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
4235,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2017-01-25,225,D,1,0,HX8G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of policy and procedures, and staff interviews, the facility failed to ensure that a staff member immediately reported a witnessed incident of staff to resident abuse for one of three sampled residents (R) (R#1) to the any department heads until 17 days after the incident. Specifically, on 12/26/16 in the dining room at the end of dinner, Certified Nursing Assistant (CNA) AA witnessed another CNA (CNA FF) grab R#1 by the back of his shirt pulling him down into his wheelchair and pull the resident backward in his wheelchair by his shirt. CNA AA did not report the incident to any department heads until 1/12/17. The Director of Nursing (DON) was able to view the facility surveillance camera and confirmed that CNA FF pulled the resident backward in his wheelchair by first grabbing the back of his shirt collar and then by the middle back of the shirt. CNA FF worked a total of 10 shifts (12/28/16, 12/29/16, 12/30/16, 1/2/17, 1/3/17, 1/4/17, 1/6/17, 1/7/17, 1/8/17 and 1/9/17) after the incident on 12/26/17 but was not assigned to R#1 during these shifts. CNA FF was terminated on 1/13/17. This failure to immediately report staff to resident abuse caused by CNA FF increased the potential of mistreatment to other residents residing in the facility. Findings include: Review of the undated policy titled Abuse Prevention Policy and Procedures documents: Training-During orientation, all new staff and volunteers will be oriented to the facility policy related to Abuse Prevention including what constitutes abuse, mistreatment, exploitation, neglect and misappropriation of resident property; what to do if they hear or see abuse, neglect, mistreatment, exploitation or misappropriation of resident property. Prevention- The facility will provide residents, families and staff information at how and whom they may report concerns, incidents and grievance without fear of retribution. Identification- Identification of injuries or events that are suspicious and may constitute abuse, neglect, exploitation or mistreatment; Identification of coverage and responsibility- Any person hearing a complaint of abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of resident property, or exploitation must immediately tell the Administrator, the Director of Nursing, the Social Service Director, any other department head or the nurse in charge. Review of the facility's follow up letter (reported 1/12/17) to the State Agency- Long Term Care Section- Compliant Unit dated 1/18/17 documented: CNA AA reported that on 12/26/16, around dinner time, she observed that R#1 was very restless and agitated that evening and kept trying to get out of his wheelchair and staff were redirecting him because they were afraid he would stand up and fall. Toward the end of the meal, CNA FF took R#1 by the back of the shirt and snatched him back into his wheelchair. The motion caused him to fall back into the chair and then she pulled him backwards in his wheelchair by the collar/back of his shirt toward the direction of his room. The Director of Nursing (DON) was able to review camera footage of the incident which occurred in the 2S dayroom area and was time stamped on 12/26/16 at 5:40 p.m. Details of incident indicated R#1 is seen seated in his wheelchair with CNA GG seated behind him. He appears restless and persists in trying to stand from the chair. CNA GG is seen redirecting him by patting his shoulders in a reassuring manner. CNA FF is then seen clearing the table of dishes, placing them in a tray rack, then turns and walks toward R#1 who is seated in his wheelchair. CNA GG walks away down the hall, then CNA FF is seen grabbing and pulling R#1 by the back of his shirt collar and begins to roll him backwards in his wheelchair by pulling on his shirt. She then changes her hand position to grab the middle of his shirt and continues pulling him backward to his room. The facility does substantiate CNA wrongdoing and suspicion of resident mistreatment in this incident. CNA FF was terminated on 1/13/17 related to this incident with R#1 for suspected mistreatment of [REDACTED]. CNA AA was given a serious disciplinary action related to not reporting incident timely to appropriate management and educated on abuse policy and reporting protocols with follow up education planned over the next three months. During an interview on 1/25/17 at 12:17 p.m., the Director of Nursing (DON) revealed CNA AA informed her that she did not initially report the abuse of R#1 she witnessed by CNA FF because she didn't want to get anyone fired. The DON further revealed that CNA AA is a mandated reporter and because she did not report the incident right away, she was written up and given a final notice based on her failure to report it. The DON further stated that CNA AA was the only witness to the incident and it was caught on surveillance camera. During an interview conducted on 1/25/17 at 2:21 p.m. with CNA AA, she stated It took me a while to report because I was back there with just her and she would have known I reported her. I didn't want to report because of exactly what's going on now. I got written up for waiting too long. I'm being threatened on face-book. I don't want people to think I will tell any and every little thing. I don't regret it, it's just been a tough couple of weeks for me. Going forward I will say something if I see something. I'm reporting everything I see with no hesitation. I won't think twice about it. I filed a police report just in case something was to happen to me. I don't like confrontation and I just wanted to be careful. We were in serviced on recognizing and reporting abuse since this incident. I have to do in-services on abuse every month for three months. I don't mind. I haven't observed any other instances of abuse before or since that incident. I accept the fact that I did not do the right thing by waiting to report it. I should have reported when it happened. Review of the Shift Assignment Forms indicated that CNA FF worked on the 3:00 p.m. to 11:00 p.m. shift (2 South Hall) on 12/28/16, 12/29/16, 12/30/16, 1/2/17, 1/3/17, 1/4/17, 1/6/17, 1/7/17, 1/8/17 and 1/9/17. The resident's assigned did not include R#1. Review of the payroll Time Detail confirmed these dates. This incident was reported to the State Agency by the local police department on 1/24/16. Review of the (Name) Police Department- CRIME REPORT dated 1/20/17 documented: While on a suspicious activity call at the [NAME]G.[NAME]Nursing Home, I was made aware of a case of elder abuse that reportedly occurred on 12/26/2016. I was speaking with (name) (CNA AA) who was concerned about her safety because she reported a co-worker for elder abuse and got the co-worker fired from her position. (Name) (CNA AA) stated that her co-worker (name) (CNA FF), had mistreated one of their Alzheimer's patients, (name) (R#1) on (MONTH) 26, (YEAR). I asked her what happened. (Name) (CNA AA) told me that (name) CNA FF) was agitating (name) (R#1) while trying to get him ready for the evening. (Name) (R#1) tried to stand up and (name) (CNA FF) grabbed him by the back of his shirt and forced him back down into his chair. (Name) (CNA AA) stated that she witnessed the incident and also knew that the area was monitored by video camera. The incident was caught on the camera and (name) (CNA AA) was able to show her supervisors the incident on video. This incident resulted in (name) (CNA FF) termination, but the criminal activity was not reported to the (name) Police Department. It is not known, at this time, if (name) (R#1) received any visible injuries from the incident.",2020-01-01
4864,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2016-05-13,278,E,0,1,L11S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facilty failed to ensure that the Minimum Data Set (MDS) accurately reflected the dental status for one (1) resident (#158) and failed to accurately assess for the use of a diuretic for six (6) residents (#45, # 59, #78, #109, #121, #156, and #209). The sample size was forty-two (42) residents. Findings include: 1. During observations on 05/10/16 at 12:43 p.m. and 05/11/16 at 8:11 a.m., of resident #158, the resident was noted to be edentulous and have no dentures in place. Review of an Oral assessment dated [DATE] noted that the resident had no natural teeth or tooth fragments (edentulous). Review of a Dentist's Progress Notes dated 06/15/15 noted the resident was edentulous. Review of a Significant Change MDS dated [DATE] noted that the resident was assessed as having no dental issues. An interview with MDS Coordinator AA on 05/12/16 at 3:12 p.m., she verified that the Dental section of the MDS, dated [DATE], was not accurately assessed, as the resident was edentulous. 2. Record Review of the Order Summary for resident #209 dated 4/1/2016 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Admission MDS assessment dated [DATE], Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. 3. Record Review of the Order Summary for resident #121 dated 2/26/2016 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Quarterly MDS assessment dated [DATE], Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. 4. Record Review of the Order Summary for resident #59 dated 3/1/2016, 12/1/2015 and 9/1/15 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Quarterly MDS assessment dated [DATE], 12/10/2015 and 9/18/2015, Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. 5. Record Review of the Order Summary for resident #109 dated 2/1/2016, 4/1/2016 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Quarterly MDS assessment dated [DATE] and 4/26/16, Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. 6. Record Review of the Order Summary for resident #45 dated 4/1/2016 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Admission MDS assessment dated [DATE], Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. 7. Record Review of the Order Summary for resident #156 dated 4/1/2016 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Quarterly MDS assessment dated [DATE], Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. 8. Record Review of the Order Summary for resident #78 dated 3/1/2016 and 12/1/15 revealed the resident had a physician's orders [REDACTED]. [MEDICATION NAME] HCL is a [MEDICATION NAME]. Review of the Quarterly MDS assessment dated [DATE] and 12/24/2015 , Section N, revealed the resident was assessed for diuretic use for seven (7) days, although there was no evidence the resident was on a diuretic. An interview on 5/12/16 at 2:03 p.m. with Registered Nurse (R.N.), MDS Coordinator AA and R.N. BB Nurse Consultant revealed that MDS Coordinator AA felt the residents (#45, 59, 78, 109, 121, 156 and 209) were on a diuertic during this time frame. Registered Nurse (R.N.) BB contacted consultant pharmacisit CC whom confirmed that [MEDICATION NAME] HCL is not a diuretic. R.N. AA revealed at this time that the residents were assessed incorrectly for diuretic use.",2019-04-01
6100,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2015-03-20,241,D,0,1,T23O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide care and services in a manner that promoted dignity during dining for two of two dining observations in the secure unit on the 2nd floor. This deficient practice had the potential to affect all 22 residents who dined in the secured unit. Findings include: On 3/16/15 at 12:35 p.m. two Certified Nursing Assistants (CNA-Employee#92 and CNA#212) placed white paper placemats on four white plastic rectangular tables. With the exception of window valances, the room was bare of homelike decorations. The only background sound was the loud noise from the call light at the Nurse's Station. Facility staff assisted 22 residents on the locked unit to the dining room between 12:38 p.m. - 12:50 p.m. Meal service did not begin until 12:54 p.m. Staff failed to offer beverages to the residents as the residents waited for lunch. Staff failed to offer residents in wheel chairs an opportunity to move from wheel chair to dining chair. As staff assisted each resident to a table, CNA#212 inquired as to their preference for a clothing protector. Two of the residents stated emphatically they chose not to wear a clothing protector. CNA#212 placed clothing protectors on both residents despite their protestations. At 1:19 p.m. the Occupational Therapist (OT-Employee#278) sat at the far end of the smallest table, between two residents. A volunteer stood to the left of OT#278 and slightly behind one of the residents. As OT#278 encouraged that resident to use a weighted spoon, OT#278 spoke to the volunteer about the resident's [DIAGNOSES REDACTED]. The table included five of the resident's peers and CNA #212 at the opposite end. After several minutes of conversation, OT#278 asked CNA#212 a question about the resident, and CNA#212 joined the conversation. Both staff and volunteer failed to engage any of the residents in social dining conversations, but spoke at length to one another about one of the resident's personal clinical information; in front of the resident and the resident's peers. During the dining observation on 3/17/15 at 12:58 p.m., as the last residents entered the dining room, a visitor accompanied one of the residents. The resident was seated at the second table to the right of the entrance. The visitor was holding a large cell phone/tablet and wore a small Bluetooth in her left ear. The visitor utilized the Bluetooth as she entered the dining room and sat on a stool inside the dining room. The visitor was speaking extremely loudly and could be heard throughout the small dining room. After eleven minutes, the visitor moved the stool and sat between the resident at the near end of the table and CNA #92. The visitor continued to talk via Bluetooth, for another 7 minutes. During this time, residents at the table attempted to answer the visitor who was talking into the Bluetooth device. Although staff was in the dining room and at the nursing station, one of the staff reacted to the situation and the visitor was permitted to disrupt the dining experience of 22 residents for a total of eighteen minutes. At 1:09 p.m., OT#278 was again observed at the table and was talking about the above referenced resident's therapeutic progress as the Assistant Director of Nursing (ADON) listened. There were five additional residents seated at the table. During an interview on 3/19/15 at 2:13 p.m., when asked about the observed differences between the main dining room and the secure dining room on the 2nd floor, the facility's Nurse Consultant (NC) stated the main dining room was fine dining. She further stated the fine dining experience included cloth table coverings, glass dishware, and goblets. She could not explain why residents who ate in the secured dining room did not have the fine dining experience. She said the facility did not have a policy to address dining and indicated staff should have intervened with the visitor. An interview on 3/19/15 at 2:59 p.m. with the Rehabilitation Director revealed that OT#278 should not have discussed any resident information in a common area such as the dining room. He further stated the volunteer's role in the therapy department was to assist therapists with the set up process before a therapy, to assist with resident transportation to and from the therapy department and to bring needed items to the therapists. He stated the incident should never have happened that all of the therapists at the facility knew resident dignity was a priority.",2018-03-01
6101,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2015-03-20,242,D,0,1,T23O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to allow a resident to make daily choices about his healthcare to ensure that he could experience the best possible quality of life. This deficient practice had the potential to affect one (R153) resident out of a Stage 2 sample of 36. Findings include: An observation of R153's room on 3/16/15 at 2:10 p.m. revealed that there was a bed in his room but he did not have an electric sleeper reclining chair. An interview conducted on 3/16/15 at 4:10 p.m. with R153 revealed that he was not allowed to bring his electric recliner into the facility. Per the resident, he preferred to sleep in his recliner rather than the facility bed. He slept in his recliner when he lived at home. R153 added that he filed a grievance some time ago with the Social Worker (SW). R153 stated that the SW told him that he would need a bigger room if he wanted to bring his reclining chair into the facility. The SW added R153's name to the waiting list for a bigger room that would house both his bed and his reclining chair. R153 stated that he did not remember when he filed the complaint with the SW but he had waited a long time. A confidential interview was conducted on 3/17/15 at 3:20 p.m. with a staff member that revealed that R153 would frequently not comply with sleeping in his bed. The staff member stated the resident complained that his bed was uncomfortable and he could not sleep lying down. The staff member stated that R153 told her that when he slept in the facility bed, he woke up frequently. The staff member added that she was not aware of any reason why R153 could not have his recliner in his room. An interview conducted on 3/18/15 at 2:00 p.m. with the Director of Nursing (DON) revealed that R153 did request a recliner in his room so he could sleep better. According to the DON, there was not enough room for both his bed and a recliner, and the bed would have to be removed, however the DON stated that the bed was necessary to provide emergency care as well as daily care therefore it could not be removed. The DON confirmed that R153 had filed a grievance some time ago about his choice to sleep in his recliner rather than the facility bed. The resident was placed on a waiting list in August 2014 to be moved to a larger private room when one became available. As of the date of the survey, the resident was still on the waiting list for a larger room. R153 was frequently non-compliant with sleeping in his bed. No further action was taken by the facility to resolve the resident's preference for a sleeping recliner. Record review for R153 reviewed he filed a Grievance/Complaint Report on 8/7/14 stating he wanted to have his bed removed from the room. Per the grievance, the resident wanted to bring in an electric recliner instead. A recommendation was made by facility staff for R153 to be placed on a waiting list for a different private room to attempt to accommodate the bed, chair, and other personal items. Review of the Grievance Report revealed that the resident was agreeable on 8/7/14. The report was signed and dated by the employee preparing the form, Administrator, Director of Social Services, and the Director of Nursing. The resident's signature was not on the form. Review of a Social Services Progress Note dated 8/7/14 for R153 revealed that the resident would like to have his bed removed and he would prefer to sleep in his power recliner instead. Per the progress note, the Social Worker (SW) explained to R153 that a bed was a must for medical emergencies and daily care. The SW documented that, the Resident will seek alternate placement and that the, Resident expressed understanding. Also, noted that room changes go through the SW. Once the SW learned of the request, the resident's name was placed on a waiting list. Record review for R153 revealed a Skin assessment dated [DATE] that documented the resident had skin discoloration on buttocks. The care plan dated 1/9/15 addressing skin breakdown noted R153 with open area to scrotum. The Skin assessment dated [DATE] noted R153 with skin intact and buttocks and scrotum noted with redness and discoloration. An interview with the DON on 3/18/15 at 2 p.m. revealed that R153 had some skin breakdown to his scrotum and buttocks from the pressure of sitting in a chair. She added that the resident needed to recline when sleeping to relieve some of the pressure to his buttock area. However, he still did not have his power recliner in his room. Review of R153's care plan dated 1/9/14 with a target date of 6/13/15 addressing skin breakdown revealed: R153 wanted to sleep in chair and have no bed; R153 does not comply with lying down at times; R153 will not get out of chair for rest periods, will not lay down for rest periods; R153 had open wound area with treatment. The intervention noted on the care plan dated 1/9/15 revealed that R153 was advised to sleep in bed. No other interventions relative to R153's choice and preference to sleep in his reclining chair rather than the facility bed were documented. Review of the Bill of Rights for Residents of Long-Term Care Facilities, Georgia Health Code, Chapter 88.19B (Georgia Laws 1981, p.149 et seq.) was viewed hanging on the wall in the front lobby of the facility. Review of the facility's Admission packet revealed a document titled, Resident Federal and State Rights which addressed a resident's right to make choices about aspects of their life in the nursing facility that is significant to them. The document also addressed a resident's rights to retain and use personal possessions including some furnishings",2018-03-01
6102,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2015-03-20,278,D,0,1,T23O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop an accurate comprehensive assessment relative to dental needs for one (R69) of two residents who were evaluated for oral and dental needs out of a Stage 2 sample of 36. Findings include: Observation of R69 on 3/17/15 at 10:30 a.m. revealed that she had many missing teeth and the three teeth that she had remaining were discolored, broken and had sharp edges. Review of the medical record revealed that R69 was admitted on [DATE]. Review of the Minimum Data Set (MDS) quarterly comprehensive assessments dated, 6/25/14, 9/24/14, 12/22/14, and the annual MDS assessment dated [DATE] revealed that staff coded the resident as having no dental or oral concerns. Review of the MDS assessments in Section L- Oral/Dental Status revealed the following questions: A. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) B. No natural teeth or tooth fragment(s) (edentulous) C. Abnormal mouth tissue (ulcer, masses, oral [MEDICAL CONDITION], including under denture or partial if one is worn) D. Obvious or likely cavity or broken natural teeth E. Inflamed or bleeding gums or loose natural teeth F. Mouth or facial pain, discomfort or difficulty with chewing G. Unable to examine H. None of the above I. WAS THE RESIDENT REFERRED TO S(NAME)IAL SERVICES TO ARRANGE FOR DENTAL EXAM? 1. Yes 2. No Review of each of the three MDS quarterly assessments and the annual MDS assessment revealed that staff had coded R69 as H, none of the above and 2 the resident was not referred to Social Services to arrange for a dental exam. Observation and interview with R69 and the Director of Nursing (DON) on 3/19/15 at 3:29 p.m. confirmed that R69's teeth were in very poor condition. The resident stated that her teeth can be painful and she would like to be referred to a dentist. The DON confirmed that R69's oral condition was poor and since her admission to this facility she had not been evaluated by a dentist. The DON added that R69's quarterly and annual MDS assessments were inaccurate.",2018-03-01
6103,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2015-03-20,371,F,0,1,T23O11,"Based on observation, interview and record review, the facility failed to ensure food safety when they did not maintain cold holding food temperatures at 41 degrees Fahrenheit (F) or below at point of service. This deficient practice had the potential to affect all of the residents who ate their meals at this facility. Findings include: Observation of the kitchen on 3/18/15 at 11:45 a.m. revealed the staff had prepared a cold apple dessert for all of the residents including those who had a physician ordered pureed diet. Observation of the upright metal serving cart that housed the cold food revealed that there were approximately 70-100 individual servings of the apple dessert. An interview with the Director of Dining Services (DDS) on 3/18/15 at 12:30 p.m. confirmed that the staff had prepared the apple dessert earlier in the morning and had placed them in the refrigerated unit to ensure food safety. The DDS stated that the meal was ready for service. Observation of the DDS taking the temperature of the apple desserts with a calibrated thermometer revealed that they were holding in the danger zone (41-135 degrees F). The DDS took the temperature of five individual servings of the dessert while still on the metal serving cart at 12:30 p.m. (at point of service) and each of the servings were holding between 72-76 degrees F. Observation of the dining room on 3/18/15 at 12:45 p.m. revealed that staff had served several residents the apple dessert before ensuring the food was holding at the appropriate temperature and safe for consumption. After removing the apple desserts from the resident trays, the DDS proceeded to take the temperature of the apple desserts that remained in the dining room, and they were also holding between 72-76 degrees F. An interview with the DDS on 3/18/15 at 12:45 p.m. confirmed that the apple desserts were holding in the danger zone and that staff should not have served them to the residents until the proper holding temperature had been realized. Review of the facility's Food Safety Audit dated 2/26/15 revealed the following question in section, Q303aM: Foods are actively cooled at the time of the audit. The auditor documented the following answer to the question: Cooling is not actively taking place at the time of the audit. In section Q303bM revealed the following question: All foods in the cooling process are cooled using proper methods and equipment. The auditor documented the following answer to the question: Cooling is not actively taking place. Per the Food and Drug Administration (FDA), cold foods should be kept at 40 degrees F to ensure that they do not become spoiled or dangerous.",2018-03-01
6104,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2015-03-20,441,D,0,1,T23O11,"Based on observation, interview and review of the Employee Handbook, the facility failed to ensure that the direct care staff utilized standard infection control practices during meal service on the secured unit (second floor). This deficient practice had the potential to affect all 22 residents who received their meals in the secured unit's north dining room. Findings include: Observation on 3/16/15 at 12:35 p.m. in the secured unit dining room revealed two Certified Nursing Assistants (CNA-Employee#92 and CNA#212) who began their shift at 7:00 a.m. wearing the same uniforms they wore during the meal service. The CNAs were observed holding the resident's clean paper placemats against their potentially contaminated uniforms while dispensing the placemats. Dining observation on 3/16/15 at 12:38 p.m. revealed staff assisted the residents to the dining area as needed and the residents who were able to ambulate independently did so. Several residents touched the handrails outside the dining room, and those who wheeled in touched the unclean wheels of their chairs prior to the meal. Meal service began at 12:54 p.m. Staff failed to provide residents any type of hand sanitation prior to the meal service. At 1:10 p.m, CNA#212 sat on a rolling stool at the end of the first table to the left from the entrance and moved freely between two residents. As she assisted each resident with various utensils, she touched the resident's hands, arms, glassware by the lip of the glasses, opened straws, readjusted wheelchairs and did not sanitize her hands after touching potentially contaminated objects or between the two residents. During meal observations on 3/16/15 and 3/17/15, CNA#212 was noted to have long acrylic fingernails that extended approximately 1/2 inch past her fingertips. During the first dining observation, (1:03pm-2:00pm) CNA#92 was at the second table to the right of the dining room entrance. CNA#92 had a haircut that was short in the back, but long on both sides of her face. Each time she leaned to assist the resident, her unsecured hair swung across the resident's face and over the plate of food. CNA#92 also had long acrylic fingernails approximately 1/2 inch past her fingertips. The second observation of meal service in the secured unit on 3/17/15 (12:58-1:56pm) revealed both CNA#92 and CNA#212 were assisting residents in the same location as the first dining observation. Both CNA#92 and CNA#212 utilized the same deficient practices relative to infection control as listed in the findings above. An interview on 3/19/15 at 3:52 p.m. with the Assistant Director of Nursing (ADON) revealed she was also the infection control nurse. Interview with the ADON and facility Nurse Consultant (NC) revealed the following: The facility could not provide a policy that addressed assisting multiple residents during meal service. The NC stated if a policy and procedure (P&P) existed, there was no need to look for it as staff had failed to follow the facility's established norm, which did not include feeding assistance to more than one resident at a time. She also indicated staff whose hair was past chin length must have their hair secured. The NC and the ADON stated the facility did not have a P&P relative to acrylic nails or the grooming of fingernails for direct care staff. The NC provided a copy of page 2 of the Employee Handbook and indicated it was the only document the facility had that addressed employee fingernails. The handbook stated, The Company's professional image can be tarnished and in some cases is a safety concern, as well as customers' negative reactions to excessively long fingernails. In October of 2002, the Centers for Disease Control (CDC) recognized the dangers inherent to acrylic nails in healthcare settings and recommended no acrylic nails on direct care staff to protect residents from the spread of infection. Interview with the ADON, the Director of Nursing and the NC on 3/19/15 at 2:30 p.m. revealed they were unaware of the CDC's stance on acrylic nails for direct care staff.",2018-03-01
6105,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2015-03-20,466,F,0,1,T23O11,"Based on interview and record review, the facility failed to establish procedures to ensure that they could distribute potable and non-potable water to all three resident floors in the event of an emergency. This had the potential to affect all of the 131 residents who resided in this facility. Findings include: During the entrance conference on 3/16/15 at 8:00 a.m. the Administrator was asked to provide the survey team with the facility's procedure to ensure water availability in the case of an emergency. Review of the, Emergency Operation Policy and Procedure Manual, revealed a document titled, Emergency Operation Procedures Utility Failure that provided the following in the Maintenance: Non-Potable Water and Dietary Department sections of the policy: In the event of a water outage the facility will provide non-potable water for basic operations. The facility has a 200 gallon container for disbursement of water to Environmental Services and for nursing bathing functions. All non-potable water will be distributed through the Maintenance department. Water will be provided by (food service company) in the event the emergency lasts longer than 3 days. Review of this policy revealed that the document did not include a protocol for distributing water to the residents in the case of an emergency that may continue for any length of time. When interviewed on 3/19/2015 at 8:15 a.m. about how the facility would remove the outside water and how they would distribute the water in the case of an emergency, the Administrator stated that the facility would need to utilize buckets to remove the water from the outside 200 gallon tank. However, he added that they would have to purchase more buckets to provide water to each floor in the case of an emergency because they did not have enough buckets on hand. The Administrator confirmed that the facility did not have any written documentation relative to how they would distribute potable and non-potable water in the case of an emergency.",2018-03-01
7396,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2017-01-25,223,G,1,0,HX8G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy and procedure and interview, the facility failed to ensure that one of three sampled residents (R) (R#1) was free from abuse. Specifically, actual harm was identified on 12/26/16 when R#1, a resident with advanced dementia and [MEDICAL CONDITION], was mistreated in the form of physical abuse, mental abuse, intimidation and corporal punishment when a Certified Nursing Assistant (CNA) FF pulled the resident backward in his wheelchair from the back of his collar and back of his shirt. R#1 would not respond to interview questions however, a telephone interview with the Family on 1/25/17 at 3:55 p.m. revealed she recalled one evening that a nurse called to report she was having problems giving R#1 his medication and reported he seemed more agitated than usual. The Family stated she talked to R#1 on this occasion on the telephone and he told her someone is pushing me around and being mean to me. A post survey interview during the Quality Assurance (QA) process, with the DON on 1/30/17 at 2:15 p.m. revealed a review of the facility video surveillance confirmed the abuse and she could actually see the shirt pressing against the resident's neck as he was being pulled backward in his wheelchair. This incident was entity reported to the State Agency on 1/12/17 (GA 510). Findings include: Review of the facility's undated policy titled Abuse Prevention Policy and Procedures documented: It is the intent of this facility to actively preserve each resident's right to be free from mistreatment, neglect, abuse, exploitation or misappropriation of resident property. We believe each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. This policy applies to anyone subjecting a resident to abuse including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals. Definitions: Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish. Physical Abuse includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Mistreatment is the inappropriate treatment or exploitation of a resident. Review of the facility's follow up letter to the State Agency- Long Term Care Section- Compliant Unit dated 1/18/17 documented: During the course of a facility investigation conducted on 1/12/17 (into an unrelated, unsubstantiated complaint involving Certified Nursing Assistant (CNA) FF reported on 1/10/17), CNA AA reported there had been an inappropriate incident that she witnessed on 12/26/16 involving CNA FF and R#1. CNA AA reported that on 12/26/16, around dinner time, she observed that R#1 was very restless and agitated that evening and kept trying to get out of his wheelchair and staff were redirecting him because they were afraid he would stand up and fall. Toward the end of the meal, CNA FF took R#1 by the back of the shirt and snatched him back into his wheelchair. The motion caused him to fall back into the chair and then she pulled him backwards in his wheelchair by the collar/back of his shirt toward the direction of his room. The Director of Nursing (DON) was able to review camera footage of the incident which occurred in the 2S dayroom area and was time stamped on 12/26/16 at 5:40 p.m. Details of incident indicated R#1 is seen seated in his wheelchair with CNA GG seated behind him. He appears restless and persists in trying to stand from the chair. CNA GG is seen redirecting him by patting his shoulders in a reassuring manner. CNA FF is then seen clearing the table of dishes, placing them in a tray rack, then turns and walks toward R#1 who is seated in his wheelchair. CNA GG walks away down the hall, then CNA FF is seen grabbing and pulling R#1 by the back of his shirt collar and begins to roll him backwards in his wheelchair by pulling on his shirt. She then changes her hand position to grab the middle of his shirt and continues pulling him backward to his room. The facility does substantiate CNA wrongdoing and suspicion of resident mistreatment in this incident. CNA FF was terminated on 1/13/17 related to this incident with R#1 for suspected mistreatment of [REDACTED]. The facility immediately followed up this incident by conducting all-staff-in-services on abuse policy and procedure and reporting protocols. R#1 was assessed for any physical injury, none noted. The Family of R#1 was notified of this incident and facility follow-up to protect residents from future occurrences. The Family stated that she recalled one evening recently that a nurse called to report that she was having problems giving R#1's medication and reported that he seemed more agitated than usual. The Family stated she talked to her husband on this occasion and he told her someone is pushing me around and being mean to me. The Family could not remember the nurse's name or the date of this conversation with the nurse and her husband but believes it may correspond with the timing of the incident. Record review for R#1 indicates this is a [AGE] year old male, admitted to the facility dementia unit on 10/26/16 with primary [DIAGNOSES REDACTED]. The resident has a history of falls with left [MEDICAL CONDITION] July 2016. He is alert with confusion, has limited speech and impulsive behaviors with no safety awareness. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 99, indicating the resident was unable to complete the interview. The resident's cognitive skills for daily decision making is moderately impaired. The resident has disorganized thinking that fluctuates, comes and goes and changes in severity. The resident did not exhibit behaviors. The resident required extensive assistance with all Activities of Daily Living (ADL) except with eating. An interview on 1/25/17 at 2:21 p.m. with CNA AA revealed the day of the incident, was the day after Christmas and it was me, CNA FF and another employee (CNA GG) in the dining area with R#1. The other employee (CNA GG) no longer works here so I'm the only witness. That day R#1 was real agitated because he hadn't seen his wife and he wanted to go see his wife that day. R#1 was walked from the north side dining room to the south side dining which is next to his room. He was agitated and CNA FF had him (sic) and it was time for his shower. CNA FF went to put the resident in the wheelchair and he got back up. CNA FF pulled R#1 by his shirt back into the chair. He wasn't injured but he was already upset and this aggravated him more. R#1 is a sweet guy. He only really wants to get in his bed. He doesn't want to get up until it's time to go to the dining room, then he wants to go back to the bed and to watch CNN. An interview with R#1 was attempted on 1/25/17 at 3:13 p.m. R#1 did not respond to any questions or engage in conversation. A telephone interview on 01/25/2017 at 3:55 p.m. with the Family of R#1 revealed that on the evening of the incident, R#1 called to tell her that a girl had pushed him around. The Family told R#1 they love you and wouldn't hurt you and they are going to put you to bed. She added, the facility called her at a later date that she could not exactly remember, and told her that the girl (CNA FF) grabbed him and jerked him around by the shirt. The Family of R#1 recalled one evening that a nurse called to report she was having problems giving R#1 his medication and reported he seemed more agitated than usual. The Family stated she talked to R#1 on this occasion on the telephone and he told her someone is pushing me around and being mean to me. A post survey interview, during the Quality Assurance (QA) process, with the DON on 1/30/17 at 2:15 p.m. revealed that during an investigation for a different situation that involved CNA FF (that was not substantiated), CNA AA told her about the incident that occurred on 12/26/16 in the dining room. She said the CNA AA told her that CNA FF snatched the back of the resident's shirt causing him to fall back into his wheelchair. The DON reviewed the facility surveillance video and stated that she could see R#1 seated in his wheelchair but could not see from that view if CNA FF pulled him into his wheelchair. The DON Stated that she could see on the video that CNA FF grabbed the back of the resident's shirt collar and began pulling him backward in his wheelchair. She said she could actually see the shirt pressing against the resident's neck as he was being pulled backward in his wheelchair. CNA FF then switched her hand position and grabbed the middle back of the resident's shirt and continued to pull him backward in his wheelchair towards the direction of resident's room. The DON stated that she called the Resident's Family member to notify her of the incident. The DON stated that the Family member remembered receiving a call from the nurse telling her he was much more agitated than usual and that R#1 wanted to talk to her. The Family stated that when she spoke to the resident on the phone that evening and he told her someone was pushing him around and being mean to him, at first she thought he was probably confused so she did not report it to the facility. The Family felt bad that she did not believe him. Review of a written statement signed by CNA FF and dated 1/13/17 documented: After dinner the resident (R#1) was very upset because he wanted to talk to his wife at the time I didn't know that he can walk so I grab him by the pants to sit him down so he won't fall and I pull him hack. So to his room so we can come him down and we took him to the shower and I played like I was his wife and he come down. Yes he was come and went to sleep. So I left out and went back and started to feed in the dinner. (sic) Review of a written statement signed by CNA GG and dated 1/18/17 documented: I did not see CNA FF grab R#1 by his shirt. I hand him over to her and walked away to get his stuff together for the shower. So once my back was turn I didn't see anything happen after that. This incident happen 12/26/16. (sic) Review of an undated written statement signed by CNA AA documented: R#1 was very restless and agitated and he kept trying to get up out of his wheelchair. The staff was trying to redirect him because they were afraid he would stand up and fall. Toward the end of the dinner meal at around 5:30 p.m., I observed the following: CNA FF took R#1 by the back of the shirt and snatched him back into his wheelchair. This caused him to fall back into his wheelchair and then she pulled him backwards in his wheelchair toward the direction of his room. Review of a facility Employee Conference form dated 1/13/17 revealed CNA FF was given a final warning. Action taken was termination based upon mistreatment of [REDACTED].#1 on 12/26/16 at 5:40 p.m.-incident reported to the State office). Review of a facility employee conference form dated 1/18/17 revealed CNA AA was given a warning for poor work performance: Failure to report suspicion of resident mistreatment timely. Action taken: Immediate improvement needed or further disciplinary action will result up to and including termination. Goal: Understanding and follow-through to timely reporting of any pertinent observations related to resident treatment and care. Approach: Monthly in-services on abuse policies and procedures for three months. Review of documents titled In-Service Training Report revealed the following: On 11/21/16 the Topic of in-service was Abuse P&P (Policy and Procedure) which included a sign in sheet on the back of the document with a signature of attendance by CNA FF. On 12/28/16 the Topic of the in-service was Abuse P&P- How to report abuse which included a sign in sheet on the back of the document with signatures of attendance by CNA FF and CNA AA. On 1/11/17 the Topic of the in-service was Abuse P&P, employees present: CNA's, Nurses. Included sign-in sheet revealed 61 employee signatures in attendance. CNA AA's signature was included on this sig-in sheet. On 1/18/17 the Topic of the in-service was Abuse P&P- Reporting Guidelines which included a sign in sheet with one signature of attendance, CNA AA. Review of the Georgia Criminal History Name and Identifier Search dated 5/25/16 for CNA FF indicated no criminal records found.",2017-04-01
8126,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2012-01-11,281,D,0,1,Z8U311,"Based on observation, review of the facility policy for filing grievances and resident and staff interviews the facility failed to follow their policy of reporting grievances for one resident (1) (A) from a sample of thirty-two (32) residents. Findings include: Interview with resident A on 01/09/12 at 1:07 p.m. revealed that a staff member had been rude to her about two (2) weeks ago. The staff member had stood over the resident, spoken to her rudely, with her hands on her hips and pointed her finger in the resident's face. The resident reported the incident to the evening/night supervisor who had come to her room and taken her statement. Review of the facility policy for filing grievances revealed that to initiate a grievance and/or complaint the resident, guardian, or representative must submit an oral or written complaint to the Administrator or Director of Social Services. In the event of an oral complaint, the substance of the issue will be promptly reduced in written form for a prompt investigation. The administrator delegated the responsibility of grievance and/or complaint investigation to the social services department. Interview with the Social Worker AA on 01/11/12 at 11:59 a.m. revealed that she did not have any complaint/grievance report regarding any staff member being rude but that the unit manager might have it. Interview with the Licensed Practical Nurse (LPN) Unit Manager 3 BB on 01/11/12 at 1:43 p.m. revealed that she was not aware of this situation and had no documentation regarding this situation. Continued interview revealed that the resident could have reported this to any one (1) of three (3) people but that all reports are not necessarily written down if they can be handled and taken care of immediately, however, this one should have been documented. Interview with the Director of Nurses (DON) on 01/11/12 at 2:12 p.m. revealed that the evening/night supervisor is very good at documenting incidences that occur but sometimes the matters are taken care of rather quickly and are not placed on the grievance log Continued interview revealed that from the resident's description, she was able to determine who the staff member was and that the staff member no longer works for the facility.",2016-06-01
8127,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2012-01-11,431,D,0,1,Z8U311,"Based on observation, review of the facility policy for medication storage and staff interview the facility failed to secure medications in a locked area for one (1) of six (6) medication rooms. Findings include: Observation on 01/09/12 at 8:34 a.m., during initial tour, revealed that the medication storage room door was opened and unlocked on the third (3rd) Floor. There were no licensed personnel in the nurses station but there were residents and unlicensed personnel in the hallway. Interview on 1/09/12 at 8:40 a.m. with Licensed Practical Nurse (LPN) BB revealed that the door to the medication room should be locked at all times. A second interview with LPN BB at 1:04 p.m. revealed that there was a problem with the medication room door and that it had to be slammed in to order to be secured. Review of the facility Policy revealed that medications and biologicals are stored safely, securely and properly following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel and pharmacy personnel.",2016-06-01
9689,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2010-04-21,441,D,0,1,9TT311,"Based on observation and staff interview, the facility failed to ensure that staff washed hands appropriately for one (1) resident (#2), of a sample of twenty-four (24) residents. Findings include: Observation on 04/20/10 at 12:20 p.m. revealed two (2) Certified Nursing Assistants (CNAs) providing incontinence care for resident #2 who had been incontinent of urine and stool. After incontinence care was completed CNA ""CC"" removed her soiled gloves, gathered a bag of soiled linens including towels and wash cloths, gathered a bag of contaminated gloves and took both bags outside to the soiled linen and trash hampers (both attached to one cart). Continued observation revealed that the CNA returned to the resident's room, arranged the resident's top covers on the bed and placed the call button in reach without washing her hands. CNA ""EE"" assisted CNA ""CC"" with care and after care had been completed, removed her gloves, assisted in positioning the resident in bed, pulled up the bed covers without washing her hands. Interviews with CNAs ""CC"" and ""EE"" on 04/20/10 at 12:45 p.m. revealed that they should have washed their hands. Interview on 4/21/10 at 2:30 p.m. with the Director of Nurses revealed that whenever you touch dirty, the hands need to be washed before touching the resident again.",2015-05-01
9690,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2010-04-21,253,C,0,1,9TT311,"Based on observation and staff interview, the facility failed to provide housekeeping services necessary to maintain a clean and sanitary environment for six (6) of six (6) halls. Findings include: Observation during intial tour on 04/19/10 and during environmental tour on 04/20/10 at 1:00 P.M. with the Plant Manager and the Housekeeping Supervisor revealed that there were dusty ceiling vents in the Interview on 4/20/10 at 1:00 p.m. with the Plant Manager and Housekeeping Supervisor revealed that the vents were dusty.",2015-05-01
9691,A.G. RHODES HOME WESLEY WOODS,115002,"1819 CLIFTON ROAD, N.E.",ATLANTA,GA,30329,2010-04-21,241,D,0,1,9TT311,"Based on observations and staff interview, the facility failed to provide a dignified dining experience and failed to promote an environment that enhanced the dignity of two (2) residents (#14 and #17) from a sample of twenty four (24) residents and two (2) randomly observed residents. Findings include: 1. Observation on 4/20/10 at 8:33 a.m. revealed resident #14 seated in the 200 South Hall dining room for breakfast being fed by staff. Continued observation revealed that the staff member, feeding resident #14, was having a conversation with another staff member across the room, who was feeding two (2) residents, instead of interacting with the residents they were feeding. 2. Observation at 1:10 pm on 4/20/2010 of the 200 South hallway revealed a staff member yelling out two (2) resident names to a staff member down the corridor. Anyone in the area could hear the resident's names. Interview on 4/21/2010 at 2:00 pm with Licensed Practical Nurse (LPN) ""AA"" Unit Manager for the 200 Floor revealed that the staff are expected to give full attention to each resident while feeding or care is being provided. Continued interview revealed that the staff had been inserviced on interaction with the resident. 3. Observation on 04/21/10 beginning at 8:15 a.m. revealed resident #17 being fed by LPN ""FF"" in the 200 South Hall dining room. The resident exhibited behaviors including being verbally and physically abusive to the staff, refusing to eat her breakfast, and pouring liquids onto the floor. Two staff persons feeding residents and the nurse all laughed at the resident's behavior. Interview with LPN ""AA"" on 04/21/10 at 8:55 a.m. revealed that these behaviors are frequent for this resident and that staff laughing at the resident could be considered a dignity concern.",2015-05-01
2019,"A.G. RHODES HOME, INC - COBB",115521,900 WYLIE ROAD,MARIETTA,GA,30067,2019-10-03,584,E,1,1,K1HZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, staff interviews, and review of the policy/procedure titled, Deep Clean, the facility failed to maintain a clean, sanitary environment in resident room (R) and bathroom (R221, R224, R225, R227, R230, R231, R233, and R235) on one of three halls. Findings include: Review of a document/policy titled, Deep Clean, provided by the Housekeeping Supervisor, revealed the following instructions for cleaning vents in bathrooms, and wall mounted fans in the resident's rooms. The policy stated, clean vents in bathroom, and clean all fans. Observations during environment rounds on 9/30/19, from 10:00 a.m. to 3:00 p.m., and on 10/1/19 from 8:30 a.m. to 12:50 p.m., of the 200/Pink Hall, revealed vents in resident bathrooms, and oscillating fans mounted on the wall in resident rooms, were found to be very heavily coated with dust as follows: Observation on 9/30/19 at 10:05 a.m., in resident room [ROOM NUMBER], revealed dust on the oscillating fan on bed A side of the room, dust observed on the vent in the bathroom, and a slow draining sink in the bathroom. Observation on 9/30/19 at 10:15 a.m., in resident room [ROOM NUMBER], revealed the vent in the bathroom, and the oscillating fan mounted on the wall on bed A side and bed B side of the room, was very dusty. Observation on 9/30/19 at 10:34 a.m., in resident room [ROOM NUMBER], revealed splatters of yellow/tan colored, unknown substance that appeared to be dried liquid nutrition, on the wall to the right of the B side headboard, and on the resident's nutrition pump. The resident received nutrition via a Percutaneous Endoscopy Gastrostomy (PEG) tube, and Covidien pump. Observation on 9/30/19 at 10:45 a.m., in resident room [ROOM NUMBER], revealed the vent in the bathroom, was very heavily coated in dust, and the oscillating fan mounted on the wall on bed A side, and bed B side, was very dusty. Observation on 9/30/19 at 11:30 a.m., in resident room [ROOM NUMBER], revealed the vent in the bathroom, was very heavily coated in dust. Observation on 9/30/19 at 11:51 a.m., in resident room [ROOM NUMBER], revealed the vent in the bathroom, and the oscillating fan on bed B side of the room, was very heavily coated in dust. Observation on 10/1/19 at 10:35 a.m., in resident room [ROOM NUMBER], revealed the vent in the bathroom, was very heavily coated in dust. Observation on 10/1/19 at 12:40 p.m., in resident room [ROOM NUMBER], revealed the vent in the bathroom, was very heavily coated in dust. On 10/3/19 at 11:20 a.m., during a walk through with the housekeeping supervisor and plant manager, both confirmed the following: room [ROOM NUMBER]: Dust on the oscillating fan on A side of the room, dust on vent in the bathroom, and slow running drain in the sink. room [ROOM NUMBER]: Verified splatter of tan colored, unknown substance, on wall to the right of the B bed headboard, and on the residents, nutrition pump, next to resident's bed, and proximal to the splattered wall. room [ROOM NUMBER]: Verified dust on the oscillating fans, on A and B side, and dust on vent in the bathroom. room [ROOM NUMBER]: Verified dust on oscillating fans on A and B side, and dust on the vent in the bathroom. room [ROOM NUMBER]: Verified dust on oscillating fan on B side, and dusty vent in the bathroom. room [ROOM NUMBER]: Verified dust on the vent in the bathroom. room [ROOM NUMBER]: Verified dust on the vent in the bathroom. room [ROOM NUMBER]: Verified dust on the vent in the bathroom. Interview on 10/3/19 at 11:25 a.m., the Housekeeping Supervisor stated it is the responsibility of all floor techs to clean the fans in resident rooms, and the vents in the bathrooms. Interview further revealed they had been shorthanded and had gotten behind. Follow-up interview on 10/3/19 at 2:25 p.m., with the housekeeping supervisor, confirmed he was aware of the cleaning concerns, and revealed he had been short staffed for a while, was behind, and that's why the vents were so dusty. Interview further revealed all rooms are deep cleaned monthly. He provided the cleaning schedule for review, and documentation showed rooms on the 200/Pink hall had not been cleaned since (MONTH) 2019. He revealed his expectation was that the resident's surroundings, were clean and safe.",2020-09-01
6755,"A.G. RHODES HOME, INC - COBB",115521,900 WYLIE ROAD,MARIETTA,GA,30067,2013-10-24,323,D,0,1,LPTM11,"Based on observation, review of facility's temperature logs, and staff interview, the facility failed to ensure that hot water for residents use was at a safe temperature in one (1) resident room of twelve (12) rooms on two (2) of six (6) halls on two (2) of two (2) resident floors. Findings include: Observations of water temperatures during the general environmental tour conducted with Facility Maintenance Director, using the facility thermometer, on 10/24/13 at 10:37 AM , revealed that the temperature of the hot water at the sink in room 234, on the green hall, was one hundred twenty one degrees (121) Fahrenheit (F). An interview conducted on 10/24/13 at 10:45 AM with the Maintenance Director revealed the water temperatures are always warmer on the green halls because this area is closest to the water heaters. He further indicated that water temperatures are checked weekly. Review of the facility's temperature logs from 8/5/13 through 10/21/13 revealed that eight (8) rooms per floor are checked weekly. The temperatures recorded on the logs revealed no temperatures above one hundred twenty degrees, (120) F in the residents' rooms checked.",2017-10-01
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
4176,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2016-02-11,252,D,0,1,QEDL11,"Based on observation and staff interview, the facility failed to provide a homelike environment during meal service in one (1) of three (3) dining areas. The census of the facility was one hundred twenty-two (122), and one hundred twelve (112) residents received an oral diet. Findings include: During observations in the second floor resident dining area on 02/08/16 at 1:25 p.m. and on 02/11/16 at 9:00 a.m. revealed six (6) nursing staff distributing twenty (20) lunch meal trays and eighteen (18) breakfast meal trays to residents. Continued observation revealed that staff delivered and set up the residents' meals by placing the brown rectangular serving tray that contained the plated food items, beverages, condiments, and silverware in front of them. Further observation revealed that the staff did not remove the items from the meal trays. Observation on 02/11/16 at 9:15 a.m. in the first floor resident dining area revealed that four (4) nursing staff distributed fifteen (15) breakfast meals to the residents. Further observervation revealed that the staff removed the food items, beverages, condiments, and silverware from the tray before placing them in front of the residents. Interview on 02/11/16 at 9:05 a.m. with the wound treatment nurse revealed that she usually assisted with feeding residents on the second floor for breakfast and lunch. Continued interview revealed that she had only been told to uncover the food items for the residents, but had not been told to take items off of the tray when the items were served. During further interview, she stated that staff had not been inserviced on how to present resident meals. The treatment nurse further stated that the residents that ate in the second floor dining room needed feeding assistance, or had decreased cognition and needed to be supervised. During interview with the Director of Nurses (DON) on 02/11/16 at 9:25 a.m., he stated that he did not expect staff to remove plated food items from the meal trays, and that he did not have a policy regarding meal delivery or meal presentation. During further interview, the DON revealed that he had not conducted any inservices regarding taking food items from the meal trays before they were placed in front of the residents. The DON further stated that several years ago, they provided place mats for each resident in the second floor dining area, but had stopped doing this because the place mats became soiled after use. Further interview with the DON revealed that the facility had talked about establishing a fine dining experience for the residents on the second floor, similar to the one in the main dining room.",2020-02-01
4177,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2016-02-11,363,D,0,1,QEDL11,"Based on observation, record review, and staff interview, the facility failed to follow the pre-planned menu at one (1) lunch meal for eighteen (18) residents receiving a pureed diet. One hundred and twelve (112) residents in the facility received an oral diet. Findings include: Review of the pre-planned dietary menu for lunch on Wednesday (02/10/16) revealed that the pureed consistency meal was listed as puree roast pork, mashed potatoes, puree squash casserole, puree bread, puree blueberry cobbler, margarine, unsweetened iced tea and whole milk. Observation of the posted menu located in the main dining room and all four (4) resident units revealed that the lunch meal was listed as country pork chops, white rice, squash casserole, dinner roll, blueberry cobbler, margarine, and unsweetened iced tea. On 02/10/16 at 12:20 a.m., dietary cook CC was observed plating a resident's pureed lunch meal, and it consisted of pureed pork, pureed rice, and pureed carrots. During interview with dietary cook BB on 02/10/16 at 12:25 p.m, she stated that the Dietary Manager told her to make pureed rice instead of pureed mashed potatoes, as well as to substitute pureed carrots for the squash casserole. During further interview, cook BB stated that they did not use production sheets that had the actual number of residents that received a regular, mechanical soft, renal, or pureed diet, but that the dietary staff just knew how much of each to prepare. During interview with the Dietary Manager on 02/10/16 at 12:50 p.m., she verified that the residents on a pureed diet received pureed white rice and pureed carrots for lunch instead of mashed potatoes and pureed squash casserole as specified by the pre-planned menu. The Dietary Manager further stated that the staff were supposed to notify the Registered Dietitian (RD) when a substitution was made to the menu, and that the dietitian was aware of the menu substitution but had not completed the form indicating which food items had been substituted. During interview with the RD on 02/10/16 at 3:50 p.m., she stated that the menu cycle was new to the dietary staff, was twenty-eight (28) days in duration, and that she and the dietary manager reviewed the menus together before approving them. During further interview, the RD stated that it was not brought to her attention until today that substitutions were being made to the pureed menu. The RD further stated that when dietary staff made substitutions, they were supposed to notify her and she would write that substitution on the form later in the day. Review of the Taste-Temperature Report for lunch on Wednesday revealed that the Substitution Log section, which included reason for the substitution and approval, was blank.",2020-02-01
4178,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2016-02-11,371,E,0,1,QEDL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to label, date, and securely wrap opened food items in the walk-in freezer and in three (3) of four (4) resident/staff refrigerators; failed to have male staff wear a beard guard at all times while preparing food items; and failed to discard expired food items in one (1) of four (4) resident/staff refrigerators. There were one hundred and two (102) residents in the facility that received an oral diet. Findings include: 1. During observations in the walk-in freezer on 02/08/16 at 10:30 a.m., the following concerns were noted: There was an opened box of SaraLee frozen dinner roll dough in a blue bag, and the blue bag had a hole the size of a grapefruit, exposing the food product inside. There was an opened and wrapped package of whole wheat tortilla shells that was not labeled with an open date. There was a brown bag of french fries that was opened, tied off at the top, but not labeled with the open date. There was an unsealed Ziploc bag that contained a plastic-wrapped pink food item, which measured six (6) inches in length, four (4) inches in width, and two (2) inches thick. This pink food item was labeled with a date, but did not identify the food product inside the plastic bag. There was a clear plastic bag that contained an off-white frozen food product that was not labeled with a date. There were two (2) hot dog buns in a clear plastic bag stored behind a case of food, and the bag was not labeled with a date. During interview with the Dietary Manager (DM) on 02/08/16 at 10:45 a.m., she verified that there was a large hole in the blue SaraLee bag, that the frozen dough could be seen, and that the staff had made this hole. During further interview, she stated that she expected the staff to unwrap the food product, then re-wrap it. Upon further interview, the DM confirmed that there was no label or date on the opened package of whole wheat tortillas, no date on the brown bag of opened frozen french fries, no date or label on the clear plastic bag of the off-white food item which she identified as fish filets, and no label or date on the two (2) hot dog buns. During further interview, the DM was not able to identify the pink food product found in the plastic Ziploc bag, and stated she believed it was deli meat. The DM further stated that she expected staff to label and date food items after opening and before storage. 2. Observation in the kitchen on 02/08/16 from 10:55 a.m. through 11:05 a.m. revealed that dietary cook AA had a beard guard around his neck, instead of covering his goatee. During interview with dietary cook AA on 02/08/16 at 11:05 a.m., he stated that he took his beard guard off to taste the food, and forgot to put it back up around his face when he was finished. During interview with the Executive Chef on 02/08/16 at 11:05 a.m., he verified that the dietary cook did not have the beard guard covering his facial hair when preparing food. During further interview, the Executive Chef stated that he assisted with inservicing staff on kitchen sanitation, and expected staff with facial hair to wear a beard guard while preparing food. 3. During observation in the second floor resident/staff pantry room on 02/08/16 at 12:45 p.m., 02/09/16 at 10:55 a.m., and 02/11/16 at 8:05 a.m. revealed that there were two (2) containers of Dannon Light and Fit yogurt that were not labeled with a name, and they had an expiration date of 02/04/16. Continued observation of the second floor pantry revealed that there was a sign posted on the cabinet door above the refrigerator that noted the following: -Please date resident food. Any food found in refrigerator not dated will be thrown away per policy. Please put name and date on items, must be sealed container. Forty-eight (48) hours is limit unless there is an expiration date beyond forty-eight (48) hours. All shift at the end of day must check refrigerator/pantry. 4. During observation in the lower level Taylor Wing resident/staff pantry room on 02/09/16 at 12:05 p.m., and on 02/11/16 at 8:00 a.m., the freezer portion of the traditional refrigerator contained one (1) gallon of Neapolitan ice cream that had been opened, partially used, but was not labeled or dated. Continued observation revealed a Stouffers frozen Lasagna that had no label or date. 5. During observation in the first floor resident/staff pantry room on 02/11/16 at 7:55 a.m., a clear plastic bag with a submarine sandwich was noted to not be labeled or dated. During interview with the Director of Nursing (DON) on 02/11/16 at 9:25 a.m., he verified that the two (2) cartons of Dannon yogurt were expired, and that he expected staff to review the refrigerator contents and discard items as appropriate. Continued interview with the DON revealed that he verified that the submarine sandwich in the refrigerator on the first floor did not have a label or a date, that the ice cream and the frozen lasagna in the freezer on the Taylor Wing did not have a label or a date, and that he expected staff to label and date food items. Review of the facility's policy for Food and Supply Storage Procedures revealed that food items should be covered, labeled, and to date unused portions and opened packages. Review of the facility's policy for Personal Appearance - Males revealed that [MEDICAL CONDITION] to be neatly trimmed, and a clean-shaven appearance maintained. Review of facility inservices revealed that dietary staff were educated on 12/12/15 regarding that all labels must have the name of the product, must have the date opened, put time the product was opened, record the expiration date and your name. Continued review of dietary inservices revealed that staff were educated on 01/26/16 on personal hygiene and appearance. Review of the temperature log sheets from the resident/staff pantry rooms revealed that all items refrigerated must be sealed, labeled and dated, and that expired items must be discarded.",2020-02-01
6569,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2013-05-16,323,D,0,1,BVHM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure that mats were placed beside the bed for safety for one (1) resident (#17) from a sample of thirty one (31) residents: Findings include: Observations made on 5/15/13 at 2:19pm and 3:00pm revealed resident # 17 in a low bed with no mats placed beside the bed. Record review revealed a physician's orders [REDACTED].#17 to be in a Low bed with two (2) mats on the floor when in bed - Day, Evening and Night shift everyday. Interview with Licensed Practical Nurse (LPN) AA on 5/16/13 at 10:02 am revealed resident #17 should have mats on the floor beside the bed when the resident is in bed at all time for safety. AA further indicated that the resident often rolls out of the bed. Interview with Certified Nursing Assistant (CNA) BB on 5/16/13 at 10:30 am revealed that she did not put the mats on the floor when she put resident #17 in the bed.",2017-11-01
8299,"A.G. RHODES HOME, INC, THE",115275,"350 BOULVARD, S.E.",ATLANTA,GA,30312,2011-11-10,309,D,0,1,MNRU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Physician's orders, the Medication Administration Records (MAR) and staff interviews, the facility failed to ensure that physician's orders were followed for one (1) resident (#154) from a sample of twenty seven (27) residents. Findings include: Review of a physician's order dated 6/16/11 for resident #154 indicated [MEDICATION NAME] HCL 25mg (3) every six (6) hours at 0500, 1100, 1700, and 2300. Hold medication for systolic blood pressure (SBP) less than 120 (SBP Review of the MARs for September, October, and November 2011 indicated that the [MEDICATION NAME] 75mg was administered fifteen (15) times when the SBP was below 120, and there were three (3) times when there was no evidence that blood pressure (B/P) or medication were done/given. September 2011 MAR: On 9/2/11 at 11:00am, B/P was 110/68 and [MEDICATION NAME] was given On 9/5/11 at 5:00am, B/P was 115/69, and medication was given On 9/5/11 at 5:00pm, B/P was 118/68, and medication was given On 9/6/11 at 11:00am, B/P was 110/60, and medication was given On 9/19/11 at 5:00pm, B/P was 102/62, and medication was given On 9/19/11 at 11:00pm, B/P was 102/62, and medication was given On 9/27/11 at 11:00am, there was no evidence on the MAR indicated [REDACTED]. October 2011 MAR: On 10/4/11 at 11:00am there was no evidence that the B/P was taken or that medication was administered. On 10/14/11 at 5:00am, B/P was 107/67, and medication was given On 10/22/11 at 5:00am, B/P was 112/67, and medication was given On 10/24/11 at 5:00am, B/P was 117/66, and medication was given On 10/24/11 at 5:00pm, B/P was 116/73, and medication was given On 10/27/11 at 5:00pm, B/P was 118/60, and medication was given On 10/28/11 at 11:00am B/P was 119/60, and medication was given November 2011 MAR: On 11/1/11 at 5:00am, B/P was 105/59, and medication was given On 11/3/11 at 11:00am there was no evidence that the B/P was taken or that medication was administered. On 11/4/11 at 11:00am, B/P was 103/57, and medication was given On 11/5/11 at 5:00am, B/P was 119/59, and medication was given Interview with Licensed Practical Nurse (LPN) AA revealed that she failed to document in the MAR indicated [REDACTED]. She further indicated that on 11/4/11 at 11:00am she documented the wrong BP and failed to correct. Interview with the Director of Nursing (DON) on 11/9/11 at 10:45am revealed all nurses had been trained on the Point Click Care system and the expectations were that nurses should read and follow physician directions related to administration guidelines for medications.",2016-03-01
5952,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2012-12-06,241,D,0,1,I2VT11,"Based on observations and staff interviews, it was determined that the facility failed to promote the dignity of one resident (#35) from a total sample of 34 residents. Findings include: Licensed nursing staff coded resident #35 as totally dependent for dressing on the 9/12/12 quarterly Minimum Data Set (MDS) assessment. The resident was observed to have been dressed in a hospital gown and sweat pants while out of bed in a geri chair on 12/4/12 at 8:32 a.m., 3:10 p.m. and 5:00 p.m., on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:44 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m., 9:45 a.m. and 11:10 a.m. During an interview on 12/6/12 at 9:50 a.m., certified nursing assistant CC stated that the reason the resident had been dressed in a hospital gown was because, it was easier. On 12/6/12 at 12:15 p.m., the Director of Nursing (DON) stated that she was not aware that resident #35 was being dressed in a hospital gown daily. The DON said that, if she would have known, the staff would have gotten the resident a different type of shirt to wear when he was out of bed.",2018-05-01
5953,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2012-12-06,282,D,0,1,I2VT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record reviews, it was determined that the facility failed to ensure that care plan interventions were implemented for one resident (#26) from a sample of two residents with gastrostomy feeding tubes and for two residents(#35 and #70) from a sample of four residents with limitations in range of motion in a total sample of 34 residents. Findings include: 1. Resident #26 had a care plan interventions since at least 1/20/09 for nursing staff to keep the head of the resident's bed elevated 30 degrees and for licensed nursing staff to continuously infuse [MEDICATION NAME] AC formula at 50 milliliters (ml) per hour through a gastrostomy tube. However, it was observed on 12/3/12 at 11:45 a.m., 1:05 p.m., 3:40 p.m. and 4:10 p.m., and on 12/4/12 at 3:30 p.m. and 4:40 p.m., that the head of the resident's bed was not elevated 30 degrees while formula was infusing at 50 milliliters per hour. It was also observed that on 12/5/12 from 8:05 a.m. until 11:10 a.m. that licensed nursing staff had failed to administer [MEDICATION NAME] AC formula to the resident as ordered. See F322 for additional information regarding resident #26. 2. Resident #35 had a care plan intervention since at least 1/4/12 for nursing staff to apply a left hand grip splint and a right hand theraplus in the morning and remove them in the afternoon. However, it was observed that nursing staff had not applied those devices to the resident's hands on 12/4/12 at 3:10 p.m. and 5:00 p.m., on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:55 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m. and 9:45 a.m. See F318 for additional information regarding resident #35. 3. Resident #70 had a care plan since 3/25/10 to address his/her dependence in activities of daily living (ADLs) related to his/her mobility and due to severe contractures. There was a handwritten intervention on that plan for the provision of a range of motion program by restorative nursing staff and for the application of bilateral carrot splints as ordered. There was documentation of an 11/11/12 restorative weekly meeting note that the resident as cooperative with the range of motion and splinting program and to continue it. However, it was observed that staff had not applied carrot splints to the resident's hands on 12/4 at 3:10 p.m., and 4:25 p.m., on 12/5/12 at 8:15 a.m., 10:30 a.m., and 4:30 p.m., and on 12/6/12 at 9:05 a.m. See F318 for additional information regarding resident #70.",2018-05-01
5954,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2012-12-06,312,D,0,1,I2VT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with a resident and staff, it was determined that the facility failed to provide assistance with nail and/or skin care for two (A and #70) of the 34 sampled residents. Findings include: 1. According to the Western Schools Nursing Care of the Older Adult, second edition, good skin care for older adults included the use of skin moisturizers daily. However, nursing staff failed to address the identified problem of dry and scaly skin for resident A. Resident A was admitted to the facility in August, 2012. Licensed nursing staff documented on the 8/24/12 Admission Nursing Assessment that resident A had dry skin on both of his/her the lower extremities. A body diagram was circled on the resident's feet and shins to designate the areas of dry skin. The nurse noted in the special treatments and procedures section the word moisturizer. On the 8/31/12 admission Minimum Data Set (MDS) assessment, licensed staff had documented that the resident needed extensive assistance with ADLs, and received hospice services. The resident had a care plan since 9/19/12 to address his/her risk for impaired skin integrity related to his/her level of mobility (bedbound) and thin, fragile skin. There was an intervention for nursing staff to observe the resident's skin daily during routine care. However, there was not an intervention to describe the treatment and services to be that provided to address the resident's dry skin. However according to the December, 2012 ADL flow sheet, Resident A was supposed to have been assisted or supervised by facility staff with bed mobility, transfers, dressing, grooming, bathing and mouth care each day on each shift It was observed on 12/05/12 at 8:30 a.m. that resident A had dry and scaly skin on the front of both of his/her legs. Resident A said that he/she only received baths and skin care (lotion) from the hospice aide on Tuesdays and Thursdays but, the facility staff did not bathe him/her or do any skin care. CNA BB was assigned to care for resident A on 12/05/12. During an observation with CNA BB on 12/05/2012 at 11:00 a.m., resident A had long, dirty fingernails on his/her right hand. There was black matter under the nails. The resident's heels were dry and flaking light brown bits of dry skin. Review of the Resident Status Sheet (the CNA assignment sheet) for resident A revealed that it included the provision of total care of the resident for grooming but CNAs had not provided nail care and skin care of his/her heels for the resident. 2. Resident #70 had a [DIAGNOSES REDACTED]. The resident was coded on the 8/30/12 quarterly Minimum Data Set (MDS) assessment as requiring total staff assistance with hygiene. The 9/13/12 care plan noted that the resident would be neat and clean. Staff had documented on the Activity of Daily Living Notebook and the Resident Status Sheet the resident required total care with grooming. However, the resident was observed to have long, jagged fingernails on both hands on 12/04/12 at 8:44 a.m. and 3:10 p.m. Although it was observed on 12/5/12 at 10:30 a.m. that the resident's fingernails had been cleaned and cut, all of his/her fingernails remained jagged. It was observed that they all remained jagged on 2/6/12 at 9:05 a.m. and 9:45 a.m. During an interview on 12/6/12 at 10:00 a.m., certified nursing assistant (CNA) CC stated that the CNAs were responsible for cutting the resident's fingernails. She checked the resident's fingernails at that time and confirmed that they were jagged.",2018-05-01
5955,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2012-12-06,318,D,0,1,I2VT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to ensure hand splints were used to prevent further decline in range of motion for two residents (#35 and #70) in a sample of four residents with range of motion limitations from a total sample of 34 residents. Findings include: 1. During an interview on 12/04/12 at 8:29 a.m., licensed nursing staff reported that resident #35 had contractures and that his/her arms were drawn up against his/her chest. Licensed nursing staff completed a quarterly Minimum Data Set (MDS) assessment on 9/12/12 and coded resident #35 with functional limitations in his/her upper extremities on both sides. There was a care plan intervention since at least 1/04/12 for nursing staff to apply a left hand grip splint and a theraplus in his/her right hand in the morning and remove them in the afternoon. However, it was observed that nursing staff had not applied any device to the resident's hands on 12/4/12 at 3:10 p.m. , on 12/5/12 at 8:10 a.m., 9:15 a.m., 10:00 a.m., 1:10 p.m., 2:25 p.m., 3:45 p.m. and 4:55 p.m., and on 12/6/12 at 7:50 a.m., 9:02 a.m. and 9:45 a.m. On 12/6/12 at 9:45 a.m., restorative certified nursing assistant DD confirmed that the resident did not have the splints in place but, she did not know why. During an interview on 12/06/12 at 12:20 p.m., the Director of Nursing (DON) did not know why staff had not applied the resident's splints/hand rolls as needed. 2. Resident #70 had a [DIAGNOSES REDACTED]. The staff coded the resident on his/her 8/30/12 quarterly MDS assessment as having impaired range of motion on both sides of his/her upper and lower extremities. The resident's care plan since 3/25/10 noted that she/he was dependent on staff to meet all of his/her activities of daily living (ADL) needs related severe contractures. Staff documented on the care plan that the restorative nursing staff would provide range of motion exercises for the resident and bilateral carrot splints to be applied as ordered. There was an 11/11/12 restorative nursing weekly meeting note that the resident as cooperative with the range of motion and splinting program and to continue it. The resident was observed in bed with both hands in a curled position on 12/4/12 at 3:10 p.m., . However, there were not splints, hand rolls or braces on either hand as planned to promote their positioning and to prevent further contractures. There were two blue carrot positioning devices on the resident's bedside table. It was observed that staff had not placed any type of positioning devices in the resident's hands on 12/5 at 8:15 a.m., 10:30 a.m. and 4:30 p.m., and on 12/6/12 at 10:00 a.m. During an interview on 12/6/12 at 10:00 a.m.,. Restorative Certified Nursing Assistant (RCNA) DD stated that the resident was supposed to have the splints/carrots placed in his/her hands every day but, sometimes she did not have time to provide care for all the residents when the second RCNA was assigned to other duties. She stated that she usually kept a tablet to record which residents she had provided care for but she did not it with her. A review of the resident's flow sheet in the restorative notebook revealed that staff had not made any entries for December 1 through 5, 2012. There was no evidence that restorative nursing staff had provided any restorative care to the resident for those first five days of December. During an interview on 12/6/12 at 10:25 a.m., the Assistant Director of Nurses (ADON) stated that she had gotten behind on having the (restorative) notebook ready but, the staff should have been writing it down in a tablet when they provided the care. She stated that the second RCNA, who was working (on 12/6/12), had to go with a resident to an appointment but would be back in the facility later to provide care for the residents.",2018-05-01
5956,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2012-12-06,322,D,0,1,I2VT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to provide appropriate services to prevent complications and to provide formula via tube feedings as ordered for one resident (#26) from a sample of two residents with gastrostomy tubes from a total sample of 34 residents. Findings include: According to the American Society of Consultant Pharmacists Medication Guide for the Long Term Care Nurse, licensed nursing staff was to ensure that the resident's head of the bed was elevated 30 - 45 degrees, and to check for stomach residual prior to administering medications. However, nursing staff failed to maintain the head of the bed elevated at 30 degrees for resident #26 and failed to check for stomach residual prior to administering medications. Resident #26 had [DIAGNOSES REDACTED]. The resident had a gastrostomy tube in place and a physician's orders [REDACTED]. There were care plan interventions since at least 1/20/09 for the following: nursing staff to keep the resident's head of the bed elevated 30 degrees; for licensed nursing staff to infuse [MEDICATION NAME] AC formula continuously at a rate of 50 ml per hour via the gastrostomy tube and; to check for residual feeding every shift and if it was greater than 100 ml to hold administration of the formula for one hour then resume it but if remained greater than 100 ml then notify the doctor. However, it was observed that staff had only elevated the head of the resident's bed 10 degrees while the tube feeding was infusing on 12/03/12 at 11:45 a.m., 1:05 p.m., 3:40 p.m. and 4:10 p.m. It was observed that the tube feeding was infusing on 12/04/12 at 3:30 p.m. and 4:40 p.m. but, the head of the resident's bed was elevated only approximately five (5) degrees. It was observed on 12/05/12 at 8:05 a.m., 8:32 a.m., 9:30 a.m., 10:30 a.m., and 10:50 a.m. that the head of the resident's bed had not been elevated so, he/she was laying flat. Although, the tube feeding was ordered to be continuous, it was not infusing during those observations. There was not a bag of formula hanging for the tube feeding. It was observed on 12/5/12 at 11:10 a.m. that licensed nurse EE checked placed of the feeding tube but, she did not check for the amount of gastric residual before administering medications through the resident's gastrostomy tube. Therefore, the nurse could not know the amount of residual to determine whether or not the tube feeding should have been held as ordered. After having given the medications to the resident, she immediately restarted the continuous infusion at a rate of 50 ml per hour.",2018-05-01
5957,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2014-10-23,174,E,0,1,N8EW11,"Based on observation, staff interviews, and resident interviews the facility failed to provide reasonable access to the private use of a telephone without being overheard by staff or other residents for four (4) residents (#13, 86, #91 and A) of a forty (40) sampled residents. Findings include: 1. Observation on 10/21/14 at 2:27 p.m. of resident # 91 standing at the nurse's station using the phone. The resident stated after getting off the phone that that she is aware that the residents are suppose to have privacy while on the phone, but doesn't know how much privacy is possible with everyone standing around during her call and she doesn't even have a chair to sit down in. An interview with the family of resident A on 10/22/14 at 10:00 a.m. revealed that when she calls and talks to her brother, she feels that he can not carry on a conversation because she can hear the conversations of people standing next to him better than she can hear him talking. She stated that his speech is not clear and he is easily distracted by the others around him. An interview on 10/22/14 at 11:15 a.m. with Licensed Practical Nurse (LPN) KK revealed that residents can come to the nurse's station whenever they want to use the phone. The residents are not allowed in the office but the staff will dial the number and pass the phone through the window. Continued interview with LPN KK revealed that they can either go to the Director of Nursing (DON)'s office or the Social Worker's office. An interview with the DON) on 10/23/14 at 3:15 p.m. revealed that residents can use any of the nursing station phones at any time and if they want to talk privately they can either use her office or the social worker's office. She stated that at one time they had a cordless phone but a resident threw the phone and broke it and it hasn't been replaced. 2. During an interview on 10/20/14 at 3:29 p.m. with resident #13 revealed that there was no privacy when using the telephone at the nursing station and that their conversation could be overheard by others. During an interview on 10/21/14 at 1:57 p.m. with resident #86 reveals that there was no privacy at the nursing station when using the telephone. And that sometimes on dayshift the resident can use a staff office telephone when the office was available. Resident #86 stated that there were times staff sat in the office listening to his conversation. During an interview on 10/22/14 at 8:25 a.m. with the Social Worker revealed that if a resident wanted to talk on the telephone in private the resident can use her office or the telephone at the nurse's station. She revealed that at one time the resident's had a cordless telephone which was broken by a resident and the other cordless telephone had connection problems. An interview on 10/22/14 at 8:34 a.m. with the Maintenance Director revealed that he was unaware of a cordless telephone for the residents. A telephone interview with the Administrator and the DON, during the Quality Assurance review, on 11/3/14 at 2:00 p.m. revealed that the Administrator is new although the DON remembered that the cordless phone had been broken since June or July of 2014.",2018-05-01
5958,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2014-10-23,279,D,0,1,N8EW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, record review and staff interviews the facility failed to develop a care plan for refusal of care for one (1) resident (#99) who refused bathing of forty (40) sampled residents. Findings include: Record review of the Point Click Care, electronic record, for Resident #99 revealed the following Diagnoses: [REDACTED]. Observation on 10/21/14 at 9:50 a.m. and 4:30 p.m. revealed the resident had moderate facial hair, matted and unkept hair and had a body odor of old urine while wearing tan pants, which were dry. An observation on 10/22/14 7:30 a.m. of the resident in bed, wearing pajamas with a continued smell of old urine. Observation on 10/22/14 at 12:50 p.m. revealed the resident ambulating in the hallway, wearing four (4) shirts, was not shaved and continued to have a strong urine odor. An observation on 10/23/14 at 8:40 a.m. of the resident sitting in the smoking area revealed the resident was clean shaven, hair neatly combed and not matted and did not smell of urine. An interview with Certified Nursing Assistance (CNA) BB on 10/23/14 at 9:00 a.m. revealed that she had bathed the resident yesterday which was the first time in one week she had been assigned to this resident. Review of the facility bathing schedule reveals the resident is to be bathed/assisted on Monday, Wednesday and Friday's. Review of the electronic CNA charting Documentation Survey Report confirmed that on 10/22/14 the resident received a bath. Further review revealed that on 10/6, 8, 10, 17 and 20/2014 the resident was coded with 8/8 which per the Code Assessment for Point Click Care reveals the care was not given. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] and 5/24/14 revealed the resident had no behaviors of refusing care during the look back period. The resident was assessed on the Quarterly MDS dated [DATE] on the Brief Mental Interview of 4 indicating the resident has severe cognitive impairment. A telephone interview with the Director of Nursing (DON), Licensed Practical Nurse KK and the Administrator during Quality Assurance review on 11/4/14 at 4:10 p.m. revealed that the 8/8 coding on the bathing CNA check list means that the care was not given and that the staff does not have the option to for checking the resident refused the bath. They both say the resident did refuse his bath on those days but there is no written evidence of the refusal. The facility was asked for a copy of the resident Care Plan. A telephone interview with the Administrator, during the QA process, on 11/5/14 at 12:02 p.m. to review the resident's care plan revealed that there is no care plan for refusal care or bathing. She agrees that it should have been care planned for this residents.",2018-05-01
5959,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2014-10-23,441,F,0,1,N8EW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview the facility failed in hand hygiene (hand washing) practices consistent with accepted standards of practice, to reduce the spread of infections and prevent cross-contamination during meal service and while filling cups with ice and water, in the facility's main dining room and on three (3) of three (halls). Findings include; 1. Observation on 10/20/14 at 5:06 p.m., on the 300 hall, a random Certified Nursing Assistant (CNA) was observed delivering trays to multiple rooms, knocking on doors and going in and out of rooms setting trays up, and not washing or hand sanitizing between residents. Observation on 10/20/14 5:10 p.m. of the food cart sitting on 200 hall outside of room [ROOM NUMBER]. A random CNA was observed in room [ROOM NUMBER] assisting the resident in the B bed, after finishing assisting resident with eating, the CNA brought the used food tray out and set it next to a undelivered unopened food tray on the open food cart. The CNA then pushed the food cart down the hall to room [ROOM NUMBER] and took the uneaten food tray into the room and did not wash/santitize her hands before or after delivering this new tray. An interview on 10/23/14 at 10:37 a.m. with the Director of Nursing (DON) she verified that staff should santitize their hands when they leave the resident's room. She confirms that hand santitizer is available in every room as you enter the room. The DON reveals that the facility has done many infection control education inservices for all staff. 2. Observation on 10/20/14 at 12:45 p.m. of a random Certified Nursing Assistant (CNA) passing out trays to residents in the Main Dining Room, without sanitizing or washing her hands between trays/residents. Observation of the CNA opening food containers, uncovering food and touching residents and tables without washing/santitizing her hands. Observation on 10/20/14 at 12:47 p.m. of CNA AA pushing a resident into dining room, in a wheelchair, then place the resident at a table. CNA AA then obtained another residen'ts tray and place on table in front of her and then set up her meal without santitizing her hands. CNA then helped another resident at the table, taking this resident's knife and fork, cut up the meat and handing the utensils back to resident. CNA AA then returned to the food line and picked up another tray without santitizing her hands. Observation of the evening meal service on 10/20/14 at 5:30 p.m. revealed a randon CNA moving from one resident to another assisting them with holding of spoons, drinking from cups and wiping food debris from mouth without washing or sanitizing hands. 3. During an observation on 10/20/2014 at 11:00 a.m. of Certified Nurse Aide (CNA) AA was observed filling Styrofoam cups with ice from an ice cooler. The CNA was observed with ice filled cups in her hand, entered the resident's bathroom, and begin filling the cups with water from the bathroom water faucet. Upon exiting the resident's bathroom the CNA would set the cup on the resident bedside table. The CNA continued to delivery ice to other rooms on the 100 Hall and part of the 200 Hall and did not sanitize her hands upon entrance or exit from each room observed. During an observation on 10/20/2014 at 12:50 p.m., CNA AA was observed picking up a chair in the dining room and setting the chair next to a resident begins to feed a resident without sanitizing her hands. During an observation on 10/21/14 9:49 a.m. of CNA AA filling Styrofoam cups with ice, on the 300 Hall, and then entered a resident room with an ice filled cup. Further observation at this time revealed CNA AA then pushed the cart in front of the next resident's room and labeled two (2) Styrofoam cups with a pen, then filled the cups with ice, walked into the resident's bathroom to fill the cups with water from the sink then placed them on each resident's bedside table. The CNA did not sanitize her hands upon entrance or exit of this room. During the Quality Assurance telephone review on 11/3/14 at 2:00 pm with the Administrator and the Director of Nursing (DON) they confirmed that the CNA's did not follow the facility's policy related to hand washing/santitizing between delivering resident's food trays and refilling the ice cups. Review of the facilities Hand-hygiene technique Policy, General Guidelines: 3. If hands are not visibly soilded, use an alcohol-based hand rub for all the following situations: (i.) After contact with inaimate objects (e.g., medical equipments) in the immediate vicinity of the resident.",2018-05-01
5960,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,157,D,0,1,BPJ811,"Based on record review and interviews, the facility failed to notify the resident's responsible party for changes in the resident's condition for one (1) resident (F) on a sample of twenty-six (26) residents. Findings include: Interview with the family of resident F on 08/10/15 at 4:40 p.m. revealed that if he falls I get a call but other than that they don't call me. Per the resident's clinical profile, this family member is the resident's responsible party. Interview on 08/14/15 at 1:30 p.m. with the resident revealed that if there are any changes in treatment or medication I want them to contact my brother. Medical record review revealed Nurse's Notes and Progress notes indicating laboratory tests with abnormal results, notes regarding treatments and medication changes. No reference was found indicating that the family of the resident was notified. Interview on 08/14/15 at 1:45 p.m. with the Social Services Director revealed that letters are not mailed to family inviting them to Care Plan Meetings. She further stated that some families were called, but no families have been called in a long time. She further stated that the last time this resident's family was called about a Care Plan Meeting was 10/13/14",2018-05-01
5961,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,161,B,0,1,BPJ811,"Based on record review and staff interview the facility failed to maintain a surety bond of appropriate value to secure residents funds. The resident census eighty-eight. Findings include A review of the Resident Trust Fund Statements revealed that the fund balances for April, May, June and July 2015 all exceeded the $75,000 value of the surety bond. Balances ranged from 63,094.22 to 98,567.95. During an interview on 08/14/15 at 3:51 p.m. with the Business Office Manager, it was confirmed that the bank statements balances for April, May, June and July 2015 exceeded the amount of the current surety bond and did not adequately secure the resident's personal funds.",2018-05-01
5962,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,223,D,0,1,BPJ813,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility self-reported incidents, interview and policy review, the facility failed to protect residents from abuse. This deficient practice affected one (R74) of two residents sampled as evidenced by the review of two incident reports for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN)2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was Social Service Designee (SSD) 1 had spoken to LPN 2 about the harsh treatment per documentation on the incident investigation report completed on 1/25/16. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Review of the record for R74 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Assessment ((MDS) dated [DATE] revealed the resident had documented behaviors of wandering. Review of the care plan dated 7/31/15, revealed staff was to redirect the resident away from the area to his room and provide medications as ordered. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 about 5:30 p.m. SSD1 stated R74 was threatening to hit another resident and she called for help because she couldn't redirect him. SSD1 stated LPN2 responded and stepped in between the residents to protect the resident who was threatened by R74. LPN2 pushed R74 in the back twice through the door way using excessive force. SSD1 felt this met the definition of abuse; however SSD1 failed to report this to the DON until Monday 1/25/16. SSD1 confirmed she should have reported the incident on 1/22/16 but the DON had left for the day and stated I should have called her at home. Interview with Nurse Aide (NA)2 at 11:15 a.m. on 2/6/16, identified LPN2 as the staff member who shoved R74 on 1/22/16 at about 5:30 p.m. NA2 reported LPN2 was trying to protect another resident from R74 because he was going to hit another resident. NA2 reported R74 swung at LPN2 and that is when LPN2 shoved R74 hard in the back. NA2 demonstrated, with the surveyor, how hard LPN2 shoved R74 in the back causing the surveyor to stumble forward. NA2 stated I think that was abuse. NA2 did not report to any other staff because SSD1 was present and the NA thought the SSD would report the abuse. Review of the facility time record revealed LPN2 continued to work until the end of the shift on Friday 1/22/16 and worked 12 hours on Saturday, 1/23/16 and Sunday 1/24/16. Interview of seven residents included R11, R36, R57, R54 and R42 identified by the facility as able to give reliable interviews and two additional residents R30 and R27 on 2/6/16 between 11:15 a.m. and 12:00 p.m. revealed they had no concerns of abuse or mistreatment by staff. Interview of staff on 2/5/16 and 2/6/16 included one LPN, four NAs and two housekeepers, revealed they had received training in the facility abuse policy and all confirmed they knew to report immediately. Review of the facility policy Abuse Prevention Policy and Procedure dated revised 3/13/14 instructed staff to report all allegations of abuse immediately to the DON and Administrator. Any allegation of abuse is reported immediately to the state agency and to all other agencies as required per state and federal guidelines. Immediately means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. The policy defined abuse as the harmful treatment of [REDACTED].",2018-05-01
5963,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,225,D,0,1,BPJ813,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of facility policy, the facility failed to report the abuse immediately (within 24 hours) of a resident (R74) for one of two residents reviewed. Findings included: Review of the facility self-reported incident dated 1/25/16 identified a staff member was observed pushing a resident down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the report was dated 1/25/16, three days after the incident occurred on 1/22/16. The report indicated the steps taken to prevent further incidents included the Social Service Designee (SSD)1 had spoken to LPN2 about the harsh treatment of [REDACTED]. LPN2 continued to work to the end of the shift and 12 hour shifts on the next two days, Saturday and Sunday, before resigning on Monday 1/25/16. In addition, the initial report of an abuse investigation to the state agency was not completed until 1/25/16. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Review of the investigation continued with the DON and with the conclusion the incident did not confirm the allegation of abuse. The DON concluded, based on the statement by LPN2, that it may have looked like she (LPN2) pushed R74 but stated she didn't. The DON was questioned regarding the two witnesses who confirmed LPN2 had used excessive force and shoved R74 down the hall; however, the DON just shrugged her shoulders and stated She already quit. The DON also verified the report was not made immediate by staff or by the facility to the state agency. Interview of SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 at about 5:30 p.m. SSD1 stated R74 was threatening to hit another resident and she called for help because she couldn't redirect him. SSD1 stated LPN2 responded and stepped between the residents to protect the resident who was threatened by R74. LPN2 pushed R74 in the back twice through the doorway using excessive force. SSD1felt this met the definition of abuse; however SSD1 failed to report this to the DON until Monday 1/25/16. SSD1confirmed she should have reported the incident on 1/22/16 but the DON had left for the day and stated I should have called her at home. Interview with Nurse Aide (NA)2 at 11:15 a.m. on 2/6/16 identified LPN2 as the staff member who shoved R74 on 1/22/16 at about 5:30 p.m. NA2 reported LPN2 was trying to protect another resident from R74 because he was going to hit another resident. NA2 reported R74 swung at LPN2 and that is when LPN2 shoved R74 hard in the back. NA2 demonstrated, on the surveyor, how hard LPN2 shoved R74 in the back causing the surveyor to stumble forward. NA2 stated I think that was abuse. NA2 did not report to any other staff because SSD1 was present and the NA thought the SSD would report the abuse. Interview of seven residents that included R11, R36, R57, R54 and R42, identified by the facility as able to give reliable interviews, and two additional residents R30 and R27 on 2/6/16 between 11:15 a.m. and 12:00 p.m. revealed they had no concerns of abuse or mistreatment by staff. Interview of staff on 2/5/16 and 2/6/16 included one LPN, four NA s and two housekeepers revealed they had received training in the facility abuse policy and all confirmed they knew to report immediately. Review of the facility time record revealed LPN2 continued to work until the end of the shift on Friday 1/22/16 and worked 12 hours on Saturday,1/23/16 and Sunday 1/24/16. Review of the facility policy Abuse Prevention Policy and Procedure dated revised 3/13/14 instructed staff to report all allegations of abuse immediately to the DON and Administrator. Any allegation of abuse is reported immediately to the state agency and to all other agencies as required per state and federal guidelines. Immediately means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. The policy defined abuse s the harmful treatment of [REDACTED]. The Investigation File Checklist included: suspend any employee suspected of abuse, neglect or misappropriation immediately after taking their written statement; maintain the employee on suspension until the investigation is concluded and is either substantiated or unsubstantiated. However; this was not a part of the facility policy. Review of the facility policy on abuse investigation with the DON on 2/6/16 at 10:45 a.m. verified there was no direction to staff to remove the staff member who committed the alleged abuse during the investigation until the investigation was complete.",2018-05-01
5964,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,226,E,0,1,BPJ811,"Based on record review, observations, and interviews, the facility failed to report to the State Agency eight (8) of eight (8) substantial incidents of potential abuse per policy and procedure for census sample of twenty-six and total number of residents being eighty-eight (88). Findings include: A review of medical records revealed an incident of resident to resident altercation occurring on 05/23/15. Although the family and Medical Doctor were notified of the incident, the facility did not report the potentially abusive occurrence to the State Agency as required by the facility policy for abuse prevention. Interview on 08/12/15 at 4:00 p.m. with the Administrator revealed that there were no investigations for this resident. Interview on 08/13/15 at 08:30 a.m. with the Administrator confirmed that the incident was not reported to the State Agency. Further record review revealed incidents dated 12/11/14, 03/11/15, another on 05/23/15, 06/28/15, 06/30/15, 07/12/15 and 07/29/15 that were not reported to the State Agency. Interview on 08/14/15 at 2:05 p.m. with the Administrator revealed that physical altercations between residents resulting in injuries should be reported to the State Agency and had not been. The Administrator stated that she expected all incidents with injuries to be reported as required.",2018-05-01
5965,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,253,E,0,1,BPJ811,"Based on observation and interview the facility failed to provide a sanitary environment for residents on three (3) of three (3) halls. Findings include: Observation of Room 100 on 08/11/15 at 8:10 a.m. showed a heavy build up of dirt on the edges of the floor and a strong urine odor was noted in the resident bathroom. Observation in Room 112 on 08/10/15 at 4:01 p.m. showed a strong urine odor in the resident bathroom and the grout of the floor tile in the bathroom had a black discoloration. A heavy build-up of dirt along edges of the floor in the resident room was also observed. Observation in Room 104 on 08/11/15 at 8:16 a.m. showed a heavy build up of dirt along the edges of the room. Observation of Room 110 on 08/11/15 at 8:35 a.m. showed a heavy build up of dirt on the floor in the resident room and bathroom. The grout was noted to be black between tiles on the bathroom floor and there was a very strong urine odor in the bathroom. Observation of Room 112 on 08/11/15 at 08:56 a.m. showed a heavy build up of dirt along the perimeter of the room. Observation of Room 116 on 08/11/15 at 9:30 a.m. showed a build up of dirt around the edges of the floor of the room. A strong urine odor was noted in the bathroom and there was a black discoloration in the grout between the bathroom floor tiles. Observation of Room 106 on 08/11/15 at 10:02 a.m. showed a build up of dirt on the edges of room. The bathroom toilet had a leak with a puddle in the corner of the bathroom which was also reported to Licensed Practical Nurse BB at this time, and she reported the leak to maintenance. Grout in floor tile of the bathroom had a black discoloration and a strong odor of urine. Observation of Room 120 on 08/11/15 at 8:14 a.m. showed that the bathroom had a heavy build up of black substance around toilet bowl. Observation of Room 102 on 08/11/15 at 10:25 a.m. showed a heavy build up of dirt around the edges of the room on floor. Black discoloration was observed in the grout on the tile floor of the bathroom and there was a strong urine odor. Observation of Room 108 on 08/11/15 at 10:44 a.m. showed a heavy build-up of dirt around the edges of room. Observation of Room 318 on 08/11/15 at 12:44 p.m. showed a heavy build up of a black substance on the bathroom floor on the grout and a heavy build up of a black substance around the bottom of toilet bowl. Interview with family members of residentsV and W on 08/11/2015 at 10:50 a.m. revealed that the facility had an odor and needed to be cleaner in the resident rooms. Observation on 8/13/15 at 9:10 a.m. of the following Rooms shows that there continued to be a build up of dirt along the edges of the resident rooms, strong urine odors in resident bathrooms, and a black discoloration of the grout of the tile floors in resident bathrooms: Room 100 Room 112 Room 314 Room 102 Room 116 Room 318 Room 104 Room 120 Room 106 Room 208 Room 108 Room 220 Room 110 Room 306 Interview and tour with Head of Housekeeping on 08/13/15 at 9:10 a.m. confirmed that the above listed rooms had a build up dirt and debris around the edges of the resident rooms, had a strong urine odors in bathrooms, black discoloration of the grout on the tile floor in the bathrooms, and the bathroom toilet in room 106 continued to have a leak that was forming a puddle on the bathroom floor.",2018-05-01
5966,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,279,D,0,1,BPJ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to develop and revise a care plan for two (2) resident's # (17 and 44) from a total of twenty-six (26) sampled residents. Review of resident #17's Comprehensive Minimum Data System (MDS) revealed the resident was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. A review of the Electronic Medical Record (EMR) revealed that the resident had falls documented by nursing staff on 02/01/15, 02/23/15 and 07/27/15. During an interview with the Director of Nurses (DON) on 08/13/15 at 4:15 p.m. it was revealed that the nurse's on the floor do the updates to the care plan. The DON confirmed that the care plan for resident #17 was not updated or revised for falls that occurred on 02/01, 02/23, and 7/27/15. Record review for resident #44 revealed a fall from a chair on 08/09/15, resulting in an injury. Further review revealed that on 08/03/15, the resident was found sitting on the floor between the wheelchair and the bed. On 07/26/15 the resident was found lying on the floor with resulting injury. Additional falls were noted on 05/16/15 and 12/07/14. A review of the resident's plan of care indicated that the resident was at high risk for falls, with communication/comprehension difficulty, gait/balance problems, and incontinence. The Care Plan was initiated 08/22/14. All interventions were dated 08/22/14. No new interventions had been added. Interview on 08/13/15 at 2:18 p.m. with the Director of Nurses revealed that nursing and other staff are expected to update care plans as soon as possible after every fall. she also stated that new interventions should be put in place with each fall. Interview with the Administrator on 08/14/15 at 4:25 p.m. revealed that care plans should be updated with each fall and new interventions should be implemented with each fall.",2018-05-01
5967,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,323,D,0,1,BPJ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide a positioning device for a wheelchair bound resident to prevent accident and/ or injury for one (1) resident (#55) from a census sample of twenty-six (26). Findings include: Review of Lists of [DIAGNOSES REDACTED].#55 had [DIAGNOSES REDACTED]. Review of the Minimum (MDS) data set [DATE] showed the resident to have both short and long term memory problems, and that he/she required limited assistance with locomotion. Observation on 08/10/15 at 4:17 p.m. showed resident #55 to be barefoot and dragging their right foot under the wheelchair with no foot pedal on wheelchair. Interview on 08/10/15 at 4:17 p.m. with Licensed Practical Nurse (LPN) BB revealed that she had been made aware that resident was dragging their foot under wheelchair and that the resident was to have a foot pedal on their wheelchair on affected right (R) side due to (R) sided weakness. Observation on 08/12/15 at 8:10 a.m. showed that resident #55 was up in a wheelchair with slipper socks on. The resident did not have foot pedal on their wheelchair. Observation on 08/13/15 at 1:18 PM of resident #55 showed that resident was up in wheelchair with no foot pedal on the right side and resident was propelling the wheelchair independently and was dragging their right foot under the wheelchair. Observation on 08/13/15 at 1:22 p.m. revealed a missing piece of linoleum in front of the door to the resident's room that was approximately 8 x 6 inches in size and that the resident rolled directly over this area with his foot dragging under the wheelchair. Review of the resident's Care plan showed a care plan for Peripheral Vascular Disease. He also had care plans for being bed and chair bound with interventions to provide appropriate physical support during mobility, transfers and locomotion enforcing comfort and safety. Interview on 08/13/15 at 2:15 p.m. with Certified Nursing Assistant (CNA) CC, revealed that he/she had noticed on 08/12/15 that resident #55 was dragging his/her foot under wheelchair and had notified the treatment nurse. Interview on 08/13/15 at 2:17 p.m. with Licensed Practical Nurse (LPN) AA, on 100-hall showed that he/she was aware that resident #55 had (R) sided weakness but was unaware of him/her dragging his/her foot under the wheelchair. Interview and observation on 08/13/15 at 2:22 p.m. with Administrator confirmed that resident # 55 was dragging (R) foot under wheelchair and that there is a piece of linoleum missing in hallway in front of resident's room.",2018-05-01
5968,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,328,D,0,1,BPJ812,Deficiency Text Not Available,2018-05-01
5969,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,356,B,0,1,BPJ812,Deficiency Text Not Available,2018-05-01
5970,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,363,F,0,1,BPJ813,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the pre-planned written menus. This deficient practice had the potential to affect all of the residents who dined in this facility. Findings included: Observation of the kitchen during a complaint investigation on 2/6/16 at 11:45 a.m. revealed that the facility had two notebooks that contained written menus with serving sizes. Review of the menus revealed that the facility prepared and served a variety of therapeutic diets which included: carbohydrate controlled renal pureed mechanical soft low sodium Observation of the food that was prepared for the residents ' lunch meal on 2/6/16 at 12:00 p.m. revealed that the food that was prepared was not the food that was written on the pre-planned menu. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00 p.m. confirmed that the facility did not prepare the foods that were listed on the preplanned menu. When interviewed about why the facility failed to prepare the food that was written on the menu, the DM stated that he just liked to mix things up. Per the DM the food that should have been prepared included: roast turkey gravy cornbread stuffing green bean casserole dinner roll margarine mandarin oranges Observation of the prepared food, revealed that the facility prepared the following foods: oven roasted turkey steamed cabbage sweet potatoes cornbread chocolate cake/icing baked lasagna salad/garlic bread An interview with the Registered Dietitian (RD) on 2/6/16 at 12:00 p.m. revealed that she completed the nutritional assessments for each resident who resided in this facility. The RD added that there were residents in the facility who required physician ordered therapeutic diets such as those residents with diabetes or [MEDICAL CONDITION]. When interviewed, about how she could complete a nutritional assessment or ensure that each resident had received the appropriate foods per their physician ordered diet if the facility did not prepare and serve the foods that were written on the preplanned menu, the RD stated it would be difficult. The RD stated that she was unaware that the facility had not prepared and served the foods that were written on the preplanned menus.",2018-05-01
5971,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,371,E,0,1,BPJ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews the facility failed to store food under sanitary conditions for the resident census sample of twenty-six (26) and the total number of residents being eighty-eight (88). During tour on 08/13/15 at 12:30 p.m. with the Dietary Manager the following were observed in the kitchen: [MEDICATION NAME] Chloride (PVC) pipe under the dish rinse sink had an area approximately six inches long with heavy build up of corrosion on the drain line. Two galvanized metal fire extinguisher pipes hanging over the range were noted to be rusty. The bottom shelf, legs, and poles of the clean dish table were noted to have large area of chipped paint and rust. The lower shelf and legs of the microwave table had large areas of chipped paint and rust. The window sash around the dirty dish receiving area was noted to have a heavy build up of rust and large flakes of rust chipping and flaking off. The conditions listed above were confirmed at the time by the Dietary Manager. Tour with the Administrator on 08/13/15 at 1:30 p.m. confirmed the conditions. During this same tour with the Administrator, two boxed of raw potatoes were on the small porch outside the kitchen. The top of the box was partially open and flies were noted in and around the boxes. Interview on 08/13/15 at 1:30 p.m. with the Administrator revealed that her expectations were that the kitchen would be clean and free from rust and chipping paint and that there would not be food items on the back porch.",2018-05-01
5972,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,372,D,0,1,BPJ811,"Based on observation and interview the facility failed to dispose of garbage and refuse properly for the census of eighty-eight (88) residents. Findings Include: 08/13/15 at 12:30 p.m. kitchen tour with the Dietary Manager revealed the following: On exiting the back kitchen door, onto the small external porch area: Clutter of multiple empty boxes, Two old unused air conditioner units, One rolling mop bucket, Two air conditioner vent covers Two boxes of raw potatoes. The top box of potatoes was noted to be partially opened and flies noted to be flying around the boxes. One fly observed on top of the potatoes box During this same tour with the Dietary Manager, the lid on the trash dumpster was noted to be raised with trash in the dumpster exposed with multiple flying insects around the inside of the dumpster. 08/13/15 at 1:30 p.m. interview with the Administrator revealed that everyone in the community uses this dumpster, especially the people in the apartments across the street. She also stated that she expected the porch area to be clean, without debris and refuse.",2018-05-01
5973,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,441,E,0,1,BPJ812,Deficiency Text Not Available,2018-05-01
5974,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,456,E,0,1,BPJ811,"Based on observations and interviews the facility failed to ensure essential equipment is maintained in safe operating condition for the resident's microwave and refrigerator in the resident snack area at nurses station one for the resident census size of twenty -six and total number of residents being eighty-eight (88). 08/13/15 at 12:30 p.m. Kitchen tour with Dietary Manager revealed the following: The right side of the resident refrigerator, in pantry room at the nurses station was noted to have long area of peeling bubbled paint with a large area of chipped and peeling rust. The resident microwave, in pantry room at nurses station one, was observed to have a large area of rust along the bottom edge of internal microwave housing. An area of rust was noted to run approximately 75% along the entire width of the bottom of the internal microwave housing. Interview and tour on 08/13/15 at 1:30 p.m. with the Administrator confirmed the above conditions and rust.",2018-05-01
5975,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,463,D,0,1,BPJ813,"Based on observation and interview, the facility failed to ensure two bathroom call systems on the 200 Hall had pull strings long enough to be reached by residents. This practice affected one of three hallways. Findings include: Observation of the 200 Hall shower room on 2/6/16 at 1:00 p.m. revealed the call light beside the toilet had a pull string approximately 4 inches in length. Observation of room 219 on 2/6/16 at 1:20 p.m. revealed the call light beside the toilet had a pull string approximately 4 inches in length. Interview with the Director of Nursing (DON) on 2/6/16 at 1:40 p.m. acknowledged the call light pull strings in the 200 Hall shower room and room 219 were too short. The DON stated if a resident were to be on the floor in either location they would not be able to reach the pull cord for the call system. An interview was conducted with the Administrator on 2/6/16 at 2:00 p.m. The Administrator stated she was not aware of the call light pull cords being so short.",2018-05-01
5976,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,465,E,0,1,BPJ812,Deficiency Text Not Available,2018-05-01
5977,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,469,E,0,1,BPJ811,"Based on observation, interview and review of pest control contract the facility failed to provide effective pest control placing the residents at risk for insect borne illness on three (3) of three (3) halls with a census sample size of twenty-six (26) and total number of residents in facility being eighty-eight. Findings include: Observation of Room 110 on 08/11/15 at 8:35 a.m. showed an insect ran across the floor in the residents' room. Observation of Room 116 on 08/11/15 at 9:30 a.m. showed a fly in the residents' room. Observation of Room 108 on 08/11/15 at 10:44 a.m. showed a fly in the resident's room. Observation in the Sitting Room on 300 hall on 08/12/15 at 8:45 a.m. showed 7 flies. Observation in Administrative Building on 08/12/15 at 12:45 p.m. showed a large reddish-brown roach crawled across the floor. Observation of Room 108 on 08/13/15 at 9:00 a.m. showed that there was a fly in the bathroom. Observation of the hallway connecting 300 and 200 hall on 08/13/15 at 12:15 p.m. showed a resident sitting in the hallway killing flies with a fly swatter. Observation of the back hallway that led into the Dining Room on 08/13/15 at 1:17 p.m. showed a fly. Observation of the 100 hall nurses station desk on 8/13/15 showed a fly crawling on the desk. Observation of the connecting hall between 200 and 300 hall on 08/13/15 at 2:00 p.m. showed a second resident sitting in the hallway killing flies with fly swatter. Observation of the sitting room on 300 hall on 08/14/15 at 10:15 a.m. showed a resident seated on a bench with two (2) flies crawling on resident's left leg and one (1) fly crawling on her right arm. Observation of connecting hallway between 200 and 300 hall showed a resident carrying a fly swatter in wheelchair with him. Interview and tour with Head of Housekeeping on 08/13/15 at 09:10 a.m. confirmed that there were flies in resident rooms, bathrooms and hallways. Interview with Administrator on 08/13/2015 at 9:15 a.m. confirmed that there were flies in the building.",2018-05-01
5978,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,493,F,0,1,BPJ812,Based on observation and staff interview the facility failed to ensure there was an Administrator in place for the management of the facility. Findings include: During an observation and interview on 1/20/16 at 9:15 a.m. with the Director of Nursing (DON) she stated that the Administrator was not at the facility and that his last day was the previous Friday (1/15/16). Further interview revealed that an Administrator from a sister facility was on her way and that a new Administrator would be starting on Monday 1/25/16. During an interview with the Visiting Administrator on 1/20/16 at 4:00 p.m. she revealed that she was the Administrator at the Eastman Facility. She stated this was her first time at this facility and she was here because surveyors were in the building.,2018-05-01
5979,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-08-13,520,F,0,1,BPJ812,"Based on record review and staff interview the facility failed to have a Quality Assessment and Assurance (QAA) process that developed and implemented an effective plan to ensure that compliance with the Plan of Correction (P(NAME)) was achieved for five (5) of ten (10) deficiencies written during the August 2015 Standard Survey (F253, F371, F372, F 456, F469). Findings include: During an interview with the Director of Nursing and Licensed Practical Nurse Unit Manager on 1/21/16 at 6:50 p.m. to 7:25 p.m. revealed that Quality Assessment and Assurance meetings are done monthly with the Administrator, Medical Director, DON, and LPN Unit Manager along with other disciplines. And, based on the data that is collected the committee decides what issues need to be addressed. The DON stated that she makes daily rounds and if issues come up she will bring it to the Quality Assurance Assessment (QAA) meeting. The DON further stated that she takes the concerns to the Administrator to address the issues and that she herself is not able to contact the Cooperate Office. She further stated that the previous Administrator informed her that he had notified the Cooperate office about the issues but had not received a response. During an interview on 1/20/16 at 4:45 p.m. with the Housekeeping Supervisor, Director of Nurses (DON) and the Visiting Administrator, Review of the the Quality Assessment Performance Improvement action plan provided by the facility, revealed the plan listed problems but did not list dates when the problems were identified. The Visiting Administrator, stated there was no way to tell when the problems were identified because it did not include dates of identification and did not address the system to identify other areas that may be affected. The surveyor questioned why the facility was in the condition it was in currently (in regards to environmental concerns) and the DON and the Housekeeping Supervisor stated that they thought it had gotten better. During an interview on 1/21/16 at 4:00 p.m. with the Visiting Administrator regarding the condition of the environment, she stated that she could not explain why the facility was in the condition that it was in. She stated the facility had not had the proper leadership to make corrections. The Visiting Administrator, further revealed the Quality Assurance Performance Improvement plan was not appropriate and that all facility identified environmental issues should have been included. She further stated that she called the facility's Corporate Office today (1/21/16) to ask what has been done regarding environmental repairs and no information was provided.",2018-05-01
5980,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2016-02-06,223,D,1,0,R5VO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility self-reported incidents, interview and policy review, the facility failed to protect residents from abuse. This deficient practice affected one (R74) of two residents sampled as evidenced by the review of two incident reports for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN)2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was Social Service Designee (SSD) 1 had spoken to LPN 2 about the harsh treatment per documentation on the incident investigation report completed on 1/25/16. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Review of the record for R74 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Assessment ((MDS) dated [DATE] revealed the resident had documented behaviors of wandering. Review of the care plan dated 7/31/15, revealed staff was to redirect the resident away from the area to his room and provide medications as ordered. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 about 5:30 p.m. SSD1 stated R74 was threatening to hit another resident and she called for help because she couldn't redirect him. SSD1 stated LPN2 responded and stepped in between the residents to protect the resident who was threatened by R74. LPN2 pushed R74 in the back twice through the door way using excessive force. SSD1 felt this met the definition of abuse; however SSD1 failed to report this to the DON until Monday 1/25/16. SSD1 confirmed she should have reported the incident on 1/22/16 but the DON had left for the day and stated I should have called her at home. Interview with Nurse Aide (NA)2 at 11:15 a.m. on 2/6/16, identified LPN2 as the staff member who shoved R74 on 1/22/16 at about 5:30 p.m. NA2 reported LPN2 was trying to protect another resident from R74 because he was going to hit another resident. NA2 reported R74 swung at LPN2 and that is when LPN2 shoved R74 hard in the back. NA2 demonstrated, with the surveyor, how hard LPN2 shoved R74 in the back causing the surveyor to stumble forward. NA2 stated I think that was abuse. NA2 did not report to any other staff because SSD1 was present and the NA thought the SSD would report the abuse. Review of the facility time record revealed LPN2 continued to work until the end of the shift on Friday 1/22/16 and worked 12 hours on Saturday, 1/23/16 and Sunday 1/24/16. Interview of seven residents included R11, R36, R57, R54 and R42 identified by the facility as able to give reliable interviews and two additional residents R30 and R27 on 2/6/16 between 11:15 a.m. and 12:00 p.m. revealed they had no concerns of abuse or mistreatment by staff. Interview of staff on 2/5/16 and 2/6/16 included one LPN, four NAs and two housekeepers, revealed they had received training in the facility abuse policy and all confirmed they knew to report immediately. Review of the facility policy Abuse Prevention Policy and Procedure dated revised 3/13/14 instructed staff to report all allegations of abuse immediately to the DON and Administrator. Any allegation of abuse is reported immediately to the state agency and to all other agencies as required per state and federal guidelines. Immediately means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. The policy defined abuse as the harmful treatment of [REDACTED]. The Investigation File Checklist included: suspend any employee suspected of abuse, neglect or misappropriation immediately after taking their written statement; Maintain the employee on suspension until the investigation is concluded and is either substantiated or unsubstantiated. However; this was not a part of the facility policy. Review of the facility policy on abuse investigation with the DON on 2/6/16 at 10:45 a.m. verified there was no direction to staff to remove the staff member who committed the alleged abuse during the investigation until the investigation was complete.",2018-05-01
5981,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2016-02-06,225,D,1,0,R5VO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of facility policy, the facility failed to report the abuse immediately (within 24 hours) of a resident (R74) for one of two residents reviewed. Findings included: Review of the facility self-reported incident dated 1/25/16 identified a staff member was observed pushing a resident down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the report was dated 1/25/16, three days after the incident occurred on 1/22/16. The report indicated the steps taken to prevent further incidents included the Social Service Designee (SSD)1 had spoken to LPN2 about the harsh treatment of [REDACTED]. LPN2 continued to work to the end of the shift and 12 hour shifts on the next two days, Saturday and Sunday, before resigning on Monday 1/25/16. In addition, the initial report of an abuse investigation to the state agency was not completed until 1/25/16. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Review of the investigation continued with the DON and with the conclusion the incident did not confirm the allegation of abuse. The DON concluded, based on the statement by LPN2, that it may have looked like she (LPN2) pushed R74 but stated she didn't. The DON was questioned regarding the two witnesses who confirmed LPN2 had used excessive force and shoved R74 down the hall; however, the DON just shrugged her shoulders and stated She already quit. The DON also verified the report was not made immediate by staff or by the facility to the state agency. Interview of SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 at about 5:30 p.m. SSD1 stated R74 was threatening to hit another resident and she called for help because she couldn't redirect him. SSD1 stated LPN2 responded and stepped between the residents to protect the resident who was threatened by R74. LPN2 pushed R74 in the back twice through the doorway using excessive force. SSD1felt this met the definition of abuse; however SSD1 failed to report this to the DON until Monday 1/25/16. SSD1confirmed she should have reported the incident on 1/22/16 but the DON had left for the day and stated I should have called her at home. Interview with Nurse Aide (NA)2 at 11:15 a.m. on 2/6/16 identified LPN2 as the staff member who shoved R74 on 1/22/16 at about 5:30 p.m. NA2 reported LPN2 was trying to protect another resident from R74 because he was going to hit another resident. NA2 reported R74 swung at LPN2 and that is when LPN2 shoved R74 hard in the back. NA2 demonstrated, on the surveyor, how hard LPN2 shoved R74 in the back causing the surveyor to stumble forward. NA2 stated I think that was abuse. NA2 did not report to any other staff because SSD1 was present and the NA thought the SSD would report the abuse. Interview of seven residents that included R11, R36, R57, R54 and R42, identified by the facility as able to give reliable interviews, and two additional residents R30 and R27 on 2/6/16 between 11:15 a.m. and 12:00 p.m. revealed they had no concerns of abuse or mistreatment by staff. Interview of staff on 2/5/16 and 2/6/16 included one LPN, four NA s and two housekeepers revealed they had received training in the facility abuse policy and all confirmed they knew to report immediately. Review of the facility time record revealed LPN2 continued to work until the end of the shift on Friday 1/22/16 and worked 12 hours on Saturday,1/23/16 and Sunday 1/24/16. Review of the facility policy Abuse Prevention Policy and Procedure dated revised 3/13/14 instructed staff to report all allegations of abuse immediately to the DON and Administrator. Any allegation of abuse is reported immediately to the state agency and to all other agencies as required per state and federal guidelines. Immediately means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. The policy defined abuse s the harmful treatment of [REDACTED]. The Investigation File Checklist included: suspend any employee suspected of abuse, neglect or misappropriation immediately after taking their written statement; maintain the employee on suspension until the investigation is concluded and is either substantiated or unsubstantiated. However; this was not a part of the facility policy. Review of the facility policy on abuse investigation with the DON on 2/6/16 at 10:45 a.m. verified there was no direction to staff to remove the staff member who committed the alleged abuse during the investigation until the investigation was complete.",2018-05-01
5982,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2016-02-06,226,D,1,0,R5VO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility self-reported incident, interview and review of the policy, the facility failed to implement the abuse policy, report the abuse immediately and failed to develop a policy with direction to protect a resident from further abuse during the investigation. This occurred for one (R74) of two investigations reviewed for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN) 2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was that the Social Service Designee (SSD)1 had spoken to LPN 2 about the harsh treatment. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN 2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN 2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 at about 5:30 p.m. SSD1 stated R74 was threatening to hit another resident and she called for help because she couldn't redirect him. SSD1 stated LPN2 responded and stepped in between the residents to protect the resident who was threatened by R74. LPN2 pushed R74 in the back twice through the door way using excessive force. SSD1felt this met the definition of abuse; however SSD1 failed to report this to the DON until Monday 1/25/16. SSD1 confirmed she should have reported the incident on 1/22/16 but the DON had left for the day and stated I should have called her at home. Interview with Nurse Aide (NA)2 at 11:15 a.m. on 2/6/16 identified LPN2 as the staff member who shoved R74 on 1/22/16 about 5:30 p.m. NA2 reported LPN2 was trying to protect another resident from R74 because he was going to hit another resident. NA2 reported R74 swung at LPN2 and that is when LPN2 shoved R74 hard in the back. NA2 demonstrated, on the surveyor, how hard LPN2 shoved R74 in the back causing the surveyor to stumble forward. NA2 stated I think that was abuse. NA2 did not report to any other staff because SSD1 was present and the aide thought the SSD would report the abuse. Review of the facility time record revealed LPN2 continued to work until the end of the shift on Friday 1/22/16 and worked 12 hours on Saturday, 1/23/16 and Sunday 1/24/16. Interview of seven residents that included R11, R36, R57, R54 and R42, identified by the facility as able to give reliable interviews, and two additional residents R30 and R27 on 2/6/16 between 11:15 a.m. and 12:00 p.m. revealed they had no concerns of abuse or mistreatment by staff. Interview of staff on 2/5/16 and 2/6/16 included one LPN, four NAs and two housekeepers revealed they had received training in the facility abuse policy and all confirmed they knew to report immediately. The DON verified the report of alleged abuse was not made immediately by staff or by the facility to the state agency as required by policy and rule. Review of the facility policy Abuse Prevention Policy and Procedure dated revised 3/13/14 instructed staff to report all allegations of abuse immediately to the DON and Administrator. Any allegation of abuse is reported immediately to the state agency and to all other agencies as required per state and federal guidelines. Immediately means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. The policy defined abuse as the harmful treatment of [REDACTED]. The Investigation File Checklist included: suspend any employee suspected of abuse, neglect or misappropriation immediately after taking their written statement; Maintain the employee on suspension until the investigation is concluded and is either substantiated or unsubstantiated. However; this was not a part of the facility policy. Review of the facility policy on abuse investigation with the DON on 2/6/16 at 10:45 a.m. verified there was no direction to staff to remove the staff member who committed the alleged abuse during the investigation until the investigation was complete.",2018-05-01
5983,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2016-02-06,363,F,1,0,R5VO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to follow the pre-planned written menus. This deficient practice had the potential to affect all of the residents who dined in this facility. Findings included: Observation of the kitchen during a complaint investigation on 2/6/16 at 11:45 a.m. revealed that the facility had two notebooks that contained written menus with serving sizes. Review of the menus revealed that the facility prepared and served a variety of therapeutic diets which included: carbohydrate controlled renal pureed mechanical soft low sodium Observation of the food that was prepared for the residents ' lunch meal on 2/6/16 at 12:00 p.m. revealed that the food that was prepared was not the food that was written on the pre-planned menu. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00 p.m. confirmed that the facility did not prepare the foods that were listed on the preplanned menu. When interviewed about why the facility failed to prepare the food that was written on the menu, the DM stated that he just liked to mix things up. Per the DM the food that should have been prepared included: roast turkey gravy cornbread stuffing green bean casserole dinner roll margarine mandarin oranges Observation of the prepared food, revealed that the facility prepared the following foods: oven roasted turkey steamed cabbage sweet potatoes cornbread chocolate cake/icing baked lasagna salad/garlic bread An interview with the Registered Dietitian (RD) on 2/6/16 at 12:00 p.m. revealed that she completed the nutritional assessments for each resident who resided in this facility. The RD added that there were residents in the facility who required physician ordered therapeutic diets such as those residents with diabetes or [MEDICAL CONDITION]. When interviewed, about how she could complete a nutritional assessment or ensure that each resident had received the appropriate foods per their physician ordered diet if the facility did not prepare and serve the foods that were written on the preplanned menu, the RD stated it would be difficult. The RD stated that she was unaware that the facility had not prepared and served the foods that were written on the preplanned menus.",2018-05-01
5984,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2016-02-06,371,D,1,0,R5VO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure food safety when they did not: 1) follow the manufacturer's recommendations when operating the dish machine, 2) date and label potentially hazardous foods to prevent serving expired items, 3) defrost meat appropriately, 4) cover ready to eat food while stored to prevent cross contamination, and 5) sanitize their dishware in clean water. This deficient practice had the potential to affect all 87 residents who resided in this facility. Findings included: 1. Observation of the kitchen on 2/4/16 at 4:00 p.m. during a complaint investigation revealed a Dietary Aide (DA 1) had been operating the dish machine. DA 1 was observed placing four racks of dishes in the dish machine and removing the dishes from the rack after they air dried. Review of the manufacturer ' s label that was affixed to the front of the dish machine revealed the minimum water temperature for both the wash and rinse cycles were 120 degrees Fahrenheit (F). Observation of the dish machine during operation for six separate trials revealed that the water temperature did not reach 120 degrees F during all six trials. The temperature ranged from 93-98 degrees F. Review of the Dishwasher Temperature/Chemical Record dated February 2016, on 2/4/16 at 4:30 p.m., revealed the water temperature and the chemical sanitizer needed to be monitored and recorded three times each day; at breakfast, lunch and dinner. Further review of the temperature log revealed the water temperature and the parts per million (PPM- chemical sanitizer) was not recorded for lunch or dinner on 2/2/16, not recorded for any of the meals on 2/3/16, and it was not recorded for any of the meals on 2/4/15. An interview with the Dietary Manager (DM) on 2/4/16 at 4:45 p.m. revealed the facility water system was not functioning properly; consequently the water in the dish machine could not reach the minimum temperature of 120 degrees F for either of the cycles. When interviewed about how he could ensure that the dishes had been washed, rinsed and sanitized effectively if the water system was not functioning properly and if staff had not monitored or recorded the water temperatures or the sanitizing solution, the DM stated he could not. 2. Observation of the walk-in refrigerator on 2/4/16 revealed two large cardboard boxes that contained 150 (75 in each box) defrosting milk shakes (a nutritional supplement). The boxes of milkshakes were wet to the touch and water was dripping from the bottom of the boxes on to the metal shelving. Closer inspection of the cardboard boxes also revealed the manufacturer ' s recommendations were printed on the side of the box and read; Store at 0 degrees F or less. Per the thermometer that was placed on the inside of the walk-in refrigerator, the internal temperature was 36 degrees F. The milkshakes were not labeled relative to the date or time that they were defrosted. Observation of the nursing nourishment room with the DM on 2/4/16 at 5:00 p.m. revealed a defrosted milk shake that was not dated or labeled. Closer inspection of the milk shake carton revealed that the manufacturer ' s recommendations read; Discard after 14 days of defrost. When interviewed at that time, about how he could ensure the defrosted milk shakes that were placed in the walk-in refrigerator and in the nourishment room were safe for consumption if they were not dated or labeled, the DM stated he could not. Review of a document titled, Resident Supplement List dated 2/4/16 revealed six residents had an order for [REDACTED]. 3. Observation of the Dietary Cook ' s food preparation area on 2/4/16 at 4:00 p.m., revealed three large loaves of raw hamburger meat that was defrosting at room temperature. The raw meat was placed in the metal sink and it did not contain running water. An interview with the DM, at that time, revealed that he was aware that it was potentially hazardous to thaw raw meat at room temperature. The DM stated that the staff should have placed the loaves of hamburger under running water or in the refrigerator. 4. Observation of the kitchen on 2/4/16 at 4:15 p.m. revealed a large cooler that was shaped like a chest. The chest shaped cooler contained beverages and it opened from the top. The top of the cooler was opened which exposed a metal lip around the bottom of the lid that contained food debris and other particles. Directly under the debris covered lip was a plastic 10 gallon bucket that contained an orange beverage. The 10 gallon bucket did not have a date or a label and the cover had fallen off which allowed the debris from the metal lip to enter the orange beverage. An interview with the DM, at that time, confirmed that the orange beverage was prepared for the residents and there was a potential for the food debris and other particles to enter the uncovered beverage and created a potential for cross contamination. 5. Observation of the third compartment sink on 2/4/16 on 5:00 p.m. revealed that the water in the sanitizing sink had floating particles and the water had a greasy appearance. The Dietary Cook was observed washing dishes and placing them in the sanitizing sink. When interviewed at that time, the DM stated that the sanitizing water should have been changed once it became soiled.",2018-05-01
5985,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2016-02-06,456,F,1,0,R5VO11,"Based on observation, record review and interview, the facility failed to maintain their essential equipment in safe operating condition. The facility failed to ensure that their kitchen equipment was maintained and functioning properly and failed to ensure water temperatures the hand sinks, shower rooms and laundry area contained warm water for bathing, hand washing and laundering of resident clothing. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings included: 1.The following observations were made in the facility kitchen on 2/4/16 from 4:00- 5:30 p.m.: a. The convection oven that was located next to the tilt skillet had black electrical tape holding the metal piping in place on the side of the oven. In addition, the face plate that covered the electrical components was missing which exposed the components. An interview with the Dietary Cook at that time, revealed that the convection oven had been broken for approximately one month. b. Observation of the tilt skillet revealed that the electrical cord had a plastic covering that was cracked and chipped which exposed the underlying components and the on/off temperature dial on the front of the skillet was missing. Staff had to put their hands inside the metal housing to operate the skillet. Additional observation underneath the skillet revealed a large metal drain that was not functioning properly. There was approximately two inches of discolored liquid surrounding the drain which allowed the discolored liquid to leak out into the kitchen. c. Observation of the two stove/ovens behind the tilt skillet were missing the bottom face plates which exposed the electrical elements and allowed the pilot lights to remain uncovered. The fire from the pilot lights were in full view. d. Observation of the milk and beverage cooler revealed the front rubber seal was broken and not held tightly in place and there was condensation around the cooler. Inside the cooler was a thermometer that did not have a face plate cover and the metal dial was broken. The temperature of the cooler could not be determined at that time. e. Observation of the walk-in freezer revealed the metal housing that contained the electrical components was broken. The door that covered the metal housing remained open and the electrical components were covered with frost and built up ice. Additional observation below the metal housing, on the floor of the freezer, revealed there was approximately three inches of ice buildup. The drain tube that was connected to the condenser was not effective, consequently the water drained all over the freezer floor, door and walls. f. Observation of the three compartment sink revealed that the faucet was broken and water was leaking on the floor. g. Observation of the dish machine revealed it was not functioning per the manufacturer ' s recommendations. The dish machine was observed during operation for six separate trials and revealed the water temperature did not reach 120 degrees Fahrenheit (F) during all six trials. The temperature ranged from 93-98 degrees F. h. Observation of the hand sink in the kitchen next to the bathroom revealed that it was not equipped with warm water. The water ran for two minutes and was tested with the Dietary Manager ' s (DM) calibrated thermometer and recorded at 75 degrees F. An interview with the DM on 2/4/16 at 5:00 p.m. confirmed that the facility had failed to maintain the essential equipment in a safe and functional fashion. An interview with the Administrator and the Regional Director on 2/5/16 at 3:00 p.m. revealed the facility did not have a policy and procedure relative to maintaining essential equipment. When interviewed about how the staff would know what to do or who to contact when the equipment had malfunctioned if the facility did not develop a policy and a procedure, the Administrator stated they would not. 2. Observation of the 100 Hall shower room on 2/5/16 at 7:10 a.m. revealed a test of the water temperature from the shower head was recorded at 87 degree Fahrenheit (F) level. A second temperature check by the Maintenance Director at the same time revealed a temperature of 92 F degrees. The water was tested at the sink and revealed the temperature was 103 degrees F. A test of the water temperature, by the Maintenance Director, in the bathroom of room 118 was 101 degrees F at 7:15 a.m.; the bathroom sink in room 202 was 103 degrees F and the shower room on the 200 Hall was not operable on 2/5/16for testing. Observation of the facility boiler room on 2/5/16 at 10:30 a.m. with the facility Construction Consultant Contractor (CCC) revealed the facility did not have a boiler to provide hot water. The facility had a 98 gallon hot water heater connected to a 75 gallon hot water heater to provide hot water to all parts of the facility. The temperature gauge in the line after the mixing valve revealed the hot water supply to the building was 110 degrees F before the mix valve and 104 degrees F beyond the mixing valve. The CCC verified this would not sustain all functions of the building at an acceptable water temperature for sanitation and comfort. Observation of the laundry facility on 2/5/16 at 10:45 a.m. with the CCC verified there was no temperature gauge in the supply line to the facility washers to ensure sanitation. The water temperature in the sink in the laundry room was 97 degrees F. Interview of the laundry staff (E1) revealed all residents ' clothing was washed together and indicated the laundry detergent and bleach were automatically dispensed while, they were uncertain if chemical sanitation was provided to the colored clothing. The CCC verified a temperature gauge needed to be placed in the laundry water supply line to ensure the water was at a temperature for sanitation. The facility did not provide any additional information in regard to the sanitation of the clothing. Review of the facility water temperature logs revealed the following: Shower room on 100 Hall: 1/21/16- 102 degrees F 1/28/16- 101 degrees F 2/2/16- 95 degrees F 2/4/16- 101 degrees F Shower room on 200 Hall: 1/25/16- 102 degrees F 1/28/16- 101 degrees F 2/2/16- 94 degrees F 2/4/16- 102 degrees F There was no documentation on the date correction was to be completed according to the P(NAME), 2/5/16. Observation of the water temperature in the shower room on the 100 Hall on 2/5/16 revealed the water was not at a comfortable temperature for a shower at 92 degrees F. Interview of facility staff on 2/5/16 revealed the following: Nurse Aide (NA)4 on 2/5/16 at 7:00 a.m. revealed residents had complained of cold shower water and bath water for about 3 weeks now. Interview of NA3 on 2/5/16 at 7:06 a.m. revealed in the past three weeks, the residents complained of the cold water used for showers and when doing a bed bath the water was still cool. Interview of Licensed Practical Nurse (LPN)3 on 2/5/16 at 1:15 p.m. stated Yes, the residents have complained of cold shower water so we do a bed bath instead but the water is just warm not hot enough. Interview of seven residents on 2/6/16 between 11:15 a.m. and 12.00 p.m., included five residents (R11, R36, R57, R54, R42 ) who were identified by the facility as able to give a reliable interview, and two additional residents (R30 and R27) were also chosen for interview. The interviews of all seven residents reported the water in the shower was cold. The seven residents also indicated the water temperatures had been cold for the past couple of weeks. The plan of correction (P(NAME)) was reviewed with the Facility Administrator on 2/6/16 at 1:00 p.m. and verified the water temperature in the shower room on the 100 Hallway continued to be a problem. The P(NAME) for the survey completed on 1/21/16 indicated the water temperature logs would be completed daily for compliance and any deficiency would be immediately be corrected, documented and brought to QA/PI (Quality Assurance Performance Improvement) meeting. The plan of correction indicated compliance by 2/5/16 and the shower water temperature was 92 degrees on 2/5/16. 3. An observation of the 200 Hall shower room on 2/6/16 at 1:00 p.m. revealed the hot water faucet was broken. The faucet would turn but no water came out. An observation of room 219 on 2/6/16 at 1:20 p.m. revealed the hot water faucet was broken. The faucet would turn but no water came out. An interview was conducted with the Administrator on 2/6/16 at 1:35 p.m. The Administrator stated I thought all of the faucets had been fixed.",2018-05-01
5986,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2016-02-06,493,D,1,0,R5VO11,"Based on record review, interview and review of policies and procedures, the facility governing body failed to ensure: 1) each facility employee was paid timely, 2) the Quality Assurance Performance Improvement (QA/PI) committee met quarterly and had the appropriate members present, and 3) develop effective policies and procedures. This deficient practice had the potential to affect all of the residents who resided in this facility. Findings included: 1. Review of two Complaint Intake IDs; GA 800 and GA 970 received on 12/16/15 and 1/27/16 respectively, revealed that the facility might have some difficulties meeting their payroll obligations. Per the complainants, who requested to remain anonymous, the facility was in a financial bind , they were concerned that some of the employees might walk out and their payroll checks were being held. An interview with a Licensed Practical Nurse (LPN1) on 2/4/16 at 4:30 p.m. revealed that some of the nurses at this facility had not been paid per the facility policy and one LPN2 quit a few days previously due to non-payment. LPN1 added that many of the facility employees received their payroll checks late and soon after they deposited the checks, they were returned for insufficient funds. Review of the personnel file revealed LPN2 had written a note that stated, I (name of the employee) resign on 1/25/16. The note did not state why LPN2 resigned. During an interview on 2/5/16 at 2:30 p.m., Employee10 (E10) (an anonymous source) stated that she was aware of the hand written note in LPN2' s personnel file. E10 added that before LPN2 left the facility, she told E10 that she was resigning due to not receiving paychecks timely. An interview with a Nurse Aide (NA1) on 2/5/15 at 11:30 a.m. revealed the facility would hold the employee paychecks until after the bank closed for the day. NA1 added that their checks were supposed to be ready at 2:00 p.m. on paydays but the facility held their checks, until 4:00 p. m. When interviewed about why the checks were held until 4:00 p.m. on paydays, NA1 stated because that was the time that the bank closed for the day. NA1 added that the facility did not want the employees to go to the bank to cash their payroll checks because they knew that they did not have the funds available, so they held the checks until after the bank closed. When interviewed about what she would do if she needed her money on payday but could not cash her check, NA1 stated that she would have to go without. An interview with the Medical Director (MD) via telephone on 2/6/16 at 11:30 a.m. confirmed the employees at this facility received checks that were returned due to insufficient funds. The MD added that the facility would pay the bank fines that the employees accrued due to insufficient funds. Review of a document titled, Returned Check Fees dated 7/10/15 through 8/13/15 revealed that 21 employees accrued fees when their payroll checks were returned for insufficient funds. The fines ranged from 5 dollars to 117 dollars. An interview with the Regional Director on 2/5/16 at 12:30 p.m. confirmed that the employees received payroll checks that could not be cashed or deposited due to insufficient funds. The Director added that each time that occurred, the facility would reimburse each employee for the fines that the bank imposed on them. Review of an undated document titled, PAYCHECKS revealed the following information: Policy Statement .Name of the facility makes every attempt to issue accurate and timely paychecks. .Name of the facility makes every effort to ensure that employees receive their paychecks on time. However, circumstances may occur that prevent the company from meeting such obligations . The document did not have a Procedures section to include topics such as what day of the week the staff could expect to get paid, what time their paychecks would be available, or what to do if their paychecks were returned for insufficient funds. 2. The governing body failed to ensure that each member of the Quality Assessment and Performance Improvement (QA/PI)) committee attended the meetings and met on a quarterly basis to address concerns that had been identified throughout the facility. The facility could not provide any documentation that the QA/PI committee meetings were held at least quarterly since their recertification survey in August of 2015 or that the appropriate members attended the meetings. Review of the undated 1st Quarter Monthly QA/PI Meeting Agenda revealed the facility was to discuss the deficient practices that were identified during the 1/20/16 revisit survey, however review of the sign in sheet, revealed that the Medical Director (MD) did not attend the meeting. An interview with the Administrator on 2/6/16 at 2:00 p.m. confirmed that the MD did not attend the QA/PI meeting that was held on 1/29/16 with the Interdisciplinary Team (IDT). She stated that the facility had to hold a separate meeting with the MD at a later date. When interviewed about what the governing body did when the QA/PI meetings were not held timely or when the appropriate committee members were not present for the meetings, the Administrator was uncertain. Review of the policies and procedures revealed that the QA/PI policy was revised on 1/31/14 but it did not include important topics such as: a. What key personnel and facility staff were mandated to attend the QA/PI meetings. b. What the facility policy was relative to absenteeism during the QA/PI meetings. c. Who was responsible for ensuring that the QA/PI committee met timely. d. How to prioritize the concerns that were identified throughout the facility. e. What were the facility ' s procedures relative to how to identify new concerns throughout the facility. The policy included: QA/PI Meeting rev.1/31/14 Schedule a date/time convenient for your Medical Director. To assess the agenda go to: shared drive, clinical manuals, QA/PI manual, Monthly QA/PI meeting. The agenda/sign in sheet consist of 4 pages for each of the 4 quarters. Example-the first Quarter is for Jan, Feb, and March meetings to cover data from the prior month. (Dec., Jan, and Feb.) The designated QA/PI coordinator should access and save the agenda in their own facility Y drive in order to create a file later for each month ' s QA/PI data. (Make sure it is not saved in the G shared drive) Several days before the meeting, the QA/PI coordinator should print a blank copy of the agenda for the appropriate month, indicate who will provide the date before each section, copy and distribute. The collected data should be put in a saved file and named for the month. Input the ADC for the moth in each page and it will figure your percentages for you. Print and copy the completed form for the meeting attendees. One main copy should be signed by everyone at the meeting and kept on file. Note- Bold numbers in Standards of Practice column are (name of facility) thresholds. Each facility must set standards for the other areas and assess progress monthly. After the meeting the QA/PI coordinator should go back in to the saved agenda and input the new business and any action plans develop from the meeting. Items to bring to the Meeting: QA/PI agenda/sign-in sheet with data from the previous month Old Business (Action Plans in place with progress updates) Pharmacy Consultant Report Concern/Comment Summary Resident Council Meeting concerns with resolution summary QI/QM report (1 month and 6 month) Safety Meeting minutes Medical Record audit summary Business Office moth-end billing/triple check barrier summary Survey audits in progress Completed Nosocomial Infection Summary (Infection control Manual: Ch.2 p.4) An interview on 2/6/16 at 2:30 p.m. revealed the Administrator revealed could not locate any other policies and procedures relative to the QA/PI process, or any policies or procedures relative to the responsibilities of the governing body. The Administrator stated that most of the facility policies and procedures were on line and difficult to find. When interviewed about how the governing body reviewed and revised policies and signed that they had been reviewed, or how the staff would know how to perform their responsibilities and duties effectively if they could not retrieve and read the facility policies and procedures, the Administrator was uncertain.",2018-05-01
5987,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2016-02-06,520,F,1,0,R5VO11,"Based on interview and record review, the facility failed to ensure that each member of the Quality Assessment and Performance Improvement (QA/PI)) committee attended the meetings and met on a quarterly basis to address concerns that had been identified throughout the facility. The facility failed to develop plans of action with measurable goals and interventions to ensure that the identified concerns would not be repeated in the future. They failed to identify and correct concerns with, 1) the environment and housekeeping, 2) maintenance of essential equipment, 3) a properly functioning water system and 4) the lack of funds to pay their employees. This deficient practice had the potential to affect all 87 residents who resided in this facility. Findings include: 1. Review of the Statement of Deficiencies, the federal 2567 report dated 1/20/16 and the Plan of Correction (P(NAME)) for the revisit with a date certain of 2/4/16, revealed that the facility had failed to maintain the environment in a safe and sanitary fashion. 2. Observation of the kitchen on 2/4/16 from 4:00pm through 5:30pm revealed that the facility failed to maintain their essential equipment in safe operating condition. The facility ' s tilt skillet, stove/ovens, water faucets, walk-in freezer, dish machine, and convection oven were either missing parts, held together with electrical tape, or and not functioning properly. For additional information refer to F456. An interview with the Dietary Manager (DM) on 2/6/16 at 12:00pm revealed that he did not have a policy and procedure relative to how to maintain the kitchen equipment effectively. The DM stated that he did attend the QA/PI meetings but the concerns about the kitchen equipment was not discussed. When interviewed about how he could ensure that these concerns would not continue in the future if they were not addressed in the QA/PI meetings, the DM stated he was unsure. Review of the 1st Quarter Monthly QA/PI Meeting Agenda revealed that the facility was to discuss the deficient practices that were identified during the 1/20/16 revisit survey, however review of the sign in sheet, revealed that the Medical Director (MD) did not attend the meeting. An interview with the Administrator on 2/6/16 at 2:00pm confirmed that the MD did not attend the QA/PI meeting that was held on 1/29/16 with the Interdisciplinary Team (IDT). She stated that the facility had to hold a separate meeting with the MD at a later date. When interviewed about how the facility could ensure that the identified concerns would be corrected and not continue in the future if the MD did not attend the meetings with the IDT to ensure that interventions with measureable goals and time tables could be developed, the Administrator was uncertain. 3. Review of two Complaint Intake IDs; GA 800 and GA 970 received on 12/16/15 and 1/27/16 respectively, revealed that this facility might have some difficulties meeting their payroll obligations. Per the complainants, who requested to remain anonymous, the facility was in a financial bind , they were concerned that some of the employees might walk out and their payroll checks were being held. For additional information refer to F493. During an interview with the MD via telephone on 2/6/16 at 11:30am revealed the some of the employees at this facility received checks that were returned due to insufficient funds. When interview about how he could ensure that this concern would not continue in the future if he did not discuss it with the QA/PI committee, the MD stated that he could not. He added that even his payroll checks were returned on occasion. The MD stated that he did not manage the facility ' s environment or payroll issues or discuss those topics in the QA/PI meetings, he stated that he only monitored the clinical aspects of this facility. 4. Observation of the kitchen on 2/4/16 at 4:00pm revealed that the dish machine had not functioned per the manufacturer ' s recommendations. Observation of the dish machine during operation for six separate trials revealed that the water temperature did not reach 120 degrees F during all six trials. The temperature ranged from 93-98 degrees F. For additional information refer to F371. An interview with the Dietary Manager (DM) on 2/4/16 at 4:45pm revealed that the facility ' s water system was not functioning properly, consequently the water in the dish machine could not reach the minimum temperature of 120 degrees F for either of the cycles. When interviewed about if he discussed the dish machine and the substandard water temperatures during the QA/PI meetings, the DM stated he did not. 5. Review of facility documentation and interview of residents and staff evidenced the facility failed to maintain water temperatures to provide a comfortable water temperature for residents in the facility to take a shower or bath. This issue was identified during a revisit on 1/20/16 and was to be corrected by a plan by the QA/PI program and completed by 2/4/16. This issue continued as identified in detail in F456. This issue continues to affect all 87 residents who resided in the facility at the time of the survey. Review of the plan of correction for facility issue of cold water in the facility for resident showers indicated QA would be a part of the plan to solve and monitor the problem and correct the issue with cold water. Review of the water temperatures revealed the plan implemented was not effective and failed to ensure residents had warm water for bathing. The QA committee failed to devise and implement a new plan of action to ensure residents had comfortable water temperatures. An interview with the facility Administrator on 2/6/16 at 2:30pm revealed that she could not locate any documentation either by record review, policy review, or review of the QA/PI committee meetings that demonstrated that the facility had a functioning and effective QA/PI program. The Administrator stated that she could not provide any documentation relative to how the facility planned to develop plans of action with measurable goals and time tables to ensure that the essential equipment, the water system and the employees paychecks concerns would not continue in the future. Review of the plan of correction for facility issue of cold water in the facility for resident showers indicated QA would be a part of the plan to solve and monitor the problem and correct the issue with cold water. Review of the water temperatures revealed the plan implemented was not effective and failed to ensure residents had warm water for bathing. The QA committee failed to devise and implement a new plan of action to ensure residents had comfortable water temperatures.",2018-05-01
6270,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-02-20,257,E,1,0,JG8W11,"Based on observation and staff interviews the facility failed to maintain a safe and comfortable temperature on one (1) (100 Hall) of three (3) halls. Findings include: During the initial tour of the facility on 2/20/15 at 10:50 a.m., the air temperature in the Men's Shower room was noted to be very cold and uncomfortable. The air temperature at that time was 65.4 degrees Fahrenheit (F). The air temperature in the Women's Shower room was 73 degrees F. During an interview with staff AA and BB on 2/20/15 at 12:15 p.m., they stated that there had not been any central heat and air for about a year. During an interview with the maintenance supervisor on 2/20/15 at 11:15 a.m., the maintenance supervisor stated that the central heating and cooling unit had been burned out since at least 3/2014. He/She further stated that he/she had submitted a bid to replace the central heating and air unit on 1/8/15 and had not yet had a response from corporate. He/She stated that it was inexcusable.",2018-02-01
6271,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2015-02-20,456,F,1,0,JG8W11,"Based on observation and staff interviews, it was determined that the facility failed maintain one of two water heaters to ensure there was hot water on three of three halls. Findings include: During the initial tour of the facility on 2/20/15 at 10:50 a.m. with the maintenance supervisor, Director of Nursing and the housekeeping supervisor, the following rooms were checked and were found to not to have adequate hot water: Women's Shower room- 86.5 degrees Fahrenheit (F.), Men's Shower Room- 83 F., room 118- 93.2 F., room 108- 91.6 F., room 102- 91.8 F., room 101- 91.4 F., room 100- 86.9 F., room 220- 91 F., room 216- 97 F., room 214- 94 F., room 204- 94.6 F., room 201- 94 F., room 304- 88 F., room 310- 88 F., room 312- 82.6 F. and room 316- 82 F. During an interview with staff AA and BB on 2/20/15 at 12:15 p.m., they stated that there had not been adequate hot water in the resident rooms or shower for about three weeks and no heat for about a year. During a random observation on 2/20/15 at 12:30 p.m., a resident told the Director of Nursing (DON) that the shower was cold this morning. During a group interview held with four (4) residents on 2/20/15 at 1:25 p.m. it was revealed that all four (4) residents concurred that there had been no hot water for a couple of months and that it was too cold in the shower. One (1) resident stated that he/she would take a sponge bath from now on. During an interview with the maintenance supervisor on 2/20/15 at 11:15 a.m., revealed that for the last six (6) to seven (7) days there had been very little hot water in the building. He/She stated that one (1) of the two (2) hot water heaters stopped functioning a couple weeks ago which left the one (1) water heater serving the entire building, except for the laundry. He/she stated that he/she had obtained two (2) bids to replace the water heater on January 8, 2015 and January 31, 2015. He/She further stated that he/she had not received approval from corporate to replace the unit. He/She stated that the delay was inexcusable.",2018-02-01
8545,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2011-11-10,280,D,0,1,1JXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to continue to implement planned interventions to address the positioning needs of one resident (#63) and failed to revise interventions to address continued falls for one resident (#38) in a total sample of 28 residents. Findings include: 1. On the 5/27/11 Minimum Data Set (MDS) assessment, licensed staff coded resident # 63 as having limitaton with range of motion to one side of his/her upper extremity. On the 9/1/11 MDS assessment, the resident was coded with a decline in the limited range of motion to include both of his/her upper extremities. There was a care plan since 8/28/10 to address his/her risk for injury from falls due to limited mobility, havig been bed to gerichair bound and having [MEDICAL CONDITION] and a [MEDICAL CONDITION] disorder. The interventions included having the call light close (to the resident) and for staff to promptly answer it, staff providing all activities of daily living, for staff to transfer the resident with the hoya lift, and staff to monitor the resident for positioning for possible injury. A new intervention was added on 8/22/11 for the resident to be screened by occupational therapy services for an evaluation if indicated. However, although the resident was observed to lean to the left in his/her geri-chair, there was no evidence that the resident was provided any restorative therapy services after his/her hospital return in July 2011 or was evaluated by the occupational therapist for further skilled therapy. See F 311 for additional information regarding resident # 63. 2. Resident #38 had a care plan and physician's orders [REDACTED]. There was an intervention for physical therapy skilled services to be provided for the resident three times a week for two weeks for therapeutic exercises therapeutic activities, gait-training, and neuromuscular re-education. However, there was no evidence that the physical therapist had evaluated and treated the resident. See F323 for additional information regarding resident #38.",2016-01-01
8546,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2011-11-10,282,D,0,1,1JXD11,"Based on observations, record review and staff interview, it was determined that the facility failed to implement care plan interventions to provide oral care for one resident A and to provide assistance with shaving for one resident (#74) in a total sample of 28 residents. Findings include: 1. On the 9/01/11 and 5/27/11 Minimum Data Sets (MDS) assessments, licensed staff coded resident A as needing total assistance for hygiene. There was a care plan since 8/28/11 to address his/her dependence on staff to meet his/her activities of daily living (ADL) needs because of his/her limited mobility. There was an intervention for staff to explain procedures prior to performing his/her daily oral care. However, the resident was observed on 11/7/11 at 3:20 p.m., 11/9/11 at 8:30 a.m. and 11:30 a.m., and on 11/10/11 at 9:50 a.m. to have teeth that were caked with debris. See F312 for additional information regarding resident A. 2. Resident #74 had a care plan since 11/8/11 to address his/her self care deficit with an intervention for nursing staff to assist him with shaving on bath days and as needed. According to staff documentation on the the resident's ADL Flow sheet that was reviewed on 11/10/11 9:10 am, the resident had been given a shower every day from 11/1 thru 11/9/11. However, resident #74 was observed to have had several days growth of facial hair on 11/8/11 at 8:17 a.m. and 4:32 p.m., on 11/9/11 at 8:50 a.m., 11:05 a.m., 3:00 p.m. and 4:05 p.m. and, on 11/10/11 at 8:00 a.m. and 10:10 a.m. See F312 for additional information regarding resident #74.",2016-01-01
8547,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2011-11-10,311,D,0,1,1JXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview and record review, it was determined that the facility failed to continue to provide services to address the maintenance or improvement of positioning for one resident (#63) in a total sample of 28 residents. Findings include: Resident # 63 had [DIAGNOSES REDACTED]. The resident had been coded on the 5/27/11 Minimum Data Set ( MDS) assessment as having limitation with range of motion on one side of his/her upper extremity. On the 9/01/11 MDS, the resident was coded to have had a decline of limited range of motion in both of his/her upper extremities. staff developed a care plan to address the resident's risk for injury due to limited mobility, being bed to chair bound and having [MEDICAL CONDITION] and a [MEDICAL CONDITION] disorder. There was an intervention for staff to monitor his/her positioning for possible injury. Staff added an intervention on 8/22/11 for the resident to be screened by occupational therapy services and evaluated as indicated. The resident was observed attending a church service on 11/9/11 at 10:30 a.m. He/she was seated in a geri-chair in the reclining position. Although staff had provided a back support and bolster for the left arm of the resident's geri-chair, his/her upper torso was leaning toward the left side. The resident was observed to still be in the activity room at 11:30 a.m. Despite the resident continuing to lean to the left side of the geri-chair, the staff, who was present in the room, failed to attempt to reposition the resident into the correct position. The resident continued to be leaning to the left side while seated in geri-chair in the day room at 3 p.m. Although there were positioning devices to the back and left arm of the geri-chair, the resident continued to inappropriately lean to the left so that there was not any support for his/her head or neck. On 11/10/11 at 8:30 a.m., the resident was observed seated in geri-chair. He/She was leaning to the left side while attempting to feed him/herself. The resident was observed to unsuccessfully attempted to pull him/herself over to the right side in the chair but, he/she was not able to reposition him/herself. The staff documentation in the resident's medical record revealed that the resident had been provided skilled occupational therapy services from 5/26/11 through 7/22/11. Then he/she was discharged with occupational therapy recommendations for restorative nursing to maintain the resident's optimum upper body range of motion strength to promote increased self performance with bed mobility and self feeding. The resident was admitted to the hospital on [DATE] and returned to the facility on [DATE]. However, there was not any evidence that after his/her hospital return that the resident had been provided any restorative nursing therapy services or was evaluated by the occupational therapist for additional skilled therapy services. During an interview on 11/10/11 at 10:45 a.m., the restorative nurse stated that, after surveyor inquiry, the resident had been started on a restorative nursing program for range of motion and positioning the previous afternoon. She stated that she was not sure why restorative nursing services had not been provided to the resident since his/her return to the facility from the hospital in July, 2011.",2016-01-01
8548,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2011-11-10,312,D,0,1,1JXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to provide oral care for one resident (A) and to assist with shaving for one resident (#74) in a total sample of 28 residents. Findings include: 1. Resident Ahad [DIAGNOSES REDACTED]. On the 9/01/11 Minimum Data Set (MDS) assessment, licensed staff had coded him/her as needing total assistance for hygiene. The resident's care plan since 8/28/11 noted that the resident depended on staff to meet his/her activities of daily living (ADL) needs because of his/her limited mobility. There was an intervention for (nursing) staff to explain procedures prior to performing the resident's daily oral care. However, it was observed that daily oral care was not provided for resident A. The 9/20/11 nurse's note at 12:30 p.m. described the resident having had a tooth come out while he/she was eating. The tooth was described as having been black in color and, chipped and broken in places. Nursing staff wrote that the other teeth surrounding the open area were dark in color. However, there was no evidence that the resident's attending physician or a dentist had been contacted about those problems with the resident's teeth. During an interview on 11/7/11 at 3:10 p.m., resident A stated that staff helped him/her to brush his/her teeth less than once a month. The resident's teeth were observed on 11/7/11 at 3:20 p.m., on 11/9/11 at 8:30 a.m. and 11:30 a.m., and on 11/10/11 at 9:50 a.m. to have been caked with debris. 2. On the 10/27/11 MDS assessment, licensed nursing staff coded resident #74 as needing total assistance with personal hygiene and grooming. Nursing staff developed a care plan dated 11/8/11 to address the resident's self care deficit with an intervention for nursing staff to assist with shaving on his/her bath day and as needed. Review of the resident's ADL flow sheet revealed nursing staff's documentation that the resident had been given a shower on 11/8/11, 11/9/11 and 11/10/11. However after those showers, the resident still had several days growth of his beard. The resident was observed on 11/8/11 at 8:17 a.m. and 4:32 p.m., on 11/9/11 at 8:50 a.m., 11:05 a.m., 3:00 p.m. and 4:05 p.m. and, on 11/10/11 at 8:00 a.m. and 10:10 a.m. to have had several days growth of facial hair.",2016-01-01
8549,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2011-11-10,323,D,0,1,1JXD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, it was determined that the facility failed to provide interventions to prevent falls for one resident (# 38) from a sample of 28 residents and to secure razors in one common shower room (100 hall) of three common shower rooms in the facility. Findings include: 1. Review of the medical record for resident #38 revealed staff documentation about the resident having fallen but not been injured on 08/12/11, 08/29/11, 09/11/11, 09/12/11, 09/12/11, 10/04/11, 10/19/11 10/23/11, and 11/09/11. The facility developed and implemented interventions to prevent falls. Record review revealed that the resident had been provided skilled physical therapy services from 9/01/11 to 9/09/11 to reduce the likelihood of falls then, a referral had been made for restorative nursing services for maintaining skill in ambulation and strength in both legs. Staff's documentation revealed that the resident was provided range of motion exercises as ordered from 09/10/11 through 11/10/11. However, the resident continued to fall with the last fall documented as happening on 11/09/11. The physician wrote an order on 10/24/11 for physical therapy staff to evaluate and treat the resident as indicated. The order was for the resident to be seen by a skilled physical therapist three times a week for two weeks for skilled physical therapy services. However, there was no evidence that those services had been provided. During an interview on 11/10/11 at 10:45 a.m., occupational therapist CC could not locate evidence that a physical therapy evaluation had been done despite the order for it or that those skilled services had been provided. During an interview on 11/10/11 at 11:00 a.m., the Restorative Nursing Services registered nurse (RN) AA and certified nursing assistant, (CNA) BB said that nursing staff was not aware of any physical therapy services but, were providing restorative nursing services. During an interview on 11/10/11 at 11:18 a.m., the Director of Nursing (DON) stated than an evaluation would have been done to obtain the frequency and specifics of the physician's orders [REDACTED]. However during an interview on 11/10/11 at 11:45 a.m., physical therapist EE explained that the resident had refused to use a merry walker but, he had not written a plan or any notes and, was going to discharge the resident from skilled therapy. However, there was no evidence that any physical therapy evaluation or services had been provided or about the resident's refusal of those services. 2. During the initial tour on 11/7/11 at 11:30 a.m., there were 14 disposable razors in an unlocked cabinet in the 100 hall common shower room. During a random observation on 11/10/11 at 11:05 a.m., there were eight (8) disposable razors in an unlocked cabinet in that common shower room.",2016-01-01
8550,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2011-11-10,371,F,0,1,1JXD11,"Based on observation, staff interview, and record review, it was determined that the facility failed to hold and serve potentially hazardous food at safe temperatures to prevent potential food borne illnesses for seven of eight residents on pureed diets and 28 of 76 residents who were served mechanical soft or regular diets. Findings include: During an observation on 11/7/11 at 12:35 p.m., foods were observed being held and served in the danger zone (above 41 degrees Fahrenheit (F.) and below 135 degrees F.) which allowed for the growth of organisms which could cause food borne illness. Pureed chicken was being held and served at 120 degrees F. The potato salad was being held and served at 54 degrees F The foods were checked with a facility calibrated thermometer. Seven residents had been served the pureed chicken. There were 28 residents who had been served the potato salad. In an interview on 11/08/11 on 12:37 p.m., the Dietary Manager said that the potatoes were warm when the salad was mixed. However, the temperature log documentation indicated that the potatoes had been at 40 degrees F at 11:55 a.m On 11/08/11 at 1:20 p.m., the Dietary Manager stated that residents on a mechanical soft diet and those eating at the first seating in the dining room had been served potato salad.",2016-01-01
10215,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2010-04-08,253,B,0,1,OHLM11,"Based on observation, it was determined that the facility failed to maintain an environment that was free from stained and dirty clean linen carts, dried food splatters, dried spills, dirt , dust, non-fitting commode tank covers, gaps in floor tiles, and rust in room 216 and on all three Halls (100 Hall, 200 Hall, 300 Hall). Findings include: Observations were made during the Initial Tour on 4/6/10 at 9:45 a.m. and the General Observations Tour on 4/8/10 between 8:30 a.m. and 10:30 a.m. 100 Hall 1. There were dust and dried liquid spills on the shelves of the clean linen cart in the hall. 200 Hall 1. There was a buildup of dirt in the corners of the bottom shelf of the clean linen cart in the hall. There were dust and dried liquid spills on the other shelves of the cart. 2. There was a loose door handle to the bathroom of room 216. There was a gap in the corner where the floor tiles met the wall. There was a rusty leg on the raised toilet seat. The commode tank cover did not fit the tank. 300 Hall 1. There were dried brown liquid spills on the shelves of the clean linen cart in the hall. There were dried liquid spills on the cart cover. Pantry 1. There were dried food splatters inside of the microwave. There were dried pink liquid spills inside the refrigerator's crisper drawers.",2014-12-01
10216,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2010-04-08,203,D,1,1,OHLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, it was determined that the facility failed to provide written notice of the discharge and of the required information for one resident (#1) of three residents discharged from the facility in a total sample of 18 residents. Findings include: According to the 2/19/10 at 9:30 a.m. nurse's notes, resident #1 had and altercation with a licensed nurse and the resident was picked up by the county sheriff's department. The licensed nurse documented on 2/19/10 at 1:45 p.m. that the psychiatric hospital was consulted about the resident's admission. There was a 2/19/2010 physician's orders [REDACTED]. On 2/26/10 (seven days later) there was a physician's orders [REDACTED]. However, there was no evidence that the facility had notified the resident and a family member or legal representative in writing of the discharge the reason for the discharge, the effective date of the discharge, the location to which the resident was being discharged , notice that the resident had the right to appeal the action to the State, and the name, address, and telephone number of the State Long Term Care Ombudsman. During an interview on 04/07/10 at 2:00 p.m., the Administrator confirmed that the facility had not provided the required written notification of the discharge and information to the resident and family member or legal representative.",2014-12-01
10217,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2010-04-08,441,D,0,1,OHLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to assure that one of four newly hired employees were free of communicable disease before allowing direct contact with residents or that one of two CNAs observed practiced proper hand hygiene after bowel incontinence care. Findings include: The facility's policy to ""New Employee Screening"" documented that the employee health coordinator (or designee) would accept documented verification of two-step TST ([MEDICATION NAME] skin test)or BAMT (blood assay for [DIAGNOSES REDACTED] [DIAGNOSES REDACTED]) results within the preceding 12 months. 1. A review of 14 employees' personnel records revealed that one certified nursing assistant was hired by the facility on 1/13/10. However, there was no evidence that the facility had performed a [MEDICATION NAME] screening test (PPD) and received the results prior to her having had direct contact with residents. The most recent PPD result documented for the resident was dated 7/1/09. However, there was no evidence that the facility had verified that it had been a two-step TST within those preceding 12 months. 2. After completion of bowel incontinence care for resident #6 on 4/6/10 at 4 p.m., it was observed that CNA ""AA"" failed to remove her soiled gloves. The CNA did not remove or change his/her gloves or wash his/her hands prior to redressing the resident and positioning him/her in a geri-chair.",2014-12-01
10218,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2010-04-08,241,E,0,1,OHLM11,"Based on observations, it was determined that the facility failed to promote a dignified dining experience for thirteen residents (#4, #13, #14, #11 and nine residents randomly observed) in the small dining room from a total sample of 18 residents. Findings include: 1. Resident #4 drank four ounces of water at lunch prior to receiving staff assistance. Resident #4 was observed on 4/6/10 at 12:35 p.m. in the small dining room being assisted to eat by a Certified Nursing Assistant (CNA). The CNA was inappropriately feeding the resident at a fast pace. The CNA did not allow the resident to swallow each bite before giving him/her more to eat. The CNA did not offer the resident any of the iced tea until after he/she had eaten all of the food on the plate. Resident #4 was observed on 4/7/10 at 12:25 p.m. in the small dining room slowly feeding himself/herself. A CNA was inappropriately giving the resident a few bites of food then walking over to another table and standing over another resident to feed him/her a few bites to eat. Resident #4 continued to slowly feed himself. At that time, another CNA was observed to be seated between two residents while assisting them to eat. However, that CNA inappropriately turned her back completely towards one resident while assisting the other resident to eat. 2. Resident #13 was observed on 4/8/10 from 12:05 p.m. to 12:31 p.m. eating lunch in the small dining room. The resident was seated at a table with resident #14 and another resident. A CNA was seated between resident #14 and the other resident. The CNA stopped assisting those two residents to eat when, she repeatedly got up and walked around the table to prompt resident #13 to continue to eat and drink fluids. At that time, it was observed that four other nursing staff members were supervising or assisting ten residents to eat. Two of the four nursing staff members were standing over the residents while assisting them to eat. 3. Resident #11 was observed on 4/8/10 from 8:10 a.m. to 8:30 a.m. in the small dining room being fed breakfast. At 8:10 a.m., a CNA was inappropriately standing over the resident while assisting him/her to eat. After the CNA left resident at 8:20 a.m., another CNA began inappropriately standing over him/her to assist the resident to eat. At 8:25 a.m., the Speech Therapist walked over to assist the resident while inappropriately standing over him/her. The resident appeared sleepy and was not eating well so, the Speech Therapist quit assisting him/her to eat. At 8:30 a.m., a CNA returned and began assisting the resident to eat while inappropriately standing over the resident. That CNA repeatedly walked back and forth to assist two other residents at the table to eat. The CNA would give each of the three residents a bite of food. 4. Random observations were made on 4/8/10 from 8:10 p.m. to 8:30 p.m. in the small dining room. A CNA was observed inappropriately standing over a resident at the first table on the left while assisting him/her to eat breakfast. A CNA was observed inappropriately standing over two residents at the second table on the right while assisting them to eat breakfast. During a random observation on 4/7/10 from 5:00 p.m. to 5:35 pm. in the small dining room, three residents were observed sitting at the back right table. At 5:00 p.m., a CNA served all three of the residents a supper tray. The CNA then sat between two of the residents and began to assist them to eat. At 5:05 p.m., the third resident stated that he wanted to eat, his/her tray was uncovered and put on the table in front of him/her. The CNA told him/her that she ""would feed him/her as soon as she had finished feeding the other two residents."" At 5:25 p.m., while the CNA was still assisting the two residents, the third resident stated that he/she wanted his/her tea. At 5:30 p.m.(30 minutes after the meal was served), the CNA got up and moved her chair between the third resident and one of the two other residents, then began assisting the third resident to eat while continuing to assist the other resident.",2014-12-01
10219,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2010-04-08,315,D,0,1,OHLM11,"Based on observations, it was determined that the facility failed to provide proper incontinence care for one (#6) of the seven incontinent residents from the total sample of 18 residents. Findings include: During an observation of bowel incontinence care being provided for resident #6 on 4/6/10 at 4:00 p.m., CNA (Certified Nursing Assistant ) ""AA"" cleaned the resident's rectal area. The CNA then inappropriately wiped up into the resident's perineal area several times using the same disposable wipe that was soiled with feces.",2014-12-01
10220,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2010-04-08,160,D,0,1,OHLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, it was determined that the facility failed to convey the personal funds of one resident (#15) to the probate jurisdiction administering the resident's estate within 30 days of the resident's death. Findings include: Resident #15 expired on [DATE]. A review of the resident's ""Resident Trust Fund Statement"" for [DATE] revealed that a balance of $50.45 remained in the resident's trust fund account. During an interview on [DATE] at 1:00 p.m., the facility's bookkeeper stated that the resident had been his/her own responsible party and that no family member had come forward to receive the resident's monies. The facility's policy on residents' funds documented that, if a balance remained in the account that was due the patient/responsible party within 30 days of discharge, a check would be issued to the patient/responsible party. If a balance remained in the account that was due to the facility, once the exact amount due was determined, the facility would issue a check to the facility's General account. During a telephone interview with the facility's CFO (Chief Financial Officer) on [DATE] at 1:30 p.m., he stated that the $50.45 remained in the resident's trust account because it had not been determined if the resident owed any money to the facility since the Explanation of Benefits for Medicare and Medicaid services had not been received by the facility.",2014-12-01
10221,ABBEVILLE HEALTHCARE & REHAB,115623,206 MAIN STREET EAST,ABBEVILLE,GA,31001,2010-04-08,205,D,1,1,OHLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide one resident (#1), who required an emergency transfer from the facility, with written notice within 24 hours that specified the duration of the facility's bed-hold policy from a total sample of 18 residents. Findings include: According to the 2/19/10 at 9:30 a.m. nurse's notes, resident #1 had an altercation with staff which resulted in injuries to the staff. The license nurse documented on 2/19/2010 at 1:45 p.m. that the behavorial (psychiatric) hospital was consulted for admission of the resident. There was a 2/19/10 physician's orders [REDACTED]. On 2/26/10 (seven days later), there was a physician's orders [REDACTED]. However, although the resident had required an emergency transfer from the facility to the behavioral (psychiatric) hospital on [DATE], there was no evidence that a written notice that specified the duration of the bed-hold policy had been given to the resident and a family member or legal representative within 24 hours of the transfer. On 4/07/10 at 2:00 p.m., the Administrator confirmed that the facility had not provided written notice to the resident and family member of the facility's bed-hold policy.",2014-12-01
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
5143,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2015-05-07,157,D,0,1,CGV611,"**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 abnormal blood pressure results for one (1) resident (#4), on a sample size of thirty-four (34) residents. Findings include: Review of the clinical record for resident #4 revealed that she was admitted to the facility on [DATE], and had [DIAGNOSES REDACTED]. Review of an Admission History and Physical dated 03/27/15 noted the resident had baseline [DIAGNOSES REDACTED] with [MEDICAL CONDITION] exacerbation and numerous medical co-morbidities. Review of the resident's Medication Administration Record [REDACTED]. Review of interdisciplinary Progress Notes noted that on 04/17/15, resident #4 refused to eat lunch or supper, and was noted to clear her throat prior to meds being given. Continued review of the Progress Notes noted that on 04/17/15 at 11:42 p.m., the resident was noted with a low oxygen saturation of 87 percent, the physician was contacted and an order for [REDACTED]. Review of Progress Notes dated 04/19/15 at 12:43 a.m. noted that the Emergency Department nurse was contacted and stated that resident #4 was admitted to the Intensive Care Unit for [MEDICAL CONDITION]. Review of resident #4's computerized vital signs records noted that on 04/16/15 at 11:11 p.m., the resident had a blood pressure (BP) of 70/35, and on 04/17/15 at 5:22 p.m. her BP was 113/44; there was no indication that the vital signs were retaken at any time those days. Review of the clinical record revealed that there was no indication that the physician was notified of these low BP's. Review of her MAR indicated [REDACTED]. During interview with Registered Nurse (RN) Unit Manager FF on 05/07/15 at 12:43 p.m., he verified that the BP was low on 04/16/15, and the diastolic BP was low on 04/17/15. Upon further interview, he verified that there was nothing documented that the physician was notified of these low BP's, and that he would have expected for the nurse to do so. Upon further interview, he stated that the times the BP's were entered in the computer (11:11 p.m. on 04/16/15 and 5:22 p.m. on 04/17/15) were the times a staff member actually entered the results in the computer, not necessarily the time the vital signs were taken, so that there was no way to know the actual time the BP's were obtained. During further interview with RN Unit Manager FF on 05/07/15 at 1:53 p.m., he stated he felt it hard to believe that the nurse would not have contacted the physician as that was their protocol, but that he did not see anything charted that this was done.",2018-12-01
5144,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2015-05-07,281,D,0,1,CGV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and records review the facility failed to check for placement and residual for one (1) resident (#154) with a Gastrostomy Tube (GT). The Sample size was thirty-four (34) residents. Findings include: Resident (#154) admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician orders [REDACTED]. 1. [MEDICATION NAME] 1.2 at 50 milliliter (ml) per hour Continuous 2. Check for placement every shift before medications, before flushes, and after episodes of vomiting 3. Check tube for residual every shift, If >100 ml, re-check in 1 hour, if still >100 ml, hold and call physician 4. Change Enteral Bottle nightly at 12:00 a.m. and discard any unused solution Observation of the administration of [MEDICATION NAME] 75 milligram (mg) per GT on 5/6/15 at 5:00 p.m. revealed that staff did not check the gastrostomy tube for residual or check the gastrostomy tube for placement per the physician's orders [REDACTED]. Observation on 5/7/15 at 3:38 p.m. of the Kangaroo Pump Screw Water flush bag revealed that there was no hang date indicated on the bag. Interview on 5/6/15 at 5:36 p.m. with Registered Nurse (RN) AA revealed he/she should have checked for residual, and placement of the gastrostomy tube before administration of [MEDICATION NAME] 75 mg via gastrostomy tube. Interview on 5/6/15 at 5:45 p.m. with RN BB the Nurse Consultant revealed that staff are expected to follow the physician's orders [REDACTED].",2018-12-01
5145,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2015-05-07,282,E,0,1,CGV611,"**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 five (5) residents (#95, #74, #8, #16, Q) that required assistance with Activities of Daily Living (ADLs); and one (1) resident (#23) with pressure ulcers who required supplements to aid in wound healing. The sample size was thirty-four (34) residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment for resident #16 revealed that his functional status was extensive with one person physical assistance for dressing, bathing and personal hygiene. Further review revealed an ADL self care performance deficit care plan with an intervention to check nail length, trim and clean on bath day as necessary and report any changes to the nurse. Observation of resident #16 on 05/07/15 at 1:40 p.m. revealed him sitting up in bed eating lunch. His fingernails and toe nails were observed to be long on both hands and feet. He was unshaved with hair on his face. He revealed that someone does shave him, but he was not able to answer the last time he had been shaved by staff. Interview on 05/07/15 at 2:00 p.m. with Certified Nursing Assistant (CNA) DD revealed that resident #16 required total care for bathing and dressing. CNA DD further revealed that the resident does refuse care frequently and can be combative towards staff. DD revealed that the resident is blind and his moods are up and down. Continued interview revealed that he gets shaved frequently but most of the times he refuses to let staff cut his fingernails. Interview on 05/07/15 at 2:15 p.m. With the RN Unit Manager CC revealed that resident #16 is uncooperative with baths, cutting nails and shaving. Continued interview revealed that when his wife visits she can get him to cooperate with staff, but now his wife is not able to visit as often due to her poor health. Interview on 05/07/15 at 4:25 p.m. with the MDS Coordinator revealed that it was care planned for staff to monitor resident #16's nails and cut as needed. She further revealed that and if the resident refused that staff was to walk away and return later or get another staff to re-check. The MDS Coordinator acknowledged that staff should report to the nurse when the resident refuses and it should be documented. 1. Review of resident #8's care plans revealed that she had an activity of daily living (ADL) self-performance deficit, and interventions included to check nail length and trim and clean on bath day and as necessary. During observations on 05/04/15 at 2:50 p.m.; 05/06/15 at 7:48 a.m.; and on 05/07/15 at 8:21 a.m., resident #8's fingernails were noted to be of differing lengths with the nails on the right hand longer than the left. Further observation revealed that the third fingernail on the left hand was much longer than the others, and the left thumb nail appeared to have broken off on one side, and was uneven. The nail polish was observed to have mostly worn off with spotty remnants remaining, and all of the fingernails had dark debris under them. This was verified during interview with Registered Nurse (RN) Unit Manager CC on 05/07/15 at 8:21 a.m. 2. Review of resident #74's care plans revealed that she had an ADL self-care performance deficit, and interventions included to check nail length and trim and clean on bath day and as necessary, and that the resident required total assistance with grooming. On 05/04/15 at 2:58 p.m., and on 05/07/15 at 12:25 p.m., the nails of resident #74's fourth finger and thumb of her left hand were long, and all fingernails of the right hand were long. This was verified during interview with Licensed Practical Nurse (LPN) GG on 05/07/15 at 12:25 p.m., who stated that the resident's fingernails were too long and she would have them cut. 3. Review of resident #95's care plans revealed that he had an ADL self-performance deficit, and interventions included to assist with ADL's at level needed, including grooming. During observations of resident #95's fingernails on 05/04/15 at 4:19 p.m.; 05/05/15 at 2:47 p.m.; 05/06/15 at 9:22 a.m.; and 5/07/15 at 8:21 a.m. revealed that there was dark debris underneath all of them. This was verified during interview with RN Unit Manager CC on 05/07/15 at 8:21 a.m. 4. Review of resident Q's ADL self-care performance deficit care plan revealed interventions including oral care daily and as needed. During interview with resident Q on 05/04/15 at 11:08 a.m., he/she stated that they did not have any teeth, but the staff didn't help him/her rinse or clean their mouth, and would like to have it done every morning. During further interview with the resident on 05/05/15 at 3:03 p.m.; 05/06/15 at 3:17 p.m.; and 05/07/15 at 8:25 a.m., the resident denied having mouth care done the whole week. During interview with Certified Nursing Assistant (CNA) HH on 05/07/15 at 12:30 p.m., she stated that she didn't remember the last time she had done mouth care for resident Q. Cross-refer to F 312. Review of the care plan for resident #23 last updated on 05/02/15 revealed the resident had an a Loss in skin integrity related to being readmitted to the facility with multiple pressure ulcers, and [MEDICAL CONDITION]. The interventions included nutrition, supplements, and hydration to aid in wound healing. Interventions indicated for nutritional risk included Multivitamin with minerals to supplement diet, and provide meals and supplements per the physician orders. Review of Medication Administration Record [REDACTED]. However, further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview on 05/07/15 at 9:00 a.m. with RN Unit Manager CC revealed that the MARS are checked by the Unit Manager and the night shift nurses. CC confirmed that licensed staff had failed to carry over the physician's orders [REDACTED]. She further verified that the Multivitamin with Minerals, Vitamin C, and Liquid Protein were all were missing from the (MONTH) (YEAR) MAR. Cross-refer to 314",2018-12-01
5146,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2015-05-07,312,E,0,1,CGV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to provide grooming assistance including trimming of fingernails, toenails, and mouth care for five (5) of five (5) residents reviewed, who needed extensive assistance for personal hygiene (#8, #74, #95, #152,Q). The sample size was thirty-four (34) residents. Findings include: 1. Review of resident #8's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Annual Minimum Data Set ((MDS) dated [DATE] noted that she required extensive assistance with personal hygiene. Review of her care plans revealed that she had an activity of daily living (ADL) self-performance deficit related to limited mobility, and interventions included to check nail length and trim and clean on bath day and as necessary. During observations on 05/04/15 at 2:50 p.m.; 05/06/15 at 7:48 a.m.; and on 05/07/15 at 8:21 a.m., resident #8's fingernails were noted to be of differing lengths with the nails on the right hand longer than the left. Further observation revealed that the third fingernail on the left hand was much longer than the others, and the left thumb nail appeared to have broken off on one side, and was uneven. The nail polish was observed to have mostly worn off with spotty remnants remaining, and all of the fingernails had dark debris under them. This was verified during interview with Registered Nurse (RN) Unit Manager CC on 05/07/15 at 8:21 a.m. 2. Review of resident #74's clinical record revealed that she had [DIAGNOSES REDACTED]. Review of her Quarterly MDS dated [DATE] noted that she required extensive assistance for personal hygiene. Review of her care plans revealed that she had an ADL self-care performance deficit related to limited range of motion, activity intolerance, and limited mobility, and interventions included to check nail length and trim and clean on bath day and as necessary, and that the resident required total assistance with grooming. During observations on 05/04/15 at 2:58 p.m., and on 05/07/15 at 12:25 p.m., resident #74 was noted to have a flexion contracture of the left wrist and fingers, with the fingernails of the left hand pressed into her palm. Further observation revealed that the nails of the fourth finger and thumb of the left hand were long, and that all fingernails on her right hand were long. This was verified during interview with Licensed Practical Nurse (LPN) GG on 05/07/15 at 12:25 p.m., who stated that the resident's fingernails were too long and she would have them cut. 3. Review of resident #95's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of his Quarterly MDS dated [DATE] noted that he needed extensive assistance with personal hygiene. Review of his care plans revealed that he had an ADL self-performance deficit related to weakness, and [MEDICAL CONDITION] related to a [MEDICAL CONDITION]. Review of the care plan interventions included to assist with ADL's at level needed, including grooming. During observations of resident #95's fingernails on 05/04/15 at 4:19 p.m.; 05/05/15 at 2:47 p.m.; 05/06/15 at 9:22 a.m.; and 05/07/15 at 8:21 a.m. revealed that there was dark debris underneath all of them. This was verified during interview with RN Unit Manager CC on 05/07/15 at 8:21 a.m. 4. Review of resident Q's clinical record revealed that he/she had [DIAGNOSES REDACTED]. Review of their Annual MDS dated [DATE] revealed that they required extensive assistance with personal hygiene. Review of his/her ADL self-care performance deficit care plan revealed interventions including oral care daily and as needed, and there were no care plans found for refusal of ADL care. During observation on 05/04/15 at 11:08 a.m., all of resident Q's fingernails were noted to be long, and during interview he/she stated that they had been cut a couple of weeks ago, and were too long for him/her. During further interview, the resident stated that they did not have any teeth, but the staff didn't help him/her rinse or clean their mouth, and would like to have it done every morning. During observation on 05/05/15 at 3:03 p.m., resident Q's fingernails were still noted to be long, and during interview the resident stated they had not received oral care in the last two days. During observation on 05/06/15 at 3:17 p.m. the resident's fingernails were noted to be long and uneven, and they denied having mouth care since yesterday. During observation and interview on 05/07/15 at 8:25 a.m., all of resident Q's fingernails and toenails were noted to be long, the thumbs had dark debris under them, and the resident denied having oral care since yesterday. This was verified during interview with RN Unit Manager CC on 05/07/15 at 8:25 a.m. During interview with Certified Nursing Assistant (CNA) HH on 05/07/15 at 12:30 p.m., she stated that if a resident did not have teeth, that they used mouth swabs and mouthwash to clean the mouth, but didn't remember the last time she had done mouth care for resident Q. During interview with RN Unit Manager CC on 05/07/15 at 8:21 a.m., she stated that the CNA assigned to a resident was responsible for doing their personal hygiene. Upon further interview, RN CC stated that showers were given three times a week, and bed baths the other days, and included with this was nail and mouth care. Upon further interview, she stated that the Activity staff sometimes did nail care, and that the nurses should be checking the residents' nails when they did weekly skin assessments. During interview with the Director of Nursing (DON) on 05/07/15 at 10:05 a.m., she stated that nail care should be done weekly and as needed. Upon further interview, the DON stated that the nurses should cut the diabetic residents' nails, and the CNA's should do the other residents. Review of the facility policy on Fingernail Care provided by the DON noted that care of the fingernails promotes circulation to the hands and helps prevent small tears around the nails that could lead to infections. Resident #152 was recently admitted to the facility on [DATE] review of the Facility Activity of Daily Living (ADL) Assessment indicated that the resident required extensive assistance of one staff with dressing and personal hygiene. Observation on 05/05/15 at 10:00 am of resident #152 revealed that all her fingernails were long with faded nail polish, the nails had jagged edges, and dark matter was observed under the fingernails. Observation on 05/07/15 at 2:30 p.m. revealed resident #152 in her room seated in her wheelchair, all ten fingernails were long with noted dark matter underneath her fingernails. The nails were still sharp with jagged edges and most of the nail polish removed. Interview on 05/07/15 at 1:15 p.m. assigned Certified Nursing Assistant (CNA) EE revealed that staff dress and groom resident #152 and give her oral care daily. Interview on 05/07/15 at 3:19 p.m. with CNA DD she verified that resident #152's nails were long and needed cleaning. CNA DD further revealed that the Activities staff usually provides nail care for the residents.",2018-12-01
5147,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2015-05-07,314,D,0,1,CGV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to consistently provide multivitamin, and protein supplements as ordered by the Physician, to help promote wound healing for one (1) resident (#23) with a Stage Four (IV) Pressure Ulcer. The Sample size was thirty-four (34) residents. Resident #23 was readmitted to facility on 1/15/15 after a hospital stay her [DIAGNOSES REDACTED]. Review of the Vohra Wound Care Specialist Evaluation Notes dated 5/4/15 revealed that the resident had 5 wounds listed as the following: 1. Stage IV pressure wound of the right mid buttock, 2. Unstageable (Due to Necrosis) of the left mid buttock 3.Unstageable Deep Tissue Injury (DTI) of the left plantar, first mid foot 4. Ustageable DTI of the left, medial ankle 5. Unstageable (Due to Necrosis) of the right ischium Review of Physician Telephone Orders dated 4/21/15 revealed orders for: 1. Multivitamin with Minerals, 1 tablet daily for thirty (30) days 2. Vitamin C 500 milligrams (mg) for fourteen (14) days, twice daily 3. 30 milliliters (ml) Liquid Protein twice daily for thirty (30) days Review of Medication Administration Record [REDACTED]. However, further review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Interview on 05/07/15 at 9:00 a.m. with RN Unit Manager CC revealed that the MARS are checked by the Unit Manager and the night shift nurses. CC confirmed that licensed staff had failed to carry over the physician's orders [REDACTED]. She further verified that the Multivitamin with Minerals, Vitamin C, and Liquid Protein were all were missing from the (MONTH) (YEAR) MAR. Interview on 05/07/15 at 4:08 p.m. with Registered Nurse (RN) Unit Manager CC revealed that resident #23 was ordered Multivitamin with Minerals, Vitamin C, and Liquid Protein for wound healing. CC further revealed that the resident has a Stage IV pressure ulcer to right buttock, and an Unstagable wound to the left buttock and right Ischium. Interview on 05/07/2015 at 9:30 a.m. with RN Unit Manager CC and RN BB the Nurse Consultant revealed that the physician was updated today 5/7/14, that the multivitamins were not carried over onto the (MONTH) (YEAR) MAR. They revealed that a new order was given to restart the medications.",2018-12-01
5148,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2015-05-07,315,D,0,1,CGV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to secure an indwelling urinary catheter tubing to prevent excessive tension on the catheter for one (1) resident (R). The sample size was thirty-four (34) residents. Findings include: Review of resident R's Annual Minimum Data Set ((MDS) dated [DATE] noted that they had no cognitive deficits and had an indwelling catheter. Review of their care plans revealed that they had an indwelling catheter related to a Stage 4 sacral pressure ulcer. Review of physician's orders [REDACTED]. During observation on 05/05/15 at 2:50 p.m., resident R was noted to have a urinary catheter attached to a drainage bag. During interview with resident R at this time, he/she stated that the staff did not ever secure the catheter to his/her thigh, and it was observed that there was nothing anchoring the catheter tubing. During interview with resident R on 05/06/15 at 8:21 a.m., he/she denied having a catheter strap in place. During observation of wound care by the Licensed Practical Nurse (LPN) Treatment Nurse and LPN MM on 05/06/15 at 10:41 a.m., no catheter strap was observed when the resident's incontinent brief was removed. During observation and interview with Registered Nurse Unit Manager CC on 05/07/15 at 8:35 a.m., she stated that resident Q's catheter should be secured to his/her thigh, and verified there was no catheter strap in place. During interview with Certified Nursing Assistant (CNA) HH on 05/07/15 at 12:30 p.m., she stated that the CNA's used a strap to secure a catheter to a resident's leg, and that every resident with a catheter should have one unless they are told otherwise. Review of the facility's policy on Indwelling Catheter Care noted to provide enough slack before securing the catheter to prevent tension on the tubing, and use a Velcro strap to secure the tubing to the thigh.",2018-12-01
5149,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2015-05-07,329,D,0,1,CGV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that there was an appropriate indication for the continued use of the drug [MEDICATION NAME] ([MEDICATION NAME], a drug used for overactive bladder) for one (1) resident (R), who had a urinary catheter. The sample size was thirty-four (34) residents. Findings include: Review of resident R's Annual Minimum Data Set ((MDS) dated [DATE] noted that he/she had an indwelling catheter. Review of their care plans revealed that they had an indwelling urinary catheter due to a Stage 4 sacral pressure ulcer. Review of the physician's orders [REDACTED]. During interview with Registered Nurse (RN) Unit Manager CC on 05/07/15 at 8:53 a.m., she verified that resident R had a Foley catheter, and stated she didn't know the indication for the [MEDICATION NAME]. Upon further interview, she verified that there were no consultant pharmacist recommendations in the active clinical record related to the [MEDICATION NAME] use. During interview with RN Unit Manager CC on 05/07/15 at 3:44 p.m., she stated that she called the attending physician about the indication for the use of the [MEDICATION NAME], and was told that the order must never have gotten discontinued when the catheter was put in. During further interview, she stated the catheter was put in shortly after the resident's admission to the facility. Review of the clinical record revealed that the resident was admitted on [DATE], and review of the Admission MDS dated [DATE] noted that the resident had an indwelling catheter.",2018-12-01
5150,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2015-05-07,428,D,0,1,CGV611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the consultant pharmacist failed to request an indication for the use of the drug Oxybutynin (Ditropan, a drug used for overactive bladder) for one (1) resident (R), who had a urinary catheter. The sample size was thirty-four (34) residents. Findings include: Review of resident R's physician's orders [REDACTED]. During interview with Registered Nurse (RN) Unit Manager CC on 05/07/15 at 8:53 a.m., she verified that resident R had a Foley catheter, and stated she didn't know the indication for the Ditropan. Upon further interview, she verified that there were no consultant pharmacist recommendations in the active clinical record related to the Ditropan use. During interview with RN Unit Manager CC on 05/07/15 at 3:44 p.m., she stated that she called the attending physician about the indication for the use of the Ditropan, and was told that the order must never have gotten discontinued when the catheter was put in. During further interview, she stated the catheter was put in shortly after the resident's admission to the facility. Review of the clinical record revealed that the resident was admitted on [DATE], and review of the Admission MDS dated [DATE] noted that the resident had an indwelling catheter.",2018-12-01
6311,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2014-04-24,312,D,0,1,Y09X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review family and staff interviews the facility failed to maintain activities of daily living related to incontinent care for one (1) resident ( X ) from a census sample of twenty-nine (29) residents Findings include: Interview on 4/21/14 at 6:20 p.m. with a family member of resident X revealed that about three (3) weeks ago she came to visit the resident between 8:30 a.m. and 9:30 a.m. and found the resident so soiled and wet that the sheets had turned brown and feces were stuck to him. During this time the resident had a sacral wound. Continued interview revealed that about a month ago he was wet and soiled to the point that when the chuck was held up, urine dripped to the floor and last week on the 7-3 shift he had emesis from his neck down his sides that had been covered up with a chuck under his back and a pillow placed over his arm to cover the emesis. Further interview revealed that the family member had complained to the Unit Manager and other staff including the Administrator. She has had these problems since December 2013. Review of facility grievance log revealed that a family member filed a grievance on 1/15/14 because on 1/14/14 and 1/15/14 between 7:30 a.m.-8:30 a.m. a family member visited and found the resident in a wet brief. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as totally dependent on staff for all Activities of Daily Living (ADLs), including personal hygiene, transfers and bed mobility and was incontinent of bladder and bowel. Continued review revealed that the resident was assessed with [REDACTED]. Interview with Certified Nursing Assistant, (CNA) AA on 4/23/14 at 10:19 a.m. revealed she takes care of this resident routinely on the 7-3 shift. He is assigned to get his showers on 3-11 shift 2 x week. Continued interview revealed that the CNA stated that she has noticed several times that the resident has been wet and soiled when she gets in at 7:00 a.m. One morning he threw up and it started drying, the 11-7 CNA tried to cover it up with pads and she has also seen brown stains where the urine has soaked through his pads. Review of the resident Care plan dated 4/21/14 for ADLs revealed that the resident has a self care performance deficit related to [MEDICAL CONDITION], debility and cognitive deficits. The goal is that the resident will be kept clean, dry and appropriately dressed daily. Interventions include to provide pericare after each incontinent episode and to monitor skin for any red or open areas. Observation on 4/24/14 at 5:35 a.m. revealed CNA BB to change the resident's brief. The brief was saturated at this time but not through to the pad. The CNA stated that the resident was last changed at 3:00 a.m. Interview with the Transitional Care Unit Manager, Registered Nurse on 4/24/14 at 1:01 p.m. confirmed that the resident had been left wet and in emesis on occasion by the 11-7 shift.",2018-01-01
