintenance Director and registered as 84.5 degrees. The West Medication Storage Area was observed on 6/29/17 at 10:20 a.m. The temperature in the room was taken by the Maintenance Director and registered 82.5 degrees. During an interview with the Maintenance director on 6/29/17 at 10:15 a.m., he stated he did not realize the medication storage area was supposed to be checked for temperature. He stated no one had been monitoring the temperatures in the rooms. During an interview with the Central Supply Manager on 6/29/17 at 10:25 a.m., she stated, I know that meds should be kept in a cool dry place, but I don't know what the temp is supposed to be.",2020-09-01
986,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,441,F,0,1,6YM511,"Based on staff interview, review of the facility's policy titled Infection Surveillance dated 11/28/16 and record review, the facility failed to maintain an infection control program that demonstrated ongoing surveillance, recognition, investigation and control of infections to prevent the onset and the spread of infection. The deficient practice affected all 110 of the 110 residents in the facility. Findings include: During interview with Licensed Practical Nurse (LPN) HH the infection control designee on 06/29/2017 at 10:12 a.m. she stated, I do not have surveillance books or logs. I look at who has antibiotic orders and I give that list to the Director of Nursing (DON). Further interview with LPN HH revealed she had been the infection control designee for a year. She stated, I never received training. When I asked anyone, no one could tell me whether I was doing things right, so, I kept on doing things the way I was doing it. The Director of Nursing (DON) was interviewed on 6/29/2017 at 1:51 p.m. regarding a system that included surveillance, investigation, prevention, control and reporting infections. He provided the following forms: Monthly Infection Rates by Site with data for (MONTH) through (MONTH) of (YEAR). Infection Log with data for (MONTH) through (MONTH) of (YEAR) and Healthcare-Associated Infection Summary Report by Resident Days for (MONTH) and (MONTH) of (YEAR). He was unable to describe how the forms were utilized or the interrelatedness. He stated that there was no other data or documentation of an ongoing system of surveillance and investigation in the facility. He further stated that there was no current surveillance system in place because there had not been a DON since March. Review of the facility's policy titled Infection Surveillance dated 11/28/16 revealed, The (designated Infection Preventionist) serves as the leader in surveillance activities, maintains documentation of incidents, findings and any corrective actions made by the facility and reports surveillance findings to the facility's Quality Assessment and Assurance committee, and public health authorities when required. In addition, the policy indicated, An annual infection control risk assessment will be used to prioritize surveillance efforts. In turn, surveillance data will provide information for subsequent infection control risk assessments. The facility failed to implement its infection control policy and procedures.",2020-09-01
987,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,465,D,0,1,6YM511,"Based on observation, interviews and review of an undated policy Cleaning and Disinfection of Environment Surfaces, it was determined the facility failed to maintain a sanitary and comfortable environment for one of six resident halls. Failure to remove urine and feces from the floor of resident room 406 for the stated past two years created an unsanitary and uncomfortable environment for residents, staff, and the public. Findings Include: During observational rounding on 6/28/17 at 10:00 a.m., there was a foul ammonia smell at the end of the West Wing 400 hall, in the proximity of room 406. An environmental tour was conducted on 6/30/17 at 10:13 a.m., accompanied by the Plant Supervisor (PS). Upon entering room 406 there was a strong ammonia smell, the PS pointed out a large yellowish-brown area on the floor tile at the head of the bed one. When the Surveyor and the PS inspected the stain, it reeked of ammonia and other indescribable smells. The Surveyor asked the PS if maintenance was responsible for removing the tiles and he said no it would up to housekeeping to remove the stain. The surveyor asked to speak to the Housekeeping Supervisor (HS), who explained when asked what the stain was that it was feces and urine. When questioned as to how often housekeeping cleans the floor, he responded housekeeping mops the floor every morning. When asked how long the stain had been there both the PS and HS responded approximately two years. The HS stated they had tried to remove stain unsuccessfully. At that time, the PS took his pocket knife out and proceeded to start scraping the yellowish-brown substance off the floor. An interview with housekeeper (HSK) HH was conducted on 6/30/17 at 10:26 a.m. HSK HH was questioned if she was aware of the stain on the floor at the head of the bed of room 406-1. She stated she was aware of it and had tried to mop and scrape it up. When asked how long she had been employed at the facility she replied about four months. HSK HH was also questioned concerning why there were no privacy curtain for 406-2 and she stated she didn't know about the curtain. An interview with the HS was conducted on 6/30/17 at 10:29 a.m. concerning the missing privacy curtain for room 406 and he stated he had been here for about 1month and doesn't remember a curtain. An interview was conducted with Registered Nurse (RN) DD on 6/30/17 at 10:30 a.m. RN DD was questioned if she knew about the stain on the floor in room 406 or where bed two's privacy curtain was located. She stated she was not aware of the floor stain but that the curtain has been down since Monday and that she was aware that the resident paints his room walls with feces. An interview was conducted with HSK BB on 6/30/17 at 10:35 a.m. She was questioned where the privacy curtain was, she stated they were taken down on Monday because there were feces smeared on them. They have replaced bed one's privacy curtain and will replace bed two's curtain today. An interview was conducted with the Administrator at 6/30/17 at 11:20 a.m. The Administrator was asked if she was made aware of the floor tiles being stained with urine and feces in room 406. The Administrator stated she was not aware of the stain but feels if the resident has a problem with smearing feces than staff needs to be toileting him every hour. A review of an undated policy Cleaning and Disinfection of Environment Surfaces, page two, paragraph nine, revealed Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. A review an undated policy Cleaning Spills or Splashes of Blood or Body Fluid, revealed Spills or splashes of blood or other body fluids must be cleaned and the spill or splash area decontaminated as soon as practical.",2020-09-01
988,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,490,J,0,1,6YM511,"Based on review of the facility Administrator Job Description signed by the Administrator and dated 2/23/16, observation, record reviews and interviews, the facility's Administration failed to implement its resources effectively and efficiently to prevent instances of sexual and physical abuse and failed to investigate and report allegations of sexual and physical abuse to protect Residents (R) #62, R#105, R#110 and R#170. This failure placed residents at further risk for ongoing sexual, physical and verbal abuse. The sample size was 42 residents. On 6/30/17, 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. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: Observations, clinical records review, and staff interviews revealed that the facility was not in substantial compliance during the standard/extended survey of 6/26/17 through 7/1/17. Refer to the following deficiencies for specific details of noncompliance: Cross reference to F223: The facility failed to ensure four Residents (R) #62, R#105, R#110, and R#170) were free from abuse to include resident to resident abuse and staff abuse of a resident. Cross reference to F225: The facility failed to investigate and report allegations of abuse for four Residents (R) (R#62, R#105, R#110, and R#170). Cross reference to F282: the facility failed to follow the Behavior Care Plan interventions to assess the need for a psych consult for mood, behavior, or psychosocial wellbeing changes; Social Services involvement if needed; inform physician of behavior for possible medication changes for one resident (R#14). Cross reference to F490: The facility's Administration failed to implement its resources effectively and efficiently to prevent instances of sexual and physical abuse and failed to investigate and report allegations of sexual and physical abuse to protect Residents (R) #62, R#105, R#110 and R#170. This failure placed residents at further risk for ongoing sexual, physical and verbal abuse. Cross reference to F520: The facility failed to maintain an effective Quality Assurance (QA) program which systematically reviewed, developed, and implemented plans to correct quality deficiencies for all 110 residents living in the facility as of 6/26/17. The facility's QA program failed to: Identify and respond to a pattern of failures regarding the identification, protection, investigation, and timely reporting of allegations of sexual and physical abuse. The Administrator Job Description, signed by the Administrator and dated 2/23/16 read, in pertinent part, Summary: Lead and direct the overall operation of the facility in accordance with resident needs, government regulations and Company policies so as to maintain care for the residents while achieving the facility's business objectives by performing the following duties personally or through subordinate supervisors; and Essential Job Functions: Implements and communicates policies and procedures for various departments; Conducts regular rounds to monitor residents needs are being addressed; Maintains a working knowledge and ensure compliance with all governmental regulations; Maintains (Company's) Quality Assurance Standards; Understands, complies with and promotes all rules regarding Residents' Rights; and Report all accidents and incidents. During an interview with R#105 on 6/29/17 at 6:10 p.m., revealed that R#14 came up beside him and hit me and bruised my right testicle. My testicle is swollen up big now, and I have to go back to the doctor again. I have a bad bruise and I may have to have surgery. I went to the doctor's office (urologist) after the doctor here got me an appointment. And that he went to Administrator on 5/25/17, and talked to her and told her I want to keep R#14 away from me and that she keeps coming in my room. The Administrator told R#105 that she was going to move him to another home. R#105 verbalized that he had reported R#14's behaviors towards him multiple times, however he was unable to recall specific names and dates of the reports. Record review revealed a Departmental Note for R#105, dated 7/9/16, documented by RN BB documented in pertinent part, Resident (R#105) reported that R#14 was sexually harassing him and further revealed he reported it to the lady in the front and Departmental Note documented by RN BB revealed that she had spoken with the DON (Director of Nursing) and the Administrator. Record review revealed a Departmental Note for R#105, dated 1/19/17 that documents, in pertinent part, Resident (R#105) reported that (R#14) came into his room without permission while he was finishing breakfast. During an interview, conducted with Licensed Practical Nurse (LPN) AAA on 6/29/17 at 5:55 p.m., revealed that LPN AAA was aware that R#14 touches peoples' privates, and that R#105 has a big issue with her. He has reported this to the Administrator several times. She (R#14) comes in his room at night and she'll touch his privates. He told me directly that he reported it to the Administrator. During an interview with RN BB on 7/1/17 at 10:25 a.m., she stated, I remember reporting to the DON and Administrator regarding the incident reported by (R#105). It was the current Administrator and the former DON. At that time, the former DON said she was aware of the situation. An interview on 6/26/17 at 5:10 p.m. with the Social Services Director (SSD) revealed that R#62 reported today, 6/26/17, further interview revealed that the Administrator stated that she did not complete a grievance or report because she didn't see it as an incident. She felt it was resolved because he stated to her they had roughly washed his hair. Post survey interview on 7/7/17 at 10:27 a.m. with the Administrator revealed that she considered that when the grievance documented that the resident's head was bumped, or that the resident verbalized that the CNA was pushy, and that he was scared of the CNA that she considered those grievances to be potential abuse and that the grievances had been investigated, but they had not been reported to the State Survey Agency (SSA). Further interview revealed that the Administrator stated that the grievances had not been reported to the SSA because they were late entries and then in further interview the Administrator stated the grievances had not been reported because these grievances had been placed in a file and that it (the grievance being reported) had just been missed. Review of deficient practices identified putting residents of the facility in immediate jeopardy: F223, F225, F282, F490, and F520 identified the facility Administrator failed to perform the duties per the job description to meet resident's needs, meet government regulation and implement or develop facility policies to protect residents from abuse, investigate abuse and report abuse as required.",2020-09-01
989,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2017-07-01,520,J,0,1,6YM511,"Based on interview and record review, the facility failed to maintain an effective Quality Assurance (QA) program which systematically reviewed, developed, and implemented plans to correct quality deficiencies for all 110 residents living in the facility as of 6/26/17. The facility's QA program failed to: Identify and respond to a pattern of failures regarding the identification, protection, investigation, and timely reporting of allegations of sexual and physical abuse. On 6/30/17, 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. An extended survey was conducted from 6/30/17 and completed on 7/1/17. On 6/30/17 at 6:17 p.m. the facility's Administrator and Director of Nurses were informed of the Immediate Jeopardy. The noncompliance related to the Immediate Jeopardy was identified to have existed on 7/9/16. The Immediate Jeopardy remained in place and was not removed prior to the survey exit date of 7/1/17, as the facility failed to implement a Credible Allegation of Compliance related to the Immediate Jeopardy prior to the survey exit on 7/1/17 at 12:30 p.m. The Immediate Jeopardy is outlined as follows: The facility failed to adequately protect residents from allegations of sexual and physical abuse, and also failed to investigate and report these allegations to the appropriate agencies. This affected four