6312,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2014-04-24,314,D,0,1,Y09X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility's policy on Measuring and Documenting Pressure Ulcer/Non-Pressure Ulcer Size and staff interview, it was determined that the facility failed to offload the heels per the Wound Care Specialist's recommendations for one resident (#169) and failed to obtain measurements of a pressure sore timely and initiate treatment timely for one resident (#69) who was readmitted from the hospital with a pressure sore sample of twenty nine (29) residents. Findings include: 1. Resident #69 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the clinical record for resident #69 revealed that the resident was readmitted to the facility on [DATE] with a Stage II pressure sore on his/her sacrum. Continued review revealed that there was no indication that an initial measurement of the pressure sore was obtained on 4/16/14 until five days later on 4/21/14 when the Wound Care specialist documented in his progress note that the pressure sore was a cluster wound and measured 7.5 centimeters (cms.) by 6 cms. by 0.2 cm. with light serous exudate. Review of the physician's orders [REDACTED]. Review of the 4/2014 Treatment Record revealed that the physician ordered treatment was not initiated until four days later on 4/20/14. Observation on 4/21/14 at 4:05 p.m. of treatment of [REDACTED]. Interview on 4/24/14 at 1:20 p.m. with the Registered Nurse supervisor for the Transitional Care Unit revealed that the nurse who admitted the resident on 4/16/14 was responsible for obtaining an initial measurement of the sacral pressure sore and initiating the physician ordered treatment that day. However, licensed nursing staff failed to obtain an initial measurement of the resident's sacral pressure sore and failed to initiate treatment for [REDACTED]. Review of the facility's Measuring and Documenting Pressure Ulcer/ Non-Pressure Ulcer Size Policy and Procedures revealed that pressure ulcer measurements were completed to provide consistent documentation of ulcer size and evaluate the healing and effectiveness of treatment to the wound. Comprehensive wound assessments were suppose to include measurements and were to be completed upon admission, weekly follow-up, as needed when there was a change in wound status, development of a new wound and as part of the discharge assessment. 2. Review of the wound care specialist initial evaluation for resident #169 dated 4/21/14 revealed that the resident had a Stage 2 pressure wound of the right medial foot that measured 0.8 centimeters (cm) x 0.7 cm x0.1 cm. The wound was to be dressed using [MEDICATION NAME] with a recommendation to float the heels when in bed. Observation of resident #169 on 4/22/14 at 1:10 p.m. while in bed revealed the resident's heels were laying on the mattress and were not offloaded as recommended by wound care specialist Observation of the residents wounds to right medial knee and left medial foot and sacrum on 4/23/14 at 2:40 p.m. with Licensed Practical Nurse (LPN) CC revealed the resident's feet were directly on the mattress not floating. Interview with LPN CC on 4/23/14 at 4:04 p.m. confirmed that his heels should have been floated while in bed.",2018-01-01
6313,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2014-04-24,441,E,0,1,Y09X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the facility's policies on Clean Dressing Change and Hand Hygiene/Handwashing and staff interview, it was determined that the facility failed to ensure that the treatment nurse washed/sanitized her hands before donning clean gloves during the provision of pressure sore treatment for two residents (#69 and #169) from a sample of twenty nine (29) and failed to ensure that certified nursing staff washed/sanitized hands between resident contact during the provision of meal service on two of two units ( TCU and LTC). Findings include: 1. Resident #69 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was hospitalized ,[DATE]-[DATE] and was readmitted with Methicillin Resistant Staphylococcus aureus (MRSA) of the sputum, [DIAGNOSES REDACTED] infection of the mid back laminectomy surgical wound and Stage II pressure sores on his/her sacrum. Review of the facility's Hand Hygiene/Handwashing Policy revealed that handwashing was the single most important procedure for preventing the spread of infection. If soap and water were not available and hands were not visibly soiled, an alcohol-based hand rub may be used for routine decontamination of hands in clinical situations. Hand hygiene was to be performed after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves were worn. Review of the facility's Clean Dressing Change Policy, dressings were applied using clean technique to promote wound healing and to prevent cross-contamination among and between residents and caregivers. During a dressing change, licensed nursing staff were suppose to perform hand hygiene before donning clean gloves and after removing soiled gloves. On 4/21/14 at 4:05 p.m., the treatment nurse washed her hands and donned gloves prior to providing treatments to the resident's sacral pressure sores and mid back surgical wound. During treatment to the resident's Stage II sacral pressure sores, the treatment nurse removed barrier cream from the resident' s sacrum and buttocks for visualization of the pressure sores. The treatment nurse then applied barrier cream on the pressure sores. The treatment nurse then removed her soiled gloves and without washing/sanitizing her hands, donned clean gloves and removed Iodaform packing from the mid back surgical wound. She then removed her soiled gloves and without washing/sanitizing her hands, she donned clean gloves and cleaned the wound with normal saline. The treatment nurse removed her soiled gloves, cut Iodaform packing with scissors, and without washing/sanitizing her hands, donned clean gloves and packed the wound with new Iodaform. Without washing/sanitizing her hands, the treatment nurse donned clean gloves and placed a 2 inch by 2 inch gauze dressing over the wound. Although the treatment nurse changed her gloves frequently during the provision of treatments, she failed to wash her hands or use sanitizer after removing her soiled gloves and prior to donning the clean gloves. 2. Review of the facility's Hand Hygiene/Handwashing Policy, hand hygiene was to be performed before and during food preparation; as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. However, during observation of the dinner meal on the Long Term Care Unit (LTC) on 4/21/14 between 5:30 p.m. and 5:41 p.m., a certified nursing assistant (CNA) failed to wash/sanitize his/her hands between residents to prevent cross contamination during the meal service. The CNA obtained a meal tray from the meal cart and served the resident in room [ROOM NUMBER]B. The CNA picked up the resident's hair brush from the overbed table, adjusted the resident's bed, pulled the privacy curtain, and touched the handles of the wheelchair for the resident in 27A. Without washing or sanitizing his/her hands, the CNA obtained a meal tray from the cart and served the resident in room [ROOM NUMBER]B. The CNA moved the resident's tea glass on the tray by holding the top of the glass, touched the resident's spoon and turned on the resident's overbed light. Without washing or sanitizing his/her hands, the CNA obtained a meal tray from the cart and served the resident in room [ROOM NUMBER]A. The CNA closed the resident's bathroom door, pulled the resident's wheelchair forward and then opened the resident's milk carton, touched the utensils, placed a fork in the resident's food and moved the plate closer to the resident by touching the inside of the plate. Without washing or sanitizing his/her hands, the CNA obtained a meal tray for the resident in room [ROOM NUMBER]B, picked up the resident's fork and placed it in the food and moved the banana that was lying on the resident's overbed table. On 4/23/14 at 3:06 p.m., Registered Nurse DD, who was responsible for infection control surveillance, stated that she/he expected staff to wash/sanitize hands between glove changes during wound treatment and between resident contact during the provision of meal service. 3. Observation of hall trays being served at the lunch meal on the long term care unit (LTC) on 4/23/14 at 12:35 p.m. revealed CNA EE enter room [ROOM NUMBER], assist the resident up in bed and set up the meal tray by removing lids off drinks and taking the knife to spread butter and place straw into drink. After leaving room [ROOM NUMBER], the CNA entered room [ROOM NUMBER] to assist the resident with preparation for their meal. The CNA did not wash/sanitize her hands between resident contact. Interview with the Staff Development Coordinator on 4/23/14 at 1:24 p.m. revealed that her expectations for staff when passing hall trays to residents was that they will wash their hands in between each and after set-up anytime if they have patient contact. Interview with CNA EE on 4/23/14 at 3:26 p.m. revealed that she should sanitize her hands prior to assisting and setup of meal tray, after touching bed controls and positioning the resident and after patient contact. 4. Observation of wound care on 4/23/14 at 2:40 p.m. performed by LPN CC revealed that with her gloved hands, she removed the socks from the resident's feet and with a gloved finger took ointment and rubbed on right medial heel and removed gloves; regloved and applied ointment to right knee with gloved finger and removed gloves; regloved and as resident turned to one side took gloved fingers and applied barrier ointment to a large maroon discolored area on the sacrum. The nurse did not wash/sanitize her hands in between wound care for the three different wounds Interview with LPN CC on 4/23/14 at 4:04 p.m. confirmed that she should have washed her hands in between treatment of multiple wounds. Review of facility guidelines on hand hygiene/handwashing dated 8/31/11 revealed hand hygiene is to be performed after touching blood, body fluids, secretions, excretions and contaminated items, whether or not gloves are worn, before and during food preparation; as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks. Decontaminate hands after contact with a patient's/patient's intact skin (e.g., when taking a pulse or blood pressure and lifting a patient)",2018-01-01
6314,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2014-04-24,463,D,0,1,Y09X11,"Based on observation, review of the facility's Maintenance Log and staff interview, it was determined that the facility failed to ensure that a bedside call light was working for one (1) resident (#31) from a sample of 29 residents. Findings include: Observation on 4/21/14 at 3:42 p.m. revealed the bedside call light for resident #31 did not work. The maintenance supervisor was notified at that time and confirmed that the call light did not work. Interview on 4/21/14 at 3:55 p.m. with the maintenance supervisor revealed that he checked the call lights monthly to ensure that they were working and that he was not aware that the call light for resident #31 did not work. Continued interview revealed that if staff or a resident identified that a call light did not work, a work order was completed and placed in his box. He checked the box daily for any needed equipment repairs. Review of the log provided by the maintenance supervisor revealed that the call lights were last checked for functioning on 3/20/14. Interview on 4/24/14 at 9:05 a.m. with certified nursing assistant (CNA) FF revealed that resident #31 was capable of using the call light and had used the call light in the past.",2018-01-01
6679,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2014-10-28,309,D,1,0,BOIU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to administer medication as ordered by the physician for one resident (#4) of thirteen (13) sampled residents. Findings include: Record review revealed that resident #4 was admitted in September of 2014 with [DIAGNOSES REDACTED]. Review of the physician's order [REDACTED]. An observation of resident #4 on 10/28/14 at 2:30 p.m. with licensed practical nurse (LPN) AA revealed a [MEDICATION NAME] to the right back dated 10/28/14 and also a [MEDICATION NAME] on the left upper chest area dated 10/14/14. Nurse AA removed and disposed of the patch on resident #4's left chest. An interview with LPN AA immediately after the observation at 2:30 p.m. revealed that medication patches were to be removed prior to application of a new patch. The LPN said that she was not sure why the older patch had not been removed. An interview on 10/28/2014 at 4:50 PM with unit manager BB, the regional nurse consultant and the director of nursing revealed that the staff should also assure any prior patches were removed before a new patch was applied.",2017-10-01
6680,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2014-10-28,514,D,1,0,BOIU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to consistently document the application site and/or removal of medication patches for seven (7) residents (#4, #7, #8, #9, #10, #11, and #12) of thirteen (13) sampled residents. Findings include: 1. Review of the physician's order [REDACTED]. A review of the Medication Administration Record [REDACTED]. The back of the MAR indicated [REDACTED]. 2. Review of the physician's orders [REDACTED]. Review of the MAR for resident #7 revealed no documentation that the [MEDICATION NAME] was administered in October nor site placement documented. 3. Review of the physician's order [REDACTED]. Review of the MR for Resident #8 revealed the [MEDICATION NAME] applied on 10/12/2014 with no site documented and 10/26/2014 to the chest with no documentation of the location on the chest. 4. Review of physician orders [REDACTED]. A review of the Monthly Administration Record for Resident #9 revealed that the [MEDICATION NAME] was applied daily 10/01/2014 through 10/28/2014 with no site documentation on 10/04/14, 10/05/14, 10/08/14, 10/09/14, 10/11/14, 10/12/14, 10/13/14, 10/14/14, 10/18/14, 10/19/14 and 10/26/14. 5. Review of the October physician's orders [REDACTED]. A review of the October MR for resident #10 revealed that the patch was applied on 10/03/14, 10/12/14, 10/15/14, 10/24/14 and 10/27/14 with no documentation of the application site. 6. A review of the physician's orders [REDACTED]. Review of the October MR for resident #11 revealed an [MEDICATION NAME] applied daily 10/20/14 through 10/28/14 with no site documented. Review of the Monthly Administration Record for resident #11 for the [MEDICATION NAME] with no documentation on it. 7. Review of the October physician's orders [REDACTED]. A review of the Monthly Administration Record for resident #12 revealed the application site was not documented on 10/01, 10/04, 10/05, 10/24 and 10/26. Review further revealed the patch removal not documented on 10/03/14, 10/12/14, 10/17/14 10/20/14 and 10/23/14. An interview on 10/28/2014 at 4:50 PM with unit manager BB, the Regional Nurse Consultant and the Director of Nursing revealed that the only patch to be utilizing the Monthly Administration Record for documentation of patch rotation sites was the [MEDICATION NAME] Patch. All other medication patches were to be documented on the back of the MAR. The staff should be assessing the site prior to application of a patch and monitoring sites after removal for any adverse reactions. When made aware of the patch remaining on resident #4, the team revealed that the staff should also assure any prior patches were removed before a new patch was applied. They acknowledged that they had just become aware of a problem with medication patch documentation as a result of the survey process today.",2017-10-01
7457,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2012-06-28,201,D,0,1,US3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure residents admitted to the facility were not discharged due to skilled services ending for one (1) resident (#132) from a sample of thirty (30) residents. Findings include: Review of pre-survey documents provided by a resident advocacy organization and dated 5/12/12 revealed a concern voiced by family members residing on the Transitional Care Unit that once therapy was completed or Medicare days exhausted were told the facility did not have any long term care beds available. Review of the Casper report dated 5/21/12 revealed that the facility has 100 duel certified beds, indicating all 100 beds are available for residents with any and all payer sources. Interview with the Director of Nurses (DON) on 6/27/12 at 8:20 a.m. revealed that they did not currently have any long term care beds available. The current census in the facility was 91, with 9 beds unoccupied. Record review for resident #132 revealed that he had been admitted to the facility from a personal care home in 01/2012 to receive skilled Occupational Therapy services. Social Service (SS) notes revealed that a Discharge of Services meeting was held with the resident's daughter on 01/06/12. The SS notes documented that the daughter was told that the facility did not currently have any long term care beds available even though the resident was currently occupying a bed in the facility. SS notes dated 02/06/12 related that an Interdisciplinary Team (IDT) meeting was held with the resident's daughter. The note documented that the resident's skilled services were ending on 2/09/12 and that the daughter stated there were no plans for the resident to return to a personal care home. A review of the Discharge Summary dated 02/22/12 revealed that the resident was discharged on [DATE] to another long term care facility. An interview with the daughter of resident #132 on 6/27/12 at 12:15 p.m. confirmed that the resident was admitted to another long term care facility because she was told there were no long term beds available. Interview with staff member HH on 6/28/12 at 9:15 a.m. revealed she has been employed at the facility for two (2) years and that it is her understanding that the beds in the Transitional Care Unit (TCU) are to be held for short term residents only. The forty (40) beds of the TCU are Medicare certified for short term stay residents. She stated she was aware that residents have been moved from the TCU to other long term care facilities due to lack of beds in the other (LTC) part of the facility.",2017-03-01
7458,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2012-06-28,225,D,0,1,US3P11,"Based upon observation, record review and staff interviews the facility failed to report allegations of sexual, physical and injury of unknown origin for three (3) residents (# 47,123, 126) to the State agency of thirty (30) sampled residents. Findings include: 1. Record review for resident #126 revealed a Nurses Note dated 4/28/12 for the 3-11 p.m. shift revealed the resident reported someone had come into the resident room, sat on the side of the bed, and had their hand down the resident's brief. The resident could not identify this person. On 4/30/12 the Social Worker had written a complaint/Grievance form after interviewing the resident with the same information which was signed by the Administrator. The Social Worker had done an investigation. The resident's Brief Interview for Mental Status (BIMS) score on the Minimum Data Set (MDS) assessment for 5/12/12 and 2/13/12 was 12 of 15 indicating the resident's cognitive skills for daily decision making are consistant and reasonable. An interview with the Administrator on 6/27/12 at 1:30 p.m. revealed she was not aware of this incident and had not reported it to the State Agency. A second interview with the Administrator on 6/27/12 at 3:45 p.m. confirmed that this should have been sent to the State Agency within twenty four (24) hours and the results of the investigation should have been sent to the State Agency within five (5) days. 2. Record review of the facility grievance file revealed that resident #47 had reported on 01/17/12 to Licensed Practical Nurse BB that a Certified Nursing Assistant (CNA) keeps hurting me and hitting me and wants to go to another nursing home. Documented under resolution was a statement that a formal investigation completed for the allegation of abuse, however an interview with the Administrator on 6/28/12 at 9:30 a.m. revealed that there was no evidence of a report to the State Agency. Record review of the facility Abuse policy reveals that the allegation of sexual, physical or injury of unknown origin should be investigated and reported to the State Agency in a timely manner. 3. Review of Nurses Notes dated 30/7/12 for resident # 123 revealed that he complained to the nursing staff that his left arm hurt. A mobile X-ray, conducted 3/08/12 of his left shoulder, humerus and elbow revealed the resident had an acute fracture involving the head of the humerus with no displacement. There was no documentation in the medical record related to how the resident fractured his humerus. Interview on 6/28/12 at 7:50 a.m. with Registered Nurse (RN) KK revealed that although she did not know how the fracture occurred she did consider it an injury of unknown origin. Interview with the Director of Nurses on 6/28/12 at 8:40 a.m. revealed no investigate of how the fracture occurred was conducted. Record review of the facility Abuse policy reveals that the allegation of sexual, physical or injury of unknown origin should be investigated and reported to the State Agency in a timely manner.",2017-03-01
7459,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2012-06-28,226,E,0,1,US3P11,"Based on record review and staff interview the facility failed to ensure that criminal background checks for staff members were conducted prior to their employment dates. This affected three (3) staff members recently hired by the facility. Findings include: A review of randomly selected personnel records of staff members recently hired by the facility revealed that three (3) of ten (10) individuals were employed prior to the facility having criminal background information for those individuals. The review of records revealed the following information: 1. Housekeeping Aide hired 5/10/12, criminal background check results not available until 6/01/12. 2. Licensed Practical Nurse hired on 5/09/12, criminal background results not available until 5/15/12 3. Certified Nursing Assistant hired on 5/21/12, criminal background results not available until 5/23/12 The above information was confirmed in an interview with the facility's Benefits Coordinator in an interview on 6/26/12 at 3:00 p.m.",2017-03-01
7460,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2012-06-28,241,G,0,1,US3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Amended 2567 on July 23, 2012. Based upon record review, staff and family interviews the facility failed to promote care in a manner that promoted dignity for one (1) resident and caused actual harm to resident L from a sample of thirty (30) residents. Findings include: Record review revealed resident L had multiple [DIAGNOSES REDACTED]. The resident's Brief Interview for Mental Status (BIMS) score on the Minimum Data Set (MDS) assessment of 5/12/12 was 12 of 15 indicating the resident's cognitive skills for daily decision making were consistent and reasonable. The resident's assessment included that she needed extensive assist with transfers, toiletling, personal hygiene and as frequently incontinent of bowel and bladder. An interview on 6/25/12 at 10:54 a.m. with resident L revealed that when resident up in her wheel chair and needs to toilet, she must returned to bed in order to use the bedpan. The resident says it frequently takes almost one (1) hour for the staff put the resident back to bed. The resident revealed this causes frequent accidents because she can't wait for an hour or longer. Last week during a four hour visit with a family member, she called for assistance with toileting and it one and one half (1 1/2) hour for staff to respond. A person on the intercom responded by saying someone would be coming right away. The resident continued to ask for assistance and family member called for the resident after staff did not respond. Before the staff responded, the resident had urinated while sitting the wheel chair. Additional interview with the resident on 6/27/12 at 3:30 p.m. revealed she does not want this (incontinence) to happen but does not see that she has a choice and it makes her feel bad when the staff takes too long and she has an accident. An interview with the Administrator on 6/27/12 at 3:45 p.m. revealed she was not aware that anyone had a complaint of staff not responding to call lights in a timely manner.",2017-03-01
7461,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2012-06-28,280,G,0,1,US3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Amended 2567 on July 23, 2012. Based on record review and staff interview the facility failed to review and revise the plan of care related to supervision to prevent accidents and caused actual harm for one (1) resident, resident # 123 on a sample of thirty (30) residents. Findings include: Record review of the physician's admissions notes revealed that the resident had a history of [REDACTED]. Physician orders [REDACTED]. The MDS assessment dated [DATE] revealed that resident # 123 was assessed as having falls with injury prior to admission in 01/2012 and having had two falls without injury since his admission to the facility. Resident #123 had experienced 6 falls since admission to the facility. Review of the care plan revealed that Hospice had a care plan dated 01/13/12 for falls and to use a bed alarm, a low bed and floor mats by the bed. The facility care plan dated 2/28/12 revealed that the staff were aware that the resident had previous falls prior to admission and they were to use the fall risk screen to identify risk factors. Interventions for falls included a low bed and fall mats on the floor. The facility also had interventions of reminding the resident and reinforce safety awareness and to educate the resident to request assistance prior to ambulation. The resident was assessed for impaired memory and cognition. Interview with LPNs LL and AA on 6/27/12 at 8:00 a.m. revealed bed or chair alarms are not used in the facility They acknowledged that the only interventions for falls was the low bed, floor mats and observation of the resident. They stated that they discuss falls in the morning clinical meetings but no one had initiated any other interventions for falls for this resident. Cross refer to F323",2017-03-01
7462,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2012-06-28,309,D,0,1,US3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that physician's orders were followed for physician notification related to finger stick blood sugar monitoring for three (3) residents (#33, #6 and #73) on a sample of thirty (30) residents. Finding include: 1. Record review of the April 2012 Physician Orders revealed documentation that resident # 33 was to have blood glucose monitoring conducted via finger stick blood sugars (FSBS) before meals and at bedtime. The resident was to receive [MEDICATION NAME] Regular insulin as indicated by sliding scale. The physician was to be notified if the FSBS was less than 60 or greater than 400. Review of the Diabetic Monitoring Flow Sheet revealed that on 4/24/12 the resident's FSBS was 446 and she was given 10 units of [MEDICATION NAME] R insulin as indicated by the sliding scale, there was no documentation in the record that the physician was notified of the elevated FSBS. Verified by interview with Licensed Practical Nurse (LPN) BB on 6/27/12 at 9:56 a.m. 2. Record review of the April 2012 Physician Orders revealed documentation that resident # 6 was to have FSBS before meals and at bedtime with sliding scale insulin coverage. The physician was to notified if the resident's FSBS was less than 60 or greater than 450, to repeat the FSBS in one (1) hour and give [MEDICATION NAME] as needed. Review of the Diabetic Monitoring flow Sheet dated 4/18/12 at 6:00 am documented the resident's FSBS was only 55, there was no indication that the MD was notified, of whether the FSBS was retaken or if the [MEDICATION NAME] was needed or given. Interview on 6/27/12 at 3:12 p.m. with LPN BB confirmed the physician orders were not followed. 3. Record review revealed resident # 73 had Physician Orders to conduct FSBS twice daily at 4:00 p.m. and 9:00 p.m. and to notified the physician if results were greater than 400 or below 60. Based on the results of the blood glucose monitoring, the resident was to receive [MEDICATION NAME] Regular insulin on sliding scale. Review of Diabetic Monitoring flow sheets revealed that on 4/12/12, 4/17/12, 5/02/12, 5/08/12, 5/15/12, 5/16/12, 5/17/12, 5/30/12 and 6/15/12 the resident's blood glucose level was greater that 400 and there was no evidence on the flow sheet or Nurses Notes that the physician's was notified. An interview on 4/26/12 at 4:09 p.m. with LPN BB revealed there is no evidence that the physician was notified when the resident's blood sugar was over 400.",2017-03-01
7463,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2012-06-28,323,G,0,1,US3P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Amended 2567 on July 23, 2012 Based on observation, record review and staff interview the facility failed to provide supervision and assistance and/or devices to prevent accidents and caused actual harm for one (1) resident (# 123) on a sample of thirty (30) residents resulting in actual harm to the resident. Findings include: Record review of the physician's admissions notes revealed that the resident had a history of [REDACTED]. The MDS assessment dated [DATE] revealed that resident # 123 was assessed as having falls with injury prior to admission in 01/2012 and having had two (2) falls without injury since his admission to the facility. Documentation of falls and/or accidents (in descending order) included: 1. Review of the Nurses Notes dated 6/24/12 at 3:00 p.m. revealed that resident # 123 was found on the floor with a small laceration above his left eye. 2. Review of the quarterly MDS dated [DATE] revealed that the resident had 2 falls with no injury and one fall with a minor injury, 3. On 4/07/12 at 2:45 a.m. the resident was found on the floor with an injury above his eye and was sent to the hospital for evaluation. he returned to the facility with documentation from the physician that he suffered an abrasion to his face and a single contusion to the head. According to care plan additional intervention of floor mat at bedside. (note already on care plan, dated 01/13/12) 4. The resident fell on [DATE] from the bed to the floor with no injury. 5. On 2/19/12 at 4:30 a.m. the resident was found on his knees beside the bed and the Nurses Notes included documentation that he hit his head on the window and the window was broken. The resident had a skin tear to top of his head and an abrasion to the right side of the forehand. He was sent to the hospital for evaluation. 6. Review of Nurses Notes included documentation that resident # 123 had a fall on 01/07/12 from the bed and told the staff he was trying to get up. Review of the care plan revealed that Hospice had a care plan dated 01/13/12 for falls and to use a bed alarm, a low bed and floor mats by the bed. The facility care plan dated 2/28/12 revealed that the staff were aware that the resident had previous falls prior to admission and they were to use the fall risk screen to identify risk factors. Interventions for falls included a low bed and fall mats on the floor. The facility also had interventions of reminding the resident and reinforce safety awareness and to educate the resident to request assistance prior to ambulation. The resident was assessed for impaired memory and cognition. Interview with Licensed Practical Nurse (LPN SS) on 6/27/12 at 7:50 a.m. revealed staff are aware that the resident makes multiple attempts to transfer himself from chair to bed. Observation from the hallway on 6/27/12 at 8:05 a.m. revealed resident # 123 to self propel himself into his room and transfer himself from the wheelchair to the bed. Interview with LPNs LL and AA on 6/27/12 at 8:00 a.m. revealed the only interventions for falls was the low bed, floor mats and observation of the resident. They stated that they discuss falls in the morning clinical meetings but no one had initiated any other interventions for falls for this resident. Surveyor was provided a Fall Interventions form that instructed an intervention was to be selected after each fall. Review of the post fall documentation revealed that no one had added any interventions for this resident.",2017-03-01
9483,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2011-01-27,156,B,0,1,Q8K411,"Based on observation and resident and staff interview the facility failed to ensure that residents were notified of their right to make a formal complaint to the State Survey and Certification agency about their care. The facility also failed to ensure that there was information with phone numbers for the State Survey and Certification agency posted in the facility. Findings include: Interview on 1/26/11 at 12:45 p.m. with resident council president revealed that the staff had never been informed the resident council of their right to contact the State Survey and Certification office to make a complaint about their care. Interview with the Activities Director on 1/26/11 at 9:05 am revealed that she had told the residents in the council meeting about there rights and also goes over rights in trivia questions about how to follow the chain of command when they have a complaint. Further review with the resident council president on 1/26/11 at 9:40 am again revealed she had never been told in a resident council meeting or elsewhere about the right to make a formal complaint to the State Survey and Certification office. Further interview with the Activities Director on 1/27/11 at 9:55 am revealed she had no documentation of informing the resident council of their right to make a complaint to the State Survey and Certification office. She also confirmed that there was no information posted in the facility listing the number for the State Survey and Certification office On 1/25/2011 at 5:00 p.m. a tour of the facility was conducted to assure required information related to reporting allegations of abuse to the State Office was prominently displayed. The information was not posted in any area accessible to residents and visitors. On 01/27/11 at 12:15 p.m., resident ""E"" stated they were not aware of how to contact the State Complaint Intake number if they needed to, and had not seen the number posted anywhere in the facility.",2015-06-01
9484,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2011-01-27,160,E,0,1,Q8K411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to close and give a final accounting of the personal funds accounts within 30 days for four (4) of four (4) deceased residents reviewed, # 1, #59, #134, and #141. Findings include: Resident # 141 expired [DATE]; the final accounting was sent [DATE]. Resident # 134 expired [DATE]; the final check was sent [DATE]. Resident # 59 expired [DATE]; the final check was sent [DATE]. Resident # 1 expired [DATE] and the final check was sent on [DATE]. Interview with the Business Office Manager on [DATE] at 9:00 a.m. revealed they are aware that accounts need to be closed within 30 days. She further stated she was aware accounts closed in 2010 were not conveyed within the required 30 days.",2015-06-01
9485,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2011-01-27,280,D,0,1,Q8K411,"Based on observation, record review and staff interview the facility failed to update the Care Plan for one resident #41 of forty-one (41) sampled residents. This was related to the resident needing total assistance for all Activities of Daily Living (ADLs), but being care planned to continue feeding herself. Findings include: Review of the current Comprehensive Care Plan for Activities of Daily Living (ADLs) updated on 11/01/2010 with a notation that the resident required total care revealed the resident was able to feed herself with a goal to maintain that level of independence. The lunch meal service was observed on 1/26/2011 at 12:50 p.m. Resident # 41 received a regular mechanical soft diet. Certified Nursing Assistant (CNA) ""HH"" set up the tray and then began feeding the resident. The resident had contractures of both hands and used a blow device to call staff. CNA ""HH"" stated the resident had to be fed. Review of the tray card revealed the resident needed to be fed. The Charge Nurse was interviewed on 1/25/2011 at 9:00 a.m. and stated the resident had contractures of both hands and was unable to move in bed without assist from staff. Interview with the Registered Dietician (RD) on 1/26/2011 at 2:50 p.m. revealed the resident was unable to feed herself. The Director of Nursing (DON) and the North Hall Charge Nurse were interviewed on 1/27/2011 at 11:30 a.m. and stated the resident was not able to feed herself and the care plan was incorrect and needed to be updated.",2015-06-01
9486,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2011-01-27,309,D,0,1,Q8K411,"**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 orders [REDACTED].#28 on a sample of forty-one (41) residents. The findings include: On 1/26/2011 at 9:00 a.m. during observation of the medication pass for resident # 28 Licensed Practical Nurse ( LPN""GG"") was observed to remove an old [MEDICATION NAME] from the resident's left chest wall. She cleaned this area with an alcohol prep and then put the new patch on the right chest wall. Review of the current physician orders [REDACTED]. The nurse who removed the old [MEDICATION NAME] reported it to the charge nurse.",2015-06-01
9487,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2011-01-27,312,D,0,1,Q8K411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview the facility failed to ensure that the appropriate grooming was done for one (1) resident (#57) on a sample of forty one (41) residents. Findings include: Review of Minimal Data Set assessment dated [DATE] for resident #57 documented that the resident required extensive assistance of staff for activities of daily living including personal hygiene and grooming. The resident's self care deficit care plan was updated on 6/13/10 for staff to assist the resident with all activities of daily living. On 01/24/2011 at 02:43 p.m., 1/25/11 at 4:35 p.m., and 1/26/11 at 8:40 a.m. the resident was observed to have multiple facial hairs to his/her chin and upper lip. Interview with a the Staff Development Registered Nurse on 1/26/11 at 8:40 a.m. confirmed that the resident had the facial hairs and should have been shaved.",2015-06-01
9488,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2011-01-27,441,E,0,1,Q8K411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to store personal care items in a sanitary manner in ten (10) resident bathrooms on two (2) of three (3) halls. Findings include: The following observations were made in bathrooms shared by more than one resident: 1. 01/24/11 at 4:43 p.m.: room [ROOM NUMBER]: One unlabeled toothbrush was directly on the shelf above the sink; this shelf felt dusty/dirty. 2. 01/25/11 at 9:38 a.m.: room [ROOM NUMBER]: An unlabeled toothbrush was in an unlabeled emesis basin on the shelf above the sink. There was also an electric toothbrush that was unlabeled on this shelf. 3. 01/24/11 at 2:41 p.m.: room [ROOM NUMBER]: There were two unlabeled bath basins on the floor; one was covered with a plastic bag, and one was not. Also, there was one unlabeled and uncovered bedpan on the floor. 4. 01/25/11 at 9:27 a.m.: room [ROOM NUMBER]: Three of four bath basins were in plastic bags, but unlabeled. There was one urinal in a plastic bag hooked to the towel bar, but it was unlabeled. Also, there was one unlabeled bedpan in a plastic bag on the shelving above the commode. 5. 01/24/11 at 11:39 a.m.: room [ROOM NUMBER]: There was one unlabeled bath basin on the floor; one unlabeled urinal hooked on the towel rack; and one unlabeled toothbrush on the shelf above the sink. 6. 01/25/11 at 9:32 a.m.: room [ROOM NUMBER]: Two of two bedpans on a shelf above the commode were in plastic bags, but not labeled with the resident's name. The following observation was made in a private bathroom: 7. 01/24/11 at 11:26 a.m.: room [ROOM NUMBER]: There was a bath basin and tube of toothpaste on the floor. During environmental tour conducted on 1/27/2011 at 10:00 a.m. with the Maintenance and Housekeeping Directors the following were observed: 8. room [ROOM NUMBER]: Numerous unlabeled and unsecured small plastic bottles of soap, shampoo and mouthwash were on the metal shelf in the bathroom under the sink. 9. room [ROOM NUMBER]: An unlabeled urinal was hanging on the towel rack in the bathroom and 6 unlabeled basins in individual plastic bags were stacked on a shelf above the commode. 10. room [ROOM NUMBER]: An unlabeled toothbrush was observed laying on the metal shelf above the sink along with several small unlabeled plastic bottles of mouthwash and shampoo. An interview with the Director of Nursing (DON) on 1/27/2011 at 12 noon revealed these items should have been labeled and in zip lock bags.",2015-06-01
9489,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2011-01-27,465,E,0,1,Q8K411,Based on observation and staff interview the facility failed to maintain the resident refrigerator and microwave in the pantry in clean and orderly condition. Findings include: During environmental tour of the facility on 1/27/ at 10:00 a.m. with the Maintenance Director and Housekeeping Supervisor the snack/ice pantry was observed. The microwave had dried splatters of food throughout and the refrigerator had a dirt stained handle and dried spills and food particles on the shelves. There were large areas of spilled dried material under both vegetable bins. The Director of Nursing (DON) was interviewed on 1/27/2011 at 12 noon and stated both the microwave and the refrigerator were used for residents.,2015-06-01
9490,ABERCORN REHABILITATION CENTER,115132,11800 ABERCORN STREET,SAVANNAH,GA,31419,2011-01-27,253,E,0,1,Q8K411,"Based on observation and staff interview the facility failed to maintain a clean and orderly environment in rooms 3, 12, 14, 17, 18, 46, 47, 52, and 54 on two of three halls. This involved scuffed walls, rusty metal shelves in bathrooms, missing tiles, splatters on ceilings and dirt build-up on floor mats. Findings include: During environmental tour with the Maintenance and Housekeeping Directors on 1/27/2011 the following areas were observed: 1. Room 3: The wall across from the foot of the bed was scuffed and the base of the commode in the bathroom had a build-up of brown material. 2. Room 12: The metal shelf under the mirror had multiple rust spots. 3. Room 14: The wall under the window and to the left of the bathroom door was scuffed. The floor mat between B bed and the window was heavily soiled with dirt. This floor mat was also observed on initial tour on 1/24/2011 at 12:29 p.m. At this time it was heavily soiled and had scraps of paper and debris and a plastic cup lid with orange liquid in it. The mat was observed again on 1/25/2011 at 9:20 a.m. The dirt , debris and plastic lid with orange liquid were still present. 4. Room 17: The base of the commode had a build-up of brownish material and the metal shelf under the mirror was rusted. 5. Room 18: There were splatters on the ceiling and a large piece of tile along the baseboard in front of the bed was broken and chipped. 6. Room 46: There were dark spots and dust on the wall above the door in the bathroom. The metal shelf under the mirror was rusted. 7. Room 47: There was a large piece of tile missing from the window sill. 8. Room 52: The walls were scuffed and the floor was dirty by the B bed. 9. Room 54: The wall was scuffed across from the B bed and the metal shelf under the mirror in the bathroom was rusted. The Maintenance and Housekeeping Directors were interviewed during the tour and stated these areas needed to be addressed.",2015-06-01
3986,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-01-11,641,D,0,1,U7VC11,"Based on record review, the facility failed to accurately assess one resident (Resident #10) of the 24 residents reviewed in the sample. Findings include: The admission Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 10/17/17 revealed in Section N0410F that antibiotics were used 0 days during the seven (7) day look back period. A review of the (MONTH) (YEAR) Medication Administration Record [REDACTED].o.) twice (bid) daily starting on 10/11/17 at 6:00 a.m. and 6:00 p.m. and continuing through the remainder of the month. The medication was signed off as admnistered as evidenced by the initials located in the boxes for the the appropriate dates and times on the (MONTH) (YEAR) MAR. A review of the signed admission orders [REDACTED].m",2020-09-01
3987,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-01-11,656,D,0,1,U7VC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to develop a person-centered comprehensive care plan addressing a serious, chronic medical condition for one of 24 residents in the sample. Record review revealed that Resident (R) #10 has a [DIAGNOSES REDACTED]. Findings include: A review of the Discharge Summary dated 10/10/2017 from the inpatient hospital states the resident with polysubstance abuse was admitted to . initially and found to have endocarditis of the tricuspid valve due to staphylococcus capitus, probably from a skin source, perhaps from injection drugs. Likely the vegetation will always be present (he completed 8 weeks of IV therapy and the vegetation actually got larger), so plan to continue indefinite Keflex suppressive therapy. A review of the accompanying Pending Outpatient Medication list includes [MEDICATION NAME] 500 milligram (mg) capsule, take one capsule by mouth (po) twice (bid) a day for suppressive therapy indefinitely. The signed admission orders [REDACTED] A physician's orders [REDACTED]. An interview on 01/09/18 at 10:07 a.m. with Licensed Practical Nurse (LPN) FF who revealed that she was unsure why R#10 was on antibiotics; she confirmed the antibiotic was discontinued 12/12/17 by the Physician. She also revealed that she was not aware of the discharge summary information including the [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) conducted on 01/11/18 at 10:14 a.m. she revealed that she was not aware of why the attending Physician discontinued the Keflex as it was ordered indefinitely for R#10's chronic endocarditis. A review of R#10's care plan revealed a problem/focus for the resident is on antibiotic therapy r/t (related to) possible pneumonia and noted the antibiotic was completed 10/26/17. R#10 had an order for [REDACTED].",2020-09-01
3988,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-01-11,812,E,0,1,U7VC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to prepare and serve food in accordance with professional standards for food service safety. The facility census was 68 and the sample size was 24. Findings include: The Food Services Director (FSD) was observed on 1/8/18 at 10:30 a.m. and 12:13 p.m. in the kitchen during food preparation and tray line with a short beard and mustache with no beard guard or other covering for facial hair. He was again observed on 1/9/18 at 11:55 a.m. in the kitchen without any type of beard guard or facial hair covering. The FSD was also observed on 1/10/18 at 5:00 p.m. in the kitchen on the tray line without a beard guard or facial hair covering. During an interview with the FSD conducted on 1/11/18 at 9:45 a.m. he revealed that he keeps his beard/mustache trimmed close and thought that was adequate to meet food service standards. He stated he did not have a policy for covering of facial hair or use of beard guards. He stated he has over [AGE] years in dietary work including executive chef and food service manager.",2020-09-01
3989,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2017-05-27,281,D,1,0,PCHO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facility failed to follow physician's orders for 2 of 3 residents. The sample size was 3 residents. Findings include: 1. Medical record review revealed that R#1 was discharged from an acute care hospital and was readmitted to the facility on [DATE] with the following discharge orders: Care: Recheck Hemoglobin and Hematocrit (lab work) in 3-4 days. Continued medical record review revealed that there was not any evidence of any documentation that R#1 had any lab work until 5/24/17. Interview on 5/27/17 at 5:43 p.m. with LPN (LPN AA) revealed that when a resident returns to the facility from the hospital then the facility receives notification from the hospital and that the hospital calls and faxes the discharge paperwork for the residents. Further interview with LPN AA revealed that when the nurse receives the discharge paperwork and the resident has lab work ordered then the nurse writes a lab requisition, writes the physician order and then the lab comes into the facility and draws the labs. Interview on 5/27/17 at 7:16 p.m. with the DON revealed that when R#1 was readmitted to the facility from the hospital, on 5/12/17, that she had discharge orders from the hospital to have lab work done and that the resident was to have a Hemoglobin & Hematocrit drawn in 3 - 4 days. Further interview with the DON revealed that the Hemoglobin and Hematocrit lab work for R#1 was not drawn until 5/24/17 and that based on the orders from the hospital the lab work should have been drawn 5/15/17 or 5/16/17. The DON further revealed that she expects staff to follow the discharge physician's orders and if they have any questions to contact the Physician and that the lab work for R#1 was not completed in the 3-4 days as the physician had ordered. 2. Medical record review revealed that R#2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Physician order dated 3/27/17 documents: send (resident) to the emergency room for evaluation. The resident was admitted to the hospital. Further medical record review revealed that R#2 was discharged from the hospital, back to the facility, on 4/24/17, with the following discharge instructions, in pertinent part: care: Diet: Low fat, Low salt, Restrict fluids. Interview on 5/27/17 at 5:05 p.m. with Medical Records , revealed that when a resident is readmitted , or admitted , to the facility, then they (the staff) pay particular attention to the resident's discharge records from the hospital especially physician orders. Further interview revealed that when a staff member needed to know the current diet for a resident then they look at the physician order for [REDACTED].>Medical record review of the Physician order for [REDACTED]. Nutrition Review/Plan dated 5/6/17 revealed, in pertinent part: 5/1/17 hospital stay with [DIAGNOSES REDACTED]. Weight history: 5/4: 250 pounds, 4/24: 236.6 pounds, 4/10: 249.8 pounds, 3/9: 260 pounds. Spoke re need for clarification. Nurse requests dietary limit fluids to 240milliters (mL) each meal until further clarified. What resident will require with med passes. Educate resident re: Importance of adherence. Addendum: Recommend: RCS, NAS, Mechanical soft with chopped meat, 1 liter fluid restriction. Diet order and Communication form dated 5/9/17 revealed the following: 1000 cubic centimeter (cc)/ 24 hours. Beverage preferences: breakfast: 240cc, lunch: 240cc, supper: 240cc. Interview on 5/27/17 at 5:29 p.m., with LPN BB revealed that when a resident is readmitted to the facility from the hospital that the nurse is responsible for reconciling the residents medications with the physician and responsible for Completing the dietary communication form, for the resident's diet orders and then give the dietary communication form to the Dietary Manager, and that if you want to know what diet the resident is currently on you look at the residents physician order for [REDACTED]. Review of the chart, for R#2, revealed a Dietary Order Communication form dated 3/19/17: resident - new resident, Diet order: regular, reduced concentrated sweets with no evidence of a Diet Communication Form for 4/24/17 when the resident was readmitted to the facility. Further medical record review revealed a clarification order dated 5/3/17, as of 4/24/17 admit resident to (facility name) under services of (physician name). Diet order: low fat/low salt/fluid restriction. Interview on 5/27/17 at 7:16 p.m. with the Director of Nursing (DON) revealed that when R#2 was readmitted to the facility, on 4/24/17, the resident had physician orders to have a low fat, low salt, restrict fluid diet; however, the diet order that was written on 4/24/17, when the resident wad readmitted to the facility, documented that the resdient was to have a Reduced Concentrated sweets with chopped meats, and not a low fat, low salt, restricted fluids diet. Further interview with the DON revealed that physician orders are supposed to be followed, but that the physician orders, for R#2, were not followed for the resident to have a fluid restricted diet until 5/3/17.",2020-09-01
3990,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2017-08-10,280,D,1,0,5YLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview the facilty failed to develop a plan of care for 1 of 3 sampled residents, which resulted in failure to provide necessary care as identified in the assessment for Resident (R#1). Specifically; the facilty did not care plan diabetes management and did not ensure the care plan for R#1 addressed specific interventions for overt behaviors that were exhibited since admisison. Finding include: Resident (R) #1 was admitted to the facility on [DATE], the Physician admission orders [REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] Section I2900 also coded the [DIAGNOSES REDACTED]. Review of a laboratory result dated 6/13/17 reflected a out of range Glucose level of 518. The facility failed to develop a care care plan to include monitoring signs and symtoms of [MEDICAL CONDITION] or [DIAGNOSES REDACTED]. The MDS dated [DATE] ,Section C1000 coded the resident as severly impaired, in Section E800 he was coded for rejection of care which includes taking medications and Activity of Living assistance. Review of a form titled Interim Plan of Care revealed it did not include specific interventions for behavioral/mental status. It was documented in the clinical record incidents of overt behaviours including refusing to eat, refusing to take medications and grabbing staff during care. During an interview on 8/10/17 at 1:00 p.m., with the Director of Nuring (DON) revealed that she acknowledge the Interim Care plan for R#1 did not include a plan to address diabetes.",2020-09-01
3991,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2017-08-10,309,D,1,0,5YLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on closed medical record review and staff interviews the facility failed to provide care and services in accordance with the admission assessment for 1 of 3 Residents (R#1) reviewed for care and services . The facilty failed to follow the physican's admission orders [REDACTED]. Finding include; Record review revealed R#1 was admitted to the facility on [DATE] and discharged to the hospital on [DATE]. Upon admission to the facility his [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment dated [DATE] Section I2900 revealed that R#1 was coded for diabetes mellitus. The facility failed to develop a care plan relative to managing diabeties. Review of the hospitial records prior to admission to the facility revealed orders dated 5/27/17 indicating that the resident was receiving insulin per sliding scale before meals and at bed time, in addition to insulin 10 units at bedtime. Upon admission to the facility a form titled, Physician's Interim/Telephone Orders dated 6/1/17 at 2:00 p.m., reflected an order to discontinue Basagllar Kwik Pen Insulin Glargihe Injections. During interview with R#1's physician on 8/10/17 at approximately 2:30 p.m., regarding the discontinued insulin order he stated, I do not remember all the details, but I believe there was no dosage for it, if I remember correctly. I held off on the insulin and did not start a sliding scale, because I was more concerned with the his behaviour since he was on multiple medications for his behavior. When asked about the blood glucose of 516 on 6/13/17, the physician said he would be more concerned with [DIAGNOSES REDACTED]. Review of the Medication Administration Record (MAR) for (MONTH) (YEAR), revealed orders to receive [MEDICATION NAME] 500 mg (milligrams) twice daily. It is documented on the MAR that R#1 refused [MEDICATION NAME] at least six times. The MAR reflects refusals of the [MEDICATION NAME] 500mg's at 9:00 a.m., on 6/3/17,6/14/17 and 6/15/17 and at 9:00 p.m., on 6/5/17, 6/1217, 6/13/17, 6/14/17 and 6/15/17. There was no documented evidence that the physician was notified of the medication refusals. During an interview with LPN AA on 8/10/17 at 1:00 p.m., regarding physican notification when resident's refuse medication revealed that, if they refuse three times I would call the physician. During a telephone interview with Licensed Practical Nurse LPN BB on 8/11/17 at 9:28 a.m., regarding the documention on a form titled, Skilled Daily Nurses Notes dated 6/13/17 at 3:30 p.m., revealed Labs including criticals are reported to the doctor. Review of laboratory results dated [DATE] on a form title, Clinical Laboratory Services, reflected a blood sugar of 518. During further interview with LPN BB he replied, when I saw the results on the desk I immediately called the Medical Doctor (MD) to report the BUN (Blood Urea and Nitrogen) and Blood Sugar, the MD said the resident was dehydrated and ordered an IV (Intervenous) fluid to hydrate the resident he was worried about the dehydration. LPN BB said, The MD (Medical Doctor) did not give any orders for ongoing assessment or vital signs and that the only intervention was IV fluids. I knew he had a change in condition when he was no longer fighting. Futher interview revealed that resident after resident started the IV fluids, that the vital signs are on the daily skilled note sheets, and we are only required to take them once on each 12-hour shift. The resident would have refused vital signs being taken and you don't have a right to do things as a nurse in Georgia without an order, I did it in Indiana but not in this state. LPN BB continued saying , I had thirty other residents to take care of and needed to pass medications, I can only do so much on a shift, you know if you don't have rights to do certain things you just can't do it, and I do the best I can from 7-7 when I get off. Upon futher record review of the Skilled Daily Nursing Notes, R#1's vital signs were documented on 6/13/17 D (Day) P ( Pulse) 102 R (Respirations) 16, B/P (Blood pressure) 120 /84, on the N (Night) P (Pulse) 105 , R (Respirations) 20 .B/P (Blood pressure) 136/93. There was no evidence found to indicate the staff assessed the resident for hypo or hyperglycemic symtoms. Recored review revealed on 6/15/17 a form titled Resident Transfer Form completed at 10:30 a.m., revealed the following documented BP (Blood Pressure) 144/92, HR (Heart Rate) 119 and RR (Respirations ) 18, FS glucose (Finger Stick Glucose) was left blank. and the reason for transfer noted , Lethergic, AMS (Altered Mental Status), not eating or drinking , chest congestion. Recod review revelaed that at 11:00 a.m., on 6/15/17 it was documented on a form titled, Physician's Interim/Telephone Orders, send to ER (emergency room ) Per Family Request, due to lethargy, not eating or drinking and chest congestion. There was no evidence that the residents blood glucose was monitored for the Glucose of 518 per the labortory results on 6/13/17. During a telephone interview with R#1's wife on 8/11/17 at 10:00 a.m., regarding his transfer to the hospital on [DATE], she stated his blood sugar was 700 when he got to the hospitial and he spent three days at the hospital in ICU (Intensive Care Unit) and then went to Hospice where he passed away. Wife stated she did not understand that he was in a diabetic coma that's what they told her at the Hospice center.",2020-09-01
3992,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2017-08-10,505,D,1,0,5YLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, interviews and review of the facilities written policy titled Laboratory, Radiology and other Diagnostic Services it was determined that the facility failed to ensure laboratory orders were implemented and results were reported timely in accordance with the facilities written policy for one Resident (R#1) out of 3 residents. Finding include: Upon admission to the facility on [DATE] R#1's [DIAGNOSES REDACTED]. Review of the clinical record it was documented on a form titled Physician's Interim/Telephone orders dated 6/5/17 notes, Admission labs: Hemoglobin A1C (HgbA1C) (blood test to monitor the glucose control of a patient over the last three months) , Comprehensive Metabolic Panel (CMP), Complete Blood Count (CBC), Lipids. During an interview with the DON on 8/10/17 at 12:00 p.m., regarding the lab ordered dated 6/5/17 the DON replied, he went to the hospital on the 5th due to a fall. Upon further review of the record a form titled Clinical Laboratory Services, dated 6/5/17 at 10:27 a.m., and the same form dated 6/6/17 at 10:27 a.m., both days were noted No Requisition Received for Comprehensive Metabolic Panel , Lipid Panel, CBC with Diff, PSA screening, and HGB A1C. Futher record review revealed the next Clinical Laboratory Services form in the clinical record was dated 6/13/17 the results reported to the facilty was on 6/13/17 at 1:46 p.m. The report revealed outside range for ; Sodium 159 (136-145), Chloride 114 (98-107), Glucose 518 (70-105). Further record review revealed that at 3:30 p.m. on 6/13/17 LPN BB documented in the 'Skilled Daily Nurses Notes' crtical labs were reported to the doctor. During an interview with Director of Nursing (DON) on 8/10/17 at 12:00 p.m., regarding the time lapse between when the lab report was received for R#1on 6/13/17 and the time LPN BB documented the physician was notified of the out of range results, she replied the labs may have been here at the time on the lab report but maybe the nurse did not get a copy of the results until the time noted, which I do not think is a delay. During interview with the Medical Records/Central supply staff on 8/10/17 at 1:12 p.m., in the presence of the DON regarding the facilities system to manage laboratory orders including out of range results she stated, all labs are faxed to the facility and placed in my mail box up front or I can view the labs right here on my computer. She continued to say, I check my box at least one time each day around 6:30 a.m., and I can pull results from my computer. I always fax the labs that are within range to the MD and I give all out of range labs directory to the nurse to call the physician. When asked about the policy regarding the documentation on a form titled Patients Log Book she replied, the sheets for R#1 labs have been removed from the book and I cannot find them, sometimes they are put in the garbage. During further intervew regarding the form titled Clinical Laboratory Services, dated 6/5/17 at 10:27 a.m., and 6/6/17 at 10:27 a.m., that was noted No Requisition Received, she said a few months ago we opened the other unit and the people from the lab did not know we had residents over there, so the labs were missed. Review of the Laboratory Radiology and other Diagnostic Services policy notes, Qualified nursing personnel will receive and review the diagnostic test reports and communicate the results to the ordering physician within 24 hours of receipt unless the report results fall outside of clinical reference ranges and require immediate attention at which time the Physician will be notified upon receipt. The laboratory policy notes the MD will be notified immediately with results that require immediate attention. And the results will be logged in the lab book upon receipt.",2020-09-01
3993,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-10-03,580,D,1,0,GHJT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined that the facility failed to notify the legal guardian of new MEDICATION ORDERS FOR [REDACTED]. Findings include: Review of the medical record for R#1 revealed a physician's orders [REDACTED]. However, there was not documentation in the medical record the legal guardian was notified of the new medication order and the increased sexual activity on 7/29/18. During an interview with the Director of Nursing (DON) on 10/3/18 at 12:00 p.m., she stated that when the legal guardian visited sometime around 8/5/18 she talked with the nurse regarding the resident that day. The DON also stated that the nurse was late in notifying the legal guardian of the medication order and the increased sexual activity.",2020-09-01
3994,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-10-03,609,D,1,0,GHJT11,"> Based on staff interview and review of the facility's Leadership Standards of Practice, Subject: Abuse, Neglect and Misappropriation of Property and the Grievance/Complaint Report, it was determined that the facility failed to report an allegation of a missing cellular telephone for resident (R) #1 from a total sample of nine residents. Findings include: Review of the facility Grievance/Complaint form dated 8/28/18 indicated that R#5's husband reported the resident's cellular phone was missing. The husband indicated he bought the resident a new phone and it was lost. A police report was taken by the Sheriff's office. Documentation on the form noted that the grievance/complaint was not revolved because it was ongoing. During an interview with the Director of Nursing (DON) on 10/3/18 at 12:00 p.m., she stated that on 8/28/18 the resident's husband came to her office upset about the resident's cellular phone missing. She stated that the husband claimed it was the third that had gone missing since the resident has been in the facility. The DON stated that the missing cellular phone was not reported to the State Survey Agency because they haven't closed the investigation. Review of an undated policy titled Leadership Standards of Practice; Subject: Abuse, Neglect and Misappropriation of Property; Component VII: Reporting/Response revealed that all alleged violations concerning abuse, neglect, or misappropriation of property are reported immediately to the Administrator/Designee and other enforcement agencies, according to state law including the State Survey and Certification Agency.",2020-09-01
3995,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-10-03,690,D,1,0,GHJT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, it was determined that the facility failed to obtain a Physician's order for the use of [REDACTED]. Findings include: 1. R#3 was admitted to the facility on [DATE] with an indwelling catheter for a chronic wound. Review of the physician's order from 5/25/18 to 10/3/18 revealed there was not a Physician's Order for the indwelling catheter. Review of the (MONTH) (YEAR) Physician's Order Form revealed an order to change the indwelling catheter every 30 days and as needed. However, there was not an order clarifying the size of the indwelling catheter to use. Review of the treatment records for 7/2018 and 8/2018 revealed the resident's indwelling catheter had been changed. The 9/27/18 Progress Notes noted the resident's Foley catheter was not producing urine and the Foley catheter was changed. However, there was not a Physician's Order to re-insert the indwelling catheter. The 10/1/18 Progress Notes documented that a 18 French (Fr) Foley catheter was inserted. However, there was not a Physician's Order to insert an indwelling catheter. After surveyor inquiry on 10/3/18 at 12:00 p.m., staff obtained a clarification order to insert an indwelling catheter 16 Fr and change as needed. 2. R#4 was readmitted to the facility on [DATE] from a hospitalization with an indwelling catheter. The indication for use was for a sacral wound. Review of the Physician's Orders from 8/24/18 to 10/3/18 revealed there was not a Physician's Order for the indwelling catheter. After surveyor inquiry on 10/3/18 at 2:10 p.m., staff obtained a clarification order to insert a 16 Fr indwelling catheter to promote wound healing and change as needed. Further review of the clinical record revealed a 6/14/18 Physician's admission orders [REDACTED]. However, the order to not include the size catheter to use or how often to change the catheter. During an interview with the Director of Nursing (DON) on 10/3/18 at 12:00 p.m., she stated that the 6/14/18 Physician's Order for R#4 was not an acceptable order for the Foley catheter. She also confirmed there were no Physician's Orders for an indwelling catheter for R#3 and R#4 until 10/3/18. Review of the undated policy titled Catheterization, Female, revealed the policy lacked the intervention that the facility needed a Physician's order for the use of [REDACTED]",2020-09-01
3996,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-12-06,623,C,0,1,ODI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to notify the resident and resident's representative in writing of the reason for transfer/discharge to the hospital for six of six Residents (R) reviewed for transfer/discharge to the hospital (R#5, R#28, R#34, R#64, R#80, and R#98). Findings include: 1. Review of R#28's Minimum Data Set (MDS) list revealed the resident was discharged from the facility with return anticipated on 5/29/18 and 9/12/18. Review of the nurse's note, on 5/29/18 R#28 was discharged to the hospital after a fall with potential [MEDICAL CONDITION] leg. Review of the nurse's note, on 9/12/18 R#28 was discharged to the hospital with uncontrolled hypertension. Review of R#28's medical chart revealed no documentation of written notification to the resident and resident's representative of the reason for transfer/discharge to the hospital. 2. Review of R#80's MDS list revealed the resident was discharged from the facility to the hospital with return anticipated on 8/14/18, 9/4/18, 10/8/18, and 10/26/18. Review of the nurse's note, on 8/14/18 R#80 was discharged to the hospital with nausea, vomiting, and elevated blood pressure. Review of the nurse's note, on 9/4/18 R#80 was at the [MEDICAL TREATMENT] center when she was transferred to the hospital with low blood pressure. Review of the nurse's note, on 10/8/18 R#80 was discharged to the hospital non-responsive to verbal stimuli and high blood sugar. Review of the nurse's note, on 10/26/18 R#80 was discharged to the hospital with bleeding from the rectum. Review of the R#80's medical chart revealed no documentation of written notification to the resident and resident's representative of the reason for transfer/discharge to the hospital. On 12/6/18 at 9:10 a.m. the Assistant Administrator (AA) and Director of Nursing (DON), in the AA's office, were asked for the written notice of the reason for transfer to the hospital for Residents #28 and #80. On 12/6/18 at 10:30 a.m. the AA presented the bed hold letter sent to the family for Resident #28 and #80. The facility was still looking for the notification of transfer letter to the family. 3. Review of R#64's MDS list revealed the resident was discharged from the facility with return anticipated on 8/21/18. Review of the nurse's note, on 8/21/18, R#64 was discharged to the hospital with slurred speech and behaviors. Review of R#64's medical record revealed no documentation of a written notification to the resident and resident's representative of the reason for transfer/discharge to the hospital. On 12/6/18 at 10:30 a.m. the AA presented the bed hold letter sent to the family of Resident #64. The facility was still looking for the notification of transfer letter to the family. 4. Review of R#5's MDS list revealed the resident was discharged with return anticipated on 10/22/18 and 11/20/18. Review of the nurse's note, on 10/22/19 R#5 was transported to the [MEDICAL TREATMENT] center and then sent to the hospital as a result of elevated blood glucose levels. Review of the nurse's note, on 11/20/18 R#5 was transported to the [MEDICAL TREATMENT] center and then sent to the hospital as a result of a hypotensive episode at the time of treatment. Review of R#5's medical record revealed no documentation of written notification to the resident and resident's representative of the reason for transfer/discharge to the hospital. On 12/6/18 at 10:30 a.m. the AA presented the bed hold letter sent to the family for R#5. The facility was still looking for the notification of transfer letter to the family. 5. Review of R#34's record revealed the resident was discharged from the facility on 8/11/18 and 8/13/18 where she was transferred to the hospital and admitted for further treatment. Review of the nurse's note, on 8/11/18 R#34 was discharged to the hospital with respiratory distress. Review of the nurse's note, on 8/13/18 R#34 was discharged to the hospital with respiratory distress. Review of the medical record for R#34 revealed no documentation of written notification to the resident or the resident's representative noting the reason R#34 was transferred/discharged to the hospital. On 12/6/18 at 3:40 p.m., the AA stated the facility does not have policy for notifying the family for transfer/discharge. 6. Review of R#98's record revealed the resident was discharged from the facility on 10/22/18. Review of the nurse's note, on 10/22/19 R#98 was discharged to the hospital with increasing [MEDICAL CONDITION], being unable to eat, drink or make her needs known. Review of the medical record for R#98 revealed no documentation of written notification to the resident or the resident's representative noting the reason R#98 was transferred/discharged to the hospital. Further interview on 12/6/18 at 2:12 p.m. the AA stated the facility has not been sending the letter notifying the family of the reason for the transfer/discharge to the hospital. Further interview on 12/6/18 at 3:40 p.m. the AA stated the facility does not have policy for notifying the family for transfer/discharge.",2020-09-01
3997,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-12-06,755,D,0,1,ODI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to ensure the disposition of all controlled drugs so that an accurate account was maintained and periodically reviewed, for one of four medication storage carts inspected. Findings include: During medication administration on 12/5/18 at 9:23 a.m. on the 300 hallway, observation of the medication cart revealed a medication card containing 44 tablets of [MEDICATION NAME] (narcotic medication) 50 mg (milligrams) for Resident (R)#79. The narcotic count reconciliation sheet indicated the count should have been 45 tablets. The Licensed Practical Nurse (LPN) GG looked in the locked narcotic drawer on the medication cart for the missing pill. The nurse reviewed the Medication Administration Record [REDACTED]. After several minutes, LPN GG remembered giving the resident one [MEDICATION NAME] during the evening medication pass on 12/4/18. Interview with LPN GG on 12/5/18 at approximately 9:23 a.m. confirmed the number of tablets in the medication card did not match the number count on the reconciliation sheet. LPN GG stated she and the night shift nurse had counted the narcotics at shift change on 12/4/18 and 12/5/18. LPN GG stated the count must have been wrong since 12/4/18 when she forgot to sign out R#79's [MEDICATION NAME] dose around 4:30 p.m. On 12/5/18 at approximately 9:50 a.m. the Director of Nursing (DON) was notified the narcotic reconciliation sheet count did not match the number of tablets in the punch card. On 12/5/18 at 9:53 a.m. all four medication cart narcotics were observed for re-count by the facility nursing staff. The other three medication carts had no issues with narcotic reconciliation. Review of the facility policy titled, Medication Ordering and Receiving From Pharmacy Provider Order and Receiving controlled Mediations, dated 7/2018, revealed in the section titled Procedure 4. The pharmacy prepares an individual resident controlled substance record/receipt/log using a duplicate label (or the nurse prepares one for medication prescribed for a resident as applicable per state law. This form is placed in the MAR indicated [REDACTED]. The facility DON provided the following nursing standards of practice, NARCOTIC COUNT (not dated), section titled Standard: The Narcotic Count and Inventory: 1. Schedule II drugs will be counted every eight (8) - or twelve (12) -hour shift by a licensed nurse reporting on duty with the licensed nurse reporting off duty. 2. The inventory of the Schedule II drugs will be recorded on the Narcotic Records and signed for correctness of count. 3. The controlled drug check list will be signed by both the nurse coming on duty and going off duty to verify that the count of all Schedule II drugs is correct. 4. The staff will follow the method of operation for the administration and control of Schedule II drugs, which will meet the requirements of state and federal narcotic enforcement agencies PRACTICE GUIDELINES: 1. At the end of every eight (8)-or twelve (12)-hour shift the authorized staff members reporting on duty and the authorized staff member reporting off duty meet at the designated medication cart or storage area to count Schedule II drugs. 2. The off-going authorized staff member reads down the Schedule II Inventory Sheet one drug at a time. 3. The on-coming authorized staff member counts the number of remaining Schedule II drugs and announces that number out loud. 4. The off-going authorized staff member checks this number against the Inventory Sheet. The remaining number is carried over to the Schedule II Inventory Sheet for the new shift. 5. Steps two (2) through four (4) are repeated for each Schedule II drug in the inventory. 6. In counting Schedule II drugs, the authorized staff member is alert for any evidence of a substitution. Inspect tablets and solutions closely. Note any defects in drug container. Immediately report any suspicion of substitution or tampering with controlled drugs to the Director of Nursing. Generate the appropriate incident statements. 7. If a discrepancy is found, check the patient's/resident's order sheets and chart to see if a narcotic has been administered and not recorded. Check pervious recordings on the Schedule II Inventory Sheets for mistakes in arithmetic or error in transferring numbers form on sheet to the next. 8. If the cause of the discrepancy cannot be located and/or the count does not balance, report the matter to the Director of Nursing/designee and generate the appropriate incident statements. The Director of Nursing/designee then contacts the pharmacy and police .",2020-09-01
3998,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-12-06,761,E,0,1,ODI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policy review, the facility failed to ensure expired medications and supplies were not available for use to be administered to the residents, for two of two medication rooms. Findings include: On 12/5/18 at 4:05 p.m. during observation of the 100/200/300 Unit medication storage rooms with Licensed Practical Nurse (LPN) GG the following expired medications were noted: -One Multidose vial of [MEDICATION NAME], Purified Protein Derivative Diluted/[MEDICATION NAME] which was opened on 11/2/18. The box had the following directions, Once entered vial should be discarded after 30 days.; and -Five vials of sterile [MEDICATION NAME] 0.5mg (milligrams)/12.5 ml (milliners), with an expiration date of (MONTH) (YEAR). Interview on 12/5/18 at approximately 4:05 p.m., with LPN GG in the 100/200/300 Unit medication storage rooms, she stated all nurses are responsible for looking and disposing of expired medications. On 12/5/18 at 4:25 p.m. during observation of the 400/500 Unit medication storage rooms with Registered Nurse (RN) HH the following expired supplies were noted: -One yellow top Vacuette with expiration date of 8/24/18; -One package of UTM (suppliers name) medium for the transport of viruses, Chlamydia, Mycoplasma, and Ureaplasma 3.0 ml with an expiration date of 12/2017; -One BD (suppliers name) Universal [MEDICAL CONDITION] Transport for Viruses, Chlamydia, Mycoplasma, and Ureaplasma with an expiration date of 4/2018; and -One Central line dressing package with an expiration date of 11/30/18. Interview on 12/5/18 at approximately 4:25 p.m. in the 400 Unit nurse's station with RN HH, she stated all nurses are responsible for looking for and disposing of outdated supplies in the medication room. Interview on 12/5/18 at 4:35 p.m. in the 400 Unit nurse station with the front unit nurse manager she stated all nurses in the facility are responsible for looking for and removing out dated medication and supplies in the medication storage room. On 12/6/18 at 3:00 p.m. the front unit nurse manager stated the central supply clerk and unit manage are also responsible for looking for outdated supplies and medications. On 12/6/18 at 3:30 p.m. the front unit nurse manager stated the facility had no policy for expired supplies. Review of the facility policy titled, Medication Storage-Storage of Medication dated 7/2018, revealed in a section titled Procedures, paragrapgh 14. Outdated, contaminated, discontinued or deteriorated mediation 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 form the pharmacy .if a current order exists.",2020-09-01
3999,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-12-06,838,F,0,1,ODI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document review and staff interview the facility failed to conduct, document and update a facility assessment based on the resident population that accurately reflects the current needs of the residents to determine what resources are necessary to care for its residents during day to day operations and emergencies. Findings include: On 12/3/18, the facility assessment was requested during the entrance conference with the Assistant Administrator (AA) at 9:00 a.m. in her office. A second request was made for the facility assessment on 12/4/18 at 10:00 a.m. in the conference room with the A[NAME] At 4:00 p.m. the AA presented for review an undated document titled Advanced Health & Rehab Twiggs County Facility Assessment. When asked when this was completed, the AA wrote the date of (MONTH) (YEAR) on the top of the document. She stated the Administrator had to request corporate to provide access to the former Administrator's email who left the facility in (MONTH) (YEAR). The document was located and printed from this email address. The AA stated the assessment was not in the facility for use by facility staff to determine the needs of the residents for staffing, activities or food preferences based on ethnic, cultural or religious preferences. Review of the assessment revealed it did not identify religious preferences, cultural preferences, ethnic preferences, or special needs of residents based on medical needs, nor did it identify the age of the population. The facility has a large population of residents under the age of 50 which was not reflected in the facility assessment. The facility assessment did not identify the secure unit in the facility, the in-house [MEDICAL TREATMENT] residents, complex IV (intravenous) medications, [MEDICAL CONDITION] residents and residents with gastrostomy feedings for full nutrition. In (MONTH) (YEAR), the facility developed a secure unit for dementia residents. They have accepted new admissions of residents with a [MEDICAL CONDITION] in (MONTH) (YEAR) and started an in-house [MEDICAL TREATMENT] unit in (MONTH) (YEAR). There were also several [MEDICAL TREATMENT] and hospice residents that were not identified on the facility assessment. The facility assessment has not been updated since (MONTH) (YEAR) to reflect the type of care to be provided to current residents. The AA stated she was aware residents had multiple religious beliefs which was not identified on the assessment. Failure to have a facility assessment that is accessible by facility staff and failure to update the facility assessment to reflect the current needs of the residents does not allow staff to provide staffing needs, activity preferences and food preferences. It does not state the staff competencies that are necessary to provide the level and type of care needed for the resident population. The AA confirmed in an interview on 12/5/18 at 3:00 p.m. in the conference room, the facility assessment was not available for staff use and had not been updated to reflect the current resident population and the type of services and needs the current residents need. She also confirmed it does not identify staff competencies needed to care for the current resident population and their medical needs.",2020-09-01
4000,ADVANCED HEALTH AND REHAB OF TWIGGS COUNTY,115727,113 SPRING VALLEY ROAD,JEFFERSONVILLE,GA,31044,2018-12-06,883,D,0,1,ODI611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on residents' medical record review and facility staff interviews the facility failed to document influenza and pneumococcal immunizations were received by two (Resident (R)#20 and R#298) of six residents whose records were reviewed for administration of influenza and pneumococcal immunizations during the (YEAR)/2019 flu season. R#20 and R#298 consented to receive the influenza and pneumococcal immunizations during this flu season. Findings include: 1. Review of the face sheet in the medical record for R#20 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #20 is his own responsible party and makes his own medical decisions. He has not been deemed incompetent. Review of the resident's Significant Change Minimum Data Set ((MDS) dated [DATE] revealed that R#20 has a BIMS (brief interview for mental status) score of 12/15. Review of the medical record for R#20 revealed a signed consent, dated 9/12/18, to receive the influenza and pneumococcal immunizations. Review of the medication administration record (MAR) and immunization record for R#20 revealed he had not received the influenza and pneumococcal immunizations as of 12/4/18. Review of the monthly Physician's Order for R#20 for the months of (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed a Physician's Order that the resident may have influenza immunization and an additional order that resident may have the pneumococcal immunization An interview on 12/4/18 at 10:30 a.m., with the Assistant Director of Nursing (ADON), at the back nurses' station, she stated R#20 had not received the immunizations he consented to because the Hospice nurse instructed her not to. There was no documentation from the ADON or the Hospice nurse stating not to administer the immunizations. A phone call to the Hospice nurse on 12/4/18 at 10:40 p.m. at the back nurses' station from the ADON confirmed the Hospice nurse did not document R#20 should not receive immunizations. The Hospice nurse stated she did not remember stating R#20 could not have his immunizations. The ADON confirmed multiple residents received influenza and pneumococcal immunizations on dates after R#20 signed his consents. She also stated most residents received the flu shot and pneumo shot on 10/22/18. 2. Review of the face sheet in the medical record for R#298 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She makes her own medical decisions and has not been deemed incompetent. She has not had a BIMS completed. Review of the medical record for R#298 revealed a signed consent, dated 11/24/18, to receive the influenza and pneumococcal immunizations. Review of the MAR and immunization record for R#298 revealed she had not received the influenza and pneumococcal immunizations as of 12/4/18. Review of the monthly Physician's Order for R#298 for (MONTH) (YEAR) and (MONTH) (YEAR), revealed a Physician's Order that resident may have influenza immunization. There was no Physician's Order to administer the pneumococcal immunization. An interview on 12/4/18 at 10:30 a.m. with the ADON, at the back nurses' station, she stated the facility did not have any influenza or pneumococcal immunizations to administer to residents. She stated she had ordered the influenza immunizations on multiple occasions, but the facility had not received any as they were on back order. The facility was not able to provide documentation from the pharmacy stating influenza and pneumococcal immunizations were not available and on back order. The ADON stated she would contact the pharmacy and get a statement to confirm the back order status of the influenza and pneumococcal immunizations. On 12/4/18, the ADON presented a typed undated and unsigned note with a dispensing Pharmacy heading stating the dispensing Pharmacy was unable to provide influenza immunization as they were in heavy demand. This note did not address availability of the pneumococcal immunizations. On 12/4/18, the ADON presented an email from the Consultant Pharmacist informing the facility Administrator and Director of Nursing (DON), the pharmacy would be sending 40 vials of influenza vaccine to the facility on [DATE]. The facility presented for review an email communication between pharmacists at the dispensing Pharmacy dated 12/4/18. The email from the Consultant Pharmacist stated, Another facility (name) needs 40 doses of [MEDICATION NAME]. NDC # =0017-01. 4 boxes of 10 PRE Filled Syringes. The last time, I think I got some from (names of other facilities). We have State Surveyors at one of our facilities and they are asking why facility doesn't have (sic). The answer is they ordered too little initially and then requested 50 more doses but that still was not enough. Thanks for any help you can give us. If we have to take the [MEDICATION NAME] MDV (multidose vial), then we will do that also. The facility presented for review immunization documentation dated 12/6/18, noting Resident #20 received his influenza immunizations on 12/6/18 after obtaining it from pharmacy. This documentation also noted R#20 received his pneumococcal immunization on 12/6/18. Documentation on 12/4/18, revealed R#298 did not receive her pneumococcal immunization. The ADON stated on 12/4/18 at 1:30 p.m. in the conference room, pneumococcal immunizations had to be ordered on an individual basis and she had not ordered one for R#298. At 2:30 p.m. on 12/4/18, in the conference room, the ADON reported she had notified the physician and ordered the pneumococcal immunization for R#298. Review of the updated immunization record for R#298 revealed she received the influenza and pneumococcal immunizations on 12/5/18 after receiving them from pharmacy. The ADON stated the physician for R#20 and R#298 was notified the residents received their influenza and pneumococcal immunizations late. Review of an undated facility policy titled, Surveillance, Prevention and Control of Infections Standards of Practice--Subject: Influenza Vaccine Administration and Disease Control, revealed in the section titled Standard: 1. Influenza vaccine will be administered to all patients/residents unless contraindicated. A second policy also undated and titled, Surveillance, Prevention and Control of Infections Standards of Practice--Subject: Pneumococcal Disease: Prevention and Control and use of Pneumococcal [MEDICATION NAME] Vaccine, revealed in the section titled Standard: 2. Patients/Residents who are at risk of pneumococcal diseases will be offered the pneumococcal vaccine as part of their therapeutic regimen unless the vaccine is contraindicated. 3. Standing orders will be used for administration of vaccines. Failure to administer influenza and pneumococcal immunizations could result in resident illness, decline in condition and/or death.",2020-09-01
2576,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2019-05-16,645,D,0,1,142F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of a policy/procedure titled, PASRR User Manualprovided by the facility, the facility failed to ensure that PreAdmission Screening/Resident Review (PASRR) Level I Assessment forms were completed accurately and timely for two residents of 33 residents (R#24 and R#15). Findings include: 1. A review of the face sheet revealed that R#24 was admitted with [DIAGNOSES REDACTED]. On the PASRR form dated 3/18/16 for R#24, number 1: Does the individual have a mental illness ., is answered NO; number 2: Primary [DIAGNOSES REDACTED]., is answered NO and the [DIAGNOSES REDACTED]. A review of current physician orders [REDACTED]. This order was written 7/1/16. R#24 is also receiving [MEDICATION NAME] ([MEDICATION NAME]), an antidepressant medication, 15 milligrams (mg) orally every night at bedtime. This order was written 2/16/19. On 5/14/19 at 3:15 p.m. during an interview with Marketing Director/Admissions Coordinator, AA she stated there was no system in place to track and check PASRRs. She stated the nurses and admissions should check the PASRR against resident [DIAGNOSES REDACTED]. 2. Resident #15 (R#15) was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the PASRR form dated 2/13/19 for R#15, number 4: Primary [DIAGNOSES REDACTED]. On 5/16/19 at 12:23 p.m. during an interview with the Social Worker BB from United Behavioral Services where he stated R#15 was not a client currently on his case load. However, he stated he and the staff at the facility have discussed the need to audit the PASRR's in the facility for needs or changes but there has been no mechanism in place to achieve this goal.",2020-09-01
2577,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2019-05-16,773,D,0,1,142F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of a facility policy titled Lab Procedures and Other Services, the facility failed to obtain the lab results as ordered by the physician and failed to report the abnormal lab results to the physician for one resident of 33 Residents (R#45). Findings include: Review of a facility policy dated 7/1/2018 entitiled Lab Procedures & Other Services states It is the standard of this facility to provide laboratory and diagnostic studies for all residents in compliance with Federal and State requirements. All tests will be completed as ordered, results obtained and reported to the attending physician or Medical Director, and other members of the Interdisciplinary Team, as appropriate to assist in management of disease process. The General Guidelines state The Licensed Nurse receives the laboratory test order from the physician and notified the lab of the requested test. The Licensed Nurse ensures lab is drawn/conducted in a reasonable time frame (unless stat order). The Licensed Nurse communicates lab results to the physician. R#45 was admitted with [DIAGNOSES REDACTED]. Due to cognitive deficits, staff anticipate her needs and provide or assist with all activities of daily living including but not limited to bathing, dressing, grooming, eating, bed mobility, transfers and locomotion. She is non-ambulatory. A review of the Minimum Data Set (MDS), a resident assessment instrument with an assessment reference date of 4/8/19, R#45 has a Brief Inventory of Mental Status (BIMS) score of 99 indicating an inability to complete the interview. A review of (MONTH) 2019 physician's orders [REDACTED]. [MEDICATION NAME] 300 mg tablet, take one tablet by mouth once daily for [MEDICAL CONDITION] at 8AM [MEDICATION NAME] 600 mg cap, take one cap by mouth at bedtime for depression at 8PM [MEDICATION NAME] 30 mg tablets, take three tablets by mouth at bedtime for [MEDICAL CONDITION] at 8PM [MEDICATION NAME] DR 125 mg capsule 500 mg (4) capsules by mouth every morning at 8AM [MEDICATION NAME] DR 125 mg capsule 750 mg (6) capsules by mouth every evening at 4PM [MEDICATION NAME] 1,000 micrograms tablet, one tablet by mouth once daily for [MEDICAL CONDITION] at 8AM The (MONTH) 2019 physician's orders [REDACTED]. Complete Blood Count (CBC) every six months (scheduled (MONTH) and October) Complete Metabolic Profile (CMP) every 6 months (scheduled (MONTH) and October) [MEDICATION NAME] (drug) level every 6 months (scheduled (MONTH) and October) [MEDICAL CONDITION] Stimulating Hormone (TSH) every 6 months (scheduled (MONTH) and October) [MEDICATION NAME] (drug) level every 6 months (scheduled (MONTH) and October) [MEDICATION NAME] (drug)level every 6 months (scheduled (MONTH) and October) A review of Nurse's Notes for the month of (MONTH) 2019 reveal that staff were unable to draw R#45's blood on three occasions. The staff notified the physician who instructed them to attempt the labs the next scheduled lab draw day (5/1/19). A review of lab results found in chart as of 5/13/19 at 3:00 p.m. included the drug level test results for [MEDICATION NAME] and pheobarbital drawn on 5/1/19. The forms have a fax receipt date of 5/5/19 at the top of the pages. None of these results were documented as reported to the physician in either the Nurse's Notes or on the lab reports themselves. There were no lab results for the [MEDICATION NAME] acid drug level, the TSH level, the CBC or the CMP. The 5/1/19 lab results for the [MEDICATION NAME] drug level (1.17 mmol/L) indicates it was within normal limits (0.60-1.20 mmol/L). The results for the [MEDICATION NAME] drug level (12.2 mg/L) indicate is was below normal range (15.0-40.0 mg/L). During an interview conducted on 5/14/19 at 9:00 a.m. with Licensed Practical Nurse (LPN) EE she confirmed that lab results are received via fax and the nurses will call the results to the physician's office. She further stated that the nurses usually document on the bottom of the lab results the date and time they contact the physician and any new orders given as a result. LPN EE stated that if the nurses don't document on the lab report the date and time they contacted the physician's office, they will document in the Nurse's Notes. During an interview conducted on 5/14/19 at 10:10 a.m. with LPN EE, she confirmed that results for the CBC, CMP, TSH level and [MEDICATION NAME] acid drug level were not in the chart. She stated that she would have to contact the lab for the remaining results. The remaining lab results from the 5/1/19 testing were provided by the nurse consultant DD on 5/14/19 at 2:34 p.m. including copies of the CBC, CMP and the [MEDICATION NAME] acid level. The forms had a fax receipt date of 5/14/19 at the top of the pages. The results for the [MEDICATION NAME] acid drug level (less than 10.0 ug/ml) indicates it was below normal range (50.0-120.0 ug/ml). The TSH level was within normal limits. The CMP results included but was not limited to a glucose level (55 mg/dl) that was below normal range (74-106 mg/dl), a creatinine level (0.40 mg/dl) that was below normal range (0.70-1.20 mg/dl), a sodium level (136 mmol/l) that was below normal range (137-145 mmol/l), and an [MEDICATION NAME] level (3.3 gm/dl) that was below normal range (3.5-5.0 gm/dl). The CBC results included but was not limited to a white blood cell count (4.76 K/UL) that was below normal range (4.80-10.80 K/UL), a red blood cell count (3.41 m/ul) that was below normal level (4.20-5.40 m/ul), There was no evidence to support that the results had been phoned or faxed to the attending physician.",2020-09-01
2578,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2019-05-16,812,F,0,1,142F11,"Based on observations, staff interviews, and review of two facility policies titled Food Storage and Pot and Pan Washing, the facility failed to store opened food items in secured or sealed containers in the dry storage room and failed to store clean pans in a dry, sanitary manner. This had the potential to affect 57 of 57 residents receiving an oral diet. Findings include: Review of an undated facility policy entitled Food Storage states 4. Metal or plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods. All containers must be legibly and accurately labeled. Review of an undated facility policy entitled Pot and Pan Washing states 5. Pots and pans must be air dried on the drain board. Dish towels must never be used. After pot and pans are dry, they must be inspected and then stored in a clean, dry, protected area. During the initial tour conducted on 5/13/19 at 10:50 a.m. with the Food Service Director (FSD), the dry storage area was found to contain seven individual bowls of dry cereal with loosely fitting disposable lids that did not seal. The seven bowls of cereal were on a tray labeled as prepared on 5/12/19 and use by 5/15/19. During the initial tour conducted on 5/13/19 at 10:50 a.m. with the FSD, three stacks of various size and shaped pans were examined and three of three pans checked were wet. A tour of the kitchen conducted with the FSD on 5/15/19 at 12:20 p.m. revealed two stacks of various size and shaped pans were examined and two of two metal pans were wet. The FSD confirmed that the pans should not be stacked or nested when wet.",2020-09-01
2579,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2019-05-16,842,D,1,1,142F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the policy titled, Medication Administration Guidelines and staff interviews it was noted that the facility failed to ensure that complete and accurate documentation of administration of medications were placed on the Medication Administration Records (MARs) for one of 33 residents reviewed (R#1). Findings include: During a review of the policy/Medication Administration Guidelines dated (MONTH) (YEAR), it was noted under the section, Documentation of Medications, the second bullet states, Document signature or initials as required for medications administered on the MAR indicated [REDACTED]. DO NOT pre-sign MAR prior to medication administration. Circle initials for those medications that were not administered and document reason for non-administration on the back of the MAR. Record review revealed that Resident #1 was admitted to the facility with [DIAGNOSES REDACTED]. Review of the MARs for (MONTH) 2019, (MONTH) 2019 and (MONTH) 2019 revealed the following areas where medication administration was not signed or initialed and there was not any evidence of documentation on the back of the MARs as to the reason they were not administered, signed, or initaled. March 2019 MAR 8:00 a.m. 3/16/19 levetiracetam 500 milligrams (mg), [MEDICATION NAME] 400 mg, [MEDICATION NAME] HCL 15 mg, [MEDICATION NAME] 7.5-325 mg 3/28/19 [MEDICATION NAME] HCL 15 mg 3/28/19 [MEDICATION NAME] 20 mg 12:00 p.m. 3/16/19 [MEDICATION NAME] 7.5-325 mg, [MEDICATION NAME] 400 mg 3/28/19 busprione HCL 15 mg, [MEDICATION NAME] 7.5-325 mg 4:00 p.m. 3/28/19 [MEDICATION NAME] HCL 15 mg 3/28/19 [MEDICATION NAME] 400 mg 8:00 p.m. 3/4/19 Levetiracetam 500 mg, [MEDICATION NAME] flextouch 20 units 3/12/19 [MEDICATION NAME] 100 mg 3/22/19 [MEDICATION NAME] flextouch 20 units 3/23/19 [MEDICATION NAME] 7.5-3.25 mg April 2019 MAR 12 a.m. 4/15/19 [MEDICATION NAME] 7.5-325 mg 6 a.m. 4/14/19 [MEDICATION NAME] 7.5-32 5 mg 4/30/19 [MEDICATION NAME] 7.5-325 mg 8:00 a.m. 12:00 p.m. 4/27 [MEDICATION NAME] 400 mg, [MEDICATION NAME] HCL 15 mg 4 p.m. 4/29/19 [MEDICATION NAME] 400 mg 6 p.m. 4/29/19 [MEDICATION NAME] 7.5 mg-325 mg 8:00 p.m. 4/1/19 Levetiracetam 500 mg 4/2/19 Levetiracetam 500 mg 4/11/19 [MEDICATION NAME] 20 units 4/15/19 [MEDICATION NAME] 500 mg, levetiracetam 500 mg, [MEDICATION NAME] HCL 15 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME], levimir 20 units 4/26/19 fiber lax, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 20 units 4/29/19 Levetiracetam 500 mg, [MEDICATION NAME] 500 mg, [MEDICATION NAME] HCL 15 mg, [MEDICATION NAME] 100 mg, [MEDICATION NAME] 20 units May 2019 MAR 8:00 a.m. [MEDICATION NAME] 15 mg 12:00 p.m. 5/4/19 [MEDICATION NAME] 400 mg, [MEDICATION NAME] 7.5-325 mg 4:00 p.m. 5/4/19 [MEDICATION NAME] 100 mg 6:00 p.m. 5/4/19 [MEDICATION NAME] 7.5-325 mg 8:00 p.m. 5/4/19 [MEDICATION NAME] 500 mg, levetiracetam 500 mg, [MEDICATION NAME] 400 mg, [MEDICATION NAME] 100 mg During an interview on 5/16/19 at 11:39 a.m. with LPN GG, she stated that she gave those medications on those dates but she just didn't sign them out like she should have. She stated she is very diligent about her care and services to the resident, but admits she is used to a computer system that flags those administrations times to be signed before you can move forward with medication administration. During an interview on 5/16/19 at 11:42 a.m. with the Regional Nurse, DD, she stated that as of next week she will be the Director of Nursing (DON) at this facility. She expects the nurses to sign out all medications at the time they are given and validate all MARs before they leave their shift. The Unit Managers and the DON should follow-up daily to ensure that this documentation is completed. Going forward this concern will be managed daily.",2020-09-01
2580,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2018-09-03,578,D,0,1,THIC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Physician order [REDACTED].#27) and labeled one resident (R#100) as DNR when Attempt Cardiopulmonary Resuscitation (CPR) was initiated on the POLST. The sample size was 33 residents. Findings include: 1. Record review for R # 27 revealed a POLST signed on [DATE] by spouse and on [DATE] by a Physician to allow natural death - do not attempt resuscitation. However, there was no concurring physician signature or any documentation found in the chart indicating R#27 spouse was the healthcare agent. Consent form for Hospice signed on [DATE]. Interview on [DATE] at 5:05 p.m. with Registered Nurse (RN) CC, who reported that R#27's wife was an authorized person to give consent for DNR per the POLST. After further review of the POLST TN CC acknowledged that hospice did not have any paperwork indicating that resident's spouse was the health care agent. RN CC further reported that hospice would revoke the DNR until a concurring physician could sign the POLST. RN CC further reported that she would notify resident's spouse of what is going on. Interview on [DATE] at 11:56 a.m. with the Director of Nursing (DON) who reported that she spoke with the hospice administrator about the need for a second physician signature on the POLST but there was no further follow up done to obtain the concurring Physician's signature. 2.Record review for R # 100, revealed an Order indicating full code status and a POLST signed on [DATE] by resident and [DATE] by Physician indicating attempt CPR. However, there was a DNR sticker on the front cover of the chart as well as a DNR sticker on the POLST form that was signed by R#100 and Physician. Interview on [DATE] at 10:06 a.m. with Licensed Practical Nurse (LPN) AA who reported that code status is determined by looking at the face sheet and the POLST form. Upon review of R # 100 face sheet LPN reported that resident was a DNR. Further review of the medical record revealed a DNR sticker on the POLST as well. LPN AA then reviewed what was indicated and acknowledged that attempt resuscitation was indicated. Interview on [DATE] at 10:08 a.m. with Admissions/Social Services who confirmed that she placed the sticker on the chart and confirmed that form indicated CPR and not DNR. Admissions/Social Services reported that an audit is done at least once a quarter to assure that the correct code status is indicated for residents. Interview on [DATE] at 10:28 a.m. with R# 100 who reported that if she is found not breathing and without a pulse she wants CPR to be initiated. Interview on [DATE] at 11:56 a.m. with the DON who reported that she has spoken with Admissions/Social Services about following up on POLST forms but she did not check behind on R#100. Done",2020-09-01
2581,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2018-09-03,584,D,0,1,THIC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, the facility failed to ensure that it was maintained in a safe, clean comfortable environment for two rooms on 100 hall (A hall) and one room on 200 Hall (B hall). These rooms contained missing paint on wall, loose baseboard, stained ceiling tiles, flickering lights, and a hole in the wall. Findings include: Observations: 1. On 9/1/18 at 1:07 p.m. in room B-205 there was missing paint from wall near the sink and loose baseboards and there were two large brown circular stains in the ceiling tiles near the window 2. On 9/1/18 at 2:30 p.m. in the shared bathroom for A-102 and A-104 on the wall there was a large hole in the wall near the ceiling with brown colored drips coming out of hole but no puddle on the floor. Environmental tour began 9/3/18 at 10:50 a.m. with the Maintenance Director and confirmed the following: 1. There is a hole in the wall in the shared bathroom between room A-102 and A-104. 2. In room A-108 there was a flickering bathroom light. 3. In room B-205 there were brown stains in the ceiling tiles near the window and there was a loose baseboard and missing paint on wall near the sink. Interview with the Maintenance Director during tour in which he reported that the drainage pipe runs behind the wall and he has been fixing and repairing a similar issue in other rooms. He reported that he had seen the wall with a dark spot about two weeks ago when it was first identified but the area had gotten worse now that there is a hole and leakage. He denied having knowledge of the flickering light in room A-108 but reported that he has bulbs to fix this issue. Lastly, he reported that he stained ceiling tiles in room B-205 may be from the drainage pipe outside as was the case in the other room. Interview on 9/3/18 at 1:06 p.m. with the Administrator who reported that General Maintenance issues have been discussed during quality assurance meetings since July. She explained that when deep cleaning is done by housekeeping that Maintenance also goes into the room and makes repairs to the room as well. The Administrator then provided documentation from (MONTH) of a Performance Improvement plan related to general maintenance related to repair of walls floors, cove base and pain, and ceiling tiles with this to be completed by 12/15/18. It was reported that the bathroom wall in the shared bathroom for rooms [ROOM NUMBERS] has been identified as an issue. However, she reported that she only has on Maintenance person and she is looking for a safe way to get him on the roof to address leaks.",2020-09-01
2582,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2018-09-03,655,D,0,1,THIC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to show evidence that a baseline care plan had been completed within 48 hours, and that the resident/family was provided with a written summary of that baseline care plan for two residents (#200, and #100) from a sample of 33 residents Findings include: Review of Policy titled, Rai/Care Planning Management last revised (MONTH) (YEAR) revealed the interim/baseline care plan is developed within 8 hours of admission and updated following completion of all assessments no later than 48 hours of admission. Within the first 8 hours, as the interim care plan is being developed, the plan of care is communicated to the caregivers, resident, and family. The baseline care plan will be the guide for completing the comprehensive care plan. Review of the clinical records revealed Resident (R) #200 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the baseline care plan for R#200 revealed it covered initial goals and orders. This baseline care plan documented that the resident had an admission date of [DATE]. However, there was no evidence to indicate when this plan was completed, or that a summary of the plan itself was shared with the resident or family. During an interview on 9/02/18 at 4:56 p.m. with Licensed Practical Nurse (LPN) BB, it was revealed she completes the baseline care plan for the residents within 48 hours, then she submits this plan to the director of nursing (DON) to be passed on to the MDS coordinator for building the comprehensive care plans. She did not review the baseline care plan with R#200 or his family. During an interview on 9/03/18 at 1:45 p.m. with the director of nursing (DON) it was revealed that the baseline care plans are usually completed within the first day after a resident is admitted . They are completed by LPN BB and she is expected to document the date the plan is completed, that she has reviewed the plan with the resident and/or family, and the date on which the review was done.",2020-09-01
2583,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2018-09-03,657,D,0,1,THIC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interviews the facility failed to revise the care plan to address the resident's actual weight loss for one resident (R) (R#17). The sample size was 33 residents. Findings include: Review of the R#17 monthly weights revealed she had a 18.6% weight loss in six months, 11.76% weight loss in three months and a 4.55% weight loss in 30 days. Record review revealed that R#17 was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. of hands, and [MEDICAL CONDITION]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] Section G Functional Status revealed that the resident was totally dependent with eating. Section K revealed that the resident was coded for Nutrition and had coughing/choking during meals and had a 5% unprescribed weight loss. Review of the care plan for Nutrition that stated R#17 was above her ideal body weight (105 +- 10%) (94-116lbs) and has a potential for alteration in nutrition and hydration. The date initiated and created was 7/20/2015, dates revised were 6/21/2017 and 9/15/2017. No new interventions to reflect recent weight loss. R#17 was on a pureed diet, protein powder one scoop three times a day (TID), 120 mililiters (ml) of HiCal supplement four times a day (QID), multivitamin daily, zinc 220 miligrams (mg) one tablet daily, and vitamin C 500mg two times a day (BID). Dietitian note dated 4/26/2018 revealed resident lost weight and she recommended adding HiCal 90ml every six hours. Dietitian note dated 5/24/2018 and 6/26/2018 revealed weight loss related to her [DIAGNOSES REDACTED].#17 was eating well. Note dated 8/24/2018 revealed resident lost weight, body mass index (BMI) almost out of normal range, and recommended to increase HiCal supplement be increased to 120ml QID. Review of the document titled Clinical Programs Manual Care Plan Development 5.4 original date 2/2016 revealed the comprehensive care plans will be reviewed and revised on a as needed basis and at least every 92 days and when a significant change in condition is noted, when outcomes were not achieved or when outcomes are completed. On 9/02/2018 at 11:45 a.m. R#17 was observed out of bed, being fed by her family and consumed 75% of lunch. Interview on 9/02/2018 at 2:33 p.m. with the MDS Coordinator revealed she will update resident care plans for weight loss when she is informed of a weight loss from the DON. She stated they are supposed to have a weekly PAR/RISK meeting and the care plans are updated then. She agreed the care plan was not updated with new interventions related to the residents weight loss. Interview on 9/03/2018 at 9:29 a.m. with the DON revealed that the resident's care plan should be kept up to date and new interventions written on care plans. She stated they have a daily PAR meeting and changes in a residents condition including weight losses are discussed in the meetings, the MDS Coordinator is also given a copy of the monthly weights. She also stated weight losses are discussed in the residents quarterly care plan meetings and during monthly Quality Assurance (QA) meetings. The DON stated the Dietitian comes in monthly. Her expectations are that the care plans need to be up dated acording to the poicy.",2020-09-01
2584,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2018-09-03,914,D,0,1,THIC11,"Based on observation and staff interview the facility failed to ensure that privacy curtains provided full visual privacy, which included a total of 4 of 8 rooms on 200 hall (B hall) affecting 1 of 3 halls. The facility census was 58 residents. Findings include: Observations: On 9/1/18 at 1:07 p.m. in room B-205 there short privacy curtains for Bed A and Bed B. On 9/1/18 at 1:21 p.m. in room B-208 there were short privacy curtains for Bed A and Bed B. On 9/1/18 at 2:59 p.m. in room B-204 there was a short privacy curtain for Bed B. On 9/1/18 at 3:13 p.m. in room B-207 there was a short privacy curtain for Bed [NAME] Environmental tour began on 9/3/18 at 10:50 a.m. with the Maintenance Director. Observation revealed resident privacy curtains with space/gap of 84 inches or less which did not ensure full visual privacy for residents including rooms B-204, B-205, B-207, and B-208. Interview on 9/3/18 at 11:29 a.m. with Maintenance who reported that he does not typically check privacy curtains and housekeeping is responsible for cleaning and hanging. Interview on 9/3/18 at 11:31 a.m. with Housekeeping Supervisor who revealed that she just assumed that all of the privacy curtains were the same size. She explained that privacy curtains are removed when laundered but her staff should pull privacy curtains to make sure they go all the way around when they are hung up. She further reported that the expectation is that a curtain will be replaced if it does not go all the way around. Housekeeping Supervisor denied having knowledge of short privacy curtains. Interview on 9/3/18 at 11:40 a.m. with Housekeeper (HSK) DD who revealed that privacy curtains are pulled and checked for staining but not necessarily to check for gaps. She further reported that if short privacy curtains are observed the supervisor will be notified. Interview on 9/3/18 at 2:20 p.m. with the Administrator who reported that the short privacy curtains that were up were temporary curtains and were only up while the others were being washed and the correct length privacy curtains are now up. She further reported that short privacy curtains have not been identified as a concern before this time and going forward she will begin an audit for privacy curtains.",2020-09-01
4795,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2016-06-09,155,D,0,1,JE9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to correctly apply the Advance Directive choice for one (1) resident (#77) from a sample of twenty-eight (28) residents. Findings include: Review of resident #77's medical record noted that the resident was admitted to the facility on [DATE] under Hospice services with [DIAGNOSES REDACTED]. Further review noted an Advanced Directive document that marked the resident to be a FULL CODE. Review of resident #77 's Care Plan, initiated on 4/8/2016 documented that the resident had requested a Do Not Resuscitate (DNR) status with goals established to honor the resident 's request for DNR status and maintain dignity. Interventions in the Care Plan included: notify the physician, the family and the clergy as necessary, maintain a copy of advance directives on the chart, to flag chart DNR status, and to provide comfort, support, and daily nutrition and hydration. In addition, a Hospice Physician Plan of Care dated 5/18/2016 through 8/15/2016 included hospice nursing visits weekly and monthly Spiritual Care through Hospice. Hospice Nurses notes indicate that resident is at peace with decisions. An interview with Social Service Director on 06/09/2016 at 9:25 a.m., he/she stated that Resident #77's medical record was found to be in error, and that the resident was a Full Code and not a DNR and that the Care Plan was not correct.",2019-06-01
4796,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2016-06-09,279,D,0,1,JE9L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and staff interview, the facility failed to care plan one (1) resident (#77)'s for Advance Directive status from a sample of twenty-eight (28) residents. Findings include: A review of resident #77's medical record noted that the resident was admitted to the facility on [DATE] under Hospice services. Further review noted an Advanced Directive document that marked the resident to be a FULL CODE. Review of resident #77 's Care Plan, initiated on 4/8/2016 documented that the resident had requested a Do Not Resuscitate (DNR) status. An interview on 06/09/2016 at 9:25 a.m., with Social Service Director staff he/she stated that Resident #77's medical record was found to be in error, and that the resident was a Full Code and not a DNR and that the Care Plan was not correct.",2019-06-01
4797,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2016-06-09,317,D,0,1,JE9L11,"Based on observation, record review and staff interview, it was determined that the facility failed to provide services to prevent a decline in range of motion (ROM) for one (1) resident (#25) from a sample of twenty eight (28) residents. Findings included: During an observation and interview with Licensed Practical Nurse (LPN) Treatment Nurse on 6/6/16 at 12:48 p.m., resident #25 was observed with both hands clinched shut with out any positioning devices in place. The ( LPN) Treatment Nurse was unable to extend the resident's fingers to full range of motion. The Treatment Nurse stated that currently there were not any positioning devices used for this resident. He/she was unable to provide information as to how long the limitation had been present. An observation on 6/7/16 at 12:16 p.m., resident #25 was observed with his/her right hand clinched shut with out any positioning device. On 6/8/16 at 8:40 a.m., the resident was observed sitting in the lobby with hand roll in left hand but no positioning device in the right hand. Review of the 11/26/13 admission Minimum Data Set (MDS) assessment and of the 3/21/16 quarterly MDS assessment, licensed nursing staff coded resident #25 with no functional limitation in range of motion of the bilateral upper extremities. Review of resident #25's (MONTH) (YEAR) Monthly Nursing Summary, the licensed nursing staff did not document any limitations in ROM. During an interview on 6/9/16 at 4:19 p.m., the Director of Nursing (DON) stated that he/she had recently noted that resident #25 had ROM limitations in both hands and approximately a week ago, noted the hands more contracted.",2019-06-01
4798,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2016-06-09,463,D,0,1,JE9L11,"Based on observations and staff interviews, the facility failed to ensure that the resident call system was functional for three (3) residents in two (2) rooms on two (2) of three (3) halls. The current facility census was fifty-seven (57) residents. Findings include: Observation on 6/6/2016 at 2:14 p.m., on 6/7/16 at 8:16 a.m. and on 6/9/16 at 10:00 a.m., the call lights for residents in room A105 A and B beds when tested did not illuminate over the room door and did not alarm at the nurses' station. The two residents in room A105 were capable of using the call lights. Interview on 6/6/2016 at 10:40 a.m., with resident (CC) in room 105, he/she stated that the call light seem to work intermittently. During a further interview on 06/09/2016 at 10:00 a.m., resident CC stated that maintenance staff had checked the call lights on 6/7/2016 and the call lights were now working. A test of the call lights for both beds revealed the call lights are still not functional. Observation on 6/6/2016 at 11:15 a.m. of room C307, beds A and B. Bed A is currently vacant, but the call light for Bed A is on Bed B. The call light for Bed A did not illuminate over the room door or alarm at the nurses station. Interview and observation on 06/09/2016 at 10:25 a.m., the Maintenance Director stated the call lights in rooms A105 beds A and B and Room C307 bed A are not in working order and that the electronic panel in the rooms need to be replaced. Further interview the Maintenance Director stated he/she checks all call lights in the facility monthly. The Maintenance Director additionally stated that staff had not submitted any work tickets of any call lights that needed repair. Interview on 06/09/2016 at 10:31 a.m., the Administrator stated that monthly call light checks are done by the Maintenance Director and a copy of the Check Sheet was provided. Administrator further stated that all employees are responsible to monitor call lights and if they are not working to contact Maintenance or complete and submit a work ticket.",2019-06-01
5194,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2015-12-11,162,D,1,0,GII211,"> Based on record review, resident and staff interviews, it was determined that the facility failed to ensure that one (1) resident (A) of three sampled residents was not charged for additional helpings of food. Findings include: Review of the facility's Scope of Services for Medicare Residents revealed that meals and snacks were charges covered by Medicare. During an interview with resident A on 12/11/15 at 12:35 p.m., he stated he had to buy his own french fries because the staff would not give him more than one serving. He stated he gave the dietary manager money to buy him some french fries so staff could cook him more than one serving because he was told that he was eating too many french fries. During an interview with staff BB on 12/11/15 at 1:00 p.m., she stated that she was instructed by the Administrator not to give the resident additional french fries if he requested them because he ate too many helpings of them. She stated the resident gave her money on 11/21/15 to purchase him three bags of fries to keep on hand when he wanted additional helpings. She stated the first serving of fries was prepared from the facility's stock but if he wanted additional helpings then they must be cooked from the supply he bought. She further stated she had purchased three additional bags this week with the residents money. During an interview with staff CC on 12/11/15 at 1:15 p.m., she stated that she had received instructions from the Dietary Manager who was instructed by the Administrator to not give additional helpings of french fries. She stated that the additional helpings must come from the resident's fries that he purchased. During an interview with staff DD on 12/11/15 at 2:15 p.m., she stated that she was instructed that if the resident wanted additional servings of fries then they had to be cooked from his purchased supply of fries.",2018-12-01
5195,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2015-12-11,242,D,1,0,GII211,"> Based on resident and staff interviews, it was determined that the facility failed to honor one (1) resident's (A) request for additional servings of french fries from a sample of three residents. Findings include: During an interview with resident A on 12/11/15 at 12:35 p.m., he stated that staff would not serve him additional servings of french fries because he was eating too many french fries. He stated he gave the dietary manager money to buy him some french fries so staff could cook him more than one serving because he was told that he was eating too many french fries. During an interview with staff BB on 12/11/15 at 1:00 p.m., she stated that she was instructed by the Administrator not to give the resident additional french fries if he requested them because he ate too many helpings of them. She stated the resident gave her money on 11/21/15 to purchase him three bags of fries to keep on hand when he wanted additional helpings. During an interview with staff CC on 12/11/15 at 1:15 p.m., she stated that she had received instructions from the Dietary Manager who was instructed by the Administrator not to give additional helpings of french fries. During an interview with staff DD on 12/11/15 at 2:15 p.m., she stated that she was instructed that if the resident wanted additional servings of fries then they had to be cooked from his purchased supply of fries.",2018-12-01
6412,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2014-06-25,441,E,0,1,OWMB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 6/23/14 at 7:44 a.m. and 1:00 p.m., on 6/24/14 at 10:35 a.m. and on 6/25/14 at 7:45 a.m., there were two (2) bedpans and two (2) bath basins on the shelf above the toilet in the adjoining bathroom for rooms [ROOM NUMBERS] on the B Hall. Staff had failed to label the bedpans and basins with the residents' names and failed to appropriately store the bedpans and basins in bags to prevent cross contamination. One (1) of the bedpans had dried fecal material inside the bowl. Observation on 6/23/14 at 7:51 a.m., on 6/25/14 at 12:32 p.m. and on 6/25/14 at 7:50 a.m., there was one (1) bedpan and three (3) bath basins on the shelf above the toilet in the adjoining bathroom for rooms [ROOM NUMBERS] on the B Hall. Staff had failed to appropriately store the bedpan and bath basins in bags to prevent cross contamination. An interview with the Licensed Practical Nurse (LPN) AA, the infection control nurse on 6/25/14 at 8:05 a.m. revealed that the residents' bath basins and bedpans were suppose to be washed completely after use, labeled with the resident's name, stored in a plastic bag and placed in the resident's bathroom on the shelf above the toilet. Observation and interview on 6/25/14 at 8:10 a.m. with LPN AA confirmed that staff failed to appropriately clean and store the residents' bedpans and bath basins in the adjoining bathrooms for rooms 203, 204, 205 and 206. Based on observations, staff interviews and handwashing policy review, facility failed to ensure that staff maintained proper handwashing between resident contact during dining observation to prevent possible cross contamination on two (2) of three (3) halls. Also, facility failed to ensure that personal care items were labeled and stored to prevent possible cross contamination on one (1) of three (3) halls. Findings include: 1.) During the dinner dining observation on the C-hall between 5:35 p.m.-6:00 p.m. on 6/22/14, revealed a Certified Nursing Assistant (CNA) took a tray into room C-4A, set up the dinner tray, then went into room C-2A, without washing her hands and touched the resident's linens, then touched the resident's hair. Continued observation revealed that this same CNA went to get the nurse for room C-2A, and then proceeded to go back into room C-2A, which at this time she washed her hands. This particular CNA went to room C-4B, set up resident's dinner tray after touching bed, linens, and overbed table, all without washing her hands, and then the CNA went onto room C-5A and set up this resident's dinner tray, all without washing her hands. Also, while she was in room C-5A, she raised the head of the bed and put the resident's glasses on her face, then went back to the tray cart out in the hallway and touched two (2) trays, still without washing her hands. Continued observation revealed that this CNA went onto room C-9B, raised the head of the bed, set up tray and then washed her hands. She then went onto room C-11B where she moved a plastic bag from the overbed table to place the resident's dinner tray, then she went back to the tray cart, and moved onto room C-12B moving around various items on the overbed table, such as the Kleenex box, and the remote control. She then set up the resident's dinner tray and washed hands, so that she could feed the resident. Interview with the Director of Nursing (DON) on 6/24/14 at 12:15 p.m., revealed that she expected staff to wash their hands between resident contact using soap and water, and before returning to the tray cart. Review of the Handwashing Policy and Procedure revealed that all personnel shall wash their hands to prevent the spread of infections and diseases to other residents, personnel, and visitors. Continued review revealed that appropriate handwashing must be performed under the following conditions before touching, preparing or serving food, and after having prolonged contact with a resident (i.e., bedbath, changing linen, etc.). Review of the Inservice Education Program Attendance Sheet dated 4/23/14 revealed that staff were inserviced on handwashing.",2018-01-01
7372,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2014-05-01,241,D,1,0,UX9R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, clinical record review, and Resident Grievance Report Form review, the facility failed to promote care in a manner that maintained an atmosphere of dignity and respect for one (1) resident (Z), of three (3) sampled residents, when responding to Resident Z's dietary request. Findings include: Clinical record review for Resident Z revealed a Quarterly Minimum Data Assessment (MDS) assessment with an Assessment Reference Date of 02/10/2014 which documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITIONS] Fibrillation, Hypertension and Arthritis. Section C - Cognitive Patterns of this MDS documented that Resident Z had a Brief Interview for Mental Status Summary Score of fourteen (14), indicating the resident was cognitively intact. Section G - Functional Status documented that Resident Z was independent with eating, and Section K - Swallowing/Nutritional Status indicated there were no dietary restrictions for Resident Z. During an interview with Resident Z conducted on 04/30/2014 at 4:15 p.m., the resident stated that recently on a Thursday, she had a banana that she took to the dining room and asked the Dietary Manager (DM) for a bowl of cereal and some milk. Resident Z stated that Dietary Manager brought the requested food items to her, but then commented to the resident that she was greedy. Resident Z stated she refused the food, took her banana and left the dining room. A Resident Grievance Report Form (RGRF) dated 04/17/14 filled out by the Social Service Director (SSD) for Resident Z documented, in the Nature of Grievance section, that the resident had asked for a bowl of cereal and the DM told her she was greedy. The Administrator's Findings section of this RGRF documented that a meeting was held with Resident Z and the DM. Notes in this section documented that the DM had asked the resident if she could wait until 10:00 a.m. for morning snack time because she had just had breakfast. Resident Z replied to the DM that this was her home and she could eat anytime she wanted. The DM got her cereal and coffee and gave it to her. Further review of the Administrator's Findings section revealed that the DM did make the remark, and that DM apologized to Resident Z. During an interview with the DM on 05/01/2014 at 1:15 p.m., the DM stated that Resident Z came to the kitchen with a banana, after having just completed breakfast, and asked for food items. The DM asked Resident Z if she was still hungry, and Resident Z replied that she was not hungry, however she had the banana and wanted to eat it. The DM then said well that is being greedy, you just had breakfast. Resident Z said you called me greedy. The DM replied that she did not call the resident greedy, she said that was greedy. The resident then went to the Social Service Director who questioned the DM who denied calling the resident greedy stating she said that was greedy. During an interview with the Social Service Director (SSD) on 05/01/2014 at 4:40 p.m., she stated that she was informed that Resident Z had alleged the DM called her greedy. The DM then stated that she had said that was greedy. The DM apologized to Resident Z and assured her that she could have anything she needed or wanted. During an interview with the Administrator on 05/01/2014 at 6:05 p.m, she acknowledged this incident involving Resident Z and the DM. The Administrator reported that the DM apologized to Resident Z. The Administrator further stated she had cautioned the DM about the way she came across to others.",2017-05-01
8023,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2012-09-13,241,D,0,1,KIIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to maintain an environment which enhanced the dignity of two residents (#40 and #46) by ensuring the privacy of confidential information about their status from a total sample of 25 residents. Findings include: There were signs posted by staff in two residents' rooms which were clearly visible to anyone entering their rooms. Those signs noted private information about the residents use of cloth diapers. One of the signs was signed by the Director of Nurses and dated 11/ 17/11. There was not any evidence of an attempt by staff to post those signs in a location to ensure the privacy of that information regarding those residents. 1. During the initial tour on 9/10/12 at 11:30 a.m. and on 9/11/2012 at 8:13 a.m., observations revealed that staff had posted instructions about the care of cloth diapers on the wall above the head of the resident #40's bed. Staff had developed a care plan to address the resident's self care deficit with an intervention for nursing staff to promptly clean him/her after each episode of incontinence. During an interview on 9/12/12 at 8:21 a.m., certified nursing assistant (CNA) JJ said that the CNAs changed resident #40's cloth diapers every two hours. She explained that if the resident had a bowel movement then, the diaper was rinsed in the hopper, placed in a clean plastic bag and taken to the laundry to be washed. The laundry returned the cleaned cloth diapers to Resident #40. In an interview on 9/12/12 at 1:00 p.m., the Social Service Director stated that the only signs that she put up in residents' rooms were the ones that noted Family will do Laundry. The Social Service Director denied having put up any signs about diapers. During an interview on 9/12/12 at 3 p.m., the Director of Nursing (DON) stated that she knew about the signs for the cloth diapers posted in Resident #40's room and they were there for a specific reason. The DON stated that she recognized that the signs needed to come down or placed where they would not be visible to visitors. 2. Resident #46 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was coded on the 10/9/11 annual Minimum Data Set (MDS) assessment as having short term and long term memory problems, impaired decision making skills, incontinent of bowel and bladder and as totally dependent on staff for toileting. A typed sign about the resident's cloth diapers was observed on 9/10/12 at 12:40 p.m., 9/11/12 at 1:20 p.m. and on 9/12/12 at 8:36 a.m., posted on the wall by the entrance door in the resident's room. The sign noted that the resident had 6 cloth diapers, make sure they are washed out if soiled and put in laundry to be washed and returned to room. The DON had signed and dated that on 11/17/11. The sign was visible to anyone who entered the resident's room.",2016-07-01
8024,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2012-09-13,280,B,0,1,KIIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to review and revise care plan interventions to accurately reflect the needs for two (#32 and #79) residents in a total sample of 25 residents. Findings include: 1. Resident #79 had [DIAGNOSES REDACTED]. Staff coded him/her on the 8/23/12 comprehensive Minimum Data Set (MDS) assessment as having short and long term memory problems, moderately impaired decision making skills, as needing total assistance with activities-of-daily living (ADLs) and as having had a fall prior to admission. There was a care plan dated 8/23/12 and reviewed 8/29/12. There was a documented problem of the resident's cognitive deficit, and some short/long term memory loss related to Dementia. However, the interventions for staff to allow the resident to make his/her own choices and to orient to the facility, other residents, and activities were not appropriate based on the resident's assessed cognitive deficits. There was a care plan problem to address the resident's self care deficit. There was an intervention for nursing staff to transfer the resident as needed, to the extent required, may use lift if warrants and require one or two assess depending on the resident and situation. That intervention was not individualized to address the specific methods to use when transferring the resident. There was a care plan problem to address the resident's potential for falls and injuries. The plan documented that the potential risk factors included his/her cognitive impairment. However, the interventions for staff to encourage the resident not to attempt to transfer without calling for assistance and to keep the call bell within reach were not appropriate based on the resident's assessed cognitive deficits. 2. Resident #32 had [DIAGNOSES REDACTED]. On the 7/23/12 quarterly MDS assessment, licensed staff coded him/her as rarely understood, rarely understands, having short and long term memory problems, and severely impaired cognitive skills. There was a care plan dated 1/23/12 and reviewed 7/23/12 and 8/24/12. There were care plan problems to address the resident's potential for falls and injury and self-care deficit. However, the interventions for staff to keep the call bell within reach and encourage the resident not to attempt to transfer without calling for assistance were not appropriate based on the assessed cognitive impairments.",2016-07-01
8025,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2012-09-13,282,D,0,1,KIIQ11,"Based on clinical record review, observation, and interviews with staff and a resident, it was determined that the facility failed to implement planned interventions to address the visual impairment of one resident (A) in a total sample of 25 residents. Findings include: Resident A was admitted in July of 2011. Licensed staff coded resident A as having impaired vision, and able to see large print but not regular print in newspapers and books on the July, 2011 Minimum Data Set (MDS) assessment and the June, 2012 MDS assessment. There was a care plan since at least 12/01/2011 to address the resident's risk for impaired visual function. The goal was for resident A to have stable visual function and be free from injury by next review. The interventions included for staff to encourage the family of resident A to bring his/her glasses so he/she would have them as needed, and to obtain an appointment with the ophthalmologist as/if warranted. That plan was reviewed by the facility staff on 03/06/12, 06/06/12, 06/24/12, 06/29/12, 07/15/12, and 08/12/12. The updates were to continue with the plan of care. However, there was no evidence that the resident's family had brought eyeglasses for the resident or that an appointment had been obtained for the resident to see an ophthalmologist. See F313 for additional information regarding resident A.",2016-07-01
8026,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2012-09-13,313,D,0,1,KIIQ11,"Based on clinical record review, observation, and staff and resident interview, it was determined that the facility failed to implement interventions to address the assessed visual impairment for one resident (A) in a total sample of 25 residents. Findings include: Resident A was admitted in July of 2011. Licensed staff coded resident A as having impaired vision, and able to see large print but not regular print in newspapers and books on the July, 2011 Minimum Data Set (MDS) asessment and the June, 2012 MDS assessment. There was a care plan since at least 12/01/2011 to address the resident's risk for impaired visual function. The goal was for resident A to have stable visual function and be free from injury by next review. The interventions included for staff to encourage the family of resident A to bring his/her glasses so he/she would have them as needed, and to obtain an appointment with the ophthalmologist as/if warranted. That plan was reviewed six times by the facility staff on 03/06/12, 06/06/12, 06/24/12, 06/29/12, 07/15/12, and 08/12/12. The updates were to continue with the plan of care (poc). In an interview on 9/12/2012 at 1:11 p.m., the MDS coordinator stated that the Social Service Director completed the vision section of the MDS assessments. The MDS coordinator stated that she wrote the care plan for vision for resident A. The MDS coordinator stated that the Social Service Director was responsible to set up an appointment for resident A to be seen by the eye doctor. However, there was no evidence that the resident's family had brought eyeglasses for the resident or that an appointment had been obtained for the resident to see an opthamologist. In an interview on 9/12/12 at 7:35 a.m., certified nursing assistant (CNA) GG stated that she had not seen resident A with any eyeglasses. CNA GG stated that the family of resident A family did not provide him/her with glasses to her knowledge. During an interview on 9/12/2012 at 11:40 a.m., resident A said that he/she used to have glasses. Resident A stated that his/her glasses were broken and at his/her home. Resident A stated that his/her family members would not help him/her get new glasses. The resident said that he/she needed eyeglasses to read. In an interview on 9/12/12 at 12:51 p.m., the Social Service Director stated that resident A had gone home for a visit and was supposed to bring his/her glasses back with him/her. After surveyor inquiry, the Social Service Director stated that she would make an appointment with the eye doctor immediately for resident A. The Social Service Director stated that the eye doctor visited the facility every other week but, resident A had not been seen and had not discussed a need for eyeglasses with her.",2016-07-01
8027,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2012-09-13,323,D,0,1,KIIQ11,"Based on observation and staff interview, it was determined that the facility failed to ensure that there was a secured grab bar on the wall next to the toilet in the connecting bathroom for three (3) of four (4) residents on one (C Hall) of three halls. Findings include: On 9/11/12 at 9:27 a.m., on 9/12/12 at 10:00 a.m. and on 9/13/12 at 9:40 a.m., there was not a secured grab bar on the wall next to the toilet in the connecting bath room for rooms C9 and C11. On 9/13/12 at 9:45 a.m., certified nursing assistant (CNA) AA stated that three of the four residents in rooms C9 and C11 were assisted by staff to the bathroom for toileting. On 9/13/12 at 10:00 a.m., the maintenance supervisor stated that he had refurbished the bathroom wall surrounding the toilet approximately three months ago and had failed to reinstall the grab bar.",2016-07-01
8028,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2012-09-13,514,D,0,1,KIIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and physician interview, it was determined that the facility failed to maintain a complete clinical record that reflected the urinary status for one resident (#1) from a sample of 25 residents. Findings include: Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was coded on the 8/7/12 annual Minimum Data Set (MDS) as being incontinent of bladder and bowel, as being totally dependent on staff for toileting and as not having had a UTI in the last 7 days. On 9/10/12 at 1:44 p.m., licensed nursing staff BB stated that the resident had an indwelling catheter due to urinary incontinence. BB stated that the resident had a Stage II pressure sore on his/her buttocks and that the indwelling catheter had been inserted to promote healing. On 9/10/12 at 3:44 p.m., resident #1 was lying in bed. The resident had an indwelling catheter that was draining clear yellow urine to the bedside bag. review of the resident's medical record revealed [REDACTED]. Review of the nurses' notes for 8/12-8/21/12 revealed that licensed nursing staff had documented that the resident had a soft, non-distended abdomen, was incontinent of bladder and bowel and was kept clean and dry by staff. Review of the Total Intake and Output Record for 8/1-8/21/12 revealed that the resident had voided 2-3 times per each 8 hour shift for those days. On 8/21/12, licensed nursing staff had documented in the nurses' notes that the resident had open areas on his/her right buttock and that a Foley catheter was inserted due to [MEDICAL CONDITION]. The [DIAGNOSES REDACTED]. However, there was no documentation in the resident's clinical record to support the [DIAGNOSES REDACTED]. On the Total Intake and Output Record for 8/24/12, licensed nursing staff had documented that the resident's indwelling catheter was leaking and had to be changed. On the Total Intake and Output Record for 8/25/12, licensed nursing staff had documented that the resident had hematuria (blood in the urine). According to the 8/25/12 nurses' notes, the resident had cloudy urine in his/her bedside catheter bag. On 8/26/12 and 8/27/12, licensed nursing staff documented that the resident had cloudy, yellow urine with sediment in his/her catheter bag. On 8/30/12, licensed nursing staff documented that the resident's urine was now amber in color and cloudy. On 9/2/12 at 2:00 a.m., licensed nursing staff documented that the resident's urine was dark amber and foul smelling. On 9/3/12 at 10:00 a.m., licensed nursing staff documented that the resident's urine was dark amber with sediment. On 9/3/12 at 7:40 p.m., licensed nursing staff documented that the resident had dark amber urine with sediment, was diaphoretic and had a temperature of 103 degrees Fahrenheit (F). The resident's physician was notified at that time and the resident was admitted to the hospital with [REDACTED]. Review of the resident's clinical record revealed that there was no indication that licensed nursing staff had notified the physician about the change in the color, clarity and odor of the resident's urine from 8/25/12 until 10 days later, on 9/3/12 when the resident was sent to the hospital for an UTI [MEDICAL CONDITION]. On 9/13/12 at 8:40 a.m., the Director of Nursing stated that an indwelling catheter was provided for the resident because, the resident had decreased urine output. She stated that when the catheter was inserted, the resident immediately had approximately 400 cubic centimeters (ccs) of output. She stated that the facility had not obtained any formal studies/tests for the resident to determine how much urine the resident was retaining. On 9/13/12 at 9:45 a.m., during a phone converstion, the resident's attending physician stated that he had been notified by nursing staff about the resident's decreased urine output and had ordered nursing staff to insert the indwelling catheter. The physician also stated that nursing staff had contacted him about the resident's abnormal urine prior to his /her admission to the hospital on [DATE] for an UTI [MEDICAL CONDITION]. He stated that the resident had recurring UTIs that usually cleared up in a day or so and he wanted to wait to see if that UTI cleared as well. Although the resident's physician stated that the resident had [MEDICAL CONDITION] that warranted the use of an indwelling catheter and that nursing staff had notified him about the resident's abnormal urine prior to his/her admission to the hospital on [DATE] for UTI [MEDICAL CONDITION], there was no documentation in the resident's clinical record about his/her [MEDICAL CONDITION] and need for an indwelling catheter or that nursing staff had notified the physician about the resident's abnormal urine from 8/25/12 to 9/3/12. The facility had failed to maintain a complete clinical record that included documentation that accurately reflected the resident's urinary status and noitifications of the physician.",2016-07-01
9905,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2011-02-09,314,D,0,1,MP2Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to follow a physician's order to promote the healing of a pressure sore for one resident (#5) from a sample of five residents with pressure sores from a total sample of 15 residents. Findings include: Resident #5 had [DIAGNOSES REDACTED]. The podiatrist's 2/3/11 progress notes documented that the resident's stage II pressure sore on his/her left heel had improved in both appearance and size. The podiatrist wrote a physician's order for nursing staff to place 2 or 3 pillows underneath the resident's left calf to offload the pressure on his/her left heel. However, during observations on 2/7/11 at 5:42 p.m., on 2/8/11 at 7:15 a.m., 10:10 a.m., 1:45 p.m., 3:03 p.m., 5:00 p.m. and 5:52 p.m., nursing staff had not put pillows under the resident's left calf.",2015-04-01
9906,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2011-02-09,328,D,0,1,MP2Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, it was determined that the facility failed to properly store nebulizer equipment for one unsampled resident (room [ROOM NUMBER]B) and failed to date the oxygen tubing and humidifier bottle for two unsampled residents (rooms 103A and 303A) from a census of 12 residents with respiratory therapy orders from a total sample of 15 residents. Findings include: According to the Johns Hopkins Hospital's Clinical Practice Manual for Respiratory Equipment, respiratory equipment was an important source of transmitting microorganisms causing respiratory diseases. The guideline for heated and cold nebulizers was for the entire set-up to be changed every 48 hours. The guideline related to the use of oxygen noted that replacing the delivery system was to be done every 7 days. The guideline for cleaning equipment documented that all equipment should have been covered when not in use. However, staff failed to properly store respiratory equipment and failed to date respiratory equipment for three unsampled residents. 1. a. During the initial tour on 2/7/11 at 11:00 a.m., the nebulizer mask in room [ROOM NUMBER]B was not dated. It was uncovered and stored on top of the nebulizer machine. b. The oxygen concentrator tubing and humidifier bottle was not dated in room [ROOM NUMBER]A. 2. During the initial tour on 2/7/11 at 11:20 a.m., the oxygen concentrator humidifier bottle and tubing in room [ROOM NUMBER]A were not dated. During the initial tour on 2/7/11 at 11:00 a.m., the licensed nursing staff described the residents in rooms 108B, 103A, and 303A as using respiratory therapy equipment.",2015-04-01
9907,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2011-02-09,514,D,0,1,MP2Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, and staff interview, it was determined that the facility failed to maintain accurate physician's orders to discontinue pleasure feedings for one resident (#3) with a gastrostomy tube from a sample of four residents with gastrostomy tubes from a total sample of 15 residents. Findings include: Resident #3 had a gastrostomy tube in place with a physician's order since at least 10/1/10 for staff to offer pleasure feedings at meal times. However, during observations on 2/7/11 at 5:55 p.m., on 2/8/11 at 7:30 a.m., 12:30 p.m. and 5:28 p.m. and on 2/9/11 at 7:40 p.m. staff did not offer him/her a pleasure feeding. During an interview on 2/9/11 at 10:50 a.m., the dietary manager stated that the resident was not being offered a pleasure feeding since his/her last return from the hospital in January 2011 because of his/her inability to tolerate the feeding. He/she stated that the Director of Nursing was supposed to get the order discontinued. During an interview on 2/9/11 at 11:05 a.m., the Director of Nursing stated that, following a discussion with the resident's attending physician, there was an order for [REDACTED].",2015-04-01
9908,ALTAMAHA HEALTHCARE CENTER,115577,1311 WEST CHERRY STREET,JESUP,GA,31545,2011-02-09,333,D,0,1,MP2Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to properly deliver medication that required controlled titration to maintain therapeutic levels for one resident (#7) of the 15 residents in the selected sample. Findings include: According to the ""Drug Information Handbook for Nursing, 8th Edition"", [MEDICATION NAME] liquid suspension was supposed to be shaken well before using. However, nursing staff administered [MEDICATION NAME] liquid without shaking it before use for resident #7. On 2/8/11, at approximately 3:40 p.m., licensed nurse ""RR"" was observed to prepare to deliver 4 milligrams of [MEDICATION NAME] liquid (a [MEDICAL CONDITION] medication) to resident #7 who had a [DIAGNOSES REDACTED]. However, ""RR"" was observed to measure the amount needed without shaking the bottle. The laboratory test to measure the level of [MEDICATION NAME] in the resident's blood was within normal limits on 1/19/11.",2015-04-01
8686,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,156,C,0,1,HP8Y11,"Based on observation and staff interview, the facility failed to display required information effecting all residents and/or responsible parties within the facility. Findings include: Observation during the three days of the survey, 8/22/11-8/25/11 revealed the state required abuse poster was not displayed. Interview on 8/25/11 at 10:00 a.m. with the nursing home Administrator confirmed that the State Abuse Hotline poster was not displayed.",2015-11-01
8687,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,253,E,0,1,HP8Y11,"Based on observation and staff interview the facility failed to provide housekeeping services for cleaning resident use areas/equipment, specifically wheelchairs and floor mats and dining tables, on three (3) of three (3) units and maintenance services for two (2) common baths, one on Unit III and one on Unit I affecting the residents in 17 rooms including sampled residents, #58, #80 and #98. Findings include: On 8/25/2011 at 9:10 a.m. on Unit III the following was observed: -In room E-9 missing tile from the window sill; bed floor mat next to the resident's bed was soiled with food spills and a dried black matter -A green vinyl chair in the telephone room of Unit III was observed with black dried spills on the seat and down the left side -Five (5) of ten (10) tables in the Unit III day/dining area had food spills from previous meals. -In room F2-3 there were two floor mats used as safety measures for falls, that were soiled with dried spills and black dirt -Room F7-1 had a dirty floor mat next to the bed. -In room E-3, two (2) floor mats, one (1) against the wall under the window and one (1) next to the bed for the resident in bed 3. Both mats were observed soiled with dried food spills and black dirt. Interview with Licensed Practical Nurse (LPN) II and Certified Nursing Assistant (CNA) JJon 8/25/2011 at 9:20 a.m. revealed that housekeeping was reasonable for cleaning the floor mats. -On Station II soiled bed floor mats were observed in rooms D5-1, D7-1, D7-2, D9-1, D9-2, C2-2, C3-2,C5-1, C6-1, C7-1, C7-2, and C11-1. Interview with CNA KKrevealed that the floor tech (in housekeeping) was responsible for cleaning the bed floor mats. -On Unit I in room A2-2 the bed floor mats were observed dirty and the mat on the left side of the bed had a tear in the vinyl with exposed foam padding . -Observations of resident #58 on 8/23/2011 at 8:45 a.m. and again on 8/25/11 at 10:05 a.m. revealed the resident sitting in their wheelchair. The left arm of the chair had torn jagged vinyl. The right arm of the wheelchair was also torn. Interview with LPN BB on 8/25/11 at 10:10 a.m. revealed the vinyl on the arms of the wheelchair needed repair. -Observation of the room of resident #98 on 8/22/2011 at 2:30 p.m. revealed that the drywall behind the resident's bed next to the baseboard was crushed inward. The wall appeared to have been patched but there was no paint and the patched dry wall had been crushed inward again. During Initial Tour, on 8/22/11 at 11:33, the following observations were made: -The bathroom between rooms 5A and 7A had missing enamel below the faucet, pitting on the faucet, and peeling paint on the sink wall. -The bathroom between rooms 10A and 12A had a pitted faucet, rust in the sink bowl, and the sink caulk was loose. Observation on 8/25/11 at 8:43 a.m. on Unit 3 revealed: -In the Common Shower area, the 4 foot fluorescent light fixture had no light bulbs. Lighting for this area was from the fixture over the sink. The drain cover was displaced, exposing a 2 inch hole in the center of the shower area. The light fixture over the toilet did not function. The trash can was cracked from rim to floor on two sides. -Observation on 8/25/11 at 9:05 a.m. of the Unit 1 Shower Room revealed the shower stall to have dark brown/black mold in the grout lines along the two back corners and on the three walls. Interview on 8/25/11 at 10:10 a.m. with the acting maintenance and housekeeping supervisor confirmed that the Unit 3 Shower Room needed repair work and the Unit 1 Shower stall walls needed to be cleaned. During initial tour observation on 8/22/11 at 11:20 a.m. of Station 3, the locked unit, the following was observed: -The door to the smoking area had a large gap at the bottom of the door which allowed smoke to come back into the resident common lobby area and one short hall. -On the E Hall, outside room 10, ceiling tiles are stained and one tile was bulging with several blacken areas on the tile. -Observation of resident # 80 on 8/22/11 at 3:00 p.m. in common lobby area revealed the resident sitting in a wheelchair. The wheelchair seat is covered with dried spilled material and debris and the outer areas of wheelchair had several dried food spills. Observation of the Station 3 dining area on 8/22/2011 at 12:30 p.m. revealed: -Five (5) tables on the right side of the dining room had table tops soiled with dried juice and food debris/ particles. Two (2) of five (5) tables on the left side of the dining room were also observed to have dried juice and/or dried coffee spots on the tops of the tables. During the lunch meal, at the time of this observation, food trays were observed served to residents without cleaning these tables.",2015-11-01
8688,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,278,D,0,1,HP8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to accurately assess two (2) residents (#80, #93) on a sample of thirty-five (35) residents. Specific issues regarding the Minimum Data Set 3.0 assessment included a significant weight loss (#80) and the use of a [MEDICAL CONDITION] medication (#90). Findings include: 1. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] assessed resident #80 as having had no weight loss in the last month. Review of the Monthly Record of Vital Signs and Weights documented that the resident's weight on 7/07/11 was 108 pounds and on 8/04/11 the resident weighed 100 pounds resulting in a weight loss of 8 pounds or 7.4% in one month. This weight loss was not reflected on the current MDS assessment. Interview with the MDS coordinator on 8/24/11 at 1:52 p.m. revealed the resident had a significant weight loss that was not assessed on the current MDS dated [DATE]. 2. Review of the current August 2011 physician order [REDACTED].#93 revealed the resident was to receive [MEDICATION NAME] 1 milligram by mouth or by injection every four (4) hours as needed for agitation. Review of the current MDS assessment dated [DATE] did not assess the resident as having had any psychoactive medications during that 7 day assessment period. Review of the July 2011 Medication Administration Record [REDACTED]. which would indicated the resident had the medication 5 times prior to the 7 days before the MDS assessment date of 7/27/11. Interview with the MDS Coordinator on 8/24/11 at 11:44 a.m. revealed she was not aware the resident had received the [MEDICATION NAME] during the 7 day assessment period prior to 7/27/11, therefore the resident was not assessed on the MDS as being on this medication. The resident should have been assessed for the [MEDICAL CONDITION] medication and a care plan should have been done.",2015-11-01
8689,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,279,D,0,1,HP8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that one (1) residents (#80) had a plan of care to address use of psychoactive medications. Findings include: Review of the Physician order [REDACTED].#80 was to receive [MEDICATION NAME] one (1) milligram every eight (8) hours as needed for agitation. The current Minimal Data Set Assessment ((MDS) dated [DATE] assessed the resident as being on antianxiety medications. Resident #80 had a physician order [REDACTED]. In addition to the routine dosage the resident was ordered (same date) to receive [MEDICATION NAME] 1 mg intramuscularly (IM) every 4 hours as needed for agitation. The current Physician Order, August 2011 was for [MEDICATION NAME] one (1) mg every eight (8) hours as needed for agitation and did not include a routine dosage for this medication. Review of the Medication Administration Record [REDACTED]. Further record review revealed no care plan had been developed to address the ongoing use of psychoactive medications. Interview with the MDS/Care Plan Coordinator on 8/24/11 at 11:36 a.m. revealed a care plan for the use of the psychoactive medication had not been developed for this resident.",2015-11-01
8690,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,309,G,0,1,HP8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interview, the facility failed to provide pain management, specifically regarding a lack of pain medication prior to pressure sore treatment for one (1) resident (D) of thirty-five (35) sampled residents. Findings include: Resident D had multiple [DIAGNOSES REDACTED]. Resident interview on 8/24/11 at 9:16 a.m. revealed that he/she had foot pain, due to the wounds on resident's heels, which was not relieved by pain medications and stated the staff had been made aware of the pain. Observation on 8/24/11 at 2:00 p.m. revealed the resident was wearing multi-purpose boots bilaterally that allowed for walking while providing protection to the resident's heels. The resident was observed at that time to be ambulating with assistance of a physical therapist. Interview with resident D on 8/25/11 at 8:30 a.m. revealed that both feet were hurting and that walking with physical therapy was painful. Observation and interview with Licensed Practical Nurse (LPN) GG the Treatment Nurse, on 8/25/11 at 8:45 a.m., revealed the resident's wound care treatments are done Monday, Wednesday and Friday's and had last been done on 8/23/11(Tuesday) without explanation as to why. She offered information that the resident has bilateral Stage II pressure ulcers that had began as blisters. She included comment that the resident's right heel was covered by eschar and that the eschar had come off over the weekend, but described the wound as a Stage II. Observation of pressure ulcer treatment to both heels at 8:50 a.m. revealed the resident yelled out when both heels were cleaned with a normal saline soaked gauze and continued to yell out while the left heel dressing was applied. When the resident complained of the pain, LPN GG, said I am not even touching the wound. She continued to finish the wound care without asking the resident if she could continue or if the resident wanted pain medication. After the resident's multi-purpose boots where re-applied the resident continued to yell that the wounds hurt. LPN GG left the resident's room. At this time LPN HH entered the resident's room to administer routinely scheduled medications and the resident continued to yell that he/she was in pain. The resident described their pain as a 10 on a scale of 1-10 and was given one (1) [MEDICATION NAME] 5/500 milligram (mg). Record review revealed the resident had physician orders [REDACTED]. Record review of the Medication Administration Record [REDACTED]. An interview with LPN GG on 8/24/11 at 9:15 a.m. revealed she does not routinely pre-medicate residents prior to pressure ulcer treatments. Interview with LPN HH revealed she had assisted LPN GG with resident D's wound care on 8/23/11 and the resident did complain of pain during the treatment. Review of the resident care plan revealed a pain management care plan due to surgical wound and pressure ulcers with approaches to give pain medication as ordered and to notify the physician of poor response to the pain medications. An interview on 8/24/11 at 4:00 p.m. with the Assistant Director of Nursing (ADON) and nurse consultant DD revealed that if it is known that a resident normally has pain during wound care, then the resident should be pre-medicated prior to treatment. An interview on 8/24/11 at 5:00 p.m. with the Administrator, ADON and Nurse Consultant DD revealed that LPN GG had taken over treatments about a month ago and has had minimal training.",2015-11-01
8691,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,314,D,0,1,HP8Y11,"Based upon observation, record review and staff interviews the facility failed to properly assess staging of one (1) pressure ulcers for one (1) resident DD. Findings include: Record review and staff interview on 8/22/11 at 4:05 p.m. with Licensed Practical Nurses (LPN) LL revealed the resident had two (2) Stage II pressure ulcers, one (1) on each heel. Observation of wound care on 8/24/11 at 8:45 a.m. LPN GG the Treatment nurse revealed the had bilateral Stage II pressure ulcers on the heels. The eschar covered ulcers were now open and she described the ulcers as Stage 11. Observation of the treatment to the left heel at 8:50 a.m. with LPN GG revealed an open area, covered by white slough, surrounded by thick white wound edges. The remaining heel area was discolored and boggy. LPN GG described the wound at that time as a Stage II ulcer. When asked why the left heel wound completely covered with slough would be assessed as a Stage II rather than unstageable she revealed that she used continued to describe the ulcer as the prior Treatment Nurse. She could not remember if the wound had changed from 8/23/11. Interview with the Administrator and Registered Nurse Consultant DD on 8/25/11 at 9:45 a.m. revealed the resident's wounds had been reassessed the night of 8/24/11 and determined the wound was unstageable. The wound was described as measuring 4.8 X 5.4 with the wound bed a gray color with slough and the surrounding tissue being white/gray pallor. They agreed this wound is not a Stage II.",2015-11-01
8692,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,323,D,0,1,HP8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure that interventions was put into place to prevent falls for one (1) resident (#93) on a sample of thirty five (35) residents. Findings include: Review of most recent Minimum Data Set (MDS) assessment dated [DATE] assessed resident # 93 as having both long term and short term memory problems and being independent with ambulation and transfers. The resident was also assessed as having had one (1) fall with injury since the last MDS assessment period. Review of the Fall Risk Assessments done on 9/01/10, 12/02/10, 02/26/10, 5/15/11, 7/15/11, 7/23/11, 8/04/11 and 8/17/11 assessed the resident as being at high risk for falls Review of Nurses Notes dated 7/15/11 at 6:30 a.m. documented the resident fell forward and hit his head and sustained a 1 and 1/2 inch laceration over the left eye. The resident was seen in the ER and received sutures to left eye area. Review of a Nurses Note dated 7/23/11 at 11:45 p.m. documented the resident was observed lying on floor next to their bed where he/she had sustained an abrasion to the left knee. Further review of Nurses Notes dated 8/04/11 at 10:15 a.m. documented the resident was sitting in the solarium and slid out of the wheelchair to the floor. No injuries with this fall. Nurses Notes dated 8/17/11 at 12:30 p.m. documented the resident was again found sitting on the floor of the lobby with no apparent injuries. Review of the care plan dated 7/15/11 revealed that after the falls on 7/15/11, 7/22/11 and 8/04/11 the interventions was to refer the resident to therapy services for evaluation and treatment. Review of the Rehabilitation Referral/Screening form dated 7/15/11 documented the resident continued to decline in cognition and was not a rehabilitation candidate at that time. It was not until after the fall on 8/17/11 that a Physical Therapy screen was actual done and physician orders [REDACTED]. Interview with the Director of Therapy Services on 8/25/11 at 8:55 a.m. revealed he felt that the falls on 7/15/11 and 7/23/11 were isolated and the resident did not need therapy. Interview with the Administrator and the Director of Nursing on 8/25/11 at 9:15 a.m. revealed they were unaware of any other interventions put into place to address the resident's falls.",2015-11-01
8693,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,329,D,0,1,HP8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that three (3) medications ordered had indications for use and that one antipsychotic medication was monitored with gradual dose reductions for one(1) resident, resident # 98 on a sample of thirty-five (35) residents. Findings include: Review of the Minimum Data Set Assessment (MDS) assessment dated [DATE] and the Significant Change Minimum (MDS) data set [DATE] revealed that resident # 98 was assessed for receiving an antipsychotic and an antidepressant medication. Review of the current physician orders [REDACTED]. Review of the initial physician orders [REDACTED]. The current monthly physician orders [REDACTED]. A staff member had written in dementia for the [MEDICATION NAME] [DIAGNOSES REDACTED]. Interview with Licensed Practical Nurse BBon 8/24/2011 at 10:50 a.m. revealed she was aware the resident was on the [MEDICATION NAME] and she thought that they had recently changed the dosage. However, review of the Medication Administration Record [REDACTED] Interview with the Administrator on 8/24/2011 at 11:30 p.m. revealed that the pharmacist needed to review this resident's medications since it had not been done. There was no documentation of any attempted dose reduction. Further review of the current physician orders [REDACTED]. The resident was ordered on [DATE] and was receiving Calcium Carb 1,250 milligrams in 5 milliliters twice a day and Trazadone 50 mg at bedtime. There were no [DIAGNOSES REDACTED]. Interview with the Assistant Director of Nurses (ADON) on 8/24/2011 at 9:05 a.m. revealed that there should be a [DIAGNOSES REDACTED].",2015-11-01
8694,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,469,C,0,1,HP8Y11,"Based on observations and staff interview the facility failed to maintain as effective pest control program so that the facility is free of pest. Pest were observed in three (3) areas, B Hall, Units 1 and 3. Findings include: 1. During the initial tour conducted on 8/22/2011 at 11:30 a.m. on the B Hall, a live roach was observed floating upside down in the toilet in the bathroom between Rooms 10 and 12. 2. Observation on 8/25/11 at 8:50 a.m. on Unit 3 in the common shower room revealed 4 tiny cockroach-like insects crawling in the sink and on the tiled surfaces of the shower stall. 3. Observation on 8/25/11 at 9:05 a.m. of the Unit 1 shower room with Certified Nursing Assistant AArevealed a small cockroach-like insect crawling on the floor near a water drain. 4. Observation of Station 3, locked unit, on 8/23/11 at 8:25 a.m. revealed one (1) live roach in nurses station, crawling along resident charts. Breakfast trays were observed near-by waiting to be served.",2015-11-01
8695,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2011-08-25,514,D,0,1,HP8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, the facility failed to maintain an accurate record related to contractures for one (1) resident (#78) from a sample of thirty five (35) residents. Findings include: Observations of resident #78 on 8/24/11 at 8:45 a.m., 11:10 a.m. and 12:20 p.m. revealed the resident in bed, legs extended with fixed contractures and foot drop. Review of a Physical Therapy (PT) evaluation and plan of treatment dated 4/20/10 revealed a [DIAGNOSES REDACTED]. Continued review revealed that the reason for the referral was contractures of bilateral lower extremities, decreased range of motion (ROM), especially of bilateral ankles. Physical therapy discharge summary dated 6/17/10 revealed discharge summary revealing the resident with essentially fixed contractures. Review of the PT discharge summary dated 6/17/10 revealed that the resident had achieved the highest practical level, had made minimal ROM gains especially at bilateral hip/knees but ankles have essentially fixed contractures. Review of the Monthly Summary forms dated 4/12/11, 5/17/11, 6/13/11 and 8/12/11 revealed no evidence that the resident was assessed as having contractures.",2015-11-01
10345,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2010-02-01,456,D,1,0,KVUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain patient care equipment in safe operating condition, related to one (1) of two (2) mechanical lifts utilized in the facility. Findings include: Record review for Resident #5 revealed a Minimum Data Set assessment of 02/02/2010 which indicated that the resident had a history of [REDACTED]. During an observation of a transfer of Resident #5 on 02/01/2010 at 11:00 a.m., two (2) certified nursing assistants (CNAs) were transferring the resident from the wheelchair to the bed via a mechanical lift. The resident was lifted up and over the bed via the lift, but then the lift malfunctioned. The lift would not respond to lower the resident onto the bed, and the resident was suspended in the lift sling above the bed. The CNAs alerted supervisors and maintenance staff, and two (2) replacement batteries were installed, but the lift continued to fail to respond, still leaving the resident suspended over the bed. Eventually, two (2) maintenance staff members evenly caused the lift to lower the resident onto the bed. The resident remained suspended in the lift over the bed for approximately 15 minutes before finally being placed in the bed via the lift. During an interview on 02/01/2010 at the time of the observation referenced above, three (3) CNAs stated that the lift had not been working correctly for weeks, and that this had been reported.",2014-07-01
10346,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2010-02-01,309,D,1,0,KVUR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide a wound treatment, as ordered by the physician, to one (1) resident (#3) on the survey sample of six (6) residents. Findings include: Record review for Resident #3 revealed that the January 2010 Treatment Record documented that the resident had [DIAGNOSES REDACTED]. A 01/07/2010 Wound Healing Center Physician order [REDACTED]. However, the January 2010 Treatment Record referenced above documented that on the dates of 01/08/2010, 01/09/2010, 01/10/2010, 01/11/2010, 01/12/2010, 01/13/2010, 01/14/2010, 01/16/2010, 01/17/2010, 01/18/2010, 01/19/2010, 01/20/2010, 01/21/2010, 01/23/2010, 01/24/2010, 01/25/2010, and 01/26/2010, the treatment had been done only once per day, on the 3:00 p.m. - 11:00 p.m. shift. During an interview with Nurse ""AA"" conducted on 01/27/2010 at 1:30 p.m., this nurse stated that it appeared that when the Wound Clinic changed the foot treatment order on 01/07/2010 from a previously existing order, the new treatment order did not get changed on the Treatment Record, and further acknowledged that treatments had been done only once daily.",2014-07-01
10347,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2009-10-08,309,J,1,0,YP7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing, and timely drug therapy, as ordered related to the administration of the anticoagulant drugs [MEDICATION NAME] and Aspirin. This resulted in serious harm to Resident #3, who was subsequently hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Record review for Resident #3 revealed an 08/24/2009 Minimum Data Set assessment which documented that the resident was admitted to the facility on [DATE]. Admission physician's orders [REDACTED].) by mouth daily, [MEDICATION NAME] 75 mgs. by mouth daily, and aspirin 81 mgs. by mouth daily. The resident's September 2009 Medication Record documented that the resident received these drugs daily during the month of September, as ordered, and documented that the resident had [DIAGNOSES REDACTED]. A physician's admission order of 08/13/2009 specified that the laboratory tests Pro-[MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) be done on 08/17/2009, and then every two weeks thereafter. Therefore, in addition to the PT/INR laboratory test due on 08/17/2009, PT/INR tests were due on 08/31/2009 and 09/14/2009. The initial PT/INR results on 08/17/2009 indicated a PT of 19.10 (reference range, 10.0-13.0) and an INR of 2.3 (reference range, 2.0-3.0), with a hemoglobin of 12.1 (reference range 12.5-16.0). However, further record review revealed no evidence to indicate that the ordered PT/INRs were drawn on 08/31/2009 or on 09/14/2009. During an interview conducted on 10/07/2009 at 3:00 p.m., Laboratory Supervisor ""CC"" acknowledged that PT/INR laboratory tests had not been done on 08/31/2009 and 09/14/2009, as ordered. A Nurse's Note of 09/20/2009 at 9:30 a.m. documented that the resident told staff that he/she had fallen while out with his/her family on 09/19/2009. Then, a Nurse's Note of 09/24/2009 at 7:00 p.m. documented that bruising was observed to the resident's inner right thigh, bilateral underarms, left outer thigh, and left side. This Note further documented that when asked what had happened, the resident told staff members that he/she had fallen and hit a wall while going up steps at his/her family member's house, causing the bruising. This Note documented that the physician was notified of the bruises, and ordered that a PT/INR laboratory test be drawn. The Physician's Telephone Orders sheet of 09/24/2009, timed at 7:54 p.m., ordered a ""Stat"" PT/INR. However, record review revealed no evidence to indicate that this ""Stat"" PT/INR ordered on [DATE] was done. A Nurse's Note of 09/26/2009 at 9:45 a.m. referenced the 08/17/2009 admission PT/INR results, but further documented that follow-up laboratory results were unavailable at that time, and documented that the laboratory had been called. A Nurse's Note of 09/26/2009 at 10:10 a.m. documented that laboratory personnel had returned the facility's earlier call and had stated that the laboratory staff had been unable to obtain the PT/INR, further stating that staff would attempt again on Sunday (09/27/2009). During an interview with Laboratory Supervisor ""CC"" conducted on 10/07/2009 at 3:00 p.m., ""CC"" stated that a laboratory technician had been sent to the facility on [DATE] to draw the blood sample for the ordered PT/INR laboratory tests of that date, but was unable to obtain a blood specimen. ""CC"" stated that when the laboratory technician informed facility Nurse ""DD"" that he/she had a problem drawing blood to complete the PT/INR, the laboratory technician was told by Nurse ""DD"" to wait until time for the resident's routine laboratory tests, and that facility nursing staff would consult with the physician for further instructions and notify the laboratory if additional instructions were obtained. However, ""CC"" stated that the laboratory received no response back from the facility, so therefore, laboratory personnel returned and drew the blood on Monday, 09/28/2009, for the PT/INR tests originally ordered as a ""Stat"" order on 09/24/2009. This represented a four (4) day delay in obtaining the ""Stat"" laboratory tests. A Nurse's Note of 09/28/2009 at 3:15 p.m. documented that the laboratory called with the laboratory results, revealing a critical PT level of 67.5 and a critical INR of 23. Additionally, review of the Laboratory Report of 09/28/2009 revealed that the resident's hemoglobin (which had been in a normal range of 12.1 on the laboratory report of 08/17/2009) had dropped to 8.7 gm/dl by that time. The 09/28/2009, 3:15 p.m. Nurse's Note referenced above documented that the physician, who was in the facility at that time, was notified of the critical laboratory results, and a Nurse's Note of 09/28/2009 at 11:00 p.m. documented that [MEDICATION NAME] had been omitted due to the laboratory results. A 09/29/2009 Physician's Telephone Orders sheet, timed at 3:00 p.m., specified to hold the resident's [MEDICATION NAME] and to check the resident's PT/INR on 10/01/2009. Review of the September and October 2009 Medication Records revealed that the resident's [MEDICATION NAME] was held as ordered. A Laboratory Report of 10/01/2009 documented that on that date, the resident's laboratory results were elevated to a more critical level, revealing a PT of 90.8 and an INR of 39.7. A Nurse's Note of 10/01/2009 at 3:05 p.m. documented that the physician was called regarding the critically elevated PT and INR levels. A 10/02/2009 Nurse's Note documented new physician's orders [REDACTED]. oral dose of Vitamin K for two days, and to recheck the PT/INR levels on 10/05/2009. This Note documented that an order had been facsimilied to the pharmacy. However, further record review, to include review of the October 2009 Medication Record, revealed no evidence to indicate that the resident received a dose of Vitamin K. During an interview with the Administrator and the Director of Nursing (DON) conducted on 10/08/2009 at 10:00 a.m., these staff members acknowledged that a dose of Vitamin K had not been administered to the resident on 10/02/2009. These staff members stated that since the physician's orders [REDACTED]. Further record review revealed no evidence to indicate that the physician was notified of the unavailability of Vitamin K for immediate administration and of the delay in obtaining the drug, despite the resident's critically elevated PT/INR levels. A 10/02/2009, 10:00 p.m. Nurse's Note documented that Resident #3 was noted to be bleeding from the gums. This Note documented that the physician was notified and ordered the resident to be transferred to the hospital for a direct admission. A hospital laboratory report of 10/05/2009 documented that while in the hospital, the resident's hemoglobin remained low at 7.4 on 10/03/2009. A 10/05/2009 hospital Discharge Order/Instruction Summary documented that while in the hospital, the resident's principal [DIAGNOSES REDACTED]. Based on the above, the facility failed to perform multiple routine PT/INR laboratory tests per physician's orders [REDACTED]. The facility failed to ensure the immediate provision of a PT/INR laboratory test ordered to be done ""Stat"" upon noting the resident's significant bruising, thus resulting in a four (4) day delay in the completion of these tests. Additionally, the facility failed to ensure the timely administration of Vitamin K to the resident when the resident's PT/INR levels were found to be at critical levels. The resident subsequently developed bleeding gums, was hospitalized and diagnosed with [REDACTED].",2014-07-01
10348,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2009-10-08,502,J,1,0,YP7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing as ordered related to the administration of the anticoagulant drugs [MEDICATION NAME] and Aspirin. This resulted in serious harm to Resident #3, who was subsequently hospitalized , diagnosed with [REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Record review for Resident #3 revealed admission physician's orders [REDACTED].) by mouth daily, [MEDICATION NAME] 75 mgs. by mouth daily, and aspirin 81 mgs. by mouth daily. A physician's admission order of 08/13/2009 specified that the laboratory tests Pro-[MEDICATION NAME] Time (PT) and International Normalized Ratio (INR) be done on 08/17/2009, and then every two weeks thereafter. A laboratory Patient Requisition of 08/14/2009 also indicated that PT/INR tests were to be done starting on 08/17/2009, and then every two weeks. Further record review revealed that the initial PT/INR laboratory tests were done on 08/17/2009, however, there was no evidence to indicate that the PT/INRs were drawn on 08/31/2009 or on 09/14/2009, as ordered and requisitioned. During an interview conducted on 10/07/2009 at 3:00 p.m., Laboratory Supervisor ""CC"" acknowledged that PT/INR laboratory tests had not been done on 08/31/2009 and 09/14/2009, as ordered. A Nurse's Note of 09/24/2009 at 7:00 p.m. documented that bruising was observed to the resident's inner right thigh, bilateral underarms, left outer thigh, and left side, and that when the physician was notified of the bruises, the physician ordered PT/INR laboratory tests. The Physician's Telephone Orders sheet of 09/24/2009, timed at 7:54 p.m., ordered a ""Stat"" PT/INR. However, record review revealed no evidence to indicate that this ""Stat"" PT/INR ordered on [DATE] was done. During an interview with Laboratory Supervisor ""CC"" conducted on 10/07/2009 at 3:00 p.m., ""CC"" stated that a laboratory technician had been sent to the facility on [DATE] to obtain the ordered PT/INR, but when unable to draw a blood specimen, the laboratory technician had been told by Nurse ""DD"" to wait until time for the resident's routine laboratory tests, unless additional instructions were obtained from the physician. Therefore, laboratory personnel returned and drew the blood on Monday, 09/28/2009, for the PT/INR tests originally ordered as a ""Stat"" order on 09/24/2009. A Nurse's Note of 09/28/2009 at 3:15 p.m. documented that the laboratory called with the laboratory results, revealing a critical PT level of 67.5 and a critical INR of 23. A 10/05/2009 hospital Discharge Order/Instruction Summary documented that the resident had been hospitalized , and while in the hospital, the resident's principal [DIAGNOSES REDACTED]. A hospital Staff Notes sheet of 10/05/2009 documented that the resident had been given four (4) units of Fresh Frozen Plasma. Cross refer to F309 for more information regarding Resident #3.",2014-07-01
10349,AMARA HEALTH CARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2009-10-08,281,J,1,0,YP7611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received services in accordance with professional standards of practice. This resulted in serious harm to Resident #3, who was subsequently hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. It was therefore determined that an immediate and serious threat to resident health and safety existed on 09/28/2009 and continues. Findings include: Article 43-26-1, The Georgia Registered Professional Nurse Practice Act, Chapter Two - Standards of Nursing Practice, Part 2.2.2., Standards Related to Registered Nurse Responsibility for Nursing Practice Implementation, specifies that the registered nurse will implement treatments and therapy, including medication administration. Based on medical record review, hospital document review, facility document review, facility staff interview, and laboratory staff interview, the facility failed to ensure that one (1) resident (#3), on the survey sample of twelve (12) residents, received laboratory testing, and timely drug therapy, as ordered. This resident received the anticoagulant drugs [MEDICATION NAME] and Aspirin. This failure to provide services in accordance with professional standards of practice resulted in Resident #3 being hospitalized with bruises, bleeding gums, and a [DIAGNOSES REDACTED]. Cross refer to F309 and F502 for more information regarding Resident #3.",2014-07-01
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
4069,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2015-08-27,253,D,0,1,P5ZT11,"Based on observation and staff interview the facility failed to clean and maintain the area of the laundry where resident's clean linen and clothing is folded and stored. The findings include: The laundry room is located in section 4 of the facility. Section 4 is closed off and the resident rooms are not being utilized. Observation of the laundry room on 8/27/15 at 9:30 a.m. noted Staff BB was folding clean linen and placing it on the large wooden table. The ceiling above the table with the clean linen had a large hole on both sides of the light fixture. The light fixture was full of visible insects and there was a pipe on the side of table with visible debris on top. There were 3 working dryers in the room. The lint screen in one of the dryers was missing and the lint was piled up on the floor. The lint screen in the second dryer was so full it was overflowing onto the floor. The third dryer was not running but there was a pile of lint on the floor under the screen. The area behind the dryers had visible lint on the walls, top of the dryers and the floor. There was a non- working exhaust fan with an open vent to the outside and it was full of debris. The sprinkler head in the clean linen area by the dryers was covered with debris. In an interview with the laundry aide on 8/27/15 at 10:00 a.m. she said she does not keep a log of when she empties the lint. She said she usually cleans them daily. There are two resident rooms where clean linen and resident clothing are stored. The air conditioning vents in both rooms were observed to have discolored spots and the ceiling around them appeared to have been wet at one point.",2020-04-01
4070,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2015-08-27,257,E,0,1,P5ZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain acceptable parameters for comfortable temperatures for residents residing in Station 2 lobby and rooms 1C and 2C. (1 of 2 common areas and 2 of 12 rooms on C hallway). This resulted in the residents being cold at night in their room and warm in the afternoon. The findings include: In an interview with Resident R on 8/25/15 at 8:44 a.m. she said the temperature in the building affects her comfort. She said it gets hot in the building in the late afternoon around 3:00 p.m. She tells maintenance and they try to make it more comfortable. The resident had a fan in the room. In an interview with Resident S on 8/25/15 at 9:02 a.m. she said the temperature in the building affects her comfort. She said it gets hot especially in the afternoon. She said they try to adjust it and make it better but it takes awhile for it to get comfortable. In an interview with Resident T on 8/25/15 at 9:42 a.m. she said the temperature in the building affects her comfort. She said it is too cold. She said I ask for more blankets. She was observed to be in bed covered with a bedspread as well as some type of personal bright colored blanket. In an interview with Resident U on 8/24/15 at 1:55 p.m. she shook her head no when asked if the temperature in her room was comfortable. Resident U was not able to speak but understands questions and is able to shake her head yes or no. The resident indicated it was too hot. The resident had a fan in her room. In an interview with resident V on 8/25/15 around 3:45 p.m. she said it has been hot in the building for a long time. She said she stays in her room where it is cool. She said the main area (station 2 lobby) is too hot for her to be in there. She said the heat is terrible. She did not know if other residents had complained about it to the administration. In an interview with Staff CC on 8/25/15 at 2:40 p.m. he said there are two air conditioning units in the C hallway. The first 6 rooms are controlled by one unit and the lobby is controlled by 2 units. He said if Residents complain we try to adjust the temperature or if one resident is cold we will close the vent. Staff CC said they have to keep it cold at night in order for it to be comfortable in the lobby area in the afternoon. He said they have ordered an attic fan to attempt to relieve some of the afternoon heat. It was later learned the attic fan has not been ordered. Station 2 lobby is a very large room and houses the nursing station. The lobby is used for a dining room and activity room for the residents who reside on that unit. This area has some younger long term care residents who enjoy watching movies on the big screen television and playing cards. During a tour of station 2 lobby and resident rooms with Staff CC on 8/25/15 at 3:53 p.m. noted: Station 2 lobby - 80.2 degrees room [ROOM NUMBER]C- 79.5 degrees room [ROOM NUMBER]C- 81.5 degrees room [ROOM NUMBER]C- 77 degrees Temperatures on 8/26/15 at 7:42 a.m. are as follows: room [ROOM NUMBER]C- 69 degrees. The resident was observed to be covered with the spread and blanket. room [ROOM NUMBER]C- 69 degrees and both residents said they are comfortable with covers. Station 2 lobby 68.5-70.5 degrees depending on which direction the thermometer is pointed. Observation of the thermostat for the first 6 rooms in hallway C where the residents reside was set at 72 degrees. During a tour with Staff CC on Station 2 lobby and resident rooms at 3:46 p.m. on 8/26/15 noted: Station 2 lobby 76.5 to 78.5 degrees. Several residents were watching television and playing cards. room [ROOM NUMBER]c-75 degrees room [ROOM NUMBER]C-75.5 degrees room [ROOM NUMBER]c-73.5 degrees Review of the log for temperatures in the evening reveal the maintenance staff is to check the ambient area temperatures in the hallways, resident care areas and common areas late morning, mid afternoon and early evening when outside temperatures exceed 90 degrees and document findings. Review of the ambient air temperature log from 7/6/15 through 8/17/15 when temperatures were document only evening temperatures and all are within 71-81 degrees with the exception of the laundry, a non resident area. There are no recorded morning temperatures. During an interview with Staff HH on 8/27/15 at 10:50 a.m. he said he normally works the night shift. He said it is really cold at night. He keeps warm by wearing extra clothes and he makes sure the residents have blankets. He said when he makes rounds if the residents are cold he will get them extra blankets. In an interview with the Director of Maintenance on 8/27/15 around 10:00 a.m. he said the facility replaced some of the air conditioning units in June. He said the station 2 lobby is so large that the older units cannot keep up with the new unit and that is why the temperatures vary throughout the room. He said if they do not keep the area turned down at night then it will not be cool in the afternoon.",2020-04-01
4071,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2015-08-27,309,D,0,1,P5ZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to accurately assess the effectiveness of the residents pain medication, failed to coordinate care between the physician, nursing staff and the resident regarding the residents pain management goals and failed to include non-pharmacy interventions to promote the residents highest practicable quality of life. This failure negatively affected 1 resident (S) from a sample of 26 residents reviewed for pain control and management. The findings include: Review of the facility policy entitled Administering Pain Medication item number two states pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. Review of the facility clinical protocol for pain states the staff will assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level. The protocol also states the physician should document periodically why reduction of [MEDICATION NAME] is not feasible. Resident S is a [AGE] year old resident with [MEDICAL CONDITION] on both extremities. Additional medical [DIAGNOSES REDACTED]. Review of the annual comprehensive assessment completed 7/16/15 documents the resident is cognitively intact Brief Interview Mental Status (BIMS of 15) and demonstrates no abnormal behaviors. Section J of the comprehensive assessment documents the resident received routine pain medication and as needed pain medication (PRN), has pain frequently which limits activities and keeps her awake at night. The resident verbalized her worst pain level at a 10. In an interview with resident S on 8/25/15 at 9:25 a.m. when she was asked, Do you have any discomfort now or have you been having discomfort such as pain, heaviness, burning, or hurting with no relief, the resident responded yes. She said sometimes the nurses do not know how to give her medication, especially the pain medication. During the interview Staff FF came into the room to administer pain medication to the resident. The Resident said the nurse caring for her last night told her there were no pain pills left and that she was waiting for the pharmacy to deliver them. Staff FF confirmed the resident did have pain medication last evening and she would check into this. The resident said the nurse who told her there was no pain medication gave her 2 Tylenol. Observation of the resident on 8/26/15 around 8:30 a.m. revealed she was in bed and was comfortable. The resident was observed most of the day in the lobby watching television and playing cards. She also participates in the smoking breaks. In an interview with the resident on 8/27/15 around 1:45 p.m. she said her pain level was a 10. She said an acceptable limit for her pain would be a 10. It was difficult to determine if the resident understands the pain scale. The resident was sitting in her reclining chair and had just finished watching a movie. Review of the current physician orders documents Tylenol 325 milligrams (mg) 2 tablets every 4 hours as needed for pain and [MEDICATION NAME]-APAP 5-325 mg ([MEDICATION NAME]) one tablet every 8 hours as needed for pain. The physician orders do not clarify at what pain level to administer the Tylenol or the [MEDICATION NAME]. Review of a physician's telephone order dated 5/6/15 documented the [MEDICATION NAME] was decreased from every 6 hours to every 8 hours. A nursing note dated 5/6/15 documented orders noted to discontinue (DC) [MEDICATION NAME] APAP 5/325 1 po every 6 hours as needed (PRN) for pain and the new order was [MEDICATION NAME] APAP 5/325 mg 1 every 8 hours PRN. Review of the resident's record revealed no documented physician visit on 5/6/15 assessing the residents pain and no written explanation as to why the frequency of the [MEDICATION NAME] was decreased. In an interview with the resident on 8/26/15 at 2:28 p.m. she said she did not know the frequency of her pain medication had been changed. She said when she received the [MEDICATION NAME] her stumps cool off then she needs the Tylenol around 3 hours later to get complete relief. In a telephone interview with the resident's attending physician on 8/26/15 at 3:16 p.m. he said her pain management has been a challenge. He said when he first met the resident she had drains in her stump and she was in a lot of pain. He said after he got to know her better he realized it was a chronic issue with phantom pain (feeling of pain in the extremity that has been amputated). He said at that point he sat down with her to discuss tapering her medication. The physician confirmed there was no documentation of this conversation. He said he was aware the resident continues to have pain. During an interview with Staff GG and Staff FF on 8/26/15 at 10:34 a.m. they said the standardized pain tool is based upon 0-10, 10 being the worst pain. They said the residents pain is assessed before and after administering the pain medication using the 0-10 scale. Review of the Medication Administration Record [REDACTED]. Review of the documentation for (MONTH) reveals the resident has a pain level of 10 most days on the day shift, 9-10 on most evening shifts and mostly 0 on the night shift. Review of the MAR for (MONTH) reveals the nurses are inconsistently using the standardized scale for documenting the effectiveness of the medication and as written in the plan of care as noted below: 8/1/15- 9 a.m.- Resident reported leg pain and there was no pain level noted before or after administration of the [MEDICATION NAME]. 8/1/15 5 p.m.- Resident reported leg pain and there was no pain level noted before after administering of the [MEDICATION NAME]. 8/2/15- 4 p.m.- Resident reported pain in her legs. There was no pain level noted before or after administering of the [MEDICATION NAME]. 8/3/15- 8:35 a.m.-Resident reported a pain level of 10/10 stump pain and the effectiveness of the [MEDICATION NAME] was not documented. 8/4/15- 920 a.m.-Resident reported a pain level of 10/10 stump pain and the effectiveness of the [MEDICATION NAME] was not documented. 8/5/15- 12:20 p.m.- Resident reported a pain level of 10/10 stump pain and the effectiveness of the [MEDICATION NAME] was not documented. The same pattern continued throughout the month of August. During an interview with the Director of Nursing on 8/26/15 at 10:07 a.m. she confirmed the effectiveness of the residents pain management was incomplete. In an interview with Staff FF on 8/26/15 at 10:29 a.m. she said the resident asked for something for pain in her right stump at a level of 9 and she gave the Resident Tylenol because it was too early to administer the [MEDICATION NAME]. She said she gives the resident Tylenol if her pain level is a 5 or less. Observation of the resident multiple times over the survey revealed she spends most of the day in a reclining chair infrequently changing her position. The staff wheel her back to the room for personal care and use a lift for all transfers. Review of the current plan of care for pain management does not include any non pharmacy interventions and does not reflect the Resident has been involved in setting her pain management goals.",2020-04-01
4072,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2015-08-27,323,D,0,1,P5ZT11,"Based on observation, staff interview, and facility policy, the facility failed to ensure that chemicals were stored in a manner to make them inaccessible to residents for two (2) of two (2) Biohazard Utility Rooms on one (1) of three (3) halls. Facility census was eighty-eight (88). Findings include: Observation of the utility closet near Unit One on 08/24/15 at 10:30 a.m. revealed a door which had a Biohazard sign on it and a coded door entry lock. The door was unlocked and the room was accessible. Inside the room was a container of Eco Lab floor cleaner. The container of floor cleaner was sitting on the floor of the utility room. Further inspection revealed a spray bottle labeled General Cleaner, which was hanging on the wall. Two (2) trash cans revealed red biohazard bags which were full and had been disposed of in the trash cans. Observation of the main hall on 08/24/15 at 10:30 a.m. revealed six (6) residents sitting, standing, and/or walking in close proximity to the Unit One utility room. Observation of the utility closet near Unit Two on 08/24/15 at 10:55 a.m. revealed a door which had a Biohazard sign on it and a coded door entry lock. The door was unlocked and the room was accessible. Inside the room was a bottle of bleach cleaner was noted to be hanging on the wall. Observation of the hall area near the Unit Two on 08/24/15 at 10:55 a.m. revealed seven (7) residents sitting, walking and/or standing in close proximity to the Unit Two utility room. Observation of the utility closet near Unit One on 08/24/15 at 10:55 a.m. revealed that the door remained unlocked and the room accessible. Administrator made aware of the unlocked utility doors by the surveyor staff on 08/24/2015 at 11:05 a.m. Interview with the Administrator on 08/24/15 at 11:05 a.m. revealed the utility doors are supposed to be locked at all times with the exception of when the staff is accessing them. The Administrator stated that the staff is supposed to ensure the doors are locked and secured after they exit the utility rooms. Interview with the Administrator of 08/24/15 at 11:30 a.m. revealed the switches on the inside of the coded locks had been moved to the unlocked position, which kept the door from locking after it was shut. The Administrator stated the locks had been fixed so that all doors locked securely when the door was shut. Review of the current facility Census and Condition revealed there were fourteen (14) independently mobile residents in the facility. Review of the Infectious/Biohazard Waste Management Policy and Procedures revealed biohazard items are to be stored in such a way to prevent the entry of unauthorized persons from obtaining entry.",2020-04-01
4073,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2015-08-27,371,E,0,1,P5ZT11,"Based on observation, staff interview and facility policy, the facility failed to label, date and secure opened food in one (1) of one (1) walk-in refrigerator and one (1) of one (1) walk-in freezer. The facility also failed to ensure that food was stored in a sanitary manner in one (1) of one (1) walk-in freezer. This had a potential to affect eighty (80) residents receiving an oral diet. Findings include: Observation of the walk in refrigerator on 08/24/2015 at 10:40 a.m. revealed one box of beef base opened, which was unlabeled and undated. Further observation revealed a food product opened and wrapped in clear plastic wrap. The plastic wrap was unlabeled and undated. When asked what the item was the Dietary Manager (DM), stated she had no idea and threw the item in the trash. Observation of the walk in freezer on 08/24/2015 at 10:40 a.m. revealed two opened cardboard boxes on the freezer shelf. Inside one of the boxes was a transparent blue bag, which was opened, unlabeled, and unsecured. Inside the bag was frozen breaded okra. The okra was noted to have a thick layer of frost covering it. The second opened cardboard box revealed an opened clear transparent bag containing more breaded okra and another food item that was not identifiable. When the DM was asked what the item was, the DM stated I don't know. Further inspection revealed another opened cardboard box which contained breaded salmon patties. The box was labeled and dated, and the salmon patties were contained in a clear plastic bag. The plastic bag was observed to be unsecured and open to the air. The salmon patties were noted to have a layer of frost covering them. Observation of the walk in freezer on 08/24/15 at 10:40 a.m. revealed three large cardboard boxes containing bread which were being stored on the floor of the freezer. All three boxes were covered with a 1/4 inch layer of ice which was formed from liquid dripping from the top of the freezer. Observation of the walk in freezer on 08/27/2015 at 10:05 a.m. revealed a box of opened pastry shells that were unsecured, unlabeled, and undated. The pastry shells were open to the air and a layer of frost was noted to be covering them. Further inspection of the walk-in freezer revealed three (3) boxes at the back of the freezer that were being stored on the freezer floor. The boxes were observed to have a 1/4 - 1/2 inch of ice accumulated on them. Liquid was noted to be dripping from the top of the freezer which had dripped onto the boxes and frozen. Interview with the DM on 08/27/2015 at 10:45 a.m. revealed that she expects her staff to label, date, and secure all opened items before placing them in their proper storage areas. The DM added that she also expects staff to label food items on the outside of the package if there is a chance the item might not be identifiable after being stored. The DM stated that she normally doesn't store boxes under the area where the condensation tends to drip, but the freezer gets full and sometimes her staff places the boxes there. The DM stated she was going to move some things around in the freezer to address this issue so it doesn't happen again. Review of the Mandatory Dietary Meeting dated 10/30/14 revealed all open food is to be labeled and dated before storage. (#6) Review of Dietary in-service dated 10/29/14 revealed all foods will be dated when opened. (Page 2) Review of Dietary In-service dated 07/29/15 revealed opened items are to be labeled and dated before storing. (Page 2, Section 5) Review of Dietary In-service dated 10/16/14 revealed (#6) all opened items are to be labeled and dated before storing.",2020-04-01
4074,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2015-08-27,465,E,0,1,P5ZT12,"Based on observation, staff interviews and review of the Plan of Correction, the facility failed to clean and maintain the laundry room in one (1) of one (1) laundry rooms. Findings include: Observation on 11/16/15 at 10:38 a.m. of the Laundry Area with the Environmental Services Director revealed a built up concrete slab with two washing machines. Both machines were in use, washing resident clothing. The concrete slab was observed to be littered with a heavy buildup of dirt and debris. The floor directly behind the concrete slab was littered with a heavy build of dirt and debris. This area was approximately two foot wide that ran approximately ninety percent (90%) of the room. There was a large area of old detergent build up on the side of the washing machine, approximately eight by twelve (8x12) inches. The area was approximately eight inches wide and approximately twelve inches long. There was a very heavy thick coating of dust along the entire silver top of the washing machine. There was a heavy buildup of dust and debris coating the multiple tubing lines that run from the back of the washing machine, on the left side of the room that ran along the length of the back wall around to the right wall. Water was puddled on the floor between both washing machines. Water was leaking from the water line down the washing machine over a large rusted area on the left side of the washing machine. Further observation behind three (3) dryers revealed heavy, thick buildup of dirt and debris on the floor. The opening in the wall where the middle dryer vent connects, was not properly sealed. The gap/opening in the wall approximately four by four (4X4) inches. Interview conducted on 11/16/15 at 11:00 a.m. with the Environmental Services Director (ESD) confirmed the above findings and stated each of these areas are supposed to be cleaned every day and they had not been cleaned. The ESD further confirmed the washing machine was leaking water from the water pipes and water was pooled on the floor behind and between the washing machines. The ESD confirmed the wall opening for the middle dryer vent connection was not properly sealed. Interview conducted on 11/16/15 at 11:11 a.m. with the Administrator revealed that all three areas (washing machine area, dryer area, and vent area) make up the resident laundry room and per the facility's Plan of Correction, the laundry area is supposed to be cleaned every day. The Administrator confirmed the thick heavy buildup of dirt and debris on the floor behind the washing machines, on the concrete slab, caked on the tubing lines behind the washing machine and along the length of the back wall around to the right wall. He confirmed the large area of buildup of old laundry detergent on the washing machine, the leaking water pipes, and the pooling water on the floor behind both washing machines. He confirmed the floor behind the three dryers was soiled with heavy, thick, buildup of dirt and debris and that there was a 4x4 opening/gap in the wall where the dryer vent connects.",2020-04-01
4075,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2015-08-27,520,F,0,1,P5ZT12,"Based on observations record review and staff interviews, the facility failed to have an effective Quality Assessment and Assurance Committee that developed and implemented a process to ensure the laundry facility was maintained in a clean environment and ensure meat was labeled, dated and properly stored by the Plan of Correction date of (MONTH) 11, (YEAR). Cross Reference F253, F371 Findings include: Review of the Quality Assurance (QAA) committee monthly sign in sheets revealed the last QAA meeting was held with all department heads in attendance was on (MONTH) 16, (YEAR). An interview conducted on (MONTH) 16, (YEAR) at 4:05 p.m. with the Administrator revealed all department heads are responsible for conducting the audits per the Plan of Correction (P[NAME]). The audits are turned in to the Administrator and the data is reviewed. The Administrator rounds periodically to ensure the P[NAME] has been implemented as developed by their Quality Assurance (QAA) committee. If there is a concern with an audit or a concern while making rounds through the facility, it is addressed and reviewed it with the QAA to develop a new action as needed, however, the Administrator was not aware of the dirty laundry facility and kitchen was not in compliance according to the P[NAME].",2020-04-01
5388,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,164,D,0,1,L1N511,"Based on observation and staff interview, it was determined that the facility failed to ensure personal privacy during the provision of care for one (1) resident (#114) from a sample of thirty four (34) residents. Findings include: Observation of wound care on 10-16-14 at 10:30 a.m. for resident # 114 provided by the wound treatment nurse reveled that the privacy curtain was not wide enough to adequately provide full visual privacy for the resident. When unfurled, the curtain did not prevent the resident from being seen from the doorway at one end, or by her roommate at the other end. If the curtain was pulled to shield the doorway, then the resident was exposed to the roommate. If the curtain was pulled between the resident and her roommate, then the resident had no privacy from the doorway. Continued observation revealed that the corporate nurse consultant, who was present during the procedure, had to hold the privacy curtain from the bottom and stretch it as much as she could toward the head of the bed in an effort to provide privacy for the resident from her roommate during the wound care procedure. When she did pull the curtain between the residents it allowed more exposure from the other end of the curtain where the entrance to the room was. Interview on 10-15-14 at 6:20 p.m. with the Director of Nursing (DON), revealed that she would expect a resident to receive total privacy during care with no openings in the curtain or the door.",2018-09-01
5389,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,246,D,0,1,L1N511,"Based on observation, record review, and staff interview the facility failed to ensure that the environment accommodated the needs of one (1) resident (#64) from a sample of thirty four (34 ) residents. 1. Interview on 10/14/14 at 3:04 p.m. with Licensed Practical Nurse (LPN) EE revealed that the resident had contracutres to both hands. Review of the quarterly Minimum Data Set (MDS) assessment for resident #64 dated 10/7/14 revealed that the resident was assessed as totally dependent on staff for all Activities of Daily Living (ADLs), was incontinent of bladder and bowel and had functional impairment to the upper extremities bilaterally. Observation on 10/15/14 at 8:05 a.m. revealed the resident being fed by staff. The resident had bilateral contractures to the hands. Continued observation revealed that the resident was unable to use the call light provided for him because the call light had a button to depress. Due to contractures, the resident was not able to depress the button.",2018-09-01
5390,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,253,E,0,1,L1N511,"Based on observations, record review and staff interview, it was determined that the facility failed to maintain a sanitary environment on three (3) of six (6) halls (A, D, and F) Findings include: During the initial tour on 10-14-14 beginning at 10:30 a.m. the following was observed: 1. In room A2D a bag of clothing was on the floor and a soiled brief was in the trash can 2. In room A8D there were stains on the bathroom floor. 3. In room F64 dirt was in the corners of the bathroom floor. 4. In room F54 dirt was observed in the corners of the bathroom and there were urine splatters on the toilet and on the floor. The bathroom sink backed up and there were soiled towels in the bath tub. 5. In room F52 dirt was observed in the corners of the bathroom and urine was splattered on the toilet and the floor. 6. In room F53 dirt was in the corners of the bathroom 7. In room D8D a ceiling tile was pushed back to accommodate the TV cable and had not been repositioned. 8. The faucet in the bathroom sink in room D9W sprayed water in all directions when turned on. Interview with the Maintenance Director, on 10-16-14 at 10:30 a.m. revealed that the Maintenance Department makes rounds weekly at the beginning of the week, in each resident 's room to check for problems. A second interview at 4:30 p.m., revealed that there is a maintenance request log at each nurse' s station to be used by staff for reporting equipment that is in need of repair. He acknowledged that he also receives verbal reports from staff for items in need of repair but he encourages staff to use the log for reporting maintenance needs. Review of the weekly maintenance log for October, 2014 revealed no entries that indicate a problem in any of the resident rooms. Interview on 10-17-14 at 11:20 a.m. with certified nursing assistant (CNA) JJ , revealed that if he finds something broken he will write it in the maintenance log or tell the nurse Interview on 10-17-14 at 11:15 a.m. with Licensed Practical Nurse (LPN) BB , revealed that there is a maintenance log to use to report things that need repair to maintenance. Observation on 10/17/14 at 4:30 p.m. with the Maintenance Director of the areas of concern listed above revealed that he confirmed the observations.",2018-09-01
5391,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,282,D,0,1,L1N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to follow the care plan to apply non-skid footwear for two residents (#88 and #104) who had a history of [REDACTED].#88) who received [MEDICAL TREATMENT] services; to obtain glasses for one resident (#53) as prescribed by the ophthalmologist; and to provide a nutritional supplement for one resident (#72) who had weight loss from a sample of thirty four (34) residents. Findings include: 1. Resident #88 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as having a Brief Interview for Mental Status (BIMS) of 3 indicating that the resident was cognitively impaired, as requiring the extensive assistance of one person for dressing, and as being independent with ambulation but, having an unsteady gait. Review of the 9/12/14 care plan revealed that the resident could ambulate without assistance but, required supervision for ambulating long distances. Further review revealed that the resident was at risk for falls related to his/her occasional unsteady gait, weakness related to his/her [MEDICAL CONDITION] and decreased safety awareness due to his/her dementia with an intervention for staff to ensure that the resident wore non-skid footwear when out of bed. However, observation of the resident on 10/16/14 between 9:26 a.m. and 11:39 a.m., revealed the resident ambulating throughout the secured unit wearing regular socks and without shoes. Staff had failed to apply non-skid footwear on the resident's feet. Refer to F323 Review of the clinical record for resident #88 revealed that the resident received [MEDICAL TREATMENT] services every Monday, Wednesday and Friday. Review of the 8/22/14 care plan revealed that the resident had a [MEDICAL TREATMENT] located on his/her right upper chest with an intervention for registered/licensed nursing staff to assess the site for signs and symptoms of infection and to document on the Medication Administration Record [REDACTED] Review of the 9/2014 and 10/2014 Medication Administration Records (MARS) and Treatment Records revealed that there was no evidence that the resident's [MEDICAL TREATMENT] had been monitored at any time for those months. Review of the nurses' notes revealed that there was no evidence that licensed nursing staff consistently assessed the resident's [MEDICAL TREATMENT] every day on all shifts for 9/2014 and 10/2014. Refer to F309 2. Resident #72 (a closed record) was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Weight Log revealed that the resident weighed 95 pounds on admission on 7/8/14 and 90 pounds on 7/17/14 which represented a 5.3 percent (%) significant weight loss in nine days. Licensed nursing staff notified the physician of the resident's significant weight loss on 7/17/14 and the physician ordered licensed nursing staff to administer 4 ounces (ozs) of Med Pass (a nutritional supplement) three times a day. Review of the 7/17/14 care plan revealed that the resident was a picky eater, did not like meat and was below his/her ideal body weight with an intervention for staff to administer Med Pass as ordered by the physician. Review of the 7/2014 Medication Administration Record [REDACTED]. However, review of the 8/2014 and 9/2014 MARS revealed that staff failed to administer the Med Pass to the resident in those months. There was no evidence that the physician had discontinued the Med Pass or that the resident had refused the supplement. Refer to F325 3. Resident #53 was admitted in 2008 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having impaired vision (able to see large print but not regular print in newspapers/books) with no corrective lenses. Review of the care plan dated 3/23/12 and reviewed quarterly, revealed that the resident had decreased vision with an intervention for staff to obtain glasses for the resident if prescribed. Observation on 10/14/14 at 1:49 p.m. revealed the resident in his/her room reading a newspaper. The resident was not wearing eye glasses and was holding the newspaper close to his/her face to see the print. review of the resident's medical record revealed [REDACTED]. However, staff failed to notify the resident's family of the prescription for eye glasses until 10/17/14. Refer to F313 . 4. Review of the clinical record for resident #104 revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Review of the Care Plan dated 2/11/14 revealed that the resident had a history of [REDACTED]. Continued review revealed that the resident takes a narcotic pain medication often and antidepressant daily which might impede her balance with an intervention for the staff to ensure that the resident had and wore properly fitting non-skid footwear for ambulation. Observation on 10/14/2014 at 11:42 a.m., 12:20 p.m., 2:40 p.m., 5:15 p.m. and 6:10 p.m. ambulating throughout the secured unit. wearing regular socks without shoes.",2018-09-01
5392,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,309,D,0,1,L1N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that licensed nursing staff monitored the [MEDICAL TREATMENT] and administered a medication as ordered by the physician for one resident (#88) from a sample of thirty four (34) residents. Findings include: 1. Resident #88 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident received [MEDICAL TREATMENT] services every Monday, Wednesday and Friday. Review of the 8/22/14 care plan revealed that the resident had a [MEDICAL TREATMENT] located on his/her right upper chest with an intervention for registered/licensed nursing staff to assess the site for signs and symptoms of infection and to document on the Medication Administration Record [REDACTED] Interview with Licensed Practical Nurse (LPN) AA on 10/16/14 at 11:50 a.m., revealed that nursing staff should monitor the resident's right upper chest [MEDICAL TREATMENT] every shift every day for bleeding, swelling and infection. Further interview with AA revealed that nursing staff should document the assessment on the Treatment Record or the nurses' notes. Review of the 9/2014 and 10/2014 Medication Administration Records (MARS) and Treatment Records with LPN AA at that time revealed that there was no evidence that the resident's [MEDICAL TREATMENT] had been monitored every shift every day for those months. Review of the nurses' notes revealed that there was no evidence that licensed nursing staff assessed the resident's [MEDICAL TREATMENT] every shift for 9/2014 and 10/2014. Interview with the Director of Nursing (DON) on 10/17/14 at 6:45 p.m., revealed that the resident's [MEDICAL TREATMENT] should be assessed at least daily and the assessment documented on the Treatment Record. Review of the physician's orders [REDACTED]. The [MEDICATION NAME] was to be discontinued on 10/2/14. However, review of the 10/2014 Medication Administration Record [REDACTED]. Interview on 10/17/14 at 11:55 a.m with Licensed Practical Nurse (LPN) AA revealed that after reviewing the 10/2014 MAR, the nurse confirmed that licensed nursing staff had failed to discontinue the [MEDICATION NAME] after 10/2/14 as ordered by the physician.",2018-09-01
5393,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,313,D,0,1,L1N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to ensure that two (2) residents (#53 and A) of three (3) residents reviewed for vision impairment received prescribed eye glasses timely from a sample of thirty four (34) residents. Findings include: 1. Review of the clinical record for resident A revealed that the resident was admitted in 2010 with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having impaired vision (able to see large print but not regular print in newspapers/books) with no corrective lenses. Review of the care plan dated 1/04/12 and reviewed quarterly, revealed that the resident had decreased vision with an intervention for staff to obtain eye exam at least annually, use large print material. Review of the Optometrist notes dated 3/11/2014 revealed that the resident needed corrective lenses and Bifocals were recommended. Review of a Trident USA clinical report revealed Glasses on order if approved. Interview on 10/17/14 at 12:45 p.m. with the Social Worker revealed that she overlooked the order for the resident to have corrective lenses. Continued interview revealed that she did not send a letter out or call the residents family and was not sure why she did not see the order form date (MONTH) 20, 2014 of this year with recommendations for the resident to have corrective lenses. Interview on 10/17/14 at 1:00 p.m. with the Administrator revealed that it is her expectation that once the facility receives an order for [REDACTED]. Interview on 10/17/14 at 1:45 p.m. with resident A revealed, that the resident was seen back in (MONTH) of 2014 by the Optometrist. Continued interview revealed that he has requested corrective lenses on several occasions and would love to have them. 2. Resident #53 was admitted in 2008 and readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed that the resident was assessed as having impaired vision (able to see large print but not regular print in newspapers/books) with no corrective lenses. Review of the care plan dated 3/23/12 and reviewed quarterly, revealed that the resident had decreased vision with an intervention for staff to obtain glasses for the resident if prescribed. Observation on 10/14/14 at 1:49 p.m. revealed the resident reading a newspaper. The resident did not have glasses and was holding the newspaper close to his/her face to see the print. Review of the eye exam evaluation done 3/11/14 revealed that the optometrist had recommended that the resident be referred to an ophthalmologist for possible cataract surgery. Interview on 10/17/14 at 2:00 p.m. with CNA OO who was responsible for making medical/dental/vision appointments for the residents, revealed that the resident was evaluated by the ophthalmologist who wrote a prescription for eye glasses. Review of the resident's medical record with OO at that time revealed a prescription for eye glasses dated 9/24/14 in the front of the resident's medical record. Continued interview with OO revealed that registered/licensed nursing staff received the prescription for eye glasses when the resident returned from his/her appointment with the ophthalmologist and were responsible for notifying the resident's family of the prescription. Interview with the Social Services Director (SSD) on 10/17/14 at 2:30 p.m., revealed that she was unaware that the resident had a prescription for eye glasses and had not notified the resident's family. Interview with LPN AA on 10/17/14 at 2:40 p.m., revealed that she/he was not aware of the resident's prescription for eye glasses and that to his/her knowledge, the resident's family member had not been notified although the family member visited the resident every weekend. Continued interview with AA revealed that the Social Services Director (SSD) was responsible for notifying family of the resident's prescription for eye glasses. Further interview with AA revealed that when a resident returned from an eye exam with a prescription for eye glasses, the nurse was suppose to make a copy of the prescription, attach it to a communication form and give it to the SSD to notify the resident's family. Staff failed to notify the resident's family of the 9/24/14 prescription for eye glasses until after surveyor inquiry on 10/17/14.",2018-09-01