of 42 Stage 2 Residents (R), R#62, R#105, R#110 and R#170. This failure was identified to have existed since 7/9/16, the date that RN BB documented that R#105 told her that R#14 hit him in the private, which subsequently caused a hematoma to his right testes, and that RN BB told the (former DON) and the Administrator. Record review and interviews revealed that the alleged sexual abuse had not been investigated and had not been reported. The Immediate Jeopardy was related to the facility's noncompliance with the program requirements at 483.12(1). The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J) 42 C.F.R 483.12( c)(1)The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, it the events that cause the allegations involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities, in accordance with State law through established procedures (F225, Scope/Severity J) 42 C.F.R 483.21(b) (3) (ii) Services by qualified persons/ per care plan (b) (3) Comprehensive Care Plans The services must be provided or arranged by the facility, as outlined by the comprehensive care plan, (F282, Scope/Severity J) Effective Administration/Resident Well-Being. (F490, S/S: J). 42 C.F.R. 483.75(o) (1), Quality Assessment and Assurance Committee Members/Meet Quarterly/Plans. (F520, S/S: J) Additionally, Substandard Quality of Care was identified with the requirements at 42 C.F.R. 483.12(1) The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation (F223, Scope/Severity: J); 42 C.F.R 483.12(c) (1) The facility must ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately (F225, Scope/Severity J). The Immediate Jeopardy remained ongoing at the time of exit on 7/1/17 at 12:15 p.m. Findings include: Interview with the Director of Nursing (DON) and Administrator on 7/1/17 at 11:10 a.m. revealed that both had shared responsibility for the facility's Quality Assurance and Performance Improvement (QAPI) program, however, the DON had only been employed at the facility for approximately three weeks prior to the survey and had not attended a QA meeting as of the time of the interview. Deficient areas that were identified through observations, interviews, and record review during the Recertification and extended survey are examples of how the facility's QAPI program failed to function. Refer to the following deficiencies for specific details of the noncompliance that was not addressed by the facility Quality Assurance Committee, including: F223: Residents Rights to be free from Abuse F225: Failed to Investigate reports of Abuse F282: Services by Qualified Persons F490: Effective Administration/Resident Well Being F520: Quality Assurance & Performance Improvement During the interview which began on 7/1/16 at 11:10 a.m., the DON and Administrator were asked if the QA committee had identified the failure to identify, immediately report, thoroughly investigate, and take immediate actions to protect residents from potential abuse. The Administrator stated, Any allegation of abuse should be brought into Q[NAME] We have what we call an incident Log. We should be using the incident log it MUST be completed and then all supporting documentation should be attached to the incident log. We should then summarize the allegations. This has not been happening up to now. They (staff) have just been reporting off on grievances, and this has included verbal reports of missing laundry and things like that. The incident log itself has not been brought into the (QA) meeting. No allegations of abuse have been reviewed in QA up to this point. Further interview with the DON and Administrator revealed that the QA committee had not identified any systemic problems with its abuse/neglect prevention program prior to the survey team bringing the allegations of abuse to their attention during the survey of 6/26/17 through 7/1/17. A request was made for the facility policy for guidance of the QA committee on 7/1/17. The facility did not have a policy for the QA committee to follow.",2020-09-01
990,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-08-08,584,D,0,1,CDOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interviews, the facility failed to ensure privacy curtains were kept clean for five resident rooms on the 600 hall. The facility census was 92 residents. Findings include: Observation on 8/5/19 at 1:57 p.m. revealed two golf ball sized brown spots on the privacy curtain in room [ROOM NUMBER]-2. During an interview at this time, resident stated that his previous roommate had a [MEDICAL CONDITION] and would come out of the bathroom and wipe his hands on the curtain. Resident stated he asked two weeks ago for it to be cleaned. The Minimum Data Set (MDS) Annual assessment dated [DATE] documented R#93 with a Brief Interview of Mental Status (BIMS) score of 13 indicating cognition intact. Further observation on 8/6/19 at 3:00 p.m. and 8/7/19 at 2:00 p.m., revealed privacy curtain in room [ROOM NUMBER]-2 still with two brown spots noted on the curtain. During observation and interview on 8/8/19 at 10:10 a.m., privacy curtain in room [ROOM NUMBER]-2 still noted with two brown spots and R#93 stated they changed it once about a year ago and he is getting ready to pull it down himself and throw it in the hall. During an observation on 8/5/19 at 11:18 a.m. and 8/6/19 at 8:30 a.m., the privacy curtain in room [ROOM NUMBER]-2 was noted to be soiled with brown spots. The privacy curtain for room [ROOM NUMBER]-1 was noted to be soiled with an unidentifiable substance. Observation on 8/5/19 at 11:30 a.m. and 8/6/19 at 8:40 a.m. revealed the privacy curtain in room [ROOM NUMBER]-1 was noted to be soiled with a white substance. The privacy curtain for 603-2 had a brown spot on the curtain. During an interview on 8/8/19 at 1:00 p.m., Housekeeper DD stated the floor techs are responsible for cleaning the privacy curtains. Interview on 8/8/19 at 2:54 p.m. with Housekeeping Supervisor, who manages housekeeping and floor techs, revealed the privacy curtains are cleaned upon request from the housekeeper. He stated housekeeper should be looking and letting him know. He stated there is no schedule for cleaning the privacy curtain and no policy. During observation and interview on 8/8/19 at 4:11 p.m., the Housekeeping Supervisor confirmed the dirty privacy curtains in room [ROOM NUMBER]-2, 604-1, 604-2, 603-1, and 603-2.",2020-09-01
991,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-08-08,606,D,0,1,CDOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure that the hiring of staff was proceeded by a completed background check to ensure that individuals who have been hired have not been found guilty of abuse, neglect, exploitation, misappropriation of property or mistreatment in a court of law. The facility census was 92 residents. Findings include: Review of employee files for date of hire, dates of licensure/certification, background process completion date, health screen and [MEDICATION NAME] tine testing, revealed one (1) maintenance staff was hired prior to the background check being completed. The maintenance staff was hired on (MONTH) 2, 2019, with continued employment in the facility. The background check was not completed at the time of the survey. An interview with the Corporate Financial Officer and the facility Human Resource Manager on 8/8/19 at 12:25 p.m. revealed the maintenance staff hired on 4/2/19 was not recognized as an active staff person and was missed. His background check was requested on 8/8/19 after the surveyor requested personnel files for the review. An observation on 8/8/19 at 12:35 p.m. revealed the maintenance staff in the hallway of the facility. An interview with the Administrator on 8/8/19 at 12:45 p.m. he confirmed the background check could not be found for the maintenance staff and the maintenance staff person was asked to leave and could not return until the background check was completed.",2020-09-01