5394,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,323,D,0,1,L1N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interview, it was determined that the facility failed to ensure that fall prevention measures were in place for two (2) residents (#88 and #104),) with a history of falls from a sample of 34 residents and failed to ensure that toilet seats were secured in seven (7) resident bathrooms (B6, B8, D6, D10, F64, F41 and F72) on three (3) of six (6) halls. Findings include: 1. Resident #88 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident was coded on the 9/9/14 Admission Minimum Data Set (MDS) as having a Brief Interview for Mental Status (BIMS) of 3 indicating that the resident was cognitively impaired, as requiring the extensive assistance of one person for dressing, and as being independent with ambulation but, having an unsteady gait. Review of the 9/12/14 care plan revealed that the resident could ambulate without assistance but, required supervision for ambulating long distances. Further review revealed that the resident was at risk for falls related to his/her occasional unsteady gait, weakness related to his/her COPD and decreased safety awareness due to his/her dementia with an intervention for staff to ensure that the resident wore non-skid footwear when out of bed. Review of the Fall Risk Evaluation dated 9/2/14 revealed that staff had assessed the resident as being at high risk for falls. Review of the 10/9/14 at 3:22 p.m. nurses' note revealed that the resident was found on the floor at the doorway of his/her room. The resident did not sustain an injury from the fall. On 10/16/14 at 9:26 a.m., the resident was observed in his/her wheelchair in the dining room of the secured unit. The resident was wearing regular socks without shoes at that time. Staff had failed to apply non-skid footwear on the resident's feet. The resident was observed at that time to get up from his/her wheelchair in the dining room and ambulate down E hall and back again to the dining room. The resident was assisted by the Occupational Therapist Assistant (OTA) to sit in a chair in the dining room. However, the OTA failed to identify that the resident was not wearing non-skid footwear. At 10:50 a.m., the resident got out of his/her wheelchair and ambulated down E hall to the exit door which he/she attempted to open. At 10:54 a.m., the resident ambulated into another resident's room but, was redirected back into the hallway by Certified Nursing Assistant (CNA) PP. However, PP failed to identify that the resident was not wearing non-skid footwear. Continued observation of the resident revealed that he/she ambulated back up E hall, in front of staff at the nurses' station, down F Hall and back again to the dining room to sit in a chair. At 11:12 a.m., the resident got up from the chair and ambulated to the front entrance door of the secured unit. CNA DD assisted the resident to a chair in the dining room and gave him/her a cookie. However, DD failed to identify that the resident was not wearing non-skid footwear. At 11:21 a.m. the resident got out of the chair and ambulated around the table several times before ambulating down E hall and back to the dining room. At 11:29 a.m., the resident ambulated to the front entrance door of the secured unit. CNA DD assisted the resident to the entrance of F hall, said There you go and then left the resident who ambulated in front of staff at the nurses' station and down E hall. At 11:39 a.m., housekeeping staff was observed mopping the E hall floor. Licensed Practical Nurse (LPN) QQ noticed the resident in the E hall and told the resident that he was going to get his/her socks wet. QQ assisted the resident to his/her wheelchair in the dining room at that time. However, QQ failed to identify that the resident was not wearing non-skid footwear. Interview with CNA RR on 10/17/14 at 11:45 a.m., revealed that staff were suppose to assist the resident when he/she ambulated because the resident had an unsteady gait at times. Interview with LPN AA on 10/17/14 at 1:00 p.m., revealed that the resident was at risk for falls and should wear shoes or non-skid socks. Interview with the Director of Nursing (DON) on 10/17/14 at 6:40 p.m., revealed that supervisory nursing staff were responsible for ensuring that staff applied non-skid footwear on the resident's feet. 2 .Review of the clinical record for resident #104 revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly MDS assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Review of the Care Plan dated 2/11/14 revealed that the resident had a history of [REDACTED]. Continued review revealed that the resident takes a narcotic pain medication often and antidepressant daily which might impede her balance with an intervention for the staff to ensure that the resident had and wore properly fitting non-skid footwear for ambulation. Observation on 10/14/2014 at 11:42 a.m., 12:20 p.m., 2:40 p.m., 5:15 p.m. and 6:10 p.m. ambulating throughout the secured unit. wearing regular socks without shoes. 3. During the initial tour on 10-14-14 beginning at 10:30 a.m. the following was observed: -The toilet seat was loose in room B8D and B6D. -The toilet seat was loose in room F64. -The toilet seat was loose in room F41. -The toilet seat was loose in room F72. -The toilet seat was loose in room D6W and D10W.",2018-09-01
5395,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,325,D,0,1,L1N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a closed record and staff interview, it was determined that the facility failed to provide a nutritional supplement as ordered by the physician for one (1) resident (#72) of four (4) residents reviewed for weight loss from a sample of thirty four (34) residents. Findings include: Review of the closed clinical record for resident #72 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the Weight Log revealed that the resident weighed 95 pounds on admission on 7/8/14 and 90 pounds on 7/17/14 which represented a 5.3 percent (%) significant weight loss in nine days. Licensed nursing staff notified the physician of the resident's significant weight loss on 7/17/14 and the physician ordered licensed nursing staff to administer 4 ounces (ozs) of Med Pass (a nutritional supplement) three times a day. Review of the 7/17/14 care plan revealed that the resident was a picky eater, did not like meat and was below his/her ideal body weight and had an intervention for staff to administer Med Pass (a nutritional supplement) as ordered by the physician. Review of the 7/2014 Medication Administration Record [REDACTED]. However, review of the 8/2014 and 9/2014 MARS revealed that staff failed to administer the Med Pass to the resident in those months. There was no indication that the physician had discontinued the Med Pass or that the resident had refused the supplement. Review of the Weight Log revealed that the resident had no additional weight loss but, weighed 93 pounds on 8/14/14, a gain of four pounds since 7/17/14. Interview with the Director of Nursing (DON) on 10/17/14 at 6:50 p.m., revealed that licensed nursing staff were responsible for administering the Med Pass to the resident and documenting the percent consumed on the MAR. She confirmed at that time that licensed nursing staff failed to administer the Med Pass to the resident as ordered by the physician for 8/2014 and 9/2014.",2018-09-01
5396,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,371,E,0,1,L1N511,"Based on observation and staff interview the facility failed to date and label food items stored in the walk in cooler and the dry storage area. The census was 91 residents. Findings include: Observation on 10-14-14 at 10:55 a.m. revealed several items in the walk in cooler that were opened and but not dated with the date opened. These were Pimento cheese, beef base, chicken base, fruit cocktail. Other items that had been opened were labeled inaccurately with only the month and date and no year. These were: tomato sauce, hard boiled eggs which were in water in a metal container covered with plastic wrap, Italian dressing, Ranch dressing, and pickles. Continued observation revealed a large plastic container of frosting which had been opened but not dated and a crate containing four 1/2 gallons of syrup that had not been opened sitting on the floor under a wire rack behind the door in the dry storage area. This is the area where rodent droppings are also observed. Interview with the dietary manager on 10-14-14 at 10:55 a.m. revealed that she would expect the items to be labeled correctly.",2018-09-01
5397,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,428,D,0,1,L1N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that the consultant pharmacist identified and reported to the attending physician and the Director of Nursing that a medication was not discontinued after thirty days as ordered by the physician for one (1) resident (#88) of five (5) residents reviewed for unnecessary medication use from a sample of thirty four (34) residents. Findings include: Review of the clinical record for resident #88 revealed that the resident was readmitted on [DATE] with [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. The Depakote should have been discontinued on 10/2/14. However, review of the 10/2014 Medication Administration Record [REDACTED]. Interview on 10/17/14 at 11:55 a.m with Licensed Practical Nurse (LPN) AA revealed that after reviewing the 10/2014 MAR, she confirmed that licensed nursing staff had failed to discontinue the Depakote after 10/2/14 as ordered by the physician. Review of the 10/1/14 to 10/31/14 physician's orders [REDACTED]. However, review of the Consultant Pharmacist's Medication Regimen Review: Listing of Residents Reviewed with No Recommendations form dated 10/14/14 revealed that the resident was on the list. The consultant pharmacist failed to identify and report to the attending physician and Director of Nursing that the Depakote was not discontinued after 30 days as ordered by the physician but, continued to be administered from 10/3/14 to 10/8/14.",2018-09-01
5398,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,431,E,0,1,L1N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to dispose of expired medication in two (2) of three (3) medication storage rooms. Findings include: 1. Observation of the medication storage room for Station three (3) on [DATE] at 1:30 p.m., revealed, two (2) prefilled Insulin syringes were placed in a storage bag labeled expired [DATE], one( 1) Lorazepam milligram per milliliter vial was expired on [DATE], and two Aspirin suppositories expired on ,[DATE], and were in the medication refrigerator. Interview with Licensed Practical NurseMM at this time, verified that the medications were expired. 2. Observation of the medication storage room for Station two (2) on [DATE] at 2:00 p.m., revealed two (2) Hepatitis Vaccine vials expired on [DATE], and two (2) Aspirin suppositories expired on ,[DATE] in the medication refrigerator. Interview with Licensed Practical Nurse PP at this time verified that the medications were expired. Interview with the Director of Nurses on [DATE] at 3:40 p.m. revealed that the night shift nurse and unit managers were responsible for removing expired medication from storage areas.",2018-09-01
5399,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,441,E,0,1,L1N511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interview, it was determined that the facility failed to ensure that staff washed or sanitized their hands during the meal service for two (2) of two (2) meals on five (5) of six (6) halls (A, B, D, E and F) . Findings include: Observation during the meal service in the dining room for the secured unit (E and F halls) on 10/14/14 at 5:23 p.m., certified nursing assistant (CNA) OO obtained a tray from the meal cart and served a resident sitting at one of the tables. OO touched the resident's shoulder when she/he spoke to the resident. Without washing/sanitizing her/his hands, OO obtained a tray from the cart for another resident, placed the tray on the table, removed the straw from its wrapper and placed the straw in the resident's cup. Without washing/sanitizing her/his hands, OO obtained a tray from the cart for another resident, pulled a chair closer to the resident, assisted the resident into the chair and set up the resident's tray. Without washing/sanitizing her/his hands, OO obtained a tray from the cart for another resident and set the tray on the table. OO then obtained a rolling chair from the nurses' station to sit in and without washing/sanitizing her/his hands, picked up the utensils and began feeding the resident. Interview with the Licensed Practical Nurse (LPN) responsible for Infection Control surveillance on 10/17/14 at 5:15 p.m., revealed that staff should wash/sanitize hands between each resident contact during meal service. 2. Observation of meal service on the A hall at 5:20 p.m. on 10/14/15 revealed a CNA take a residents tray into his room, touch the overbed table and cut the sandwich in half touching it with her fingers. Without washing/sanitizing hands , the CNA picked up another residents tray, took it into the resident's room, touched the resident's over bed table several times and then cut the residents sandwich in half touching it with her fingers. 3. Observation of lunch trays being served at 12:40 p.m. on 10/16/14 revealed a CNA dropped a resident's applesauce on the floor , picked it up, placed it back on the residents bedside table along with the residents meal and then adjusted the residents table so that the resident could eat his meal. The CNA did not wash/sanitize her hands after retrieving the applesauce from the floor. Interview on 10/17/14 at 5:15 p.m. with infection control nurse revealed that she expects all staff to wash their hands or use hand sanitizer in between passing out the residents trays and if any food items are dropped on the floor, staff are expected to dispose of the food item. The infection control nurse also revealed that staff are not expected to touch any of the residents food Continued interview revealed that the facility has mandatory computer training for staff on infection control polices and that each staff member is expected to pass the competencies with an 80% or higher. Mandated in-services are done on a monthly basis. 3. Meal observation for B- Hall on 10/14/14 at 5:15 p.m. revealed a CNA taking a tray to room [ROOM NUMBER]B-A. The CNA touched the over bed table, adjusted the resident in bed, touched the remote control, and then performed tray set ,opening straws, removing lids and plastic covers from drinks. The CNA did not wash/sanitize her hands. Continued observation revealed that the CNA then went to room [ROOM NUMBER]-B-B touched tables, adjusted bedding and performed tray set up without washing/sanitizing her hands. The CNA then went to 11B-A set up the tray, opening lids on drinks, opening straws, and adjusting bedding without washing/sanitizing her hands. 4. Meal observation on 10/15/14 at 12:25 p.m. on the B hall revealed a CNA wheel the meal cart down near room [ROOM NUMBER]B, removed tray from cart, deliver the tray into the room, touch linens on the bed, touch the curtains, and perform tray set up by removing straws from the wrapper, and removing lid from drinks without washing/sanitizing her hands. The CNA then delivered a tray to room [ROOM NUMBER]B, bed A, where she removed a floormat from the floor and set it up against wall, moved the overbed table near the bed, and then began to setup tray, removing lids/plastic covers from drinks without washing/sanitizing her hands. Continued observation revealed that the CNA then delivered a tray to room [ROOM NUMBER]B bed B, touching curtains and the bedside table, before setting up the tray by removing covers from drinks and handling straws, without washing/sanitizing her hands. Finally, the CNA went to room [ROOM NUMBER]B Bed A to feed the resident. The CNA manually elevated the head of the bed, helped position the resident in bed, set up the tray by opening lids on drinks, handling utensils and began to feed resident all without washing/sanitizing her hands.",2018-09-01
5400,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,456,F,0,1,L1N511,"Based on observation and staff interview, the facility failed to maintain equipment in the laundry. Census=91 residents Findings include: Observation of the laundry area on 10/15/14 at 12:15 p.m., 3:30 p.m. and on 10/16/14 at 9:00 a.m. revealed that the washing machine room had two washers, one had not been working for over a month, and the other was leaking. There was a blue blanket in front of the washer to catch the water. The sink on the wall next to the washer was dirty with soiled towels on top of it; there was a large hole in the wall behind the sink with a piece of wood in front of it and some of the ceiling tiles were stained and bulging from the ceiling. Interview on 10/15/14 at 12:15 p.m. with Laundry aide NN revealed that the facility has two washers but only one working machine at this time, however, this machine leaks. Continued interview revealed that the second washer had been broken for over a month and that the facility is waiting on a part before the washer can be fixed.",2018-09-01
5401,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,463,E,0,1,L1N511,"Based on observations, record review and staff interview, it was determined that the facility failed to ensure that call lights were functioning at the bedside or in the bathrooms for five (5) resident rooms (A6/W, A2/D, A8/D, A2/W and B6/D) on two (2) of six (6) halls (D and W). Findings include: During the initial tour on 10-14-14 beginning at 10:30 a.m. the following was observed: 1. In room A6W and A8D the bathroom call light was not visible above the hallway door when the bathroom call light was activated. 2. In room A2W and A2D, the light on the box in the room did not light up when the call light was activated. 3. In room B6D, the call light box was loose from the wall. Interview with the Maintenance Director, on 10-16-14 at 10:30 a.m. revealed that the Maintenance Department makes rounds weekly at the beginning of the week, in each resident's room to check for problems. A second interview at 4:30 p.m. revealed that there is a maintenance request log at each nurse's station to be used by staff for reporting equipment that is in need of repair. He stated that he checks these logs at the beginning of each day. Review of the weekly maintenance log for October, 2014 revealed that rounds had been made for each week in (MONTH) by the maintenance department. There were no entries that indicated a problem with the call system in any of the resident rooms. Interview on 10-17-14 at 11:20 a.m. with certified nursing certified nursing assistant (CNA) JJ , revealed that if he found something broken he would write it in the maintenance log or tell the nurse Interview on 10-17-14 at 11:15 am with Licensed Practical Nurse (LPN) BB, revealed that there is a maintenance log to use to report things that need repair to maintenance.",2018-09-01
5402,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,469,D,0,1,L1N511,"Based on observation, interview, and record review the facility failed to maintain an effective pest control program. Findings include: Observation on 10-14-14 at 10:45 a.m. and on 10/15/14 at 9:30 a.m. revealed rodent droppings in the dry storage area in a corner under a wire storage rack behind the door into the dry storage room. Observation and interview on 10-16-14 at 4:30 p.m. with the, Maintenance Supervisor revealed that the droppings were in the same location. The maintenance supervisor stated that it looks like rodent droppings. Continued interview revealed that the exterminator comes every month. Review of the pest control log revealed that Borden Pest Control services the facility monthly. Tamper proof rodent traps are placed around the foundation of the building during the visit.",2018-09-01
5403,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-17,514,D,0,1,L1N511,"Based on observation, record review and staff interview the facility failed to maintain a complete and accurate medical record for one (1) resident (#48) from a sample of thirty four (34) residents. Findings include: Observation on 10/16/14 at 10:00 a.m. revealed resident #48 in bed. The resident had a contracture to the left hand. Review of Physician Order's revealed a current order for passive range of motion to the left upper extremity, left elbow,and left wrist and finger digits for Resident #48. Review of treatment record for October, 2014 revealed no evidence that this order had been transcribed to the treatment record for the month of October. Interview with Restorative Nurse on 10/16/14 at 2:00 p.m. revealed that the resident was not being seen by the Restorative Program and that Nursing was responsible for passive range of motion for the resident. Interview with the Unit Manager, Licensed Practical Nurse BB on 10/17/14 at 11:00 a.m. revealed that there was no transcription to the Treatment administration record for (MONTH) 2014, as in previous months, (8/2014, and 9/2014), for passive range of motion to the left upper extremity, left elbow and left wrist and finger digits. Continued interview revealed that this was an oversight.",2018-09-01
6681,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,156,D,0,1,6UUW11,"Based on record review and staff interview, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) prior to termination of Medicare-A covered skilled services, and failed to ensure the responsible party (RP) received the denial notice for one (1) of one (1) residents reviewed (#7). Findings include: During interview with Minimum Data Set (MDS ) Coordinator HH on 01/09/13 at 2:20 p.m., she stated she was able to locate only one resident (#7) since the facility's last standard survey who had been discharged from Medicare Part A services, without having used up their 100 days of eligibility, or been discharged to the hospital. Upon further interview, she stated that resident #7 had remained in the facility after termination of skilled therapy. Review of the denial letter entitled SNF Determination On Continued Stay revealed that resident #7 was discharged from skilled services on 12/23/11. Further review revealed that the form had not been signed by the RP, and a handwritten notation at the bottom of the form noted the facility was not able to reach the RP by phone on 12/20/11, and the denial letter was mailed to them on that date. There was no documentation that the letter had been received by the RP. During interview with MDS Coordinator HH, she stated that there was no proof that the denial letter was ever received by the RP, and did not know why it was not sent by certified mail, as they had done in the past. During interview with MDS Coordinator HH on 01/10/13 at 11:05 a.m., she stated that she did not know why the NOMNC (used to inform the beneficiary of their right to an expedited review of a service termination by a Quality Improvement Organization), was not issued for resident #7.",2017-10-01
6682,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,241,E,0,1,6UUW11,"Based on observation and staff interview, the facility failed to ensure that residents were treated with dignity and respect during a dining observation on one (1) of four (4) days of survey. Findings include: During lunch time dining observation for station three (3) between 12:45 p.m.-1:25 p.m. on 01/07/13, the following concerns were identified: 1.) There were twenty-one (21) residents sitting at various locations with a total of ten (10) square tables and no residents were observed, at the start of the meal, to have on a clothing protector. Staff did not pass out clothing protectors until 1:05 p.m. Initially there was one (1) staff member passing out trays and then approximately five (5) minutes later another staff member came to help; however, neither staff assisted residents with cutting up their angel hair pasta. During observation of lunch, three (3) residents were eating the angel hair pasta with their hands and the pasta observed to be sitting on their shirts and dripping down their clothing. At the change of shift, two (2) of the three (3) residents, were observed to be wearing food stained clothing. 2.) One (1) randomly observed resident, leaning towards the side of the chair with her head almost touching the armrest. the resident was asleep off and on, while the other three (3) residents sitting at her table were eating and had finished their meal prior to this resident being served her meal at 1:18 p.m. When staff sat the resident's tray on the table in front of her she started grabbing at the food on the tray. 3.) One (1) randomly observed resident, who was sitting in a Merry Walker, at the table with another resident since 12:45 p.m., received his meal after the tablemate had already completed their meal. Interview with the Director of Nursing (DON) on 1/10/13 at 10:25 a.m., revealed that she expected staff to assist residents with their meals whether it be with eating and/or cutting up their food, and placing a clothing protector if needed on all the residents prior to dining time. She also stated that all residents should be served at the same time if sitting at the same table.",2017-10-01
6683,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,242,D,0,1,6UUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to honor one (1) resident's (S) choice related to the frequency of getting showers. The sample size was forty-three (43) residents. Findings include: During an interview on 01/08/13 at 9:53 a.m., resident S stated that they got a shower only once every two to three weeks, and that they would like a shower once a week. The resident added that they received a bedbath on the days they weren't showered, and that they had told the staff in the past about their shower preference. Review of resident S's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that they were cognitively intact, and totally dependent on staff for personal hygiene and bathing. During interview with Certified Nursing Assistant (CNA) II on 01/09/13 at 12:00 p.m., she stated that they went by a shower list made by the unit manager to know who needed a shower on a particular day. Review of Resident Care Flow Records noted that resident S received bedbaths instead of a shower the following number of times: January 2013: received a bedbath every day through 01/06/13. December 2012: received a bedbath every day; documented that refused a bath/shower on four occasions. November 2012: received a bedbath every day except got a shower on three days. The resident refused a bath/shower on two occasions. October 2012: received a bed bath daily. Review of the CNA Care Plan revealed that the resident was scheduled for showers on Mondays, Wednesdays and Fridays on the 3-11 shift. During interview with Unit Manager KK on 01/09/13 at 4:30 p.m., she stated the facility's routine was for residents to be showered three (3) times a week and as needed. Additionally, she stated that the unit managers added residents to the Shower Assignment book; on the Activities of Daily Living (ADL) sheet for the CNA's; and was also entered on the daily CNA Assignment sheet. During further interview, Unit Manager KK stated that resident S was scheduled to have showers on Monday, Wednesday, and Friday, and that in November was changed to have showers on the 7-3 shift instead of the 3-11 shift. The Unit Manager verified that it was documented on the October through January ADL sheets that the resident received only three showers, and did not know why. The Unit Manager reviewed the Nurse's Notes and was able to find only one shower refusal documented on 12/03/12 that had not already been documented on the Resident Care Flow Records.",2017-10-01
6684,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,253,E,0,1,6UUW11,"Based on observation and staff interview, it was determined that the facility failed to maintain housekeeping and/or maintenance services for a sanitary resident use area on four (4) of six (6) halls (A, B, D,and F). Findings include: During initial tour of the facility on 1/7/13 between 11:30 a.m.-12:40 p.m., the following concerns were identified: A.) D-Hall: 1.) Room D-1: In the bathroom on the left wall after entering the room, there was three (3) patched, unpainted areas, two (2) medium light brown colored ceiling tiles, one (1) of two (2) call light buttons were broken, the nightstand on the left had the first drawer missing the first handle, and the blinds were broken on the right side (sixth and seventh up from the bottom and seventh down from the bottom). 2.) Room D-3: The bedroom blinds are bent on the eight (8th) and broken on the nineteenth (9th), both coming up from the bottom of the blinds. 3.) Room D-4: The bedroom wall facing the bathroom door is marred exposing mess sheetrock, and the vent behind the bedroom door has a build up of gray like unknown matter in the vent tracks. The bottom one-third (1/3) of the privacy curtain had unknown multiple, in various locations, orange and brown colored spots. 4.) Rooms D-6B and D-11: The privacy curtains had various brown and orange spots/splatters on the bottom one-third (1/3) half. 5.) Room D-7: The left knob was missing from the second drawer of the built in dresser and the blinds are broken from the tenth through thirteen (10-13) slates on the right side from the bottom up, and sixteenth (16) slat from the bottom up on the right side. 6.) Room D-10: The first drawer was off the nightstand on the right, the bathroom cover fan was missing, and the tenth (10) and eleventh (11) slat on the blind is broken on the right side coming up from the bottom, nineteen (19) up from the bottom on the right is bent, and twenty-five (25) and twenty-six (26) up from the bottom is bent on the right. B.) F-Hall: 1.) Room F-5: In the bathroom, there is brown, orange, and black caulking around the base of the toilet. 2.) Room F-7: In the bathroom, the caulking around the sink was cracked. C.) During random observation on 01/09/13 at 4:30 p.m. on the B-Hall, the following concerns were identified: 1.) Room B-1: Above bed A, toward the end of the bed, the ceiling vent was bent. 2.) Room B-2: In the bathroom, the toilet's water reservoir covering was the wrong size, hung over approximately two to three (2-3) inches on each side. 3.) Rooms B-3A and B-1W: The privacy curtains had light brown stains. 4.) Room B-5: The bathroom light switch was away from the wall, approximately one (1) inch and was loose when touched. The bathroom pipes underneath the sink and behind the toilet are exposed with four (4) various sized cut outs in the lower half of the sheet rock. 5.) Room B-9: There is a medium brown circle with dark edges large to ex-large on the ceiling tile over the closet next to the window and a small, light brown circle over the built-in dresser. 6.) Room B-10: The blinds on the right side are broken from the bottom up on the nineteenth (19th) slate. 7.) Room B-11: The first (1st) and twenty-eight (28th) slate on the right side of the right blind is broken. D.) During random observation on 01/09/13 at 5:00 p.m. on the A-hall and C-hall, the following concerns were identified: 1.) Room 4-A: The call light over the doorframe out in the hallway is cracked on the left side. 2.) Room 6-A: The overbed table has a broken wheel, which caused it to be unstable. 3.) Rooms A-1W, A-8D, A-8W, A-6D, A-6W: The privacy curtains had brown stains. E.) During environment rounds on 1/10/13 between 12:05 p.m.-12:50 p.m., the following concerns were identified: 1.) The third (3rd) window panel down on the left side of the exit door on the F-hall has a small hole, approximately half (1/2) inch, with nine (9) cracked lines that run off in different directions. F.) The following observations were made on Station 1, Hall B, on 01/07/13 between 2:46 p.m. and 3:55 p.m.: 1. Rooms B-10/B-12: There was no light fixture cover over the light bulbs on the ceiling in the bathroom; one of the two lights had burned out. The commode lid was off the commode and paced behind the base of the commode on the floor (there was an elevated commode seat in use). 2. Room B-9-W: There were two brown-stained ceiling tiles above the closet door and the dresser area. 3. Room B-3-W: There were multiple brown splatters on one ceiling tile above the bed. Interview and environmental round with the Environment Services Director on 01/10/13 between 12:05 p.m.-12:50 p.m., he indicated that he and his staff make round each morning, and that a maintenance log is kept at each nursing station, which is checked throughout the day.",2017-10-01
6685,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,282,D,0,1,6UUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to implement a care plan intervention related to the prevention of accidents. This affected one (1) resident, #85, from a sample of forty-three (43) residents. Findings Include: Record review for resident #85 revealed that she was alert and oriented but was occasionally confused. The resident had [DIAGNOSES REDACTED]. The resident was confined to a wheelchair and she had a history of [REDACTED]. A review of the resident's clinical record revealed that on 12/24/12 the resident was found on the floor by he bedside after attempting to get into bed from her wheelchair without assistance. No injury resulted from the incident. Further record revealed that on 12/28/12 the resident was again found on the floor in her room. The resident stated that she was trying to get into her wheelchair to go the the bathroom. She had not requested assistance from staff members. This incident resulted in two small skin tears to her left forearm. Her physician and family were notified. On 01/06/13 she was found in her room on the floor. She stated that she was getting out of wheelchair into her bed and fell . The resident had not requested staff assistance. No injuries resulted from this incident and her physician and family were notified. A review of the resident's care plan revealed that she had an intervention for an automatic wheelchair locking device. The device was not observed on the resident's wheelchair during the first three days of the survey (01/07/13-01/09/13). An interview with a facility Registered Nurse (RN) DD and the Minimum Data Set Coordinator on 01/09/13 at 12:10 p.m. confirmed that the auto-locking device was not attached to the resident's wheelchair. An interview with the facility's Maintenance Director on 01/09/13 revealed that the resident recently went on a leave of absence around New Year's Day and someone had removed the device from her wheelchair. When the resident returned to the facility the safety device was never reattached and no one at the facility noticed that is was not in place.",2017-10-01
6686,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,323,E,0,1,6UUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that safe water temperatures were maintained in resident bathrooms on two (A Hall and B Hall) of six halls; failed to ensure that an antilock device was applied to the wheelchair as care planned to prevent falls for one (#85) of three residents with a history of falls; failed to ensure that a grab bar in one adjoining resident bathroom was secured to the wall on one (A Hall) of six halls; failed to ensure that two toilets in the adjoining resident bathrooms were adequately secured to the floor on two (D Hall and B Hall) of six halls; and failed to ensure that the toilet seat in one adjoining resident bathroom was secured on one (B Hall) of six halls. Findings include: 1. Observations on 01/07/13 between 11:32 a.m. and 12:05 p.m., revealed hot water temperatures above 120 degrees Fahrenheit (F) in the adjoining bathrooms for 12 of 12 rooms on the A Hall and for 12 of 12 rooms on the B Hall. A Hall: 1. In the adjoining bathroom for rooms 1A and 3A, the water from the sink was 139.8 degrees F. 2. In the adjoining bathroom for rooms 2A and 4A, the water from the sink was 140 degrees F. 3. In the adjoining bathroom for rooms 5A and 7A, the water from the sink was 135.3 degrees F 4. In the adjoining bathroom for rooms 6A and 8A, the water from the sink was 132.4 degrees F. 5. In the adjoining bathroom for rooms 9A and 11A, the water from the sink was 134.4 degrees F. 6. In the adjoining bathroom for rooms 10A and 12A, the water from the sink was 131 degrees F. B Hall: 7. In the adjoining bathroom for rooms 1B and 3B, the water from the sink was 139 degrees F. 8. In the adjoining bathroom for rooms 2B and 4B, the water from the sink was 136.4 degrees F. 9. In the adjoining bathroom for rooms 5B and 7B, the water from the sink was 131.9 degrees F. 10. In the adjoining bathroom for rooms 6B and 8B, the water from the sink was 132.3 degrees F. 11. In the adjoining bathroom for rooms 9B and 11B, the water from the sink was 133.9 degrees F. 12. In the adjoining bathroom for rooms 10B and 12B, the water from the sink was 128.2 degrees F. On 01/07/13 at 12: 10 p.m., the Administrator was notified of the unsafe water temperatures. He stated that he was not aware of any problems with elevated unsafe hot water temperatures. During further interview, both the Administrator and the Director of Nurses (DON) stated that none of the residents had been burned. On 01/07/13 at 12:38 p.m., using the the maintenance assistant's digital thermometer, an unsafe hot water temperature was verified in the bathroom for rooms 9A and 11A on the A Hall and was 134.5 degrees F. The maintenance assistant adjusted the temperature gauge at the water heater at that time. On 01/09/13 at 10:00 a.m., the Maintenance Supervisor stated that water temperatures in the residents' bathrooms were checked every week. He provided documentation of the facility's weekly water temperature monitoring at that time. However, review of the Weekly Water Temperature Check form revealed that water temperatures were obtained for only two resident bathrooms in the facility each week since 05/09/12. The water temperature for only one resident bathroom on each floor was obtained monthly on average. The last water temperatures documented on the form were obtained on 12/26/12. Maintenance staff had failed to obtain water temperatures for resident bathrooms as scheduled on 01/03/13. Observations of residents on A Hall and B Hall revealed that there were no burns/injuries observed. 2. Record review for resident #85 revealed that she was alert and oriented but was occasionally confused. The resident had [DIAGNOSES REDACTED]. The resident was confined to a wheelchair and had a history of [REDACTED]. A review of the resident's clinical record revealed that on 12/24/12 the resident was found on the floor by he bedside after attempting to get into bed from her wheelchair without assistance. No injury resulted from the incident. On 12/28/12 the resident was again found on the floor in her room. The resident stated that she was trying to get into her wheelchair to go the the bathroom. She had not requested assistance from staff members. This incident resulted in two small skin tears to her left forearm. On 01/06/13 she was found in her room on the floor. She stated that she was getting out of wheelchair into her bed and fell . The resident had not requested staff assistance. No injuries resulted from this incident. A review of the resident's care plan revealed that she had an intervention for an automatic locking wheelchair device. The device was not observed during 01/07/13 and 01/10/13. 3. On 01/08/13 at 8:28 a.m., the commode seat in the bathroom shared by rooms B-1/B-3 was observed to be freely moveable approximately four (4) inches to the left side. This was verified by the Administrator at 8:50 a.m. The same observation of the loose commode seat was made on 01/10/13, and verified by the Maintenance Director at 8:11 a.m. On 01/08/13 at 9:50 a.m., Licensed Practical Nurse (LPN) GG stated that none of the four residents that shared this bathroom could ambulate independently. 4. During initial tour of the facility on 01/07/13 between 11:30 a.m. and 12:40 p.m., the toilet in bathroom 4-D moved freely back and fourth from the left to the right. The Administrator was notified of this at 2:30 p.m. During random observation on 01/09/13 on the B-hall at 4:30 p.m., in room B-6, the toilet moved freely back and fourth from left to right. The Administrator was notified at 5:13 p.m. 5. During random observation on the A-Hall on 01/09/13 at 5:00 p.m., in room 5-A, the grab bar to the right of the toilet was loose. The Administrator was notified of this on 01/09/13 at 5:30 p.m.",2017-10-01
6687,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,332,E,0,1,6UUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and resident interview, the facility failed to ensure that two (2) of eight (8) nurses on two (2) of six (6) halls administrated medications in a manner to prevent five (5) errors out of fifty-six (56) opportunities, resulting in a 8.92% medication error rate. Findings include: 1.) During medication observation pass with Licensed Practical Nurse (LPN) BB on 01/08/13 at 3:35 p.m. for resident Q, she placed [MEDICATION NAME] one hundred (100) mg, Carvedilol 3.125 mg, and [MEDICATION NAME] one hundred fifty (150) mg. in a white medication cup, along with drawing up in an insulin syringe [MEDICATION NAME]-R of six (6) units of insulin. The LPN stated this was all that resident Q was to receive at that time. Review of the Medication Record for January 2013 revealed that resident Q was to receive [MEDICATION NAME] in the morning and had received this medication on the morning of 01/08/13. Also, Carvedilol was given out of it's timeframe, it was not due until 5:00 p.m. During further review of the Medication Record revealed that [MEDICATION NAME] 20 mg was not given as ordered for 4:30 p.m. Interview with LPN, BB, she concurred that the initials on the Medication Record for January 8, 2013 for [MEDICATION NAME] were hers and also concurred that the [MEDICATION NAME] was left blank (indicating as not given). Further interview with LPN BB at 5:20 p.m., she indicated that she did go back and give resident Q the 4:30 p.m. [MEDICATION NAME]; however, just did not chart it. LPN BB did confirm that the [MEDICATION NAME] was a medication error. Record review revealed resident Q had a MDS, dated [DATE] indicating a cognition score of 15. Interview with resident Q on 1/10/13 at 9:00 a.m., she indicated that on 01/08/13 the nurse did not give her a second insulin injection before supper. 2.) During medication observation pass with LPN AA on 01/09/13 at 8:40 a.m., he was observed to place one (1) white whole twenty-five (25) milligram (mg) [MEDICATION NAME] in a small white medication cup and one (1) ten (10) mg [MEDICATION NAME], in a small white medication cup. LPN AA agreed at the time, along with seven (7) other medications, that this was all the medications that resident #71 was to receive at that time. Observation of the medication cup revealed there was no half pills. However, the blister package of the [MEDICATION NAME] medication said to give a twenty-five (25) mg one-half (1/2) tablet in the morning and at bedtime and one (1) tablet at noon and the [MEDICATION NAME] blister package indicated to give the ten (10) mg tablet in the morning. Review of the Physician order [REDACTED].#71 was to receive [MEDICATION NAME] twenty (20) mg every morning, and [MEDICATION NAME] twenty-five (25) mg one-half (1/2) tablet in the morning and bedtime and one (1) tablet at noon. Interview with LPN AA at 3:20 p.m. on 01/09/13, he confirmed the listed errors.",2017-10-01
6688,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,356,B,0,1,6UUW11,"Based on record review and staff interview, the facility failed to include all of the required information on the nurse staffing posting on three (3) of four (4) days of the survey. Findings include: During observations on initial tour on 01/07/13 beginning at 11:00 a.m., required staffing was not posted, that contained the required nurse staffing information. At 2:20 p.m., a Daily Staffing schedule was noted to be posted across from the Station 1 nurse's station. This form contained the name of the facility, the date, and the names of the staff that were scheduled to work that day per shift. However, the form did NOT contain the census and number of hours worked per category of licensed and unlicensed direct care nursing staff per shift. On 01/08/13 at 8:30 a.m., the Daily Staffing schedule that contained the above information was again observed posted. On 01/09/13 at 9:00 a.m., no posting of nurse staffing information was seen. During interview with the Director of Nurses at 5:20 p.m., she verified that was she was posting the daily staffing schedule, and that it did not contain the census or number of hours worked per staff type.",2017-10-01
6689,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,441,D,0,1,6UUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and inservice review, the facility failed to ensure that personal resident care items and oxygen tubing were stored in a manner to prevent cross contamination. Findings include: During initial tour of the facility on 01/07/13 between 11:30 a.m.-12:40 p.m., the following infection control concerns were identified: 1. On D-Hall: room [ROOM NUMBER]-D: In the bathroom, one (1) unlabeled, uncovered urinal was observed hanging to the right of the toilet on the grab bar and one (1) unlabeled, uncovered green bar of soap to the right of the sink. room [ROOM NUMBER]-D: In the bathroom, one (1) unlabeled, toothbrush on the sink wrapped up in a brown napkin. room [ROOM NUMBER]-D: In the bathroom, one (1) pink oval colored bar of soap on the right side of the sink was observed uncovered and unlabeled. 2. On F-Hall: room [ROOM NUMBER]-F: In the bathroom, one (1) pink unlabeled and uncovered basin was sitting on top of the trash can. The resident room contained four (4) beds. The first bed to the right after entering the room, the oxygen tubing was curled up, uncovered, unlabeled and resting on top of the oxygen concentrator. room [ROOM NUMBER]-F: In the bathroom, one (1) of two (2) pink bath basins were uncovered sitting on the floor in the right corner of the bathroom. room [ROOM NUMBER]-F: In the bathroom, one (1) pink bath basin, sitting on the left corner of the bathtub, unlabeled and uncovered. 3. During random observation on 01/08/13 at 10:13 a.m., the tubing for the oxygen was wrapped once around the leg of the first bed to the right after entering the bedroom then coiled on top of the oxygen concentrator. 4. During random observation on 010/9/13 at 4:30 p.m., one (1) gray unlabeled and uncovered bath basin resting on the back of the toilet in room B-8. 5. On B-Hall On 01/07/13 at 2:46 p.m., and 01/09/13 at 9:15 a.m., an uncontained and unlabeled bath basin was observed on the top of the commode tank in a bathroom shared by four residents in rooms B-9 and B-11. This observation was verified by Certified Nursing Assistant (CNA) II on 01/10/13 at 10:50 a.m., who stated she thought the basin might belong to resident #114. Interview with the Director of Nursing (DON) on 01/10/13 at 10:20 a.m., revealed all personal items were to be labeled, and covered in a bag on stations one (1) and two (2), then on station (3) they are to labeled and covered in a bag and locked in the closet.",2017-10-01
6690,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,456,E,0,1,6UUW11,"Based on observation and staff interview, the facility failed to maintain the working order of laundry equipment used for the entire facility. Findings include: Observation 01/10/13 9:15 a.m. of the facility laundry, two (2) industrial sized washers were in use. One was not working. Two (2) large dryers were noted to be working. One (1) was not. Also observed were three (3) containers 2 and 1/2 feet by 3 and 1/2 feet and approximately 3 feet deep of resident clothing piled double the depth of the containers. Observation in the drying room revealed 2 containers of resident clothing waiting to be dried and 2 bins that contained linens waiting to be dried. The folding area revealed a stack of wash cloths and a stack of towels. The towels were rough to the hand and dingy gray in color. Interview 1/10/13 8:35 a.m. with laundry aide EE revealed that the small washer and one (1) dryer had been out of service for about two (2 ) months. The volume of resident's clothes was about 15 loads and should be completed by the end of the day and that the turn around time was about 2 days for all the clothes. In response to the dingy towels, employee EE responded that the wash cloths were new. She stated that the towels are pulled from use when they get old. Interview on 1/10/13 at 11:25 a.m. with employee FF revealed that at times it was difficult to get residents out of bed because their clothes have not returned from laundry. On 01/07/13 at 2:56 p.m., two pillows without pillowcases were observed on resident #21's bed; the resident resided on B-hall. On 01/08/13 at 11:59 a.m., resident #21 was observed lying in bed with his head on a pillow that did not have a pillowcase on it. On 01/09/13 at 11:30 a.m., a person who visited the facility on a regular basis told the survey team that they had heard that there were broken washing machines in the facility, and had recently observed two large barrels of dirty, odorous laundry in an empty resident room. During interview with Certified Nursing Assistant II on 01/09/13 at 12:20 p.m., she stated there had been a problem with them running out of linen over the last two weeks. At 12:25 p.m., no pillowcases were seen on the B-hall linen cart. The towels on the cart appeared very dingy and gray. Observations on the A-hall linen cart at this time revealed that it contained six pillowcases, but they all appeared gray. During interview with the Laundry Supervisor on 01/09/13 at 12:52 p.m., he stated that one (1) each of the three (3) washers and dryers were currently not working, and they were waiting on parts to fix them.",2017-10-01
6691,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2013-01-10,469,E,0,1,6UUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff and family interviews, the facility failed to ensure that the residents were living in a pest free environment on four (4) of six (6) halls (B, D, E and P). Findings include: A.) During initial tour of the facility on 01/07/13 between 11:30 a.m. and 12:40 p.m., and at 3:55 p.m., the following concerns were identified: 1.) Room D-1: In the bathroom, on the right side wall above the sink a small brown roach was crawling up and in the bedroom closet on the right side two (2) live roaches, crawling and one (1) dead roach observed on the doorframe. Also, one (1) small brown roach crawling on the overbed light for bed B. 2.) Room D-5: When the closet next to the bathroom was opened, on the bottom of the door frame, one (1) medium and two (2) small brown roaches observed. 3.) Room D-4: On the bathroom doorframe, one (1) small brown roach observed. 4.) Room A-14: Two roaches were observed crawling on the bathroom wall. B.) During environmental tour of the facility with the Environmental Services Director, on 1/10/13 between 12:05 p.m.-12:50 p.m., the following concerns were identified: 1.) Room D-1: In the bedroom when the surveyor opened up the closet to the left of the bathroom door one (1) small brown roach was crawling on the lower half of the inside door. 2.) Room D-5: When the closet next to the bathroom was opened one (1) live small brown roach was crawling on the interior wall. Review of the pest control contract dated 10/26/12 revealed that facility was to have services on a monthly basis to the food service area, common areas, and front and back outside areas with twelve (12) each rodent stations. The last visit was on 11/02/12, and at that time the kitchen, offices, refrigerator/stove/dish room were treated. Review of a second contract dated 4/29/12 revealed services were to be provided to the facility to treat rats, mice, and cockroaches. the last visit by this company was on 11/15/12, at which time twenty (20) unidentified rooms were treated for [REDACTED]. C.) Observation on 01/08/13 at 10;10 a.m. on E Hall, room 3, revealed two, live, roaches noted on resident's beverage glass and on floor beside the resident's bedside table. Observation on 01/10/13 at 8:55 a.m. on E Hall revealed a live roach to be crawling on the wall beside the door to the shower room. D.) During the initial tour of the facility on 01/07/13 at 11:30 a.m. an observation of the bathroom between rooms 12P and 14P revealed the presence of (6-7) live roaches on the floor and on the wall. These roaches ranged in size from 1/4-inch to 1-inch in length. Subsequent observations of this bathroom on 1/8/13 at 9:30 a.m. , 01/09/13 at 11:00 a.m. and 01/10/13 at 9:15 a.m. revealed the presence of live roaches crawling on the walls and floor. E.) On 01/09/13 at 1:24 p.m., a family member of resident R stated that they visited the facility three or four times a week, and saw roaches crawling up the walls in resident R's room on each visit. The family member added that they washed resident R's clothing, and noted that roaches were in the laundry brought home from the facility. F.) On 01/10/13 at 10:54 a.m., one live light-brown crawling insect, approximately one-inch long, was observed on the floor at the entrance to room B-7. Interview with Administrator on 1/10/13 at 9:30 a.m., he indicated that the quality assurance committee meets on a monthly meeting which the department heads and other staff members attend and pest control has been addressed in the committee for sometime now. This has been an ongoing issue, the facility has two (2) current pest contracts, that do completely different things and is looking into changing into another one. One (1) pest company treats the resident rooms and one (1) only treats the common areas.",2017-10-01
6692,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-03,279,D,1,0,RF7P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to develop a care plan related to wandering behaviors for one (1) resident (#1) from a sample of fourteen (14) residents. Findings include: Review of the clinical record for resident #1 revealed that the resident was admitted to the facility in January, 2014 with a [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) 3.0 dated 2/10/2014 revealed that the resident wanders on a daily basis and intrudes on the privacy of others. Further review of the Care Area Triggers (CAT) Worksheet dated 9/26/14 revealed that resident had displayed inappropriate behaviors and was currently on [MEDICATION NAME], currently being monitored and a care plan would be developed. Review of the care plan revealed no evidence that a care plan had been developed related to wandering behaviors. Interview with the MDS Coordinator on 9/26/14 at 11:45 a.m., revealed that the Social Worker completes sections B,C,D,E and Q, which includes the behavioral section. Continued interview revealed that there was no care plan for wandering for resident #1 and confirmed that resident #1 was a wandering resident.",2017-10-01
6693,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-03,281,E,1,0,RF7P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and staff interviews, facility failed to ensure that six (6) residents (#1,#6, #7, #8, #9, and #10) out of ten (10) wandering residents had a colored arm band per facility policy from a total sample of fourteen (14). Findings include: 1. Review of the clinical record for resident #1 revealed that the resident was admitted to the facility in January, 2014 with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed with [REDACTED]. Observation of resident #1 on 10/3/14 at 10:34 a.m., revealed the resident walking up to the nursing station talking with staff, no red arm band was on either arm. Continued observation at 11:00 a.m. revealed that resident sitting in the day area without a red arm band on either arm. 2. Review of the clinical record for resident #6 revealed that the resident was admitted to the facility in August, 2014 with [DIAGNOSES REDACTED]. Review of the resident care plan related to wandering updated 8/7/14 revealed that the resident would wear a red arm band. Observation between 10:58 a.m.-11:05 a.m. on 10/3/14 with Registered Nurse (RN) BB, revealed that the resident did not have a red arm band on either arm. 3. Review of the clinical red for resident #7 revealed that the resident was admitted to the for facility in October, 2013 with [DIAGNOSES REDACTED]. Review of the resident care plan revealed a care plan developed 9/12/14 related to wandering . Observation on 10/3/14 at 10:20 a.m revealed the resident sitting in the day area enjoying an activity with no arm band no either arm. RN BB confirmed that the resident did not have a red arm band in place at 11:50 a.m. 4. Review of the clinical record for resident #8 revealed that the resident was admitted to the facility in March, 2014 with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed that resident #8 had a history of [REDACTED]. Observation with Registered Nurse (RN) BB on 10/3/14 at 10:58 a.m., revealed that resident did not have a red arm band on. 5. Review of the clinical record for resident #9 revealed the resident was admitted to the facility in June, 2013 with [DIAGNOSES REDACTED]. Review of the resident care plan for elopement related to wandering behavior dated 8/7/14 revealed and intervention for the resident to wear a red arm band. Observation with RN BB on 10/3/14 at 10:55 a.m., revealed that resident did not have a red arm band on. 6. Review of the clinical record for resident #10 revealed that the resident was admitted to the facility in March, 2012 with [DIAGNOSES REDACTED]. Observation with RN BB between 10:58-11:05 a.m. on 10/3/14, revealed that the resident did not have a red arm band on. Interview with the Administrator on 10/3/14 at 12:10 p.m., revealed that all wandering residents should have a red arm band on and should be care planned for this. Review of the Wandering and Elopement Policy dated 9/21/02 revealed that a resident who is identified as being at risk for wandering and/or elopement will be identified by wearing a colored bracelet or some easily identifiable item of clothing.",2017-10-01
6694,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-03,282,D,1,0,RF7P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility wandering and elopement policy, and staff interview, facility failed to follow the care plan for three (3) residents (#8,#9, and #10) of the ten (10) wandering residents on the secure unit regarding wearing a red arm band from a total sample of fourteen (14) residents. Findings include: 1. Review of the clinical record for resident #8 revealed that the resident was admitted to the facility in March, 2014 with [DIAGNOSES REDACTED]. Review of the significant change Minimum Data Set ((MDS) dated [DATE] revealed that resident has a history of wandering four (4) to six (6) days, but less than daily. Review of resident's care plan for elopement secondary to wandering and exit seeking behavior dated 9/26/14 revealed to wear a red arm band to signify that resident was at risk for elopement. Observation with Registered Nurse (RN) BB on 10/3/14 at 10:58 a.m., revealed that resident did not have a red arm band on. 2. Review of the clinical record for resident #9 revealed the resident was admitted to the facility in June, 2013 with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/16/11 revealed actual elopement secondary to wandering and exit-seeking behavior. Continued review revealed an intervention for the resident to wear a red arm band. Observation with RN BB on 10/3/14 at 10:55 a.m., revealed that resident did not have a red arm band on. 3. Review of the clinical record for resident #10 revealed that the resident was admitted to the facility in March, 2012 with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/1/14 revealed that he was at risk for elopement secondary to wandering and exit seeking behavior due to dementia. Continued review revealed an intervention for the resident to wear a red arm band to signify at risk for elopement. Observation with RN BB between 10:58-11:05 a.m. on 10/3/14, revealed that resident did not have a red arm band on. Interview with the Administrator on 10/3/14 at 12:10 p.m., revealed that all wandering residents should have a red arm band on. Review of the Wandering and Elopement Policy dated 9/21/02 revealed that a resident who is identified as being at risk for wandering and/or elopement will be identified by wearing a colored bracelet or some easily identifiable item of clothing.",2017-10-01
6695,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-03,319,D,1,0,RF7P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and interview with the Psychiatrist, facility failed to ensure that appropriate treatment and services related to psycho social well being were provided for one (1) resident (#2) from a total sample of fourteen (14) residents. Finding include: Review of the clinical record for resident #2 revealed that the resident was admitted to the facility in July, 2014 with a [DIAGNOSES REDACTED].Diff), [DIAGNOSES REDACTED], Chest Pain and [MEDICAL CONDITION]. Review of the /admission Minimum Data Set (MDS) assessment dated revealed that the resident was assessed with [REDACTED]. Review of the resident care plan related to verbal behaviors revealed that the resident was care planned for rude and demanding behavior toward staff. Review of the Nurses Notes dated July 8, 2014-August 10, 2014 revealed that resident was demanding, and rude toward staff, insisting to do what she wanted to do. Continued review revealed that she had to be reminded several times about her isolation about the [DIAGNOSES REDACTED], refusing to bathe, going into other resident's rooms and asking them to contact 911, attempting to exit the facility, demanding that staff give her extra food. She was noted to be yelling and coming behind the nursing station, taking things. Review of the Social Service Note dated 8/5/14 revealed that daughter in law had to come take the phone from resident due to her current behavior (calling 911 and asking numerous residents to call 911), and she was placed on a behavior management program. Review of the Behavior Management Minutes dated August 7, 2014 revealed that resident had been displaying inappropriate behaviors, such as call 911 on a regular basis, very demanding, and having exit seeking behavior. Continued review revealed that family has taken resident's phone, resident has been moved to secure unit, and a consult for a psychiatrist evaluation had been made. Review of the Behavior Management Minutes dated August 14, 2014 revealed that resident continue to display inappropriate behaviors, she is still demanding. She is on the list to see the Psychiatrist. Review of the Behavior Management Minutes dated August 21, 2014 revealed that resident continues to be demanding and hard to redirect when she goes behind the nursing station. Continued review revealed that behavior has decreased some because she is able to engage in some conversation with staff. She is on the list to see the Psychiatrist. Review of the Behavior Management Minutes dated August 27, 2014 revealed that resident is still demanding and refuses to change her house coat. Continued review revealed that staff will continue to redirect her and she remains on the Psychiatrist list for 8/27/14. Review of the August 2014 Psychiatrist's List revealed that the resident was placed on list as #3 out of seven (7) residents in the facility to see the Psychiatrist. Continued review revealed that her behavior included rudeness, and demanding toward the staff, and that she calls 911 often and has had exit seeking behaviors. There was no evidence that the Psychiatrist ever visited or evaluated the resident. Review of the September 2014 Psychiatrist's List revealed no evidence of resident #2 being on that list. Interview with the Administrator and Social Service Director (SSD) on 9/25/14 at 12:52 p.m., revealed that resident was asleep when the Psychiatrist arrived on the unit, he did not wake her up. However, the SSD said that she was already on a behavior management plan, which was reviewed weekly. The Administrator said that the resident was not in the facility when he came back in September 2014, and it usually takes about a week to get the evaluations. Continued interview with the SSD at 1:00 p.m., revealed that the Psychiatrist came to the facility on [DATE]. Interview with the Psychiatrist on 9/29/14 at 2:27 p.m., revealed that he did not see resident #2 on his visit back in August because the facility staff had told him she was doing better. Continued interview revealed that even if a resident is asleep, he would attempt to wake them, it is not his practice to just go past them.",2017-10-01
6696,AMARA HEALTHCARE & REHAB,115150,2021 SCOTT ROAD,AUGUSTA,GA,30906,2014-10-03,323,D,1,0,RF7P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to adequately monitor wandering behavior's to ensure safety for one (1) resident (#1) from a total sample of fourteen (14) residents. Findings include: Review of the clinical record for resident #1 revealed that the resident was admitted to the facility in January, 2014 with a [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) dated [DATE] revealed that the resident had daily wandering behavior with intruding on the privacy of others. Continued review of the Quarterly MDS dated [DATE] revealed that resident wandered at least four to six (4-6) times per day; however, not on a daily basis. Review of a Nurse's Note dated 9/15/14 revealed at 2:15 p.m. resident #1 was involved in an an altercation with another resident. Review of the facility incident report form and the facility investigation revealed that resident #1, who is assessed as a wandering resident, entered another residents room, began touching the other resident's things, moved the privacy curtain aside and began pulling on the resident's legs in an attempt to get her out of the bed. The second resident grabbed a fork and began stabbing the resident. The residents were separated and the physician was notified, along with the responsible party. Review of a physician progress notes [REDACTED].#1 was seen by the physician after the altercation and was assessed with [REDACTED]. The resident was placed on Keflex for prophylaxis and given a Tetanus Toxoid 0.5 cubic centimeters (CC) injection. Interview with the Physician on 10/2/14 at 3:06 p.m., revealed that he came to the facility after the altercation and assessed resident #1, who had superficial puncture wounds on her hand, left chest and abdomen area. Continued interview revealed that he ordered an antibiotic because he did not know if the fork had been in anyone's mouth prior to this incident, but there was no need to send out and it was not a life threatening and/or morbid event. Review of the Treatment Record for September, 2014 revealed an order to apply triple antibiotic ointment (TAO) to all new open areas to face, forehead, hand, abdomen and bilateral lower extremities after cleaning on a daily basis. Review of Nurses Notes dated 9/16/14-9/26/14 revealed that resident continues to be out of her bed and room, in the common day are most of the time, wanders up and about the hallway, and in and out around other resident's rooms, needing lots of redirection from staff. Continued review revealed when redirected to sit back in the day area, resident gets back up and continues with the same behavior. Interview with Licensed Practical Nurse (LPN) EE on 9/25/14 at 1:50 p.m., revealed that resident #1 is one (1) of three (3) wandering resident on the secure unit, and she has to be redirected a lot. Continued interview revealed that the staff attempt to keep her in the day most of the time; however, she requires a lot of redirection. Interview with Registered Nurse (RN) BB on 10/3/14 at 11:40 a.m., revealed that residents who wander are redirected and kept in the day area. During another interview at 1:10 p.m., she stated that there really is not a set time that staff goes around a watch each resident, and stated that the staff tries to keep all the residents in the day area. Continued interview revealed that the staff knows who wanders and if that particular resident leaves the day area, and then the staff will go and redirect them back to the day area.",2017-10-01
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
4135,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2017-03-08,323,J,1,0,03RZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon observation, record review, staff and family interviews the facility failed to provide an environment that was free of accident hazards, including one resident (R#1), with wandering and elopement behaviors and was wearing a Wanderguard, who was found in the parking lot, by staff, the evening of 9/28/2016 then who eloped from the facility's main door, on Saturday, 10/1/2016, and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. This had the likelihood to affect eleven residents (R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11) with wandering behaviors who wore Wanderguard bracelets. The facility's Interim Administrator, Director of Regulatory Compliance, and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/6/2017 at 2:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 9/28/2016, when R#1, wearing a Wanderguard bracelet, was found by staff in the parking lot and then on 10/1/2016 eloped through the front door of the facility and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. The noncompliance related to the Immediate Jeopardy continued through 3/7/2017 and was removed on 3/8/2017. The Immediate Jeopardy is outlined as follows: The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at 42 C.F.R.: 483.25(h), Accidents/Hazards (F323 S/S: J) 483.75, Administration (F490 S/S: J) 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. 483.25(h), Accidents/Hazards (F323 S/S: J). On 3/8/2017, the facility provided a Credible Allegation Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on 3/8/2017. Although based on observations, record reviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/8/2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of residents with Wanderguards to prevent any future elopements from the facility. The oversight process included the analysis of facility staffs' conformance with the facility's Policy and Procedures governing Wanderguards and Elopement. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's Policies and Procedure for Wanderguards and Elopement. Resident records were reviewed to ensure that resident assessments for elopement were completed, that Physician Orders were current and accurate and that care plans were updated for resident with wandering behaviors. Findings include: A telephone interview with the family of R#1 on 2/20/2017 at 5:02 p.m., revealed that the resident had eloped from the facility on 10/1/2016, fell on the main road (Anderson Mill Road), sustained a hematoma to the back of the resident's head and was transferred to the hospital for evaluation on the same day. The family member further revealed that the resident was wearing a Wanderguard bracelet and used a walker for ambulation at the time of the accident. Review of the care plan for R#1 dated 3/15/2016 and revised on 2/20/2017 revealed plans for: Elopement risk/wanderer by attempting to leave facility unattended with intervention including to distract resident from wandering offering pleasant diversions, structured activities, food, conversation, television, book. Wander Alert: Wanderguard bracelet. Review of the resident's care plan initiated 3/15/2016 identified R#1 had a problem with wandering due to confusion. The interventions included distracting the resident from wandering and the care plan interventions did include placement checks, of the Wanderguard, every shift as ordered by physician. Additionally, the care plan revealed a focus note dated 9/28/2016 that the resident was noted in the parking lot. Returned to facility. Further review of the care plan for R#1 revealed that new interventions to prevent elopement were not put into place which is the date the Immediate Jeopardy began. Review of the medical record for R#1 revealed that the resident was admitted into the facility 3/3/2016. Medical [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of eight (8) indicating mild cognitive impairment. Wandering behavior occurred one to three days of the look back period. Review of the functional status revealed R#1 required limited assistance for transfers, walking in her room and in corridors and on the unit and limited assistance for ambulation off the unit. Use of mobility devices include walker and wheelchair. R#1 was assessed to have no falls during the assessment period of 9/29/2016. Interview on 3/6/2017 at 3:27 p.m. with Licensed Practical Nurse (LPN) KK, MDS Coordinator, revealed that she updated R#1 care plan on 9/29/2016 due to the elopement into the parking lot. She further revealed she received the information in the Clinical meeting, where information is shared through reading or hearing the information about a resident. She also stated on the Wednesday morning of 9/29/2016, she was unable to recall, who gave her the information, that resident was found in the parking lot of facility on 9/28/2016. She further revealed that she did not ask for any paper work about the incident or discuss with staff possible new interventions to prevent another elopement. A review of the physician's orders dated 3/9/2016 revealed an order for [REDACTED]. Review of Medication Administration Record (MAR) for R#1 for (MONTH) (YEAR) and October, (YEAR), revealed Wanderguard was checked for placement every shift. An interview with the former Administrator on 2/20/2017 at 6:14 p.m. revealed that she was not aware of a resident with a Wanderguard leaving the facility on 10/1/2016 nor was she aware of R#1 being found in the parking lot on 9/28/2016. She looked at the resident's record, and stated that R#1 did leave from the facility on 10/1/2016 and fell in the street outside of the facility and had to be sent to the hospital. The Administrator further revealed that she is to be called, by staff, for any unusual incident within the facility and doesn't remember getting a phone call about R#1 eloping from the facility. She stated that in the morning meeting at 9 a.m. daily, the Director of Nursing (DON) will read from the 24 Hour Report and the team members will discuss the situation. She revealed that she attends the Morning Meeting but was not certain if she was in the meeting on 10/1/2016 and that she was not aware of the resident's elopement. Review of the facility 24 hour reports for the month of (MONTH) (YEAR) revealed there was no notation of the elopement of R#1 on 9/28/2016. Interview and observation of the door alarm system on 2/20/2017 at 6:30 p.m. with the former Maintenance Director (MD) EEE, revealed that she did not remember a resident eloping from the facility on 10/1/2016 or any resident eloping from the facility. She stated they use a Wanderguard activator to close the door at 7:00 p.m. nightly and open the door at 6:00 a.m. daily. She stated when you press on the door for twenty (20) seconds, the door will reopened and the alarms on the A hall are activated. Additional test by the MD EEE, and observed by the surveyor, of the main egress door indicated a chirping sound when the Wanderguard bracelet was near the door. All Wanderguards (11 residents) were checked at this time for functioning by MD EEE and all were functioning. Interview on 2/21/2017 at 3:41 p.m., by telephone, with LPN FF revealed she was assigned to work on 200 and 400 Halls on the 11:00 p.m. to 7:00 a.m. shift beginning on 9/30/2016 through 10/1/2016 and R#1 was one her residents. She stated that on 10/1/2016 the resident was returned to her unit by Registered Nurse (RN) HH who stated that R#1 had left the building and fell in the street, outside the facility, and was brought back in the facility in a wheelchair. She stated the resident was ok except for a bump on the back of her head. She stated the resident was sent out to the hospital for examination. LPN FF further revealed that she informed the doctor, the family member and the facility Administrator. LPN FF stated it took a minute to get in touch with the Administrator and she told the Administrator what had happen to the resident, the resident elopement and a bump to the back of R#1 head. She also told the Administrator the resident was sent to the hospital. LPN FF stated the Administrator thanked her for the information and stated that RN HH had already contacted her. She stated the Wanderguard was checked and it was working and that she conducted a neurological check on R#1 although she did not document it. She also stated the incident was recorded on the 24 Hour report. Interview on 2/21/2017 at 4:18 p.m. by telephone with RN HH revealed she was assigned to 500 and 600 Halls on 9/30/16 and at around 6:30 a.m. on 10/1/2016 a housekeeper came into Room 618 and told her a resident had fallen on the street outside of the facility. She stated she ran to the street and saw the resident on the sidewalk with her walker. She stated she assessed the resident and the CNA brought a wheelchair outside and she placed R#1 in the wheelchair and returned her to LPN FF for further assessment. RN HH stated it was a very busy night and that she sent a text to the former Administrator with information about the night shift, including the elopement and the resident's name to the Administrator. She further revealed that the Administrator responded by saying what a busy night. Interview on 2/21/2017 at 12:40 p.m. with the Director of Nursing (DON) revealed she was not present in the facility until (MONTH) (YEAR). She further revealed she could not locate any information about the elopement addressed by the interdisciplinary team or any investigation of how the elopement occurred on either 9/28/2016 or 10/1/2016. A telephone interview on 2/21/2017 at 3:15 p.m. with Housekeeper EE revealed that she arrived at the facility on 10/1/2016 at approximately 6:30 a.m. when she saw a female parked half way in the driveway and half way on the street. She stated her husband continued into the facility's parking lot and parked the car. She further revealed that while walking into the facility she heard the lady say one of your resident has fallen in the middle of the street. The housekeeper entered the facility through an open door and got a nurse to help the resident. Two CNAs also helped her to bring the resident back into the facility. Housekeeper EE further revealed that the lady with the black car, at the driveway, was on her phone and called 911. Review of the 911 report, revealed the call came in to Fire and Rescue at 6:38 a.m. on 10/1/2016 but was canceled by the police department who was on scene. Review of Sunrise Sunset times for Austell Georgia on 10/1/2016 revealed that sunrise occurred at 7:08 a.m. and that R#1 fell in the street at approximately 6:30 a.m. on Saturday, 10/1/2016 while it was dark outside. Interview on 2/22/2017 at 2:49 p.m. with the Facility Medical Director (FMD) revealed if the documentation stated he was informed, then he was informed. He further revealed that on 10/2/2016 he was in the building, and did not discuss elopement with anyone. The FMD stated he did not remember elopement being discussed in the QAPI meeting in (MONTH) (YEAR), but falls were discussed including the root cause analysis. Observation, by the surveyor, on Tuesday, 3/7/2017 at 6:40 a.m. until 7:05 a.m. revealed that it was dark, although with street lights, a flashlight was not needed. Observation of the cars along the road revealed a total of one hundred and ninety-four (194) motor vehicles were observed on Anderson Mill Road, directly in front of the facility's entrance to the parking lot. The road has a total of two (2) lanes, measuring twenty-five (25) feet across the street. The motor vehicles included cars, vans, small trucks, SUV, one (1) small school bus, and (1) regular size school bus. The speed limit was thirty-five (35) miles per hour. Anderson Mill Road connects to Highway 5 which is a major thoroughfare in the area. Review of the Progress Notes dated 10/1/2016 at 7:00 a.m. revealed The resident was observed outside the facility by a housekeeping employee, which notified staff at A Hall station. Nursing staff from A Hall Nurse's station observed the resident laying in the road (Anderson Mill Road), and they directed traffic around this resident to avoid her being hit by a car. They then assisted her back into the facility with a wheelchair. Upon assessment, resident able to ambulate with walker, is alert with confusion, which is normal for her. She does have a hematoma on the back of her head. Neurological check done and were within normal limits (WNL) for her. Family notified on 10/1/2016 at 7:00 a.m. and the resident's physician on 10/1/2016 at 6:45 a.m. which was signed by LPN FF. Review of the Transfer Form documents that R#1 was transferred to the hospital on [DATE]. Progress notes dated 10/1/2016 at 11:11 a.m. revealed the resident is in the emergency room . Review of the 24 hour Report/Change of Condition Report dated 9/30/2016 (to include any condition changes within the past 24 hours) revealed that R#1 was sent to the emergency room (ER) at 7:15 a.m. Review of remarks: Elopement (Wanderguard in place) visitor let her out front door. fell in road-hit head (on 10/1/2016), sent to ER 7:15 a.m. Family notified. Physician paged, awaiting response. The surveyor reviewed all 24 hour Report/Change of Condition reports for the month of (MONTH) (YEAR) which did not contain a notation of finding the resident in the parking lot on 9/28/2016. Review of the hospital Emergency records dated 10/1/2016 from 7:45 a.m. until 11:21 a.m. revealed the resident had a small hematoma to scalp. No other complaints, but considering age and relatively frailty, in addition to being on ASA (Aspirin), will get CT scan of head, C-spine x-ray, chest x-ray and pelvis x-ray and labs. Findings on the same day at 9:55 a.m. revealed that labs and imaging unremarkable. Patient feels well and patient's sister at bedside, agrees that she is at her baseline. Will arrange EMS (Emergency Medical Services) transport back to her NH (Nursing Home). Review of the Progress Notes dated 10/1/2016 at 12:46 p.m. revealed resident returned from hospital via EMS per stretcher accompanied per family member without broken or bruised areas. No new orders. Vital signs are stable. No c/o (complaints) voiced. Review of the Direct Supply TELS LOGBOOK D[NAME]UMENTATION for 9/19/2016 through 9/24/2016, 9/27/2016 through 10/1/2016 and 10/3/2016 through 10/8/2016 revealed that seven doors are checked daily to determine: Door is secured, Door opens freely, Door closes smoothly, Door closes quickly, Door latches properly. Review of the Logbook revealed that the current MD FFF checks these doors daily but does not indicate if the Wanderguard system is checked. An interview with the interim MD FFF on 3/7/2017 at 12:32 p.m. revealed that the company responsible for maintaining the Wanderguard system and the door locks was in the building on 2/22/2017 and found there was a cross up between the Wanderguard and the key pad on the main entrance door. He further revealed that the cross up, if someone entered the code into the key pad, would disable the Wanderguard system. The company separated the key pad and the Wanderguard system to ensure that, if someone used the key pad, it would not disable the Wanderguard system. The doors automatically lock between 8:00 p.m. and 8:10 p.m. and reopen automatically between 6:00 a.m. and 6:10 a.m. which MD FFF has checked and are working properly. Review of the Progress Notes dated 10/4/2016 at 11:50 p.m. revealed the resident was complaining of chest pain mid-sternum and transferred to the emergency room . The resident returned from the hospital on the same day at 11:50 a.m. without new orders. Review of the Progress Notes dated 10/9/2016 at 12:35 p.m. revealed the resident has increased confusion, denies pain or discomfort when voiding. Resident has tried to elope and is more confused. The hospital physician called and ordered Macrobid (antibiotic) for seven days for a Urinary Tract Infection (UTI). Record review of the facility policy titled Resident Elopement Revised (MONTH) 2012 revealed: Policy: The facility strives to provide a safe environment and preventive measures for elopement. Personnel must report and investigate all reports of missing residents. Fundamental Information: It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the DON and the Administrator and to document the occurrence. Procedure: Prevention, 1. Facility creates a photographic directory of residents identified at risk for elopement. a. Photograph residents identified at risk for elopement by the Nursing Admission Assessment upon admission. b. Store printed photographs, labeled with resident name and room number, in a binder. Multiple binders may be created if facility has multiple egress locations. Wander/Elopement Alarm Activation: 1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm. b. If a resident is observed attempting to elope, follow the steps outlined below for Attempted Elopement. 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; ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure all residents are accounted for. Attempted Elopement, 1. If an employee observes an attempted elopement, he or she should: a. Be courteous in preventing the departure and in returning the resident to the facility. b. Obtain assistance from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the DON and the Administrator that a resident is attempting to leave the premises. 2. Upon return of the resident to the facility, the Director of Nursing and the Administrator should: a. Examine the resident for injuries (DON), b. Contract the attending physician, report what happened, and follow the physician's orders; c. Contact the resident's legal representative and inform them of the incident; d. Complete and file an Incident/Accident Report, (Briggs), e. Make appropriate notations in the resident's medical record (DON), f. Investigate how the resident attempted to elope and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement Committee; and g. Update the resident's care plan with preventive interventions for elopement (DON). Observation of R#1 on 2/27/2017 at 11:59 a.m. revealed the resident was sitting in her wheelchair, watching television, very pleasant when approached and stated everything was ok. The resident's Wanderguard bracelet was in place. The facility could not produce evidence that the elopement of R#1 had been investigated prior to 2/20/2017, for either the 9/28/2016 or 10/1/2016 elopement, nor to determine the cause of the elopement or interventions to prevent the elopement of R#1 or the 10 residents with Wanderguard bracelets. The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 2/20/2017 a review of the facility Resident Elopement policy was completed by the Facility administration team. An addendum was created, Elopement Response which includes instituting a staff alert/announcement procedure identifying a missing resident as a Code Yellow, location for staff to report to initiate a comprehensive search, notification of the family, physician, facility Administrator, Facility Director of Nursing and the police when necessary. 2. On 2/20/2017 the facility Unit Managers completed a chart review and all residents that are identified at risk for elopement and had Wanderguard in place. 11 residents were reviewed and 1 resident's Wanderguard was discontinued. As of (MONTH) 8, (YEAR) there are 11 residents remain with Wanderguards at this time. These Wanderguards will be checked for placement by the licensed nurse and documented on the Medication Administration Record every shift. These Wandergards are being checked for proper function by a Licensed Nurse and documented on the Medication Administration Record every day. New Admission residents are assessed upon admission for Elopement Risk using the Nursing Data Collection Form. If a resident is found to be at risk a physician order for [REDACTED]. The Wanderguard placement will be checked by the licensed nurse and documented on the Medication Administration Record. The Wanderguard function will be checked by the licensed nurse daily and documented on the Medication Administration Record. 3. On 2/20/2017 the facility Unit Managers completed a new Elopement Assessment on all residents documenting this assessment in the Elopement Assessment form located in Point Click Care. 4. On 2/20/2017 the facility Unit Managers reviewed and updated the care plans for residents at risk for elopement. 5. On 2/20/2017 the interdisciplinary team reviewed and updated the Elopement Risk Binders located at each Nurses station and the front desk. 6. On 2/20/2017 the facility Unit Managers reviewed and updated physician orders for check for placement and functioning of the Wanderguard for every shift. This occurred for 11 residents. 7. On 2/20/2017 the Wanderguard system for the front door of the facility was upgraded, allowing it to remain active even when in Night mode. A new keypad was added for the inside of the building to operate the doors at night, and separated the Wanderguard system from the timer. This allowed the Wanderguard system to remain active and capable of locking the doors 24/7. 8. On 2/20/2017 the District Director of Clinical Services checked the front lobby Wanderguard system and it was functioning properly. 9. On 2/24/2017 the Maintenance Director checked all Wanderguards for functioning and all were functioning properly. Maintenance Director completes checks of Wandergard door system every day and documenting these checks on Weekly Checklist for Door Modules. 10. On 3/6/2017 the Contract Company installed 4 annunciators throughout the facility and installed 1 additional Annunciator panel for staff to be able to quickly tell what door has been breached. 11. On 2/20/2017 at 8:00 p.m. continuous front lobby door monitoring started. An employee was assigned to the front lobby door to observe entrance/exit of staff/visitors/vendors/residents. These observations are documented every hour on the Door Monitoring form. Documentation includes if the door alarms, if the door alarmed, why and what action was taken. 12. On 2/23/2017 the Administrator was placed on Administrative leave and is no longer employed at Anderson Mill as of 3/7/2017. 13. On 3/7/2017 signage was added to the doorways alerting visitors to please do not assist any of our residents outside without checking with the nursing staff. 14. On 2/20/2017 the managers began to educate staff on the Elopement policy. As of 3/7/2017, (89.6%) 138 out of 154 employees which includes the contracted staff were educated and 1 RCS, 1 RN supervisor, 1 Maintenance on LO[NAME] The following employees received the education; 2 Activity employees, 2 Admissions Coordinators, 2 Business office, 1 medical records, 17 LPNs, 2 Maintenance department, 4 MDS, 15 Occupational therapists, 2 front office, 1 receptionist, 30 RCS, 1 Respiratory therapist, 2 Restorative RCS, 1 RN, 2 Social Services, 1 SDC, 1 RN unit manager, 3 LPN unit managers, 1 LPN wound care, 11 Dietary, and 12 Housekeeping/Laundry, 5 Speech Therapists, 1 Rehab aide, 14 physical therapists, 1 DON (interim contracted DON) and 4 agency nurses. Any staff that has not received this education will not be permitted to work until education is completed. Newly hired employees and any new agency staff will receive this education prior to working. The interim Administrator has been educated by the Director of Nursing related to the Elopement policy. 15. On 2/24/2017 the facility department managers began questioning 1 employee per day while in the facility on: What type of events would you report to the Administrator of DON? What would you do if the Administrator or DON did not respond to your call? What would you do if you felt your reported issue was not taken seriously? What would you do if you felt that your supervisor or another manager was not being truthful about events occuring in the facility? Are you aware of any events that have occured that may not have been reported? Do you know where the corporate compliance hotline is? What is code Yellow? What would you do if the Wanderguard system, was alarming, but when you went to the front lobby there was no resident in the area? The Staff Survey Questions monitoring forms were completed with 34 employees from 3/2/24- 3/5/17, 20 employees on3/6/2017, 19 employees on 3/7/2017 and documented on Staff Survey Question monitoring forms. 16. An Adhoc QAPI meeting was held on 3/6/2017 at 12:30pm. Medical Director attended by conference call and the following employees were present; interim Administrator, A/R coordinator, interim DON, Medical Records Coordinator, LPN DD, Unit Manager, Registered Nurse HHH, MDS Manager, Social Services (SS) Director QQ, SS assistant III, Admission Coordinator, Interim Rehab Program Manager, Business Office Director, Activity Director, interim Maintenance Director and the Director of Regulatory Compliance. Agenda items related to both complaint surveys. 17. On 2/20/2017 the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance Committee each month by the Administrator and/or the DON, to allow the QA committee to monitor staff compliance with the facility's policies and procedures regarding Resident Elopement and Elopement Response. The State Survey Agency validated on 3/8/2017 the corrective action taken by the facility as follows: 1. Review of the addendum to the Elopement Policy titled Elopement Response dated 2/20/2017 signed by the interim Administrator. Notification by using Code Yellow for missing resident was implemented then to follow the current policy for notification. 2. Review on 3/8/2017 of the facility Wanderguard list revealed eleven (11) residents on the list. Review of the Medication Administration Record (MAR) for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10 and R#11, revealed that the documentation of the Wanderguards are on the MARs with note to check for placement and functioning, a Physician's order for the Wanderguard was noted for each resident. Review of the Elopement Books revealed that all eleven resident's had their photographs and information entered into the Elopement Books kept at the Nurse's Station. There were no new admissions to check at this time. 3. Review of Point Click Care for the eleven residents with wandering behaviors the surveyor confirmed that all eleven residents were assessed for Elopement risk on 2/20/2017. Two residents, R#8 and R#10, were assessed with [REDACTED]. Review of the Elopement Assessment, dated 2/20/2017, for R#17, R#18, R#19, R#20, R#21, R#22, R#23, R#24, R#25, R#26, R#27, R#28, R#29, R#30, R#31 and R#32 revealed the residents were not at risk nor had behaviors that would warrant the use of a Wanderguard. 4. Review of the Care Plans for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10 and R#11 revealed an update dated 2/20/2017 that the residents are an elopement risk/wander. Resident wanders aimlessly, impaired safety awareness. Interventions: Check placement and function of safety monitoring device every shift, Observe location at regular and frequent intervals. Document wandering behavior and attempted diversional interventions. The care plans were additionally personalized for each resident. 5. Review of the Elopement Risk Binders located at each Nurse's Station and the Front desk revealed the binder's had been updated to include the 11 resident's currently at risk for elopement. 6. Review of the Physician's Orders revealed the orders were updated for check for placement and functioning of Wanderguard for every shift for the eleven residents with Wanderguards. 7. Review of the Contractor invoice dated 2/22/2017 that the Wanderguard has been separated from the Key Pad and locks to work independently. Further review reveals the Contractor also educated staff on the Egress Locks. Observation on 3/8/2017 at 3:00 p.m. with the Maintenance Director revealed the new keypad and the separation of the Wanderguard from the timer and the Wanderguard system is working properly. 8. Review on 3/8/2017 of the checklist titled Wanderguard System Check dated 2/20/2017 through 2/23/2017 was completed by the Director of Clinical Services three times each day. 9. Review on 3/8/2017 revealed that the interim MD was checking the Wanderguard system daily and was noted on the daily door checklist. 10. Review of the Contractor invoice dated 3/6/2017 revealed that one secondary Wanderguard annunciator had been installed on the rear Nurse's Station (B Hall) which will allow staff to see which door had been breached. Additionally, four alarms had been added throughout the facility to alarm staff of a Wanderguard breach. This was confirmed by Observation, by the surveyor, on 3/8/2017 at 3:00 p.m. with the interim MD. 11. Review of the hourly monitoring of the front door sign off sheets revealed that staff had been assigned to the door and noted hourly beginning 2/20/2017 at 8:00 p.m. and continued through 3/7/2017 at 9:00 a.m. 12. Notification via e-mail was received by the State Survey Agency on 2/28/2017 at 12:48 p.m. from the facility's corporate office that the Administrator had been placed on administrative leave as of 2/23/2017, pending investigation of R#1's elopement on 10/1/2017 . Review of the Separation Noticed dated 3/8/2017 revealed that the Administrator (referred to as previous) had been terminated from employment as of 3/7/2017. 13. Observation on 3/8/2017 at 3:15 p.m. revealed the signage at the doorways stating Attention Visitors and Family Members: For the safety of our resident's please do not assist other residents outside of the facility without staff approval. 14. Review of the in-service sign-in sheets revealed that in-services were held on 2/20/2017 with 68 staff in-serviced, 2/22/2017 with 52 staff in-serviced, on 2/23/2017 with six staff members in-serviced and one staff member was in-serviced on 2/24/2017 and 10 employees in-serviced on 3/7/2017 for a total of 137 staff members (direct employees and contract employees) of",2020-03-01
4136,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2017-03-08,490,J,1,0,03RZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family and staff interviews, record review and review of the facility's Policy and Procedure for Elopement, it was determined the facility failed to be administered in a manner to investigate an Elopement of one resident (R#1) as to the cause and to prevent the likelyhood of elopement for the additional ten (10) at risk residents (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11) of a total of eleven residents with wandering behaviors and wearing a Wanderguard bracelet. The facility's Interim Administrator, Director of Regulatory Compliance, and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/6/2017 at 2:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 9/28/2016, the date a resident (R#1) wearing a Wanderguard, was found in the parking lot by staff on the 3:00 p.m. to 11:00 p.m. shift followed on 10/1/2017 when the resident eloped through the front door of the facility and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. The noncompliance related to the Immediate Jeopardy continued through 3/7/2017 and was removed on 3/8/2017. The Immediate Jeopardy is outlined as follows: The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at 42 C.F.R.: 483.25(h), Accidents/Hazards (F323 S/S: J) 483.75, Administration (F490 S/S: J) 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. 483.25(h), Accidents/Hazards (F323 S/S: J). On 3/8/2017, the facility provided a Credible Allegation Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on 3/8/2017. Based on observations, record reviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/8/2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of residents with Wanderguards to prevent any future elopements from the facility. The oversight process included the analysis of facility staffs' conformance with the facility's Policy and Procedures governing Wanderguards and Elopement. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's Policies and Procedure for Wanderguards and Elopement. Resident records were reviewed to ensure that resident assessments for elopement were completed, that Physician Orders were current and accurate and that care plans were updated for resident with wandering behaviors. Findings include: During a telephone interview with a family member of R#1 on 2/20/2017 at 5:00 p.m., the family member revealed that R#1 had eloped from the facility on 10/1/2016 and had fallen in the main road (Anderson Mill Road). R#1 had sustained a hematoma to the back of the resident's head and was transported to the emergency room for evaluation. The family member confirmed that R#1 was wearing a Wanderguard bracelet at the time of the elopement on 10/1/2016 and used a walker for ambulation. Review of the resident's care plan dated 3/15/2017 and revised on 2/20/2017 revealed the resident was care planned for wandering behaviors, confusion and for the use of a Wanderguard bracelet due to exit seeking behaviors. Additionally, the care plan revealed a focus note dated 9/28/2016 that the resident was noted in the parking lot. Returned to facility. Further review of the care plan for R#1 revealed that new interventions to prevent elopement were not put into place which is the date the Immediate Jeopardy began. An interview with the former Administrator on 2/20/2017 at 6:14 p.m. revealed that she was not aware of a resident with a Wanderguard leaving the facility on 10/1/2016 nor was she aware of R#1 being found in the parking lot on 9/28/2016. She looked at the resident's record, and stated that R#1 did leave from the facility on 10/1/2016 and fell in the street outside of the facility and had to be sent to the hospital. The Administrator further revealed that she is to be called, by staff, for any unusual incident within the facility and doesn't remember getting a phone call about R#1 eloping from the facility. The Administrator revealed that the facility has a morning meeting daily at 9:00 a.m. which she attends although she was not certain if she had attended the meeting on 10/1/2016 and that she was not aware of the resident's elopement. Review of the facility 24 hour reports for (MONTH) (YEAR) revealed there was no notation of the elopement of R#1 on 9/28/2016. Interview and observation of the door alarm system on 2/20/2017 at 6:30 p.m. with the former Maintenance Director (MD) EEE, revealed that she did not remember a resident eloping from the facility on 10/1/2016 or any resident eloping from the facility. Test by the MD EEE, and observed by the surveyor, of the main egress door indicated a chirping sound when the Wanderguard bracelet was near the door. All Wanderguards (11 residents) were checked at this time for functioning by MD EEE and all were functioning. Interview on 2/21/2017 at 3:41 p.m., by telephone, with Licensed Practical Nurse (LPN) FF revealed she was assigned to work on 200 and 400 Halls on the 11:00 p.m. to 7:00 a.m. shift on 9/30/2016 and R#1 was one her residents. She stated the resident was returned to her unit by Registered Nurse (RN) HH who stated that R#1had left the building and fell in the street, outside the facility, and was brought back in the facility in a wheelchair. She stated the resident was ok except for a bump on the back of her head. She stated the resident was sent out to the hospital for examination. LPN FF further revealed that she informed the doctor, the family member and the facility Administrator. LPN FF stated it took a minute to get in touch with the Administrator and she told the Administrator what had happen to the resident, the resident elopement and a bump to the back of R#1 head. She also told the Administrator the resident was sent to the hospital. LPN FF stated the Administrator thanked her for the information and stated that RN HH had already contacted her. She stated the Wanderguard was checked and it was working and that she conducted a neurological check on R#1 although she did not document it. She also stated the incident was recorded on the 24 Hour report. Interview on 2/21/2017 at 4:18 p.m. by telephone with Registered Nurse (RN) HH revealed she was assigned to 500 and 600 Halls on 9/30/16 and at around 6:30 a.m. on 10/1/2016 a housekeeper came into room [ROOM NUMBER] and told her a resident had fallen on the street outside of the facility. She stated she ran to the street and saw the resident on the sidewalk with her walker. She stated she assessed the resident and the Certified Nursing Assistant (CNA) brought a wheelchair outside and she placed R#1 in the wheelchair and returned her to LPN FF for further assessment. RN HH stated it was a very busy night and that she sent a text to the former Administrator with information about the night shift, including the elopement and the resident's name to the Administrator. She further revealed that the Administrator responded by saying what a busy night. Record review of the facility policy titled Resident Elopement Revised (MONTH) 2012 revealed: Policy: The facility strives to provide a safe environment and preventive measures for elopement. Personnel must report and investigate all reports of missing residents. Fundamental Information: It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the DON and the Administrator and to document the occurrence. Procedure: Prevention, 1. Facility creates a photographic directory of residents identified at risk for elopement. a. Photograph residents identified at risk for elopement by the Nursing Admission Assessment upon admission. b. Store printed photographs, labeled with resident name and room number, in a binder. Multiple binders may be created if facility has multiple egress locations. Wander/Elopement Alarm Activation: 1. If an employee hears a door alarm, he or she should: a. Immediately go to the site of the alarm. b. If a resident is observed attempting to elope, follow the steps outlined below for Attempted Elopement. 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; ii. Notify the Director of Nursing and the Administrator immediately; and iii. Complete a head count to ensure all residents are accounted for. Attempted Elopement, 1. If an employee observes an attempted elopement, he or she should: a. Be courteous in preventing the departure and in returning the resident to the facility. b. Obtain assistance from other staff members in the immediate vicinity, if necessary; and c. Instruct another staff member to inform the DON and the Administrator that a resident is attempting to leave the premises. 2. Upon return of the resident to the facility, the Director of Nursing and the Administrator should: a. Examine the resident for injuries (DON), b. Contract the attending physician, report what happened, and follow the physician's orders; c. Contact the resident's legal representative and inform them of the incident; d. Complete and file an Incident/Accident Report, (Briggs), e. Make appropriate notations in the resident's medical record (DON), f. Investigate how the resident attempted to elope and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement Committee; and g. Update the resident's care plan with preventive interventions for elopement (DON). The facility could not produce evidence that the elopement of R#1 had been investigated prior to 2/20/2017, for either the 9/28/2016 or 10/1/2016 elopement, nor to determine the cause of the elopement or interventions to prevent the elopement of R#1 or the 10 residents with Wanderguard bracelets. Cross refer to F323 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 2/20/2017 a review of the facility Resident Elopement policy was completed by the Facility administration team. An addendum was created, Elopement Response which includes instituting a staff alert/announcement procedure identifying a missing resident as a Code Yellow, location for staff to report to initiate a comprehensive search, notification of the family, physician, facility Administrator, Facility Director of Nursing and the police when necessary. 2. On 2/22/2017 the Wanderguard system for the front door of the facility was upgraded, allowing it to remain active even when in Night mode. A new keypad was added for the inside of the building to operate the doors at night, and separated the Wanderguard system from the timer. This allowed the Wanderguard system to remain active and capable of locking the doors 24/7. 3. On 2/20/2017 at 8:00 p.m. continuous front lobby door monitoring started. An employee was assigned to the front lobby door to observe entrance/exit of staff/visitors/vendors/residents. These observations are documented every hour on the Door Monitoring form. Documentation includes if the door alarms and if the door alarmed, why and what action was taken. 4. On 2/23/2017 the Administrator was placed on Administrative leave and is no longer employed at[NAME]Mill as of 3/7/2017. The State Survey Agency validated on 3/8/2017 the corrective action taken by the facility as follows: 1. Review of the addendum to the Elopement Policy titled Elopement Response dated 2/20/2017 signed by the interim Administrator. Notification by using Code Yellow for missing resident was implemented then to follow the current policy for notification. 2. Review of the Contractor invoice dated 2/22/2017 that the Wanderguard has been separated from the Key Pad and locks to work independently. Further review reveals the Contractor also educated staff on the Egress Locks. Observation on 3/8/2017 at 3:00 p.m. with the Maintenance Director revealed the new keypad and the separation of the Wanderguard from the timer and the Wanderguard system is working properly. 3. Review of the hourly monitoring of the front door sign off sheets revealed that staff had been assigned to the door and noted hourly beginning 2/20/2017 at 8:00 p.m. and continued through 3/7/2017 at 9:00 a.m. 4. Notification via e-mail was received by the State Survey Agency on 2/28/2017 at 12:48 p.m. from the facility's corporate office that the Administrator had been placed on administrative leave as of 2/23/2017, pending investigation of the 10/1/2016 Elopement of R#1. Review of the Separation Noticed dated 3/8/2017 revealed that the Administrator (referred to as previous) had been terminated from employment as of 3/7/2017.",2020-03-01
4137,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2017-03-08,520,J,1,0,03RZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and staff interview, it was determined that the facility failed to maintain a Quality Assurance Performance Improvement (QAPI) committee that identified, developed and implemented corrective action plans to correct a problem of the Wanderguard System not functioning properly to prevent the Elopement of one resident (R#1) and to ensure that ten (R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10, and R#11) additional residents with wandering behavior, who were wearing Wanderguards bracelets did not exit the facility unattended. The facility's Interim Administrator, Director of Regulatory Compliance, and the Interim Director of Nursing (DON) were notified of the Immediate Jeopardy on 3/6/2017 at 2:00 p.m. The non-compliance related to the Immediate Jeopardy was identified to have existed on 9/28/2016, when R#1, wearing a Wanderguard bracelet, was found by staff in the parking lot and then on 10/1/2016 eloped through the front door of the facility and fell on the main road (Anderson Mill Road) sustaining a hematoma to the back of her head. The noncompliance related to the Immediate Jeopardy continued through 3/7/2017 and was removed on 3/8/2017. The Immediate Jeopardy is outlined as follows: The Immediate Jeopardy was related to the facility's non-compliance with the program requirements at 42 C.F.R.: 483.25(h), Accidents/Hazards (F323 S/S: J) 483.75, Administration (F490 S/S: J) 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. 483.25(h), Accidents/Hazards (F323 S/S: J). On 3/8/2017, the facility provided a Credible Allegation Compliance (A[NAME]) of Jeopardy Removal alleging that interventions had been put into place to remove the immediate jeopardy on 3/8/2017. Based on observations, record reviews and review of the facility's policies as outlined in the Credible Allegation of Compliance, it was validated that the corrective plans and the immediacy of the deficient practice was removed on 3/8/2017. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of residents with Wanderguards to prevent any future elopements from the facility. The oversight process included the analysis of facility staffs' conformance with the facility's Policy and Procedures governing Wanderguards and Elopement. In-service materials and records were reviewed. Observation and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's Policies and Procedure for Wanderguards and Elopement. Resident records were reviewed to ensure that resident assessments for elopement were completed, that Physician order [REDACTED]. Findings include: An interview on 3/8/2017 at 6:22 p.m., with the interim Administrator, revealed that the QAPI meets monthly. The interim Administrator revealed that the QAPI meetings were held on 10/19/2016 and 12/21/2016 although there was no evidence that Elopement was discussed in these meetings. The interim Administrator did produce sign-in sheets from the Adhoc QAPI meeting held on 3/6/2017 where the Immediate Jeopardy related to Elopement and Wanderguards was discussed, the Allegation of Credible Compliance (A[NAME]) was addressed and the Action Plan, to prevent further elopement which the facility began immediately on 2/20/2017 when the problem with the main entrance was brought to the facility's attention. An interview with the Medical Director on 2/22/2017 at 2:49 p.m. revealed that he attended the (MONTH) (YEAR) QAPI meeting but does not remember discuss anything related to elopements. He further revealed he does remember that falls were discuss during that meeting. Review of the QAPI meeting sign-in sheets revealed that on 10/19/2016 the QAPI committee met with the Administrator and the Medical Director were in attendance. Review of the QAPI sign-in sheet for 12/21/2016 revealed that the Administrator and the Medical Director were in attendance. Review of the QAPI sign-in sheet for 3/6/2017 revealed the interim Administrator, the interim Director of Nursing (DON), and the Medical Director, via conference call, plus representatives of multiple departments of the facility. An interview with the interim Administrator on 3/8/2017 at 7:30 p.m. revealed that the facility could not produce evidence that the Elopement of R#1 on 9/28/2016 and on 10/1/2016 was addressed by the QAPI committee until 3/6/2017. Cross refer to F323 The facility implemented the following actions to remove the Immediate Jeopardy: 1. On 2/20/2017 a review of the facility Resident Elopement policy was completed by the Facility administration team. An addendum was created, Elopement Response which includes instituting a staff alert/announcement procedure identifying a missing resident as a Code Yellow, location for staff to report to initiate a comprehensive search, notification of the family, physician, facility Administrator, Facility Director of Nursing and the police when necessary. 2. On 2/20/2017 the facility Unit Managers completed a chart review and all residents that are identified at risk for elopement and had Wanderguard in place. 11 residents were reviewed and 1 resident's Wanderguard was discontinued. As of 3/8/2017 there are 11 residents remaining with Wanderguards at this time. These Wanderguards will be checked for placement by the licensed nurse and documented on the Medication Administration Record every shift. These Wandergards are being checked for proper function by a Licensed Nurse and documented on the Medication Administration Record every day. New Admission residents are assessed upon admission for Elopement Risk using the Nursing Data Collection Form. If a resident is found to be at risk a physician order [REDACTED]. The Wanderguard placement will be checked by the licensed nurse and documented on the Medication Administration Record. The Wanderguard function will be checked by the licensed nurse daily and documented on the Medication Administration Record. 3. On 2/20/2017 the facility Unit Managers completed a new Elopement Assessment on all residents documenting this assessment in the Elopement Assessment form located in Point Click Care. 4. On 2/20/2017 the facility Unit Managers reviewed and updated the care plans for residents at risk for elopement. 5. On 2/20/2017 the interdisciplinary team reviewed and updated the Elopement Risk Binders located at each Nurses station and the front desk. 6. On 2/20/2017 the facility Unit Managers reviewed and updated physician orders [REDACTED]. This occurred for 11 residents. 7. On 2/22/2017 the Wanderguard system for the front door of the facility was upgraded, allowing it to remain active even when in Night mode. A new keypad was added for the inside of the building to operate the doors at night, and separated the Wanderguard system from the timer. This allowed the Wanderguard system to remain active and capable of locking the doors 24/7. 8. On 2/20/2017 the District Director of Clinical Services checked the front lobby Wanderguard system and it was functioning properly. 9. On 2/24/2017 the Maintenance Director checked all Wanderguards for functioning and all were functioning properly. Maintenance Director completes checks of Wandergard door system every day and documenting these checks on Weekly Checklist for Door Modules. 10. On (MONTH) 6, (YEAR) the contractor installed 4 annunciators throughout the facility and installed 1 additional Annunciator panel for staff to be able to quickly tell what door has been breached. 11. On 2/20/2017 at 8 p.m. continuous front lobby door monitoring started. An employee was assigned to the front lobby door to observe entrance/exit of staff/visitors/vendors/residents. These observations are documented every hour on the Door Monitoring form. Documentation includes if the door alarms, if the door alarmed, why and what action was taken. 12. On 2/23/2017 the Administrator was placed on Administrative leave and is no longer employed at Anderson Mill as of (MONTH) 7, (YEAR). 13. On 3/7/2017 signage was added to the doorways alerting visitors to please do not assist any of our residents outside without checking with the nursing staff. 14. On 2/20/2017 the managers began to educate staff on the Elopement policy. As of 3/7/2017 , (89.6%) 138 out of 154 employees which includes the contracted staff were educated and 1 RCS, 1 RN supervisor, 1 Maintenance on LO[NAME] The following employees received the education; 2 Activity employees, 2 Admissions Coordinators, 2 Business office, 1 medical records, 17 LPNs, 2 Maintenance department, 4 MDS, 15 Occupational therapists, 2 front office, 1 receptionist, 30 RCS, 1 Respiratory therapist, 2 Restorative RCS, 1 RN, 2 Social Services, 1 SDC, 1 RN unit manager, 3 LPN unit managers, 1 LPN wound care, 11 Dietary, and 12 Housekeeping/Laundry, 5 Speech Therapists, 1 Rehab aide, 14 physical therapists, 1 DON (interim contracted DON) and 4 agency nurses. Any staff that has not received this education will not be permitted to work until education is completed. Newly hired employees and any new agency staff will receive this education prior to working. The interim Administrator has been educated by the Director of Nursing related to the Elopement policy. 15. On 2/20/2017 the facility department managers began questioning 1 employee per day while in the facility on: What type of events would you report to the Administrator of DON? What would you do if the Administrator or DON did not respond to your call? What would you do if you felt your reported issue was not taken seriously? What would you do if you felt that your supervisor or another manager was not being truthful about events occuring in the facility? Are you aware of any events that have occured that may not have been reported? Do you know where the corporate compliance hotline is? What is code Yellow? What would you do if the Wanderguard system, was alarming, but when you went to the front lobby there was no resident in the area? The Staff Survey Questions monitoring forms were completed with 34 employees from 2/24/2017 through 3/5/17, 20 employees on 3/6/2017, 19 employees on (MONTH) 7, (YEAR) and documented on Staff Survey Question monitoring forms. 16. An Adhoc QAPI meeting was held on 3/6/2017 at 12:30pm. Medical Director attended by conference call and the following employees were present; interim Administrator, A/R coordinator, interim DON, Medical Records Coordinator, LPN DD, Unit Manager, Registered Nurse HHH, MDS Manager, Social Services (SS) Director QQ, SS assistant III, Admission Coordinator, Interim Rehab Program Manager, Business Office Director, Activity Director, interim Maintenance Director and the Director of Regulatory Compliance. Agenda items related to both complaint surveys. 17. On 2/20/2017 the facility implemented a procedure by which the results of the monitoring referenced above, to be documented on the audit monitoring and completed tools form, would be presented to the Quality Assurance Committee each month by the Administrator and/or the DON, to allow the QA committee to monitor staff compliance with the facility's policies and procedures regarding Resident Elopement and Elopement Response. The State Survey Agency validated on 3/8/2017 the corrective action taken by the facility as follows: 1. Review of the addendum to the Elopement Policy titled Elopement Response dated 2/20/2017 signed by the interim Administrator. Notification by using Code Yellow for missing resident was implemented then to follow the current policy for notification. 2. Review on 3/8/2017 of the facility Wanderguard list revealed eleven (11) residents on the list. Review of the Medication Administration Record (MAR) for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10 and R#11, revealed that the documentation of the Wanderguards are on the MARs with note to check for placement and functioning, a physician's orders [REDACTED]. Review of the Elopement Books revealed that all eleven resident's had their photographs and information entered into the Elopement Books kept at the Nurse's Station. There were no new admissions to check at this time. 3. Review of Point Click Care for the eleven residents with wandering behaviors the surveyor confirmed that all eleven residents were assessed for Elopement risk on 2/20/2017. Two residents, R#8 and R#10, were assessed with [REDACTED]. Review of the Elopement Assessment, dated 2/20/2017, for R#17, R#18, R#19, R#20, R#21, R#22, R#23, R#24, R#25, R#26, R#27, R#28, R#29, R#30, R#31 and R#32 revealed the residents were not at risk nor had behaviors that would warrant the use of a Wanderguard. 4. Review of the Care Plans for R#1, R#2, R#3, R#4, R#5, R#6, R#7, R#8, R#9, R#10 and R#11 revealed an update dated 2/20/2017 that the residents are an elopement risk/wander. Resident wanders aimlessly, impaired safety awareness. Interventions: Check placement and function of safety monitoring device every shift, Observe location at regular and frequent intervals. Document wandering behavior and attempted diversional interventions. The care plans were additionally personalized for each resident. 5. Review of the Elopement Risk Binders located at each Nurse's Station and the Front desk revealed the binder's had been updated to include the 11 resident's currently at risk for elopement. 6. Review of the physician's orders [REDACTED]. 7. Review of the Contractor invoice dated 2/22/2017 that the Wanderguard has been separated from the Key Pad and locks to work independently. Further review reveals the Contractor also educated staff on the Egress Locks. Observation on 3/8/2017 at 3:00 p.m. with the Maintenance Director revealed the new keypad and the separation of the Wanderguard from the timer and the Wanderguard system is working properly. 8.8. Review on 3/8/2017 of the checklist titled Wanderguard System Check dated 2/20/2017 through 2/23/2017 was completed by the Director of Clinical Services three times each day. 9. Review on 3/8/2017 revealed that the interim MD was checking the Wanderguard system daily and was noted on the daily door checklist. 10. Review of the Contractor invoice dated 3/6/2017 revealed that one secondary Wanderguard annunciator had been installed on the rear Nurse's Station (B Hall) which will allow staff to see which door had been breached. Additionally, four alarms had been added throughout the facility to alarm staff of a Wanderguard breach. This was confirmed by Observation, by the surveyor, on 3/8/2017 at 3:00 p.m. with the interim MD. 11. Review of the hourly monitoring of the front door sign off sheets revealed that staff had been assigned to the door and noted hourly beginning 2/20/2017 at 8:00 p.m. and continued through 3/7/2017 at 9:00 a.m. 12. Notification via e-mail was received by the State Survey Agency on 2/28/2017 at 12:48 p.m. from the facility's corporate office that the Administrator had been placed on administrative leave as of 2/23/2017. Review of the Separation Noticed dated 3/8/2017 revealed that the Administrator (referred to as previous) had been terminated from employment as of 3/7/2017. 13. Observation on 3/8/2017 at 3:15 p.m. revealed the signage at the doorways stating Attention Visitors and Family Members: For the safety of our resident's please do not assist other residents outside of the facility without staff approval. 14. Review of the in-service sign-in sheets revealed that in-services were held on 2/20/2017 with 68 staff in-serviced, 2/22/2017 with 52 staff in-serviced, on 2/23/2017 with six staff members in-serviced and one staff member was in-serviced on 2/24/2017 and 10 employees in-serviced on 3/7/2017 for a total of 137 staff members (direct employees and contract employees) of 154 employees related to the updated Elopement Policy and Procedures and the Reporting Process for direct care and indirect staff. In-services continued, including re-in-service of staff on 3/6/2017 with 12 staff receiving in-service, 3/7/2017 with two staff in-serviced and 3/8/2017 for both direct and indirect resident care staff. An interview with the Social Service Director (SSD) QQ on 3/8/2017 at 3:55 p.m. revealed that she had been in-serviced on the updated Elopement Policy and Procedures and the Reporting Process. She was questioned on her knowledge of the process and was aware of the updated policy and procedure and who to contact should someone elope or attempt to elope from the facility. Interviews with Resident Care Specialists (RCS), also known as Certified Nursing Assistant (CNAs) on 3/8/2017 revealed that RCS RR at 3:58 p.m., RCS TT at 4:05 p.m., RCS VV at 4:15 p.m., RCS XX at 4:25 p.m., RCS YY at 4:30 p.m. and RCS ZZ at 5:00 p.m. had attended in-services regarding the updated Elopement Policy and Procedures, Reporting Process and ensure that resident's with Wanderguards had them in place. They were aware of what events to report to the DON and/or Administrator and what to do if they did not respond to their call, what a Code Yellow is and what to do if the Wanderguard system is alarming. They were aware of how to report to the Corporate Compliance line and the SSA complaint number as well. An interview with Housekeeper OO on 3/8/2017 at 3:50 p.m. revealed that he had attended in-service on 2/22/2017 regarding the updated Elopement Policy and Procedure and Reporting Process. He was aware of what events to report to the DON and/or Administrator and what to do if they did not respond to their call, what a Code Yellow is and what to do if the Wanderguard system is alarming. He was also aware of how to report to the Corporate Compliance line and the SSA complaint number as well. An interview, on 3/8/2017 with Licensed Practical Nurses (LPNs) revealed that LPN NN at 3:40 p.m., LPN SS at 4:00 p.m., LPN UU at 4:10 p.m., LPN WW at 4:20 p.m. and LPN DD, Unit Manager at 5:30 p.m. had all attended in-services regarding the updated Elopement Policy and Procedure and Report Process. They were aware that Wanderguards are to be checked for placement every shift and documented. They knew what events to report to the Administrator and/or DON and who to contact should the incident no be addressed or if they did not received a response. They were aware of the Corporate Compliance line number and how to contact the SS[NAME] Interviews on 3/8/2017 with Dietary Training Manager BBB at 6:40 p.m., Dietary Manager CCC at 6:47 p.m. and Dietary Aide DDD at 6:49 p.m. revealed that they had attended in-services on the updated Elopement Policy and Procedure and were aware of what to do if they heard the Wanderguard system alarming, who to report this incident to and who to report if there was no response. They were aware of the Corporate Compliance line and how to report to the SS[NAME] 15. Review of the Staff Survey Questions form revealed that the facility department managers were questioning one employee per day utilizing the Staff Survey Questions form. Review of the Staff Survey Questions revealed that on 2/24/2017, 25 staff had completed questionnaires, on 2/25/2017, two staff had completed questionnaires, on 2/26/2017 one staff member had completed the questionnaire, on 2/27/2017, 14 staff had completed questionnaires, on 2/24/2017, 14 staff had completed questionnaires, on 3/1/2017, two staff had completed questionnaires, on 3/2/2017, two staff had completed questionnaires, on 3/3/2017, six staff had completed questionnaires, on 3/4/2017, one staff had completed questionnaires, on 35/2017, one staff had completed questionnaires, on 3/5/2017, one staff had completed questionnaires, on 3/6/2017, 43 staff had completed questionnaires, on 3/7/2017, 55 staff had completed questionnaires, on 3/8/2017, 30 staff had completed questionnaires and were knowledgeable of the Policy and Procedure on Elopement and what/who to contact if the DON or Administrator did not respond to a notification of events that require notification. 16. Review of the sign in sheets for the Adhoc Quality Assurance/Performance Improvement (QAPI) meeting dated 3/6/2017 revealed the following members in attendance: The Medical Director via conference call, the interim Administrator, Accounts Receivable Coordinator, the interim DON, interim Maintenance Director, Director of Regulatory Compliance, and other management staff. The Immediate Jeopardy was discussed, as well as, the related complaints. The findings of the monitoring/audit tools will be reviewed at the monthly QAPI meetings. An interview with the Medical Director on 3/8/2017 at 1:34 p.m. revealed that he participated in the 3/6/2017 Adhoc QAPI meeting where the issue of elopement was discussed and what measures had been put into place to prevent a reoccurrence.",2020-03-01
4172,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2017-02-03,225,D,1,0,KWE811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on clinical record review, review of the facility's Abuse and Neglect Prohibition Policy and resident and staff interview, the facility failed to report to the State Survey Agency (SSA) an allegation of abuse for one resident (R#8) from a sample of (3) residents reviewed. The Census was 135 residents. Findings include: Review of the facility's Abuse and Neglect Prohibition Guidelines noted: Facility supervisors will immediately correct and intervene in reported or identified situations in which abuse, neglect, injuries of unknown origin, or misappropriation or resident property are at risk of occurring. The facility will conduct an investigation of any alleged abuse/neglect, exploitation, mistreatment, injuries of unknown origin or misappropriation of resident property in accordance with state law. The facility will report such allegations to the state within 24 hours Review of the facility's Reporting and Response section of their Abuse and Neglect Prohibition Guidelines noted. The facility will report all investigation findings to the state within five (5) calendar days. The facility will report all allegations and substantiated occurrences of abuse, neglect, injuries of unknown origin, and misappropriation of property to the state agency and law enforcement officials within twenty-four (24) hours of identification. The facility will complete an incident/accident report in accordance with OP2 0401.02 incident/accident reporting for residents Review of the clinical record for R#8 revealed that she had [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 13 indicating she is cognitively intact. During interview with R#8 on 2/1/17 at 2:30 p.m., she was noted to speak slowly but clearly. R#8 indicated during interview that about a week prior to the interview, a nurse came into her room to give her medication about 9:30 p.m. or 10:00 p.m. R#8 further indicated that she told the nurse the potassium pill needed to be dissolved and the nurse got huffy, left the room and returned with a spoonful that contained the dissolved pill in applesauce. R#8 further indicated the nurse jammed and forced the spoon into R#8s mouth. R#8 revealed she was not physically injured but it caused her to be angry and upset. When asked if she had told anyone R#8 responded yes and indicated that on the following morning, she told the Activities person who comes by the room to check on each day and the Activities person put in a report about the incident. R#8 added, she only feels safe now when she knows the person taking care of her because she had never seen the accused nurse before that night. R#8 then indicated no one had talked to her about the incident since she reported it. R#8 further indicated she had not seen the accused nurse since the incident. During interview with the Activities Assistant AA on 2/1/17 at 3:02 p.m., revealed that she is the Ambassador to R#8 and stated She did tell me about the nurse jamming the spoon in her mouth. I went and told the Administrator and that the Administrator was going to go and talk to her. Activity Assistant AA further revealed she did not write a grievance regarding the incident involving the spoon and R#8 because she told the Administrator directly. Activity Assistant AA further indicated she did not know who the accused nurse is. When asked why she did not complete a written report of the abuse complaint, Activity Assistant AA revealed, I should have written it. During interview with the Administrator on 2/1/17 at 3:56 p.m., she denied knowing anything about the incident reported by R#8. The Administrator indicated the Ambassador is to go around to residents and find out what has happened. We discuss it in morning meeting and allegations are investigated beginning that day. The nurse would have been suspended pending the outcome of the investigation. When asked what her expectation is regarding staff reporting allegations of abuse, the Administrator indicated she expects abuse allegations to be written up and brought to her. During interview with the Activities Director (AD) on 2/2/17 at 10:15 a.m., he indicated that Activity Assistant AA did not report the incident with R#8 because she thought it was just an attitude issue. AD further indicated he would have told the Activity Assistant AA to follow-up to make sure the issue she reported was addressed. AD stated to me, the resident presented it as the resident was just saying the nurse was being a smart ass. AD further indicated, he did not consider the incident abuse so he would not have considered it an official grievance and it should not have been written up as one. AD went on the say For me, no matter what your perceptions are, even the smallest thing should be written down as a grievance. During an interview with the Interim Director of Nursing (DON) on 2/2/17 at 10:30 a.m. she revealed that she was not employed with the facility at the time of the incident and could not speak to the incident specifically.",2020-02-01
4173,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2017-02-03,226,D,1,0,KWE811,"> Based on staff interview and review of the facility's policies and procedure for the truly listening to our customers program, it was determined that the facility had failed to implement their policy and procedure for one resident (R#8), who felt that she was verbally and emotionally abused and intimidated by staff in a sample of three residents. The facility's failure to implement their policy and procedure resulted in no actual harm but had the potential for more than minimal harm. Findings include: The facility's policy and procedure for abuse and neglect prohibition documented that the facility will address all concerns in accordance with the truly listening to our customers' policy. The facility's policy and procedure for truly listening to our customers documented that if a resident, a resident's representative, or another interested person has a concern, a staff member should encourage and assist the resident, or person acting on the resident's behalf to file a written concern with the facility. The concern can be documented using the concern form. If the facility receives a concern orally, staff should document the concern using the concern form. If the concern relates to nursing care or alleged abuse, neglect or mistreatment, the concerns should be forwarded to the supervisor or the Administrator/Director of Nursing for follow-up. R#8 had reported to Ambassador/Activities Assistant that she had been verbally, and mentally abused and intimidated by a nurse. However, an interview with Activities Assistant AA on 2/1/17 at 3:02 p.m. confirmed that staff had not documented this allegation of abuse involving R#8. An interview with the Administrator on 2/1/17 at 3:56 p.m. revealed staff did not report this allegation of abuse involving the resident to her. Cross refer to F225",2020-02-01
4174,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2017-02-03,315,E,1,0,KWE811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff and resident interviews, facility policy and record review, it was determined that the facility failed to follow policy by not anchoring or securing the Foley catheters for four Residents (R#12, R#3, R#8 and resident K) of 11 residents with catheters, from a sample of six residents. The facility census was 135 residents. Findings include: Review of the facility's policy Indwelling Urinary Catheter (Foley) Care and Management updated (MONTH) 11, (YEAR), reveals that staff are required to have a catheter securement device, are required to make sure that the catheter is properly secured, and are required to assess the securement device daily. Observation on 2/3/2017 at 9:45 a.m. with Wound Care Nurses (WCN's) FF and GG of resident R#12 receiving wound care with an unsecured Foley Catheter. Observation on 2/3/2017 at 10:10 a.m. of R#3 reveals that resident has a Foley Catheter that is not secured. Treatment provided by WCN's FF and G[NAME] Resident repositioned and catheter bag was moved from the left side of the bed to the right. R#3 had a [DIAGNOSES REDACTED]. Review of the 1/7/17 Nurse's Progress Notes revealed an antibiotic was started for a UTI. Observation and interview on 2/3/2017 at 3:40 p.m. with WCN GG who confirms that R#3's catheter was not secured, and that during observation of R#12 with GG at 3:45 p.m. that resident's catheter was unsecured. Observation and interview with R#8 on 2/3/2017 at 3:50 p.m. who is lying supine in the bed and states that her catheter is not secured and it is sometimes very uncomfortable. The resident then removed the bed sheets to reveal an unsecured Foley catheter extending from her brief and down the middle of the bed. Observation and interview on 2/3/ (YEAR) at 3:55 p.m. of resident K who reveals that she has a catheter that causes irritation. The resident then removed her bed clothes to reveals a Foley catheter extending from her adult brief and wrapped around her left ankle. Interview 2/3/2017 at 4:00 p.m. with CNA DD who agrees that R#8 and resident K have Foley Catheters that are unsecured. Interview on 2/3/2017 at 4:10 p.m. with the Administrator and the Director of Nursing (DON) who confirm that all residents with catheters should have the device secured.",2020-02-01
4175,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2017-02-03,456,F,1,0,KWE811,"> Based on observation, interview and record review, it was determined that the facility failed to follow facility policy for auditing two of two emergency carts, failed to record the audit and failed to ensure that the emergency carts contents were complete and in working order. Findings include: Review of the facility's policy Medical Emergency Management revised (MONTH) (YEAR) reveals that staff are required to check at a minimum of monthly to ensure supplies are ready for use. An interview with the Administrator and the interim Director of Nursing (DON) on 2/3/2017 at 5:00 p.m. the records for Cart A could not be located and audit records for Cart B were not completed per policy. Review of the 'Crash Cart Supplies' form used for the audits states that audits will be performed daily rather than monthly as states in the policy. Review of the 'Crash Cart Supplies' form contains a list of supplies that is inconsistent with the supply list in the Medical Emergency Management policy. Observation and Audit of crash cart A, with the Administrator and DON on 2/3/17 at 5:05 p.m., reveals that Cart A is missing the stethoscope, and the flashlight and pulse oximeter are not in working. Observation and Audit of crash cart B with the Administrator and DON on 2/3/17 at 5:07 p.m., reveals the pulse oximeter and the flashlight are not in working order and the backboard is missing. An interview with the Administrator and the DON on 2/3/2017 at 5:10 p.m. reveals that the audit forms are not correct and the batteries for the flashlight and the pulse oximeter are not working. The Administrator agrees that policy is not being followed regarding audits of the crash cart and making sure the supplies are available and in working order.",2020-02-01
5209,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2015-01-15,371,E,0,1,FM7311,"Based on observation, review of the facility policies and staff interview, the facility failed to ensure that foods were served at the appropriate temperatures for the residents on a mechanical soft diet. The facility had (24) twenty-four residents on mechanical soft diet. Findings Include: Observation of lunch service conducted 01/13/2015 1:10 PM with Dietary Manager AA , revealed steam table temperature for pork for the Mechanical Soft diets was 130 degrees Fahrenheit (F). The food service continued after low temperature were identified and two trays of mechanical soft diet were delivered by the Corporate Dietary manager BB to the 100 Hall. At 1:30 PM staff started delivery of the trays to the residents. At 1:35 PM AA checked the temperature of the pork on the last two trays which were mechanical soft diets. The temperature of the pork was 90 degrees F. Further interview with AA on 1/13/2015 at 2:10 PM revealed it is his expectation that foods being served to the residents are at least 140 degrees in temperature. Review of facility policy on Holding Foods revealed Temperatures must meet or exceed 135 degrees for hot foods. The facility policy for Serving Foods indicates foods will be served at the proper temperatures, attractively, and under sanitary conditions.",2018-11-01
5210,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2015-01-15,431,E,0,1,FM7311,"Based on observations, review of the facility's policies, and staff interviews, the facility failed to ensure that expired medications were discarded timely from four (4) of seven (7) medication carts and two (2) of three (3) medication storage rooms. Findings include: Observation of medication cart with Licensed Practical Nurse (LPN) CC on 01/14/15 at 9:10am revealed one (1) floor stock bottle of Enteric Coated Aspirin 325mg with a manufacturer expiration date of 11/14. Interview with CC at the time of the observation, revealed all nurses are to check their individual medication carts for expired medications weekly. CC further indicated the pharmacist comes in monthly and checks the medication storage rooms and medication carts. Observation of medication cart with LPN HH on 01/14/15 at 9:35am revealed one (1) floor stock bottle of Enteric Coated Aspirin 325mg with a manufacturer expiration date of 11/14. Observation of medication cart with LPN FF on 01/14/15 at 9:45am revealed one (1) floor stock bottle of Enteric Coated Aspirin 325mg with a manufacturer expiration date of 11/14. Observation of medication cart with LPN DD on 01/14/15 at 10:30am revealed one (1) bottle of Humulin R which had a labeled a thirty-one (31) day expiration date of 11/12/14. Interview with LPN DD revealed that Humulin R for the resident whose name appeared on the label was discontinued in (MONTH) 2014. DD further revealed the facility's pharmacist comes in once a month to check each medication cart and each storage room. The nurses will also check their own carts in-between the pharmacist visits, at least twice a month. All expired meds are labeled and removed from the medication carts and placed in a designated box in the medication storage room. Observation of Station A medication storage room with LPN Unit Manager EE conducted 01/14/15 at 10:50am revealed the following: One (1) bottle of Mineral Oil with manufacturer expiration dates of 11/14, One (1) bottle of Iron Supplement Elixir with a manufacturer expiration date of 11/14, One (1) bottle of ProSight Vitamin and Minerals with a manufacturer expiration date of 09/14, One (1) bottle of Vitamin D 2000 i.u. with a manufacturer expiration date of 11/14. Observation of Central medication storage room with LPN Unit Manager EE conducted 01/14/15 at 11:30am revealed three (3) bottles of floor stock Mineral Oil with manufacturer expiration dates of 11/14. Interview conducted, at this time, with EE revealed the facility has a process where the pharmacist comes once a month to check all the storage areas and each medication cart. The nurses will individually check their carts weekly. She acknowledged that these medication should not be on the medication supply shelves. They should have been removed and placed in the out-dated or expired box for pharmacy to pick up. Review of the facility policy for medication Storage and Expiration of Medications revealed that medications should not be retained longer than recommended by the manufacturer or supplier guidelines. The facility policy for Disposal/Destruction of Expired or Discontinued Medications indicated that discontinued or out-dated medications should be in a designated, secure location which is solely for discontinued medications or marked to identify the medications are discontinued and subject to destruction.",2018-11-01
6464,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2013-04-17,282,E,0,1,Q1N611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff Interviews, the facility failed to follow care plan interventions for five (5) of six (6) [MEDICAL TREATMENT] residents (#5, #29, #74, #219, and #291) from a sample of forty four (44) residents. Findings include: 1. Review of the care plan for resident #5 indicated an intervention to check bruit/thrill after [MEDICAL TREATMENT] and whenever necessary (prn). There was no evidence/documentation on the April 2013 Medication Administration Record [REDACTED]. 2. Review of the care plan for resident #29 indicated interventions for a colored arm band on the arm with shunt indicating no blood pressure (B/P) in that arm, and to check bruit/thrill two (2) times per shift on day resident returned and daily. Review of the April 2013 MAR indicated [REDACTED]. Review of the nurses notes from 4/5/13 through 4/15/13 revealed one (1) entry for bruit/thrill documentation from three (3) [MEDICAL TREATMENT] visits. Observation of resident on 4/16/13 at 1:30pm revealed the resident was not wearing a colored bracelet on either arm. 3. Review of the care plan for resident #74 indicated to monitor pre and post [MEDICAL TREATMENT] sheets. Review of that sheet revealed vital signs were completed prior to [MEDICAL TREATMENT], but there was no area on sheet indicating any post [MEDICAL TREATMENT] vital signs. There was no evidence available that the intervention was completed. 4. Review of the care plan for resident #219 indicated interventions to check vital signs every shift for 24 hours post [MEDICAL TREATMENT], and check bruit/thrill 2 times per shift on day resident returned, and then daily. Review of the April MAR indicated [REDACTED]. Further review of the nursing notes dated 2/20/13 through 4/3/13 indicated one (1) set of vital signs with-in 24 hours of one (1) [MEDICAL TREATMENT] visit on 3/25/14. 5. Review of the care plan for resident # 291 indicated an intervention to check bruit/thrill per protocol and after [MEDICAL TREATMENT] and prn. The only evidence/documentation on the April MAR indicated [REDACTED]. Interview with the Unit Manager AA on 4/16/13 at 1:00pm revealed that there was no consistent evidence/documentation available on the nursing notes, [MEDICAL TREATMENT] communication record, MAR, or treatment sheet, for vital signs as per facility policy. Interview with the Director of Nursing (DON) on 4/17/13 at 10:15am revealed that [MEDICAL TREATMENT] residents' interventions for care are not consistently followed as per care plan or facility policy. Some systems had floundered as a result of numerous DONs in the past year. However, there had been no negative outcomes and she is aware of the problem.",2017-12-01
6465,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2013-04-17,309,E,0,1,Q1N611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy/procedure on [MEDICAL TREATMENT] Care of Residents, interview with the Medical Director and staff interviews, the facility failed to follow physician's orders for five (5) of six (6) [MEDICAL TREATMENT] residents (# 29, # 74, # 204, # 219, and # 291) from a sample of forty four (44) residents. Findings include: 1. Resident # 29 had signed physician orders for March and April 2013 to check bruit/thrill two (2) times per shift, on day of return from [MEDICAL TREATMENT] then daily, and to check vital signs every shift times twenty four (24) hours post [MEDICAL TREATMENT]. There was no evidence in the medical record that those orders were consistently done. 2. Resident # 74 had a physician order for [REDACTED]. 3. Resident # 204 had a physician order for [REDACTED]. 4. Resident # 219 had signed physicians orders for March and April 2013 to check vital signs every shift times 24 hours past [MEDICAL TREATMENT] and check bruit/thrill 2 times per shift on day return from [MEDICAL TREATMENT] then daily. There was no evidence in the medical record that those orders were consistently done. 5. Resident # 291 had signed orders for March 2013 to check vital signs every shift times 24 hours post [MEDICAL TREATMENT], and to check bruit/thrill to left arm fistula times 2 post [MEDICAL TREATMENT] then daily. There was no evidence in the medical record that those orders were consistently done. Review of the facility policy/procedure for [MEDICAL TREATMENT] Care of Residents indicated the following: Check vital signs every shift for the 24 hours post [MEDICAL TREATMENT] or per physician (MD) orders. Upon return from [MEDICAL TREATMENT], the nurse will check for thrill and bruit twice during the shift for which the resident returned. Interview with the Unit Manager AA on 4/16/13 at 1:00pm revealed that there was no documentation available on nursing notes, [MEDICAL TREATMENT] communication record, Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 4/17/13 at 10:15am revealed that [MEDICAL TREATMENT] interventions for [MEDICAL TREATMENT] residents care were not consistently followed as per facility policy. Follow up monitoring had not been consistent. Interview with the Medical Director on 4/17/13 at 2:00pm revealed that he expected nurses to check the site, observe for unusual bleeding, check vital signs, and report any discrepancies to the physician. He also expected the facility to follow their policies and procedures.",2017-12-01
6466,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2013-04-17,356,B,0,1,Q1N611,"Based on observations and staff interview, the facility failed to ensure staffing was posted daily and contained the name of the facility as required, for four (4) days of a four (4) day survey. Findings include: Observation on 4/14/13 at 10:00am revealed the Posted Staffing sheet was dated 4/12/13. No Facility Name was on the sheet. Observation on 4/15/13 at 7:15am and 3:00pm revealed the staffing sheet posted however, the name of the facility was not on the sheet. Observation on 4/16/13 at 7:45am, 12 noon, and 2:30pm revealed no facility name present on Posted Staffing Sheet. Observation on 4/17/13 at 7:30am and 1:15pm revealed the posted staffing sheet did not have the facility name on it. Interview with staff BB on 4/17/13 at 1:15am revealed that she was unaware the posted staffing on 4/14/13 was dated 4/12/13. BB further revealed that it is the nursing supervisors working on the weekends responsibility to update the posted staffing. She was also unaware that the facility name was required to be on the posted staffing.",2017-12-01
7464,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2014-03-05,157,D,1,0,J2H411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to inform the physician that the one (1)resident (#1) refused to have the blood drawn for a [MEDICATION NAME] trough level, Complete Blood Count, Chem 7l in a survey sample of three (3) residents. Review of the admission orders [REDACTED]. Review of the laboratory findings for resident(#1) revealed there were no results shown for the labs ordered on 1/13, 1/16 and 1/20. Interview with the Director of Nursing(DON)on March 5, 2014 at 2:30 PM. revealed the Phlebotomist failed to obtain the blood for the labs on the days identified above. This information was not provided to the nurse manager by the Phlebotomist. The physician was never informed of the resident's refusal to have the blood work drawn. Consequently when the blood was obtained on January 27, 2014 the reference range for this medication is 5.0 - 10.0 ug/ml. The resident's results were outside the range 55.9 ug/ml with results repeated. A letter from the clinical laboratory services company confirms that the phlebotomist failed to inform the nurse manager of the resident's refusal or document the information.",2017-03-01
8293,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2011-11-03,157,E,0,1,GB2M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Blood Glucose Tracking/ Sliding Scale Insulin Administration Records, the facility Sliding Scale Protocol, and staff interviews, the facility failed to ensure that physicians were not notified of bed time (HS) blood sugar higher than 200 milligrams per deciliter (mg/dl) as per facility protocol for fourteen (14) residents ( #17, #22, #32, #43, #56, #86, #92, #122, #127, #144, #155, #161, #169, and #187) from a sample of fifty (50) residents. Findings include: Review of the facility Blood Glucose Tracking/ Sliding Scale Insulin Administration for residents #32, #56, #86, #92, #144, #155, #161, #169, and #187, for the months of June, July, August, September, and October 2011 indicated the following: 1 On 10/26/11 at 9:00pm resident #32 had a blood sugar of 220, the physician was not notified. 2. On 10/28/11 at 9:00pm resident #56 had a blood sugar of 230, the physician was not notified. 3. On 10/16/11 at 9:00pm resident #86 had a blood sugar of 269, 10/25/11 at 9:00pm the blood sugar was 239, 10/26/11 at 9:00pm the blood sugar was 300, 10/29/11 at 9:00pm the blood sugar was 301, 10/30/11 at 9:00pm the blood sugar was 202, the physician was not notified of any of those blood sugars over 200mg/dl 4. On 10/12/11 at 9:00pm resident #92 had a blood sugar of 376, on 10/14/11 at 9:00pm the blood sugar was 210, the physician was not notified of either blood sugar. 5. On 6/ 7/11 at 9:00pm resident # 144 had a blood sugar of 211, the physician was not notified. 6. On 7/2/11 at 9:00pm resident #155 had a blood sugar of 208, 7/12/11 at 9:00pm the blood sugar was 341, 6/13/11 at 9:00pm the blood sugar was 210, 8/1/11 at 9:00pn the blood sugar was 262, 8/14/11 at 9:00pm the blood sugar was 291, 9/16/11 at 9:00pm the blood sugar was 205, 9/17/11 at 9:00pm the blood sugar was 289, 9/30/11 at 9:00pm the blood sugar was 248, 10/22/11 at 9:00pm the blood sugar was 213, 10/31/11 at 9:00pm the blood sugar was 243, the Physician was not notified of any of those blood sugars over 200mg/dl. 7. On 10/12/11 at 9:00pm resident #161 had a blood sugar of 225, the physician was not notified 8. On 10/28/11 at 9:00pm resident #169 had a blood sugar of 285, on 10/29/11 at 9:00pm the blood sugar was 280, the physician was not notified of either blood sugar 9. On 10/19/11 at 9:00pm resident # 187 had a blood sugar of 203, the physician was not notified. 10. Review of the September blood glucose tracking record revealed that on 9/6/11 at 9:00pm resident #17 had a blood sugar of 226, and the physician was not notified. Facility Protocol for Sliding scale indicates that if the bed time (HS) blood glucose was greater than 200mg/dl notify the physician before administering any sliding scale coverage, if 70 or below follow [DIAGNOSES REDACTED] protocol and notify the physician. Interview with the unit manager XX on 11/1/11 at 3:30pm revealed the blood glucose protocol is facility wide and for every diabetic resident. She further acknowledge that there were residents with blood sugars above 200 and physicians had not been notified. Interview with the Director of Nursing (DON) on 11/3/11 at 10:30am revealed that facility expectation is for Diabetic Sliding Scale Protocol to be followed. The protocol is specific according to the Medical Director's guidelines. Inservices are done frequently, all nurses currently on staff had been inserviced. The physician's should have been notified of any blood sugar levels higher than 200 at the HS accucheck. 11. Review of the Blood Glucose Tracking/Sliding Insulin Administration Record indicated that resident # 122 had a blood glucose result of 238 mg/dl at 9:00 pm on 10/31/11 and that there was no evidence that the MD was notified. 12. Review of the August Blood Glucose Tracking/Sliding Scale Insulin Administration Record for resident # 22 indicated that on 8/11/11 at 9:00pm the residents' blood glucose was 204 mg/dl, and the physician was not notified. Review of the September record indicated that at 9:00pm on 9/6/11the blood glucose level was 215 mg/dl, on 9/14/11 the level was 202, on 9/16/11 the blood glucose level was 242, and the physician was not notified of any of these levels. Review of the October record indicated a level of 214 on 10/1/11 at 9:00pm and the physician was not notified. 13. Review of the Blood Glucose Tracking/Sliding Scale Insulin Administration Record for October 2011 revealed the blood glucose level for resident # 43 was 241 on 10/21/11 at 9:00pm and there was no evidence the physician was notified. 14. Review of the August blood glucose levels for resident # 127 indicated that at 9:00pm on 8/10/11 the blood glucose level was 263 and on 8/14/11 the blood glucose level was 234. The physician was not notified. Review of the September blood glucose levels for resident #127 indicated on 9/1/11 the blood glucose level was 204, on 9/7/11 the level was 239, on 9/8/11 the level was 289, on 9/13/11 the blood glucose level was 240, and the physician was not notified.",2016-03-01
8294,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2011-11-03,166,D,0,1,GB2M11,"Based on review of the facility's Grievance Log and Policy, and resident, families and staff interviews, the facility failed to ensure that the facility followed its policy related resolving grievances for two (2) residents ( 'A' and 'B'), from a sample of fifty (50) residents. Findings include: 1. Interview with resident 'B' on 10/31/2011 at 11:00a.m. revealed that she had complained of missing clothing items from her closet. These items included: three (3) gowns, one (1) green jogging suit and two (2) shirts. The resident indicated the jogging suit was new and had never been worn. She indicated that she reported this to a Certified Nursing Assistant (CNA) and laundry personnel. The resident further revealed that she had received no response from the facility related to her missing items. Interview with Administrator on 11/1/2011 at 2:00 p.m. revealed that she had not received any report of resident B missing items. She revealed that It is facility policy that if a resident or family member or another interested party has a concern, a staff member should document the concern using the Concern Form and submitted to her for review and investigated by a designated staff member. She revealed that all staff are trained to follow these procedures. She further revealed that although the facility have no written policy regarding missing items replacement, it is the practice of the facility to attempt to replace the items by reimbursement or purchasing a similar item of complainant choice. Interview with laundry staff DD conducted on 11/2/2011 at 8:38 a.m. revealed that she was not informed of residents A and B missing items. She further revealed that when laundry receives a report of a missing item, they search for the items. DD revealed that she is aware of the Concern Form, but has never receive one for missing items nor completed one to report missing laundry. The laundry has no written tracking system for missing items. Review of Facility Grievance Policy revealed the following: 1. If a resident, a resident's representative, or another interested person has a concern, a staff member should encourage and assist the resident, or person acting on the resident's behalf to file a written concern with the facility. The concern can be documented using the Concern Form. 2. If the Facility receives a concern orally, staff should document the concern using the Concern Form. 2. Interview with a family member of resident 'A' on 10/31/2011 at 12:35 p.m., revealed that last Christmas the family brought new clothing for the resident. The items included a gray velour suit, black pants, red pants and a black and red shawl. The family member indicated that before the resident was able to wear the clothing, the items were missing. The family member also reported that the nurse was notified of the missing items, and the family member was not given the opportunity to fill out a concern form. The family member reported that the items are still missing, and the facility has not followed up regarding them. Interview with the Administrator on 11/01/2011 at 2:25 p.m., revealed that there was no concern form found related to the missing items. She indicated the process for grievance reports is that once staff is notified of a missing item, the staff member is to complete a concern form and presented to the her for review and to be followed-up by Social Services. Interview with the Social Worker on 11/01/2011 at 2:30 p.m. revealed that he was not aware of the missing items, and he was not employed at the time of the initial report of missing items. However, he reported that staff are trained on how to report missing items using the concern form and to forward to him or the administrator.",2016-03-01
8295,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2011-11-03,309,D,0,1,GB2M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility Blood Glucose Tracking/ Sliding Scale Insulin Administration Record, the facility Sliding Scale Protocol, and staff interviews, the facility failed to ensure nurses did not administer insulin coverage for a bedtime (HS) blood sugar higher than 200mg/dl, for two (2) residents (#17, and #155) from a sample of fifty (50) residents. Findings include: 1. Review of the September blood glucose tracking record revealed that on 9/6/11 at 9:00pm resident #17 had a blood sugar of 226, insulin should have been held until further direction from the physician, but four (4) units were given. 2. Review of the August blood glucose tracking record revealed that on 8/1/11 at 9:00pm resident #155 had a blood sugar of 262, insulin should have been held until further direction from the physician, but six (6) units were given. Also on 8/14/11 at 9:00pm the resident's blood sugar was 291, insulin should have been held until further direction from the physician, but six (6) units were given. Facility Protocol for Sliding scale indicates that if the bed time (HS) blood glucose was greater than 200mg/dl notify the physician, do not give HS sliding scale coverage, if 70 or below follow [DIAGNOSES REDACTED] protocol and notify the physician. Interview with the unit manager XX on 11/1/11 at 3:30pm revealed the blood glucose protocol is facility wide. She further acknowledged that residents #17 and #155 received insulin that should have been held. Interview with the Director of Nursing (DON) on 11/3/11 at 10:30am revealed that facility expectation is for diabetic sliding scale protocol to be followed. This was facility specific according to the Medical Director's guidelines. Inservices are done frequently, all nurses currently on staff had been inserviced. Review of Inservice records revealed Blood Glucose inservices were held on 1/24/11, and 2/13/11.",2016-03-01
8296,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2011-11-03,500,D,0,1,GB2M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure that Hospice developed a care plan one (1) Hospice resident (#71) of three (3) Hospice (#71, #37 and #95) residents reviewed from a sample of fifty (50) residents. Finding includes: Review of the medical record for resident #71 revealed that the resident was admitted to Hospice on 7/12/2011 will the following [DIAGNOSES REDACTED]. Further review revealed no evidence of a Hospice care plan. The facility had developed a care plan dated 7/12/2011 which included goals related to end of life Hospice referral, comfort measures and to inform MD and hospice of changes. There were no care, goals or interventions on this care plan which define the care for resident to be provided by Hospice. Interview with Care Plan coordinator CC on 11/3/2011 at 9:00a.m. revealed that the facility's care plan for end of life was written without the collaboration of Hospice. CC further revealed that Hospice never attended a care plan meeting and did not develop, contribute to the facility's care plan nor provided a Hospice care plan that incorporated Hospice care. Interview with Hospice Nurse conducted on 11/3/2011 at 11:37a.m revealed that she has never attended a care plan meeting for resident #71 with the facility.",2016-03-01
8297,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2011-11-03,514,D,0,1,GB2M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of physician's orders, the Medication Administration Record [REDACTED]. Findings include: Review of physician's orders for resident #50 dated 10/26/2011 revealed the physician decreased [MEDICATION NAME] from one (1) milligram (mg) twice a day (BID) to 0.5mg BID. Review of November 2011 MAR indicated [REDACTED]. Interview with License Practical Nurse AAconducted on 11/2/2011 at 10:00 a.m. revealed that the MAR indicated [REDACTED]. Review of medication cart and narcotic sheet on 11/2/2011 at 10:05 a.m revealed resident #50 medication supply contained [MEDICATION NAME] 0.5mg and that documentation on the narcotic sign out sheet was for 0.5mg. Interview with Unit Manager BB on 11/2/2011 at 1:00 p.m. revealed that the documentation error on the MAR indicated [REDACTED].",2016-03-01
9022,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2012-05-31,282,G,1,0,BQZB11,"Based on medical record review and staff interview, the facility failed to provide care in accordance with the Care Plan of one (1) resident (#1), related to the application of a self-release seat belt with an alarm, in a survey sample of five (5) residents. The resident subsequently fell and sustained a laceration to the forehead approximately one (1) inch in length, and a skin tear to the left knee. Findings include: Cross refer to F323 for more information regarding Resident #1. Record review for Resident #1 revealed the resident's current Care Plan identified as a Problem that the resident had dementia with behaviors and a history of falls, requiring the use of a self-release belt. This Care Plan also indicated that the resident could release the belt upon command, and an Approach to address the resident's fall-risk specified the application of a self-release belt while up in the wheelchair. A Change Of Condition Nurse's Note timed at 6:30 p.m. documented that on 04/03/2012, the resident fell from the wheelchair to the floor, hitting the forehead and causing a laceration to the forehead about one (1) inch in length, as well as a skin tear to the left knee. However, there was no documented evidence in the medical record to indicate that a self-release seat belt with an alarm had been applied to the resident, as specified by the Care Plan, at the time of the fall. During an interview with the Social Service Director (SSD) conducted on 04/16/2012 at 10:20 a.m., the SSD stated that on 04/03/2012, he had observed Resident #1 on the floor with a wheelchair positioned on her and had removed the wheelchair, but had not released any restraint while removing the wheelchair. During a subsequent interview on 04/16/2012 at 10:30 a.m., the SSD stated that he did not recall hearing an alarm when the resident fell . During an interview with the Director of Nursing (DON) conducted on 04/16/2012 at 12:10 p.m., the DON stated that during the facility's investigation of Resident #1's fall, three (3) staff members who were interviewed did not recall hearing an alarm sound when the resident fell .",2015-08-01
9023,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2012-05-31,323,G,1,0,BQZB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a self-release seat belt with an alarm, as ordered by the physician, as a safety device for one (1) resident (#1) in a survey sample of five (5) residents. The resident subsequently fell and sustained a laceration to the forehead about one (1) inch in length, and a skin tear to the left knee. Findings include: Record review for Resident #1 revealed that the April 2012 physician's orders [REDACTED]. The physician's orders [REDACTED].#1 had [DIAGNOSES REDACTED]. A Change Of Condition Nurse's Note timed at 6:30 p.m. which referenced Resident #1 documented that on 04/03/2012, the resident fell from the wheelchair to the floor, hitting the forehead and causing a laceration to the forehead about one (1) inch in length. This Note documented that the forehead laceration was cleaned and Steri Strips were applied, and that a skin tear to the left knee was cleaned and Xeroform was applied and covered with 4-by-4 gauze and tape, per a physician's orders [REDACTED].#1 had been sent to the hospital. There was no documented evidence on this Change Of Condition form, or elsewhere in the medical record, to indicate that a self-release seat belt with an alarm had been applied to the resident at the time of the fall. During an interview with the Social Service Director (SSD) conducted on 04/16/2012 at 10:20 a.m., the SSD stated that on 04/03/2012, he heard a loud sound, walked out of the office and observed Resident #1 on the floor with a wheelchair positioned on the resident's legs, from the knees down. The SSD stated he went to the resident and removed the wheelchair off the resident, further stating that he did not release any restraint while removing the wheelchair from the resident. During a subsequent interview with the SSD on 04/16/2012 at 10:30 a.m., the SSD stated that he did not remember hearing an alarm when the resident fell . During an interview with Licensed Practical Nurse (LPN) ""BB"" conducted on 04/16/2012 at 10:40 a.m., this LPN stated that the alarm for the self-release belt for Resident #1 was very loud when it sounded, and that staff would have heard the alarm if it had sounded. During an interview with Certified Nursing Assistant (CNA) ""AA"" conducted on 04/16/2012 at 11:15 a.m., this CNA stated that the seat belt alarm for Resident #1 would sound whenever the seat belt was unattached, and would continue to alarm until someone turned the alarm off. During an interview with the Director of Nursing (DON) conducted on 04/16/2012 at 12:10 p.m., the DON stated that during the facility's investigation of this 04/03/2012 fall involving Resident #1, three (3) staff members who were interviewed related to the resident's fall did not remember hearing an alarm go off when the resident fell .",2015-08-01
9698,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2012-01-20,279,E,1,0,2VSV11,"**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 which reflected quantifiable Approaches to address the turning and repositioning care needs of four (4) residents (#s 1, 3, 4 and 5), who had pressure sores, and the [MEDICAL CONDITION] care needs of one (1) resident (#10), from a survey sample of ten (10) residents. Findings include: Record review for Resident #s 1, 3, 4 and 5 revealed Care Plan entries of 11/23/2011, 12/07/2011, 11/21/2011, and 02/18/2011, respectively, identifying these residents to have actual pressure ulcers, and identifying Approaches which included to reposition in the chair frequently, and to turn and reposition while in bed frequently, for comfort and pressure reduction. However, these Care Plans failed to identify specific parameters to define the actual frequency of repositioning of the residents while in the chair and the turning and repositioning of the residents while in bed, but instead only directed staff to perform these functions ""frequently"". During interview with the Administrator and Director of Nursing conducted on 01/06/2012 at 10:00 a.m., these staff members acknowledged that the Care Plans of Residents 1, 3, 4 and 5 did not identify parameters for repositioning in the chair or turning and repositioning in the bed. It was also stated that the Turn and Repositioning Detail Report for each of the residents directed the resident to be turned and repositioned as directed by the plan of care. Additionally, record review for Resident #10 revealed that the resident had had the [DIAGNOSES REDACTED]. However, review of the resident's Care Plan revealed that the Care Plan did not address the care of the resident's [MEDICAL CONDITION]. During an interview with the Director of Nursing conducted on 01/06/2012 at 3:20 p.m., the Director of Nursing acknowledged that the resident's Care Plan did not address the care of the [MEDICAL CONDITION].",2015-05-01
9699,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2012-01-20,314,E,1,0,2VSV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital document review, staff interview, and review of the facility's Skin Management Policy, the facility failed to provide pressure sore prevention and treatment as ordered by the physician to promote healing of pressure sores for three (3) residents (#s 1, 2, and 6) who had pressure sores, failed to obtain physicians' treatment orders but still treated the existing pressure sores of two (2) residents (#s 1 and 3) without orders for treatment, and failed to assess, develop, and implement interventions to ensure pressure relief for the heels of one (1) resident (#1), on the total survey sample of ten (10) residents. Findings include: 1. Record review for Resident #1 revealed the residents' Weekly Pressure Ulcer Record of 11/23/2011 documented that the resident was admitted to the facility with pressure ulcers which included a pressure ulcer on the coccyx. This Weekly Pressure Ulcer Record documented that the Stage Two pressure ulcer measured 8.5 centimeters (cms.) in length by 4.0 cms. in width, with a depth of 0.1 cm., and documented that new treatment orders had been received. A Progress Note of 11/28/2011 documented that the treatment order for this coccyx wound had been changed to Santyl daily and as needed. However, review of the resident's November and December 2011 Treatment Records revealed, and interview the Director of Nursing on 01/06/2012 at 9:40 a.m. acknowledged, that the treatment order noted on 11/28/2011 was not started until 12/02/2011. The 11/23/2011 Weekly Pressure Ulcer Record for Resident #1 also documented that the resident was admitted to the facility with a blister on the left heel measuring 5 cms. in length and 2.5 cms. in width. An 11/23/2011 Progress Note documented that a treatment order for skin prep and a Suresite dressing had been received from the physician. Record review, to include review of the November 2011 Treatment Record, revealed no evidence to indicate that this treatment was done from 11/23/2011 through 11/31/2011. However, the resident's December 2011 Treatment Record documented that the resident's left heel was cleaned with wound cleanser/normal saline then skin prep, and Teagderm was applied every three days and as needed beginning on 12/01/2011 and continuing through 12/22/2011. Further review of the medical record, to include the physician's orders [REDACTED]. During an interview with the Director of Nursing (DON) conducted on 01/06/2012 at 9:40 a.m., the DON acknowledged that there was no evidence of a physician's orders [REDACTED]. In addition, there was no evidence provided to indicate that the treatment to the left heel ordered by the physician on 11/23/2011 had been done. Review of the resident's Weekly Pressure Ulcer Record revealed 12/05/2011 entries which documented an open blister on the left heel measuring 4.5 cms. by 2.0 cms., and a right heel blister measuring 5.0 cms. by 4 cms. The facility's Skin Management Policy specified that wounds were to be documented and assessed on the Weekly Pressure Ulcer Record. However, record review, to include review of the resident's Weekly Pressure Ulcer Record, revealed no evidence of listing or assessment of the wounds on the resident's left and right heels, which would have been due on 12/12/2011 and 12/19/2011, after the 12/05/2011 referenced above. Additionally, although the Weekly Pressure Ulcer Record entries referenced above documented the presence of blisters on both heels, there was no evidence to indicate that interventions were developed or implemented to off-load the pressure from the resident's heels. Review of the resident's Care Plan revealed no interventions to decrease the pressure on the heels. A Nurse's Note of 12/24/2011 at 5:30 p.m. documented that the physician had ordered for Resident #1 to be transferred to the hospital at that time. During an interview with the DON conducted on 01/06/2012 at 9:45 a.m., the DON acknowledged there was no evidence to indicate that the resident's heels were elevated to off-load pressure during his stay in the facility. 2. Record review for Resident #2 revealed a Physician's Telephone Orders form dated 11/09/2011 which referenced a physician's orders [REDACTED]. The November 2011 treatment record documented that this coccyx wound treatment was initiated on 11/11/2011, and was also done on 11/13/2011 and 11/15/2011. However, a notation on this treatment record indicated that the treatment order had been changed, and the last day this treatment was done for the month of November 2011 was on 11/15/2011. However, further record review revealed no evidence of a new order for treatment of [REDACTED]. During an interview with the DON conducted on 01/05/2012 at 4:00 p.m., the DON acknowledged that there was no evidence that any treatment was done on the coccyx wound from 11/15/2011 until the order was rewritten on 11/30/2011 and treatment was begun on 12/01/2011. The December 2011 and January 2012 physician's orders [REDACTED]. However, observations of the resident conducted on 01/03/2012 at 11:15 a.m. and 2:30 p.m., on 01/04/2012 at 10:50 a.m. and 12:05 p.m., and on 01/05/2012 at 10:30 a.m. revealed the resident's heels were observed not to be floated. Additionally, review of the December 2011 Treatment Record revealed an entry for staff to document flotation of the resident's heels while in bed, but there was no documentation to indicate that the resident's heels had been floated, per the physician's orders [REDACTED]. 3. Record review for Resident #3 revealed a Weekly Pressure Ulcer Record which documented that on 12/08/2011, the resident was admitted with redness to both heels and a blister on the left outer leg. A 12/07/2011 entry on the Care Plan - Non-Pressure Ulcer Skin Impairment form documented redness to the resident's buttock, and a 12/15/2011 entry on the Care Plan - Pressure Ulcers form documented areas to the resident's left and right heels. Record review revealed no documented evidence of a pressure sore on the resident's coccyx. However, during an interview with the treatment nurse conducted on 01/04/2011 at 5:10 p.m., this nurse stated the resident that had been transferred to the hospital and upon transfer, the resident had an open are on the coccyx to which a DuoDerm had been placed the previous Friday. The treatment nurse acknowledged that the physician had not been notified of the wound, and that no order for treatment was obtained. This nurse also acknowledged that there was no evidence of the coccyx wound in the resident's medical record. A hospital wound assessment form of 01/05/2011 documented wounds which included a wound on the buttocks of partial thickness with slight bleeding. 4. Record review for Resident #6 revealed a physician's orders [REDACTED]. However, review of the December 2011 Treatment Record revealed no evidence to indicate that this treatment was done on 12/05/2011, 12/07/2011, 12/09/2011, and 12/16/2011 as ordered. Record review also revealed a physician's orders [REDACTED]. However, review of the December 2011 Treatment Record revealed no evidence to indicate that this treatment was done on 12/07/2011, 12/08/2011, and 12/16/2011. During an interview with the Administrator conducted on 01/06/2011 at 9:35 a.m., it was acknowledged that the treatments identified were not done as ordered.",2015-05-01
9700,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2012-01-20,361,D,1,0,2VSV11,"Based on record review and staff interview, the facility failed to ensure an initial nutritional assessment by the Registered Dietitian which included the assessment of pressure sores for one (1) resident (#1) on the survey sample of ten (10) residents. Findings include: Record review for Resident #1 revealed the residents' Weekly Pressure Ulcer Record of 11/23/2011 documented that the resident was admitted to the facility with an open pressure ulcer on the coccyx, a blister on the left heel measuring 5 centimeters (cms.) in length and 2.5 cms. in width, and a blister on the right heel measuring 5 cms. in length and 3.1 cms. in width. However, review of the resident's Medical Nutritional Therapy Review dated 11/23/2011 completed by the Registered Dietician revealed no reference to the resident's coccyx and bilateral heel pressure sores, and no evidence of assessment of these pressure sores by the dietician. During an interview with the Registered Dietician conducted on 12/30/2011 at 2:30 p.m., the dietician stated that she was not aware of the resident's breakdown, and acknowledged that the skin breakdown was not addressed in the nutritional assessment.",2015-05-01
9701,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2012-01-20,502,D,1,0,2VSV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to do a drug sensitivity test for a sputum specimen as ordered by the physician for one (1) resident (#1) in a survey sample of ten (10) residents. Findings include: Record review for Resident #1 revealed an undated Physician's Telephone Orders sheet, included with the November 2011 physician's orders [REDACTED]. However, further record review revealed no evidence that this sensitivity test had been done. During an interview with the Director of Nursing conducted on 01/06/2011 at 2:00 p.m., the Director of Nursing acknowledged that the laboratory sensitivity test for the drugs identified in the physician's orders [REDACTED].",2015-05-01
10501,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2011-02-28,225,D,1,0,Y1TN11,"Based on clinical record review, facility document review, and staff interview, it was determined that facility staff failed to immediately report an injury of unknown source, related to bruising, to the administrator for one (1) resident (#1) in a survey sample of four (4) residents. Findings Include: Review of a facility investigation into an injury of unknown source for Resident #1 revealed a statement from Certified Nursing Assistant (CNA) ""AA"" which documented that during the 3:00 p.m.-11:00 p.m. shift of 01/25/2011, she had noted bruising on the resident's left hip and down the leg. CNA ""AA"" further documented that she had reported this to Nurse ""BB"". However, further record review revealed no evidence to indicate that Nurse ""BB"" assessed the resident's bruising at that time or notified the administrator of this injury of unknown source. Further review of the facility's investigative documents revealed a statement by Nurse ""BB"" in which the nurse acknowledged that on 01/25/2011, at around 8:00 p.m. or 9:00 p.m., CNA ""AA"" had mentioned bruising on the resident's left leg, and that he had intended to look to determine if it was a documented wound or not, but that he had gotten busy and had forgotten. A Nursing Daily Skilled Summary, labeled as a late entry for 01/26/2011 at 5:00 a.m., documented that nursing staff had again been notified by direct care staff of thigh bruising for Resident #1, and that the nurse had assessed Resident #1 at that time and observed bruising. However, further record review revealed no evidence to indicate that the administrator was notified of this injury of unknown source at that time. A Nurse's Note of 01/26/2011 at 2:30 p.m. documented that nursing assessment revealed bruising to the resident's let hip down the lateral side of the leg, and noted the resident's left leg appeared slightly shorter and slightly rotated inward. Further review of facility investigative documents revealed that it was only at that time that the facility initiated an investigation into the resident's injury of unknown source, including bruising. During an interview with the Director of Nursing on 02/28/2011 at 2:00 p.m., the Director of Nursing acknowledged that both Nurse ""BB"" of the 01/25/2011 3:00 p.m.-11:00 p.m. shift, and the nurse of the 01/26/2011 11:00 p.m.-7:00 a.m. shift, failed to immediately notify the administrator of the resident's injury of unknown source, related to bruising.",2014-06-01
10612,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2010-10-13,157,D,,,Y3K611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to immediately notify the family of a dislocated right hip arthroplasty for one (1) resident (#1) in a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed an Accumulative [DIAGNOSES REDACTED]. A physician's note referencing a physician's visit of 08/21/2010 documented that Resident #1 had experienced a dislocation of the right hip and had undergone a closed reduction in the hospital on [DATE], and was then admitted to the nursing facility on 08/20/2010. A Physician's Telephone Order of 08/20/2010 specified that the resident was to have an x-ray of the right hip prior to the a physician's appointment scheduled on 09/17/2010. A Radiology Report dated 09/02/2010 documented that the impression was a dislocation of the right arthroplasty. A Nursing Daily Skilled Summary dated 09/02/2010 at 10:30 p.m. documented that the x-ray result had been received and was positive for a dislocation of the right hip arthroplasty, and that the resident's physician was notified of the results. However, further record review, to include review of the Nursing Daily Skilled Summary, revealed no evidence to indicate that the resident's family had been notified of this resident's significant change in physical status. During an interview with the Director of Nursing (DON) conducted on 10/13/2010 at 11:10 a.m., the DON acknowledged that the resident's family was not notified of the results of the x-ray done on 09/02/2010 that indicated a dislocation of the resident's right hip arthroplasty.",2014-02-01
10613,ANDERSON MILL HEALTH AND REHABILITATION CENTER,115145,2130 ANDERSON MILL RD,AUSTELL,GA,30106,2010-10-13,309,D,,,Y3K611,"Based on record review and staff interview, it was determined that the facility failed to provide care, in accordance with a physician's order for a surgical consultation, for one (1) resident (#1) in a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed a Physician's Telephone Order of 08/20/2010 which specified that the resident was to have an x-ray of the right hip prior to the a physician's appointment scheduled on 09/17/2010. A Radiology Report dated 09/02/2010 documented that the impression was a dislocation of the resident's right arthroplasty. A Nursing Daily Skilled Summary dated 09/02/2010 at 10:30 p.m. documented that the resident's attending physician had been made aware of the x-ray result which was positive for a dislocation of the right hip arthroplasty, and documented that the attending physician ordered for staff on the 7:00 a.m.-3:00 p.m. shift to follow-up with the surgeon the next morning. However, further record review, to include review of the Nursing Daily Skilled Summary, revealed no evidence to indicate that the surgeon was notified of the x-ray results, as specified by the resident's attending physician's order. During an interview with the Director of Nursing (DON) conducted on 10/13/2010 at 11:10 a.m., the DON acknowledged that the surgeon was not notified of the results of the x-ray, as specified by the attending physician's order.",2014-02-01
3977,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2018-07-03,805,D,1,0,7H2511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, record review, review of the facility's menu guide, and staff interviews, the facility failed to ensure mechanical soft - chopped meats were prepared properly for one resident (R) (#2) out of seven sampled residents. Findings include: Observation on 7/2/18 at 1:15 p.m. revealed R#2 in the dining room. Resident received meat cut into four large pieces without gravy and whole pieces of broccoli. Speech Therapist (ST) AA was observed cutting up the meat and broccoli. ST AA obtained gravy from the kitchen and poured over the meat. Interview with ST AA at this time revealed that the meat did not come out chopped as ordered. The meat came out in large cup up pieces. Observation on 7/2/18 at 6:15 p.m. during supper meal revealed R#2 received turkey pot pie which contained large chunks of turkey. Resident was unassisted for the entire meal and attempted to cut the turkey with a fork unsuccessfully. Resident did not eat any turkey pot pie. Review of the lunch and supper meal tickets for R#2 dated 7/2/18 indicated mechical soft: chopped. Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] revealed R#2 with a Brief Interview of Mental Status (BIMS) score of 12, indicating cognition intact and an active [DIAGNOSES REDACTED]. Review of the physician order [REDACTED].#2 on a mechanical soft - chopped meat diet. Speech/Language Pathology Daily Notes for R#2 documented Skilled Services Provided: treatment of [REDACTED]. On 6/11/18, resident seen in the dining room for the noon meal. Resident given a trial of a whole piece of chicken. Resident does not cut meat and bites a big bite off the bone. Resident is unable to cut meat into small pieces. Resident will be left on mechanical soft chopped. On 6/21/18, resident seen in dining room. Resident did not receive the correct diet. Resident received a whole piece of chicken. On 6/29/18, resident seen in dining room. Resident did not receive the correct diet and received a whole filet of fish. Speech/ Language Pathologist cut up fish in very small pieces and put tartar sauce on it. Review of the [NAME]ina Nutrition Menu Guide with no revision dated revealed the mechanical soft, chopped meat diet may be used for residents who have difficulty chewing and/or swallowing regular textured foods. Guidelines for this diet follow the Dysphagia Advanced Level 3 diet (foods should be moist and in bite-sized pieces that are about the size of your thumb nail). Meats that are difficult to chew are chopped and moistened with broth or gravy. Further interview with ST AA on 7/2/18 at 2:15 p.m. revealed that the meats often come out of the kitchen without being properly chopped. She stated that the kitchen staff have been educated on the proper consistency of the different diets. Interview with Dietary Manager on 7/2/18 at 4:31 p.m. revealed that chopped meats should be chopped with a knife into thumbnail size pieces. Review of the Nursing and Dietary Inservice dated 9/6/17 revealed education provided on diet consistencies: mechanically altered - meats will be specified chopped (cut into bite size pieces) or ground, and meats should always contain a moistener. Inservice/ Training Report dated 10/4/17 revealed education provided related to consistencies of liquids and solids, safety risks for patients and liability risks. Telephone interview with the Director of Dining Services on 7/3/18 at 1:19 p.m. revealed that she expects chopped meats to be round and pea size. She expects staff to have a close relationship with the residents and to follow appropriate guidelines per ST.",2020-09-01
3978,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2018-07-22,655,D,0,1,QMOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure that a Baseline Care Plan was created related to the use of Intravenous(IV) medications for one Resident (R)#52 of one residents reviewed for hospitalization out of a sample of 21 residents. The census was 52. Findings included: A review of the clinical records for R#52 revealed he was admitted to the facility on [DATE] with the relevant [DIAGNOSES REDACTED]. Review of the Admission Physician order [REDACTED]. A review of the Electronic Medication Administration Record [REDACTED]. A review of the clinical record revealed that there was no documentation of a Baseline Care Plan for R#52 related to the use of a IV medication. A comprehensive care plan was documented as being created on 5/16/18 related to use of [MEDICATION NAME] evidenced by the [DIAGNOSES REDACTED]. An interview was conducted with the Minimum Data Set (MDS) Coordinator EE on 7/22/18 at 12:44 p.m. She has been employed at the facility since (YEAR). She stated that R#52 was admitted on [DATE] with an order for [REDACTED]. She stated that Baseline Care Plan was created on 5/16/18 and that the MDS department was educated two weeks ago related to completing the Baseline Care Plan within 48 hours. She was asked if she was aware of the recent changes to the regulations related to baseline care plans and she stated, I don't believe that rule was in place when he was here. When asked why the care plan related to the [MEDICATION NAME] IV medication use was created after the completion date of the medication, she could not provide an answer. During an interview with the Asistant Director of Nursing (ADON) on 7/22/2018 at 1:04 p.m. she stated that she has been at the facility for one year and that she was not sure of the facility policy or process related to the Baseline Care Plans. During an interview with the Director of Nursing (DON) on 7/22/2018 at 1:10 p.m. she stated that the facility has twenty-one days to complete the Baseline Care Plan. She was asked if she was aware the regulation changes related to creating a Baseline Care Plan within 48 hours of a resident's admission. She stated that she was aware. She stated that the comprehensive care plan is the Baseline Care Plan and that the reason that the dates don't reflect that it was created within the 48 hours is because the MDS staff changed the dates. She stated that there was no way to retrieve the original dates that the care plan was created. She was asked why the care plan had been changed by the MDS department to reflect the use of the [MEDICATION NAME] when he was no longer receiving the [MEDICATION NAME] IV treatment and she stated that she could not answer that question. During an interview via telephone with the Director of Clinical Assessments on 7/22/18 at 2:04 p.m. she stated that the policy is the regulation related to creating a Baseline Care Plan. She stated that she will send over the training and the process at which they train the staff. A review of the Process documentation provided by the Director of Clinical Assessments and the Nursing Home Administrator on 7/22/18 revealed that the admission nurse begins the process of developing the patients Baseline Care Plan as this is formed from the Admissions Nursing Assessment. The admitting Nurses are to review the care plan for each patient, after completing the admission assessment . must be individualized and specific to the patient. Review the problem, goal, and interventions . to update and revise to meet the needs of the patient.",2020-09-01
3979,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2018-07-22,656,D,0,1,QMOW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to develop a plan of care related to the use of [MEDICAL CONDITION] medications for three residents (#4, #11, and #26) from a sample of 21 residents. Findings include: 1. Review of the clinical records for resident (R) #11 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed a Quarterly MDS assessment of 5/20/18 which documented [DIAGNOSES REDACTED].#11 on 12/1/17 and this assessment documented that the resident was being administered an antidepressant medication daily. Under the Care Area Assessment Summary (CAAS) of that annual assessment, [MEDICAL CONDITION] drug use triggered, and the decision was made to create a plan of care for that area. A review of the care plan records for R#11 revealed there was no plan of care related to the use of a [MEDICAL CONDITION] medication (an antidepressant). 2. A review of the clinical records for R#26 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the most recent comprehensive assessment for R#26 - a Significant change MDS dated [DATE] revealed the resident was assessed as having active [DIAGNOSES REDACTED]. The assessment also documented that the resident was receiving antidepressant and antianxiety medications daily. Under the Care Area Assessment Summary, [MEDICAL CONDITION] drug use triggered and a decision was made to complete a plan of care for that area. A review of the care plan records for R#26 revealed there was not a plan of care related to the resident's use of [MEDICAL CONDITION] medications (anxiolytic and antidepressant). 3. A review of the clinical records for R#4 revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the Annual MDS assessment dated [DATE] revealed the resident was assessed as having an active [DIAGNOSES REDACTED]. Under the Care Area Assessment Summary, cognitive loss/dementia, behavioral symptoms, and [MEDICAL CONDITION] drug use triggered and the decision was made to complete a plan of care for those areas. A review of the care plan records for R#4 revealed there was not a plan of care related to the resident's use of [MEDICAL CONDITION] medications (antipsychotic and antidepressant). Review of the policy titled Patient's Plan of Care last reviewed and updated (MONTH) (YEAR) revealed that the care plan is developed from the patient assessment (MDS) and incorporates identified problem areas. During an interview on 7/21/18 at 4:06 p.m. with MDS Coordinator CC revealed that care plans for R#11, R#26, and R#4 related to the use of a [MEDICAL CONDITION] medication was not completed as planned and this was an oversight. She confirmed that the residents were receiving [MEDICAL CONDITION] medications.",2020-09-01
3980,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2018-07-22,812,F,0,1,QMOW11,"Based on observation, staff interview, and policy review the facility failed to properly store clean dishware; failed to hold cold food items at/or below 41 degrees Fahrenheit as well as hot foods above 135 degrees Fahrenheit on the steam table; and dietary staff failed to properly wash hands after touching soiled dishware before touching clean dishware. This deficient practice had the potential to effect 51 residents receiving an oral diet. Findings include: Observation on 7/21/18 at 12:20 p.m. of Dietary Aide AA revealed she exited the dish room with a cart that had clean dishware on the top shelf and was taking the items to their appropriate areas. Continued observation revealed Dietary Aide AA took a green colored cloth and dried the inside of measuring cup before placing on the storage rack. Observation on 7/21/18 at 12:28 p.m. revealed Dietary Aide BB exiting the dish room wiping a metal spatula dry with a green colored cloth and placing it in a wire metal basket hanging from the wall. Further observation revealed a box labeled Foodservice Counter Towel on a shelf under a food preparation table which contained the green colored clothes Dietary Aide AA and Dietary Aide BB were using to dry the dishware. Steam table temperatures were attained on 7/21/18 at 12:30 p.m. using the facility's calibrated thermometer and the Dietary Manager (DM) assisted with obtaining and verifying the food temperatures. The following food items were not held at the proper temperatures: - Chopped Smoked Sausage was 107 degrees Fahrenheit. - Puree Cauliflower was 127 degrees Fahrenheit. - Glass of Skim Milk was 49 degrees Fahrenheit. Continued observation of the steam table revealed that the chopped smoked sausage was in a small pan, resting on the back ledge on the steam table, the pan was not directly inside the steam table. Observation of the pureed cauliflower revealed it was in a small pan and that pan was placed inside another pan that was in the steam table. Further observation revealed an open cart the multiple shelfs, and one shelf had a bin that contained beverages poured into glasses. There was ice in the bin that covered the bottom one inch of the glasses, the top 4 inches of the beverage glasses were not covered with ice. Interview on 7/21/18 at 12:30 p.m. with the Dietary Manager revealed that the chopped smoked sausage, pureed cauliflower, and milk were not at the correct temperatures. Continued interview with the Dietary Manager revealed that one more resident was to receive the chopped smoked sausage and one more resident was to receive the pureed cauliflower. Continued interview with the DM stated that the dietary aides get the cold food prep cart ready for lunch. Observation on 7/21/18 at 12: 40 p.m. of Dietary Aide BB revealed she exited the dish room wiping 2 metal ice cream type scoops dry with a green colored cloth. Observation on 7/21/18 at 12:50 p.m. of Dietary Aide AA revealed she took a soiled plate from the window ledge in the dish room placed it in the wash sink, then took the water hose and sprayed sink. Continued observation revealed Dietary Aide AA exited the dish room and touch a stack of 4 resident meal trays sitting on the food preparation table. Dietary Aide AA was observed placing the 4 meal trays on top of a larger stack of trays next to the steam table which the cook was using to serve the resident lunch meal. Dietary Aide AA did not wash her hands after touching the soiled plate before touching the clean resident trays. Interview on 7/21/18 at 1:00 p.m. with Dietary Aide BB revealed she confirmed that she dried the metal spatula and scoops with the green cloth. She stated that the scoops were needed by the cook, so she wiped them dry for the cook to use. When asked why she wiped the metal spatula dry earlier and placed it in the storage basket she was not able to provide an answer. Interview on 7/21/18 at 1:05 p.m. with Dietary Aide AA revealed she confirmed that she did not wash her hands after touching the dirty plate and before touching the clean trays. Further interview with Dietary Aide AA she stated that she usually washes her hands between touching dirty to clean but forgot. Interview on 7/21/18 at 2:25 p.m. with the DM revealed that the documents she provided for review were the policies the dietary department follows. Continued interview revealed that the DM expects dietary staff to wash hands between handling dirty dishes and before touching clean dishes. The DM expects dietary staff to allow washed dish items to air dry before storing and not to wipe dry. Review of the document titled Ready 365 Best Practice Standard of the Week: Hand Washing revealed when to wash hands: after touching anything else that may contaminate hands, such as dirty equipment, work surfaces, or cloths. Review of the document titled Ready 365 Best Practice Standard of the Week: Monitoring temperatures during meal service revealed Food that is being held for service (either hot or cold) is at risk for time-temperature throughout meal service and maintain proper safe food handling practices to minimize risks. Proper holding temperatures, hot food is 135 degrees or higher, cold food is 41 degrees or lower. Continued review of the document revealed that cold items should be kept in the refrigerator for as long as possible; keeping the items in smaller batches and utilizing ice baths will help maintain proper temperatures. Further review of the document revealed all hot items should be appropriately inside a steam table well. Placing items above the steam table will not hold food at proper temperatures. Review of the document titled Ready 365 Best Practice Standard of the Week: Three compartment sink revealed to air dry items on a clean and sanitized surface (place the items upside down so they will drain, Never use a towel to dry items as it could contaminate them). Review of the document titled Ready 365 Best Practice Standard of the Week: High Temperature Dish Machine stated that dishes must be air-dried prior to storing them. Review of the document titled Resident Diets revealed that 4 residents receive a chopped diet and 2 residents receive a pureed diet. Review of the Food and Nutrition Competency Checklist for Dietary Aide BB revealed the dietary competency were completed however there was no dated documentation. Dish Machine topic was discussed with her and air drying was indicated, discussed infection control with dirty verses clean areas. Review of the Competencies for Food and Nutrition Services Employees revealed that Dietary Aide AA completed competencies on 5/10/18. The competency checklist indicated that the Dietary Aide has knowledge regarding stores dishware in a clean, dry location, not exposed to splash, dust, or other contamination and covered or inverted. Competencies included, understands infection control precautions, maintains appropriate practice for handling clean and sanitized equipment and utensils to protect them from contamination. Also, competencies in, properly washes hands with soap and water to prevent cross-contamination. Review of the in-service dated 2/6/18 revealed that the dietary staff were in-service regarding Measuring temp of food and the education provided included reheating food, measuring temps, cleaning food thermometer, monitoring controls on thermometer and adjusting. Review of the in-service regarding the Three compartment sink conducted on 8/14/18, revealed that neither Dietary Aide AA or BB had attended. Review of the in-service titled Hand washing conducted on 8/4/18 revealed that neither Dietary Aide AA or BB had attended. Review of the in-service titled High Temperature Dish Machine conducted on 10/3/17 revealed that neither Dietary Aide AA or BB had attended.",2020-09-01
3981,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2017-08-19,371,E,0,1,MGBL11,"Based on observation, staff interview, and documentation review the facility failed to label, date, and cover opened food items in one of one walk-refrigerators; failed to discard food items past the use by date; and failed to ensure storage racks in the dry storage area were free from food debris to prevent pests/rodents. This deficient practice has the potential to effect 54 residents receiving an oral diet from a census of 55 residents. Findings include: Observation on 8/18/17 at 8:00 a.m. during the initial kitchen tour revealed the following in the walk-in refrigerator: 1) A five pound container of sour cream with a use by date of 7/21/17. 2) A one gallon container of Italian salad dressing opened with no lid. 3) A five pound bag of shredded cheddar cheese opened with no date. 4) A five pound bag of grated parmesan cheese opened with no date. 5) A square clear plastic container with sliced American cheese with no label or date. 6) A one gallon container of Home Style Ranch salad dressing opened with no date. 7) A square clear plastic container with a white liquid food item with no label or date. Observation on 8/18/17 at 8:20 a.m. and 8/19/17 at 3:50 p.m. of the dry storage area revealed a white granular substance on the storage rack that was present on three shelves, top, middle, and bottom. Interview on 8/18/17 at 8:25 a.m. with the Food Service Director (FSD) revealed she confirmed that the Italian dressing was opened with no lid, the ranch dressing opened with no label or date, the shredded cheddar cheese, parmesan cheese and sliced American cheese were all opened with no date. Continued interview with the FSD revealed she confirmed that the container of sour cream had a use by date of 7/21/17 and should have been discarded. She confirmed that the container with the white liquid food item was not labeled or dated. The FSD stated that staff are to label and date any opened food item, excepts staff to cover opened food items and to discard items past the use by date. Observation on 8/18/17 8:30 a.m. outside the door near the walk-in refrigerator revealed an undated sign title Discard Date Guidance which stated the manufacturer's expiration date, when available, is the use by date for unopened items. Interview on 8/18/17 at 3:50 p.m. with the FSD revealed she confirmed the white food substance on the storage rack in the dry storage room. The FSD revealed that the dry storage area is on the weekly cleaning schedule and excepts staff to clean the shelves. Review of the Serv Safe document dated 2008 title How to Store Food Properly: Best Practices for Storing Food revealed label and date all stored food and also keep storage areas dry and clean. Review of the Nutritional Services Procedural Guidelines revised (MONTH) (YEAR) of Food Preparation, Storage and Serving revealed it is the intent of this center to serve safe food and practice basic safe food handling principles. Procedure Guidelines: 1) Food service associates will follow best practice standards from ServSafe, GA Dept. of Health, FDA, and CMS Regulations.",2020-09-01
4428,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2016-04-20,371,E,0,1,3W8H11,"Based on observations and interviews, the facility failed to ensure that one (1) of four (4) ice machines were free from brown buildup on the dispensing lid and failed to ensure that foods were stored in a safe and sanitary manner in one (1) of one (1) cafe refrigerator and in two (2) of two (2) food pantries. Findings include: Observation and interview on 04/20/16 at 9:01 a.m. with the Food Service Manager revealed that the dining room Cafe refrigerator had two (2) forty-six ounce (oz) containers of thickened water dated 4/12/16 to be used by 4/18/16, that were expired. Interview with the Food Service Manager at this time confirmed that the items were out of date. Observation on 04/20/16 at 9:22 a.m. of the first floor food pantry revealed two (2) bowls of cereal were covered but not labeled or dated. Observation on 04.20/16 at 9:36 a.m. of the second floor food pantry revealed four (4) yogurt containers two (2) yogurt containers with a sell by date of 4/11/16 and two (2) yogurt containers with a sell by date of 4/13/16. Observation on 04/20/16 at 9:38 a.m. revealed the Ice Machine dispensing lid had a buildup that was brownish in color. Observation on 04/20/16 9:40 a.m. revealed one (1) Taco [NAME] rice bowl located in the cabinet of the second floor food pantry was not labeled with the residents name that had an expiration date of (MONTH) 17, (YEAR). Interview on 04/20/16 at 9:44 a.m. with the Resident Care Coordinator (RCC) Coordinator/Unit Manager for the second floor confirmed the brownish build up on the ice machine dispensing lid and reported that maintenance is responsible for the cleaning and servicing of the ice machine. The RCC Coordinator/Unit Manager for the second floor confirmed that the expired yogurt and rice bowl would be discarded. Interview on 04/20/16 date at 10:36 a.m. with the RCC Coordinator/Unit Manager for the first floor at confirmed that the cereal in the food pantry cabinet should have been labeled and dated prior to being placed in the cabinet.",2019-11-01
5590,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2015-03-12,157,D,0,1,J36O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow physician's order regarding physician notification for one (1) resident (#279) from a sample of twenty-five (25) residents. Findings Include: Record review for resident #279 revealed [DIAGNOSES REDACTED]. A physician's order dated 2/27/15 indicated the resident was to have daily weights and to notify physician of a gain of two (2) to three (3) pounds in 24 hours or five (5) pounds in a week Review of Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) reveal a weight gain of ten pounds from 2/28/2015 until 3/2/2015. Further review of these MARs revealed a weight of 190.4 pounds on 2/28/15 but no other weights unit 3/2/15, when the resident's weight was 200 pounds. The resident was not weighed again until 3/5/15, and his weight was 204 pounds. There was no evidence that the facility notified the physician of the weight gain. Interview with Licensed Practical Nurse (LPN) AA on 3/11/2015 at 11:35 AM revealed she was not aware of the physician's order for daily weights for resident (#279). After record review she determined that the physician was not notified of the ten (10) pound weight gain discovered on 3/2/2015. Interview with the Director of Nurses (DON) conducted 3/11/2015 at 12:53 PM revealed she had reviewed this resident's chart and the was no evidence the physician was notified of the resident's weight gain.",2018-08-01
5591,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2015-03-12,282,D,0,1,J36O11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to follow a the plan of care for weight and physician notification for one (1) resident (#279) from a sample of twenty-five (25) residents. Findings Include: Record review for resident #279 revealed [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. Review of the resident's plan of care dated 3/10/15 revealed a care plan for nutrition. The goal was for the resident not to have a significant weight change. An intervention was to observe weights and notify the physician of significant weight changes. Interview with Licensed Practical Nurse (LPN) AA on 3/11/2015 at 11:35 AM revealed she was not aware of the physician's orders [REDACTED].#279). After record review she determined that the physician was not notified of the ten (10) pound weight gain discovered on 3/2/2015. Interview with the Director of Nurses (DON) conducted 3/11/2015 at 12:53 PM revealed she had reviewed this resident's chart and the was no evidence the physician was notified of the resident's weight gain. Cross Refer to F157.,2018-08-01
5592,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2015-03-12,309,D,0,1,J36O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow a physician's order for daily weights for one (1) resident (#279) from a sample of twenty-five (25)residents. Findings Include: Record review for resident #279 revealed [DIAGNOSES REDACTED]. A physician's order dated 2/27/2015 indicated the resident was to have daily weights and to notify physician of a gain of two (2) to three (3) pounds in 24 hours or five (5) pounds in a week. Review of Medication Administration Records (MARs) for (MONTH) and (MONTH) (YEAR) reveal a weight gain of ten pounds from 2/28/2015 until 3/2/2015. Further review of these MARs revealed a weight of 190.4 pounds on 2/28/15 but no other weights unit 3/2/15, when the resident's weight was 200 pounds. The resident was not weighed again until 3/5/15, and his weight was 204 pounds. There was no evidence that the resident was weighed daily according to the physician order. Interview with Licensed Practical Nurse (LPN) AA on 3/11/2015 at 11:35 AM revealed she was not aware of the physician's order for daily weights for resident (#279). Record review with AA indicated weights were taken three times since his admission. After record review, she determined that the resident had a ten (10) pound weight gain as of 3/2/2015. Interview with LPN BB on 3/11/2015 at 11:40 AM revealed daily weights were not done on this resident and she was not aware of the physician's order. Interview with the Director of Nurses (DON) conducted 3/11/2015 at 12:53 PM revealed she had reviewed this resident's chart and the physician's ordered for daily weights and daily weights had not been done.",2018-08-01
6454,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2014-05-29,280,D,0,1,Z2QD11,"Based on review of the Care Plan Conference Sheet, resident, and staff interviews, the facility failed to ensure one (1) resident R had participated in planning care and treatment from a sample of twenty-two (22) residents. Findings include: Review of the Care Plan Conference Sheet dated 8/30/13 revealed a care plan meeting was conducted with the attendance of one (1) Registered Nurse and the Activities Coordinator who also functioned as the Social Service Director at that time. There was no evidence that the resident had been invited or attended this meeting. There was no other documentation related to any care plan conferences having been conducted until 5/16/2014. Interview conducted on 05/27/14 at 2:00pm with resident R revealed she was not involved with decisions about her care. During this interview she indicated she had concerns with Activities. She felt there were not enough and some were boring. She would like activities related to going outdoors, using the spa, snacks more than once a day, and more exercise such as walking. The resident revealed she was invited to a care plan conference once a long time ago but it was canceled. Interview conducted on 05/29/14 at 10:45am with the Social Service Director revealed care plan conferences with invitations to resident and family members should take place with each quarterly review. She further revealed that she had no knowledge of why this residents' care plan meeting was canceled in August and does not know why the resident had not been invited to the meeting. She does not know why the meeting were not held in November and February for the quarterly assessments. Interview conducted on 5/29/14 at 11:10am with the Activities Director revealed she does not know why the resident and her family were not invited to the meeting that did take place in August or why there were no further care plan meetings. She revealed that care plan meetings should include the dietary manager, social service director, activity director, therapist, and charge nurses.",2018-01-01
6455,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2014-05-29,309,D,0,1,Z2QD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the medical records, physician and staff interviews, the facility failed to ensure physician's orders were followed for two (2) residents (# 84 and #143) from a sample of twenty-two (22) residents. Findings include: 1. Review of the physician's orders for resident # 143 revealed an order dated 5/5/14 for house supplement one hundred and twenty (120) milliliters (ml) three times per day (tid). Further review of the May 2014 Medication Administration Record [REDACTED]. Interview with the Licensed Practical Nurse (LPN) GG on 5/27/14 at 2:40pm revealed the supplement was not on the MAR. She was not aware of the resident being on a house supplement, and she had not administered a supplement to this resident. 2. Observation conducted on 5/29/14 at 9:25am revealed resident #84 was up in wheelchair with an immobilizer on the Right arm. The resident was moaning with pain and a Licensed Practical Nurse (LPN) was assisting her with her medications. Observation conducted on 5/29/14 at 4:08pm revealed the resident in her wheelchair in the hallway crying out in pain and holding her right shoulder. A staff member assisted her back to her room. Review of the medical record revealed an admission date of [DATE] and on 5/20/14 she was [DIAGNOSES REDACTED]. Review of the physician's orders revealed an order dated 5/20/14 for [MEDICATION NAME] 5/325mg by mouth (po) every (q) six (6) hours as needed (PRN) for mod-severe pain; cold compress to (R) shoulder PRN fifteen (15) to twenty (20) minutes on and Biofreeze to (R) shoulder q 4 hours PRN. Further review revealed an order dated 5/21/14 to discontinue (DC) [MEDICATION NAME] and give [MEDICATION NAME] 75mg po twice a day (BID) for pain. D/C [MEDICATION NAME] when [MEDICATION NAME] arrives. Change Tylenol to 650mg po q 8 hours scheduled for pain. Review of the May 2014 MAR indicated [REDACTED]. Interview with the physician for resident #84 conducted on 5/29/14 at 4:00pm revealed that due to allergies [REDACTED]. The physician further revealed that Tylenol 650mg every 8 hours, [MEDICATION NAME] 75mg BID, cold compresses to right shoulder as needed (PRN) for 15-20 minutes and Biofeeze to the right shoulder every 4 hours PRN were ordered to manage the resident's pain. Review of the May 2014 Medication Administration Record [REDACTED]. Interview conducted on 5/29/14 at 4:10pm with Registered Nurse (RN) JJ revealed that he signed off the order for Biofreeze and faxed it to the pharmacy. JJ then gave the orders to the medication nurse and they are supposed to add the new orders to the MAR. JJ further revealed that he did not check to make sure it had been done.",2018-01-01
6456,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2014-05-29,371,F,0,1,Z2QD11,"Based on observations, staff interviews, and review of the USDA Cold Storage Chart, the facility failed to discard potentially hazardous foods timely. Findings include: On 5/27/14 at 10:40am during the initial tour of the kitchen, observation of one (1) reach-in cooler revealed various expired condiments as follows: One (1) squeeze bottle of BBQ sauce with a prepared date of 10/11/13, One (1) squeeze bottle of Thousand Island dressing with a use by date of 3/25/14, One (1) squeeze bottle of Honey Mustard dressing with a use by date of 3/25/14, One (1) squeeze bottle of French dressing with a use by date of 3/25/14, One (1) squeeze bottle of Creamy Italian dressing with a use by date of 3/25/14, One (1) squeeze bottle of Mustard with a prepared date of 4/3/14, The kitchen manager was present during this observation and acknowledged all should have been discarded. She removed all the squeeze bottles of condiments at this time and placed them in the sink area to be emptied and cleaned. Observation of the dry storage area at 10:50am revealed one (1) bag of cake mix dated 5/2/14 that was not covered and the top was loosely folded over. Interview with the Kitchen manager at this time confirmed the cake mix should have been stored in a closed zip lock baggie. Continued observations conducted at 11:00 am of the walk-in cooler revealed : One (1) smoked ham loaf, approximately half, used wrapped in saran wrap with no open date on the clear wrapping. Raw hamburger meat in an uncovered plastic bin, wrapped in clear saran wrap, but had a prep date of 5/14/14. One (1) large covered plastic storage container of roast beef and gravy with a preparation date of 5/22/14. An uncovered plastic container with eleven (11) hard boiled eggs submerged in water. The egg shells were shattered, cracked and broken. There were pieces of egg yolk, egg whites and egg shells in the water. The water was discolored with odor. The container was labeled with the date of 5/24/14. One (1) covered plastic container with nine (9) large bratwurst links. The skins were dry and splitting open. The label on the container indicated vegetable soup with a preparation date of 5/18/14. Five (5) quart size cartons of Heavy Cream with an expiration date on each of them of 5/22/14. Interview on 5/27/14 at 11:25am with the Administrator revealed Ethica, as a corporation, does not have specific written polices for food storage and labeling. They follow State guidelines for food storage and she could get me a copy of the guidelines they use. She said the staff is oriented on food storage during the initial orientation process. She provided a Cold Storage Chart by the USDA. which indicated the following: Mayonnaise/Dressings/Condiments are to be refrigerated after opening for one (1) month. Raw hamburger is to be refrigerated for two (2) days. Meat leftovers consisting of cooked meat and meat dishes are to be refrigerated for three (3) to four (4) days. Meat leftovers consisting of gravy and meat broth are to be refrigerated for one (1) to two (2) days.",2018-01-01
6457,ANSLEY PARK HEALTH AND REHABILITATION,115722,450 NEWNAN LAKES BLVD,NEWNAN,GA,30263,2014-05-29,502,D,0,1,Z2QD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the physician's orders, Medication Administration Record [REDACTED]#33) from a sample of twenty two (22) residents. Findings include: Review of the physician's orders for Resident # 33 revealed an order dated 7/12/13 to obtain H & H every other Tuesday, give [MEDICATION NAME] 20,000 units (u) subcutaneous (SQ) every two weeks on Wednesdays, hold if the Hemoglobin (Hgb) was greater than ten (10). Review of the Laboratory (lab) reports revealed there was no evidence of an H&H obtained on 4/8/14, 5/6/14 or 5/20/14. A new order was transcribed on 5/21/14 for H&H every two (2) weeks on Monday. Give [MEDICATION NAME] 10,000u every two (2) weeks on Thursday. Do not give [MEDICATION NAME] if Hgb is greater than ten (10). Draw H&H in morning (am). Further review of the lab report revealed this H&H was not obtained until 5/26/14. Interview with the Licensed Practical Nurse (LPN) charge nurse AA on 5/29/14 at 2:30pm revealed lab request were placed in the lab book under the date the lab was due, and the lab sheet was also placed in the lab book. When the lab technician came to draw blood, she looked at the lab book for the day and obtained what was listed. The lab tech initialed all labs drawn. Return lab results were placed in the physicians' book for their review and signature. The LPN was not sure why the labs were not done as ordered. Interview with the Director of Nurses (DON) on 5/29/14 at 4:05pm revealed that during the two (2) months of missed H&Hs there were agency nurses working the medication cart on A-hall. The process was in place of hiring a new LPN to work that hall. The Resident Care Coordinator (RCC) responsible for oversite of labs due, resigned 5/1/14. Audits given to the DON were not correct. Delinquent labs were discovered by the interim RCC, during her audits. The Physician was informed and wrote a new order dated 5/21/14 to obtain H&H every two (2) weeks on Mondays.",2018-01-01
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
4304,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2015-07-23,287,C,0,1,E39D11,"Based on review of the state agency (SA) Minimum Data Set (MDS) Missing OBRA Assessment Report and staff interview, the facility failed to ensure that eight (8) MDS Assessments were transmitted to the SA in a timely manner. Findings include: Review of the SA MDS Missing OBRA Assessment Report having a run date 6/29/2015, revealed that as of that date, the facility had eight (8) missing MDS Assessments. During an interview on 07/22/15 at 12:40 p.m. with the MDS coordinator, he/she acknowledged there were late or missing MDS assessments.",2019-11-01
4305,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2015-07-23,371,E,0,1,E39D11,"Based on observation, staff interview and review of facility policy, the facility failed to dispose of expired food products in a timely manner and to refrigerate items that required refrigeration to prevent food-borne illness on two (2) of three (3) halls with a total of sixty-two (62) residents receiving oral alimentation. Findings include: Observation on B-hall on 07/22/15 at 12:16 p.m. in the pantry refrigerator, where resident snacks were kept, revealed three (3) expired milks. Interview on 07/22/15 at 12:18 p.m. with Registered Nurse DD , unit manager confirmed that the milks were expired. Observation on C-hall on 07/22/15 at 12:21 revealed a bottle of Ranch Dressing sitting on the counter at room temperature in the pantry that contains resident snacks. The bottle of Ranch Dressing was approximately 1/3 to 1/4 full with the label stating to refrigerate after opening. Review of Policy regarding storage of foods revealed that perishable food items were to be stored in the refrigerator in dated and labeled containers between thirty-eight (38) and forty-one (41) degrees Fahrenheit. Interview conducted with Licensed Practical Nurse EE, at the time of the observation confirmed that the ranch dressing was sitting on the counter and should have been refrigerated.",2019-11-01