992,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-08-08,640,B,0,1,CDOM11,"Based on record review and staff interview, the facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was transmitted within 14 days of discharge to the Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for three of six residents (R) reviewed for discharge (#1, #2, and #3). Findings include: 1. Review of the discharge record revealed R#1 was discharged from the facility on 3/14/19. Review of R#1's MDS list revealed there was an Admission assessment completed on 3/7/19, and the MDS discharge assessment was not completed. 2. Review of the alphabetical census of the current residents dated 8/5/19 revealed R#2 no longer resides in the facility. Review of R#2's MDS list revealed there was an Admission assessment completed on 3/8/19, but there was no MDS discharge assessment listed. 3. Review of the alphabetical census of the current residents dated 8/5/19 revealed R#3 no longer resides in the facility. Review of R#3's MDS list revealed there was an Admission assessment completed on 3/8/19, but there was no MDS discharge assessment listed. During an interview on 8/8/19 at 1:48 p.m., MDS Coordinator AA revealed the facility did not have an MDS Coordinator for four months. She has been employed for two weeks and confirmed the above discharge assessments had not been completed. She stated they pulled the schedule from (MONTH) 1 until now and have been trying to catch up. MDS Coordinator AA stated that she is unable to transmit assessment because she does not yet have her password. Interview with the Director of Nursing on 8/8/19 at 5:04 p.m. revealed she expects staff to conduct and transmit assessments timely. She stated that the corporate nurse could have been transmitting the assessment in the meantime while the new MDS staff are waiting on passwords. Review of the document titled Chapter 5: Submission and Correction of the MDS assessment dated (MONTH) 2019 revealed for all non-Admission OBRA and PPS assessments, the MDS Completion Date must be no later that 14 days after the Assessment Reference Date.",2020-09-01
993,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-08-08,656,D,0,1,CDOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility failed to develop a person-centered care plan related to use of an indwelling Foley catheter for one resident (R) (#12) of 38 sampled residents. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] and Quarterly assessment dated [DATE] for R#12 documented resident with [DIAGNOSES REDACTED]. Section H - Bladder and Bowel revealed resident has an indwelling catheter. The Care Area Assessment (CAA) Summary triggered urinary incontinence and indwelling catheter with the option to be included in the care plan. Observation and interview on 8/6/19 at 3:12 p.m. and 8/7/19 at 8:55 a.m. revealed R#12 has an indwelling Foley catheter and refused catheter care. Review of the current Physician Orders for R#12 revealed an order dated 5/31/19 to change Foley catheter monthly and as needed. Review of the care plan last updated on 8/2/19 revealed no care plan related to an indwelling Foley catheter. Interview with the MDS Coordinator NN on 8/8/19 at 1:48 p.m. revealed the facility did not have an MDS Coordinator for four months and they have been playing catch up with assessments and care plans. Interview with the Director of Nursing on 8/8/19 at 5:00 p.m. revealed she was unaware that the resident did not have a care plan for the indwelling catheter and expects there to be a care plan for the catheter to include refusing catheter care. Review of the facility policy titled Care Planning - Interdisciplinary Team revised (MONTH) 2013 revealed policy statement: facility's care planning team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is developed within seven days of completion of resident assessment.",2020-09-01
994,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-08-08,684,D,0,1,CDOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interviews, the facility failed to administer eye drops per Physician Orders in a timely manner for one resident (R) (#57) of 38 sampled residents. Findings include: Review of the clinical record revealed R#57 was admitted to the facility with a [DIAGNOSES REDACTED]. Review of the MDS Quarterly assessment dated [DATE] revealed R#57 with a Brief Interview of Mental Status (BIMS) score of 4 indicating severe cognitive impairment. Observation and interview on 8/5/19 at 2:54 p.m. revealed R#57 with crust on eyes and eyes were red. She stated the nurse put drops in for about two days and she has not received any drops since then and did not know what was going on with her eyes. Observation and interview on 8/7/19 at 8:55 a.m. revealed R#57 up walking around in the room. Resident stated she just washed off in the bathroom. Residents eyes no longer had crust on them but lower lid was drooping and bright red. Review of the current Physician Orders revealed an order dated 8/3/19 for [MEDICATION NAME] 0.0025 % drops one drop in each eye every 12 hours for five days and was discontinued on 8/6/19 and an order dated 7/27/19 for [MEDICATION NAME] 0.3 % eye drops one drop to left eye every 8 hours for five days. Review of the Medication Administration Record for (MONTH) 2019 revealed the medication [MEDICATION NAME] 0.0025 % ordered 8/3/19 was documented as administered 8/3/19 through 8/6/19 with the exception of the morning dose on 8/5/19 which was documented as unavailable. Interview with Nurse Practitioner (NP) FF on 8/8/19 at 11:56 a.m. revealed she comes one time per week and was at the facility on Friday 8/2/19 and ordered the eyes drops for five days. She was unsure of why the eyes drops were not given for the full five days. Review of a fax document dated 8/6/19 revealed the facility authorized the non-covered medication on 8/6/19. NP FF provided a fax document of notification to the physician dated 8/6/19 which indicated the [MEDICATION NAME] eye drops would not be available until 8/7/19. Interview with Licensed Practical Nurse (LPN) EE on 8/8/19 at 3:06 p.m. revealed the medication was supposed to be available to the resident on 8/7/19 and was not available prior to that date. She was unable to explain why it was documented on the MAR as being administered to the resident. Interview with the Director of Nursing on 8/8/19 at 5:00 p.m. revealed the facility receives a fax for any non-covered medication and the facility will usually go ahead an get the medication for the resident. She stated the expectation is for staff to clarify with the physician and to notify her if any medication is unavailable for the resident. Observation with LPN MM on 8/8/19 at 7:30 p.m. revealed only [MEDICATION NAME] eye drops in the medication cart and no [MEDICATION NAME] eye drops for R#57. She demonstrated on the electronic MAR that each medication if shown and signed off individually. The ordered medication was still not available at this time for administration and could not have been administered previously as indicated on the MAR. Review of the facility policy titled General Dose Preparation and Medication Administration dated (YEAR) revealed that during medication administration, the facility staff should take all measures required by facility policy and applicable law, including, but not limited to the following: administer medications within timeframes specified by facility policy.",2020-09-01