4306,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2015-07-23,441,D,0,1,E39D11,"Based on observation, record review, and staff interview, the facility failed to provide care during wound care in a manner to help prevent the development of infection for one (1) resident (#30) from a survey sample of twenty-four (24) residents. Findings include: Observation of wound care for resident #30 on 07/23/15 at 10:10 a.m. with Treatment Nurse BB revealed during the wound dressing change BB cleansed the wound and apply applied clean dressing and failed to change dirty gloves or wash he/she hands throughout this proceedings. Review of Policy for Dressing changes showed that gloves were to be removed, hands washed and a clean pair were to be donned aseptically after removal of a dirty dressing, and before treatment performed as ordered, and hands were to be washed after discarding of waste. Interview with the Director of Nursing (DON) on 07/23/15 at 10:32 a.m. revealed that he/she would expect that hands would be washed before starting treatment, with removal of a dressing, and with cleansing of wound, etc. as appropriate for infection control.",2019-11-01
7163,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2012-09-20,223,G,0,1,J9CX11,"Based on resident interview, staff interviews and record review, it was determined that the facility to ensure that one resident (O) from a sample of 21 residents was free from verbal abuse from other residents. Findings include: Verbal abuse is defined as any use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents within their hearing distance, regardless of age, ability to comprehend, or disability. However, the facility failed to identify known behaviors of some residents towards resident O as verbally abusive so did not report and investigate to prevent recurrences. During an interview on 9/19/12 at 3:30 p.m., resident O stated that resident P talked about him/her, told resident O that he/she did not want to talk to him/her and to leave resident P alone. Resident O stated that there was a group of residents that made fun of him/her by making fun of how he/she talked. He/she stated that it made him/her cry. Resident O said that he/she stayed in his/her room most of the day and ate in his/her room because resident P bothered him/her. At that time, the family member of resident O stated that the resident had been moved about four times because resident P was mean to him/her (resident O). During an interview on 9/19/12 at 12:00 p.m., staff EE confirmed that a group of ladies on the resident's hall talked about the resident and whispered about the resident when he/she went down the hall to his/her room. Staff EE stated that, over the weekend, it was reported that the resident rolled past that group of ladies and resident P said Look at that shady dog. Staff EE said that resident O was crying over the weekend because of that statement. He/she stated that, yesterday, the Administrator discussed moving resident O to a different hall. During an interview on 9/19/12 at 4:30 p.m., the nurse manager stated that the certified nursing assistants (CNAs) had reported to her that the group of ladies which included resident P talked about resident O. The nurse manager stated that she just told resident O not to say anything to them and just roll on by. She stated that today a CNA reported that resident M called resident O a hairy dog this past Sunday during church service. She stated that resident O had been moved twice because of resident P. The nurse manager said that a CNA had previously reported to her that a resident had told resident O that he/she did not have any sense but, the nurse could not remember when it had been reported to her. During an interview on 9/20/12 at 10:00 a.m., staff BB stated that a couple months ago they were pushing resident O in a wheelchair down the hall past resident P's room and resident P called resident O a dog. Staff BB stated that it hurt resident O's feelings and the resident started crying. BB stated that he/she had reported it to the charge nurse. He/she stated that he/she had also witnessed that group of residents in activities look at resident O and then start laughing. Staff BB stated that, a couple weeks ago in the activity room, the group of residents were mocking the way resident O talked in front of him/her. He/She said that he/she reported it to the charge nurse. During an interview on 9/20/12 at 12:00 p.m., staff CC stated that they had overheard resident P and another resident talk about resident O saying Look at that thing or would tell the resident they did not want him/her sitting with them. Staff CC stated that those residents were loud enough where the resident could hear them. She said that it was hard to say how often that happened and that they talked about everybody. Staff CC stated that one time resident O came to activities and had been crying and reported to him/her that a group of residents had been talking about him/her. Staff CC stated that he/she had reassured the resident and told him/her not to listen to them. CC stated that he/she and the rest of the staff tried to reassure resident O and cheer him/her up. She said that resident O enjoyed the activities and participated well. She said that the only thing that brought the resident down (in mood) was the group of residents that talked about him/ her. During an interview on 9/20/12 at 12:45 p.m., the Administrator stated that the staff tried to keep the residents separated and that they probably had not done all that they should to make the situation better. She stated that the staff had discussed moving one of the residents to a different hall on 9/17/12 but, did not have a vacant room. She said that she was not aware of the resident being called a dog, or that residents had made fun of his/her speech. She stated that, a few months ago, they had moved resident O towards the front of the hall so he/she could be closer to activities. However, that room was across the hall from resident P so they moved resident O to the other end of the hall per the resident's request. However, resident O still had to go past the room of resident P. The Administrator said that, on 8/02/12, the staff had a meeting with the residents and discussed residents being disrespectful to other residents and no concerns were brought up by the residents in attendance. Review of the 8/02/12 Call meeting notes revealed that the topic of discussion was disrespecting other residents. The documentation noted that it was explained to the residents that staff were not to disrespect residents and the same for other residents. The notes documented that there were a few residents that wanted to sit in groups and disrespect others due to their disabilities, whether it was physical or mental. Staff noted that no concerns were voiced by the residents in attendance. Staff documented that resident P stated that if you did not like someone, to move on and not bother them. Review of the 7/23/12 Complaint/Grievance Form noted that resident O had complained that resident P had been picking on him/her and had called him/her names. The form noted that, per resident O's request, he/she was moved back down to the end of the hall away from resident P. Although facililty staff had witnessed derogatory remarks made to resident O and been aware of the resident's mental distress (crying) over them, there was no evidence that the facility had identified those derogatory remarks as verbal abuse of resident O. Therefore, the facility had not reported it to the appropriate State agency and had not done a thorough investigation to determine the cause or reason for the abuse to prevent further recurrence of it for resident O.",2017-07-01
7164,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2012-09-20,244,E,0,1,J9CX11,"Based on record review, resident interview and staff interview, it was determined that the facility failed to act on food complaints voiced by residents in Resident Council Meetings. Findings include: 1. Review of the 9/4/12 Resident Council Meeting minutes revealed that residents requested that the menus be changed with new foods, and complained that they were served the same food every week, just in different ways. The meeting notes documented that there were also complaints by residents about hard chicken that was black on the inside, the meatloaf not being done and hard buns that were cold and unfit to eat. The Dietary Manager noted that the issue about the chicken being black was part of the slaughtering process and that he would check on food being undercooked. He noted that he had told the residents that it was impossible to heat up buns for 100 plus people. The 8/6/12 Resident Council Meeting minutes noted that the dietary department had a long list of complaints. The documentation in the minutes noted that residents complained that the 8/05/12 supper was terrible. The notes recorded that residents had complained that the soy burgers caused some residents to have upset stomachs, the pork chops were too tough to eat, the same foods were served every week, chicken thighs were often undercooked, the coffee was cold and weak, the beans were too salty and the rolls were too hard. The 7/2012 Resident Council Meeting minutes noted that residents had complained that the toast was still hard and the pork chops were still tough. It was noted that a staff person from the dietary department was present in the meeting and told the residents that their complaints would be reported to the Dietary Manager. The meeting minutes noted that the residents complained about hard toast, weak coffee, tough pork chops, and tough and dry fried chicken. The 4/2012 Resident Council Meeting minutes noted that the residents had complained that the pork chops were tough, the biscuits were hard, and the coffee was cold. There was no evidence the facility had attempted to act on the grievances about the food served to them as reported in their Resident Council Meetings. During an interview on 9/18/12 at 9:00 .m., resident P stated that there was blood in the fried chicken and the fried meats were too hard to eat. The resident stated that residents had made numerous complaints in the Resident Council Meetings but, it did not get any better. During an interview on 9/20/12 at 10:00 a.m., resident Q stated that the residents were not served enough vegetables, were served too many starches and the meat was too hard. During an interview on 9/20/12 at 11:10 a.m., resident Z stated that, during the Council meetings, the residents had complaints regarding the food about not having any variety but, staff had failed to act upon those complaints. Resident Z stated that the Dietary Manager had been present during some of the meetings in the past when residents had voiced their grievances. However, resident Z stated that he/she (Dietary Manager) never did anything about it.",2017-07-01
7165,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2012-09-20,371,F,0,1,J9CX11,"Based on observation and staff interview, it was determined that the facility failed to cover, label and/or date foods appropriately in the walk-in refrigerator to promote safe refrigerated storage. Findings include: During a tour of the kitchen's walk-in refrigerator with the Dietary Manager on 9/17/12 at 1:30 p.m., there was a plastic container with sausage, bacon and sausage gravy that was not dated. There was also a pan of blueberry pie that was not covered, labeled or dated. In an interview at that time, the Dietary Manager stated that the left-over breakfast foods should have been dated with today's date. The Dietary Manager stated that he thought that the pie did not need to be covered because it was on a baker's rack with a pan on the shelf above the pie that shielded it from debris.",2017-07-01
9031,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,323,E,0,1,MIWW11,"Based on observations, it was determined that the facility failed to maintain an environment free of potentially hazardous chemicals on three (A hall, B hall and C hall) of three halls in the facility. Findings include: A Hall In the common bath area, there was an opened door with direct access into the supply room in which the following hazardous chemicals were observed: 1. One plastic spray bottle of a chemical substance with a hand written label of ""Virex."" 2. One bottle of Invacare Disinfectant with manufacturer's instructions to keep out of the reach of children and to call the poison control center or a physician for immediate treatment if ingested. 3. One bottle of Invacare Heavy Duty Cleaner with manufacturer's instructions to keep out of the reach of children, corrosive, may cause irreversible eye damage and skin burns, hazardous to humans and domestic animals, and may be harmful or fatal if swallowed. B Hall The door to the beauty shop located on the B hall was opened. The following observations were made in the beauty shop: 1. There was a bottle of Hair Color Rinse with manufacturer's instructions to keep out of the eyes. 2. There were three bottles of Fanci-Ful Rinse with manufacturer's instructions to keep out of the eyes, may cause skin irritation and to keep out of the reach of children . 3. There were two pairs of scissors in an accessible tray. 4. There was one pair of scissors in an unsecured top drawer of a wicker storage bin. 5. There was one unlabeled container of a cream colored substance. C Hall In the common bath area, there was an opened door with direct access into the supply room in which the following hazardous chemicals were observed: There were three small bottles and a one gallon jug of Horizon Glisten non-acid bathroom cleaner with manufacturer's instructions to be used for industrial use only, to keep out of the reach of children, to avoid contact with skin or eyes and to not take internally.",2015-08-01
9032,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,280,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to revise the care plan for one resident (""R"") to include the use of a perma-catheter from a total sample of 20 residents. Findings include: Resident ""R"" had a [DIAGNOSES REDACTED]. Licensed nursing staff documented in the 12/18/10 nurse's notes that the resident had a new perma-catheter in his/her right chest wall area and had no bleeding, redness or swelling at the insertion site. The resident's care plan dated 11/18/2010 included information that the resident was receiving [MEDICAL TREATMENT] three times a week but, it did not include any revisions to include interventions to address the use of a perma-catheter. See F309 for additional information regarding resident ""R"".",2015-08-01
9033,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,309,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with a resident and staff, and record reviews, it was determined that the facility failed to monitor a perma-catheter for one resident (""R""), to follow the physician's orders [REDACTED].#20), to change a dressing for one resident (#7) and, to send fingerstick blood sugar level results to the physician for one resident (#19) from a total sample of 20 residents. Findings include: 1. Resident ""R"" had a [DIAGNOSES REDACTED]. Licensed nursing staff documented in the 12/18/10 nurses notes that the resident had a new perma-catheter in his/her the right chest wall area and there was no bleeding, redness or swelling at the site. During an interview on 2/15/11 at 5:10 p.m., resident ""R"" stated that the [MEDICAL TREATMENT] nurses checked his/her perma-catheter each day when he/she received [MEDICAL TREATMENT] but, the nursing home staff only changed the dressing (on the insertion site) on his/ her shower days because it got wet. He/she stated that the nursing home staff did not check his/her catheter area when she returned to the facility after [MEDICAL TREATMENT]. Although licensed nurse ""AA"" stated during an interview on 2/16/11 at 9:20 a.m., that the resident's catheter site was checked every day by the nursing staff, there was no evidence in the resident's medical record, Medication Administration Record [REDACTED]. 2. Resident # 20 was admitted on [DATE] with a [DIAGNOSES REDACTED]. The 11/5/10 physician's orders [REDACTED]. However, a review of nursing staff's documentation on the Medication Administration Record [REDACTED]. On the back of the MAR, the Nurse's medication notes for 11/6/10 through 11/8/10 documented that the medication was not available. There was no evidence that the physician had been informed that the medication was not available to be given. The resident also had an 11/5/10 order to be given two packets of Neutrophos two times a day. Licensed nursing staff's documentation on the MAR indicated [REDACTED]. The nurse's medication notes on the back of the MAR indicated [REDACTED]. A review of the nurse's notes dated 11/9/10 revealed documentation that the physician's office was notified that the pharmacy had informed the facility that the medication was no longer being produced. However, there was no evidence that the physician responded to that information or that nursing staff followed-up with the physician. On the 11/16/10 nurse's notes, licensed nursing staff documented that the physician was notified again and that he instructed the nursing staff to contact the resident's nephrologist. The nephrologist was informed on 11/16/10 and the following day, 11/17/10, the nephrologist responded and gave a new order for the resident to receive whole milk products. During an interview on 2/16/11 at 11:35 a.m., licensed nurse ""BB"" stated that the resident had been admitted late on 11/5/10 and that the medication was not available from the hospital pharmacy at that time. The nurse was not able to provide any evidence that the physician had been informed that the Slo-Mag was not available until 11/9/10. She did not know why the physician was not notified about the Neutrophos packets no longer being produced until 11/9/10 or why the nursing staff did not follow up when the physician did not reply to that information. 3. On a 2/8/11 ""Readmission Nursing Summary,"" licensed nursing staff documented that resident #7 was readmitted with a large skin tear on his/her left elbow. There was a 2/8/11 physician's orders [REDACTED]. However, during observations on 2/14/11 at 2:10 p.m. and 3:20 p.m., and on 2/15/11 at 8:45 a.m. and 1:15 p.m., the resident's dressing was dated 2/9/11. On 2/16/11 at 10:45 a.m., the Treatment Nurse stated that the nurses on the floor provided dressing changes on residents' skin tears and that it was supposed to have been labeled with the date it had been changed. A review of the Treatment Record document revealed that the dressing on the resident's left elbow was scheduled to have been changed on 2/12/11, and had been incorrectly initialed as having been changed on 2/12/11. 4. Resident #19 had [DIAGNOSES REDACTED]. There was a 9/16/10 physician's orders [REDACTED]. However, a review of the nurse's notes and the September 2010 MAR indicated [REDACTED]. During interviews on 2/16/11 at 10:30 a.m. and 11:10 a.m., licensed nurses ""BB"" and ""LL"" stated that notification of the physician about the resident's blood sugar levels should have been documented in the nurse's notes or on the resident's MAR.",2015-08-01
9034,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,322,E,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility failed to provide appropriate services to prevent potential complications for five residents (#1, #2, #7, #11, and #12) with gastrostomy feeding tubes in a sample of eight residents with gastrostomy tubes in a total sample of 20 residents. Findings include: 1. Resident #12 was admitted with [DIAGNOSES REDACTED]. He/She was coded on the 4/12/10 Minimum Data Set (MDS) assessment as being totally dependent on staff for all his/her care needs. On 2/15/11 at approximately 10:25 a.m., during the observation of incontinence care, nursing staff had inappropriately lowered the resident's head of the bed to a flat position while the feeding was still infusing. 2. According to the facility's policy and procedure for checking tube placement, 10-20 milliliters (ml) of air was supposed to have been used by nursing staff to check placement of the tube. However, nursing staff did not implement that procedure for resident #11. Resident #11 was admitted with [DIAGNOSES REDACTED]. He/She was coded on the 1/27/11 MDS as being dependent on staff for all activities of daily living. He/She had a gastrostomy tube since 2007. During observation on 2/15/11 at approximately 9:55 a.m., licensed nurse ""WW"" checked placement of the resident's gastrostomy tube by incorrectly infusing 60 ml of air into his/her stomach. 3. Resident #2 was admitted with [DIAGNOSES REDACTED]. He/she had a gastrostomy tube in place with a physician's orders [REDACTED]. However, during an observation on 2/15/11 at 10:10 a.m., licensed nurse ""ZZ"" incorrectly gave the resident 120 ml. of water before the feeding and 180 ml. of water after the feeding. Licensed nurse ""ZZ"" stated that he/she always gave the resident extra amounts of water. In addition, during an observation of urinary incontinence care being provided immediately following the bolus feeding on 2/15/11 at 10:15 a.m., certified nursing assistant ""XX"" inappropriately lowered the resident's head of the bed to 10 degrees during care. 4. Resident #1 was admitted with [DIAGNOSES REDACTED]. He/she had a gastrostomy tube in place with a physician's orders [REDACTED]. of water flush before and after bolus feedings. However, during an observation on 2/15/11 at 12:05 p.m., licensed nurse ""ZZ"" flushed the resident's tube with 120 ml. of water, added 30 ml. of water to his/her bolus feeding and then flushed the tube with 180 ml. of water after the feeding. Licensed nurse ""ZZ"" stated that he/she had poured too much water for the flush so, he/she used 180 ml of water to flush the tube. In addition, immediately following the bolus feeding on 2/15/11 at 12:10 p.m., the treatment nurse inappropriately lowered the resident's head of the bed to a flat position to provide wound treatment. 5. Resident #7 was admitted with [DIAGNOSES REDACTED]. During the Initial Tour of the Facility on 2/14/11 at 11:30 a.m., licensed nurse ""WW"" stated that resident #7 had been readmitted the prior week after being hospitalized for [REDACTED]. During an observation of nutrition administered through his/her gastrostomy tube on 2/15/11 at 1:15 p.m., the licensed nurse administered one bottle of Nepro in addition to 600 ml of water flush. Immediately after that, on 2/15/11 at 1:25 p.m., certified nursing assistant (CNA) ""MM"" and ""NN"" lowered the head of the resident's bed to a flat position while providing care following an episode of bowel incontinence. The CNAs assisted the resident to turn to his/her left and right during the provision of care, at which time the resident coughed twice.",2015-08-01
9035,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,157,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to promptly consult with the attending physician about a significant change in the physical condition of one resident's (#9) foot and ankle, from a total sample of 20 residents. Findings include: Resident #9 had [DIAGNOSES REDACTED]. Licensed nursing staff documented in the 2/3/11 at 6:35 p.m. nursing notes, that the resident's left foot was swollen and that he/she stated that it was painful. Licensed nursing staff documented that they would report the findings to the resident's physician the next morning. However, a review of the nurses's notes and physician's progress notes revealed no evidence that the physician had been consulted about the swelling and pain in the resident's left foot. In the 2/6/11 nurses notes, licensed nursing staff documented at 6:00 a.m. that the resident had swelling in his/her left ankle and, the oncoming nurse would be notified of those findings. However, there was no evidence that the physician had been consulted about that swelling in the resident's left ankle. The nurse's ""shift communication book"" which was reviewed with the Unit Manager on 2/16/11 at 10:45 a.m., revealed that the licensed nursing staff was aware of the swelling in the resident's left foot and ankle from 2/3/11 through 2/7/11. However, there was no evidence in the clinical record that the resident's physician had been consulted about it. Observation with the restorative certified nursing assistant (RCNA) ""KK"" on 2/16/11 at 8:30 a.m. revealed that the resident had slight swelling in his/her left ankle and foot.",2015-08-01
9036,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,282,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to ensure that care plan interventions were implemented for three residents (#2, #1 and #18) with gastrostomy tubes in a sample of eight residents with gastrostomy tubes from a total sample of 20 residents. Findings include: 1. Resident #2 had a care plan intervention since at least 2/28/10 for licensed nursing staff to provide flushes and additional fluids as ordered by the physician. The resident had a physician's orders [REDACTED]. However, during an observation on 2/15/11 at 10:10 a.m., licensed nurse ""ZZ"" gave the resident 120 ml. of water before the bolus feeding and approximately 180 ml. of water after the feeding. See F322 for additional information regarding resident #2. 2. Resident #1 had a care plan intervention since 5/31/10 for licensed nursing staff to provide flushes and additional fluids as ordered by the physician. The resident had a physician's orders [REDACTED]. of water flush before and after feedings. However, during an observation on 2/15/11 at 12:05 p.m., licensed nurse ""ZZ"" gave the resident 120 ml. water flush before the bolus feeding, then added 30 ml. of water to the feeding and then flushed with 120 ml. water flush after the feeding. See F322 for additional information regarding resident #1. 3. Review of resident #18's closed record revealed that he/she had a care plan intervention since 12/23/10 for nursing staff to provide supplements as ordered by the physician. The resident had a physician's orders [REDACTED]. However, review of the December 2010 Medication Administration Record [REDACTED].",2015-08-01
9037,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,328,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility failed to cover nasal cannulas and nebulizer masks when not in use and to change humidifier bottles when ordered for four unsampled residents on the A hall in a census of 20 residents with respiratory therapy needs. Findings include: According to the Johns Hopkins Hospital's Clinical Practice Manual for Respiratory Equipment, respiratory equipment was an important source of transmitting microorganisms causing respiratory diseases. The guideline for heated and cold nebulizers was for the entire set-up to be changed every 48 hours. The guideline related to the use of oxygen noted that replacing the delivery system was to be done every seven days. The guideline for cleaning equipment documented that all equipment should have been covered when not in use. However, staff failed to properly store respiratory equipment and failed to date respiratory equipment. Observations were made on A hall during the initial tour on 2/14/11 between 11:30 a.m. and 12:45 p.m.. 1. A nasal cannula connected to an oxygen concentrator was not in use and not covered in room [ROOM NUMBER]. 2. There was a nebulizer mask stored uncovered on top of the nebulizer machine in room [ROOM NUMBER]. There was an oxygen concentrator with the tubing attached. The nasal cannula at the end of the tubing was not covered and was on the floor. 3. There was a nebulizer mouth piece attached to the nebulizer tubing in room [ROOM NUMBER] that was not covered. The nasal cannula attached to the oxygen concentrator was not covered and was coiled on top of the concentrator. On 2/14/11 at 2:30 p.m. and on 2/15/11 at 1:00 p.m., the nasal cannula was not covered. 4. There was an oxygen concentrator with the humidifier bottle dated 1/15/11 in room [ROOM NUMBER]. The nasal cannula was not covered and coiled on top of the machine. On 2/15/11 at 3:30 p.m. and 5:10 p.m., the humidifier bottle was still dated 1/15/11 and the nasal cannula was not covered.",2015-08-01
9038,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,325,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to provide a dietary supplement as ordered by the physician for one resident (#18) in a sample of 10 residents that received nutritional supplements from a total sample of 20 residents. Findings include: Review of resident #18's closed record on 2/16/11 at 9:55 a.m., revealed that he/she was admitted on [DATE]. He/she weighed 99 pounds at that time. Licensed nursing staff documented in the nurses notes that the resident's appetite was poor and a care plan was developed on 12/23/10 to address the resident's potential for weight loss. On 12/28/10, the resident's weight was recorded as 96.2 pounds and he/she was sent to the emergency room for evaluation because of nausea. The resident returned to the facility on the same date with physician's orders [REDACTED]. However, review of the December 2010 Medication Administration Record [REDACTED].",2015-08-01
9039,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,315,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to secure indwelling urinary catheter tubing and position a resident appropriately to prevent unnecessary pressure from catheter tubing for one resident (#7) of two residents reviewed with indwelling urinary catheters, from a total sample of 20 residents. Findings include: The facility's Policy and Procedure on ""Foley Catheter Care"" instructed staff to secure the catheter to the resident's leg to prevent pulling and/or contamination. However, nursing staff failed to implement that procedure for resident #7. Resident #7 had clinical [DIAGNOSES REDACTED]. There was a physician's orders [REDACTED]. During observations on 2/14/11 at 2:10 p.m., on 2/15/11 at 9:35 a.m. and 1:25 p.m., and on 2/16/11 at 10:45 a.m., the resident's catheter tubing was not secured to his/her leg. Following personal care provided by certified nursing assistants (CNAs) ""MM"" and ""NN"" on 2/15/11 at 9:35 a.m. and 1:25 p.m., the indwelling urinary catheter tubing was incorrectly positioned beneath the resident's left leg. On 2/15/11 at 1:25 p.m., while CNAs ""MM"" and ""NN"" were providing care, there was an approximately one-quarter inch reddened round indention in the back of the resident's left thigh where his/her leg had been positioned on top of the catheter tubing and port. During an interview on 2/16/11 at 12:15 p.m., nurse manager ""EE"" and licensed nurse ""FF"" stated that the resident should have had the catheter tubing secured to his/her leg.",2015-08-01
9040,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,333,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to ensure that one resident (""A"") was free of a significant medication error in a sample of five residents observed during medication administration. Findings included: Resident ""A"" had a physician's orders [REDACTED].",2015-08-01
9041,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,365,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined that the facility failed to ensure that one resident (#2) with swallowing difficulties was provided with nectar thickened liquids as ordered from a total sample of 20 residents. Findings included: Resident #2 had a [DIAGNOSES REDACTED]. He/She was coded on the 11/26/10 Minimum Data Set (MDS) assessment as needing total staff assistance to eat. There was a physician's orders [REDACTED]. However, during observations on 2/14/11 at 5:00 p.m., on 2/15/11 at 7:05 a.m., 3:32 p.m. and 5:30 p.m. and on 2/16/11 at 7:25 a.m., a water pitcher at his/her bedside contained regular water.",2015-08-01
9042,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,441,D,0,1,MIWW11,"Based on observations, it was determined that the facility failed to ensure that licensed nursing staff administered medication in a manner to prevent the spread of infection on one of three halls (C hall). Findings include: During observation of medication pass on the C hall on 2/15/11 at 8:10 a.m., licensed nurse ""WW"" took a cloth that was on top of the medication cart and wiped an area on the cart then, used that same contaminated cloth to wipe around the rim of a medication bottle prior to replacing the lid on that stock bottle of liquid medication.",2015-08-01
9043,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,318,D,0,1,MIWW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to ensure that hand rolls were used to prevent further decrease in range of motion for one resident (#8), in a sample of eight residents with range of motion needs from a total sample of 20 residents. Findings include: Resident #8 had [DIAGNOSES REDACTED]. There was a 2/10/11 physician's orders [REDACTED]. However, during observations on 2/15/11 at 8:45 a.m., 3:15 p.m. and 4:30 p.m., staff had not placed a hand roll in the resident's right hand. During those observations, the resident was observed to hold his/her right hand with the fingers flexed in a fisted position. On 2/14/11 at 12:00 p.m. and 1:45 p.m., staff had not put a hand roll in the resident's right hand but, there was a long white foot sock over his/her right hand and arm.",2015-08-01
9044,APPLING NURSING AND REHABILITATION PAVILION,115262,163 EAST TOLLISON STREET,BAXLEY,GA,31513,2011-02-16,241,D,0,1,MIWW11,"Based on observations and staff interview, it was determined that the facility failed to promote or enhance the dignity of one resident (#8) from a total sample of 20 residents, and failed to provide a dignified dining experience for seven residents in the assisted dining room, from a total of 20 residents observed in the assisted dining room. Findings include: 1. During the Initial Tour of the facility on 2/14/11 at 12:00 p.m. and on 2/14/11 at 1:45 p.m., resident #8 had a long, white foot sock covering his/her right hand and arm. During the observation on 2/14/11 at 12:00 p.m., licensed nurse ""WW"" stated that the sock had been placed on the resident's arm to prevent the resident from scratching himself/herself and to prevent the resident from pulling on his/her gastrostomy tube. 2. Observation of 20 residents in the assisted dining room at lunch on 2/15/11 at 11:45 a.m. revealed that two certified nursing assistants (CNAs) stood over four residents while assisting them to eat. 3. On 2/15/11 at 4:50 p.m., one CNA stood and walked around a dining table repeatedly while assisting three residents to eat supper.",2015-08-01
4001,ARCHWAY TRANSITIONAL CARE CENTER,115728,4373 HOUSTON AVENUE,MACON,GA,31206,2018-02-13,656,D,1,0,NTDQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, staff interviews, and the review of facility records, the facility failed to ensure that one (1) resident (#1) remain inside of a locked unit by assuring that all doors were secured to prevent an elopement and safety on one (1) of four (4) halls. Findings include: Review of the Admission Minimum Data Set (MDS) for Resident #1 (R#1) dated 1/12/17 revealed the resident was assessed for delusions, physical and verbal behaviors toward others and wandering. Review of the re-admission MDS dated [DATE] the resident was assessed with [REDACTED]. Review of the care plan for R#1 date 11/27/17 and updated on 2/27/18 related to wandering included interventions to: observed the residents location to ensure safety, Observe wandering behaviors during the night time hours. R#1 eloped from the facility on 2/4/18 and was found walking in the middle of the street, near the facility, by a passerby and a Certified Nursing Assistant (CNA) who was coming to work around 6:30 a.m. An interview with CNA BB on 2/12/18 at 11:35 a.m. revealed that on her way to work on 2/4/18 that she found R#1 walking in the street near the facility. She stopped, in an attempt to protect the resident, and called Dietary staff person BB to report that R#1 was outside the building. CNA BB revealed that she had brought the resident back to faciity, with police officer who had been called by the passerby. An interview with Dietary staff JJ on 2/12/18 at 11:40 a.m. confirmed that CNA BB had contacted him on 2/4/18 and he was asked to let the nurse on the 300 hall (where R#1 resided) which he did. Interview on 2/12/18 at 6:02 p.m with the Nurse Supervisor MM revealed that she was notified at about 6:40 a.m. that R#1 had gotten out of the facility. She revealed that R#1 had went out the 300 Hall door. She revealed that the only staff that can go in or out of that door is the Security Guard KK and the Maintenance Director LL. She revealed a head count was done and confirming that R#1 was missing. She revealed that the Police was there (near the end of the employee parking lot) with the CNA BB and R#1. Review of written statement from security guard on 2/13/18 indicated that on (MONTH) 4, (YEAR) around about 6 a.m. he entered from outside the 300 Hall and he returned to main entrance front desk.",2020-09-01
4002,ARCHWAY TRANSITIONAL CARE CENTER,115728,4373 HOUSTON AVENUE,MACON,GA,31206,2018-02-13,689,D,1,0,NTDQ11,"> Based on observation, staff interviews, and the facility records, the facility failed to ensure that one (1) resident (#1) remain inside of a locked unit by assuring that all doors were secured to prevent an elopement and safety on one (1) of four (4) halls. Findings include: Observation on 2/12/18 at 9:30 a.m. revealed that the facility is a locked facility that requires all doors to be locked at all times. Interview on 2/12/18 at 11:35 a.m. with Certified Nurse Assistant BB revealed that on her way to work on 2/4/18 at 6:45 a.m. she found R#1 walking in the street about one to two blocks from the facility. Interview on 2/12/18 at 11:40 a.m. with Dietary Staff JJ revealed that he was called by CNA BB and told to notify the nurses of the 300 Hall that R#1 was outside which he did. Interview on 2/12/18 at 3:21 p.m. with the Complainant revealed that R#1 stepped out into the road in front of their car across from the facility at about 6:30 a.m.and that they followed her her down the road until staff came and got the resident. Interview on 2/12/18 at 5:36 p.m. with Security guard KK revealed that he did not know that the resident was missing until the next day. He revealed that he did not know that the nurses did not have the codes to the doors. He revealed that he checked the doors every hour and they were all locked. He revealed that he only enter the facility through the front door. He revealed that the staff could not use the 300 Hall doors. Interview on 2/12/18 at 6:02 p.m with the Nurse Supervisor MM revealed that she was notified at about 6:40 a.m. that R#1 had got out of the facility. She revealed that R#1 had went out the 300 Hall door. She revealed that the only staff that can go in or out of that door is the Security Guard KK and the Maintenance Director LL. She revealed a head count was done and which confirmed that R#1 was missing. She revealed that a car was at the end of the employee parking lot, across the street from the facility, and that the Police were there with the CNA BB and R#1. Interview on 2/13/18 at 11:40 a.m. with CNA RR revealed that she last saw R#1 sitting at the nurse station at about 6:20 a.m. She revealed that she saw the security guard come through the door on the 300 Hall, where R#1 went out. She revealed that at 6:50 a.m a call came in that R#1 was outside the building in the street. She revealed that the staff can not go out of the doorway of the 300 hall because the Security guard is the only one that has the code. She revealed that the 300 Hall exit door is directly in front of the street where the resident was found. She revealed that all doors were checked and that they were locked at this time. Review of the Facility Security Agreement dated 2/12/18 indicated that the Security Guard are to make security rounds inside and out side of building, as well as, on all halls of building. The agreement further indicated that security guards are to make rounds every hour. Review of the Security Office Daily Log dated 2/3/18 indicated tour of the interior and exterior from 2300, 0001, 0100, 0200, 0300, 0400, 0500, 0600, and 0700 were all secured. Review of written statement from security guard on 2/13/18 indicated that on (MONTH) 4, (YEAR) around about 6 a.m. he entered from outside the 300 Hall and he returned to main entrance front desk.",2020-09-01
4003,ARCHWAY TRANSITIONAL CARE CENTER,115728,4373 HOUSTON AVENUE,MACON,GA,31206,2018-10-04,550,E,0,1,DBSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of records, and staff and resident interview, it was revealed that the facility failed to consider and provide for the individuality of its residents when it provided inappropriate eating utensils to most of the residents in an attempt to address the behavioral needs of just one resident during meals on two of four halls. The facility's census was 81 residents. Findings include: On 10/1/18 at 12:10 p.m. during service of the lunch meal which consisted of barbecued chicken breast, greens, roasted red potatoes, roll, and pie, 10 residents were observed seated at five tables in the main dining room off the 100 hall, and each were observed to receive only one item of flatware - a metal spoon - with which to eat the meal. No other flatware was provided and some residents (those receiving a meal of regular texture) were observed struggling to cut some food items (like the chicken breast) with this only item of flatware. On 10/1/18 at 12:41 p.m., 8 residents were observed eating lunch at three tables in the small dining room on the locked unit of the 100 hall. All residents in this dining room were observed to be provided with a plastic spoon, and no other flatware, with which to consume their meals. Two residents - one in room [ROOM NUMBER] and the other in room [ROOM NUMBER] - were served in their rooms. The resident in room [ROOM NUMBER] was assisted by a certified nursing assistant (CNA). The residents eating in their rooms were also provided with a plastic spoon for consuming their meals. On 10/2/18 at 12:28 p.m. during observation of the lunch meal consisting of Swiss steaks, mashed potatoes, steamed broccoli, a roll, and pudding in the dining room on the 200 hall, 14 of 15 residents were served with plastic flatware in cellophane packets such as those served at a picnic or a fast food restaurant. The15th resident - Resident (R) #5 was served with metal flatware which included a spoon, fork, and knife. During an interview on 10/2/18 at 12:30 p.m. with CNA EE, it was revealed that residents in the facility are served with plastic flatware because of concerns that they might poke themselves or others with metal flatware. On 10/2/18 12:36 p.m., during observation of the lunch meal in the main dining room of the 100 hall, it was again revealed that all the residents were provided with a metal spoon as the only flatware. During an interview on 10/2/18 at 12:46 p.m. with member of the kitchen staff AA, it was revealed that residents in the main dining room of the 100 hall were provided with only a metal spoon for eating meals because of concerns that they might use other flatware in an appropriate manner. AA said (but could not remember the exact details, including when the incident occurred) there was an incident wherein one resident attempted to stab another resident with an eating utensil. After said incident, the regional dietitian had informed the kitchen staff that the residents on the 100 hall were to be provided with only a spoon with which to eat their meals. During an interview on 10/3/18 at 12:20 p.m. with the Food Service Director, it was revealed that residents on the 100 and 200 halls are served only with metal spoons or plastic flatware because of safety concerns. He said that in the past, some of the residents had attempted to stab at each other with the metal forks. The dietary manager said the facility had no policy or procedures for this practice. The staff were simply aware that they needed to follow this practice. During an interview on 10/3/18 at 2:10 p.m. with CNA BB, it was revealed that she had worked at the facility for several months, and from observation, she was aware that most of the residents on all the hallways were routinely served with plastic utensils or with a spoon only. She was told that the facility was concerned that the behaviors of some residents limited the type of flatware/utensils they are provided with for eating. However, this CNA knew not every resident in the building had behaviors and she did not believe it was fair to those without behaviors to not have proper utensils with which to eat their meals. CNA BB said she felt the kitchen staff simply found it to be more convenient to have the residents in the facility use plastic utensils or only provides metal spoons because it gave them less clean up to do. On 10/3/18 at 5:41 p.m. during the dinner meal in the main dining room on 100 hallway 10 residents were observed eating dinner with complete sets of metal flatware - spoons, forks, and knives. On 10/3/18 at 5:44 p.m., observation of the small dining room on the 100-hall revealed two residents finishing the dinner meal. Each was using a full set of metal flatware. On 10/3/18 at 5:50 p.m., 9 residents were observed in the dining room of the 200 hall, and all were noted to be using full sets of metal flatware. Residents eating in their rooms on the 200 hall were also observed to be eating their dinner meal with metal flatware sets which included forks, knives, and spoons. During an interview on 10/3/18 at 5:52 p.m., CNA CC confirmed that the residents on the 200 hall were served with metal flatware at that meal, but said they were usually served with plastic flatware because of their behaviors. The CNA admitted never witnessing any of the residents attempting to harm another resident with their flatware, but had observed the residents on the 100 hall go at each other and one of them had attempted to a stab a member of staff with a fork. On 10/4/18 at 7:52 a.m. during observation of the breakfast meal in the small dining room on the 100 hall, five residents were seen eating eggs, ground meat or bacon, and hash browns. Three of these residents were eating on their own using metal flatware - forks, knives, spoons. Two residents receiving assistance from staff had plastic spoons only. Three residents were observed eating in their rooms; two had only a plastic spoon; and one of these residents was receiving assistance with eating his meal. On 10/4/18 at 8:09 a.m., 10 residents were observed eating breakfast in the dining room on the 200 Hall. All, including R#5, and R#59 were observed to be using metal flatware sets - spoons, knives, forks. During an interview on 10/4/18 at 09:20 a.m. with R#5, it was revealed that she was always served with metal flatware and this without asking. However, she had noticed the other residents in her dining room being served with plastic flatware and some of these residents appeared to have difficulties with the plastic. R#5 said some of the residents with tremors appear to find it difficult to use the plastic ware because the handles on these items are too short to be properly grasped. She recalls an incident in which one of the plastic utensils/flatware had broken off in the mouth of one of the residents. She said the staff had to assist with extricating the plastic from between that resident's teeth. During an interview on 10/4/18 at 9:29 a.m., R#59 said his nerves are so bad that he finds it difficult to pick up the plastic flatware with which most of his meals are served. They know the silver ones are the ones I have to have; it helps me to have that heavy ware. However, he went on to say that one day he is served with the silver ones and the next day the plastic ones. They know it makes me mad, but they do it anyway. Review of the records for R#59 revealed an Occupational Therapy (OT) certification of 7/19/18 which documented that the resident had demonstrated difficulties in scooping food from plate and gripping silver utensils. The OT discharge summary of 9/14/18 revealed the resident had: performed self-feeding task using raised inner edge plate and built up utensils independently. Review of the care plan records for R#59 revealed a plan of care for nutrition which was updated on 10/1/18 to document that the resident's needed a weighted spoon and fork. During an interview on 10/4/18 at 1:15 p.m. the Regional Dietician said he did not give authorization for the dietary staff at the facility to provide anything other than regular flatware for the residents to use at mealtimes. Due to concerns related to dignity, all residents should be served with regular flatware. If for some reason, a resident needed to use an alternative form of flatware/silverware, that resident would be care planned for that need and the staff would discuss the best way to implement this exception. During a follow-up interview on 10/4/18 at 1:22 p.m. with the Food Service Director, he reiterated that the residents eating meals with spoons only or plastic flatware was a measure implemented because some of the residents had behaviors. He (the food service director), not the regional dietitian, had put this in place as a temporary measure after one resident on the 200 hall had attempted to use his flatware as a weapon. That resident was care planned for using alternative flatware, but since the resident wanders around the dietary manager said he felt it would be in the best interest of the other residents if regular flatware were not available on the hallways for the resident with behaviors to use as a weapon against the other residents. The dietary manager said he did not remember when this measure was first implemented, but said that this had not been in place for very long.",2020-09-01
4004,ARCHWAY TRANSITIONAL CARE CENTER,115728,4373 HOUSTON AVENUE,MACON,GA,31206,2018-10-04,577,F,0,1,DBSC11,"Based on observation, resident, and staff interviews, the facility failed to post notice of the availability of the State survey results so that residents (R) and/or visitors were aware of its location for four of four days of the survey. The facility census was 81 residents. Findings include: During an interview on 10/2/18 at 10:00 a.m. about the facility's Resident Council, five of five residents in the meeting stated that they did not know where the State inspection results were located, and that this was something they would be interested in reviewing. R A and R B each reported that they would review the survey book if they knew where it was located. They further reported that they do not think they are allowed to leave their unit as the doors are locked. Tour of units on 10/3/18 at 10:50 a.m. revealed that survey results were not found. Tour of front lobby sitting area on 10/3/18 at 11 a.m. revealed survey book located in front lobby sitting area. Interview on 10/3/18 at 4:10 p.m. with Activities Director and Social Services Director (SSD). Activities Director reported that residents are informed of where the survey book is located during resident council meetings. SSD reported that residents are brought up to the front daily by family members and staff. SSD also reported that residents can request to come to the front lobby area without telling staff why they want to come up front. Interview with Administrator on 10/3/18 at 4:15 p.m. who reported that she has a second survey book that is located in her office. She further reported that the doors must remain locked to ensure the safety of the residents and if residents want to see the book staff can bring them up to look at the book. The Administrator acknowledged that with the doors being locked residents would not be able to access the survey book without having to ask for assistance. Interview on 10/4/18 11:09 a.m. family of R C reported not being aware of where the survey book is located. Interview on 10/4/18 at 12:24 p.m. with family of R D who reported not being aware of the location of the survey book. Interview on 10/4/18 at 12:43 p.m. with the Guardian for R [NAME] who denied being aware of where the survey book is located and has not seen signs posted regarding this. Interview on 10/4/18 at 1:15 p.m. with family of R F who reported that not being aware of where the survey results book is located.",2020-09-01
4005,ARCHWAY TRANSITIONAL CARE CENTER,115728,4373 HOUSTON AVENUE,MACON,GA,31206,2018-10-04,578,D,0,1,DBSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy Advance Directives, and staff interviews, the facility failed to provide a Physician's signature and a concurring Physician's signature for an Allow Natural Death (AND) order for one Resident (R#13) and failed to provide written documentation for one of three Residents (R#45) reviewed. Findings include: 1. Record review for R#13 revealed an AND order which was signed on 9/11/18 by daughter and on 9/12/18 by a Physician. However, there was no concurring physician signature, or any documentation found in the chart indicating R#13 daughter was the healthcare agent. Review of the Quarterly Mininum Data Set ((MDS) dated [DATE] the resident was assessed with [REDACTED]. An iInterview on 10/3/18 at 10:50 a.m. with the Social Services Director (SSD) who reported that if a resident does not have decision making capacity and spouse signs the AND order then two physician signatures would be needed. SSD further reported that anytime a Physician order [REDACTED]. Review of Resident # 13 medical record in electronic record system did not reflect an Advanced Directive nor any documentation that Resident # 13 daughter is the health care agent. SSD reported that she and the Admission's Coordinator work together to assure that Advance Directives and orders are carried out per residents wishes. On 10/3/18 at 11:42 a.m. the SSD provided a copy of the Allow Natural Death ([NAME]N.D.) Request for R #13. Review of the policy titled, Advanced Directives last reviewed/revised (MONTH) (YEAR) revealed that during the admission or preadmission process or shortly thereafter, residents are asked if they have an Advanced Directive and encouraged to provide the facility with a copy if there is one. If the resident has not executed an Advanced Directive, the facility will inform the resident/family of the right to establish one. Written and verbal information is given to the resident on the subject during admission/preadmission, and an Advanced Directive Checklist form is completed and filed with the resident's record. This form indicates that written information was provided and whether the resident requested further information or had an Advanced Directive. Review of the clinical records revealed Resident (R) #45 was admitted since 10/12/17. A further review of the clinical records revealed no documentation indicating whether written or verbal information was provided to the resident during the admission/preadmission process about Advanced Directives or the right to establish one. On 10/03/18 at 5:21 p.m., an interview with the Admission Coordinator revealed that upon admission, she has the resident/family indicate if they have an advanced directive or if they would like to have information about Advanced Directives. If the resident and/or family say the resident has an Advanced Directive, they are asked to provide a copy for the resident's records. After searching the clinical records for R #45, the Admission Coordinator could not provide evidence of an Advanced Directive documentation was filed on his behalf.",2020-09-01
4006,ARCHWAY TRANSITIONAL CARE CENTER,115728,4373 HOUSTON AVENUE,MACON,GA,31206,2018-10-04,661,D,0,1,DBSC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a discharge documents that included a recapitulation of the resident's stay, a final summary of the resident's status, and a reconciliation of the resident's medications upon discharge for one resident (#80) from a sample of 43 residents. Findings include: Review of the clinical records revealed Resident (R)#80 was admitted to the facility on [DATE] and discharged home on[DATE]. A further review of the records revealed a note from the Social Services Director (SSD) on 7/17/18 documenting that the resident would discharge home with family on day 21. On 7/25/18, the SSD documented that a referral was made to home health, and on 8/6/18 the SSD documented that the resident was discharged home. A review of the discharge records for R#80 revealed a Discharge Summary that was partially completed by social work and signed by the physician. However, nursing, nutritional services, activity, and therapy sections on the summary were not completed. A further review of the discharge records for R#80 revealed a Discharge Instructions that were not completed. This information covered current status, diet, and discharge medications. During an interview on 10/3/18 at 5:31 p.m. with the SSD, it was revealed that the Discharge Summary which includes a recapitulation of the resident's stay is supposed completed in its entirety upon the discharge of a resident. Social services completes part, and the other disciplines such as nursing completes other parts. The SSD said she was not sure why the entire summary was not completed in this instance because the resident's discharge went according to plan. During an interview on 10/3/18 at 5:58 p.m. with Registered Nurse (RN) DD, it was revealed that the nurses are responsible for filling out part of the discharge paperwork required when a resident is discharged . This includes the education that was provided to the resident/family, the discharge instructions, and a transfer form. Two copies of these discharge documents are printed and signed by the resident/responsible party. One signed copy is given to the resident, and the other is scanned and becomes part of the resident's clinical records. During an interview on 10/4/18 at 11:15 a.m. with the Director of Nursing (DON), it was revealed when a resident is discharged , the nurse fills out a Discharge Instructions for Care form which delineates any follow-ups, discharge medications, and the current status of the resident. The nurse also fills out a Transfer Form if the resident is not being picked up by family. All disciplines, including nursing, social services, activity, therapy, etc., fill out the Interdisciplinary Discharge Summary which includes the Recapitulation Summary. The Discharge Instruction and the Discharge Summary is printed out and signed by the resident/family. Copies of the signed forms are given to the resident and other copies are kept by the facility to be scanned and entered into the resident's record. During a follow-up interview with the DON on 10/04/18 at 1:02 p.m. it was revealed that the facility had no policy/guidelines for discharges.",2020-09-01
2201,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2019-02-07,580,D,1,0,B1BH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to notify the Medical Doctor (MD) or the Responsible Party (RP) for one resident of three sampled residents (R#1) after she sustained a witnessed fall in the facility on 1/14/19. Findings include: Review of the undated face sheet in the electronic medical record (EMR) revealed R#1 was admitted to the facility on [DATE] and was discharged on [DATE]. Further review revealed her [DIAGNOSES REDACTED]. Further review of the face sheet revealed no emergency contact information in the emergency contact section. Review of the discharge Minimum Data Set (MDS), dated [DATE], section C, revealed R#1 was rarely or never understood. Review of section G revealed R#1 required extensive assistance for dressing, toileting, personal hygiene, and required supervision only for ambulation and eating. The resident was not assessed as a fall risk. Review of section H revealed R#1 was always incontinent of bowel and bladder. Review of a Falls Risk assessment dated [DATE] revealed the resident was at low risk for falls. Review of nurse's notes dated 1/11/19 at 1:35 p.m. revealed R#1 was admitted to the facility at that time for a short respite-care stay at the facility. Further review revealed she was alert, disoriented, and ambulated independently. Review of all nurses' notes in R#1's EMR did not reveal any documentation of a fall or adverse event on any date or time, however, review of nurse's notes dated 1/16/19 at 8:30 a.m. revealed the R#1 had a discoloration under her right eye. An interview on 2/7/19 at 10:40 a.m. with the Admissions Coordinator revealed that she handled R#1's admission work and R#1 was only going to stay for five days for family respite care. She stated a hospice made the referral for respite care and this was done fairly often. She stated sometimes the RP contact information was not available. She stated it was policy that all admission documentation be complete but if it were not it would be left to the nurse or someone to get the information from the family or the hospice. She further revealed that the contact information really should have been available in the EMR. A telephone interview on 2/7/19 at 12:55 p.m. with the family member of R#1's revealed that he was her Responsible Party (RP), but not her Power of Attorney. He further revealed that the resident was admitted to the facility on [DATE] for respite care as the resident was under hospice care for late-stage [MEDICAL CONDITION]. He further revealed that the resident was received, at home from a non-emergency transport van, on 1/16/19 and at that time he noticed a knot on her head and some bruising on her face. He stated he questioned the transport driver, who told him picked R#1 up at the nursing home in that condition. The family member revealed that the nursing home never notified him or the hospice about a fall and they did not send her to the hospital to be checked out. He stated he called the hospice and they sent a nurse out who suggested R#1 be taken to a hospital to be checked. He stated the hospital tests were all negative and R#1 returned home the same day, 1/16/19. He stated he contacted the Administrator on that day and she did not seem to know anything about it. Review of the Quality and Performance Improvement Ad Hoc document, dated 1/17/19, contained in the Facility Self-report (FSR) to the State Survey Agency (SSA) which revealed that the resident had a fall on 1/14/19 and that the Physician was notified. Review of a letter from the Administrator to the SSA dated 1/17/19 revealed that R#1's did have a fall on 1/14/19, was witnessed by two nurses, a Certified Nursing Assistant (CNA), and a resident with a BIMS score of 14. Further review revealed the Physician (MD) was notified although there was no evidence that the Physician/MD, RP or Hospice were notified. Further review revealed a note signed, but not dated, by Registered Nurse (RN) BB stating that the resident had attempted to get out of her wheelchair and fell on [DATE] at 6:45 p.m. Further review revealed there was not contact information in the computer for the RP and there was no record of notifying the MD. Review of the Assessing Falls and Their Causes document dated (MONTH) 2010 revealed facility policy that nursing staff will notify the attending physician and the resident's family in an appropriate time frame of any fall. A telephone interview on 2/7/19 at 2:15 p.m. with the Medical Director revealed that he did not recall being notified about R#1 having a fall on 1/14/19. He stated, as Medical Director, he expected the Physician to be notified of any fall or adverse event of any resident at any time in the facility. Review of the undated Nursing Home Resident Rights policy revealed the right to be fully informed of changes in medical or health status. Review of the Accidents and Incidents - Investigating and Reporting F 689 document, revised (MONTH) 2010, revealed the Report of Incident/Accident Form should contain the date/time the attending Physician and family were notified of a resident who had an accident.",2020-09-01
2202,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2018-05-10,656,D,0,1,ZXJG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to implement observations of target behaviors, side effects and adverse reactions of psychoactive medications according to the care plan interventions for one resident (R) #56, from a sample of 22 residents. Findings include: Record review revealed that R #56 was admitted to the facility on [DATE] with psychiatric [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] for dementia, [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for anxiety on admission. Review of the resident care plan dated 2/20/18 revealed the resident was care planned for [DIAGNOSES REDACTED]. She takes psyche (sic) meds. Further review of the care plan revealed the following interventions were to be implemented: Administer medications as ordered. Observe/document for side effects and effectiveness. Observe/record occurrence for target behavior symptoms and document per facility protocol. Observe/record/report to MD as needed (prn) side effects and adverse reactions of psychoactive medications. Review of R #56's electronic medical record, Medication Administration Record [REDACTED]. An interview was conducted with Licensed Practical Nurse (LPN) BB on 5/9/18 at 8:45 a.m. at the medication cart. LPN BB was asked what type of behavioral monitoring was conducted for the medications given to R #56. She stated she would have to look it up in the Physician's Desk Reference (PDR). LPN BB was asked where this is documented, and she replied that it is documented in the nursing notes or on a behavior monitoring record in the electronic chart. An interview was conducted with the Director of Nursing(DON) on 5/9/18 at 10:59 a.m. in the DON's office. The DON was requested to locate any documentation related to behavioral monitoring and side effects/effectiveness of psychoactive medications for R #56. The DON was unable to produce the behavioral monitoring documentation for February, March, and (MONTH) (YEAR). An interview was conducted on 5/9/18 at 4:14 p.m. with LPN EE in the conference room. LPN EE was asked where the nursing staff documents behaviors and effectiveness of medications. LPN EE stated it is documented on the behavioral monitoring record and on the Medication Administration Record [REDACTED] A review of the facility's policy titled, Behavior Assessment and Monitoring, dated (MONTH) 2014, page 1 of 2, paragraph titled Monitoring, section 1. If the resident is being treated for [REDACTED]. Section 2, The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors: number and frequency of episodes; preceding or precipitating factors; interventions attempted (if psychoactive drug is used as an intervention, institute appropriate psychoactive drug monitoring); and outcomes associated with interventions.",2020-09-01
2203,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2018-05-10,842,D,0,1,ZXJG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and facility document review it was determined the facility failed to document accurately the administration of medications for one resident (R) (#56)from a census of 106 residents. Findings include: Record review revealed #56 was admitted to the facility on [DATE] with psychiatric [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], Section C Cognitive Patterns, C indicated the resident did not receive a Brief Interview for Mental Status (BIMS) due to resident is rarely/never understood. The staff assessment for mental status section C1000 indicated R #56 cognitive skills were severely impaired. Review of R #56's physician's orders [REDACTED]. Review of the resident's electronic Medication Administration Records (MAR) for February, March, (MONTH) and (MONTH) (YEAR) indicated that both the donepezil five mg twice daily and [MEDICATION NAME] 10 mg once daily was documented as given from 4/19/18 through 5/8/18 by nursing for a total dose of 20 mg daily for 20 days. An observation was conducted on 5/9/18 at 8:45 a.m. during the morning medication pass with Licensed Practical Nurse (LPN) BB. LPN BB pointed out the duplicate order on the electronic MAR and stated, This is wrong, I need to get it clarified by pharmacy and the physician, before I can give it. The nurse proceeded to call pharmacy and spoke to Pharmacist AA at 9:10 a.m., who verified that both orders were on the MAR. A review of the Pharmacy Consultation Report dated 4/30/18 revealed the Consultant Pharmacist' comment has order for donepezil 5mg twice daily. The recommendation was Please consider changing donepezil to 10 mg in the evening (d/c previous order). Physician's Response was marked as I decline the recommendation above and do not wish to implement any changes due to the reasons below: Resident currently on donepezil 10mg daily in am. (dated 5/3/18) Order was faxed to physician's office. Spoke with (Medical Doctor) MD regarding recommendations, stated keep resident on current order. An interview was conducted on 5/9/18 at 10:15 a.m. with the LPN DD at her desk. LPN DD was asked what the process was for transcribing orders into the computer. LPN DD stated, First she receives the Pharmacist Consultant's Report (which is either faxed or handed to her), then she will fax the forms over or call the physician's office. The physician's office will then fax back a signed physician's orders [REDACTED]. LPN DD was shown a copy of the consultant's recommendations and asked to look at the resident's MAR. After looking at both, LPN DD verified the consultation order and that the donepezil five mg twice daily should have been discontinued. A telephone interview was conducted with the attending physician on 5/9/18 at 10:30 a.m., the Physician was asked if he was aware of the duplicate order of [MEDICATION NAME] and donepezil for R#56, he stated, No. He further stated that had he Ordered the medication it would have been in either the brand name or the generic name but not both. The Physician also stated that If the resident had taken the medication as indicated on the MAR there would be no harm for it is not unusual for resident to receive up to 20 mg twice a day of this medication. An interview was conducted with the Director of Nursing (DON) on 5/9/18 at 10:59 a.m. in the DON's office. The DON was asked what the expectation of nursing was related to the duplicate order of [MEDICATION NAME] and donepezil. The DON stated, The expectations would be that the order be transcribed correctly and for nursing to recognize the duplicate medications and question the order, call the pharmacist. A telephone interview was conducted on 5/9/18 at 2:00 p.m. with the Pharmacist CC, who initially reviewed the resident's record. Pharmacist CC was asked what the process was when reviewing the resident's medications? Pharmacist CC stated Look at the physician's orders [REDACTED]. Pharmacist CC was asked if she was aware of the duplicate order for R #56 and the Pharmacist stated Yes, that is one of the reasons it had been recommended to discontinue twice daily and to use the [MEDICATION NAME] 10mg daily. The other reason for the change in the order was due to the insurance not covering that particular medication. Observation made on 5/9/18 at 3:00 p.m. of the R #56's medications, donepezil ([MEDICATION NAME]) 10mg daily (filled 4/19/18) revealed there was nine pills left on card out of 30 pills. There was no medication card present for the donepezil five mg twice daily. Individual interviews were conducted with LPN BB, LPN DD, LPN EE, Registered Nurse (RN) FF, and LPN GG on 5/9/18 starting at 4:14 p.m. through 5:50 p.m. in the conference room. These nurses were responsible for medication administration on both day and evening shifts. The nurses were shown the MARs indicating where they had documented giving the donepezil 5 mg twice daily and were asked if they remembered giving the medication or not? All five nurses indicated they had not given the medication but had documented in error and that they should have gone back and corrected the error but had not done so. The nurses also denied cutting the 10mg tablet in half to deliver the doses. A review of the Pharmacy Manifest revealed the facility received the following medications from the pharmacy for R#56's: - 2/8/18 donepezil five mg tablet - quantity 30 - 2/21/18 donepezil five mg tablet - quantity 30 - 2/21/18 donepezil five mg tablet - quantity 30 - 4/5/18 donepezil five mg tablet- quantity 10 - 4/17/18 donepezil 10mg tablet - quantity 30 A total of 100 (five mg) tablets and 30 (10mg) had been received, indicating there was not a discrepancy and the resident could not have received a duplicate dose.",2020-09-01
2204,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2017-06-15,156,D,0,1,4B7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy for Medicare Claims Processing Manuel Chapter 30 - Financial Liability Protections, the facility failed to ensure one of three residents reviewed for receipt of liability notice for Medicare non-coverage of skilled services (Resident (R)#78). Findings include: A review of information in the Medicare Claims Processing Manuel Chapter 30, with a revision date of 1/27/17, .260.3.8 NOMNC Delivery to Representatives . The NOMNC may be delivered to a beneficiary's appointed or authorized representative . However, if the beneficiary is temporarily incapacitated a person (typically, a family member or close relative) whom the provider has determined could reasonable represent the beneficiary . in these instances of delivering a notice to an unnamed representative, the provider should annotate the NOMNC with the name of the staff person initiating the contact, the name of the person contacted and the date, time, and method (in person or telephone) of the contact. Per clinical record review, R#78 was admitted to the facility on [DATE]. The physician ordered R#78 be evaluated for skilled services on 5/4/16. On 7/19/16, the speech therapy notes indicated R#78 was to be discharged from skilled services. A review was conducted of the liability notice (Notice of Medicare Non-Coverage) for R#78. The Notice of Medicare Non-Coverage (NOMNC) for R#78, identified R#78 was discharged from skilled services with an effective dated of 7/19/16. There was no documented evidence a liability notice was provided to R#78 or to the resident's representative prior to the end of skilled services. This notice would have provided information, to the resident and/or the resident's representative, on the potential liability for non-covered services and the resident's right to appeal the facility's decision to end skilled services. There were no Progress Notes located in the electrical medical records, that indicated R#78 or his representative was given notice for the end of skilled services. An interview was conducted with the Business Office Manager (BOM) on 6/14/17 at 1:18 p.m. The BOM stated the Social Worker was to provide notice prior to the end of skilled services. The BOM stated the facility had a new Social Worker and the NOMNC was given by a prior Social Worker. She said if the resident was not able to be notified, the resident's representative would be notified in person or by telephone, along with the right to appeal the facility's decision to end skilled services.",2020-09-01
2205,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2017-06-15,160,B,0,1,4B7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of facility policy for Conveyance of Funds upon a Resident's Discharge, Eviction or Death, the facility failed to ensure resident funds were conveyed timely for three out of five resident accounts reviewed (Resident (R)#16, R#9 and R#110). Specifically, resident funds were not conveyed within 30 days of discharge in accordance to the facility's established policy. Findings include: Per the facility policy, titled Conveyance of Funds upon a Resident's Discharge, Eviction or Death. Item #3 states, within 30 days of discharge eviction or death of a resident the facility will convey the resident's personal funds and a final accounting of those funds to the individual or probate judication administering the resident's estate, in accordance with State law. During an interview with the Business Office Manager (BOM) on [DATE] at 1:29 p.m., she discussed the circumstances below with R#16, R#9 and R#110. Regarding R#16's funds, the BOM stated she was notified of his death approximately one week after R#16 expired in the hospital. She stated R#16's Social Security check for (MONTH) (YEAR) was deposited into the facility's Auto Care Cost Account (corporate accounts). Review of the Trial Balance Form, during the interview, indicated R#16 had a negative balance of 1,012.93 - expired on [DATE]. Upon further review, the facility received a Social Security Administration letter dated [DATE]; the letter informed the facility they were paid $1,170.00 too much in benefits. The BOM stated, Corporate is working on returning the money to Social Security; it has not come back to me yet. When asked if she could contact corporate for an interview to determine what date the funds will or whether the funds had been returned to Social Security, she replied, the corporate person that is working on this account is out of the office today, but I will call her tomorrow to get an update. Review of the Closed Account Summary Report for R#9, who expired on [DATE], indicated the closing balance on the report was dated [DATE]. Interview with the BOM regarding conveyance of R#9's funds credited in the amount of $5,000.64 she provided checks dated [DATE] in the amount of $2,601.35 and $2,586.34 payable to R#9. The BOM stated the checks were originally sent to the funeral home, and when the funeral home did not respond, the facility wrote a check dated [DATE] in the amount of $5,000.64 payable to Social Security. The BOM could not provide evidence of the date the checks were post marked as mailed to the funeral home or to Social Security. Review of the Closed Account Summary Report indicated R#110's closing balance on [DATE] was $765.03. The BOM said R#110 was discharged to a Personal Care Home on [DATE]. Review of a check payable to R#110 for $615.00 was dated [DATE]. The BOM confirmed the money was not conveyed within 30 days of discharge from the facility, and the BOM could not provide evidence of the date the check was postmarked as mailed to R#110.",2020-09-01
2206,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2017-06-15,253,E,0,1,4B7G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and review of the facility policy for Work Orders, Maintenance, the facility failed to maintain an environment that was clean and in good repair for 12 of 41 sampled residents residing on both hallways (Resident (R)#5, R#6, R#7, R#28, R#37, R#44, R#47, R#86, R#89, R#98, R#111 and R#127). Findings include: The facility policy titled Work Orders, Maintenance, dated as revised in (MONTH) of 2010, indicated, Maintenance work orders shall be completed in order to establish a priority of maintenance service . It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director. The facility provided a copy of the housekeeping contract with an outside vender. The date of this contract was signed by the facility on 3/24/11. The contract did not include how often the residents' rooms and living areas were cleaned. The deep clean schedule titled DEEP CLEAN SCHEDULE MONTH: JUNE indicated: SCHEDULE. IF YOU ARE UNABLE TO DO THE ASSIGNED ROOM, YOU MUST INFORM MANAGER BEFORE 10:00 a.m. YOU ARE RESPONSIBLE TO DO A DEEP CLEAN ROOM DAILY. NO EXCEPTIONS. 1. The following were observed on 6/12/17: -R#37's room was observed at 8:45 a.m. and the handle to the resident's door was loose. There was paint scrapped off of the lower part of the door which lead to the resident's room. The wall located behind R#37's headboard had a baseboard that was damaged exposing the wood underneath and was partially separated from the wall. R#37 was interviewed at this time and R#37 stated his room was only cleaned 2 to 3 times per week, and the same for the bathroom. He stated the baseboard was damaged by the air conditioner, which leaked. -R#7's room was observed at 12:29 p.m. The floor was sticky and had multiple raised green-colored spots on it. The baseboards in this room were covered in dust and yellow stains. The window ledge was missing tile. The glass window had a large crack approximately 12 inches in length. The right side of the window screen was bent and pulled away from the window frame, leaving an opening. The sink in this room had two wooden doors underneath the sink which were partially off the hinges. There was a strong urine smell in this same location. The walls next to the outside of the bathroom had yellow and brown grime in the corners. Paint was observed to be scraped off of the same walls. Upon entering the bathroom, the toilet roll holder was broken off of the wall. Toilet paper was stacked on the back of the toilet. There was a strong smell of urine in this bathroom. There was loose porcelain tile behind the base of the toilet. There was a rust colored stain around this toilet. -R#47's room was observed at 12:51 p.m. Upon entering the bathroom of this room, there were porcelain tiles missing around the toilet. There was peeled off grout around the toilet. A yellow stained male urinal (uncovered) was on top of the back of the toilet. There was a strong urine smell in this location. -R#28's bathroom was observed at 1:10 p.m. The toilet roll holder, attached to the wall, was loose. -R#98's bathroom was observed at 1:30 p.m. There were missing porcelain tiles behind the toilet. -R#127's room was observed at 3:55 p.m. and there was a large stain on the bathroom ceiling. The following were observed on 6/15/17: -Room 110 was observed at 9:40 a.m. There was and a large bolus syringe observed on the floor, next to the trash can. -R#111's room was observed at 9:45 a.m. The headboard, which was attached to her bed frame, was loose. Per resident interview at this time, she stated her headboard had been loose for a while. An interview was conducted with the resident's roommate R#44 at 9:50 a.m. It was observed that R#44's bed was located next to the window and her bed was pushed up against the same wall. R#44 stated that her room was cleaned 1 time per week. R#44's headboard had white splatters and drips of dried paint or similar substance on it. The resident said that the staff did not clean her headboard. The wall directly behind the head of the resident's bed had yellow stains on it. The floor at the foot of R#44's bed was sticky. Upon entering the residents' bathroom in this room, the toilet paper roll was broken off the wall and toilet paper was stacked on the top of the toilet. -On the left side nursing station at 10:00 a.m., there were 14 large standing decorative columns which framed the restorative dining and activity area. This area was open for the residents to come and go. Each column was painted white and had dust, scraped painted areas, and yellow stains. -R#6's room was observed at 10:30 a.m. The laminate on the over-the-bed table was separated from the table. R#6's bedside dresser had veneer separated from the edges, exposing uneven surfaces. -R#86's room was observed at 10:40 a.m. Behind the head of the resident's bed there was an unpainted, patched area on the wall. There was a window located on the left side of R#86's bed. The blinds attached to the windows were rusted and damaged. The blinds were raised at this time, which exposed a window dripping transparent, honey-colored, jellied substance with multiple insects stuck to this unknown material. Upon entering the bathroom at 10:45 a.m. there was a bedside commode placed over the toilet. The lid to the bedside commode was lifted and underneath the lid there were splattered yellow and brown stains. There were rust stains around the base of the porcelain toilet. There was chipped paint around the base of the door frame of the bathroom. An interview was conducted on 6/15/17 at 11:10 a.m. with the Maintenance Director and the Housekeeping Director. The Maintenance Director stated it was his expectation that staff alerted him by writing a concern in the maintenance book to create a work order. The Maintenance Director stated staff was good at letting him know of issues associated with building repairs. The Maintenance Director said that it was his responsibility to replace over-the-bed side tables and damaged furniture. The Housekeeping Director was interviewed at this same time. He said it was his expectation that housekeeping staff cleaned resident room twice a day and that this included each resident bathroom. An environmental and housekeeping tour commenced after this initial interview on 6/15/17. Both staff members were taken into each resident room identified above on 6/12/17 and 6/15/17. A final interview was conducted with the Maintenance Director and the Housekeeping Director at 11:30 a.m. on 6/15/17, confirming the problems identified above. The Maintenance Director stated he was not previously aware of the needed repairs identified during the tour. The Housekeeping Director stated he did not believe the facility was clean. 2. Observations of R#89's room were conducted on 6/12/17 at 2:00 p.m. Trash was on the floor in front of her bed, behind and under the bed. Tooth swabs were on the floor next to the bedside table. The sink was dirty and the baseboards in the room were cracked, peeling paint and very dirty. The dust was very thick in the room. The bathroom tile was cracked and dirty. Trash was in the bathroom. R#89 required the use of a [DEVICE] (feeding tube) pump and pole daily to receive nutrition. The resident's [DEVICE] pump and pole had a thick layer of dust, and the pole was dirty and grimy. The bottom base of the [DEVICE] pole had thick layers of dried liquid on it. R#89's [DEVICE] pump was running and a scheduled tube feeding was in process. An interview was attempted with R#89, but the resident was not interviewable. Observations of R#89's room were conducted on 6/13/17 at 10:15 a.m. The room had trash behind the bed and under the bed. The condition of the bathroom was very dirty and grimy. The floor was dirty and had black scruff marks on it. The [DEVICE] feeding pump and pole had a thick layer of dust on it. The pole was dirty and grimy and the pole bottom base had thick layers of dried liquid on it. The resident pump was running and a scheduled tube feeding was in process. On 6/14/17 at 11:40 a.m., R#89 was observed in the right unit resident sitting area. R#89's tube feeding pole was next to her Geri-chair, the [DEVICE] feeding pump was running and a scheduled tube feeding was in process. The feeding pump pole had a thick layer of dust on it, and was dirty and grimy. The bottom base of the pole had thick layers of dried liquid on it. On 6/14/17 at 2:00 p.m., R#89 was observed in her room, sitting in her Geri-chair. R#89's tube feeding pole had been placed next her Geri-chair. The feeding pump pole had a thick layer of dust on it and was dirty and grimy. The bottom base of the pole had thick layers of dried liquid on it. An interview was conducted on 6/14/17 at 2:41 p.m. with Certified Nursing Assistant (CNA) CNA EE said the CNAs rotated caring for which residents on a weekly basis. She said the tasks she had done for R#89 today included making her bed, emptying the trash can and cleaning her bedside table. CNA EE said in orientation with the facility the CNAs received a list of the tasks they were required to complete. In an interview conducted on 6/14/17 at 3:00 p.m. with the Assistant Director Nursing (ADON), she said the CNAs were not responsible for the cleaning of medical equipment which included the cleaning of the [DEVICE] poles. She stated housekeeping staff were supposed to clean the [DEVICE] poles. The ADON said the housekeeping staff currently in the facility were new to the facility. In an interview conducted on 6/14/17 at 3:55 p.m., the Housekeeping Supervisor said he was not aware that cleaning of the [DEVICE] poles was the responsibility of housekeeping. The Housekeeping Supervisor said the only equipment he had been requiring his staff to clean was the residents' wheelchairs. The Housekeeping Supervisor stated he had only been at this facility for six days, and he was using the same routine checklist for cleaning details at this building, that he had used at his prior facility. On 6/14/17 at 5:29 p.m. an interview was conducted with the Administrator. The Administrator said it was her understanding nursing should takes care of the [DEVICE] pump and Housekeeping should take care of the pole. The Administrator stated communication was not done; it was a failure on both sides. The facility had changed the housekeeping staff to address a problem, but had not made the new team aware of what was expected from them.",2020-09-01
2207,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2017-06-15,371,F,0,1,4B7G11,"Based on observation and interview, the facility failed to ensure food was stored, prepared, and distributed appropriately for 97 of 108 residents residing in the facility. Specifically, food was not securely wrapped, dated or labeled, thawing food was at an unsafe temperature, and there was no evidence the facility had a policy for use and storage of food. Findings include: Observation during the initial tour of the centralized kitchen on 6/12/17 at 9:50 a.m. with Dietary Aide DD revealed several open food items in the walk-in refrigerator and/or freezer that were not completely wrapped, labeled and/or dated. A large piece of lunch meat in the refrigerator was partially covered with plastic wrap and was not labeled or dated. A plastic bag found in the freezer containing frozen potato-battered fish, and a large plastic bag with biscuits was not labeled or dated. Dietary Aide DD removed all of the above items from the refrigerator and freezer and stated, The food should have been covered properly, labeled and dated. During a subsequent tour of the kitchen on 6/15/17 at 9:43 a.m., a two-compartment sink was full of chicken soaking in stagnant water. The Food Service Director (FSD) said the chicken was for the lunch meal. When asked to take the temperature of the water it was observed to be 80 degrees Fahrenheit. Upon further inquiry, the FSD took the temperature of a piece of chicken soaking in the water and it was 80 degrees Fahrenheit (F). Sitting on the counter was a 33-pound box of ice-glazed chicken in packs of eight pieces per bag; there were three bags of chicken in the box. The FDS took the temperature of the chicken that was in the box and it was 42 degrees F. During interview with Cook BB on 6/15/17 at 10:00 a.m., regarding the time the chicken was placed in the sink, she stated, the chicken was placed in the sink at 8:00 a.m. in the morning and the water was hot when she first turned it on then it cooled down . I have to soak and clean it before cooking. The policy and procedure on food thawing practices was requested from the FSD and Cook BB on 6/15/17 at approximately 10:00 a.m.; however, no policy was provided by the end of the survey. At this time, the FSD stated, people from the south feel chicken must be washed and cleaned before cooking. At 10:11 a.m. the FSD said I will throw this chicken out it will not be served. The surveyor observed the FSD discarding the chicken into a box and then taking it outside to the dumpster at 10:19 a.m. During an interview with the Administrator on 6/15/17 at 10:45 a.m., regarding the observation in kitchen and the temperature of the chicken, she acknowledged and understood the potential risk to residents, and stated she just returned from the store purchasing fresh chicken for the lunch meal service.",2020-09-01
2208,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2017-06-15,431,D,0,1,4B7G11,"Based on observation, interview, and record review of the facility policy for Storage of Medications, the facility failed to ensure medications were stored under proper temperature controls and in accordance with manufacturer specifications for one of two medication storage rooms. Findings include: Review of the policy titled Storage of Medications, last revised in (MONTH) of 2007, revealed the facility shall store all drugs and biologicals in a safe, secure, and orderly manner. In section nine of the policy it indicated medications requiring refrigeration must be stored and locked in the drug room at the nurses' station or other secured locations. Medications must be stored separately from food and must be labeled accordingly. An inspection of the left-wing medication room was conducted on 6/15/17 at 10:00 a.m. in the presence of Licensed Practical Nurse (LPN) HH. The inspection of the medication room refrigerator revealed the temperature thermometer scale reading 32 degrees Fahrenheit (F). This was below the manufacturer specifications for the medications that were being stored in the left- wing medication refrigerator. Found inside the medication refrigerator were Ativan (lorazepam) multi-use vials that needed storage temperature between 36 to 46 degrees F and unopened Levemir insulin pens requiring storage temperature between 36 to 46 degrees F. Also inside the medication refrigerator were insulin vials in unopened boxes with manufacturer recommendations for storage temperature ranging from 36 to 46 degrees F. The medications were moved to another location for storage. A second refrigerator temperature reading was conducted at 12:15 p.m. in the presence of LPN HH which revealed the temperature reading at 27 degrees F. During an interview conducted with LPN HH at 12:20 p.m., LPN HH stated she had not noticed the refrigerator temperature reading during her count of medications at the beginning of her shift. She said she had noticed the ice compartment was not showing ice, but thought a prior shift had done the task of defrosting the medication refrigerator. In an interview conducted with the Director of Nursing (DON) at 1:30 p.m., she said the medication storage refrigerator temperature must be within proper range. The DON said if the refrigerator was not reading within the proper temperature range, the nursing staff must notify the supervisors so repairs could be made or the refrigerator could be replaced. The DON said the pharmacy would be notified and the medications that may have been compromised would be replaced with new medications right away.",2020-09-01
2209,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2019-07-05,609,D,0,1,JNZ011,"Based on record reviews, interviews, and review of the facility's Abuse Investigations policy and Investigating Unexplained Injuries policy, the facility failed to report injuries of unknown origin for one resident, resident (R) #86, of 36 sampled residents. Findings include: A review of the facility policy titled Abuse Investigations indicates injuries of unknown source shall be promptly and thoroughly investigated by facility management. The facility policy titled Investigating Unexplained Injuries indicates an investigation of unexplained injuries will be conducted by the Director of Nursing and/or other individual appointed by the Administrator. The Nurse Supervisor on duty must complete an accident/incident form and record such information into the resident's clinical record. The policy states, documentation shall include information relevant to risk factors and conditions that could cause or predispose someone to similar sign and symptoms; any descriptions in the medical record shall be objective and sufficiently detailed; the physician will be notified, and the Director of Nursing or Designee will complete the investigation and provide a summary to the Administrator. During review of medical record for R#86, an entry dated 5/4/19 at 4:46 p.m. indicates resident was found bleeding from the forehead. In an interview with the Administrator, the Minimum Data Set (MDS) Coordinator, and the Director of Nursing (DON) on 7/3/19 at 9:45 a.m. revealed that the DON stated there is no documentation about an investigation related to the injury of the resident's forehead on 5/4/19. The Administrator reports no state report was filed for this incident of injury of unknown origin. A follow up interview on 7/3/19 at 3:10 p.m. with the DON she reported she did not have investigative notes for the injury that occurred on 5/4/19 although she reported that no one said they actually saw the incident. She reports she does not have anything more than what is in the medical record. She further revealed that an investigation into the resident's injury was not completed and the event was not reported to the State Survey Agency (SSA). In an interview with the Regional Director of Operations and the Regional Nurse, on 3/3/19 at 5:52 p.m., the Regional Director of Operations reports there is no information available for what is stated in the medical record on 5/4/19 for the injury to the forehead. They agreed that the injury was of unknown origin and should have been reported and investigated.",2020-09-01
2210,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2019-07-05,657,D,0,1,JNZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews, the facility failed to update the care plan for interventions related to psychiatric needs for one resident, (R) #86, of a sample size of 36. Findings include: A review of the progress notes for R#86 revealed he was admitted to the facility on [DATE] following a hospitalization with the following [DIAGNOSES REDACTED]. A review of the resident's PASRR II, dated 5/1/2018, revealed resident has serious mental illness and needs specialized services. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident was not assessed for behaviors. A review of the care plan developed on 5/16/18 indicates a focus area of has actual mental or psychosocial adjustment disorder related to mental illness, cognition, emotion regulation or behavior. Interventions: Monitor/document/report potential signs and symptoms of adjustment disorder or [MEDICAL CONDITION] such as decreased social interaction, increase in withdrawal behavior, anger, and/or [MEDICAL CONDITION]. A review of the progress notes revealed R#86 was admitted for psychiatric evaluation on 7/8/2018 after he was acting out by showing his penis and running up behind other residents and staff and acting like he was going to hit them. He returned to the facility eight days later on 7/16/2018. Review of the care plan revealed no update related to the behaviors which required a psychological evaluation. Review of the Quarterly MDS dated [DATE] revealed the resident did have other behaviors, one to three days of the look back period. On 10/3/2018, R#86 was admitted for psychiatric evaluation and returned to the facility six days later on 10/9/2018. Resident was refusing care, going into other resident's rooms and taking personal property from other residents, slamming doors, not easily redirected, and trying to hit staff. Review of the resident's care plan did not provide evidence of an update related to the behaviors of 10/3/18. On 11/16/2018, R#86 was admitted for psychiatric evaluation and returned to the facility 14 days later on 11/30/2018. Resident was agitated, pulled a sink off the wall, climbing up the walls, touching staff inappropriately, pulled the sharps container off the wall, pulled the fire alarm, kicked and hit staff, ran outside and disrobed, and sexually inappropriate behavior. Review of the resident's care plan did not provide evidence of an update related to the 11/16/18 psychiatric admission. Review of the Quarterly MDS dated [DATE] revealed the resident was not assessed with [REDACTED]. A review of the resident's care plan revealed no evidence of an update or development related to the resident's aggressive, wandering, or of sexually inappropriate behaviors. An interview with the Administrator, Director of Nursing (DON) and the MDS Coordinator was conducted on 7/3/19 at 9:45 a.m. confirmed that the care plan was not updated related to the resident's behaviors since admission on 5/4/19 to address the behaviors which required hospitalization . A follow up interview with the MDS Coordinator on 7/3/19 at 2:44 p.m. revealed there is a morning meeting that includes the department heads although the findings do not address updates to the care plan. An interview with the DON and the MDS Coordinator on 7/4/19 at 10:00 a.m. revealed that the MDS Coordinator is not involved with the facility Patient at Risk (PAR) meetings and that MDS Coordinator gets information to update the care plans from her review of the 24-hour report and by reviewing the medical record. They could not explain how the resident's care plan was not updated or developed after the frequent behaviors and hospitalization s.",2020-09-01
2211,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2019-07-05,689,D,0,1,JNZ011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, review of the facility policy titled Accidentsand interviews the facility failed to assure the safety of one resident (R#86) who entered the shower room, unattended, then broke the mirror resulting in cuts to his hand and foot on 1/11/19. The sample size is 36. Findings include: A review of the facility policy titled Accidents with a revised date of (MONTH) (YEAR), indicates the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision are facility-wide priorities. Safety risks and environmental hazards are identified on an on-going basis. Record review revealed that R#86 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident was not assessed for a Brief Interview for Mental Status (BIMS), section C, due to the resident is rarely/never understood. An observation, on 6/30/19 at 1:45 p.m. revealed R#86 in the shower room on the Right Hall, unattended which has no exterior lock on the door. The sign on the shower door indicated the shower room was not in use and upon opening the shower door revealed the resident was standing behind the door, fully clothed, holding two paperback books. He exited the room, stood in the hallway for a few minutes, and then quickly walked away. The resident's speech could not be understood when he spoke. A review of the medical record revealed R#86 was injured in the shower room on 1/11/19. Review of the Nurse's Note dated 1/11/19 indicate the resident was found in the shower room sitting up in a chair with glass on the floor; the resident had broken the mirror in the shower room and told the nurse he wanted to see what was behind the mirror. The resident sustained [REDACTED]. A review of the medical record for R#86 revealed he has been hospitalized four times since his admission of 5/12/18 for behaviors of aggression, ripped the sharps container off the shower room wall, pulled the sink off the wall in his room, wandering in and out of other resident's rooms, inappropriate sexual behavior, pulled the fire alarm, bizarre behavior, and refusal to be redirected. An interview on 7/3/2019 at 9:45 a.m. with the Administrator and the Director of Nursing (DON) revealed that the DON reports the shower room door is closed when it is not in use. The Administrator reports that the shower room doors have no locks on the door and anyone can go in there at any time. The Administrator and the DON agree nothing was done to prevent the resident, or any other resident, from going into the shower room, unattended. An observation on 7/4/2019 at 2:00 p.m. revealed there are no locks on the outside of both the left and right shower room door. In an observation on 7/4/19 at 2:04 p.m. the resident is attended by a CNA; he is sleeping in his bed and the CNA is sitting outside the room in a chair just outside the doorway after the facility implemented one on one care for R#86.",2020-09-01
2212,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2019-07-05,812,E,0,1,JNZ011,"Based on observations, interviews, and a review of policies titled Food Safety Requirements the facility failed to maintain cleanliness of fans and air vents in the kitchen and failed to label and securely close opened food products. The facility census is 109. Findings include: Review of the facility policy titled Food Safety Requirement dated as revised on (MONTH) (YEAR), Policy Interpretation and Implementation, 1. Food Services, or other designated staff, will maintain clean food storage areas at all times. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (used by date). Such foods will be rotated using a first in-first out system. The initial observation tour of the kitchen on 6/30/19 at 1:44 p.m. revealed one black small desk-type fan sitting on the counter between the 3-compartment sink and the dishwasher and it is blowing on the clean dishes that are coming out of the dishwasher. The small fan is coated with thick dust on the front and back of the metal cage. A large black floor-fan is at the entrance of the dry good storage and it is on and blowing into the room facing the 3-compartment sink area and an area used to cook and process food. The fan is coated with thick dust. A third large floor-fan is located near the kitchen manager's office and it is facing to area of the oven and the steam table. It is coated with thick dust and it is not running at this time. The air vent on the ice machine is coated with thick dust. The fire-suppression bar over the over is coated with dust. The ceiling air vent is coated thick with dust. An observation in the kitchen on 07/1/19 at 9:33 a.m. revealed the small desk-size fan remains on the counter and is blowing on the clean glasses and dishes sitting in racks that have come out of the dishwasher. The ice-machine vent, the ceiling air vent, and the fire-suppression bar over the oven remain coated with dust. The two large floor fans remain coated with dust. Neither fan is blowing, at this time. An observation on 7/1/19 at 9:33 a.m. of food items in the dry storage room revealed the following: One bag of confectioner's powdered sugar is open and has no opened date. One bag of brown sugar is open and has no opened date. One bag of Roseli pasta noodles is open and has no opened date. One bag of Barilla pasta noodles is open, and the bag is not secured with any type of closure and the bag has no opened date. One white plastic container of peanut butter is open and has no opened date. One box of mashed potatoes is open and has no opened date. In an interview on 7/1/19 at 9:45 a.m. with the Acting Dietary Supervisor and the Kitchen Assistant Supervisor, they report all opened products on the shelf should have an open date and an expiration date. An observation in the kitchen on 07/02/19 at 10:43 a.m. and on the same day at 11:50 a.m. revealed the small desk-size fan remains on the counter and is blowing on the clean glasses and dishes sitting in racks that have come out of the dishwasher. The ice-machine vent, the ceiling air vent, and the fire-suppression bar over the oven remain coated with dust. The two large floor fans remain coated with dust. The large fans are not on. An interview on 7/2/19 at 12:15 p.m. with the Acting Dietary Supervisor and the Kitchen Assistant Supervisor, revealed they cannot provide a policy related to expiration dates. An observation in the kitchen, on 7/3/19 At 8:45 a.m. and on 7/4/19 at 8:25 a.m. revealed the small fan remains in the same location on the counter and it is blowing on clean dishes sitting outside the dishwasher. The ice-machine vent, the ceiling air vent, and the fire-suppression bar over the oven remain coated with dust. The two large floor fans remain coated with dust. The large fans are not on. An interview with the Dietary Assistant Supervisor on 7/4/19 at 8:31 a.m. revealed that maintenance cleans the overhead vents and would identify during his facility rounds or the kitchen staff would tell him. She revealed that the kitchen staff are responsible for cleaning and dusting in the kitchen, and for cleaning the ice machine vent. She further revealed that it is the responsibility of the weekend dietary manager to clean the vent hood and the fire-suppression bar. On the stove hood there is black lettering reading, Dietary Manager Cleaning Assignment Clean Every Week-end. An interview on 7/4/19 at 8:50 a.m., in the Administrator's office, with the Maintenance Director, revealed that he responsible for cleaning the overheard vents in the kitchen. An interview with the Administrator and the Maintenance Director on 7/4/19 at 9:10 a.m., in the kitchen, confirmed that the kitchen air vent on the ice maker, the fire suppression bar over the stove, the two large floor fans, the overhead ceiling vent, and the small desk-size fan and agree all those items are caked with dust. The Administrator agrees the smaller fan should not be blowing on clean dishes. She reports the larger fans were used during a time when they had difficulty with controlling the temperature in the kitchen and they should have been removed once the air conditioning was repaired. The Maintenance Director and the Administrator agree the air vent for the ice machine is coated with dust and should be cleaned, that the fire-suppression bar is dusty and should be cleaned and that the overhead ceiling vent in the kitchen is coated with dust and should be cleaned. The Administrator agrees all opened foods should have an expiration date and should be securely closed.",2020-09-01
2213,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2019-09-04,880,D,1,0,CHTR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, and staff interviews the facility failed to ensure proper infection control practices for one resident (R#2) who receiving oxygen via a [MEDICAL CONDITION]. Findings include: Observation of R#2 in her room on 9/4/2019 at 8:45 a.m. and at 10:04 a.m. revealed a portion of her [MEDICAL CONDITION] oxygen tubing was directly onto the floor as well condensate that was collected in the tubing from the oxygen humidifier. An interview with Licensed Practical Nurse (LPN) AA on 9/4/2019 at 11:45 a.m. revealed that she just recently performed [MEDICAL CONDITION] care on the resident, along with repositioning her with the assistant of another staff for the first the time today, and did not notice the oxygen tubing on the floor.Continued interview with LPN AA revealed that she had training for [MEDICAL CONDITION] care and infection control practices a couple of months ago, but could not give the specific date. However, she understood that the tubing on the floor was a violation of infection control practices. An interview on 9/4/19 at 1:30 p.m. with both the facility staff trainer and the Infection control nurse revealed that the facility does not have a respiratory therapy on site although a contract respiratory company is on call. They confirmed that all nursing staff received training for [MEDICAL CONDITION] care as well as the proper infection control practices earlier this year although they were unable provide documentation of the dates or what was covered during the training. An interview with the Director of Nursing (DON) on 9/4/19 at 1:45 p.m. revealed that she was unaware that the [MEDICAL CONDITION] oxygen tubing was on the floor and was unsure if it was due to the tubing being too long and if a shorter tubing could be used.",2020-09-01
4684,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2015-08-07,241,D,0,1,1EOS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, family interview, and staff interview, The facility failed to promote care in a manner that maintained the dignity of one (1) resident (R) related to bedpan use, getting out of bed, and maintained on a shower regimen as preferred/requested for eighteen (18) sampled residents. Findings include: Record review for resident R revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 03/08/15 which documented the resident's 05/23/13 Entry Date to the facility, and documented in Section C - Cognitive Skills for Daily Decision Making, indicating that the resident is independent for decision making, with no Short-Term or Long-Term Memory Problems. Section H - Bladder and Bowel of this MDS documented that resident R had always been incontinent of both bowel and bladder during the look back period, and Section G - Functional Status documented that the resident required extensive assistance of staff for bed mobility and total dependence on staff for toilet use. This MDS for resident R also documented [DIAGNOSES REDACTED]. Further record review for resident (R) revealed two (2) quarterly MDS assessments having an Assessment Referenced Dated 4/08/15 and 7/08/15 documented in Section C - Cognitive Skills for Daily Decision Making, indicating that the resident is Severely Impaired, with Short-Term and Long-Term Memory Problems. Interview with the MDS coordinator revealed that the resident was not cognitively impaired. She also stated that she conducted many cognitive assessments of the resident, which she assessed the resident as having BIMS score of 13. The MDS Coordinator further revealed that resident R was able to make her needs known. During observation and interview with Resident R conducted on 08/03/2015 at approximately 12:00 p.m. she appeared alert and oriented times three (3). Further observation revealed that the resident was itching on both arms, and she stated that it had been a year since she had received a shower. The resident further stated that she always had to wait over three (3) hours for a diaper change by staff. She further revealed that the staff would always tell her that they could not change her by themselves because she was too heavy, and that she would have to wait until other staff came back from their break. The resident revealed that she had been asking for a shower for a year. The resident stated the staff did not want to clean her up because of her size, and the staff turn up their faces when looking at me in a scornful way. During additional interview with resident R on 08/03/15 at 12:49 p.m., she stated that she had been asking the staff to take her out of bed for over a year now, and she cannot take being in bed anymore. Resident R revealed mental distress, feelings of hopelessness, embarrassment and shame, after having to call 911 four times within the past year, due to being left in feces over three (3) hours, screaming, and crying for help. During an interview with the Licensed Practical Medication Nurse DD on 08/06/15 at approximately 11:00 a.m., it was revealed that according to the resident's shower book, the resident is supposed to have a shower on Tuesday, Thursday, and Saturday. Record review of the residents shower book revealed documented shower sheets for only the month of (MONTH) and August. The LPN DD revealed on 8/06/15 at 12:00 p.m. that there are no other shower sheets for resident R , because the resident only received bed baths. She further stated that if the resident refused a shower, the Certified Nursing Assistant (CNA) would write refused on the shower/bath sheet. Further record review of the residents shower book was conducted with LPN DD and revealed no refusals documented on the shower/bath sheet for the resident in the shower book During an interview with a family member of Resident R conducted on 08/07/15 at 10:00 a.m. revealed that resident R had been in this facility for three (3) years and resident R only received two (2) to (3) showers in two (2) years and four (4) months of being here. The family member further stated that they made numerous complaints and grievances to the Director of Nurses (DON) and social worker, and nothing was done. She has not gotten any help from staff, the resident has to wait three (3) to four (4) hours at times for staff to come and change her diaper. Resident R had called 911 a couple of times, because staff would not come into her room to change her. The family member further stated, that the family stopped making grievances, due to family members being tired of complaining, and nothing is done. Family member then stated I am beat up stated feels bad, and hopeless, that member resident R is having such a horrible experience in this facility.",2019-08-01
4685,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2015-08-07,246,D,0,1,1EOS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, family interview, and staff interview, The facility failed to accommodate one (1) resident (R) related to preference/request for showers, and preference/request to get out of bed for eighteen (18) sampled residents. Findings include: Record review for Resident R revealed an Annual Minimum Data Set (MDS) assessment having an Assessment Reference Date of 03/08/15 which documented the resident's 05/23/2013 Entry Date to the facility, and documented in Section C - Cognitive Skills for Daily Decision Making, indicating that the resident is independent, with no Short-Term or Long-Term Memory Problems. Section H - Bladder and Bowel of this MDS documented that Resident R had always been incontinent of both bowel and bladder during the look back period, and Section G - Functional Status documented that the resident required extensive assistance of staff for bed mobility and total dependence on staff for toilet use. This MDS also documented [DIAGNOSES REDACTED]. During observation and interview with resident R conducted on 08/03/15 at approximately 12:00 p.m., she appeared alert and oriented times three (3). Observation revealed the resident was itching on both arms, and she stated that it has been a year since she has received a shower. The resident further stated that she always have to wait over three (3) hours for a diaper change by staff. She further revealed that the staff would always tell her that they are not changing her by themselves because she is too heavy, and have to wait until other staff come back from there break. The resident revealed that she has been asking for a shower for a year. Resident stated the staff do not want to clean her up because of her size. During further interview on with resident R on 08/03/15 at 12:49 p.m., she stated that she had been asking the staff to take her out of bed for over a year. During an interview with the Licensed Practical Nurse DD on 08/06/2015 at approximately 11:00 a.m., revealed that according to the resident's shower book, the resident is scheduled for a shower on Tuesday, Thursday, and Saturday. Record review of the residents shower book revealed documented shower sheets for only the month of (MONTH) and August. LPN DD revealed that there were no other shower sheets done for resident R, because the resident only received bed baths. She further stated if the resident refused a shower the Certified Nursing Assistant (CNA) would write refused on the shower/bath sheet. Further record review of the residents shower book was conducted with LPN DD and revealed no refusals documented on the shower/bath sheet for the resident in the shower book.",2019-08-01
4686,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2015-08-07,253,E,0,1,1EOS11,"Based on observations and staff interviews, the facility failed to maintain a clean, and comfortable environment as evidenced by stained or damaged ceiling tiles; broken or missing floor tiles; patched or spackled, but not painted, scraped and/or bubbling and peeling paint on doors, walls and doorframes, and bathroom vanities on one (1) of two (2) halls. Findings include: During tour of the facility on 08/07/15 at 2:15 p.m., the following concerns were identified on the 100-Hall and the main dining area: 1.) In bathrooms for rooms 108 and 120: the vanity knobs were missing and the pointed end of the screw was exposed. In addition, in room 108, the toilet paper holder was missing one bracket, the toilet paper was sitting up right on top of the toilet tank. The toilet seat was approximately two (2) inches too short for the bowl. 2.) Ceiling tiles were water stained in the following areas: Room 101: First (1st) tile; on the left corner on window side, opposite the bathroom, there was a water stain in a long semi-circle approximately four (4) inches wide by six (6) inches long. A second water stain on the same tile was another corner semi-circle three (3) inches by 3 inches long form corner to radius. Second (2nd) tile; 3 water stained semi-circles on corners, each approximately from corner to outer radius. On the opposite end of the same tile, over half of the tile was stained in a semi-circle. Third (3rd) tile; there was a water stain in the center of the tile approximately four (4) inches long and 2 inches wide. Room 107: The 3rd row: entire length of tile had a water stain approximately 2 inches wide. Room 114: The 2nd row, 2nd tile; had a circular water stain approximately 6 inches by 6 inches. Main Dining Room: Tiles eight (8) and nine (9) in the middle of the ceiling had very dark brown water stains approximately ten (10) inches long by five (5) inches wide. Other ceiling concerns: Main Day Room: Across from room 107, there was a gaping hole next to the fan mount. Room 101: The fire sprinkler near the bathroom and next to bed B was missing the mount or flushing. 3) Chipped or broken floor tiles in the following areas: Rooms 103, 104, 107, 111, 112, 113 and the center decorative column in the Day Room by room 114. 4) Bathroom Vanity concerns: The drawers in every bathroom vanity did not close flush with the facing of the vanity. The Vanity face plate below the sink was warped and the paint was bubbled in every bathroom. Wall Concerns: Room 106: Behind bed D, the wall was bubbled and had been patched, but was not sanded or painted. The window sill behind bed C had been spackled or patched directly over the over the tile and on the wall, covering the bottom window sill. The patching material was not sanded or painted. Room 111: Behind the television to the right of the sink in front of Bed B the wall was patched, but was not sanded or painted. Day Room: The bottom half of the wall in the Day Room outside room 107 was bubbled, warped, patched, but was not sanded or painted. A high back wheelchair in the dining room in which a resident was seated, had the cushion pad missing on the left arm, exposing metal to the resident's skin. In addition, the raw metal edge was exposed to the outside of the chair. All of the doors and doorframes had scraped and peeling paint. During the entire survey, in room 101, the wall air conditioning near bed B was set on cool at 69 degrees and the fan was set on the high setting. However, warm air was blowing from the air conditioning unit at a low level. A table top, black oscillating fan was noted on the bed side table for bed B . This fan was on high and turned on during the entire survey. Interview with Certified Nursing Assistant FF revealed that she agreed the room was warm and that she assumed that is why there was an oscillating fan in the room. Interview with the Maintenance Director revealed he was unaware that the unit was not blowing cool air. Interview with the Maintenance Director on 08/07/15 at 3:35 p.m., revealed he addresses issues as the nursing staff notify him of concerns.",2019-08-01
4687,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2015-08-07,279,D,0,1,1EOS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that care plans were developed for one (1) resident (#70) for Activities of Daily Living (ADL), from a total sample of thirty-eight (38) residents. Findings include: Review of the clinical record for resident #70 revealed that the resident was thirty -seven (37) years old admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS), Care Area Assessment (CAA) Summary dated 06/13/15 revealed that resident had impairment on both sides of upper and lower extremities Further review revealed no care plan on file regarding contracture care. On 08/03/15 at 11:15 a.m., 08/04/15 at 8:00 a.m. and 3:00 p.m. and on 08/05/15 at 11:30 a.m. revealed the resident with no splints or rolled washcloths on upper extremities; bilateral contractures were noted at the elbows, wrists, hands. The left hand was severely contracted and curled toward the resident's face. Interview with the MDS Coordinator on 8/07/15 at 8:47 a.m., confirmed that there was no care plans for this resident regarding her contractures. Cross refer to F 318",2019-08-01
4688,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2015-08-07,312,D,0,1,1EOS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to ensure that one (1) resident #70 who required total assistance with grooming, received assistance from a sample size of thirty-eight (38) residents. Findings include: Review of the clinical record for resident #70 revealed the resident is a thirty-seven (37) year old resident admitted to the facility on [DATE]. Review of the Admission Minimum Data Set (MDS) assessment for resident #70 dated 06/13/15 revealed a [DIAGNOSES REDACTED]. Further review of the MDS dated [DATE] Section V. Care Area Assessment and Care Planning revealed the resident did not trigger for Activities of Daily Living (ADL). However, a plan of care was developed dated 06/13/15 that indicated that resident #70 required total assist for ADL cares from staff. She's unable to help. Interventions for Activities of Daily Living included for Staff to do all ADL care. Resident is unable to help. Record review revealed the resident was dependent for all activities of daily living (ADL) and required assistance of two (2) persons with dressing, personal hygiene, and bathing due to physical limitations. On 08/03/15 at 11:15 a.m., 08/04/15 at 8:00 a.m., and 08/04/15 at 3:00 p.m. the resident was observed with eyes open, lying on her back, dressed in a light blue checked hospital gown. Dried blood was on right side of pillow near resident's right ear. No dressing was observed on ear or on the left elbow. Three hospital identification bands were noted on right wrist. The resident's fingernails were very long, uneven with old gold nail polish at the end of the nails. On 08/05/15 at 8:30 a.m. an interview with Certified Nursing Assistant (CNA) DD revealed she usually does not tend to taking care of the resident since she is a restorative Certified Nursing Assistant (CNA). Upon observation of the resident's feet, with the CNA, DD agreed her toenails were growing into her skin and her finger nails were jagged and too long. In addition, her feet were very dry and scaly. The CNA stated that she did not trim toenails, that the doctor trims toenails. On 08/06/15 at 10:00 a.m. an interview with CNA EE stated that the resident's mother probably cuts her nails. On 08/06/15 at 9:05 a.m. an interview with CNA FF revealed that her mother visits, or the doctor. That she does not cut the resident's nails. CNA FF confirmed that the resident's toenails were growing into her skin and her finger nails were jagged and too long. On 08/06/15 at 09:35 a.m. an interview with Licensed Practical Nurse (LPN) II revealed that the facility expectation was that when a CNA is giving baths or daily care, the CNA is to trim the nails unless the resident has diabetes or another issue, then the CNA is not allowed to trim nails. The CNA is to notify the Charge Nurse and they will place the resident on the Eye and Foot Log for a doctor visit. On 08/06/15 at 10:00 a.m. an interview with the Assistant Director of Nursing (ADON) revealed there is an Eye and Foot log. If there is a resident who needs to see the podiatrist, the CNA will make the Charge Nurse aware and the Charge Nurse will put the resident's name on the list to be seen by the doctor who visits every three months. Review of the log revealed the resident's name was not on the list.",2019-08-01
4689,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2015-08-07,318,D,0,1,1EOS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure restorative nursing services were provided for two (2) residents (#39 , #70) of thirty-eight (38) sampled residents. Findings include: 1. Record review of the Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #39 was initially admitted to the facility on [DATE]; was re-admitted to the facility on [DATE], 02/01/15, 03/11/15 and 07/30/15. He was admitted with following Diagnoses: [REDACTED]. The Significant Change Minimum Data Set (MDS) assessment dated [DATE] under Section V. CAA and Care Planning, revealed that resident # 39 did not Trigger and was not Care Planned for Activities of Daily Living (ADL/ Rehabilitation Potential.) However, review of the medical record demonstrated the following care plan for resident #39: The interventions for resident #39 were as follows: Will not have a decline in his current mobility. He requires 2 staff assist for transfers. Passive Range Of Motion (PROM) to lower extremities, provide pillow in between legs as needed. Bilateral Lower Extremities (BLE): Passive Range Of Motion (PROM). Left AROM in all planes, with moderate to maximum assistance. Document progress and refusals per facility protocol. Reevaluate program as needed for effectiveness. On 08/06/15 at 3:30 p.m. an interview with Licensed Practical Nurse (LPN) II revealed the Certified Nursing Assistants (CNA) was to inform the unit manager or supervising nurses if they notice a change in a resident. The nurse completes a Hey Therapy notice and gives it to Rehabilitation Therapy. The Hey Therapy notice alerts Rehabilitation Therapy to assess the resident. Interview on 08/06/14 at 4:45 p.m. with Rehabilitation Director LL revealed he or one of the other therapists performs weekly rounds of all residents. The assessment also includes new admits and any residents they have been notified that are declining in mobility or activity. The Therapy Screening Log book is separated by month and contains all of the initial screening records for each resident assessed for that month. Review of Therapy Screening Logs revealed resident # 39 was not listed. physician's orders [REDACTED]. There was no evidence of any other Rehabilitation or Restorative therapy for this resident. On 08/04/15 at 4:00 p.m., 08/05/15 at 12:30 p.m., 08/06/15 at 5:30 p.m. and on 08/07/15 at 8:00 a.m. the resident was observed in a high backed Geri-chair in the day room covered with green blanket. Observation of his upper left hand revealed a contracture. The lower extremities were curled into a fetal position. No splints were noted for upper or lower extremities; no rolled wash cloths were noted in the resident's palms. No splints were noted for upper or lower extremities; no rolled wash cloths were noted in the palms. On 08/07/15 at 3:15 p.m. the resident was observed in bed. Observation of the left hand revealed a contracture and lower extremities were curled up to the chest. No splints were noted for upper or lower extremities; no rolled wash cloths are noted in the palms. 2. Review of the clinical record for resident #70 revealed that the resident was admitted into the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) Care Area Assessment (CAA) Summary dated 06/13/15 revealed that the resident did not triggered for Activities of Daily Living (ADL) Functional/Rehabilitation Potential. However, during further review of the MDS findings included under the Section G., entitled Functional Limitation in Rehabilitation Potential it was indicated the resident had impairment on both sides of upper and lower extremities. Further review revealed no care plan on file regarding contracture care. On 08/06/15 at 1:30 p.m. an interview with Licensed Practical Nurse (LPN) II revealed the resident was fitted for splints, but she only wore them a few times because they did not fit her properly. They were given back to rehabilitation and they were supposed to re-fit them for the resident. Interview on 08/06/15 at 4:45 p.m. with the Director of Rehabilitation LL revealed he or one of the other Certified Occupational Therapist Assistants (COTA) performs weekly rounds of all residents. Review of Therapy Screening Log revealed a log for (MONTH) (YEAR). This log provided by Registered Nurse (RN) JJ did not have resident #70 listed. The resident was admitted in (MONTH) 6, (YEAR). Interview with the Administrator on 08/06/15 at 5:30 p.m. confirmed that resident # 70 was not on the (MONTH) (YEAR) log. On 08/07/15 at 07:50 a.m., RN JJ provided a second (MONTH) (YEAR) log. This log repeated the previous names of the residents on the previous log, however, resident # 70 was on this second log provided by RN JJ. According to this log, resident #70 was assessed on 06/06/15 and referred to Physical Therapy (PT), Occupational Therapy (OT), and Speech Therapy (ST). However the resident was not assessed by the MDS Coordinator until 06/13/15. On 08/03/15 at 11:15 a.m., 08/04/15 at 8:00 a.m., 08/04/15 at 3:00 p.m. the resident was observed with eyes open, looking around the room, lying on her back. No splints or rolled washcloths were observed on upper extremities; bilateral contractures were noted at the elbows, wrists, hands. The left hand was severely contracted; curled toward the resident's face. Review of Occupational Therapist (OT) Progress Notes and Discharge Summary revealed the following summary information: Patient discharged to SNF with restorative nursing with recommendations including PROM to bilateral upper extremities (BUE) and donning bilateral resting hand splints or soft wash cloths as tolerated. On 08/05/15 at 11:30 am, the resident was noted to be dressed in a different gown and different linens were on the bed. The resident was positioned on her back with gel pillow at her neck and a pillow between knees. No splints applied to hands or wash cloths rolled in hands.",2019-08-01
5935,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2014-06-19,309,D,0,1,VBNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to follow a physician's order for a dietary supplement, and weekly weights for one (1) resident (#92) from a sample of thirty one (31) residents. Findings include: Review of the medical record for resident #92 revealed a physician's order dated 5/28/2014 for Med Pass 2.0 one-hundred and twenty (120) milliters (ml) by mouth (po) three times per day (TID), and weekly weights. On 6/18/2014 at 12:35pm during an interview with the Consulting Dietitian EE, she revealed that she wrote an order for [REDACTED]. Review of the June 2014 MAR indicated [REDACTED]. Review of the computer Point Click record for this resident revealed no evidence of weekly weights after the 5/28/2014 order. Interview on 6/18/2014 at 10:30am with the medication nurse BB revealed that the resident is not receiving any supplement at this time. Interview on 6/18/2014 at 11:15am with the restorative aide CC revealed that all of the weights are in the computer in Point Click. She pulled up the weights for the resident and only the monthly weights were in the computer. No weekly weights were available.",2018-05-01
5936,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2014-06-19,372,B,0,1,VBNL11,"Based on observation and staff interview the facility failed to maintain the proper disposal of garbage around one (1) of one (1) outside dumpster. Findings include: Observation conducted 6/16/14 at 11:17am of the outside dumpster area revealed forks, straws, straw wrappers, disposable gloves, paper towels, Styrofoam food containers, broken tiles and other debris were scattered area the dumpster. Further, there was an open, clear, tied garbage bag of nursing supplies sitting on the ground beside the dumpster. Observation on 6/16/14 at 11:20am revealed Certified Nursing Assistant (CNA) HH came outside and picked up the garbage bag and put it in the dumpster. On 6/16/14 at 2:20pm interview with the Maintenance Director revealed the dumpster area is typically checked and cleaned daily. He indicated there was more trash around the dumpster because of the weekend and he had just not gotten to it yet today. Observation at the time of interview, revealed some of the trash and debris had been picked up but plastic forks, straw wrappers, gloves and the pile of broken tiles were still scattered about the grass and concrete area.",2018-05-01
5937,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2014-06-19,431,D,0,1,VBNL11,"Based on observation, review of the facility Insulin Storage Recommendations, Medication Administration Records (MARs) and staff interview the facility failed to ensure two (2) vials of insulin were discarded timely and not used past the discard date on one (1) medication cart (Right Wing Cart 1) from four (4) medication carts. Findings include: Observation conducted on 6/19/14 at 9:41am revealed that one (1) vial of Humulin R insulin with the open date of 5/11/14 and the discard date of 6/12/14 and one (1) vial of Lantus insulin with the open date of 5/3/14 and the discard date of 6/2/14 were found in the Right Wing Medication Cart One (1). Review of the MARs corresponding to the vials of insulin revealed the vial of Humulin R insulin was given eight (8) times for sliding scale insulin coverage for eight (8) days past the discard date. Review of the MAR indicated [REDACTED]. Review of the facility's Insulin Storage Recommendations indicated Humulin R should be discarded 31 days after opening and Lantus should be discarded 28 days after opening. Interview conducted on 6/19/14 at 10:15am with the Director of Nursing (DON) revealed the Humulin R should have been discarded on 6/12/14 and the Lantus should have been discarded on 6/2/14. Further, she expects nurses to monitor the date of opening and discard date with each administration and to reorder the medication before the discard date. The recommendations are located on the front of the MARs on each cart and should be used when opening insulin.",2018-05-01
5938,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2014-06-19,469,E,0,1,VBNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility records, resident and staff interviews, the facility failed to maintain effective pest control on two (2) of two (2) resident wings. Findings include: ' Observation on 6/16/14 at 4:00pm revealed a large [MEDICATION NAME] roach crawling across the nurse's station and up the wall. Interview on 6/17/14 at 8:16am with resident #26 revealed that every night big roaches come into her room and spiders too. The resident indicated that she is afraid of them and she will either leave the room or make sure her covers do not touch the floor so they want crawl on her. Interview on 6/17/14 at 8:32am with resident #158 revealed that at night time the [MEDICATION NAME] bugs come out on a consistent basis. He indicated that sometimes they are in his shoes in the morning. Interview on 6/17/14 at 8:47am with resident #39 revealed bugs are a problem in this building. He further revealed there are big roaches in his room and he sees them every night. He revealed that they get into his closet. Observation on 6/17/14 at 10:32am revealed a roach crawling across the counter top. Another interview with resident #158 conducted 6/18/14 at 9:55am revealed he saw two [MEDICATION NAME] bugs late yesterday afternoon. One ran under his bed and another was by his shoe. Second interview with resident #39 conducted 6/18/14 at 1:05pm revealed that he saw pest control staff at the front of the building yesterday but he did not see them spray in his room. He indicated that he knows when there is a roach in his room because the staff will scream when they enter his room and say there is a big bug in here!. Interview with resident #26 on 6/18/14 at 1:50pm revealed she had to kill a big roach in her room the previous night. She indicated it was crawling by the sink. She killed it then picked it up with a paper towel and discarded it in a trash can. She said she can not sleep if she sees one and is unable to kill it. Interview on 6/18/14 at 3:40pm with the Certified Nursing Assistant (CNA) FF revealed that big roaches have been a problem in the facility. She sees them on a nightly basis, most often in the resident's rooms. Especially the rooms where there is a lot of clutter and food items. FF indicated that the exterminators do not seem to be helping. Interview on 6/18/14 at 3:55pm with the CNA GG revealed that she has seen huge roaches on a regular basis. GG is concerned for the residents, especially the ones who have to have their beds close to the ground due to fall risk. She worries the roaches will get into the resident's bed. GG revealed about a month ago, a family member called her to a resident's room because there was a huge roach crawling up the privacy curtain. GG indicated she felt so embarrassed and called someone to remove the roach. On 6/19/14 at 8:05am resident #39 was interviewed again and revealed that concerns regarding roaches have been discussed in several Resident Council meetings and the facility has been made aware of the concern. He said the exterminator comes but whatever is sprayed does not work and usually makes the roaches come out even more. Interview on 6/19/14 at 9:30am with the Maintenance Director revealed he was not aware of resident complaints of roaches. He has only been in this position for a month. He acknowledged that he has seen large roaches by the back door and employee lockers. He indicated there is no weather stripping at the bottom of the doors and roaches come in under the doors. Review of the Pest Elimination Services Agreement dated 11/18/13 revealed that visit are done monthly and that resident's room are rotated. Interview with the Administrator on 6/19/14 at 10:25am revealed that the Exterminator explained that 1/6 of the resident rooms are selected to be treated each month alternating between the Right Wing and Left Wing. The laundry, exterior of building, kitchen, storage closets, offices, hallways, nurses station and main hallways are treated monthly. Further interview at 12:10pm revealed that last year there was a real problem with roaches so they changed exterminators. She indicated that staff have educate and re-educate the residents to keep food in plastic container with a lid and not leave food out. The facility has provided plastic container for the residents. Staff are supposed to report any bugs via a work order. The area will be clean and sprayed. Review of the the Pest Control Service Invoice revealed the following: 11/20/13 the facility was treated for [REDACTED]. 11/29/13 the facility was treated for [REDACTED]. 12/17/13 the facility was treated for [REDACTED]. The sites include Kitchen Area, Storage Area, Exterior Area and Patient/Guest Rooms. 12/27/14 facility was treated for [REDACTED]. 1/14/14 facility was treated for [REDACTED]. 2/28/14 facility was treated for [REDACTED]. 3/25/14 facility was treated for [REDACTED]. 4/29/14 facility was treated for [REDACTED]. 5/27/14 facility was treated for [REDACTED]. 6/2/14 facility was treated for [REDACTED]. There is no documentation on the monthly reports related to the monthly treatment of [REDACTED]. The last documentation of treatment to the resident rooms was on 12/27/13.",2018-05-01
5939,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2014-06-19,502,D,0,1,VBNL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow physician's order for a laboratory test one (1) resident (#33) from a sample size of thirty-one (31) residents. Finding include: Record review revealed a physician's order dated 12/5/13 for an Glycated Hemoglobin (A1C) in the AM. There was no evidence in the clinical record of the A1C being drawn. Interview conducted 6/19/14 at 10:25am with the Director of Nursing (DON) revealed that she had contacted the laboratory and the A1C ordered on [DATE] had not been drawn.",2018-05-01
7194,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-09-20,157,D,0,1,BVMN11,"Based on record review and staff interview, the facility failed to ensure that the family and physician were notified of a weight change for one (1) resident (#120) from a sample of twenty-nine (29) residents. Findings included: Review of Vital Signs and Weight Record for resident # 120 revealed a weight gain of ten (10) pounds (lbs) within five (5) days between 7/25/12 and 7/30/12. Further review revealed a weight gain of seven (7) pounds between 8/6/12 and 9/5/12, with a reweigh on 9/20/12 that revealed an additional six (6) pound gain. Record review revealed no evidence that the physician or family was notified of weight changes. Review of the care plan dated 3/29/12 and updated on 9/20/12 included an alteration in nutrition with a goal to maintain his current weight during the next 90 days. Approaches included alert physician and family of significant loss or gain. Interview with the facility Dietician on 9/18/12 at 2:00 p.m. revealed that she was not aware of the resident's weight changes. Interview on 9/20/12 at 10:00 a.m. with the Dietary Manager DD revealed that he records the weights, and that if he identifies a problem he will observe the resident meals . Further interview revealed that if the resident is eating well, he will not worry about the weight. Interview on 9/20/12 at 1:45 p.m. with the Left Wing Unit Manager FF revealed that when a resident has a sudden weight gain or loss, the MD and the family needs to be notified. Further interview revealed that there was no evidence in the chart that the MD or family was notified.",2017-07-01
7195,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-09-20,166,D,0,1,BVMN11,"Based on record review, staff interview and review of facility policy and procedure related to Grievances/Complaints, the facility failed to make an effort to resolve a grievance in a timely manner for one (1) resident (#78) from a sample of twenty-nine (29) residents. Findings Include: Interview with resident #78 on 9/18/12 at 10:26 a.m. revealed she had an electric razor that went missing not quite two (2) months ago. She further revealed that she reported it to the social worker, and to staff who looked for it in her room. Review of the monthly grievance log since 4/1/12 revealed there was no report for the resident's missing electric razor. Interview with the Social Worker on 9/18/12 at 4:20 p.m. revealed that she was aware of the missing razor and that it was still missing. Further interview revealed she had a separate Missing Item Log that she also keeps. Review of this log with the social worker revealed that on 7/31/12 the resident reported missing clothing and a pink battery shaver that were last seen weeks ago. Review of the facility's grievance policy revealed the resident will be informed of the findings of the investigation, as well as any corrective actions recommended, within 7 working days of the filing of the grievance or complaint. There was no evidence that the facility provided prompt efforts to locate missing items.",2017-07-01
7196,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-09-20,309,D,0,1,BVMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow Physician's orders for one (1) resident (#111) from a sample of twenty-nine (29) residents. Findings include: Interview with resident #111 on 9/17/12 at 2:06 p.m. revealed the Orthopedist ordered a knee brace for him in July, and that he had not received it. Review of Physician's order dated 7/20/12 revealed an order for [REDACTED].>Interview with Licensed Practical Nurse (LPN) FF on 9/20/12 at 10:25 a.m. revealed resident #111 saw an orthopedist for a follow-up visit for his ankle fracture and came back with a prescription for a hinged knee brace. She wrote the order as a verbal order, and LPN AA gave the original prescription from the orthopedist to the Therapy Manager. Review of Physical Therapy notes dated 8/4/12 and 8/15/12 indicated awaiting knee brace. Interview with Occupational Therapy Assistant HH on 9/20/12 at 10:17 a.m. revealed that when there is a Physician's order for an orthotic, nursing gives a therapist a copy of the order. He further revealed that once the order goes through, it usually takes no more than a week to receive the orthotic, even if it is a custom fit appliance. Further interview with HH on 9/20/12 at 11:20 a.m. revealed the knee brace for resident #111 was not a custom brace, so it would have been ordered through central supply. He confirmed that the brace had not been ordered until 9/20/12. Interview with Central Supply staff II on 9/20/12 at 12:50 p.m. revealed that she never saw the order for a knee brace for resident #111.",2017-07-01
7197,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-09-20,323,D,0,1,BVMN11,"Based on observations and staff interview, the facility failed to maintain water temperatures for resident use below 120 degrees Fahrenheit in one (1) of seven (7) resident rooms. Findings include: Environmental rounds conducted with the Maintenance Director on 9/19/2012 between the hours of 1:00 p.m. and 2:15 p.m., revealed the water temperature in Room #145 was 120.6 degrees Fahrenheit. This is a four (4) resident ward with three (3) residents that independently use the sink. Interview with the Maintenance Director conducted during environmental rounds revealed that water temperatures are checked in random rooms daily, and adjustments are made to keep the temperature between 100 and 110 degrees.",2017-07-01
7198,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-09-20,428,D,0,1,BVMN11,"Based on record review and staff interview, the consulting pharmacist failed to identify and report medications given incorrectly to one (1) resident (#1) from a sample of twenty nine (29) residents. Findings include: Review of the Pharmacy Consultation Report for resident #1 dated 5/30/12 revealed a recommendation to re-evaluate continued need for Omeprazole and consider discontinuing, and to consider increasing Lantus to 20 units sq qhs. Further review revealed that on 6/5/12 the Physician agreed and wrote the order to discontinue Omeprazole and increase Lantus. Reveiw of the Physician Telephone Order dated 6/10/12 revealed an order to change the Lantus and to discontinue the Omeprazole. Review of the Medication Administration Record (MAR) revealed Omeprazole was discontinued from 6/10/12 to the end of the month. Further review of the Medication Records revealed that Omeprazole was transcribed on following months and given. Medication Regimen Review was done monthly with no evidence that the Pharmacist identified or reported a medication error. Consulting Pharmacist was interviewed at 8:30 a.m. on 9/19/12 and confirmed that the order should have been transcribed from consult report to Medical Doctor (MD) order and then documented on the Medication Administration Record (MAR). Interview with Licensed Practical Nurse (LPN) BB on 9/19/12 at 8:43 a.m. revealed that the procedure for the receiving nurse is to contact the MD and let them know what the Pharmacist is recommending and transcribe the order. LPN BB also agreed that Omeprazole was still on the MAR, and that it was still being administered to the resident. Interview with the Right Wing Unit Manager on 9/19/12 at 11:00 a.m. revealed that the Omeprazole should have been discontinued and removed from the MAR.",2017-07-01
7199,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-09-20,465,D,0,1,BVMN11,"Based on observation and staff interview, the facility failed to maintain one (1) of two (2) hoyer lifts, and one (1) of one (1) wheelchair scale in a sanitary manner. Findings include: Environmental rounds of the facility conducted with the Housekeeping Manager on 9/19/2012 between the hours of 1:00 p.m. and 2:00 p.m revealed one (1) hoyer lift on the left wing had an accumulation of a brown substance and dust particles on the base of the lift. Further observation revealed a wheelchair scale with a grey sticky substance accumulated on the landing of the scale. During environmental rounds, the Housekeeping Manager agreed that the hoyer lift and wheelchair needed to be cleaned.",2017-07-01
8493,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,164,E,0,1,NH2211,"Based on observation and staff interview the facility failed to provide full visual privacy in two (2) of two (2) common shower rooms. Findings include: During the environmental tour, with the maintenance manager, at 9:50 a.m. on 3/10/2011 the shower curtains in both shower rooms did not reach to the seat of a shower chair. When the shower door was opened residents could be seen by visitors or other residents in the hallway.",2016-01-01
8494,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,223,G,0,1,NH2211,"Based on record review, resident and staff interviews the facility failed to ensure that one (1) resident (Q) was free of abuse from a sample of thirty (30) residents. This failure resulted in harm for this resident. Findings include: Interview on 3/10/2011 at 8:30 a.m. with resident Q revealed that the staff turned the resident roughly and during the turning process, the indwelling urinary catheter was pulled out. Continued interview revealed that blood was on the inside and outside of the incontinence brief. Review of a report, Resident Report of Abuse dated 2/16/2011 for resident Q revealed that on 2/14/2011, a Certified Nursing Assistant (CNA) II threatened the resident, and while turning the indwelling urinary catheter was pulled out which resulted in a meatal tear with bleeding. Continued review revealed that Licensed Practical Nurse (LPN) JJ heard the altercation and went into the room to diffuse the situation. Review of nurses note dated 2/14/2011 revealed, LPN JJ was in the resident's room and the resident complained that CNA II removed the indwelling urinary catheter which caused bleeding. Review of nurses note dated 2/15/2011 at 6:30 a.m. revealed an assessment of bloody drainage of the indwelling urinary catheter which required medication for pain. Review of nurses note dated 2/16/2011 at 10:15 a.m. revealed blood at urethral meatus. Review of the skin assessment sheet dated 2/17/11 revealed that the meatus had a partial thickness wound with no exudate, no odor and pink tissue. Skin assessment date 2/23/11 revealed that the assessment remained the same and on 3/01/11 the wound was resolved.",2016-01-01
8495,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,225,D,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to investigate an injury of unknown origin and failed to report the injury of unknown origin for one (1) resident (#76) of thirty (30) sampled residents. Findings include: Review of the nurse's notes for resident #76 dated 10/2/10 at 2:00 p.m. revealed that during wound care the resident complained that he/she could not lift his/her left leg and had heard something pop in the knee and told the staff. Review of the clinical record for this resident revealed that the resident's physician was called, ordered an X-ray and to transfer the resident to the hospital for an evaluation. Continued review revealed that the resident was admitted to hospital for left [MEDICAL CONDITION] and returned to the facility on [DATE]. Review of the hospital history and physical dated 10/2/10 revealed that the resident stated that the nursing home staff were lifting him/her in a hoyer lift when the patient heard a loud snap of the hip and began having left hip pain. The physician noted in the history and physical that the resident sustained [REDACTED]. During an interview with the Administrator on 3/10/11 at 3:45 pm, she stated that an investigation of the resident's left [MEDICAL CONDITION] was not done and was not reported to the state agency because the resident reported to staff that nothing out of the ordinary happened. During an interview with the Director of Nursing on 3/10/11 at 4:50 p.m., she stated that she did not get written statements from staff because she did not know which staff were present at the time of the injury because the resident stated that it happened on either Thursday or Friday. She also stated that the resident told her nothing out of the ordinary happened therefore an investigation was not done to determine the possible cause of the resident's left [MEDICAL CONDITION].",2016-01-01
8496,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,226,G,0,1,NH2211,"Based on clinical record review, review of the facility abuse policy and resident and staff interviews, the facility failed to ensure that their abuse policy was followed for one (1) resident (Q) of the sampled thirty (30) residents. This failure resulted in actual harm for this resident. Findings include: Review of a Resident Report of Abuse dated 2/16/2011 for resident Q, revealed that on 2/14/2011, a Certified Nursing Assistant (CNA) II threatened the resident, and while turning the resident the indwelling urinary catheter was pulled out which resulted in a meatal tear with bleeding. Continued review revealed that Licensed Practical Nurse (LPN) JJ heard the altercation and went into the room to diffuse the situation. There is no evidence that the LPN reported the incident to the Director of Nurses, Administrator or nurse supervisor. Continued review of the Resident Report of Abuse revealed that CNA II returned to work on the evening of 2/15/2011, and was assigned to resident Q again. The resident complained to a nurse that he was afraid of CNA II who then changed CNA II assignment. Review of the facility work schedule revealed that the CNA II was on the schedule for 2/14/2011 and 2/15/2011. Interview on 3/14/2011 at 12:30 p.m. with Administrator revealed that CNA II did return to work on 2/15/2011, which is against the facility abuse policy. Review of the facility policy for abuse revealed that any allegation of abuse should be reported to the Administrator immediately and that employee involved in any allegation of abuse will be suspended pending investigation.",2016-01-01
8497,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,248,E,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff/resident interviews and clinical record review, it was determined that the facility failed to provide an activity program to promote the psychosocial well being for four (4) residents (S, P, L and #11) of the thirty (30) sampled residents. Findings include: 1. Interview on 3/7/11 at 1:30 p.m., resident S, revealed the Activities offered at the facility were boring, that the cable television had not worked for a month, newspapers were not provided and there was no method to keep up with current events. Continued interview with the resident revealed that there were not any activities for high functioning residents and the facility did not have puzzles or supplies available. Review of the clinical record revealed a plan of care dated 10/5/2010, updated on 12/4/2010, with interventions as follows: to promote psychosocial functioning; decrease depression; and provide an activity calendar every month, however, the plan of care did not include individualized activities or interventions to address resident interests, needs, functional status, nor any evidence that the plan of care had been evaluated for effectiveness. Review of a physician progress report dated 2/20/11, revealed the resident stated, All I do is play bingo. Observation on 3/8/2011 from 9:30 to 10:30 a.m., 3/9/2011 from 9:00 a.m. to 11:00 a.m., 3/10/2011 at 2:30 p.m. and 3/11/2011 at 10:30 a.m. revealed resident S, in the Right Wing mall area in a semi circle with other residents in front of the television. Continued observation revealed there was no interaction with the other residents and the resident sat with eyes closed not watching television. 2. Observation of resident #11 3/8/2011 from 9:30 to 10:30 a.m., 3/9/2011 from 9:00 a.m. to 11:00 a.m., 3/10/2011 at 2:30 p.m. and 3/11/2011 at 10:30 a.m. revealed the resident, who has a [DIAGNOSES REDACTED]. Observation on 3/14/2011 at 10:30 a.m. revealed that the resident had been placed approximately nine (9) feet way from the television and another resident was sitting in front of him/her. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident was assessed as being involved in activities 1/3 to 2/3 of the time and being unable to be verbally understood. Review of the activities care plan dated 11/30/2011, revealed one to one activities were going to be continued to be provided for socialization but, it did not include the specific type of one to one activity, the duration or the frequency. 3. Interview on 3/9/11 at 10:10 a.m, with resident L revealed that the facility did not provide supplies for independent activities. Interview on 3/15/11 at 1:30 p.m. with the Activity Director revealed that the facility had limited supplies for the activity program. 4. Review of the MDS assessment dated [DATE] for resident P revealed that the resident had not been assessed for interests prior to admission to the facility. Review of the resident care plan revealed that reading materials of choice were to be given to the resident. Interview on 3/08/11 at 9:30 a.m. revealed that the resident liked to read but his glasses had been missing for two (2) days. Continued interview revealed that he was interested in motorcycles and would like to look at motorcycle magazines but there were none available",2016-01-01
8498,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,253,E,0,1,NH2211,"Based on observation and staff interview the facility failed to provide services to maintain an orderly and sanitary environment for two (2) of two (2) wings (Left wing and right wing) Findings include: During observations on initial tour on 3/07/11 beginning at 9:20 a.m. and during environmental tour with the maintenance manager on 3/10/2011 at 9:50 a.m. and 3/14/2011 at 10:00 a.m. the following concerns were identified: Right Wing: 1. Room 130- The grab bars in the bathroom were loose, there was an area of crumbled plaster to the left of the sink and the sink caulking had a split completely around the sink. The wall across from the toilet was plastered over and has not been sanded or painted. The C bed footboard was loose with one screw hanging out. An extension cord ran from the television across the closet door floor to a power strip that was mounted on the wall. The Bed D footboard was loose and the bedrail was slanted outward. An eighteen (18) inch area of baseboard was coming loose from the wall. 2. Room 131- There was a twelve (12) inch area of baseboard to the right of the door that was loose. The bathroom floor had a buildup of dirt and dust in the corners and at the base of the baseboard. 3. Room 133- The dry wall was pulling away from the baseboard behind the sink and toilet. 4. Room 139- The mattress did not meet the footboard on bed A by seven (7) inches. The headboard on bed B curved inward and was loose. A power cord between the beds was not secured. The safety bar in the bathroom slid back and forth. Two (2) ceiling tiles were stained and one had a missing piece two (2) inches wide. The area above the headboard on Bed A was marred. 5. Room 141- The bathroom had dirt and dust in the corners and at the baseboard. There were two (2) cracked tiles by the bathroom door. 6. Room 142- The wall, on the left side of bed A was marred. The door frame was cracked and peeling paint with a metal strip exposed. The air conditioner grid was missing with a wire mesh covering the area where the grid should be, there were no vents and there was a sharp area to the left of the wire mesh. The area where the vents would be had an accumulation of dust. Bed A had a mattress that was seven (7) inches short of the footboard. The wall between both resident beds marred. There was a torn area of vinyl one (1) one inch by one (1) inch on each of the arms of the Gerichair for the resident in A bed. 7. Room 143- There was exposed plaster to an area to the left of the sink. The ceiling tiles were not intact. There was crumbled plaster on the bathroom floor to the left of toilet. 8. Room 144- The C bed mattress was seven (7) inches short of the footboard. The heater/air conditioner had a broken slat. There was gray grout repair over tiles that were white. The bathroom corners were dirty and dusty. 9. Room 146-The walls were marred behind each bed. 10. Room 148-The headboard for bed B was loose. The baseboard, to the left of the sink, had an area 8 Inches by 8 inches that was loose. There was a two (2) inch by two (2) inch gash in the wall behind the sewing machine. The front of the chest of drawers was marred. The water fountain on the right wing was unplugged and the water supply shut off. When it was turned on by the maintenance manager it worked but was leaking. Left Wing: 1. Room 121- The footboard for bed C was loose. 2. Room 123- The head board was loose. 3. Room 107- The window had a large area of exposed gray grout where white tile had been removed. The ceiling tiles were cracked and sagging in the bathroom. 4. Room 105- The ceiling tiles in the bathroom were off the grid. The water fountain on the left wing did not work at all.",2016-01-01
8499,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,272,D,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review the facility failed to conduct an initial assessment related to dental/oral status and pressure ulcers for three (3) residents (Z, #83 and #29) from a sample of thirty (30) residents. Findings include: 1. Record review for resident #29 revealed that the resident was readmitted to the facility on [DATE] after hospitalization . Review of the admission skin assessment dated [DATE] revealed mushy left and right heels with an area of [DIAGNOSES REDACTED] on the left heel. Skin assessment dated [DATE] revealed a Stage 2 wound with blister to the interior left heel and a Stage 1 pressure area to the right heel. Review of the readmission Minimum Data Set ((MDS) dated [DATE] revealed no evidence that the right heel pressure area had been assessed. Interview on 3/14/11 at 11:00 a.m. with the treatment nurse revealed that the resdient is non compliant with suggested treatments for feet -refuses heel protectors and refuses to keep feet elevated when up in wheelchair. 2. Observation of resident #83 during initial tour on 3/07/11 at 10:00 a.m. revealed the resident sitting in a reclining geri-chair in the day room. Continued observation revealed missing front teeth with other teeth stained and broken. Review of the admission MDS assessment dated [DATE] and the quarterly MDS assessment dated [DATE] revealed no evidence that the residents oral/dental status had been assessed. 3. Observation of resident Z during initial tour on 3/07/11 at 9:30 a.m. revealed that the resident had broken and stained teeth. Review of the readmission MDS assessment dated [DATE] and the quarterly 10/19/10 revealed that the resident needs assistance in all areas of Activities of Daily Living including personal hygiene. There was no evidence that an assessment had been completed for dental/oral status.",2016-01-01
8500,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,279,E,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive care plan for seven (7) residents (#158, 75, 28,11, 76, 09, and 68) of the thirty (30) sampled residents. Findings include: 1. Review of the clinical record for resident #11 revealed that the resident was admitted to hospice for palliative services on 8/25/2010. Review of the resident's care plan revealed that the facility and the hospice had failed to develop an integrated care plan identifying their responsibilities for the resident's care and services. Continued review of the care plan developed on 12/10/2010, revealed there was no evidence that any hospice staff had participated. Interview with the Director of Nurses (DON) on 10:20 am on 3/15/2011 revealed that hospice was not involved in the resident's care planning. Review of the 8/25/2010 hospice care plan revealed that the resident was having back pain. Review of the Hospice Physician Face to Face Eligibility and Encounter Attestation form signed by hospice physician 1/19/11, revealed that the physician noted that the resident was in severe pain due to [MEDICAL CONDITION] joint disease and [MEDICAL CONDITION] and had severe dementia with psychotic fear. Continued review revealed that the hospice physician noted that the the resident appeared to be suffering in acute and chronic pain. However, the facility staff had not developed a care plan to address her/his potential for pain. 2. Review of the care plan for resident #75 dated 10/5/2010 revealed no evidence that any individualized activity program with interventions to address the resident's interests, needs and to promote his/her psychosocial functional status were included. 3. Review of the care plan for resident # 68 revealed that the resident's care plan does not include restorative nursing services. The resident was discharged from skilled physical therapy services on 12/19/10 with a referral to restorative nursing. 4. Review of the clinical record for resident #28 revealed the resident had a [DIAGNOSES REDACTED]. Review of the 12/8/10 Physical Therapy Discharge summary noted that the resident had been discharged to the restorative nursing program. The program was to include passive range of motion to the bilateral lower extremities and bed mobility. There was also a 12/8/10 Occupational Therapy Discharge Summary which noted a restorative nursing program had been established for the resident and included passive range of motion to the bilateral upper extremities. Review of the resident care plan revealed no evidence that a care plan had been developed to address the residents severe contractures or to reflect the restorative nursing plan developed by physical and occupational therapy. During an interview with staff AA on 3/15/11 at 9:05 am, he/she stated that physical therapy and occupational therapy had established a restorative nursing program on 12/8/10 for the resident. During an interview and review of the clinical record with staff DD on 3/15/11 at 11:00 a.m., he/she confirmed that a care plan had not been developed to address the residents severe contractures or to reflect the restorative nursing plan developed by physical and occupational therapy. 5. Review of the Initial Minimum Data Set for resident #76, completed on 9/21/10, revealed that the resident was assessed as requiring extensive assistance with bed mobility, total dependence with transfer, and mode of transfer as bed rails and lifted manually. However, review of the resident's plan of care revealed there were no interventions in place to address the resident's transfer needs. 6. Observation on 3/7/11 at 1:05 pm, revealed resident #9 reclined back in his adaptive wheelchair while staff was feeding him lunch. The resident had one (1) coughing episode at that time. Observation on 3/10/11 at 8:15 am revealed staff feeding the resident breakfast while he was reclined back in his wheelchair. Observation on 3/10/11 at 1:15 p.m. revealed staff feeding the resident lunch while he was reclined back in the adaptive wheel chair. Interview with staff FF on 3/07/11 at 1:10 p.m. revealed that the resident's mother had instructed staff to recline the resident to make it easier for the resident to eat. Continued interview revealed that they had to mix the resident's food with liquids to make it easier for him to swallow, but that they had never seen the resident choke Review of the care plans for resident #9 revealed a care plan dated 4/3/09 for being at risk for alteration in nutrition related to puree diet. However, there were no interventions put into place to address the positioning during meals and the potential complications of being fed in the reclined position. During interview with a family member for this resident on 3/15/11 at 12:15 pm, revealed that the resident had always eaten in a reclined position and that the had been instructed on how to feed resident in a reclined position. During an interview with staff BB on 3/15/11 at 12:00 pm, he/she confirmed there was not a care plan to address the residents positioning during meals and the potential complications. 7. Review of the clinical record for resident #158 revealed that the resident was admitted to the facility on [DATE]. Initial Minimum Data Set (MDS) assessment completed 2/03/11 assessed the resident at risk for skin breakdown with one (1) Stage 2 pressure ulcer, one (1) Stage 3 pressure ulcer and one (1) Stage 4 pressure ulcer. Review of the Care Area Assessment Summary (CAA) revealed that pressure ulcers were to be care planned. Review of the initial care plan dated 1/25/11 revealed that the care plan addressed turning, positioning, heel protectors, pericare, treatment as ordered. There was no evidence that a care plan had been developed to address the specific resident needs related to pressure ulcer with measurable goals and interventions. Interview 3/10/11 @1:55p.m. with a sister facility Administrator,assisting with MDS/careplan assessments, revealed that the careplan dated 1/25/11 in the clinical record was an initial care plan.",2016-01-01
8501,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,280,D,0,1,NH2211,"Based on record review and resident and staff interview, the facility failed to have a care planning meeting for one (1) resident (Q) of the sampled thirty (30) residents. Findings include: Interview on 3/10/2011 at 8:20 a.m. with resident Q revealed that he/she was unaware of care planning meetings, and would like the opportunity to participate in them so that he/she could help make up the treatment plan and regimen. Review of care plan for resident Q revealed no evidence that a care plan had been developed other than the initial care plan on admission. admitted was 1/25/2011. Interview with Social Services Director on 3/10/11 at 10:10 a.m. revealed that the resident had not had a care plan meeting. Continued interview revealed that she had mentioned in passing to the resident in February that they would be having a care plan meeting and that the resident expressed an interest in attending. Interview with Administrator on 3/10/2011 at 10:00 a.m. revealed that the Minimum Data Set (MDS) Coordinator position was vacant and that many of the MDS and Care Plan meetings were behind.",2016-01-01
8502,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,282,D,0,1,NH2211,"Based on observation, record review and staff interview, the facility failed to follow the care plan related to oral hygiene for one (1) resident Z from a sample of thirty (30) residents. Findings include: Observation of resident Z during initial tour on 3/07/11 at 9:30 a.m. revealed that the resident had broken and stained teeth with food residue encrusted on the front teeth. Observation on 3/08/11 at 12:15 p.m. revealed the resident with food encrusted on the front teeth. Review of the resident care plan dated 10/19/10 revealed that the plan for oral problems were to assist with oral care twice daily. Resident with inability to complete self care task independently,due to visual loss. Interview on 3/14/11 at 3:15 p.m. with a Certified Nursing Assistant (CNA) providing care for this resident revealed that she was unaware that the resident's teeth were to be brushed twice a day but thinks she has brushed her teeth before. Continued interview revealed there were no care guides for oral care in the Activities of Daily Living guide for the CNAs.",2016-01-01
8503,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,309,D,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to clarify how often Tylenol should be given to one (1) resident (#159) from a sample of 30 residents. Findings include: 1. Review of the medical record for resident #159 revealed a 3/1/11 physician's orders [REDACTED]. However, the frequency was not clarified. Interview with licensed staff on 3/10/11 at 3:00 pm, confirmed that the frequency of the medication needed to be clarified with the physician.",2016-01-01
8504,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,311,D,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to provide appropriate services to maintain dental hygiene for one (1) resident (Z) from a sample of thirty (30) residents. Findings include: Observation of resident Z during initial tour on 3/07/11 at 9:30 a.m. revealed that the resident had broken and stained teeth with food residue encrusted on the front teeth. Observation on 3/08/11 at 12:15 p.m. revealed the resident with food encrusted on the front teeth.The teeth were stained and there was a sour odor to the resident's breath. Interview on 3/08/11 at 12:15 p.m. with resident Z revealed that the resident had not brushed his/her teeth since admission to facility on 12/17/10. Observation on 3/14/11 at 3:00 p.m. with the Unit Manager/ Assistant Director Of Nurses revealed a toothbrush in an unopened packet and an unopened tube of toothpaste in the resident's bedside table drawer. Review of the Minimum Data Set assessment dated [DATE] revealed that the resident needs assistance in all areas of Activities of Daily Living (ADLs) including personal hygiene. Review of the resident care plan for oral/dental problems revealed that the resident was to be assisted with oral care two times a day. Review of the care plan for ADLs revealed that the resident had the inability to complete self care tasks independently due to visual loss. Interview on 3/14/11 at 3:15 p.m. with a Certified Nursing Assistant (CNA) providing care for this resident revealed that she was unaware that the resident's teeth were to be brushed twice a day but thinks she has brushed her teeth before. Continued interview revealed there were no care guides for oral care in the Activities of Daily Living guide for the CNAs.",2016-01-01
8505,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,318,D,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to provide services to prevent a further reduction in range of motion for three (3) residents (#28, #68, and #87) from a sample of thirty (30) residents. Findings include: 1. Review of the quarterly Minimum Data Set assessments for resident # 68 dated 9/23/2010 and 12/22/10 revealed that the resident was assessed as requiring extensive or total staff assistance with activities of daily living (ADL). Review of the Physician order [REDACTED]. Continued review revealed that , although there was no evidence that the order for the splint had been discontinued, it was not printed on the 2/11 or 3/11 order sheets. Interview on 3/14/2011 at 10:00 a.m with the Director of Nursing (DON), revealed that she did not know why the splints, ordered 1/11, were not on the physician orders [REDACTED]. Observation of resident #68 on 3/8/11 at 9:15 a.m. and 12:30 p.m. revealed the resident had misshapened hands with the bones in the fingers crooked and no splint in place Review of the Restorative Report, Section 3, revealed that restorative staff put the splint on the resident for fifteen (15) minutes on 2/7,2/10, 2/12, 2/17, 2/18, 2/21, 2/23-2/26, 3/2 and 3/9/11. There was no evidence that the splint had been applied in January as ordered. Continued review revealed that although range of motion exercises were ordered to be done six (6) days a week, they were only done twelve (12) times in February, 2011 and had only been done four (4) of ten (10) days in March, 2011. Restorative nursing staff did not apply splints or provide range of motion exercises as ordered. 2. Review of the clinical record for resident #87 revealed that the resident had Occupational Therapy services from 10/5/2010 through 12/17/2010 and was released to restorative nursing. Restorative staff were trained on use of a right hand grip and left hand carrot. Continued review revealed that the resident's tolerance had progressed to six (6) hours of splinting without complication and the splints were to be worn four (4) to six (6) hours per day. Review of the Functional Maintenance Program sheet indicated that the resident was to have a right hand grip and left hand carrrot applied daily. Observation of the resident on 3/9/2011 at 10:00 a.m., 12 noon, and 2:00 p.m. and 3/10/2011 at 8:05 a.m., 10:05 a.m., 12:25 p.m., and 3:45 p.m. the resident was not wearing splints. Review of the Restorative therapy sheets revealed no evidence that splints were being used. The resident's splints were found in the drawer of the bedside table. 3. Review of the clinical record for resident #28 revealed that the resident had a [DIAGNOSES REDACTED]. Review of the 12/8/10 Physical Therapy Discharge summary noted that the resident had been discharged to the restorative nursing program for passive range of motion to the bilateral lower extremities and bed mobility. Continued review revealed an Occupational Therapy Discharge Summary dated 12/8/10 which noted a restorative nursing program had been established for the resident and included passive range of motion to the bilateral upper extremities. There was no evidence that the restorative nursing program was ever initiated Interview with staff FF on 3/14/11 at 4:15 p.m. revealed that the resident had not been on the restorative nursing program. Continued interview revealed that the certified nursing assistant (CNA) that was assigned to the resident should provide range of motion everyday. Staff was unable to provide any documentation of where the restorative nursing program was ever initiated. Interview with the Rehab services Supervisor,on 3/15/11 at 9:05 a.m. revealed that physical therapy and occupational therapy had estalished a restorative nursing program on 12/8/10 for the resident. Interview and review of the clinical record with staff DD on 3/15/11 at 11:00 a.m., revealed that a care plan had not been developed to address the residents severe contractures or to reflect the restorative nursing plan developed by physical and occupational therapy.",2016-01-01
8506,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,329,D,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify a specific medical condition for which an antipsychotic medication was being administered for one (1) resident (#89) from a sample of thirty (30) residents. Findings include: Review of the physician's orders [REDACTED]. Interview with Nursing Staff CC on 3/14/2011 at 2:00 p.m. revealed that the resident had come from another facility on 1/28/2011, was already receiving the medication and that was the reason it had been ordered. Review of the Drug Regimen Review dated 3/1/2011 revealed that the pharmacist did not inform the facility that there was not an appropriate [DIAGNOSES REDACTED].",2016-01-01
8507,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,364,E,0,1,NH2211,"Based on observations, resident interviews and a test tray, the facility failed to serve food at the right temperatures and that was palatable. Findings include: 1. Interview on 3/08/11 at 9:30 a.m. with resident P revealed that the food served on the Right Wing was not hot and did not taste good. 2. Interview on 3/07/11 at 1:58 p.m. with resident S revealed that the food on the Right Wing was often served cold and thast the soup was always cold. 3. Interview on 3/9/11 at 10:13 a.m. with resident L revealed that the food did not taste very good it was very bland and nothing fresh was ever served. During a random observation on 3/14/11 at 1:00 p.m. while walking through the dining room revealed at least 90% of the mixed vegetables remained uneaten on the plates served regular diets. A test tray was requested on 3/14/2011 at 12:15 p.m., to be served for lunch on the Right Wing . Dietary staff began plating food to be served on the Right Wing at 12:30 p.m. Two (2) carts were sent to the Right Wing, one (1) at 12:45 p.m. and the other at 1:00 p.m. When the second cart arrived on Right Wing, there were ten (10) trays remaining on the first cart which had not yet been served , which were subsequently delivered to residents in their rooms. The trays on the second cart were all served before those on the first cart. After all the trays were served from both carts at 1:15 p.m., the food on the test tray was tasted with the charge nurse. Soup, smothered pork chops, pinto beans, mixed vegetables, yeast roll and pineapple cake were served on the test tray. The soup was lukewarm. The vegetables were cold, mushy and tasteless. The beans were lukewarm and mushy. The facility did not have any ice for the tea served on the floor or in the dining. Although someone had gone to buy ice and returned prior to the end of food service for the second cart, there was no ice was in the glasses of tea served to residents on either wings or in the dining room.",2016-01-01
8508,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,411,D,0,1,NH2211,"Based on observation ,record review and resident interview, the facility failed to provide dental services for one (1) resident (Z) from a sample of thirty (30) residents. Findings include: Observation of resident Z during initial tour on 3/07/11 at 9:30 a.m. revealed that the resident had broken and stained teeth with food residue encrusted on the front teeth. Observation on 3/08/11 at 12:15 p.m. revealed the resident with food encrusted on the front teeth. Interview on 3/08/11 at 12:15 p.m. with resident Z revealed that the resident had not brushed his/her teeth since admission to facility on 12/17/10. Review of the resident care plan for oral/dental problems revealed that the resident was to be assisted with oral care two times a day. Review of the care plan for ADLs revealed that the resident had the inability to complete self care tasks independently due to visual loss. Review of the clinical record revealed no evidence that the facility had provided rooutine dental care for this resident.",2016-01-01
8509,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,441,F,0,1,NH2211,"Based on record review and staff interview the facility failed to establish an infection control program which identified organisms, calculated rates of infection, and maintained a tracking and surveillance system. Findings include: Review of the facility infection control log from July 2010 through February 2011 revealed that the organism were not being identified when a culture was performed and the rates of infection were not being calculated. Interview with the Director of Nursing at 2:45 p.m. on 3/15/2011 revealed there had been no tracking in the last year. In January began having nursing staff complete a form on residents who had current infections and printed laboratory information. Continued interview revealed that all the infection control for January surveillance was not compiled and it had not been been compiled for the last year. There had not been a system in place. The infection control program was being implemented but it was not actually up and running.",2016-01-01
8510,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,468,E,0,1,NH2211,"Based on observation and staff interview the facility failed to equip corridors with handrails on a 12 foot by 12 foot corridor to the outside on one (1) of two (2) wings. Findings include: Observation during the environmental tour on 3/10/2011 at 9:50 a.m., with the environmental manager, revealed that there were no handrails on either side of the corridor (12 feet by 12 feet) leading to the outside smoking area on the right wing.",2016-01-01
8511,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,502,D,0,1,NH2211,"**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].#158 and #89) from a sample of thirty (30) residents. Findings include: 1. Review of the physician's orders [REDACTED]. Review of the laboratory results revealed that blood had been drawn from this resident on 1/27/11 and on 2/08/11 but there was no evidence that a pre-[MEDICATION NAME] had been done as ordered. Interview with the Left Wing Unit Manager/Assistant Director of Nurses on 3/11/11 at 12 noon revealed that the laboratory test was not done as ordered. 2. Review of the physician's orders [REDACTED]. Review of the nurse's notes dated 2//8/2011 indicated the specimen was obtained and sent to the laboratory. There was no evidence in the laboratory reports that the laboratory test had been done as ordered. Interview with Nursing Staff CC on 3/15/2011 at 10:a.m. revealed that the laboratory had not performed the test because there was a name discrepancy and that the laboratory had not notified the facility that there had been a problem. Review of the clinical record for resident #89 revealed no evidence that the facility had identified that the ordered laboratory test had not been done.",2016-01-01
8512,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2011-03-15,514,D,0,1,NH2211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that the clinical record accurately reflected the use of a wander guard for one (1) resident (#11) form a sample of thirty (30) residents. Findings include: Review of the clinical record for resident #11 revealed a physician's orders [REDACTED]. Review of the Minimum (MDS) data set [DATE] revealed that the resident was assessed with [REDACTED]. However, the order remained on the 3/1/2011 physician's orders [REDACTED]. Interview on 3/15/2011 at 10:20 a.m. with the Director of Nurses revealed that the nursing staff should have recommended to the physician that the order be discontinued.",2016-01-01
9212,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-06-12,282,D,1,0,XB4V11,"Based on medical record review, Accident/Incident Report form review, facility investigative report review, and staff interview, the facility failed to transfer one (1) resident (#6), on the survey sample of eighteen (18) residents, via a Hoyer lift with the assistance of two-persons, as specified by the resident's Care Plan. Resident #6 subsequently experienced a fall. Findings include: Please cross refer to F323 for more information regarding Resident #6. Review of the medical record for Resident #6 revealed a Care Plan entry originally dated 07/14/2011 which identified the resident to be at risk for falls, and indicated that the resident was dependent on others to assist with all transfers. Approaches to address this resident's fall-risk included the use of a Hoyer Lift with the assistance of two (2) staff members for transfer. A facility Accident/Incident Report form documented that on 05/21/2012 at 6:00 a.m., Resident #6 had experienced a fall during the use of the Hoyer Lift, but a facility investigative report documented that the resident was being transferred from the bed to a geri-chair with the assistance of only one (1) certified nursing assistant (CNA) at the time of the fall. During a telephone interview with CNA ""AA"" conducted at 10:15 a.m. on 06/12/2012, this CNA stated that on the date of Resident #6's fall, she had transferred the resident with a Hoyer Lift, and that Nursing Supervisor ""BB"" was ""spotting"" her during the transfer, but that the nurse was not actually assisting with the transfer hands-on.",2015-08-01
9213,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-06-12,309,D,1,0,XB4V11,"Based on record review and staff interview, the facility failed to monitor two (2) residents (#1 and #4) after falls, per facility protocol, from a survey sample of eighteen (18) residents. Findings include: During an interview with the Director of Nursing (DON) conducted on 04/26/2012 at 11:30 a.m., the DON stated that there was no written policy for assessment of a resident after a fall, but that the protocol was for nurses to monitor vital signs and range of motion for every shift for seventy-two (72) hours after a fall. 1. Record review for Resident #1 revealed a 04/18/2012 entry in the Progress Notes, which was titled as being a late entry for 04/17/2012 at 8:45 p.m., which documented that the nurse was called to the resident's room by a certified nursing assistant and found the resident sitting on the floor on the buttocks. It was recorded that vital signs were assessed, passive range of motion was performed, and no visible injuries were observed. Another 04/18/2012 entry in the Progress Notes, titled as a late entry for 04/17/2012 at 10:30 p.m., documented that the resident had been visualized, with no distress noted. However, further record review, to include review of the Progress Notes, revealed no evidence of additional monitoring after the resident's 04/17/2012, 8:45 p.m. fall, until a 04/18/0212, 7:45 a.m. Progress Notes entry documented that the nurse had been called to the room of Resident #1 by a certified nursing assistant, and upon assessment noted the resident to respond to tactile stimuli but to be lethargic. This Progress Notes entry documented that vital signs were taken at that time, and oxygen was placed on the resident. There was no evidence to indicate that staff had monitored the status of Resident #1, including monitoring the resident's vital signs and range of motion, during the 11:00 p.m. to 7:00 a.m. shift of 04/17/2012, per facility protocol, even though the resident had experienced a fall on the previous shift of 04/17/2012. During an interview with the DON conducted on 04/26/2012 at 2:00 p.m., the DON stated that the nursing staff on duty at the time of the resident's 04/17/2012, 8:45 p.m. fall (which occurred during the 3:00 p.m. to 11:00 p.m. shift) did not report the fall to the nursing staff of the on-coming 11:00 p.m. to 7:00 a.m. shift, and thus staff were unaware of the resident's fall. The DON stated that roommate of Resident #1 had told the nurse on 7:00 a.m. to 3:00 p.m. day shift of 04/18/2012 that the resident had a fall the previous evening. 2. Record review for Resident #4 revealed a Progress Notes entry of 04/18/2012 at 7:00 a.m. which documented that the resident was observed on the floor in the bathroom. This Progress Notes entry documented that the resident was assessed for injuries and that vital signs were taken. However, further record review revealed no evidence to indicate that the resident's vital signs were monitored, per facility protocol, on the 3:00 p.m. to 11:00 p.m. of 04/18/2012 shift following the resident's fall. A Progress Notes entry of 04/19/2012 at 4:00 a.m. documented that Resident #4 was observed sitting on the floor in his bathroom. This Progress Notes entry documented that the resident was assessed for injuries and that vital signs were taken. However, further record review revealed no evidence to indicate that the resident's vital signs were monitored, per facility protocol, after this resident's 04/19/2012, 4:00 a.m. fall, during the 7:00 a.m. to 3:00 p.m. shifts on 04/19/2012 and 04/20/2012, during the 3:00 p.m. to 11:00 p.m. shift on 04/19/2012, and during the 11:00 p.m. to 7:00 a.m. shift on 04/21/2012. A Progress Notes entry of 05/11/2012 at 10:30 a.m. documented that Resident #4 was observed on the floor, and that vital signs were taken. However, further record review revealed no evidence to indicate that the resident's vital signs were monitored, per facility protocol, after the 05/11/2012, 10:30 a.m. fall during the 11:00 p.m. to 7:00 a.m. shift of 05/11/2012, the 7:00 a.m. to 3:00 p.m. shift on 5/13/2012, and the 3:00 p.m. to 11:00 p.m. shift of 05/12/2012. During interview with Unit Manager ""DD"" conducted on 06/12/2012 at 10:20 a.m., ""DD"" acknowledged the lack of resident monitoring after the falls referenced above.",2015-08-01
9214,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2012-06-12,323,D,1,0,XB4V11,"Based on medical record review, Resident Information Sheet review, facility investigative report review, and staff interview, the facility failed to ensure the safe transfer one (1) resident (#6), on the survey sample of eighteen (18) residents, by failing to provide a two-person transfer via the Hoyer lift in accordance with the resident's assessed needs. Resident #6 subsequently experienced a fall. Findings include: Review of the medical record for Resident #6 revealed a Care Plan entry originally dated 07/14/2011 which identified the resident to be at risk for falls, with Approaches which included the use of a Hoyer Lift with the assistance of two (2) staff members for transfer. Additionally, the Resident Information Sheet for Resident #6 specified, in the Assistive Devices section, that a Hoyer Lift was to be utilized with the assistance of two (2) persons. A facility Accident/Incident Report form documented that on 05/21/2012 at 6:00 a.m., the resident had experienced a fall during the use of the Hoyer Lift. Review of the facility's investigative report regarding this resident's fall incident revealed the report to document that Resident #6 was being transferred from the bed to a geri-chair with the assistance of one (1) certified nursing assistant (CNA). The CNA pulled the emergency release handle on the lift and the resident was lowered to the floor and landed on top of the CNA as she was attempting to assist the resident. The investigative report documented staff were actually transferring the resident into a seating device just outside of the resident's room because space in the resident's room did not allow for the lift device and the geri-chair to both fit in the room. During a telephone interview with CNA ""AA"" conducted at 10:15 a.m. on 06/12/2012, this CNA stated that she had transferred Resident #6 with the Hoyer Lift, and as the lift was going up, it would not shut off and was beginning to tilt, so she pushed the emergency button. However, the lift then tilted over, and the CNA fell and the resident fell on top of her. When the CNA was asked if anyone was assisting her with the transfer of Resident #6, she stated that Nursing Supervisor ""BB"" was ""spotting"" her during the transfer and was nearby, but was not actually assisting with the transfer hands-on. During a telephone interview with Nursing Supervisor ""BB"" on 06/11/2012 at 12:50 p.m., this nurse stated that at the time of Resident #6's fall, she was in the room flushing a tube feeding, heard a commotion, went outside to the location of the fall, and noted the resident to be on the floor. Based on the above, the facility failed to provide the assistance of two (2) staff while transferring Resident #6 via Hoyer Lift. Rather, one (1) CNA was transferring Resident #6 via the Hoyer Lift, the lift tipped over, and the resident fell to the floor.",2015-08-01
10454,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2009-10-15,456,F,0,1,901T11,"Based on observation and staff interview, the facility failed to maintain equipment in proper operating condition including a freezer and three (3) of three (3) dryers used for the one-hundred and two (102) residents in the facility. Findings include: 1. Observation on 10/13/09 at 12:23 p.m., of the laundry room, revealed that three (3) of the three (3) dryers had lint filters with a thick, heavy, white covering of lint. During interview on 10/13/09 at 12:25 p.m., the Environmental Supervisor acknowledged the dryers had a heavy covering of lint and needed to be cleaned. 2. Observation on 10/13/09 at 9:30 a.m. with the Dietary Manager (DM) of the walk-in freezer, revealed a build up of ice at the left hand corner of the exterior of the freezer door seven (7) inches high by eight (8) inches wide. The interior door frame had an ice sheet coating around the door frame. There were frozen drops over the entire ceiling of the interior of the freezer. The freezer door would not completely close when the DM exited the freezer. Interview on 10/14/09 at 9:40 a.m. the DM revealed that the problem with the freezer door was not new and had been reported earlier during the year at which time a gasket on the door had been replaced. Continued interview revealed that the ice build up is scraped off the door each week on Tuesday.",2014-07-01
10455,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2009-10-15,468,F,0,1,901T11,"Based on observation and staff interview, the facility failed to ensure that two (2) of the two (2) wings had handrails installed in the resident corridors. Findings include: Observations on 10/13/09 at 9:00 a.m., 11:30 a.m.-12:30 p.m. and 10/14/09 at 7:45 a.m.-8:10 a.m., 8:11 a.m.-8:15 a.m. revealed no hand rails in the following areas: RIGHT WING: 1. Between room 129 and 130 2. The left side of the wall, beginning at room 130, and extending to the opening of the back hallway 3. The left side of the hallway, across from room 136, beginning at the day area to the pass through hallway 4. The left side of the hallway, across from room 135, from the beginning of the back hallway to the pass through hallway, including the whole length of the therapy department 5. The left or right side of the back hallway 6. The left or right side of the pass through hallway between the therapy and supply rooms 7. The left side of the hallway, across from room 125, between the pass through hallway and the entry to the day area 8. The left side of the hallway, across from room 128, between the pass through hallway and the back hallway 9. The left side of the hallway between room 131 and the entry of the back hallway. 10. Between room 143 and the entry to the dining/day area. LEFT WING: 1. The right side of the wall between room 120 and the end of the hall. 2. The right side of the wall between room 107 and opening of the day area. During observation and interview on 10/14/09 beginning at 9:00 a.m. the Environmental Supervisor, acknowledged that residents did use the above areas and there were no hand rails.",2014-07-01
10456,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2009-10-15,164,D,0,1,901T11,"Based on observation and staff interview the facility failed to ensure that full visual privacy was provided during care for one (1) resident (#12) of the twenty-one (21) sampled residents. Findings include: Observation on 10/14/09 at 10:50 a.m. of incontinence performed by Certified Nursing Assistant (CNA) ""BB"" for resident #1, revealed the CNA failed to pull the privacy curtains completely around the bed prior to the beginning of the care. The resident was in a bed beside the entrance doorway and the curtain was not pulled to enclose the foot of the bed. During the care another CNA entered the room, opening the door and leaving the resident exposed. Interview on 10/14/09 at 11:05 a.m. with Licensed Practical Nurse/ Unit Manager (LPN/UM) ""AA"" revealed that the CNA should have pulled the curtains entirely around the resident to ensure privacy.",2014-07-01
10457,ARROWHEAD HEALTH AND REHAB,115539,239 ARROWHEAD BOULEVARD,JONESBORO,GA,30236,2009-10-15,441,D,0,1,901T11,"Based on observation and staff interview the facility failed to maintain infection control practices to decrease the likelihood of the transmission of infection for one (1) resident (#12) on a sample of twenty-one (21) residents. Findings include: Observation on 10/14/09 at 10:50 a.m. of incontinence care for resident #12 provided by Certified Nursing Assistant (CNA) ""BB"" revealed that the privacy curtain was only partially closed during the care. Another CNA attempted to enter the room after knocking, CNA ""BB"" stopped care and attempted to close the section of the curtain that was opened with her gloved hands and then resumed incontinence care for the resident without changing her gloves. Interview with Licensed Practical Nurse/Unit Manager ""AA"" on 10/14/09 at 11: 05 a.m. revealed that the CNA should have changed her gloves once they became contaminated by touching the curtains, prior to continuing incontinence care.",2014-07-01
2616,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2020-01-15,584,E,1,0,S0LW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observations, complainant and staff interviews, the facility failed to ensure that the facility was free of odors, on two (2) Halls (B and C), of five (5) Halls. Findings include: Observation on 1/14/19 at 9:00 a.m. revealed a strong urine odor upon entrance into the facility. A strong urine odor was throughout the facility on the B Hall, and near the conference room. Observation on 1/14/19 at 10:38 a.m. of a random check of resident's rooms for odor revealed the following: room [ROOM NUMBER] -strong urine odor B Hall rooms at 10:40 a.m. revealed: room [ROOM NUMBER]- strong odor Observation on 1/14/2020 at 10:50 a.m. on the B Hall of a random walk through of resident rooms revealed following; a strong odor at the end of the Hall B. Observation on 1/14/2020 at 11:00 a.m. of random check of resident lounge revealed strong pungent odor, five residents in room. Observation on 1/14/2020 at 2:25 p.m. of a random walk through on the C Hall revealed a strong urine odor, residents doors open, no ADL care being provided at this time. Observation on 1/15/2020 at 9:00 a.m. of a random walk through of the facility revealed a strong pungent, musty, smell in the hallway (C) around the Employee Lounge, the Business Office, the Conference Room, Rooms-134, 135, 136, and 137. A strong old urine odor in room [ROOM NUMBER]. Residents were not being changed at that time, residents doors open. Observation on 1/15/2020 at 10:09 a.m. revealed a strong (pungent) odor at end of hall (C) near conference room, business office and employee lounge. No incontinent care being provided at this time. Observation on 1/15/2020 at 10:11 a.m. of a random walkthrough of hall way (C) revealed a strong old urine smell around rooms # 131, and 132. No ADL care being provided at this time. Observation on 1/15/2020 at 3:30 p.m. of a walk through in the hall way (C) near room [ROOM NUMBER], the conference room, and the employee lounge, revealed a strong pungent odor. No ADL care being provided at that time. Interview on 1/15/2020 at 9:15 a.m. with Licensed Practical Nurse (LPN) AA, (B Hall), revealed that there was a resident #5 (R#5) that would pee on the floor and her bed. She revealed that housekeeping clean, spray, and mop resident's room. She revealed that it helps with odors sometimes. 2. Observation conducted on 1/14/2020 at 9:00 a.m. revealed a strong urine odor in the facility front lobby area, as well as the B and C Halls. Continuous observations of the odor on the C-hall at 10:00a.m., 11:20 a.m.,12:30 p.m. 2:00p.m. and 3p.m. During these observations, the resident's room doors were open and it did not appear that the resident's care was being provided. Observation on 1/15/2020 at 8:50 a.m., accompanied by the facility's Administrator, revealed an extremely strong odor throughout the C-hall and continued to linger consistently throughout the day. Random observations conducted at 9:30a.m, 10:50a.m. 11:30 a.m. 1:00 p.m. 2:30 p.m., 3:00 p.m. and 4:00 p.m. The conference room was located at the end of C-hall and the door was unable to remain open due to the odor in the hallway. Interview with Unit Manager (UM) BB conducted on 1/15/2020 at 11:24 a.m. revealed that the odor on C-hall may be coming from a resident in room for R#4. He stated that one of the residents that reside in that room family does her laundry and haven't done them lately and maybe the source of the odor. UM BB also stated that this same resident urinates on the floor and in her bed and will not allow staff to provide care for her until she gives permission and therefore may also be another source of the odor. During a random observation on B-hall conducted on 1/15/2020 at 11:20 a.m. revealed a strong pungent odor at the end of B- hall. The odor continued to be observed at 1:00 p.m and 2:15 p.m. Observations throughout the investigation conducted on 1/14/2020 and 1/15/2020 revealed housekeeping staff continuously spraying a deodorizer throughout the building to mask the odor. Interview with the housekeeping director conducted on 1/15/2020 at 4:38 p.m. revealed that his staff clean resident's rooms daily, which includes mopping the floors and emptying the trash. He also stated that a lemon blast spray is used throughout the facility to help with the odors.",2020-09-01
2617,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2018-03-09,584,D,0,1,UXT911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to have hot water readily available for resident use in two of five halls. The facility census was 84 Findings include: Observation on 3/6/18 at 9:47 a.m. revealed the hot water tap in the bathroom between rooms [ROOM NUMBERS] on the B hall produced only a trickle of cold water when turned on. Interview with Resident (R)#72 at the time of this observation revealed the facility had been unable to regulate the hot water in the bathroom and had decided to turn it off a few months before. Interview on 3/6/18 at 11:43 a.m. with family member A revealed the water in the bathrooms on B hallway usually takes too long to heat up to a temperature appropriate for washing up. Observation on 3/6/18 of the hot water temperature in the bathroom between rooms [ROOM NUMBERS] on the B hallway revealed the water remained cold after five minutes of continuous running. Interview on 3/8/18 at 1:55 p.m. with Certified Nursing Assistant (CNA) MM revealed she regularly works with residents on the B hall. It takes several minutes for the hot water in some of the rooms on that hallway to come to a temperature that is appropriate for giving the residents a bed bath or taking care of other personal care needs. To mitigate this lack, the CNAs bring hot water from other rooms on the hallway if hot water is needed immediately and the CNA cannot wait for the water in the resident's bathroom to heat up to a comfortable temperature. Observation on 3/9/17 at 7:34 a.m. revealed that the hot water (which was turned off the previous day) had been turned on in the bathroom shared by residents in rooms [ROOM NUMBERS] on the B hall. The hot water tap now had good pressure, but the water temperature had not changed upwards after five minutes. Interview on 3/9/18 at 7:53 a.m. with the maintenance director revealed he was aware that some of the rooms in the building had inadequate hot water. He said he attributed this to a malfunctioning circulating pump and planned to replace it. Observation on 3/9/18 at 3:00 p.m. with the maintenance director water from the hot water taps in the following bathrooms only reached the following temperatures after five or more minutes of having the taps turned on: 1. Hallway B, bathroom shared by rooms [ROOM NUMBERS] = 98 degrees Fahrenheit (F). 2. Hallway B, bathroom shared by rooms [ROOM NUMBERS] = 91 degrees F. 3. Hallway A, bathroom in room [ROOM NUMBER] = 100 degrees F. 4. Hallway A, bathroom in room [ROOM NUMBER] = 99 degrees F. 5. Hallway A, bathroom shared by rooms [ROOM NUMBERS] = 101 degrees F. Interview on 3/9/18 at 3:15 p.m. with the maintenance director revealed he checks water temperatures, weekly, and tries to have the water temperatures between 100 degrees F and 110 degrees F. He does not perform preventative maintenance, but fixes problems as they are reported to him; He has been having some issues with the circulation pump and this contributes to the hot water taking a long time to rise to acceptable levels in some of the rooms. When the pump goes out, he fixes it, but it has been going in and out recently and he plans to go to the local hardware store to purchase a replacement pump he can have one ordered and available to him within 24 hours.",2020-09-01
2618,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2018-03-09,656,D,0,1,UXT911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review. observation, and Interview the facility failed to implement a Comprehensive Care Plan for three (3) residents (R) #16 related to smoking, R#72 related to helping the resident with daily oral care, and R#82 related to ensuring the resident's medication goals and interventions to meet resident needs. This deficient practice had the potential to effect residents who smoke, residents that require assistance with Activities of Daily Living (ADL) care, and residents that have a daily drug regimen. The facility census was 84, and the sample size was 21. Findings Include: Record Review revealed the resident (R) #16 was admitted the facility on 6/7/17 with [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] section C-cognitive patterns; the resident has a Brief Interview for Mental Status (BIMS) score of 9 indicating the resident has moderate cognitive impairment. Further review of the quarterly MDS of section J- health conditions sub-section J1300 tobacco use; indicates the resident uses tobacco. Review of the comprehensive care plan initiated 6/8/17 for R#16 does not indicate the resident is care planned for tobacco use or smoking. Observation of R#16 smoking on 3/6/18 at 11:00 a.m. while in the designated smoking area revealed the resident smoking with a smoke apron that was torn and not fitting properly, and a large white plastic industrial size bucket half filled with water is noted for disposal of the resident's ashes and cigarettes after smoking. Observation of R#16 smoking on 3/8/18 at 2:00 p.m. while in the designated smoking area revealed the resident wearing a torn smoking apron not fitting properly, a large white plastic industrial sized bucket is used for the disposal of the resident's ashes and cigarette's after smoking. Interview on 3/8/18 at 1:09 p.m. with the MDS Coordinator revealed when a resident is admitted to the facility a smoking assessment is completed on admission and then annually. Interview revealed if the resident is assessed to be a smoker; a care plan is completed to note the residents is a smoker with goals and interventions in place. Interview on 3/9/18 at 2:53 p.m. with the Director of Nursing (DON) revealed when a resident is assessed on admission to be a smoker; staff are expected to develop and implement a comprehensive care plan for the resident to meet the goals and interventions to ensure the resident is smoking safely. During the interview the DON revealed his expectation is for staff to follow the facility's smoking policy and procedures, and ensure the smoking residents have the proper materials such as smoke aprons and ashtrays for safe smoking. Review of the facility's policy and procedure titled Smoking revealed; metal containers with self-closing cover devices into which ashtray can be provided in all areas where smoking is permitted. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revealed: 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. Resident #82 Record Review revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Current medications listed: [MEDICATION NAME] 100 units/ml vial sliding scale per accu check before meals. [MEDICATION NAME] 100 units/ml give 35 units at night and 15 units in the morning. [MEDICATION NAME] 0.25 mg TID as needed for anxiety; Discontinued 2/14/18, donepezil 10 mg at bedtime, [MEDICATION NAME] 10 mg daily, Eliquis 5 mg twice daily, [MEDICATION NAME] powder 17 gm in 8 ounces (oz.) of liquid, [MEDICATION NAME] 20 mg daily, and potassium 10 MEQ daily. Review of annual Minimum Data Set ((MDS) dated [DATE] section C- cognitive patterns; revealed the resident has a Brief Interview for Mental Status score (BIMS) of 15, indicating the resident is cognitively intact. Review of section N- medications indicates the resident receives injections for insulin, insulin solution, opioids, and antipsychotic medications. Further review of the annual MDS section V- Care Area Assessment (CAA) revealed the R#82 triggered for [MEDICAL CONDITION] drug use, falls, pressure ulcer, and nutritional status, with the issues to be addressed in the resident's care plan. Review of the Care Plan initiated 11/17/17 revealed there is no care plan related to the residents' antidepressant or antipsychotic drug use to reflect person centered goals and interventions. Interview with the Director of Nursing (DON) on 3/9/18 at 2:47 p.m. revealed if a care area for the resident triggers to be addressed on the person-centered care plan; the responsible staff is expected to place the area of concern on the residents' person-centered care plan with goals and interventions to be implemented daily. Review of the facility's policy titled Care Plans, Comprehensive Person-Centered revealed: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs was developed. Review of the annual Minimum Data Set (MDS) assessment of 2/12/18 revealed R#72 had [DIAGNOSES REDACTED]. No behavioral symptoms such as rejection of care was documented. Under the Care Area Assessment Summary (CAAS) of the assessment, ADL/Functional rehab triggered and the decision was made to complete a plan of care for that area. Review of the plan of care initiated 2/26/17 for assistance with all ADLs secondary to weakness, intellectual disability, and [MEDICAL CONDITION] revealed interventions which included mouth care daily and as needed. During an interview on 3/6/18 at 9:17 a.m., R#72 said she was unable to brush her own teeth, but staff did not always assist in brushing her teeth. In fact, staff had failed to, regularly, brush her teeth for several weeks, even months. Observation of the resident's oral cavity at the time of the above interview revealed teeth that were stained a dark yellow and had an extensive amount of plaque and food. Review of dental progress notes for the resident from 3/17/17, 9/28/17 and 12/11/17 revealed the resident's oral hygiene was described as having heavy calculus, plaque, and food. Observation of the resident's mouth on 3/7/18 at 12:30 p.m. and again on 3/8/18 4:35 p.m. revealed her teeth to have the same appearance - dark yellow with extensive plaque and food build-up. Interview on 3/9/18 at 7:16 a.m. with Licensed Practial Nurse (LPN) DD revealed he works the 7:00 p.m. to 7:00 a.m. shift on the resident's hall. The Certified Nursing Assistants (CNAs) that work the 11:00 p.m. to 7:00 a.m. shift are responsible for completing ADL tasks for each resident as needed. The nurse on the unit is responsible for overseeing the CNAs' work and ensuring that the ADLs are completed. R#72 is totally dependent on staff for ADL care such as oral hygiene. The nurses rely on the CNAs to accurately report that ADLs are completed for the resident, but the nurse is also responsible for checking the resident's oral status during the administration of medications or during other interactions with the resident; Observation of the resident's oral area on 3/9/18 at 7:29 a.m. with LPN DD in attendance revealed the resident's teeth had been recently brushed. The teeth were still discolored, but appeared to have no build-up of food or other materials. Interview again with LPN DD at the time of this observation revealed that the resident's oral care/condition is affected by the CNA assigned to the resident on any given day. Some CNAs are meticulous with the resident's oral hygiene; for others (from another hall for example), oral care may be done in a careless manner or not at all. CROSS-REFERENCE TO F677",2020-09-01
2619,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2018-03-09,677,D,0,1,UXT911,"**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 daily oral care for one dependent resident (#72) for 3 of 5 survey days. The sample size was 84. Findings include: Review of the clinical records for Resident (R)#72 revealed [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment of 2/12/18 revealed R#72 had a Brief Interview for Mental Status BIMS score of 11, indicating moderate cognitive impairment and had an active [DIAGNOSES REDACTED]. The annual MDS also documented that the resident needed extensive assistance with personal hygiene and was totally dependent on staff for assistance with other activities of daily living (ADLs) such as eating, dressing, toilet use, and bathing. No behavioral symptoms such as rejection of care was documented. During an interview on 3/6/18 at 9:17 a.m., R#72 said she was unable to brush her own teeth, but staff did not always assist in brushing her teeth. In fact, staff had failed to brush her teeth, daily, for several weeks, even months. Observation of the resident's oral cavity at the time of the above interview revealed teeth that were stained a dark yellow and was covered with an extensive amount of plaque and food. Review of a progress note from a mobile dentistry firm which visits the facility and provides dental service to the residents revealed the resident was seen for a recall exam on 3/17/17. The dental note on that day documented under oral hygiene that the resident had heavy calculus, plaque, and food present. Review of the dental progress notes from recall exams on 9/28/17 and 12/11/17 again described the resident's oral hygiene as heavy calculus, plaque, and food. Observation on 3/7/18 at 12:30 p.m. revealed the resident sitting outside the dining room waiting to go in for lunch. The resident's teeth were observed to be still stained yellow with an extensive amount of plaque and food. Interview on 3/8/18 at 1:52 p.m. with Certified Nursing Assistant (CNA) MM revealed she assists the resident with ADLs such as changing and eating during the 7:00 a.m. to 3:00 p.m. shift. However, the resident receives a shower and oral care from the CNAs on the 11:00 p.m. to 7:00 a.m. shift. Interview on 3/8/18 at 3:06 p.m. with Licensed Practical Nurse (LPN) CC revealed that the unit nurse is responsible for ensuring that the CNAs perform daily oral hygiene for the residents. She ensures that this is done by observing residents' oral area during medication administration and other services. Observation on 3/8/18 4:35 p.m. of R#72 revealed her teeth were in the same condition as the previous two days - dark yellow with extensive plaque and food build-up. Interview on 3/9/18 at 7:16 a.m. with LPN DD revealed he works the 7:00 p.m. to 7:00 a.m. shift on the resident's hall. The CNAs that work the 11:00 p.m. to 7:00 a.m. shift are responsible for completing ADL tasks for each resident as needed. The nurse on the unit is responsible for overseeing the CNAs' work and ensuring that the ADLs are completed. R#72 is totally dependent on staff for ADL care such as oral hygiene. The nurses rely on the CNAs to accurately report that ADLs are completed for the resident, but the nurse is also responsible for checking the resident's oral status during the administration of medications or other interactions with the resident; Observation of the resident's oral area on 3/9/18 at 7:29 a.m. with LPN DD in attendance revealed the resident's teeth had been recently brushed; the teeth were still discolored, but there appeared no build-up of food or other materials. Interview again with LPN DD at the time of this observation revealed that the resident's oral care/condition is affected by the CNA assigned to the resident on any given day. Some CNAs are meticulous with the resident's oral hygiene; for others (from another hall for example), oral care may be done in a careless manner or not at all.",2020-09-01
2620,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2018-03-09,684,D,0,1,UXT911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician's orders were followed for one resident (#48) to repeat laboratory tests and arrange for an outside consult with the nephrologist. The sample size was 84 residents Findings include: Review of the clinical records for Resident (R)#48 revealed she was admitted on [DATE] after a stay at an acute care facility where she was treated for [REDACTED]. Review of the admission Minimum Data Set (MDS) assessment of 1/19/18 for R#48 revealed active [DIAGNOSES REDACTED]. The assessment also documented that the resident had received insulin injections 3/7 days and a diuretic for 7/7 days during the assessment period. Review of the laboratory (labs) results of a Basic Metabolic Panel (BMP) completed for the resident on 1/8/18 revealed a creatinine level of 1.4 and a protein level of 5.2. These were noted to be outside of the acceptable ranges. Further review of these laboratory results revealed the nurse practitioner (NP) documented on 1/11/18 that the resident had acute kidney injury and had a baseline [MEDICATION NAME] of 1.2 per hospital notes and noted that the resident should follow up with nephrology, Pro-Stat 30cc twice a day for 30 days should be added to her diet, and the BMP should be repeated in two weeks. Review of the physician order sheet for 1/11/18 revealed orders were written for staff to repeat the labs in 2 weeks, add Pro-Stat, 30 cc for 30 days to the resident's diet, and make a follow-up appointment with the nephrologist for the resident. Review of the clinical records for the resident revealed documentation on the Medication Administration Records for (MONTH) (YEAR) and (MONTH) (YEAR) that the resident received Pro-Stat 30 cc twice a day. However, there was no evidence that the resident was sent for a follow-up appointment with nephrology nor that the BMP lab were repeated as ordered. Interview on 3/8/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) NN revealed that neither follow-up labs nor a nephrology appointment had been completed for R#48 per the physician's orders of 1/11/18. He was not sure why these had been overlooked. The process when new orders are written for residents are for the doctor/NP to flag the charts to indicate when new orders have been written. The unit nurse is then responsible for adding the orders in the computer system. For orders for appointments such as to the nephrologist, the nurse fills out a form requesting that the appropriate appointment be made and this is given to the scheduler to make the appointment. To ensure that orders are not overlooked, the evening nurses also complete and sign a 24-hour chart check. Further interview on 3/8/18 at 2:26 p.m. with LPN NN revealed he had spoken with the NP who gave new orders for the resident to have labs drawn on 3/9/18 and for an appointment to be made with the nephrologist. The nephrology appointment was scheduled for 3/20/18. Interview on 3/8/18 at 3:26 p.m. with the Director of Nursing (DON) revealed the facility has a straightforward process in place to ensure that doctor's orders are followed. The doctor/NP writes the orders, and flags the chart, thus notifying the unit nurse that new orders are being requested for that resident. The nurse puts the orders for medication, etc. into the computer system, and completes requisitions, if needed, for labs. The night nurses are also to perform a 24-hour chart check to ensure orders are not missed. The DON had no explanation, under the circumstances, why this process was not followed and how two orders from 1/11/18 for this resident were overlooked. Interview on 3/9/18 at 2:25 p.m. with the NP, OO revealed she had requested the repeat labs for R#48 because the resident's albumen was low and since she had ordered a protein supplement, she wanted to follow up to see if it had any effect. She did not expect any negative effects from the oversight and would check the new labs that were done that morning. She had ordered the follow up for the nephrologist because of the resident's history of renal function, but had not given a time frame on the order sheet as to when the follow-up should be made.",2020-09-01
2621,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2018-03-09,693,D,0,1,UXT911,"**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 as written for one of three residents (R) #79 who receive nutrition via a [DEVICE] (GT). On 3/5/18 at 7:00 p.m. R#79s tube feeding of [MEDICATION NAME] 1.5 noted to be running at 90cc per hour (hr) On 3/6/18 at 8:33a.m. [MEDICATION NAME] 1.5 hanging at 90cc per hr. At 12:15 p.m. noted [MEDICATION NAME] 1.5 continues to flow at 90cc per hr. At 2:30 p.m. [MEDICATION NAME] 1.5 continues at 90cc per hr. On 3/6/18 at 2:42 p.m. review of R#79s record revealed a physician order dated 2/22/18 for [MEDICATION NAME] 1.5 to run at 75cc per hr. A nutrition note dated 3/5/18 read, monthly wound assessment. Tube feeding decreased per last recommendation to 75cc per hr. for 19 hrs. and Zinc supplements started. On 3/6/18 at 3:33 p.m. an interview with the Registered Dietician (RD) revealed that she does not always physically visualize the tube feeding flow rates. She looks at the physician orders to determine what the resident should be receiving. When asked if she noted that R#79s tube feeding was flowing at a rate of 90 cc per hr. rather than the 75cc per hr. she documented on, she stated she did not note the discrepancy. On 3/6/18 at 3:35 p.m. a conversation with Unit Manager, BB, indicated that her duties are to review charge nurse activities daily. This includes review of physician orders and following through to make sure they are properly carried out. This included visualizing order changes. When asked if she physically looks at the Medication Administration Records (MARS) and reconciles them with the physical order, she stated yes. In this case she would have reviewed the physician's order, reviewed the MAR indicated [REDACTED]. When the Unit Manger BB was asked to escort surveyor to room where she confirmed that the tube feeding was flowing at the rate of 90 cc per hr. Employee GG, who has not been observed for his skills competency since 6/18/16, was providing care for R#79 when the concerns were identified. On 3/6/18 at 3:41 p.m. requested the Unit Manger BB to show surveyor the 24 hour MARS in the Electronic Medical Record (EMR) system. Review of the MAR indicated [REDACTED]. Employee BB was unable to state how long the rate had been wrong. On 3/7/18 at 2:37 p.m. review of R#79s MARs dated 2/22/18 through 3/6/18 revealed staff documented tube feeding rate was flowing at 75cc per hr.",2020-09-01
2622,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2018-03-09,849,D,0,1,UXT911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review facility failed to obtain a physician's order for one resident (R) #78 for hospice services. Sample size was 22. Resident #78 was admitted [DATE] with [DIAGNOSES REDACTED]. His medications include but not limited to [MEDICATION NAME] 1 milligram (mg) by mouth (PO) every (q) 4hours (hr). [MEDICATION NAME] 5-325 mg po twice daily (BID), [MEDICATION NAME] 20 mg po q 2 hr as needed (PRN), [MEDICATION NAME] 2.5 mg via nebulizer q 6 hr prn, [MEDICATION NAME] 2 mg po q 6 prn. Review of R #78 medical record revealed he was placed on hospice effective 1/27/18 per hospice benefit election form. When R# 78 was admitted to the facility, another hospice began providing services. Further review of resident's record did not evidence an order for [REDACTED]. On 3/8/18 at 2:04 p.m. an interview with Charge Nurse GG, revealed R #78 was transferred from a facility providing hospice services. Nurse GG stated R # 78 was receiving service through the current company providing services at the facility; therefore R #78 came to the facility and hospice care continued. Further conversation revealed the charge nurse was unable to locate the order and that the hospice nurse would be notified. On 3/9/18 at 11:08 a.m. a telephone interview with Hospice Nurse NN revealed that she had no knowledge of the resident receiving hospice care through her company while R# 78 was at the previous facility. She stated she first met resident three days after his return to facility. When asked if she recalled seeing or if she had a copy of the physician's order for the resident to receive hospice she stated she would have that information faxed to surveyor. As of 3/9/18 2:11 p.m. no was information received from Hospice Nurse NN. On 3/9/18 at 2:15 p.m. an interview with Assistant Director of Nursing (ADON) revealed that during R # 78's stay at the previous facility he was receiving hospice through that facility but care was not through the current company. When asked where the order for hospice services would be located for services provided in this facility she stated she would locate them. On 3/9/18 at 2:40 p.m. ADON return indicating there was no physician's order for hospice care to be administered at this facility.",2020-09-01
2623,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2019-03-14,577,C,0,1,TB9111,"Based on observation, resident and staff interview, the facility failed to post the state survey results or notification of the availability and location of said results for residents and visitors/family during four of four days of the survey. The facility census was 90. Findings include: During an interview with members of the resident council on 3/13/19 beginning at 11:34 p.m., 7 of 7 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 6 of 7 had scores ranging between 13 and 15 indicating that they were considered to be cognitively intact. Observation of the lobby area and resident accessible areas in the facility on 3/13/19 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. During an observation in the company of the administrator on 3/14/19 at 12:53 p.m. revealed she could not locate the state survey results in the lobby/reception area nor on the wall near the nurses' station at the intersection of the A and B halls. There was also no indication that the results were usually located in these areas except for an empty metal receptacle on the wall near the nurses' station on the A/B halls. After a brief search of her office and other areas, the administrator was observed to locate a binder with the survey results in her office and these she placed in the receptacle near the nurses' station on the A/B halls. During this observation, the administrator indicated that the state survey results were usually available at the nurses' stations to be accessed by residents and in the lobby area to be available for visitors. During an interview with the social worker on 3/14/19 at 1:00 p.m. it was revealed that she usually reviewed the results of the annual and complaint state surveys with the residents in resident council, especially after the completion of said surveys, and that she often informed them at such times where the results could be located. The social worker also said that residents and their families and visitors have access to at least three copies of the state survey results. The first of these copies is usually kept in the reception area where families and visitors can have access to it. The two other copies are kept at the nurses' stations on the A/B halls and on the memory care unit/E hall. The residents have access to the copies that are located on the halls. During an observation of the nurses' station on the memory care unit/E hall accompanied by the MDS coordinator on 3/14/19 at 1:08 p.m., it was revealed that there was no available copy of the state survey results and the MDS coordinator said she would need to ask the administrator where the results might be located. During an interview with the administrator on 3/14/19 at 2:31 p.m. it was revealed that copies of the survey results are usually kept in the reception area and at the nurses' stations to be available to residents/families/visitors. The results were usually kept at a level convenient for the residents to reach. The administrator said that she did not know who had removed all copies of the results from their usual locations nor why these and the signs pointing to their locations had been removed, but she had located the folder with the missing results from the A/B hall nurses' station area and had replaced it along with the sign documenting that these were the state survey results. During an observation on 3/14/19 at 2:41 p.m. of the wall next to the A/B hall nurses' station it was revealed a metal wall receptacle with the survey results in a black binder and a new label on the wall indicating these were the Survey Results.",2020-09-01
2624,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2019-03-14,640,D,0,1,TB9111,"**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) assessment were transmitted within 14 days of completion to Centers for Medicare and Medicaid Services (CMS) Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) System for five resident (R) 6, R#4, R#5, R#1, R#7. The facility also, failed to complete a discharge MDS assessment for four residents R#2, R#9, R#3, R#8. Total of nine records reviewed. The sample size was 32. Finding Included: An interview was conducted on 03/5/19 at 4:30 p.m. - 5:20 p.m. with the MDS Coordinator and the Assistant Director of Nursing (ADON) regarding MDS record over 120 days' old. The following was revealed. 1. R#6 was admitted on [DATE] and remains in the facility. Review of a listing of R#6's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#6. The MDS coordinator revealed that R#6 quarterly assessment dated [DATE] was completed, closed, transmitted to the QIES ASAP System on 12/31/18. 2. R#4 was admitted on [DATE] discharged from the facility 10/1/18. Review of a listing of R#4's completed and transmitted MDS revealed admission assessment dated [DATE] was the last assessment transmitted for R#4. The MDS coordinator revealed that R#4 discharge assessment 10/2/18 was completed, closed and transmitted. MDS coordinator could not locate facility's MDS 3.0 NH Final Validation Report for the month of (MONTH) (YEAR). 3. R#5 admitted [DATE] remains in the facility. Review of a listing of R#5's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#5. The MDS Coordinator revealed that R#5 quarterly assessment was on 12/30/18 was completed, closed, transmitted to the QIES ASAP System on 12/31/18. 4. R#1 admitted on [DATE] remains in the facility. Review of a listing of R#1's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#1. The MDS Coordinator revealed that R#1 quarterly assessment dated [DATE] was completed, closed transmitted to the QIES ASAP System on 12/31/18. 5. R#7 admitted [DATE] remains in the facility. Review of a listing of R#7's completed and transmitted MDS revealed quarterly assessment dated [DATE] was the last assessment transmitted for R#7. The MDS Coordinator revealed that R#7 annual assessment dated [DATE] was completed, closed and transmitted to the QIES ASAP System on 12/31/18. 6. R#2 admitted [DATE] discharged from the facility on 10/28/18. The MDS coordinator revealed R#2 discharge assessment was not completed. 7. R#9 admitted [DATE] discharged from the facility on 1/24/19. The MDS coordinator revealed R#9 discharge assessment was not completed. 8. R#3 admitted on [DATE] discharged from the facility on 12/15/18. The MDS coordinator revealed R#3 discharge assessment was not completed. 9. R#8 admitted on [DATE] discharged from the facility on 1/15/19. The MDS coordinator revealed R#8 discharge assessment was not completed. An interview was conducted on 03/5/19 at 5:25 p.m. with the MDS Coordinator revealed she did not complete the discharge assessment on R#2, R#9, R#3, and R#8. The MDS Coordinator and ADON revealed R#6, R#4, R#5, R#1, R#7 MDS assessments were completed and transmitted on 12/31/18. The MDS Coordinator revealed she would review the MDS 3.0 NH Final Validation Report for that time frame of the MDS assessment that were transmitted. The following information was requested from the MDS Coordinator and ADON a copy of the facility's MDS 3.0 NH Final Validation Report for that time frame of the MDS record 120 day's old. Copy of the facility policy on regarding completing MDS and transmitting assessments. The requested items were not provided to the surveyor. Interview on 3/5/19 at 5:30 p.m. with the Administrator and Regional Vice President regarding expectations of the MDS/Care Plan department. Both revealed assessment should be completed/transmitted timely. The Administrator revealed that she does not have an audit in place to check for completion/transmission of assessments. The Surveyor requested copy of the facility policy on regarding completing MDS and transmitting assessments. This information was not provided to the surveyor. Review of the Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.14, page 2-36 dated (MONTH) (YEAR) revealed: Discharge Assessment Return Not Anticipated. Must be completed when the resident is discharge from the facility and the resident is not excepted to return to the facility within 30 days. Must be completed within 14 days after the discharge date . Must be submitted within 14 days after the MDS completion date.",2020-09-01
2625,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2019-03-14,801,F,0,1,TB9111,"Based on staff interview and record review, 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 89 out of 90 residents that received an oral diet. Findings include: A review of the personnel file for the Dietary Manager revealed a change of status from dietary cook to dietary manager effect date of 12/28/16. A further review of the file revealed an active ServSafe Certification since 10/23/18. However, there was no evidence that the Dietary Services Supervisor had any additional dietary or food service certification or degree. An interview was conducted on 3/4/19 at 11:00 a.m. with the Dietary Manager (DM) regarding a food service management certification or degree. The DM revealed that he did not have a food service management certification or degree. An interview was conducted on 3/5/19 at 10:10 a.m. with the Administrator. The Administrator revealed that she reviewed the regulations and the DM should have food service management certification or degree.",2020-09-01
2626,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2019-03-14,812,F,0,1,TB9111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy Georgia Nutrition Consulting, Inc. Expiration, Use By and Best if Used By Dates, the facility failed to discard expired food items. These deficient practices had the potential to affect 89 of 90 residents receiving an oral diet, of whom seven received thickened liquids. Findings included: Review of the policy of the policy Georgia Nutrition Consulting, Inc. Expiration, Use By and Best if Used By Dates revealed: Expiration This date determines when the food is no longer safe to eat. An observation of the dry storage area while accompanied by the dietary manager during the initial kitchen tour on [DATE] at 10:20 a.m. revealed two 8 ounce Thicken Nectar use by date [DATE]. One 46- ounce Honey like Consistency Thickened Sweetened Tea used by date [DATE]. Twenty-seven 4-ounce Honey like thickened lemon flavored water used by date [DATE]. Three 4-ounce Honey like thickened lemon flavored water used by date [DATE]. One gallon jar of Maraschino Cherries expired date [DATE]. An interview was conducted on [DATE] at 11:00 a.m. with the Dietary Manager (DM) regarding the expired items in the dry storage area. The DM confirmed that the items were expired. He also revealed that he is solely responsible for checking the dates for expired food items. He revealed he checks the dates on all food items when the delivery comes in twice a week. The DM revealed that he does educate the staff on checking for expired food items. An interview was conducted on [DATE] at 3:50 p.m. with the Administrator and the DM regarding the expired food items found during the initial kitchen tour. The Administrator revealed that she was not aware of the expired items in the kitchen and she was sorry the surveyor had to find the expired items. An interview was conducted on [DATE] at 4:30 p.m. with the administrator regarding the expired items in the dry storage area. Administrator revealed her expectations that the food items in the kitchen are checked daily for expiration dates. An interview was conducted on [DATE] at 4:45 p.m. with Administrator and DM regarding how the facility discard expired food items. The DM revealed that all food items are marked with a date that is delivered. The food items are discarded thirty days after opening or the expiration date if it comes first. Review of the list provided by the Administrator revealed six residents with a physician order [REDACTED].>",2020-09-01
2627,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2018-10-11,684,E,1,0,VTF411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff and Physician interview, review of facility policy for insulin administration and education records for carrying out Physician orders, the facility failed to administer medications in accordance with Physician orders for four (4) residents (R), (R#1, R#2, R#3, and R#5) from a sample of six (6) residents reviewed for medications. The facility census was ninety (90) residents. Findings include: Review of the facility policy titled Insulin Administration revised (MONTH) 2014, revealed Step 8 is to check the order for the amount of insulin. Step 12 is to double check the order for the amount of insulin. Review of facility education summary dated 3/13/18 for Physician Orders- How to Carry Out revealed the Licensed Nursing Staff are to make sure to clarify order with Physician/Nurse Practitioner (NP) if the order is not clear. The 11-7 Charge Nurses must conclude the daily activity by checking charts for new orders and ensure they are already entered into the system . The Education Attendance Record indicated fifteen (15) Licensed Nurses signed the roster. Review of the clinical record for R#1 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. R#1 was transferred from the facility to a hospital on [DATE]. Review of the Physician orders for R#1 revealed an order dated 6/5/18 to discontinue all current orders for [MEDICATION NAME] (Quetiapine [MEDICATION NAME]) and decrease (indicated by downward arrow) [MEDICATION NAME] 25 milligrams (mg) by mouth (PO) twice a day (BID) and 50 mg PO every bedtime (Q HS) for a diagnosis (dx) of [MEDICAL CONDITION]. Review of the (MONTH) (YEAR) Medication Administration Record (MAR) for R#1 revealed on 6/5/18 the previous orders for [MEDICATION NAME] had been discontinued and a new order for [MEDICATION NAME] dated 6/5/18 had been added as follows: Quetiapine [MEDICATION NAME] 25 mg tab take [MEDICATION NAME] 25 mg by mouth two times a day for [MEDICAL CONDITION]. The administrations were scheduled for 9:00 a.m. and 5:00 p.m. Continued review of the (MONTH) (YEAR) and (MONTH) (YEAR) MAR's revealed the order to administer [MEDICATION NAME] 25 mg PO BID had been documented as administered from 6/6/18 at 5:00 p.m. through 7/25/18 at 5:00 p.m. There were no documented administrations of [MEDICATION NAME] 50 mg PO at HS. There was no order transcribed to the (MONTH) (YEAR) and (MONTH) (YEAR) MAR's for [MEDICATION NAME] 50 mg PO at HS and there was no corresponding order transcribed to the monthly electronic Physician order for [REDACTED]. An interview regarding Physician orders not transcribed correctly was conducted with the Director of Nurses (DON) on 10/11/18 at 8:40 p.m. The DON revealed he had been unaware the [MEDICATION NAME] order for R#1 on 6/5/18 had not been transcribed correctly. The DON confirmed the process of twenty-four (24) hours chart checks for all new orders should capture any orders not completely or correctly transcribed. Review of the clinical record for R#2 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. R#2 was transferred from the facility to a hospital on [DATE]. Review of Physician orders for R#2 revealed an order dated 3/21/18 as follows: Humalog 100 units/ml cartridge accu-check with Humalog 100 units/ml vial sliding scale 201-251=4 units (U) 251-300=6U 301-350=8U 351-400=10U 401-500=12U Call MD for blood sugar less than ( ) 500 Review of the (MONTH) (YEAR) MAR for R#2 revealed on 3/22/18 at 11:00 a.m. the finger stick blood sugar (FSBS) result was documented to be 166 and R#2 was documented to have had 4 units of Humalog Insulin administered in the right upper quadrant (RUQ). There was no FSBS result recorded on 3/22/18 at 4:00 p.m. and the 9:00 p.m. FSBS result was documented on the MAR as low. The Nurse's progress notes were reviewed for symptoms and treatment of [REDACTED]. Review of the (MONTH) (YEAR) MAR for R#2 revealed on 5/3/18 at 4:00 p.m. a FSBS result was documented to be 189 and 4U Humalog Insulin was documented to have been administered in the left lower quadrant (LLQ). A review of the Nurse's Notes for R#2 for 5/3/18 did not reveal any signs, symptoms or treatment of [REDACTED]. Continued review of the (MONTH) (YEAR) MAR revealed on 5/18/18 at 11:00 a.m. R#2 had a documented FSBS result of 127. R#2 was documented to have been administered 4U of Humalog Insulin in the RLQ. On 5/23/18 at 11:00 a.m. R#2 was documented to have had a FSBS result of 143 and was documented to have been administered 4U Humalog in the LLQ. The Nurses Notes were reviewed for R#2 on 5/18/18 and 5/23/18 and there were no documented concerns or treatment for [REDACTED]. An interview regarding insulin coverage administration was conducted with Licensed Practical Nurse (LPN) CC on 10/11/18 at 3:12 p.m. LPN CC confirmed documenting administration of Humalog Insulin coverage for R#2, for FSBS results less than 201 on 3/22/18 at 11:00 a.m., 5/18/18 at 11:00 a.m., 5/23/18 at 11:00 a.m. and on 5/3/18 at 4:00 p.m. LPN CC indicated he knows the sliding scale coverage order does not include FSBS results less than 201 and did not have any idea why he documented these administrations. LPN CC was sure he had not administered Humalog Insulin for coverage of FSBS less than 201. An interview with the DON regarding documentation of insulin coverage administration was conducted on 10/11/18 at 8:40 p.m. The DON revealed the documentation of insulin coverage administration for FSBS less than 201 had not been noticed when all the resident's MAR's were reviewed at the end of (MONTH) (YEAR) and at the end of (MONTH) (YEAR). All the MAR's are reviewed to check for errors, omissions and correct transcription of orders. The DON revealed the current electronic MAR program asks the nurse when documenting the FSBS result if the result is high or low, and if the nurse answers the question it will record high or low instead of the numerical FSBS result. The DON revealed the nurses have been educated not to answer if the FSBS is high or low. Review of the clinical record for R#3 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician orders for R#3 revealed an order dated 10/2/18 to decrease Trazadone 25 mg po q 2:00 p.m. A previous order for R#3 dated 9/20/18 was also on the MAR for Trazadone 150 mg, give half tab by mouth at noon every day. There were no clarification orders for Trazadone on the (MONTH) (YEAR) Physician orders until the surveyor made an inquiry on 10/11/18. Review of the (MONTH) (YEAR) MAR for R#3 revealed R#3 had been documented as being administered Trazadone 50 mg , take half tablet = 25 mg by mouth every evening. This was scheduled for 5:00 p.m. and initialed from 10/3/18 through 10/10/18. An additional order on the MAR for the former order for Trazadone 150 mg tablet, give one half tablet by mouth at noon every day was also documented as continuing to be administered at 12:00 p.m. daily from 10/1/18 through 10/11/18. Review of the Psychiatric Consult physician progress notes [REDACTED]. R#3 had documented administrations of 100 mg Trazadone daily for nine (9) days, with an order to administer Trazadone 25 mg daily. Review of the Nurse's Notes and incident log for R#3 revealed there had been no falls during the 9 days. An interview on 10/10/18 at 1:20 p.m. was conducted with the DON regarding the order to decrease Trazadone to 25 mg po daily at 2:00 p.m. for R#3. The DON revealed the order, written by the Psychiatric Consult Physician, was not clear and should have been clarified. An interview regarding the order to decrease Trazadone for R#5 was conducted on 10/10/18 at 2:00 p.m. with the Physician who wrote the order. The Physician revealed she had thought the order was clear. The Physician did not remember anyone calling her to clarify the order. The Physician confirmed she had meant to decrease the dosage of Trazadone for R#5 to a total of 25 mg to be administered once a day to try to prevent falls. Review of the clinical record for R#5 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Physician orders for R#5 revealed an order dated 10/2/18 to discontinue all [MEDICATION NAME] orders at family's request. Additionally, the Physician ordered [MEDICATION NAME] 250 mg po BID and q HS. Review of the (MONTH) (YEAR) MAR for R#5 revealed documented administration of [MEDICATION NAME] 250 mg po BID at 9:00 a.m. and 5:00 p.m. and HS on 10/3/18, 10/4/18, 10/5/18, 10/6/18, 10/7/18, 10/9/18, and 10/10/18. Continued review of the (MONTH) (YEAR) MAR for R#5 revealed the prior order, dated 6/26/18 for [MEDICATION NAME] 375 mg po BID had not been discontinued and R#5 had documentation of continued administrations of [MEDICATION NAME] 375 mg po BID at 9:00 a.m. and 5:00 p.m. until 10/8/18. Review of the Psychiatric Consult physician progress notes [REDACTED]. R#5 received an increase in the [MEDICATION NAME] dose for six (6) days. An interview regarding the administration of two different doses of [MEDICATION NAME] for R#5 was conducted on 10/11/18 at 6:55 p.m. with LPN BB. LPN BB revealed she could not remember administering two different doses of [MEDICATION NAME] to R#5 at the same time. LPN BB confirmed her initials on the (MONTH) (YEAR) MAR documenting she had administered [MEDICATION NAME] 250 mg PO at 5:00 p.m. on 10/4/18 and 10/5/18, and [MEDICATION NAME] 375 mg PO at 5:00 p.m. on 10/4/18 and 10/5/18. LPN BB revealed she does not think she would have given both doses at [MEDICATION NAME] but should have checked the order. An interview was conducted with LPN CC regarding the administration of two different doses of [MEDICATION NAME] was conducted on 10/11/18 at 7:05 p.m. LPN CC revealed he could not be sure he had administered two different doses of [MEDICATION NAME] to R#5 at the same time. LPN CC confirmed he had documented administering [MEDICATION NAME] 375 mg PO and [MEDICATION NAME] 250 mg PO concurrently at 9:00 a.m. on 10/3/18, 10/4/18, 10/5/18, and 10/9/18. LPN CC revealed he did not think he had administered both doses of [MEDICATION NAME] but could not be sure because he does not document administering medications unless he has administered the medications. During an interview regarding administering medications according to Physicians orders conducted with the DON on 10/11/18 at 8:41 p.m. the DON revealed he was concerned regarding Physician orders not being completely transcribed and R#2 having documented administrations of insulin coverage with blood sugars not sufficient to require coverage. The DON revealed the 24 hour chart check should be finding these incomplete transcription errors. The continuing process of checking the prior months orders and comparing them with the MAR's and checking the next months MAR's and comparing them with the latest Physician orders should be discovering the errors at the end of the month. This process also checks for errors in administration such as documenting insulin coverage errors. The DON acknowledged the processes did not capture the errors for R#1, R#2, R#3, and R#5. Cross refer to F756",2020-09-01
2628,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2018-10-11,756,D,1,0,VTF411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the Consultant Pharmacist Agreement, and Consultant Pharmacist interview, the Consultant Pharmacist failed to address an error in transcription of an order for [REDACTED]. Findings include: Review of facility Consultant Pharmacist Agreement, Required Consultant Services, signed by the facility on 11/30/16, revealed the Consultant Pharmacist is required to strive to assure that medications and/or biologicals are requested, received and administered in a timely manner as ordered by the authorized prescriber ( in accordance with Applicable Law) Review of the clinical record for R#1 revealed a physician's orders [REDACTED].#1 was transferred from the facility to a hospital on [DATE]. There were no additional orders for Quetiapine [MEDICATION NAME] for R#1 after 6/5/18. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Record [REDACTED].m from 6/6/18 through 7/25/18. There were no documented administrations of Quetiapine [MEDICATION NAME] 50 mg PO at HS from 6/6/18 through 7/25/18. R#1 missed fifty (50) administrations of Quetiapine [MEDICATION NAME] 50 mg PO at HS. Review of the Pharmacy Progress Notes for R#1 revealed the Consultant Pharmacist had reviewed his medication regimen on 6/20/18 and 7/20/18. There were no references to Quetiapine [MEDICATION NAME] on those dates on the Pharmacy Progress Notes. Review of the clinical record for R#2 revealed a Physician order [REDACTED]. 201 - 251 = 4 units (U) 251 - 300 = 6 U 301 - 350 = 8 U 351 - 400 = 10 U 401 - 500 = 12 U Review of the (MONTH) (YEAR) MAR for R#2 revealed on 3/22/18 at 11:00 a.m. documentation indicated R#2's fingerstick blood sugar (FSBS) result was one hundred sixty-six (166) and she was documented to have been administered 4 U Humalog Insulin in the right upper quadrant (RUQ). Review of the (MONTH) (YEAR) MAR for R#2 revealed on 5/3/18 at 4:00 p.m. the FSBS reading was one hundred eighty- nine (189) and was documented to have been administered 4 U Humalog Insulin in the left lower quadrant (LLQ). On 5/18/18 at 11:00 a.m. R#2 had a documented FSBS result of one hundred twenty-seven (127) and was documented to have been administered 4 U Humalog Insulin in the right lower quadrant (RLQ). On 5/23/18 at 11:00 a.m. R#2 was documented to have had a FSBS result of one hundred forty-three (143) and was documented to have been administered 4 U Humalog Insulin in the left upper quadrant (LUQ). A review of Consultation Reports for R#2 indicated the Consultant Pharmacist reviewed the medication regimen on 4/19/18 through 4/20/18 and 6/20/18 through 6/22/18. There was no recommendation regarding sliding scale insulin coverage. An interview was conducted regarding review of resident's medication regimens with the Consultant Pharmacist on 10/15/18 at 1:00 p.m. The Consultant Pharmacist revealed she reviews each resident's medication regimen every month by checking orders on the hard copy of the clinical records and then checking the electronic MAR's. The Consultant Pharmacist revealed she checks for errors in transcribing orders as well as any irregularities in the documentation of medication regimen. The Consultant Pharmacist revealed she has to share a computer with the nursing staff who are documenting in the electronic clinical records. The Consultant Pharmacist confirmed she may have missed the incomplete transcription of the Quetiapine [MEDICATION NAME] on 6/5/18 for R#1 and the errors in documentation of sliding scale insulin coverage for R#2 in (MONTH) (YEAR) and (MONTH) (YEAR), because she may not have had full access to the Medication Administration Records. Cross refer to F684",2020-09-01
4907,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2015-09-24,279,D,0,1,YH7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review,and staff interviews the facility failed to develop a care plan for one (1) resident #12 with a foley catheter from a sample size of five (5)census residents with foley catheters in the facility. Finding includes: Resident #12 is a seventy-eight (78) year old female admitted to Autumn Breeze Healthcare Center on 07/28/2015 under Hospice Care. She has a right above the knee amputation, a gastric tube with continuous feeds, and a Foley catheter due to a stage IV sacral ulcer located on her right Ischium. Further review of Resident #12 medical record revealed the Minimum Data Set (MDS) admission assessment dated [DATE] Section H assessed as having the use of indwelling Foley catheter. Review of the same assessment in Section V.Care Area Assessments (CAA) indicated that a care plan would be developed to address the use of the Foley catheter with goals and interventions. Resident #12 medical record also revealed a comprehensive care plan dated 8/14/2015 was developed with no evidence of a care plan to address resident's Foley catheter. Interview conducted on 09/23/15 at 2:25 p. m. with Licensed Practical Nurse (LPN) FF who acknowledged that the care plan for urinary incontinence with indwelling catheter was not present on the comprehensive care plan. Interview conducted with the Director of Nursing (DON) on 09/23/15 at 2:35 p. m. also acknowledged that a care plan for urinary incontinence with indwelling catheter was not found in resident medical record. She further revealed that a care plan should have been completed as indicated in the CAA. Interview conducted with the MDS Coordinator on 09/23/15 at 2:50 p. m. who acknowledged that a care plan for urinary incontinence with indwelling catheter was not completed on the comprehensive assessment as indicated on the CAA. She also revealed that this was an oversight and would make the corrections immediately.",2019-04-01
4908,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2015-09-24,282,D,0,1,YH7R11,"Based on observations, staff interviews and record reviews it was determined that the facility failed to ensure resident ' s written plan of care was followed. This was evident for one (1) resident #17 of thirty three (33) sampled resident's. Findings Include: Record review of resident #17 revealed a care plan dated 7/17/2014 indicating the resident is at risk for decline in nutrition/hydration status with appropriate goals and interventions including offer resident diet and supplements per orders. Cross reference F309",2019-04-01
4909,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2015-09-24,309,D,0,1,YH7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observations, record review, and staff interviews it was determined that the facility failed to follow a physician order [REDACTED]. Findings Include: Observation on 9/22/2015 at 1pm with resident #17 during lunch in the dining room revealed no ice cream, yogurt or health shake on the resident ' s tray and observation on 9/23/2015 at 1pm with resident #17 during lunch in the dining room revealed no ice cream, yogurt or health shake on the resident ' s tray. Record review revealed a physician order [REDACTED]. Review of facility policy dated (MONTH) 2000 revealed that diet orders will be conveyed in writing via a diet change form to the dietary department. Review of dietary cards for resident #17 revealed that no supplements were indicated for the lunch tray for 9/23/2015. Review of dietary progress notes dated 7/15/2014 indicate adding another health shake on dinner tray, dated 10/7/2014 indicates supplemented with health shake, dated 12/30/2014 indicates health shake twice daily, dated 4/7/2015 indicates reducing health shake to daily, dated 7/7/2015 indicates no nutritional concerns, and dated 7/15/2015 indicates add another health shake on dinner tray. The Registered Dietitian Nutritional recommendations dated 7/15/2014 indicate weight decreased - health shake on lunch and dinner tray, and dated 4/21/2015 indicate weight gain - discontinue health shake twice daily and start health shake daily on lunch tray. Staff interview on 9/23/2015 at 1:15pm with Dietary Manager revealed that resident #17 did not receive a health shake, yogurt or ice cream on her tray for lunch on 9/23/2015. When further questioned about the order for a health shake, yogurt and ice cream on the resident ' s tray at lunch she indicated that the order had been changed to a health shake on the lunch tray, however when further questioned she could not produce an order indicating that change. Interview on 9/23/2015 at 2pm with the Registered Dietitian revealed that the resident should have been getting the health shake, yogurt and ice cream on her lunch tray. #2 Per medical record review a physician order [REDACTED]. Physician order [REDACTED]. Observation conducted on 09/23/15 at 2:25 p. m., by surveyor accompanied by Licensed Practical Nurse (LPN) FF revealed, foley bag covered, and draining clear yellow urine. Foley bag was labeled with a dark orange sticker reflecting the date the foley bag and catheter was placed which was 07/20/15 at 10:30 a. m., prior to resident #12's admission. As of 09/23/15 resident #12 had been in the facility for fifty-eight (58) days and the foley catheter has not been changed as ordered. Interview was conducted on 09/23/15 at 2:25 p. m., with LPN FF who acknowledged that the TAR did not reflect documentation of the resident ' s foley being changed since admission. Interview conducted with the Director of Nursing (DON) on 09/23/15 at 2:35 p. m. DON acknowledged that the TAR did not reflect that the foley had been changed. She stated her expectation is that the staff follow the physician orders [REDACTED].",2019-04-01
4910,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2015-09-24,371,F,0,1,YH7R11,"Based on observations and a staff interview, the facility failed to properly store food under sanitary conditions in the walk in freezer. Findings include: Tour of the facility kitchen conducted on 9/21/2015 at 9:30 am revealed icicles hanging from the ceiling of the walk in freezer with water dripping on to several boxes of magic cups supplement. The next observation later this same day at 1pm revealed icicles continues hanging from the ceiling in the walk in freezer and continue to drip on several boxes of frozen supplements. Final observation conducted on 9/23/2015 at 9 am revealed icicles still remain in the freezer and continue to drip on several boxes of frozen supplements. Interview on 9/23/2015 at 9:05 am with the Director of Food Service revealed that she would have the maintenance look at the freezer and get it repaired. She also indicated that the magic cups were disposed of that were dripped on the last two (2) days.",2019-04-01
4911,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2015-09-24,431,D,0,1,YH7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the Facility policy Medication Storage in the Healthcare Centers, and staff interview, the facility failed to ensure proper medication storage were maintained for one (1) of four (4) medication carts on one (1) of five (5) wings. Findings include: During observations of medication pass on [DATE] at 5:10 p.m. the B hall Licensed Practical Medication Nurse (LPN) AA was observed to leave a cup of medications which includes, vitamin C 500 mg 1 tab, Gabapentin three (3) 100 mg caps PO (By Mouth), Hydralazine 50 mg 1 tab PO, Tramadol Hydrochloride 50 mg 1 tab PO unattended on top of the medication cart. Further observations revealed two (2) residents sitting in their wheel chairs adjacent to the medication cart. Interview conducted with LPN AA on [DATE] at 5:40 p.m., revealed she should not have left the cup of medications unattended on top of her medication cart. During observations of medication storage on [DATE] at 9:25 a.m., revealed one (1) bottle of Humalog one hundred (100) units was dated opened on [DATE] and dated expired on [DATE]. Further review of the medication label revealed the medication should discard twenty-eight days from open date. Interview conducted with LPN Medication Nurse BB on [DATE] at 9:25 a.m., revealed that the Humalog insulin medication is expired and should have been discarded. Interview conducted on [DATE] at 11:18 a.m., with the Director of Nursing (DON) revealed her expectation for nurses is that they follow standards and the facilities protocols and guidelines during medication pass and storage. The DON further revealed that there should be no expired medication stored in the medication cart, and medications should not be left unattended on the medication cart. Medication administration a protocols were followed secured was that the nurse will lock the cart when it is not in view. Further narcotics are kept double locked. Review of facility policy Medication Storage and Medication Administration in the Healthcare Centers, revealed note the date on the label for insulin when first used .Outdated medications are immediately removed .disposed of according to procedures for medication. Further review of the facility policy on medication administration revealed No medications are kept on top of the cart, the cart must be clearly visible to the personnel administering medications.",2019-04-01
4912,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2015-09-24,514,D,0,1,YH7R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record reviews, staff/resident interviews the facility failed to transcribe the written physician orders [REDACTED].#121) out of a random sample of thirty-three (33) residents. Findings include: Per medical record review resident #121 is a sixty-two (62) year old female admitted to Autumn Breeze Healthcare Center on 09/15/2015 with status [REDACTED]. Physician orders [REDACTED]. foley catheter care every shift, and anchor catheter at all times. Per review of the medical record, the physician orders, Medication Administration Record (MAR) and Treatment Administration Record (TAR), the TAR did not reflect the physician orders [REDACTED]. The admission checklist was completed however not signed. The twenty-four( 24) hour chart checks were documented as completed, however staff failed to note that the foley treatment orders were not present on the TAR. Review of the nurses notes since admission did not reflect foley catheter care performed from 09/15/15 - 09/21/15. Review of the Certified Nurse Assistant (CNA) activities of daily living (ADL) documentation in Point Click Care (PCC) does not specify foley care has been performed. Interview conducted with resident #121 who stated she has a permanent foley due to a urinary blockage diagnosed in (MONTH) (YEAR). She stated she has had a foley continuously since (MONTH) (YEAR). She stated her foley and bag are changed monthly and as needed. Resident further stated her foley was last changed on 09/06/15 prior to admission to Autumn Breeze and on 08/06/15 prior to her surgery for [REDACTED]. She acknowledged that the staff were performing foley care at least twice day and sometimes more. She stated just can ' t say yes they are providing foley every shift meaning at minimum three times a day. She stated they keep the foley anchored properly and are very attentive to my needs. Interview was conducted on 09/23/15 at 2:07pm with Licensed Practical Nurse (LPN) FF who upon review of the MAR and TAR, acknowledged the written MD orders for foley catheter care were not transcribed and or placed in the treatment book. LPN GG further acknowledged she has taken care of the resident several times since admission and foley catheter care has been performed by herself and her assigned CNAs when pericare or bathing is performed. Interview conducted with the Director of Nursing (DON) at 2:25 p. m. who acknowledged the nurse who transcribed the admission orders [REDACTED]. She further stated this was a new nurse who she assigned another nurse to supervise her through this task. The DON further stated it is her expectation that physician orders [REDACTED]. The DON later stated she found the transcribed treatment orders which were left on a shelf at the nurses station. No documentation of foley care was noted on the treatment sheet and the monthly foley changes were not transcribed. The DON stated she added the monthly foley changes and placed the corrected treatment order sheet in the TAR.",2019-04-01
4913,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2015-09-24,520,F,0,1,YH7R12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of policy and procedure, facility Plan of correction review and staff interviews, the facility failed to have an effective Quality Assessment and Assurance (QAA) committee that developed and implemented a process to ensure all opened medications were properly dated and discarded timely by the plan of correction date of 11/06/2015. Cross refer F431 Review of the policy titled(NAME)Health System Quality Improvement Principles documented: We as a company will ensure that our processes or systems identify areas to improve the outcomes that will benefit all our staff and residents. Process improvement is a systematic or scientific approach to studying work and making improvements to how work gets done. It involves fact finding, not fault finding, through data collection and root cause analysis to identify and measure the problem and its source. Once the source of the problem is identified, improvement comes through generating salutations that address the root cause of the problem. Review of the Plan of Correction documented: The Director of Nursing (DON), Assistant Director of Nursing (ADON) and Nursing Consultant will monitor staff for compliance with respect to medication administration and storage. The DON, ADON and RN Supervisors will audit medication dates to ensure outdated medications will be disposed of properly. Review of the facility's in-service records revealed education was provided to staff members on 10/19/15 through 10/23/15 related to checking of the medication cart for out of date medications and unattended medication cart every shift. During a health revisit conducted on 03/14/16 an observation of the medication cart C/D at 10:30 a.m. revealed one (1) open vial of [MEDICATION NAME] that was not dated. Observation of medication cart E at 10:52 a.m. revealed two (2) multi-dose opened vials of normal saline that were not dated. Observation of the medication refrigerator for the A,B,C, and D halls on 03/14/2016 at 10:54 a.m. revealed two (2) opened vials of [MEDICATION NAME] purified protein. One vial was dated 1/15/16. The second vial was not dated. Interview on 03/14/2016 3:45:43 PM with the Corporate Nurse revealed that medication carts were checked daily on the night shift (11:00 p.m. -7:00 p.m.) twice a week by management staff. Telephone interview with the Corporate Nurse on 03 /17/16 at 9:28 a.m. revealed that the previous ADON had done morning rounds and checked the medication carts. The Corporate Nurse further stated the previous ADON is no longer employed with the facility and she could not provide documentation of monitoring, audits or collected data. The current auditing tool in use did not begin until (MONTH) 9, (YEAR), when the facility was notified that they were not in compliance. Telephone interview with the Administrator on 03/17/16 at 10:50 a.m. revealed she had located the ADON's notebook which documented that the medication carts had been checked on 2/5/16, 2/22/16, and 3/9/16. The Administrator was unable to provide further evidence of monitoring and/or auditing. The Administrator further confirmed the current medication monitoring tool had begun on (MONTH) 9, (YEAR), when the facility was notified that they were not in compliance.",2019-04-01
6090,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-10-16,167,C,0,1,SM1J11,"Based on observation, interview with one (1) resident (S) and facility staff, the facility failed to make survey results readily accessible to the residents. The census was ninety (90) residents. Findings include: Interview with resident S conducted on 10/15/14 at 1:21 P.M. revealed he was not aware he had access to the state survey results and has never seen them anywhere. Observation conducted on 10/15/14 at 2:08 P.M. revealed the State Survey results was in a binder, located in a bin on the wall of the front lobby. The lobby and the residents' halls have a locked door between them preventing residents access to the survey results, Interview conducted with the Administrator on 10/15/14 at 2:12 P.M. confirmed the survey results are in a binder on the wall of the front lobby and the results are not posted anywhere else in the facility. The administrator further confirmed the residents do not have access to the survey results kept in the lobby. She said she will make a second copy and place them on the wall in the hallway by the nurse's station.",2018-04-01
6091,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-10-16,272,D,0,1,SM1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to provide a comprehensive assessment related to dental care for one (1) resident (R), from a sample of twenty-eight (28) residents. Findings include: Observation conducted 10/14/2014 at 3:04 PM revealed resident R had easily visible, broken, jagged and discolored front upper and lower teeth. Record review for resident R revealed an Admission Minimum Data Set ((MDS) dated [DATE] which assessed the resident as having no broken, missing or damaged teeth. Interview with resident R conducted on 10/14/14 at 3:05 PM revealed she had broken her front teeth prior to admission to the facility and that she is very concerned about her broken teeth. She does not have discomfort from them and is able to eat but she knows dental problems can make her very ill. She further revealed that no one has spoken with her about this problem. Interview with the MDS nurse AA conducted on 10/16/14 at 8:56 AM revealed she completed the assessment for resident R and did not record the residents' dental problems. She further revealed that she should have done so to ensure the Social Service Director would address the problems. Interview with the Social Services Director conducted on 10/16/14 at 10:15 AM revealed dental services are offered in house, however, she was unaware of the dental issues of resident R.",2018-04-01
6092,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-10-16,280,D,0,1,SM1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to update and revise the care plan for one (1) resident (#130) from a sample of twenty-eight (28) residents. Findings include: Record review for resident #130 revealed a Minimum Data Set (MDS) Admission assessment dated [DATE] which assessed the resident as requiring supervision/oversight with Activities of Daily Living (ADLS) including toileting. The resident was assessed as always continent of bowel and bladder. Further review of the MDS Quarterly assessment dated [DATE] assessed the resident as having occasional urinary incontinence during the seven day look back period. Review of the care plan revealed it was not revised to identify occasional urinary incontinence with goals and interventions. Interview with a direct care Certified Nursing Assistant (CNA) conducted on 10/16/14 at 8:05 AM revealed the resident is continent most all of the time. He is ambulatory and takes himself to the bathroom. Only on occasion has the resident had an accident and wet himself. The resident does not call to tell the staff he is wet, it is found during every two (2) hour rounding checks. Interview conducted on 10/16/14 at 9:31 AM with the MDS Registered Nurse (RN)AA revealed she does not do the care plans for the Dementia Unit but did confirm if is a change in continence, the care plan should be updated for urinary incontinent. Interview MDS RN for the Dementia Unit CC conducted on 10/16/14 at 9:47 AM revealed the information obtained for the seven day look back period for incontinence is found in the CNA's ADL flowsheet. If the resident is having occasional incontinence it would be care planned. She further confirmed there is no revised care plan related to urinary incontinence for resident #130.",2018-04-01
6093,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-10-16,312,D,0,1,SM1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and family and staff interview, the facility failed to provide nail care for two (2) residents (# 24 and X), requiring extensive assistance with all areas of personal cleanliness, from a sample of twenty-eight (28) residents. Findings include: 1. Observation of resident #24 conducted on 10/14/2014 at 2:21 PM revealed brown debris under untrimmed fingernails. Review of the Minimum Data Set (MDS) Quarterly assessment for resident #24 dated 09/03/2014 assessed the resident as needing extensive assistance in all areas of personal hygiene. The care plan for resident #24 indicated her fingernails are to be kept clean and trimmed. Observation and interview with the Director of Nursing (DON) conducted on 10/15/14 at 3:30 PM revealed resident #24 had an accumulation of brown debris under untrimmed nails. The DON indicated the Certified Nursing Assistants (CNAs) are all aware that every residents nails are to be checked with each bedbath or shower every day, cleaned and trimmed as needed. She acknowledged resident # 24 needed nail care. 2. Observation of resident X conducted on 10/14/14 at 3:30 PM revealed brown debris under untrimmed finger nails. Review of the MDS Quarterly assessment dated [DATE] assessed resident X as requiring extensive assistance in all areas of personal hygiene. Review of the care plan included interventions listed under Activity of Daily Living indicating her nails are to be kept clean and trimmed. Interview with a family member of resident X conducted on 10/14/2014 at 3:30 PM revealed her finger nails are not cleaned or trimmed with bathing. The family member further indicated the resident sometimes attempts to feed herself with her hands.",2018-04-01
6094,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-10-16,441,E,0,1,SM1J11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility inservice attendance sheets and staff interviews, the facility failed to store personal care equipment in a sanitary manner in resident bathrooms on three (3) of five (5) halls. Findings include: C Hall Observation conducted on 10/15/14 at 1:08 P.M. in the bathroom shared by five (5) residents in rooms C-133 and C-135 revealed a two (2) wash basins stacked one inside of the other inside a clear plastic bag. One (1) basin was labeled and the other one was not. Observation conducted on 10/15/14 at 1:27 P.M. of the bathroom shared by four (4) residents in rooms C-132 and C-134 revealed two (2) wash basins, one stacked inside of the other in a clear plastic bag. One basin was labeled and the other was not. D Hall Observation conducted on 10/15/14 at 1:34 P.M. of the bathroom shared by four (4) residents in rooms D-149 and D-147 revealed three (3) wash basins, two (20 were labeled with different names stacked on inside the other, one (10 was unlabeled. There were also two (2) unlabeled urinals in one clear plastic bag. A second clear plastic bag contained a toilet commode bucket with no label. B Hall Observation conducted on 10/15/14 at 1:41 P.M. of the bathroom shared by four (4) residents on rooms B-128 and B-130 revealed four (4) wash basins all stacked inside each other in one (1) clear plastic bag. One basin had a resident label on it, the other three (3) were unlabeled. Observation conducted at 10/15/14 at 1:58 P.M. with the Assistant Director of Nursing (ADON)/Infection Control RN acknowledged the above findings. Interview conducted on 10/15/14 at 2:05 P.M. with the ADON/Infection Control RN revealed that staff know better than to bag personal equipment in one bag and they know personal equipment is to be labeled. Interview conducted on 10/15/14 at 4:31 P.M. with the ADON/Infection Control Nurse revealed there is no policy for proper storage and labeling of personal care equipment. There have been a couple of in-services given related to personal care items. Further, she was extremely disappointed to see the personal care items unlabeled and in shared bags. when she rounded with me. Review of facility's In-Service attendance sheets dated 5/14/14 and 9/17/14 revealed that Certified Nursing Assistants (CNA) need to bag all toiletries, bed pans, urinals and label them and bagged individually. 2. Observations of resident bathrooms on B Hall revealed the following: On 10/14/2014 at 2:19:50 PM the bathroom shared by three (3) residents between rooms [ROOM NUMBERS] had an unlabelled wash basin on the floor, not in a plastic bag and two (2) unlabeled tooth brushes, not in containers, on the sink. On 10/14/2014 at 2:36:11 PM the bathroom shared by four (4) residents between rooms [ROOM NUMBERS] revealed one (1) pink bedpan in plastic bag- unlabeled hanging tied on the towel bar. On 10/14/2014 at 3:18:29 PM the bathroom between rooms [ROOM NUMBERS] had three (3) unlabeled bedpans and one (1) unlabeled emesis basin. Interview conducted 10/16/2014 at 10:37:25 AM with the Director of Nursing (DON) revealed that personal care equipment should be labeled, stored in plastic bags and toothbrushes kept at the bedside. Interview conducted 10/16/2014 at 10:56:17 AM with BB revealed bedpans , washbasins and toothbrushes should be labeled, stored in plastic bags and toothbrushes kept at the bedside.",2018-04-01
6779,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-10-03,309,D,1,0,78SO11,"Based on observation, record review, resident, family and staff interviews the facility failed to follow physician's order and ensure timely transportation for one (1) resident ('X) from seven (7) sampled residents. Findings include: Review of a facility Concern Form dated 8/18/14 revealed that resident X family member reported to the Social Worker that resident X was complaining about her itchy, scratchy scalp. According to the documentation on the Concern Form the Nursing Supervisor was notified and follow up actions were initiated. Review of the Physician Telephone Orders revealed a dermatology consult due to scratchy dry itchy scalp was written on 08/21/2014. On 8-25-2014 the Administrator signed the Concern Form acknowledging that Resident X concerns were resolved and indicated that a dermatology consult was scheduled. Review of the facilities Transportation Request Form revealed the resident was scheduled on 9-10-2014 at 11:00 a.m. and 9-16-2014 at 10:00 a.m. for a dermatology appointment. On 9-10-2014 there was a notation on the form that transportation was late and the doctor office refused to see the resident and she was rescheduled for 9-16-2014. On 9-16-2014 there was documentation that transportation arrived late for her appointment and resident was rescheduled for 10-10-2014. On 10/03/14 at 1:10 p.m. an interview with the Social Worker confirmed that resident X was scheduled for dermatology appointments but was unable to participate due to transportation problems. On 10/03/14 at 2:53 p.m. observation revealed resident X was sitting in her room visiting with a family member. An interview , at this time, revealed the resident continues to complain about her itchy scalp. Her family member confirmed that the resident continues to complain of having an itchy scalp. Continued interview revealed that resident X was aware of her dermatology appointments but missed them because staff had not gotten her up and ready in time. When transportation arrived at the facility, she was not ready and they left without taking her. She further revealed she had not received any medication to relieve the itching and scabs had occurred on her scalp from excessive scratching. On 10/3/14 at 3:00 p.m. an interview with the facility's scheduler revealed resident X was scheduled to be transported on the 9-10-14 and 9-16-14 for dermatology appointments but the transport service arrived late to the facility. On the 10th the resident was transported to the dermatologist office but they refused to see her and she was brought back to the facility. Continued interview revealed that on the 16th transportation services arrived late again and she called the dermatology office to report the late arrival and requested that she be seen but they refused and she remained at the facility. On 10/03/14 at 3:10 p.m. an interview with the Certified Nursing Assistant (CNA) A revealed she was assigned to accompany resident X to her dermatology appointment on 9-16-14, however the transport service arrived late to pick them up and was told by the scheduler they would not be going because the dermatology office refused to see her. On 10/03/14 at 3:31 p.m., an interview and observation with Licensed Practical Nurse (LPN) BB confirmed the resident was not seen for her dermatology appointments citing transportation as the cause. Continued interview and observation revealed when the LPN BB examined Resident X scalp she revealed a moderate amount of dry skin flakes throughout the top section of head and three (3) scabs ranging from 2-3 cm. The LPN further revealed that the physician had not been notified of the missed appointments and there was no treatment ordered to relieve the resident's itchy scalp. Interview with the unit manager AA on 10/3/14 at 4:01 p.m. revealed the transportation service arrived late to the facility and resident X did not make it to her dermatology appointments. Interview on 10/03/14 at 4:10 p.m. with the Director of Nursing (DON) revealed that the the physician and family had not been notified of the missed appointments. Continued interview revealed there was no attempt to resolve the late transportation arrivals to the facility with the transportation company that prevented resident X from gaining access to medical treatment. An interview with the administrator on 10/03/14 at 4:41 p.m. revealed that the resident experienced a delay in two (2) dermatology appointments due to transportation issues. The administrator further indicated that no interventions had been developed to resolve transportation services arriving late and causing the resident to miss her appointments.",2017-10-01
7092,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2013-01-24,274,D,0,1,TD5P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure that a Significant Change assessment was completed for one (1) resident (# 21) from a sample of thirty-nine (39) residents. Findings include: Record review revealed a physician's orders [REDACTED].# 21 to have a Hospice evaluation. The evaluation was completed that afternoon and the resident was admitted to Avista Care Hospice. There was no significant change assessment done reflecting this change for the resident. Interview with the Minimum Data Set (MDS) nurse CC on 1/ 24/13 at 10:45am revealed that a significant change assessment was not done as required.",2017-08-01
7093,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2013-01-24,315,D,0,1,TD5P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to ensure a urinary catheter was secured to prevent excessive tension on the catheter for one (1) resident (#21) from a sample of thirty-nine (39) residents. Findings include: Observation of resident # 21 on 1/24/13 at 10:30am with Certified Nursing Assistant (CNA) GG revealed the resident did not have the urinary catheter secured. The penis had a small ulcerated area on the head and a reddened area at the meatus. GG found several catheter securing devices in the resident's room that had not been used. Review of the resident's care plan dated 11/29/12 indicated the resident had a Foley catheter related to [MEDICAL CONDITION], and a pressure ulcer. An intervention was in place to anchor the catheter to prevent excessive tension. Further record review revealed the resident had a healing stage 2 pressure ulcer to the sacral area, and had a [DIAGNOSES REDACTED]. Further interview with the CNA GG on 1/24/13 at 10:40 am revealed that all catheters should be secured.",2017-08-01
7703,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-01-08,157,D,1,0,TEVL11,"**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 changes in the health condition of two (2) residents (#1, #2) of five (5) sampled residents. Findings include: 1. Resident #1, the nurse failed to notify the physician of a discrepancy between his response to an abnormal urinanalysis laboratory value report and the actual laboratory tests that were ordered. Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, wait for culture and no culture ordered. The lab report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results.The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had known that there was no culture and sensitivity of the urine in progress he would have treated Resident #1 with antibiotics for the abnormalities identified in the urinanalysis. The primary physician said that the nurse should have informed him that there was no urine culture and sensitivity ordered for Resident #1. Additionally for Resident #1, review of the Admission Record indicated the resident was admitted into the facility on [DATE]. Review of the Cumulative [DIAGNOSES REDACTED].#1 dated 11/27/13 indicated [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED].#1 indicated that the primary physician ordered treatment to the coccyx wound and right gluteal deep tissue injury on 11/27/2013. Review of the admission Non-Decubitus Skin Condition Record dated 11/27/13 indicated that Resident #1 ' s coccyx pressure ulcer measured 7.0 x 9.5 with no depth. The color of the wound bed was pink/yellow. Review of the Wound Care note dated 12/6/13 indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. According to the treatment nurse's documentation t pressure ulcer on the coccyx had deteriorated and had 100 percent (%) necrotic tissue. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. The wound nurse said that the initial wound assessment was done on 11/27/13 for Resident #1. According to the wound nurse, there was no depth to the coccyx wound and there was 50% pink health tissue, 10% granulation tissue and the wound bed was scattered with yellow slough on 11/27/13. The wound nurse added that there was no visible muscle, cartilage or bone and there was no black tissue and no odor when Resident #1 ' s wound was initially assessed. The wound care nurse said that the wound specialist visited weekly on Tuesday. Resident #1 was admitted on a Wednesday. The next scheduled visit for the wound specialist was on 12/03/13 but that visit was not made. Resident #1 was first seen by the wound specialist on 12/10/13, thirteen (13) days after being admitted into the facility and after the wound had deteriorated. The wound nurse stated that the facility does not contact the wound care specialist to notify them of newly admitted residents. The facility notified the wound care specialist of new residents with wounds only when they were in the facility for weekly rounds. Interview with the assistant director of nursing (ADON) and the wound nurse on 1/2/14 at 10:40 AM revealed that the wound specialist was not notified of new residents with wounds until rounds were made on Tuesdays. No phone notification or written notification was made. The wound care specialist was not notified of the presence of Resident #1 or the deterioration of the pressure ulcers and deep tissue injuries until 12/10/13. Telephone interview with the primary physician on 01/2/14 at 12:00 PM revealed that the primary physician deferred to the wound care specialist for wound care. The primary physician stated that he was unsure whether he was notified of the deterioration of Resident #1 ' s wound but that he left the management of wounds to the wound care team. On 12/10/13 the wound care physician ordered [MEDICATION NAME] Ointment to the coccyx wound bed daily for seven (7) days. According to reference material in Web MD, [MEDICATION NAME] ointment was indicated for treatment of [REDACTED]. The physician continued the daily wound dressings. Review of the facility Skin Program protocol indicated in Step 6 that residents with wounds would have appropriate treatment. If there was deterioration or no change in a wound within two (2) weeks the treatment would be changed. Review of the Care Plan for Pressure Ulcers dated 12/06/13 for Resident #1 indicated that there was a Stage III pressure ulcer on the coccyx and the presence of a deep tissue injury on the right gluteal fold on admission. One of the interventions for the pressure ulcers was to notify the MD as needed (prn) with any changes in skin integrity. 2. Clinical record review of the Admission Record for Resident #2 revealed that the resident was admitted into the facility in October of 2013. Further review of the Admission Record for Resident #2 indicated [DIAGNOSES REDACTED]. There was no reference to a pressure ulcer on the Admission Record. Review of the Treatment Record for Resident #2 indicated that the resident was given pressure ulcer care to a new sacral wound on 10/21/2013. Interview with the wound care nurse on 1/2/14 at 12:56 PM revealed that Resident #2 was admitted into the hospital on [DATE] and readmitted into the facility on [DATE]. The wound nurse said that she was off from work on the weekend of 10/19/13 and 10/20/13 and did not perform the skin check on Resident #2 until Monday 10/21/13. At that time the wound nurse noted the Stage III pressure ulcer to Resident #2 ' s sacrum. The wound nurse said that she thought the wound was hospital acquired because she did not know whether Resident #2 was turned while at the hospital. Further interview with the wound nurse on 1/2/14at 2:00 PM revealed that there was another wound nurse that did a skin assessment on Resident #2 on the weekend of 10/19/13 and 10/20/13, but there was no documentation of the assessment. The wound nurse said that though she documented that she observed Resident #2 ' s pressure ulcer on 10/18/13 she did not actually see and assess the wound until 10/21/13. Further interview with the wound nurse on 1/2/14 at 2:15 PM revealed that she did not actually see the wound on Resident #2 on 10/18/13 but heard by word of mouth of the ulcer. The certified nursing assistant ( AA ) reported the wound to the other wound nurse. Interview with the CNA ( AA ) on 1/2/14 at 2:30 PM revealed that AA worked on 10/19/13. AA said that Resident #2 had a tear/open area on her backside that was red and close to the crack. AA said that when she reported the wound to the other wound nurse on that Saturday the 19 of October the nurse remarked that Resident #2 needed treatment. Interview with the ADON on 1/2/14 at 2:30 PM revealed that she agreed that the wound seemed worst by Monday 10/21/13. The wound should have been treated over the weekend. During the interview with the wound care nurse on 1/2/14 at 2:30 PM the nurse stated that the Stage III ulcer to Resident #2 ' s coccyx measured 3.2 x 2.0 x 0.2 cm on Monday 10/21/13. The wound was reported to the physician on that Monday. Review of the Focused Wound Exam by wound care specialist on 10/22/13 indicated that the Pressure Ulcer on Resident #2 ' s sacrum measured 3.5 cm x 4.5 cm x 0.1 cm depth with necrotic tissue. The physician performed a surgical excisional debridement of the wound. Review of the facility Skin Program protocol indicated in the fourth step that a certified nursing assistant (CNA) will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse. Step 5 indicated that all open areas would be identified and documented on the appropriate forms. Step 6 indicated that residents with wounds would have appropriate treatment. If there was deterioration or no change in a wound within two (2) weeks the treatment would be changed. Review of the Care Plan for Risk for Skin Breakdown dated 10/09/13 for Resident #2 included interventions to report any signs of skin breakdown to the treatment nurse, responsible party and physician (MD).",2017-01-01
7704,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-01-08,281,D,1,0,TEVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, state board of nursing nurse practice act review and laboratory report review the facility failed to ensure that the nursing services provided met professional nursing standards of quality for two (2) residents (#1, #2) that were at risk for the development of pressure ulcers and one resident (#1) with abnormal laboratory results of five (5) sampled residents. The nursing staff failed to fully inform the physician of the status of laboratory results for Resident #1 which delayed the treatment for [REDACTED].#1 and failed to inform the physician of the development of a pressure ulcer for Resident #2. Findings include: The Georgia Registered Nurse Practice Act, Article 43-26-3(6) indicates that the Practice of Nursing includes the provision of nursing care: administration, supervision, evaluation, or any combination thereof, of nursing practice. 1. Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, and said to wait for culture. The nurse documented on the Lab Report that there was no culture ordered. The Lab Report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results. The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had known that there was no culture and sensitivity of the urine in progress he would have treated Resident #1 with antibiotics for the abnormalities identified in the urinanalysis. The primary physician said that the nurse should have informed him that there was no urine culture and sensitivity ordered for Resident #1. 2. Review of the Admission Record for Resident #1 indicated the resident was admitted into the facility on [DATE]. Review of the Physician order [REDACTED].#1 indicated that the primary physician ordered treatment to the coccyx wound and right gluteal deep tissue injury on 11/27/2013. Review of the admission Non-Decubitus Skin Condition Record dated 11/27/13 indicated that Resident #1 ' s coccyx pressure ulcer measured 7.0 x 9.5 with no depth. The color of the wound bed was pink/yellow. Review of the Wound Care note dated 12/6/13 (9 days after admission) indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. The wound had deteriorated and had 100 % necrotic tissue. There was no documentation on the health record that the primary physician and wound specialist were notified of the deterioration of the pressure ulcer on Resident #1's coccyx. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. According to the wound nurse there was no depth to the coccyx wound and there was 50% pink healthy tissue, 10% granulation tissue and the wound had scattered with yellow slough on admission. Resident #1 was first seen by the wound specialist on 12/10/13, thirteen (13) days after being admitted into the facility and after the wound had deteriorated. On 12/10/13 the wound care physician ordered [MEDICATION NAME] Ointment to the coccyx wound bed daily for seven (7) days. According to reference material in Web MD, [MEDICATION NAME] ointment was indicated for treatment of [REDACTED]. Interview with the assistant director of nursing (ADON) and the wound nurse on 1/2/14 at 10:40 AM revealed that the facility was that the wound specialist was not notified of new residents with wounds until rounds were made on Tuesdays. No phone notification or written notification was made. The wound care specialist was not notified of the presence of Resident #1 or the pressure ulcers and deep tissue injuries until 12/10/13. Telephone interview with the primary physician on 01/2/14 at 12:00 PM revealed that the primary physician deferred to the wound care specialist for wound care. Review of the Care Plan for Pressure Ulcers dated 12/06/13 for Resident #1 indicated that one of the interventions for the pressure ulcers was to notify the MD as needed (prn) with any changes in skin integrity. 3. Clinical record review of the Admission Record for Resident #2 revealed that the resident was admitted into the facility in October of 2013. There was no reference to a pressure ulcer on the Admission Record. Review of the facility Skin Program protocol indicated in the fourth step that a certified nursing assistant (CNA) will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse. Step 5 indicated that all open areas would be identified and documented on the appropriate forms. Step 6 indicated that residents with wounds would have appropriate treatment. Review of the Care Plan for Risk for Skin Breakdown dated 10/09/13 for Resident #2 included interventions to report any signs of skin breakdown to the treatment nurse, responsible party and physician (MD). Review of the Treatment Record for Resident #2 indicated that the resident was given pressure ulcer care to a new sacral wound on 10/21/2013. Interview with the wound care nurse on 1/2/14 at 12:56 PM revealed that Resident #2 was admitted into the hospital on [DATE] and readmitted into the facility on [DATE]. The wound nurse said that she was off from work on the weekend of 10/19/13 and 10/20/13 and did not perform the skin check on Resident #2 until Monday 10/21/13. At that time the wound nurse noted the Stage III pressure ulcer to Resident #2 ' s sacrum. Further interview with the wound nurse on 1/2/14 at 2:15 PM revealed that she did not actually see the wound on Resident #2 on 10/18/13 but heard by word of mouth of the ulcer. The certified nursing assistant ( AA ) reported the wound to the other wound nurse. Interview with the CNA ( AA ) on 1/2/14 at 2:30 PM revealed that AA worked on 10/19/13. AA said that Resident #2 had a tear/ open area on her backside that was red and close to the crack . AA said that when she reported the wound to the other wound nurse on that Saturday the 19 of October the nurse remarked that Resident #2 needed treatment. Interview with the ADON on 1/2/14 at 2:30 PM revealed that she agreed that the wound seemed worst by Monday 10/21/13. The wound should have been treated over the weekend. During the interview with the wound care nurse on 1/2/14 at 2:30 PM the nurse stated that the Stage III ulcer to Resident #2 ' s coccyx measured 3.2 x 2.0 x 0.2 cm on Monday 10/21/13. The wound was reported to the physician on that Monday. Review of the Focused Wound Exam by wound care specialist on 10/22/13 indicated that the Pressure Ulcer on Resident #2 ' s sacrum measured 3.5 cm x 4.5 cm x 0.1 cm depth with necrotic tissue. The physician performed a surgical excisional debridement of the wound.",2017-01-01
7705,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-01-08,314,D,1,0,TEVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility pressure ulcer protocol review the facility failed to ensure that two residents (#1, #2) of five (5) sampled residents received the necessary treatment and services to promote healing and prevent infection of pressure ulcers. Findings include: 1. Review of the Admission Record for Resident #1 indicated the resident was admitted into the facility on [DATE]. Review of the Physician order [REDACTED].#1 indicated that the primary physician ordered treatment to the coccyx wound and right gluteal deep tissue injury on 11/27/2013. Review of the admission Non-Decubitus Skin Condition Record dated 11/27/13 indicated that Resident #1 ' s coccyx pressure ulcer measured 7.0 x 9.5 with no depth. The color of the wound bed was pink/yellow. Review of the Wound Care note dated 12/6/13 (9 days after admission) indicated that Resident #1 ' s pressure ulcer to the coccyx measured 7.0 x 9.5 x 0.2 cm and was un-stageable. The wound had deteriorated and had 100 % necrotic tissue. The primary physician and wound specialist were not notified of the deterioration of the pressure ulcer on Resident #1's coccyx. Interview with the wound care nurse on 01/02/13 at 9:30 AM revealed that the nurse recalled Resident #1. The wound nurse said that the initial wound assessment was done on 11/27/13 for Resident #1. According to the wound nurse there was no depth to the coccyx wound and there was 50% pink healthy tissue, 10% granulation tissue and the wound had scattered with yellow slough. The wound nurse added that there was no visible muscle, cartilage or bone and there was no black tissue and no odor when Resident #1 ' s wound was initially assessed. Resident #1 was first seen by the wound specialist on 12/10/13, thirteen (13) days after being admitted into the facility and after the wound had deteriorated. The wound nurse stated that the facility does not contact the wound care specialist to notify them of newly admitted residents. The facility notified the wound care specialist of new residents with wounds when they were in the facility for weekly rounds. Interview with the assistant director of nursing (ADON) and the wound nurse on 1/2/14 at 10:40 AM revealed that the wound specialist was not notified of new residents with wounds until rounds were made on Tuesdays. No phone notification or written notification was made. The wound care specialist was not notified of the presence of Resident #1 or the pressure ulcers and deep tissue injuries until 12/10/13. Telephone interview with the primary physician on 01/2/14 at 12:00 PM revealed that the primary physician deferred to the wound care specialist for wound care. On 12/10/13 the wound care physician ordered [MEDICATION NAME] Ointment to the coccyx wound bed daily for seven (7) days. According to reference material in Web MD, [MEDICATION NAME] ointment was indicated for treatment of [REDACTED]. Review of the Care Plan for Pressure Ulcers dated 12/06/13 for Resident #1 indicated that there was a Stage III pressure ulcer on the coccyx and the presence of a deep tissue injury on the right gluteal fold on admission. One of the interventions for the pressure ulcers was to notify the MD as needed (prn) with any changes in skin integrity. 2. Clinical record review of the Admission Record for Resident #2 revealed that the resident was admitted into the facility in October of 2013. Further review of the Admission Record for Resident #2 indicated [DIAGNOSES REDACTED]. There was no reference to a pressure ulcer on the Admission Record. Review of the Treatment Record for Resident #2 indicated that the resident was given pressure ulcer care to a new sacral wound on 10/21/2013. Interview with the wound care nurse on 1/2/14 at 12:56 PM revealed that Resident #2 was admitted into the hospital on [DATE] and readmitted into the facility on [DATE]. The wound nurse said that she was off from work on the weekend of 10/19/13 and 10/20/13 and did not perform the skin check on Resident #2 until Monday 10/21/13. At that time the wound nurse noted the Stage III pressure ulcer to Resident #2 ' s sacrum. Further interview with the wound nurse on 1/2/14 at 2:15 PM revealed that she did not actually see the wound on Resident #2 on 10/18/13 but heard by word of mouth of the ulcer. The certified nursing assistant ( AA ) reported the wound to the other wound nurse. Interview with the CNA ( AA ) on 1/2/14 at 2:30 PM revealed that AA worked on 10/19/13. AA said that Resident #2 had a tear/ open area on her backside that was red and close to the crack . AA said that when she reported the wound to the other wound nurse on that Saturday the 19 of October the nurse remarked that Resident #2 needed treatment. Interview with the ADON on 1/2/14 at 2:30 PM revealed that she agreed that the wound seemed worst by Monday 10/21/13. The wound should have been treated over the weekend. During the interview with the wound care nurse on 1/2/14 at 2:30 PM the nurse stated that the Stage III ulcer to Resident #2 ' s coccyx measured 3.2 x 2.0 x 0.2 cm on Monday 10/21/13. The wound was reported to the physician on that Monday. Review of the Focused Wound Exam by wound care specialist on 10/22/13 indicated that the Pressure Ulcer on Resident #2 ' s sacrum measured 3.5 cm x 4.5 cm x 0.1 cm depth with necrotic tissue. The physician performed a surgical excisional debridement of the wound. Review of the facility Skin Program protocol indicated in the fourth step that a certified nursing assistant (CNA) will observe resident skin condition daily during care and report skin conditions to the Licensed Nurse. Step 5 indicated that all open areas would be identified and documented on the appropriate forms. Step 6 indicated that residents with wounds would have appropriate treatment. Review of the Care Plan for Risk for Skin Breakdown dated 10/09/13 for Resident #2 included interventions to report any signs of skin breakdown to the treatment nurse, responsible party and physician (MD).",2017-01-01
7706,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2014-01-08,502,D,1,0,TEVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to fully inform the physician of the status of a laboratory report for one (1) resident (#1) of five (5) residents sampled. Finding include: Review of the Urinanalysis Lab Report for Resident #1 dated 12/12/13 indicated abnormalities that included moderate blood in the urine, moderate leukocytes or white blood cells and cloudy color. There were hand written notes on the Lab Report that documented the physician was notified, and to wait for culture. The nurse documented on the Lab Report that there was no culture ordered. The Lab Report was initialled by the nurse. Review of the Nurse's Notes for Resident #1 dated 12/12/13 indicated that the urinanalysis results were reported to the physician but the physician stated to wait for the culture results. The nurse failed to notify the physician that there was no urine culture ordered. This failure resulted in a no treatment for [REDACTED].#1. Interview with the assistant director of nursing (ADON) on 12/31/13 at 1:50 PM revealed that the nurse failed to notify the primary physician that a urine culture and sensitivity was not ordered or in progress for Resident #1. When the physician replied to the abnormal report of the urinanalysis that he would wait for the culture and sensitivity results the nurse should have told him that only a urinanalysis was ordered not a culture and sensitivity. On 12/31/2013 at 2:10 PM a telephone interview was made with the assistant director of nursing (ADON) via speaker phone to Resident #1 ' s primary physician regarding the physician's order [REDACTED]. The primary physician said that he was not notified that a culture and sensitivity was not in progress for Resident #1 when the nurse gave him the abnormal urinanalysis results on 12/12/13. He stated that if he had known that there was no culture and sensitivity of the urine in progress he would have treated Resident #1 with antibiotics for the abnormalities identified in the urinanalysis. The primary physician said that the nurse should have informed him that there was no urine culture and sensitivity ordered for Resident #1.",2017-01-01
8189,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2013-06-06,309,D,1,0,A7MV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medications as ordered by the physician to one (1) resident (#1) of four (4) sampled residents. Findings include: The admission orders [REDACTED]. On 4/25/2013 there was an order to discontinue the [MEDICATION NAME] 1 mg at bedtime and start [MEDICATION NAME] 25 mg orally at bedtime for hallucinations. An additional order dated 5/17/2013 documented to discontinue the [MEDICATION NAME] 1 mg orally at bedtime when the supply was depleted and start [MEDICATION NAME] 0.5 mg orally at bedtime for dementia. Review of the Medication Administration Record [REDACTED]. However, review of the May Medication Administration Record [REDACTED]. The [MEDICATION NAME] 1 mg was changed to 0.5 mg as directed by the 5/17/2013 order. Interview with the administrative nursing staff on 6/6/2013 at 3:00 pm revealed that the 5/17/2013 order was the result of a pharmacy recommendation. The pharmacist was not aware of the 4/25/2013 order to discontinue the [MEDICATION NAME] and administer [MEDICATION NAME] because the resident was still receiving the [MEDICATION NAME] 1 mg. The nurse also stated at 4:00 pm that the order written on 4/25/2013 to discontinue [MEDICATION NAME] and administer [MEDICATION NAME] was the order that should have been followed from 4/25/2013 to the present. A new physician's orders [REDACTED].",2016-06-01
8527,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2011-07-28,502,D,0,1,ENIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of physician's orders, Medication Administration Record (MAR), and staff interview, the facility failed to timely obtained a [MEDICATION NAME] level according to physician's order for one (1) resident (#7) from a sample of thirty one (31) residents. Findings include: Record review for resident #7 revealed a physician's order dated 7/14/11 for [MEDICATION NAME] 300mg by mouth (po) should be changed from every morning (AM) to every evening (PM) at bedtime, then repeat the [MEDICATION NAME] level in one (1) week. There was no evidence in the medical record that the repeated [MEDICATION NAME] level had been done. Review of the July 2011 MAR indicated the repeat [MEDICATION NAME] level order had been transcribed to the MAR and should have been done one (1) week for 7/14/11. There was no evidence on the MAR that the repeat [MEDICATION NAME] level had been done. Further record review revealed a [MEDICATION NAME] level done 7/26/11. Interview with the Licensed Practical Nurse (LPN) AA on 7/26/11 at 2:30pm revealed the repeat [MEDICATION NAME] level ordered 7/14 was not completed by 7/21/11, one week, as ordered.",2016-01-01
8750,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2012-11-13,279,D,1,0,2T8B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Transfer and Bed Mobility Status Tool review, and staff interview, the facility failed to ensure the development of a Care Plan which described the services, related to the assessed need of a lift for transfer, to be provided to one (1) resident (#1) from the survey sample of five (5) residents. Findings include: Please cross refer to F323 for more information regarding Resident #1. Review of the medical record for Resident #1 revealed that the resident's Care Plan documented an admission date of [DATE]. A Transfer and Bed Mobility Status Tool, also dated 11/07/2011, indicated the resident required extensive assistance and was unable to bear weight on the lower extremities, and referenced an Intervention specifying the use a total lift with a full body sling. Further review of the resident's Care Plan referenced above revealed an entry of 11/14/2011 which identified that Resident #1 required assistance with activities of daily living related to decreased mobility/[MEDICAL CONDITION]. An Intervention was to provide adaptive/safety equipment as needed. An additional 11/14/2011 Care Plan entry identified the resident to be at risk for falls/injuries related to needed assistance with mobility, and Interventions included to provide the assistance needed with mobility. However, further review revealed no reference on the resident's Care Plan of the resident requiring the use of a total lift with full body sling, even though the resident's need for a total lift with sling had been identified on the Transfer and Bed Mobility Status Tool on 11/07/2011, one week prior to the development of this Care Plan. During an interview conducted on 11/06/2012 at 3:45 pm., the Director of Nursing acknowledged Resident #1's use of a lift during transfer.",2015-11-01
8751,AUTUMN BREEZE HEALTH AND REHAB,115580,1480 SANDTOWN ROAD SW,MARIETTA,GA,30008,2012-11-13,323,D,1,0,2T8B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Bruise Investigation and Supervisor Report review, Bed Safety Device Risk Review Tool review, Transfer and Bed Mobility Status Tool review, and staff interview, the facility failed to ensure adequate supervision during the transfer by lift for one (1) resident (#1), who had been identified as having difficulty with balance/trunk control, from the survey sample of five (5) residents. Findings include: Review of the medical record for Resident #1 revealed a Care Plan entry of 11/14/2011 which identified that Resident #1 required assistance with activities of daily living related to decreased mobility/[DIAGNOSES REDACTED]. One of the Interventions to was to provide adaptive/safety equipment as needed. A Bed Safety Device Risk Review Tool completed on 11/07/2011 identified Resident #1 as having difficulty with balance or trunk control. A Transfer and Bed Mobility Status Tool dated 11/07/2011 indicated the resident required extensive assistance, being unable to bear weight on the lower extremities. One of the Interventions referenced on this Transfer and Bed Mobility Status Tool was to use a total lift with a full body sling. A Nurse's Notes entry dated 10/25/2012 at 2:30 p.m. documented that Resident #1 had been injured by the lift while being transferred. The same Notes entry also documented that the doctor was notified and an order was received to apply ice to the left eye every two (2) hours for six (6) hours to decrease swelling. A subsequent Nurse's Notes entry of 10/25/2012 at 10:00 p.m. documented that the resident was noted with bruising to the left side of the eye. A Bruise Investigation report form dated 10/26/2012 documented Resident #1's left eye injury, and documented that the bruise had occurred upon transfer with the mechanical lift. A Supervisor Report dated 10/27/2012 documented that the incident occurred when the employee removed the strap from the mechanical lift, the resident moved, and the lift hit the resident's eye. In a written statement by Certified Nursing Assistant (CNA) AA dated 10/25/2012, CNA AA indicated that while transferring Resident #1 from the bed to the wheelchair, as she was removing the straps from the lift, the bar swung to the left side of the resident's cheek. During an interview conducted on 11/06/2012 at 3:45 pm., the Director of Nursing acknowledged that Resident #1 was hit by the lift bar while CNA AA was transferring her via total lift. During a telephone interview conducted on 11/13/2012 at 4:45 p.m. with CNA BB, CNA BB stated that she had assisted CNA AA during the transfer of Resident #1 on 10/25/2012. CNA BB stated that while transferring the resident from the bed to the wheelchair, CNA AA removed the straps from the lift by accident, and the bar swung to the resident and hit her upper left cheek. During interview on 11/13/2012 at 5:00 p.m., the Staff Development Coordinator stated that CNA AA should have followed the facility's protocol to remove one lift strap at a time slowly so the bar would remain stable during the transfer process.",2015-11-01
8809,AUTUMN BREEZE HEALTH CARE CTR,115580,1480 SANDTOWN ROAD,MARIETTA,GA,30008,2012-10-24,157,D,1,0,3XTZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to notify the family of one (1) resident, (A) in a survey sample of four (4) residents regarding changes in treatment orders and change in condition of a wound. Findings include: Review of the physician's telephone orders for resident A dated 9/7/2012, revealed an order for [REDACTED]. Review of the 9/12/2012 physician orders [REDACTED]. An additional physician's orders [REDACTED]. An interview with family member of resident A was conducted on 10/24/2012 at 2:45 p.m. and revealed the family member was not aware the resident had a Stage IV pressure area until 9/28/2012 when observed at the wound clinic and the condition of the wound. Further, said was never aware of the area on the sacrum until appointment. An interview with Nurse AA on 10/24/2012 at 12:40 p.m., revealed that the responsible party had not been notified of the physician's orders [REDACTED]. In addition, it was stated that on 9/24/2012 the wound consult was ordered because the sacral wound was unstageable, had purulent drainage with slough and necrotic tissue and the responsible party had not been notified of the condition of the wound.",2015-10-01
8810,AUTUMN BREEZE HEALTH CARE CTR,115580,1480 SANDTOWN ROAD,MARIETTA,GA,30008,2012-10-24,314,D,1,0,3XTZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide the necessary treatment and services in wound care to promote healing to one (1) resident, (A), in survey sample of four (4) residents as ordered by the physician. Findings include: Review of the physician's orders [REDACTED]. There was also a sacral wound treatment order to tuck ? strength Dakins moistened gauze into wound and necrotic tissue, apply Zinc barrier cream around the good tissue, cover with an abdominal pad and secure with tape. However, there was no evidence found in the medical record that these new treatment orders were done as ordered on [DATE] or 9/30/12. During an interview with Nurse AA on 10/24/2012 at 4:50 p.m., who confirmed that the orders were not followed. It was stated by the Director of Nursing that [MEDICATION NAME] was not use for treatments at the facility. There was no evidence in the medical record that the nurse receiving the order on 9/28/2012 called and notified the ordering physician of the facility policy regarding [MEDICATION NAME] and obtaining a clarification of the treatment order.",2015-10-01
9246,AUTUMN BREEZE HEALTH CARE CTR,115580,1480 SANDTOWN ROAD,MARIETTA,GA,30008,2012-04-24,315,D,1,0,XS6611,"Based on record review and staff interview, the facility failed to change an indwelling urinary catheter in conformance with a physician's order for one (1) resident (#1) from a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed a 02/07/2012 Physician's Telephone Orders Form which ordered that a Foley catheter be inserted in relation to the resident's Stage III sacral wound, and ordered that the Foley catheter be changed every month and as needed. Further record review revealed a 03/17/2012 Nurse's Note which documented that Resident #1 had been transferred to the hospital. However, further record review revealed no evidence to indicate that the resident's indwelling urinary catheter had been changed, per the physician's order, between the 02/07/2012 order date and the 03/17/2012 hospital transfer, representing a period of approximately five-and-one-half (5 1/2) weeks, even though the physician's order specified for the catheter to be changed monthly. During an interview with the Director of Nursing (DON) conducted on 04/24/2012 at approximately 4:00 p.m., the DON acknowledged the physician's order specifying that the urinary catheter be changed monthly.",2015-08-01
10602,AUTUMN BREEZE HEALTH CARE CTR,115580,1480 SANDTOWN ROAD,MARIETTA,GA,30008,2010-11-17,224,D,,,C9BJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and hospital document review, the facility failed to provide the services necessary to assess and obtain timely treatment for one (1) resident (""C"") from a survey sample of three (3) residents. Findings include: Record review for Resident ""C"" revealed a 04/20/2010 Physician's Admission History and Physical which documented that the resident's breast exam had been deferred. A physician's Progress Note dated 10/25/2010 documented that during the April 2010 History and Physical, the palpation portion of the breast exam had been deferred, but that visualization for asymmetry and assessment for nipple drainage had been unremarkable. Further review of the resident's record revealed documentation indicating that weekly assessments had been done, with no notations indicating that staff had either identified or documented any changes or dimpling of the right breast. However, a Nurse's Note of 10/24/2010 at 6:00 p.m. documented that the resident's family member had reported a lump in the resident's right breast. This Note documented that upon assessment, a lump approximately the size of a golf ball was palpated on the inner portion, and extending toward the middle, of the resident's right breast, with indentation observed. This Note further documented that the physician was notified, and an order was received to send the resident to the hospital emergency room . A hospital ED Record of 10/24/2010 documented that Resident ""C"" was diagnosed with [REDACTED]. A Physician's Progress Note of 10/27/2010 documented that a breast exam had revealed considerable induration with skin retraction. During an interview with the Assistant Director of Nursing (ADON) conducted on 11/17/2010 at 1:20 p.m., she stated that she expected staff to do a head-to-toe assessment and to report any changes or abnormal findings. The ADON stated that she had examined Resident ""C""'s breasts and noted that the right breast looked different. The ADON further stated that she would have expected staff to have made the appropriate notification regarding this change. However, during an interview with the Regional Clinical Director conducted on 11/17/2010 at 1:50 p.m., she stated that the nurse who had performed the weekly skin assessments had stated that she had not noted any changes. An observation of the resident on 11/17/2010 at 12:05 p.m. revealed that the resident had dimpling of the right breast.",2014-03-01
1658,AUTUMN LANE HEALTH AND REHABILITATION,115466,302 GEORGIA 18 EAST,GRAY,GA,31032,2017-07-23,371,F,0,1,O2P311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure that the ice machine was maintained in a sanitary manner related to one of one ice machines. Findings included: On 7/21/2017 at 9:17 a.m. the initial kitchen tour was conducted. The ice machine was observed. A paper towel was used to see if there was any built up residue inside the machine. Upon wiping the inside surface where the ice drops down, a slime like black substance was observed. The Kitchen Manager was present during the observation and stated that the Maintenance Department cleans and sanitizes the ice machine. She stated that she was going to report the observation to maintenance immediately. On 7/21/2017 at 10:06 a.m. the Maintenance Director stated that the ice machine is cleaned by him monthly and that they have a company that does a full sanitization and cleaning of the machine every 90 days. On 7/21/2017 at 10:56 a.m. the company technician that routinely cleans the ice machine was observed in the kitchen with the Maintenance Director and the Administrator. The ice machine covering was dismantled and the ice machine was observed with black colored build up residue inside the machine in the area that touches the ice (curtain shelf). The technician confirmed that the machine needed to be cleaned. He stated that he had been out last month and cleaned the machine. He stated that it could not be determined how long it would take for the type of buildup to occur in the machine. The NHA stated that the machine is [AGE] years old and is temperamental but that it is functioning properly and needs a more frequent cleaning. On 7/22/17 at 10:14 a.m. the Administrator stated that the build-up in the ice machine was calcium deposits from the water. On 7/22/2017 at 11:17 a.m. the Administrator confirmed that there was no policies related to the maintenance of the kitchen equipment.",2020-09-01
1659,AUTUMN LANE HEALTH AND REHABILITATION,115466,302 GEORGIA 18 EAST,GRAY,GA,31032,2019-09-06,689,G,0,1,31TR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the fall risk assessments and staff interview, it was determined that the facility failed to have two person assist when using the Hoyer lift to prevent accidents for Resident (R)#2 which resulted to harm when the resident fell from the lift resulting in a laceration to the head. A total resident sample was 18 residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], for R#2, revealed a Brief Interview for Mental Status (BIMS) summary score of 99, indicating severe cognitive impairment. Review of section G of the MDS assessment referring to the functional status revealed that the resident required two-person assistance and extensive assistance with bed mobility and transfers and had functional limitations in Range of Motion (ROM). Record review revealed that the resident was admitted to the facility on [DATE] with the following Diagnosis: [REDACTED]. Review of the Fall Risk assessment dated [DATE] and 2/7/18 revealed the resident was assessed as a high risk for falls, needs assistance with mobility and extensive assistance for transfers. Review of the Fall Risk assessment dated [DATE] indicated the resident was at high risk for falls, had one fall in the last six months, and required extensive assistance for transfers. Review of the Event - Initial Note dated 4/22/19 located in the electronic health record revealed R#2 fell from the sling of the Hoyer lift while being transported to chair that resulted in skin tear and laceration to head, the Medical Director (MD) was notified, and neuro checks completed. Review of the Nurse's Notes dated 4/22/19 at 7:01 a.m. revealed a nurse was called to room of R#2 by a Certified Nursing Assistant (CNA) (later identified as CNA FF) who stated the resident had fallen out of the sling of the Hoyer lift. The nurse observed R#2 lying on her back on floor with blood near head, indicated a head to toe assessment performed, the resident was able to move all extremities. A small laceration was noted to back of the head with moderate amount of bleeding noted. No other bruises or lacerations noted at the time of observation. A pressure dressing was applied, neuro checks initiated. A second Nurse's Note for 4/22/19 revealed that the Nurse Practitioner returned the call at 6:45 a.m., with report given. Orders received to send resident out for evaluation of scalp laceration depth with need for possible sutures. Review of the electronic physician's orders [REDACTED]. Review of the hospital emergency room (ER) records date 4/22/19 revealed the Chief Compliant: Fall, Head Injury. History and Physical Notes: Presents to the ER from nursing home with a complaint of fall. Patient was being transferred from bed to chair when the resident fell hitting the back of her head. Patient has bleeding from back of head. Findings of Physical Exam: 1 cm (centimeter) laceration left occipital scalp. The Physician ordered a CT scan (Computerized [NAME]ography Scan) which was negative. Procedures: Left occipital laceration repaired with one staple. Discharge Summary dated 4/22/19: Staple to be removed in seven days. Review of the electronic Nurse's Notes dated 4/22/19 revealed the resident was returned to the facility via ambulance on a stretcher. There was no acute distress noted upon the resident's return and the resident was noted as alert, oriented to name, calm, quiet, and pleasantly confused. Additionally, it was noted the resident had a staple noted intact to laceration to back of left side of head. Review of the physician progress notes [REDACTED].#2 had a laceration to her head and was sent to the ER, the resident had one staple placed to the laceration and returned to the facility. The progress notes also indicated the size of the laceration was 2x0x0 centimeters (cm). The physician progress notes [REDACTED]. Review of the education sign in sheet dated 2/18/19 titled Procedure Using Hoyer Lift revealed two people must be present when using the Hoyer lift. Additional education that was covered on 2/18/19 revealed Hoyer lift-2-person procedure .Never do by yourself. Safety, injury to you and resident, huge fall risk, make resident feel safe and secure. Review of the in-service sign in sheet revealed that CNA FF did not sign the in-service sheet for the 2/18/19 education. Review of the Performance Improvement Project (PIP) dated 2/18/19 revealed the facility put a PIP into place to monitor safe transferring with a Hoyer lift. Review of the policy titled Using a Portable Lifting Machine dated (MONTH) 2019 revealed mechanical lifts should be used, as appropriate when transferring patients to promote resident safety and comfort as well as to promote workplace safety for associate. Procedural Guidelines: 1. Nursing personnel should follow the manufacture's recommendations in using appropriate numbers of staff to operate the lift, 3. Staff should receive educational and complete a skill check off prior to use of lifting equipment. Review of the Electric Mobile Patient Lift (Hoyer) manufacture's manual, page 20, Operating the Patient Lift, revealed the following: Although the (name of the manufacture) recommends that two assistants be used for all lifting preparation, transferring from and transferring to procedures, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case. An interview on 9/5/19 at 3:23 p.m. with the Director of Nursing (DON) stated there was only one CNA at the time of transfer, and she verified there are supposed to be two CNA's available at the time of transfer. She confirmed that CNA FF, who was transferring the resident by herself, received a write up and education on use of the Hoyer lift after the resident's fall. An interview on 9/5/19 at 5:55 p.m. with the Assistant Director of Nursing (ADON) confirmed that the resident was not care planned for lift transfers until after the fall of 4/22/19. An interview on 9/5/19 6:23 p.m. with the Administrator revealed he had a conversation with CNA FF, had given her a written warning and gave her education on how to properly use a Hoyer lift with using two-person. He confirmed that he contacted the resident family of the fall. The Administrator also indicated CNA FF name would not be on the electrical life in-service skills check off because the training was provided to CNA FF during the written warning. An interview on 9/6/19 at 11:08 a.m. with CNA DD stated she has received education, in (MONTH) 2019 and training on how to use a Hoyer lift. She stated she is to always have two people with her when using a Hoyer lift. She said she can look the information of a resident needing one or two person transfers in her hand-held device (P[NAME]). An interview on 9/6/19 at 11:31 a.m. with CNA EE stated she received education and training on how to use a Hoyer lift in (MONTH) 2019. She said she is always to use two people when using the Hoyer lift. She said the hand-held P[NAME] will indicated whether a resident is a two-person assist. A post survey telephone interview on 9/10/19 at 2:01 p.m. with CNA FF revealed she transferred R#2 on 4/22/19 by herself and the resident fell from the lift. She further revealed that she placed lift hooks on the lift and checked to make sure the hooks were secure. She said the resident then pushed back with her feet and the pad slipped from under the resident and the resident fell . CNA FF said that she didn't see anyone to help her transfer the resident and felt she could do it herself. She further revealed that she received a write up and received education from the DON on how to transfer a resident with a lift. Post Survey interview with the Administrator and DON on 9/19/19 at 11:28 a.m. revealed that CNA FF (who was transferring the resident) was given a written warning and was given education on how to use a Hoyer lift. The Administrator further revealed that the 2/18/19 PIP and education was put into place due to a near miss during transfer with the Hoyer Lift. He confirmed that the facility policy was not updated to reflect the new standard to always use two persons when transferring with the Hoyer lift. The DON attempted to provide the previous hand held device plan of care for the resident but she explained that once the new information is entered into the computer system the old information is deleted.",2020-09-01
4459,AUTUMN LANE HEALTH AND REHABILITATION,115466,302 GEORGIA 18 EAST,GRAY,GA,31032,2015-10-22,371,D,0,1,UWWR11,"Based on observation and staff interview the facility failed to clean kitchen equipment during pureed food items to prevent food borne illness. This deficient practice had the potential to effect eight (8) resident receiving a puree consistency diet from a total of fifty one (51) residents receiving an oral diet. Findings include: Observation on 10/21/15 at 4:45 p. m. of AA , dietary cook prepare pureed food items for the dinner meal revealed that she pureed the broccoli in the food processor. Continued observation revealed that the Dietary Manager (DM) took the food processor bowl, blade, and lid from the cook to the dish room area. The DM sprayed the equipment with water from the spray hose in the dish room and gave the items back to the cook to continue puree the spaghetti with meat sauce. The DM did not wash the food processor bowl, blade, or lid with soap and did not sanitize between food items. Interview on 10/21/15 at 4:48 p. m. with the DM revealed that she acknowledged that she did not wash the food processor bowl, blade, and lid with soap and did not sanitize between pureeing food items. The DM could not explain why she did not wash and sanitize the kitchen equipment. Continued interview with the DM revealed that she does expects dietary staff to wash the food processor bowl, blade, and lid in the dish machine or three (3) compartment sink in-between food items.",2019-10-01
4460,AUTUMN LANE HEALTH AND REHABILITATION,115466,302 GEORGIA 18 EAST,GRAY,GA,31032,2015-10-22,406,D,0,1,UWWR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview revealed that the facility failed to provide scheduled psychiatry services for two (2) of three (3) resident ' s reviewed from seven (7) Pre-Admission Screening and Resident Review (PASRR) residents at the facility. The resident sample size was twenty one (21). Findings include: #1. Resident #20 was a seventy three (73) year old term care resident that was admitted to the facility on [DATE]. The resident is alert, oriented, and able to make his needs known. His [DIAGNOSES REDACTED]. Review of the medical record history and physical revealed that the resident was admitted from Coliseum Behavioral Health. The resident had been at Coliseum Behavioral Health due to depression. Review of 2 Quarterly Minimum Data Set (MDS) Assessments dated 05/19/15 and 07/21/15 revealed that the resident had a Brief Interview for Mental Status (BIMS) Score of eleven (11) indicating that the resident was cognitively aware. Continued review of the MDS revealed that the resident was assessed as having moods of feeling down, depressed, and hopeless. The resident was also assessed as having trouble falling or staying asleep or sleeping too much. Review of the care plan revealed that the resident had attention seeking behavior. An intervention for the resident ' s behaviors was to have a psychological/psychiatric evaluation as needed. Review of the PASRR Level II documentation revealed that the resident was assessed on 02/19/15. The PASRR information revealed that the resident was no longer able to care for self and live independently [MEDICAL CONDITION] 09/14/14. Continued review revealed that the resident had vision loss with [DIAGNOSES REDACTED]. The resident was transferred 02/10/15 for psychiatric stabilization. The PASRR recommendations was for individual therapy. Review of the psychiatrist consults revealed that Care Now Services conducted an assessment on 08/18/15. The psychiatrist revealed that the next visit is to be scheduled for one to three (1-3) months. Review of the Interdisciplinary Notes in the medical record revealed that the nursing staff documented on 06/11/15 that the resident had numerous repetitive complaints and attention seeking behavior. Resident has major [MEDICAL CONDITION]. Review of the medical record revealed that the social worker documented a Quarterly Note on 05/27/15. The social worker ' s documentation revealed that the resident is part of the PASRR population however they cannot see him until he is approved for Medicaid. The social worker spoke with Care Now services, and they stated that they would see resident during the next clinic and charge the visit to Medicaid part-B. The next clinic was scheduled for 06/18/15. Interview on 10/22/15 at 10:15 a. m. and 12:45 p. m. with the social worker revealed that she acknowledged that the resident was admitted to the facility on ,[DATE] and the first time a psychiatrist visited him in the facility was not until 08/18/15. The social worker revealed that Care Now Services does not provide services until the resident has approval from Medicaid. She revealed that the facility received notification of the resident ' s Medicaid benefits on 06/12/15. Continued interview with the social worker revealed that psychiatrist doctors had changed during the time where the resident was to be seen. The social worker reviewed that the resident was scheduled to use the Tele Med psychiatrist on (MONTH) 18, (YEAR). The social worker revealed that she had set the resident up with the computer for the psychiatric services and the psychiatrist did not show up. She revealed that Care Now had canceled the session that day and did not notify her. She revealed that Care Now did not re-schedule the session. The social worker revealed that the next Tele Med session was (MONTH) 18, (YEAR). #2. Resident #30 was a sixty (60) year old long term care resident that was admitted to the facility on [DATE]. He was alert and pleasantly confused. Staff were able to understand his needs. His [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] revealed that the resident did not have a mood interview conducted due to resident is rarely/never is understood. The MDS revealed that the resident was assessed having hallucinations. He also was assessed as having other behavior symptoms not directed toward others which occurred one (1) to 3 days during the look back period. Continued review of the MDS revealed that the resident did not refuse care and his behavior improved since the last assessment. Review of the residents care plan revealed that the resident was identified as having a problem with behaviors. Intervention for the resident ' s behaviors is that the resident receives Care Now psychiatric services, refer to psychiatrist as needed, PASRR Program. Review of the resident ' s medications revealed that he was ordered [MEDICATION NAME] (antipsychotic medication) two milligrams (2 mg) orally daily Review of the resident ' s PASRR documentation revealed that it was completed on 12/08/2009. Continued review of the PASRR documentation revealed that the resident had been considered to be mentally retarded all of his life. The PASRR documentation revealed that the resident needs specialized MR Services and requires rehabilitation services. Recommendations for the resident were Behavior Change Intervention, Psychiatric Assessment/Care, Individual or Group Activity/Counseling, and Case Management. Review of the physician progress notes [REDACTED]. The physician revealed that the resident does occasionally have verbal outbursts but no other behavioral disturbances this assessment period. The physician revealed that the resident is followed by psychiatry and was last seen 09/02/15 without any changes to medications regimen. Review of the medical record revealed that the resident receives Care Now Services. The Care Now consult dated 11/20/14 recommended to follow up in 3 months. Review of the documentation revealed that the next session the resident had with Care Now Services was not until 09/02/15, ten (10) months past the recommendations of Care Now Services. The Care Now Services dated 09/02/15 revealed that the resident yells and cries at times. Medications were reviewed medications, reviewed chart, discussion of medication options, risk/benefits of treatment review. Recommendations: no medication changes. Next visit scheduled for one to three (1-3) months. Interview on 10/21/15 at 4:15 p. m. with the Social Worker revealed that the resident does receive Care Now Services. She revealed that there was an interruption in psychiatry services, there was a change in psychiatrists. The social worker revealed that the resident had been seeing Tele Med, psychiatry services over the computer. Interview on 10/22/15 at 9:30 a. m. with the social worker and the administer revealed that they both acknowledged that the resident had not been seen by psychiatry services from (MONTH) 2014 until (MONTH) (YEAR). The social worker revealed that the resident was missed to be seen in (MONTH) (YEAR) and did not get seen until (MONTH) (YEAR). The social worker revealed that she is notified when the psychiatrist will be visiting the facility to conduct resident sessions. She revealed that once the psychiatrist leaves the facility she does not receive a list of resident's that the psychiatrist had seen or any recommendations or when they plan to follow-up with residents. The social worker revealed that the psychiatrist documentation is faxed back to the facility and she places the consult in the physician ' s mail box for review and signature. Once the physician has reviewed and signed the psychiatric consult she will file it in the resident ' s chart.",2019-10-01
2081,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2017-04-06,371,E,0,1,1BPE11,"Based on observation, interview and record review, the facility failed to ensure that food was stored in a proper manner related to uncovered food items in the walk-in refrigerator and failed to ensure that dishes were cleaned and sanitized related to the dish machine water not reaching the required temperature and a lack of sanitizer in the dish machine. The Census was 80 with one tube fed resident. Findings included: During the initial tour of the kitchen on 4/3/17 at 10:35 a.m. In the walk-in refrigerator there were two pans with individual serving bowls of pudding dated 4/1/17. All the bowls were uncovered. The Certified Dietary Manager (CDM) told kitchen staff to cover the pudding. She stated that the pudding was prepared on 4/1/17 and was just scooped into the bowl this morning and placed in the refrigerator and that it should have been covered. During the initial tour of the kitchen on 4/3/17 at 10:35 a.m. the Low Temperature Dish Machine was observed being operated by Kitchen Aide A[NAME] The thermostat on the dish machine was observed and revealed that the water temperature measured at 100 degrees Fahrenheit for the wash cycle and 110 degrees Fahrenheit for the rinse cycle. Kitchen Aide AA was asked if she checked the thermostat today and she stated that she did not. She stated, I don't look at that. I really don't pay it any attention. She stated that she checks the sanitation. She was observed to check the sanitation at this time with the sanitation strips which measures the concentration in parts per million (ppm) (mg/L) of the sanitizing solution. The strips revealed that the sanitation was measuring at zero ppm's in the machine. She confirmed that according to the strip, there was no sanitation during this process. The Certified Dietary Manager (CDM) came over at that time and stated, It was noticed yesterday that it was not pumping and reading properly. She confirmed that the ppm's were measured earlier yesterday and the strips were reading that there was sanitation in the machine. She stated that later yesterday the strips revealed that there was no sanitation being measured in the machine. She was asked if the kitchen monitored and logged the temperature of the water. She stated, I was told that as long as long as the ppm was reading, that was sufficient. She was asked what the facility policy was on monitoring and logging the temperature of the dish machine. She stated, Im not quite sure. She confirmed that she has worked in the facility since (MONTH) (YEAR) and that the kitchen staff has never monitored or logged the dish machine temperature. She confirmed that they only monitor the chemical sanitizer and that the logs reflect the chemical sanitizer monitoring only. She stated, As long and the water is less than 120 (degrees Fahrenheit) it's okay. When asked about the sanitizer not measuring any ppm's, she stated, We know its pumping but the strips are not reading it. She explained that she knows that the sanitation is pumping into the machine because the levels on the bucket of sanitation was going down. She stated, We know it's coming out. It's just not reading. She confirmed that due to the levels on the buckets going down, they felt that the dishes were being cleaned and sanitized. The CDM was asked for logs of the past 12 months of dish machine logs and the facility policy on the dish machine. Interview with the Administrator on 4/3/17 at 10:23 a.m. she stated that there was a problem with the dish machine in the past and that recently had it serviced. On 4/3/2017 at 11:08 a.m. Administrator stated that the Maintenance Director monitors the dish machine temperatures weekly. She stated that he documents this in the TELS system. She provided the Weekly Water Temps and Equipment Instructions dated 2004-2009 with Reviewed and Updated date of (MONTH) 2014) revealed (2) Kitchen dish machine should be at least 120 degrees (Fahrenheit) or per manufactures recommendations. On 4/3/17 at 11:10 a.m. the chemical was measured by the CDM and continued to measure at zero chemical.",2020-09-01
2082,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2017-04-06,441,E,0,1,1BPE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to store personal care and hygiene items in a sanitary manner to prevent potential cross-contamination in 14 of 18 bathrooms observed on two of two nursing units. The facility census was 80 residents, and the sample size was 27 residents. Findings include: During observations in resident bathrooms which were shared by four residents in two adjoining rooms, the following personal care items were noted to be stored unlabeled and/or unbagged: 4/3/17 at 9:57 a.m. for rooms [ROOM NUMBERS]: One unlabeled toothbrush on the sink. 4/3/17 at 10:04 a.m. for rooms [ROOM NUMBERS]: Four bath basins, one bedpan, one urinal, and one bedside commode liner on the floor, and one hair comb and one toothbrush on the sink. 4/3/17 at 10:13 a.m. for rooms [ROOM NUMBERS]: Two bath basins on the floor and one hair comb on the sink. 4/3/17 at 10:16 a.m. for rooms [ROOM NUMBERS]: one bedside commode liner and one bath basin on the floor. 4/3/17 at 10:30 a.m. for rooms [ROOM NUMBERS]: one bath basin and one urinal on the floor. 4/3/17 at 10:36 a.m. for rooms [ROOM NUMBERS]: four bath basins and one urinal on the floor. 4/5/17 at 7:34 a.m. for room [ROOM NUMBER] (this bathroom was shared by two residents in one room): One bedpan, one urinal, one half-hat specimen collection device, and an insulated drinking mug on the floor under the sink. During interview with the Director of Nursing (DON), who was also the Infection Control Coordinator on 4/6/17 at 11:59 a.m., she stated that personal care and hygiene items such as bedpans, bath basins, urinals, toothbrushes, and denture cups should be labeled with the resident's name and stored in a bag. She further stated that the facility did not have a policy and procedure related to storage of these items. During continued interview, the DON stated that she verbally told staff on a regular basis on how to correctly store personal care items, but did not have anything in writing related to ongoing education. During a walk-through of resident bathrooms with the DON on 4/6/17 beginning at 12:04 p.m., she verified the following observations related to storage of hygiene and personal care items. Unless noted otherwise, all of the following items were observed to be unlabeled and unbagged in a bathroom shared by four residents: rooms [ROOM NUMBERS]: There was one labeled urinal on the grab bar next to the commode, and the DON stated that she preferred for it to be bagged. rooms [ROOM NUMBERS]: One bath basin on top of the toilet tank cover, and one urinal on the grab bar next to the commode. rooms [ROOM NUMBERS]: One half-hat specimen collection device on the floor by the commode, and one bath basin on the floor under the sink. rooms [ROOM NUMBERS]: One half-hat specimen collection device wedged between the wall and grab bar next to the commode, one half-hat specimen collection device on the floor by the commode, and two bath basins on the floor under the sink. rooms [ROOM NUMBERS]: One urinal on the grab bar next to the commode, and one half-hat specimen collection device on the floor next to the commode. There were four bath basins nested inside each other, and these bath basins were stored on top of a bedpan on the floor under the sink. Only one of the four basins was labeled. rooms [ROOM NUMBERS] (shared by three residents): One urinal on the grab bar next to the commode, and two bath basins nested together on the floor under the sink. rooms [ROOM NUMBERS]: One urinal hooked on the frame of the commode extender, and one unlabeled toothbrush in a cup on top of the paper towel dispenser. rooms [ROOM NUMBERS]: Four bath basins and an emesis basin nested inside each other which were bagged and on on the floor, but only one of the bath basins was labeled. rooms [ROOM NUMBERS]: One bedpan stored on top of two bath basins nested inside each other on the floor under the sink. rooms [ROOM NUMBERS]: One upside-down half-hat specimen collection device on the floor under the sink, and one empty denture cup on the sink top. rooms [ROOM NUMBERS]: Two unlabeled bath basins on the floor under the sink. rooms [ROOM NUMBERS]: One unlabeled toothbrush on the sink top. During interview with the DON following the above observations, she stated that she would just throw out anything that was not labeled, and that the half-hat specimen collection devices were intended for one-time use only and then should be disposed of. During interview with Certified Nursing Assistant FF on 4/6/17 at 12:55 p.m., she stated that items such as bath basins were labeled with the resident's name and room number, and placed in a bag in their closet.",2020-09-01
2083,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2017-04-06,456,E,0,1,1BPE11,"Based on observation, interview and record review, the facility failed to ensure that the dish machine was operating related to the water not reaching the required temperature and a lack of sanitizer and failed to ensure that one of one commercial stove was operational in a safe and functional manner related to two of six pilots lights observed not functioning. Findings included: During the initial tour of the kitchen on 4/3/17 at 10:35 a.m. the Low Temperature Dish Machine was observed being operated by Kitchen Aide A[NAME] The thermostat on the dish machine was observed and revealed that the water temperature measured at 100 degrees Fahrenheit for the wash cycle and 110 degrees Fahrenheit for the rinse cycle. Kitchen Aide AA was asked if she checked the thermostat today and she stated that she did not. She stated, I don't look at that. I really don't pay it any attention. She stated that she checks the sanitation. She was observed to check the sanitation at this time with the sanitation strips which measures the concentration in parts per million (ppm) (mg/L) of the sanitizing solution. The strips revealed that the sanitation was measuring at zero ppm's in the machine. She confirmed that according to the strip, there was no sanitation during this process. The Certified Dietary Manager (CDM) came over at that time and stated, It was noticed yesterday that it was not pumping and reading properly. She confirmed that the ppm's were measured earlier yesterday and the strips were reading that there was sanitation in the machine. She was asked if the kitchen monitored and logged the temperature of the water. She stated, I was told that as long the ppm was reading, that was sufficient. She was asked what the facility policy was on monitoring and logging the temperature of the dish machine. She stated, I'm not quite sure. She confirmed that she has worked in the facility since (MONTH) (YEAR) and that the kitchen staff has never monitored or logged the dish machine temperature. She confirmed that they only monitor the chemical sanitizer and that the logs reflect the chemical sanitizer monitoring only. She stated, As long and the water is less than 120 (degrees Fahrenheit) it's okay. When asked about the sanitizer not measuring any ppm's, she stated, We know its pumping but the strips are not reading it. She explained that she knows that the sanitation is pumping into the machine because the levels on the bucket of sanitation was going down. She stated, We know it's coming out. It's just not reading. She confirmed that due to the levels on the buckets going down, they felt that the dishes were being cleaned and sanitized. The CDM was asked for logs of the past 12 months of dish machine logs and the facility policy on the dish machine. Interview with the Administrator on 4/3/17 at 10:23 a.m. she stated that there was a problem with the dish machine in the past and that recently had it serviced. On 4/3/17 at 11:08 a.m. Administrator stated that the Maintenance Director monitors the dish machine temperatures weekly. She stated that he documents this in the TELS system. She provided the Weekly Water Temps and Equipment Instructions dated 2004-2009 with Reviewed and Updated date of (MONTH) 2014) revealed (2) Kitchen dish machine should be at least 120 degrees (Fahrenheit) or per manufactures recommendations. On 4/3/17 at 11:10 a.m. the chemical was measured by the CDM and continued to measure at zero chemical. Initial tour of the conducted on 4/3/17 at 10:35 a.m. The stove was observed with grease build up. The CDM was asked to test the pilot lights. She confirmed that two of six pilot lights were not functioning at that time. During an interview with the Administrator on 4/5/17 at 4:25 p.m. she stated that the maintenance are to check the pilot lights annually. They last checked them on 1/17/17 and all worked. She stated that the kitchen staff are to notify the maintenance department when they have problems such as the pilot light being out. She provided the facility policy Equipment (Kitchen) service Instructions & Log last updated (MONTH) 2009: All kitchen equipment should be . inspected one time per year. Check all pilot lights and burners.",2020-09-01
2084,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2017-04-06,460,E,0,1,1BPE11,"Based on observations, resident and staff interview the facility failed to ensure that privacy curtains in eight resident rooms on one of two wings (East and West) provided full visual privacy for eight residents who resided in those rooms. The facility census was eighty (80). Findings include: Observation of incontinence care on 4/5/17 at 10:15 a.m. for R#122, revealed the privacy curtain would have to be drawn across the bed, and over the residents' neck and chest area to be pulled. The bed was in the corner of the room with the head of the bed against the wall. Interview 4/5/17 at 10:20 a.m. with Resident (R) #122 revealed she prefers the bed against the wall because it gives more area to move around the room in her wheelchair. R#122 confirmed the privacy curtain is not used because it would be across her chest and would not provide privacy. Interview 4/5/17 at 10:25 a.m. with Certified Nursing Assistant (CNA) BB revealed the privacy curtain cannot be used because it would be across the residents' chest and if someone opened the door the resident would be exposed. The following observations were made with the Director of Nursing (DON) on 4/6/17 between 12:10 p.m. and 12:50 p.m.: 1. An observation was conducted in room 20 [NAME] The curtain did not give full visual privacy. If pulled the privacy curtain would be across the residents' neck and chest area. If the curtain was pulled enough to clear the bed the resident would be exposed. 2. Observation in room 35 A revealed the privacy curtain was not effectively providing visual privacy because it would extend across the bed at the level of the residents' neck and chest area. Opening the door would expose the resident becuase the curtain would not enclose the bed. 3. During observations in room 40 A the privacy curtain would extend across the residents' neck and chest if pulled. The resident would not be provided full visual privacy if the door was opened. 4. Observation in room 41 A revealed the privacy curtain did not give full visual privacy. If pulled the curtain would be across the residents' neck and chest and if the door was opened the resident would be exposed. 5. During observations in room 43 A the privacy curtain did not give full visual privacy. If pulled the privacy curtain would be across the residents' neck and chest and if pulled enough to clear the bed the resident would be exposed if the door were opened. 6. During observations in room 45 A the privacy curtain did not give full visual privacy. If pulled the privacy curtain would be across the residents' neck and chest and if pulled enough to clear the bed the resident would be exposed if the door were opened. 7. Observation in room 47 A revealed the privacy curtain did not give full visual privacy. If pulled, the privacy curtain would be across the residents' neck and chest and if pulled enough to clear the bed the resident would be exposed if the door were opened. 8. An observation was conducted in room 50 [NAME] The privacy curtain would extend across the residents' neck and chest if pulled. The curtain would leave the resident exposed if the door was opened by staff, family or another resident. Interview on 4/6/17 at 12:50 p.m. with the DON revealed the curtains in rooms 20 A, 35 A, 40 A, 41 A, 43 A, 45 A, 47 A, and 50 A are on tracks that would cause the curtains to be pulled across the beds and the residents' neck and chest area, do not provide full visual privacy. The DON expects the curtains to give the residents full visual privacy so when any form of care is done and the door is opened by another resident, employee or family, the resident is not exposed. The DON acknowledged no one had noticed or reported the privacy curtains could not be drawn and explained there is no policy regarding visual privacy.",2020-09-01
2085,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2017-04-06,514,E,0,1,1BPE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain progress notes from a contracted psychiatric services provider for one resident (R) #96. The sample size was 27 residents. Findings include: Review of the Consulting Agreement for Psychological Services between the facility's former psychiatric services provider and the facility dated 7/20/16 revealed the following: Documentation: Consultant shall submit to Company, on a weekly basis, appropriate documentation of services provided hereunder; such documentation shall be in the form and shall contain the information as may be reasonably requested by Company. Review of a Psychiatric Follow-up Progress Note dated 8/3/16 noted that R #96 had [DIAGNOSES REDACTED]. Review of Psychotherapy Progress Note: Evaluation and Management forms for R #96 dated 11/28/16, 2/7/17 and 2/9/17 noted that the Licensed Clinical Social Worker (LCSW) would continue to follow treatment plan at two sessions per week. During interview with the Social Services Director (SSD) on 4/6/17 at 4:58 p.m., she stated that a former contracted psychiatry group had been seeing R #96 since (MONTH) of (YEAR), but had only provided progress notes for the visit dates of 11/28/16, 2/7/17, and 2/9/17. During interview with the facility's Administrator on 4/6/17 at 5:14 p.m., she stated that they recently terminated the contract with their psychiatric services provider, because they were not fulfilling what they said they would do in their contract. She further stated that she was aware that this provider had not been furnishing the progress notes from their visits. The Administrator verified that other than the psychiatric provider's initial assessment of R #96 on 8/3/16, the only progress notes made available to the facility were dated 11/28/16, 2/7/17, and 2/9/17. She verified during further interview that R #96 was being seen by the psych provider twice a week per notation on their progress notes. The Administrator further stated that she checked all 15 of the residents' records who the previous psychiatric services group was seeing, and the only progress notes left or e-mailed by the provider in (YEAR) were for the dates of 2/7/17 and 2/9/17.",2020-09-01
2086,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2018-05-31,656,D,0,1,2XH011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to follow the plans of care related to behaviors for two residents (#29, and #65) from a sample of 23 residents. Findings include: 1. Review of the clinical records for Resident (R)#29 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Review of the current physician's orders [REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed a Quarterly MDS of 3/1/18 which documented a Brief Interview for Mental Status (BIMS) score of 1 (indicative of a severe cognitive disability), some mood symptoms, and active [DIAGNOSES REDACTED]. The assessment also documented behaviors such as rejection of care and wandering which occurred 1-3 days during the assessment period. Further review of the MDS records revealed the last comprehensive MDS - the annual assessment - was completed for R#29 on 8/29/17, which revealed that the assessment also documented wandering and rejection of care behaviors. Under the Care Area Assessment Summary (CAAS) of the comprehensive assessment, cognitive loss/dementia and behavioral symptoms triggered and the decision was made to create a plan of care for these areas. A review of a plan of care dated 4/17/18 for R#29 related to behavioral changes revealed the resident's goals were to have decreased episodes of anxiety and for her behaviors not to have a negative impact on herself or others. Staff interventions included reducing stimuli, moving her to a quieter environment during anxious episodes, and redirecting and refocusing her. Observation on 5/29/18 at 3:24 p.m. revealed that R#29 was noted to be sitting in her room when R#65 wandered in and walked to the window. Soon after R#65 entered the room, R#29 shouted in a loud, angry voice: get your ass out of this room! this is not your room! Staff in the vicinity did not intervene to redirect or refocus either resident. Observation on 5/30/18 at 8:40 a.m. revealed R#29 was sitting quietly in her room when R#65 wandered in and headed towards the window at the far side. R#29 immediately jumped up and yelled in an angry voice, get your ass out of here! I'm calling the sheriff to come get you! Go on, get out! As R#65 turned and ambled slowly out of the room, R#29 followed and slammed the door shut behind him. Staff in the vicinity did not intervene to redirect or refocus. 2. Review of the clinical records for R#65 revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Annual Minimum Date Set (MDS) assessment of 4/24/18 the revealed resident had such a severe cognitive deficit that the Brief Interview for Mental Status could not be completed. The assessment also documented some existing depression symptoms; behaviors such as daily rejection of care and daily wandering, and active [DIAGNOSES REDACTED]. Under the Care Areas Assessment Summary (CAAS) behavioral symptoms use triggered and the decision was made to complete a plan of care for that area. Review of the resident's plan of care dated 4/23/18 for behaviors, including ambulating aimlessly, and pacing, revealed a goal for the resident's behaviors to not have a negative impact on self or others. Interventions directed staff to: assist to return to room as needed; distract with activity or food or beverage; monitor behaviors for frequency; move to quieter environment as needed; redirect/refocus; reduce stimuli; and remove from situation. Observation on 5/29/18 at 3:09 p.m. revealed that R#65 wandered up and down hallway and in and out of the dining room and seven residents' rooms (several of them on multiple occasions) on his unit without staff intervention; On one occasion, he entered room [ROOM NUMBER] (the resident's room was room [ROOM NUMBER]) as a Certified Nursing Assistant exited the room, but she did not redirect him. Observation on 5/29/18 at 3:24 p.m. revealed that R#65 wandered in and walked to the window of room [ROOM NUMBER]. Soon after R#65 entered the room, R#29, one of the occupants of that room, shouted in a loud, angry voice: get your ass out of this room! this is not your room! Staff in the vicinity did not intervene. Observation on 5/30/18 beginning at 8:35 a.m. revealed that R#65 was noted to be roaming up and down the hallway of the locked unit, entering several rooms on the hallway, some occupied, some not; several members of staff passed him during his wanderings, but did not redirect him. Observation on 5/30/18 at 8:40 a.m. revealed that R#65 wandered in and walked to the window of room [ROOM NUMBER]. Soon after R#65 entered the room, R#29, one of the occupants of that room, immediately jumped up and yelled in an angry voice, get your ass out of here! I'm calling the sheriff to come get you! Go on, get out! As R#65 turned and ambled slowly out of the room, R#29 followed and slammed the door shut behind him. Staff in the vicinity did not intervene. An interview on 5/31/18 at 2:00 p.m. with the Director of Nursing (DON) revealed that R#29 experiences anxiety related to others encroaching on her personal space and this anxiety and accompanying behaviors such as lashing out verbally and physical at staff and other residents had escalated in recent weeks. While other residents encroaching on the resident's personal space was recognized by staff as one of the triggers to this lashing out, they would not prevent other residents from wandering into her room because this is what residents on the secure unit do. The residents on that unit had the right to wander freely, including wandering into the room of R#29 and staff of the facility would not impede that right. Cross-refer to F740",2020-09-01
2087,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2018-05-31,740,D,0,1,2XH011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of records, the facility failed to minimize/eliminate situations that triggered emotional distress for one cognitively impaired resident (#29) by refusing to limit the intrusion of other cognitively impaired residents into her personal space. The sample size was 23 residents. Findings include: Review of the clinical records for Resident (R)#29 revealed the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment records for the resident revealed a Quarterly MDS of 3/1/18 which documented a Brief Interview for Mental Status (BIMS) score of 1 (indicative of a severe cognitive disability), some mood symptoms, and active [DIAGNOSES REDACTED]. The assessment also documented behaviors such as rejection of care and wandering which occurred 1-3 days during the assessment period. Further review of the MDS records revealed the last comprehensive MDS - the annual assessment - was completed for R#29 on 8/29/18. That assessment also documented wandering and rejection of care behaviors. A review of the nurses' notes of 4/28/18 at 3:28 p.m. revealed that the resident was very agitated all evening, cursing at other residents and staff, being physically abusive to staff, hitting, kicking, pushing and threatening serious bodily injury to staff, and unplugging the television in day room stating it belonged to her and threatening to call the police; A review of a Facility Reported Incident dated 4/28/18 revealed R#29 was involved in a physical altercation with another resident after the other resident exited the room of R#29 and accused R#29 of trying to jump on her. The incident was recorded as occurring at 8:20 p.m. that evening. A review of the nurses' notes during the evening of 4/29/18 revealed documentation that the resident continued with behaviors like that of the evening before. A review of the monthly nurses' note of 5/15/18 documented under the mood section that the resident had an abnormal sleep pattern, showed little interest in anything, was restless/fidgety/anxious, short-tempered and annoyed. Under behaviors was listed inappropriate verbal behaviors, refusal of care, wandering, and being at risk for elopement/intruding on others. Review of the current behavior monitoring records revealed R#29 was being monitored for physically aggressive behaviors. During observation on the secure unit on 5/29/18 at 3:24 p.m. R#29 was noted to be sitting in her room when R#65 wandered in and walked to the window. Soon after R#65 entered the room, R#29 shouted in a loud, angry voice: get your ass out of this room! this is not your room! Staff in the vicinity did not intervene. During observation on 5/30/18 at 8:40 a.m. R#29 was observed sitting quietly in her room when R#65 wandered in and headed towards the window at the far side. R#29 immediately jumped up and yelled in an angry voice, get your ass out of here! I'm calling the sheriff to come get you! Go on, get out! As R#65 turned and ambled slowly out of the room, R#29 followed and slammed the door shut behind him. Staff in the vicinity did not intervene. During an interview with Licensed Practical Nurse (LPN) AA on 5/30/18 at 2:01 p.m., it was revealed that staff were aware that R#65 wanders on the unit and into other residents' rooms, but staff does not usually intervene. They consider the facility to be the residents' home, as a result, they can do what they would normally do in a home setting, including wandering into other rooms. There were some situations under which residents would be redirected on entering another resident's room. For example, if R#65 (or any resident on the unit) wandered into another resident's room while that other resident was receiving personal care, then he/she would be redirected. The other residents are usually not bothered by R#65 wandering in and out of their rooms. If, occasionally, another resident does object to R#65 being in his/her room, staff would then redirect. For the most part, however, the staff allows the residents on the unit to wander freely. During an interview with Certified Nursing Assistant (CNA) BB on 05/30/18 at 5:00 p.m., it was revealed that staff allows the residents to wander freely on the secured unit. The staff sometimes redirects residents when they go into other residents' rooms and lie on other residents' beds. However, the residents usually just return a few minutes later to do the very same thing. Most residents do not seem to care when other residents come into their room. R#29 is the only resident who seemed to care when other residents intrude into her room and will usually ask them to leave. This is usually not a problem, however, since R#29 is not always in her room to see other residents when they come in uninvited. Interview with (LPN) CC on 5/31/18 at 9:48 a.m. revealed the staff sometimes try to redirect the residents when they wander up and down the hallway and into other residents' rooms. However, it is hard because they have so many walkers. R#29 does object when the other residents enter her room uninvited. She becomes very upset and has tried to hit some of them in the past. On some occasions, however, she sits in her room and just watches them as they walk in and out. It is as if she knows they are going to do it anyway, so why bother? Interview on 5/31/18 at 11:04 a.m. with CNA DD revealed R#29 becomes upset when other residents wander into her room, especially if the resident who wanders in is a male. At such times, she might complain to staff that someone is in her room or she will tell the resident to leave. Staff will try to redirect the resident who wanders into her room and keep the door closed when she is not in her room to deter them. The resident does become upset when R#65 wanders into her room. Most often, however, before she can say anything to him, he has wandered in and out again. During an interview on 5/31/18 at 2:00 p.m. with the Director of Nursing (DON), it was revealed that R#29 experiences anxiety related to others encroaching on her personal space and this anxiety and accompanying behaviors such as lashing out verbally and physical at staff and other residents had escalated in recent weeks. While other residents encroaching on the resident's personal space was recognized by staff as one of the triggers to this lashing out, they would not prevent other residents from wandering into her room because this is what residents on the secure unit do. The residents on that unit had the right to wander freely, including wandering into the room of R#29 and staff of the facility would not impede that right.",2020-09-01
2088,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2019-08-15,689,E,0,1,9QJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the policies titled Housekeeping Services and Pharmacy Services-Medication Administration/General, and staff interviews, the facility failed to provide an environment that was free from potential accidents and hazards on two of three nursing units. Specifically, the facility failed to properly identify and dispose of a medication found on the floor and failed to ensure a medication signed out as given was not left at the bedside of one resident (R) (#17) that was sleeping. Findings include: 1. During the observational medication pass conducted with Licensed Practical Nurse (LPN) AA on 8/14/19 at 8:30 a.m., in the hallway outside the dining room of the secured East Memory Unit, a small white pill with ridge on top was observed on the floor next to the Floor Tech's dry mop. The Floor Tech was in the process of sweeping around the medication cart with the medication and other floor debris present. When alerted regarding the pill on the floor, Floor Tech BB stated ok and continued to sweep the pill with the other floor debris. During an observation with LPN AA of the pill on the floor at this time, she stated ok and that it wasn't hers, it must be from night shift. LPN AA left the pill on the floor until asked if she should discard it. At the time of the medication discovery, one male resident was observed wandering in the hall. During an interview on 8/14/19 at 9:40 a.m., the Director of Nursing (DON) explained the procedure the LPN and Floor Tech should follow when finding a medication on the floor. The DON stated the expectation is for the nurse to place the pill in the sharp's container, try to identify it, who it might belong to, and then replace the medication if easily identified as belonging to the resident. The DON explained that housekeeping staff have been taught to tell the nurse when they find medications in the room or on the floor, and the nurses would handle it from there. An interview was conducted on 8/15/19 at 10:16 a.m. with the Housekeeping Supervisor (HS) where he explained he was new to the facility, as of three weeks ago, but confirmed he was responsible for the floor techs, housekeepers and the laundry staff. The HS confirmed he has had talks with his housekeeping staff that if they find medication or pills in the rooms or on the floor, they are to stand over the medication, call for a Certified Nurse Assistant (CNA) or nurse, and not to leave the medication until someone comes. He confirmed he had this talk with his staff about three days ago but could not recall an exact time. 2. An observation was conducted on the West Unit on 8/14/19 at 12:15 p.m. of R#17 who was observed asleep in his shared room. A large white pill in a medication cup was observed on his bedside table. The medication nurse, Registered Nurse (RN) CC, was asked about the medications at the bedside, where she explained the resident likes to take his medications on his own time. At this time, the resident was awakened by the nurse and asked to take his medication. Review of the electronic Medication Administration Record [REDACTED]. Documentation reflected that [MEDICATION NAME] was scheduled to be given before meals at 6:30 a.m., 11:30 a.m., 4:30 p.m. and 9:00 p.m. It was documented as given on 8/14/19 at 11:30 a.m. During an interview with the DON on 8/14/19 at 1:19 p.m., she confirmed that it is her expectation that no medication is left at the bedside, if the resident is unable to take the medication or refuses, the nurse is to remove it and sign refused, then reattempt later. The DON confirmed that RN CC had come to her and told her what medications she had left in the room. A review was conducted of the facility policy titled, Housekeeping Services dated (MONTH) 2019 documenting the intent of the center to maintain a clean and sanitary center that is free from odor and environmental factors that may affect the quality of life of the patients. Review of the undated facility policy titled Pharmacy Services-Medication Administration/General revealed that medications are to be administered as prescribed, in accordance with good nursing principals. Procedural Guidelines: 4. Medications are administered at the time they are prepared. 17. For patients not in their rooms or otherwise unavailable to receive medication on the pass, the MAR indicated [REDACTED].",2020-09-01
4530,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2015-06-11,242,D,0,1,STSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interviews, review of the Middle Hall Bath List and the facility Grievance Log, the facility failed to honor one (1) resident's (F) choice related to the frequency of showers from a sample of twenty five (25) residents. Findings include: An interview conducted on 6/9/15 at 3:50 PM with resident F revealed she was told on admission her shower days would be Monday, Wednesday and Fridays. She indicated that she has only been receiving her showers once a week on Fridays and sometimes a Monday or Wednesday. She revealed she did not receive her shower yesterday on Monday, 6/8/15. She revealed that she was about to wash her hair in the sink when the Certified Nursing Assistant (CNA) told her it was her shower day and she would tell the bath team to make sure her hair got washed. She waited but never heard anything and never got the shower. A second interview conducted on 6/10/15 at 3:50 PM with resident F revealed she did not get a shower today which is her scheduled shower day. She had to wash her hair in the sink. She cleans herself in between her showers but that is just not the same as hot water running over her body where she can wash herself good. She indicated her showers are very important to her. Review of the resident' s Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed she was assessed as requiring physical help for bathing. Review of the Plan of Care dated 9/6/14 identified the resident as requiring supervision with Activities of Daily Living (ADL) with an intervention to assist with ADLs as needed. Review of the facility's Grievance Log revealed the resident filed a grievance on 10/22/14 related to not receiving her bath on 10/21/14. The investigation results and action taken was that the resident would receive showers on her designated days and when she prefers. A review of the Middle Hall Bath List dated from (MONTH) (YEAR) through (MONTH) (YEAR) revealed no evidence that the resident had received showers on her designated bath days every Mondays, Wednesdays and Fridays. Interview conducted 6/11/15 at 9:18 AM with the CNA BB revealed that she is on the Monday, Wednesday and Friday Bath Team. BB indicated the Bath Team is often pulled and assigned to floor care. If the Bath Team is pulled, the floor CNAs are responsible for bathing residents. Bathing is documented in the bath books. Interview conducted 6/11/15 at 10:18 AM with the Restorative Nurse, AA revealed bathing is documented in the Accu-Nurse when it has been reported as refused. Baths/showers are documented on the Bath List and kept in the Bath Log Notebooks. She indicated that the Bath team has been getting pulled to floor care quite often and the CNAs are then responsible for their assigned resident's bath.",2019-09-01
4531,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2015-06-11,372,B,0,1,STSR11,"Based on observations and staff interviews, the facility failed to properly dispose of garbage and refuge for one (1) of four (4) dumpsters. Findings include: Observations conducted on 6/9/15 at 4:20 PM and 6/10/15 at 8:00 AM, from the window of the conference room, revealed a very large open dumpster with card board boxes and trash in it. Interview conducted 6/10/15 at 2:35 PM with the Maintenance Director revealed the large twenty (20) yard open dumpster behind the building is intended for card board and boxes only. Observation conducted 6/10/15 at 2:40 PM of the large open dumpster, with the Maintenance Director, revealed mainly card board boxes on the right end but the left end was completely full of trash bags containing food, cups and other trash Items. Chicken bones were noted in the dumpster with flies flying around. Further interview conducted 6/10/15 at 2:42 PM with the Maintenance Director revealed there is not supposed to be trash or food items thrown in the dumpster at any time and staff have been informed of this. He revealed there are two (2) covered dumpsters around the corner that are specifically for trash and food items.",2019-09-01
4532,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2015-06-11,431,E,0,1,STSR11,"Based on observations, review of the facility's guidelines for Administering Medications, and staff interviews, the facility failed to ensure two (2) of three (3) medication carts containing drugs and biologicals were stored locked and in secure area. Findings include: Observation conducted 6/10?15 at 9:25am during medication pass on the East Hall revealed that on approaching the medication cart the cart was unlocked. and unattended. The nurse was observed giving medications to a resident in the day area. There were ten (10) other residents located in the day area participating in activities and several residents walking in the hallway. The nurse returned to the cart at 9:30am and began to prepare medications for another resident, who had an antibiotic stored in the medication room refrigerator. The nurse left the cart and went to the resident pantry to pick up a Supplement, then to the medication room for the antibiotic and returned to the medication cart at 9:45am to where she finished preparing the medications. She went into the day area and brought the resident back out into the hallway to administer the medications to the resident. The nurse then returned to the medication room to put the antibiotic back into the refrigerator. The medication cart remained unlocked until 9:55am when the nurse returned. Interview with the Licensed Practical Nurse (LPN) EE on 6/10/15 at 9:55am revealed that she usually locks the cart if she is going to be away from it. She indicated she should have locked the cart when she went to get the antibiotics. EE also revealed the touch pad on top of the cart does not work but has a key that unlocks the cart from the back. Observation conducted during check of medication storage on 6/10/15 at 4:20pm revealed the West Hall medication cart was unlocked and parked at end of nursing station. Interview with the MDS nurse on 6/10/15 at 4:25pm revealed medications carts are to be kept locked any time the nurse steps away from the cart. Interview conducted on 6/11/14 at 9:15am with the Staff Development Coordinator revealed all nurses are taught to always keep the medication carts locked if they step away from or are not within sight of the cart. Review of the facility's guidelines for Administering Medications revealed the medication cart is to be kept locked at all times unless in use and within medication nurse's direct sight and control.",2019-09-01
4533,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2015-06-11,514,D,0,1,STSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of (MONTH) Medication Administration Record [REDACTED]. Finding Include: Record review for resident #114 revealed a physician order [REDACTED]. Continued review revealed a physician's clarification order dated 6/7/15 for [MEDICATION NAME] 20mg take one (1) tablet every day. Review of the Hospital Discharge Orders dated 6/5/15 revealed an order for [REDACTED]. Review of the (MONTH) MAR from 6/5/15 thru 6/30/15 revealed [MEDICATION NAME] Oxalate 20mg ([MEDICATION NAME]), one(1) tablet by mouth (po) daily at 8:00am and another entry for [MEDICATION NAME] Oxalate 20mg ([MEDICATION NAME]), one (1) tablet po daily at 8:00am. Both entries had initialed that the medication was given. Review of the blister pack of [MEDICATION NAME] for Resident #114 revealed (4) tablets had been given since admission. Interview conducted the Resident Care Coordinator CC on 6/11/15 at 9:20am revealed were not aware of duplicate order on the MAR for [MEDICATION NAME]. She revealed has met with nursing and they will be checking all physician's orders [REDACTED].",2019-09-01
6601,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2014-11-25,333,D,1,0,FYTK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed initiate and administer antibiotic medication therapy for one (1) resident (#1) of six (6) sampled residents. Findings include: Resident #1 was admitted into the facility in June of 2010. His [DIAGNOSES REDACTED]. Review of the Client [DIAGNOSES REDACTED].#1 had sacral pressure ulcers 2010 and 2013. Review of the Treatment Record-wound Assessment form dated 9/29/2014 indicated that resident #1 developed a new pressure ulcer to his coccyx. The pressure ulcer worsened and became infected. On 10/27/14, the physician ordered an antibiotic, Keflex 500 milligrams by gastrostomy tube twice a day for seven (7) days. There was no documentation on the Medication Administration Record [REDACTED]. Review of the Nurse ' s notes revealed no documentation of antibiotic therapy for resident #1. Observation of the health record and interview with the director of nurses on 11/25/14 at 11:15 a.m. revealed that there was no documentation that the Keflex was administered to resident #1. At 2:30 p.m. on 11/25/14, the facility administrator and DON acknowledged that there was no indication that the antibiotic for the infected pressure ulcer was administered to resident #1.",2017-11-01
8363,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2013-02-04,502,D,1,0,7D3511,"br>Based on record review and staff interview, the facility failed to obtain a laboratory test in accordance with the physician's order for one (1) resident (#1) of four (4) sampled residents. Findings include: Record review for Resident #1 revealed a handwritten physician's order dated 01/18/2013 on the January 2013 Physician's Order sheet specifying that a complete blood count (CBC) laboratory test be done on 01/21/2013. However, further record review conducted on the date of this survey, 02/04/2013, revealed no evidence of the results for this test ordered to be done on 01/21/2013, nor was there any evidence to indicate that blood had been drawn to obtain this test. During an interview conducted on 02/04/2013 at 3:30 p.m., the Director of Nursing acknowledged that there were no laboratory results in the resident's medical record, nor was there a requisition in the laboratory book, for the CBC which had been ordered to be completed on 01/21/2013.",2016-02-01
8730,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2012-11-14,309,D,1,0,3UTO11,"**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 physician's order was followed to notify the physician prior to medication administration if the pulse rate was greater than 90 or lower than 60 for one (1) resident (# 4) on the survey sample of five (5) residents. Findings include: During medication pass with LPN GG at 9:15 a.m. on 11/14/12, the LPN checked resident #4s blood pressure and pulse stating the blood pressure was 140/90 and the pulse was 105. She then administered [MEDICATION NAME] 25 mg per the resident's [DEVICE]. During reconciliation of the medication pass, a review of the physician's order for this resident revealed an order for [REDACTED]. During an interview with the LPN GG on 11/04/2012 at 11:00 a.m., she stated she had missed the order related to the pulse at time of medication administration. Review of the pulse rate documented on the resident's current November 2012 medication administration record (MAR) revealed a total of 8 days between the dates of November 1 and November 15, 2012, in which pulses recorded were greater than 90, ranging from a low of 92 to a high of 110. For each of these days, metaprolol was documented as given, but there was no documentation the physician was notified, per the order, of the resident's elevated pulse rate. During the previous month, October 2012, the resident's pulses were recorded on the MAR as being greater than 90 for a total of 27 days between the dates of October 1 and October 29, ranging from a low of 93 to 118. This MAR documented that [MEDICATION NAME] was given on these dates but there was no documentation that the physician had been notified about the pulse rate being greater than 90. An interview conducted on 11/15/2012 at 3:40 p.m. with the assistant director of nursing revealed she did not find any documentation related to physician notification on the days when the pulse exceeded 90.",2015-11-01
9203,AVALON HEALTH AND REHABILITATION,115528,120 SPRING STREET,NEWNAN,GA,30263,2011-02-10,441,D,0,1,D9JZ11,"Based on observations, review of the facility's policy for Blood Glucose Testing Device Quality Control Program, the Super Sani-Cloth manufactures' recommendations and product directions, and staff interviews, the facility failed to clean and disinfect glucometers appropriately to prevent potential cross contamination for three (3) residents (#10, #15, and #45) from a sample of thirty-six (36) residents. Findings include: 1. Observation on 2/7/11 at 3:35pm of a Licensed Practical Nurse (LPN) ""BB"" performing an accu-check on resident #15 revealed after completing the accucheck, ""BB"" put the glucometer into the zippered pouch it came with, placed it inside the medication cart and locked the cart without cleaning the glucometer. Interview with LPN ""BB"" at 3:45pm revealed that as far as ""BB"" knew the nurses cleaned glucometers with alcohol but was not sure. 2. Observation on 2/9/11 at 11:15am revealed LPN ""CC"" did an accu-check on resident #45. ""CC"" cleaned the glucometer by wiping it down with a Super Sani-Cloth. The device sat wet for one (1) minute and thirty (30) seconds. The accucheck was completed and the glucometer was cleaned with Super Sani-Cloth. The glucometer set twenty (20) seconds then the device was put into its' pouch. ""CC"" then preceded to roommate resident #10. 3. A second observation on 2/9/11 of LPN ""CC"" performing an accucheck for resident #10 revealed that after completeing the accucheck the glucometer was cleaned with Super Sani-Cloth, and while still wet was placed in the pouch and locked in the Medication Cart. Interview on 2/10/11 at 10:15am with the Infection Control Nurse 'AA' revealed she/he is responsible for in-services and training of the use of accu-check devices. ""AA"" further revealed the procedures for cleaning devices is to clean with sani wipes when taken out of the pouch, wait two (2) minutes. Place in cup and carry to the residents' room. Clean after use and let set for two (2) minutes. Review of the facility's policy, Blood Glucose Testing Device Quality Control Program revealed that under Blood Monitoring Practice Standards meters are to be cleaned and disinfected between patient use. Review of the manufactures' information located on the containers of Super Sani-Cloth revealed that the cloth is a pre-moistened, non-woven durable wipe containing a quaternary/alcohol based solution used where the hazards of cross-contamination on surfaces exist. Some organisms are removed from the surface by thoroughly wiping the surface with the wipe. Most remaining organisms are killed with in two (2) minutes by exposure to the liquid on the wipe. To disinfect and deodorize contact surfaces one wipe may be used to remove heavy soil. Unfold a clean wipe and thoroughly wet surface. Treated surface must remain visibly wet for a full two (2) minutes. Use additional wipes if needed to assure continuous two (2) minute contact time. Let air dry.",2015-08-01
6275,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2015-02-04,280,D,1,0,X29711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review the facility failed to revise the plan of care related to safety for one (1) resident (#6) from a sample of seven (7) residents. Findings include: Review of the Patient Information Summary indicated that resident #6 was admitted into the facility in May of 2012. Review of the Client [DIAGNOSES REDACTED].#6 had [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set for resident #6 dated 11/13/14 revealed that she was totally dependent on the assistance of two persons for bed mobility and for transfers to or from the bed, chair or wheelchair. Resident #6 ' s brief interview for mental status score (BIM) was zero (0) on this assessment. Review of the Interdisciplinary Progress Notes for resident #6 dated 01/02/2015 indicated that while putting resident to bed she turned and hit her forehead on assist bar with small one-fourth inch hematoma noted and yellowish bruise noted and starting to form. A review of the Fax form for Physician Communication indicated on 01/02/2015 at 11:35 a.m. revealed that while putting the resident to bed, she hit her right forehead on the assist bar resulting in a small one-fourth inch hematoma noted and bruising starting to form. A review of the Plan of Care for Resident #6 revealed a problem dated 03/13/2014 for resident having thin, fragile skin with history of bruising and skin tears and remained at risk. The goal dated 03/19/2014 stated that the resident would have no infection related to bruising and skin tears during the review period. Interventions included 1) observing signs of abnormal bruising and skin tears and notifying the charge nurse and 2) using caution when transferring the resident as not to bruise or tear skin. An observation of resident #6 on 02/04/2015 at 11:05 a.m. revealed resident with hard light-colored assist rails up on both sides of the bed. Resident #6 was observed lying on her left side gripping left the assist rail with both hands and rocking. The rocking motion caused her head to bump the assist rails. Interviews with the treatment nurse on 02/04/2015 at 1:20 p.m. and 2:15 p.m. revealed that she, the MDS coordinator or the resident care coordinators would be responsible for updating interventions, if needed, on the plan of care for residents with incidents involving bruises. She would do it if she knew about its occurrence. She revealed she was unaware of the incident involving resident #6 hitting her head on the assist rail on 01/02/2014. It may have been discussed in the morning meeting if it had been put on the twenty-four (24) hour report and may have been discussed in the Interdisciplinary Team meeting. She was not sure why the plan of care for Resident #6 was not updated to reflect the injury on 01/02/15. Interviews with the Director of Nursing (DON) and regional nurse consultant on 02/04/2015 at 1:25 p.m. and 2:30 p.m. revealed the facility padded assist rails when needed. They said that an intervention was expected to be put in place for resident #6 ' s safety after the incident involving the assist rail on 01/02/2015. A review of the facility Procedural Guidelines for the Patient ' s Plan of Care indicated the intent of the center was to develop and maintain an individualized plan of care for each patient. It further indicated that the plan of care was to include identified problem areas and incorporate risk factors associated with the identified problems. The care plan was also to be revised as changes in the resident's condition dictated.",2018-02-01
6276,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2015-02-04,282,D,1,0,X29711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow the resident's individualized Care Plan to change the indwelling urinary catheter as ordered by the physician for one (1) resident (#2) of seven (7) sampled residents. Findings include: Review of the Patient Information Summary for Resident #2 indicated that she was admitted into the facility in March of 2008. Review of the physician's orders [REDACTED]. The physician's orders [REDACTED]. Review of Section H of the Quarterly Minimum Data Set ((MDS) dated [DATE] indicated that resident #2 had an indwelling catheter. A review of the Plan of Care dated 05/13/2014 for resident #2 revealed a plan for the indwelling catheter related to a [DIAGNOSES REDACTED]. A review of the Medication Administration Records (MARS), the Treatment Administration Records (TARS), the 24-hour report logs and the Interdisciplinary Team (IDT) notes for October 2014 through February 2015 revealed the indwelling urinary catheter was not changed every three weeks as the Physician ordered. The catheter was changed on October 05, 2014 per the twenty-four (24) hour report, November 11, 2014 according to the MAR and January 13, 2015 per the 24-hour report. Interviews with the Director of Nursing (DON) on 02/04/2015 at 1:10 p.m. and 3:15 p.m. revealed that scheduled Foley catheter changes were to be done on the 7 PM - 7 AM shift. The DON said that she was unable to verify that the Foley catheter had been changed according to the physician's orders [REDACTED].",2018-02-01
6277,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2015-02-04,312,D,1,0,X29711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide nail care for one (1) resident (F) of seven (7) residents sampled. Findings include: Review of the Patient Information Summary indicated that resident F was admitted into the facility in May of 2012. Review of the Client [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set for the resident dated 11/13/14 revealed that he/she was totally dependent on the assistance of two (2) persons for bed mobility and for transfers to or from the bed, chair or wheelchair. The resident's Brief Interview for Mental Status (BIMS) assessment was zero (0) on this assessment indicating the resident was severely cognitively impaired. Observation on 2/4/15 at 10:20 a.m. revealed the resident had very long fingernails. During an interview on 02/04/15 at 12:15 p.m., a family member of resident F said that he/she visited most Fridays and Sundays and that the staff was supposed to keep the resident's nails trimmed. The treatment nurse stated on 02/04/15 at 1:20 p.m. that either she, the activity aide or the weekend supervisor were responsible for providing nail care to the residents. The treatment nurse stated that the resident's nails were done as needed and that nail care was not scheduled. Interviews on 02/04/15 at 1:25 p.m. and 2:30 p.m. with the Director of Nursing (DON) and the Regional Nurse Consultant revealed there was no schedule for resident nail care. According to the DON, the treatment nurse was responsible for fingernail care. There were Spa Days that included nail care offered by the activity department. The weekend supervisor could also do nail care. The DON added that she had clipped the resident's nails in the past but had not done so lately. Further interview revealed that normally a certified nursing assistant (CNA) or the family would tell him/her if the resident's nails needed clipping. A review of the facility Procedural Guidelines for Personal Care of Fingernails and/or Toenails revealed the intent of the center was to provide appropriate nail care to all patients.",2018-02-01
6278,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2015-02-04,315,D,1,0,X29711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide indwelling urinary catheter care in a manner to prevent infection related to catheter changes for one (1) resident (#2) of seven (7) sampled residents. Findings include: Review of the Patient Information Summary for Resident #2 indicated that she was admitted into the facility in March of 2008. Review of the physician's orders [REDACTED]. A review of the physician's order [REDACTED]. A review of the Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed that resident #2 usually understood and was able to understand others with a Brief Interview for Mental Status (BIMS) score of 13. Review of Section H of the quarterly MDS dated [DATE] indicated that resident #2 had an indwelling catheter. A review of the Plan of Care dated 05/13/2014 for resident #2 revealed a plan for the indwelling catheter related to a [DIAGNOSES REDACTED]. A review of the Medication Administration Records (MARS), the Treatment Administration Records (TARS), the 24-hour report logs and the Interdisciplinary Team (IDT) notes for October 2014 through February 2015 revealed the indwelling urinary catheter was not changed every three weeks as the Physician ordered. The catheter was changed on October 05, 2014 per the twenty-four (24) hour report, November 11, 2014 according to the MAR and January 13, 2015 per the 24-hour report. Interviews with the Director of Nursing (DON) on 02/04/2015 at 1:10 p.m. and 3:15 p.m. revealed that scheduled Foley catheter changes were to be done on the 7 PM - 7 AM shift. The DON said that she was unable to verify that the Foley catheter had been changed according to the physician's orders [REDACTED].",2018-02-01
6539,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2014-01-30,282,D,0,1,P2R811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview and record review the facility failed to provide one resident (A ) with a referral for an orthotic device from a total sample of thirty two (32) residents. Findings include: An interview on 1/28/14 at 10:46 a.m., with Resident A revealed that the therapist was supposed to be getting him/her a splint for his/her right leg. The resident was assessed on the 10/9/14 Annual Minimum Data Set (MDS) as requiring extensive assistance with transfers. The 10/23/13 care plan, revised on 1/15/14, listed that the resident had a decreased weakness noted to the right side related to a [MEDICAL CONDITIONS] with [MEDICAL CONDITION]. The interventions included to follow up with skilled therapy as needed. A review of the resident's medical record revealed [REDACTED]. The PT wrote a recommendation to the nursing staff for the resident to be referred to an orthotic specialist for a device for the resident's right leg in order to continue with skilled physical therapy. However, there was no evidence that the nursing staff had made a referral for the device. Cross to F318",2017-12-01
6540,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2014-01-30,318,D,0,1,P2R811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and record review the facility failed to obtain a orthotic referral for one resident (A), from a total sample of thirty two (32) residents. Findings include: Review of the medical record for Resident A revealed that the resident had a [DIAGNOSES REDACTED]. An interview with the resident on 1/28/14 at 10:46 a.m., he/she stated that the therapist was supposed to be getting him/her a splint for his/her right leg. A review of the resident's medical record revealed [REDACTED]. The PT had written a recommendation to the nursing staff for the resident to be referred to an orthotic specialist for a device for the resident's right leg in order to continue with skilled physical therapy. The therapy note also listed that nursing education had been provided to the Minimum Data Set nurse (MDS) and nurse on duty for referral to orthotic specialist. Review of the physician order [REDACTED]. However, there was no evidence that the nursing staff had obtained the referral. An interview on 1/30/14 at 11:15 a.m., with the Resident Care Coordinator licensed nurse CC for the B wing, revealed that whenever a skilled therapist referred to nursing for an orthotic device for a resident the order should be taken off the chart by the nursing staff and a form should be left for the Restorative nurse to order the referral. An interview on 1/30/14 at 11:20 a.m. with the licensed restorative nurse, (DD) revealed that she was not aware of a brace order for the resident but thought that the therapy department had ordered it and would obtain the information. An interview with the Physical Therapist on 1/30/14 at 11:39 a.m., revealed that she has spoken to licensed nurse BB about the brace and had informed the nurse that she (PT) could not treat the resident until the resident received an orthotic device for his/her right leg. An interview with the Licensed Practical Nurse BB on 1/30/14 at 11:45 a.m. revealed that an appointment should have been made for the resident to see an orthotic specialist but it had not been done.",2017-12-01
6541,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2014-01-30,431,D,0,1,P2R811,"Based on observations and staff interviews the facility failed to properly monitor for expired medications and to store medications properly on one(1) hall (A) of two (2) medication rooms (A and B Hall). Findings include: During observation of medication storage room on A hall on 1/29/13 at 2:15 p.m., three (3) Novolog 70/30 prefilled insulin syringes for resident #22 were found in medication refrigerator with an expiration date of 12/20/13 and one (1) unopened vial of Humalog for resident #65 with an expiration date of 10/20/13. An interview with Licensed Practical Nurse EE, on 1/29/14 at 2:15 p.m. revealed that resident #22 was not being administered insulin with a prefilled flex pen and that resident #65 was not being administered the Humolog insulin. She confirmed that the both medications were out of date.",2017-12-01
7428,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2012-05-03,279,D,0,1,C3ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to develop a comprehensive plan of care for one resident (#18) to address his/her risk for bruising from a sample of 33 residents. Findings included: Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident received 81 milligrams of Aspirin every day. Licensed nursing staff had documented the presence of bruises on the resident on 1/25/12, 2/01/12, 2/08/12 and 4/11/12. Although the resident's care plan since 3/01/11 addressed his/her risk for skin impairment due to incontinence, it did not address his/her potential for bruising. The staff had not developed any interventions to address the services needed to prevent bruising related to his/her medical condition, age and aspirin therapy. On 5/2/12 at 2:30 p.m., after surveyor inquiry, staff initiated a care plan to prevent the resident from developing bruises related to his/her use of his/her elbows to reposition him/herself in the wheelchair. See F323 for additional information regarding resident #18.",2017-04-01
7429,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2012-05-03,323,D,0,1,C3ZZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the nursing staff failed to assess recurrent bruises on one resident (#18) and ensure that preventative measures were implemented from a total sample of 33 residents. Findings include: Resident #18 was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident received 81 milligrams of Aspirin every day. He/She had a care plan since 3/01/11 for being at risk for skin impairment due to incontinence. However, staff had not developed a care plan with interventions to prevent the resident from bruising. According to the 1/25/12 nurses' note, licensed nursing staff observed numerous discolorations of small bruises and age spots on the resident. Licensed nursing staff documented on the 2/01/12 nurses' note that the resident had an old, dark blue bruise on his/her left hand. On 2/08/12, licensed nursing staff documented that the resident had a small discolored area on his/her right hand. According to the 4/11/12 nurses' note, the resident had a small bruise on the back of his/her left hand. On 4/30/12 at 3:16 p.m., the resident was wearing a short-sleeved shirt. There was an irregular purplish area on his/her right forearm near the elbow. The resident was observed using his/her arms to reposition himself/herself in the wheelchair on 5/02/12 at 1:55 p.m. On 5/02/12 at 2:10 p.m., certified nursing assistant (CNA) CC stated that she/he would immediately report any bruises on the residents to the charge nurse but, she was not aware that resident #18 had any bruises. On 5/02/12 at 2:15 p.m., supervisory nurse DD stated that the CNAs were supposed to immediately report any bruises on residents to a nurse. The nurse was then supposed to fill out a form and give it to the Resident Care Coordinator who would investigate the possible causes of the bruise in order to implement preventative measures. DD stated that nursing staff had not notified her/him about the bruises on resident #18 which had been documented in the 1/25/12, 2/01/12, 2/08/12 and 4/11/12 nurses' notes. There was not any evidence that facility staff had investigated the possible causes of those bruises or implemented any preventative measures.",2017-04-01
9802,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2010-08-19,253,D,0,1,TOCN11,"Based on observation, it was determined that the facility failed to maintain one of three common shower rooms (A wing) and two of 26 residents' bathrooms free of dirt, debris and dark substances on the floors, and raised toilet seats. Findings include: 1. During the General Observations Tour of the Facility on 8/19/10 at approximately 9:45 a.m., the common shower room on A Wing had dirt and an unidentifiable dark substance on the floor at the base of the Arjo tub. The raised toilet seat on the commode had brown debris and stains inside of the seat, The shower stall's floor was littered with small pieces of debris. There was a black substance inside the corner of the shower stall. The following observations were made on the A wing during the intial tour on 8/17/10 between 11:00 a.m. and 12:00 noon.: 1. There was a build up of dirt,dust and debris in the corner of the floor next to the sink in room 16. There was a build-up of dirt on the rusty caulk between the back edge of the sink and the wall. 2. There was a build up of dirt, dust and debris in all of the corners in room 24.",2015-05-01
9803,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2010-08-19,315,D,0,1,TOCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, it was determined that the facility failed to ensure proper catheter care for two (#7 and #13) of three residents with indwelling catheters in the sample in a total sample of 14 residents. Findings include: According to the American Medical Directors Association's Clinical Practice Guideline for ""Urinary Incontinence,"" an indwelling catheter should be positioned, secured and managed properly to minimize urethral damage and other complications. The facility's documented procedures for catheter care instructed nursing staff to hold the catheter near the insertion site and avoid tugging on it. However, nursing staff failed to support the catheter tubing during the provision of care for resident #7 and #13. 1. Resident #7 was admitted with [DIAGNOSES REDACTED]. He had an indwelling urinary catheter. On 8/18/10 at approximately 10:45 a.m., catheter care was observed being provided by certified nursing assistant (CNA) ""DD"". During the course of care, CNA ""DD"" failed to support the resident's catheter at the insertion site while cleaning it. In addition, CNA ""DD"" only dabbed up and down the tubing to clean it. The leg strap was in place and the tubing was taut which increased pressure at the insertion site. During an interview on 8/19/10 at 10:30 a.m., the Director of Nursing said that certified nursing assistants had been instructed to hold catheter tubing at the insertion site to clean it. 2. Resident #13 had [DIAGNOSES REDACTED]. He/She required the use of an indwelling urinary catheter. During an observation of indwelling urinary catheter care on 8/19/10 at 10:30 a.m., CNA ""CC"" failed to support the catheter tubing at the insertion site when cleaning it.",2015-05-01
9804,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2010-08-19,441,E,0,1,TOCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review , observation and staff interview, it was determined that the facility failed to maintain a complete and accurate record of incidents and corrective actions related to infections for two residents (#6 and #10), failed to implement appropriate precautions for one resident (#6) with Clostridium difficile infection in a total sample of 14 residents, and failed to ensure that one of 11 employees reviewed were free of communicable disease prior to employment. Findings include: According to the Centers for Disease Control (CDC) and Prevention,[DIAGNOSES REDACTED].-associated disease could be prevented in healthcare settings by: the use of Contact Precautions; and implementing an environmental cleaning and disinfection strategy. Patients were to be placed in private rooms. If private rooms were not available, those patients would be placed in rooms (cohorted) with other patients with [DIAGNOSES REDACTED]-associated disease. Gloves were to be used when entering patients' rooms and during patient care. Gowns were to be used if soiling of clothes was likely. Equipment was to be dedicated to that patient whenever possible. Those precautions were to continue until diarrhea ceased. The facility's Infection Control Surveillance Program included a ""Organisms or Infections and Precautions Needed"" form. It included a brief summary of room requirements and /or precautions to be observed with specific organisms or infections. Under the heading for Clostridium difficile infection, the room requirements included a private room or cohort with the same diagnosis/organism or discuss room placement with management/corporate. The duration for the private room was listed as ""until the diarrhea ceases."" The precautions were listed as ""Contact Precautions"". At the bottom of the form, there was a Summary of ""Contact Precautions"". The summary included the use of a Stop sign posted on the door; gloves to enter the room; gowns to enter the room; trash and linen containers in the room until the trash and linen could be placed in the soiled utility room or taken to the laundry. It also listed that no special bags were needed and that the linen should be washed separately. The Contact Precautions fact sheet listed that the Stop sign instructed staff and visitors that contact precautions were to be used and to see a nurse for instructions. During an interview on 8/19/10 at 10:45 a.m., the Director of Nurses explained that the facility's ""Infection Patient List"" form included where the infection was acquired. She said that if the resident was admitted with the infection, the infection was coded as a community acquired infection (CAI). If the resident acquired the infection at the nursing home then, it was coded as a nursing home infection (NI). She stated that when an infection was coded as a CAI, it was not included in the facility's ""Monthly Infection Control"" detail list or included in the facility's ""Infection Rate Graph"". 1. During the intial tour of the facility on 8/17/10 at 11:10 a.m. and 12:00 noon, licensed charge nurse ""RR"" stated that resident #6 had a colonoscopy completed on Friday. He/she stated that morning (8/17) the physician, who performed the colonoscopy, had called to inform them that the resident had Clostridium Difficile (C-Diff). Licensed nurse ""RR"" stated that the resident had a history of [REDACTED]. However, upon entering the resident's semi private room, it was observed that there were not any infection control precautions posted on the resident's door or inside the resident's room. There were not any gloves or gowns outside the resident's room for use by the staff. The nurse confirmed that the resident had a room mate who shared the same bathroom. A review of the room-mate's clinical record revealed no evidence that he/she had a[DIAGNOSES REDACTED]. associated disease. A review of the 8/17/10 nursing notes revealed documentation that licensed nurse ""RR"" had received a telephone call from the physician's office that morning informing him/her that resident #6 had[DIAGNOSES REDACTED]. Resident #6 was observed in his/her room on 8/17/10 at 12:45 p.m., 1:20 p.m., 3:30 p.m., and 4:40 p.m. However, there was no evidence that contact precautions had been implemented by nursing staff. There was not a Stop sign posted on the resident's door. On 8/18/10 at 8:10 a.m. and 11:00 a.m., the resident was observed in his/her room but, there were not any contact precautions in place. On 8/19/10 at 10:00 a.m., the resident was observed sitting in his/her wheelchair in his/her room visiting with another resident but, there were not any contact precautions in place. There was not a Stop sign posted on the door to instruct visitors to see a nurse prior to entering that room. During an interview on 8/19/10 at 10:45 a.m., the Director of Nurses stated that she was not aware that resident #6 had the[DIAGNOSES REDACTED] diagnosis. Nursing staff sent a fax to the attending physician on 6/2/109 that resident #6 was complaining about painful urination and frequent urination. A urinalysis with a culture and sensitivity was obtained on 6/4/10 . On 6/7/10, the culture and sensitivity report revealed that the resident had an infection of Escherichia Coli (E. Coli) bacteria of over 100,000 colony count. The resident was treated with 250 milligrams of [MEDICATION NAME] (an antibiotic), twice a day for 10 days. A repeat urinalysis with a culture and sensitivity was obtained on 6/23/10 with the results of E. Coli bacteria of over 100,000 units. The resident was treated with 100 milligrams of [MEDICATION NAME] (an antibiotic), twice a day for 10 days. However, a review of the June 2010 ""Patient Infection List"" recorded resident #6 as having an Urinary Tract infection on 6/4/10 and 6/21/10. The infections were listed as Community Acquired Infections (CAI) and therefore were not included on the Monthly Infection Control Detail report. This failure resulted in the facility having an inaccurate Infection Rate for the month of June. 2. Resident #10 had a urinalysis collected on 7/9/10 with a culture and sensitivity test completed on 7/12/10. The results of that culture revealed an infection of Proteus Mirabilis with over 100,0000 colony count. The resident was treated with 500 milligrams [MEDICATION NAME] a day for 10 days. A repeat urinalysis with a culture and sensitivity was obtained on 7/29/10 and revealed an infection of E.Coli with over 100,00 colony count. The resident was treated with one gram of [MEDICATION NAME] (an antibiotic) every day for 7 days. Although the facility's July ""Patient Infection List"" revealed that resident #10 had an urinary tract infection , nursing staff failed to list the results of the cultures and identify that the resident had two different infections. This failure caused the Monthly Infection Detail list and Infection Rate to be inaccurate for the month of July. 3. During a review of 11 employees' personnel records on 8/18/10, it was determined that one employee had been hired on 9/1/09. However, there was no evidence that the facility had obtained the results of his/her [DIAGNOSES REDACTED] screening test until 9/15/09. In an interview on 8/18/10 at approximately 4:30 p.m., the Administrator stated that, since this employee was transferred from another facility within the corporation, she was not aware that a new PPD was required before working at the facility.",2015-05-01
9805,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2010-08-19,309,D,0,1,TOCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record reviews, it was determined that the facility failed to provide [MEDICATION NAME] to one resident (#6) as ordered by the physician from a total sample of 14 residents. Findings include: Resident #6 had [DIAGNOSES REDACTED]. He/She had an appointment on 6/4/10 with a hematologist at [MEDICAL CONDITION] Center because of a history of a low hemoglobin count and his/her [DIAGNOSES REDACTED]. Although the 6/5/10 nurse's notes documented that the resident's primary physician had been notified about the need for prior approval for [MEDICATION NAME] medication, there was no evidence that prior approval was obtained. Despite the 6/4/10 hematologist's order, the resident was not given any [MEDICATION NAME] in June. There was no evidence that nursing staff notified the hematologist about the requirement for prior approval of the [MEDICATION NAME] or contacted the resident's primary physician about the requirement for prior approval before the [MEDICATION NAME] could be acquired for administration to the resident. Although the CBC laboratory tests were obtained weekly, the results were not sent to the hematologist who ordered them but to the resident's attending physician. The resident returned to the hematologist on 7/2/10. The hematologist ordered another 40,000 units of [MEDICATION NAME] to be given to the resident subcutaneously every week. There was no evidence in the resident's medical record that the resident received the [MEDICATION NAME]. There was not any evidence that nursing staff attempted to obtain prior approval for the medication or notified the hematologist that prior approval was required before the [MEDICATION NAME] could be acquired. A review of the resident's August Medication Administration Record [REDACTED]. During a phone interview on 8/18/10 at 11:55 a.m., the consultant pharmacist stated that the order for [MEDICATION NAME] had been filled on 8/6, 8/11 and 8/16. He stated that there was not any other record of [MEDICATION NAME] having been filled for the resident at any other time. During an interview on 8/18/10 at 4:50 p.m., the Director of Nurses stated that the [MEDICATION NAME] required a prior approval. She stated that when the primary physician did not complete the prior approval form, [MEDICAL CONDITION] Center was notified. The DON stated that the prior approval was then obtained from [MEDICAL CONDITION] Center and the medication was started on 7/6/10. However, after reviewing the medical record, the DON confirmed that the resident had not received the [MEDICATION NAME] until 8/6/10.",2015-05-01
10473,AZALEA HEALTH AND REHABILITATION,115642,300 CEDAR ROAD,METTER,GA,30439,2009-03-31,364,E,1,0,ZVRN11,"Based on resident interview and a test tray, the facility failed to serve foods at the proper temperature for four (4) residents of ten (10) sampled residents. Findings include: During an interview conducted on 03/31/2009 at 10:30 a.m., Resident ""D"" stated that the food that was served was cold, and that staff did not ask to reheat the food. During an interview conducted on 03/31/2009 at 10:05 a.m., Resident ""A""stated the food that was served earlier that morning was cold and that the three (3) meals served the previous day were all cold. Also, the resident stated that the food had always been cold since he/she had lived in the facility. Resident ""B"" stated during an interview conducted on 03/31/2009 at 10:20 a.m. that the food was sometimes cold and that staff never asked if they could reheat the food. Resident ""C"" stated during an interview conducted on 03/31/2009 at 10:55 a.m. that the food was always cold at breakfast. The surveyor was served a test tray at 12:15 p.m. on 03/31/2009, and the pork chop and gravy were only lukewarm.",2014-07-01
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
5275,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2015-04-30,282,D,0,1,G64611,"**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 plan related to falls. This occurred for one (1) resident (#18) from a sample size of thirty six (36) residents. Findings include: Resident #18 was admitted to the facility on (MONTH) 8, 2014. Current [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set assessment dated [DATE] revealed that that the resident was assessed as requiring supervision x 1 person with bed mobility and transfers. Her balance during transition and walking was not steady, but able to stabilize without assistance. Further review revealed that she was coded as having no falls since her prior assessment. Review of the care plan initiated 5/15/2014 and last updated 4/6/15 revealed that the resident was at risk for falls related to deconditioning. The care plan was updated with the falls on 2/17/15, 4/1/15, and 4/6/15. The Interventions included to assess for pain and medicate as ordered, keep call light or personal items available and in easy reach, footwear to prevent slipping, and to keep the environment well lit and free of clutter. The care plan was updated to reflect the falls that occurred on 2/17/15, 4/1/15, and 4/6/15. A new intervention was added on 4/6/15 for a wheelchair alarm. There was no evidence of documentation on the care plan that the resident removes the chair alarm, or that the chair alarm was discontinued. Review of the clinical record for resident #18, the Progress Notes revealed that the resident had falls on 11/30/14, 12/7/14, 2/17/15, 4/1/15, and 4/6/15. Further review revealed that on 4/1/15 the resident sustained [REDACTED]. On 4/6/15 the resident was sent to the hospital with hip swelling and dislocation. Further review revealed that the resident was diagnosed with [REDACTED]. Observation of resident #18 on 4/28/15 at 3:34 p.m. revealed the resident up in her wheelchair rolling herself down the hallway. No chair alarm was observed. Observation of resident #18 on 4/29/15 at 8:43 a.m. and 12:00 p.m. revealed the resident in the dining room in her wheelchair with no chair alarm observed. Observation of resident #18 on 4/29/15 at 1:30 p.m. revealed the resident sitting at end of the hall in her wheelchair reading the paper with no chair alarm observed. Interview with Licensed Practical Nurse (LPN) AA on 4/29/15 at 1:31 p.m. revealed that resident #18 had a chair alarm but removed it frequently. LPN AA further revealed that the resident does not use her call light consistently. AA noted that staff check on resident #18 frequently. Continued interview revealed that there has been consideration of moving the resident closer to the nurse's station. Interview with Certified Nursing Assistant (CNA) BB on 4/29/15 at 2:03 p.m. that she was unaware of a chair alarm for resident #18. Interview with LPN CC on 04/29/2015 5:06 p.m. revealed that resident #18 does not have a wheelchair alarm because she continuously removed it. LPN CC revealed that the resident is very independent and wants to ambulate independently. Continued interview revealed that the bed is kept at the level of the chair so the resident can transfer easily. CC revealed that she instructs the CNAs to check on resident #18 at thirty minute intervals. Cross-refer to F 323",2018-10-01
5276,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2015-04-30,323,D,0,1,G64611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to ensure that one (1) resident (#18) who was at risk for falls received supervision and assistance device to prevent accidents. The sample size was thirty-six (36) residents. Findings include: Resident #18 was admitted to the facility on (MONTH) 8, 2014. Current [DIAGNOSES REDACTED]. Review of the clinical record for resident #18, the Progress Notes revealed that the resident had falls on 11/30/14, 12/7/14, 2/17/15, 4/1/15, and 4/6/15. Further review revealed that on 4/1/15 the resident sustained [REDACTED]. On 4/6/15 the resident was sent to the hospital with hip swelling and dislocation. Further review revealed that the resident was diagnosed with [REDACTED]. Review of the care plan initiated 5/15/2014 and last updated 4/6/15 revealed that the resident was at risk for falls related to deconditioning. The care plan was updated with the falls on 2/17/15, 4/1/15, and 4/6/15. The Interventions included to assess for pain and medicate as ordered, keep call light or personal items available and in easy reach, footwear to prevent slipping, and to keep the environment well lit and free of clutter. The care plan was updated to reflect the falls that occurred on 2/17/15, 4/1/15, and 4/6/15. A new intervention was added on 4/6/15 for a wheelchair alarm. There was no evidence of documentation on the care plan that the resident removes the chair alarm, or that the chair alarm was discontinued. Observation of resident #18 on 4/28/15 at 3:34 p.m. revealed the resident up in her wheelchair rolling herself down the hallway. No chair alarm was observed. Observation of resident #18 on 4/29/15 at 8:43 a.m. and 12:00 p.m. revealed the resident in the dining room in her wheelchair with no chair alarm observed. Observation of resident #18 on 4/29/15 at 1:30 p.m. revealed the resident sitting at end of the hall in her wheelchair reading the paper with no chair alarm observed. Interview with Licensed Practical Nurse (LPN) AA on 4/29/15 at 1:31 p.m. revealed that resident #18 had a chair alarm but removed it frequently. LPN AA further revealed that the resident does not use her call light consistently. AA noted that staff check on resident #18 frequently. Continued interview revealed that there has been consideration of moving the resident closer to the nurse's station. Interview with Certified Nursing Assistant (CNA) BB on 4/29/15 at 2:03 p.m.revealed that she was unaware of a chair alarm for resident #18. Interview with LPN CC on 04/29/2015 5:06 p.m. revealed that resident #18 does not have a wheelchair alarm because she continuously removed it. LPN CC revealed that the resident is very independent and wants to ambulate independently. Continued interview revealed that the bed is kept at the level of the chair so the resident can transfer easily. CC revealed that she instructs the CNAs to check on resident #18 at thirty minute intervals.",2018-10-01
6301,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2014-02-22,253,B,0,1,0MF911,"Based on observation, it was determined that the facility failed to maintain a clean and comfortable environment on one (1) hall (Hall 1) of three (3) halls. Findings include: 1. Observation on 2/19/14 at 2:28 p.m. revealed a large red stain on the privacy curtain between the two beds in room 8. One corner of the overbed table for bed B had missing laminate on the side and top exposing the particle board. 2. Observation on 2/19/2014 at 2:58 p.m. revealed there were dead bugs inside the ceiling light cover and black smears on the ceiling in the bathroom for room 5. 3. Observation on 2/19/2014 at 4:15 p.m. revealed the privacy curtain for bed B in room 16 was dirty 4. Observation on 2/19/14 at 11:18 a.m. revealed numerous dead insects inside the ceiling light cover and numerous black smears on the ceiling in the bathroom for room 1. Interview on 2/22/14 at 11:29 a.m. with the housekeeping assistant supervisor confirmed the above concerns.",2018-01-01
6302,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2014-02-22,278,D,0,1,0MF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to accurately reflect a resident's status on the Minimum Data Set (MDS) for four (4) residents (K, #118, #88, #117) from a total sample of 33 residents. Findings include: 2. Review of the clinical record for resident #88 revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED].) twice a day and an order dated 5/2/13 for [MEDICATION NAME] (an antidepressant) 10 mgs every bedtime. Review of the 10/10/13 Quarterly Minimum Data Set (MDS) assessment revealed that nursing staff had coded the resident as not having received an antianxiety medication in the last 7 days prior to the assessment reference date of 10/10/13. However, review of the Medication Administration Record [REDACTED]. Review of the 12/28/13 Quarterly MDS assessment revealed that nursing staff had coded the resident as not having received an antianxiety medication or an antidepressant medication in the last 7 days prior to the assessment reference date of 12/28/13. However, review of the MAR for 12/2013 revealed that licensed nursing staff had administered the Klonopin and the [MEDICATION NAME] to the resident from 12/21/13 to 12/27/13. Licensed/Registered nursing staff had failed to accurately reflect the resident's medication status on the 10/10/13 and 12/28/13 Quarterly Minimum Data Sets. 2. Review of the clinical record for resident #117 revealed that the resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. However, review of the Incident Reports revealed that on 9/28/13 at 5:00 a.m., the resident had rolled out of his/her bed onto the floor and on 10/10/13 at 11:00 p.m., the resident had fallen while ambulating to the bathroom. The resident had two falls since his/her admission on 9/14/13. Licensed/Registered nursing staff had failed to accurately reflect the resident's fall status on the 12/10/13 Quarterly Minimum Data Set. Interview on 2/22/14 at 12:25 p.m. with the MDS coordinator/Licensed Practical Nurse DD confirmed the inaccurate assessments for residents #88 and #117. DD stated at that time that she/he reviewed a resident's medical record including the Medication Administration Records (MARS) for the types of medications that a resident received and the incident reports to determine the number of falls that a resident had. 3. Review of a Level II PASRR Review Outcome Notification dated 09/19/13 noted resident K met a nursing facility (NF) level of care and was eligible to receive additional specialized services and/or supports according to an individualized plan of care to treat their serious mental illness. Continued review revealed that the resident had a [DIAGNOSES REDACTED]. Review of the Recommended Specialized Services section of this form noted that Diagnostic/Ongoing Psychiatric Care and Individual Therapy were recommended after the NF admission. Review of the admission MDS assessment for resident K dated 10/01/13 revealed that the resident was coded as not evaluated by Level II PASRR. Interview on 02/22/14 at 8:35 a.m. with MDS Coordinator DD revealed that she did not know that resident K was approved for Level II services, and verified the MDS did not reflect this. Cross-refer to F 406. 4. Review of the clinical record for resident # 78 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was bed bound, with contractures of the upper, and lower extremities, and was totally dependent of staff for all care. Review of the physician's orders [REDACTED].) minutes a day as tolerated. Review of the quarterly minimum data set (MDS) assessments section G0400 and section O0500 dated 08/01/13, 11/01/13, and 02/01/14 revealed that the resident was inaccurately assessed as having no functional limitation in ROM of the upper or lower extremities. Continued review of Section O revealed that the resident was assessed as not receiving PROM services with the Restorative Nursing Program during the seven (7) day look back period. Interview with MDS Coordinator/Licensed Practical Nurse DD on 02/22/14 at 12:40 p.m., revealed that she completed the three (3) inaccurate MDS assessments for resident # 78 and confirmed that the resident did have contractures of both her upper, and lower extremities. Continued interview revealed that when she reviewed the restorative book for the look back period it was blank, and that was why she coded that the resident did not receive any ROM services with Restorative Nursing. Interview with the Director of Nursing (DON) on 02/22/14 at 12:20 p.m., revealed that she had two (2) full time MDS nurses to complete the required resident MDS assessments. Continued interview revealed that it was her expectation that an accurate assessment be done by the MDS nurse by doing a visual assessment of the resident at the bedside.",2018-01-01
6303,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2014-02-22,279,D,0,1,0MF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan for behavior for one (1) resident (#27) from a sample of thirty-three (33) residents. Findings include: Review of the clinical record for resident #27 revealed the resident was admitted to the facility in September, 2013 with a [DIAGNOSES REDACTED]. The resident was ordered [MEDICATION NAME] one hundred (100) milligrams (mg) three times per day (TID), which is an anti-psychotic medication. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with [REDACTED]. Continued review of the Care Area Assessment (CAA) revealed that behavior triggered and would be care planned; however, there was no evidence of care plan being developed. Review of the Social Services Progress Notes dated 10/2/13 and 10/9/13 revealed that the resident is physical and verbally abusive with staff, and refuses care at times. Interview with the Social Service Director on 2/21/14 at 9:20 a.m., revealed that there was no care plan developed. Interview with the MDS Coordinator on 2/21/14 at 11:30 a.m., revealed that when behaviors trigger during the observation period then social services is responsible for completing the care plan.",2018-01-01
6304,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2014-02-22,280,D,0,1,0MF911,"Based on observation, record review, and staff interview, the facility failed to revise the care plan related to pressure ulcer for one (1) resident (#80) from a sample of thirty-three (33) residents, Findings include: Review of the resident careplan initiated 12/16/13 for resident #80 for alteration in skin integrity revealed that the resident was at risk for pressure ulcer actual or at risk area on right lower leg some abrasive spots from cast. Interventions included nutritional support, skin assessment, turning and repositioning. The care plan was updated on 2/6/14 to indicate that the area to right lower leg was in the final stage of healing no drainage, no pain. There was was no evidence that the care plan had been updated to reflect the new pressure ulcer, that was discovered on 2/05/14, with appropriate interventions. Interview with Director of Nursing on 2/22/14 at 12:23 PM revealed that careplan should have been updated with the right ankle outer stage II that was noted on 2/5/14.",2018-01-01
6305,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2014-02-22,406,D,0,1,0MF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to provide the recommended specialized psychiatric services outlined in the Preadmission Screening and Annual Resident Review (PASRR) for one (1) resident (K). The sample size was thirty-three (33) residents. Findings include: Review of a Level II PASRR Review Outcome Notification dated 09/19/13 noted resident K met a nursing facility (NF) level of care and was eligible to receive additional specialized services and/or supports according to an individualized plan of care to treat their serious mental illness. Further review of the document noted that the Nursing Facility must fax the letter (Level II approval) and Summary of Findings to the provider they chose to deliver specialized services to the resident. Continued review of this document noted the resident was currently in and had a history of [REDACTED]. major [MEDICAL CONDITION]. Review of the Recommended Specialized Services section of the form noted that Diagnostic/Ongoing Psychiatric Care and Individual Therapy were recommended after the NF admission. Review of resident K's medical record revealed that they were admitted to a behavioral health hospital on [DATE], and admitted to the NF on 09/24/13. Review of the Admission Minimum Data Set ((MDS) dated [DATE] noted that the resident was not evaluated by Level II PASRR. Review of the physician's orders [REDACTED]. Review of the care plans revealed the resident was care planned for antidepressant drug use, but there was no mention of the PASRR status nor interventions for referral for psychiatric care. Interview on 02/21/14 at 9:20 a.m. with the Social Services Director (SSD) revealed that she thought the resident was on PASRR Level II due to dementia. Interviews on 02/22/14 at 8:25 a.m. with the SSD revealed that resident K was not a PASRR Level II, because the Admissions Coordinator would have let her know this; at 8:35 a.m. the MDS Coordinator DD stated that she did not know resident K was approved for Level II services, and verified the MDS did not reflect this nor was the resident care planned for it; at 8:55 a.m., the Admissions Coordinator stated that all new admissions' paperwork, including the PASRR information, were copied and given to the Day Shift RN (Registered Nurse) Supervisor. The Admissions Coordinator added that the department heads discussed new admissions daily in Stand-Up Meetings, and was sure she mentioned resident K's PASRR status during one of these meetings; at 9:02 a.m. the Day Shift RN Supervisor stated that she was given admission paperwork for all new residents, including the PASRR review, but that she usually didn't read it and did not know who was responsible for notifying the staff when a resident was approved for Level II services because the facility did not get that many of them; at 9:30 a.m., Licensed Practical Nurse EE stated that she did not know what PASRR was, and did not see any physician orders [REDACTED]. After reviewing the PASRR Recommended Specialized Services, the SSD verified that she would have been the one to arrange for the psychiatric services had she known about them.",2018-01-01
6306,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2014-02-22,441,E,0,1,0MF911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to sanitize hands between serving residents during dining on three (3) of three (3) units and one (1) of two (2) dining rooms; failed to store an ice scoop in a sanitary manner on one (1) observation for two (2) residents; failed to change gloves before cleaning a glucometer or wash hands afterwards; and failed to store personal care items in a sanitary manner in five (5) rooms on three (3) of three (3) units. The facility census was eighty (80) residents, and the sample size was thirty-three (33) residents. Findings include: 1. Observations on 02/20/14 beginning at 5:54 p.m. revealed staff distributing supper trays to residents eating in their rooms on Unit 1. One Certified Nursing Assistant (CNA) took a tray into room [ROOM NUMBER] and grasped the overbed table to position it for the resident. Without sanitizing or washing her hands, the CNA picked up a tray for a resident in room [ROOM NUMBER] and set the tray on the overbed table, came out of the room, rubbed her nose with the back of her hand and delivered the tray for the other resident in room [ROOM NUMBER] positioning it on their overbed table; next, the CNA picked up and delivered a tray to room [ROOM NUMBER] and positioned the overbed table and then assisted to reposition a resident in room [ROOM NUMBER]. Only after finishing the delivery of all these trays and repositioning the resident did the CNA wash her hands. The Admissions Director pushed her long hair back with her hand, scratched her throat, delivered a tray to room [ROOM NUMBER], positioned the overbed table, pushed her hair back with her hand twice more, and then set up the resident's food, including handling the resident's utensils to cut up the food never washing her hands. Interview on 02/22/14 at 11:50 a.m. with the Assistant Director of Nursing (ADON) revealed that staff should not be touching their hair and should be sanitizing their hands between residents when serving meal trays. Review of facility Policies and Procedures revealed the following: -Nursing Responsibilities at Meal Service: Distribution: Staff should wash their hands as needed, such as after touching a patient. -Hand Washing: After touching bare human body parts such as face, mouth, ears, or eyes; after touching hair; after handling any soiled or contaminated equipment, cleaning cloths, utensils, dishes trays, soiled aprons or trash can lids; before handling cooked or ready-to-eat foods; all staff will sanitize hands prior to serving a meal to a patient. 2. Observation on 02/19/14 at 10:30 a.m. revealed three unlabeled urinals in one plastic bag tied to a grab bar in the bathroom shared by rooms [ROOM NUMBERS] on Unit 3. Observation on 02/19/14 at 11:13 a.m., and 02/20/14 at 8:10 a.m. revealed an unlabeled, uncovered bedpan on top of the commode seat in the bathroom shared by rooms [ROOM NUMBERS] on Unit 2. Observation on 02/19/13 at 11:30 a.m. revealed two unlabeled, uncovered bedpans directly on the floor in the bathroom beside the commode in a bathroom shared by residents in rooms [ROOM NUMBERS] on Unit 1. Observations on 02/20/14 beginning at 4:55 p.m. revealed the following: -There was one unlabeled and uncovered urinal on the grab bar by the commode in a bathroom shared by rooms [ROOM NUMBERS]. -There was an uncovered bedpan on the floor by the commode in a bathroom shared by rooms [ROOM NUMBERS]. -There was one unlabeled bedpan in a plastic bag on the floor next to the commode, and another uncovered, unlabeled bedpan nested inside of it in a bathroom shared by rooms [ROOM NUMBERS], The observations made on 02/20/14 at 4:55 p.m. were verified by the Registered Nurse (RN) Assistant Director of Nurses (ADON) on 02/20/14 at 5:17 p.m. Interview at this time revealed that urinals should be labeled and kept at the bedside if the resident was able to use it, or wrapped in a plastic bag and kept in the bedside drawer if not. Continued interview revealed that bedpans should be labeled and stored in a plastic bag. Review of infection control inservice documents revealed that labeling and storing of bedpans and urinals was covered on 09/27/12; 01/04/13; and 04/12/13. 3. Observation on 02/21/14 at 3:45 p.m. revealed a Certified Nursing Assistant (CNA) distributing ice that was in a thermal chest on top of a rolling cart to the residents in room [ROOM NUMBER]. The CNA used a scoop to put the ice in the resident's pitcher, then laid the scoop flat on top of the ice in the ice chest, with the handle touching the ice. The CNA was then observed to walk into room [ROOM NUMBER] to deliver the pitcher, leaving the lid to the ice chest open in the hallway. This was observed a second time for another resident in room [ROOM NUMBER]. Interview on 02/22/14 at 11:50 a.m. with the ADON revealed that staff were supposed to store ice scoops on the outside of the ice chest, and close the lid of the ice chest when it was unattended. 4. During observation of the supper meal service on Hall 3 on 2/20/14 between 6:02 p.m. and 6:25 p.m., a certified nursing assistant (CNA) knocked on the door of room [ROOM NUMBER] and turned the door knob to open the door to speak to another staff person in the room. The CNA then pushed the meal tray cart to room [ROOM NUMBER] and without washing or sanitizing his/her hands, obtained a tray from the cart and placed it on the overbed table for the resident in the A bed. The CNA then pushed the meal tray cart to room [ROOM NUMBER] and without washing or sanitizing his/her hands, obtained a tray from the cart for the resident in the B bed, placed the tray on the resident's overbed table and turned on the resident's overbed light. The CNA went back to the tray cart and without washing or sanitizing his/her hands, obtained a tray for the resident in room [ROOM NUMBER] B bed, placed the tray on the overbed table, raised the head of the resident's bed, opened and touched the resident's utensils, cut the resident's meat, removed the straw from its wrapper and used the straw to stir the sweetener in the resident's tea. The CNA then pushed the meal tray cart to room [ROOM NUMBER] and without washing or sanitizing his/her hands, obtained a tray from the cart for the resident in the B bed, placed the tray on the resident's overbed table, adjusted the overbed table, removed the straw from its wrapper and placed the straw in the resident's tea. The CNA left the resident's room and pushed the meal tray cart to room [ROOM NUMBER]. Without washing or sanitizing his/her hands, the CNA obtained a tray for the resident in the B bed and placed the tray on the resident's overbed table. The CNA left room [ROOM NUMBER], pushed the meal tray cart to room [ROOM NUMBER] and without washing or sanitizing his/her hands, obtained a tray for the resident in the B bed, opened the utensils and gave the spoon to the resident. 5. Observation of lunch 02/19/14 at 12:40 p.m. in the Garden dining room revealed fifteen (15) residents that required assistance and or cueing with meals. One CNA sat down and fed two (2) residents after passing trays, cutting up food, and opening condiments, she did not sanitize or wash her hands. Another CNA was observed to take the bread out of the package with her bare hands, and continue to feed the resident. She did not sanitize her hands, while passing trays or before sitting down to assist feeding the resident. Other staff members were observed to touch the delivery cart, pick up the resident's tray, uncover the food, cut up the food, add condiments, remove the covers from the drinks, and then sit down to feed the residents without ever washing or sanitizing their hands. Continued observation at 1:00 p.m., revealed a total of ten (10) nursing staff members in the dining room to assist feeding residents, only two (2) of the ten (10) nursing staff members used hand sanitizer that was located on the wall as you entered the dining room. The additional staff carried chairs into the dining room, sat down, and fed residents without washing, or sanitizing their hands. There were eleven (11) residents that were fed by ten (10) nursing staff members. During a second observation of the Garden dining room on 02/21/14 at 5:30 p.m., revealed there were approximately nine (9) residents seated awaiting dinner to be served. there were eight (8) nursing staff members, CNA's and Nurses, passing trays to the residents. They touched the cart, picked the tray off the cart, and uncovered the food, peeled the skin off the oranges that were cut into four (4) pieces with their bare hand and cut the fish hero sandwiches into quarter pieces, securing the sandwich with their bare hands. A CNA positioned a resident in her wheelchair, pick up the tray cover, return it to the cart, and then sit down and feed another resident without sanitizing or washing their hands. None of the (8) nursing staff members were observed to wash their hands or use hand sanitizer, although it was located on the wall as you enter the dining room. 6. Observation on 2/20/14 at 6:00 p.m. revealed staff passing dinner trays on station two (2) to residents in rooms 18, 19, 21, 22, 28, 29. The staff assisted residents with cutting up meat and then pushed tray cart down the hall from one room to the next room, taking trays and entering rooms without washing and/or sanitizing hands between residents. 7. Observation during medication administration pass on 2/20/14 at 3:54 p.m. revealed Licensed Practical Nurse, (LPN) FF enter room [ROOM NUMBER] to perform a fingerstick blood sugar test. After completing the fingerstick blood sugar test, the LPN left the room, wiped glucometer, removed gloves and continued on to next resident, preparing the medications for administration. The nurse did not wash her hands after removing her gloves. Interview with the ADON on 2/22/14 at 12:05 p.m. revealed that she would expect nurses to wash hands prior to and after procedures with each resident. Review of blood glucose monitor decontamination reveal after performing the glucose testing, the nurse, wearing gloves, will use a dispatch wipe to clean all external parts of the monitor. A second wipe will be used to disinfect the blood glucose monitor. Gloves will be removed and hand hygiene performed.",2018-01-01
6307,AZALEA HEALTH AND REHABILITATION CENTER,115044,1600 ANTHONY ROAD,AUGUSTA,GA,30907,2014-02-22,463,D,0,1,0MF911,"Based on observation and staff interview, it was determined that the facility failed to ensure that there were functioning call lights in three (3) resident rooms on two (2) of three (3) halls (Hall 2 and Hall 3). Findings include: Hall 2 1. Observation on 2/19/14 at 10:58 a.m. revealed the call light for room 25 A bed did not work. 2. Observation on 2/19/14 at 1:30 p.m .revealed the call light for room 16 A bed did not work. The resident was physically capable of using the call light to call for staff assistance. Hall 3 3. Observation on 2/19/14 at 10:00 a.m. revealed the call light for room 40 B bed did not work. Interview on 2/19/14 at 2:00 p.m. with the maintenance supervisor revealed that he was not aware that the call lights were not working. Continued interview revealed that he checked the call lights once a month but, that he did not document when the call lights were checked and could not remember when the call lights were last checked for functioning.",2018-01-01
1712,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2017-07-13,280,D,1,0,B4O811,"**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 update a care plan for one (1) resident (#2) who had been assessed with [REDACTED]. Findings include: Resident #2 had been admitted to the facility on [DATE]. A 4-17-17 nurse's note (NN) at 4:20 PM documented that the resident had Altered Mental Status (AMS), able to ambulate and wanders. The wanderguard was placed on the resident for safety. A 4-17-17 plan of care for potential for wandering behavior was initiated at the time of admission. The plan of care was updated again on 4-22-17 and 4-24-17 when resident tried to exit the building through back entrance parking lot and had an unsuccessful attempt to exit the gated area and the front door. Review of a Nursing Home Leave of Absence Form for the resident revealed that he had been signed out of the facility at 10:30 a.m. on 6-25-17 by a friend. This friend had been listed on the resident's face sheet as a person who could take the resident out. Review of the 6-25-17 at 9:30 p.m. Nurses Note revealed that the resident was returned to the second floor at 9:15 p.m. by the first floor staff. Further documentation revealed that the first floor staff had informed the writer (of the 9:30 p.m. Nurses note) that the resident had been found outside of the front door left by himself. The review of the twenty-four (24) hour report log for 6-25-17 and 6-26-17 revealed that the family had been notified that the resident had been left alone outside of the building on the night of 6-25-17. Even though the first floor staff had brought the resident inside on the night of 6-25-17 and had notified the family of the 6-25-17 incident, review of the plan of care revealed no new interventions were added to address that the resident had been left outside of the front door by himself by the friend on the night of 6-25-17. Interview with the second floor Careplan Coordinator (CC) on 7-6-17 at 5:45 p.m. revealed that she had not been aware of this 6-25-17 incident and confirmed that she had not added new interventions to address this incident.",2020-09-01
1713,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2018-10-04,582,D,0,1,5KQV11,"Based on record review and staff interview, the facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) (Form CMS- ) to two residents (R) (#56 and #245) of five residents who remained in the facility from a sample of six residents who were discharged from Medicare Part A services in the last six months. Findings include: 1. Review of the Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review (Form CMS- ) revealed that R #56 was discharged off Part A services on 8/8/18 with benefit days remaining. Review of the Beneficiary Notice-Residents discharged Within the Last Six Months form revealed that she remained in the facility after skilled services ended. Review of the Beneficiary Notices revealed that only the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (Form CMS- ) was provided, which was signed but not dated by the responsible party (RP). There was no evidence that the facility had issued a NOMNC to R#56 or the RP. 2. Review of the Form CMS- revealed that R #245 was discharged off Part A services on 7/27/18, with 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 SNFABN was provided, which was sent by certified mail on 7/25/18. There was no evidence that the facility had issued a NOMNC to R#245 or the RP. During an interview on 10/04/18 at 2:01 p.m., Minimum Data Set (MDS) Coordinator BB revealed that when the new form came out this year, she thought that the new form took the place of all forms and only issued the SNFABN for R#56 and R#245. Review of the document titled Quick Reference for Expedited Review (Generic and Detailed Notice), Advanced Beneficiary Notices (ABN) and Therapy Caps updated 4/5/12 revealed: Reason for Notices - Skilled Nursing Facility, off part A, days left and stays in the facility, give generic notice and ABN.",2020-09-01