995,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-08-08,761,E,0,1,CDOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure medications were dated with an opened date and failed to remove expired medications on three of three medication carts. Findings include: A review of the facility policy titled 6.0 General Dose Preparation and Medication Administration revised 1/1/13 revealed in section 3, item 3.11: facility staff should enter the date opened on the label of medications with shortened expirations dates (e.g., insulins, irrigation solutions, etc.). Item 3.11.1 on page two indicated facility staff may record the expiration date based on date opened on the label of medications with shortened expiration dates. Section 4, item 4.1.3 indicated (facility staff should) check the expiration date on the medication. A review of the facility policy titled 5.3 Storage and Expiration of Medications, Biologicals, Syringes, and Needles revised 10/31/16 revealed the policy sets for the procedures for relating to the storage and expiration dates of medications. Section 4 indicated the facility should ensure that medications that have an expiration date on the label are stored separately from other medications. Section 5 indicated facility staff should record the date opened on the medication container when the medication has a shortened expiration date. Item 16 indicated the facility should destroy or return all outdated/expired medications in accordance with Pharmacy return/destruction guidelines. A review of the facility Insulin Storage Recommendations document, dated (MONTH) 2019, revealed [MEDICATION NAME] and [MEDICATION NAME]expire 28 days after opening when held at room temperature. An observation of the West wing medication cart on 8/7/19 at 8:45 a.m. with LPN GG revealed one vial of [MEDICATION NAME] 70/30 insulin for resident #20 with an expiration date of 8/3/19. The medication had been expired for four days. An opened bottle of floor stock [MEDICATION NAME] with no open date was found on the West wing cart. In an interview with LPN GG on 8/8/19 at 8:45 a.m., she reported it is the responsibility of the nurse to date medications when they are opened, and it is the responsibility of the nurse to remove expired medications from the cart and to notify the pharmacy of the need for more medication. An observation of the East Wing/300-hall medication cart on 8/7/19 at 9:10 with LPN LL revealed: one vial of [MEDICATION NAME] with no opened date, one bottle of eye drops with an opened date of 6/1/19 for resident #20, one opened bottle of eye drops with no date and one vial of [MEDICATION NAME]with an expiration date of 7/4/19 for resident #350. An observation of the East Wing/100-hall medication cart on 8/7/19 at 9:25 a.m. with LPN II revealed: one opened bottle of Levetiracetam Oral solution with no opened date; and one opened bottle of Latanoprost Ophthalmic solution 0.005% with expiration date of 7/11/19 for resident #22. In an interview with LPN II on 8/7/19 at 9:25 a.m., she reported the nurses are responsible for checking the medication cart for expired medications and the nurse is responsible for writing the open date on medications when they are opened. She reported this is important because medications have different expiration dates, some expire in 28 days, some expire in 48 days, and some expire according to the manufacture's expiration date. She reported she does not know when the expiration date is for the Levetiracetam oral solution. She reported the expired Latanoprost Ophthalmic solution should have been removed from the cart and reordered. A review of the medical record confirmed resident #20 has a physician order for [REDACTED]. A review of the Medication Administration Record [REDACTED]. The resident received [MEDICATION NAME] nightly at 9:00 p.m. on (MONTH) 1 through 6. A review of the medical record confirmed resident #22 has an order for [REDACTED]. A review of the medical record confirmed resident #350 has an order for [REDACTED]. The resident did not receive the eye drops in (MONTH) 2019. An interview the Director of Nursing on 8/7/19 at 1:10 p.m. revealed nursing is supposed to check the medication cart for expired medications and should check the medication prior to administration to ensure no expired medications are given. She reported expired medications should be removed from the medication cart by the nurse and placed in the pharmacy pick-up box for disposal.",2020-09-01
996,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-08-08,812,E,0,1,CDOM11,"Based on observations and staff interviews, the facility failed to ensure the microwave and pantry freezer were clean and that all items in the resident pantry refrigerator were labeled and dated on the 600 and 300 halls. Findings include: Observation on 8/8/19 at 5:00 p.m. of the night kitchen located on the 600 hall revealed the following: one loose individually wrapped frozen food item in the freezer with no label or date, one grocery bag with one capri sun and two breakfast sandwiches with no label or date. The microwave was noted to two large areas of rust colored spots on the left back corner of the microwave and on the right side of the microwave door. Observation on 8/8/19 at 5:15 p.m. of the night kitchen located on the 300 hall revealed the following: one loose individually wrapped frozen food item in the freezer with no label or date, the freezer had ice buildup and an unknown spilled substance. The microwave was noted to be rust colored around the frame of the microwave and on the inside at the back, and the lower edge was peeling away. Interview with Unit Manager CC and the Dietary Manager on 8/8/19 at 5:20 p.m. revealed they did not know why the items are undated and unlabeled and that the freezer needed defrosting. UM CC stated the microwave in the night kitchens are used to warm resident's food. After observing the microwave, the UM confirmed the condition of the microwave and stated it was in poor condition to be used for the residents. Review of the undated facility policy titled Use and Storage of Food Brought in by Family or Visitors which was located on the wall in the night kitchen revealed: 2. All food items that all food items that are already prepared or visitor brought in must be labeled with content and dated.",2020-09-01
997,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-08-08,880,D,0,1,CDOM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to store and label personal care items in a sanitary manner to prevent cross contamination on one of five halls. Findings include: A review of the facility policy titled Dentures, Cleaning and Storage with a revised date of (MONTH) (YEAR), revealed under the heading Steps in the Procedure, #17 Clean your equipment and return it to its designated storage area (i.e., bedside stand, bathroom, etc.). A review of the facility policy titled Brushing and Combing Hair with a revised date of (MONTH) (YEAR), revealed under the heading Steps in the Procedure, #11 Clean the brush and comb as necessary. Store the brush, comb and mirror in the bedside stand. An observation on 08/05/19 at 11:30 a.m., revealed in the shared bathroom between rooms [ROOM NUMBERS], two tubes of opened toothpaste, one toothbrush, and one hairbrush in a small basin on the shelving above the sink. These items were un-labeled and uncovered. This bathroom is shared between four female residents, three of which have independent access to this bathroom. An observation on 08/05/19 at 11:30 a.m., revealed in the shared bathroom between rooms [ROOM NUMBERS], two tubes