1714,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2018-10-04,656,D,0,1,5KQV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review and review of the facility policy titled Care Planning, the facility failed to follow the care plan related to keeping water within reach for one resident (R) (A) out of 43 sampled residents. Findings include: Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed R A was admitted to the facility on [DATE] and was unable to complete the Brief Interview of Mental Status (BIMS) Assessment. [DIAGNOSES REDACTED]. Review of the care plan revised 7/24/18 documented R A at risk for constipation and dehydration related to impaired cognition, impaired mobility and use of Mirilax (a laxative medication) daily. Interventions included but were not limited to: provide water at bedside within reach. Observation on 10/1/18 at 12:35 p.m., revealed R A sitting in the hall by the nurse's station being assisted with lunch. Resident picked up the milk carton independently. During an interview on 10/2/18 at 10:41 a.m., Family of R A revealed that a water pitcher is kept in the resident's room but is always out of reach. Observation on 10/03/18 at 2:40 p.m. revealed R A up in Geri-chair in room dressed and clean. Water noted on bedside table which was located out from the foot of the Geri-chair and out of the resident's reach. The resident was asleep holding a teddy bear. Observation on 10/03/18 at 4:05 p.m. revealed R A in bed. Water pitcher was located on the bedside table at end of bed out of resident's reach. Observation on 10/04/18 at 8:30 a.m. and 11:30 a.m. revealed R A in bed with water pitcher noted to be on dresser located on other side of room and out of the resident's reach. Interview with the Director of Nursing (DON) on 10/4/18 at 3:05 p.m. revealed that she expects staff to place water pitcher within reach for R A as indicated in the care plan. Review of the policy titled Care Planning initiated 11/15/16 documented the procedure for administering the care plan conference program of the facility includes, but is not limited to the following: 12. DON, Registered Nurse (RN) supervisor, and Licensed Charge Nurses are responsible for assuring provision of care in accordance with the care plan. Cross Refer F692",2020-09-01
1715,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2018-10-04,661,D,0,1,5KQV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy titled Discharge Procedure, and staff interview, the facility failed to develop a discharge summary and a recapitulation of the resident's stay for one resident (R) (#95) who was discharged to another facility. The sample size was 43 residents. Findings include: Review of the clinical record revealed R#95 was admitted to the facility on [DATE] and discharged on [DATE]. The Minimum Data Set (MDS) Admission assessment dated [DATE] revealed nothing checked related to discharge status. Resident was unable to complete the Brief Interview of Mental Status (BIMS) Assessment and unable to participate in goal setting. Review of the discharge care plan dated 6/8/18 documented Social Service Director (SSD) was informed by family that R#95 will possibly be transferred to skilled nursing facility in Alabama. Interventions included but were not limited to: provide information related to present medical condition/illness and its effect of change in lifestyle. Review of the Discharge Instructions for R#95 dated 7/13/18 revealed information on: medications, diet, contact information for the resident's family, safety issues, and information that the resident was to discharge to another nursing facility. No other information related to the resident's stay, status, or discharge was provided. Interview with the Director of Nursing (DON) on 10/04/18 at 2:44 p.m. revealed that she only provides the discharge instructions. She was unaware of the need for a discharge summary with recapitulation of resident's stay. Review of the policy titled Discharge Procedure initiated on 3/1/12 revealed the discharge of the resident from the long-term care facility is a constant consideration of the Interdisciplinary Team. Procedure: 5. Complete discharge record. 6. Chart necessary information and resident status at time of discharge.",2020-09-01
1716,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2018-10-04,692,D,0,1,5KQV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review and review of the facility policy titled Hydration and Nutrition, the facility failed to ensure that water was within reach for one resident (R) (A) out of 43 sampled residents. Findings include: Observation on 10/1/18 at 12:35 p.m., revealed R A sitting in the hall by the nurse's station being assisted with lunch. Resident picked up the milk carton independently. During an interview on 10/2/18 at 10:41 a.m., Family of R A revealed that a water pitcher is kept in the resident's room but is always out of reach. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed R A was admitted to the facility on [DATE] and was unable to complete the Brief Interview of Mental Status (BIMS) Assessment. [DIAGNOSES REDACTED]. Observation on 10/03/18 at 2:40 p.m. revealed R A up in Geri-chair in room dressed and clean. Water noted on bedside table which was located out from the foot of the Geri-chair and out of the resident's reach. The resident was asleep holding a teddy bear. Observation on 10/03/18 at 4:05 p.m. revealed R A in bed. Water pitcher was located on the bedside table at end of bed out of resident's reach. Observation on 10/04/18 at 8:30 a.m. and 11:30 a.m. revealed R A in bed with water pitcher noted to be on dresser located on other side of room and out of the resident's reach. Review of the care plan revised 7/24/18 documented R A at risk for constipation and dehydration related to impaired cognition, impaired mobility and use of Mirilax (a laxative medication) daily. Interventions included but were not limited to: provide water at bedside within reach. Interview with Unit Secretary CC on 10/04/18 at 12:09 p.m. revealed that R A can pick up her beverages and small finger foods like cookies, when ready. Interview with Licensed Practical Nurse (LPN) DD on 10/04/18 at 12:30 p.m. revealed that R A can pick up a drink and drink it. LPN DD confirmed that the resident can grab the ice water pitcher and drink from it. Interview with the Director of Nursing (DON) on 10/4/18 at 3:05 p.m. revealed that she expects staff to place water pitcher within reach for R [NAME] Review of the policy titled Hydration and Nutrition initiated on 3/1/12 revealed that the nutrition and hydration status of each resident is maintained as close to optimal level as possible: fluid is available to residents at all times. Further review of the clinical record for R A revealed no adverse consequences related to the facilities failure to keep water within reach.",2020-09-01
1717,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2018-10-04,880,D,0,1,5KQV11,"Based on observation, record review, and interview the facility failed to maintain infection control during medication administration with one of four medication nurses on three of four halls. The sample size was 43 residents. Findings include: Review of the policy, Medication Administration-General Guidelines. Reviewed and updated (MONTH) 2012: Medications are administered as prescribed, in accordance with good nursing principles. #20. hands are washed with soap and water or alcohol gel prior to handling tablets. Review of the facility policy statement, Infection Prevention Manual for Long Term Care, Hand Hygiene dated (MONTH) 1, 2012. Purpose: To decrease the risk of transmission of infection by appropriate hand hygiene. Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare associated infections. Observation on 10/03/18 at 9:06 a.m. during medication administration with Licensed Practical Nurse (LPN) AA revealed that LPN AA was observed to put resident R#73's medication, from the pharmacy labeled bag, into the medication cup. However, one medication pill popped out of the medication cup and landed on the top of the medication cart. LPN AA picked up the pill with her bare hand and placed it back into the medication cup. Interview on 10/4/18 11:17 a.m. with the Director of Nursing (DON) revealed that the nurse should have put on gloves before picking up a medication that fell on to the medication cart and should not have picked it up with their bare hand.",2020-09-01
1718,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2016-10-14,225,D,0,1,5ZK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview and staff interviews, the facility failed to thoroughly investigate an injury of unknown origin for 1 of 28 sampled residents (R) 32. A family member (F) reported to the Director of Nursing (DON) that R32 had a bruise of unknown origin; however, the DON failed to ensure the injury of unknown origin was reported and thoroughly investigated. Findings include: During an interview on 10/12/16 at 1:40 p.m. with family member (F) 2 she stated that on 7/7/16 she and her daughter noticed that R32 had a new bruise under her right chin going up the jaw that was not there the day before. She stated that they reported it to the Director of Nursing (DON) and their sister F1 who is also a housekeeper at the facility. They were told by F1 a few days later that it was due to her [MEDICATION NAME] use and her laying on her hand in bed. The family stated that the facility staff would not discuss the incident or show them any documentation regarding the investigation. The family was concerned as they did not believe that the resident was receiving [MEDICATION NAME]. F2 showed a picture to this writer of the bruising but there was no corresponding date with the photo. During an interview on 10/13/2016 12:47 p.m. with F1 who is also an employee of the facility she stated, that her mom had a bruise on her chin from when she first came in. She had a small bruise later that her niece had asked her about. F1 stated that she just believed the bruise was related to her mom being restless and always moving. According to F2, R32 bruises easily because she is on blood thinner medication. Record Review: Review of the (MONTH) (YEAR) physician orders [REDACTED]. The admission Minimum Data Set (MDS - a comprehensive assessment completed by facility staff that drives the care planning process), with an Assessment Reference Date (ARD) of 7/6/16, documented resident #32 (R32) had clear speech (B0600), she and sometimes understood others (B0800). The MDS did not address R32 [DIAGNOSES REDACTED]. She was given a score of 99 on the Brief Interview for Mental Status (BIMS) which indicated she was unable to complete the interview. Section N0410 E. documented that R32 has received an anticoagulant for the last 7 days. Review of the 10/11/16 care plan documented the following pertinent information: Problem: Anticoagulant use; resident is at risk for increased bruising. Bleeding, and other complications related to use of anticoagulants. Goal: Resident will obtain therapeutic effect of anticoagulant without complication such as bleeding or bruising. Interventions: Monitor resident closely for signs of active bleeding-nosebleeds, bleeding gums, petechiae, purpura, ecchymotic (bruised) areas, and blood in urine or stool. Protect resident from injury by handling resident gently. Review of the nurses progress notes dated 6/29/16 through 8/5/16 documented that the residents skin was warm and dry to the touch, there was no documentation regarding bruising to the resident's chin. Review of the incident/investigations reports on 10/13/16 provided by medical records technician revealed that there were no incident/investigation reports found for R32 for the entire month of (MONTH) (YEAR). On 10/13/2016 12:05 p.m. Licensed Practical Nurse (LPN4) stated that she has worked with R32 since her admission and she was not aware of any facial bruising, and if the resident had any bruising, the staff would have reported it. During an interview with the DON on 10/14/16 at 8:27 a.m. she stated that it was brought to her attention by the family of R32 that the resident had a bruise under her chin. The DON stated that she did not complete and incident report, did not report the injury of unknown cause to the state agency and she did not interview other residents or staff members. The DON said she went into room of R32 and determined that due to the resident's hand position in bed and her use of [MEDICATION NAME] that the bruising was caused by pressure from the resident sleeping with her hand under her chin. When asked if she completed an incident report/investigation, she stated that she did not but should have, based on the facilities policy. She also confirmed that she did not document her findings anywhere so there was no evidence proving that the DON had looked into and fully addressed the report made by the family about the bruise under R32's chin. Facility policy titled, Abuse Prohibition Policy and Procedures revised (MONTH) (YEAR) stated in pertinent part; Policy intent .Whenever a resident, family member or anyone else makes a complaint on behalf of the resident that alleges abuse, corporate punishment, involuntary seclusion, neglect, mistreatment, misappropriation of resident property, or exploitation has occurred, the procedures listed in this policy will be adhered to .10. Injuries of Unknown Source: An injury for which both of the following conditions are met: a. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident .Procedure: 5. Reporting: [NAME] Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property 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. 2. The initial report of the incident will be telephoned or faxed within 24 hours of discovery to the Complaint Investigation Intake and Referral Unit. Prior to calling in the incident, the facility Complaint Report Fax Form will be completed. B. 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 the investigation information: a) Details of the incident and injury; b) Signed statements from pertinent parties; c) Cognitive status of the victim(s) and resident(s) who are witnesses; (Are they alert, oriented, and able to answer questions appropriately this would help in determining if she/he would be a credible witness and able to testify.) d) Information gathered from the investigation; e) Action taken by the facility- safeguarding the resident and preventing a reoccurrence. The final action/conclusion made by the facility .",2020-09-01
1719,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2016-10-14,226,D,0,1,5ZK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement their Abuse Prohibition policy for 1 of 28 sampled residents (R) 32 related to reporting and investigating a resident injury of unknown source. On 7/716, a bruise was discovered on R32's chin, the facility failed to report and investigate the injury of unknown source in accordance with the facility's policy. Findings Include: During an interview on 10/12/16 at 1:40 p.m. with family member (F) 2 she stated that on 7/7/16 R32 had a new bruise under her right chin going up the jaw. According to F2, the bruise was reported it to the Director of Nursing (DON Review of the incident/investigations reports on 10/13/16 provided by the medical records technician revealed that there were no incident/investigation reports found for R32 for the entire month of (MONTH) (YEAR). During an interview with the DON on 10/14/16 at 8:27 a.m. the DON stated R32's family had told her about a bruise under the resident's chin. The DON stated that she did not complete and incident report, did not report the bruise/injury of unknown origin to the state agency, nor did she interview other residents or staff members. The DON said went into the room of R32 and determined that due to the resident's hand position in bed and the use of [MEDICATION NAME] that the bruising was caused by pressure from the resident sleeping with her hand under her chin. When asked if she completed an incident report/investigation, she stated that she did not but should have, based on the facilities policy. She also confirmed that she did not document her findings anywhere so there was no evidence proving that the DON had looked into and fully addressed the report made by the family about the bruise under R32's chin. Review of the a policy provided by the medical records technician on 10/13/16 titled, Abuse Prohibition Policy and Procedures revised (MONTH) (YEAR) stated in pertinent part; Policy intent .Whenever a resident, family member or anyone else makes a complain on behalf of the resident that alleges abuse .the procedures listed in this policy will be adhered to .10. Injuries of Unknown Source: An injury for which both of the following conditions are met: a. the source of the injury was not observed by any person or the source of the injury could not be explained by the resident .Procedure: 5. Reporting: [NAME] Once a complaint or situation is identified involving alleged mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property the incident will be immediately reported . B. 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 the investigation information: a) Details of the incident and injury; b) Signed statements from pertinent parties; c) Cognitive status of the victim(s) and resident(s) who are witnesses;(Are they alert, oriented, and able to answer questions appropriately this would help in determining if she/he would be a credible witness and able to testify.) d) Information gathered from the investigation; e) Action taken by the facility- safeguarding the resident and preventing a reoccurrence. The final action/conclusion made by the facility .",2020-09-01
1720,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2016-10-14,241,D,0,1,5ZK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a resident's dignity in that one resident (R) (R22) in the sample of 28 was observed wearing wet pants for one and one half hours without staff intervention and assistance with changing his clothing. Findings include: On 10/10/16 at 11:45 a.m., R22 was observed in his wheelchair wearing pants that were noticeably wet from his groin area down the entire right pant leg. R22 was a below the knee [MEDICAL CONDITION] and the bottom portion of the right pants leg was tucked and folded underneath his thigh. R22 clothing emitted a strong urine odor. R22 wheeled his wheelchair past the nurse's station where LPN9 and LPN10 were seated and both nurses were observed to make eye contact with R22, however, neither nurse intervened and assisted R22 with changing his wet pants. On 10/10/16 at 12:15 p.m., R22 was observed to wheel himself into the dining room. His right pant leg was still noticeably wet and smelled of urine. Certified Nursing Assistant (CNA) 1 pushed R22 to the table and placed a clothing protector on him from behind. CNA1 did not offer to assist R22 with changing his pants. R22 began to leave the dining room at 1:00 p.m. CNA1 took off the clothing protector and did not offer any assistance with changing his pants. The resident wheeled himself out of the dining room. R4 noticed the pants leg for R22 was wet and indicated that he would find staff to assist him. LPN7 approached R22 and confirmed that the residents pants were noticeably wet. LPN7 assisted the resident to his room. R22 wore the wet pants approximately until 1:15 p.m. at which time a nurse aid came to R22's room to assist with changing his pants. Review of the medical record for R22 revealed he was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. The Annual Minimum Data Set, for R22, dated for 8/9/16 revealed a Brief Interview for Mental status (BIMs) score of 7 which indicated that R22 showed cognitively impairment. Physician ordersfor R22 dated for (MONTH) (YEAR) revealed an order for [REDACTED].>On 10/14/16 at 8:16 a.m., during an interview, LPN6 was asked how often staff should be checking R22. LPN6 stated that, CNAs should be checking every 2 hours whether the resident is on the second floor or downstairs. She also stated that, He is usually alert and can tell you but, staff should have noticed him during that amount of time. On 10/14/16 at 8:22 a.m., during an interview, LPN1 stated that the residen' s bag had come undone. LPN1 further stated, CNAs and nurses should have noticed that he was wet and emitted an odor. She further stated that it did not matter who his assigned staff was for that day, we are all responsible. On 10/14/16 at 9:13 a.m., during an interview, the Director of Nursing (DON) stated that her expectation was to check residents frequently, every 2 hours if not more. She stated that she would have expected the staff to have noticed his wet pants and the urine odor within the hour and half. Review of the undated policy titled, Dignity of Residents revealed, Policy: It is the policy of this facility to provide care and services in a manner which protects the dignity and rights of each resident.",2020-09-01
1721,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2016-10-14,253,E,0,1,5ZK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, family and staff interviews, and facility policy review, the facility failed to maintain an environment that was clean, in good repair and free of odors for 12 residents (R63, R29, R170, R5, R7 R119, R70, R113, R85, R99, R32, and R47) out of a sample of 28; for 1 of 4 hallways (100 hallway) and for 1 of 2 dining rooms (2nd floor dining room.) Findings include: Initial tour observations of the 100 halls on 10/10/16 at 9:20 a.m. revealed that down both hallways, the walls were marred, dirt build up around the cove base, cracked flooring usually around the residents' doorways leading into their rooms and missing cove base along the wall. The bathroom floor for R63 floor was dirty, with dried yellow build up in the caulking around the toilet. The closet and bathroom doors had missing varnish. The bedroom for R29 revealed that there was a missing threshold piece which separated the hall floor from the bedroom floor. The crack between the hall and entry way was filled with dirt. Stage I Observations: On 10/11/16 at 10:08 a.m., the bedroom for R32 revealed many scraps and holes in the walls, particularly behind the bed, missing varnish on the closet and entry door, reddish stains behind the toilet, dirty caulking around the toilet and the bathroom was in needed to be painted. On 10/12/16 at 2:08 p.m. family member of R32, F2, stated that the rooms are horrible. In R32's the room R32 had previously there were holes in the ceiling and currently her room needs to be painted as well as the bathroom. She discussed the cracks in the floor, the old bathroom floor and she felt staff did not clean the resident's bedroom and bathroom very well. On 10/11/16 at 10:46 a.m. The room for R47 was observed. The walls were marred and the floor was cracked by the doorway. The bathroom had old flooring which showed white/greyish wear marks, the caulking was dirty around the base of the toilet and around the wall. On 10/11/16 at 10:36 a.m. R47 stated that the building was old, and she felt that the cleanliness and up kept of the building had gone downhill in the last three years. The following was observed during Stage 1 survey conducted on 10/10/16: a. The room for R5 was observed at 3:19 p.m. and the bathroom had a strong urine smell. The following was observed during Stage 1 survey conducted on 10/11/16: a. The room for R119 was observed at 11:47 a.m. and the bathroom had a strong urine smell. The outside of the toilet bowl was discolored with a brown grime. The following observations and interviews were conducted during the environmental/housekeeping tour which was conducted on 10/13/16 at 4:00 p.m.: a. The tour began with an observation of the second floor dining/activity room. There were large ceiling to floor windows that covered seventy five percent of the wall in this room. The threshold of the windows had a thick brown and yellow substance on the bottom of each window sill. Per the Director of Housekeeping, these window sills should be cleaned once a day. b. The bathroom for R170, R70, R113, and R85 had a strong urine smell. Around the base of the porcelain toilet was a wax build up. Per interview with the Director of Housekeeping, housekeeping staff should scrape this area on a daily basis. c. The bathrooms for R5 and R99 had a strong urine smell. The toilet seat in the bathroom for R99 was lifted by the Housekeeping Director and there was a large, dried yellow stain under the toilet seat. Per the Maintenance Director, the toilet seat also needed to be replaced since the spacers under the lid were damaged. The Director of Housekeeping stated that there was heavy wax build up and grout on the floor and around the base of the toilet that needed to be removed. The grout and wax build up was stained yellow. d. The bathroom toilet for R70 had a thick coat of grime on top of the porcelain base. There were yellow splatter stains on the wall behind the toilet. The Director of Housekeeping lifted the toilet seat and the spacers underneath were observed to be damaged and/or broken. Dried yellow stains were observed under the toilet lid and black grime was observed around the rim inside the toilet bowl. e. The bathroom for R7 had dried yellow stains on the outside of the toilet and the toilet base. There was heavy wax build up and caulking around the base of the toilet. An interview was conducted with the Administrator on 10/14/16 at 8:45 a.m. The Administrator stated that he wants to do the best but the residents were living in a [AGE] year old building. The Administrator stated that in the past, he has spoken with his staff to do better. A facility's undated policy titled, Housekeeping Policy & Procedures the policy noted that service areas included resident rooms and bathrooms. Under a heading titled Washrooms and Bathrooms the housekeeping staff is to .Clean and sanitize lavatory and toilet bowls and lids inside and out with a germicidal solution .Wet clean floors with a germicidal solution .",2020-09-01
1722,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2016-10-14,329,D,0,1,5ZK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy review, the facility failed to ensure that 1 resident (R) 103 out of 28 sample residents level of pain was assessed prior to the administration of pain medication to ensure the necessity of the use of the pain medication. Findings include: Per clinical record review, it was indicated that R103 was admitted to the facility 4/11/16 with [MEDICAL CONDITION]. Review of the care plan dated 4/29/16, identified a goal for R103 that the resident would have pain relief with present medications and the intervention identified was Evaluate response and efficacy of medication . A physician's orders [REDACTED]. This narcotic was to be administered for greater pain. Review of the quarterly Minimum Data Set (MDS) assessment, dated 7/18/16, Section J identified that the resident had pain almost constantly. A review was conducted of the Medication Administration Record (MAR) for (MONTH) and (MONTH) (YEAR) as well as the corresponding Nurses' Notes. The resident was administered [MEDICATION NAME]/APAP on the following dates: a. On the MAR for 8/1/16 at 6:00 a.m., 5:30 p.m., and at 9:30 p.m.: There were no entries documented on the MAR to indicate what level of pain the resident experienced prior to the administration of the [MEDICATION NAME]. The Nurse's Notes contained no documentation of a pain scale rating for this date. b. On the MAR for 8/5/16 at 5:20 a.m.: There were no entries documented on the MAR to indicate what level of pain the resident experienced prior to the administration of the [MEDICATION NAME]. The Nurse's Notes contained no documentation of a pain scale rating for this date. c. On the MAR for 8/7/16 at 3:00 a.m., and at 8:45 a.m.: There were no entries documented on the MAR to indicate what level of pain the resident experienced prior to the administration of the [MEDICATION NAME]. The Nurse's Notes contained no documentation of a pain scale rating for this date. d. On the MAR for 9/6/16 at 12:00 a.m. and at 6:00 a.m.: There were no entries documented on the MAR to indicate what level of pain the resident experienced prior to the administration of the [MEDICATION NAME]. The Nurse's Notes contained no documentation of a pain scale rating for this date. e. On the MAR for 9/12/16 at 4:00 a.m. and at 11:00 a.m.: There were no entries documented on the MAR to indicate what level of pain the resident experienced prior to the administration of the [MEDICATION NAME]. The Nurse's Notes contained no documentation of a pain scale rating for this date. An interview was conducted with the Director of Nursing (DON) on 10/14/16 at 8:45 a.m. The DON stated that the standard of care for pain assessments were to use a pain scale of 1 to 10. The number 10, as the worse pain identified. She went onto state that she used the Wong Baker pain scale to identify pain for residents. A facility policy entitled, Pain Assessment and Management dated 3/1/12, identified .Residents who experience pain receive a comprehensive pain assessment .A pain scale is used when having the resident describe his/her pain and amount of pain .severity (must use pain scale) .",2020-09-01
1723,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2016-10-14,356,B,0,1,5ZK111,"Based on observation and staff interview, the facility failed to ensure required nurse staffing information, was updated daily for 4 of 7 days and posted at the beginning of each shift in a location that was easily accessible to residents and visitors. Findings include: During the initial tour on 10/10/16 at 9:20 a.m., the nursing staff information was observed posted in the first floor hallway leading to the 100 even number rooms across from the nursing station. There was a nurse staffing form which had the staffing completed for 10/5/16 and 10/6/16. The form was not completed daily. The following dates were left blank 10/7/16, 10/8/16, 10/9/16, and 10/10/16. During an interview on 10/10/16 at 12:45 p.m. with the Director of Nursing (DON) she stated the nurse staffing totals would always be a day behind due to having call offs and to ensure the daily nurse staffing sheet was accurate she completed them the next day not the same day. The DON stated she used the staffing book located on the front desk to complete the nurse staffing information for the days when she was not present at the facility. According to the DON, she not familiar with the regulation regarding nurse staffing posting daily.",2020-09-01
1724,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2016-10-14,431,D,0,1,5ZK111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy and procedure, the facility failed to ensure 1 of 2 treatment carts on the second floor were locked. The deficient practice had the potential to affect one resident R (78) identified as cognitively impaired and ambulatory who was seen in the immediate area. Findings include: On 10/11/16 at 5:30 p.m. the second floor treatment cart was observed unlocked and unattended. The following items were observed in the treatment cart; nail clippers, prescribed ointment for R23, Nystatin cream (used to treat yeast infections) for R59 and Cetaphil cream (moisturizer) for R5. There was a cognitively impaired resident near the treatment cart. On 10/11/16 at 5:30 p.m. resident seventy-eight (R78) was observed sitting in her wheelchair which she was able to self-propel across from the treatment cart. Her quarterly Minimum Data Set ((MDS) dated [DATE] identified that the resident scored a 6/15 on the Brief Interview for Mental Status (BIMS) which identified that the resident had severe/moderate cognitive impairment. Review of the product information on Nystatin cream on the website Drug.com indicated Nystatin cream could be harmful if swallowed. On 10/11/16 at 5:35 p.m. Licensed Practical Nurse (LPN8) stated that the treatment cart was everyone's responsibility to make sure it is locked. She stated that it was the facilities policy that the treatment cart be locked when not being attended. On 10/11/16 at 5:36 p.m. LPN7 stated that there was one treatment cart for the entire second floor. She stated that the treatment cart should always be locked when not attended. The Medication Storage Policy, reviewed and updated (MONTH) 2012, listed under Procedural Guidelines #2. Only Licensed nurses, the consultant pharmacist, and those lawfully authorized to administer medications are allowed to access medication. Mediation rooms, carts and medication supplies are locked and attended by persons with authorized access.",2020-09-01
1725,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2016-10-14,441,D,0,1,5ZK111,"Based on observation, interview and policy review, the facility failed to assure that 2 of 2 (CNA 3 and CNA6) nursing staff prevented the clean clothing protectors from being contaminated during the transportation of linen. Findings include: On 10/10/16 at 12:05 p.m., during an observation, Certified Nursing Assistant (CNA) 3 entered the dining room carrying the clothing protectors pressed against her chest and her uniform. On 10/11/16 at 4:50 p.m., during an observation, CNA6 entered the dining room carrying the clothing protectors that were pressed against her chest and her uniform. On 10/13/16 at 3:08 p.m., during an interview, the Restorative Supervisor stated, Staff should have known better than carry clothing protectors pressed against their chest and their uniform. On 10/14/16 at 9:20 a.m., during an interview, the Director of Nursing (DON) stated, Linens are to be transported away from the body. It is basic training from school. Review of the undated policy titled Linen Handling reads, Policy: It is the policy of Azalea Trace Nursing Center to handle linen using standard/ universal precautions to prevent and control infection transmission. Procedure: . 2. Employees are instructed to hold resident linen, both clean and soiled, without touching the employee's body or clothing.",2020-09-01
1726,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2017-11-16,156,B,0,1,NUQ511,"Based on record review, resident interview, and staff interview the facility failed to ensure that resident's rights were reviewed with residents throughout the duration of their stay at the facility. The facility census was 100 with a sample size of 32. Findings include: Review of resident council minutes for (YEAR) revealed that there was no indication that resident rights were being discussed with residents during council meetings. Interview on 11/16/17 at 9:27 a.m. with the Resident council president who reported that resident rights are not discussed and she is not aware of where the rights are posted. Interview on 11/16/17 at 9:40 a.m. with Resident (R) #2 who reported that staff do not talk about resident's rights on a regular basis. R#2 reported that no one has asked her if she wants to attend a resident council meeting. R#2 further stated that she is aware a little of her rights but it has been a while since they were discussed. R#2 reported being a resident at this facility for more than two (2) years. Interview on 11/16/17 at 9:44 a.m. with R#34 who reported that resident rights were discussed at admission but has not been discussed since. R#34 reported being a resident in the facility for about a year. Interview on 11/16/17 at 9:50 a.m. with the Admissions Director who confirmed that resident's rights are not discussed during resident council meetings but going forward she would discuss resident rights with residents. Admissions Director reported that she basically followed the template of the previous Admission Director regarding resident council meetings and notes. Admissions Director reported that now that she is aware that resident rights need to be discussed she will do so. Interview on 11/16/17 at 1:43 p.m. with R#89 who was unable to identify a time in which resident rights are discussed other than at admission. Interview on 11/16/17 at 5 p.m. with the Administrator who reported that he does not think it is correct that resident rights are not discussed. It was reported that previous Activity directors did discuss resident rights with residents during the resident council meetings.",2020-09-01
1727,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2017-11-16,371,F,0,1,NUQ511,"Based on observation, interviews and record review, the facility failed to discard outdated items in the reach in refrigerator and dry storage and failed to store food items in the dry storage in a sanitary manner. This deficient practice had the potential to affect 90 of 100 residents receiving an oral diet. Findings include: Review of the Food Service Policy and Procedure: Receiving and Storing Perishable, Non-Perishable Foods, Dry Storage with no creation or revision date revealed that each item will be monitored weekly for date of expiration and/or damaged; dented cans, as they are received, will be discarded; at no time will products be left on the floor within the dry storage room or area; heavy items such as sugar will be stowed on the bottom shelf to prevent unnecessary strain. Observation on 11/13/17 at 10:22 a.m. during the initial kitchen tour revealed the following expired items located in the Reach in refrigerator: one container of Fresh Salad expired on 11/3/17; four containers of Quality Deli Salad expired on 11/6/17 and two containers of barbeque sauce expired 11/6/17. Continued observation at 10:30 a.m. revealed the following expired items located in the dry storage area: two cans of Chicken and Rice Soup expired on 9/23/17 and one gallon of Red Hot Buffalo Sauce with a best by date of (MONTH) (YEAR). Other observations at this time included sugar bin sitting on the floor with lid open while staff in dry storage unpacking boxes; and Light Chunk Tuna can dented on the shelf with good cans. During an interview on 11/13/17 at 10:40 a.m., the dietary manager (DM) stated that she felt that the items in the reach in cooler were still good because they had been frozen. She also stated that no dented cans should be accepted off the delivery truck and she was unaware of why the dented can was on the shelf to use. Further interview with the DM on 11/16/17 at 11:33 a.m. revealed that the following items were discarded due to being out of date: chicken salad, buffalo sauce, chicken and rice can soups and pasta salad. She stated that the staff member responsible for monitoring for expired items is new to the kitchen and used to be a certified nursing assistant (CNA). She stated that he checks for expired items on Monday, Wednesday and Friday when the delivery truck comes. Interview with the Administrator on 11/16/17 at 3:30 p.m. revealed that his expectation is for items to be used prior to the expiration date and that pasta salad and/or chicken salad should not be put in the freezer.",2020-09-01
1728,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2017-11-16,441,F,0,1,NUQ511,"Based on observation and staff interview the facility failed to assure the sanitary storage of clean linens as evidenced by staff personal items being stored on top of linens in the clean linen carts in two of four clean linen carts on 200 hall. The facility census was 100 and the sample size was 32. Findings include: Observation on 11/13/17 at 3:20 p.m. revealed two (2) Zaxby's cups, one (1) blue bag sitting on linens in linen cart on 200 hall. In a second linen cart there was a camouflage bag sitting on top of clean linens in the linen cart. Observation on 11/14/17 at 3:05 p.m. revealed one (1) brown bag sitting on top of clean linens on 200 hall. Observation on 11/15/17 at 3:37 p.m. with Director of Nursing (DON) who observed two (2) cartons of orange juice sitting on clean linens in the clean linen cart that was outside of the clean linen room for 200 hall. Observation of a second linen cart revealed a maroon [NAME]et lying on top of clean linens. DON was unsure if the [NAME]et belonged to staff or a resident but reported either way it should not have been stored on the linen cart. DON reported that staff have been informed that items should not be stored on the clean linen cart. There are a total of four clean linen carts on 200 hall of which 2 of the four had items on them. Interview on 11/16/17 at 5 p.m. with the Administrator revealed that having personal items on linen carts has been discussed in staff meetings before and personal items should not be kept on the linen carts.",2020-09-01
5178,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2015-06-18,441,E,0,1,5FSN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review the facility failed to ensure that staff sanitized their hands between serving residents' meal trays on two (2) of two (2) floors, and in one (1) of two (2) dining rooms during three (3) dining observations with eighty-eight (88) of one hundred-three (103) residents receiving oral alimentation with a census sample size of twenty-seven (27.) Findings include: Observation in the ADAP Dining Room on 06/15/15 at 12:02 p.m. revealed that Certified Nursing Assistant (CNA) CC touched a resident's arms and proceeded to serve and set-up next resident's tray without sanitizing their hands. The CNA touched a second resident's arm and proceeded to set up that resident's tray, without sanitizing their hands. CNA CC approached and touched a third resident's shoulder and wheelchair then served and set up the meal tray for the resident, still without sanitizing their hands. Observation in ADAP Dining room [ROOM NUMBER]/15/15 at 12:06 p.m.showed that CNA CC touched a fourth resident on the leg and continued to serve and set-up trays. Observation in ADAP Dining Room on 06/15/15 at 12:05 p.m. showed that CNA DD touched a rolling bedside table and then served and set-up two resident trays and never sanitized or washed their hands. Observation of meal pass on 06/18/2015 at 07:35 a.m. on the second floor showed that CNA AA touched her clothes and served and set-up a meal tray without sanitizing their hands. Interview with CNA AA on 06/18/15 at 08:45 a.m. revealed that she was unaware of having touched her clothing. Observation of meal pass on 06/18/15 07:40 a.m. on the second floor showed that CNA BB served a tray to a resident, pulled the resident up in bed, did not sanitize and continued to set-up the tray. Interview with CNA BB on 06/18/15 at 08:24 a.m. confirmed that she did serve the resident a tray, then pulled resident up in bed and without sanitizing her hands, continued setting up resident's meal tray. Observation of breakfast tray pass on the first floor on 06/18/15 from 07:45 AM - 08:00 a.m. revealed CNA EE to remove a tray from the cart and deliver it to a resident's room. CNA EE was then observed setting up the tray which included removing the lid from the plate and using the utensils to prepare the food. After leaving the room CNA EE was then observed removing another tray and without using any hand sanitizer he/she knocked on another resident's door, and delivered the tray to the resident. CNA EE was then observed to remove lid from plate and set it aside. Without using any hand sanitizer, CNA EE was then observed removing his/her third tray and delivering this tray to a third resident. For this third resident, CNA EE was observed to set the tray on the over the bed table then walk to the side of the bed and placed both of his/her hands on the resident's shoulders and re-positioned resident. CNA EE then picked up the bed control and repositioned the bed. CNA EE, without using any hand sanitizer, was then observed to set up resident's breakfast tray, removing the lid, open the silverware, open the milk, open the straw and touch the straw at both ends and in the middle, and then place the straw in the cup. CNA EE was then observed to set up the remainder of resident's breakfast. Interview on 06/18/25 at 8:58 a.m. with CNA EE confirmed that she delivered and set up meals for three (3) residents while also providing repositioning and did not wash or sanitize her hands. Review of Policy showed that hands are to be washed or sanitized before and after contact with residents or any source of contamination. Interview with Director of Nurses on 06/18/15 at 09:00 a.m. revealed she had in-serviced all the CNAs the first week in (MONTH) and that she expected staff to wash or sanitize hands before and after resident contact.",2018-12-01
5179,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2015-06-18,456,E,0,1,5FSN11,"Based on observation, staff interview and review of facility policy, the facility failed to maintain snack refrigerator temperatures in such a way as to prevent food-borne illness on one (1) of two (2) floors. Census in facility was one hundred-three (103), with eighty-eight (88) residents on oral alimentation. Findings include: Observation on 06/18/15 at 1:15 p.m. revealed the snack refrigerator on second floor was 52 degrees Farenheit and that the snack refrigerator in ADAP Dining Room did not have a thermometer. The temperature was not being monitored. These findings were confirmed by Registered Nurse HH. Review of the facility policy showed that temperatures in refrigerators are to be monitored daily and are to be kept between 36 and 46 degrees Farenheit. Observation and interview on 06/18/15 at 2:30 p.m. with Head of Maintenance and Housekeeping confirmed that temperature by laser thermometer in ADAP Dining Room was 46.5 degrees Farenheit and the second floor snack refrigerator was 49 degrees Farenheit. Observation with the Dietary Manager on 06/18/15 at 2:55 p.m. confirmed that when the temperature of thickened water, stored in refrigerator on ADAP unit, was measured by Dietary Manager it was confirmed to be 43 degrees Farenheit. Temperature in snack refrigerator on second floor confirmed by Dietary Manager to be 49 degrees Farenheit by measuring the temperature of a box of Fiber Source Liquid stored in the refrigerator. Interview with the Director of Nurses (DON) on 06/18/15 at 1:30 p.m. confirmed that the refrigerators are to be monitored daily for temperature.",2018-12-01
5180,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2015-12-16,441,D,1,0,TMY811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record reviews, review of a written statement by licensed staff and review of the facility ' s Infection Control Policy and the Line Listing of Resident Infections (LLRI), it was determined that the facility had failed to ensure that the surveillance data was complete and accurate for three (3) residents (#1, #5 and #6), from a total sample of eight (8) residents. Findings include: 1. Record review for resident #1 revealed that the resident 's plan of care for skin impairments documented that the resident had blisters on the left abdomen and thigh on 11-14-15 and on the pubic area and irritation under right breast fold on 11-15-15, with interventions and orders to treat with Calzine lotion. The plan of care documented on 11-27-15 that the resident had blisters to the neck. It also documented that the resident ' s family had escorted the resident to the emergency room for evaluation of the blisters. A wound culture was performed on 11-27-15, with results reported on 11-30-15, which indicated moderate growth of Methicillin Resistant Staph Aureus (MRSA) and Proteus Mirabilis. The interventions for 11-30-15 included to obtain consult for infectious disease Physician per physician's order [REDACTED]. The Physician ordered on 12-1-5 [MEDICATION NAME] 50 milligrams (mg.) three times a day (tid) for ten days and [MEDICATION NAME] intravenously (IV) for ten days. Review of the LLRI for (MONTH) (YEAR) revealed that the facility failed to completely and accurately document findings on the LLRI as follows. Under the symptoms and date, there were no symptoms or dates documented, only the notation of the organisms, MRSA (wound culture) and Proteus Mirabilis (wound culture). There was no documentation in the section for other actions (if needed), nor clarification if the infection was healthcare associated infection (HAI) or community acquired infection (CAI). The admitted for the resident was inaccurate, with a date 11-28-15, instead of the 4-3-2013 date of admission. 2. Record review of the nurses' notes for resident #5 revealed that on 9-30-15 at 1:30 pm, he/she had symptoms of an elevated temperature of 101.3 degrees Fahrenheit (F.), unable to tolerate by mouth intake, gags each time. The Physician ordered for the resident to be sent to the hospital for evaluation on 9-30-15. The resident was admitted to the hospital on 9-30-15 and was discharged back to the facility on [DATE] with a discharge [DIAGNOSES REDACTED]. Review of the LLRI for (MONTH) (YEAR) revealed that the facility failed to completely and accurately document findings on the LLRI as follows. Under the symptoms and date, there were no symptoms listed, only the final [DIAGNOSES REDACTED]. The admitted for the resident was inaccurate, with a date 10-06-15, instead of the 9-22-15 date of admission. On 10-14-15 at 8:10 a.m., nurses' notes, it was documented that the resident had nausea and vomiting times one, poor appetite and difficulty swallowing. The Physician was called and ordered to send to the emergency room . The resident was returned to the facility on [DATE] with a [DIAGNOSES REDACTED]. one tablet twice a day (bid) for ten (10) days. Review of the LLRI for (MONTH) (YEAR) revealed that the facility failed to completely and accurately document findings on the LLRI as follows. Under the symptoms and date, there were no symptoms or date listed, only the final [DIAGNOSES REDACTED]. The admitted for the resident was inaccurate, with a date of 10-14-15 noted under admitted , instead of the 9-22-15 date of admission. Also, the facility did not have the results of the 10-14-15 urinalysis or culture reports from the hospital, during the 12-15-15 and 12-16-15 complaint survey. On 10-20-15 at 9:00 am nurses' note, it was documented that the resident refused to eat or drink. On 10-20-15, the Physician was called and ordered for the resident to be sent to the hospital. The resident was admitted to the hospital on 10-20-15 and returned to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the LLRI for (MONTH) (YEAR) revealed that the facility failed to completely and accurately document findings on the LLRI as follows. Under the symptoms and date, there were no symptoms listed, only the final [DIAGNOSES REDACTED]. There was no documentation of the cultures, with dates/time or source. The admitted for the resident was inaccurate, with a date 11-06-15, instead of the 9-22-15 date of admission. 3. Record review for resident #6 revealed a 10-2-15 nurses note that the resident started an antibiotic related to eye infection, eye red, with order [MEDICATION NAME] 0.3% two drops every two hours to the left eye. Review of the LLRI for (MONTH) (YEAR) revealed that the facility failed to completely and accurately document findings on the LLRI as follows. There was no documentation in the section for other actions (if needed), nor clarification if the infection was HAI or CAI. The admitted for the resident was inaccurate, with a date 10-02-15, instead of the 3-02-15 date of admission. Further record review for resident #6 revealed a 09-25-15 at 10:00 p.m. nurses note that the resident started an antibiotic for infection left leg. A written statement by the Infection Control Licensed Nurse on 12-16-15 acknowledged that the resident was observed on 9-25-15 with the Nurse Practitioner to have a left lower leg that was red, warm and swollen. Review of the LLRI for (MONTH) (YEAR) revealed that the facility failed to completely and accurately document findings on the LLRI as follows. Under the symptoms and date, there were no symptoms or date listed, only the final [DIAGNOSES REDACTED]. There was no documentation in the section for other actions (if needed), nor clarification if the infection was HAI or CAI. The admitted for the resident was inaccurate, with a date 09-22-15, instead of the 3-02-15 date of admission.",2018-12-01
6382,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2014-04-10,161,D,0,1,D9ZT11,"Based on record review and staff interview the facility failed to secure resident funds with the appropriate amount to cover balances recorded on the facility ledger and end of month balances of the resident funds for four (4) of the six (6) months of balances reviewed. Findings include: The facility surety bond is for the amount of $45,000. The resident trust fund balance for October 2013, December 2013, January 2014 and February 2014 exceeded $45,000.00. An interview on 4/10/14 at 9:40 a.m. with the facility bookkeeper revealed that the corporate office reconciled the statements every month but had not addressed the bond issue.",2018-01-01
6383,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2014-04-10,371,D,0,1,D9ZT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of records and staff interviews, The facility failed to ensure that enteral feeding formula was not expired with sixteen (16) residents receiving enteral feeding diets. The facility census was one-hundred and six (106) residents, and the sample size was thirty-four (34). Findings include: Observation on 4/9/14 at 10:45 a.m. of the Medical storage panty located on the first (1st) floor, revealed that there was one (1) case of [MEDICATION NAME] Tube Feeding Nutritional Formula; eight (8) individual servings of [MEDICATION NAME] Tube Feeding Nutritional Formula 250 milliliter (ml) on the shelf; and four(4) individual servings of [MEDICATION NAME] Tube Feeding Nutritional Formula 250 ml in refrigerator, all of which expired on 1/28/14. Observation on 4/9/14 at 11:00 a.m. of the Main Medical Supply Storage area revealed that there were two (2) cases of [MEDICATION NAME] Tube Feeding Nutritional Formula 250 ml with twenty four (24) individual servings in each case, all of which expired on 1/28/14; and two (2) cases of Diabetisource AC Tube Feeding Formula 1500 ml with six (6) individual servings in each case, all of which expired on 12/9/13. Review of the 4/7/14 resident enteral feeding list revealed the facility currently has sixteen (16) residents who were receiving nutritional formula through a gastrointestinal tube. An interview on 4/9/14 at 10:50 a.m. with Registered Nurse (RN) AA, nurse manger, who confirmed the tube feeding formulas were expired and stated the formulas should have been thrown away and not kept in the pantry. An interview on 4/9/14 at 11:10 a.m. with materials supervisor BB revealed that he is responsible for ordering the Enteral Feeding Formulas and confirmed the formulas were ordered were expired and should not be stored in the main supply room.",2018-01-01
6384,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2014-04-10,514,D,0,1,D9ZT11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to thoroughly and completely document the events leading up to and after the expiration of one (1) resident (#76) out of thirty four (34) sampled residents. Findings include: Review of the closed record for resident #76 revealed the resident expired at the facility on [DATE] at 7:20 a.m. although there was no certificate of pronouncement included in this closed record. An interview with the acting Director of Nursing on [DATE] at 11:30 a.m. revealed that the Pronouncement of Death should have been included with the documentation and could not be located.,2018-01-01
7792,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,157,D,0,1,66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy for Status Change Notification, and interviews with family and staff, it was determined that the facility failed to notify the responsible party in a timely manner about a significant change of condition and hospitalization for one resident (B) from a sample of 35 residents. Findings include: Licensed nursing staff documented in the 1/10/12 nurse's notes that resident B was transferred to the hospital at 12:45 p.m. and returned from the hospital on [DATE] at 3:00 p.m However, there was no evidence that the resident's responsible party was notified. During an interview on 7/24/12 at 10:51 a.m., the responsible party for resident B said that the facility had not notified him/her regarding any changes in the residents' condition. The responsible party stated that he/she had learned from another relative that resident B had been in the hospital in January 2012 . In an interview on 7/25/12 at 4:00 p.m., the Director of Nursing confirmed that the responsible party for resident B should have been notified about any significant changes or concerns.",2016-11-01
7793,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,160,D,0,1,66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to convey the balance of one resident's (#50) trust fund money within 30 days of his/her death in a sample of five residents. Findings include: On [DATE] at 1:48 p.m., Business office personnel verified that resident #50, who expired on [DATE], had a trust fund account balance of $859.29. She verified that resident #50's account had not been closed within thirty (30) days after resident expired.",2016-11-01
7794,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,246,D,0,1,66611,"Based on a resident and staff interview, record review and observations, it was determined that the facility failed to accommodate one resident's (C) likes and dislikes in a total sample of 35 residents. Findings include: During an interview on 7/24/12 at 8:47 a.m., resident C stated that, even after repeatedly telling staff that he/she did not drink apple juice, staff continued to serve her/him apple juice every morning instead of orange juice. Review of the resident's diet slip revealed staff had incorrectly documented that the resident liked apple juice. During an interview on 7/26/12 at 10:10 a.m., the dietary supervisor provided documentation regarding the breakfast likes of resident C which included two containers of orange juice, no coffee and no milk. He/she confirmed the information printed on the diet slip was inaccurate.",2016-11-01
7795,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,253,D,0,1,66611,"Based on observation and staff interview, it was determined that the facility failed to ensure a clean and comfortable environment as evidenced by a gouged bathroom door; missing baseboard; debris in an air conditioning vent; stained flooring; and a broken dresser drawer in a sample of five resident rooms (#220, #247, #139, #145 and #147) on both floors of the facility. Findings include: 1. On 07/23/12 at 2:01 p.m., the inner aspect of the hinged side of the wooden bathroom door in room 220 had several gouged, rough sections of wood at wheelchair height. Sections of the baseboard were missing between the hall and bathroom doors. 2. On 7/24/2012 at 10:07 a.m., there was a broken dresser drawer in room 247B. The top of the drawer was on the floor next to the wall. The resident's clothes, being stored in that drawer, were visible. During observation on 7/26/12 at 4:59 p.m., the Maintenance Director verified that the top of the dresser drawer was on the floor next to wall. The above observations were verified by the Maintenance Director on 07/26/12 at 4:25 p.m. During residents' rooms observations on 7/23/12 at 3:05 p.m. the following observations were made: 3. The air conditioner vent cover had a build up of dirt and debris in room #147. 4. The floor around the toilet had a build up of dirt and debris in room 139. There was a large brown stain on a ceiling tile near the window in the room.",2016-11-01
7796,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,278,D,0,1,66611,"Based on record review and staff interview, it was determined that the facility failed to accurately code one resident (#115) for the number of falls since their previous Minimum Data Set (MDS) assessment had been done in a total sample of 35 residents. Findings include: The MDS 3.0 User's Manual directed that, Any Falls Since Admission/Entry or Reentry or Prior Assessment (OBRA or Scheduled PPS), whichever was most recent was to be coded at J1800. However, the Minimum Data Set (MDS) Coordinator incorrectly used an unscheduled PPS assessment as the most recent prior assessment for resident #115. Licensed staff incorrectly coded resident #115 on the 5/15/12 significant change of status MDS assessment as having had one fall with no injuries since the prior 30-day MDS assessment on 04/13/12. However, a review of licensed nursing staff's documentation in the resident's Nurse's Notes revealed that the resident fell four times between those dates (on 04/14/12, 04/19/12, 04/20/12, and 04/24/12). On 07/26/12 at 9:54 a.m., the Registered Nurse (RN) MDS Coordinator stated that she had reviewed the Nurse's Notes back to the prior MDS assessment to determine how to code the number of falls on the current MDS. However, she had incorrectly used assessment information from an unscheduled Pay Per Services (PPS) assessment done on 4/21/12 for her information instead of the previous OBRA assessment of 4/13/12.",2016-11-01
7797,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,280,D,0,1,66611,"Based on observation, record review and staff interview, it was determined that the facility failed to revise the care plan to address the specific assistance needs with transfers for one resident (# 46) with the potential for falls, and failed to review the care plan interventions to maintain accuracy of the Nurse Aide's Information Sheet for one resident (#115) in a total sample of 35 residents. Findings include: 1. Resident #115 had a care plan since 3/19/12 to address his/her potential for falls. There was an intervention for the use of floor mats. On 3/26/12, an additional intervention was included for the use of bolsters on both sides of the resident's bed. There was documentation on the 5/21/12 care plan that that the resident had fallen on 3/18/12, 3/23/12, 3/24/12, 3/25/12, 3/28/12, 4/21/12, and 4/24/12. There was an intervention for the use of one-half siderail on the bed to assist the resident with turning and positioning. Review of previous care plans and the facility's Quality Improvement (QI) Falls Investigation Reports revealed no evidence that the resident's care plan was reviewed or revised following his/her falls on 4/05/12, 4/06/12, 4/12/12, 4/20/12, and 5/25/12. During observations on 7/23/12 at 2:49 p.m. and 7/24/12 at 3:50 p.m., the siderails on the resident's bed were not in the raised position. On 7/25/12 at 1:15 p.m., Certified Nursing Assistant (CNA) LL stated that she used the Nurse Aide's Information Sheet to know a resident's care needs. However, review of resident #115's undated Nurse Aide Information Sheet revealed that it did not include the use of bolsters on both sides of the bed or the use of mats on both sides of the bed. On 7/25/12 at 3:00 p.m., the Director of Nurses (DON) stated that when a resident fell , the nurse on duty was supposed to implement corrective actions immediately. He stated that, in the morning meetings, falls were discussed and interventions were reviewed or revised. On 7/26/12 at 9:54 a.m., the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator KK stated that she attended the morning meetings, and the care plan was revised at that time for falls. She said that siderails had not been used on the resident's bed since the use of a low bed was implemented (on 4/03/12) so, they should have been removed from the care plan. Despite having had eight falls between 4/03/12 and 7/10/12, the resident's care plan interventions continued to include the use of siderails. On 7/26/12 at 12:55 p.m., the DON stated that the weekend supervisor and staff nurses were supposed to check the Nurse Aide's Information Sheet for accuracy. He stated that the sheet should have included the use of bolsters instead of siderails. He added that, because the resident had right-side neglect, the original intervention had been to put the mat on the left side only. See F323 for additional information regarding resident #115. 2. The 6/04/10 MDS for the comprehensive assessment of resident #46 and the quarterly MDS assessments dated 3/8/12 and 12/31/11 coded the resident as needing extensive assistance of two or more people for transfers. There was a care plan with an original date of June 28, 2011 and updated on 9/21/11, 12/21/11, 1/16/12 and 3/13/12 to address the resident's needing assistance with all mobility and transfers. Review of licensed nursing staff's documentation in the nurses notes for resident #46 revealed that the resident had fallen on 1/16/12 and 5/20/12. During an interview on 7/26/12 at 3:35 p.m., CNA II stated that a one person assist was always used when transferring resident #46. However, that was contradictory to the resident's assessments since 6/04/10. During an interview on 7/26/12 at 3:37 p.m., the Registered Nurse unit manager AA confirmed that the resident's annual and quarterly MDS assessments were coded for a two or more person assist with transfers but, staff had not developed care plan interventions to reflect that. See F323 for additional information regarding resident #46.",2016-11-01
7798,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,281,D,0,1,66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to complete an initial plan of care on admission for one resident (#124) from a total sample of 35 residents. Findings include: Resident #124 was admitted on [DATE] with [DIAGNOSES REDACTED]. There was documentation that the resident's left AKA was because of gangrene and he/she had 23 staples in place. The resident went to [MEDICAL TREATMENT] three times a week. The resident had a peg tube in place for nutritional needs and had two, stage 2 sacral pressure ulcers. However, there was no evidence that staff had developed a plan of care to address the resident's needs. During an interview on 7/25/12 at 1:33 p.m., licensed nurse KK confirmed that the admitting nurse had failed to complete an initial care plan for the resident that described the care and services to be provided to meet his/her needs.",2016-11-01
7799,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,282,D,0,1,66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to implement care plan interventions to promote the safety of one resident (#115) with a history of repeated falls in a total sample of 35 residents. Findings include: Resident #115 had [DIAGNOSES REDACTED]. There was a care plan since 3/19/12 to address the resident's potential for falls. There were interventions for the use of one-half side rails on the resident's bed for turning and positioning, and floor mats on the floor (beside the bed). On 3/26/12, there was an added intervention for the staff to provide bolsters on both sides of the bed. Resident #115 was observed on 07/23/12 at 2:49 p.m. and 07/25/12 at 7:40 a.m. in a low bed with fall mats on each side of the bed. However, staff had not put bolsters on the bed. On 07/25/12 at 1:15 p.m., Certified Nursing Assistants (CNA) LL, MM, and NN were observed transferring the resident from the wheelchair to the bed. Two bolsters were observed in the middle section of each side of the bed. After the transfer, CNA LL stated that she frequently took care of resident #115, and had not seen bolsters on the bed before that day. At 2:50 p.m., Licensed Practical Nurse (LPN) Shift Coordinator OO stated that nursing staff had been told to put the bolsters on the bed that day. At 3:00 p.m., the Director of Nurses (DON) stated that the bolsters had been on the bed at one time but, he could not remember how long the bolsters had been off the resident's bed. He provided an invoice for two bolsters having been ordered on [DATE]. See F323 for additional information regarding resident #115.",2016-11-01
7800,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,323,D,0,1,66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to implement the use of an assistive device to help prevent falls from the bed for one resident (#115), to provide the assistance needed with transfers for two residents (#115, and # 46) in a total sample of 35 residents and to maintain secured toilet equipment to prevent a potentially hazardous environment in two rooms (225 and 145). Findings include: 1. a. Resident #115 had [DIAGNOSES REDACTED]. There was a care plan since 3/19/12 to address his/her potential for falls. There was an intervention for the use of floor mats. On 3/26/12, there was an additional intervention for the use of bolsters on both sides of the resident's bed. There was staff documentation on the 5/21/12 care plan that that the resident had fallen on 3/18/12, 3/23/12, 3/24/12, 3/25/12, 3/28/12, 4/21/12, and 4/24/12. There was an intervention since 3/19/12 for the use of one-half siderails on the resident's bed for turning and positioning. Review of previous care plans and the facility's Quality Improvement (QI) Falls Investigation Reports revealed no evidence that the staff had reviewed the effectiveness of the interventions to prevent falls or revised the care plan following the resident's falls on 4/05/12, 4/06/12, 4/12/12, 4/20/12, and 5/25/12. Review of the licensed nursing staff's documentation in the Nurse's Notes revealed that the resident had eleven additional falls since 3/18/12 (on 3/19/12, 3/29/12, 4/03/12, 4/05/12, 4/06/12, 4/12/12, 4/14/12, 4/19/12, 4/20/12, 5/25/12, and 7/10/12). It was observed on 7/23/12 at 2:49 p.m. and 7/24/12 at 3:50 p.m. that the siderails on the resident's bed were not in the raised position. On 7/25/12 at 1:15 p.m., Certified Nursing Assistant (CNA) LL stated that she used the Nurse Aide's Information Sheet to know a resident's care needs. However, a review of resident #115's undated Nurse Aide Information Sheet revealed that it included the use of half rails and a floor mat only on the left side of the bed. It did not include the use of bolsters or floor mats on both sides of the bed. On 7/26/12 at 9:54 a.m., the Registered Nurse (RN) Minimum Data Set (MDS) Coordinator KK stated that she attended the morning meetings, and the care plan was revised at that time for falls. She added that siderails had not been used on the resident's bed since a low bed was implemented (on 4/03/12) so, they should have been removed from the care plan. On 7/26/12 at 12:55 p.m., the DON stated that the weekend supervisor and staff nurses were supposed to check the Nurse Aide's Information Sheet for accuracy. He stated that the sheet should have included the use of bolsters instead of siderails. He added that, because the resident had right-side neglect, the original intervention was to put the mat on the left side only. There was a 3/18/12 Supervisor Incident Investigation form with staff documentation that, after the resident had fallen from the bed, bolsters were ordered for the bed. The 3/19/12 care plan noted that the use of bolsters were added as an intervention on 3/26/12. The 3/22/12 Fall Risk Assessment noted that the resident was at high risk for falls. There were not any bolsters observed on the resident's bed on 07/23/12 at 2:49 p.m., and 07/24/12 at 3:50 p.m During an observation of the resident being transferred from the wheelchair to the bed on 07/25/12 at 1:15 p.m., two bolsters were in the middle on each side of the bed. Certified Nursing Assistant (CNA) LL, who assisted with the transfer, said she often took care of the resident. CNA LL stated she had not seen bolsters on the resident's bed until that day. At 2:50 p.m., Licensed Practical Nurse (LPN) Shift Coordinator OO stated that the bolsters were delivered from Central Supply that day and they were told to put them on the bed. Review of Nurse's Notes and Incident Reports revealed that the resident had fallen from his/her bed five times since the addition of bolsters as an intervention to prevent falls on 3/26/12. The resident fell out of bed on 03/28/12; 03/29/12; 04/03/12; 04/14/12; and 04/20/12. However, there was no staff documentation to note if the bolsters were in use at the time of the falls. On 7/25/12 at 3:00 p.m., the Director of Nurses (DON) stated that bolsters had been on the bed at one time but, it had not been for awhile. There was no an evaluation of their effectiveness to prevent falls or documentation of when the staff stopped applying them. b. Review of the 5/25/12 Incident Report revealed that resident #115 slid to the floor when being transferred to the wheelchair by one CNA. Review of the 5/15/12 significant change of status Minimum Data Set (MDS) assessment revealed that the staff coded the resident as being totally dependent for transfers and needing two-plus person assistance for transfers. On 07/26/12 at 5:40 p.m., the DON confirmed that #115 was supposed to be transferred by two persons only. 2. Licensed staff coded resident #46 as needing the extensive assistance of two or more staff for transfers on the Minimum Data Set (MDS) for the annual comprehensive assessment and the 12/31/11 and 3/08/12 quarterly assessments. There was a care plan since 6/04/10 to address the resident's need for assistance with all mobility and transfers. However, there was not a specific intervention about the need for two staff to assist the resident with transfers. Review of the 1/16/12 and 5/20/12 nursing notes revealed that the resident had been assisted to the floor during a transfer from the bed to a gerichair. However, there was no evidence that the resident's care plan interventions were evaluated for their effectiveness to prevent falls and promote safety. During an interview on 7/26/12 at 1:39 p.m., registered nurse, unit manager AA stated that when a resident fell , the resident was added to the Patient-at-Risk (PAR) list for review at the next meeting. However, a review of the PAR documentation following the resident's fall on 1/16/12 only documented an intervention for a two person assist which had already been assessed as a need for the resident. During an interview on 7/26/12 at 3:35 p.m., certified nursing assistant II said she always used a one person assist when transferring resident #46. In an interview on 7/26/12 at 3:37 p.m., AA confirmed that the annual and quarterly MDS assessments coded resident #46 as needing a two or more person assist for transfers but the care plan did not reflect that information. 3. There was a loose toilet seat in the bathroom in room #145. It slid approximately six inches. 4. On 7/23/12 at 12:15 p.m., the base of the toilet shifted approximately four (4) inches to the left and right in room 225. That observation was verified by the Administrator and the Maintenance Director at 5:30 p.m. on 7/23/12.",2016-11-01
7801,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,334,D,0,1,66611,"Based on record review, and staff interview, it was determined that the facility failed to administer one pneumonia vaccination to one resident (#120) in a sample of five (5) residents reviewed. Findings include: There was a signed authorization form to administer the Pneumonia vaccine to resident #120 and documentation of education provided to resident #120 on 5/18/12. On the authorization form, resident #120 had checked his/her wanted to receive the pneumonia vaccine. However, the Admission Minimum Data Set (MDS) assessment completed on 5/28/12 coded that the pneumonia vaccine was not offered. On 7/26/12 at 2:17 p.m., the Director of Nursing (DON) verified that staff had not administered the pneumonia vaccine to the resident as of 7/26/12.",2016-11-01
7802,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,371,E,0,1,66611,"Based on observation and staff interview, it was determined that the facility failed to adhere to safe food storage for cheese and dinner rolls. Findings Include: 1, During a tour of the kitchen on 7/24/12 at 11:20 a.m., one opened package of mozzarella cheese was observed in the walk in cooler with a label that the package had been opened on 4/03/12. The cheese was covered with a green substance on the underside of the package. During an interview at that time, dietary manager FF acknowledged that the opened package of cheese was outdated and moldy. 2. On 7/24/12 at 11:20 a.m., two unopened packages of mozzarella/provolone cheese did not have an expiration date. During an interview at that time, dietary manager FF stated that the packages were supposed to have an expiration date. 3. During an observation of the dry food storage on 7/24/12 at 11:40 a.m., an unopened package of dinner rolls did not have an expiration date. During an interview at that time, dietary manager FF stated that those rolls should have had an expiration date.",2016-11-01
7803,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,386,D,0,1,66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that Physician's Progress Notes were provided for each visit for three residents (#115, #111 and # 105 ) in a total sample of 35 residents. Findings include: 1. Resident #115 was admitted to the facility on [DATE]. However, the only physician progress notes [REDACTED]. Although the Nurse's Notes dated 06/06/12 at 12:15 p.m. documented that the attending physician visited the resident, there was not a corresponding dated and signed progress note of such a visit. On 07/26/12 at 10:03 a.m., Licensed Practical Nurse (LPN) Shift Coordinator OO stated that she could not find any other Progress Notes for the attending physician in the current or overflow medical records. On 07/26/12 at 12:55 p.m., the Director of Nurses stated that he called resident #115's attending physician the previous week requesting the Progress Notes but, still had not received them. 2. Review of resident #111's record revealed that the most recent attending physician's progress note was dated 2/24/12. Although, nursing staff had documented in the nurses notes on 6/20/12 that the attending physician had visited the resident, the physician failed to write, sign and date a progress note. 3. Review of resident #105's record revealed that the most recent attending physician's progress note was dated 2/3/12. Although, nursing staff had documented in the nurses notes on 4/18/12 that the attending physician had visited the resident, the physician failed to write, sign and date a progress note.",2016-11-01
7804,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,387,D,0,1,66611,"Based record review and staff interview, it was determined that the facility failed to ensure that two residents' (#111 and #105) attending physician visited the residents at least every 60 days from a total sample of 35 residents. Findings include: 1. Review of resident #111's record revealed the attending physician visited on 2/24/12 and 6/20/12 but, failed to visit the resident in April 2012. 2. Review of resident #105's record revealed the attending physician visited on 2/3/12 and 4/18/12 but, failed to visit the resident in June 2012. During an interview on 7/26/12 at 5:35 p.m.,Director of Nursing was unable to provide any additional information regarding physicians' visits for resident #111 and #105.",2016-11-01
7805,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,441,F,0,1,66611,"Based on staff interview and record review, it was determined that the facility failed to maintain an infection control program that had accessible evidence of their surveillance and investigations, and their monitoring and tracking of infections to prevent the onset and spread of infections since March 1, 2012 in a census of 104 residents. Findings include; During an interview on 7/26/12 at 2:17 p.m., the Director of Nursing (DON) verified that the facility did not have an Infection control log or Infection control policy and procedure manual accessible in the facility. The DON stated that he received reports of residents on antibiotics and had only been monitoring the urinary tract infections in the facility. He said that the Infection Control Officer from another nursing home facility had been scheduled to meet with him on July 9, 2012 and the infection control information from that other facility had been sent to him on June 25,2012 to introduce the new infection control log and surveillance log that the facility was to implement. However, because the meeting did not take place, the new infection control log and surveillance log had not been initiated. The DON verified that there was not and had not been an infection control policy or procedure, tracking or trending of infections log in place since March 1, 2012 when a new company bought the facility. The DON verified that, since March 1, 2012, there had not been any infection control in-services for staff at the nursing home. On 7/26/12 at 4:23 p.m., Nurse Manager AA verified that there had not been any infection control policy and procedures in the facility or in-services for staff on infection control since March 1, 2012. On 7/26/12 at 4:28 p.m., the Laundry/Housekeeping Supervisor/Medical Supply verified that there had not been in-services conducted for staff on infection control since March 1, 2012. Although random interviews with facility staff revealed that they had knowledge of the procedures to implement for infection control, a review of the facility's in-service records revealed that there had not been any in-services about Infection Control from January through July 2012. There was not a policy or procedure on infection control to review in the facility.",2016-11-01
7806,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,502,D,0,1,66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to perform a laboratory test as ordered for one resident (#116) in a total sample of 35 residents. Findings include: Review of the June 2012 physician's orders [REDACTED].#116 was receiving Potassium Chloride 20 milliequivalents (mEq) twice a day. There was a Basic Metabolic Panel (BMP) laboratory test result dated 06/12/12 with the resident's serum potassium level elevated at 5.3 mEq/liter (reference range 3.5-5.2). There was a 6/13/12 physician's orders [REDACTED]. However, there was no evidence of that laboratory test in the clinical record. On 07/25/12 at 11:40 a.m., the Director of Nurses (DON) stated that the BMP ordered for 06/27/12 had been recorded in the facility's lab book but, the lab test was never actually ordered in the computer and so was not done. The DON added that the facility had identified a problem with not obtaining (missing) laboratory tests and had started a compliance tool to monitor them. However, the DON verified that resident #116's repeat BMP had not been identified as one of the missing laboratory tests. Review of the resident's June and July Medication Administration Records (MAR) revealed that staff continued to give the resident the potassium supplement daily from 06/14/12 to 07/16/12.",2016-11-01
7807,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,514,D,0,1,66611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to maintain complete records and document the reason one resident (#116) did not attend two scheduled Wound Center (WC) visits in a total sample of 35 residents. Findings include: Resident #116 had [DIAGNOSES REDACTED]. Review of Treatment Record documentation revealed that the resident was currently being treated for [REDACTED]. According to the wound measurements, all of those wounds had improved since admission to the facility. According to the Wound Center's 6/22/12 report, the resident had been scheduled to return to the Wound Clinic on 07/06/12. A 7/13/12 Wound Clinic report documented that the resident was scheduled to return to the Wound Center on 07/24/12. However, there was no evidence that the resident went to those scheduled appointments, and no documentation of a reason that the resident missed them. On 07/25/12 at 1:45 p.m., the Treatment Nurse stated that resident #116 went to the Wound Center every two weeks. She said that the next scheduled appointment was 07/31/12. She said that the 07/24/12 appointment was canceled because, a family member could not come. At 4:45 p.m., the Treatment Nurse stated that she called the Wound Clinic to see if the resident attended the 07/06/12 appointment but, was told it was canceled and did not know why. On 07/26/12 at 12:45 p.m., Licensed Practical Nurse (LPN) Shift Coordinator OO verified that there was no documentation in the resident's chart as to why the Wound Clinic visits were canceled. The clinical record was incomplete about the resident's scheduled Wound Clinic appointments on 7/06/12 and 7/24/12.",2016-11-01
7808,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-07-26,520,D,0,1,66611,"Based on record review and staff interview, it was determined that the facility failed to have a designated physician attend two of four Quality Assurance quarterly meetings from July 2011 through July 2012. Findings include: On 7/26/12 at 5:15 p.m., the facility's Quarterly Quality Assurance meeting sign in sheets were reviewed with the Administrator. During an interview at that time, the Administrator verified that a physician had only attended two Quality Assurance meetings since July 2011. The Medical Director attended October 19, 2011 and another physician attended on June 27, 2012. Although the administrator stated that it was acceptable that the physician's assistant (PA) come to the Quality Assurance meetings, a physician designated by the facility must attend the meetings.",2016-11-01
8360,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2013-02-01,157,D,1,0,Y16711,"br>Based on medical record review, the facility failed to immediately consult with the physician for one (1) resident (#1), after the resident had a fall and subsequently displayed physical symptoms, on the survey sample of six (6) residents. Findings include: Please cross refer to F323 for more information regarding Resident #1. Record review for Resident #1 revealed a Nurses' Notes entry of 01/12/2013 at 3:20 p.m. which documented that during a transfer, certified nursing assistants had sat the resident on the floor to prevent from dropping her. This entry documented that assessment revealed no injuries at that time. The facility's summary, completed by the Director of Nursing (DON), of the investigation of this fall involving Resident #1 documented that the resident had been lowered to the ground, landing on her knees, during transfer from the bed to a shower chair. A subsequent Nurse's Notes entry of 01/13/2013 at 9:30 p.m. documented that the resident was complaining of pain in the knees and that the knees were swollen. However, there was no evidence to indicate that the physician was notified of the resident's symptoms at that time, even though the resident had experienced a fall in which she landed on her knees the day before, 01/12/2013. A Nurse's Notes entry of 01/14/2013 at 9:00 a.m. documented that the physician's office was notified of the resident's fall at that time, and that an order was obtained for an x-ray for both knees related to the fall. This represented an approximate twelve (12) hour delay in physician consultation after the resident presented with pain in the knees and knee swelling on 01/13/2013 at 9:30 p.m. until the physician was contacted on 01/14/2013 at 9:00 a.m.",2016-02-01
8361,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2013-02-01,282,G,1,0,Y16711,"br>Based on medical record review, facility investigative summary review, and staff interview, the facility failed to ensure that services were provided during transfer per the care plan for one (1) resident (#1), whose care plan specified the use of a Hoyer lift with two-person assistance during transfers related to the risk for falls, on the survey sample of six (6) residents. This resulted in Resident #1 sustaining a fall during transfer and a left femur shaft fracture. Findings include: Please cross refer to F323 for more information regarding Resident #1. Record review for Resident #1 revealed a 12/21/2012 Minimum Data Set assessment which indicated that the resident was totally dependent for transfer, requiring the assistance of two persons, and that the resident had impaired lower extremity range of motion on both sides. The care plan for Resident #1 identified the resident's decreased mobility and impaired lower extremity range of motion. This care plan identified a 02/03/2012 Problem indicating a fall-risk, with an Intervention being to use a Hoyer lift with two-person assistance during transfer. A Nurses' Notes entry of 01/12/2013 at 3:20 p.m. for Resident #1 documented that certified nursing assistants (CNAs) were attempting to manually place the resident in a wheelchair, but had sat the resident on the floor during the transfer. The facility's investigative summary, completed by the Director of Nursing (DON), regarding Resident #1's fall documented that on 01/12/2013, the resident had been lowered to the ground, landing on her knees, when two CNAs attempted to transfer her from the bed to a shower chair without using the lift as required by the care plan. A Nurse's Notes entry of 01/13/2013 at 9:30 p.m. documented that the resident complained of knee pain, with knee swelling noted. A subsequent Nurse's Notes entry of 01/14/2013 at 9:00 a.m. documented that an order was obtained for an x-ray for both knees, and a Nurse's Notes entry of 01/14/2013 at 9:30 p.m. documented that the x-ray report indicated that the resident had a leg fracture. During interview with the Administrator and the DON conducted on 01/18/2013 at approximately 3:10 p.m., and subsequently on 02/01/2013 at 10:30 a.m., the above findings were acknowledged.",2016-02-01
8362,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2013-02-01,323,G,1,0,Y16711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital Operative Report review, facility investigative summary review, and staff interview, the facility failed to ensure the adequate supervision/assistance to prevent an accident for one (1) resident (#1), who was assessed as being dependent on staff for transfer and mobility, on the survey sample of six (6) residents. This resulted in Resident #1 sustaining a fall during transfer and a left femur shaft fracture, requiring femur closed reduction nail fixation surgical repair. Findings include: Record review for Resident #1 revealed a Minimum Data Set (MDS) assessment dated [DATE] which indicated that the resident required the extensive assistance of two persons for bed mobility, and was totally dependent for transfer, requiring the assistance of two persons. This MDS also indicated that the resident had impairment of lower extremity range of motion on both sides, and had [DIAGNOSES REDACTED]. The care plan for Resident #1 identified, as did the MDS referenced above, that the resident required assistance with activities of daily living related to decreased mobility and impaired range of motion of the lower extremities. This care plan also identified a Problem, initially dated 02/03/2012, indicating the resident was at risk for falls secondary to impaired physical mobility, with one of the Interventions being to use a Hoyer lift with two-person assistance during transfers. The Nurse Aide's Information Sheet for Resident #1 also specified the use of a Hoyer lift with two people during transfer. A Nurses' Notes entry of 01/12/2013 at 3:20 p.m. for Resident #1 documented that certified nursing assistants (CNAs) were attempting to place the resident in a wheelchair, but further documented that the resident was too heavy to manually lift and the CNAs had to sit the resident on the floor to prevent from dropping her. This Notes entry documented that the resident's vital signs were taken and that no injuries were noted at that time. The facility's summary, completed by the Director of Nursing (DON), of the investigation of this fall involving Resident #1 documented that on 01/12/2013 at approximately 10:00 a.m., the resident had been lowered to the ground, landing on her knees, when two CNAs attempted to transfer her from the the bed to a shower chair without using the lift as required by the care plan and as instructed by the Nurse Aide's Information Sheet. This investigation summary also documented that assessment at the time of the incident revealed no complaints of pain or discomfort. However, a Nurse's Notes entry of 01/13/2013 at 9:30 p.m. documented that the resident was complaining of pain in the knees and that the knees were swollen. A Nurse's Notes entry of 01/14/2013 at 9:00 a.m. documented that the physician's office was notified of the resident's fall, and that an order was obtained for an x-ray for both knees related to the fall. In the facility's investigative summary referenced above, the DON documented that upon her arrival at the facility on 01/14/2013, she reviewed the Fall Incident Report for Resident #1's fall, and spoke with the resident, who complained of some pain in the right knee. The DON also noted the resident to have mild edema to both knees, so she therefore notified the physician of the resident's symptoms and received the order for the x-ray of the bilateral knees and upper legs. A Nurse's Notes entry of 01/14/2013 at 9:30 p.m. documented that the x-ray report results for Resident #1 had returned and indicated that the resident had a leg fracture. This Notes entry also documented that the doctor was notified of the results and gave an order to transport the resident to the emergency room for evaluation. This Notes entry also documented that the resident had been transported to the hospital for evaluation. Review of the Medication Administration Record (MAR) for Resident #1 for the period of time from the fall of 01/12/2013 through the hospital transfer of 01/14/2013 revealed that the resident had received the pain medication Vicodin 5/500 milligrams, as routinely ordered for rheumatoid arthritis, three times daily, at 9:00 a.m., 1:00 p.m., and 9:00 p.m., during 01/12/2013, 01/13/2013 and 01/14/2013. This MAR also documented that the resident had received an additional as-needed dose of Vicodin 5/500 milligrams at 3:15 a.m. on 01/14/2013. The hospital Operative Report of 01/16/2013 for Resident #1 documented the resident had a left femur shaft fracture, and documented that the resident had undergone a left femur closed reduction nail fixation. During interview with the Administrator and the DON conducted on 01/18/2013 at approximately 3:10 p.m., and subsequently on 02/01/2013 at 10:30 a.m., the above findings were acknowledged.",2016-02-01
9168,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,246,D,0,1,HV0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to accommodate the needs of two residents (""A"" and #10) to provide secure transport and showers as scheduled in a total sample of 21 residents. Findings include: 1. Resident ""A"" was admitted with [DIAGNOSES REDACTED]. There was a 7/7/10 care plan for the nursing staff to assess the resident's need for assistive and/or supportive devices, and to provide a shower for the resident three times weekly. During observations on 9/28/10 at 12:50 p.m., 1:30 p.m. and 4:20 p.m., on 9/29/10 at 8:25 a.m., 10:10 a.m., 12:20 p.m., 1:20 p.m. and 2:25 p.m., and on 9/30/10 at 8:45 a.m., 9:30 a.m., 11:45 a.m. and 12:10 p.m., the resident was in bed. During an interview on 9/29/10 at 12:20 p.m., resident ""A"" stated that although he/she knew he/she needed to be out of the bed, he/she did not get out of bed because of being afraid and not feeling secure in the Hoyer lift. Resident ""A"" stated that while being weighed, he/she felt as if he/she was slipping from the sling on the lift. On 9/29/10 at 10:20 a.m., licensed nurse ""CC"" and certified nursing assistant (CNA) ""BB"" stated that they were not aware of why resident ""A"" did not get out of the bed. On 9/29/10 at 2:50 p.m., the restorative CNA stated that the resident refused to be weighed because of a fear of the Hoyer lift. On 9/30/10 at 8:55 a.m., the Unit Manager stated that the resident did not get out of the bed because of being afraid of the Hoyer lift. The Unit Manager stated that the staff had discussed using a larger chair and Hoyer lift pad, which had been ordered about two weeks ago. On 9/30/10 at 9:25 a.m., facility staff ""DD"", who was responsible for ordering and purchasing, stated that he had not been made aware of the the resident's fear about the use of the Hoyer lift. Staff ""DD"" said that larger Hoyer lift slings were available but, he was not aware as to whether one had been utilized for resident ""A"" yet. On 9/30/10 at 9:35 a.m., CNA ""BB"" stated that she had not attempted to get the resident out of bed using the larger Hoyer lift sling since the resident was readmitted to that floor on 8/24/10. On 9/30/10 at 9:30 a.m., an extra large Hoyer lift sling was brought to the resident's room. Resident ""A"" stated that he/she had not tried that sling. At 12:10 p.m., the resident said that he/she would try the extra large lift sling because it looked like it would support him/her. He/She stated that he/she would now shower. Although the facility was aware of the resident's fear of being transferred with the Hoyer lift and the availability of the larger Hoyer lift pads in the facility, there was no evidence that they addressed the resident's fear or attempted interventions to accommodate the resident's need and desire to be out of bed for showers and other activities. 2. Resident #10 was admitted with [DIAGNOSES REDACTED]. The care plan since 8/23/10 had an intervention for nursing staff to give him/her a shower three times weekly with bed baths on the other days. However, according to nursing staff's documentation, bedbaths were given to the resident daily. There was no evidence that showers had been given to the resident three times weekly as planned from 7/4/10 until 9/26/10, after surveyor inquiry. In an interview on 9/30/10 at 11:30 a.m., licensed nurse ""PP"" stated that staff were afraid to transport the resident since the resident experienced sudden movement on 7/4/10 and slid off the Hoyer lift sling. There was no evidence that the facility addressed a means to accommodate the residents' needs during transfers to enable him/her to be given a shower.",2015-08-01
9169,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,282,G,0,1,HV0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, it was determined that the facility failed to implement care plan interventions to provide activities of daily living (ADL) care for two residents (#13 and #12), to provide passive range of motion exercises for one resident (#13) to assess the intensity of pain and review the pain management plan as needed for one resident (""A""), to provide oxygen as ordered for one resident (#5), to provide nail care for one resident (#13), from a total sample of 21 residents. This failure caused actual harm for resident ""A"". Findings include: 1. Resident ""A"" had a care plan since 7/7/10 for nursing staff to assess the location, frequency, duration and intensity of his/her pain, to document the assessment and report an increase in pain trend to the physician, and to review the resident's pain management plan as needed and document the findings. However, despite the resident frequently requesting pain medication, the nursing staff failed to consistently assess the intensity and identify an increase in the intensity of pain for resident ""A"". See F309 for additional information regarding resident ""A"". Resident ""A"" had a care plan since 7/7/10 for staff to assess the resident's need for assistive and/or supportive devices and to provide a shower three times weekly. However, resident and staff interviews revealed that nursing staff had not been assisted the resident to get out of bed to the shower since being readmitted to the facility on [DATE] because of his/her fear of being transferred using the Hoyer lift. See F246 for additional information regarding resident ""A"". 2. Resident #13 had a care plan since 2/22/10 for requiring total assistance from nursing staff for activities-of-daily living (ADLs). There was an intervention for nursing staff to provide showers three times weekly and bed baths on all other days. There was an intervention to provide nail care with baths. However during an observation of a bed bath on 9/29/10 from 8:45 a.m. to 9:10 a.m., nursing staff failed to bath the resident's entire body and provide nail care. See F312 for addition information regarding resident #13. Resident #13 had a care plan since 2/22/10 for behavioral concerns that included the resident scratched him/herself. There was an intervention for nursing staff to keep the resident's nails trimmed short. However, the resident's nails were observed to have been jagged and uneven on 9/29/10 from 8:45 a.m. to 9:10 a.m. and at 11:30 a.m. See F323 for additional information regarding resident #13. The resident had a care plan intervention since 2/22/10 for staff to provide range of motion exercises to his/her extremities during care. However, range of motion exercises were not provided by nursing staff during an observation of morning care on 9/29/10 from 8:45 a.m. to 9:10 a.m. See F318 for additional information regarding resident #13. 3. Resident #12 had a care plan intervention since 8/17/10 for nursing staff to provide showers three times weekly and bed baths on all other days. However, during an observation of a bed bath on 9/29/10 from 9:45 a.m. to 10:08 a.m., nursing staff failed to bathe the resident's entire body. See F312 for additional information regarding resident #12. 4. Resident #5 had a care plan since 9/23/10 to address his/her potential for shortness of breath because of a recent hospitalization and [DIAGNOSES REDACTED]. There was a 9/23/10 physician's orders [REDACTED]. However, during the initial tour on 9/28/10 between 10 a.m. and 12 p.m., at 12:35 p.m., 2:20 p.m. and 4:25 p.m., on 9/29/10 at 8:10 a.m., 11:00 a.m., 1:40 p.m. and 4:10 p.m., and on 9/30/10 at 7:20 a.m., 10:00 a.m. and 11:05 a.m., nursing staff had incorrectly set the resident's oxygen to infuse at a rate between 2 and 2.5 liters a minute. See F328 for additional information regarding resident #5.",2015-08-01
9170,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,328,D,0,1,HV0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to ensure that the one resident (#5) was provided oxygen at the ordered infusion rate in a sample of two residents who received oxygen therapy from a total sample of 21 residents. Findings include: Resident #5 had a 9/28/10 care plan to address his/her potential for shortness of breath due to a [DIAGNOSES REDACTED]. There was a 9/23/10 physician's orders [REDACTED]. However, it was observed during the initial tour on 9/28/10 between 10 a.m. and 12 p.m., at 12:35 p.m., 2:20 p.m. and 4:25 p.m., on 9/29/10 at 8:10 a.m., 11:00 a.m., 1:40 p.m. and 4:10 p.m., and on 9/30/10 at 7:20 a.m., 10:00 a.m. and 11:05 a.m., that nursing staff had incorrectly set the resident's oxygen to infuse at a rate between 2 and 2.5 liters a minute instead of 3 liters.",2015-08-01
9171,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,253,E,0,1,HV0O11,"Based on observations, it was determined that the facility failed to maintain an environment that was free from dirt, dust, debris, scuffed door frames, peeling sheet rock, dead insects, loose mounted hand sanitizers, flaking paint, stained ceiling tiles, holes in plaster, dirty floors, missing cobase, loose drawer handles, broken and missing drywall, cracked plaster, a missing wheelchair arm rest and stained tile grout on both floors (1st and 2nd) of the facility. Findings include: Observations were made during the Initial Tour of the facility on 9/28/10 from 10:00 a.m. to 12:00 p.m. and during the General Observations tour on 9/30/10 from 10:00 a.m. to 11:15 a.m. 1st floor 1. There was a build up of a black substance in the window frame in room 129. There was a hole in the plaster in the window sill. 2. There was one brown stained ceiling tile in the bathroom of room 140. There was a hole in one ceiling tile. 3. A piece of cobase was missing in room 134. 4. There were brown stains on seven ceiling tiles and the metal tracking above the first bed in room 132. 5. There was peeling paint on the baseboard in the tub area and on the doorframe of the entrance door in the men's shower. 6. The floor in the medication room was littered with trash, dirt and dust. 2nd floor 1. The left arm rest was missing from resident #4's wheelchair. 2. The top drawer handle on the bedside table in room 220A was loose . 3. The air conditioner vent covers were dusty in rooms 220 and 222. 4. The baseboard was missing off of the walls next to the closets in rooms 227 and 228. The drywall was broken and pieces of it were missing in those rooms. 5. The bathroom ceiling vent was dusty in room 222. 6. The wall above the air conditioner had cracked plaster and was unfinished in room 228. 7. The doorframe was scuffed to the physical therapy room. 8. There was a buildup of dust, dirt, and trash in the sunroom's window sill . 9. There were numerous dead bugs in the cabinet under the pantry sink. The drywall behind the sink was peeling . 10. The hand sanitizer dispenser next to the clean utility room was loose and hanging off of the wall. 11. There was a black and brown substance on the tiles and tile grout in the shower stall in the women's shower.",2015-08-01
9172,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,309,G,0,1,HV0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, and record reviews, it was determined that the facility failed to thoroughly assess and address one resident's (""A"") complaints of pain and failed to administer medication as ordered for one resident (#13) from a total sample of 21 residents. This failure resulted in actual harm for resident ""A"". Findings include: 1. Resident ""A"" had [DIAGNOSES REDACTED]. Nursing staff coded the resident on his/her 7/5/10 initial Minimum Data Set (MDS) assessment as having full loss of range of motion of both arms and hands. There was an 8/31/10 Occupational Therapy Daily Note that the resident, the resident's nurse and the charge nurse were educated on the schedule for the resident to be wearing his/her hand and wrist splints and for preventing skin breakdown. There was a care plan intervention since 7/7/10 for nursing staff to assess the location, frequency, duration and intensity of the resident's pain, to document that pain assessment and to report a trend of increased pain to the physician. There was also an intervention nursing staff to review the resident's pain management plan as needed and to document the findings. On 9/28/10 at 1:30 p.m., resident ""A"" stated that he/she had not been wearing the hand and wrist splints because of having increased pain in his/her fingers. The resident stated that the pain in his/her fingers was ""pretty intense"" especially in the index fingers. On 9/29/10 at 1:20 p.m., resident ""A"" stated that the nursing staff had tried to wash his/her hands that morning but, his/her hands were too painful. He/She rated his/her pain at 10 out of 10 on a 0 to 10 pain scale. Resident ""A"" said that he/she had pain in his/her hands daily but, the pain medication was not effective. Resident ""A"" said that he/she had reported the increase in pain and ineffectiveness of the pain medication to all of the nurses who provided care for him/her. Resident ""A"" stated that the nursing staff replied that the nurse practitioner had to be notified but, he/she did not know whether or not the nursing staff had followed up with the nurse practitioner. A review of the September 2010 Medication Administration Record [REDACTED]. A review of the August 2010 MAR indicated [REDACTED]. On 9/30/10 at 9:00 a.m., licensed nurse ""CC"" stated that resident ""A"" had reported to her on 9/29/10 that his/her pain medication was ineffective. ""CC"" said that she told the resident that she would follow-up with the nurse practitioner. However, licensed nurse ""CC"" stated that she had not yet contacted the nurse practitioner. During an interview on 9/30/10 at 2:25 p.m., the nurse practitioner stated that she had not been contacted or made aware of the resident's report that his/her pain medication was not effective. 2. Resident #13 had a physician's orders [REDACTED]. However a review of the Medication Administration Records revealed that nursing staff failed to administer the ordered [MEDICATION NAME] as scheduled 4/2, 4/30, 6/4, 6/11, 6/18, 6/25, 7/2, 7/16, 8/6, 8/13, 8/20, and 8/27/10.",2015-08-01
9173,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,371,F,0,1,HV0O11,"Based on observations, it was determined that the facility failed to maintain sanitary conditions in the storage and food preparation areas, and failed to ensure the cleanliness and calibration of the thermometer used to check food temperatures in the kitchen. Findings include: General observations were made on 9/28/10 at 11:00 a.m., 9/29/10 at 12:00 p.m., and on 9/30/10 at 9:45 a.m. 1. There was food debris and dried food spills on the floor of the cooler. 2. On 9/28/10 at 11:00 a.m., following completion of the dietary staff having washed the breakfast dishes, the concentration of sanitizer in the third sink of the three compartment sink measured ""0"" part per million (ppm). The third sink was used to sanitize dietary equipment and utensils with the chemical sanitizing agent used by the facility. 3. Paint was peeling off of the ceiling above the automatic dishwasher. 4. There was a build up of dust on the air conditioner vents above the dry food storage bins and above the three compartment sink. 5. There was food debris on the microwave cart and on clean pans being stored it. Dietary staff stated that those pans were used when thawing out frozen meat. 6. There was a heavy build up of grease and food debris on the toaster. 7. There was food debris around the edges of the utensil drawer. 8. There was trash and food debris on the cook's utility cart. 9. There was food debris and dried food on the shelf under the steam table and on the clean pans stored on that shelf. 10. There was a build up of a black substance around the base of the can opener where the unit was attached to the prep table. 11. On 9/29/10 at 12:00 p.m., the Dietary Manager removed the thermometer to check food temperatures from her pocket, removed the sheath off of the thermometer, and wiped the thermometer with a dry napkin prior to checking the temperatures of the foods on the steam table. She did not ensure that the thermometer was kept clean and sanitized.",2015-08-01
9174,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,318,D,0,1,HV0O11,"Based on observations, interviews, and record reviews, it was determined that the facility failed to provide range of motion exercises for one resident (#13) and assess the use of hand splints for one resident (""A"") from a sample of 12 residents with range of motion limitations from a total sample of 21 residents. Findings include: 1. Resident #13 was coded on the 8/17/10 quarterly Minimum Data Set (MDS) assessment as having limited range of motion in his/her arms, hands, legs, and feet. There was a care plan intervention since 2/22/10 for nursing staff to provide range of motion and passive exercises during care to his/her extremities as indicated and as tolerated. Certified Nursing Assistant (CNA) ""RR"" stated on 9/29/10 at 8:45 a.m. that she provided exercises every time she checked the resident for incontinence and provided incontinence care. However, during an observation of morning care on 9/29/10 from 8:45 a.m. to 9:10 a.m. that included a bed bath, incontinence care, and clothing change, CNA ""RR"" only did one repetition of movement of the resident's leg at the knee joint. She said that she had to move the resident's legs like that to change him/her so, that was like exercising him/her. CNA ""RR"" did not provide range of motion exercises to the resident. 2. Resident ""A"" was coded on the 7/5/10 initial MDS assessment as having full loss of range of motion of both arms and hands. There was a care plan since 7/7/10 for staff to assess the resident's need for assistive and/or supportive devices. There was an 8/31/10 Occupational Therapy (OT) Daily Note indicating that the resident, resident's nurse and the charge nurse were educated on the schedule for the resident to wear hand and wrist splints. The OT staff wrote that the resident was ""left in the care of nursing staff."" A review of the resident's August Medication Administration Record [REDACTED]."" There was no entry on the resident's September MAR indicated [REDACTED]. On 9/28/10 at 1:30 p.m., resident ""A"" stated that his/her family member applied the splints but, he/she had not worn worn the splints ""lately"" because of having ""pretty intense"" pain in his/her fingers. On 9/30/10 at 8:45 a.m., licensed nurse ""CC"" stated that she was not aware that the resident was not wearing the splints as ordered or why he/she was not wearing them. In an interview on 9/30/10 at 8:55 a.m., the nurse manager said that she did not know that the resident was not wearing his/her splints or why he/she was not doing it. The nurse manager stated that the resident should be wearing the splints. The nurse manager stated that the splint application and wearing time were monitored by nursing and the restorative nursing program. On 9/30/10 at 10:00 a.m., the Director of Rehabilitation/Occupational Therapist stated that nursing staff had not been made him/her aware that the resident was not wearing the splints. On 9/30/10 at 10:05 a.m., the licensed nurse who supervised the Restorative Nursing Program, and the restorative CNA stated that they were not aware the resident was not wearing the hand and wrist splints.",2015-08-01
9175,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,312,D,0,1,HV0O11,"Based on observations and record review, it was determined that the facility failed to ensure that two residents received thorough bed baths (#12 and #13) and one resident received thorough perineal care (#2) to maintain good personal hygiene from a total sample of 21 residents. Findings include: 1. Resident #12 was coded on the 8/10/10 initial Minimum Data Set (MDS) assessment as being dependent for bathing. The resident had a care plan intervention since 8/17/10 for nursing staff to provide showers three times weekly and bed baths on all other days. However, during an observation of a bed bath on 9/29/10 from 9:45 a.m. to 10:08 a.m., certified nursing assistant (CNA) ""OO"" did not bathe the resident's back, legs, and feet. In addition, the CNA did not thoroughly rinse the soap from the resident's skin before he/she dried the resident's skin with a towel. 2. Resident #13 was coded on the 8/17/10 quarterly MDS assessment as being dependent for bathing and personal hygiene. The resident had care plan interventions since 2/22/10 for nursing staff to provide showers three times weekly and bed baths on all other days and to provide nail care with baths. However, during an observation of a bed bath on 9/29/10 from 8:45 a.m. to 9:10 a.m., CNAs ""OO"" and ""RR"" did not bathe the resident's legs and feet or provide nail care. The resident's fingernails and left great toe nail were observed to be dirty and had a brown substance under them. The CNAs did not thoroughly rinse the soap from the resident's skin but instead they re-wiped his/her skin with the soapy rag before drying it. 3. Resident #2 was coded on the 8/30/10 quarterly MDS assessment as being dependent for bathing and requiring extensive assistance for hygiene and toileting. However, during an observation of care on 9/29/10 at 9:15 a.m., CNA ""FF"" failed to rinse the soap from the resident's perineal area before drying it and applying a clean brief. The manufacturer's instructions indicated that the soap was to be rinsed off of the skin.",2015-08-01
9176,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,323,D,0,1,HV0O11,"Based on observation, interviews and record review, it was determined that the facility failed to ensure that one resident's nails were trimmed to prevent self-inflicted scratches from a total sample of 21 residents. Findings include: Resident #13 had a care plan since 2/22/10 that addressed him/her scratching him/herself. There was an intervention for nursing staff to keep his/her nails trimmed short. During an observation of morning care on 9/29/10 from 8:45 a.m. to 9:10 a.m., the resident had multiple scratches on the top of his/her left hand and on his/her right thigh near the knee. At that time, CNAs ""RR"" and ""OO"" stated that the resident scratched him/herself. Although the resident's nails were short, they were uneven and had jagged edges. CNA ""OO"" stated that the charge nurse clipped the resident's nails. However, on 9/30/10 at 10:35 a.m. charge nurse ""ZZ"" stated that the CNAs were supposed to clip the nails of all of the residents except those with diabetes. On 9/29/10 at 11:30 a.m., the resident's nails remained uneven with jagged edges.",2015-08-01
9177,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,428,D,0,1,HV0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the consultant pharmacist failed to identify and report to the attending physician and director of nursing that medication was not administered as ordered for one resident (#13) from a total sample of 21 residents. Findings include: Resident #13 had a physician's orders [REDACTED]. However a review of the resident's Medication Administration Records revealed that nursing staff failed to administer the Fosamax as scheduled and as ordered on 4/2, 4/30, 6/4, 6/11, 6/18, 6/25, 7/2, 7/16, 8/6, 8/13, 8/20, and 8/27/10. Although the consultant pharmacist reviewed the resident's drug regimen on 4/20, 5/17, 6/22, 7/22, 8/18, and 9/15/10, he/she failed to identify and report that the Fosamax had not been administered weekly in April, June, July, or August.",2015-08-01
9178,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2010-09-30,314,D,0,1,HV0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to ensure that a blister was reported to the treatment nurse for one resident (""A""), and failed to accurately stage a pressure sore for one resident (#1), of seven residents reviewed with existing pressure sores or at risk of developing pressure sores, from a total sample of 21 residents. Findings include: According to the National Pressure Ulcer Advisory Panel's Pressure Ulcer Staging System, a (suspected) deep tissue injury was a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. A Stage III pressure ulcer had full-thickness tissue loss and, slough may be present but does not obscure the depth of tissue loss. A Stage IV pressure ulcer had full-thickness tissue loss and, slough or eschar may be present on some parts of the wound bed. However, nursing staff failed to report the presence of a blister and failed to accurately stage a pressure ulcer for resident #1. Resident ""A"" had [DIAGNOSES REDACTED]. Licensed staff coded him/her as totally dependent for all activities of daily living (ADLs) on the 7/5/10 initial Minimum Data Set (MDS) assessment. There was a care plan intervention since 7/7/10 for staff to observe his/her skin condition and report any abnormalities found. According to the 7/7/10 Braden Scale completed by licensed nursing staff, resident #1 was at high risk for developing pressure ulcers. There was weekly assessment documentation since 6/29/10 about a pressure sore on the resident's sacrum on the ""Wound Evaluation Flow Sheet"" form for pressure ulcers. During an observation of the resident's skin on 9/28/10 at 4:20 p.m. with certified nursing assistant (CNA) ""EE"", there was a dark red/purple blister on the lateral side of the resident's right heel. A review of the nurse's notes and most recent skin assessment performed on 9/23/10 revealed no evidence that the facility was aware of that blister. On 9/30/10 at 11:45 a.m., the resident's right heel was observed with the treatment nurse. At that time, the treatment nurse stated that, although staff were supposed to report any areas of skin impairment to her, they had not. She said that she did not know about the ""reabsorbing"" blister on the resident's right heel prior to that observation. At that time, a family member of resident ""A"" stated that the blister had been there since ""last Friday"" (9/24/10). On 9/30/10 at 11:50 a.m., certified nursing assistant ""BB"", who had provided a bed bath for the resident on 9/29/10 and care for him/her on 9/29/10 and 9/30/10, stated that she was not aware of the blister on the resident's right heel. 2. Resident #1 was admitted to the facility on [DATE] with a pressure ulcer on his/her sacrum. At that time, the treatment nurse assessed the pressure ulcer as being 70% covered with yellow slough and inaccurately staged it as a III. However, according to the National Pressure Ulcer Advisory Panel's Pressure Ulcer Staging System, it should have been staged as a IV. On 7/5/10, the treatment nurse assessed the ulcer as being 100% covered with yellow slough but, continued to assess it as a stage III. Despite describing the presence of yellow slough over 70% of the wound bed on 7/12/10, 7/19/10 and 7/26/10, the treatment nurse inaccurately staged it as a stage III. According to the licensed nurse's weekly assessments, the resident's sacral pressure sore was present from 6/29/10 until 8/9/10.",2015-08-01
9179,AZALEA TRACE NURSING CENTER,115478,910 TALBOTTON RD,COLUMBUS,GA,31904,2012-05-04,363,E,1,0,OOQN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's menus, medical record reviews, observations of food service, meal observations, and staff interview, the facility had failed to ensure that menus were followed during two (2) of two (2) meal observations, for four (4) residents (#2, #4, #5 and #7) from a survey sample of eleven (11) residents and for observations of nine (9) diets served on the serving line. Findings include: Interview with the facility's administrator on 05/01/2012 at 4:00 p.m. revealed that the facility had been without a full-time dietary manager for at least three weeks. He further stated that a dietary manager from a sister facility had been coming in intermittently during those three weeks. Review of the menus with the person serving as intermittent Dietary Manager on 05/02/2012 at 4:05 p.m., this acting Dietary Manager had difficulty locating the current menus. The acting Dietary Manager further stated that food items had been changed in order to try to use up some of the overstocked food items in the pantry before purchasing additional food items. However, these changes had not been made to the current menus until after surveyor inquiry on 05/02/2012 at 4:05 p.m. 1. Record review for Resident #7 revealed a current physician's orders [REDACTED]. The planned menu for a renal diet for the supper meal on 05/01/2012 was one low sodium tuna patty, low sodium noodles, vegetable sticks and fruit of the day. However, during the supper meal on 05/01/2012 at 5:40 p.m., Resident #7 was observed to be served salmon croquettes, vegetable sticks, grits and fruit cocktail. The planned menu for the lunch meal for a renal diet on 05/02/2012 was low sodium roast pork, low sodium broccoli rice casserole, carrots and angel food cake and a roll. During the lunch meal on 5/2/2012 at 12:45 p.m., Resident #7 was served pork roast and gravy, broccoli and rice casserole, roll and pudding. There were no carrots served on the resident's plate, and there was no dislike of carrots noted on the resident's dietary card. 2. Record review for Resident #2 revealed a current physician's orders [REDACTED]. The planned menu for a renal diet for the supper meal on 05/01/2012 was one low sodium tuna patty, low sodium noodles, vegetable sticks and fruit of the day. However, during the supper meal on 05/01/2012 at 5:40 p.m., Resident #2 was observed to be served salmon croquettes, vegetable sticks, grits and fruit cocktail. 3. Record review for Resident #4 revealed that she had a current physician's orders [REDACTED]. The planned menu for a regular diet/no added salt diet for the supper meal on 05/01/2012 was salmon patty, cheese grits, vegetable sticks and fruit of the day/omit salt packet. However, during the supper meal on 05/01/2012 at 5:25 p.m., Resident #4 was observed to be served salmon croquette, grits, vegetable sticks, mixed fruit and a salt packet on her tray. 4. Record review for Resident #5 revealed that the resident had a current physician's orders [REDACTED]. The planned menu for a mechanical soft diet for the lunch meal on 05/02/2012 was ground roast pork with gravy, broccoli and rice casserole, carrots, rolls and pudding. Observation of Resident #5 during the lunch meal on 05/02/2012 at 12:35 p.m. revealed that the resident was served ground pork with gravy, rice and broccoli casserole, ice cream/pudding and milk. There were no carrots on the resident's plate. There was no dislike of carrots noted on the resident's dietary card. 5. During the observation on 05/02/2012 at 12:00 p.m. of the service of the lunch meal, the dietary aide serving the meal failed to put the planned carrots on seven (7) regular diet plates and failed to put the planned pureed carrots on two (2) pureed diet plates. There were no dislikes of carrots on any of these diet cards.",2015-08-01
2131,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2020-01-09,635,D,1,1,VKRX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility failed to ensure the medication, [MEDICATION NAME] (a [MEDICAL CONDITION] medication) was ordered upon admission for one resident (R) (#70) of 34 sampled residents. Findings include: Review of R#70's medical record revealed she was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the hospital record titled Sound Physicians Hospitalist History and Physical dated 12/2/19 revealed the resident has past medical history of [REDACTED]. Her [MEDICAL CONDITION] stimulating hormone (TSH) blood level completed on 12/2/19 was within normal range at 1.31 with a reference range of 0.47-4.68. Review of R#70's hospital record titled Sound Physicians Hospitalist Nursing Home Orders dated 12/6/19 revealed the resident was ordered [MEDICATION NAME] 100mcg one tablet PO daily. Review of R#70's Physicians Orders dated 12/7/19 did not have an order for [REDACTED]. Review of the routine laboratory results dated [DATE] conducting by the facility revealed an elevated TSH level of 9.380 with a range of 0.270-4.200. A note written on the laboratory record indicated to recheck on 12/11/19. Review of the laboratory results dated [DATE] revealed an elevated TSH level of 12.240 with a reference range of 0.270-4.200. A note written on the laboratory record indicated no [MEDICATION NAME] therapy start 50 mcg and recheck TSH level in eight weeks. An interview held on 1/09/2020 at 9:49 a.m. with the Registered Nurse (RN) Assistant Director of Nursing (ADON) revealed when a resident is admitted to the facility either she or the Director of Nursing (DON) review the orders and input them into the system. She looked at R#70's discharge orders from the hospital and verified the resident had an order for [REDACTED]. She indicated all orders are double checked after orders are transcribed. They check the orders against the actual orders from the hospital. She stated the order for the [MEDICATION NAME] was overlooked. An interview held on 1/09/2020 at 10:41 a.m. with the DON revealed new admission orders [REDACTED]. She indicated she completed R#70's admission orders [REDACTED]. She indicated the orders are transcribed according to the hospital orders and if the facility Physician wants something different, she completes a Post Admission Order and another nurse will double check for correctness/errors. She stated the orders were originally put in by her and verified by RN EE. The DON reported no other problems with transcription of orders.",2020-09-01
2132,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2018-08-09,640,D,0,1,JD6Z11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to complete a discharge Minimum Data Set (MDS) assessment for one (1) resident (R#1). The facility census was 72 residents and the sample size was 18 residents. Findings include: Record review for R#1 revealed he was admitted to the facility on [DATE] and was discharged from the facility on [DATE]. Review of the completed MDS's for R#1 revealed a discharge MDS was not completed in a timely manner. Review of the document titled Daily Stand-Up dated [DATE] revealed R#1was to be discharged on [DATE]. All department employees receive a copy of this report daily. Interview with the MDS Coordinator on [DATE] at 11:03 a.m. revealed she received a message from the State Agency MDS Coordinator on [DATE] stating a discharge MDS was not completed or transmitted to them. She agreed a discharge MDS was not completed for R#1. She revealed when a resident is discharged or expired from the facility she receives a notice of discharge. Interview with the Director of Nursing (DON) on [DATE] at 3:33 p.m. revealed admissions and discharges are discussed in the morning meetings. All department head employees receive a copy of the report daily. She stated the MDS Coordinator is responsible for completing all the MDS's in a timely manner. The MDS Coordinator is expected to attend the morning meeting held Monday through Friday.,2020-09-01
2133,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2018-08-09,655,D,0,1,JD6Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to provide the resident and or the resident's representative a copy of the Base Line Care Plan to ensure the resident and or the resident's representatives were aware of the instructions needed to provide effective and person-centered care to meet the professional standards of quality of care for two Residents (R) (R#10, R#51). The sample size was 29 residents. Findings Include: Review of the care plan reveals that the Base Line Care Plan was not provided to R#10 or her representative. R#10 was re-admitted to the facility on [DATE] with multiple [DIAGNOSES REDACTED]. During an interview with the Director of Nursing (DON) on 8/7/18 at 9:58 a.m. she revealed that this resident does not have a signature on the page of the Base Line Care Plan that would indicate that the resident or her representative received a copy of the Base Line Care Plan. She stated that she makes a note in the nursing notes that this was given but confirmed that there was no documentation in the nursing notes to indicate that the Base Line Care Plan was provided to R#10 or her representative. 2. R#51 was admitted to the facility on [DATE] under the services of Hospice Care. Review of the care plan for R#51 revealed that the document titled Base Line Care Plan dated 6/29/2018 was not signed by the resident or her representative. Review of the residents medical record revealed no documentation that the resident or representative received a copy of the Base Line Care Plan. During an interview with the Director of Nursing (DON) on 8/7/2018 at 9:58 a.m. she revealed that this resident did not have a signature on the page of the Base Line Care Plan that would indicate that the resident or her representative received a copy of the Base Line Care Plan.",2020-09-01
2134,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2018-08-09,914,E,0,1,JD6Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff and resident interviews, the facility failed to ensure rooms had privacy curtains that provided full visual privacy for the residents in 22 rooms out of a total of 49 rooms on three (3) of three (3) halls. This deficiency affected 41 residents out of a facility census of 72. Findings include The environmental tour began on 8/7/18 at 9:32 a.m. with the Director of Nursing (DON), and at 11:39 a.m. with the Contract Maintenance Director. Observation revealed resident privacy curtains that had a space/gap of 54 inches or less that did not provide full visual privacy coverage during patient care in the following rooms: #1, #3, #4, #7, #8, #9, #10, #11, #16, #18, #24, #26, #27, #28, #29, #30, #31, #34, #36, #37, #39 and #44. During an interview with the Director of Nursing (DON) on 8/7/18 at 9:32 a.m. while on a walk through of random rooms (room [ROOM NUMBER]-#13) she agreed that the privacy curtains did not provide the full visual privacy for those residents required to meet Federal Regulations. During an interview on 8/7/18 at 11:39 a.m., with the Contract Maintenance Supervisor, AA, (housekeeping), revealed that no training had been provided to her regarding the privacy curtains. During an interview with BB at which time he revealed that facility maintenance is responsible for putting up and removing the privacy curtains. He stated that his expectations are that if the Account Manager, CC, has any problems with the curtains it should be reported at once to the facility. During an interview with CNA, DD, on 8/7/18 at 11:44 a.m. she stated that she was not aware that the curtains should provide privacy from one end of the rod to the other end. She felt that as long as the curtain hid the person from the opening of the door there wasn't a problem. She reported that she understood if another resident or staff member were to come into the room it would be a privacy issue for the resident. She also stated that she has received in-services on the privacy curtains. During another interview with the DON on 8/7/18 at 1:56 p.m. revealed that her expectations are for her staff to ensure the privacy curtains are pulled during patient care and that the curtains provide full visual privacy. She stated that she was not aware that the curtains did not provid full visual privacy until it was identified during the survey. She further stated that the facility did not have a policy pertaining specifically to privacy curtains. During an interview on 8/7/18 at 2:17pm with Resident #64 (R#64), she stated that the gap in the privacy curtain does not give her privacy and that it bothers her because people would be able to see her when she was receiving care.",2020-09-01
6761,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2013-06-27,253,D,0,1,51F011,"Based on observations and staff interview the facility failed to assure that three (3) of thirty (30) resident bathroom facilities and three (3) of twenty-one (21) resident over-the-toilet assist seats were in good repair, and that one (1) of thirty (30) resident toilets were clean. Findings include: Observations made on 06/24/2013 beginning at 9:37 a.m revealed that the bathrooms in rooms eight (8), shared with room six (6,) and room ten (10), shared with room twelve (12), had white over-the-toilet seats with areas of rust and white paint chipping off the legs. The toilet for rooms 10/12 also had brown matter behind the toilet seat and at the bottom of the connecting pipe on the back of the toilet. Observations made on 06/25/2013 at 9:30 a.m. and 2:30 p.m., 06/26/2013 at 9:10 a.m. and 06/27/2013 at 8:45 a.m. continued to reveal brown matter behind the toilet seat and at the bottom of the pipe in the bathroom for rooms 10/12. Observations on 06/25/2013 at 1:00 p.m. revealed bathrooms for room twenty-nine (29), shared with room twenty-eight (28), room forty-four (44), shared with room forty-three (43), and room forty-six (46), shared with room forty-five (45) had paint cracked and peeling off the walls. Interviews and tour with the maintenance director on 06/25/2013 at 12:35 p.m. and 06/27/2013 at 10:25 a.m. revealed he is in charge of inspecting resident equipment used for toileting and transfers and for the bathrooms being painted and that he was not aware of the rusty, peeling over-the-toilet seats or paint peeling off the walls in the indicated bathrooms. Interviews on 6/27/2013 at 11:05 a.m with Certified Nursing Assistant (CNA) DD and at 11:09 a.m. with housekeeping staff GG revealed that both housekeeping and CNA's are responsible for assuring resident toilets are clean.",2017-10-01
6762,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2013-06-27,282,D,0,1,51F011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow interventions listed on the Comprehensive Care Plan related to the monitoring of three (3) residents (# 76,#77 and #83) taking antipsychotic medications for behaviors and potential side effects from a sample of thirty-five (35) residents. Findings include: 1. Review of the Clinical Record for Resident # 77 indicated the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Nurses Notes indicated the resident developed behaviors including scratching and grabbing at staff, making inappropriate sexual advances toward staff and resisting care. Review of the physician's orders [REDACTED]. The medication was increased to 50 mg twice a day on 3/23/13. Review of the Care Plan that was developed 3/26/13 to address the use of the [MEDICATION NAME] revealed an intervention to monitor the resident for side effects of the medication which was listed on the Medication Administration Record. (MAR). Review of the Medication Administration Record [REDACTED]. Interview on 6/26/13 at 2:15 p.m. with the Director of Nursing confirmed the side effects had not been monitored for the resident after the medication was started in March 2013 and in April 2013. Continued interview revealed that there were no blank forms available to initiate the monitoring of behaviors and side effects. 2. Resident #83 was admitted to the facility on [DATE] from home with a [DIAGNOSES REDACTED]. Upon admission, [MEDICATION NAME] was her only medication. Review of the physician orders [REDACTED]. Review of the the resident's Care Plan, updated 4/10/13 revealed that the resident exhibited increased behaviors that included, hallucinations and delusions, request to die or be killed and physical and verbally aggressive behaviors Review of a physician's orders [REDACTED]. Review of a Care Plan developed 4/16/13 for the use of the [MEDICATION NAME] and [MEDICATION NAME] revealed interventions that included to visually observe for changes in the resident's functional status, visually observe for side effects of the medications which were listed on the Medication Administration Record [REDACTED]. Review of the MAR indicated [REDACTED]. Interview on 6/26/13 at 3:00 p.m. with the Director of Nursing (DON) confirmed there was no monitoring of the side effects of the medications or consult with the physician about the possibility the [MEDICATION NAME] could be causing the increased agitation and yelling. 3. Review of the clinical record for resident #76 revealed that the resident was admitted to the facility 09/30/11 with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment completed 05/09/13 revealed that the resident was assessed as alert with confusion, behaviors of yelling out, resisting care and receiving antianxiety medications daily. Review of the Nurses Notes dated 05/13/13 at 9:00 p.m., revealed the resident hollered, pushed medications away, talked about things that did not make any sense, and thought she was in New York. Continued review revealed that the resident was resistant to care and kicked at staff. Review of the Nurses Notes dated 05/15/13 at 11:00 p.m., revealed the resident was hollering, tearing the diaper and throwing it on the floor, refused to eat and spitting out some medication. Review of the physician's orders [REDACTED]. by mouth every evening secondary to residents behaviors especially in the p.m. - Yelling, refusing care - verbally abusive to staff. Review of the care plan for [MEDICAL CONDITION] medication dated 09/25/13 and updated 05/29/13 revealed the following interventions: Monitor for changes in functional status, Inform physician of any adverse reactions to medication, Monitor for changes in mood/behavior, and Visually observe for side effects listed on MAR Review of the Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) AA on 06/27/13 at 11:25 a.m., revealed that per the care plan the nurses are expected to write the type of behaviors observed on the Behavior Monitoring sheet for each shift. Continued interview revealed that when a resident is started on [MEDICAL CONDITION] medication the pharmacy should be notified to send a preprinted Behaviors Monitoring Sheet for the new [MEDICAL CONDITION] medication ordered. The nurse confirmed that behavior monitoring was not documented for June 2013.",2017-10-01
6763,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2013-06-27,329,D,0,1,51F011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to monitor three residents (# 76, 77 and 83) taking antipsychotic medications for behaviors and potential side effects on a sample of thirty-five residents. Findings include: 1. Review of the Clinical Record for Resident # 77 indicated the resident was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the Nurses Notes indicated the resident developed behaviors including scratching and grabbing at staff, making inappropriate sexual advances toward staff and resisting care. Review of the physician's orders [REDACTED]. The medication was increased to 50 mg twice a day on 3/23/13. Review of the Medication Administration Record [REDACTED]. Interview on 6/26/13 at 2:15 p.m. with the Director of Nursing confirmed the side effects had not been monitored for the resident after the medication was started in March 2013 and in April 2013. Continued interview revealed that there were no blank forms available to initiate the monitoring of behaviors and side effects. 2. Review of the closed medical record indicated resident #83 was admitted to the facility on [DATE] from home with a [DIAGNOSES REDACTED]. Upon admission [MEDICATION NAME] was her only medication. Review of the Nurses Notes for February and March 2013 indicated no evidence of behaviors or anxiety. Review of the Physician order [REDACTED]. Review of the resident's clinical record revealed there was no [DIAGNOSES REDACTED]. Review of the Nurses Notes dated 4/10/13, revealed the resident was confused, angry at the staff, was hitting and yelling. On 4/11/13 the resident continued to exhibit verbal and physically aggressive behaviors. Review of a Physician order [REDACTED]. The medication was increased to 50 mg twice a day on 4/24/13 related again to escalation of behaviors. Review of the MAR for March and April 2013 indicated no evidence the resident was monitored for behaviors or for potential side effects of the medications. Review of the facility's procedure for behavior monitoring indicated the resident would be monitored for behaviors and potential side effects of the medication every shift. Interview on 6/26/13 at 3:00 p.m. with the Director of Nursing (DON) confirmed there was no monitoring of the side effects of the medications and the physician was not consulted about the possibility that the [MEDICATION NAME] could be causing the increased agitation and yelling. Continued interview confirmed there was no [DIAGNOSES REDACTED]. Review of the Manufacturer's Physician Prescribing Information Document indicated adverse reactions such as stimulation, sleep disturbances, hallucinations and other adverse behavioral effects such as agitation, rage, irritability, and aggressive or hostile behavior had been reported. 3. Review of the clinical record for resident #76 revealed that the resident was admitted to the facility 09/30/11 with diagnoses that included [MEDICAL CONDITION](CAD), status [REDACTED]. Review of the Minimum Data Set (MDS) Quarterly Assessment completed 05/09/13 revealed that the resident was assessed as receiving antianxiety medications daily and exhibiting verbal behaviors one (1) to three (3) days during the assessment period. Review of the Nurses Notes dated 05/13/13 at 9:00 p.m., revealed the resident hollered, pushed meds away, talked about things that did not make any sense, and thought she was in New York. Continued review revealed that the resident was resistant to care and kicked at staff. Review of the Nurses Notes dated 05/15/13 at 11:00 p.m., revealed the resident was hollering, tearing diaper and throwing it on the floor, refused to eat and spit out some medication. Review of the physician's orders [REDACTED]. by mouth every evening secondary to residents behaviors especially in the pm - Yelling, refusing care - verbally abusive to staff. Review of the Medication Administration Record [REDACTED]. Interview with Registered Nurse (RN) AA on 06/27/13 at 11:25 a.m., revealed that per the care plan the nurses are expected to write the type of behaviors observed on the Behavior Monitoring sheet for each shift. Continued interview revealed that when a resident is started on [MEDICAL CONDITION] medication the pharmacy should be notified to send a preprinted Behaviors Monitoring Sheet for the new [MEDICAL CONDITION] medication ordered. The nurse confirmed that behavior monitoring was not documented for June 2013.",2017-10-01
6764,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2013-06-27,371,E,0,1,51F011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to serve beverages and desserts that were covered until delivery for seventy-one (71) residents receiving meals and failed to dispose of expired and outdated foods in a timely manner from two of two (2 of 2) refrigerators used for residents. Findings include: 1. Observation on 6/24/13 at 12:15 p.m. revealed food trays were delivered from the kitchen to the dining room on an open cart. The iced tea, water and the dessert of pineapple upside down cake were not covered. Continued observation of meals delivered to the halls for distribution to residents revealed the beverages and desserts to be covered when leaving the kitchen, but were uncovered when placed on the tray before being carried down the hall for presentation. Observation of the noon meal on 6/25/13 and 6/26/13 revealed the same process. Interview on 6/26/13 at 12:20 p.m. with the Dietary Manager revealed she was not aware of the delivery system after the meals left the kitchen and that it needed to be remedied . 2. Observation on 06/26/2013 at 11:00 a.m. of the Skidaway/Colonial hall resident's refrigerator revealed: two (2) cans of expired Glucerna supplement dated June 1, 2013 , one (1) 14 ounce (oz) container of expired Danimals vanilla yogurt dated June 17, 2013, one (1) expired container of 4 oz Dannon light and fit yogurt dated May 30, 2013, one (1) container of expired SmartGels strawberry fraise labeled best if used by September 7, 2012 and one (1) container of Breakfast Blend Yogurt dated March 10, 2013. Continued observation revealed one (1) jar of preserves with the seal popped, not dated or labeled, one (1) opened container of 46 oz orange juice not dated, one (1) 64 oz Healthy Balance apple juice with splenda not dated, one (1) 48 oz container of Thick and Easy thickened ice tea open and not dated and one (1) 48 oz container of thick and easy apple juice opened and not dated. Observation on 06/26/2013, at 10:45 a.m. of the Brogden Hall resident's refrigerator revealed: one (1) 64 oz V8 splash opened and not dated, one (1) 46 oz Lyons ready care thickened water opened and not dated, one (1) 46 oz Thirsty orange juice opened and not dated, two (2) 48 oz Thick and Easy iced tea opened and not dated and two (2) 48 oz Thick and Easy [MEDICATION NAME] drink opened and not dated. Interview with the Housekeeping Supervisor and housekeeping staff member HH on 06/26/2013 at 11:42 a.m. revealed that expired food should not be present in the resident's refrigerators and that it is housekeeping's responsibility to check the refrigerator daily for outdated and/or expired food and remove from the refrigerator. Interview with the Director of Nursing (DON) on 06/26/2013 revealed all containers should be dated when they are opened. Interview with Licensed Practical Nurse (LPN) EE on 06/26/2013 revealed that nursing staff is responsible for checking the dates on nutritional supplements such as Glucerna 1.0 as they are stocked in the refrigerator and as they are removed prior to giving to the resident to assure no outdated supplements are given. Interview with LPN FF on 06/27/2013 revealed that one (1) resident on Skidaway hall was receiving one (1) Glucerna 1.0 can daily as a nutritional supplement. Record review of the Medication Administration Record (MAR) for the resident receiving Glucerna 1.0 revealed he was receiving the Glucerna one (1) can daily at six-thirty 6:30 p.m. Review on 06/27/2013 of the Policy and Procedure for Pantry refrigerator maintenance revealed that in order to store, distribute and serve nourishment under sanitary conditions: the refrigerators would be cleaned daily by the housekeeping staff with cleaning recorded on the refrigerator maintenance record, opened and unused food items would be labeled and dated, and outdated perishable foods would be removed and recorded on the refrigerator maintenance record. Perishable food older than three ( 3) days would be considered outdated.",2017-10-01
6765,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2013-06-27,441,D,0,1,51F011,"Based on observation and staff interview, the facility failed to store personal care items in a sanitary manner for one (1) resident # 78 in one (1) shared bathroom during three (3) of four (4) days of the survey from a sample of thirty five (35) residents. Findings include: Observations of the shared bathroom for resident # 78 on 06/24/13 at 9:50 a.m., on 6/25/13 at 1:45 p.m. and on 6/26/13 at 11:00 a.m. revealed a bath basin with the resident's name on it on the floor under the sink uncovered. Interview with the DON on 06/27/13 at 10:05 a.m. revealed that it was her expectation that the staff would secure all personal equipment covered, and not left on the floor.",2017-10-01
8286,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2011-12-08,323,E,0,1,Inf,"Based on observation, record review and staff interview, the facility failed to keep water temperatures below 120 degrees Fahrenheit (F) for four (4) resident rooms on two (2) of three (3) halls, and in one (1) of three (3) common shower rooms. The facility also failed to ensure that chemicals were kept in a locked area in two (2) of three (3) common shower rooms, and one (1) Storage Room on one (1) of three (3) halls. There were seven (7) residents in the facility identified as being independently mobile and cognitively impaired. The facility census was eighty-seven (87) residents. Findings include: 1. On 12/05/11 starting at 1:35 p.m., the following water temps were taken using the surveyors' thermometers: Room 18 on the Skidaway Hall: 120.4 degrees F Common Bathroom 1 on Colonial Hall: 121.6 F Room 13 on the Colonial Hall: 123 degrees F At 2:10 p.m., the Maintenance Director checked water temps with the facility's thermometer and obtained the following readings: Colonial Bathroom 1: 120.1 degrees Room 18 on Skidaway Hall: 126 degrees; the faucet was hot to touch Room 24/25 on Skidaway Hall: 124.7 degrees The Maintenance Director stated he tried to keep the water temps between 110 and 116 degrees. 2. On 12/06/11 at 7:40 a.m., observations in the unlocked Bathroom 1 on the Colonial Hall revealed a cabinet on the wall that had a lock on it with the key inserted in the lock. However, the key did not have to be turned to open the cabinet. Contents of the cabinet included one full bottle with a screw-on cap, and one 1/3-full spray bottle of Comet Cleaner with Bleach. Labeling included that it was an eye and skin irritant, and that a physician should be called immediately if swallowed. This was verified by the Director of Nurses (DON), who said the cabinet should be kept locked. At 7: 56 a.m., observations in the unlocked Bathroom 2 on the Skidaway Hall revealed an unlocked wall cabinet that contained a full can of Betco Glybet Disinfectant spray. Label precautions included that it caused eye and skin irritation. This was verified by the DON, who removed the chemical. On 12/06/11 at 3:36 p.m., observations in the unlocked Storage Room across from the Brogden Nurses Station revealed an unlocked lower cabinet that contained a full gallon bottle of Betco Fiber Pro Foam Control Liquid Defoamer Concentrate. Label Safety Instructions included that it may cause eye irritation, and to contact a physician if swallowed. Also in this cabinet was a full gallon bottle of Betco SuperKemite Heavy Duty Cleaner and Degreaser. Label warnings included that it was toxic, corrosive, and caused burns. This was confirmed by the DON, who removed the containers. On 12/07/11 at 9:00 a.m., the DON stated the chemicals in the Storage Room on Brogden were left by a contractor. She provided a listing of residents in the facility who were independently mobile and cognitively impaired. This included two residents on Colonial Hall; two on Skidaway Hall; and three on Brogden Hall.",2016-04-01
8287,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2011-12-08,332,E,0,1,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure that their medication error rate was less than 5%. Four (4) errors out of fifty-three (53) opportunities for two (2) of ten (10) residents were noted by two (2) nurses on one (1) of three (3) halls for a med error rate of 7.54%. Findings include: On 12/06/11 at 9:55 a.m., Licensed Practical Nurse (LPN) 'AA' was noted to give resident # 115 his/her morning medications, including [MEDICATION NAME], and [MEDICATION NAME]. Later review of the physician's orders [REDACTED].#115 at 8:00 a.m. This was verified by LPN 'AA' at 2:20 p.m. On 12/06/11 at 4:05 p.m., LPN 'BB' was noted to give resident # 31 the medications Carvedilol and [MEDICATION NAME]. Later review of the physician's orders [REDACTED]. This was verified by LPN 'BB,' who stated she usually gave the Carvedilol at the same time as the [MEDICATION NAME]. On 12/07/11 at 3:15 p.m., the Director of Nurses (DON) stated the staff had one hour before, and one hour after the scheduled time to give a med.",2016-04-01
8288,AZALEALAND NURSING HOME,115534,2040 COLONIAL DRIVE,SAVANNAH,GA,31406,2011-12-08,505,D,0,1,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure for one (1) resident (#88), that follow up on abnormal laboratory results with the physician was done in a timely manner. Findings include: Resident #88 who had multiple [DIAGNOSES REDACTED]. Record review revealed the resident had a critical high potassium blood result on 11/23/11 of 6.4 (normal is 3.5-5.3). The physician ordered the administration of [MEDICATION NAME] 30 grams and a second dose to be given on 11/24/11. The potassium level was to be checked six (6) hours after the second dose was administered. The order was modified to give the second dose of [MEDICATION NAME] 30 grams on 11/25/11 and then repeat the potassium level. On 11/25/11 the potassium level was elevated at 5.5. The lab results were faxed to the physician's office on 11/26/11. Review of the resident's record did not reveal follow up from the physician or the facility staff. An interview with Register Nurse (RN) CC, Unit Manager on 12/07/11 at 11:57 p.m. revealed that she had not received a response from the physician regarding the elevated lab results and should have followed up with the physician to verify the need for addition medication or labs. An interview with the Director of Nursing (DON) on 12/07/11 at 1:20 p.m. revealed it was the Unit Manager's responsibility for ensuring follow up on all laboratory results.",2016-04-01
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
4829,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2015-09-03,282,E,0,1,5QYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews it was determined the facility failed to implement care plan interventions for pressure ulcer treatments as ordered by the physician for two residents (#106 and #65), for monitoring of potential side effects of [MEDICAL CONDITION] medications and the ongoing signs and symptoms of depression and/or behaviors for two residents (#101 and #51) from a sample size of thiry-five (35) sampled residents. Findings include: 1. Resident #106 had a plan of care in place since 8/27/15 for skin breakdown. The plan of care included an intervention to licensed nursing staff to provide wound care as ordered by the physician. There was a physician's orders [REDACTED]. An observation of pressure ulcer treatment was done on 9/2/15 at 2:30 p.m. with licensed nurse AA. Licensed nurse AA stated that he/she did not usually provide pressure ulcer treatments but had been asked to do so at that time. During the observation of pressure ulcer treatment, Licensed nurse AA incorrectly used the same saline soaked gauze to clean each pressure ulcer. In addition, licensed nurse AA incorrectly applied the hydrogel to the open wound beds of the pressure ulcers and the surrounding intact skin before applying dry dressings to cover the pressure ulcers. The Assistant Director of Nursing (ADON) confirmed during an interview on 9/4/14 at 9:47 a.m. that the hydrogel is only applied to the open wound beds, not the surrounding intact skin. The Director of Nursing (DON) also confirmed on 9/4/15 at 10:29 a.m. that the hydrogel is for the open wound bed, not the surrounding intact skin. Cross reference to F314 2. Resident #101 had a plan of care in place since 3/22/15 for the use of an antidepressant medication. The plan of care included an intervention to monitor/document the side effects and effectiveness of the medication. There was also an intervention to monitor/document ongoing signs or symptoms of depression unaltered by the antidepressant medications. However, a review of the clinical record revealed no evidence the potential side effects or behavhiors were being monitored/documented for (MONTH) or (MONTH) (YEAR). Cross reference to F329 3. Resident #51 had a plan of care in place since 2/25/15 for a [DIAGNOSES REDACTED]. The plan of care included interventions to monitor/document for side effects of medications and for signs or symptoms of depression or risk for harming others. However, a review of the clinical record revealed no evidence the potential side effects or behaviors were being monitored/documented for (MONTH) or (MONTH) (YEAR).",2019-05-01
4830,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2015-09-03,309,D,0,1,5QYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, it was determined the facility failed to provide pressure ulcer treatments as ordered for one (1) resident with pressure ulcers (#106) from a total sample of 35 residents. Findings include: A review of the pressure and nonpressure wound list provided by the facility on 9/2/15 revealed that resident #106 had three stage 3 pressure ulcers to the left buttocks, right buttocks, and left upper buttocks. There was a physician's orders [REDACTED]. An observation of pressure ulcer treatment was done on 9/2/15 at 2:30 p.m. with licensed nurse AA. Licensed nurse AA stated that he/she did not usually provide pressure ulcer treatments but had been asked to do so at that time. During the observation of pressure ulcer treatment, Licensed nurse AA incorrectly used the same saline soaked gauze to clean each pressure ulcer. In addition, licensed nurse AA incorrectly applied the Hydrogel to the open wound beds of the pressure ulcers and the surrounding intact skin before applying dry dressings to cover the pressure ulcers. The Assistant Director of Nursing (ADON) confirmed during an interview on 9/4/14 at 9:47 a.m. that the Hydrogel is only applied to the open wound beds, not the surrounding intact skin. The Director of Nursing (DON) also confirmed on 9/4/15 at 10:29 a.m. that the Hydrogel is for the open wound bed, not the surrounding intact skin.",2019-05-01
4831,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2015-09-03,318,D,0,1,5QYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on record review and staff interviews, the facility failed to ensure that a recommendation by Physical Therapy for restorative nursing Stretch-N-Flex and Ambulation with a roller walker, was put into place for one (1) resident #67 from a census sample of thirty-five (35) residents. Findings Include: Review of Clinical Medical Records on 9/3/15 at 11:43 a.m. revealed a Physical Therapy Progress and Discharge Summary dated 4/15/15 had recommendations that include Walk to Dine and Restorative Nursing Program. Further investigation revealed Physical Therapist EE provided written instruction for ambulation and Active Rang of Motion (AROM) with a written acknowledgement from a Restorative Certified Nurse Aid (CNA). There was an written Physician order [REDACTED]. However, there was no documentation to support that resident #67 had received restorative nursing as recommended by Physical Therapy (PT). Reviewed of PointClickCare Restorative Notes dated 4/16/15 on 9/3/15 at 9:34 a.m. revealed that resident #67 was added to restorative caseload for ambulation and Active Range of Motion. Further investigation revealed no documentation to support resident #67 had received restorative nursing services. An interview on 9/3/15 at 12:05 p.m. with Restorative Certified Nursing Aide (CNA) DD acknowledged that resident #67 was not placed on restorative nursing caseload as recommended by PT in (MONTH) (YEAR). DD stated that he/she was told restorative service was as needed. And resident #67 would start restorative nursing program today. An interview on 9/3/15 at 12:15 p.m. with Physical Therapist EE stated that resident #67 had received physical therapy under Medicare part B and had made recommendation following discharge from PT to restorative nursing for walk and dine, and AROM in (MONTH) (YEAR). And at this time stated resident would not know if resident had decline without doing a therapy screen. An interview on 9/3/15 12:30 p.m. with Social Worker (SW) acknowledged that there were no progress notes for restorative services as recommended in PointClickCare for resident #67. And that resident #67 were to have received restorative nursing services following discharge from PT in (MONTH) (YEAR). An interview on 9/3/215 at 2:12:19 p.m. with Director of Therapy stated that he/she had conducted an in-services to other nursing department staff to facilitate the recommendation of physical therapy for resident #67. And that resident #67 had a history of [REDACTED].",2019-05-01
4832,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2015-09-03,329,E,0,1,5QYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to ensure adequate monitoring for adverse consequences, including behaviors and side effects per physician orders [REDACTED].#51,#80,#43,#37,and #101) receiving [MEDICAL CONDITION] medications. The census was seventy six (76) with a survey sample census of thirty five (35) residents. Findings include: Record review for Resident #43 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 08/05/2015 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Section N - Medication documented that the resident received antidepressant medications. The current (MONTH) (YEAR) physician's orders [REDACTED].#43 specified that the resident was to receive the antidepressant [MEDICATION NAME] 50 milligrams (mg) by mouth every day at bedtime for Depression and [MEDICATION NAME] 0.25 mg by mouth every four (4) hours as needed for agitation. Further orders are to Target Behavior for the use of [MEDICATION NAME] is defined as (crying Spells. Note the number of episodes every shift for Behavior Monitoring. Note the number of episodes or the target behavior. Review of Behavior Monitoring Flow records revealed no evidence of monitoring for the months of July, August, or Sept. Review of the residents record on 9/2/15 @ 3.30 p.m. with the DON confirmed that monitoring had not been conducted. Record review for Resident #37 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 06/25/2015 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. The current (MONTH) (YEAR) physician's orders [REDACTED].#37 specified that the resident was to receive [MEDICATION NAME] 75 mg by mouth every morning for Depression. Further orders are for Psychoactive Behavior Monitoring the target behavior for the use of ([MEDICATION NAME]) is defined as (withdrawn). Note number of episodes) every shift for Behavior Monitoring. Note the number of episodes. Review of Behavior Monitoring Flow records reveal no evidence of monitoring for the months of July, August, or Sept. Review of the residents record on 9/2/15 @ 3.30 p.m. with the DON confirmed that monitoring had not been conducted. Record review for Resident #80 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 08/12/2015 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. Section N - Medications document resident #80 receives an Antidepressant. The current (MONTH) (YEAR) physician's orders [REDACTED].#80 specified that the resident was to receive [MEDICATION NAME] 15 mg by mouth daily at bedtime for Depression. Further orders are for Target Behavior for the use of ([MEDICATION NAME]) is defined as (depression). Note the number of episodes every shift for Behavior Monitoring. Review of Behavior Monitoring Flow records reveal no evidence of monitoring for the months of July, August, or Sept. Review of the residents record on 9/2/15 @ 3.30 p.m. with the DON confirmed that monitoring had not been conducted. 1. Resident #51 had [DIAGNOSES REDACTED]. A review of the resident's current physician's orders [REDACTED]. 10 milligrams (mg) of [MEDICATION NAME] three times daily for anxiety, 150 mg of quetiapine [MEDICATION NAME] three times daily for [MEDICAL CONDITION], 50 mg of [MEDICATION NAME] daily at bedtime for depression, and 2.5 mg of [MEDICATION NAME] daily and 5 mg at bedtime for depression. The resident was also receiving 500 mg of [MEDICATION NAME] sodium (a mood stabilizer) twice daily for dementia with behavior disturbances. A further review of the physician's orders [REDACTED]. However, a review of the clinical record, including the Medication Administration Records (MAR's) revealed no evidence that potential side effects or target behaviors were monitored for the months of (MONTH) and (MONTH) (YEAR). 2. Resident #101 had [DIAGNOSES REDACTED]. A review of the resident's current physician's orders [REDACTED]. 60 mg of duloxetine daily for depression and 50 mg of [MEDICATION NAME] daily at bedtime for depression. The resident was also receiving 250 mg of [MEDICATION NAME] sodium (a mood stabilizer) three times daily for dementia with behaviors disturbances. A further review of the physician's orders [REDACTED].",2019-05-01
4833,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2015-09-03,441,D,0,1,5QYW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to provide treatment to a pressure wound without cross contamination. This was evident during wound treatment for one(1) resident #65 from a sample size of Thirty-five (35) residents. Finding includes: During an observation on 9/2/15 at 10:35 a.m. Licensed Practical Nurse (LPN) AA during a wound care treatment for resident #65 sacral stage IV wound, AA was observed irrigating the wound bed with a prefilled normal saline syringe. AA then took a tube of [MEDICATION NAME] gel and squeeze the gel into the wound bed. However, the outer rim of the [MEDICATION NAME] gel tube was touching the skin surrounding the wound and the tip portion of the tube was touching the bottom opening of the wound as [MEDICATION NAME] gel was being squeezed into the wound. After the wound care was completed LPN AA took the opened normal saline with a foil lid from resident #65 room and placed into the treatment cart among the unopened normal saline four ounce containers. During an observation on 9/3/15 at 10:55 a.m. the LPN BB during resident #65 wound care treatment was observed irrigating the wound bed with normal saline. BB took a tube of [MEDICATION NAME] gel and squeezed onto a 4 x 4 gauze and placed into the wound bed, then covered the 4 x 4 with a calcium alginate pad followed by an adhesive border dressing. Review of the physician orders [REDACTED]. Pat dry with gauze, apply [MEDICATION NAME] gel to wound bed. Then cover wound with calcium alginate, 4 x 4 gauze and dry dressing daily and as needed for soiled and dislodged. Every day shift for pressure wound. An interview on 9/3/15 at 11:11 a.m. LPN BB stated he/she irrigated the wound with normal saline, then place [MEDICATION NAME] gel on a 4 x 4 gauze and packed into the wound bed, followed by a calcium alginate pad on top of the gauze and finally had covered the wound with a border adhesive pad. BB acknowledged that wound care treatment was not follow as ordered An interview via phone on 9/3/15 at 11:24 a.m. LPN AA acknowledged that he/she did not use proper technique during the wound care performed on 9/2/15. AA continued to state that he/she tried not to touch the skin while applying the [MEDICATION NAME] gel tube. And he/she realized that the [MEDICATION NAME] gel tube came in contact with the resident skin and wound bed during wound care.",2019-05-01
5618,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2015-07-13,282,D,1,0,W5X811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed provide pressure sore treatment as ordered, as specified by the Care Plan, for two (2) residents (#2 and #3) having pressure sores, of four (4) sampled residents with pressure sores, from a total survey sample of four (4) residents. Findings include: 1. Resident #2's 12/11/13 Admission Minimum Data Set (MDS) assessment documented that upon facility admission on 12/04/2013, the resident had diagnoses, as documented in Section I - Active Diagnoses, including, but not limited to, Diabetes Mellitus, Arthritis, and [MEDICAL CONDITION]/[MEDICAL CONDITION]. Section M - Skin Conditions documented that Resident #2 had one Stage 2 pressure ulcer and three unstageable pressure ulcers upon admission. The Care Plan for Resident #2 identified as a Focus area, originally dated 12/17/2013, that the resident had pressure ulcers with treatment in progress. Interventions for Resident #2's identified pressure ulcers included for staff to administer treatments as ordered. Resident #2's Order Recap Report specified a 07/09/2015 physician's orders [REDACTED]. During a 07/13/2015, 3:15 p.m. observation, Licensed Nurse AA removed the dressing on Resident #2's sacral pressure sore, but without irrigating the pressure sore with normal saline as ordered, applied Silver [MEDICATION NAME] Cream, in error, instead of the ordered [MEDICATION NAME] gel, and failed to cover the pressure sore with Calcium Alginate as ordered. During interview with Licensed Nurse BB on 07/13/2015 at 5:40 p.m., Nurse BB acknowledged that the Silver [MEDICATION NAME] Cream different than [MEDICATION NAME] gel. Cross refer to F314, example 1, for more information regarding Resident #2. 2. Resident #3's Annual MDS of 06/26/2015 documented diagnoses, in Section I - Active Diagnoses, including but not limited to, Dementia, Arthritis, and Diabetes Mellitus, and Section M - Skin Conditions documented one Stage 2 pressure ulcer. The Care Plan for Resident #3 identified as a Focus area that the resident had an open pressure sore in the gluteal crease, with an Intervention specifying that the resident receive wound care as ordered. Resident #3's Order Summary Report specified a 07/02/2015 order to cleanse the gluteal crease wound with normal saline and pat dry with gauze, apply [MEDICATION NAME] paste skin barrier to the wound bed, and cover with Bordered gauze every other day and as needed. During an observation of Resident #3 on 07/13/15 at 3:30 p.m., Nurse AA removed a disposable diaper to reveal no Bordered gauze over the open gluteal wound as ordered. During interview at that time, Nurse AA stated that as Resident #3's treatment was applied earlier that day, only [MEDICATION NAME] paste was applied to the pressure sore. Cross refer to F314, example 2, for more information regarding Resident #3.",2018-07-01
5619,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2015-07-13,309,D,1,0,W5X811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, the facility failed to provide care in accordance with physician's orders for treatment of [REDACTED].#1) from a survey sample of four (4) residents. Findings include: Record review for Resident #1 revealed a Quarterly Minimum Data Set assessment having an Assessment Reference Date of 03/26/2015 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. A 03/12/2015 entry on the Wound Treatment and Progress Record for Resident #1 documented a wound on the resident's right outer ankle measuring 0.5 centimeters (cms) by 0.5 cms, with black eschar tissue. A 03/12/2015 Physician's Telephone Orders form for Resident #1 specified to apply skin prep to the resident's right outer ankle daily. However, further record review for Resident #1, to include review of the (MONTH) (YEAR) and (MONTH) (YEAR) Wound and Treatment and Progress Records, revealed no evidence to indicate that the skin prep treatment had been applied daily to the right outer ankle as as ordered on the following dates: 03/15/2015; 03/21/2015; 03/22/2015; 03/28/2015; 03/29/2015; 04/01/2015; 04/02/2015; 04/03/2015; 04/04/2015; 04/05/2015; 04/06/2015; 04/07/2015; 04/10/2015; 04/11/2015; 04/12/2015; 04/13/2015; 04/17/2015; 04/18//2015; and 04/19/2015. The progress note of 03/26/2015 at 8:50 a.m. for Resident #1 noted the right outer ankle had a dry wound bed, 100% eschar tissue, periwound tissue red, and was firm and intact. Subsequent notes on the Nursing Weekly Skin Condition Reports of 04/03/2015, 04/09/2015, and 04/14/2015 revealed no change in the right outer ankle vascular wound, as noted in the 03/26/2015 progress note referenced above. In addition, a 04/16/2015, 8:57 a.m. progress note for Resident #1 documented multiple dark red areas on the right lower leg and foot, and black round eschar on the right posterior calf with redness around edges of the wound measuring 3 cms by 2.5 cms. A Physician's Telephone Orders form for Resident #1 documented a 04/16/2015 physician's order specifying to apply skin prep film barrier to the black eschar tissue and discoloration on the right foot and leg daily, and to also apply skin prep on the wound to the resident's posterior calf daily. However, further record review for Resident #1 revealed no evidence to indicate that the treatments to the resident's right foot, leg, and posterior calf were done as ordered, per the 04/16/2015 physician's order referenced above, on 04/17/2015, 04/18/2015, and 04/19/2015.",2018-07-01
5620,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2015-07-13,314,D,1,0,W5X811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide pressure sore treatment as ordered for two (2) residents (#2 and #3), who had pressure sores, of four (4) sampled residents with pressure sores, from a total survey sample of four (4) residents. Findings include: 1. Record review for Resident #2 revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 12/11/2013 which documented the resident's 12/04/2013 admission to the facility. This MDS assessment documented in Section I - Active [DIAGNOSES REDACTED].#2 had [DIAGNOSES REDACTED]. Section M - Skin Conditions of this MDS documented that upon facility admission, Resident #2 had one Stage 2 pressure ulcer and three unstageable pressure ulcers. The (MONTH) (YEAR) Order Recap Report for Resident #2 documented a current 07/09/2015 physician's new order specifying the following sacral wound care: Irrigate the resident's wound cavity with normal saline, dry with gauze, apply [MEDICATION NAME] gel to the wound bed, and cover wound with Calcium Alginate and 4-by-4 gauze/Bordered gauze daily and as needed for soiled and dislodged dressings. On 07/13/2015 at 3:15 p.m., a wound care treatment performed by Licensed Nurse AA to the sacral area of Resident #2 was observed. Licensed Nurse AA removed the existing dressing and then, without irrigat ing the pressure sore with normal saline as ordered, applied Silver [MEDICATION NAME] Cream 1% (in error) to the wound base with a 4-by-4 gauze pad, instead of the ordered [MEDICATION NAME] gel. Nurse AA also failed to cover Resident #2's sacral pressure sore with Calcium Alginate, as ordered. During an interview with Licensed Nurse BB conducted on 07/13/2015 at 5:40 p.m., Nurse BB stated he/she had done wound care treatments in the past and was familiar with wound care treatment agents. He/she acknowledged that the Silver [MEDICATION NAME] Cream was not the same as the [MEDICATION NAME] gel. Nurse BB was then observed to check the treatment cart on 07/13/2015 at 5:55 p.m. and acknowledge that he/she could find only Silver [MEDICATION NAME] Cream 1%, but could not find any [MEDICATION NAME] gel on the treatment cart for Resident #2. 2. Record review for Resident #3 revealed an Annual MDS assessment having an Assessment Reference Date of 06/26/2015 documented in Section I - Active [DIAGNOSES REDACTED]. Section M - Skin Conditions of this MDS documented that at the time of assessment, Resident #3 had one Stage 2 pressure ulcer. The Wound Treatment and Progress Record of Resident #3 documented that on 04/03/2015, a Stage 2 pressure ulcer, as referenced on the 06/26/2015 MDS as above, had been identified on the resident's gluteal crease. The current Order Summary Report for Resident #3 documented a physician's orders [REDACTED]. During an observation of Resident #3 with Licensed Nurse AA in attendance on 07/13/2015 at 3:30 p.m., as Nurse AA removed the resident's disposable diaper, no Bordered gauze was observed to over the open area on the gluteal area as ordered. Rather, only [MEDICATION NAME] paste was observed over the area. During an interview conducted at the time of this observation, Nurse AA stated he/she stated had applied Resident #3's treatment earlier that day, and that Resident #3 had received only [MEDICATION NAME] paste to the gluteal pressure sore.",2018-07-01
6039,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2014-11-13,159,C,0,1,B9YH11,"Based on resident interview, record review and staff interview, the facility failed to have resident's personal funds available on weekends and holidays for eighty two (82) resident accounts. Findings include: An interview with resident A on 11/11/14 at 9:39 a.m. reveals the resident has a personal fund account but does not have access to the money on the weekends or holidays. An interview with resident B on 11/11/14 at 11:49 a.m. reveals the resident has a personal fund account but does not have access to the money on the weekends or holidays. An interview with resident C on 11/11/14 at 8:57 a.m. reveals the resident has a personal fund account but does not have access to the money on the weekends or holidays. Interview on 11/12/14 at 2:50 p.m. with the Business Office Manager DD revealed that the facility is working on a system so funds will be available on weekends and holidays but at present they are not. She stated that she goes around on Fridays before the weekend and asks residents if they need money for the weekend. If they do she gets them the money they ask for. Interview with Certified Nursing Assistant (CNA) AA on 11/12/14 at 3:05 p.m. revealed that if a resident asked for money on the weekends that she would tell them they would have to wait until Monday morning when the business office opened. Interview with Licensed Practical Nurse (LPN) BB on 11/12/14 at 3:10 p.m. revealed that if a resident asked her about how to get money on the weekends she would tell them they would have to wait until Monday and speak with the business office. Interview with the Social Worker CC on 11/12/14 at 3:15 p.m. revealed that funds are not available on the weekends but if it was an emergency someone from the Business office could come in to get them money. Record review of typed statement received from the Administrator on 11/12/14 confirming that the facility does not have funds available on the weekends and holidays, but they do go around on Fridays before the weekend and the day before the holiday and ask residents if they need money.",2018-04-01
6040,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2014-11-13,282,D,0,1,B9YH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview the facility failed to follow the Plan of Care regarding diabetic monitoring of finger stick blood sugars (FSBS) for two (2) residents (#38 and #53) of thirty two (32) sampled residents with diabetes. Findings include: Review of resident (#38) Plan of Care initiated 8/14/13 for diabetes mellitus revealed intervention for diabetes medication as ordered by doctor. Notify MD if blood sugar less than 60 or greater than 400. Medical record review for resident (#38) indicated a [DIAGNOSES REDACTED]. Review of Nursing Progress Notes on 10/1, 10/2, 10/12, and 10/25 revealed no evidence of MD notification of FSBS greater than 400. Additionally, review of resident (#53) Plan of Care initiated 8/1/13 for diabetes mellitus revealed intervention for diabetes medication as ordered by doctor. Accuchecks and labs as ordered. Notify MD as needed. Review of Physician order [REDACTED]. Notify MD for FSBS less than 60 or greater than 400. Medical record review for resident (#53) indicated a [DIAGNOSES REDACTED]. Review of Nursing Progress Notes on 9/14, 10/12, 10/17, 10/20, and 10/21 revealed no evidence of MD notification of FSBS less than 60. Interview on 11/13/14 at 9.00 a.m. with Director of Nursing (DON) concurred the orders read to notify physician if FSBS is less than 60 or greater than 400. Review of resident #38 and #53 Nursing Progress Notes with the DON verified the nurses did not notify the physician of blood sugars out of parameters on 9/14, 10/1,10/2, 10/12, 10/17, 10/20,10/21 and 10/25/14.",2018-04-01
6041,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2014-11-13,309,D,0,1,B9YH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow physician orders [REDACTED].#38 and #53) from a total sample of thirty two (32) residents with diabetes. Findings include: Review of resident #38 physician orders [REDACTED]. Medical record review for resident (#38) indicated a [DIAGNOSES REDACTED]. Review of Nursing Progress Notes on 10/1, 10/2, 10/12, and 10/25 revealed no evidence of MD notification of FSBS greater than 400. Additionally, review of resident (#53) physician orders [REDACTED]. Medical record review for resident (#53) indicated a [DIAGNOSES REDACTED]. Review of Nursing Progress Notes on 9/14, 10/12, 10/17, 10/20, and 10/21 revealed no evidence of MD notification of FSBS less than 60. Interview on 11/13/14 at 9.00 a.m. with Director of Nursing ( DON ) concurred the orders read to notify physician if FSBS is less than 60 or greater than 400. Review of resident #38 and #53 Nursing Progress Notes with the DON verified the nurses did not notify the physician of blood sugars out of parameters on 9/14, 10/1,10/2, 10/12, 10/17, 10/20,10/21 and 10/25/14.",2018-04-01
7020,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2013-02-07,241,D,0,1,D29V11,"Based on an observation, it was determined the facility failed to provide a dignified dining experience for residents in one of two dining rooms. Findings include: It was observed on 2/4/13 from 12:35 p.m. to 12:55 p.m. that 13 residents and four staff members were in the restorative dining room for the lunch meal. Facility staff did not serve or assist a table with four residents to eat in a consistent and timely manner. It was observed that staff had only served one of the four residents at 12:35 p.m. Although that resident was eating lunch, staff had not served lunch to the other three residents. Staff served another one of the four residents at the table at 12:45 p.m. However, staff did not assist that resident to eat at that time nor did the resident attempt to feed him/herself. A staff member sat down to assist that resident to eat eight ( 8) minutes later. Staff served the third resident at the table at 12:49 p.m. and she/he began eating. Staff had not sent a lunch tray to the dining room for the fourth resident at the table so, a staff member had to go to the kitchen to get it. Staff served the tray to the fourth resident and assisted him/her to eat at 12:55 p.m. There was a 20 minute delay between the time that the first resident at the table was observed to have been eating until when the fourth resident began to eat. In addition, it was observed that one of the four residents at table began to groan, moan and holler continuously from 12:35 p.m. until 12:53 p.m. when a staff member sat down to assist that resident to eat. The resident's continuous noise agitated a resident at another table who began cursing at the resident making those loud noises. It was observed that staff did not intervene to attempt to calm the resident, who was making the loud noises, or the resident who began cursing.",2017-08-01
7021,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2013-02-07,282,D,0,1,D29V11,"Based on observation and record review, it was determined the facility failed to implement care plan interventions to prevent falls and to provide assistance needed with activities of daily living (ADL) for one resident (#27) from a total sample of 34 residents. Findings include: According to staff's coding on the resident's comprehensive assessment of 11/12, he/she required staff assistance with dressing, activities of daily living and bathing. There was a care plan since 1/15/12 to address the resident's risk for falling. There was an intervention to prevent falls since 1/18/12 for staff to put nonskid socks on resident #27. However, it was observed on 2/4/13 at 2:01 p.m. and 2/5/13 at 10:30 a.m. that the staff had not put nonskid socks on the resident's feet. See F323 for additional information concerning resident #27. Resident #27 also had a care plan intervention since 11/15/12 for nursing staff to assess the resident's needs often and to anticipate his/her wants and needs and to provide necessary care. However, the resident was observed on 2/4/13 at 2:01 p.m. to have dried food on his/her upper lip and clothes. It was observed at 2:18 p.m. revealed that there was still dried food on the resident's upper lip. The resident was observed on 2/5/13 at 10:30 a.m. to have been wearing a shirt with dried stains on it. The resident had long toenails. He/she had a dried dark substance caked on two of his/her fingers and underneath his/her fingernails. The resident's fingernails were still dirty on 2/6/13 at 11:45 a.m. and 2 p.m. See F312 for additional information concerning resident #27.",2017-08-01
7022,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2013-02-07,312,D,0,1,D29V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined the facility failed to ensure that one resident (#27) was provided assistance with nail care and grooming from a total sample of 34 residents. Findings include: Resident #27 had [DIAGNOSES REDACTED]. Staff coded the resident on the 11/12 Minimum Data Set (MDS) for his/her annual comprehensive assessment as having been provided with extensive staff assistance with personal hygiene. The resident had a care plan intervention since 11/15/12 for nursing staff to assess the resident's needs often and to anticipate the resident's wants and needs and to provide the necessary care. However the resident was observed on 2/4/13 at 2:01 p.m. with pieces of food pieces all over his/her bed and dried food on his/her upper lip and clothes. It was observed 2:18 p.m. that although staff had removed the food from the bed and changed the resident's shirt, they had failed to clean the dried food from his/her upper lip. The resident was observed on 2/5/13 at 10:30 a.m. to have had dried stains on his/her shirt. He/she had long toenails and a dried dark substance caked underneath his fingernails and on two of his/her fingers. During observations on 2/6/13 at 11:45 a.m. and 2 p.m., it was noted that staff had not removed the dark substance from underneath the resident's fingernails. Although, there was staff documentation in the 11/12 care plan that the resident was resistive to care at times and also at times refused baths and personal hygiene, there was no nursing staff documentation on the printout of ADL report provided by the Director of Nursing (DON) for 2/4/13 and 2/5/13 that the resident had refused care. During an interview on 2/6/13 at 3:26 p.m., the DON said that the resident had refused to come out of his/her room for care from the podiatrist. However, she did not know if the facility had attempted alternatives to facilitate that care in the resident's room.",2017-08-01
7023,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2013-02-07,323,D,0,1,D29V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record review, it was determined the facility failed to implement an intervention to prevent falls for one resident (#27) at risk for falls from a total sample of 34 residents. Findings include: Resident #27 had [DIAGNOSES REDACTED]. The resident had a care plan since 11/15/12 to address being at risk for falls because of his/her very unsteady gait and poor balance. There was staff documentation that the resident ambulated as he/she desired in his/her room. The care plan included an intervention since 1/18/12 for the staff to put nonskid socks on the resident's feet to prevent falls. However, it was observed on 2/4/13 at 2:01 p.m. that staff had not put nonskid socks on the resident's feet. The resident was wearing a thin white sock on one foot and the other one was bare. The resident's feet were observed to have been bare on 2/5/13 at 10:30 a.m.",2017-08-01
7024,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2013-02-07,431,E,0,1,D29V11,"Based on observation, staff interview and review of the facility policy, it was determined the facility had failed to label medications with the date that they had initially been opened. The facility failed to ensure that expired medications were discarded within policy time frame. Findings include: The facility policy recommended the following minimum medication storage parameters: multiple-dose vials for injection (non insulin) were supposed to be dated when opened and the unused portion discarded after 28 days or in accordance with manufacturer's recommendations. Insulin products (all vials) should be dated when opened and then discarded 28 days after opening (except for Levemir, Novolin R, Novolin N, and Novolin 70/30). Levemir, Novolin R, Novolin N, and Novolin 70/30 could be used for up to 42 days after having been opened. The following opened multi-dose medications were observed in medication refrigerator in the one (1) medication storage room for three (3) halls on 02/05/13 at 4:00 p.m.: one (1) vial of Tuberculin Purified Protein Derivatives (PPD) with a manufacturer's expiration date 02/2014 and an opened date of 10/31/12; one (1) vial of Desmopressin Acetate injection (DDAVP) with a manufacturer's expiration date 02/2014 and one with an opened date of 09/23/12 and; one (1) vial of Levemir Insulin without an opened date. During an interview on 02/05/13 at 4:10 p.m., the Assistant Director of Nursing (ADON) revealed that she did not know the expiration dates of the opened medications, but she would find out that information. In an interview on 02/05/13 at 4:15 p.m., the Director of Nursing (DON) said that all of the nurses were responsible for checking for expired and not labeled medications in the refrigerator and the medication carts. She confirmed that the three (3) vials in the refrigerator were expired and should have been removed from the refrigerator. During observations of the facility's three (3) medication carts on 02/07/13 at 12:45 p.m., it was noted that two (2) of the three (3) carts contained medications that had expired or were not labeled. Medication cart # 2 contained the following five (5) opened vials of insulin that were not labeled or expired: one (1) vial Novolin R Insulin opened 12/20/12; one (1) vial Novolin R Insulin opened 12/12/12; one (1) vial Humulin R Insulin opened 12/05/12; one (1) vial Levemir Insulin opened 12/08/12 and one (1) vial Novolin R Insulin without an opened date. Medication cart # 3 contained one (1) vial of Novolin R Insulin opened 12/21/12.",2017-08-01
8698,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2011-09-22,241,D,0,1,NEX711,"Based on observations, staff interviews and record review, it was determined that the facility failed to promote care in a manner that enhanced the dignity of one resident (# 7) who was dressed in clothing that was not in good repair in a total sample of 36 residents. Findings include: On the 3/8/11 initial Minimum Data Set (MDS) assessment, nursing staff coded resident #7 as needing extensive assistance with dressing. There was a care plan since 3/7/11 with an intervention for staff to assist him/her for all activities of daily living (ADLs). He/She was observed sitting in the main dining room on 9/20/11 at 8:00 a.m. and in the activity room on 9/21/11 at 8:30 a.m. The resident was wearing a knit sweater that was torn on the right shoulder and left sleeve. During an interview on 9/21/11 at 11:45 a.m., certified nursing assistant (CNA) AA stated that resident #7 had been dressed by the 11 p.m. -7 a.m. nursing staff and was seated in his/her wheelchair when he/she arrived at work at 7 a.m. that morning. CNA AA did not know if that torn sweater was one that the resident preferred to wear. CNA AA said that the resident wanted to wear something on his/her arms. He/She said that the resident had other jackets and/or sweaters to wear in his/her closet. On the morning of 9/22/11, the resident was observed wearing a different sweater that was in good repair.",2015-11-01
8699,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2011-09-22,279,D,0,1,NEX711,"Based on record review, resident interview and staff interview, it was determined that the facility failed to develop a plan of care to maintain or improve one resident's (A) ability to ambulate from a sample of 36 residents. Findings include: Review of the 7/16/10 care plan for resident A revealed documentation that he/she had a problem of not being able to ambulate because of paraparesis in his/her lower extremities. There was a 3/9/11 update to the resident's care plan noting that the resident worked with therapy and could ambulate some with a quad cane and two person assistance. However, there were no interventions developed to address the services to be provided to maintain or improve the resident's ambulation ability. Resident A had a 3/5/11 physical therapy discharge summary which noted that the resident had progressed through therapy with improvement in gait mechanics to 100 feet with a rolling walker using minimum to moderate assistance. However, there were no recommendations from physical therapy of a plan to maintain the resident's ambulation status. See F311 for additional information regarding resident A.",2015-11-01
8700,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2011-09-22,309,D,0,1,NEX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, it was determined that the facility failed to transcribe and implement a physician's medication order for one resident (#78) to promote bowel functioning from the sample of 36 residents. Findings include: According to the Drug Information Handbook for Nursing 8th Edition, the elderly may be particularly susceptible to the constipating effects of narcotics ([MEDICATION NAME]). Potential adverse reactions to the use of [MEDICATION NAME] and [MEDICATION NAME] included constipation. Resident #78 was admitted with a [DIAGNOSES REDACTED]. There was a care plan since 3/11/11 to address the resident's risk for alteration in comfort related to chronic pain. There was an intervention for nursing staff to monitor the resident for signs and symptoms of constipation. According to documentation in the nurse's note on 4/11/11 at 1:30 p.m., the resident had complained that he/she needed to have a good bowel movement. Licensed nursing staff documented that she had checked and found a fecal impaction that was high up. The nurse documented that hospice staff had been called and the resident was given a Fleets enema with poor results. The 6 p.m. nurse's note documented that the resident had not had a bowel movement. There was a 4/11/11 physician's orders [REDACTED]. In an interview on 9/21/11 at 3:30 p.m., the Director of Nursing (DON) stated that the physician's orders [REDACTED]. In addition, according to staff's documentation on the resident's bowel movement record form, although the resident had bowel movements on 4/12, 4/15 and 4/1711, there was no evidence that nursing staff had addressed the resident's failure to have a bowel movement from 4/18/11 to 4/23/11 (when he/she was discharged from the facility).",2015-11-01
8701,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2011-09-22,311,D,0,1,NEX711,"Based on record review, resident interview and staff interview, it was determined that the facility failed to develop a plan of care to maintain or improve one resident's (A) ambulation ability in a sample of 36 residents. Findings include: Review of the 7/16/10 care plan for resident A revealed documentation that he/she had a problem of not being able to ambulate because of paraparesis in his/her lower extremities. He/She had a 3/5/11 physical therapy discharge summary which noted that the resident had progressed through therapy with improvement in gait mechanics to 100 feet with a rolling walker using minimum to moderate assistance. There was a 3/9/11 update to the resident's care plan noting that the resident worked with therapy and could ambulate some with a quad cane and two person assistance. However, there were not any care plan interventions developed to address the services to be provided to maintain or improve the resident's ambulation ability. Review of the 9/5/11 Minimum Data Set (MDS) assessment and the 6/4/11 MDS assessment revealed that licensed staff had assessed and coded the resident as not having been observed to ambulate during the seven day assessment period. They coded the resident as not having had any impairments in his/her lower extremities. In an interview on 9/22/11 at 10:10 a.m., resident A stated that he/she was able to walk a short distance with a belt (gait belt) and with someone helping him/her to walk. The resident said he/she could not remember the last time that staff had helped him/her to walk. During an interview on 9/22/11 at 10:45 a.m., the Director of Nurses (DON) confirmed that the resident was not on restorative/maintenance services program. She stated that the resident had been screened by skilled therapy staff quarterly and had not declined. During an interview on 9/22/11 at 11:00 a.m., the skilled rehabilitation services director stated that a restorative or maintenance program was not established for the resident after discharge from skilled therapy services because the resident chose to use a wheelchair for mobility. Therefore, although she confirmed that the resident had been ambulating 100 feet with staff assistance when he/she was discharged from skilled therapy services on 3/5/11, a plan was not developed to maintain or improve the resident's ambulation ability.",2015-11-01
9102,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2012-05-09,241,E,1,0,VJQA11,"Based on observations, it was determined that the facility failed to promote an environment that enhanced each resident's dignity during a lunch meal in the dining room for one resident (#1) in a total sample of 25 residents who ate lunch in the dining room. Findings include: Observations were made in the main dining room on 5/09/12 between 12:40 p.m. and 1:40 p.m. and revealed the following: 1. Resident #1 was served a meal at 1:15 p.m. but, did not receive assistance to eat it until 1:40 p.m.. There were two other residents at the table who ate their lunch and left the dining room prior to this resident being provided assistance to eat. 2. At 1:25 p.m., although there were residents still eating in the dining room, a certified nursing assistant (CNA) proceeded to clean off the tables. She took a cart to the tables and removed plates, cups and silverware from tables as residents still continued to eat their lunch. She was observed to scrape food off plates in front of other residents who were still eating lunch. She and another CNA would discuss the percentages of food eaten by the residents who had already left the dining room while that other CNA assisted residents to eat.",2015-08-01
9103,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2012-05-09,312,D,1,0,VJQA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and record review, it was determined that the facility failed to provide one resident (#1) with assistance to eat in a timely manner in a total sample of 25 residents who ate lunch in the dining room. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The resident had been coded on the 4/22/12 Minimum Data Set (MDS) as needing oversight, encouragement or cueing for eating. There was a current plan of care to address his/her risk for alteration in nutrition related to dementia and [MEDICAL CONDITION]. There was an intervention for nursing staff to set up each meal tray and to assist as needed. During observation of lunch in the dining room on 5/9/12 at 12:25 p.m., the resident was served the lunch meal at 1:15 p.m. but, was not assisted by staff to eat until 1:40 p.m.. Observations in the main dining room between 12:25 p.m. and 1:40 p.m. revealed that there were three certified nursing assistants (CNAs) and one dietary staff member in the dining room. Two licensed nurses were observed to come in and out of that dining room during this timeframe. However, none of those staff observed that the resident was not eating and/or provided assistance to the resident to eat the lunch.",2015-08-01
9104,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2012-05-09,514,B,1,0,VJQA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to maintain clinical records for two residents (#1 and #5) that was complete with sufficient information to reflect the current status of the resident in a sample of five residents. Findings include: 1. A review of the physician's progress notes for resident #1 revealed notes were written on 2/15/12, 3/21/12, and 4/23/12. Although the resident had been hospitalized with pneumonia, [MEDICAL CONDITION] secondary to the pneumonia, and decompensation of chronic [MEDICAL CONDITION] from 12/27/11 to 1/02/12, the 2/15/12 written progress note did not include any reference to her respiratory or renal status. There was no evidence that the physician had reviewed the resident's total program of care, including treatments and evaluated the resident's condition. The resident had been hosptalized on [DATE] until 4/26/12 for altered mental status. However, there was a 4/23/12 written progress note that documented the resident as having had advanced dementia, as being pleasantly confused and as having no concerns at that time. 2. A review of the physician's progress notes for resident #5 revealed a written progress of 4/23/12 that said the resident had multiple skin issues that was being followed by the treatment nurse. There was no evidence that the physician had reviewed the resident's total program of care, including treatments and/or evaluated the resident's skin condition.",2015-08-01
10172,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-01-12,323,D,1,0,B1HX11,"Based on record review, staff interview, and observation, it was determined that the facility failed to ensure adequate supervision for two (2) residents (#2 and #3), who had been assessed as having the potential for falls, from a survey sample of six (6) residents. Findings include: 1. Record review for Resident #2 revealed Nurse's Notes of 09/24/2009, 09/26/2009, 10/08/2009 and 10/24/2009 which documented that the resident had experienced falls. The resident's Care Plan referenced a 10/10/2009 entry identifying the resident to be at risk for falls and noting that the resident had experienced several falls. Approaches to address this fall-risk included the use of Assure non-skid footing, and the use of a bed alarm and a chair alarm. However, observation of the resident on 12/09/2009 at 3:15 p.m. revealed that the resident was in the wheelchair in his/her room, but there was no chair alarm on the wheelchair. Another observation of the resident with Nurse ""AA"" in attendance on 12/09/2009 at 5:15 p.m. revealed the resident was in the dining room in the wheelchair with no chair alarm on the wheelchair and no non-skid footwear on the feet. Nurse ""AA"" acknowledged during interview at the time of this observation that there was no alarm on the wheelchair nor were there any non-skid socks on the resident's feet. The resident was instead wearing regular socks, as acknowledged by this staff member. During observation of the resident's bed on 12/09/2009 at 5:20 p.m. with Nurse ""AA"" in attendance, there was no bed alarm on the bed. Nurse ""AA"" acknowledged the absence of a bed alarm during interview conducted at the time of this observation. 2. Record review for Resident #3 revealed a 09/14/2009 Care Plan entry which identified the resident to be at risk for falls for reasons including an unsteady gait, cognitive impairment, and the use of psychotropic medications. The Care Plan specified the use of a Merri-Walker as an Approach to address this risk. However, this 09/14/2009 Care Plan entry referenced above also documented that the resident would crawl out of the Merri-Walker and attempt to ambulate independently. Nurse's Notes of 10/18/2009, 11/17/2009, 11/18/2009 and 12/08/2009 documented that the resident had been observed by nursing staff to crawl under the bar of the Merri-Walker. During an interview with the Director of Nursing (DON) conducted on 12/09/2009 at 5:40 p.m., the DON acknowledged that the resident would crawl under the bar of the Merri-Walker. There was, however, no evidence to indicate that the facility had reevaluated the effectiveness of the use of the Merri-Walker or to assess for another device that would be more effective.",2014-12-01
10173,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,157,D,0,1,Z66Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to consult with the physician about a significant change in the physical condition of one (#6) of 19 sampled residents. Findings include: According to licensed nursing staff's documentation in the 8/25/09 at 5:15 a.m. nursing notes, resident #6 attempted to get out of his/her wheelchair unassisted and fell on the floor. At that time, nursing staff noted that he/she denied pain and had received a skin tear on his/her left elbow. Review of the 8/27/09 at 3:20 p.m. nurses notes for resident #6 revealed nursing staff had observed a fading purple bruise on his/her left lower forearm and elbow, and ""some [MEDICAL CONDITION]"" to his/her lower left lower forearm. Nursing staff noted the resident withdrew when his/her arm was manipulated by staff. Nursing staff noted that they had applied a sling to elevate that arm. However, nursing staff did not consult the resident's physician until 8/28/09 at 10:00 a.m. Upon receiving notification of the resident's injury, the physician ordered an x-ray of the left arm. The X-ray report noted that the resident had a fracture to his/her left elbow. During an interview on 2/11/10 at 2:15 p.m., the Director of Nursing confirmed that the physician was not notified about the resident's change in condition until 8/28/09 at 10:00 a.m.",2014-12-01
10174,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,281,D,0,1,Z66Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, it was determined that the facility failed to ensure that the licensed nursing staff notified the physician as ordered when one resident's (#12) blood sugar levels were greater than 300 in a total sample of 19 residents. Findings include: According to 43-26-3 and 43-26-32 of the Georgia Nursing Practice and Regulation Acts, nursing responsibility included an evaluation of 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. However, licensed nursing staff failed to communicate with the attending physician when the blood sugar levels of resident #12 were greater than 300. Resident #12 had physician's orders [REDACTED]. Although nursing staff documented on the Medication Administration Record (MAR) revealed that the resident's blood sugar levels at 4:30 p.m. were greater than 300 on 2/6/10 ( blood sugar level of 322), 1/1/10 (304), 1/9/10 ( 397), 1/12/10 (391), 1/27/10 (314), 12/11/09 (382) and 12/28/09 (322),11/1/09 (409), 11/2/09 (397), 11/3/09 (417), 11/4/09 (411), 11/5/09 (341), 11/6/09 (301), 11/7/09 (444), 11/8/09 (373), 11/9/09 (351), 11/10/09 (360), 11/11/09 (302), 11/12/09 (429), 11/13/09 (311), 11/16/09 (402), 11/17/09 (353), 11/18/09 (336), 11/19/09 (368), 11/22/09 (365) and 11/23/09 (411), the physician was not notified. During an interview on 2/11/10 at 10:20 a.m., the Assistant Director of Nursing (ADON) stated that if and when the physician was notified about the elevated blood sugar levels, the licensed nurse was supposed to document that information on the nurse's notes or MARs.",2014-12-01
10175,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,282,D,0,1,Z66Y11,"Based on observations and record review, it was determined that the facility failed to implement care plan interventions to promote independence in eating for one resident (#4), and failed to provide assistance with activities of daily living for one resident (#2), from a sample of 19 residents. Findings include: 1. On the 1/4/10 quarterly Minimum Data Set (MDS) assessment, licensed nursing staff coded resident #4 as requiring limited assistance of one staff person with eating. The December 2009 Nursing Restorative Care Program interventions were for staff to problem moderate to maximum visual cues to initiate eating and to use hand over hand assistance as needed when eating with weighted utensils. The 1/12/09 care plan described the resident as being at risk for altered nutrition related to his/her use of adaptive equipment. There was a care plan intervention for nursing and dietary staff to provide adaptive devices including a plate guard and weighted cup. However, it was observed during meals served in the dining room on 2/9/10 at 1:35 p.m., 2/10/10 at 8:40 a.m. and 1:30 p.m., and 2/11/10 at 1:45 p.m., that staff had not set up the resident's tray using a plate guard or weighted cups. See F369 for additional information regarding resident #4. 2. Resident #2 had a care plan intervention since 12/29/09 for nursing staff to provide routine hair, nail,and skin care for him/her. However, the resident was observed to have approximately one-fourth of an inch growth of facial hair on his/her upper lip and chin on 2/9/10 at 4 p.m., 2/10/10 at 1:35 p.m., and on 2/11/10 at 8:25 a.m. See F312 for additional information regarding resident #2.",2014-12-01
10176,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,309,D,0,1,Z66Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to consistently treat and assess an arterial ulcer identified on one resident's heel (#15), failed to follow physician's orders [REDACTED].#12) had an elevated blood sugar level and for the correct dosage of insulin, and failed to ensure that hospice services was integrated into the care plan for one resident (#2), from a sample of 19 residents. Findings include: 1. Resident #12 had physician's orders [REDACTED]. Although nursing staff documented on the Medication Administration Record (MAR) revealed that the resident's blood sugar levels at 4:30 p.m. were greater than 300 on 2/6/10 ( blood sugar level of 322), 1/1/10 (304), 1/9/10 ( 397), 1/12/10 (391), 1/27/10 (314), 12/11/09 (382) and 12/28/09 (322), 11/1/09 (409), 11/2/09 (397), 11/3/09 (417), 11/4/09 (411), 11/5/09 (341), 11/6/09 (301), 11/7/09 (444), 11/8/09 (373), 11/9/09 (351), 11/10/09 (360), 11/11/09 (302), 11/12/09 (429), 11/13/09 (311), 11/16/09 (402), 11/17/09 (353), 11/18/09 (336), 11/19/09 (368), 11/22/09 (365) and 11/23/09 (411), the physician was not notified. During an interview on 2/11/10 at 10:20 a.m., the Assistant Director of Nursing (ADON) stated that if and when the physician was notified about the elevated blood sugar levels, the licensed nurse was supposed to document that information on the nurse's notes or MARs. After reviewing the resident's elevated Hemoglobin A1c level, the physician ordered an increase of the resident's daily morning dose of [MEDICATION NAME] from 45 units to 50 units on 11/19/09. However, according to the licensed nurses's documentation on the MARs, licensed nursing staff failed to follow the physician's orders [REDACTED]. Nursing staff had incorrectly continued to administer 45 units of [MEDICATION NAME] each morning. 2. Resident #2 had a 1/11/10 physician's orders [REDACTED]. The resident was subsequently admitted for hospice services on 1/15/10. However, the facility failed to coordinate an integrated care plan which designated the specific interventions for care and services that would be the responsibility of the facility and/or the hospice staff. 3. During an examination on 1/26/10, the podiatrist diagnosed an ulcer on resident #15's right heel as being an arterial ulcer. According to the nurses notes, the arterial ulcer was first identified on 11/5/09. The nursing staff had documented that the resident had a 2 x 3 centimeter (cm) blister on his/her right heel. The nurse's note entry also documented that nursing staff had cleaned that blister with wound cleanser and applied a dry dressing, but there was not a physician's orders [REDACTED]. [REDACTED]. heel to determine appropriate treatment. There was no further documentation in the clinical record until an 11/9/09 nurses note that documented the physician and family had been notified about the resident's right heel ulcer. At that time, the nurse wrote that a treatment order had been obtained.",2014-12-01
10177,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,314,D,0,1,Z66Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record record review and staff interviews, it was determined that the facility failed to consistently monitor and thoroughly assess pressure sores for two (#2 and #7) of eight residents sampled for pressure sores from a total sample of 19 residents. Findings include: The ADON stated during an interview on 2/10//10 at 3:50 p.m. that the facility did not have a policy and procedure to address pressure sores. 1. Resident #2 was readmitted to the facility from the hospital on [DATE]. His/her [DIAGNOSES REDACTED]. The 12/21/09 nursing admission assessment documented the resident as having had a stage I pressure sore on his/her left heel. The nursing staff described the heel as mushy and discolored. However, the assessment did not thoroughly describe the pressure sore. It did not include a measurement of the stage I pressure sore or a clarification of ""discolored."" A review of the nurses' notes, weekly skin assessments, pressure sore reports and treatment records revealed licensed nursing staff had treated that pressure sore daily and assessed it on 12/29/09, 1/5, 1/6, 1/15/10, 1/20,1/23, 1/26, 2/1, and 2/3/10. However, nursing staff did not stage the pressure sore at the same stage on the 1/6/10 pressure sore report and the 1/5/10 the weekly skin assessment. On the 1/5/10 weekly skin assessment, nursing staff assessed the pressure sore as being an unstageable necrotic area on the resident's left heel. On the 1/6/10 pressure sore report, nursing staff described it as as a stage I pressure sore. Nursing staff did not thoroughly describe the pressure sore in either the 1/5 assessment or 1/6/10 report to include a description of the characteristics of the wound to clarify whether it was a stage I or necrotic area. On 2/10/10 at 10:35 a.m., the resident's left heel had an unstageable hard eschar cap on it. 2. The 10/16/09 Nurses notes identified resident #7 as having a Stage I pressure sore on his/her right and left buttocks. However, nursing staff did not thoroughly assess the wound to include size and appearance. Nursing staff did not document a descriptive assessment of the pressure sores that included its size and appearance from 10/16/09 to 12/22/09 when it was described as being healed.",2014-12-01
10178,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,323,D,0,1,Z66Y11,"Based on observation, record review and staff interview, it was determined that the facility failed to address and implement alternative interventions for one resident (#4), of nine residents reviewed with a history of falls, from a total sample of 19 residents. Findings include: During the Initial Tour of the facility on 2/9/10 at 10:15 a.m., the Social Services Director (SSD) stated that resident #4 got out of the bed unassisted by climbing over the siderails. The SSD stated that the resident had recently fallen by climbing over the siderails. On the 10/15/09 nurse's note, licensed nursing staff documented at 6:30 a.m. that the resident attempted to get out of the bed and slipped to the floor. On the 10/15/09 Incident Report, licensed nursing staff indicated that new interventions may include a bed alarm and referral to therapy for equipment or strengthening. A ""Siderails Assessment"" for the resident was done on 4/20/09 and reviewed on 10/20/09, with licensed nursing staff documenting that one-half length side rails were used on the resident's bed. The nurse wrote that the resident crawled to the foot of the bed to get out of bed without assistance. A review of the nursing notes and Incident Reports revealed that the resident fell out of bed seven times between October 2009 and February 2010. New interventions indicated on the 10/30/09 Incident Report, following a fall on 10/30/2009, included a referral to therapy for equipment or strengthening, to keep his/her call bell within reach, and for nursing staff to increase the frequency of assisting the resident to the bathroom. However, at that time the resident was already receiving skilled occupational therapy for strengthening. The resident was seen by the Occupational Therapist for strengthening activities from 10/2009 through 12/2009. There was an 11/12/09 care plan intervention for staff to assist the resident to the bathroom for toileting every two hours. Licensed nursing staff documented that new interventions following a fall on 11/12/09 included applying a bed alarm and to increase the frequency of assisting the resident to the bathroom. However, a review of the resident's care plan identifying the resident as being at risk for falls revealed no new intervention planned for the use of a bed alarm. Following a fall on 11/14/09, licensed nursing staff documented on the Incident Report that new interventions would include a referral to therapy, use of siderails and to increase the frequency of assisting the resident to the bathroom. Following a fall on 12/5/09, licensed nursing staff documented new interventions on the Incident Report form as increasing the frequency of assisting the resident to the bathroom and that a scheduled toileting program was in progress. There were 12/9/09 interventions for staff to frequently make rounds and to continue assisting the resident to the bathroom. Despite the planned interventions to assist the resident to the bathroom every two hours and for nursing staff to do frequent rounds, the resident continued to fall out of bed. The same interventions had been documented as 'new' interventions since at least 10/30/09. In the nurse's notes on 10/30/09 at 10:20 p.m., 11/12/09 at at 10:30 p.m., 11/14/09 at 2:35 a.m., 12/5/09 at 10:00 p.m. and 1/9/10 at 3:55 p.m., licensed nursing staff documented that the resident fell after attempting to get out of bed without assistance. A review of the Incident Reports revealed that on 10/30/09, 11/12/09, 11/14/09, and 12/5/09, the resident fell after getting out of the bed unassisted while both siderails were raised. Staff coded the 1/4/10 quarterly Minimum Data Set (MDS) assessment to indicate that the resident had fallen during the prior six months. A Physical Restraint Assessment was performed on 1/5/10 and indicated that the resident used one-half length siderails to assist with turning side to side. The resident was observed in the bed on 2/9/10 at 3:00 p.m. with one-half length siderails raised along the middle section of the bed. Although the facility's interventions included the use of the bed alarm, there was not evidence that one had been used. During an interview on 2/11/10 at 2:00 p.m., the Assistant Director of Nursing (ADON) stated that a bed alarm had not been used for resident #4. The ADON stated that new interventions to address the resident's falls from the bed included offering to assist the resident to the bathroom more frequently than every 2 hours, ambulation by staff with the ""walk to dine"" program and the use of proper footwear. However, the planned intervention to provide the resident with assistance to the bathroom every 2 hours or more frequently as needed was not being done. On the scheduled toileting program grid form initialed by CNA staff, staff only initialed on 2/9 and 2/10/2010 having assisted the resident to the bathroom at 9:00 a.m., 3:00 p.m., and every two hours during sleeping hours. During an interview on 2/11/10 at 2:35 p.m., certified nursing assistant (CNA) ""TT"" confirmed that the resident was assisted with toileting only upon getting out of bed prior to 8:30 a.m., and again at 2:30 p.m. CNA ""TT"" stated that the CNA staff were supposed to offer to assist the resident with toileting every two hours (instead of more frequently) and to indicate the time the resident was toileted on the grid form located on the bathroom door. Although the resident continued to experience falls from the bed with the siderails raised, the facility failed to thoroughly assess the resident's falls and implement then evaluate interventions planned to address the resident's falls and to prevent injury from continued falls.",2014-12-01
10179,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,369,D,0,1,Z66Y11,"Based on observations, and record review, it was determined that the facility failed to provide special eating equipment and utensils for one resident (#4) who needed them in a total sample of 19 residents. Findings include: On the 1/4/10 quarterly Minimum Data Set (MDS) assessment, licensed nursing staff coded resident #4 as requiring limited assistance of one staff person with eating. The December 2009 Nursing Restorative Care Program interventions were for staff to problem moderate to maximum visual cues to initiate eating and to use hand over hand assistance as needed when eating with weighted utensils. The 1/12/09 care plan described the resident as being at risk for altered nutrition related to his/her use of adaptive equipment. There was a care plan intervention for nursing and dietary staff to provide adaptive devices including a plate guard and weighted cup. However, it was observed during meals served in the dining room on 2/9/10 at 1:35 p.m., 2/10/10 at 8:40 a.m. and 1:30 p.m., and 2/11/10 at 1:45 p.m., that staff had not set up the resident's tray using a plate guard or weighted cups.",2014-12-01
10180,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,428,D,0,1,Z66Y11,"Based on record review and staff interview, it was determined that the facility failed to ensure that the attending physician's were made aware of pharmacist's recommendations in a timely manner for three residents (#3, #12 and #13) from a total sample of 19 residents. Findings include: During an interview on 2/10/10 at 10:00 a.m., the Assistant Director of Nursing (ADON) stated that when the pharmacist made recommendations, they were taken to the attending physician's office by the medical records department, and picked up by them after the recommendations had been signed. 1. Resident #3 had a 7/17/09 order for one Darvocet 100-650 twice daily. A review of the clinical record for resident #3 revealed that on 9/25/09, the consultant pharmacist identified the use of Darvocet, and recommended considering an alternative medication because of the affects of the use of Darvocet in the elderly. However, there was no evidence that the physician was made aware of the pharmacist's recommendation until 10/27/09. 2. A review of the clinical record for resident #12 revealed that on 10/23/09 the consultant pharmacist identified that a recent Hemoglobin A1c level was out of range. However, there was no evidence that the attending physician was made aware of the pharmacist's report about the abnormal laboratory value until 11/19/09, at which time the physician adjusted the resident's medication. 3. A review of the clinical record for resident #13 revealed that on 12/20/09 the consultant pharmacist identified the use of Simvastatin, with recent laboratory levels out of range. The pharmacist recommended rechecking the AST and ALT levels on the next laboratory day. The pharmacist recommended discontinuing the use of Prilosec and starting Zantac. However, there was not any evidence that the pharmacist's recommendations were reported to the physician until 1/19/10, at which time, he ordered the laboratory tests to be drawn, discontinued the Prilosec and ordered Zantac to be given to the resident.",2014-12-01
10181,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,441,D,0,1,Z66Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review it was determined the facility failed to ensure that one of seven newly hired employees were free of communicable disease. Findings include: During a review of the personnel files of newly hired employees, it was determined that the facility had not obtained [MEDICATION NAME] (TB) test results in a timely manner for one of those employees. One employee was hired on 4/20/09 but, the results of her TB test was not known until 4/22/09.",2014-12-01
10182,BAINBRIDGE HEALTH AND REHAB,115324,1155  WEST COLLEGE STREET,BAINBRIDGE,GA,39819,2010-02-11,502,D,0,1,Z66Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain laboratory tests as ordered for two residents (#3 and #4) from a total sample of 19 residents. Findings include: 1. Resident #3 had a 1/19/10 physician's orders [REDACTED]. However, there was not any evidence in the clinical record that the Pre-[MEDICATION NAME] level had been obtained as ordered. During an interview on 2/10/10 at 10:00 a.m., the Assistant Director of Nursing (ADON) stated that the Pre-[MEDICATION NAME] level had not been obtained as ordered. 2. Resident #4 had a 10/16/09 physician's orders [REDACTED]. However, there was no evidence in the clinical record that the facility had obtained either of the ordered laboratory tests. During an interview on 2/10/10 at 4:45 p.m., the ADON confirmed that the urinalysis with culture and sensitivity level had not been obtained as ordered.",2014-12-01
2944,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2019-06-06,578,D,0,1,1X3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, and review of the facility policy titled, Advanced Directives the facility failed to obtain a Physician's signature and a concurring Physician's signature for Do Not Resuscitate Consents for two of 30 people reviewed (R#199 and R#131). Findings include: 1. Review of the medical record for R#199 revealed a Do Not Resuscitate (DNR) Consent for a person without decision making capacity signed on 5/22/19 by family members who were not the health care agents and one physician. In the signature line for a concurring physician there was a note indicating a verbal consent received from a concurring physician on 5/22/19 at 2:15 p.m. Interview with the Administrator on 6/5/19 at 3:33 p.m. revealed that nursing reported that R#199 began to take a sudden decline and verbal consents were received from two physicians because of the sudden decline. However, in reviewing the residents medical record the Administrator revealed that since R#199 did not pass, until a week later, that staff actually would have had time to get a concurring physician's signature. Interview on 6/5/19 at 5:42 p.m. with Nurse Lead Licensed Practical Nurse (LPN) FF it was revealed that R#199 had a change in condition and imminent death was perceived. It was reported that as a result of the decline the family was conferred, and a decision was made not resuscitate. Nurse Lead LPN FF revealed that she received instructions from the Assistant Director of Nursing that verbal consent from both physicians is all that was needed. Nurse Lead LPN FF reported that she should have gotten two signatures on the form. 2. Review of the Quarterly Minimum Data Sets ((MDS) dated [DATE] revealed a Brief Interview of Mental Status score of one, indicating that the resident was severely cognigitley impaired. Review of [DIAGNOSES REDACTED]. Review of the Do Not Resuscitate (DNR) Consent Form for a person without decision making capacity revealed a consent signed on 11/8/18. The form was signed by one physician and the responsible party. Review of the Physician Orders revealed an order for [REDACTED]. An interview on 6/5/19 at 10:03 a.m. with the Admissions Coordinator CC confirmed that there was only one physician signature on the DNR consent form and there was not a Durable Power of Attorney (DPOA) for R#131 in the E-chart or in her office. Review and interview on 6/5/19 at 10:04 a.m. with LPN/MDS Coordinator HH confirmed that there was not a copy of a DPOA on the hard copy chart for R#131. Interview, and review of the Advance Directives, on 6/5/19 at 10:18 a.m. with the Admissions Coordinator CC revealed that her role in obtaining Advance Directives was to clarify if the resident had written wishes or if they wish to discuss Advanced Directives with anyone. She stated that the Financial Coordinator would go through the admission book with the residents and or their family members and she also clarified if the resident had an Advanced Directive at the time of Admission. She stated that Social Services (SS) was also involved in obtaining the Advanced Directives. Interview on 6/5/19 at 10:27 a.m. with the Social Service Director II revealed that her role in obtaining Advanced Directives was that during the resident's care plan meeting the Advance Directive wishes were reviewed with the family. During the care plan meeting if the resident had not previously expressed an interest in a DNR, they were asked if their preference had changed. She stated that for a DNR to be legal for a resident without decision making capacity, the resident's physician, a concurring physician and the responsible party must sign it. She stated that several people were responsible for obtaining Advanced Directives including SS, the MDS nurse, and nursing. She confirmed that there was no DPOA and only one physician signature for R#131. An interview on 6/5/19 at 10:37 a.m. with the Director of Nursing (DON) revealed that for a DNR without decision-making capacity to be legal there had to be two physician signatures. Her expectation was that this form would contain the family signature, two physician signatures and a Physician order for [REDACTED]. A review of the policy titled, Advanced Directives revealed on page 2 under Do Not Resuscitate, Paragraph B that a DNR order for a person without decision-making capacity, first determined that a resident was a candidate for non-resuscitation and this was determined by the physician and a concurring physician signing in agreement.",2020-09-01
2945,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2019-06-06,582,D,0,1,1X3T11,"Based on record review and staff interview, the facility failed to get signatures on the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) and the Notice of Medicare Non-coverage (NOMNC) for one of three residents (R# 15) and failed to provide advance notice to one of three residents (R#52) discharged from Medicare Part A services. Findings include: 1. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R# 15 was discharged off Part A services on 3/18/19 and remained in the facility with benefit days remaining. Further record review revealed that the SNFABN and NOMNC were provided to R#15 on 3/18/19 and there was not any evidence that advance notification provided. 2. Review of a Beneficiary Notice-Residents discharged Within the Last Six Months form, provided by the facility, revealed that R #52 was discharged off Medicare Part A skilled services on 4/4/19. Further review of the record revealed that the SNF ABN was not signed by the resident or the family representative and there was not any evidence that this form was discussed. Review of the NOMNC revealed that on 3/29/19 a verbal notification was provided to the representative for R#52. However, there is no documentation or evidence that R#52 or representative received copies of these notices. Interview on 6/5/19 at 5:45 p.m. with Minimum Data Set (MDS) Coordinator QQ revealed that typically a three-day notice is provided to residents when discharging from Medicare Part A skilled services. It was further reported that a copy of the notification is left at the front desk for the family representatives to receive. However, if the family does not want a copy of the notification it is noted in the resident's medical record. Interview on 6/6/19 at 3:05 p.m. with MDS Coordinator QQ who confirmed that SNF ABN and NOMNC were not provided to R# 52 and/or family member because notice was given via the telephone. MDS Coordinator also reported that the family declined wanting to receive a copy of the notice; however, there was not any evidence of any documentation that the SNF ABN was refused. Further interview with the MDS Coordinator QQ revealed that MDS Coordinator QQ could not explain why an advanced notice was not provided to R#15.",2020-09-01
2946,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2019-06-06,623,D,0,1,1X3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to provide the family or the resident with a written summary of the reason for transfer to the hospital for one of three residents (R#26) reviewed for hospitalization . Findings include: Review of the Minimum Data Sets (MDS) for resident (R)#26 revealed a discharge assessment on 2/28/19 to an acute hospital with an entry MDS to the facility dated 3/2/19 documenting readmission from the hospital. Review of the Quarterly MDS dated [DATE] revealed a Brief Interview for Mental Status score of 04 indicating that R#26 was severely cognitively impaired. Review of the Nurses Progress Note dated 2/27/19 documented that the resident had a cough with congestion and was medicated with cough syrup that was ordered as needed. The resident was assessed with [REDACTED]. Review of the Nurses Progress Note dated 2/28/19 revealed further deterioration in the resident's condition with the resident being admitted to an acute hospital on [DATE]. An interview on 6/5/19 at 2:25 p.m. with Licensed Practical Nurse (LPN) JJ and LPN KK revealed that when a resident was sent to the hospital that they assessed the resident and then notified the charge nurse of a change in condition. They stated that the charge nurse then assessed the resident also and was the one responsible for making sure that the appropriate paperwork was sent with the resident on transfer to the hospital. An interview on 6/6/19 at 8:29 a.m. with the Admissions Coordinator CC revealed that the families and/or the resident were not notified in writing of the reason for transfer to an acute care hospital. She stated that the nurses call the family and notify them verbally that the resident was being transferred. An interview on 6/6/19 at 8:37 a.m. with the Social Service Director II revealed that nursing staff notified the residents family by phone of why the resident was sent to the hospital, but nothing was sent in writing to the family and/or to the resident summarizing why the resident was sent to the hospital. An interview on 6/6/19 at 9:07 a.m. with the Administrator revealed that the family of residents, that are transferred to the hospital, are notified by the nurse calling the family member. She stated that a summary explaining to the family and/or the resident the reason for transfer was not sent out. Interview on 6/6/19 at 10:14 a.m. with the Administrator confirmed that a summary was not sent out to the family or given to the resident about the reason for the resident being transferred to the hospital. The Administrator stated that the transfer paper work was sent with the resident to the hospital, but stated she was unfamiliar with where the paperwork went or to whom the paperwork was given when the resident arrived at the hospital. The Administrator revealed that she thought that the resident was given the transfer form which would provide a summary statement.",2020-09-01
2947,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2019-06-06,732,B,0,1,1X3T11,"Based on observation and staff interviews, the facility failed to assure the nurse staffing information form was complete for one of four days in the main building. Findings include: During a tour of the facility on 6/5/19 at 4:30 p.m. the nurse staff posting was observed near the receptionist desk at the entrance of the facility. Interview with Receptionist PP on 6/06/19 at 4:13 p.m. who reported that staffing information is posted daily by the receptionist. Upon review of the nurse staff postings for the week it was confirmed that total hours were not documented on the form or on the board that displayed the information. Receptionist PP revealed that she did not know the hours and that someone in corporate may be responsible for them. During an interview with the Administrator on 6/6/19 at 4:23 p.m., it was confirmed that the nurse staffing form did not have total hours. The Administrator reviewed the posted staffing template that was in the nurse staffing book and confirmed that the total hours were not being posted this week. The Administrator further reported that she was not sure why the total hours were not being posted.",2020-09-01
2948,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2019-06-06,761,E,0,1,1X3T11,"**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 discard expired biologicals prior to the expiration date printed on the medications in two of three medication storage rooms inspected. Findings include: Review of the facility policy titled Pharmacy Services Medication Storage in the Care Center (not dated) 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. On 6/6/19 at 9:09 a.m. an observation and inspection made of the Station Two Medication Room with Licensed Practical Nurse (LPN) MM revealed two bottles of aspirin 325 milligrams (mg) had an expiration date of (MONTH) 2019 printed on the bottle. An interview with LPN MM, at this time, verified the meds were expired. She stated when meds are expired they are removed from supply and put in the medication disposal box located on Unit One. On 6/6/19 at 9:20 a.m. an observation and inspection made of the Station One Medication Room with Registered Nurse (RN) NN revealed one bottle of [MEDICATION NAME] coated aspirin 325 mg had an expiration date of (MONTH) 2019 printed on the bottle and two bottles of [MEDICATION NAME] 5 mg had an expiration date of (MONTH) 2019 printed on the bottle. An interview with RN NN, at this time, verified the medications were expired and should have been pulled and put in the medication disposal box located in Unit One. An interview on 6/6/19 at 9:31 a.m. with the Pharmacy Consultant OO revealed when she comes to the facility she checks the refrigerators in the drug rooms but does not check for expired medications. She stated a nurse consultant comes out quarterly from the pharmacy and checks the medication carts and medication rooms. An interview on 6/6/19 at 12:01 p.m. with the Director of Nursing (DON) revealed the 11p.m. -7 a.m. nurses are responsible for checking the drug rooms during their shift and the Unit Supervisors are responsible for checking them during the day. She did not have any verification this was completed. Her expectations were to not have any expired medications in the medication rooms or in the medication carts.",2020-09-01
5951,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2014-09-11,431,E,0,1,3E7P11,"Based on observations and staff interviews, the facility failed to ensure expired medications were disposed of timely in two (2) of five (5) medication storage rooms (Hall 700 and Hall 800) and two (2) of eight (8) medication carts (Hall 300 and 500). Findings include: Observation conducted 9/11/14 at 8:00 a.m. of medication storage on the 700 hall, the following medications were found to be expired: One (1) unopened bottle of Q:PAP (Acetaminophen) liquid with an expiration date of August 2014 One (1) unopened bottle of Natural Fiber Powder with an expiration date of July 2014. Interview on 9/11/14 at 8:10 a.m. with charge nurse CC, revealed the medications were expired. Observation on 9/11/14 at 8:15 a.m. of medication storage on 800 hall revealed the following medications were found to be expired: One (1) unopened bottle of Q:PAP liquid with an expiration date of August 2014 One (1) unopened bottle of Natural Fiber Powder with an expiration date of July 2014. Interview on 9/11/14 at 8.20 a.m. with charge nurse BB revealed the medications were expired. Observation on 9/11/14 at 8:30 a.m. of the medication cart on 500 hall revealed one (1) opened bottle of M:PAP (Acetaminophen) liquid with an expiration date of June 2014. An Interview on 9/11/14 at 8:30 a.m., at the time of the observation, with the medication nurse DD revealed this medication was expired. Observation on 9/11/14 at 9:15 a.m. of the medication cart on 300 hall revealed two (2) Lantus Insulin vials and one (1) Humalog Insulin vial were open with no opened date. Interview on 9/11/14 at 9:20 a.m. with the Licensed Practical Nurse (LPN) AA, acknowledged the vials were open and not dated. She revealed that the nurse who opened the insulin should date and initial the insulin vials. Review of the facility policy/procedure for Insulin Administration indicated that ALL insulin vials should labeled with the date of first puncture and be replaced twenty-eight (28) to thirty (30) days after first use.",2018-05-01
7382,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2012-11-07,281,D,0,1,727N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined that the licensed nursing staff failed to consult with the physician about potential side effects from an increase in dosage of antipsychotic medication and to clarify physician's orders [REDACTED].#50) in a total sample of 38 residents. Findings include: According to the Georgia Practical Nurses Practice Act, the practice of a licensed practical nurse included the administration of medications under the supervision of a physician [MEDICATION NAME] medicine or a registered nurse [MEDICATION NAME] in accordance with applicable provisions of law. The licensed practical nurse was to participate in the implementation and evaluation of the delivery of health care services. However, licensed nursing staff failed to evaluate potential side effects of a medication, to consult with a physician about those side effects, and clarify an ordered dosage of an antipsychotic medication for resident #50. Resident #50 had a [DIAGNOSES REDACTED]. There was a 9/14/12 order for a 4.6 milligram (mg) patch of Excelon to be applied every 24 hours. Prior to 9/28/12, nursing staff was ordered to give the resident half (1/2) of a 0.25 milligrams (mg) tablet of [MEDICATION NAME] twice a day at 8 a.m. and 8 p.m. This meant that the resident was being given 0.125 mg of [MEDICATION NAME] at those times. The 9/28/12 consulting psychiatrist's progress note about the resident having 'sundowning included an order for [REDACTED]. However, the nurse incorrectly transcribed that order on the September Medication Administration Record [REDACTED]. Further down on that MAR, a nurse wrote to give [MEDICATION NAME] 0.25 mg 1/2 tablet (.125 mg) after lunch 1 p.m. There was no nursing staff documentation on the resident's September MAR indicated [REDACTED]. There was no documentation by nursing staff to indicate that the resident was given any [MEDICATION NAME] on 9/30/12. Although licensed nursing staff documented on 9/30/12 that the resident was weak and was reporting that he/she might pass out, there was no evidence that the nurse consulted with the physician about it or that [MEDICATION NAME] had not been given to the resident. There was a phone order transcribed on the October 2012 physician's orders [REDACTED]. because of lethargy. Although the 10/3/12 physician's assistant's progress note included his/her plan to decrease the resident's [MEDICATION NAME] from 0.25 mg to 0.125 mg of [MEDICATION NAME] twice a day to address the lethargy, the resident was already on that dose. There was no evidence that the resident had ever received 0.25 mg of [MEDICATION NAME]. Upon receiving the physician's assistant's 10/3/12 order to decrease the resident's dosage to 0.125 mg of [MEDICATION NAME], there was no evidence that the nurse clarified that order with the physician and informed him about the increase in the dosage of the Excelon patch. There was a 10/09/12 physician's progress note that the resident had lethargy. According to documentation in the 11/01/12 nursing notes, the resident appeared very confused and weak. During an interview on 11/06/12 at 2:30 p.m., Charge nurse AA reviewed the resident's clinical record and said that the nurse had not correctly transcribed the (9/28/12) order for [MEDICATION NAME]. In an interview on 11/07/12 at 10:30 a.m., the Director of Nurses (DON) stated that she was unsure of reason why the physician's assistant had written the 10/3/12 order for 0.125 mg of [MEDICATION NAME].",2017-05-01
7383,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2012-11-07,282,D,0,1,727N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to implement a care plan intervention to address one resident's (#246) [MEDICAL TREATMENT] related needs in a total sample of 38 residents. Findings include: Resident #246 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Staff had updated the resident's care plan on 9/13/12 to address his/her needs related to receiving [MEDICAL TREATMENT] services three times a week. Staff documented on the resident's care plan that he/she had an AV/[MEDICAL TREATMENT] placed in his/her upper left arm on 5/13/11. Facility staff developed an intervention for nursing staff to assess the resident's [MEDICAL TREATMENT] for signs and symptoms of infection and for patency every day and as needed (prn). However, there was no evidence that the nursing staff had implemented that planned intervention. See F309 for additional information regarding resident #246.",2017-05-01
7384,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2012-11-07,309,D,0,1,727N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, it was determined that the facility had failed to follow a physician's order to assess a resident's [MEDICAL TREATMENT] (shunt) for one resident (#246) in a total sample of 38 residents. Findings include: Resident #246 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The facility updated the resident's care plan (9/13/12) to include the resident's problem of being given [MEDICAL TREATMENT] services three times a week. Facility staff documented on that care plan that the resident had an AV/[MEDICAL TREATMENT] placed in his/her left upper arm on 5/13/11. One of the care plan intervention was that the nursing staff was supposed to assess the resident's [MEDICAL TREATMENT] (shunt) every day and as needed (p.m.) for signs and symptoms of infection and for patency. There was a physician's order since 12/20/11 for nursing staff to assess the resident's [MEDICAL TREATMENT] (shunt) daily and as needed. However, there was no evidence that the nursing staff had followed that order and care plan intervention. During an interview on 11/7/12 at 9 a.m., licensed nurse Y said that the 3-to-11 p.m. shift nurses checked the [MEDICAL TREATMENT] (shunt) of residents, who were receiving [MEDICAL TREATMENT] services, and initialed their Medication Administration Records (MAR) to indicate that it had been done. However, despite the order to check [MEDICAL TREATMENT] daily and prn being printed on resident #246's MARs for June, August, September, October and November, 2012, there were not any nursing staff's initials documented to indicate that they had assessed it. There were not any nursing staffs' initials on the July MAR for eight (8) of 31 days (the 23rd through the 31st) to indicate that nursing staff had assessed the [MEDICAL TREATMENT]. With the exception of the 9/7/12 nursing note, there was not any evidence in the nurse's notes for June, eight (8) days in July (the 23 rd through the 31st), August, September, October and November 2012 that nursing staff had assessed the resident's [MEDICAL TREATMENT] (shunt). During interviews on 11/6/11 at 3:45 p.m. and on 11/7/12 at 9:15 a.m., when she was asked what nursing staff would have to do for resident #246 upon his/her return from [MEDICAL TREATMENT], nurse Z replied that nothing special was done for residents who returned being given [MEDICAL TREATMENT] other than to record his/her weight which would be provided by the [MEDICAL TREATMENT] center. In an interview on 11/07/12 at 9:00 a.m., licensed nurse Y said that there was not anything in particular that (nursing staff) needed to do for the resident when he/she returned from [MEDICAL TREATMENT]. However, during the review of the resident's November MAR indicated [REDACTED]. Nurse Y said that the nurse should have initialed it. Despite the physician's order since 12/10/11 and the care plan since 9/12/12 for nursing staff to check the resident's [MEDICAL TREATMENT] daily and as needed, one nurse, who was interviewed, did not know that it was supposed to be done and the other nurse assumed that nurses on another shift were doing it. There was no evidence in the nursing notes or on the MARs from June until November 7th, 2012 that nursing staff had assessed the site as ordered.",2017-05-01
9449,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2011-06-09,156,D,0,1,RJCG11,"Based on staff interview, and review of the facility's ""Skilled Nursing Facility Advance Beneficiary Notice"" forms, it was determined that the facility failed to provide the estimated cost of continued services to three residents, who had been discharged from Medicare Part A services, in order to allow them to make an informed decision about whether or not they wanted to pay for the continuation of those services. Findings include: According to the CMS' instructions on the 70.4.3.5- ""Providing Cost Estimations for Items or Services on the Form CMS- Skilled Nursing Facility Advance Beneficiary Notice (SNFABN),"" estimated cost amounts could be provided either with the description of extended care items and services (i.e., in the ""Items or Services"" section) or on the ""Estimated Cost"" line. The facility believed that three residents were to be discharged from Medicare Part A services because they no longer required skilled rehabilitation and/or skilled nursing services. The facility had issued CMS form to those residents or authorized representatives on 12/08/10, 2/26/11, and 3/12/11. However, the facility failed to include the estimated cost for the continuation of the services for the three residents in order to allow them to make an informed decision about whether or not they wanted to pay for those services themselves. The facility's ""Skilled Nursing Facility Advance Beneficiary Notice"" forms (CMS ) for those three residents had no estimated cost and no contact information on the form. During an interview on 6/9/11 at 10:55 a.m., financial staff ""OO"" stated that the estimated cost (for the continuation of skilled services) was only filled out on the notice of discharge form for the Medicare Part B residents. She said that she had not ever provided that information to residents on the CMS forms.",2015-07-01
9450,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2011-06-09,280,D,0,1,RJCG11,"Based on record review, it was determined that the facility failed to revise the care plan to include interventions for one resident (#190) in order to maintain supported positioning when in a geri-chair in a total sample of 31 residents. Findings include: Resident #190 had a 5/11/11 Occupational Therapist's (OT) note that staff was to make sure that a right side lateral support and head support were positioned on his/her geri-chair when he/she was seated. There was a 5/11/11 OT discharge note that the head support and right side lateral support had been tried with the resident having achieved a more midline, upright and increased functional seated position in the geri-chair. However, a review of the resident's care plan, revised on 4/21/11, revealed that it had not been revised to include those specific interventions to promote functional positioning for resident #190.",2015-07-01
9451,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2011-06-09,318,D,0,1,RJCG11,"Based on observation, staff interview, and record review, it was determined that the facility failed to provide hand positioning devices to prevent any decrease in range of motion for one resident (# 62) in a total sample of 31 residents. Findings include: Resident # 62 had been coded on the 3/11/11 Minimum Data Set (MDS) assessment as having had no limitations of his/her upper extremities. There was a care plan since 10/23/10 for restorative nursing services six times a week because of the resident's impaired physical mobility and chair bound status. During observations on 6/7/11 at 11:57 a.m., the resident's left hand was curled in a fisted position. The resident was not able to completely extend his/her fingers. On 6/7/11 at 4:45 p.m., on 6/8/11 at 8:10 a.m., 10 a.m. and 10:35 a.m., the resident's last three fingers on his/her left hand were in a clenched position. He/She had his/her index finger and thumb partially extended. There were no devices in use for functional positioning of the resident's hand. During an interview on 6/8/11 at 10:35 a.m., certified nursing assistant (CNA) ""QQ"" stated that she had not ever seen the resident fully extend his/her fingers. During an interview on 6/8/11 at 1:45 p.m., the licensed restorative nurse ""RR"" stated that range of motion services were provided for the resident between 6 a.m. and 7:30 a.m. while he/she was in the bed. She said that by noon or later the resident kept his/her hands clenched. After surveyor inquiry, on 6/8/11 at 3:30 p.m., the resident had a rolled washcloth in his/her left hand. All of the resident's fingers were extended around that washcloth in a functional position.",2015-07-01
9452,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2011-06-09,323,D,0,1,RJCG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility failed to ensure that the use of positioning equipment was evaluated and utilized appropriately to prevent injury for one resident (#190), from a total sample of 31 residents. Findings include: Resident #190 had [DIAGNOSES REDACTED]. He/She was coded on the 4/14/11 Minimum Data Set (MDS) assessment as needing total staff assistance with bed mobility, transfers and locomotion. There was a care plan, revised on 4/21/11, to address his/her risk for injury related to his/her confusion, impaired decision making skills, poor vision and mobility limitations. There were interventions for the use of a geri-chair for locomotion and for non-slip padding in the seat of the geri-chair. A review of the ""Nurse's Note for Occurrence"" forms revealed that the resident sustained [REDACTED]. Observations of the resident on 6/7/11 at 10:48 a.m. revealed bruises and skin tears on his/her left forearm with one dressing in place near his/her elbow. On 6/8/11 at 1:20 p.m., the resident was observed to have four to five small (approximately 1/2 inch) bruised areas on his/her right shin and, a bruise and an approximately two inch skin tear on his/her right shin. His/Her left leg had three to four bruises on the shin and steri-strips were in place on the inner aspect of his/her left shin. On 6/9/11 at 9:35 a.m., the resident had blood draining from a skin tear on his/her right elbow. On 6/7/11 at 4:45 p.m., resident #190 was seated in the geri-chair in front of the nurse's station. At that time, the resident was scooting down and leaning off the right side of the geri-chair. The resident's right elbow was hanging down over the right armrest. On 6/8/11 at 8:45 a.m., the resident was again observed leaning to the right while positioned in the geri-chair. On 6/8/11 at 4:50 p.m., the resident was observed leaning toward the right side and positioned diagonally in the geri-chair. On 6/8/11 at 1:20 p.m., certified nursing assistants (CNA) ""JJ"" and ""KK"" stated that they were not aware of how the resident obtained the skin tears or bruises. On 6/8/11 at 3:45 p.m., CNA ""LL"" stated that the skin tears and bruises might have been caused by the resident moving and scooting a lot while in the bed and in the geri-chair. CNA ""MM"" indicated that the resident was being positioned straight in the geri-chair at that time but, he/she would not be that way very long. CNA ""MM"" stated that the resident had a seat cushion and a lateral support to assist with positioning, but, the lateral support would slide down. Observation of the right lateral support at that time revealed that it had not been appropriately applied. It had been placed down below the arm rest of the geri-chair. It was between the seat and the side of the geri-chair. On 6/9/11 at 9:00 a.m., licensed nurse ""NN"" stated that the skin tears and bruises were probably from the resident wiggling, squirming, and turning sideways in the geri-chair. Documentation on the 5/11/11 ""Occupational Therapy Discharge Note"" revealed that the resident had been evaluated for geri-chair positioning. A head support and right side lateral support were used which ""provided a more midline, upright and increased functional seated position in the geri-chair."" The 5/11/11 ""Functional Nursing Program"" from Occupational Therapy staff to the nursing staff instructed the nursing staff to make sure the right side lateral support and the head support were positioned on the geri-chair when the resident was seated in it. However, during an observation on 6/7/11 at 4:45 p.m., on 6/8/11 at 8:45 a.m., 9:30 a.m. and 11:00 a.m., the resident was observed leaning and scooting to the right side of the geri-chair. The right lateral positioning device was not observed. On 6/8/11 at 1:20 p.m. and 3:45 p.m., and on 6/9/11 at 9:25 a.m., the right lateral support was observed to have been inappropriately positioned below the arm rest. It was between the seat and the side of the geri-chair. During an observation of the resident and interview on 6/9/11 at 9:35 a.m., the Occupational Therapy Assistant (COTA) stated that the lateral support utilized for the resident was for use in a wheelchair and was not the appropriate size for use in a geri-chair. The facility had not evaluated the effectiveness of the right lateral side support to provide functional positioning and, had not planned effective interventions to prevent the potential for skin tears and bruises for resident #190 while seated in the geri-chair.",2015-07-01
10246,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2010-01-07,502,D,0,1,NX9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to obtain [MEDICATION NAME]/INR tests as ordered by the physician for two residents (#1 and #27) of nine residents who received [MEDICATION NAME] therapy from a total sample of 30 residents. Findings include: 1. Resident #1 had a [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. On 12/2/09, the resident's [MEDICATION NAME]/INR was reported as having been low at 15.1/1.14 on the laboratory report. The physician was notified and ordered licensed nursing staff to increase the [MEDICATION NAME] dose to 3 milligrams and to obtain a [MEDICATION NAME]/INR in two weeks. However, licensed nursing staff had failed to obtain a [MEDICATION NAME]/INR in two weeks as ordered. Licensed nursing staff did not obtain a [MEDICATION NAME]/INR until five weeks later on 1/6/10. The [MEDICATION NAME]/INR on 1/6/10 was abnormally high at 41.7/4.39 (normal rage of 12.1-14.7/0.0-2.0). The physician was notified about those abnormal test results on 1/06/2010. On 1/6/10 at 2:55 p.m., the Director of Nursing confirmed that the [MEDICATION NAME]/INR tests had not been obtained as ordered by the physician. 2. Resident #27 had a history of [REDACTED]. He/She had a 12/2/09 physician's orders [REDACTED]. However, review of the resident's medical record revealed [REDACTED]. During an interview on 1/07/10 at 12:10 p.m., licensed nurse ""AA"" confirmed that the ordered laboratory tests had not been done. He/she stated that the order had not been transcribed into the ""laboratory test book"" by the nurse so, it was not done.",2014-11-01
10247,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2010-01-07,272,E,0,1,NX9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to utilize the Resident Assessment Protocol (RAP) guidelines for the triggered area of physical restraints to further assess and clinically analyze relevant information for three residents (#6, #19 and #24) from a total sample of 30 residents. Findings include: 1. Resident #6 had a physician's orders [REDACTED]. However, when the licensed staff completed the resident's 9/14/09 significant change of status Minimum Data Set (MDS) assessment, the RAP guidelines for the triggered area of physical restraints was not worked to further assess the resident's external risk factors of his/her use of [MEDICAL CONDITION] and diuretic medications. There was no documentation that staff had reviewed specific environmental/situational factors to determine whether modifications were needed. Although staff noted that the documented information was for the ""Falls/Physical Restraints"" RAP, there was no information about the resident's behavioral symptoms associated with restraint use and his/her response to the use of the restraint. There was no documentation that staff had assessed the resident's behavior including the potential causes that could be addressed. See F221 for additional information regarding resident #6. 2. Resident #19 had a physician's orders [REDACTED]. However, when the licensed staff completed the resident's 9/7/09 initial and 11/23/09 significant change of status Minimum Data Set (MDS) assessments, the RAP guidelines for the triggered area of physical restraints was not work to further assess the resident's external risk factors of his/her [MEDICAL CONDITION] and diuretic medications. There was no documentation to indicate that staff had reviewed specific environmental/situational factors to determine whether modifications were needed. Although staff noted that the information on the RAP was for both of the triggered areas of Falls and Physical Restraints, there was no information about the resident's behavioral symptoms associated with restraint use and his/her response to the restraint. There was no indication that staff had assessed the resident's behaviors including the potential causes that could be addressed. See F221 for additional information regarding resident #19. 3. Resident #24 had a geri-chair with a table top restraint in use since at least 12/22/04. Staff completed an annual MDS assessment on 9/17/09. However, staff failed to thoroughly work the Physical Restraint RAP to include the current medical symptom exhibited by the resident, any reduction attempts, or assessments for the least restrictive device to justify the continued use of the restraint. See F221 for additional information regarding resident #24.",2014-11-01
10248,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2010-01-07,323,G,0,1,NX9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that each resident was provided adequate supervision to prevent accidents for one resident (#19) in a total sample of 30 residents. This failure resulted in the actual harm of a hip fracture for resident #19. It was therefore determined that a period of noncompliance existed from 11/15/09 to 11/20/09 when the facility took action to correct the deficient practice. Findings include: Resident #19 was admitted to the facility on [DATE]. The resident had a [DIAGNOSES REDACTED]. The resident had a plan of care since 9/10/09 for being at risk for falls and/or injuries related to his/her confusion and poor decision making skills. There were interventions for the Certified Nursing Assistants (CNAs) to provide stand-by/hands-on assistance of 1 to 2 persons for transfers. On the 9/7/09 initial MDS, the licensed nurse coded the resident as being dependent upon staff for transfers (3/2), ambulation (3/3), dressing (4/2), hygiene (4/2) and bathing (4/2). On the 9/7/09 Resident Assessment Protocol (RAP) for Falls, the licensed nurse documented that the resident had fallen three times since his/her admission to the facility. Review of the licensed nursing staff's documentation on the ""Nurse's Note for Occurrence"" form revealed that on 11/5/09 the resident had fallen from the toilet onto the floor with a licensed nurse at his/her side. During an interview on 1/07/10 at 11:00 a.m., the Assistant Director of Nursing (ADON) stated that the resident had gotten up from the toilet so quickly that the nurse was unable to assist him/her. The resident did not sustain an injury from that fall. The Falls Committee reviewed the fall on 11/11/09 but, no new interventions were developed. Review of the ""Nurse's Note for Occurrence"" form for 11/15/09 revealed that the resident again fell from the toilet. The resident was sent to the hospital emergency room and was diagnosed as having sustained a fracture to his/her right hip. The resident was hospitalized due to the fracture from 11/15/09 to 11/19/09. During an interview on 1/07/10 at 11:00 a.m., the ADON stated that on 11/15/09, CNA ""CC"" had left the resident unattended on the toilet in his/her room and he/she fell . Based on the above, a period of past noncompliance existed from 11/15/09-11/20/09. Review of the facility's relevant documents revealed that the facility had taken the following actions to correct the deficient practice: 1. Certified Nursing Assistant (CNA) ""CC"" was terminated for leaving a dependent resident (#19) unattended on the toilet which resulted in a fall with a right hip fracture. 2. All nursing staff were inserviced that any resident who required direct supervision with toileting was to have stand by assistance when toileting and was not to be left unattended during the toileting. 3. All residents that required stand by assistance when toileting had their plans of care updated to reflect that intervention. The facility had implemented the interventions listed above and ensured that the actions remained in effect for the continued correction of the deficient practice prior to and during the standard survey conducted from 1/05/10-1/07/10.",2014-11-01
10249,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2010-01-07,221,E,0,1,NX9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to ensure that residents with physical restraints had a medical symptom to indicate the need for the use of the restraint, failed to document evidence that the potential negative outcomes from the use of restraints had been discussed with the resident and/or resident's responsible party, failed to assess the resident for the use of the least restrictive device and failed to attempt physical restraint reductions for three residents (#6, #19 and #24) with physical restraints from a total sample of 30 residents. Findings include: According to the facility's policy and procedure for physical restraints, medical symptoms that warranted the use of restraints would be reflected in the resident's comprehensive assessment and care planning. Also, the resident's comprehensive assessment would be used to identify the need for a physical restraint device. Although the lead sentence on the facility's restraint assessment form was that the ""primary reason for applying a restraint was to protect residents from falls and accidents,"" according to the federal regulations, the residents must have a medical symptom that warranted the use of restraints. The facility's ""Consent for Use of Physical Restraints/Enablers"" form noted that staff were to document when, what and to who the explanation of the risks and benefits of restraint use was done. However, there was no documentation to indicate what or when it had been done. 1. Resident #6 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. He/She had been hospitalized due to the fracture from 8/29/09 to 9/4/09. The facility investigated the fracture and determined that no known fall had occurred. The resident had a physician's orders [REDACTED]. review of the resident's medical record revealed [REDACTED]. member requested that the resident be placed in a geri-chair with a table top for the resident's safety and protection. Review of the 9/5/09 ""Consent for Use of Physical Restraints"" form revealed that the indication for use was documented as ""behavior unmanageable by any other means."" However, the area on that form for ""Conditions for consideration in restraint use,"" which required staff to assess if problem behavior created the need for the use of a restraint, was blank. The areas on the form which asked staff to describe the restraint's function if it was utilized to enhance self-sufficiency, was also blank. According to the staff's documentation, the only alternative that had been tried was a bed exit alarm. The resident's 9/5/09 Restraint Assessment form completed by the licensed nurse documented that the restraint was being utilized to protect the resident from falls and accidents. Documentation provided by the facility revealed that on 8/29/09, the resident was standing with weight on his/her right leg and bed covers at his/her feet. Staff noted that the resident denied having fallen, but complained about right hip pain, so was sent to the emergency room where a right [MEDICAL CONDITION] was diagnosed . Staff recorded a fall on 9/5/09 when the resident was getting out of bed. On 9/25/09, the resident told staff that he/she was climbing into a chair and they noted a skin tear was sustained. On 10/6/09 and 11/10/09, staff documented that the resident had either fallen trying to get out of bed or lost his/her balance getting into bed. Although all of the above falls occurred when the resident was attempting to get into or out of bed, the physician's orders [REDACTED]. During an interview on 1/06/2010 at 11:30 a.m., the MDS coordinator said that the resident had been continuously attempting to get out of bed unassisted. Review of the resident's 9/14/09 Resident Assessment Protocols (RAPs) for Falls and Physical Restraints, completed by the licensed nurse, documented that the resident had falls on 9/5/09 and 4/4/09. Nursing staff noted that no other falls had occurred since before 1/22/08. The licensed nurse documented that the physical restraint was instituted for the resident's safety and a restraint free trial was to be initiated on 9/17/09. However, a review of the 9/17/09 nurse's notes revealed that the licensed nurse documented that the resident had not demonstrated any attempt to get up without assistance since 9/5/09 and again noted that a restraint free trial was to be initiated. However, there was no documentation to indicate that a restraint free trial had been attempted. On 9/21/09, the licensed nurse documented that the staff had reported that the resident attempted to get up without assistance from a reclined geri-chair so the use of the physical restraint was to continue when the resident was out of bed. Although licensed nursing staff documented on the resident's 12/9/09 Restraint Elimination Assessment that the resident was a good candidate for a restraint elimination attempt, a reduction was not attempted. The licensed nurse documented that the resident lacked the cognitive ability to understand danger and lacked mobility. During an observation of restorative nursing services being provided on 1/6/10 at 11:30 a.m., the resident was in a wheelchair and was propelling him/herself in the hallway with stand-by assistance from staff. During an interview on 1/06/10 at 11:30 a.m., the MDS Coordinator stated that the resident was being physically restrained to prevent falls. Contrary to the nurse's notes for a time period from 9/4-9/17/09, he/she stated that since 9/4/09, the resident had been continuously attempting to get up out of the low bed unassisted so, the physical restraint (gerichair with table-top) was applied. He/she stated that the resident attempting to get up unassisted from the bed indicated that the resident was unsafe and therefore required the use of a physical restraint when he/she was out of bed in the chair. During an interview on 1/06/10 at 12:00 p.m., the Director of Nursing (DON) stated that restraint reduction attempts had not been tried since 9/09 because of the resident's impaired cognitive ability related to safety. 2. Resident #19 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. There was a 9/4/09 physician's orders [REDACTED]. Review of the resident's 9/4/09 ""Consent for Use of Physical Restraints"" form revealed that the indication for the use of the restraint was ""behavior unmanageable by any other means."" There was no documentation to indicate what and when the potential negative outcomes associated with the use of a physical restraint were discussed with the resident's responsible party. Review of the 9/4/09 Restraint Assessment form completed by the licensed nurse revealed that the restraint was being utilized for the resident's safety because of his/her ""falling all the time"". The alternatives attempted were documented by the licensed nurse as redirecting the resident to the hall and room, and that the resident tried to wander and was unable to ambulate safely due to leaning. Review of the facility's documentation revealed that the resident had a fall on 8/29/09 when he/she climbed out of the geri-chair. There was documentation that a table-top was applied to the geri-chair on 9/4/09. There was also documentation that the resident had fallen when he/she stood up from a wheelchair on 9/4/09. On 9/6/09, staff described the resident as having fallen while ambulating to the bathroom. On 10/2/09, staff noted that the resident was found sitting on the floor and leaning on the wall by his/her bed. On 11/5/09 and 11/15/09, staff documented that the resident had falls in the bathroom. On 11/15/09 licensed nursing staff documented that the resident had slid off the toilet and complained of right hip pain. Staff noted that the resident had been sent to the emergency room and was diagnosed with [REDACTED]. Review of the resident's RAP for Falls and Physical Restraints completed by the licensed nurse on 11/24/09 revealed that the resident had a geri-chair with table top in place at the family's request. During an interview on 1/07/10 at 11:00 a.m., the DON stated that the resident required the physical restraint to prevent falls. He/she stated that a less restrictive device had not been assessed for or attempted because, the resident might fall. He/she stated that a restraint reduction assessment had not been completed on the resident because the restraint was put in place since 9/4/09 because of the resident's cognitive impairment and partial weight bearing status. 3. Resident #24 had a geri-chair with a table top restraint in place since at least 12/22/04. A review of the 12/29/04 ""Consent for Use of Physical Restraints"" form, signed by the resident's responsible party, revealed the reason for use was the resident's ""behaviors unmanageable by any other means."" However, no specific medical symptom was documented. During the initial tour on 1/5/10 between 10:15 a.m. to 11:35 a.m., licensed nursing staff ""LL"" stated that the restraint was used because the resident would hover over others (residents) and hit. A review of the restraint assessments completed by staff from 10/5/06 to 9/17/09 revealed that there had not been any attempts at a restraint reduction. The restraint assessments documented a history of behaviors that put the resident and others at risk but not a current medical symptom to warrant the continued use of the restraint. However, there was not any documentation in the clinical record that the resident continued to exhibit the behaviors of hovering and hitting, or that those behaviors warranted the use of a physical restraint. There was no documentation in the clinical record that the geri-chair with a table top restraint was the appropriate and least restrictive device for resident #24.",2014-11-01
10250,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2010-01-07,309,D,0,1,NX9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, it was determined that the facility failed to administer medications as ordered by the attending physician for three residents (#3, #4 and #21) from a total sample of 30 residents. Findings include: 1. Resident #3 had a 1/29/09 physician's orders [REDACTED]. 2009 Medication Administration Record [REDACTED]. In addition, this resident had a 5/28/09 physician's orders [REDACTED]. However, review of the resident's October 2009 MAR indicated [REDACTED]. 2. Resident #4 had a 11/24/09 physician's orders [REDACTED]. However, review of the resident's December 2009 MAR indicated [REDACTED]. 3. Resident #21 had a 10/5/09 physician's orders [REDACTED]. Review of the October 2009 revealed that licensed nursing staff failed to administer the medication on 10/9/09. During an interview on 1/07/10 at 1:00 p.m., nursing supervisor ""BB"" confirmed that those medications for residents #3, #4 and #21 were not administered as ordered.",2014-11-01
10251,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2010-01-07,428,D,0,1,NX9T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the consultant pharmacist failed to identify and report medication discrepancies for two residents (#3 and #21) from a total sample of 30 residents. Findings include: 1. Resident #3 had a physician's orders [REDACTED]. However, review of the resident's Medication Administration Record [REDACTED]. In addition, resident #3 had a physician's orders [REDACTED]. Review of the resident's October MAR indicated [REDACTED]. Although, the consultant pharmacist reviewed the resident's MARs on 11/5/09 and 12/18/09, he/she failed to identify and report to the Director of Nursing and the resident's attending physician that staff had not administered those medications as ordered. 2. Resident #21 had a physician's orders [REDACTED]. However, review of the resident's November 2009 MAR indicated [REDACTED]. Review of the October 2009 MAR indicated [REDACTED]. Although the consultant pharmacist reviewed the resident's MARs on 11/5/09 and 12/18/09, he/she failed to identify and report to the Director of Nursing and the resident's attending physician that staff had not administered that medication as ordered.",2014-11-01
10471,"BAPTIST VILLAGE, INC.",115615,2650 CARSWELL AVE,WAYCROSS,GA,31502,2009-08-03,225,D,1,0,0HJT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to report an injury of unknown origin and send the findings of their investigation to the State Survey and Certification Agency for one (1) resident, Resident #1, on a survey sample of five (5) residents. Findings include: Record review for resident #1 revealed a Departmental Note dated 7/20/09 at 9:52 a.m., that documented right leg pain. Medications were administered and the physician was notified with resulting orders to monitor the resident. At 3:12 p.m. the resident continued to complain of right leg pain from the thigh down. The family elected to have the resident evaluated in the emergency room due to a history of blood clots in that extremity. The physician was notified and the resident was transported to the hospital for evaluation. The resident was subsequently admitted with a [DIAGNOSES REDACTED]. Interview with the Director of Nursing (DON), on 8/3/09 at 3:00 p.m., revealed that an investigation was conducted of the incident once it was reported to the facility by the family member after the emergency room surmised the resident had a fall. The cause of the injury was of unknown origin, thus requiring the incident to be report to the State Survey Agency. However the facility did not report the injury of unknown origin to the State Survey and Certification Agency, as required.",2014-07-01
2729,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,156,D,0,1,GXK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to provide the Notice of Medicare Non-Coverage (Form CMS- -NOMNC) for two (2) residents (# 80, and #74) who were discharged to home from Medicare Part A Skilled Services from a sample of twenty-seven (27). Findings include: 1. Record review revealed that Resident #80 was admitted to the facility on [DATE]. A Rehab Discharge Notification facility form dated 6/13/16 is on file to indicate resident # 80 end of skilled services. Further investigation revealed that resident #80 did not receive a Notice of Medicare Non-Coverage (Form CMS- -NOMNC), which would indicate the effective date the coverage of Skilled Services would end on 6/15/16 prior to being discharge home on 6/16/16. 2. Record review revealed that Resident #74 was admitted to the facility on [DATE]. A Rehab Discharge Notification facility form dated 4/21/16 is on file to indicate resident #74 end of skilled services. Further investigation revealed that resident #74 did not receive a Notice of Medicare Non-Coverage (Form CMS- -NOMNC) which indicated the effective date the coverage of Skilled Services would end on 4/27/16 prior to being discharge home on 4/23/16. During an interview with the Financial Coordinator on 9/8/16 at 3:50 p.m. revealed that resident #80 and resident #74 did not receive the Notice of Medicare Non-Coverage prior to being discharge to home. Financial Controller revealed that no residents who were discharged to home from Medicare Part A skilled services had received the CMS- form because she had been told the form were not needed for resident returning home and was not aware the form was required.",2020-09-01
2730,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,253,D,0,1,GXK411,"Based on observation and interview, the facility failed to ensure a clean and well maintained environment for ten (10) out of forty-four (44) rooms. Findings include: Observation on 09/06/2016 at 11:09 a.m., on 09/08/2016 at 12:06, 09/09/2016 at 08:11 a.m. in Room 313 revealed staining around the base of the toilet, missing paint on lower wall entering room and the baseboard on the wall next to the window and below the air conditioner had a thick build-up of powdery white dust. Interview and observation on 09/09/2016 at 09:35 a.m. in Room 313 with the Head of Maintenance and Head of Housekeeping confirmed that there was staining around the base of the toilet, missing paint on lower wall entering room and the baseboard on the wall next to the window and below the air conditioner had a thick build-up of powdery white dust. Observation on 09/06/2016 at 11:12 a.m., 09/08/2016 at 12:05 p.m., and 09/09/2016 at 08:09 a.m. in Room 310 revealed a build-up of dust on the housing unit for the air conditioner. In the bathroom there was a stain around the base of the toilet. The foam arm rest on the raised toilet seat was split and a brown stain was observed on the call cord in the bathroom. Interview and observation on 09/09/2016 at 09:34 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 310 confirmed that there was a build-up of dust on the housing unit for the air conditioner. In the bathroom there was a stain around the base of the toilet. The foam arm rest on the raised toilet seat was split and a brown stain was observed on the call cord in the bathroom. Observation on 09/06/2016 at 11:15 a.m., 09/08/2016 12:04 p.m. and 09/09/2016 at 08:10 a.m. in [RM #]9 revealed that there was missing paint on the wall to the right of entrance into room and the bathroom call cord had brown and yellow stains. Interview and observation on 09/09/2016 at 09:32 a.m.with the Head of Maintenance and Head of Housekeeping in [RM #]9 confirmed that there was missing paint on the wall to the right of entrance into room and the bathroom call cord had brown and yellow stains. Observation on 09/06/2016 at 11:24 a.m., 09/08/2016 at 11:42 a.m. and 09/09/2016 at 08:07 a.m. in Room 105 bathroom revealed staining around the base of the toilet and a stained bathroom call cord. Interview and observation on 09/09/2016 at 09:31 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 105 bathroom confirmed staining around the base of the toilet and a stained bathroom call cord. Observation on 09/06/2016 at 11:26 a.m., 09/08/2016 at 11:40 a.m. and 09/09/2016 at 08:06 a.m. in Room 109 bathroom revealed staining around the base of the toilet and a stained bathroom call cord. Interview and observation on 09/09/2016 at 09:00 a.m. in Room 109 bathroom confirmed staining around the base of the toilet and a stained bathroom call cord. Observation on 09/06/2016 at 03:00 p.m., 09/08/2016 at 12:00 p.m. and 09/09/2016 at 09:44 a.m. in Room 219 revealed peeling paint on the wall behind the bathroom sink and a loose baseboard behind the door to the room. Interview and observation on 09/09/2016 at 09:44 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 219 confirmed peeling paint on the wall behind the bathroom sink and a loose baseboard behind the door to the room. Observation on 09/06/2016 at 3:12 p.m. in Room 214, 09/08/2016 at 11:56 a.m. and 09/09/2016 at 08:15 a.m. revealed scuff marks on the bottom of the bathroom door, a black substance on the floor at the foot of A-bed and a black scuff mark about half way up the wall beside A-bed. There was a build-up of dust on the air conditioner housing unit, missing paint on the wall and a brown stain on bathroom ceiling approximately three (3) inches in diameter. Interview and observation on 09/09/2016 at 09:41 a.m. in Room 214 revealed scuff marks on the bottom of the bathroom door, a black substance on the floor at the foot of A-bed and a black scuff mark about half way up the wall beside A-bed. There was a build-up of dust on the air conditioner housing unit, missing paint on the wall and a brown stain on bathroom ceiling approximately three (3) inches in diameter. Observation on 09/07/2016 at 02:11 p.m., 09/08/2016 at 11:48 a.m. and 09/09/2016 at 08:17 a.m. in Room 210 revealed that there was missing paint on the wall that the door to the room was on, the floor had a build-up of dirt near the baseboards and the bathroom call cord was stained yellow and brown. Interview and observation on 09/09/2016 at 09:39 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 210 confirmed that there was missing paint on the wall that the door to the room was on, the floor had a build-up of dirt near the baseboards and the bathroom call cord was stained yellow and brown. Observation on 09/07/2016 at 1:51 p.m., 09/08/2016 at 11:49 a.m. and 09/09/2016 at 08:11 a.m. in Room 209 revealed that the emergency call cord in the bathroom was stained yellow and the tile around the toilet was stained. Interview and observation on 09/09/2016 at 09:36 a.m. with the Head of Maintenance and the Head of Housekeeping in Room 209 confirmed that the emergency call cord in the bathroom was stained yellow and the tile around the toilet was stained.",2020-09-01
2731,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,279,D,0,1,GXK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans related to [MEDICAL CONDITION] drug use for one (1) resident #90; failed to develop individualized care plan related to planned weight loss for one (1) resident #48; failed to develop individualized care plan related to care and comfort for one (1) resident #31. Total sample is twenty-seven (27) residents. Findings include: 1. Resident #90 was admitted to the facility on [DATE] with the diagnose but not limited to Hypertension, Dementia with Behavior Disturbances, Alzheimer ' s Disease, Personality Changes, Major [MEDICAL CONDITIONS] and [MEDICAL CONDITIONS] as noted in Section I Active Diagnose of the Admission Minimum Data Set ((MDS) dated [DATE]. Section N medications: [REDACTED]. Review of the Physician's Orders dated 7/29/16 on 9/9/16 at 2:27 p.m. revealed that resident #90 has a [MEDICAL CONDITION] medication use of [MEDICATION NAME] capsule 20 milligram (mg) twice a day routinely, and antidepressant medication use of [MEDICATION NAME] XR 75 mg capsules Extended Release one time a day routinely. Review of resident #90 care plan dated 7/6/16 on 9/9/16 at 2:55 p.m. revealed that there was no mention of these specific medications which resident #90 was receiving, no individualized interventions for these [MEDICAL CONDITION] drugs, nor monitoring for possible gradual dose reduction of the medications on this care plan. During an interview with the MDS Coordinator on 9/9/16 at 3:34 p.m. revealed that she was aware of resident #90 was on [MEDICAL CONDITION] drugs and admitted she overlooked writing a care plan for [MEDICAL CONDITION] medications. 2. Resident #48 was readmitted to the facility on [DATE] with the diagnose but not limited to Sick Sinus Syndrome, [MEDICAL CONDITION], Abnormality of [MEDICATION NAME], Major [MEDICAL CONDITION], Pacemaker, [MEDICAL CONDITION], Diabetes Mellitus, [MEDICAL CONDITIONS] Stage 3, Gastro-[MEDICAL CONDITION] Reflux, [MEDICAL CONDITION], and [MEDICAL CONDITION] Fibrillation. A Review of a copy of the Progress Note dated 7/27/16 on 9/9/16 at 10:26 a.m. revealed an order that reads continue weight loss which is signed by the Medical Doctor and Family Nurse Practitioner. Review of resident #48 nutrition care plan dated 12/4/15 on 9/8/16 at 4:50 p.m. revealed that resident #48 is care planned as At Risk for weight loss related to resident ' s goals. Review of the interventions for the nutrition care plan included assist resident with healthier meal options; encourage resident to exercise as frequently as tolerated. These interventions revealed that they were not individualized for the actual planned weight loss or the expected outcome for resident #48. During an interview with the MDS Coordinator on 9/9/1616 at 3:34 p.m. revealed that resident #48 is an actual plan weight loss and that she did not care plan resident #48 as such. 3. Resident #31 was admitted to the facility on [DATE] with the diagnose but not limited to [MEDICAL CONDITION], Abnormal Posture, Stiffness of Unspecified Joint, Diverticulitis of Intestine, History of Falling, Difficulty in Walking, Altered Mental Status, Dementia without Behavioral Disturbance, Heart Failure, Dysphagia, Generalized Muscle Weakness, Major [MEDICAL CONDITIONS] Fibrillation. Review of resident #31 care plan dated 10/13/16 on 9/8/16 at 11:16 a.m. revealed that resident #31 is care planned as a resident with Advance directive choices which includes Do Not Resituate (DNR) and Care and Comfort status. Review of the interventions revealed interventions Advance directives will be shared with other medical providers as a need to ensure that advance directive choices are honored; Advance directives will be placed in the chart; Assist resident with DNR form, ensure all parties have signed and this form is in place on the chart. Provide copies to any other medical facility that provide service; Obtain order for DNR. However, there were no specific interventions to address the death and dying, spiritual, or type of comfort care to provide to resident #31. During interview with the MDS Coordinator on 09/8/16 at 1:05 p.m. revealed that she had not individualized resident #31 with specific interventions because she was waiting on a family member to verbalized specific end of life decisions for resident #31. And in regards to specific interventions for the facility staff, MDS Coordinator could not explain the lack of interventions. Review of the facility policy Care Plans-Comprehensive: Policy Interpretation and Implementation; number 2. The comprehensive care plan has been designed to: a. Incorporated identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident ' s strengths; d. Reflect treatment goals and objectives in measurable outcomes; e. Identify the professional services that are responsible for each element of care; f. Prevent decline in the resident ' s functional status and/or functional levels; and g. Enhance the optimal functioning of the resident.",2020-09-01
2732,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,323,D,0,1,GXK411,"Based on observation, interview and record review, the facility failed to maintain a safe environment for one (1) resident (#36 in Room 111) with an unsecured raised toilet seat. The sample size was twenty-seven (27). Findings include: 1. Observation on 09/06/2016 at 03:47 p.m. in Room 111 bathroom revealed a raised toilet seat that was not secured. Interview and observation on 09/06/2016 at 3:48 p.m. in Room 111 bathroom with Licensed Practical Nurse (LPN), KK confirmed that the raised toilet seat was not secure and that this was not acceptable practice. Observation on 09/06/2016 at 03:49 p.m. revealed that LPN, KK immediately called the Head of Maintenance to secure the raised toilet seat. Observation on 09/06/2016 at 04:00 p.m. revealed that the raised toilet seat had been secured. Received list of residents with raised toilet seats on 09/07/2016 at 08:25 a.m. and they included Room 111, Room 204, [RM #]8 and Room 310. Observation on 09/07/2016 at 08:29 a.m. of [RM #]8 bathroom revealed that the raised toilet seat was secure. Observation on 09/07/2016 at 08:32 a.m. of Room 310 bathroom revealed that the raised toilet seat was secure. Observation on 09/07/2016 at 08:52 a.m. of Room 204 bathroom revealed that the raised toilet seat was secure.",2020-09-01
2733,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,329,D,0,1,GXK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to assure the monitoring of side effects and behaviors, in (MONTH) (YEAR), for one (1) resident (#51) who was prescribed an antipsychotic medication of twenty seven (27) sampled resident . Findings include: Resident #51 admitted to this facility on 8/3/16 with multiple [DIAGNOSES REDACTED]. Review of the Order Summary Report from (MONTH) 1-August 31, (YEAR) revealed a physician's orders [REDACTED]. Record review of the resident's care plan included: Use antidepressant medications and [MEDICAL CONDITION] medications related to depression. Goal: The resident will be free from discomfort or adverse reactions related to antidepressants therapy through the review date. Interventions: Administer antidepressant medications as ordered by physician; Monitor /document side effects and effectiveness every shift. Monitor/document/report PRN (as needed) for adverse reactions to antidepressant therapy. Interview on 9/09/2016 at 7:26 a.m. with Licensed Practical Nurse (LPN) CC revealed that the resident is encouraged to allow staff to help her but resident is independent. The resident ambulates safely with walker but has to be reminded to use it at times. Resident is also encouraged to attend activities. There are no behavioral concerns. LPN CC reported that the side effects from medications ([MEDICATION NAME] and [MEDICATION NAME]) was monitored in (MONTH) Medication Administration Record (MAR) but was not monitored on the (MONTH) (YEAR) MAR. Review of the MAR with LPN CC revealed that behaviors or adverse reactions where not being documented on the (MONTH) (YEAR) MAR. Interview on 09/09/2016 at 11:49 a.m. with the Director of Nursing (DON) who reported that adverse reactions for antipsychotic medications are documented on the MAR. The DON reviewed the resident's MAR for (MONTH) and (MONTH) and confirmed that there was no tracking of side effects and behaviors in (MONTH) (YEAR).",2020-09-01
2734,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,371,E,0,1,GXK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interviews the facility failed to assure that foods were used by the expiration date; temperatures were monitored for both the refrigerator and freezer in main dining room resident refrigerator and in food pantry refrigerator; and failed to assure that residents and staff food were kept separate. This affected fifty-eight (58) residents who received oral feedings out of a census of sixty (60). The findings include: 1. Observation on 9/2/16 at 11:19 a.m. during initial tour with Dietary Services Manager revealed the following: three (3) containers of Table grind black pepper five (5) pound (lb) containers with an expiration date of 8/13/15 and one (1) container with an expiration date of 9/5/14. One (1) container of Extra Virgin Olive Oil with an expiration date of 3/31/16. One forty (40) ounce (oz) container of Thick and Easy Instant Food thickener with an expiration date of 6/17/16. One (1) one (1) gallon of [NAME] distilled Vinegar with a best by date of 6/19/15. There were two (2) different stickers indicating receive dates of 2/22/15 and 2/22/16. Eleven (11) three (3) pound (lb) cans of Heinz Chicken Noodle Soup with a best by date of 7/8/16. Six (6) packages of Meritta Hamburger buns 8 (eight) count with use by dates: four (4) for [DATE], (YEAR); Sarah Lee whole wheat bread one (1) lb observed to have mold on it with an expiration date of (MONTH) 1, (YEAR); one (1) 16 oz loaf of Swirl Cinnamon Raisin Bread with use by date of (MONTH) 24, (YEAR). Dietary Service Manager (DSM) acknowledged that these items where not identified as expired prior to today. The DSM reported that no one has typically been checking expiration dates when items are received from the vendor as they are assumed to be good. The DSM reported that the Heinz Chicken Noodle Soup was received on 8/30/16. It was revealed that bread was delivered on 9/2/16 because there was no bread on 9/1/16. DSM also reported that she hasn't been looking at expiration dates during delivery. Once an item has been identified as expired it should be placed on top shelf of bread cart and a sign should be posted stating to not use the bread. Upon observation there were no signs posted to indicate that bread on the top shelf should not be used. Further observation revealed that expired bread was spread throughout the bread cart. 2. Observation and interview with the DSM on 9/08/2016 at 11:50 a.m. revealed refrigerator temperature of thirty-two (32) degrees Fahrenheit (F) in the refrigerator in main dining room. There was ice cream in the freezer that remained firm to touch but there was no log of freezer temperatures. DSM reported that the facility is not currently keeping log of freezer temperatures. 3. Observation on 09/08/2016 at 11:55 a.m. in the resident food pantry there was no thermometer found in the refrigerator or in the freezer. In the freezer there was one Orange Bar that was not labeled and did not have an expiration date. In the refrigerator was three (3) eight (8) fluid (fl)oz Ensure Shakes with an (MONTH) 1, (YEAR) expiration date on bottom of each container; four (4) eight (8) fl oz containers of Glucerna 1.0 Cal Specialized Nutrition with an expiration date of (MONTH) 1, (YEAR); one (1) four 4 oz container of Peach Activia yogurt and two (2) four (4 oz) strawberry yogurts with expiration of [DATE], (YEAR); one (1) six (6) oz container of blueberry non-fat yogurt with an expiration date of 8/22/16; seven (7) containers being eight (8) fl oz each of Boost complete nutritional drink with a use by date of (MONTH) 30 (YEAR). An interview on 9/08/2016 at 11:59 a.m. with the DDS who provided copy of the temperature log for refrigerator in main dining and confirmed that the refrigerator in pantry is used by both residents and staff. An interview on 9/08/2016 at 2:22 p.m. with the Director of Nursing (DON) reported that the housekeeping staff is responsible for cleaning of the food pantry and is unsure if logs are kept of temperatures for the refrigerator and freezer. The DON further reported that nursing labels and dates items placed in the refrigerator for the residents. An interview on 9/08/2016 at 2:31 p.m. with Housekeeping Supervisor (HSK) who reported that temperature logs are not done for the food pantry refrigerator. It was further reported that housekeeping staff clean the refrigerator daily but do not look at expiration dates. HSK reported that housekeeping staff have not been discarding anything that belongs to residents and confirmed that residents and staff share the refrigerator in the pantry on the hall. HSK reported that he/she was promoted to this position last week and he/she was not aware that temperature logs were needed for this refrigerator and freezer. An interview on 9/08/2016 at 2:49 p.m. with the Administrator who confirmed that there are no thermometers to monitor the freezer or refrigerator temperatures in the food pantry on the hall. The Administrator reported that this refrigerator has never been monitored and housekeeping is responsible for the upkeep of the food pantry refrigerator. The Administrator reported that sometimes families bring items in and staff need to check the items to assure that they are not expired. Review of the facility policy Title: Dietary Services Purpose: To prevent contamination of food products and therefore prevent foodborne illness. Policy: V. Food Storage E. Refrigerated foods must be stored at temperatures of 41 degrees F or less. Frozen foods must be stored at 0 degrees F or less. Interview on 09/09/2016 at 7:45 a.m. with the Administrator who reported that the food pantry refrigerator should have a thermometer for monitoring the temperature and he/she is unsure as to why there was no thermometer in the refrigerator.",2020-09-01
2735,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,431,D,0,1,GXK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to ensure that for one (1) of three (3) medication carts was locked when unattended. Findings include: Observation on 09/08/2016 at 07:55 a.m. of Licensed Practical Nurse (LPN), II during medication administration revealed that he/she left the medication cart unlocked and out of visual range when he/she entered room [ROOM NUMBER]. Observation on 09/08/2016 at 07:58 a.m. of LPN, II during medication administration revealed that he/she left the medication cart unlocked and out of visual range when he/she entered room [ROOM NUMBER] A, first to obtain vital signs and then to administer medications. Observation on 09/08/2016 at 08:06 a.m. of LPN,II during medication administration revealed that he/she left the medication cart unlocked and out of visual range when he/she entered room [ROOM NUMBER] B first to obtain vital signs and then to administer medications. Interview on 09/08/2016 at 08:10 a.m. of LPN, II confirmed that he/she forgot to lock the medication cart. He/she stated that they were having to manually lock the cart because the electronic key card was broken. He/she stated that the key card broke and the electronic key pad was broken also. The LPN stated that they had reported this to the Head of Maintenance. Review of Medication Storage Policy revealed that the medication carts were to be locked or attended by persons with authorized access. Interview on 09/08/2016 at 10:29 a.m. with LPN, II revealed that she thought that she reported that the electronic locking system for the medication cart was not working approximately a week ago. Interview on 09/08/2016 at 10:32 a.m. with the Head of Maintenance confirmed that he had been told that the electronic locking system for the 300 hall medication cart was not working. Interview on 09/08/2016 at 10:35 a.m. with the Administrator and the Director of Nursing confirmed that they expect the medication carts to be locked any time the nurse walks away from the medication cart. An interview with the Director of Maintenance during the Quality Assurance Review on 9/23/16 at 1:55 p.m., by telephone, revealed that he was aware that one (1) number on the key pad was not working but that the locking function, using the key, still worked. He revealed that a nurse had accidentally taken the key card home for this medicine cart on 9/8/16 and that with the key card the medicine cart could be locked automatically.",2020-09-01
2736,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,441,D,0,1,GXK411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to label and store personal care items in a sanitary manner in one (1) room out of forty-four (44) rooms. Findings include: Observation on 09/06/2016 at 11:15 a.m., 09/08/2016 at 12;04 p.m. and 09/09/2016 at 08:10 a.m. in room [ROOM NUMBER] shared bathroom revealed that there were two (2) unbagged and unlabeled basins and one (1) unbagged and unlabeled urine specimen measuring device stacked inside each other. Interview and observation on 09/09/2016 at 08:17 a.m. with the Assistant Director of Nursing/ Clinical Supervisor confirmed that in room [ROOM NUMBER] shared bathroom that there were two (2) unbagged and unlabeled basins and one (1) unbagged and unlabeled urine specimen measuring device stacked inside each other. She also confirmed that this was not accepted practice. Interview on 09/09/2016 at 09:28 a.m. with the Director of Nursing revealed that they do not have a policy for the storage of personal items.",2020-09-01
2737,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2016-09-09,504,D,0,1,GXK411,"**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 ensure that a Physician ordered laboratory test was obtained in a timely manner for two (2) residents (#51 and #65) from a sample of three (3) residents reviewed for laboratory tests and from a total sample of twenty-seven (27) residents. Findings include: 1. Resident #65 had a physician's orders [REDACTED]. Review of the medical record revealed that resident #65 received laboratory testing on 2/16/16, 2/23/16, 3/1/16, and 3/8/16 for CBC. Further review revealed that CMP testing was done for 2/16/16, 2/23/16, and 3/8/16 but did not have CMP testing on 3/1/16. 2. Resident # 51 had a physician's order [REDACTED]. Review of the medical record revealed that resident #51 received laboratory testing on 8/4/16 and 8/23/16 for CBC and CMP. Further review revealed that CBC and CMP testing was not done for the weeks of 8/7/16 and 8/14/16. Labs for (MONTH) requested from RN Quality Assurance Performance Improvement (QAPI) DD for resident #51 on 9/9/16 at 8:04 a.m. Interview on 9/9/16 at 8:30 a.m. with RN QAPI DD who reported that a services with Clinical Laboratory Services, Incorporated (CLS) were began in (MONTH) (YEAR). RN QAPI DD explained that the facility submitted requisitions for all orders on new admissions to the laboratory provider but when this was done it caused all follow up orders to override the initial order for weekly labs to be drawn for CBC and CMP. Interview on 9/9/16 at 8:36 a.m. with RN QAPI DD , who provided copies of lab requisitions for resident which revealed q week x 4 weeks for Comp and CBC with the first scheduled draw date 8/4/16. In another requisition Comp and CBC requested every 3 months (due February, May, August, and November) with the first scheduled draw date of 8/4/16. It was further reported that once this issue was identified as being a problem it was placed inot the facility's quality assurance meeting for monitoring. Interview on 9/9/16 at 11:49 a.m. with Director Of Nursing (DON) reported that if there is not an order on the file to discharge the two (2) weeks of labs that were missed for resident #51 that there probably was not an order. DON reported that the facility was following the instructions of the lab to submit two (2) separate requisitions for the labs (weekly and every three (3) months). DON reported that CLS sends a manifest but it is hard to read. DON further reported that it was by reviewing the manifest that the facility learned that the monthly lab was overriding the weekly labs. DON suggested that surveyor follow up with RN QAPI DD for further information about lab services. Interview on 9/9/16 at 12:23 p.m. RN QAPI DD reported that the laboratory services prior to (MONTH) were with Mayo. Mayo services were reported as being present at the facility on Tuesdays. The requisitions were completed and faxed to them on Mondays. There was an appointment book in which RN QAPI DD reported residents needing to be seen for the week were written on the schedule and whenever the laboratory technician arrived to provide service the residents were seen.",2020-09-01
2738,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2018-10-18,656,E,0,1,KBPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to develop a comprehensive care plan that included monitoring of vital signs for a high risk medication for three of four residents receiving the heart medication, [MEDICATION NAME], Resident (R) #56, R#22 and R#6. The sample size was 31 residents. The facility census was 55 residents. Findings include: [MEDICATION NAME] is a prescription medication used to treat heart failure and heart rhythm problems. It is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. The U.S. National Library of Medicine notes the amount of [MEDICATION NAME] needed to help most people is very close to the amount that could cause serious problems from overdose. It also states that some early warning signs of overdose include but are not limited to an uneven, pounding or slow heartbeat. A drug guide notes that [MEDICATION NAME] has a heightened risk of causing significant patient harm when it is used in error. It further states to monitor apical pulse for one full minute before administering and to withhold the dose and notify the physician if pulse rate is less than 60 beats per minute or if there is a significant change in rate, rhythm, or quality of the pulse. (reference [NAME]'s Drug Guide for Nurses, sixteenth edition, Copyright 2019 by F. [NAME] [NAME] Company). 3. R#6 is an [AGE] year old resident with [DIAGNOSES REDACTED]. A review of current physician's orders [REDACTED]. The original order is dated 5/15/18. There is no order to monitor or check the apical pulse rate and hold the medication if the pulse is less than 60 beats per minute. A review of the care plans for R#6 reveals a care plan focus stating the resident is on [MEDICATION NAME]/[MEDICATION NAME] therapy r/t (related to) [MEDICAL CONDITIONS]. The goal states the resident will be free from discomfort or adverse reactions related to [MEDICATION NAME] use through the review date. Interventions include but are not limited to: report to physician if pulse falls below 60 or rises above 110 or if you detect skipped beats or other changes in rhythm. An interview was conducted on 10/18/18 at 1:23 p.m. with the MDS Coordinator revealed taht she usually puts high risk medications like [MEDICATION NAME] in the care plans. She also acknowledged that two other residents did not have care plans for [MEDICATION NAME]. 2. Resident (R)#56 was admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. R#56 was noted to have a physician order [REDACTED]. Further review of Medication Administration Record [REDACTED]. During review of the care plans for R#56, it was noted that there was no care plan developed to communicate treatment plan and risk factors for a resident who is prescribed [MEDICATION NAME]. During an interview 10/18/18 at 11:15 a.m., the Director of Nursing (DON) verified that R#56 was admitted with a medication order for [MEDICATION NAME] at the time of her admission, received [MEDICATION NAME] the month of (MONTH) (YEAR) and (MONTH) (YEAR), and was not care planned for the medication. Further interview revealed that the Minimum Data Set (MDS) Coordinator is responsible for all care plans. The DON further stated that she does not supervise what care plans should be developed or created. During an interview on 10/18/18 at 1:14 a.m., with the (MDS) Coordinator, verified that R#56 's did not have a care plan to address her use of [MEDICATION NAME] and that the facility's policy is that any residents who have a [DIAGNOSES REDACTED]. A review of policy titled Care Plans-Comprehensive Policy Statement revealed that the facility 's care plan stated that residents 'care plan should: (i) Reflect currently recognized standards of practice for problem areas and conditions. and (11) A list of current medications and dietary instructions, and Services and treatments to be administered by the facility and personnel acting on behalf of the facility",2020-09-01
2739,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2018-10-18,756,D,0,1,KBPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on physician, pharmacist and staff interviews and record reviews the facility's consulting pharmacist failed to recognize and report an irregularity in the medication regimen for one resident (R), R#56 and report the irregularity to the facility and the physician. The sample size was 31 residents. Findings include: [MEDICATION NAME] is a prescription medication used to treat heart failure and heart rhythm problems. It is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. The U.S. National Library of Medicine notes the amount of [MEDICATION NAME] needed to help most people is very close to the amount that could cause serious problems from overdose. It also states that some early warning signs of overdose include but are not limited to an uneven, pounding or slow heartbeat. A drug guide notes that [MEDICATION NAME] has a heightened risk of causing significant patient harm when it is used in error. It further states to monitor apical pulse for one full minute before administering and to withhold the dose and notify the physician if pulse rate is less than 60 beats per minute or if there is a significant change in rate, rhythm, or quality of the pulse. (reference [NAME]'s Drug Guide for Nurses, sixteenth edition, Copyright 2019 by F. [NAME] [NAME] Company). A review of a document entitled Current resident listing for Bayview Nursing and Rehab with medication regimen review activity between 9/18/18 and 9/18/18 reveals the medication regimen for R#56 was reviewed by the consulting pharmacist on that date. The document is signed electronically by the facility's consulting pharmacist. Review of the Medication Administration Records (MARs) for R#56 (MONTH) and (MONTH) of (YEAR), there was not an order on the MAR indicated [REDACTED]. There was evidence of R#56's pulse being checked daily during the months of (MONTH) and (MONTH) (YEAR) but not consistently at the medication administration time of 9:00 a.m. There were three occasions when the pulse was documented as checked after the time the medication was administered. The MARs revealed that on 9/30/18, the pulse was checked at 11:52 a.m. with a result of 61 beats per minute, but the medication was documented as administered at 9:00 a.m. The MARs reflect that on 10/10/18 the pulse was checked at 1:26 p.m. with a result of 54 beats per minute but the medication is documented as administered at 9:00 a.m. Again, on 10/12/18, the pulse was checked but not until 12:24 p.m. with a result of 63 beats per minute and the medication was documented as administered at the 9:00 a.m. time. The (MONTH) MAR indicated [REDACTED]. The medication is documented as administered at 9:00 a.m. There is no documentation that the medication was held when the pulse was less than 60 beats per minute. During an interview conducted on 10/18/18 at 11:15 a.m., the Director of Nursing (DON) stated it is her expectation that nurses will monitor a resident's apical pulse prior to administering [MEDICATION NAME] and will hold the medication if the resident's pule's is less than 60 beats per minute. She also stated she would expect the nurses to notify the physician if medications were held. An interview was conducted on 10/18/18 at 10:34 a.m. with the consulting Pharmacist, who confirmed she reviewed the medication regiment of R#56 on 9/18/18 and provided one recommendation to the facility and physician regarding a needed [DIAGNOSES REDACTED]. There were no other recommendations provided to the facility or the physician. The pharmacist confirmed that R#56 was receiving [MEDICATION NAME] 125 micrograms (mcg) daily. She also confirmed that she would expect the nurses to have an order for [REDACTED].#56, the pharmacist stated the resident was a new admission (9/14/18) and had a [MEDICATION NAME] blood level checked in the hospital so they would not have done another level yet. She confirmed that she reviews the physician's orders [REDACTED]. She confirmed that she did not write any recommendations to the facility or physician to include monitoring of the apical pulse prior to administering [MEDICATION NAME], documenting the pulse and holding the medication if the pulse rate is below 60 beats per minute. The consulting pharmacist stated she would not expect the nurses to contact the physician for one missed dose but if the resident's pulse is less than 60 for several days and they hold the [MEDICATION NAME], she would expect the physician to be notified. During an interview conducted on 10/18/18 at 11:45 a.m., the attending Physician for R#56 who is also the facility medical director, confirmed it is his expectation that nurses would monitor a resident's pulse rate if they are taking [MEDICATION NAME]. He also stated that he would expect the nurses to monitor for signs of [MEDICATION NAME] toxicity. If a resident's pulse level is less than 60 and the nurses hold the medication the physician stated he would expect the nurses to get a [MEDICATION NAME] blood level and notify him if the level was abnormal. When asked to clarify his expectations, he confirmed again, that he would expect the nurses to monitor a resident's pulse, and if it was below the 60 beats per minute, to obtain a [MEDICATION NAME] level blood test and contact him if the level was abnormal.",2020-09-01
2740,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2018-10-18,760,D,0,1,KBPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on physician, consulting pharmacist and staff interviews, record reviews, and a review of a facility policy entitled Administering Medications, the facility failed to follow accepted standards of practice by not adequately monitoring the apical pulse for two residents (R), R#56 and R#6 receiving the cardiac medication [MEDICATION NAME] and administering the [MEDICATION NAME] when a resident's pulse was below 60 beats per minute. The sample size was 31. Findings include: [MEDICATION NAME] is a prescription medication used to treat heart failure and heart rhythm problems. It is used to improve the strength and efficiency of the heart, or to control the rate and rhythm of the heartbeat. The U.S. National Library of Medicine notes the amount of [MEDICATION NAME] needed to help most people is very close to the amount that could cause serious problems from overdose. It also states that some early warning signs of overdose include but are not limited to an uneven, pounding or slow heartbeat. A drug guide notes that [MEDICATION NAME] has a heightened risk of causing significant patient harm when it is used in error. It further states to monitor apical pulse for one full minute before administering and to withhold the dose and notify the physician if pulse rate is less than 60 beats per minute or if there is a significant change in rate, rhythm, or quality of the pulse. (reference [NAME]'s Drug Guide for Nurses, sixteenth edition, Copyright 2019 by F. [NAME] [NAME] Company). Findings include: Based on a review of R#56's Medication Administration Records (MARs) for (MONTH) and (MONTH) of (YEAR), there was not an order on the MAR indicated [REDACTED]. There was evidence of R#56's pulse being checked daily during the months of (MONTH) and (MONTH) (YEAR) but not consistently at the medication administration time of 9:00 a.m. The MARs revealed that on 9/30/18, the pulse was checked at 11:52 a.m. with a result of 61 beats per minute, but the medication was documented as administered at 9:00 a.m. The MARs reflect that on 10/10/18 the pulse was checked at 1:26 p.m. with a result of 54 beats per minute but the medication is documented as administered at 9:00 a.m. Again, on 10/12/18, the pulse was checked but not until 12:24 p.m. with a result of 63 beats per minute and the medication was documented as administered at the 9:00 a.m. time. The MAR indicated [REDACTED]. The medication is documented as administered at 9:00 a.m. There is no documentation that the medication was held when the pulse was less than 60 beats per minute. Based on a review of R#6's MARs for (MONTH) and (MONTH) of (YEAR), the facility staff did not have an order on the MAR indicated [REDACTED]. There was evidence of R#6's pulse being checked daily during the months of (MONTH) and (MONTH) (YEAR); however, there was one day, 10/9/18 at 9:17 a.m. when R#6's pulse was documented as 48 beats per minute and regular. The (MONTH) MAR indicated [REDACTED]. Also, on 9/2/18, the MAR indicated [REDACTED] During an interview conducted on 10/18/18 at 11:15 a.m., the Director of Nursing (DON) stated it is her expectation that nurses will monitor a resident's apical pulse prior to administering [MEDICATION NAME] and will hold the medication if the resident's pulse is less than 60 beats per minute. She also stated she would expect the nurses to notify the physician if medications were held. An interview was conducted on 10/18/18 at 10:34 AM with the consulting pharmacist,The pharmacist confirmed that she would expect the nurses to have an order for [REDACTED]. During an interview conducted on 10/18/18 at 11:45 a.m., the attending physician for R#56 who is also the facility medical director, confirmed it is his expectation that nurses would monitor a resident's pulse rate if they are taking [MEDICATION NAME]. He also stated that he would expect the nurses to monitor for signs of [MEDICATION NAME] toxicity. If a resident's pulse level is less than 60 and the nurses hold the medication the physician stated he would expect the nurses to get a [MEDICATION NAME] level and notify him if the level was abnormal. When asked to clarify his expectations, he confirmed again, that he would expect the nurses to monitor a resident's pulse, and if it was below the 60 beats per minute, to obtain a [MEDICATION NAME] level blood test and contact him if the level was abnormal. Review of a facility policy dated 3/22/17 entitled Administering Medications includes Medications shall be administered in a safe and timely manner, and as prescribed. 5. If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication shall contact the resident's Attending Physician or the facilty's Medical Director to discuss the concerns.",2020-09-01
2741,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2018-10-18,761,D,0,1,KBPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of a facility policy dated [DATE] entitled Discarding and Destroying Medications the facility failed to provide safe and secure storage for discontinued or expired controlled medications. Findings include: During a review of the facility's one medication storage room conducted on [DATE] at 11:30 a.m., Licensed Practical Nurse (LPN), DD stated their process for destruction/removal of discontinued or expired controlled substances is to place the controlled drug along with their count sheets into a locked/secured drawer in the medication room. She stated the drawer is supposed to be secured with a lock for which the Director of Nursing (DON) maintains the key. The drawer has two rectangular shape openings enabling the nurses to slide in the discarded controlled substances without accessing them for security purposes. The drawer for storage of discontinued or expired controlled medications was found unlocked and confirmed by LPN DD. During a review of the medication room with the DON conducted on [DATE] at 11:58 a.m., she confirmed the storage drawer was not locked and that she is the only person in the facilty with a key to the drawer. She confirmed that access to the medication room was limited to herself, the Registered Nurse (RN) supervisor, and the three nurses on duty who had keys to the medication carts. The DON further confirmed that neither she nor the nurses account for or monitor the amount of controlled medications that are in the drawer on a regular basis. Review of a facility policy dated [DATE] and entitled: Discarding and Destroying Medications reveals that medications will be disposed of in accordance with federal, state and local regulations governing management of non-hazardous pharmaceuticals, hazardous waste and controlled substances. 1. All unused controlled substances shall be retained in a securely locked area with restricted access until disposed of.",2020-09-01
2742,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2018-10-18,880,E,0,1,KBPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of a facility policy dated 4/5/17 entitled Handwashing/Hand Hygiene, the facility failed to distribute and serve food in a manner that prevents the spread of infection. During the observation of hall tray service for lunch on 10/16/18, a total of two Certified Nursing Assistants (CNAs), one on each hall, failed to sanitize their hands between passing trays to residents. The census was 55 residents. Findings include: 1. Review of the facility policy (4/5/17) entitled Handwashing/Hand Hygiene reveals the facility considers hand hygiene the primary means to prevent the spread of infections. The policy also notes 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 . l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . p. Before and after assisting a resident with meals. During observation of lunch service on the 300 Hall at 11:45 a.m. on 10/16/18, Certified Nursing Assistant (CNA) EE served a tray to the resident in room [ROOM NUMBER]-A, came out of room, did not sanitize her hands, removed another tray from the cart, entered room [ROOM NUMBER]-B and set up the tray by removing lids from beverages, opening packages and cutting up food items. Another staff member entered room [ROOM NUMBER]-B and assisted CNA EE, to reposition the resident by physically pulling her up in the bed. CNA EE then left room [ROOM NUMBER]-B, removed another tray from cart without sanitizing her hands, entered room [ROOM NUMBER]-B and set the tray in front of the resident. CNA EE left room [ROOM NUMBER]-B and sanitized her hands. An interview was conducted with the Director of Nursing (DON) on 10/16/18 at 12:17 p.m. where she confirmed the facility policy is for staff to wash or sanitize their hand between passing trays. She stated that if the staff member only takes a tray into a resident and doesn't touch the resident they do not have to sanitize or wash their hands. 2. Observation on 10/16/18 at 09:00 a.m. observation revealed LPN AA administering medications to Resident # 37. LPN AA entered resident's room with three medication cups of pills, a bottle of nasal spray, a bottle of eye gtts, a tube of icy hot topical cream, and a plastic cup of light tan liquid with a straw. LPN AA placed all of the medication on paper towel on bedside table. LPN AA administered the pills in the plastic medication cups and gave the resident the liquid to drink. LPN AA picked up the inhaler and put it in the resident's mouth. LPN administered medication per inhaler. LPN AA administered the nasal spray in each nostril, handed the resident a tissue, LPN AA then opened the bottle of eye gtts and administered one gtt in each eye and gave the resident more tissues to wipe her eyes. LPN AA then applied icy hot topical cream to the resident's bilateral knees. LPN then removed the gloves and threw them in the trash can. LPN AA left the resident's room walked to her med cart and sanitized her hands with gel hand sanitizer. Interview on 10/16/18 at 9:15 p.m. with LPN AA revealed that she confirmed that she did wear the same pair of gloves during the medication pass to Resident # 37 and stated this is always how she does it and doesn't know if it's right or wrong. Interview on 10/18/18 at 11:02 a.m with the Director of Nursing (DON) revealed that it is not her expectation for nurses to change gloves between administering medications through various routes. Further interview revealed that if a resident was receiving eye drops, nasal spray, and inhaler, it would not be her expectation for nurses to change gloves between administering the medications. 3. Observation on 10/16/2018 at 11:40 a.m. during lunch service, CNA (CC) was observed going into resident (R#9) with her meal tray. CNA CC placed the tray on the residents bed side table, assisted the resident out of bed into her wheelchair, then went around the residents bed, moved the bed side table with the tray on it and put it in front of the resident. She removed the lid on the plate and removed the dinner roll from the package with her ungloved hands and removed the silverware from the napkin. CNA CC dropped the spoon on the floor. She picked the spoon up off the floor and left the room. She walked to the kitchen, got a new set of silverware, and handed the dirty spoon the the kitchen helper and returned to the residents room and handed her the new set of silverware. She did not sanitize her hands any time during the above. She the went to the 100 wing, went into the food cart and removed the tray for R#7, she did not sanitize hands after leaving R#9's room and going into food cart, or before going into R#7's room. She assisted resident to sit up in the bed and put the food tray in front of resident. She removed the dinner roll from the bag with her ungloved hands and put it on the residents tray. She did not sanitize or wash her hands after leaving R#7's room. Interview with the Infection Control Nurse on 10/18/2018 at 10:26 p.m. revealed that she has inserviced the staff on hand washing. She does daily spot checks to ensure proper handwashing during daily care. She stated that an employee should wash there hands or sanitize hands when ever care was done on a resident, during meals if they came in contact with a resident or equipment. She would expect the employee to sanitize there hands after positioning a resident for meals and after before passing another tray. Interview with the DON on 10/18/2018 at 10:33 a.m. revealed she would expect the staff to wash there hands or sanitize there hands between care of residents. She would expect the staff to sanitize or wash there hands after positioning a resident for a meal and before passing a tray to another resident. Review of policy titled Hand washing/Hand Hygiene dated 4/5/18 revealed use of alcohol-based hand rub to be used before and after direct care with residents, before and after assisting a resident with meals.",2020-09-01
7906,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2012-07-12,282,D,0,1,S9FY11,"Based on observation and record review, it was determined that the facility failed to implement interventions to prevent skin tears and falls for one resident (#46) from a total sample of 25 residents. Findings include: Resident #46 had care plan interventions since 9/30/11 for nursing staff to keep his/her fingernails trimmed and filed as much as he/she would allow and for the side rails to be padded to minimize skin tears and bruising. However, when the resident was observed on 7/11/12 at 9:10 a.m. and 11:30 a.m. lying in the bed, the side rails had not been padded as planned. The resident's fingernails were long. There was a care plan intervention since 5/17/12 for nursing staff to not leave the resident unattended in his/her room when up in the gerichair. However, the resident was observed sitting in the gerichair in his/her room with no staff present on 7/11/12 at 2:05 p.m. and 2:45 p.m. and on 7/12/12 at 9:20 a.m. See F323 for additional information regarding resident #46.",2016-10-01
7907,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2012-07-12,309,D,0,1,S9FY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to assure the administration of five medications to one resident (#24) as ordered by the physician in a total sample of 25 residents. Findings include: Resident #24 had [DIAGNOSES REDACTED]. A review of nursing staff's documentation on the resident's April Medication Administration Record [REDACTED]. The licensed nurse noted on the back of the resident's MAR indicated [REDACTED]. However, there was not a physician's orders [REDACTED]. There was a 5/02/12 physician's orders [REDACTED]. However, the resident's systolic blood pressure on 4/3/12 was recorded as 102. During an interview on 7/11/12 at 3:00 p.m., the Director of Nursing stated that she would have expected nurses to give medications through the resident's gastrostomy tube ([DEVICE]) if not able to be administered orally. She said that, if nursing staff could not give medications through the [DEVICE], the nurse should have contacted the physician. She stated that nurses were not instructed to hold residents' medications without a physician's orders [REDACTED].#24.",2016-10-01
7908,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2012-07-12,323,D,0,1,S9FY11,"Based on observation, staff interview and record review, it was determined that the facility failed to implement planned interventions to prevent skin tears and falls for one resident (#46) from a total sample of 25 residents. Findings include: Resident #46 was coded on the 5/25/12 Minimum Data Set (MDS) assessment as needing total staff assistance with all activities of daily living and as cognitively impaired. The resident had a care plan since 9/30/11 to address the potential for skin changes and bruising due to the resident frequently moving his/her arms and legs. There was documentation on the care plan that the resident would pick at his/her skin at times causing skin tears and discolorations. There were interventions since 9/30/11 for nursing staff to keep his/her fingernails trimmed and filed as much as he/she would allow and for the side rails to be padded to minimize skin tears and bruising. On 7/11/12 at 2:30 p.m., the Director of Nursing (DON) stated that the resident could be combative during the provision of care, picked at his/her skin, and had constant movements. She stated the resident's skin was fragile. The resident was observed on 7/11/12 at 9:10 a.m. and 11:30 a.m. lying in the bed with the upper side rails raised on both sides of the bed. However, staff had not padded the right side rail. Only one of the two rungs on the left side rail was padded, but, that padding was partially detached. The fingernails on the resident's left hand were observed to be long but, his/her right hand was not visible. On 7/12/12 at 9:20 a.m. the resident's fingernails on both hands were observed to be long. There was a care plan since 9/30/11 to address the resident's risk for falls due to a history of falls, psychotropic medication use daily and needing total assistance with transfers. A review of the 5/16/12 nurse's notes and the 5/16/12 facility's incident report documentation revealed that the resident was found on the floor in his/her room on 5/16/12 after having slid out of the gerichair. The resident's care plan was revised on 5/17/12 to include an intervention for staff not to leave the resident unattended in his/her room when up in gerichair. However, the resident was observed in the gerichair in his/her room with no staff present on 7/11/12 at 2:05 p.m. and 2:45 p.m. and on 7/12/12 at 9:20 a.m.",2016-10-01
7909,BAYVIEW NURSING HOME,115593,12884 CLEVELAND STREET WEST,NAHUNTA,GA,31553,2012-07-12,371,F,0,1,S9FY11,"Based on observation and staff interview, it was determined that the facility failed to ensure that an appropriate level of sanitizer was maintained in the low temperature dishwasher to effectively sanitize dishware for a census of 56 residents who were served food from the kitchen. Findings include: During the initial observation of the kitchen on 7/9/12 from 11:50 a.m. to 12:15 p.m., dietary staff were observed washing dishes from the lunch meal in the automatic dishwasher. The Dietary Supervisor stated, at that time, that the dishwasher was a low temperature dishwasher. The manufacturer's recommendation posted on the machine was that the sanitizer level should be 50 parts per million (ppm) of chlorine. However, when the Dietary Supervisor checked for the concentration of sanitizer present in the water after completion of the wash and rinse cycle, the chlorine test strips did not register any chlorine present. On 7/9/12 at 12:45 p.m., the Dietary Supervisor stated that when the sanitizer level was checked that morning, it registered 100 ppm. However, there was no evidence that dietary staff checked the sanitizer level prior to washing the lunch dishes. A review of the dietary staff's documentation revealed that water temperatures during the wash and rinse cycles had been recorded but, there was no evidence that the concentration of sanitizer had been tested .",2016-10-01
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
5070,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2015-04-30,323,E,0,1,4NRP11,"Based on observations, review of the facility water temperature monthly log and staff interviews, the facility failed to ensure safe hot water temperatures on two (2) of two (2) halls (A Hall and B Hall) and two (2) of two (2) shower rooms( A Hall and B Hall). Findings include: Observations conducted on 4/28/15 beginning at 11:49 AM and ending at 12:13 PM with the Maintenance Director, revealed the following hot water temperatures: B Hall: Room 4 was 120 degrees Fahrenheit (F.) Room 11 was 128 degrees F. Room 14 was 128 degrees F. Room 15 was 126 degrees F. B Hall Shower Room: Shower Stall #2 was 126 degrees F. A Hall: Room 7 was 120 degrees F. A Hall Shower Room: Shower Stall #1 was 120 degrees F. Shower Stall #2 was 120 degrees F. Review the facility's Water Temperature Monthly Logs revealed hot water temperatures were identified in (MONTH) 2014, (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) on the A Hall, A Hall Shower Room, B Hall and B Hall Shower Room that ranged from 111-130 degrees F. Interview conducted 4/28/15 at 12:15 PM with the Maintenance Director revealed water temperatures were hot and he was going to turn the temperature down on the two systems and recheck. Interview conducted 4/28/15 at 4:19 PM with the Administrator revealed that she was not aware of hot water temperatures until today. She further indicated that a new mixing valve had been ordered and a certified plumber will be in the facility on 4/29/15 to replace the valve.",2019-01-01
5593,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2015-07-20,282,G,1,0,HZGZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, hospital emergency room (ER) Services form review, facility Resident Control-Code Status form review, and staff interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible, related to bed grab bar repair, for one (1) resident ( ) on the total suvey sample of eight (8) residents. Resident #1 sustained a fourteen centimeter (cm) leg laceration to the fascia requiring emergency room transfer and subcutaneous closure with [MEDICATION NAME] sutures and wound closure with Nylon sutures. Findings include: Resident #1's Admission Minimum Data Set assessment of 05/25/2015 documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Hypertension, Heart Failure, Arthritis, and [MEDICAL CONDITION], and Section G-Functional Status documented he/she required extensive assistance for transfer. The Care Plan for Resident #1 documented that the resident had an Activities of Daily Living deficit, with an Intervention identifying that the resident required the extensive assistance of two staff persons with transfer, and further documenting an Outcome of the resident improving his/her current level of function. A 05/29/2015, 07:30 p.m. Progress Notes entry for Resident #1 documented that Licensed Practical Nurse (LPN) AA was called to Resident #1's room and observed the resident on the bed with a left lower extremity laceration. Certified Nursing Assistants (CNAs) BB and CC obtained towels for bleeding, and LPN AA contacted Emergency Medical Services (EMS) 911, who then arrived to transport Resident #1 to the hospital. A hospital emergency room (ER) Services form for Resident #1 documented the resident's hospital 05/29/2015 examination for a cut leg, which was documented as a fourteen centimeter (cm) leg laceration to the fascia. This ER Services form further documented that subcutaneous closure was accomplished with 3-0 [MEDICATION NAME] sutures and the wound was closed with 4-0 Nylon sutures. This hospital ER Services form documented that on 05/29/2015 at 11:40 p.m., Resident #1 was discharged from the hospital, and a 05/30/2015, 4:10 p.m. nursing facility Progress Notes entry documented that Resident #1 had returned to the nursing facility. During an interview with LPN AA conducted on 06/23/2015 at 4:05 p.m., LPN AA stated that he/she had observed Resident #1 to have a laceration to the lower leg on 05/29/2015, and that he/she was told by the CNA that during transfer, Resident #1's leg was pulled across the metal tubing, causing the leg laceration. LPN AA stated that he/she examined Resident #1's bed rail and observed the plastic cap was not in place on the rail, and observed blood. During a 06/23/2015, 4:15 p.m. interview, CNA CC stated that on 05/29/2015, as he/she and CNA BB were transferring Resident #1 to bed, Resident #1's leg was scraped by the bed rail. CNA CC stated that he/she observed that when this incident occurred, the rail on Resident #1's bed did not have a black plug. During a 06/23/2015, 4:00 p.m. interview, CNA BB stated that at the time of Resident #1's transfer, the resident was seated in a chair and that as he/she and CNA CC manually transfered Resident #1, the resident stated Owe, my leg. CNA BB stated he/she observed blood on Resident #1's leg and skin inside the round metal tubing of the bed grab bar, further stating that the edge of the bed grab bar tubing caused Resident #1's leg injury. During a 06/23/2015, 10:35 a.m. interview, the Maintenance Director the Maintenance Director was asked about the 05/29/2015 incident involving Resident #1, and acknowledged the facility was in the process of obtaining plugs to repair bed grab bar ends. Based on the above, despite Resident #1's Care Plan identifying the resident to have an Activities of Daily Living deficit and identifying the need for assistance with transfers for an Outcome of improving the resident's current level of function, the facility failed to maintain the resident's bed rail in a safe manner, to thereby prevent injury and enable safe transfer, to allow for the maintenance of the current level of function. Cross refer to F323 for more information regarding Resident #1.",2018-07-01
5594,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2015-07-20,323,G,1,0,HZGZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, hospital emergency room (ER) Services form review, facility Resident Control-Code Status form review, and staff interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible, related to bed grab bar repair, for one (1) resident ( ) on the total suvey sample of eight (8) residents. Resident #1 sustained a fourteen centimeter (cm) leg laceration to the fascia requiring emergency room transfer and subcutaneous closure with Vicryl sutures and wound closure with Nylon sutures. Findings include: Record review for Resident #1 revealed an Admission Minimum Data Set (MDS) assessment having an Assessment Reference Date of 05/25/2015 which documented, in Section C-Cognitive Patterns, that the resident had a Brief Interview for Mental Status Summary Score of 03, thus indicating that the resident had severe cognitive impairment. Section I-Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. A Progress Notes entry for Resident #1 labeled as a Late Entry Nurse ' s Note dated 05/29/2015, and timed at 07:30 p.m., documented the following: Licensed Practical Nurse (LPN) AA was called to Resident #1 ' s room due to the resident sustaining an injury while being transferred into bed. Upon arrival to Resident #1 ' s room, the resident was observed lying on the bed with a significant laceration to the left lower extremity. Another LPN directed the certified nursing assistants (CNA BB and CNA CC ) to obtain towels to stop bleeding from Resident #1 ' s wound, and LPN AA contacted Emergency Medical Services (EMS) 911 to transport the resident to the hospital. LPN AA assisted the other LPN with the application of pressure to Resident #1 ' s left leg wound. EMS staff then arrived at the facility to transport Resident #1 to the hospital. The hospital emergency room (ER) Services form for Resident #1 documented, in the Exam Star Date/Time section, that the resident was examined in the hospital on [DATE] at 9:05 p.m. for the Chief Complaint of a cut leg. This hospital ER Services form documented that information provided by the family of Resident #1 revealed that, as nursing facility staff was putting the resident in bed, the resident sustained [REDACTED]. A notation documented in the Progress Comment section of this ER Services form documented Resident #1 to have a fourteen centimeter (cm) gapping leg laceration to the fascia. The ER Services form further documented in the Progress section that at 10:55 p.m. on 05/29/2015, anesthesia was provided to Resident #1 ' s leg wound with one percent Lidocaine, devitalized fat was removed, the wound edges were revised, subcutaneous closure was accomplished with 3-0 Vicryl sutures, and the wound was closed with 4-0 Nylon sutures. The Disposition section of this hospital ER Services form documented that on 05/29/2015 at 11:40 p.m., the decision was made to discharge Resident #1 from the hospital, and the ER Aftercare Instructions documented that discharge care instructions for Resident #1 had been provided by hospital staff to nursing facility staff regarding the resident ' s leg laceration. A nursing facility Progress Notes entry labeled as an eMAR Medication Administration Note, dated 05/30/2015 and timed at 4:10 p.m., then documented that Resident #1 had returned to the nursing facility. The (MONTH) (YEAR) Medication Review Report for Resident #1 documented a physician's order [REDACTED]. A subsequent Progress Notes entry for Resident #1 dated 06/03/2015, timed at 4:22 p.m., and labeled as a Skin/Wound Note, documented the resident's sutures to remain intact at that time. During an interview with CNA CC (who, along with CNA BB, transferred Resident #1 on 05/29/2015 at the time the resident sustained [REDACTED].#1 to bed. CNA CC stated that as he/she and CNA BB transferred Resident #1 to the bed, the resident's leg was scraped by the rail on the bed. CNA CC further stated that he/she observed that at the time of the incident, the rail on Resident #1's bed did not have a black plug in place. During an interview with CNA BB conducted on 06/23/2015 at 4:00 p.m., CNA BB acknowledged that he/she assisted CNA CC to transfer Resident #1 on 05/29/2015. CNA BB stated that at the time of the transfer, Resident #1 was seated in a chair near the bed. CNA BB stated that he/she assisted CNA CC to manually transfer Resident #1, and then as Resident #1 was in the seated position in the bed, the resident stated Owe, my leg. CNA BB stated that he/she observed a lot of blood on Resident #1's leg and notified the licensed nurse. CNA BB stated that at that time, he/she observed a portion of Resident #1's skin inside the round metal tubing of the bed grab bar, and that the edge of the bed grab bar tubing caused Resident #1's leg injury. CNA BB stated that the day after the 05/29/2015 incident during which Resident #1 sustained the leg laceration during transfer, this CNA observed that the end of the grab bar tubing (inside of which he/she observed Resident #1's skin after the transfer to bed) had been covered with tape. CNA BB then stated that two days after the Resident #1's incident and leg laceration of 05/29/2015, the CNA observed that a plug had been placed in the end of the grab bar tubing on Resident #1's bed. During an interview with LPN AA (who assessed Resident #1 upon discovery of the resident's left leg laceration, as documented in the 05/29/2015, 07:30 p.m. Progress Notes entry referenced above) conducted on 06/23/2015 at 4:05 p.m., LPN AA stated that CNA BB came to the nursing station and informed the LPN that Resident #1 had a severe leg injury. LPN AA stated he/she went to Resident #1's room and observed the resident lying in bed and having a severe laceration to the lower leg. LPN AA stated he/she placed towels on Resident #1's leg to stop the bleeding and called EMS. LPN AA stated he/she was told by the CNA that during transfer, Resident #1's leg was pulled across the metal tubing which caused the leg laceration. LPN AA stated that at that time, he/she examined the bed rail on the bed of Resident #1 and noted that the plastic cap (plug) was not in place on the bed rail, and observed blood all over the area. LPN AA further stated that he/she then taped the end of the metal rail on Resident #1's bed with gauze and tape so that the metal would not be exposed. During an interview conducted on 06/23/2015 at 9:50 a.m., the Maintenance Director stated that he/she had ordered the plugs to repair the bed rails/grab bars. A quote sheet dated (MONTH) 9, (YEAR) documented a quote for five (5) sets of Assist Rail Plug Kits (with each Kit containing 10 Plugs). During an interview with the Maintenance Director conducted on 06/23/2015 at 10:35 a.m., the Maintenance Director was asked about the 05/29/2015 incident during which Resident #1 sustained the left leg laceration. The Maintenance Director stated he/she was unaware of any past resident injuries resulting from beds/rails, but acknowledged that the facility was in the process of obtaining Assist Rail Plugs to install in the bed grab bar ends. Review of a Resident Control-Code Status form dated 6/23/15 revealed a list of rooms throughout the facility, and documented forty-nine (49) highlighted beds that were electric which had been repaired with padding or plugs. During a subsequent observation conducted on 06/23/2015 at 7:45 p.m. with the Assistant Maintenance Director and the Director of Nursing in attendance, forty nine (49) beds having grab bar rails had been repaired.",2018-07-01
7711,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2012-08-02,322,D,0,1,26UW11,"Based on observation, record review and staff interview the facility failed to follow their policy for checking placement of a Percutaneous Endoscopic Gastrostomy (PEG) tube and the presence of residual gastric content before administering medications for one (1) resident, #84 during medication pass. This had the potential to affect two (2) residents currently receiving enteral feedings. The facility's total census was 98. Findings include: During the medication pass on 8/01/12 at 8:22 a.m. Licensed Practical Nurse (LPN) AA was observed administering medications to resident #84 through a PEG tube. Prior to administering the medication the nurse poured approximately ten to fifteen milliliters (10-15ml) of water into a syringe connected to the PEG tube, and using the plunger, pushed it into the abdomen while listening with her stethoscope for correct tube placement. LPN AA then administered three (3) medications, flushing each with 15 ml of water. Interview with the Director of Nursing (DON) on 08/01/12 at 9:35 am revealed that when checking for tube placement the LPN should auscultate by listening while pushing air and not water into the tube. She further revealed that the LPN should also first aspirate for stomach contents before administering anything through the tube. Review of the current Physician Orders for August 2012 revealed the resident's tube placement was to be checked prior to administering anything through the tube, and gastric residuals should be checked and reported to the Physician if greater than sixty milliliters (60 ml) every shift. Review of the facility policy on Medication Administration revealed PEG tube placement is checked with 15-20 ml of air, not water. LPN AA was interviewed on 8/01/12 at 12:50 p.m. and stated she did not use the correct technique for checking placement of the peg tube and also did not check for residual stomach contents.",2016-12-01
7712,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2012-08-02,371,E,0,1,26UW11,Based on observation and staff interview the facility failed to ensure that the temperatures of all food items held on the kitchen steam table were at or above the level necessary to prevent potential food borne illnesses. This affected all residents on oral alimentation (census = 98). Findings include: A check of temperatures of food items being served to residents at the lunch meal on 8/01/12 at 12:10 p.m. revealed that a pan of meat loaf was being held on the steam table at one hundred and twenty-three degrees Fahrenheit (123 F). This temperature was not at a level high enough to prevent a possible foodborne illness. The temperature check was made by the Food Service Director (FSD) using a calibrated facility-supplied thermometer. The FSD confirmed at the time of the finding that this food item should have been held at or above the minimum standard of one hundred and thirty five degrees Fahrenheit (135 degrees F).,2016-12-01
8600,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2012-12-17,309,D,1,0,975211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to identify and provide wound care for one (1) resident, resident #4, from a sample of seven (7) residents. Findings include: After an observation of incontinence care on 12/11/2012 at 2:00 p.m. with CNAs DD and CC, a wound was observed on the resident's upper left foot that had a small amount of slough noted over the wound measuring approximately 1.5 x 1 x 0 centimeters. There was also a very small abrasion observed on the right shin, measuring 0.8 x 0.4 centimeters that had a small dark scab. During an interview with the two bath aides LL and MM on 12/11/2012 at 2:20 p.m., both stated they had showered the resident on 12/10/2012 as well as on 12/11/2012 and had not noted any skin breakdown. During further observation and interview with the treatment nurse GG at 3:00 p.m. on 12/11/2012, stated no one had made her aware of the wounds. During interview with the resident's physician on 12/11/2012 at 3:25 p.m., who stated the wound looked like a surface area abrasion that was not caused from pressure. He confirmed the wound with the scabbed area was not a new wound. The physician then gave new orders on 12/11/2012 that resulted from his observation of the two wounds, one on the left foot and one on the right shin, to cleanse both areas with normal saline, apply Bactracin ointment, and cover with a band aide every day until healed. Review of resident #4's medical record indicated the resident had [DIAGNOSES REDACTED]. During an observation on 12/17/2012 at 10:20 a.m. of resident's #4 's foot with the treatment nurse S , the date observed on the band aide in place over the wound of the left foot indicated it was changed on 12/14/2012. Observation of the wound under the band aide revealed the area had lessened in size from the previous observation of 12/11/2012, although the open area still had a small amount of slough on it. The treatment nurse stated she had not been on duty 12/15/2012 and 12/16/2012; but she would have expected the band aide to the wounds to have been changed every day. She confirmed the date was 12/14/2012 on the band aide on the foot wound. There was also no dressing /band aide observed on the less than one (1) centimeter scabbed wound on the shin. During an interview with LPN BB on 12/17/2012 at 12:45 p.m., she stated she had gotten confused and thought the wounds were both on one leg and had healed so she charted the wound as healed and just treated the other leg. Review of the Treatment Administration Record indicated that LPN BB had initialed that she had treated both the wounds on 12/15/2012 and 12/16/2012. Review of the nursing notes dated 12/15/2012 indicated that LPN BB documented the area as healed. The wound on the foot was dated as last being changed on 12/14/2012 and there was no dressing observed on the other wound area on the shin, and based on documentation the wound had been documented as healed on the 12/15/2012. Thus, there had been a 2 and 3 day delay in wound treatment being provided as ordered to the open areas.",2015-12-01
9480,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2011-03-30,279,D,0,1,R60011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to develop a care plan for one (1) resident (#82) on a sample of thirty (30) residents that was on [MEDICAL CONDITION] medications. Findings include: Review of the medical record for resident # 82 revealed there was physician's orders [REDACTED]. Review of most recent Minimal Data Set (MDS) assessment dated [DATE] assessed the resident as having had a antianxiety medication in the past 7 days of the MDS assessment. Review of the Care Area Assessment (CAA) documented the resident should be care planned for the [MEDICAL CONDITION] medication, however there was no evidence of a care plan being developed related to antianxiety medication. Interview with the MDS nurse (""AA"") on 3/29/11 at 2:38 p.m. revealed the MDS 3.0 does direct them to develop a care plan for [MEDICAL CONDITION] medications but revealed that it was not done for this resident.",2015-06-01
9481,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2011-03-30,333,D,0,1,R60011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and resident interview the facility failed to ensure that one (1) resident (""D"") on a sample of thirty (30) residents was free from a significant medication error. The error concerned receipt of a medication that the resident was known to have an allergy. Findings include: Review of the Minimal Data Set (MDS) assessment revealed resident ""D"" had minimal problems with memory recall. During an interview conducted on 3/29/11 at 8:15 a.m. the resident was able to answer questions appropriately. Review of the resident's printed monthly Physician order [REDACTED]. Record review revealed a Nurses Notes dated 10/29/10 at 11:24 a.m. documented the resident had a productive cough. A Nurses Note dated 10/29 at 6:37 p.m. documented the facility received a physician's telephone order for this resident to receive [MEDICATION NAME] 500 mg three (3) times daily for 10 days to treat an upper respiratory infection. Interview with the resident on 3/30/11 at 8:05 a.m. revealed when he/she had taken [MEDICATION NAME]'s in the past he/she would have a smothering feeling and a feeling of shortness of breath. The resident did remember having a respiratory infection but did not recall having increased shortness of breath when she/he received the [MEDICATION NAME]. Review of the Medication Administration Record [REDACTED]. Interview with the Director of Nursing (DON) on 3/29/11 at 4:12 p.m. confirmed the resident received the [MEDICATION NAME] and that there was documentation in the clinical record of the resident having an allergy to [MEDICATION NAME] drugs. Interview with the resident's physician 3/30/11 at 9:42 a.m. revealed that he was unaware the resident had an allergy to [MEDICATION NAME] drugs and was he informed of an allergy when he ordered the [MEDICATION NAME] on 10/29/10.",2015-06-01
9482,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2011-03-30,468,E,0,1,R60011,Based on observation and interview the facility failed to provide secure handrails on each sides of all corridors. This affected all ambulatory residents in the facility (census = 98). Findings include: An observation of the facility during a random tour of the facility on 3/28/11 at 9:15 a.m. revealed that the corridor on hallway C did not have handrails except for a small section located across from the facility's beauty shop. Further observation revealed that there were no handrails along the short corridor leading from the entrance foyer to hallway C. This observation was confirmed in an interview with the facility's Administrator on 3/30/11 at 8:15 a.m.,2015-06-01
9696,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2012-01-04,272,D,1,0,SDOR11,"Based on record review and staff interview, the facility failed to assess the use of a geri-chair for one (1) resident (#1) of twenty-one (21) sampled residents. Findings include: During an observation in the room of Resident #1 conducted on 10/27/2011 at 9:30 a.m., a geri-chair with a cushion was observed. Review of the medical record for Resident #1 revealed a 04/05/2011 plan of care entry for Activities of Daily Living which indicated that the resident required the extensive assistance of one person for bed mobility and the extensive assistance of two persons for transfers. Additionally, a 04/05/2011 plan of care entry documented the resident as having a fall-risk, with an Intervention being the use of a wheelchair. However, further record review revealed no evidence of an assessment for the use of a geri-chair for Resident #1 to determine if the geri-chair would be a restraint or an enabler for this resident, and to determine if the use of the geri-chair would be safe for the resident. During an interview with the Administrator conducted on 10/27/2011 at 9:20 a.m., the Administrator stated that the resident used both a wheelchair and a geri-chair, according to how she was evaluated for each day. However, the Administrator acknowledged that there was no documented assessment for the use of the geri-chair. During an interview with the Director of Nursing (DON) conducted on 10/27/2011 at 1:05 p.m., the DON stated that Resident #1 would be evaluated daily in order for staff to decide what chair to put her in, either the wheelchair or geri-chair. The DON acknowledged that there was no documentation regarding an assessment for the use of the geri-chair. During an interview with the Minimum Data Sets/Care Plan Director on 10/27/2011 at 2:30 p.m., this staff person stated that she had observed the resident up in a geri-chair for at least 2 - 3 weeks.",2015-05-01
10525,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2009-11-11,332,E,,,TBSG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and record reviews, it was determined that for two (2) of the eight (8) residents observed the facility failed to ensure a medication error rate that was less than 5%. Two (2) of four (4) nurses observed during forty-six (46) opportunities made three (3) errors resulting in a medication error rate of 6.25%. Findings include: During the morning medication pass on 11/10/09 the following errors were observed: 1. A resident on the B 1 Hall was given his medications at 8:45 a.m. Record review for this resident revealed current physician orders [REDACTED]. 2. A resident on the B 2 Hall was given his medications at 8:55 a.m. and an antihypertensive medication, [MEDICATION NAME] was included. The medications were given with water. Review of the current physician's orders [REDACTED]. 3. The same resident on the B 2 Hall was given an anticonvulsant medication, [MEDICATION NAME], 200 milligrams at 8:55 a.m. Review of the current physician's orders [REDACTED].",2014-04-01
10526,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2009-11-11,441,F,,,TBSG11,"Based on observation and staff interview the facility failed to ensure for a resident census of one hundred and one (101) that linen was handled in a manner to prevent development or transmission of infection. On 11//10/09 at 10:20 a.m. observations of the laundry room revealed the following: The Housekeeping Supervisor (HS) and the Floor Technician (FT) were observed folding clean linen. The clean sheets were observed to touch the floor, the employees clothing and the employee chin, face, nose and body. Employees HS and FT were observed to handle soiled linen wearing no clothing protectors and only disposable gloves. Personal drink containers were observed on the folding table. Interview at that time with HS revealed they have to work in the laundry a couple of times a week. During a second observation on 11/11/09 at 8:50 a.m. the Housekeeping Supervisor, Floor Technician and a Housekeeper were observed in the laundry folding linen and the linen was again observed to touch the floor. Review of the facility protocol The Laundry Process , 6-15 1/1/2000, section: Transferring Soiled Linen, third paragraph instructs that personal protective equipment is to be used when handling laundry.",2014-04-01
10527,"BELL MINOR HOME, THE",115020,2200 OLD HAMILTON PLACE NE,GAINESVILLE,GA,30507,2009-11-11,253,B,,,TBSG11,"Based on observation and staff interview the facility failed to ensure for one (1) of two (2) common bathing areas (B Hall), and for two (2) of twelve (12) rooms observed that the environment was clean and not in need of repairs. Findings include: During environment observations on 11/10/09 at 11:25 a.m. the following was observed: 1. A build up of black mold was observed around the edges of the showers and wall in the common bathing areas on B Hall. Two (2) broken tiles were observed in the shower area. 2. Two (2) air conditioner/heater units in rooms B-23 and B-24 had broken control panel covers. On 11/11/09, accompanied by the Maintenance Director and Housekeeping Director, the common bathing area on B Hall was observed. The black mold in the first shower had been partially removed but the other shower, tub and sink area continued to have black mold and only one (1) of two (2) broken tiles had been repaired.",2014-04-01
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
4320,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2016-12-08,469,F,1,0,OO2Z11,"> Based on observation, staff interview, contracted pest control services interview and record review, the facility failed to maintain an effective pest control program that effectively sealed 10 of 13 doors leading directly outside which allowed the potential for insects and rodents to enter the facility. The investigation was part of a complaint allegation that the facility had roaches and rats in the resident rooms and the potential to affect all the residents within the facilty. Facility reported census of 95 (MONTH) 5, (YEAR). Findings include: On 10/7/16 at 11:30 AM, CNA (Certified Nursing Assistant) EE stated during an interview, I work nights and I just saw a roach the other night in the hallway. If we see any insects or rats, we tell maintenance and they take care of it. I have seen rat droppings in the closets and cockroaches in the halls and the resident rooms at least once a month. On 12/8/16 at 9:45 AM, a cockroach scurrying along a baseboard in the West Wing hall, close to Room 145 and the service hallway was observed. On 12/8/16 at 11:15 AM, during a tour with the Maintenance Supervisor DD, an observation of all the exterior doors leading directly to the outside areas, revealed 10 of 13 doors had a space at the threshold large enough for sunlight to shine through and for insects and rodents to enter the building. An interview, at this time, the Maintenance Supervisor DD indicated, (Local pest control service) comes out once a month to spray for insects, including roaches and ants, once a month. When I get work orders that insects or rodents have been seen, I call them and they come and spray again. I would say I get 2 work orders a month on average. If mice are seen, I put non-toxic wafers in the areas that they have been seen and (local pest control service) comes and places traps around the outside of the building. The doors need shims under the thresholds and door sweeps for a good seal. On 12/8/16 at 11:40 AM, a telephone interview with the pest control service technician that the facility used for pest control since 2/12/13 was conducted. The pest control technician indicated he was familiar with the facility. He indicated that the facility had called only once in the last year to ask for a second service call (other than the monthly service) and that was for ants in (MONTH) of (YEAR). The technician could not remember specifically if the facility had been told about fixing possible entry points for pests when the facility service began but usually the first service call involved a complete inspection and recommendations for prevention of pests. On 12/8/16 at 11:55 AM, during an interview, the Maintenance Supervisor DD indicated, I don ' t remember if (local pest control service) pointed out any entry points or made any recommendations related to the exterior doors. A review of the facility pest control records revealed the facility has had pest activity on a regular basis involving ants and cockroaches. None of the invoices for the past year indicated that entry points should be resolved.",2019-11-01
6223,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2014-01-16,225,D,0,1,W90O11,"Based on staff interview and record review it was determined the facility failed to report a written allegation of abuse timely to the State Agency for one (1) resident (B) from a total sample of twenty three (23) residents. Findings include: An interview on 1/13/14 at 1:25 p.m. with a family member of resident B revealed that a written allegation of abuse had been submitted to the administrator during a meeting on 12/23/13. The administrator confirmed during an interview on 1/14/14 at 4:10 p.m. that the family had submitted a complaint in writing on 12/23/13. A review of the written complaint revealed allegations of abuse included in the complaint. However, there was no evidence the facility had reported the allegations of abuse to the State Agency until 1/10/14.",2018-02-01
6224,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2014-01-16,244,D,0,1,W90O11,"Based on resident interviews, staff interviews and record reviews, the facility failed to respond to grievances voiced by the resident council members, average of twenty (20) resident per monthly meeting. Findings include: An interview on 1/14/14 at 2:35 p.m. with resident A reveals that the facility staff does not respond to the concerns of the resident council. He/she stated that the previous staff member who assisted with the resident council meetings always wrote up the concerns during the meeting and went over them with him and had him sign the form. He further stated that process was no longer being done. An interview on 1/15/14 at 8:00 a.m. with the dietary manager revealed that when there was a grievance/concern from the resident council, she either was in attendance or it was given to her in a written form. She further revealed that she would discuss the concern with the Activity director (AD) and then determine if it was a legitimate concern. She stated that when she determined what needed to be done about the concern, she wrote a response on the concern form so the Resident Council could be informed. An interview on 1/16/14 at 8:35 a.m. with the Activity Director revealed that when she received concerns from the resident council she filled out the concern form for the other departments and gave copies to the appropriate departments, the administrator and the social service director. She stated that she reviewed the response with the residents at the next resident council meetings. She further stated that she did not always go back and make sure she had a response from the appropriate department before the next meeting. A review of the resident council minutes dated 6/24/13 revealed that the residents had requested hot dogs. The minutes reflected that the Activity director would write the concern and wait on a response. The 7/1/13 minutes listed that the council was still waiting on response about the hot dogs. A review of all the minutes for the remaining months in 2013, failed to reveal a response about the hot dogs. A review of the Resident Council minutes dated 11/18/13 revealed that the residents had complaints of missing silverware on their meal trays, special silver ware missing for one (1) resident, a request for pancakes on Sundays, complaints of pork chops being too hard. However there was no follow up for these concerns until the next meeting on 12/2/13 when the residents complained again.",2018-02-01
6225,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2014-01-16,280,D,0,1,W90O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews the facility failed to revise the care plan for one (1) resident (#99) with a history of falls from a total sample of twenty three (23) residents. Findings include: Review of the clinical record for resident #99 revealed that a significant change assessment dated [DATE] listed the resident had a history of [REDACTED]. The interventions included use of safety precautions, encouraged to wear proper footwear, remind to use call light, winged mattress, bed in low position, tab sensor while in wheelchair, bed alarm while in bed, mat on floor beside bed. Review of the nurse's notes dated 1/1/14 at 1945 revealed that the resident was found sitting on the floor in an empty resident room. The nurse's notes dated 1/5/14 at 2:45 p.m., revealed that the resident was found on the floor in front of the wheelchair. An interview with Licensed Practical Nurse (LPN) AA, on 1/15/14 at 3:00 p.m., revealed that anytime a resident had a fall, the LPN should revise the care plan at that time, and that the facility staff would discuss the resident at the next interdisciplinary team ( IDT) meeting that was held daily. She further stated that if a fall occurred on the weekend, it would be discussed on Monday but new interventions should have been put in place immediately. The nurse reviewed her IDT meeting notes for the 1/1/14 fall and revealed that the plan was to revised the care plan to reflect educating staff to check the sensor tabs and she reviewed the IDT notes for the 1/5/12 fall which was discussed, however a review of the care plan did not reveal the revision or an update to prevent further falls.",2018-02-01
6226,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2014-01-16,282,D,0,1,W90O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews, it was determined that the facility failed to implement the care plan for one (1) resident (#99) with a history of falls and for one (1)resident (B) who was dependent on transfer from total sample of twenty three (23) residents. Findings include: 1. Review of the Minimum Data Set (MDS) Significant Change Assessment, of 12/27/13, for resident #99 revealed the resident had a history of [REDACTED]. The interventions included the use of safety precautions, resident was encouraged to wear proper footwear, reminded to use call light, use of a winged mattress, keep bed in the low position, tab sensor while in wheelchair, bed alarm while in bed, mat on floor beside bed. However observations on 1/13/14 at 1:10 p.m., 1/15/14 at 7:45 a.m. and 2:10 p.m. of the resident in the bed although there was no winged mattress on the resident's bed. 2. Record review of Resident B 9/23/13 Quarterly Minimum Data Set (MDS) revealed the resident is assessed as being dependent for transfers and nonambulatory. Review of the resident's care plan revealed there was a care plan intervention since 3/25/13 for staff to use a Hoyer lift during transfers. However, a review of the resident's clinical record, Physician Communication Sheets and additional facility documentation revealed that nursing staff had inappropriately transferred the resident, without the use of the Hoyer lift, on 11/12/13 and 12/19/13. The resident sustained [REDACTED]. Cross refer to F323",2018-02-01
6227,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2014-01-16,323,D,0,1,W90O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record reviews, the facility failed to prevent one (1) resident from falls from the wheelchair ( #99) and failed to correctly transfer one (1) resident (B) using a Hoya lift of twenty three (23) sampled residents. Findings include: Review of resident (#99) medical record revealed that the resident had a [DIAGNOSES REDACTED]. The resident was assessed on the 12/27/13 Significant Change Minimum data set as requiring total assistance with transfers and mobility. A review of the nurse's notes revealed that the resident had a fall from the wheelchair to the floor on 1/1/14 and 1/5/14. An interview with the Director of Nurses (DON) on 1/15/14 at 2:10 p.m., revealed that although the facility had identified on 1/2/14 that there was a fall problem in the facility, the staff had not identified the actual residents who were at high risk for falls. An interview with Licensed Practical Nurse AA, on 1/15/14 at 3:00 p.m. revealed that anytime a resident had a fall, the LPN's should revise the care plan at that time, and that the facility staff would discuss the resident at the next interdisciplinary team (IDT) meeting that was held daily Monday thru Friday. She further stated that if a fall occurred on the weekend, it would be discussed on Monday but that new interventions should have been put in place immediately. The nurse reviewed her IDT meeting notes which revealed the resident's 1/1/14 fall had been discussed and it was listed that the LPN should revised the care plan to educate staff to check the sensor tabs, however a review of the care plan did not reveal the revision. She confirmed that the 1/5/14 fall had been reviewed in the IDT meeting but that no new interventions had been put into place after the meeting to prevent future falls. Resident B had [DIAGNOSES REDACTED]. The resident was assessed on the 9/23/13 Quarterly Minimum Data Set (MDS) as being dependent for transfers and nonambulatory. The facility had identified the resident as being at risk for falls and there was a care plan intervention in place since 3/25/13 for staff to use a Hoyer lift during transfers. However, a review of the resident's clinical record, Physician Communication Sheets and additional facility documentation revealed that nursing staff had inappropriately transferred the resident without the use of the Hoyer lift on 11/12/13 and 12/19/13. The resident sustained [REDACTED]. Record review of facility investigative interview conducted on 12/20/13 with Certified Nursing Assistant (CNA) DD revealed that on 12/19/13 she was asked by CNA CC to assist with the transfer from the bed to the chair. CNA DD revealed that CNA CC had collected two (2) Hoyer pads for the transfer although upon entrance to the resident's room found that no Hoyer lift was present and that the resident was transferred without using the lift. An interview on 1/16/14 at 10:25 a.m. with the Risk Management nurse revealed that CNA's CC and DD) did not use the Hoyer lift during the 12/19/13 transfer because she was unable to position the Hoyer lift correctly or get it to roll correctly. Therefore, the CNA CC chose to manually lift the resident during a transfer from the bed to a chair. However, there was no evidence that CNA CC reported this concern with the Hoyer lift to LPN to ensure that the alternate method of transfer was appropriate and safe prior to transferring the resident.",2018-02-01
6228,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2014-01-16,328,D,0,1,W90O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation and staff interviews the facility failed to properly store respiratory equipment in two (2) resident's rooms on two (2) wings (wing one (1) and five (5)) of seven (7) wings and from a total of eighteen (18) residents receiving respiratory care. Findings include: A random observation on 1/13/14 at 3:10 p.m. of room [ROOM NUMBER] A on wing one (1) revealed an oxygen high flow nebulizer mask which was laying on bedside table uncovered. A random observation on 1/14/13 at 8:00 a.m. of room [ROOM NUMBER] A on wing one (1) revealed an oxygen nasal cannula tubing laying draped over the oxygen concentrator and the oxygen nasal cannula tubing nose prongs were observed resting on the floor. A random observation on 1/13/14 at 10:15 a.m. of room [ROOM NUMBER] A on wing five (5) revealed the nebulizer mask was sitting on top of nebulizer machine uncovered. A random observation on 1/13/14 at 12:59 p.m. of room [ROOM NUMBER] A on wing five (5) revealed the nebulizer mask was sitting on top of nebulizer machine uncovered. An interview on 1/16/14 at 10:26 a.m. with the Director of Nursing revealed that her expectations are that any oxygen tubing or High Flow Nebulizer masks are to bagged when not in use. An interview with Licensed Practical Nurse (LPN) on 1/16/14 at 10:10 a.m. revealed that the facility changes oxygen/nebulizer tubing weekly and as needed, She revealed that oxygen tubing and nebulizer masks that are in residents rooms and should be bagged if not in use.",2018-02-01
7177,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2014-07-02,323,E,1,0,5LW611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to complete assessments for the safe use of side rails for four (4) residents of eleven (11) residents on the sample. Findings include: Resident number (#1) Resident number one (#1), was admitted on [DATE] after a fall at home which had resulted in multiple contusions to her face, a large subcutaneous hematoma and a left distal radius fracture. [DIAGNOSES REDACTED]. Her admission Minimum Data Set (MDS)assessment for 06/18/2014 revealed the resident with a Brief Interview for Mental Status (BIMS) score of 04. She required extensive assistance of two persons for bed mobility and transfers. Her Interim plan of care(POC)approaches for fall risk, included assistive devices as needed and a Side Rail/ Restraint Reduction Committee Recommendation for one side rail for bed mobility. Interviews with the risk manager on 07/03/2014 at 9:50 AM and certified nursing assistant (CNA) AA at 10:05 AM revealed there had been an incident on June 12 th involving the resident and the bed rails. Per AA the resident was seen laying sideways in the bed, with her feet against the wall and her head up to her ears through the siderail of the bed. No injuries were reported. Record review revealed an incomplete Evaluation for use of Side Rails form signed by an RN and dated 06/06/2014. Resident number three (#3) Record review revealed resident number three (#3) was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident received medications including (but not limited to) lasix and celexa. Her quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status score of 03. She required extensive assistance of two people with bed mobility and was totally dependent with two people assistance for transfers. The resident's plan of care included potential for injury due to side rail use and additional information of four quarter rails to the bed. Observations on 07/02/2014 at 11:30 AM and 07/03/2014 at 9:20 AM revealed the resident lying in bed with both upper and lower side rails engaged. Record review for resident #3 revealed an incomplete Evaluation for use of side rails dated 10/03/2013. Resident number seven (#7) Record review for resident #7 revealed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Medications included (but were not limited to): lasix 20 milligrams daily as needed. His MDS annual assessment dated [DATE] revealed the resident with a BIMS score of 07. He required extensive assistance of one person for bed mobility and transfers. Review of the plan of care revealed approaches for self care deficit included one side rail for bed mobility and a Side Rail/ Restraint Reduction Committee Recommendation for one side rail for bed mobility. Interview and observation made on 07/03/2014 at 11:40 AM revealed the resident's bed with one rail, of the long type centered on the side of the bed, engaged on the left-hand side of the bed. The resident revealed he used it for bed mobility. Record review failed to reveal an Evaluation for use of Side Rails. Resident number eight (#8) Record review for resident #8 revealed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. His annual MDS assessment dated [DATE] revealed a BIMS score of 05. Resident was totally dependent with two person assist for bed mobility and transfers. Review of the plan of care for self care deficit revealed padded side rails as indicated and a Side Rail/ Restraint Reduction Committee Recommendations of two padded side rails. Observation of resident's bed made on 07/02/2014 at 3:35 PM and 07/03/2014 at 11:45 AM revealed the bed up against the wall with the one side rail, of the long type centered on the side of the bed, engaged against the wall. An interview with CNA on 07/03/2014 at 2:35 PM revealed when the resident was put to bed the front side rail was engaged. Record review for this resident failed to reveal an Evaluation for use of side rails. Interviews with the DON on 07/03/2014 at 1:15 PM, 1:55 PM and 2:30 PM revealed that the Evaluation for use of Side Rails should be completed on admission and if there was a change. It should be completed front and back. The form was usually completed by the unit manager or Minimum Data Set (MDS) Coordinator. Incomplete and/or missing Evaluations for use of side rails were reviewed with the DON for residents #1, resident #3, resident #7 and resident #8. The DON was unable to locate any further information on the side rail evaluation for these residents. Neither could she locate a facility policy directing the use of the evaluation for side rails.",2017-07-01
7608,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2012-04-19,280,D,0,1,6IBP11,"Based on observations, staff interviews and record reviews, it was determined that the facility failed to revise the care plan for one resident (A) to include interventions to prevent further bruising and skin tears, from a total sample of 31 residents. Findings include: Resident A had a care plan initially dated 9/23/11, and reviewed on 12/13/11, 2/18/12, and 3/6/12, to address his/her potential for impaired skin integrity because of a decrease in sensation and circulation and fragile skin. The care plan had documented entries on 11/2412, 1/17/12, 1/22/12 and 2/23/12 of the resident having had skin tears. On 4/17/12 at 10:31 a.m., the resident was observed with bluish/red discolorations on his/her arms and hands. There was a dark, bluish bruise on his/her left hand between the thumb and index finger. On 4/18/12 at 9:00 a.m., the resident was observed with several small bruised areas on his/her arms and a larger bruised area on his/her left elbow. Although there were interventions for nursing staff to provide treatment to skin impairments as prescribed, monitor the effectiveness and take action as indicated, the plan had not been revised to address the possible use of personal and environmental protective devices to prevent the recurrences of bruises and skin tears. See F323 for additional information regarding resident A.",2017-02-01
7609,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2012-04-19,323,D,0,1,6IBP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews with staff and a family member, and record review, it was determined that the facility failed to monitor the effectiveness of planned interventions and implement personal and environmental interventions to address one resident's (A) recurrent bruises and skin tears in a total sample of 31 residents. Findings include: Resident A had [DIAGNOSES REDACTED]. He/She had a care plan initially dated 9/23/11 and reviewed on 12/13/11, 2/18/12, and 3/6/12, to address his/her potential for impaired skin integrity because of a decrease in sensation and circulation and fragile skin. The care plan had documented entries on 11/2412, 1/17/12, 1/22/12 and 2/23/12 of the resident having had skin tears. Resident A was observed on 4/17/12 at 10:31 a.m. with bluish/red discolorations on both of his/her arms and hands. A dark bluish bruise was observed on his/her left hand between the thumb and index finger. At that time, the resident was in bed. The 1/4 top metal side rails were raised and the head of the bed was elevated. There were not any protective devices on the side rails or on the resident's upper extremities. On 4/18/12 at 9:00 a.m., the resident was observed in bed. Observations with a certified nursing assistant (CNA) revealed that there were several small bruised areas on both of his/her arms and, a larger bruised area on his/her left elbow. There was a dark, bluish area on his/her left hand. There were not any protective devices on the side rails or on the resident's upper extremities. There was a 4/6/12 skin assessment completed by a licensed nurse with documentation that the resident had scattered old bruises and discoloration of both arms. The 4/13/12 skin assessment documented that the resident had scattered old bruises and discolorations to both arms. During an interview on 4/17/12 at 10:31 a.m., the family member of resident A said that the resident had a history of [REDACTED]. He/She stated that the resident's skin was thin and bruised very easily. During an interview on 4/19/12 at 11:15 a.m., the registered nurse (RN) CC stated that geri-sleeves had been used at times with the resident, although the resident was not wearing them at the time. She stated that skin assessments were also completed by the CNAs who gave the resident a bath. A review of the body diagram on the Skin Observation tool, that was completed by a CNA on 3/27/12, revealed numerous circled areas on the diagram on both arms that were noted as bruises. There was no documentation that there were any skin impairments on the resident's hands. On 4/3/12, 4/5/12 and 4/12/12, the CNAs had circled both arms on the resident's body diagram and noted the areas as old bruises. On 4/17/12, both of the resident's arms were circled on the body diagram and noted as bruises. The RN was not able to determine when the bruises documented as old bruises had occurred. During an interview on 4/19/12 at 11:45 a.m., the Risk Management RN KK stated that she had tracked all of the resident's skin tears. On 1/17/12, staff documented that the resident had been combative with staff during care and had obtained a 2 x 1.3 centimeter (cm) skin tear on the top of his/her hand. On 1/22/12, staff documented that the resident had obtained a skin tear on his/her elbow when it bumped the side rail. On 2/23/12, staff documented that the resident was combative during care and obtained a 1.3 x 1.2 cm skin tear on his/her left elbow. On 4/19/12 at 11:00 a.m., the resident was sitting up in a wheelchair in the day room. He/She had on a short sleeved shirt. There were numerous bruises on both of his/her arms and hands. Although there were interventions for nursing staff to provide treatment to skin impairments as prescribed, monitor the effectiveness and take action as indicated, the plan had not been revised to address interventions for the use of personal and environmental protective devices to prevent the recurrences of bruises and skin tears. There was no documentation in the clinical record about the staff having used geri-sleeves on the resident for protection.",2017-02-01
7610,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2012-04-19,371,F,0,1,6IBP11,"Based on observation and staff interview, it was determined that the facility had failed to ensure that all food items in the kitchen's coolers and freezers were not expired and/or labeled and dated as to when they were opened, failed to store pot lids appropriately, and failed to maintain food at the correct holding temperatures on the steam table for one meal. Findings include: The following observations were made on 4/16/12 at 10:15 a.m.: 1. There were three plastic cups that contained brown and wilted lettuce in the reach-in cooler. The cups were not dated or labeled with the contents or date prepared. 2. There was one carton of milk with an expiration date of 3/26/12. 3. There were five sealed packages of pancakes and five sealed packages of french toast sticks in the walk-in freezer. The packages were not in their original boxes and were not labeled with an expiration or use by date. 4. There was a plastic bin of clean metal pot lids on the lower shelf of the preparation table across from the stove. There was a pair of soiled oven mitts laying on top of those clean pot lids. During an observation of lunch service and steam table temperatures on 4/18/12 at 11:20 a.m., the whole pieces of fried beef patties were being held at 120 degrees Fahrenheit (F.). The chopped beef patties were being held at 118 degrees F. A review of the dietary staff's temperature log documentation of the food items on the steam table prior to service revealed no recorded temperatures for the whole fried beef patties or chopped beef patties. Dietary staff LL stated that he/she checked the temperature of the meat after it was removed from the fryer but, did not check it once it was put on the steam table. Ten plates with the fried beef patties and four plates with the chopped beef patties had been assembled and placed in a serving cart.",2017-02-01
7976,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2013-07-10,309,D,1,0,XZWJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to obtain and administer medication as ordered by the physician for one resident (#2) from a total sample of twenty- three residents. Findings include: Review of the Medication Record for Resident #2 referenced a physician's orders [REDACTED]. The nursing staff documented on the Medication Record that the [MEDICATION NAME] was administered each night at 8:00 PM from April 1, 2013 until April 22, 2013 and from April 24 2013 until April 30, 2013. However, during an interview on July 9, 2013 at 3 p.m. licensed nurse AA stated the medication was not obtained and started until April 10, 2013. The [MEDICATION NAME] was initially filled by the pharmacy on April 10, 2013 for thirty (30) tablets, it was refilled on May 4, 2013 for thirty (30) tablets. If the [MEDICATION NAME] was administered each night as ordered by the Physician the sixty (60) tablets would have been completed on June 8, 2013. However, after June 8, 2013, there was no evidence the [MEDICATION NAME] was refilled. The nurses continued to document that the [MEDICATION NAME] was administered nightly at 8 PM June 9, 2013 through June 28, 2013 and June 30, 2013. The Nurses also documented on the Medication Record that [MEDICATION NAME] was administered to Resident #2 on July 1, 2013 through July 3, 2013. Interview with the Director of Nursing and Nurse AA on July 9, 2013 at 3:00 PM confirmed that the last date that the Pharmacy filled the [MEDICATION NAME] for Resident #2 was May 4, 2013. Both nurses stated that the nurses had signed the Medication Record and documented that the [MEDICATION NAME] was given though the [MEDICATION NAME] was not on the cart and was unavailable. Nurse AA added that the [MEDICATION NAME] was not a covered medication with Resident #2's insurance so his family paid for the medication. According to Nurse AA when the family did not pay for the [MEDICATION NAME] the pharmacy did not send the medication. Review of the Medication Record for Resident #2 that was dated July 2013 referenced an order to discontinue the [MEDICATION NAME] on July 4, 2013. There was no evidence the facility notified the physician of the delay in starting the [MEDICATION NAME] from April 1, 2013 until April 9, 2013 or the failure to continue to administer the [MEDICATION NAME] after June 8, 2013.",2016-07-01
7977,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2013-07-10,514,D,1,0,XZWJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate medication records for two residents (#2 and #5) of twenty three sampled residents. Findings include: 1. Review of the Medication Record for Resident #2 referenced a physician's orders [REDACTED]. The nursing staff documented on the Medication Record that the [MEDICATION NAME] was administered each night at 8:00 PM from April 1, 2013 until April 22, 2013 and from April 24 2013 until April 30, 2013. However, during an interview on July 9, 2013 at 3 p.m. licensed nurse AA stated the medication was not obtained and given until April 10, 2013. The [MEDICATION NAME] was initially filled by the pharmacy on April 10, 2013 for thirty (30) tablets, it was refilled on May 4, 2013 for thirty (30) tablets. If the [MEDICATION NAME] was administered each night as ordered by the Physician the sixty (60) tablets would have been completed on June 8, 2013. However, after June 8, 2013, there was no evidence the [MEDICATION NAME] was refilled. The nurses continued to document that the [MEDICATION NAME] was administered nightly at 8 PM June 9, 2013 through June 28, 2013 and June 30, 2013. The Nurses also documented on the Medication Record that [MEDICATION NAME] was administered to Resident #2 on July 1, 2013 through July 3, 2013. Interview with the Director of Nursing and Nurse AA on July 9, 2013 at 3:00 PM confirmed that the last date that the Pharmacy filled the [MEDICATION NAME] for Resident #2 was May 4, 2013. Both nurses stated that the nurses had signed the Medication Record and documented that the [MEDICATION NAME] was given though the [MEDICATION NAME] was not on the cart and was unavailable. Nurse AA added that the [MEDICATION NAME] was not a covered medication with Resident #2's insurance so his family paid for the medication. According to Nurse AA when the family did not pay for the [MEDICATION NAME] the pharmacy did not send the medication. 2. Review of the Medication Record and Controlled Drug Records for Resident #5 referenced a physician's orders [REDACTED]. A review of the July 2013 Medication Record revealed that licensed nursing staff documented that Resident #5 received two doses of [MEDICATION NAME] on July 2, 2013 at 12 a.m. and 8 a.m. as scheduled. However, a review of the Controlled Drug Record form for Resident #5, which documented the number of [MEDICATION NAME] tablets available on July 2, 2013 indicated that there was not a dose available for the 8 a.m. dose. Interview with the Director of Nursing on 7/10/13 at 11:45 a.m. confirmed that the Controlled Drug Record form was accurate for the number of [MEDICATION NAME] tablets available, and there would not have been a dose available for the July 2, 2013 8 a.m. scheduled administation. The licensed nursing staff inaccurately documented that an 8 a.m. dose of [MEDICATION NAME] was administered to Resident #5.",2016-07-01
9517,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2010-07-08,157,D,0,1,6GPQ11,"Based on record review and staff interview, it was determined that the facility failed to consult with the physician about one resident's (#17) vomiting and diarrhea from a total sample of 21 residents. Findings include: Licensed nursing staff documented on 1/18/10 at 8 p.m. that resident #17 vomited three times during that shift. Licensed nursing staff documented on the 1/19/10 facility's twenty four hour report at 6 a.m. that the resident had four episodes of diarrhea. The nurse's notes on 1/19/10 at 1:25 p.m. documented that the resident had had two more episodes of diarrhea. However, licensed nursing staff failed to consult the resident's attending physician about the resident's vomiting and diarrhea until 1/20/10. On 1/20/10 at 2:50 p.m., the physician's Nurse Practitioner visited the resident and documented that the resident had a stomach virus. The Director of Nursing (DON) stated during an interview on 7/8/10 at 1 p.m. that she would have expected the nurses to have notified the physician sooner than 1/20/10. See F281 for additional information regarding resident #17.",2015-06-01
9518,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2010-07-08,281,D,0,1,6GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to intervene and consult with a physician in a timely manner about the significant changes in the physical condition of one resident (#17) from a total sample of 21 residents. Findings include: According to the ""Georgia Professional Nurse Practice Act"", licensed nurses were to communicate and collaborate with other health care providers in the management of health care and, implement nursing care to meet patients' health care needs. However, licensed nursing staff failed to provide interventions and consult with the physician in a timely manner about a significant change in the physical condition of resident #17. Resident #17 had signed physician's orders [REDACTED]. Nursing staff were to administer 20 milliliters (ml) of [MEDICATION NAME] after the first loose stool then 10 ml after each loose stool as needed and no more than 40 ml per day. Licensed nursing staff documented in the 1/18/10 at 8 p.m. nurse's notes that resident #17 vomited three times during that shift. However there was no indication that the nurse thoroughly assessed the resident during that shift or provided any nursing interventions to address the resident's vomiting. Licensed nursing staff documented on the 1/19/10 facility's twenty four hour report at 6 a.m. that the resident had four episodes of diarrhea and that [MEDICATION NAME] (anti-diarrheal medication) was administered. There was no evidence of any other interventions implemented to address the resident's diarrhea. There was no evidence that [MEDICATION NAME] had been administered as ordered after each loose stool. The nurse's notes on 1/19/10 at 1:25 p.m. documented that the resident had had two more episodes of diarrhea but, there was no evidence that any interventions were provided by the nursing staff. Licensed nursing staff failed to consult the resident's attending physician about the vomiting and diarrhea until 1/20/10. On 1/20/10 at 2:50 p.m., the physician's Nurse Practitioner visited the resident and documented that the resident had a stomach virus. The Director of Nursing (DON) stated during an interview on 7/8/10 at 1 p.m. that she would have expected the nurses to have consulted the physician sooner and intervened for the vomiting on 1/18/10 and diarrhea on 1/19/10.",2015-06-01
9519,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2010-07-08,502,D,0,1,6GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to notify the physician about abnormal laboratory test results for two residents #3 and #16) from a total sample of 21 residents. Findings include: 1. Licensed nursing staff documented in the 5/19/10 nurse's notes that resident #3 complained of burning with urination and a foul urine odor. A physician's orders [REDACTED]. The final urine culture report was available on 5/21/10 and was positive for E. Coli. bacteria. However, there was no evidence that licensed nursing staff notified the physician about that report until 5/24/10 at which time an antibiotic was ordered. The 5/24/10 nurses notes documented that the resident was still symptomatic on 5/24/10, complaining of burning upon urination. Licensed nursing staff documented in the 6/28/10 nurse's notes that the resident had foul smelling urine. A physician's orders [REDACTED]. The final urine culture report was available on 6/30/10 and was positive for E. Coli. bacteria. However, there was no evidence in the clinical record that licensed nursing staff notified the physician about that report until 7/2/10 at which time an antibiotic was ordered. 2. Resident #16 had a physician's orders [REDACTED].. Licensed nursing staff documented on 4/8/10 at 4:30 p.m. that the resident's blood sugar level was 538, the laboratory was notified and blood drawn to verify that result. The laboratory's blood sugar level result was documented as 467. However, there was no evidence that the physician was notified. On 4/24/10 at 6:10 a.m., licensed nursing staff documented the resident's blood sugar level as 473, and a recheck as 520. The laboratory was called to verify those results. The laboratory blood sugar level result was documented as 468. However, there was no evidence in the clinical record that licensed nursing staff notified the physician.",2015-06-01
9520,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2010-07-08,309,D,0,1,6GPQ11,"Based on observation, staff interview and record review, it was determined that the facility failed to ensure that newly identified skin tears were promptly reported to licensed nursing staff for one resident (#7), from a sample of 21 residents. Findings include: On the 6/30/10 significant change Minimum Data Set (MDS) assessment, licensed nursing staff coded resident #7 as having short and long term memory impairments, as having severely impaired decision making skills, and as dependent on staff for bed mobility, transfers, aand all activities of daily living (ADLs). There was a 5/16/10 plan of care which identified the resident as being at risk for impaired for skin integrity because of impaired mobility and fragile skin. There were interventions for nursing staff to monitor his/her skin integrity for evidence of irritation, redness and warmth, and to monitor skin during ADL care. There was an intervention for nursing staff to instruct the resident to notify staff of any skin impairments. However, that intervention was not appropriate based on the facility's comprehensive assessment of his/her cognitive impairments. During an observation of the resident's skin on 7/6/10 at 2:05 p.m., after certified nursing assistant (CNA) ""TT"" removed the Prevalon boot from the resident's left leg, two skin tears were observed on the lateral side of his/her left leg. The first skin tear was open, and measured approximately 1 and 1/2 inches in length by 1/2 inch in width. Just below that area was a second open skin tear that measured approximately 1/2 inch in diameter. During that observation, CNA ""TT"" acknowledged the skin tears and stated that she had not been aware of the skin tears before that time. During an observation of skin tears on the resident's left leg on 7/7/10 at 3:45 p.m., the treatment nurse stated that she had not been made aware of the skin tears prior to that time. As the treatment nurse removed the Prevalon boot from the resident's left leg, there was dried drainage from the skin tears observed in the boot. The treatment nurse stated that CNA staff were supposed to report any newly identified skin tears or open areas to the treatment nurse or charge nurse. On 7/7/10 at 4:15 p.m., the treatment nurse described a 4.5 centimeter (cm) by 3.0 cm open area on the posterior side of the resident's left leg. She noted that there was no skin intact over that open area. She documented that there was a separate, red ""abrasion"" just below that open area that measured 1.5 cm by 0.5 cm area, with some drainage. During an interview on 7/7/10 at 1:25 p.m., the treatment nurse stated that she performed weekly skin assessments on resident #7. However, a review of the clinical record on 7/7/10 revealed that the most recent weekly skin assessment had been performed on 6/11/10. On 7/7/10 at 4:20 p.m., licensed charge nurse ""VV"" stated that she had not been made aware of any skin tears on the resident's left leg. On 7/8/10 at 9:30 a.m., licensed charge nurse ""WW"" stated that she had not been made aware of any skin tears on the resident's left leg until after surveyor observation with the treatment nurse on 7/7/10. On 7/8/10, after surveyor inquiry, additional weekly skin assessments were added to the record with the most recent skin assessment having been performed on 6/30/10.",2015-06-01
9521,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2010-07-08,387,D,0,1,6GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that one of three physicians made the required visits for two residents (#17 and #11) from a total sample of 21 residents. Findings include: 1. Resident #17 was admitted to the facility on [DATE] and discharged on [DATE]. Although the Nurse Practitioner visited the resident on 1/20/10, there was no evidence in the clinical record that attending physician had seen the resident. The Director of Nursing (DON) stated on 7/8/10 at 11:25 a.m. that she was unable to locate any evidence that the physician had visited the resident as required. 2. Resident #11 was admitted to the facility on [DATE]. There was no evidence in the clinical record that the attending physician had seen the resident until 3/23/10.",2015-06-01
9522,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2010-07-08,323,E,0,1,6GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined that the facility failed to thoroughly assess the use of side rails and provide interventions to prevent falls for one resident (#2), failed to re-evaluate the effectiveness of a table top restraint for one resident (#21), and failed to ensure that hot water temperatures were below 120 degrees Farenheit (F) in 8 rooms on five of seven wings from a total sample of 21 residents. Findings include: 1. Resident #2 had [DIAGNOSES REDACTED]. Licensed nursing staff documented in the 12/29/09 nurses notes that the resident's legs were over the siderails. On 1/27/10, the resident was found on the floor. Nursing staff documented at that time that the resident had apparently climbed over the siderails. On 2/1/10, licensed nursing staff documented that the resident was again found on the floor and had one hand on the side rail. On 2/2/10, the resident was documented as yelling and attempting to climb over the side rails. The nurse wrote that the resident had already thrown his/her legs over them. On 3/18/10, the resident was documented as yelling and trying to get over the siderails. The nurse wrote that the resident had tried getting over them several times during the night. Nursing staff documented on the ""Restraint/Siderail Prevention and Reduction Committee Recommendation"" form that side rails were used while the resident was in bed for positioning with a tab sensor applied while in and out of bed. Despite the resident's falls out of the bed with the side rails present, and the continued attempts to climb over the side rails, there was no evidence that staff had attempted any additional interventions until 4/30/10. There was no evidence that staff had evaluated the effectiveness of the continued use of the side rails to promote the resident's safety. Nurse supervisor ""MM "" stated on 7/8/10 at 11 a.m. that the resident had been given a new bed with only half side rails on 4/30/10 and mats were put on either side of his/her bed on 5/6/10. The resident was observed in a low bed with both upper side rails elevated on 7/6/10 at 2:35 p.m. 2. During the initial tour of the facility on 7/6/10 at between 9:30 a.m. and 10:30 a.m., and between 1:45 p.m. and 1:55 p.m., the sinks and/or bathrooms in the following rooms had hot water temperatures greater than 120.0 degrees Fahrenheit (F.): Wing 2 1. The hot water temperature at the sink in room 110 was 123 degrees F. Wing 3 1. The hot water temperature at the sink in room 117 was 121 degrees F. 2. The hot water temperature at the sink in room 122 was 120.6 degrees F. 3. The hot water temperature at the sink in room 123 was 121.4 degrees F. 4. The hot water temperature at the sink in room 125 was 123.2 degrees F. 5. The hot water temperature at the sink in room 126 was 121.9 degrees F. Wing 4 The hot water temperature in the bathroom in room 131 was 121 degrees F. Wing 5 The hot water temperature in the bathrooms in rooms 136 and 139 was 121 degrees F. On 7/6/10 at 12:00 p.m., the maintenance supervisor stated that water temperatures were checked weekly, and provided the Maintenance Daily Checklist. The Maintenance Daily Checklist was reviewed and revealed that water temperatures were checked through the hot water storage on both the East and West Wings. Hot water temperatures recorded for July 5 through July 9, 2010, June 28 through July 2, 2010, June 21 through June 25, 2010, June 14 through June 18, 2010, June 7 through June 11, 2010 and May 31 through June 4, 2010 were 110 degrees F. On 7/6/10 at 3:50 p.m., the maintenance supervisor confirmed that the facility's thermometers used to measure the water temperatures were not calibrated but, new thermometers were purchased as needed. On 7/7/10 at 2:00 p.m., the maintenance supervisor stated that a new thermometer had been purchased and was being used. He said that the thermometer used prior to 7/7/10 was ""off 10 degrees."" 3. On the 2/09/10 comprehensive and the 4/27/10 quarterly Minimum Data Set (MDS) assessment, licensed staff coded resident #21 as having short and long term memory impairments, as having moderately impaired decision making skills, as requiring extensive to total assistance with transfers and locomotion, and as having fallen in the past 31 to 180 days. According to documentation in the nurse's notes, staff had been utilizing a gerichair with table top device for the resident since at least 11/16/09 ""to keep the resident safe."" On the 12/21/09 nurse's note, licensed nursing staff documented that the resident had involuntary spastic movements of his/her legs and arms and sat in a gerichair with a tabletop because of being unsafe without the tabletop. The nurse noted that the involuntary movements were forceful and resulted in the resident having a leaning posture and needing to be repositioned in the gerichair several times each shift. Documentation on the 12/27/09 nurse's note revealed that the resident slid out of the gerichair in the day room. A handwritten note by by the nurse manager dated 12/27 documented that the table top had come loose and fell off of the gerichair then, the resident slid out of the gerichair. On the 2/9/10 Resident Assessment Protocol (RAP) summary, licensed nursing staff documented that the resident was to be up in the gerichair with the table top device because of the resident's positioning, balance and safety awareness. On the 3/16/10 nurse's notes, licensed nursing staff documented that the resident had slid to the floor from the gerichair. A handwritten note by the nurse manage dated 3/16 documented that the resident slid down to the floor under the table top.. On the 4/30/10 nurse's note, licensed nursing staff documented that staff continued to assist the resident up in the gerichair daily with the table top device. During a random observation on 7/8/10 at 1:00 p.m., resident #21 was observed in the hallway seated in a gerichair with the table top device in place. The resident had slid down and turned in the chair so that the right side of his/her face was resting on the right arm rest of the chair. The resident's moans could be heard from the nurse's station to the other end of the hall where the resident was seated. At that time, certified nursing assistant (CNA) ""XX"" stated that the resident slid down in the gerichair and had to be repositioned at least three to four times during the shift. On 7/8/10 at 1:15 p.m., licensed nurse ""YY"" confirmed that the resident would frequently slide down in the gerichair and as a result, the table top had been applied because of the resident's [DIAGNOSES REDACTED] and rigidity. An observation of the resident's gerichair with CNA ""XX"" on 7/8/10 at 1:30 p.m., revealed a pressure relieving cushion in the gerichair extending from the top of the chair to the bottom of the leg rest. CNA ""XX"" stated that no other devices had been attempted to prevent the resident from sliding in the gerichair . During an interview on 7/8/10 at 2:00 p.m., the physical therapist (PT), occupational therapist (OT) and speech therapist (ST), who served as the rehabilitation manager, stated that the resident had not been seen by the therapy department for positioning since at least the Fall of 2009. The occupational therapist stated that she had screened the resident earlier in the year but, at that time the resident did not slide down in his/her gerichair. The PT, OT and ST department representatives stated that they had not recently been asked to screen the resident for positioning needs or for interventions to address the resident's sliding down in his/her gerichair. There was no evidence that the facility had evaluated the effectiveness of the continued use of the tabletop device to promote the resident's safety and the potential hazard for the resident with his/her identified behavior of sliding down in the chair while the device was in use.",2015-06-01
9523,BERRIEN NURSING CENTER,115343,405 LAUREL AVE.,NASHVILLE,GA,31639,2010-07-08,314,D,0,1,6GPQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, it was determined that the facility failed to identify a newly acquired unavoidable pressure sore for one resident (#7), in a sample of five residents with pressure sores from a total sample of 21 residents. Finding include: Resident #7 had medical [DIAGNOSES REDACTED]. disease, hypertension, organic psychotic condition, altered mental status, [MEDICAL CONDITION] and acute [MEDICAL CONDITION]. On the 6/30/10 significant change Minimum Data Set (MDS) assessment, licensed nursing staff coded resident #7 as having short and long term memory impairments, as having severely impaired decision making skills, and as dependent on staff for bed mobility, transfers, and all activities of daily living (ADLs). There was a 5/16/10 plan of care which identified the resident as being at risk for impaired for skin integrity because of impaired mobility and fragile skin. There were interventions for nursing staff to monitor his/her skin integrity for evidence of irritation, redness and warmth, and to monitor skin during ADL care. There was an intervention for nursing staff to instruct the resident to notify staff of any skin impairments. However, that intervention was not appropriate based on the facility's comprehensive assessment of his/her cognitive impairments. Although the facility had implemented pressure relieving interventions including the use of a low air loss mattress, Prevalon boots on both lower extremities and the addition of a protein supplement to promote wound healing, they facility to identify a newly acquired, unavoidable pressure sore. During an observation of care being provided by certified nursing assistants (CNA) ""TT"" and ""UU"" on 7/6/10 at 2:05 p.m., there was a 3/4 inch in diameter intact round, dark reddened area with a brown center on the lateral aspect of the resident's right foot. During an observation of that area on 7/7/10 at 3:45 p.m., the treatment nurse said that she had not previously been made aware of that area prior to that time. The treatment nurse stated that CNA staff were supposed to report any newly identified pressure sores or open areas to the treatment nurse or charge nurse. On 7/7/10 at 4:20 p.m., licensed charge nurse ""VV"" stated that she had not been made aware of any newly identified pressure sores or open areas on the resident's right foot. On 7/8/10 at 9:30 a.m., licensed charge nurse ""WW"" stated that she had not been made aware of the pressure sore on the resident's right foot until after surveyor observation with the treatment nurse on 7/7/10. After the observation on 7/7/10 at 4:15 p.m., the treatment nurse assessed the area as a discolored pressure sore on the side of the resident's right foot. She measured it as 0.9 cm by 0.8 cm with less than 0.1 cm depth and described it as having a reddish-brown center with brown edges. She described it as unstageable at that time.",2015-06-01
4210,"BLUE RIDGE HEALTHCARE OF BUCHANAN, LLC",115587,144 DEPOT STREET,BUCHANAN,GA,30113,2017-02-23,371,E,1,0,MJVM11,"> Based on observation, staff interview and record review the facility failed to maintain potato salad at a safe temperature to prevent foodborne illness. This deficient practice had the potential to effect fifty (50) residents receiving an oral diet. The facility census was 50. Findings include: Observation on 2/22/17 at 4:45 p.m. of food steam table revealed potato salad being held at a temperature of 90 degrees Fahrenheit (F). The temperature was obtained by Dietary Aide (DA) AA, with the facility thermometer. During an interview on 2/22/17 at 4:45 p.m. with DA AA he confirmed the temperature of the potato salad at 90 degrees (F). He also stated he thought the potato salad was a hot food item. Additionally, he stated he did not record the potato salad temperature on the Food Temperature Chart and the recorded Starch temperature was for the mashed potato. During an interview on 2/22/17 at 4:50 p.m. with DA BB, revealed that 17 residents received the potato salad at the improper temperature. During an interview on 2/22/17 at 5:06 p.m. with the Dietary Manager (DM) revealed that she expected the potato salad to be served as a cold item and to be held at a temperature of 41 degrees (F) or lower. The DM requested DA AA, to place the container of potato salad in a pan of ice water to cool it down. The DM confirmed the temperature of the potato salad at this time to be 78 degrees (F). Observation on 2/22/17 at 5:15 p.m. revealed DA BB disposing of the potato salad. Review of the facility recipe for Dilled Potato Salad revealed Critical Control Points: Finished product must maintain a temperature below 41 F during entire service period. Keep covered whenever possible. Take and record temperature of unserved product every 30 minutes. Maximum holding time: 4 hours. Discard unused product. Quality cannot be maintained during storage and/or reheating. Review of the facility Trayline Setup and Service Policy review date of 5/24/16 revealed Food temperatures are recorded prior to every meal and at midway point using the Food Temperatures Log. Review of the facility menu for 2/22/17 dinner revealed the Fall/Winter (YEAR) Menu for Week 2 Wednesday Evening included: Oven Roasted Turkey Sandwich, Lettuce and [NAME]toes, Potato Salad.",2020-02-01
6188,"BLUE RIDGE HEALTHCARE OF BUCHANAN, LLC",115587,144 DEPOT STREET,BUCHANAN,GA,30113,2014-08-15,157,D,0,1,7GX111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and physician interview, the facility failed to notify the physician of bruising one (1) resident (#5), who was receiving daily antiplatelet medication. The sample size was twenty-five (25) residents. Findings include: Review of the medical record for resident #5 revealed that the resident was received antiplatelet medication, [MEDICATION NAME], daily. Record review revealed a Nurses Notes dated 7/15/14 at 10:14 PM that indicated three (3) purple areas of discoloration noted to left inner. On 7/16/14 at 10:58 PM indicated bruising continues on bilateral inner thighs. The nurses notes on 7/17/14 at 2:20 PM; 7/18/14 at 6:58 AM; 7/18/14 at 1:47 PM and on 7/30/14 4:22 AM the note indicates that bruising continues to the inner thighs and arms. A Nurses Notes dated 7/23/14 at 11:20 AM revealed the resident has bruising on area where a splint was. Record review of physician's progress note dated 7/30/14 indicated he was asked to see from bleeding in teeth/gums. No progress notes were on the chart from 5/30/2014 through 7/30/2014. Interview with the Director of Nursing (DON) on 8/15/14 at 8:00 AM revealed that the only area to document physician notification/calls is in nurses progress notes. Interview on 8/15/14 at 9:05 AM with nurse AA revealed she did not call the physician to report this residents unusual bruising. The physician should have been called on 7/15/14 when the bruising to her inner thighs was first noted. Interview 8/15/14 at 10:00 AM with Unit Manager/Wound Care Nurse revealed she does not know of any calls to the resident's physician to notify him of bruising and she would have expected the nurse who first noted the bruises to notify the physician. Interview 8/15/14 at 10:15 AM with nurse BB revealed she would normally have notified physician, but she thought another nurse had notified him. Interview 8/15/14 at 10:35 AM with the physician of resident #5 revealed there had been no notification of unusual bruising or bleeding until he was notified of residents bleeding gums , and made a progress note regarding the bleeding gums on 7/30/14 and discontinued the [MEDICATION NAME].",2018-03-01
6189,"BLUE RIDGE HEALTHCARE OF BUCHANAN, LLC",115587,144 DEPOT STREET,BUCHANAN,GA,30113,2014-08-15,282,D,0,1,7GX111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff and physician interview the facility failed to follow a care planned intervention for one (1) resident (#5), receiving daily antiplatelet medication, from a sample of twenty-five (25) residents. Findings include: Review of the medical record revealed resident #5 receives a daily antiplatelet medication, [MEDICATION NAME], which can with possible adverse reactions of excessive bleeding and bruising. This medication was given to this resident for a [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan for resident #5 revealed the resident was care planned to be at risk for complications related to use of an antiplatelet medication (bleeding, bruising). One of the interventions was to observe for signs of bleeding and report to the physician. This care plan was last revised on 7/24/14. Record review of Nurses Notes revealed entries regarding the new onset of bruising on 7/15/14 at 10:14 on resident's left inner thigh. On 7/16/14 at 10:58 PM the bruising was bilateral inner thighs. Nurses Notes of 7/17/14 at 2;20 PM, 7/18/14 at 6:58 AM and 7/18/14 at 1:47 PM indicated the bruising continued on the resident's bilateral inner thighs. The record had not evidence that the physician was notified of the bruising to the resident's inner thighs. Interview on 8/15/14 at 9:05 AM with nurse AA revealed she did not call the physician to report this residents unusual bruising or bleeding. The physician should have been called on 7/15/14 when the bruising to her inner thighs was first noted. Interview 8/15/14 at 10:00 AM Unit Manager/Wound Care Nurse revealed she does not know of any calls to the residents physician between 7/15/14 and 7/30/14, to notify him of bruising or bleeding and she would expect the nurse who first noted the bruising or bleeding to have notified the physician. Interview 8/15/14 at 10:35 AM with the physician of resident #5 revealed he had not been notified of this bruising or bleeding until he was notified of residents bleeding gums on 7/30/14.",2018-03-01
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
4182,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2016-02-04,253,D,0,1,YZLO11,"Based on observation and interview, it was determined that the facility failed to provide an environment free of chipped and flaking paint, damaged ceilings and walls and scuffs on one (1) of five (5) resident halls. Findings include: The following observations were made on the 400 Hall: 1. On 2/01/16 at 1:15 p.m., 2/02/16 at 9:30 a.m. and on 2/03/16 at 4:28 p.m. in the shared bathroom for rooms 402 and 404 there was an area on the ceiling near the exhaust fan cover that had exposed dry wall tape and dry wall mud. The area was not sanded to blend into the existing ceiling and was not painted. 2. On 2/01/16 at 2:50 p.m. and on 2/03/16 at 4:25 p.m. in the bathroom in room 401 the paint on the underside of the toilet seat was flaking off and missing pieces. 3. On 2/01/16 at 10:45 a.m., 2/02/16 at 3:00 p.m., 2/03/16 at 9:18 a.m., and on 2/04/16 at 8:00 a.m. in room 405 there was a hole approximately one and half inches (1 1/2) long by one-half (1/2) inch wide on the wall on the right side of the room. The bathroom door frame on the lower right side was noted to be scuffed and had three areas of chipped and missing paint approximately one-half (1/2) inch in size. 4. On 2/01/16 at 10:50 a.m. and on 2/03/16 at 9:20 a.m. in room 413 there was sheetrock mud running along the right side of the ceiling for the width of the room. Chipped and peeling paint was noted in several different areas and around the light fixture. 5. On 2/01/16 at 10:55 a.m. and on 2/03/16 at 9:20 a.m. the ceiling in the 400 hallway had three separate cracks that ran across the ceiling from one side of the hallway to the other side of the hallway. During an interview and observation with the Maintenance Director on 2/4/16 at 12:35 p.m., he confirmed the previously listed findings on the 400 Hall. He stated that the facility uses the Guardian Angel program and expected staff to write a work order for any maintenance concerns that were found in the residents' rooms. He stated that he had not received work orders for the concerns identified in room 401, room 405, room 413, or for the ceiling in the 400 hallway. He stated that the exhaust fan cover had been replaced in the shared bathroom for rooms 402 and 404 but the project had not been completed and he had not rechecked it.",2020-02-01
4183,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2016-02-04,329,D,0,1,YZLO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that the facility failed to monitor for potential side effects or behaviors for two (2) residents (#5 and #18) who received [MEDICAL CONDITION] medications from a total sample of twenty-three (23) residents. Findings include: The facility's policy for the Monitoring of Antipsychotics documented that when antipsychotic therapy is initiated, the resident is monitored quantitatively and qualitatively to determine the effectiveness of the medication and the presence of adverse reactions. The procedure section of the policy included documenting behaviors and side effects daily on each shift. 1. Resident #5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record revealed the resident was receiving the following [MEDICAL CONDITION] medications and had been since admission on 1/6/16: 0.25 milligrams (mg) of [MEDICATION NAME] twice daily for anxiety, 50 mg of [MEDICATION NAME] daily at bedtime for psychotic mood disorder, and 150 mg of [MEDICATION NAME] daily for depression. The current (MONTH) (YEAR) physician's orders [REDACTED].>There was a plan of care in place since 1/22/16 for the use of antipsychotic and antidepressant medications. The plan of care included interventions to assess the resident daily for behaviors and to monitor for side effects. However a review of the clinical record revealed no evidence that potential side effects and behaviors were monitored for the use of the antidepressant medication as careplanned from 1/6/16 through 1/31/16. There was also no evidence that potential side effects or behaviors were monitored with the use of the antipsychotic medication from 1/6/16 through 1/31/16 as per facility policy or as careplanned and ordered. The Director of Nursing (DON) confirmed during an interview on 02/04/16 at 11:30 a.m. that licensed nursing staff did not monitor for behaviors or side effects of the antipsychotic medication for resident #5 from 01/06/16 through 01/31/16. The DON stated licensed nursing staff were expected to document behaviors and side effects for residents receiving an antipsychotic medication. 2. Resident #18 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record, including the physician's orders [REDACTED]. There were plans of care in place for the use of antidepressant and antipsychotic medication with interventions to observe for side effects and assess daily for behaviors. However a review of the clinical record revealed no evidence that potential side effects and behaviors were monitored for the use of the antidepressant medication as careplanned from 12/23/15 through 12/31/15. There was also no evidence that potential side effects or behaviors were monitored with the use of the antipsychotic medication from 12/23/15 through 12/31/15 as per facility policy or as careplanned. During an interview on 02/04/16 at 10:07 a.m. Licensed Practical Nurse (LPN) AA stated that when a resident is newly admitted to the facility and is on an antipsychotic medication, or is started on an antipsychotic as a new medication, then behaviors and side effects are monitored and documented every shift starting as soon as the resident is started on the antipsychotic medication. LPN AA stated that behavior monitoring and side effect monitoring should have started as soon as resident #18 was admitted to the facility but was not done from 12/23/15 through 12/31/15. The DON confirmed during an interview on 02/04/16 at 11:30 a.m. that behaviors or side effects were not monitored for resident #18 from 12/23/15 through 12/31/15, but should have been.",2020-02-01
4184,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2016-02-04,371,F,0,1,YZLO11,"Based on observation, staff interview, and documentation review the facility failed to properly thaw frozen fish filets to prevent food borne illness, label and date opened food items in the dry storage area, and failed to demonstrate the proper technique for using the three (3) compartment sink to prevent cross contamination. This deficient practice had the potential to effect one hundred seven (107) residents receiving an oral diet. Findings include: During an observation of the dietary department on 2/01/16 at 10:40 a.m., in a stainless sink, there was a stainless steel pan that was twenty (20) inches in length, twelve (12) inches in width, and two (2) inches deep that had a clear plastic bag containing frozen fish filets. The faucet was running cold water and the bag of fish filets were half submerged in water with the top half of the bag exposed to the air. On 2/01/16 at 10:50 a.m. in the dry storage area there was an opened bag of Kellogg's Fruit Loop cereal that did not have a date when opened. There was a clear plastic bin that contained packages of dried gelatin mixes. One opened package of orange gelatin was not dated. Further observation of the dry storage area revealed a poster that was hung on the wall near the canned food items that read: Label, Date, and Rotate. During an interview on 2/01/16 at 11:00 a.m. the Dietary Manager (DM) confirmed that the frozen fish filets were not completely submerged in water. She stated that dietary staff were expected to completely submerge frozen food items in water with the water running for thawing. The DM also confirmed that the bag of Fruit Loops and orange gelatin were opened with no label or date. She stated dietary staff were to label and date all foods after opening and before placing in storage. On 2/03/16 at 10:05 a.m. dietary cook BB, was observed using the 3 compartment sink. After washing and rinsing a food processor bowl, lid, and blade, he then dipped the items in the Quaternary sanitizing solution for only 2 seconds before placing them on a rack to dry. An EcoLab Chemical poster that was hung above the 3 compartment sink documented that items were to be completely submerge for one minute or longer in the sanitizing solution. Dietary cook BB confirmed on 2/3/16 at 10:05 a.m. that the kitchen items he washed were in the sanitizing solution for two seconds. When asked how long kitchen items need to be submerged in the sanitizing solution the cook incorrectly stated twenty (20) seconds. During an interview on 2/03/16 at 10:08 a.m. the DM stated that dietary staff were expected to use the 3 compartment sink correctly and submerge kitchen items for one minute or longer. The DM revealed that she had conducted an in-service regarding the 3 compartment sink a few months ago. A review of the documented in-service conducted on 01/15/16 revealed that dietary staff were educated on the 3 compartment sink. The in-service also covered proper labeling of items. A review of the Pot and Pan Wash Procedure revealed that if a chemical sanitizer is used, items must remain submerged for minimum of one minute.",2020-02-01
5408,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2015-01-29,246,D,0,1,NNRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, the facility failed to accommodate the needs of two (2) residents, resident (X) related to [MEDICATION NAME] care, and resident (Z) related to her physical environment. The sample size was thirty-one (31). Findings include: 1.) Review of the clinical record for resident Z revealed that the resident had [DIAGNOSES REDACTED]. Review of the Comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview Mental Status (BIMS) was thirteen (13), indicating that the resident was cognitively intact. Observation on 1/26/15 at 12:42 p.m., from the doorway revealed resident Z in bed her lunch tray was served by Certified Nursing Assistant (CNA) AA. The resident informed CNA AA that her bag needed to be changed. Continued observation revealed that CNA AA told the resident that she needed to eat first. CNA AA set up the resident's tray and left the room. Observation on 1/26/15 at 1:00 p.m. revealed that resident Z had a [MEDICATION NAME] bag, which was located on her right side. The bag was observed to be completely full of yellow-brownish liquid. Resident Z revealed that she wished that staff would have just changed the bag when she asked them to. Continued interview revealed that she was unable to remember if that was the first time that staff had made her wait to empty the [MEDICATION NAME] bag. Observation on 1/26/15 at 1:27 p.m., revealed that staff entered the room of resident Z and removed the lunch tray, but the [MEDICATION NAME] bag was not emptied. The [MEDICATION NAME] bag was observed to still be full. Observation on 1/26/15 at 1:51 p.m., revealed that resident Z was still sitting up in bed and the [MEDICATION NAME] bag was still full of yellow-brownish liquid. Resident Z revealed that she wished they would change it, as it needs it. Continued observation revealed the resident pushed the call light and the nurse came to the room at 1:53 p.m., to drain the [MEDICATION NAME] bag. Interview with Registered Nurse (RN) BB on 1/26/15 at 1:55 p.m., revealed that if a resident asked for their [MEDICATION NAME] bag to be drained when their lunch tray was being served, then she would put up the tray, drain the bag and give the tray back to the resident. Interview with the Director of Nursing (DON) on 1/28/15 at 2:15 p.m., revealed that if a resident requested for his/her [MEDICATION NAME] bag to be drained and their lunch tray had arrived, then she would have them eat first and then after picking up the resident's lunch tray, she would expect staff to go back within thirty (30) minutes, to complete their request. Continued interview revealed that she was unsure if there was a facility policy on this. The DON further revealed that the CNA providing care for resident Z did check her [MEDICATION NAME] bag before serving her lunch and stated the bag was not full. 2.) Review of the clinical record for resident X revealed the Quarterly MDS assessment dated [DATE] revealed that the resident's BIMS was fifteen (15), indicating that the resident was cognitively intact. Interview with resident X on 1/28/15 at 12:45 p.m. revealed that she spoke with the maintenance man again yesterday after speaking with him for two (2) or three (3) months, that she needed her light bulb changed in her lamp which was located on the right side of her nightstand. Resident X further revealed that she uses the lamp for a nightlight because she could not see. Continued interview revealed that she does not want to leave the bathroom door open because the bathroom was really cold without a heater in there. The resident revealed that the maintenance person told her that he did not do anything unless he had a written report. She further revealed that the nightlight on the wall between the built in cabinet and bathroom door did not work, and that it had never worked. Observation on 1/28/15 at 12:45 p.m. confirmed the resident's concerns. The lamp for resident Z did not work and had a burnt out light bulb. Continued observation revealed that the nightlight on the wall between the cabinet and the bathroom had no light. Interview with the Maintenance Director on 1/28/15 at 3:28 p.m., revealed that a few days ago resident Z did request a new light bulb for her lamp, however he had not gotten to it yet. The Maintenance Director further revealed that to his knowledge he does not remember the resident requesting one for longer than that. Continued interview revealed that when he gets a written request, these requests are taken care of immediately, which usually means that same day. The Maintenance Director revealed that the requests are kept at the nursing station and any staff member can write a written request, however, if it is not written and just told to him, then he gets to the request when he remembers. Interview with the Maintenance Director on 1/28/15 at 3:35 p.m., he revealed that when a written request was completed, they are then placed on the outside of a plastic hanging file with a paperclip and once completed, the request is signed off and placed in a box. He further revealed that he checks the hanging file for requests every time he passes the nursing stations, which is a couple times a day.",2018-09-01
5409,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2015-01-29,247,D,0,1,NNRH11,"Based on record review, resident and staff interviews the facility failed to follow the policy for documenting when a resident receives a new roommate. The sample size was thirty one (31) residents. Findings include: Review of the Quarterly Minimum Data Set (MDS) assessment for resident Q dated 11/13/14 revealed that the resident had a Brief Interview for Mental Status (BIMS) of fifteen (15), which indicated that the resident was cognitively intact. Interview on 01/26/14 at 1:25 p.m. with resident Q revealed that she received a new roommate a few months ago and did not receive any notification prior to the new resident being placed in the room with her. Interview on 01/28/15 at 9:45 a.m. with the Social Services Director (SSD) confirmed that resident Q did receive a new roommate about three (3) months ago. The SSD further revealed that she informed resident Q verbally that she was receiving a new roommate, but she did not document that conversation in the resident's medical record. Continued interview revealed she knew that she should be documenting when she discusses room changes or new roommates with the residents, or their responsible party (RP). Review of the medical record for resident Q revealed there was no evidence of documentation of the resident receiving notification of a new roommate. Review of the Social Services Documentation Policy last updated (MONTH) 2014 revealed that it was often necessary for Social services to write progress notes and initiate care plan updates in between quarterly reviews and for reasons other than a significant change in the patient. These notes included room or room-mate changes.",2018-09-01
5410,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2015-01-29,253,E,0,1,NNRH11,"Based on observations, record review and staff interviews, the facility failed to maintain a clean, and comfortable environment as evidenced by stained or damaged floors, broken or missing tiles, doorframes, towel racks and cracking, peeling ceiling paint on four (4) of five (5) halls. Findings include: A.) During initial tour of the facility on 1/26/15 at 10:15 a.m., the following concerns were identified: 200-Hall: 1.) In the bathroom between room 201 and 203: the left side of the towel rack was missing with the end sitting up and only two (2) screws in the wall on the right side, the toilet paper holder was loose on the left side and coming away from the wall, the doors and door frames were marred, another towel rack on the right side under the window was loose, and there were three (3) green border tiles missing to the right of the toilet. 2.) In room 205: the door and door frame was marred. 3.) In the bathroom between room 205 and 207: the door and door frames were marred, the towel rack on the left side under the window was missing, two (2) beige tiles to the right of the toilet were loose and coming away from the wall, and there was a black unknown substance around the base of the toilet. 4.) In room 206: the bathroom door frame was marred. 500-Hall: 1.) In the bathroom between rooms 508 and 510: there were two (2) tiles, approximately 5 x 3, coming loose from the wall. B.) During environmental tour on 1/28/15 between 10:56 a.m. to 1:00 p.m., the following concerns were identified: 100-Hall: 1.) In the bathroom between rooms 102 and 104: the ceiling light cover was off and the door frames were marred. 2.) In room 102: the bathroom door had a small oblong hole and the bathroom door frames were marred. 3.) In the bathroom between 101 and 103: the door frames were marred, and the towel rack on the left side over the toilet was loose. 4.) In room 101: the wall to the left side after entering the room was marred. 5.) In the bathroom between rooms 105 and 107: the door frames were marred, the towel rack on the left and right sides under the window were loose, the door into room 105 had a crack approximately six (6) to eight (8) inches in the middle, and the ceiling paint was peeling on one (1) of four (4) sides of the ceiling vent. 6.) In room 107: the door frame into the bathroom was marred, and the wall between the built in four (4) drawer cabinet and bathroom door had a light to medium black strip approximately one (1) foot from the baseboard. 7.) In the bathroom between room 109 and 111: the doors and door frames were marred, the towel rack on the left side under the window was loose, and four (4) pink baseboard square tiles to the left of the toilet were loose. 8.) In the bathroom between room 110 and 112: the door frames were marred, and the right back metal leg of the vanity was off and leaning against the wall, the vanity was separating away from the wall with an approximate half (1/2) inch gap. The vanity was moveable when touched. 200-Hall: 1.) In the bathroom between room 201 and 203: the left side of the towel rack was missing with the end sitting up and only two (2) screws in the wall on the right side, the toilet paper holder was loose on the left side and coming away from the wall, the doors and door frames were marred, another towel rack on the right side under the window was loose, and there were three (3) green border tiles missing to the right of the toilet. 2.) In room 205: the door and door frame was marred. 3.) In the bathroom between room 205 and 207: the door and door frames were marred, the towel rack on the left side under the window was missing, two (2) beige tiles to the right of the toilet were loose and coming away from the wall, and there was a black unknown substance around the base of the toilet. 4.) In room 206: the bathroom door frame was marred. 400-Hall: 1.) In the bathroom between room 403 and 405: the doors and door frames were marred, the ceiling fan was loose on the right side, and the door frame to room 405 had an irregular shaped piece that appeared to be cut out of the frame, that was dark brown in color, without any sharp edges. 2.) In the bathroom between room 407-409: the ceiling fan was loose, with one (1) missing screw on the right side. 3.) In room 411: the wall was marred between the built in four (4) drawer cabinet and bathroom door. 4.) In room 414: the bedroom door knob was loose 500-Hall: 1.) In room 500 A: the nightstand was missing the handle on the first drawer. 2.) In the bathroom between 500 and 502: the door to room 502 had a small irregular oblong shaped hole in the right bottom corner, and there were four (4) missing oblong white floor tiles on the left side after entering the bathroom. 3.) In the bathroom 504: around the back half of the toilet base there was a dark brown rust colored unknown substance. 4.) In the bathroom between 508 and 510: the towel rack on the right side of the sink was loose, there was a brown rust colored unknown substance around the back of the toilet base, the first (1st) beige tile behind the toilet was loose and on the floor, the fifth (5th) beige baseboard tile behind the toilet was loose and the sixth (6th) beige tile behind the toilet was missing. 5.) In room 510: the ceiling paint was cracking and peeling around the light fixture for bed B. 6.) In the bathroom between room 512 and 514: the doors and door frames were marred, there was one (1) of five (5) missing border tiles on the right side of the toilet. 7.) In room 512: the ceiling paint was cracking and peeling around the light fixture for bed B. 8.) In the bathroom between room 511 and 513: the ceiling fan cover was missing, the doors and door frames were marred, there was a heavy black/brown unknown substance build up in the door frame corners and under the vanity area, the bathroom floor had a light black film of unknown substance over the floor, which was sticky to the touch, especially under the vanity area. 9.) In the bathroom between room 507 and 509: the door frame for room 509 had approximately a twelve (12) to fourteen (14) inch gap removed on the right side with no sharp edges noted, the door frame for room 507 had an irregular right triangle shaped gap removed on the bottom left side with no sharp edges noted and the brass metal stripping on the floor going into room 509 was coming loose on the left side, no sharp edges noted. Interview with the Maintenance Director on 1/28/15 at 3:35 p.m., revealed that he completes preventative maintenance on a weekly, monthly, quarterly and annual basis; however, each nursing station does have maintenance request that can be filled out by any staff member, these requests are then placed on the outside of a plastic hanging file with a paperclip and once completed, the request is signed off and placed in a box, until the box gets full and then the box is thrown away. Continued interview revealed that he checks the hanging file for requests every time he passes the two (2) nursing stations and stated that was a couple times a day. Interview with the Maintenance Director on 1/29/15 at 8:30 a.m., revealed that preventative maintenance includes checking fire extinguishers, checking door alarms, checking fire door alarms, changing air conditioner filters, and checking different equipment (kitchen and laundry). The Maintenance Director further revealed that the facility has a guardian angel program, which the supervisors go into all rooms and if there is anything wrong, then he would get a written request after their rounds. He further revealed that he was unsure of how often these rounds were held and that he can get written request from the Certified Nursing Assistants (CNA) and housekeeping staff as well. Interview with the Maintenance Director on 1/29/15 at 9:18 a.m. revealed that the 100-hall bathroom floors are being replaced starting in (MONTH) and will be completed two (2) rooms at a time. During environmental rounds with the Maintenance Director on 1/29/15 between 8:35 a.m. to 9:15 a.m., he confirmed the above concerns. Interview with the Administrator on 1/29/15 at 9:20 a.m., confirmed the renovations on the 100-hall bathrooms, and the 100 and 200 hall shower rooms. Continued interview revealed that the tile was already here in the facility. Review of the (MONTH) (YEAR) Calendar revealed that the week of 2/1/15-2/7/15 rooms 101, 106 and 111 will be completed, and the week of 2/8/15-2/14/15 rooms 108, 109, and 107 will be completed.",2018-09-01
5411,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2015-01-29,282,D,0,1,NNRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews the facility failed to ensure that staff provided care according to the fall interventions in the plan of care for one (1) resident (#62); and failed to monitor the [MEDICAL TREATMENT] for one (1) resident (#132), from a sample of thirty-one (31) residents. Findings include: Review of the clinical record for resident #132 revealed he/she was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of monthly Physician order [REDACTED]. Interview with RN Supervisor EE on 1/28/15 at 5:15 p.m. revealed that nursing staff were not documenting that the [MEDICAL TREATMENT] was being monitored for resident #132. RN EE further revealed that it was her fault, because she did not include monitoring the access site daily on the Treatment Administration Record (TAR), when the care plan was developed. Continued interview revealed that sometimes there was documentation in the Nurses Notes, but this was inconsistent. Interview with RN FF on 1/28/15 at 5:30 p.m., revealed that when resident #132 returns from [MEDICAL TREATMENT], staff assists the resident to bed, completes a physical assessment, check vital signs and documents the vital signs on the TAR. RN FF further revealed that staff then checks the left forearm fistula dressing for any bleeding. Continued interview revealed that the nurses are supposed to document daily monitoring of the access site on the TAR, but have not been doing this. Interview with the DON on 1/29/15 at 8:17 a.m., revealed that it was her expectation for nursing staff to be checking [MEDICAL TREATMENT] daily, and they should be documenting this on the TAR. Review of the (MONTH) (YEAR) TAR revealed that although the staff was documenting blood pressures before and after [MEDICAL TREATMENT], there was no indication that staff was documenting monitoring of the resident's left forearm fistula. Review of the clinical record for resident #62 revealed that she had a history of [REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed the she required extensive assistance with bed mobility, transferring and toileting. Review of the Interdisciplinary Progress Notes (IPN) dated 8/29/14 at 7:30 p.m., revealed that the resident had a fall on 8/29/14 from her wheelchair to the floor with no injuries. Two new interventions were put into place, a chair alarm was applied to her wheelchair and a maintenance requisition was completed for anti-rollbacks. Observation of the resident's wheelchair on 1/28/15 at 3:27 p.m., revealed that anti-rollbacks were not present on the wheelchair. Interview on 1/28/15 at 3:04 p.m., with RN CC and Licensed Practical Nurse (LPN) DD regarding the lack of anti-rollbacks on resident #62's wheelchair revealed that the purchase order was never received and the anti-rollbacks were never applied to the resident ' s wheelchair. Further review of the clinical record revealed that resident #62 fell on [DATE] from her bed to the floor with no injury. A new fall intervention was added to her Fall Intervention Plan (FIP) requiring that the resident be kept in areas for close observation by staff. Multiple observations of resident #62 on 1/27/15 at 2:24 p.m., 4:22 p.m., on 1/28/14 at 8:22 a.m., 9:43 a.m., on 1/29/15 at 10:23 a.m., and 11:26 a.m., revealed the resident in her bed. The only time she was observed out of the room was at lunch otherwise she remained in her room in bed. Interview with the DON and RN CC on 1/29/14 at 10:22 a.m., revealed that resident #62 gets out of bed for lunch and otherwise remains in her room in bed. The DON further revealed that the resident's family wanted her to be more interested in activities and spend time with other residents, but the resident likes to stay in bed. Continued interview with the DON, she agreed that the intervention implemented on 1/2/15 to keep the resident at the nursing station in her wheelchair was ineffective since the resident is never up. The DON further revealed that she would review the interventions already in place and implement a more appropriate intervention for resident # 62.",2018-09-01
6716,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2013-05-09,164,D,0,1,8ZR011,"Based on observation and staff interview, the facility failed to provide privacy during the provision of care and medication administration for two (2) residents (#95 and #97) from a sample of twenty eight (28) residents. Findings include: 1. Observation on 5/17/13 at 9:35 a.m. revealed Registered Nurse (RN) AA in the bathroom with resident #95. The door to the resident's room and the bathroom door were open and the resident was exposed below the waist, Interview with the nurse on 5/7/13 at 10:05 a.m. revealed that one of the doors should have been closed during patient care. Review of training schedule under resident's right for skilled nursing facilities dated 2/20/12 revealed to ensure privacy included the door should be shut when care is being given. 2. Observation on 5/17/13 at 11:52 a.m. of Licensed Practical Nurse (LPN) BB giving an Insulin injection to resident #97 in the abdomen. The resident's door was open and the privacy curtain was not closed, exposing the resident's abdomen. Interview with the nurse on 5/7/13 at 11:56 a.m. revealed that the door should have been closed and/or the privacy curtain closed. Interview with the Education Coordinator on 5/9/13 at 11:50 a.m. revealed that staff are given in-service education of resident's rights that privacy during orientation and quarterly. Review of training schedule under resident's right for skilled nursing facilities dated 2/20/12 revealed to ensure privacy included the door should be shut and the privacy curtain closed when care is being given.",2017-10-01
6717,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2013-05-09,328,D,0,1,8ZR011,"Based on observation and review of facility policy, the facility failed to store nasal cannulas properly to prevent the possibility of cross contamination for two (2) residents (#103 and #62) from ten (10) residents receiving oxygen therapy. Findings include: 1. Observations in resident #103's room on 5/7/13 at 8:46 a.m. and 5/8/13 at 7:59 a.m. revealed an uncovered nasal cannula lying across the resident's bed. Observations of resident #103 in her room on 5/7/13 at 11:13 a.m. and 4:40 p.m. and on 5/8/13 at 7:43 a.m. revealed the resident lying in bed. The wheelchair was beside the bed and a nasal cannula attached to a portable tank on the back of her wheelchair was uncovered, with the tubing wrapped around the wheelchair handle. Observations in the resident's room on 5/8/13 at 10:38 a.m. and 4:55 p.m. revealed the resident lying in bed; a nasal cannula was in the wheelchair seat, uncovered, with a pair of slippers on top of it. 2. Observations in resident #62's room on 5/8/13 at 12:55 p.m. and 4:58 p.m. revealed a nasal cannula attached to the oxygen concentrator in the resident's recliner, uncovered. Review of the facility's procedure for Respiratory Care, Oxygen Therapy - Simple Mask and Nasal Cannula revealed that when masks and cannulas are not in use, they are to be stored in a plastic bag.",2017-10-01
6718,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2013-05-09,371,E,0,1,8ZR011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview , the facility failed to ensure that food was prepared and stored properly to prevent the possibility of food-borne illness for one hundred four (104) residents receiving oral alimentation. Findings include: Observation in the kitchen on 5/6/13 at 9:40 a.m. revealed two (2) pork loins long vacuum-packed together lying in a deep sink labeled Meat prep sink. A sink [MEDICATION NAME] was in place, and the sink was three-quarters (3/4) full of cold water. The pork loins were placed diagonally in the sink and not completely immersed in the water. There was no water running over the meat. Interview with a kitchen staff member GG revealed that meat was not usually thawed that way. Interview with the Food Service Manager on 5/6/13 at 9:50 a.m. revealed that the pork was to be used for dinner on 5/6/13.",2017-10-01
6719,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2013-05-09,372,D,0,1,8ZR011,"Based on observation, the facility failed to ensure that refuse was disposed of properly. Findings include: Observation of the dumpsters with the Food Service Manager (FSM) on 5/6/13 at 10:20 a.m. revealed there were two (2) dumpsters. There was trash/debris around and behind the dumpsters, including disposable gloves, a clear plastic Chick-fil-A bag containing a box and a box containing a Michelina brand frozen dinner. The FSM confirmed the presence of the gloves scattered around the dumpsters and the fast food bag. Interview with the FSM on 5/6/13 at 10:20 a.m. revealed the Housekeeping department is responsible for keeping the area around the dumpsters clean. Interview with the administrator on 4/6/13 at 10:25 a.m. revealed he was aware of the gloves scattered around the dumpsters.",2017-10-01
6720,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2013-05-09,441,E,0,1,8ZR011,"Based on observation, staff interview and review of facility guidelines and manufacturer's recommendations, the facility failed to ensure a blood glucose monitor was properly cleaned and disinfected for one (1) resident (#97) from a sample of twenty-eight (28) residents Findings include: Observation on 5/7/13 at 11:37 a.m. reveled Licensed Practical Nurse (LPN) CC wipe a glucometer with a sanitizer wipe and immediately dry the glucometer with Kleenex tissue before and after performing a finger stick blood sugar test. Interview with the nurse on 5/7/13 at 12:03 PM revealed that she was confused, because she had been told two different ways to clean and disinfect the glucometer. Review of the facility guidelines for cleaning the glucometer and review of the manufacturer's recommendation for use of the sanitizer wipes revealed that the glucometer must remain visibly wet for a full 2 minutes. Use additional wipe(s) if needed to assure continuous two (2) minute wet contact time. Let air dry thoroughly.",2017-10-01
8147,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2011-12-22,241,D,0,1,BW4W11,"Based on observation and staff interviews the facility failed to provide care in a manner to maintain personal dignity during dining for one (1) randomly observed resident (Z). Findings include: Observation on 12/19/11 at 12:47 p.m. in the 400 Hall Solarium, during the lunch meal, revealed one (1) Certified Nursing Assistant (CNA) GG serving trays and setting up food for seven (7) residents at one table. After setting up the trays for each of the seven (7) residents, the CNA sat to feed one (1) resident. Five (5) other residents at the table fed themselves, while the seventh resident Z sat at the table with the food tray in front of her and her head down. When the first resident being fed had finished eating, the CNA began to feed the resident Z. Review of the quarterly Minimum Data Set (MDS) assessment 3.0 dated 10/27/11 assessed the resident as requiring extensive assistance with feeding and one person assist. Interview on 12/21/11 at 2:10 p.m. with CNA GG revealed she is usually without other staff members when feeding the residents in the 400 Hall Solarium. Continued interview revealed that the resident would feed herself, depending on how she is feeling. CNA GG revealed most days there are five (5) to six ( 6) residents eating lunch at the same table in the Solarium. Interview on 12/21/11 at 2:30 p.m. with Registered Nurse ( RN), Assistant Director of Nursing (ADON) concurred that any resident not being fed or receiving assistance while six (6) other residents were eating and/or being fed at the same table was a dignity issue. Continued interview revealed that the resident has days when she is very alert and other days when she is very lethargic.",2016-06-01