of opened toothpaste, a bottle of opened mouth rinse, and one toothbrush sitting on the shelving above the sink; one toothbrush in a toothbrush holder above the sink, and a bar of soap uncovered on the soap tray. These items were unlabeled and uncovered. This bathroom is shared between three male residents, two of which have access to this bathroom. An observation made on 08/06/19 at 10:16 a.m., revealed the uncovered and unlabeled personal use items remain in the shared bathroom of rooms [ROOM NUMBERS] and the shared bathroom of 603 and 604. An observation made on 08/07/19 at 10:16 a.m., revealed the uncovered and unlabeled personal use items remain in the shared bathrooms of rooms [ROOM NUMBERS] and the shared bathroom of 603 and 604. In an interview conducted on 8/8/19 at 3:55 p.m. with CNA JJ, she reported resident toiletries are kept in zip lock bags or plastic totes in the nightstands or closets. She reported if she finds personal items not labeled or stored properly, she would find out who it belongs to then label and store them appropriately. In an interview conducted on 8/8/19 at 4:05 p.m. with CNA KK she reported personal items are supposed to be in a drawer in zip lock bags, but they don't give us zip lock bags anymore, so we use small plastic can liners. She reported she would place toothbrush and toothpaste in one bag, hair comb and hairbrush in a separate bag. She reported these items should be labeled with the resident name or room number and items are to be bagged and in the resident room. In an observation on 8/8/19 at 4:05 p.m. with CNA KK in the shared bathroom for room [ROOM NUMBER] and 602 and the shared bathroom for 603 and 604, she confirmed the personal items were not covered or labeled. In an interview conducted on 8/8/19 at 4:15 p.m. with the Director of Nursing (DON), she reported resident personal toiletries and other personal care items are to be kept in bags with the room number and stored in the bathroom with their names on them and all should be labeled. In an observation on 8/8/19 at 4:15 p.m. of the shared bathroom for room [ROOM NUMBER] and 602, and the shared bathroom for 603 and 604, with the DON, she agreed the personal items in the separate bathrooms were uncovered and not labeled and she reported that she would expect these items to be labeled and bagged.",2020-09-01
998,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2019-10-28,600,G,1,0,NHRP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on interviews, record review and review of the facility policy titled, Abuse Prohibition the facility failed to ensure that one resident (R#1) was free from sexual abuse; and, one resident (R#8, the roommate of R#1), who witnessed the abuse, was free from psychosocial harm from a sample of eight residents. Findings include: The facility had an Abuse Prohibition policy. The policy included a definition of sexual abuse as non-consensual sexual contact of any type with a resident. The policy includes a definition of mental abuse as includes, but not limited to, humiliation, harassment, threats of punishment or deprivation. Identification of Abuse: Neglect, and Exploitation-6. The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: a) resident, staff or family report of abuse; f) physical abuse (sexual abuse) of a resident observed; and g) Psychological abuse of a resident observed. 1. Resident #1(R#1) was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED].); and hypertension. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 7, indicating the resident is severely impaired. Review of the care plan with a start date of 8/22/13 for R#1 revealed a problem area related to assistance required with Activities of daily living (ADL) due to [MEDICAL CONDITIONS], incontinence and impaired mobility and Impaired thought processes related to [MEDICAL CONDITION], that the resident is non-verbal but can answer yes/no by nodding his head. Record review of the facility investigation, dated 8/29/19, revealed an allegation that Certified Nursing Assistant (CNA) AA had sexually assaulted R#1 on 8/26/19. 2. Resident #8 (R#8) was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] revealed a BIMS score of 3, indicating the resident has severe cognitive impairment. Review of R#8's care plan with a start date of 12/30/16 revealed the resident has difficulty communicating needs related to a history [MEDICAL CONDITIONS]. The resident is also care planned for potential mood/behavior due to impaired communication and depression. The resident will refuse medications at times, will cry at times and ask for his family member to be called. The care plan was reviewed and updated on 8/1/19. Review of the written statement from CNA NN, dated 8/27/19, revealed that during patient care for R#8 (roommate of R#1) he was attempting to tell staff something regarding R#1. R#8 was then asked if it was a nurse or a CNA, man or a woman, and when the staff said a man, R#8 responded yeah. When staff asked R#8 what had happened, he pointed to his private area. R#8 was asked if the man did something to R#1's private area and R#8 nodded his head yes. R#8 was asked why he had not turned on his call light and he pointed to the wall where the call light was out of reach. R#8 was very upset and crying. Record review of a written statement by CNA YY, dated 8/27/19, revealed that she had come into help her co-worker with R#8 who was trying to explain something about his roommate, R#1. The statement stated that R#8 was clearly upset. The CNA then asked R#1 if something had happened and if he knew what had happened and R#1 nodded yes. They asked if a CNA had done something to R#1's private area and he nodded yes. When asked why R#1 had not turned on his call light, he pointed to the overbed light, where the call light was out of reach. Record review of a written statement by CNA XX, dated 8/28/19, revealed that she had entered the room of R#1 and R#8 to see if her co-workers needed help. She further revealed that R#8 was trying to explain that something had happened to his roommate (R#1). She further revealed that R#1 was asked if he knew what had happened and he nodded his head yes. R#1 was then asked why he didn't turn on his call light and he pointed to his overbed light on the wall, where the call light was located, out of reach. She stated that R#8 was upset and crying and that the CNA assured the resident that she would get help. Review of a written statement by Licensed Practical Nurse (LPN) FF, dated 8/27/19, revealed that at approximately 4:20 p.m. she was called to the room of R#1, by staff, stating that she was needed to help the resident. The staff believed that something had happened to R#1, sexually, by CNA AA, on the night before. LPN FF interviewed R#1 asking did something happen to him the night before with CNA A[NAME] R#1 bowed his head up and down, indicating yes. LPN FF then asked what had happened, and R#1 pointed to his groin area. LPN FF asked R#1 if CNA AA had touched him and the resident moved his head right to left indicating no. When asked again what had happened, R#1 held his hand in a fist and opened his mouth, making an up and down motion. LPN FF then checked the resident's skin, with permission, which indicated no skin issues. LPN FF then stated that she notified the Administrator, Director of Nursing (DON), family, Physician and the police. A review of the police report dated 8/27/19 at 17:28 (5:28 p.m.) revealed that Police Officer ZZ was notified by LPN FF, that R#1 is non-verbal but can communicate using gestures and can answer yes/no questions. Police Officer ZZ then notified a Detective who then came to the facility and interviewed the R#1 who's family member was now present. Further review revealed that CNA AA was arrested on 8/28/19 and was charged with sodomy, sexual assault and reckless conduct. A review of facility investigation summary which is not dated, revealed that CNA AA was suspended on 8/27/19 when the facility became aware of the allegation of abuse. Review of the facility Separation Notice, dated 8/28/19, revealed that CNA AA was terminated from employment. Review of the personnel file for CNA AA indicated a start date of (MONTH) 2019. Review of the Background check (Georgia Crime Information Center-GCIC) for CNA AA, dated 7/11/19, was performed after the CNA had begun working at the facility, revealed that no adverse records were found. Record review for R#1 revealed Physician Orders, dated 8/29/19, for [MEDICAL CONDITION] panel laboratory test. An interview on 8/29/19 at 1:56 p.m. with R#1, revealed through nodding his head and using hand gestures, that the sexual assault occurred at night and that he knew who did it. The resident gestured with his left hand (the resident is unable to move his right hand) that oral sex (pointed to genital area and his mouth) had occurred. The resident answered no, when asked if he had asked CNA AA for oral sex. When asked if sexual acts were performed in his mouth or rectal area the resident indicated no by moving his head from side to side. When asked if the resident he had witnessed CNA AA abusing other residents the resident moved his head from side to side indicating no. The resident was asked how many times the sexual act occurred, he held up five fingers, indicating it had occurred five times. The resident further indicated that the sexual assault occurred in his bed by pointing at the bed and the privacy curtain. The resident further indicated that he had told a nurse but indicated that the nurse did not understand him. An interview with LPN FF on 8/29/19 at 2:30 p.m. revealed that on 8/27/19 at about 4:30 p.m. that a CNA reported to her that R#1 needed help. The CNA revealed that she went to the resident's room and he communicated, with motion, that oral sex had occurred. An interview on 8/29/19 at 3:40 p.m. with R#8 (R#1's roommate) revealed by pointing behind the curtains, that he saw CNA AA through the curtains. He further revealed that the sexual assault had occurred four times by holding up four fingers. R#8 revealed pointing to his call light and saying no that he pressed the call light, and no one came. An interview with the DON on 8/29/19 at 3:30 p.m. revealed that the sexual assault was reported that afternoon and an investigation was started immediately. She revealed that she did not know how many times the assault had occurred. She revealed that R#1 only reported one occasion; and, had never reported anything to the facility. She revealed that CNA AA never worked again when the allegation was discovered. The DON further revealed that the facility terminated CNA AA on 8/28/19. The DON further revealed that the facility had been notified, by the police, that CNA AA had confessed to sexually assaulting R#1. A follow up interview with R#8 (R#1's roommate) on 10/8/19 at 2:00 p.m. revealed that the sexual act towards his roommate still bothers him. R#8 repeats I saw, I saw and points and pulls the curtain. He further revealed that no one ever came to answer the call light by pointing to the call light and saying No. A post survey telephone interview with the Administrator on 10/24/19 at 2:10 p.m. confirmed that the background check for CNA AA was completed after the start date. The Administrator revealed that background checks were identified during the Recertification Survey of 8/8/19 and was cited as deficient practice. He revealed that all background checks have been completed on existing employees and are completed prior to staff beginning work. A post survey telephone interview with the Detective on 10/28/19 at 9:50 a.m. revealed that during a video investigation interview with CNA AA, that the CNA confessed to sexually assaulting R#1. The Detective further revealed, that during the same video interview, CNA AA confessed to having a chronic [MEDICAL CONDITION]. This confession resulted in an additional charge of reckless conduct. The Detective further revealed that CNA AA remains in jail without bond. A post survey telephone interview with the DON on 11/4/19 at 12:52 p.m. revealed that the Social Worker (SW) had conducted interviews with all male resident's in the building on 8/29/19 related to if they had been abused or had witnessed abused while in the care of the facility, and if they knew how to report abuse if they were a victim or witnessed abuse. The sign-in sheet revealed that 14 male residents were interviewed, and none reported any abuse. A post survey telephone interview on 11/4/19 at 1:17 p.m. with LPN FF revealed that she was notified by the Detective that CNA AA had confessed to sexually assault on CNA AA during the investigation interview. Additionally, the Detective informed LPN FF that CNA AA had also confessed to having a chronic [MEDICAL CONDITION], although he had no laboratory proof. LPN FF further revealed that she had notified the Physician for R#1 who order laboratory test for [MEDICAL CONDITION]. A post survey telephone interview with the Physician for R#1 on 11/4/19 at 1:37 p.m. revealed that she and her Nurse Practitioner are seeing this resident. The laboratory tests were ordered as a precaution and all were negative. She further revealed that the laboratory test will be repeated to ensure the that R#1 remains free of infection.",2020-09-01
999,LAGRANGE HEALTH AND REHAB,115354,2111 WEST POINT ROAD,LAGRANGE,GA,30240,2018-12-18,609,D,1,0,TXXR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on Complainant and staff interviews, and review of the Grievance Log, the facility failed to initiate an investigation of an allegation of missing narcotics for one (1) resident (R#2) from a sample of eight (8) residents. Findings include: Interview on 12/18/18 at 10:50 a.m. with the East Unit Manager EE revealed that a family thought that they had brought medication but home to the facility; but, they had not brought any medication. She revealed that the resident was a Hospice resident from the Hospital and no medications were brought with the resident from the hospital. She revealed that she did not report the allegation because she never received any medication. She revealed that she should have filed this information on a complaint allegation form. Interview on 12/18/18 at 11:55 a.m. with the Complainant revealed that a family member of the resident was concerned about the resident's [MEDICATION NAME]. He revealed that a family member stated that a blister pack of [MEDICATION NAME] was stuck in a Bible although when she checked the Bible the pills were missing. He revealed that the family member had reported the missing narcotic to the staff and that the staff did not do anything about it. Interview on 12/18/18 at 12:55 p.m. with LPN FF revealed that the resident's family member had call her into the room and revealed that the family member had placed a card of medication in a book and it is now missing. She revealed that she referred the family member to the Director of Nursing (DON). She revealed that this was reported to her supervisor immediately. She revealed that she did not fill out a complaint investigation form for the missing medication. Interview on 12/18/18 at 1:10 p.m. with the DON revealed that she talked to the family member, who had a several complaints, although she was never informed of any missing narcotics. She revealed that an investigation was never completed on allegation of missing medication. She revealed that there is not policy of what to do with medications brought into the facility nor the use of the inventory sheet. She revealed that she was not aware of the allegation of the missing medications but that an investigation should have been initiated for the allegation of a missing narcotics. Review of the Grievance Log dated 10/2018, 11/2018, and 12/2018 indicated no investigations about missing medications. Review of the Abuse Policy indicated each resident has the right to be free from abuse, neglect, misappropriation of resident's property. Policy Explanation and Compliance Guidelines indicated that: 1. staff should report allegations or suspected abuse, neglect or exploitation immediately to: Administrator, other Officials in accordance with State Law, State Survey and Certification agency through established procedures. 9. Response and Reporting of Abuse, Neglect and Exploitation- Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: (c.) Initiate an investigation immediately, (e) Obtain witness statements, following appropriate policies, (f.) contact the State Agency and local Ombudsman office to report the alleged abuse.",2020-09-01
1000,DUBLINAIR HEALTH & REHAB,115356,300 INDUSTRIAL BLVD,DUBLIN,GA,31021,2017-05-18,225,D,1,0,3W2811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Grievances, Abuse Policy and Procedure and family and staff interviews, the facility failed to ensure that an allegation of abuse was thoroughly investigated and reported to the Administrator and State Agency (SA) for one resident (R) (R#1) of three residents reviewed for facility investigations of allegations of abuse. Findings include: Review of the facility Grievances, Abuse Policy and Procedures (n.d.) revealed that any person hearing a complaint of abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation must immediately report it to the Administrator, the Social Service Director, the Director of Nursing, and any other department head or nurse in charge. It will be the responsibility of any department head receiving the complaint of alleged abuse, corporate punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation to inform the administrator or designee immediately. [NAME] Review of the facility Reporting of Incidents Policy (n.d.) revealed that once a complaint or situation is identified involving alleged mistreatment, neglect or abuse, the incident will be immediately reported. 1. The Administrator or designee will immediately notify the Complaint Investigation Intake and Referral Unit and the legal representative and/or interested family member of the incident and the pending investigation. The Administrator or designee will direct the investigation. 2. The initial report of incident will be telephoned or faxed in within 24 hours of the incident to the Complaint Intake and Referral Unit. Prior to calling in the incident, the Center Complaint Report Fax Form will be completed. B. A written report of the investigation will be reported to the administrator and the Long Term Care section Complaint Coordinator within five (5) working days of the incident. The investigation includes an interview conducted with all parties. Written signed statements from any and all parties will be obtained if possible. Statements will be gathered from the suspect, person making accusations, patient involved, reliable patients who may have witnessed the incident, and any other persons who may have information. Review of the Quarterly Minimum Date Set (MDS) for Resident (R#1), dated 3/29/17 identified the resident with a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. R#1 is totally dependent on staff and requires assistance for all Activities of Daily Living (ADLs) Review of current care plans in place revealed R#1 has behaviors that include; resistance to ADL care at times by refusing showers and refusing to get out of bed, easily annoyed with staff and at care received. She is noted with forgetfulness, has a history of depression and her mental function varies. Her current [DIAGNOSES REDACTED]. Resident (#1) was not responsive to surveyor attempts in interview during the investigation. Interview with the Resident #1's Family Member on 5/22/17 at 3:17 p.m. revealed that a couple of weeks ago, she informed Registered Nurse (RN) AA that R#1 said that she had been slapped, hit and yelled at by Certified Nursing Assistant (CNA) BB. The family member revealed R#1 said BB had been hollering at her, slapped her, and told R#1 she was going to bathe her even though R#1 did not want the bath. R#1 additionally informed the family member, CNA BB pulled her covers up and hit her underneath the cover. The family member denied seeing any marks on R#1 and does not know when the incident occurred but added, she spoke with RN AA about the incident the next day and was told CNA BB would not be allowed back in R#1's room. The family member is not sure if the CNA ever returned to R#1's room. The family member revealed she expected the nurse to take care of the complaint but she does not believe it was ever investigated. Review of facility grievance logs, and State reportable incidents (MONTH) (YEAR) to current date revealed no grievance report, incident report, progress notes or investigation regarding R#1. Interview with RN AA on 5/18/17 at 10:22 a.m. revealed R#1's family member told her that R#1 said CNA BB was rough with her in the shower but R#1 does not go into the shower. RN AA further revealed she told CNA BB not to go into R#1's room anymore and CNA BB has not entered the room since. When asked about why she did not report or investigate the incident, RN AA added, at the time, I did not see it as an incident or allegation , we have alot of people with behaviors here. I should have written up every allegation and reported it to the family and the doctor. If a patient says someone has abused them or if you see it, you should report it to the immediate supervisor. That is our process and I have been in-serviced on that. Interview with CNA BB on 5/18/17 at 3:09 p.m. revealed she was not aware of what the allegation was against her. CNA BB: further revealed she is on the bath team and has provided bathing care for R#1; however, she made sure that she had a co-worker with her the last few times she bathed R#1 because R#1 is difficult to bathe because of her size. CNA BB also revealed she was not aware of any allegation from the resident about her hitting or cursing her and after she was told that R#1 said something about her, RN AA told her it would be best if she did not provide care for R#1 anymore and CNA BB did not provide care for R#1 again after that incident. CNA revealed she has received in-service training on the abuse reporting process. Interview with the Director of Nursing (DON) on 5/18/17 at 1:24 p.m. revealed that she would expect the nurse in charge to notify her of any abuse investigation so she could investigate. The DON also revealed the RN AA should have notified the physician and family of any allegation of a resident being roughed up and there should have been an assessment. The accused would have been suspended until staff determined she didn't do anything. Interview with the facility Administrator on 5/18/17 at 8:35 p.m. revealed, that her expectation is that the policy is followed, then staff can investigate and let the proper people determine if an allegation is true or not. The allegation should have gone through the investigation process. The Administrator agreed the reporting process was not done per the facility policy.",2020-09-01