8148,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2011-12-22,309,D,0,1,BW4W11,"**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].#11) from a sample of thirty-seven (37) residents. Findings include: Review of the interdisciplinary progress note dated 12/16/11 revealed resident #11 was found lying on her back, on 12/15/11 at 3:15 p.m., on the floor beside her bed. An assessment was completed and no injuries were noted. However,the Physician Assistant (PA) was in the facility, notified, and assessed the resident. Neurochecks were ordered to be done per protocol for three (3) days. Review of the neurocheck worksheet revealed that neuro checks were to be done every fifteen (15) minutes for the first hour, every thirty (30) minutes for the second hour, every hour for six (6) hours, every four (4) hours for twenty-four (24) hours and then every shift up to seventy two (72) hours. Continued review revealed that after the first hour a summary should be written in the Inter Disciplinary Team (IDT) notes of the findings during neuro checks and also at the end of each shift. Review of the neurocheck worksheet for resident #11 dated 12/15/11 revealed that after the second hour, there was no evidence that the neurochecks were completed as ordered. The level of consciousness (LOC), pupils equal, round, reactive to light and accommodation (PERRLA) and hand grip were not summarized in the IDT notes, only that neurochecks were in progress or neurochecks x twenty four (24) hours on 12/16/11. Review of the IDT notes for 12/17/11 revealed no evidence of neurochecks being done. Interview with the Director of Nursing (DON) and Nurse Consultant BB on 12/21/11 at 11:15 a.m., revealed that that there was no evidence that the neurochecks were completed as ordered. Continued interview revealed that the neuro check sheet was only a worksheet and she expected the nurses to write a summary in the interdisciplinary progress notes for the seventy-two (72) hours that the neurochecks were ordered.",2016-06-01
8149,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2011-12-22,425,D,0,1,BW4W11,"Based on observations, record review, and staff interviews, the facility failed to ensure that expired medication was disposed of timely on one (1) of five (5) halls (400 Hall). Findings include: Observation on 12/20/11 at 3:15 p.m. of the Medication Cart on the 400 Hall, with Licensed Practical Nurse (LPN) EE and Consultant Registered Nurse (RN) BB revealed two (2) vials of Novolin Regular Insulin with expired disposal dates. One (1) vial was opened and dated 10/15/11 and the second vial was opened and dated 10/18/11. Labeling on both Insulin boxes revealed the Insulin should have been disposed of in forty-two (42) days. The Insulin opened 10/15/11 should have been disposed of on 11/16/11 and the Insulin opened 10/18/11 was to be disposed of 11/29/11. Interview on 12/20/11 at 3:15 p.m. with Consultant Registered Nurse concurred that the Insulins were past the disposal date. Review of the Medication Administration Record [REDACTED]. Review of the facility's policy for medication storage and disposal of Insulin revealed the Novolin Insulins had a forty-two (42) day shelf life after the first use.",2016-06-01
8150,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2011-12-22,441,E,0,1,BW4W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to maintain appropriate infection control measures to prevent the likelihood of the spread of infection for one (1) ice machine on the 200 hall and one (1) ice machine in the kitchen. Findings include: 1. Observation on 12/19/11 at 10:30 a.m. and 11:50 a.m. revealed an ice scoop in an uncovered bucket on top of the ice machine outside the chapel area at the end of the 200 hall. Interview with the Environmental Supervisor on 12/19/11 at 1:59 p.m. revealed that it is her department's responsibility to keep the ice machine by the chapel area clean and to place the ice scoop in the container in a lined bag. Continued interview revealed that the scoop should always be covered. 2. Observations on 12/19/11 at 12:00 p.m. and on 12/21/11 at 2:30 p.m. revealed an ice scoop, stored in a container with no cover, mounted on the wall next to the ice machine in the kitchen. Interview with the food service director on 12/21/11 at 2;30 p.m. revealed that the ice scoop should always be covered but that the lid to the ice scoop container was recently knocked off and a new container was ordered on [DATE] but had not arrived.",2016-06-01
8151,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2011-12-22,463,E,0,1,BW4W11,"Based on observations, staff and resident interviews, and review of Daily Room Audit log the facility failed to maintain a functioning call light system for eleven (11) of one hundred three (103) call lights checked on four (4) of five (5) halls. Findings include: 1. Observations on 12-19-11 beginning at 3:00 p.m. revealed that ten (10) call lights were not working in the following rooms: The call light cord for bed 405B was cut and the push button at the end of the cord was missing and the call light cord for bed 408A had a damaged push button and was not working. Continued observation revealed call lights for bed 110A, 203A, 500, 502A, 502B, 502C, 510A, 510B and the bathroom call light for room 510 would not light up or sound at the nursing station. Interview with Administrator and Regional Environmental Service Manager on 12-19-11 at 3:30 p.m. confirmed that the call lights were not working. Continued interview revealed that the facility has a Daily Room Audit-Maintenance sheet and that two (2) rooms are checked for repairs weekly. Interview on 12-20-11 at 10:30 a.m. with the Regional Environmental Service Manager revealed that the wires had been cut in the overhead crawl space and that was why the call lights for room 502 were not working. Further interview revealed that it was unknown how they were cut or for how long it had been that way. Review of Daily Room Audit - Maintenance log on 12-20-11 revealed that a room audit is done on two (2) rooms a week and the call light systems are checked at that time. Continued review Daily Room Audit revealed that room 110 was checked on 10-05-11, room 203 was checked on 10-04-11, room 405 was checked on 11-15-11, room 408 was checked on 11-10-11, room 500 was checked on 10-05-11, room 502 was checked on 10-10-11, and room 510 was checked on 09-22-11. There was not a separate call light check log sheet kept by the facility. 2. Observation on 12/19/11 of the call lights on the two hundred (200) hall beginning at 3:00 p.m. with Licensed Practical Nurse (LPN) AA, revealed that the call light was not working in room 203A Interview with resident X on 12/20/11 at 12:25 p.m. revealed that the call light had not been working for awhile but was unsure of how long. Continued interview revealed that the problem with the call light was fixed on 12/19/11.",2016-06-01
8152,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2011-12-22,468,D,0,1,BW4W11,"Based on observation and staff interview the facility failed to maintain firmly secured handrails on one (1) of five (5) halls. Findings include: Observation on 12-19-11 beginning at 10:15 a.m., during environmental tour, revealed that there was no hand rail at the end of 200 hall on the right wall in front of the Chapel. Further observation revealed that there was about a fourteen (14) foot section of the wall that did not have a handrail in place. Residents pass this area going to activities, meals and Church Services. Interview with the Regional Environmental Service Manager on 12-20-11 at 11:10 a.m. confirmed that there was a rail there at one time and that there should be one there now.",2016-06-01
9998,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2010-04-14,241,D,0,1,RQ0O11,"Based on observations, it was determined that the facility failed to promote a dignified dining experience in one (1) of (3) three dining rooms and failed to promote an environment that enhanced the dignity of one (1) resident (""A""). Findings include: 1. Observation on 4/12/10 from 12:35 p.m. to 12:55 p.m., of lunch served in the chapel dining room, revealed Certified Nursing Assistants (CNAs) ""AA"" and ""GG"" sitting at a table with four (4) residents while assisting them to eat. The CNAs were talking with each other about personal issues instead of interacting with the residents while they were assisting them. Continued observation revealed Licensed Practical Nurse ""BB"" entered the dining room and began speaking to a CNA in a loud, disruptive, angry tone. 2. During an interview on 4/14/10 at 8:45 a.m. with resident ""A"", CNA ""AA"" knocked on the door to the resident's room and after receiving permission to enter the room, CNA ""AA"" opened the door but continued to talk loudly to another person in the hall. The CNA entered the resident's room, looked behind the curtain, indicated that he had been looking for someone and left the room without acknowledging the resident's presence in the room. 3. Random observation on 4/13/10 at 12:20 p.m., of lunch served in the chapel dining room, revealed a resident, who was sitting in a merry walker being assisted by staff to a table. The resident was positioned, while remaining in the merry walker, along the side of the table with his/her left side closest to the table. When the resident's tray was served, the resident had to reach over the arm of the merry walker making it difficult to reach the food. Continued observation revealed that at 12:40 p.m., another staff member pulled a chair in front of the merry walker and began feeding the resident.",2015-03-01
9999,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2010-04-14,368,E,0,1,RQ0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on three (3) of four (4) residents in group interview and staff interviews, the facility failed to offer a bedtime snack to all residents. The facility has a census of 117 residents that have the potential to be effected by this failure. Findings include: During the Group Interview on 4/13/10 at 11:00 a.m., three (3) of the four (4) residents in attendance indicated that the staff did not consistently offer bedtime snacks. Resident ""B"" revealed that bedtimes snacks were only offered an average of three (3) times per week. Resident ""C"" revealed that bedtime snacks were only offered one (1) to two (2) times per week. Resident ""D"" indicated that he/she was never offered a bedtime snack. Interview on 4/13/10 at 4:30 p.m., Certified Nursing Assistant (CNA) ""CC"", who worked on the 400 hall, revealed that residents who had a [DIAGNOSES REDACTED]. Interview on 4/13/10 at 4:40 p.m. with CNA ""DD"", who worked on the 500 hall, revealed that only two (2) residents on her assignment received bedtime snacks. Continued interview revealed that the CNA was not aware of how it was determined which residents received bedtime snacks. Interview on 4/13/10 at 4:50 p.m. with CNA ""FF"" s revealed that snacks were sent from the kitchen and were labeled with residents' names. Continued interview revealed that if there are extra snacks or if residents asked for a snack, then the staff would provide them with a snack.",2015-03-01
10000,BOLINGREEN HEALTH AND REHABILITATION,115346,529 BOLINGREEN DRIVE,MACON,GA,31210,2010-04-14,369,D,0,1,RQ0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review and staff interviews, it was determined that the facility failed to provide correct adaptive drinking devices for two (2) residents (#12 and #17) of the sampled twenty-four (24) residents. Findings include: 1. Review of the clinical record for resident #12, revealed a Functional Feeding Program which included a self-feeding assessment completed by the Occupational Therapist (OT), dated 2/2/10. The OT assessed the resident to need a cup with a lid for all meals. Observation on 4/12/10 at 12:20 p.m., revealed resident #12 in the chapel dining room. A staff member poured tea from a plastic tumbler into a sippy cup (without handles) and a sip lid. The resident as observed drinking from the sippy cup. Observation on 4/13/10 at 7:50 a.m., revealed resident #12, in the solarium being fed by a staff member. The staff member gave the resident liquids from a sippy cup with two (2)handles. However, the lid of the cup was on the table and not attached to the cup. Review of the diet card revealed that the resident was to use a two (2) handled cup without the lid. At that time, the staff member stated that after reading the diet card, he/she had removed the lid. Observation on 4/13/10 at 12:20 p.m., revealed resident #12, in the chapel dining room, drinking tea from a regular plastic tumbler. A sippy cup was located on the table next to the plate of food. However, staff did not pour the tea into the cup. Interview on 4/14/10 at 10:15 a.m. with the Dietary Manager (DM) revealed that information about adaptive devices is sent through a communication slip from the therapy department. Review of the resident's diet card with the DM, revealed that the resident was to be served liquids in a two (2) handled cup with no lid. At that time, the DM, indicated that there was a mistake on the diet card and corrected it. Observation 4/14/10 at 11:00 a.m., with the DM, revealed the original communication slip from the therapy department which was dated 10/6/09, indicating that the resident should receive a cup with a lid. Interview on 4/14/10 at 11:00 a.m. with the DM revealed that she did not know where the information about the resident needing a two (2) handled cup had come from and that further investigation was indicated. 2. Review of the clinical record for resident #17, revealed a physician's orders [REDACTED]. Continued review of the clinical record revealed a plan of care to include a sippy cup with a straw. Observation on 4/14/10 at 8:00 a.m., revealed resident #17 in the solarium being assisted by staff to eat breakfast. The resident had juice in a sippy cup with a straw, but there was no lid on the cup. Interview on 4/14/10 at 10:15 a.m., the DM revealed that the resident's family had requested that the resident use a sippy cup with a straw. Continued interview revealed that the cup had a lid for a straw and that the lid should have been on the cup when the resident was being served.",2015-03-01
9900,BONTERRA NURSING CENTER,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2010-08-03,166,D,0,1,MZEE11,"Based on record reviews, review of facility's grievance policy, resident and staff interviews the facility failed to make prompt efforts to resolve grievances regarding a missing cell phone for one resident (B) and missing clothing for one (1) residents (C) from a sample of thirty (30) residents. Findings include: 1. Interview on 8/02/10 at 2:30 p.m. with resident ""B"" indicated that the resident could not locate his/her cell phone, and that it had been missing for about two (2) weeks. The resident indicated that this concern was reported to staff two (2) weeks ago, adding that his/her daughter was also aware of the missing phone. Interview on 8/02/10 at 2:45 p.m. with Unit Manager ""DD"" indicated that she was not aware of the missing cell phone. Interview on 8/02/10 at 3:00 p.m. with the daughter of resident ""B"" indicated that she reported the missing cell phone to Unit Clerk ""EE"" two (2) weeks ago and was told that since this item was not on the resident 's admitting inventory list, there was nothing that the facility could do. The daughter added that as a result, she just cancelled the cell phone service. Review of the facility's grievance log/file revealed that there was no grievance regarding the missing cell phone. 2. Interview on 8/3/10 at 9 :00 a.m. with resident ""C"" revealed that three (3)-four (4) months ago the resident reported to staff that he/she was missing about twelve (12) tee shirts. During an interview on 8/03/10 at 9:20 a.m. with Certified Nursing Assistant (CNA) ""GG"", she acknowledged that the resident had lost several tee shirts and that she continues to look for them in the laundry. ""GG"" further indicated that she would label the resident's clothing if needed and has done so in the past. She indicated that she had not told anyone about the missing clothing, adding that she would periodically try to find the clothes herself. Review of the facility's grievance log/file revealed that there was no grievance regarding this resident 's missing tee shirts. Interview on 7/30/10 at 11: 10 a.m. with Social Worker revealed that if facility staff are informed that a resident is missing personnel belongings, it should be considered a grievance and the grievance policy should be followed. Review of the facility's grievance policy revealed that if a grievance is given orally, it is the responsibility of the staff to transfer the grievance in writing. If the staff person cannot resolve the grievance immediately, the written grievance should be turned in to the Charge Nurse or Supervisor. The Charge Nurse must then submit the written grievance to the Director of Nurses or the Social Services Director for proper follow-up. There was no indication that these grievance procedures were followed for any of the above residents.",2015-04-01
9901,BONTERRA NURSING CENTER,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2010-08-03,278,D,0,1,MZEE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interview the facility failed to ensure that a resident's assessment accurately reflects the resident status for one (1) resident (#14) with wounds, and for one (1) resident (#45) for their involvement in activities, from a sample of thirty (30) residents. Findings include: 1. Record review revealed that resident #14 had been diagnosed with [REDACTED]. Wound assessments prior to June 2010 also identified the wound type as perineal [MEDICAL CONDITION]. However, review of the Minimum Data Set ((MDS) dated [DATE] revealed that the resident had a Stage IV pressure ulcer and was receiving ulcer care. Record review revealed that the resident only had one wound that was located on the sacrum. 2. Record review revealed that resident #45 had a [DIAGNOSES REDACTED]. The resident was assessed on the Minimum Data Set ((MDS) dated [DATE] as spending an average of 1/3 to 2/3 of his time involved in activities. Observation of the resident during activities on 7/26 /10 at 3:00 p.m. and on 7/27/10 at 10: 00 a.m. revealed the resident would look down at his hands and would frequently close his eyes. There was no indication that the resident was engaged in the activity. Interview on 7/30/10 at 8:30 a.m. with Activity Director confirmed that the resident was verbally incoherent and would often look away or fall asleep during an activity.",2015-04-01
9902,BONTERRA NURSING CENTER,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2010-08-03,253,E,0,1,MZEE11,"Based on observations, the facility failed to maintain repairs to ensure a sanitary, orderly and comfortable interior, for two (2) of two (2) common showers, one (1) of two (2) pantries, thirty four (34) of forty eight (48) rooms on two (2) of two (2) units. Findings include: Observations during initial tour conducted 7/26/10 at 9:15am, further observations conducted 7/27/10 at 10:00am, and environmental rounds conducted 8/2/10 at 10:00am, the following observations were made. EAST WING: Initial tour on 7/26/10 at 9:15am revealed sticky,scuffed, appearance unclean floors on east wing. A mop bucket contained dark, moldy smelling water and the bucket was dirty. 7/27/10 at 11:15am, the bathroom of resident room 127 revealed scared walls, the floor around toilet was soiled, urine was in toilet bowl and urine odor was noted within the room. 7/27/10 at 1:30pm resident room 129 had a broken drawer; resident room 135 bathroom door had a loose/broken knob; and resident room 137 had two (2) closet doors hanging off the tracks, and a strong urine odor in the bathroom. 8/2/10 at 10:00am the following were observed: Pantry had one (1) upper cabinet door missing and the ice scoop was stored in standing water. A Geri chair, parked across from Resident room 129, had peeling/cracked vinyl down outside edges of both arm rests. Resident rooms: 101= Closet doors were off track, the bathroom floor was sticky, and had a musty odor. 105= Closet doors were off track. 107= the sink cabinet left side was gouged/uneven, the bathroom floor was dirty, and rust stained. Bed 1 privacy curtain was soiled; Bed 2 headboard had a four (4) inch area of veneer broken off; Bed #4 had a rust spot on the floor due to the metal bed hitting the floor. 109= the bathroom walls were scarred, the floor sticky with a buildup of dirty in the corners, the mirror over the sink had lost it's finish and the closet doors did not close properly. 111= the molding gone around the sink was missing, Bed 1 had a soiled privacy curtain; and the closet doors were off track. 113= Closet doors were off track. 115= the right closet door was off track and a two (2) by ten (10) inches of tile was missing in front of the toilet. 119= the floor under the bedside table of bed 1had seven (7) tiles that were brown with rust; at bed 2 the over bed light had no pull cord. The floor tile was missing under the air conditioning ( AC) unit. 121= the closet doors were off track and Bed 2 privacy curtain was soiled/stained. 123= Tube feeding pump/stand was leaning, and rocked easily side to side, closet doors were off tracks, the bathroom had missing tile, two (2) by ten (10) inches, in front of toilet. 125= Closet doors were off track. 127= An area around the toilet had cracked/ brown caulking, the door was scuffed, and the wall above closet was unfinished sheet rock. WEST WING: On 8/2/10 at 10:00 am the following were observed: Pantry= the door edges of the ice machine were wrapped with peeling frayed electrical tape. Cabinet doors were off the hinges, molding was missing around the floor, floor was dirty and the lid was hanging off the trash can. Common Shower= missing eighteen (18) 2X2, and three (3) 2X2 cove tiles in the toilet area. The emergency light cover located at the tub area was missing. The back wall was missing fifteen (15) 2X2 cove moldings. The tub was out of order, but the facility indicated the part was on order. Main dining room had three (3) light bulbs that were burned out of ceiling fixtures. Resident Rooms: 108= floor tile was missing under the two (2) AC units 110= molding was missing from around the hand washing sink, and toilet seat did not fit the bowl. 114= Closet doors were off track, and the floor was scarred. 122= Closet doors were off track 126= Bed 1 had two (2) drawers that were off track and hanging, the closet doors were off tracks, molding was missing from right side of the AC unit, and the bath room light did not work. 128= Closet doors were off track 130= Two (2) drawers of a four drawer chest had missing pull handles with the screws sticking out of front that held handles, the floor under the AC unit was broken concrete, and there was cracked raised tile at bathroom doorway 134= Molding missing from the sink, scarred walls were located at bed , and at bed 1 a resident was sitting in wheelchair that was missing right handle grip. 136= Stained privacy curtain between bed 3 and Bed 4 138= Bed 2 had had one (1) drawer missing from the bedside table, three (3) closet doors were off track, and walls were scarred. 140= Bed 1 had an extension cord, walls were streaked; the bathroom floor and base boards were soiled/stained and paint was peeling from door. 142= the AC molding was missing on left side, and cove molding was missing at the sink. 146= Bed 1 had three (3) drawers of a chest off track and would not close properly; had a soiled privacy curtain; the AC molding was loose and no tile under unit. 148= Bed 2 had a mattress on the bed that was taped with electrical tape.",2015-04-01
10313,BONTERRA NURSING CENTER,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2011-04-11,309,D,1,0,W6V511,"Based on clinical record review, staff interview, and review of the facility's Policy and Procedure for Transporting Residents, the facility failed to ensure that one (1) resident (#1), on the survey of eight (8) residents, received timely surgery as ordered by the physician. Findings include: Review of the facility's Policy and Procedure for Transporting Residents revealed that the policy specified the family should always come to the facility to sign the resident out before going to any appointments, and that the family member could not meet the resident at the appointment location. Record review for Resident #1 revealed a Physician's Interim/Telephone Orders sheet of 03/23/2011 which referenced the resident having surgery on 03/29/2011. However, a Nurse's Notes entry of 03/29/2011 at 4:40 a.m. documented that the transporter was at the facility to transport the resident, but that no escort was at the facility for the resident, and therefore, the resident did not go for the procedure due to there being no escort. A Nurse's Notes entry of 03/29/2011 at 10:15 a.m. also documented that the resident had an appointment at the surgery clinic at the medical center that morning, but that the resident was unable to be transported to the appointment related to the family member not being at the facility to escort the resident. During an interview with the Director of Nursing (DON) on 04/11/2011 at 3:35 p.m., the DON stated that arrangements had been made by facility staff for a family member of Resident #1 to accompany the resident for her appointment, and that the date, time, and name of the escort had been recorded. The DON stated that the family member had called the facility's evening shift nurse prior to the appointment, and the nurse had told the family member, in error, that the family member could meet the resident at the appointment. The DON stated that when the facility discovered what the family member had been told, it was too late to transport the resident to the appointment. The DON acknowledged that the nurse should not have told the resident's family member to meet the resident at the appointment, and that the nurse had not been trained to check the Transportation Book for information regarding resident appointments. The DON stated that if the nurse had checked the Transportation Book, she would have known that the resident's family member was to accompany the resident to her surgical appointment. During an interview with Licensed Practical Nurse (LPN) ""AA"", who was the Unit Manager, on 04/11/2011 at 3:50 p.m., this LPN acknowledged that the nurse did not check the Transportation Book, nor did she look at the instruction letter that had been placed on the Medication Administration Record, [REDACTED].",2014-08-01
2363,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2018-08-02,812,F,0,1,852K11,"Based on observation, interview, record review and policy review, the facility failed to ensure the kitchen was maintained in a sanitary manner and meals were prepared and served in accordance with sanitation standards. This created the potential for food borne illness to all 116 residents who resided in the facility. Findings include: 1.Initial Kitchen Inspection The initial kitchen inspection was conducted on 7/30/18 from 9:05 a.m. - 9:31 a.m. with Dietary DD. Upon entering the kitchen, the surveyor went to the only handwashing sink located in the kitchen to perform handwashing. No soap came out of the soap dispenser. Dietary CC , who was also present in the area, stated the battery in the soap dispenser was dead and the dispenser did not work without charged batteries. Dietary DD stated the soap dispenser had been working earlier that morning. Dietary DD was asked how the surveyor could wash her hands and he stated housekeeping would have to put new batteries into the dispenser, and until that time no handwashing could be done in the kitchen. At 9:10 a.m., the dish machine area was observed. There was a black substance adhered to the stainless-steel wall located behind the dish sprayer (used for removing food from dishware prior to placing the items into the dish machine). The black substance covered an area of approximately 8 x 6. The black substance was also observed along the horizontal seam of the stainless surface approximately 18 in length on the wall behind the sprayer. A staff member, wearing gloves, was removing clean dishes from the dish machine. This staff member bent down and picked up the soiled floor mat rolled up on the floor and adjusted it with her gloved hands. The staff member then removed clean dishes from the dish machine, touching them with the contaminated gloves. She was observed to remove a couple of trays of clean dishware. She did not wash her hands or remove the soiled gloves. The batteries to the soap dispenser had not been replaced; there was no soap in the kitchen available for handwashing. At 9:25 a.m. as the surveyor and Dietary DD were exiting the kitchen to go outdoors, Dietary DD saw the Housekeeping Supervisor in the service corridor outside the back entrance of the kitchen and notified him the batteries needed to be changed for the soap dispenser. 2. Dining observation on the East Unit On 7/30/18 at 12:37 p.m. carts with residents' meals arrived on the East Unit. Dinner rolls were observed on most residents' trays in bags constructed of wax paper. At 12:44 p.m. Certified Nurse Assistant (CNA) AA was observed setting up a resident's tray. She removed a roll from the bag with her bare hands and placed it on the resident's plate. Licensed Practical Nurse (LPN) BB opened the bag with a different resident's roll and touched the roll with her bare hand while removing it from the bag. At 12:48 p.m. CNA AA was observed setting up another resident's tray and removed the roll from the bag using her bare hands. At 1:10 p.m. staff were observed placing residents' cups of coffee on top of the counter of a half wall separating the dining area in a large open room. They put sugar, sugar substitute and creamer into the beverages, stirred them and then distributed them to residents. The counter was soiled with a sticky layer as well as sugar and creamer residue. A brown colored crawling insect, confirmed by CNA AA to be a cockroach, scurried across the top of the counter where cups of coffee were sitting. This was pointed out by the surveyor to CNA A[NAME] CNA AA chased the insect around the top and side of counter, where it disappeared into a crack in the wall. The incident was also observed by LPN HH, while he was feeding dependent residents sitting at the table next to the half wall. After the insect disappeared, CNA AA went back to assisting residents with the meal. Neither CNA AA nor LPN HH notified Maintenance or Housekeeping of the insect at this time. 3. A follow up kitchen inspection on 8/1/18 between 10:15 a.m. - 10:30 a.m. The inspection was conducted with the Dietary Manager. The black substance, noted two days earlier on the initial inspection, continued to be present on the stainless-steel wall behind the sprayer in the dishwashing area. The Dietary Manager was asked what the substance was. He stated it was paint and it would not come off. However, when asked to try and scrub it off, the substance was easily removed when scrubbed with a stainless steel scrubby. The Dietary Manager verified the substance could be mildew or mold. Two staff were in the process of washing dishes. One staff member was scraping food off the dishes and stacked the soiled dishes on the dirty side of the counter at the dish machine, with gloved hands. The second staff member placed the dirty dishes into racks and then slid the rack the machine, touching the soiled items. The staff member then pulled out the clean racks of dishes from the machine. This staff member removed a rack of clean trays from the dish machine, touching them with her contaminated gloved hands, without washing her hands, sanitizing them, or removing her gloves. The Dietary Manager was present during the observation; however, did not intervene or say anything to the staff member who contaminated the clean items. The batteries had been replaced in the soap dispenser and the surveyor was able to wash her hands. 5. Staff interviews The Director of Nursing was interviewed on 8/2/18 at 10:19 a.m. in the conference room. She stated staff notified her of the cockroach observed in the dining room on 8/1/18. She stated she called Maintenance and the Administrator after she was notified. She stated she saw Maintenance going to the East Wing on 8/1/18 with the sprayer (to spray for bugs) after she notified him. She stated the facility sprayed and there was also a pest control provider that came and sprayed for bugs. When asked about how nursing staff were supposed to remove rolls from the wax bags during meal service, she stated staff were trained to tear the bags open without touching the bread with their bare hands. The DON stated, Staff are not supposed to touch the food. The Dietary Manager was interviewed on 8/2/18 at 10:59 a.m. at the East Nurses' Station and was asked about staff touching clean dishware with soiled gloves. He stated staff should be more aware during dishwashing when going from touching dirty items to clean items. He stated he was not aware of this problem. When asked about cleaning assignments/schedules, he stated the dish area was on the cleaning assignment and this included cleaning the stainless-steel wall behind the sprayer. He gave the surveyor a copy of the completed cleaning forms for (MONTH) (YEAR) and stated the dish area was to be deep cleaned twice a week. When asked if he was aware of the cockroach in the dining room during lunch on 7/30/18, he stated he was not aware of it. He stated housekeeping staff was responsible for cleaning the half wall/counter in the East Dining Room where beverages were prepared. The District Manager of Housekeeping was interviewed on 8/2/18 at 1:33 p.m. in the corridor to the West Unit. He stated the Housekeeping Supervisor's last day was on 8/31/18 and he was in the facility this week training a new Housekeeping Supervisor. When asked about the soap dispenser in the kitchen, he stated the soap dispensers were battery operated and used D batteries. He stated he had not been made aware of the need for the dispenser in the kitchen to have the batteries changed. He stated he was not aware it was the responsibility of the housekeeping staff to change the batteries and stated Anyone can do it. It is not hard at all. He stated the cover of the dispenser popped off, batteries were replaced, and the cover was then popped back on. When asked about cockroaches, he stated he saw one this morning in the service hall between the kitchen entrance and door to the outside dumpster area. He stated he did not usually see them in the facility, stating they were much worse in other facilities. 6. A performance improvement plan titled Pests and Rodents had been initiated on 1/1/18 with a target completion date of (MONTH) 31, (YEAR). The root cause analysis identified contributing factors, in pertinent part, towards the problem of bugs and rodents: kitchen sanitation and housekeeping services not available in evening hours to clean thoroughly after meals. 7. Policies Review of the undated policy titled, Handwashing Procedures Policy revealed the technique for handwashing consisted of having towels available to prevent touching the tile dispenser, turning on the water to a comfortable temperature, covering hands with germicidal liquid soap, rubbing hands together using rotary motion and some friction for 10 to 15 seconds, rinsing hands well under running water, drying hands with paper towel, and turning off the faucet with paper towel. A cleaning and sanitation policy as well as hand hygiene policy were requested of the Dietary Manager on 8/2/18 at 11:15 a.m. No additional policies were provided. 8. Cleaning Schedules/Sign off Review of the dietary department document titled Signoff Daily Sheet for the month of (MONTH) (YEAR) revealed daily cleaning assignments were in full: freezer; cooler and storeroom; trash cans and flour bins; oven, stove tops; three compartment sinks; steam table and prep table; snack carts; tray carts and pot rack; and walls, shelves, and steamer. The dish machine area (including the stainless wall with black substance on it) was not included on the Signoff Daily Sheet, indicating it was not cleaned on a daily basis. Weekly cleaning assignments were documented on the Deep Cleaning Roster in which items were cleaned the first and third Tuesday of each month. The dish machine was one of the items identified on the Deep Cleaning Roster. Although the Deep Cleaning Roster indicated areas would be cleaned twice a month, review of the roster for (MONTH) (YEAR) indicated the dish machine was cleaned once in (MONTH) (YEAR), on 7/1/18. 9. Reference Review of the Food Code U.S. Public Health Service, Food and Drug Administration, U.S. Department of Health and Human Services, 2013, Section 3-301.11 Preventing Contamination from Hands, indicated food employees shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment when serving ready to eat foods.",2020-09-01
2364,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2018-08-02,814,F,0,1,852K11,"Based on observation, interview, and record review, the facility failed to ensure the outdoor garbage refuse area was maintained in a sanitary manner. One dumpster was missing a lid for more than two days and the side doors of both dumpsters were not always closed by staff. The dumpster area was strewn with garbage during three of three days in which observations were made. Findings include: 1. An inspection of the dumpster area was conducted on 7/30/18 at 9:30 a.m. with the Dietary DD. There were two large metal dumpsters. The side doors to both dumpsters (square openings of several feet wide and high) were open; there were no staff present in the area actively throwing out garbage. Each dumpster was designed to have two plastic lids in place for covering the top of the dumpster. Each lid covered half of the top area of the dumpster. One dumpster had only one lid. Half of the top surface area of the dumpster was open to air without a mechanism to close off the dumpster to insects and rodents. During the inspection Dietary DD stated the garbage was picked up three times a week. There were multiple pieces of garbage scattered in a large area around the dumpsters, covering an area of approximately 50 feet in diameter. Garbage on the ground included rags, soiled incontinence briefs, multiple plastic items such as empty black garbage bags, lids to cups, cups, straws as well as multiple pieces of paper refuse including napkins, salt and pepper packets, sugar/sugar substitute packets, disposable gloves, numerous cigarette butts, mayonnaise and other condiment packets, and soda cans. In addition, there were two 55-gallon garbage cans filled with plastic bags of garbage that did not have lids on them. Dietary DD stated the Maintenance staff was responsible for keeping the area clean; he verified the area needed to be cleaned up and the side doors to the dumpsters should be closed. 2. An additional observation of the dumpster area with the Dietary Manager was conducted two days after the first observation, on 8/1/18 at 10:30 a.m. One of the dumpsters continued to have only one of two lids on top; half of the top surface of the dumpster was open to air, without a mechanism in place to contain the garbage from bugs and rodents. During this observation the Dietary Manager stated he called it in two days ago to the garbage disposal company and today was garbage pickup day. He also stated he expected a new dumpster with two lids to be delivered. The Maintenance Director joined the surveyor and the Dietary Manager. When asked who was responsible for cleaning the area around the dumpster, the Maintenance Director said Dietary and Housekeeping were responsible. The Maintenance Director further stated whoever put garbage into the dumpster was responsible for making sure the area was clean. When asked who was responsible for the grounds around the facility he stated that Maintenance was. The Maintenance Director verified he put a work order in to replace the lid to the dumpster. The Maintenance Director stated the lid was probably knocked off over the weekend when the last pickup was made to haul the trash. The area around the dumpster continued to have numerous pieces of garbage on the ground including a biscuit, disposable glove, cardboard, numerous pieces of paper refuse, a plastic fork, cigarette butts, etc. Although it looked like some of the refuse had been cleaned up from Monday, there continued to be a significant amount of garbage on the ground. The Dietary Manager stated his staff had cleaned up the area after the surveyor's initial observation on Monday. The side doors to the dumpsters were closed with paper signs affixed that indicated the doors were supposed to be kept closed. 3. A third observation of the dumpster area was made with the Dietary Manager on 8/2/18 at 11:05 a.m. There continued to be garbage on the ground around the dumpsters including plastic items, paper garbage, cardboard, and cigarette butts. There was a second lid on the dumpster that previously had only one lid. The Maintenance Director joined the surveyor and Dietary Manager and stated the garbage company brought it this morning. 4. The District Manager of Housekeeping was interviewed on 8/2/18 at 1:33 p.m. in the corridor to the West Unit. He stated the Housekeeping Supervisor's last day was on 7/31/18 and he was in the facility this week training a new Housekeeping Supervisor. When asked about maintaining the cleanliness of the outdoor dumpster area, he stated, We (Housekeeping staff) would help with that area, indicating it was ultimately Dietary's responsibility. The District Manager of Housekeeping stated he noticed the dumpster area was strewn with garbage on Monday and said, It didn't look good Monday. He also stated he went out and cleaned up the area. The District Manager further stated he was frustrated because when he went back out to check the area on Tuesday and Wednesday, there continued to be garbage on the ground. He stated, Racoons get in it. That's how garbage was on the ground. The District Manager of Housekeeping stated had been informed of this by staff. When asked about cockroaches, he stated he saw one this morning in the service hall (between the kitchen entrance and door to the outside dumpster area). He added that he did not usually see them in the facility, stating they were much worse in other facilities. 5. A performance improvement plan titled Pests and Rodents was initiated on 1/1/18 with a target completion date of (MONTH) 31, (YEAR). In the root cause analysis, trash around the dumpster areas and dirty dumpsters were identified as contributing factors to the problem of bugs and rodents. Review of the facility's form titled Waste Pro Collection Service Agreement Terms and Conditions dated 8/15/15 indicated under loading restrictions, the customer must adhere to recommended safety precautions when loading the container. The document read, This includes, but is not limited to weight restrictions capacity limits, and material restrictions as stated above. Materials must be loaded into the container to be removed. Service will not be rendered until these requirements are met.",2020-09-01
2365,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2017-08-31,253,E,0,1,6JHN11,"Based on observations and staff interview, the facility failed to ensure there was a clean and comfortable environment as evidenced by holes and scrapes to bedroom walls which were not repaired, closet doors being off their tracks, loose handles, door frames rusting, cove molding missing, light covering missing on a ceiling fan, and air conditioner vent covered with dirt and dust. These environmental concerns were observed in 13 resident's rooms in two of two resident wings and the West resident common area. Findings include: On 8/30/17 at 8:55 a.m., the Maintenance Manager (MM) accompanied the surveyor to the 13 rooms and common area. The following observations were made: Room 137 at 9:03 a.m. the closet doors had loose handles and were missing hasps for locking. Room 135 at 9:08 a.m. the closet doors were off the tracks. Room 133 at 9:10 a.m. there were numerous marks and cuts in the wall next to the bathroom and in need of repair. Room 127 at 9:12 a.m. the closet was being reframed and that the framework was exposed. The MM stated the reframing was started on 8/24/17. Room 117 at 9:18 a.m. the closet had exposed edges and needed to be trimmed out. Room 113 at 9:19 a.m. there was flaking paint located under the air conditioning unit and the closet doors were off the track. Room 118 at 9:39 a.m. the wall located at the head of bed two had paint peeling and in need of painting. Room 108 at 9:42 a.m. the wall located at the head of bed one was marked and gouged, and the wall located at the head of bed four was marked and gouged and in need of repair. Room 110 at 9:44 a.m. the bathroom door was marked and gouged, and had paint peeling. The cove molding was missing between the bathroom door and the room entrance door. Room 130 at 9:50 a.m. the cover plate was missing from the four-plug box electrical outlet, located between the beds. Room 136 at 9:53 a.m. the bathroom door frame was rusted through on both sides.The bathroom door had a loose handle, the wall next to bed one had multiple marks and gouges, and the closet door was off the tracks. Room 138 at 9:55 a.m. the wall located at the head of bed one had numerous marks and gouges and was in need of repair. At 10:00 a.m., in the West wing common area, the air conditioner vent, located outside of Room 116, was full of dust and dirt. Observations further revealed the ceiling fan located outside of Room 116 was missing a light cover. On 8/30/17, in the East shower area, at 10:03 a.m., stall one had broken wall tile and stall three had loose tiles. On 8/30/17, in the West shower area, at 10:05 a.m., stalls one, two, and three had markings of unknown origin located at the base of the walls, and in stall three the wall panel was pulled away from the wall. During an interview with MM, on 8/30/17 at 10:10 a.m., when asked to describe the system used by the facility to report and track maintenance issues, he stated that he normally received an email for the request and then placed it intoMaintenanceCare.com. This allowed him to track the progress and document the completion of the project. He provided a copy of thePreventive Maintenance manual for review. The manual provided a record of daily, weekly, monthly, quarterly, semiannual, and annual projects. He stated that there was a current plan to replace all of the closet doors but did not have a time line for the completion of the project.",2020-09-01
2366,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2017-08-31,468,D,0,1,6JHN11,"Based on observations and staff interview, the facility failed to ensure a safe environment as evidenced by a loose handrail, in one of two resident common areas (East common area). Findings include: Observations performed during the initial tour of the facility, on 8/28/17 at 8:51 a.m., revealed a loose handrail located outside of Room 113. The handrail could be pulled away from the wall approximately 1 to 1.5 inches. On 8/30/17 at 9:19 a.m., while touring the facility with the Maintenance Manager (MM), he was shown and made aware of the loose handrail located outside of Room 113. The handrail could still be pulled away from the wall approximately 1 to 1.5 inches. The MM stated, at that time, that he was not aware that the handrail was loose. During additional observations, on 8/31/17 at 9:15 a.m., the handrail located outside of Room 113, continued to be loose. The handrail could still be pulled away from the wall approximately 1 to 1.5 inches.",2020-09-01
2367,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2019-12-05,641,D,0,1,93QQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were accurate for one Resident (R) R#65 of 44 sampled residents for the use of oxygen (02). Findings include: Record review revealed R#65 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician Orders 12/2019, related to respiratory care, documented the following on order date of 5/29/19: 02 saturation- check each shift if less than 92 percent, see prn (as needed) oxygen order, every shift for shortness of breath (SOB); change and date all respiratory supplies and tubing weekly on Sunday, if oxygen concentrator is present, clean filter every night shift, every Sunday for oxygen. Oxygen at 3 Liters (L) per minute via nasal cannula as needed (PRN). A review of the Minimum Data Set (MDS) Admission assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) was coded at 14, which indicates minimal cognitive impairment. Section [NAME] Other Health Conditions- J1100 C. documents shortness of breath or trouble breathing when lying flat, J1300 documents tobacco use. Section O. Special Programs/Treatments, documents with a check mark- oxygen use while not a resident, and while a resident. A review of the MDS Quarterly assessment dated [DATE] in Section [NAME]- Other Health Conditions- J1100 C., documents shortness of breath or trouble breathing when lying flat, J1300 documents tobacco use. In Section O., Special Programs/Treatments, O0100 Respiratory Treatments, at oxygen- no check mark, section is blank. A review of the MDS Quarterly assessment dated [DATE] in Section [NAME] Other Health Conditions J1100 C., documents shortness of breath or trouble breathing when lying flat, J1300 documents tobacco use. In Section C., Cognitive- BIMS score 11 moderately impaired, in Section O. Special Programs/Treatments) O0100- Respiratory Treatments, at oxygen- no check mark, section is blank. A review of the resident's care plans effective 8/28/19 and 11/19/19 revealed no documentation that the resident required the use of oxygen as needed (PRN) for shortness of breath. An observation on 12/3/19 revealed that R#65 was observed asleep on his right side, the head of the bed flat, from 8:05 a.m. to 8:48 a.m. with the 02-concentrator beeping; which was heard from outside the room. An observation on 12/4/19 at 9:00 a.m. revealed the resident was observed asleep on right side with the oxygen nasal cannula in place with the 02-flow rate set at 4.5 L/min. An interview on 12/4/19 at 9:08 a.m. with Licensed Practical Nurse (LPN) LPN AA revealed that the resident is always turning up the 02-flow rate. LPN AA further revealed that the resident goes to some activities and all smoke breaks when he is awake. An interview with on 12/05/19 at 8:50 a.m. with LPN AA revealed that the resident wears the oxygen when in bed and that the resident spends most of his time in bed, and does not wear O2 while in his wheelchair. An interview was conducted with Minimum Data Set (MDS) Coordinator CC on 12/5/19 at 8:15 a.m. revealed that information is brought to the MDS Coordinators by the nursing and CNA staff and from Admissions for new residents. She confirmed the resident did wear oxygen while up in a wheelchair for the first assessment, however the resident has not been assessed on the MDS assessments for utilizing oxygen and therefore is not care planned. A review of the facility policy titled, Care Plan Policy revision date of 12/2017, reflects that each resident will have a plan of care to identify problems, needs, and strengths that will identify how the facility staff will provide services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Standard of Practice No. 1 documents that each resident will be assessed by the interdisciplinary team on admission, quarterly, annually and with a significant change in status. No. 10 documents that departmental documentation will be completed by each department representative at the completion of each assessment and will reflect pertinent care plan goals and approaches within the summary.",2020-09-01
2368,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2019-12-05,761,E,0,1,93QQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and policy review of Medication Storage/Storage of Medication, the facility failed to ensure medications were dated when opened to determine the discard date, in three of four medication carts, located on the East and West wings of the facility. Findings include: An observation was conducted on 12/03/19 starting at 2:55 p.m. of the facility's four (4) mediation carts, and a check of the three (3) medication storage rooms. An observation was conducted with Licensed Practical Nurse (LPN) LPN DD of the locked medication storage room, the room was locked, clean and organized. The locked medication refrigerator was not working. The dated 11/25/19 temperature log reflected 46 degrees Fahrenheit, the thermometer inside the refrigerator was reading 79-80 degrees Fahrenheit. No opened medications, no vaccines, no [MEDICATION NAME] tests were found. Observation on 12/3/19 at 3:00 p.m. of the West wing medication cart #2 with LPN DD revealed the following medications were found to be opened but not dated when opened for use. 1. [MEDICATION NAME] (a proton-pump inhibitor to treat heartburn) 20 mg (milligram) tablet- an opened box found containing eleven (11) tablets. 2. Two (2) [MEDICATION NAME] HCL (anesthetic and antiarrhythmic) 1% (percent) 10 ml (milliliter)/vials- both vials found opened with residual medication observed in vials. Observation on 12/3/19 at 3: 30 p.m. with Registered Nurse (RN) EE of the East Wing Medication Cart #2 revealed the following medications were found to be opened, but not dated when opened for use, that would determine the discard date as follows: 1. [MEDICATION NAME] (a daily [MEDICATION NAME] supplement) Saccharomyces boulardii lyo CNCM 1-745- an opened 20 capsule box found containing sixteen (16) capsules. 2. [MEDICATION NAME] (stool softener) 100 mg/capsule- an opened container 2/3 full of capsules remaining in the container. 3. [MEDICATION NAME] Solution (an ammonia reducer and laxative) 10 grams/15 ml- an opened 16-ounce bottle found 10% remaining in the container. 4. Geri [MEDICATION NAME] (for cough and congestion relief) [MEDICATION NAME] syrup 100 mg/5 ml- an opened 16-ounce bottle found, unable to determine content amount. 5. [MEDICATION NAME][MEDICATION NAME] (for the treatment of [REDACTED]. 6. [MEDICATION NAME](for the treatment of [REDACTED]. Observation on 12/4/19 at 1: 30 p.m. with LPN FF of the East Wing Medication Cart #1 revealed the following medications were found to be opened, but not dated when opened for use, that would determine the discard date as follows: 1. [MEDICATION NAME] HFA Discus ([MEDICATION NAME][MEDICATION NAME]) [MEDICATION NAME] and salmeterol oral inhaler 250/50- an opened box with inhaler, no resident name or open date found. 2. [MEDICATION NAME] HFA ([MEDICATION NAME][MEDICATION NAME]) 90 mcg (microgram) oral inhaler- an inhaler found, no resident name or open date found. 3. ProMod (liquid protein supplement) 32-ounce bottle- an opened 32-ounce bottle found. 4. Calcium [MEDICATION NAME] (nutritional supplement for low calcium levels) 500 mg/tablet- an opened 150 tablet container. 5. CMP Hyzing Cream 1:1 (topical cream to treat pain and inflammation) 4-ounce jar opened. An Interview conducted on 12/4/19 at 1:45 p.m. with the Director of Nursing (DON) revealed that all medications should have an open date marked on the box or the container. She also confirmed that it is the nursing staff's responsibility to date medications that are to be used multiple times, at the time they opened. A review was conducted of the facility policy titled, Medication Storage/Storage of Medication, Section 4.1, dated 2007. Policy reflects that medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure #12 documents that insulin products should be stored in the refrigerator until opened. Note the date on the label for insulin vials and pens when first used. The opened insulin vial may be stored in the refrigerator or at room temperature. Procedure #14 documents that outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately remove from stock, and disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.",2020-09-01
4248,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,155,D,0,1,BE2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy and procedure review, review of the Hospice Provider agreement and staff interviews, the facility failed to ensure the Do Not Resuscitate (DNR) status for one (1) resident (R#22) of the forty (40) sampled residents. Findings include: Review of the facility's policy titled Do Not Resuscitate (DNR) documented: A written physician's orders [REDACTED]. If there was no written DNR order, respond to a medical emergency with CPR and implement a full code. All DNR orders require two physician signatures for residents that do not sign the DNR form. Review of Agreement to Provide Services to Hospice Residents by the hospice provider revealed that hospice will furnish the facility with a copy of the patient's self-determination documents, the hospice patient's plan of care and communicate which services will be furnished by the facility for each hospice patient. At the time of admission, hospice shall provide the following: relevant documents relating to aggressiveness of care. The hospice shall provide a copy of any revisions, modifications and updates to the facility. Review of the clinical record for R#22 revealed [DIAGNOSES REDACTED]. Review of the Annual MDS dated [DATE] noted the resident did not have a condition that may result in a life expectancy of less than six months, and was receiving hospice care. Review of the care plans revealed one developed for admission to hospice services for end-stage Alzheimer's. Review of a Hospice Election and Informed Consent dated [DATE] noted a terminal [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of the facility's Advance Directive Acknowledgment form for resident R#22 dated [DATE] revealed that an advanced directive had not been executed at that time. Review of the Hospice DNR Request/Refusal form noted that the section to elect to be a DNR was checked, but the line for the resident's name was blank. Further review of this form revealed that the responsible party (RP) signed it on [DATE], but there was no physician signature as required. Review of the hospice POLST (Physician order [REDACTED]. During interview with LPN CC on [DATE] at 10:22 a.m., she stated that they had resident R#22 listed as a full code, and if they found the resident without a pulse they would do cardiopulmonary resuscitation (CPR). During further interview, she stated that they have care plan meetings with hospice staff, but the hospice staff have never let them know that R#22 was a DNR. During interview with the Social Services Director (SSD) on [DATE] at 11:14 a.m., she stated that the hospice provider had never completed their Advance Directive for R#22, as they never got their physicians to sign it. Upon further interview, she stated that when hospice completed their DNR forms, they told us (the facility) so that we could adjust our information to reflect if the resident had a change from full code to DNR. During further interview, the SSD stated that the facility had been going under the assumption that the R#22 was a full code, because hospice never let them know otherwise. The SSD further stated that when they held a care plan meeting, they just asked if there had been any changes in the advance directive, but didn't actually say what the current advance directive was. During interview with the Hospice DON on [DATE] at 11:20 a.m., she stated that when a resident was admitted to their services, they obtained a POLST form, as well as their own DNR form. During further interview, she stated that the responsible party wanted R#22 to be a DNR when the resident was placed on hospice services on [DATE], and that they put the initial DNR form in the resident's chart that had the RP's signature but had not yet been signed by the hospice physician. Upon further interview, the hospice DON stated that she did not know where the breakdown occurred as far as getting the physician-signed copy of the DNR on the resident's chart. The Hospice DON further stated that a DNR was signed by the RP when the resident was in the hospital on [DATE]. She further stated that it would have been the responsibility of the hospice case manager to put the signed DNR on the resident's chart, and that she (the hospice DON) would be responsible for talking with the SSD at the facility to let her know that they had obtained a DNR. During further interview, she stated that a hospice representative(s) usually attended residents' care plan meetings, and that it would be prudent to discuss each time what the current advance directive was so that everyone was clear. Upon further interview with the hospice DON, she provided the names of the three (3) other residents in the facility that received hospice services from their company. Review of the advance directives for these three (3) residents revealed that both the facility and hospice had the residents listed as full codes. During interview with the facility DON on [DATE] at 11:36 a.m., she stated that R#22 had not had a cardiopulmonary arrest, and so they have not had to make the decision to perform CPR on her. During interview with LPN Unit Manager EE on [DATE] at 11:55 a.m., she stated they had a list of all residents in the facility that had a DNR status. Review of this list revealed that R#22 was not on it. During interview with the SSD on [DATE] at 12:01 p.m., she stated that after talking to the resident's RP a few minutes earlier, that the RP wanted R#22 to be a full code, and to be sure that hospice was aware of this. Review of Agreement to Provide Services to Hospice Residents by the hospice provider revealed that hospice will furnish the facility with a copy of the patient's self-determination documents, the hospice patient's plan of care and communicate which services will be furnished by the facility for each hospice patient. At the time of admission, hospice shall provide the following: relevant documents relating to aggressiveness of care. The hospice shall provide a copy of any revisions, modifications and updates to the facility.",2020-01-01
4249,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,164,D,0,1,BE2O11,"Based on observation, record review, review of policy and procedure, resident and staff interviews, the facility failed to ensure privacy for one (1) non-verbal resident #130 while providing personal care in the East Wing common day area. Findings include: Review of the policy subject titled Resident's Rights effective (MONTH) 2011 documented: The 1987 Nursing Home Reform Law requires each nursing home to care for it's residents in a manner that promotes or enhances the quality of life of each resident ensuring dignity, choice and self-determination. The resident has the right to privacy during treatment and care of one's personal needs. Observation on 04/12/2016 at 11:17 a.m. revealed non-verbal R#130 seated in the common day area of East Hall. Certified Nursing Assistant (CNA) EE was observed rubbing a substance on the resident's face (later identified as A&D ointment). Although the resident was resisting by trying to block CNA EE he continued to apply the ointment to the resident's face in the East Wing common day area and did not provide the resident with privacy. Interview on 02/12/16 at 11:17 a.m. with the Licensed Practical Nurse (LPN)/Charge Nurse LL revealed the CNA should have taken the resident to his room to apply the ointment after first, telling the resident what was going to happen. Interview on 4/13/16 at 2:54 p.m. with the Director on Nursing (DON) revealed she expects all resident's dignity and privacy to be maintained and all personal care is to be given in the privacy of the resident's room with doors closed, privacy curtain pulled and blinds closed. Review of care plans created on 9/24/15 and revised on 10/15/16 documented the staff are to promote dignity by ensuring privacy for resident while providing Activity of Daily Living (ADL) care.",2020-01-01
4250,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,241,D,0,1,BE2O11,"Based on observation, record review, policy and procedure review and staff interviews, the facility failed to maintain dignity, and respect for one (1) resident (R#130), by persisting to apply ointment to the resident's face despite his/her non-verbal, physical objection in the common day area of the East Hall. The sample was forty (40) residents. Findings include: Review of the policy subject titled Resident's Rights effective (MONTH) 2011 with not revision date documented: The 1987 Nursing Home Reform Law requires each nursing home to care for it's residents in a manner that promotes or enhances the quality of life of each resident ensuring dignity, choice and self-determination. The resident has the right to refuse medication or treatment. The resident has the right to be treated with consideration, respect and dignity, to be free from mental, physical abuse, corporal punishment, involuntary seclusion and physical and chemical restraint. The resident has the right to self-determination. Observation on 04/12/2016 at 11:17 a.m. revealed R#130 seated in the common day area of the East Hall. Certified Nursing Assistant (CNA) LL was observed rubbing a substance (later identified as A&D ointment) on R#130's face. The resident resisted by blocking with his hands and shaking his head. CNA LL persisted in rubbing the substance on the resident's face while resident continued to resist. Charge Nurse EE noticed the incident and ordered CNA LL to stop. Interview with the Charge Nurse (EE) at the time of the observation revealed CNA LL should have stopped when the resident resisted. Charge Nurse EE further stated the expectation is that a CNA would take a resident into his room to apply ointment after first telling the resident what was going to happen. If a resident resists, the expectation is for the CNA to back off and let the nurse know the resident is resistive to care. Interview on 4/13/16 at 2:54 p.m. with the Director of Nursing (DON) revealed that once a resident displays any type of verbal or non-verbal refusal he expects staff to immediately step back and notify the charge nurse or supervisor of the situation. The DON revealed he also expects all resident's dignity and privacy to be maintained, and that Activity of Daily Living (ADL) care is expected to be given in the resident's room with doors closed, privacy curtain pulled and blinds closed. Review of the Incident Report dated 04/12/16 written by the East Wing Unit Manager documented: This statement certifies that I, the writer, did observe the CNA attempting to apply protective skin ointment to R#130' face. R#130 tried to resist application of ointment, began blocking his face with his arm and hand. The CNA held the resident's arm back and continued to attempt to apply ointment until finished. This occurred out in the common day area. CNA LL was suspended until further notice. Review of the Quality Assurance and Performance improvement statement written by the DON documented: The CNA was interviewed and followed up with concerns for resident rights and dignity violation and questionable abuse as CNA continued care with resident swinging hands. The CNA reported she was only trying to moisturize the resident's face and that was all. The DON assessd the resident, no bruise or pain noted upon palpitation. The family was made aware and resident is seen by Psych Services for agitation.",2020-01-01
4251,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,247,B,0,1,BE2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to provide documentation that two (2) residents (Q and R) were notified of a change in roommate. The sample size was forty (40) residents. Findings include: During interview with resident Q on 04/11/16 at 2:38 p.m., he stated that they got a new roommate about a week after they were admitted to the facility, but was not notified of this. Review of resident Q's clinical record revealed that they were admitted on [DATE]. Review of the new roommate's clinical record revealed that he was admitted to resident Q's room on 02/04/16. Review of the computerized interdisciplinary progress notes revealed there was no documentation that resident Q had been notified that he was going to get a new roommate in February. Review of resident Q's Admission Minimum Data Set ((MDS) dated [DATE] revealed that they were assessed as being cognitively intact. During interview with resident R on 04/12/16 at 9:59 a.m., he stated that they had recently gotten a new roommate, but they could not remember the date. Upon further interview, resident R stated that the staff just brought the new roommate in the room, and that he (resident R) didn't know anything about it. Review of resident R's computerized interdisciplinary progress notes since (MONTH) of (YEAR) revealed that there was no documentation of the resident being notified that they were getting a new roommate. Review of resident R's MDS dated [DATE] revealed that they were assessed as having moderately-impaired cognition. During interview with the Social Services Director (SSD) on 04/14/16 at 8:25 a.m., she stated that whenever there was a new admission to the facility, either herself, the nurse, or someone in the Admissions department would tell the resident(s) already in the room that they were going to get a new roommate. Upon further interview, she stated that this notification was always done verbally, and not documented anywhere. During interview with Licensed Practical Nurse (LPN) Unit Manager AA on 04/14/16 at 8:40 a.m., she stated that the nurses or SSD notified the resident or responsible party whenever a resident was going to get a new roommate. During further interview, she stated that she remembered telling resident R that he was going to be getting a new roommate, but that this notification was done verbally, and was not documented anywhere. During interview with the SSD on 04/14/16 at 1:47 p.m.,she verified that there was no documentation that resident Q was notified that they were getting a new roommate on 02/04/16. Upon further interview, the SSD stated that she found a SSD progress note for resident R's roommate dated 03/02/16 noting that this resident was going be moved into resident R's room, but verified there was no documentation that resident R was notified that he would be receiving a new roommate. During interview with the SSD on 04/14/16 at 2:47 p.m., she stated that the facility did not have a policy and procedure that addressed notification of residents of a change in roommate, but that it was just the facility's protocol to verbally tell them.",2020-01-01
4252,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,278,B,0,1,BE2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, hospice and facility staff interview, the facility failed to ensure that the Minimum Data Set (MDS) was accurate related to receiving hospice services for one (1) resident #22. In addition, the facility failed to ensure that the MDS was accurate related to receiving [MEDICAL TREATMENT] services and being edentulous (no teeth) for one (1) resident (#11). The sample size was forty (40) residents. Findings include: 1. Review of resident #22's Annual MDS dated [DATE] noted that they were receiving hospice care. Review of the Quarterly MDS dated [DATE] noted that they were coded as not receiving hospice care. Review of resident #22's clinical record revealed a care plan for admission to hospice services for end-stage Alzheimer's. Interview with the hospice Director of Nursing on 04/14/16 at 11:20 a.m. revealed that resident #22 had been on hospice services since 10/31/14. During interview with the Registered Nurse (RN) MDS Coordinator BB on 04/13/16 at 2:14 p.m., she stated that resident #22 should have been coded as being on hospice on the Quarterly MDS on 02/10/16. 2. During observation on 04/12/16 at 1:12 p.m. and 4:12 p.m., resident #11 was noted to be edentulous. Review of an Oral/Dental assessment dated [DATE] noted that the resident was edentulous, and had no dentures. Review of resident #11's Annual MDS dated [DATE] noted that the item of no natural teeth or tooth fragment(s) (edentulous) in the Dental section of the MDS was not selected. In addition, the Special Treatments and Programs section of this MDS revealed that the resident was coded as receiving [MEDICAL TREATMENT] services. Review of the care plans revealed that a Dental care plan had not been developed for resident #11, nor were any interventions found in any of the care plans to address the missing teeth. Further review of the care plans revealed that resident #11 received [MEDICAL TREATMENT] three times a week for a [DIAGNOSES REDACTED]. Review of the Quarterly MDS dated [DATE] revealed that the resident was coded as not receiving [MEDICAL TREATMENT] services. During interview with the RN MDS Coordinator BB on 04/13/16 at 2:14 p.m., she stated that resident #11 should have been coded as being on [MEDICAL TREATMENT] on the 03/14/16 Quarterly MDS. During further interview at 2:52 p.m., she verified that resident #11 had no teeth, and that she should have been coded as edentulous on the 12/14/15 Annual MDS.",2020-01-01
4253,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,280,D,0,1,BE2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to revise the care plan to include checking a [MEDICAL TREATMENT] for thrill and bruit to ensure patency for one (1) resident (#11). The sample size was forty (40) residents. (Refer F281) Findings include: During observation on 04/12/16 at 4:12 p.m., resident #11 was noted to have two Band-Aids to the [MEDICAL TREATMENT] on her left upper arm after she returned from [MEDICAL TREATMENT]. Upon further observation and interview at this time, the resident pointed to several healed scars on her left upper arm and stated she had had several surgeries on this arm to provide access for her [MEDICAL TREATMENT]. Review of resident #11's clinical records revealed care plans were developed for [MEDICAL TREATMENT]. Further review of these care plans revealed interventions to monitor for signs and symptoms of bleeding, but no interventions for checking the access site for thrill and bruit to ensure that it was patent. Review of the Medication Administration Records revealed no documentation that the thrill and bruit was being checked. Review of the computerized interdisciplinary progress notes revealed sporadic documentation that the thrill and bruit was being checked. During interview with the Registered Nurse (RN) Minimum Data Set Coordinator BB on 04/14/16 at 2:30 p.m., she stated that she usually did not include to check the thrill and bruit in the [MEDICAL TREATMENT] care plan.",2020-01-01
4254,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,281,D,0,1,BE2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of policy and procedure, review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10), and staff interviews, it was determined the facility failed to ensure services provided met professional standards. The facility failed to provide documentation that the thrill and bruit of a [MEDICAL TREATMENT] was being assessed consistently for one (1) resident (#11) that received [MEDICAL TREATMENT]. The sample was forty (40) residents. Findings include: Review of the policy titled [MEDICAL TREATMENT], Care of Residents Receiving [MEDICAL TREATMENT] documented: Standards- to prevent complications such as fluid overload, infection or clotting of the access area, or hemorrhage of residents receiving [MEDICAL TREATMENT]. Monitor for infection or clotting of the access area: Do not take blood pressure in arm with the [MEDICAL TREATMENT] site, Monitor for swelling, pain, redness or drainage of the shunt, Monitor bruit as ordered. Review of the National Council of State Boards of Nursing, Chapter 410-10-.02 Standards of Practice for Licensed Practical Nurses, Authority: O.C.G.[NAME] 43-1-25, 43-26-2, 43-26-3, 43-26-5, 43-26-32, and 43-26-42 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; During observation on 04/12/16 at 4:12 p.m., resident #11 was noted to have two Band-Aids to the [MEDICAL TREATMENT] on her left upper arm after she had returned from [MEDICAL TREATMENT]. Upon further observation and interview at this time, the resident pointed to several healed scars on her left upper arm and stated she had had several surgeries on this arm to provide access for her [MEDICAL TREATMENT]. Review of resident #11's clinical record revealed [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of resident #11's [MEDICAL TREATMENT] Care Plans revealed that there were no interventions to check the [MEDICAL TREATMENT] for thrill and bruit to ensure that it was patent. During interview with Licensed Practical Nurse (LPN) CC on 04/13/16 at 2:40 p.m., she stated that she checked the thrill and bruit when she gave resident #11 her medications, but did not document this. During interview with the Director of Nursing (DON) on 04/14/16 at 8:48 a.m., she stated that she would expect the staff to check a [MEDICAL TREATMENT] resident's thrill and bruit and check the [MEDICAL TREATMENT] site for bleeding, and document it in the nurse's notes. During interview with the LPN Unit Manager AA on 04/14/16 at 9:09 a.m., she stated that the thrill and bruit should be checked before the resident went to [MEDICAL TREATMENT], and when they returned. During interview with the DON on 04/14/16 at 4:10 p.m., she stated that their [MEDICAL TREATMENT] facility policy did not specify to check the thrill and bruit. Review of the interdisciplinary progress notes revealed that the thrill and bruit was checked twenty-seven (27) times since 01/29/16, over a total of seventy-six (76) days.",2020-01-01
4255,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,282,G,0,1,BE2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of policies and procedures, resident and staff interviews, the facility failed to provide care in accordance with care plan interventions caused actual harm to one resident (S) that did not receive pain medication as ordered, because it was not available. The facility also failed to provide care in accordance with care plan interventions to ensure privacy during personal care and failed to acknowledge means of communication through signs and gestures of resistance to care for one (1) non-verbal resident (#130). The sample was forty (40) residents. Findings include: 1. Review of the policy subject titled Care Plan Process effective (MONTH) 2011, with no revision date, documented: The Interdisciplinary Team will coordinate with the patient/resident/family a care plan appropriate for his/her needs or wishes based on the assessment and reassessment process within the required time frames. The team direct care planning toward attaining and maintaining the highest optimal physical, psychosocial, and functional status including advance directives. The Plan of Care identifies the date, problem, goal- measurable and realistic, time frames for achievement, interventions, specific services, frequency, resolution/goal analysis and discharge options. Review of the policy titled Pain Assessment and Management documented: Pain is assessed upon all new complaints of pain/discomfort from resident or resident's family and upon all change of behavior of resident (e.g. decreased appetite, increased depression, agitation, aggression etc.) The pain evaluation Form will be used. After the assessment is completed and if pain is identified, nursing will establish a plan of care with interventions to include non-pharmacological measures. Interview on 04/11/16 at 8:30 a.m. with resident S revealed he was in pain from pressure sores and is supposed to have [MEDICATION NAME] pain medication every four (4) hours, however he did not receive pain medication on 04/10/16 or 04/11/16 upon request. Resident S revealed he kept ringing the call light the previous evening, asking for pain medication. He was hurting and could not sleep. The staff kept telling him they were waiting on the pharmacy to deliver the medication. Review of the physician's orders [REDACTED].O.) every four (4) hours and as needed for pain (Q4 PRN). Review of the MAR for (MONTH) (YEAR) for Resident S indicated [MEDICATION NAME] five milligrams (5 mg), two (2) tablets was administered on 04/10/16 at 4:00 a.m. and the resident did not receive pain medication again until 04/12/16 at 11:30 a.m. On 04/12/16 at 6:30 p.m. S received pain medicine ([MEDICATION NAME]) and did not receive pain medication again until 12:00 a.m. on 04/13/16. Review of the care plan identified resident S had pain in her legs when up in a chair with a focus date initiated on 11/19/16. The goal documented: the resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The interventions included: Administer [MEDICATION NAME] (specify medication) as per orders; Give 1/2 hour before treatments of care; Anticipate the resident's need for pain relief and respond to any complaint of pain; Evaluate the effectiveness of pain interventions; Review for compliance, alleviating of symptoms, dosing schedule and resident satisfaction with results, impact on functional ability and impact on cognition; Monitor and documents side effects of pain medication; Monitor/record/report to the nurse any signs or symptoms of non-verbal pain, and; Notify physician if interventions are unsuccessful or if current complaint is a significant change of resident ' s past experience of pain. Further review of care plan identified resident S had Stage IV pressure area to left and right ischium and Stage III pressure area to the left heel with a focus date initiated on 12/30/15. Revision dated 03/31/16. An intervention listed related to pain was to monitor for pain and medicate as needed. Interview on 04/13/16 at 10:42 a.m. with the Licensed Practical Nurse (LPN) GG revealed he is aware of complaints of pain made by resident S. The staff reposition the resident and administer him PRN [MEDICATION NAME] as needed for pain intervention. LPN GG further stated that resident S informed them that he was in pain upon arrival to work on Monday 04/11/16. Interview on 04/13/16 at 3:46 p.m. the Administrator on 04/13/16 at 3:46 p.m. revealed revealed his expectation was for orders to be requested when a resident was down to three to five (3-5) days worth of medication. Interview with the facility Physician on 04/14/16 at 4:15 p.m. revealed that he expects pain medication to be available to resident S for pain and the pharmacy should have been contacted to re-order if the resident's [MEDICATION NAME] was running out. 2. Review of the policy subject titled Resident's Rights effective (MONTH) 2011 with not revision date documented: The 1987 Nursing Home Reform Law requires each nursing home to care for it's residents in a manner that promotes or enhances the quality of life of each resident ensuring dignity, choice and self-determination. The resident has the right to refuse medication or treatment. The resident has the right to privacy during treatment and care of one's personal needs. The resident has the right to be treated with consideration, respect and dignity, to be free from mental, physical abuse, corporal punishment, involuntary seclusion and physical and chemical restraint. The resident has the right to self-determination. Observation on 04/12/16 at 11:17 a.m. of non-verbal resident #130 revealed the resident was seated in the common area of the East hall, The Certified Nursing Assistant (CNA) EE was observed rubbing a substance (later identified as A&D ointment) on the resident's face. Resident #130 resisted by blocking the CNA with his hands and shaking his head side to side. CNA EE persisted in rubbing the substance on resident's face while resident continued to resist. Interview on 04/12/16 at 11:20 a.m. with the Licensed Practical Nurse (LPN)/Charge Nurse LL revealed the CNA should have stopped when the resident resisted and added that the CNA should have taken the resident into his/her room to apply the ointment after first, telling the resident what was going to happen. The LPN/Charge Nurse LL further stated if the resident resists, the expectation is for the aide to back off, come and get a nurse and let the nurse know that resident is resistive to care. Interview on 4/13/16 at 2:54 p.m. with the Director on Nursing (DON) revealed she expects that once a resident displays any type of verbal or non-verbal refusal, the staff to immediately step back and notify the charge nurse or supervisor of the situation. The DON further said she expects all resident's dignity and privacy to be maintained. Activities of Daily Living Care (ADL) care is expected to be given in the privacy of the resident's room with doors closed, privacy curtain pulled and blinds closed. Review of the Care Plan for Resident #130 identified the resident was unable to communicate needs due to [DIAGNOSES REDACTED]. The goal documented: The resident's needs will be anticipated and met by staff through the next review. The interventions included: Staff adhere to care plan and doctors orders; Staff to anticipate needs, and;Observe resident for signs and gestures to communicate needs. The care plan identified resident #130 had problematic manner in which resident acts characterized by ineffective coping; Agitation related to; Frustration, resistive of care with a focus date initiated on 4/12/16. The goal documented; Reduced incidents of agitated behavior. The interventions included: Allow resident time to acknowledge care that is to take place; Be careful of not invading resident's personal space and speak directly to resident before starting care, and; Approach resident slowly and explain all exercises before starting. The care plan identified resident #130 had an ADL Self Care Performance Deficit related to Stroke with an intervention to promote dignity by ensuring privacy. The care plan for identified resident #130 had chronic/progressive decline in intellectual functioning characterized by; deficit in memory, judgement, decision making and thought process related [MEDICAL CONDITION] a focus date initiated on 9/25/15. The goal documented: All resident's needs will be anticipated and met through the next review. All needs will be anticipated and performed by staff. An intervention listed documented: Explain each activity/care procedure prior to beginning it.",2020-01-01
4256,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,309,G,0,1,BE2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy and procedure review, resident and staff interviews, the facility failed to ensure pain medication was made available and administered to one (1) resident (S) that experienced daily, moderate to severe pain in the legs and pain from multiple Stage Three (III) to Stage Four (IV) pressure ulcers, this failure caused actual harm. The sample was forty (40) residents. Findings include: Review of the policy titled Pain Assessment and Management documented: Standards- All residents will be assessed for pain at time of admission, re-admission and as needed. Pain is assessed upon all new complaints of pain/discomfort from resident or resident's family. Pain management is initiated in the Medication Administration Record [REDACTED]. If the resident has pain, assess and document the score. Treatment should be provided and followed up on with 1-2 hours to document the pain score to determine the effectiveness of the treatment on the back of the MAR. Record the date and time the medication dose or treatment is administered along with the pain rating and location. A licensed nurse will sign the pain management MAR indicated [REDACTED]. The pain management MAR indicated [REDACTED]. Notify the physician if resident's response to their medication or treatment is not satisfactory and obtain a new order. Interview on 04/11/16 at 8:30 a.m. with resident S revealed he was in pain from pressure sores and is supposed to have [MEDICATION NAME] pain medication every four hours, however he did not receive pain medication on 04/10/16 or 04/11/16 upon request. Resident S further stated the facility had run out of his pain medication and were waiting on the pharmacy to deliver it and had been waiting for three (3) days. Record review for resident S revealed multiple [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented in Section C- Cognitive Patterns that resident S had a Brief Interview for Mental Status (BIMS) summary score of fifteen (15), indicating the resident was cognitively intact. Section J- Health Conditions documented the resident had been on scheduled pain management, had received pain medication in the past five (5) days, and expressed occasional, mild pain. The resident did not receive non-pharmaceutical methods of pain relief. Review of the physician's orders [REDACTED].= 0, mild pain = 1, moderate pain = 2, intolerable pain = 3, and; [MEDICATION NAME] five milligrams (5 mg), two (2) tablets by mouth (PO) every four hours (Q4) as needed (PRN) for pain. Review of the (MONTH) (YEAR) MAR for resident S indicated [MEDICATION NAME] 5 mg, two (2) tablets was administered on 04/10/16 at 4:00 a.m. and the resident did not receive pain medication again until 04/12/16 at 11:30 a.m. in which [MEDICATION NAME] 5 mg, two (2) tablet was administered. There is no documentation on the back of the MAR indicated [REDACTED] Continued review of the (MONTH) (YEAR) MAR indicated [REDACTED]. On (MONTH) 10, (YEAR) the pain scale indicated the resident had moderate pain on all three (3) shifts. On (MONTH) 11, (YEAR), the MAR indicated [REDACTED]. On (MONTH) 12, (YEAR) the MAR indicated [REDACTED]. - 11:00 p.m. shift. Review of the pharmacy form titled Controlled Substances Proof of Use form for resident S prescribed [MEDICATION NAME] HCL 5 mg, take two (2) by mouth every four hours. 04/09/16 at 7:00 p.m. the Quantity Used was two (2) and Quantity Remaining was two (2). On 04/10/16 at 4:00 a.m. the Quantity Used was two (2) and the Quantity Remaining was zero (0). Review of the Progress Notes revealed no documentation related to complaints of pain, request for pain medication by resident S or that the pain medication ([MEDICATION NAME] 5 mg) was not available for resident S. On 04/11/2016 at 7:55 a.m., a nurse documented a call was placed to the physician concerning [MEDICATION NAME] order for the resident and given permission to have pharmacy fax the prescription to the Physician's office. The resident made aware and understands. On 04/12/2016 at 10:43 a.m., a nurse documented they called the pharmacy for authorization to enter the medication emergency box (EBox). Four tablets removed and given to the charge nurse. On 04/12/2016 at 4:42 p.m. a nurse documented the Pharmacy fax confirmation indicated the [MEDICATION NAME] HCL 5 mg, two (2) tablets Q4, PRN, order is received and will be sent tonight. Resident was made aware and verbalizes understanding after visualizing the paper. Review of the Personal history and physical examination [REDACTED]. Interview on 04/13/16 at 10:42 a.m. with the Licensed Practical Nurse (LPN) GG revealed he is aware of resident's complaints of pain and that resident S had received [MEDICATION NAME] consistently since admission. LPN GG further stated resident S informed them that he was in pain upon arrival to work on Monday 04/11/16. Interview with the Director of Nursing (DON) and the Administrator on 04/13/16 at 3:46 p.m. revealed there was no specific person responsible for requesting medication orders. The Administrator revealed his expectation was for orders to be requested when a resident was down to three to five (3-5) days worth of medication. The DON further stated she planned to hold the staff on all three (3) shifts who were aware that the PRN [MEDICATION NAME] was not available for resident S accountable. Interview on 04/13/16 at 4:15 p.m. with LPN HH revealed resident S is consistent with taking his pain pills even though they are PRN. A follow up interview on 4/13/16 at 5:00 p.m. with resident S revealed he takes PRN [MEDICATION NAME] regularly. Resident S further revealed he kept ringing the call light the previous evening, asking for pain medication. He was hurting and could not sleep. The staff kept telling him they were waiting on the pharmacy to deliver the medication. Resident S described the pain as sharp and achy and rated the pain a five (5) on a scale of one to five (1-5) with five being the most painful. Review of the MAR indicated [REDACTED]. Further review of the Controlled Substances Proof of Use sheet for resident S indicated on 04/13/16 at 12:00 a.m. [MEDICATION NAME] 5 mg, quantity used was two (2) and quantity remaining was twenty eight (28). Interview on 04/14/16 at 9:31 a.m. with the Administrator revealed she interviewed resident #S and based on the interview, resident S did not miss any of the PRN [MEDICATION NAME] administration because he never asked for the medication. The Administrator added that if in fact the resident did ask for the medication, the doctor should have been called because re-orders have to be in to the pharmacy by noon. Because this was an emergency situation there could have been a written prescription over the weekend. The Administrator said this was an isolated situation that unfortunately occurred in which a resident ran out of PRN pain medication. The facility could have handled it differently by calling the pharmacy and obtaining a verbal prescription, however that was not the standard practice. The Administrator added that she or DON should have been notified by the nurse on duty when they needed assistance since it was not the normal re-ordering process. The Administrator further added that she believed this happened because an almost full pack of medication in ordinary circumstances would lasted. The quantity of pills resident S consumed led to her consuming them all in a short period of time. This was the first time the facility had to re-order for resident S since his re-admission. The Administrator concluded the nurse should have asked the pharmacy for the EBox code earlier when she learned the hard script had not been received. Interview with the facility Physician on 04/14/16 at 4:15 p.m. revealed the resident is also prescribed [MEDICATION NAME] which is a Selective Serotonin Re-uptake Inhibitor (SSRI) and can be used to help with chronic pain in conjunction with pain medication such as [MEDICATION NAME]. The physician added that he expects pain medication to be available to resident S for pain and the pharmacy should have been contacted to re-order if the resident's [MEDICATION NAME] was running out. The physician also explained that he did speak with the facility staff about making sure medications are ordered on time.",2020-01-01
4257,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2016-04-14,371,E,0,1,BE2O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy and procedure review and staff interviews the facility failed to properly maintain one (1) of two (2) ice machines in the nourishment pantry in a clean and sanitary manner. Ninety seven (97) residents from a total census of one hundred six (106) residents received an oral diet. The facility also failed to date and label open foods used to administer crushed medications in one (1) of two (2) snack refrigerators (East Hall). Two (2) residents received crushed medications on the East Hall. The sample was forty (40) residents. Findings include: 1. Observation on 04/12/16 at 8:20 a.m. of the West Hall resident nourishment pantry revealed the bin liner inside the ice machine had a substance along the front that was light brown and dark brown in color. The substance extended the entire length of the front of the bin liner. Interview on 04/12/2016 at 8:24: a.m. with the Maintenance Director revealed he/she performs preventative maintenance on the ice machine quarterly. The last service was on 03/23/16 and the brown substance must have overlooked during the last cleaning. Interview on 04/12/2016 at 8:35 a.m. with the Administrator revealed he/she did not have an explanation as to why the ice machine was dirty. The Admiinistrator instructed the Maintenance Director to shut the ice machine down immediately for cleaning. Review of the Scotsman [MEDICATION NAME] Cubers Maintenance manual documented: scale should be removed from the water system and filters changed a minimum of every six months. The bin liner should be cleaned and sanitized at the same time of scale removal and ice machine sanitation. Review of the Ice Machine Quarterly Log provided by the Maintenance Director indicated preventive maintenance was last conducted on the ice machine on 3/23/16. 2. Review of the policy titled Dietetic Service Standards of Practice documented: Food that is repackaged will be place in a leak proof, pest proof, non absorbant, sanitary container with a tight fitting lid. The container will be labeled with name of the contents and dated with the date it was transferred to the new container. Observation on 04/12/2016 at 8:12 a.m. of the East Hall snack refrigeratorin in the pantry revealed two (2) unlabeled, undated small black bowls that contained what appeared to be pudding, yellowish in color. Interview on 04/12/16 at 8:15 a.m. with the Licensed Practical Nurse (LPN) CC confirmed the black bowls contained banana pudding that is used during medication pass for crushed medications. The pudding should have been labeled and dated and he/she did not know why it was placed in the snack refrigerator without a label or date. LPN CC further stated she planned to send the pudding back to the kitchen for disposal and replacement.",2020-01-01
5539,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2015-03-12,309,D,0,1,4KF711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Findings include: Record review for resident #4 revealed a physician's orders [REDACTED]. In addition, the physician ordered [MEDICATION NAME] Sliding Scale as follows: 200 -249 = 4 units 250 - 299 = 5 units 300 - 349 = 6 units 350 - 399 = 7 units 400 - 449 = 8 units 450 - 499 = 9 units 500 = 10 units & over 500 call MD Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Further review of this MAR indicated [REDACTED]. Review of the MAR indicated [REDACTED]. The finger stick blood sugar results for those dates were as follows: 4:30 p.m. 3/1/15 = 275, 5 units [MEDICATION NAME]should have been administered 3/3/15 = 292, 5 units [MEDICATION NAME]should have been administered 3/4/15 = 200, 4 units [MEDICATION NAME]should have been administered 3/5/15 = 314, 6 units [MEDICATION NAME]should have been administered 3/6/15 = 210, 4 units [MEDICATION NAME]should have been administered 3/7/15 = 215, 4 units [MEDICATION NAME]should have been administered 3/8/15 = 200, 4 units [MEDICATION NAME]should have been administered 3/9/15 = 215, 4 units [MEDICATION NAME]should have been administered 9:00 p.m. 3/1/15 = 325, 6 units [MEDICATION NAME]should have been administered 3/3/15 = 280, 5 units [MEDICATION NAME]should have been administered 3/5/15 = 304, 6 units [MEDICATION NAME]should have been administered 3/7/15 = 208, 4 units [MEDICATION NAME]should have been administered 3/9/15 = 300, 6 units [MEDICATION NAME]should have been administered Interview on 03/12/2015 at 9:44 am with Licensed Practical Nurse (LPN) CC revealed LPN EE had failed to follow the physician's orders [REDACTED]. CC also acknowledged that there was no evidence that a blood sugar finger stick was done on 3/2/15 for 4:30 pm and 9:00 pm sliding scale coverage. She also acknowledged that there was no evidence that the [MEDICATION NAME] 14 units at 4:00 pm or [MEDICATION NAME] 47 units at 9:00 pm on 3/2/15 had been administered. Interview conducted 03/12/2015 at 9:59 am with the Director of Nursing (DON)revealed that LPN EE had not administered the sliding scale [MEDICATION NAME] per the physician order [REDACTED].",2018-08-01
5540,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2015-03-12,322,D,0,1,4KF711,"Based on record review, staff interview and review of facility policy, the facility failed to follow physician's order for one (1) resident (#70) receiving medications per eternal feeding tube, from a sample of twenty-nine (29) residents. Findings include: Observation of medication administration via enteral tube for resident #70 conducted 3/10/2015 at 9:40 a.m. revealed Licensed Practical Nurse (LPN) AA did not flush peg tube prior to administering medication. Record review for resident #70 revealed a physician's order dated (MONTH) 1, (YEAR) to flush tube with 60 milliliters (ml) of water before and after medications. Interview with AA conducted with during observation on 3/10/2015 at 9:45 a.m. revealed that she forgot to flush the tube before administering the medications. Review of facility policy for enteral tubes indicated that the tube should be flushed with at least 30 ml of water before administering medications. Interview with Director of Nursing (DON) conducted 3/12/2015 at 10:00 a.m. revealed that all licensed nurses are to follow physician's orders for flushing enteral feeding tubes before and after medication administration.",2018-08-01
6622,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2013-08-28,252,B,0,1,05JI11,"Based on observations, family, and staff interviews the facility failed to maintain an odor-free environment on one (1) of two (2) wings (East). Findings include: Observations conducted from 8/25/13 at 3:00pm until 8/28/13 at 8:30am revealed the following: On 8/25/13 at 3:00pm and 3:25pm resident room 133 had strong urine odor. On 8/26/13 at 10:00am resident room 133 smelled of urine. On 8/26/13 at 9:45am resident room 135 had an extremely strong odor of urine. On 8/26/13 at 2:00pm resident rooms 133, 135, and the common area had strong urine odors. 8/26/13 at 2:45pm resident room 108, had a strong urine odor. 8/27/13 at 10:15am strong urine odors in East wing atrium area. 8/28/13 at 8:30am resident rooms 133 and 135 had strong urine odors. Interview with a family member of resident OO conducted 8/25/13 at 3:00pm revealed that the family member visits at least two (2) times per month, and the room usually smelled of urine. An pervasive odor of urine was noted in the room during the interview. Interview with the Housekeeping Director DD on 8/28/13 at 9:35am revealed facility used an enzyme called Foul Odor Digester to break up feces/urine odors. Floor cleaners were Emerald and Liminate, both have a good smell. No family or visitors had complained of odors to the manager. Facility staff had requested housekeeping for particular odors in a particular room, and they were addressed. Deep cleaning for resident rooms are done one (1) time per month including walls, doors, floors, furniture. Compliance tours are completed morning and evening on the day shift. There are no housekeeping staff on evening or night shift. Interview with the Licensed Practical Nurse (LPN) EE on 8/28/13 at 10:00am revealed if odors are identified, housekeeping is alerted, they are prompt in attempting to rid the unit or room of odor. EE further indicated that when a urine odor is noted, the resident is checked for incontinence, as well as the room to locate the source of odor, and then the appropriate staff are notified to take care of that issue. Interview with the Administrator revealed that Grand Rounds are conducted weekly on random days, and times. Grand Rounds consist of the Administrator, Director of Nurses (DON), Infection Control nurse, Housekeeping director, and Maintenance director. Those rounds had been conducted for the past four months and no issues with odors, either in particular rooms or common areas, have been identified. The Administrator indicated that had a concern related to with odors when she first came to the facility and she had installed odor automizers through out the building.",2017-11-01
6623,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2013-08-28,281,D,0,1,05JI11,"Based on medication pass observation, review of facility policy and staff interviews, the facility failed to ensure that appropriate procedure was used when checking for placement and residual of a gastrostomy/peg tube for one (1) resident (#8) from a sample of twenty seven (27) residents. Findings include: Observation of the morning medication pass conducted 8/26/13 revealed that the Licensed Practical Nurse (LPN) FF used ten (10) cubic centimeters (cc) of water to check the placement of the peg tube for resident #8. She did not check for residual. Interview conducted 8/27/13 at 9:30AM with medication nurse FF revealed that the procedure she used to check peg placement was to place a stethoscope on the abdomen, then insert 10cc of water and then listen to hear if water goes into the stomach. FF then indicated she would administered medications and make sure no residual. She indicated that she had been inserviced and instructed to check for placement using 10cc of water. Interview conducted 8/26/13 at 1:30PM with the Director of Nursing revealed as per nursing practice and facility policy the nurse should insert a small amount of air into the tube with the syringe and listen to stomach with stethoscope for gurgling sounds and check residual. She revealed that the nurse should not have inserted 10cc of water into the tube to check for placement. Review of the facility policy for Enteral Tubes revealed that placement of the tube should be checked by inserting a small amount of air into the tube and then with the stethoscope listen to the stomach for gurgling sounds.",2017-11-01
6624,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2013-08-28,315,D,0,1,05JI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of facility policy/procedures, inservice records and staff interviews the facility failed to ensure that a urinary catheter was secure for one (1) resident (#48) from a sample of twenty-seven (27) residents. Findings Include: Record review revealed that resident #48 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Further record review revealed the resident also has Traumatic [DIAGNOSES REDACTED] from his chronic indwelling Foley. Observation of catheter care for this resident was conducted 8/26/13 at 2:40 PM and revealed there was no catheter strap in use. Review of facility policy indicated that a catheter strap was to be used to anchor the catheter to a resident leg to prevent trauma. Interview with treatment nurse AA conducted 8/26/13 at 2:45 PM revealed that the resident was born with Hypospadious and due to long term use of Foley catheter that area has reopened. AA further revealed that Urology consults have been conducted but have decided not to repair Hypospadious. The resident receives wound care daily and as necessary with Foley care. During a second interview with AA on 8/26/13 at 3:15 PM, she acknowledged that resident #48 did not have a catheter strap in use. Interview with the Director of Nursing on 8/27/13 at 9:00 AM revealed that her her expectation is that each resident with a Foley catheter will have a leg strap to secure catheter as per policy. Interview with Registered Nurse (RN) CC conducted 8/27/13 at 10:15 AM revealed all Certified Nursing Assistants (CNA) are trained on catheter care per facility's nursing standard of practice. CNAs are trained that a catheter strap is to be used to anchor the catheter to a resident's leg, to prevent trauma.",2017-11-01
6939,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2014-09-16,281,G,1,0,L74L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the Georgia Practical Nurses Practice Act, the facility failed to ensure care was provided in accordance with physician's orders [REDACTED].#1) from a sample of four (4) residents with pressure ulcers. This failure resulted in harm to this resident related to deterioration of the wound. Findings include: Review of the clinical record revealed that resident #1 was admitted in December of 2013 with [DIAGNOSES REDACTED]. Continued record review revealed that on 12/17/13 a small red area was noted to the resident's sacral area. The physician was notified and an order was obtained to cleanse the area with normal saline, apply a [MEDICATION NAME] dressing and secure with tape or [MEDICATION NAME]. On 12/29/13 the treatment was changed to cleanse the gluteal area with normal saline and apply Santyl (a [MEDICATION NAME]), cover with gauze and tape daily and as needed. Review of the treatment records for resident #1 dated 1/7/14, 1/14/14, 1/21/14 and 1/28/14 revealed that the treatment provided was not the one ordered by the physician on 12/29/13. A [MEDICATION NAME] dressing was apllied instead of the Santyl. Review of the Georgia Practical Nurses Practice Act Scope of Practice Section 2.3.2, Standards Related to Licensed Practical Nurse revealed: (c) that the nurse demonstrates attentiveness and provides client surveillance and monitoring; (j) implements appropriate aspects of client care; Cross refer to F 314.",2017-09-01
6940,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2014-09-16,282,G,1,0,L74L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and plan of care review, the facility failed to follow the plan of care related to treatment of [REDACTED].#1) from a sample of four (4) residents with pressure ulcers. This failure resulted in harm to the resident related to the deterioration of the wound. Findings include: Review of the clinical record revealed that resident #1 was admitted in December of 2013 with [DIAGNOSES REDACTED]. Continued record review revealed that on 12/17/13 a small red area was noted to the resident's sacral area. The physician was notified and an order was obtained. On 12/29/13 the order was changed to cleanse the gluteal area with normal saline and apply Santyl, cover with gauze and tape daily and as needed Review of the treatment records for resident #1 dated 1/7/14, 1/14/14, 1/21/14 and 1/28/14 revealed that the treatment were to have cleansed the gluteal/sacral area with normal saline, applied a [MEDICATION NAME] dressing and secured with [MEDICATION NAME]. Review of the Care Plan for alteration in skin integrity related to a partial thickness to gluteal cleft initiated on 12/17/13 and updated on 12/31/13, 01/07/14 and 01/22/14 revealed the facility had failed to follow one of the the interventions, which was to apply the dressing as ordered. Cross refer to F 314.",2017-09-01
6941,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2014-09-16,314,G,1,0,L74L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a observation, record review and staff interviews, the facility failed to follow physician's orders related to treatment of [REDACTED].#1) from a sample of four (4) residents with pressure ulcers. This failure resulted in harm to the resident related to deterioration of the wound. Findings include: Review of the clinical record for resident #1 revealed that the resident was admitted to the facility in December 2013 with [DIAGNOSES REDACTED]. Review of a Nurse's note dated 12/17/2013 at 3:00 p.m. revealed that the resident slid down in her wheelchair and was pulled back up into the chair by the Certified Nursing Assistant (CNA). Continued review revealed that during toileting on 12/17/13 a small red area was noted to the resident's sacral area and was attributed to friction and shearing from repeated sliding up and down in the wheelchair. The physician was notified and an order obtained to cleanse the area with normal saline, apply a [MEDICATION NAME] dressing and secure with tape or [MEDICATION NAME]. Review of the Non Decubitus Skin condition Record Form dated 12/17/13 revealed that the red area on the sacrum was described as a gluteal cleft excoriation that measured 4.5 centimeters (cm) by 2.5 cm. with scant serous drainage, no odor, tender to touch and moisture to surrounding skin. Review of a Physician's Interim/Telephone Order dated 12/29/13 revealed an order to cleanse the gluteal area with normal saline and apply Santyl (a collangenase), cover with gauze and tape daily and as needed. Review of the Non-Decubitus Skin Condition Record weekly evaluation revealed the following: -12/24/13 - The wound site was the gluteal cleft, progress was stable, measuring 4.5 cm by 3.5 cm with scant serous drainage, no odor, and pink wound bed. -12/31/13-The wound site was the gluteal cleft, progress deteriorating, measuring 7.5 cm by 6.5 cm with serosanguinous drainage, no odor, and was pink, red, and beige in color with increased excoriation. -01/07/14-The wound site was gluteal, progress was deteriorating, measuring 6.5 cm by 8.5 cm by 1 cm in depth with serosanguinous drainage, no odor, beige, brown and black in color with a note indicating an increase in the size to the sacrum. -01/14/14-The wound site was gluteal/sacral, progress was increased deterioration, measuring 13 cm by 14 cm, with moderate sersanguinous drainage, beige, brown and black in color and painful. -01/21/14-The wound site was gluteal/sacral, progress increased deterioration, measuring 14.5 cm by 15 cm, with heavy serosanguinous drainage, foul odor, beige, brown and black color. A culture was obtained. -01/28/14 The wound site was sacral/buttocks, progress deteriorating, measuring 20cm by 19cm with serosanguinous drainage and a foul odor. The color was described as multinecrotic tissue and the wound was described as painful. Review of the Wound Care Specialist Initial Evaluation done on 01/03/14 revealed that resident #1 had an unstageable wound on the left buttock, due to necrosis. The wound measured 5.5 cm in length by 6 cm in width and the depth was not measurable. There was 100% devitalized necrotic tissue. There was a light serosanguinous exudate associated with the wound. Continued review revealed in the Assessment and Plan section of the Initial Evaluation dated 01/03/14, the physician ordered a Foam, [MEDICATION NAME] (Santyl) dressing daily. Review of the treatment records for resident #1 dated 1/7/14, 1/14/14, 1/21/14 and 1/28/14 revealed that the treatment nurse cleansed the gluteal/sacral area with normal saline, applied a [MEDICATION NAME] dressing and secured with [MEDICATION NAME]. Review of a Nurse's Note dated 1/14/2014 by the wound treatment nurse revealed that the gluteal cleft wound had spread from the sacrum to the right and left buttocks. Continued review revealed that nurse documented that the treatment of [REDACTED]. The note indicated that the physician was notified and agreed with the plan of care (POC) initiated. However, there was no evidence that a physician's order had been written to change the treatment from the Santyl to the [MEDICATION NAME] dressing. Interview with the Director of Nursing (DON) and Treatment Nurse BB on 09/15/14 at 10:00 a.m. revealed that there was a discrepancy between the physician's order for treatment to resident #1 and the treatment provided by the wound care nurse. Interview with the wound physician by phone on 09/16/14 at 1:00 p.m. revealed that he remembered this resident and had ordered a [MEDICATION NAME]/Santyl dressing for treatment of [REDACTED].",2017-09-01
8185,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2012-03-01,278,D,0,1,DVKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to insure that the assessment for one (1) resident (#132) adequately reflected the resident's status from a sample of thirty-three (33) residents. Findings include: Record review for resident #132 revealed a quarterly Minimum Data Set ((MDS) dated [DATE] which assessed the resident as having no impairment of the upper or lower extremities, yet the admission MDS dated [DATE] did assess the resident as having bilateral lower extremities. A nurse's noted dated 11/14/11 indicated the resident's lower extremties were very contracted. Review of the monthly nursing summary dated 11/10/11 revealed bilateral leg contractures. Observation conducted 3/1/12 at 10:00 a.m. revealed the resident lying in bed with bilateral contractures of lower extremties and a pillow was between legs. Interview with Nursing Supervisor AA conducted 02/29/2012 at 11:00 a.m., revealed the resident does have bilateral lower extremity contractures. Interview with the MDS Coordinator BB conducted 03/01/12 at 10:20am, revealed that the MDS dated [DATE] was inaccurate and should have included bilateral lower extremity contractures.",2016-06-01
8186,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2012-03-01,279,D,0,1,DVKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the care plan, and staff interviews, the facility failed to develop a comprehensive care plan for Care Area Assessment (CAA) that triggered related to [MEDICAL CONDITION] drug use for one (1) resident (#65) from a sample of thirty-three (33) residents. Findings include: Record review revealed a Minimum Data Set (MDS) for resident #65 dated 01/30/12 which assessed the resident as receiving antipsychotic medications. Review of physician's orders [REDACTED]. The Care Area Assessment (CAA) dated 02/13/2012 indicates that [MEDICAL CONDITION] drug use was triggered and would be addressed in the Care Plan. Review of the care plan dated 02/21/12 revealed no care plan for [MEDICAL CONDITION] medications. Interview with MDS Coordinator CC conducted 02/29/12 at 10:50am. revealed, that after reviewing the CAA, a care plan should have been developed for [MEDICAL CONDITION] drug use. Interview with Nursing Supervisor AA conducted 02/29/2012 at 11:00am revealed the resident is receiving [MEDICAL CONDITION] medications and should have been included in the care plan.",2016-06-01
8187,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2012-03-01,318,D,0,1,DVKV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews and staff interviews, the facility failed ensure that a decline did not occur for one (1) residents (# 132) with limited range of motion from a sample of thirty- three (33) residents. Findings include: Record review revealed that resident #132 was admitted to the facility 10/22/11 and Minimum Data Set ((MDS) dated [DATE] assessed the resident as having bilateral contractures of lower extremities. Review of the care plan dated 10/22/11 for resident #132 revealed the resident was care planned for limited mobility of lower extremities and requires extensive to total assistance with Activities of Daily Living. Observation conducted 3/1/12 at 10:00 a.m. revealed the resident lying in bed with bilateral contractures of lower extremities and a pillow was between her legs. Review of monthly nursing summary dated 11/10/11 reveals resident has bilateral leg contractures. A nurses' note dated 11/14/11 revealed the resident's lower extremities were very contracted. Interview with Nursing Supervisor AA conducted 02/27/2012 at 11:00 a.m. revealed the resident does have bilateral lower extremity contractures but does not receive Occupational Therapy (OT), Physical Therapy (PT) or Restorative nursing care. Interview with Certified Nursing Assistant (CNA) EE conducted 02/29/2012 at 9:30am revealed the resident does have bilateral lower leg contractures, and remains in bed. EE revealed that the resident is not on the Restorative nursing program. Further interview with Nursing Supervisor AA on 03/01/12 at 10:30am revealed that the resident has not been receiving any therapy that would prevent further decline of her contractures. AA indicated a screening would be conducted and the resident would be place on the Restorative nursing program.",2016-06-01
8188,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2012-03-01,371,D,0,1,DVKV11,"Based on observations, and review of facility policy, the facility failed to store and discard food properly in the refrigerator and freezer. Findings include: Initial tour of the kitchen was conducted on 2/27/12 at 8:30 a.m. with the Dietary Director, and the Assistant Dietary Director. Observations revealed the following: 1. There was a case of chocolate milk in the refrigerator that was out of date. The use by date was 02/25/2012, staff acknowledged it was out of date and discarded the milk. 2. The freezer contained a large pot covered with plastic wrap that contained mixed vegetables and was dated 01/24/2012. The vegetables had obvious freezer burn with ice crystals, and the contents were dry and cracked. Staff acknowledged that the vegetables had freezer burn and should be discarded. Review of the facility's policy for refrigerator/freezer maintenance indicated that all leftovers must be labeled, dated and discarded after thirty (30) days.",2016-06-01
8289,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2013-04-03,253,E,1,0,X3PR11,"Based on observation and staff interview, the facility failed to provide the necessary maintenance services to address roof leaks and maintain ceiling tiles that were in good repair on one (1) wing (East Wing) of two (2) wings observed. Findings include: During an observation conducted, with the Administrator in attendance, on 04/03/2013 at 1:35 p.m. in the East Wing solarium, approximately twenty (20) ceiling tiles, located throughout the solarium room ceiling, were observed to have round water stains. Additional observation in this solarium revealed water stains on the portion of ceiling tiles which ran approximately three-fourths the length of the ceiling in this room, with the tiles being located on both sides of the center tile supporting frame. During an interview with the Administrator conducted at the time of the observation referenced above, the Administrator acknowledged that the roof leaked and that the ceiling tiles contained water stains.",2016-04-01
8643,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2012-12-12,202,D,1,0,BRIU11,"br>Based on record review, discharge document review, and staff interview, the facility failed to ensure physician documentation in the medical record regarding the involuntary discharge of one (1) resident (A), who was documented as having been discharged due to becoming a danger, on the complaint survey sample of seven (7) residents. Findings include: Record review for Resident A revealed a Nurse's Note of 11/06/2012 at 12:25 p.m. which documented that the resident had been transported to the hospital emergency room for evaluation. A facility memorandum of 11/09/2012 by the facility's Admissions Nurse, addressed to a family member of the resident, documented that the resident was unable to return to the facility due to the facility being unable to provide safe treatment. This memorandum further documented that the resident had become a danger to herself, other residents, and staff, and therefore it had been determined that the resident at that time could not be cared for at the facility. During interview with the Admission Nurse conducted on 12/12/2012 at 3:00 p.m., this nurse acknowledged that the memorandum given to the responsible party of Resident A did indicate that the resident could not return to the facility. However, further record review revealed no evidence to indicate that the physician had documented in Resident A's medical record regarding the reason for the facility's involuntary discharge of the resident.",2015-12-01
8644,BONTERRA TRANSITIONAL CARE & REHABILITATION,115555,2801 FELTON DRIVE,EAST POINT,GA,30344,2012-12-12,203,D,1,0,BRIU11,"br>Based on record review, discharge document review, and staff interview, the facility failed to provide for one (1) resident (A), on the survey sample of seven (7) residents, a written notice of discharge which included the location to which the resident was discharged , notification of the right to appeal the discharge to the State, and the contact information of the State long term care ombudsman. Findings include: Record review for Resident A revealed a Nurse's Note of 11/06/2012 at 10:00 a.m. which documented that the resident was sitting on the floor and was agitated. A subsequent Nurse's Note of 11/06/2012 at 12:25 p.m. documented that the resident had been transported to the hospital emergency room for evaluation. A facility memorandum of 11/09/2012 by the facility's Admissions Nurse, addressed to a family member of the resident and entitled Unable To Accept Resident A to the facility, documented that the resident was unable to return to the facility. This memorandum further documented that the resident had become a danger to herself, other residents, and staff, and therefore the resident at that time could not return to the facility. However, further record review, to include review of the 11/09/2012 memorandum referenced above, revealed no evidence to indicate that Resident A and the resident's family member were provided a written notice of discharge which included the location to which the resident was being discharged , a statement that the resident had the right to appeal the action to the State, and the name, address, and telephone number of the State long term care ombudsman. During an interview with the Admission Nurse conducted on 12/12/2012 at 3:00 p.m., this nurse stated that the facility had initially transferred Resident A to the hospital for evaluation, but acknowledged that the letter dated 11/09/2012 referenced above had cited potential endangerment for the safety of the resident and other residents for a reason not to return to the facility. She acknowledged that the letter given to the responsible party did indicate that the resident could not return to the facility, and acknowledged that the facility had not provided a written notice of the right of appeal.",2015-12-01
4022,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2018-05-17,656,D,0,1,QXJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to develop comprehensive care plans for vision and nutrition for one resident (R) (R #33) and for [MEDICAL CONDITION] drug use for one resident (R #45). The sample size was 33 residents. Findings include: 1. Review of R #33's clinical record revealed that he had [DIAGNOSES REDACTED]. Review of R #33's Admission Minimum Data Set ((MDS) dated [DATE] revealed that he had impaired vision with no corrective lenses; a Brief Interview for Mental Status (BIMS) score of 15 (a BIMS score of 13 to 15 indicates no cognitive impairment); needed supervision and set-up help for eating; and received [MEDICAL TREATMENT] services. Review of the Care Area Assessment Summary (CAAS) for this MDS revealed that Visual Function and Nutritional Status triggered as areas of concern, with the decision made to care plan for them. Review of R #33's care plans revealed that one was not seen for vision. Further review of his care plans revealed that an activity care plan had been developed which included interventions that he liked to read the Bible and watch television. Review of R #33's Nursing Admission Screening/History dated 3/14/18 revealed that the glasses section of the form was unchecked, indicating that he had no eyeglasses on admission to the facility. Review of a Person Centered Plan of Care Meeting Narrative Progress Note dated 3/15/18 revealed the IDT (interdisciplinary team) met with the resident for his initial person-centered plan of care meeting. Further review of this note revealed that R #33 stated that he usually wore readers for reading but didn't have any, and that the Social Services Director (SSD) would assist in trying to get him a pair. On 5/16/18 at 9:01 a.m., R #33 was observed sitting in his wheelchair in the common area on his unit, and he did not have any eyeglasses on. During interview with R #33 at this time, he stated that when he was admitted to the facility his eyeglasses were not sent from where he was previously living, and that he wore those glasses most all of the time, and especially for reading. During interview with the Licensed Practical Nurse (LPN) MDS Coordinator on 5/17/18 at 4:04 p.m., she verified that Visual Function triggered on the CAAS, with the decision to care plan, and that she did not see a care plan for vision. She further stated that each discipline did their own CAAS and developed the care plan related to their area, and that Social Services would have been responsible for developing R #33's vision care plan. During interview with the SSD on 5/17/18 at 5:54 p.m., she stated that the nurses, not her, were responsible for developing a care plan for vision. 2. During interview with R #33 on 5/16/18 at 9:01 a.m., he stated that he went to [MEDICAL TREATMENT] on Tuesdays, Thursdays, and Saturdays, and that the facility sent a snack with him as he left for the [MEDICAL TREATMENT] center. He further stated that he was not on a fluid restriction, but had been on [MEDICAL TREATMENT] for [AGE] years and knew from past experience how much fluids he could drink. Review of R #33's weights revealed that there were wide variations as follows: 3/14/18: 134.2 4/5/18: 146.4 5/2/18: 177.2 Review of a Registered Dietician's Nutrition/Dietary Note dated 5/16/18 revealed that R #33's current weight was 177.2 pounds, a gain of 43 pounds since 3/14/18, and that his IWR (ideal weight range) was 139 to 169 pounds. Further review of this dietary note revealed a plan to monitor for further weight gain. Review of R #33's care plans revealed that no care plan was seen for nutrition. During interview with the LPN MDS Coordinator on 5/17/18 at 4:04 p.m, she verified that Nutritional Status triggered on the CAAS with the decision to care plan for it, but that she did not see a nutrition care plan. During further interview, she stated that the Dietary Manager would have been responsible for developing R #33's nutrition care plan. During interview with the Dietary Manager on 5/17/18 at 4:11 p.m., she stated that the nutrition care plan was developed jointly with MDS, and that [MEDICAL TREATMENT] residents should be care planned for nutrition. She stated during further interview that R #33's nutrition care plan had gotten missed. 2. Review of the clinical record for R#45 revealed he was admitted with [DIAGNOSES REDACTED]. The resident's quarterly Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) coded as O, which indicates severe cognitive impairment. Resident's medications were coded as 7 anti-psychotics and 7 antidepressants medications were received during the last 7 days, and behaviors coded as behavior symptoms not directed towards others. (e.g., physical symptoms such as hitting or scratching self). Review of the Physician orders [REDACTED]. Review of the care plans revealed a behavioral care plan was developed with appropriate interventions including but not limited to resident will be referred to a Mental Health Behavioral Center for evaluation and a cognitive memory care plan was developed with appropriate interventions including but not limited to resident doing word puzzles; however, there was no care plan developed for [MEDICAL CONDITION] drug use. Observations on 5/16/18 at 3 p.m., and 5/17/18 at 10:00 a.m. revealed R#45 sitting at the table in the day room with other residents doing activities. He was completing word puzzles throughout the activity times with no noted distress or behaviors. Interview on 5/17/18 at 9:00 a.m. with Licensed Practical Nurse (LPN) AA, stated R#45 receives [MEDICATION NAME] and [MEDICATION NAME] as ordered by the physician. Stated when R#45 was admitted to the facility, he was not on [MEDICAL CONDITION] medications. Stated on admissions he had a flat affect, refused care and medications and was transferred to a Mental Health Center for an evaluation. Stated he was started on [MEDICATION NAME] and [MEDICATION NAME]. On 5/17/18 at 10:00 a.m., the Minimum Data Set (MDS) Coordinator was interviewed. She verified that there is no care plan for [MEDICAL CONDITION] drug use for R#45 and it should be and she will develop it now. She stated R#45 started [MEDICATION NAME] on 02/26/18 and started [MEDICATION NAME] on 2/12/18. Stated the nurses should have ensured the care plan for [MEDICAL CONDITION] medications was completed. An interview was conducted on 5/7/18 at 3:45 p.m. with the Director of Nursing (DON). She stated her expectations are for care plans to be developed and updated as needed and expects when there is a change in resident's medications or interventions for care plan updates and revisions to be completed. The DON revealed when R#45 was admitted to facility, he had self-injurious behaviors with refusal of care and refusal of medications. Stated R#45 was transferred to a Mental Health for evaluation and was started on [MEDICATION NAME] and [MEDICATION NAME]. Stated a care plan should have been developed for [MEDICAL CONDITION] medication use.",2020-09-01
4023,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2018-05-17,689,D,0,1,QXJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the failed to ensure the environment was free from potential accident hazards by not ensuring that a toilet seat was securely fastened to the commode base in one bathroom shared by two residents (R) (R #36 and R #34). The sample size was 33 residents. Findings include: 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 15 (a BIMS score of 13 to 15 indicates no cognitive impairment), and that he needed supervision with set-up help only for walking in his room and toilet use. Observation on 5/15/18 at 9:40 a.m. revealed that the commode in the bathroom shared by R #34 and R #36 had no toilet seat, and the Maintenance Director was notified. Observation of the toilet in R #34 and R #36's bathroom on 5/15/18 at 11:09 a.m. revealed that a toilet seat had been placed on top of the commode base, but it was not securely fastened and was freely movable back and forth and even became unattached from one side of the commode when it was pushed to the side. This was verified by the Maintenance Director at this time. Interview with Licensed Practical Nurse (LPN) AA at this time revealed that both R #34 and #36 were ambulatory and would independently take themselves to the bathroom. Review of R #36's Skin/Wound Note dated 4/5/18 at 5:45 p.m. revealed that the resident was noted with a burst blister to his left upper thigh, and he stated the toilet seat had come off and pinched his skin. During an interview with R #36 on 5/17/18 at 10:10 a.m., he stated that the toilet seat in his bathroom swayed to the side when he went to sit on it a month or two ago, and that it created a blister on the back of his thigh. He stated during further interview that the toilet seat was removed a couple of weeks ago because it was cracked, and that he had to use the commode without a seat on it since then. Review of a Work Order Request dated 4/5/18 revealed that the commode top was loosen (sic) in (R #36's) room, and that the toilet seat top was repaired on 4/6/18. Review of a Work Order Request dated 5/15/18 revealed that the toilet seat was loose and tightened in (R #34 and #36's) room. During interview with the Maintenance Director on 5/17/18 at 4:36 p.m., he stated that he went around and checked all the commode seats in the facility. During interview on 5/17/18 at 5:09 p.m., the Maintenance Director stated that today was the first day that he had checked the commode seats to ensure they were safe.",2020-09-01
4024,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2018-05-17,770,D,0,1,QXJP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to obtain labs timely for one resident (Resident (R) #18). This deficient practice affected one of five sampled residents. The facility census was 55. Findings include: Review of the medical record revealed that R#18 has [DIAGNOSES REDACTED]. Further review revealed an order for [REDACTED]. Interview on 5/17/18 at 4:12 p.m. with the Unit Manager Registered Nurse CC revealed that she could not see that labs were drawn for R#18 for the lab ordered on [DATE]. RN CC further revealed that the lab provider does not come to draw labs unless called by the facility. RN CC reported that she has began tracking labs that were ordered through this provider starting the middle (MONTH) but she has not reviewed any labs prior to (MONTH) to assure that they were drawn as ordered. Interview on 5/17/18 at 5:15 p.m. with the Director of Nursing (DON) revealed that there was no system in place in (MONTH) for ensuring that labs were drawn per Physician orders. and that this was brought up in the Quality Assurance meeting at the end of (MONTH) and that they are currently addressing this issue. The plan now includes that the Pharmacy Consultant, the lab company, and the Physician are involved with making recommendations for labs. The DON further revealed that the order will be written and sent to the lab company for standard lab draws for residents and that requisitions will only be completed if labs are needed outside of routine labs. Futher interview with the DON revealed that the Unit Manager is responsible for ensuring that the follow up for labs has been completed. Interview on 5/17/18 at 6:55 p.m. with the DON clarified that the Pharmacy Consultant is to identify labs that are needed to be drawn that have not been drawn. Once the recommendations are received they are sent to the Physician for orders to be written and then to lab. The DON further revealed that the Pharmacy Consultant identified the need for labs for R#18 when present at facility today. Review of documentation from the Pharmacy Consultant on 4/27/18 revealed that missed labs from 2/23/18 were identified. The Physician notated that he thought that the lab was reordered. However, the DON revealed that the lab had not been reordered. The form was supposed to go to nursing but was found in the Physician's folder and as a result nursing staff failed to follow up on the labs. All lab reports can be viewed online and that staff do not have to wait for lab reports to be sent. Review of the online lab report on 5/17/18, revealed that there had not been any labs drawn for R#18.",2020-09-01
4025,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-08-01,576,E,0,1,8U2K11,"Based on observation and resident and staff interview, the facility failed to provide mail delivery service to residents on Saturdays. This deficient practice affected all residents in the facility. The facility census was 170. Findings included: During an interview with members of the resident council on 7/31/19 at 10:30 a.m., it was revealed that residents did not received mail or packages on Saturdays. An interview on 7/31/19 at 10:40 a.m. with Resident (R) A during the resident council meeting revealed that she has received emails on Saturdays stating that her package was undeliverable. R A revealed this has happen twice that package/mail was undeliverable on Saturdays. An interview on 7/31/19 at 5:35 p.m. with the Administrator revealed that the mail is delivered to the residents by the security staff on Saturday. An interview on 7/31/19 at 6:02 p.m. with Security Guard DD revealed that the mail is delivered by the post office around 10:00 a.m. on Saturdays and placed in the mailbox located outside in front of the main entrance of the facility. He also revealed sometimes the postal worker brings the mail/packages inside to the front desk. He revealed all mail is secured and locked in the Director of Nurses (DON) office. The Security Guard revealed during orientation he was in-service to place the mail inside the DON's office and has never been in-serviced or instructed to deliver mail to the residents. An interview on 8/1/19 at 10:20 a.m. with the Administrator revealed that the facility does not have a policy on mail delivery. The Administrator revealed he was informed by the supervisor of security that the mail should be delivered to the residents by the security staff on Saturdays and cannot explain why it is not deliver.",2020-09-01
4026,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-08-01,578,D,0,1,8U2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews and the facility policy Advance Directives, the facility failed to ensure that the documentation for two of three residents (R) (R#61 and R#136) reviewed had matching information on the electronic health record (EHR), the Physician order [REDACTED]. The facility also failed to communicate the code status to the staff responsible for the resident care. The sample size was 58 residents. Findings included: 1. Review of R#136's Physician order [REDACTED]. Review of R#136's POLST form signed by the resident on [DATE] and by two physicians on [DATE] revealed that Allow Natural Death (AND)-Do Not Attempt Resuscitation was checked in the Code Status section of the form. Review of a Social Services Quarterly Review Note dated [DATE] revealed: Reviewed POLST and resident (R#136) now wants to be a DNR (Do Not Resuscitate). Form signed and forwarded to (the attending physician). Review of R#136's Profile page in the facility's EHR revealed that he had a Code Status of Full Cardiopulmonary Resuscitation (CPR). Review of R#136's Physician order [REDACTED]. Review of R#136's Advance Directives care plan dated [DATE] revealed that he wanted everything done in the event of a medical emergency, and that he had signed a POLST. During interview with the Director of Nursing (DON) on [DATE] at 4:24 p.m., she verified that R#136 had a POLST signed on [DATE] designating him as a full code, and another POLST signed on [DATE] indicating that he wanted to be a DNR. The DON verified during continued interview that the Physician order [REDACTED]. During interview with the DON on [DATE] at 12:53 p.m., she stated that when a resident's code status changed, that the Social Services Director (SSD) was usually the one to update the profile in the EHR, as well as update the advance directives care plan. The DON further stated that the SSD should communicate with the nurse if a resident's code status changed, and the nurse would be responsible for contacting the physician and writing the order for the updated code status. 2. Medical record review for R#61 revealed he was admitted to the facility on [DATE] with diagnoses, that include but not limited to: adult failure to thrive, dementia, [MEDICAL CONDITION], senile degeneration of brain. Review of the document titled Physician order [REDACTED]. Review of the EHR dashboard revealed code status full code. Review of R#61 active orders as of [DATE] revealed CPR-Full Code. Review of the care plan dated [DATE] revealed Focus: Advance Directive I have signed a POLST form, I am a Do not resuscitate (DNR). Goals: I would like for the facility to honor my wishes and Allow Natural Death to Occur. Interventions: POLST form will be reviewed upon admission and quarterly and in the event of a significant change. An interview on [DATE] at 10:38 a.m. with the Social Service Director (SSD) FF revealed it is her responsible for reviewing the residents code status during care plan and communicate any updates and changes of the code status to the nurses so that a Physician order [REDACTED].#61decided he wanted a DNR status and the care plan was updated but she failed to communicate the information to the nurse to obtain an order from the Physician. An interview on [DATE] at 10:55 a.m. with the Director of Nursing (DON) revealed she is aware there was a problem with the documentation and communication with the direct care staff of the residents in the facility code status. She revealed the facility is in the process of completing a full audit on all the residents code status for accuracy. An interview on [DATE] at 11:00 a.m. with Licensed Practical Nurse (LPN) HH revealed she would review the EHR dashboard, POLST form, and/or the Physician Order. She reviewed R#61 code status and revealed R#61 is a full code. LPN HH revealed if she walked in the room and found R#61 unresponsive with no blood pressure, no pulse and no respiration she would initiate CPR. She further revealed that when a resident's code status change the SSD would notify the nursing staff and an order would be obtain from the Physician. Review of the policy titled Advance Directive with a revised date 0f (MONTH) (YEAR) revealed: 10. The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive. 19. Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan. 20. The Director of Nursing Services or designee will notify the Attending Physician of advance directives so that appropriate orders can be documented in the resident's medical record and plan of care.",2020-09-01
4027,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-08-01,656,D,0,1,8U2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the plans of care related to gastrointestinal disorders for one resident (R#44) from a sample of 58 residents. Findings include: A review of the clinical records for Resident (R)#44 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].A further review of the resident's clinical records revealed current orders for a bowel protocol to include: milk of magnesia suspension 30 milliliters (ml) daily, as needed; [MEDICATION NAME] 1 packet in the mornings; Senna 8.6 milligrams (mg) in the mornings; [MEDICATION NAME] 1 packet in the mornings. A review of the plan of care records for the resident revealed a current plan of care for constipation. The interventions included instructions for staff to follow the facility bowel protocol for bowel management. Review of the policy titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol last revised September, 2012 revealed that staff and physician are to identify residents with gastrointestinal (GI) tract conditions and symptoms, identify and order any pertinent diagnostic evaluations necessary, identify and order cause-specific interventions, and monitor and follow-up as necessary. A review of the discharge records that accompanied R#44 from the hospital on [DATE], after he was treated there for small bowel obstruction, revealed the discharge instructions included directions for the resident to follow up with the nursing home Physician regarding outpatient colon transit study. The discharge records also documented that the resident's charge nurse at the facility was contacted to verify receipt of this referral order. A further review of the clinical record for R#44 revealed no evidence that the resident was sent out for the recommended colon transit study. However, the clinical records revealed that the resident was again admitted to the hospital on [DATE] where he was diagnosed with [REDACTED]. During an interview on 8/01/19 at 12:31 p.m. with Licensed Practical Nurse (LPN) BB who functions as the unit manager for the resident's unit, it was revealed that staff had never followed up on the referral from the hospital on [DATE] for the resident to have a bowel transit study following repeated admissions with small bowel obstruction.",2020-09-01
4028,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-08-01,657,D,0,1,8U2K11,"**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 related to pressure ulcers for one resident (#31) of three residents reviewed for pressure ulcers. Findings include: A review of the clinical records for resident (R) #31 revealed he was admitted to the facility on [DATE] with current [DIAGNOSES REDACTED]. A review of the Skin Observation Tool of 6/5/19 revealed the resident was assessed as having a pressure ulcer of the left inner ankle. A review of a Skin and Wound Weekly Re-Assessment note of 7/26/19 revealed that treatment to the wound on the left ankle of R#31 was ongoing with the wound then measuring 3cm length x 2.2cm width x 0.3cm depth. An interview on 8/01/19 at 10:51 a.m. with the Wound Care Nurse revealed that she assumed care for this resident's left ankle wound the week before and that the wound was a stage III. A review of the current physician's orders [REDACTED]. A review of the care plan records for R#31 that was last updated on 7/2019 revealed a current care plan for the resident's risk for skin breakdown and a care plan for a pressure ulcer to the left hip that had healed. There were no revisions of the pressure ulcer care plans to reflect that the resident had a current pressure ulcer on his left ankle that was being treated.",2020-09-01
4029,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-08-01,684,D,0,1,8U2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, and review of the policy, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol, the facility failed to follow up on a referral made more than 60 days before for one resident (#44) to have a gastrointestinal screen completed despite the resident being admitted to an acute care facility several times during the past six months with a [DIAGNOSES REDACTED]. The sample size was 58. Findings include: An interview with R#44 on 7/29/19 at 2:54 p.m., he revealed that he had been hospitalized several times during the previous months with gastro-intesitial (GI) issues. About two weeks prior to the date of his interview, he was again hospitalized with severe GI symptoms. Upon admission, he was diagnosed with [REDACTED]. After he was discharged back to the facility, the staff sent him back to see the surgeon at the hospital, but the surgeon said he could not see the resident because the resident needed to see a [MEDICATION NAME] in the community. A review of the clinical records for Resident (R)#44 revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the Minimum Data Set (MDS) assessment records revealed the resident had five discharge/return anticipated assessments done since (MONTH) 2019. A review of the clinical records for R#44 revealed that four of those discharges were to an acute care facility where the resident was treated for [REDACTED]. A review of the nurses' notes on 1/27/19 to 1/28/19 which documented that the resident was treated over several hours for nausea and vomiting before being sent to the acute care facility where he was admitted with abdominal and gastric pain and discomfort. A review of the nurses' notes from 4/25/19 to 4/25/19 revealed the resident again complained of abdominal pain with an episode of emesis. He was sent to the hospital where he was admitted with a [DIAGNOSES REDACTED]. A review of the nurses' notes from 5/10/19 to 5/11/19 revealed the resident was again complaining of severe abdominal pain with vomiting and was sent out to the hospital where he was admitted with a [DIAGNOSES REDACTED]. A review of a nurses' note of 5/17/2019 revealed the resident returned from the hospital stay with dietary orders and a consult order. A review of the discharge records that accompanied R#44 from the hospital on [DATE] revealed the discharge instructions included directions for the resident to follow up with the nursing home physician regarding outpatient colon transit study. The discharge records also documented that the resident's charge nurse at the facility was contacted to verify receipt of the referral order. A further review of the clinical record for R#44 revealed no evidence that the resident was sent out for the recommended colon transit study. However, the clinical records revealed that the resident was admitted to the hospital on [DATE] where he was again diagnosed with [REDACTED]. During an interview on 8/01/19 at 12:31 p.m. with Licensed Practical Nurse (LPN) BB who functions as the unit manager for the resident's unit, it was revealed that the charge nurse is responsible for making the necessary appointment when the facility receives a referral for an outside consult. If the charge nurse is unable to, then the unit manager makes the appointment. LPN BB said she was not aware when R#44 was discharged from the hospital on [DATE] that he returned with a referral to do a colon transit study. The discharge paperwork said the hospital had called the charge nurse on duty at the time to confirm that the referral was received and she would need to speak with that nurse to ascertain why the resident was not referred out for this study. During a follow-up interview on 8/01/19 at 1:16 p.m. with LPN BB it was revealed that the charge nurse had left the referral for the colon transit study with the medical records. LPN BB said the medical records clerk was responsible for making appointments at that time, but said the clerk said she had never seen the referral or made the appointment. During an interview on 8/01/19 at 5:15 p.m. with Nurse Practitioner (NP) CC, it was revealed she was not aware that the resident had returned from his hospital stay on 5/17/19 with a referral for a colon transit study. She was only aware that he had returned from his most recent hospital stay in (MONTH) with a referral for to see a GI specialist. An appointment was made for him to see the GI surgeon at the hospital, but when the GI surgeon would not see him, a referral was made to another GI specialist. That specialist would not see the resident because of his payor source, so she was working with the nurse to schedule a GI consult with another practitioner. Now that she was aware that the resident was referred for a colon transit study, she would ensure that this study was specifically requested for him on his GI visit. The NP said that it was possible the colon transit study may have prevented the resident's re-hospitalization with GI issues in July, but it was hard to say so conclusively. During an interview with the Director of Nursing (DON) on 8/01/19 at 6:31p.m. it was revealed that the facility was working on locating a GI specialist who would see R#44 based on his payor source. It was her understanding that the charge nurse did not receive a referral order, but a verbal report that the surgeon wanted the resident to have the colon transit study upon his return from the hospital on [DATE]. The DON said further that the resident has been followed by the NP since his return from the hospital, and the facility maintains the resident on a bowel protocol. Review of the policy titled, Bowel (Lower Gastrointestinal Tract) Disorders - Clinical Protocol last revised September, 2012 revealed that staff and physician are to identify residents with gastrointestinal (GI) tract conditions and symptoms, identify and order any pertinent diagnostic evaluations necessary, identify and order cause-specific interventions, and monitor and follow-up as necessary.",2020-09-01
4030,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-08-01,689,D,0,1,8U2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident and staff interview, the facility failed to provide medication administration to one resident (#119) in a safe manner to avoid accidents. Specifically, the charge nurse failed to directly administer three medications to the resident on 7/29/19. Instead, the charge nurse left the resident's medication on his over-the-bed table while he was in the shower and his roommate was left unsupervised in the room. There were four residents with a [DIAGNOSES REDACTED].#119. Findings include: During an interview on 7/29/19 at 3:22 p.m. with Resident (R)#119, it was revealed that his evening medications were left unattended by staff on his over-the bed table while he was in the shower. Observation of the resident's over-the bed table during this interview revealed a plastic pill cup containing two white pills and one tan-colored pill which the resident said he recognized as his [MEDICATION NAME] and which he should have received with his 5:00 p.m. medications. R#119 said he did not recognize the other two pills in the cup. Since he was not supposed to receive his medication until 5:00 p.m., he planned to leave the pills lying on his over-the-bed table until that time. A review of the clinical records for R#119 revealed current [DIAGNOSES REDACTED]. A further review of the clinical records revealed current orders for: [MEDICATION NAME] 3 milligrams (mg) daily for prevention of [MEDICAL CONDITION] events; [MEDICATION NAME] 20 mg in the afternoon for cholesterol; and quetiapine 75 mg daily for anxiety/agitation. A review of the Quarterly Minimum Data Set (MDS) assessment completed for R#119 on 6/9/19 revealed a Brief Interview for Mental Status (BIMS) score of 11. A score of 8-12 indicates a moderate cognitive impairment. During an interview on 7/29/19 at 3;40 p.m. with R#35, the roommate of R#119, it was revealed that a member of staff had placed the cup containing the pills on his roommate's over-the-bed table while the roommate was in the shower. A review of the Quarterly MDS assessment dated [DATE] for R#35, revealed a Brief Interview for Mental Status (BIMS) of 15. A score of 13-15 indicates the individual is cognitively intact. During an interview on 7/29/19 at 3:54 p.m. with the charge nurse on the unit, Registered Nurse (RN) AA, it was revealed that R#119 was not assessed as being able to, nor did he have a plan of care to self-administer medications. RN AA said the charge nurse is responsible for administering all medications to the resident. RN AA also said that she gave the evening medications to R#119 around 3:00 p.m., but did not stay to ensure he took them because she was busy. She confirmed that the resident had three pills in a pill cup on his over-the bed-table - one tan-colored oblong pill with 1715 written on one side and TV 3 written on the other (identified as [MEDICATION NAME] 3 mg), and two white pills - one with the number 2 imprinted on one side (identified as [MEDICATION NAME] 20 mg), and one with the number 337 imprinted on the one side (identified as 50 mg quetiapine). During an interview on 7/29/19 at 4:10 p.m., the Director of Nursing (DON) confirmed that the nurses were not to leave medications unattended in the resident's rooms. During a follow-up interview on 7/29/19 05:04 p.m., the DON said, after a brief investigation, it was determined that the charge nurse, RN AA had taken the medications found in the cup into R #119's room and had not ascertained that the resident had taken the medication before leaving. The medication was prepackaged to be given to the resident during the evening and her investigation determined that the nurse had left the medication in the resident's room unattended. The nurse was relieved of duty and the other nurses were being re-educated about the safe administration of medications. A review of the facility's incidents/accidents reports for the previous 12 months did not reveal any incidents/accidents involving medications left in residents' rooms;",2020-09-01
4031,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-08-01,842,D,0,1,8U2K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to document treatment administration for two residents (R) (#214 and #30) of three residents reviewed for pressure ulcers. Findings include: 1. Review of the Minimum Data Set (MDS) Quarterly Assessment for R#214 dated 4/26/19 revealed resident had a Brief Interview of Mental Status (BIMS) score of 15 indicating cognition intact. Resident was admitted to the facility with a stage two and stage three pressure ulcer. Review of a Physician order [REDACTED]. The Treatment Administration Record (TAR) for R#214 for April, May, and (MONTH) 2019 revealed the following dated were blank with no documentation indicating the treatment was completed: 4/20/19, 4/23/19, 4/30/19, 5/3/19, 5/6/19, 5/9/19, 5/12/19, 5/15/19, 5/30/19, 6/2/19, 6/5/19, and 6/11/19. Review of the current Physician order [REDACTED]. Review of the TAR for R#214 for (MONTH) and (MONTH) 2019 revealed the following dates were blank with no documentation indicating the treatment was completed: 6/15/19, 6/20/19, 6/25/19, 6/30/19, 7/15/19, and 7/20/19. During an interview on 8/1/19 at 11:00 a.m., R#214 revealed that the staff do change his dressing and that his wound is doing much better. Interview with the Director of Nursing (DON) on 8/1/19 at 8:48 p.m. revealed that she was not aware of so many blanks on the TARs. She stated she has told the nurses and expects them to document all treatments when given. 2. Review of the facility Weekly Pressure Ulcer Report dated 7/26/19, revealed resident (R) #30 had five facility acquired pressure wounds as follows: 1. Left Ankle - Stage 4, measures 3.0 x 4.0 x 0.4 centimeters (cm), no tunneling, with drainage and/or exudate 2. Right Ankle - Stage 4, measures 4.0 x 3.5 x 0.4 cm, no tunneling, with drainage and/or exudate 3. Right Gluteal Fold - Stage 4, measures 5.0 x 5. x 6.0 cm, with tunneling or undermining, drainage and/or exudate 4. Left Heel - Unstageable, 5.0 x 6.0 x 0 cm, no tunneling, with drainage and/or exudate 5. Right Heel - Unstageable, 5.5 x 7.0 x 0 cm, no tunneling, with drainage and/or exudate The electronic Annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident was assessed as having pressure ulcers, one Stage 2, one Stage 4, and one Unstageable pressure ulcer with suspected Deep Tissue Injury (DTI). He required extensive assistance of two staff with bed mobility and transferring. Review of the electronic physician's orders [REDACTED]. 1. Order date 7/4/19 - Dakins Solution 0.25% Apply to left (L) lateral (lat) ankle ulcer topically every day and evening shift for Health Promotion related to [MEDICAL CONDITION], clean with Normal Saline (NS), pat dry, fill with dakins wet/dry dressing (drsg), wrap with kling (type of wrap dressing), secure with tape. 2. Order date 7/4/19 - Dakins Solution 0.25% Apply to right (R) lat ankle ulcer topically every day and evening shift for Health Promotion related to [MEDICAL CONDITION], clean with Normal Saline (NS), pat dry, fill with dakins wet/dry drsg, wrap with kling, secure with tape. 3. Order date 7/22/19 - Dakins Solution 0.25% Apply to right gluteal fold topically every day and evening shift for wound wet to dry dressing, secure with foam boarder (sic) dressing. 4. Order date 7/15/19 - Dakins Solution 0.25% Apply to right gluteal fold topically every day and evening shift for wound wet to dry dressing, secure with foam boarder (sic) dressing. (discontinued 7/22/19) 5. Order date 7/31/19 - Santyl Ointment 250 Unit/Gram (gm) ([MEDICATION NAME]) Apply to left (L) heel topically every day shift for heel ulcer after cleaning with NS. Apply calcium alginate and secure with foam dressing. 6. Order date 7/4/19 - Santyl Ointment 250 Unit/GM ([MEDICATION NAME]) Apply to per additional directions topically every day shift for wound care to Left Calcaneus (heel) and cover with bordered foam dressing daily. (discontinued 7/31/19) 7. Order date 7/22/19 - Santyl Ointment 250 Unit/GM ([MEDICATION NAME]) Apply to per additional directions topically every day shift for wound care to right Calcaneus (heel) and cover with bordered foam dressing daily. 8. Order date 7/4/19 - Santyl Ointment 250 Unit/GM ([MEDICATION NAME]) Apply to per additional directions topically every day shift for wound care to right Calcaneus (heel) and cover with bordered foam dressing daily. (discontinued 7/22/19) 9. Order date 7/4/19 - Santyl Ointment 250 Unit/GM ([MEDICATION NAME]) Apply to per additional directions topically every day shift for wound care to right lower buttocks. Cleanse wound with wound cleanser, apply Santyl and gauze. Secure with abd pad and tape. (discontinued 7/15/19) Futher review of the electronic Treatment Administration Record (TAR) dated 7 1/19 - 7/31/19, revealed that multiple dates were left blank with no evidence that dressing changes and treatments were conducted. July 2019: Santyl to right heel daily, start date 7/5/19: No evidence the dressing change was done on 7/6/19; 7/7/19; 7/9/19; 7/20/19. The Santyl order was discontinued on 7/22/19, and restarted on 7/23/19. No evidence the dressing change was done on 7/27/19 and 7/28/19. Santyl to left heel daily, start date 7/5/19: No evidence the dressing change was done on 7/6/19; 7/7/19; 7/9/19; 7/20/19; 7/27/19; 7/28/19. (discontinued 7/31/19) Santyl to right lower inner buttocks daily, start date 7/5/19: No evidence the dressing change was done on 7/6/19; 7/7/19; 7/9/19; 7/15/19. (discontinued 7/15/19) Dakins Solution to right gluteal fold every day and evening shift, start date 7/22/19: No evidence the dressing change was done on the day shift on 7/27/19 and 7/28/19. No evidence the dressing was changed on the evening shift 7/23/19; 7/25/19; and 7/27/19 through 7/29/19. Dakins to left lateral ankle every day and evening shift, start date 7/4/19: No evidence the dressing was changed on the day shift on 7/6/19; 7/7/19; 7/9/19; 7/20/19; 7/27/19; 7/28/19. No evidence of dressing change on the evening shift on 7/7/19 through 7/12/19; 7/14/19 through 7/17/19; 7/19/19; 7/22/19; 7/23/19; 7/25/19; 7/27/19 through 7/29/19. Dakins to right lat ankle every day and every evening shift, start date 7/4/19: No evidence the dressing was changed on the day shift on 7/6/19; 7/7/19; 7/9/19; 7/20/19; 7/27/19; 7/28/19. No evidence of dressing change on the evening shift on 7/7/19 through 7/12/19; 7/14/19 through 7/17/19; 7/19/19; 7/22/19/ 7/23/19; 7/25/19; 7/27/19 through 7/29/19. Interview with Nurse Practitioner (NP) CC on 8/1/19 at 8:05 p.m., revealed that R#30 has [MEDICAL CONDITION], had a recent decline and was hospitalized . He developed pressure ulcers in the facility due to positioning. He was given a specialty mattress when he returned from the hospital. He goes to the wound clinic and is turned and positioned every two hours. NP CC further revealed a Magnetic Resonance Imaging (MRI) was pending for R#30, it was ordered by the wound clinic to rule out [DIAGNOSES REDACTED] of the ankles. NP CC felt the wounds would heal with care and time. Interview with the DON on 8/1/19 at 9:00 p.m., revealed she was not aware that clinical staff were not completing treatments on the weekends and the evening shift. She revealed that she identified the need for another wound care nurse and hired an experienced one about two weeks ago. Continued interview revealed that she believes that treatments were being conducted and that clinical staff just forgot to sign the TAR. The DON further revealed that the electronic dashboards gives alerts for missed documentation, however, she was not aware that R#30 had so many missing days of treatments not signed on the TAR.",2020-09-01
4032,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-08-01,868,D,0,1,8U2K11,"Based on record review and staff interview, the facility's Quality Assessment and Assurance (QAA) committee failed to meet at least quarterly during the previous year. Findings include: On 8/1/19 at 4:30 p.m., a review of the QAA records for the past year revealed that the committee last met on 3/29/109 During an interview on 8/01/19 at 8:48 p.m. with the Administrator, it was revealed that QAA committee met monthly until (MONTH) of 2019. After that time, the committee had not met. The Administrator said he had no explanation as to why the committee had not met since that time to review and work on identified quality assurance issues in the facility. The Administrator also said since he had assumed his position a month before, he had planned to convene a meeting of the committee as soon as possible, but that he had not yet had the opportunity to do so.",2020-09-01
4033,BOSTICK NURSING CENTER,115732,1700 BOSTICK CIRCLE,MILLEDGEVILLE,GA,31061,2019-11-19,923,D,1,0,ETBZ11,"> Based on observation, interview and service record review, the facility failed to maintain adequate ventilation in the bathroom of one room on the 700 hall. Findings include: During an interview on 11/19/19 at 11:50 a.m., Resident A stated that the bathroom air vent in his room did not work and had not worked since he had been at the facility. RA stated that when he takes a shower in the bathroom with the door closed, the bathroom steams up so much that he can barely see. He stated he had filed a complaint with the ombudsman's office about it. During an interview on 11/19/19 at 12:20 p.m., the Administrator stated that the air system was serviced routinely by an air conditioning company, and he had not received any complaints regarding bathroom ventilation. During an interview and observation on 11/19/19 at 1:20 p.m., Air Conditioning Technician BB stated that a test and balance was performed when the building was first built, before it opened, and the bathroom exhaust vents were set to draw up 70 cubic feet of air per minute (cfu). During an observation of the ceiling air vent in the bathroom for RA, air conditioning technician BB stated that there was probably something wrong with the vent, but he would need to return with equipment to determine what the problem was. A subsequent visit to assess the bathroom ventilation was completed on 11/22/19. A review of the air conditioning company service record revealed that a problem was identified. The service record documented that one main exhaust fan motor starter had tripped for the odd halls. The starter was reset and checked and operation was normal.",2020-09-01
7188,BOSWELL-PARKER HEALTH AND REHABILITATION,115496,1211 SILOAM ROAD,GREENSBORO,GA,30642,2013-09-05,160,D,0,1,PDPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews, the facility failed to remit the ending balance in the trust fund account within thirty (30) days of death for two (2) random residents and three (3) residents (A, B, and C) from a sample of twenty three (23) residents. There were a total of thirty-three (33) resident trust fund accounts. Findings include: Review of the Discharge Census from [DATE] through [DATE] revealed that there were fourteen (14) residents that expired within the last six (6) months. The facility failed to convey the balance of the trust account within thirty (30) days to the resident's estate for five (5) residents as follows: 1. Two (2) random residents had a date of death of [DATE], one (1) with an outstanding balance of $14.21 and one (1) with a balance of $150.07. Neither balance was remitted to the responsible parties. 2. Resident A had a date of death of [DATE], with an outstanding balance of $240.73. This was not remitted to the responsible party until [DATE], fifty-four (54) days after death. 3. Resident B had a date of death of [DATE], with an outstanding balance of $15.00, this had not been remitted to the responsible party as of [DATE]. 4. Resident C had a date of death of [DATE], with an outstanding balance of $865.46. This was not remitted to the responsible party until [DATE], forty-nine (49) days after death. Interview with the Administrator on [DATE] at 10:10 a.m., revealed that the Financial Comptroller was terminated on [DATE] and that the Regional Comptroller was in the process of reviewing the resident accounts. Continued interview revealed that she wrote up a Performance Improvement (PI) today, [DATE]. Interview with the Administrator on [DATE] at 8:15 a.m., revealed that she knew they had an issue, but didn't understand the severity of it until they started pulling the accounts for Surveyor review.",2017-07-01
7189,BOSWELL-PARKER HEALTH AND REHABILITATION,115496,1211 SILOAM ROAD,GREENSBORO,GA,30642,2013-09-05,312,D,0,1,PDPP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews, the facility failed to provide nail care for three (3) residents (#19, #20, and #23) who required assistance with Activities of Daily Living (ADLs) from a total sample of twenty-three (23) residents. Findings include: 1. Observation of resident #20 on 09/03/13 at 3:30 p.m., revealed the resident seated in a wheelchair. Continued observation revealed that her nails were long, jagged, and broken on both hands. Observation of the resident on 09/04/13 at 12:55 p.m. and on 09/05/13 at 8:15 a.m., revealed that resident's nails were long and untrimmed. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #20 required extensive assistance with one (1) person assist with personal hygiene. Review of the Comprehensive Care Plan dated 02/24/13 revealed that the resident required assistance with Activities of Daily Living (ADLs). Continued review revealed interventions to encourage participation in ADL care, and to assist with ADLs as needed. Interview with Certified Nursing Assistant (CNA) AA on 09/05/13 at 9:00 a.m., revealed that resident gets a shower every Tuesday, Thursday, and Saturday on the third (3rd) shift and a bed bath on the opposite days. Continued interview revealed that the resident can wash her face, but staff have to do everything else for her. Interview with Licensed Practical Nurse (LPN) BB on 09/05/13 at 9:30 a.m., revealed that nail care is the responsibility of all staff. Continued interview revealed that If staff see that a resident's nails are too long, they clip them down and that a podiatrist comes every three (3) months to do the resident's toenails, but nurses and CNAs are responsible for doing nail care. Interview with LPN BB on 09/05/13 at 10:10 a.m., revealed that she just finished cutting the resident's nails, and confirmed that they were too long. 2. Observation of resident # 19 on 09/03/13 at 2:30 p.m., revealed that the resident was seated in a gerichair in his room. Continued observation revealed that his fingernails were long and untrimmed with dark matter under the nails on both hands. Observation of the resident on 09/04/13 at 9:30 a.m. revealed that his fingernails were untrimmed with dark matter underneath the nails and the palm of his right hand was irritated with small fine bumps. Observation on 09/05/13 at 8:40 a.m., revealed the resident sitting up in his gerichair in his room. Continued observation revealed that both hands were bandaged with a Kling dressing, his fingers were exposed, and the nails were observed to be long, and untrimmed with dark matter underneath. Review of the Quarterly MDS assessment dated [DATE] revealed that the resident was totally dependent with one (1) person assist for personal hygiene. Review of the Comprehensive Care Plan dated 01/12/12 revealed that the was totally dependent for ADLs with interventions to provide resident with all ADL's. Interview with CNA CC on 09/05/13 at 9:05 a.m., revealed that she takes care of resident, and he requires total care. Continued interview revealed that sometimes he fights, scratches, and curses, at staff when he is receiving care; however, she does not provide nail care. Interview with the Director of Nursing (DON) on 09/05/13 at 10:00 a.m., revealed that CNA's are responsible for nail care as part of their ADL care. Continued interview revealed that her expectation was that if a resident's nails were dirty and/or untrimmed that staff would clean and/or cut the nails. 3. Observation of resident # 23 on 09/03/13 at 11:00 a.m., revealed the resident seated in her wheelchair in her room with her left hand fingers in her mouth. Continued observation revealed that her fingernails were long and untrimmed. Observation of the resident on 09/04/13 at 8:40 a.m., revealed the resident in her room seated in her wheelchair. The nails on both hands were long and the nails on the left hand had dark material underneath them. Observation of the resident on 09/05/13 at 9:00 a.m. revealed the resident in her room, seated in her wheelchair with her fingers in her mouth. Continued observation revealed her nail polish was old, and chipped, with the nails long and untrimmed and dark material underneath them. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that she required limited assistance with personal hygiene with one (1) person assist. Review of the Comprehensive Care Plan dated 01/23/13 revealed that she required extensive assistance with ADLs. Continued review revealed interventions to assist with ADLs, and encourage to assist with ADLs as able. Interview with Certified Nursing Assistant (CNA) CC on 09/05/13 at 9:05 a.m., revealed that she gives resident # 23 her shower on Tuesdays, and Thursdays and trimming nails is not a part of the bath routine, but that each CNA is responsible for checking the resident's nails, and trimming, and cleaning them as needed. Continued interview revealed that she comes in the afternoons to clean resident's nails and determines who may need their nails cleaned by observing the nails or by asking the resident if they want their nails cleaned. Interview with the Director of Nursing (DON) on 09/05/13 at 10:00 a.m., revealed that CNA's are responsible for nail care as part of their ADL care. Continued interview revealed that her expectation was that if a resident's nails were dirty and/or untrimmed that staff would clean and/or cut the nails.",2017-07-01
8475,BOSWELL-PARKER HEALTH AND REHABILITATION,115496,1211 SILOAM ROAD,GREENSBORO,GA,30642,2012-03-07,272,D,0,1,NY2U11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that one (1) resident (#15) on a sample of twenty-four (24) residents was accurately assessed for oxygen therapy. Findings include: Review of the current physician order [REDACTED]. Review of the most recent significant change Minimum Data Set (MDS) assessment dated [DATE] did not assess the resident as being on oxygen therapy. Interview with the Administrator on 03/07/12 at 7:52 a.m. revealed the resident should have been assessed on the MDS for the use of the oxygen .,2016-01-01
8476,BOSWELL-PARKER HEALTH AND REHABILITATION,115496,1211 SILOAM ROAD,GREENSBORO,GA,30642,2012-03-07,328,D,0,1,NY2U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that three (3) residents (#15, #28, #33) on a sample of twenty-four (24) residents received the proper respiratory care and maintenance of respiratory equipment. 1. Review of the current physician order [REDACTED]. Observations during the survey on 03/05/12 at 11:14 a.m. and 3:10 p.m., 3/06/12 at 10:12 a.m. and 1:10 p.m., and on 03/07/12 at 7:50 a.m. revealed the resident was receiving oxygen at 2 liters a minute by nasal cannula. The oxygen concentrator being used to deliver the oxygen had no filter and dust was collecting in the area where the filter should have been. The oxygen tubing and nasal cannula was observed to be on the floor during the observations on both 03/06/12 and 03/07/12. Review of the facility's policy on Respiratory Care documented that when masks and cannulas are not in use, they should be stored in plastic bags. Review of the policy on the Use of Oxygen documented that the oxygen tubing should be kept off the floor and the filter on the concentrator should be checked at least every month. Interview with the Administrator on 3/07/12 at 7:52 a.m. revealed the concentrator should have a filter and the oxygen tubing and cannula should not be on the floor. 2. During the initial tour on 03/05/12, between 10:20 and 10:40 a.m. the supplemental oxygen cannula was draped over the concentrator for resident #33 and the nasal prongs were touching the floor. According to the facility Policy and Procedure Manual, the cannula should have been stored in a plastic bag when not in use. 3. Observation during initial tour of resident #28 revealed the resident was using supplemental oxygen from a concentrator and the concentrator did not have the foam filter over the air intake panel. The filter was missing when observed again at 2:20 p.m. and on 03/06/12 at 7:20 a.m. and 2:30 p.m.",2016-01-01
10231,BOSWELL-PARKER HEALTH AND REHABILITATION,115496,1211 SILOAM ROAD,GREENSBORO,GA,30642,2011-07-11,441,F,1,0,EBIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to design and provide a sanitary environment to help prevent the spread of infection, related to the handling of facility laundry. This had the potential to affect all facility residents for whom the facility provided laundry services. Findings include: During observation of a room labeled as the Utility Room conducted on 07/11/2011 at 11:00 a.m., there were two soiled dust mops to the left of the hamper where residents' clothing was stored while waiting to be washed. There were two trash cans with lids in front of a double stainless steel sink. A certified nursing assistant (CNA) came into the room with a soiled brief in a plastic bag, opened the lid of one of the trash cans, and placed the soiled brief in the can. To the left of the washing machine, clean clothing was spilling out of a basket and onto the counter next to the sink. Hanging on the wall behind the washer and dryer was a large buffing disk, and the buffing machine was on the floor. Underneath the rack where residents' processed clothes was hung was a red Biohazard container containing a used needle box. The vacuum cleaner was beside it. There were two large yellow mop buckets and a housekeeping cart in the room. During an interview with the Director of Nursing (DON) conducted at 10:30 a.m. on 07/11/2011, the DON stated that the CNAs would rinse out any stained/soiled resident clothing in the bath house, put it in a plastic bag, and then place it in the dirty clothing hamper in the room referenced above. All soiled resident clothes were placed in this one hamper, except for one resident whose clothes were processed with [MEDICATION NAME] detergent and run through the rinse cycle twice. The DON stated that the 3:00 p.m. - 11:00 p.m. CNAs washed, dried, sorted, folded and distributed all resident clothing. Linen was sent to an outside laundry service, and there were a few residents whose families did their laundry. During this interview, a request was made for a written procedure for how CNAs were to sort, wash, dry and deliver resident clothing during the interview, but the DON acknowledged that there was no written policy about how staff were to go about this process specifically. The DON stated that CNAs were to removed the clothing from the dryer and then hang it immediately on the rack (which was above the Biohazard box containing the dirty needle container). Socks were to be matched and other garments that could not be hung were to be folded and then sent back to the residents. However, during the 07/11/2011, 11:00 a.m. observation referenced above, no gloves, folding table or plastic aprons for staff use were observed in the room. During interview at 2:00 p.m. on 07/11/2011 with the Administrator and the DON, it was stated that there was no other room in the building that was available for use as a laundry room.",2014-11-01
8166,BRANDON WILDE PAVILION,115524,4275 OWENS ROAD,EVANS,GA,30809,2011-12-01,225,D,0,1,7WO111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview the facility failed to report an allegation from one (1) resident (A) from a sample of thirty-two (32) residents of verbal abuse to the State Regulatory Agency. Findings include: Record review revealed resident A had a BIMS score on the 10/03/11 MDS assessment of 14, indicating the resident was cognitive intact with no memory problems. The resident was assessed on the Quarterly Minimum Data Set (MDS) assessment dated [DATE] as needing Extensive Assist for transfer and toileting, with one (1) person assist. Interview on 11/29/11 at 9:32 a.m. with resident A revealed that approximately three (3) weeks prior, Certified Nursing Assistant (CNA) BB made an inappropriate remark and cursed at the resident while assisting her with toileting. This was reported by the resident to the Executive Director. The resident revealed that several days later CNA BB came to her room and apologized. An interview with the Director of Nursing (DON) and the Executive Director on 11/29/11 at 10:30 a.m. revealed they were aware of the resident's allegations and they did an investigation. The Executive Director revealed the facility process was for an allegation of abuse to be investigated by the Director of Nurses (DON) and to report the occurrence to the State Agency. A copy of the investigation was provided for review. Interview on 11/29/11 at 11:35 a.m. with the DON revealed the allegation was investigated but had not been reported to the State Agency. Interview with the Executive Director on 11/30/11 at 9:00 a.m. revealed the investigation should have been reported to the State Agency.",2016-06-01
9202,BRANDON WILDE PAVILION,115524,4275 OWENS ROAD,EVANS,GA,30809,2012-08-09,309,D,1,0,15YD11,"**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, as specified by physicians' orders, for two (2) residents (#10 and #17) from a survey sample of nineteen (19) residents. Findings include: 1. Record review for Resident #10 revealed a current physician's orders [REDACTED]. However, during an observation conducted on 07/10/2012 at 1:30 p.m. of wound care to Resident #10's right foot with Licensed Practical Nurse (LPN) ""EE"" in attendance, the dressing on the foot was noted to have a date of 07/06/2012, four days prior to this observation. At the time of this observation, Nurse ""EE"" acknowledged the date on the dressing as being 07/06/2012, and stated she had changed the dressing on 07/06/2012. 2. Record review for Resident #17 revealed a Non-Pressure Skin Condition Report of 08/07/2012 which documented a purple fluid-filled blister on the back of the resident's left lower leg. An 08/07/2012, 9:00 p.m. Physician's Progress Notes entry also documented this fluid-filled blister to the back of the resident's left lower leg and documented that the physician was informed. An 08/07/2012, 10:00 p.m. Physician's Interim Orders form specified to apply a dry dressing to the fluid-filled blister to the posterior left lower leg (calf) for protection every 3 days, and as needed, until healed. The August 2012 Medication Administration Record [REDACTED]. However, during an observation conducted on 08/09/2012 at 2:50 p.m., Resident #17 was observed to have a large fluid-filled purplish blister on the left posterior calf, but no dressing was covering the blister at that time. During an additional observation of wound care for Resident #17 with LPN ""MM"" in attendance at 3:30 p.m. on 08/09/2012, the purple fluid-filled blister, approximately ten (10) centimeters by five (5) centimeters, was again noted on the back of the left calf, but the wound was not covered.",2015-08-01
1031,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2018-06-22,657,J,0,1,RKM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines, and staff interview, it was determined that the facility failed to provide consistent evidence of interdisciplinary team (IDT) input into development and revision of interventions for falls, and for evaluation of the effectiveness of current interventions to prevent falls for four residents (R) (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated [DATE] revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On [DATE], 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 [DATE] at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on [DATE]. 1. IJ was determined to exist as of [DATE], when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated [DATE] revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and [DATE], which included falls on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. In addition, the fall on [DATE] resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on [DATE]. Further review of the clinical record revealed that she had falls on [DATE], [DATE], [DATE], and [DATE]. Further record review revealed the fall on [DATE] resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on [DATE] resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on [DATE], [DATE], and [DATE], and she sustained a nasal fracture after the fall from her wheelchair on [DATE]. 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 (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on [DATE], an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revision date of [DATE] revealed: Overview: 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. Clarification: 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. Assessment: 2. Upon admission/readmission, the nurse will complete the Falls Risk Assessment and address the risk factors related to the patient on the plan of care and implement appropriate interventions as identified. When a Fall Occurs: 3. Implement intervention/s to prevent recurrence and maintain patient safety. 1. Review of R#85's clinical record revealed an original admission date of [DATE] and that he had [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that R#85 had a Brief Interview for Mental Status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment); had two or more falls with injury, and one fall with major injury, since the prior assessment. Further review of this MDS revealed that falls triggered as an area of concern with the decision to care plan. Review of his Quarterly MDS dated [DATE] revealed that he had short-term and long-term memory problems and severely impaired cognitive skills for daily decision making, and one fall with non-major injury since the prior assessment. Review of a Fall Risk assessment dated [DATE] revealed that he was assessed with [REDACTED]. Further review of this assessment revealed that the section Care plan Indicated/updated was answered No. Review of Interdisciplinary Progress Notes (IPN) dated [DATE] at 9:00 p.m. revealed that R#85 was observed on the floor in his room at 8:20 p.m., and the resident alleged that his roommate had knocked him down, and had a skin tear to right elbow. Review of an IPN dated [DATE] at 7:00 a.m. revealed R#85 was observed laying on his back on the floor behind the door to his room around 6:05 a.m., resident could not tell how or what happened, laceration to left forehead and also observed a small laceration to the bridge of resident's nose, and a bruise coming up around his left eye. Transported to ER (emergency room ) around 6:30 a.m. Review of a radiology report dated [DATE] revealed an impression of comminuted [MEDICAL CONDITION] proximal humerus. Review of a CT (computerized axial tomography) of the head dated [DATE] revealed mild nasal bone deformity suggesting fracture of indeterminate age, this could also be chronic. Review of a CT cervical spine dated [DATE] revealed findings suspicious for a tiny, nondisplaced [MEDICAL CONDITION] of the odontoid (a projection from the second cervical vertebra). Review of R#85's risk for injury related to falls comprehensive care plan with an original date of [DATE] and an effective date of [DATE] revealed the following interventions: [DATE]: Move recliner closer to bed. [DATE]: Bed in lowest position. [DATE]: Call light within reach and educate on use-consider cognition. Undated interventions to this care plan included night light on due to [MEDICAL CONDITION] and visual impairment (which was discontinued on an unknown date as the resident was immobile); electric bed in place; fall mat; bolsters in place; and chair alarm in place. Review of the [DATE] falls documentation revealed there was no documentation of the height of the bed at the time of the fall to determine if an intervention for bed in lowest position was an appropriate intervention, and no investigation as to how the fall occurred to determine what additional interventions may have been appropriate. Review of an undated QA (Quality Assurance) fall audit for R#85 revealed that the only intervention for the fall on [DATE] was for bed in lowest position. Review of a Falls Report from [DATE] to [DATE] revealed that R#85 had a witnessed fall in his room on [DATE]. Review of an undated QA (Quality Assurance) fall audit revealed that no interventions were placed on the falls care plan. Review of a PAR (Patients at Risk) Review form dated [DATE] revealed that R#85 had a fall on [DATE] with injuries/fracture and on [DATE] resident was attempting to ambulate unassisted and had a fall. Resident encouraged to call for assistance but due to cognitive impairments we will have to monitor ambulation. Review of the section on this PAR Review form Review patients plan of care revealed that the No boxes were checked for were care plan revisions indicated ? and care plan updated by PAR team ? Further review of the team members signatures in attendance revealed that there were only nurses in attendance, and it did not reflect an interdisciplinary approach. Review of an IPN dated [DATE] at 10:40 p.m. revealed that R#85 was observed sitting on the floor in front of a chair in his room by staff around 10:15 p.m., resident was trying to go to the bathroom without assistance from staff. Resident stated that his right hip was hurting. No chair alarm was in use, bed alarm working and in place. Review of a right hip X-Ray dated [DATE] revealed an acute [MEDICAL CONDITION] right femur. No documentation was found of an investigation conducted for the root cause of the fall on [DATE], nor interdisciplinary discussion of possible interventions to try to prevent future falls. Review of R#85's risk for falls care plan with an effective date of [DATE] and a risk for falls care plan developed on [DATE] and revised on [DATE] revealed there were no interventions listed for a bed alarm as noted in the IPN note on [DATE], and the intervention on the [DATE] care plan for a chair alarm was undated, so it was not known when it was implemented. Review of a Nurse's Note created by the Director of Nursing (DON) dated [DATE] at 12:23 p.m. revealed that R#85 was no longer trying to get out of bed, so the bed alarm was discontinued. Review of an Occupational Therapy Certification with service dates from [DATE] to [DATE] noted R#85 was currently on low-high bed with B (bilateral) bed bolsters and sensor alarm. Review of R#85's risk for falls and other injuries related to falls comprehensive care plan with an onset date of [DATE] and updated date of [DATE] revealed the following interventions were all dated [DATE]: Administer first aid as needed; anticipate patient's needs-check frequently; assess contributing factors related to fall history; assess medications for contributing factors; bed bolsters; bed wheels in locked position; call light in reach-consider his cognition; low bed; mat at bedside: left; notify physician and family/responsible person of fall; obtain x-ray as ordered; provide ADL (activity of daily living) care, transfer with mechanical lift. Further review of additional interventions for this care plan dated [DATE] (during the survey) revealed moved to room closer to nurse's station on [DATE]; and encourage to spend time in day room for better observation/social stimulation. An Event-Initial Note dated [DATE] at 12:05 a.m. revealed the resident scooted to foot (of bed) past bed bolster and got up unassisted. Resident fell to floor and received a skin tear to rt (right) elbow. Resident noted with plain socks on. New intervention added after the fall included to provide non-skid socks, and mat at bedside on left. Review of the falls care plan with a developed date of [DATE] revealed there were no interventions added for use of non-skid socks after the fall on [DATE]. A PAR (Patients at Risk) Review dated [DATE] revealed: the patient had a recent fall, he scooted to foot of bed past bolster and got up unassisted. He fell to floor and received a skin tear to rt (right) elbow. Resident was in plain socks no skid protection. Previous interventions implemented included bed in low locked position, bed against wall, patient closer to day room bed bolsters, etc. See care plan. Interventions work for most part. Changes made to the plan of care bed mat added to left side, make sure patient has on no skid socks. Further review of this PAR Review revealed that an interdisciplinary team was in the meeting. However, there was no evidence for a discussion of the safety for continued use of the bed bolsters. Observation on [DATE] at 12:41 p.m. revealed that R#85 was in bed with a fall mat to one side, with a winged mattress and bed bolsters attached to the bedframe bilaterally in the middle of the bed between the winged portions of the mattress. During interview with the Director of Nursing (DON) on [DATE] at 3:28 p.m., she stated that either herself or the ADON (Assistant DON) reviewed the notes after a fall, and they talked about it in their weekly PAR meeting and the day after a fall during morning meetings, and ensured that appropriate interventions were in place. During interview with the DON on [DATE] at 5:02 p.m., she stated that either she or MDS staff updated the care plan after every fall, after the fall was discussed in morning meetings. During interview with the DON on [DATE] at 9:08 a.m., she stated that in morning meetings, which was attended by an interdisciplinary team, they reviewed the 24-hour report from the previous day for any falls, and decided if a therapy screen should be done. She stated during further interview that there was no discussion of review of the current interventions to see if they were appropriate. She stated that after the morning meeting, the ADON and herself discussed any falls, and if any new interventions should be put in place. She further stated that most of the interventions, on the electronic care plan, were dated [DATE], as that was when the facility implemented their new electronic documentation system. During further interview with the DON at this time, she stated that an intervention of a night light and for the bed to be in low position were added after the fall on [DATE], that she did not know the height of the bed at the time of this fall, and did not know why these were the interventions were added other than the resident liked for his room to be dark. 2. Review of the closed clinical record for R#96's revealed that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was admitted on hospice on [DATE] and expired on [DATE]. Review of R#96's Admission MDS dated [DATE] revealed that he had short and long term memory problems with inattention and disorganized thinking, needed limited assistance for ambulation, had a fall with fracture in the six months prior to admission, and one fall with no injury and one fall with a non-major injury since admission. Review of his Quarterly MDS dated [DATE] revealed that he had a BIMS score of 5, he did not walk in his room or corridor over the seven days of the assessment period, and had one fall with a major injury since the last assessment. Review of R#96's clinical record revealed a baseline care plan was not found. Review of a comprehensive care plan for risk for falls related to a history of falls with injuries and unsteadiness was developed on [DATE]. Further review of this falls care plan revealed that it was revised on [DATE] and [DATE] (due to falls since admission-although it was not put into place due to lack room availability) for a room change closer to the nurse's station; on [DATE] to toilet after breakfast; on [DATE] to re-educate to use call light for assistance; on [DATE] to keep wheelchair nearby during toileting; on [DATE] for a therapy screen; on [DATE] for non-skid shoes when out of bed and gripper socks; and an undated intervention for a leg bag for catheter when out of bed when able. Review of a falls care plan with a developed date of [DATE] revealed the following interventions and dates: [DATE]: Assess medications for contributing factors [DATE]: Assess contributing factors related to fall history [DATE]: Wheelchair [DATE]: Bed in low position [DATE]: Call light in reach: consider resident's cognition and re-educate as needed [DATE]: Activity referral [DATE]: Assist patient with ADLs (activities of daily living) as needed [DATE]: Keep call light and most frequently used personal items within reach [DATE]: Transfer to acute care setting for evaluation [DATE]: Administer first aid as needed [DATE]: Notify physician and family/responsible person of fall [DATE]: Observe X 72 hours for possible injury related to a fall [DATE]: Bed alarm sensor [DATE]: Needed and desired items in reach/easy access [DATE]: Place patient in open area for maximum observation opportunities [DATE]: Notify hospice nurse as needed Review of a Falls Report from [DATE] to [DATE], and a Records List (of falls) from [DATE] to [DATE] revealed that R#96 had 10 falls between admission on [DATE] and [DATE]. In addition, there was one fall on [DATE] that was not captured on the falls reports. Review of clinical record documentation related to falls for R#96 revealed the following: An IPN dated [DATE] (the day of admission) at 10:00 p.m. revealed that upon med rounds found this resident lying on the floor between his bed and his roommate's bed. Review of an IPN dated [DATE] at 7:55 p.m. revealed the resident was on the floor in bathroom with feet pointing out of bathroom, on buttock/back, naked, catheter on floor. S/T (skin tear) noted X 2 to left elbow. Resident educated on call light use importance of assistance. Non skid socks placed on feet, bed moved against wall and a bedside commode at bedside. Call light clipped to gown. Staff keeps reminding resident to use call light. Review of a Skilled Services Review Notes completed [DATE] revealed that patient found on floor in restroom on his buttock/back [DATE]. On [DATE] patient noted on floor between bed and roommate's bed attempting to move pillow from between his legs. Further review of this note revealed it was signed by a nurse and therapist, but no evidence that an evaluation of interventions were done. An IPN dated [DATE] at 10:00 a.m. revealed that R#96 was noted on the floor near his bed in his room. No documentation was found as to the height of the bed, use of non-skid footwear, where he was prior to the fall, to be able to determine what new interventions should be tried. An IPN dated [DATE] at 1:30 p.m. noted resident sitting on floor in his room next to his bed, stated he was getting into bed. Was re-educated to use call light when he needs assistance. (No mention of any new falls interventions other than re-educated on call light use). An IPN dated [DATE] at 7:15 p.m. noted resident found on bathroom floor by CNA (Certified Nursing Assistant). Educated resident on call light use for bathroom assistance. Review of the intervention on the care plan dated [DATE] was to keep wheelchair nearby when toileting, but no notation found of why this intervention was appropriate. An SBAR (Situation-Background-Appearance-Review) Communication Form dated [DATE] revealed resident noted lying side lateral on floor by dresser, trying to get up. Resident noted wearing plain socks and feet kept slipping with attempts to get himself up. Non-skid socks were placed on and resident educated to use call light (an intervention after a fall on [DATE] was to place non-skid socks on feet). Review of the intervention on the falls care plan for this fall was for a therapy screen. However, review of a Comprehensive Rehabilitation Screen dated [DATE] noted that R #96 was already on PT caseload. An untimed IPN dated [DATE] (sic) noted found resident lying on floor. Had been to bathroom. Encouraged to use call light. No intervention was found on the care plan for this fall, and no notation found of what interventions were in place at the time of the fall. An IPN dated [DATE] at 1:24 p.m. noted patient assisted to the floor with the assistance of the CN[NAME] Patient encouraged to use the call light when help is needed. No intervention was found on the care plan for this fall. An SBAR Communication Form dated [DATE] noted patient assisted to floor with assistance of CN[NAME] No notation was found of any new or existing interventions discussed. A Nurse's Note dated [DATE] at 3:24 a.m. revealed that R#96 was found lying on the floor on back in doorway of bathroom. Reminded to use call light when he needs to get up to go to bathroom. Call light is within reach. Review of the risk for falls care plan revealed that interventions dated [DATE] were for call light in reach, but the Nurse's Note noted the call light was in reach. Further review of this care plan revealed an intervention dated [DATE] for bed in low position, but there was no notation in any of the falls documentation that the bed was not in lowest position. An Event-Initial Note dated [DATE] revealed R#96 was found lying in the doorway of bathroom and room on back. Is forgetful and does not use call light for assistance. New intervention added after the fall included bed in low position, call light in reach. Rationale for selecting above intervention(s) listed as effective and efficient. Review of an Observation Data report dated [DATE] at 10:52 a.m. for follow-up fall revealed new orders/interventions not effective. A PAR (Patient at Risk) Review Note dated [DATE] revealed that the resident has had several falls within the last month with the most recent falls on [DATE] and [DATE] (it does not mention the fall on [DATE]). On both occasions resident attempted to use the bathroom unassisted. He has periods of confusion with disorganized thought process and considered to have impaired judgement and safety awareness. Previous interventions implemented: Resident's room change closer to nurses station (resident resided in room C-12 at the time of this note, which was the last room on the C-hall, furthest away from the nurse's station), staff to assist with toileting after breakfast, re-direct and reinforced to use call light for assistance, keep wheelchair nearby during toileting, therapy screen-assisted by staff with dressing, non-skid socks, bed against the wall, and leg bag for catheter when out of bed. No documentation was found of a discussion of the effectiveness of these interventions. A Nurse's Note dated [DATE], late entry for fall that occurred on [DATE] at 12:20 a.m. revealed that R#96 was observed by staff lying halfway in the hall and halfway in his room on the floor. Resident had discoloration to bridge of nose, and active bleeding from both nostrils. Resident stated I was getting up to go the bathroom and fell . Encouraged resident to call staff for assistance if he wants to use the bathroom. Resident left the facility via stretcher accompanied by EMS at 12:40 a.m. in route to hospital. Review of a hospital Discharge Summary dated [DATE] revealed R#96 stated he tripped and fell . Review of the Discharge [DIAGNOSES REDACTED]. Review of an Event-Initial Note dated [DATE]: Resident was observed lying in between the doorway of his room and hallway. Per resident attempting to ambulate unassisted to the bathroom. New intervention added after the fall: Call light in reach. Toileting: encourage patient to call for assistance. A Nurse's Note dated [DATE] at 12:39 p.m.: Writer (the DON) told daughter that we would also look at a possible room change to move this resident closer to the nurses station (pending), resident will also be evaluated by therapy upon return to facility, other fall interventions include placement of bed and chair alarm, bed in lowest position and fall mat. Will await residents (sic) return to facility and then further evaluate needs. Review of the falls care plan revealed that a room change closer to the nurse's station was also an intervention dated [DATE]. Nurse's Notes dated [DATE] at 10:06 a.m. revealed that R#96 was observed on his knees kneeling on his bed, attempting to transfer from his wheelchair to his bed unassisted. Patient educated on the importance of using his call light for assistance. Bed alarm in place and working. Review of an Event-Initial Note dated [DATE] revealed that a bed alarm was in place call light in reach educated on importance of using call light for assistance. New intervention added after the fall: Bed alarm: sensor; call light in reach; needed and desired items in reach/easy access; place patient in open area for maximum observation opportunities. Review of a Skilled Services Review dated [DATE] revealed patient continues to have falls the plan is to move him closer to nurse station as room becomes available. Fall on [DATE] had small laceration to nose other fall no injury. Patient has bed alarm and we are going to add chair alarm. We will continue to remind patient to ask for assistance. Encourage and assist him to activity lobby for better observation and socialization. Review of interventions mentioned in the clinical record immediately after a fall or later discussion of the fall revealed that encouraging the resident to ask for assistance to get up and/or use of call light encouraged was mentioned for nine of the 11 falls ([DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]), despite the resident's cognitive impairment. During interview with the DON on [DATE] at 1:29 p.m., she stated that R#96's care plan had interventions for bed in low position and call light in reach on [DATE], and assumed that the bed was not in low position and call light not in reach if that was what the new interventions were. She stated that the intervention on [DATE] was to move R#96 closer to the nursing station, and that he was not assessed for a toileting plan as he had a suprapubic catheter. The DON stated during continued interview that they did not evaluate to see if R#96 was falling at a certain time of day, or review his meds as possibly contributing to the falls. 3. Review of R#70 clinical record revealed the resident was admitted to the facility on [DATE] at around 11:30 a.m. and she arrived in a wheelchair accompanied by family. The resident was admitted from an area acute hospital due to [DIAGNOSES REDACTED], volume depletion, urinary infection, general decline, dementia. Review of the Face Sheet for R#70 revealed the following admission Diagnoses: [REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Health Status (BIMS) of 3, indicating that she was cognitively impaired. She required extensive assistance of one person in bed mobility, transfer, walk in room, wall in corridor, locomotion off unit, dressing, eating, toileting, personal hygiene, and had occasional episodes of being incontinent of bowel and bladder. She required physical assistance of one person to help partially with her bathing needs. She had no impairments of upper and lower body range of motion and used a cane for mobility. Her medication used for the past seven days consisted of an antibiotic for a urinary tract infection. The resident was assessed as having no falls or fractures in the last month and the last six months, prior to admission. Further review of this MDS revealed that fall triggered as an area of concern with a decision to care plan. Review of the MDS dated [DATE] revealed R#70 had a (BIMS) of 99. She was totally dependent on two persons for assistance in bed mobility, dressing, eating, toileting, personal hygiene, and was incontinent of bowel and bladder. She had no impairment of her upper body range of motion and impairment of one side of her lower body range of motion. The resident was assessed as having no falls since admission although the resident had several falls in the facility, including a major fall with fracture. R#70 medications used in the past seven days included antibiotics for pneumonia and an opioid for pain management for a fall that has occurred during this past quarters review period. Review of the Fall Risk Form dated, [DATE] at 7:09 p.m., revealed the resident was assessed with [REDACTED]. The assessment revealed R#70 high risk for falls was due to wearing glasses, cognitive impairment, being restless, needing assistance with behaviors, needing assistance with mobility, being independent with supervision for transfers, non- weight bearing, has a wheelchair, was incontinent, receives one high risk medication, has anxiety and was care planned for falls. Review of R#70's care plan revealed a baseline care plan that was to be completed within 48 hours of admission to the facility was absent from the resident record. An interview on [DATE] at 3:35 p.m. with Registered Nurse (RN) DD revealed a confirmation that a baseline care plan was not completed on R#70. Review of the Data Collection, Skilled Services Nursing Assessment document dated [DATE] revealed the resident's cognition varies throughout the day, was pleasant, wanders, had difficulty walking used a wheelchair and walker. Although the Admission MDS dated [DATE] assessed the resident as using a cane. Review of the Nurse Note documentation dated [DATE] 12:50 p.m. revealed the R#70 was a new admit and had to be redirected to sit down this shift several times and has an unsteady gait. R#70 was sitting in the dining area of unit and was continued to be monitored. Review of Nurse Note documentation dated [DATE] at 2:39 p.m. revealed that the resident had a fall in the hallway of B- unit. No injuries from that fall were noted with assessing the resident after the fall. A rash was noted on her lower back. Medical was made aware of both issues and no treatment for [REDACTED]. Family was notified of the fall and back rash. Non-skid socks were given to this resident to prevent future falls. Non-skid socks were not added to the care plan. Review of the Observation Data documentation dated [DATE], [DATE], [DATE], revealed that on follow up for the fall there had been no change in condition. Review of the Nurse Note Documentation dated [DATE] at 2:33 p.m. revealed that the resident was working with therapy and was up dancing the Cha-Cha with the therapist. Night shift reported that the resident was up all-night wandering around the special care unit. The resident has slept most of the day shift except during meals, which consumption was poor, and she requested to go home several times. The resident also slides her bottom out from under her in the wheelchair. Therapy aware of resident sliding down. Non-skid socks also on resident feet. Review of the Nurse Note Documentation dated, [DATE] at 9:53 a.m. revealed that the Physician examined the resident for routine visit. No new orders. Review of the Nurse Note Documentation dated [DATE] at 10:08 a.m. revealed the resident was complaining of right leg pain, Physician notified, and new order received for [MEDICATION NAME] 325 milligrams (mg) two tablets, by mouth, four times per day for pain/fever. [MEDICATION NAME] 325 milligrams (mg) two tablets given, by mouth, to the resident with effective results. Review of the Nurse Note Documentation dated [DATE] at 4:18 p.m. revealed family visited the resident and right leg pain was better, but the resident complained of abdominal pain. The family requested a urinalysis due to the resident's past history of urinary tract infections and the nurse obtained an order from the physician. Review of the Event Initial Note [DATE] at 8:30 p.m. revealed the resident was found lying on the floor on her right side near the foot of her bed. The document further revealed that the resident was ambulating around her room without assistance using her cane at the time of the fall. The resident stated she did not hit her head and she was still hurting in (TRUNCATED)",2020-09-01
1032,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2018-06-22,689,J,0,1,RKM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines, corporate, physician, and staff interview, it was determined that the facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) or Skilled Services meetings per facility guidelines so that the root cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for four residents (R) ( R#85, R#96, R#70, R#71). In addition, the facility failed to reassess for the continued use of bed bolsters after one resident (R#85) climbed past them and fell out of bed, and failed to reassess for the continued use of a motorized wheelchair after two accidents involving use of the chair for one resident (R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, 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 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. 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 (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revision date of 5/1/17 revealed: Overview: Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Each patient's risk for falls is evaluated by the interdisciplinary team (IDT). 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. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Each center will take a proactive approach for new patients admitted and will consider all patients to be at risk for falls until reviewed by the IDT. A care plan for falls will be initiated upon admission for each patient identified as a fall risk. Clarification: 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. Assessment: 2. Upon admission/readmission, the nurse will complete the Falls Risk Assessment and address the risk factors related to the patient on the plan of care and implement appropriate interventions as identified. 5. Patients should be reviewed in the Patient at Risk (PAR) or UR (Utilization Review) meeting as indicated. When a Fall Occurs: 1. Conduct a head to toe assessment to identify any injuries or changes in condition. 2. Observe and interview the patient or witnesses to determine possible cause of the fall. 3. Implement intervention/s to prevent recurrence and maintain patient safety. 4. Complete the Event Management Report to capture the investigation of the fall and assessment of the patient. This information should be entered into event management database for tracking and trending. 10. Review falls with the IDT in the morning meeting to ensure appropriate actions have been taken and documentation is accurate and complete (including Event Management Report). 11. Review the event and patient status at the next scheduled PAR and/or UR meeting as indicated. 1. Review of R#85's clinical record revealed an original admission date of [DATE] and that he had [DIAGNOSES REDACTED]. Review of an Annual Minimum Data Set ((MDS) dated [DATE] revealed that R#85 had a Brief Interview for Mental Status (BIMS) score of 3 (a score of 0 to 7 indicates severe cognitive impairment); needed extensive assistance for walking in his room; had two or more falls with injury, and one fall with major injury, since the prior assessment. Review of his Quarterly MDS dated [DATE] revealed that he had a BIMS score of 99 (unable to complete one or more questions of the interview), had short-term and long-term memory problems, severely impaired cognitive skills for daily decision making, and fluctuating inattention. Further review of this MDS revealed that walking in his room did not occur during the 7-day assessment period. Review of R#85's risk for injury related to falls comprehensive care plan with an original date of 6/4/14 and an effective date of 12/13/17 noted he had a recent fall resulting in laceration to forehead and fracture to right arm and fracture of odontoid (neck). Further review of this care plan revealed that it was updated to reflect a fall on 11/30/17 where he was observed on floor sitting next to sink; on 12/11/17 for ambulating unassisted; and on 12/29/17 observed sitting on floor in front of recliner. Review of the interventions to this care plan revealed: 6/30/17: Move recliner closer to bed. 12/1/17: Bed in lowest position. 12/13/17: Call light within reach and educate on use-consider cognition. Undated interventions to this care plan included night light on due to [MEDICAL CONDITION] and visual impairment (which was discontinued on an unknown date as the resident was immobile); electric bed in place; fall mat; bolsters in place; chair alarm in place. Review of R#85's risk for falls and other injuries related to falls comprehensive care plan with an onset date of 2/20/18 and updated date of 6/21/18 revealed the following Care Area/Problem statement: Fall risk was related to a history of wandering, unsteady gait, drags his feet when he ambulates, and history of prior falls with fractures. Recent falls with injuries of fractures to cervical spine, humerus and femur. He has a [DIAGNOSES REDACTED]. He is at risk for functional decline related to falls. He has history of ambulating without assistance prior to fracture of femur. He is confined to bed/chair most of time since his injury. He receives medications for diabetes which increases his risk for hypo/hyperglycemic episodes which increases his risk for falls and other injuries. Review of the Interventions for this care plan included the following dated 2/20/18: Administer first aid as needed; anticipate patient's needs-check frequently; assess contributing factors related to fall history; assess medications for contributing factors; bed bolsters; bed wheels in locked position; call light in reach-consider his cognition; low bed; mat at bedside: left; notify physician and family/responsible person of fall; obtain x-ray as ordered; provide ADL (activity of daily living) care, transfer with mechanical lift. Further review of additional interventions for this care plan dated 6/21/18 (during the survey) revealed moved to room closer to nurse's station on 12/1/17; and encourage to spend time in day room for better observation/social stimulation. Further review revealed the resident requires assistance with daily care, care plan reviewed on 6/4/18 revealed the assistance was due to several factors such as recent fractures to humerus, cervical (sic) and femur; he has had a significant decline in ADL care since his hospitalization requiring total assistance with daily care; and he resides in Memory Care Unit (MCU) due to [DIAGNOSES REDACTED]. Review of a Fall Risk assessment dated [DATE] revealed that R#85 was assessed with [REDACTED]. Further review of this assessment revealed that the section Care plan Indicated/updated was answered No. Review of R#85's Bed Rail/Assist Bar assessment dated [DATE] noted no equipment was currently attached to his bed. Review of a Falls Report from 6/3/17 until 2/20/18 (at which time the facility went to an electronic health record (EHR) and a different procedure for collecting falls data) revealed that R#85 had unwitnessed falls in his room on 6/30/17 at 10:30 a.m.; 11/30/17 at 8:20 p.m.; 12/1/17 at 6:05 a.m.; 12/11/17 at 7:05 p.m. (marked as witnessed); and 12/29/17 at 10:15 p.m. Review of a Records List report for falls dated 2/21/18 to 6/19/18 (after the facility transitioned to an EHR) revealed that R #85 had a fall on 4/10/18. Review of clinical record documentation related to falls for R#85 revealed the following: -Falls on 11/30/17 and 12/1/17: Interdisciplinary Progress Notes (IPN) dated 11/30/17 at 9:00 p.m. revealed that R#85 was observed on the floor in his room at 8:20 p.m., and the resident alleged that his roommate had knocked him down. Skin tear to right elbow noted. R#85 stated that his right arm and shoulder hurt. Doctor notified of event and new order given to have x-ray of right arm and shoulder in a.m. (NOTE: This fall was unwitnessed, and the facility did a self-report to the State Survey Agency with their investigation for an allegation of resident to resident abuse, #GA 680). IPN dated 12/1/17 at 7:00 a.m. revealed R#85 was observed laying on his back on the floor behind the door to his room around 6:05 a.m., resident could not tell how or what happened, writer observed blood coming from the left side of his forehead, writer applied gauze to laceration to left forehead and applied pressure to stop bleeding. Writer also observed a small laceration to the bridge of resident's nose, and a bruise coming up around his left eye, he had a skin tear from fall last night. R#85 stated that his neck hurt while writer was wrapping his head. Transported to ER (emergency room ) around 6:30 a.m. Review of a hospital History of Present Illness dated 12/1/17 revealed a final impression of laceration to left side of forehead, and closed comminuted fracture of right proximal humerus. Review of a radiology report dated 12/1/17 revealed an impression of comminuted [MEDICAL CONDITION] proximal humerus. Review of a CT (computerized axial tomography) of the head dated 12/1/17 revealed mild nasal bone deformity suggesting fracture of indeterminate age, this could also be chronic. Review of a CT cervical spine dated 12/1/17 revealed findings suspicious for a tiny, nondisplaced [MEDICAL CONDITION] of the odontoid (a projection from the second cervical vertebra). IPN dated 12/1/17 at 6:25 p.m. revealed R#85 returned to facility at 4:00 p.m. with right arm in sling. Resident has bruising around and under left eye with bandage on forehead. Review of an FNP (Family Nurse Practitioner) Progress Note dated 12/6/17 revealed that resident had falls that occurred on 11/30/17 and 12/1/17. On 12/1/17 he was observed on the floor by nursing staff. He had bruising and laceration to the left side of the forehead and complained of neck pain. Hospital imaging revealed comminuted right humerus fracture. Transferred to another hospital for further evaluation by Ortho (orthopedics). Sling placed to RUE (right upper extremity). Suture closure performed to laceration site to forehead. No surgical intervention performed. Review of the Plan of this Progress Note included fall precautions to be implemented. Review of a PAR (Patients at Risk) Review form dated 12/17/17 revealed that R#85 had two falls. On (MONTH) 1st (2017) he had a fall with injuries/fracture and on (MONTH) 11th (2017) resident was attempting to ambulate unassisted and had a fall. Resident encouraged to call for assistance but due to cognitive impairments we will have to monitor ambulation. The section on this PAR Review form Review patients plan of care revealed that the No boxes were checked for were care plan revisions indicated? and care plan updated by PAR team? Further review of the team members signatures in attendance revealed that there were only nurses in attendance and it did not reflect an interdisciplinary approach, and there was no notation of an investigation of the root cause of the fall, such as footwear on at the time of the fall, bed in low position, etc. Fall on 12/29/17: Review of an IPN dated 12/29/17 at 10:40 p.m revealed that the resident was observed sitting on the floor in front of his rocking chair in his room by staff around 10:15 p.m., resident was trying to go to the bathroom without assistance from staff. Skin tear to right arm below elbow noted, resident stated that his right hip was hurting and felt like he couldn't stand on it. No chair alarm was in use, bed alarm working and in place. An IPN dated 12/30/17 7A-7P noted the resident was seen by FNP F/U (follow-up) fall. Dislocation of some sort noted to right leg. N.O. (new order) to send to hospital. An FNP Progress Note dated 12/30/17 noted resident is status [REDACTED]. He is a poor historian and uncertain of how he fell . Resident is complaining of right hip pain. Xray ordered and reveals acute [MEDICAL CONDITION] right femur. He currently has neck and right humerus fractures from previous falls in-facility. Review of a right hip X-Ray dated 12/30/17 revealed an acute [MEDICAL CONDITION] right femur. A Hospital Course summary with date of admission of 12/30/17 and date of discharge 1/4/18 noted nh (nursing home) resident with cervical (C2) and right humeral fx (fracture) (from recent fall) managed nonop (non-operatively) due to advanced medical conditions. Apparently fell again on 12/30/17 suffering right intertrochanteric femur fx. S/P (status [REDACTED]. An Occupational Therapy Daily Note with service dates from 1/5/18 to 2/3/18 noted R#85 was currently on low-high bed with B (bilateral) bed bolsters and sensor alarm. Review of a Nurse's Note created by the Director of Nursing (DON) dated 3/27/18 at 12:23 p.m. revealed that R#85 was no longer trying to get out of bed. Since recent falls in the past few months resulting in hip and shoulder fractures he is no longer ambulatory and less active. Will discontinue bed alarm at this time and continue with other fall interventions. No documentation was found of an investigation conducted for the root cause of the fall on 12/29/17, including where the resident was prior to the fall, the footwear he had on, etc. -Fall on 4/10/18: An Event-Initial Note dated 4/10/18 at 12:05 a.m. revealed the resident scooted to foot of the bed, past the bed bolster and got up unassisted. Resident fell to floor and received a skin tear to rt (right) elbow. Resident noted with plain socks on. New intervention added after the fall included to provide non-skid socks, and mat at bedside on left. An Initial C[NAME] (Change of Condition) Report to MD (Medical Doctor) dated 4/10/18 revealed the resident had a fall in room at 12:05 a.m. Writer noted resident on floor at foot of bed. Resident scooted to foot of bed pass (sic) bed bolsters and was able to get out of bed unassisted. Roommate in room stated resident fell trying to walk. Resident noted with plain socks on and received a skin tear with flap to rt elbow. Resident voiced pain to rt elbow. Non skid socks placed on resident and fall mat placed on left side of bed. A PAR (Patients at Risk) Review dated 4/10/18 revealed the patient had a recent fall, he scooted to the foot of bed past bolster and got up unassisted. He fell to floor and received a skin tear to rt (right) elbow. Resident was in plain socks no skid protection. Previous interventions implemented included bed in low locked position, bed against wall, patient closer to day room, bed bolsters, etc. See care plan. Interventions work for most part. Changes made to the plan of care bed mat added to left side, make sure patient has on no skid socks. Further review of the falls documentation revealed that there was no notation of the height of the bed at the time of the fall, why he was attempting to get up, or what other interventions were in place. A Therapy Referral dated 4/11/18, completed by the Director of Nursing (DON) revealed that the resident was previously able to walk prior to fractures. Review of the Noted change of condition section on the form revealed a fall on 4/10/18 out of bed scooted past the bolster and fell to floor. An Observation Data form dated 4/11/18 and 4/13/18 noted reason for observation was fall, no injuries. Review of the question on this form Are new orders/new interventions effective? revealed the response was NA (not applicable). An IPN dated 1/29/18 at 2:22 p.m. revealed that R#85 was pulling at bolsters and trying to unclip them off of bed. Review of all of the above documentation related to the fall on 4/10/18 revealed that the facility did not assess for continued use of the bed bolsters after this fall. Other than the documentation above that PAR Reviews were conducted on 12/17/17 and 4/10/18, there was no evidence found in the paper or EHR that PAR meetings and/or Skilled Services reviews were held to discuss R#85's falls. Review of a PAR Review dated 3/6/18 noted R#85 had a fall in (MONTH) with a [MEDICAL CONDITION], but the discussion in the review was for his weight loss only. Review of a PAR Review dated 4/18/18 revealed that R#85's weight change only was discussed. Review of a PAR Review dated 5/8/18 revealed that R#85's weight change and wound only were discussed. Observation on 6/18/18 at 3:44 p.m. revealed that there were bolsters attached to the bedframe of R#85's bed on each side in the middle of the mattress. Observation on 6/20/18 at 9:18 a.m. revealed that R#85 was in a reclining gerichair in the activity room. Observation in his room at this time revealed that he had a winged mattress with elevated sides on the top and bottom thirds on each side of the mattress. Further observation revealed that the bolsters were laying on top of the bed at this time and not attached to the bedframe, and there was a fall mat on one side of the bed. Observation on 6/21/18 at 12:41 p.m. revealed that R#85 was in bed with a fall mat to one side, with a winged mattress and bed bolsters attached to the bedframe bilaterally in the middle of the bed between the winged portions of the mattress. Further observation revealed that the winged portions of the mattress were raised approximately three inches from the surface of the mattress as measured with the surveyor's tape measure, and the height of the bed bolsters was measured at eight inches above the level of the mattress. During interview with Certified Nursing Assistant (CNA) CC on 6/21/18 at 1:00 p.m., she stated R#85 had bolsters on his bed because he didn't have bedrails, and the bolsters helped him to turn and kept him from falling out of the bed. She further stated she was not aware of him ever trying to climb over or past the bolsters. During interview with the Director of Nursing (DON) on 6/21/18 at 3:28 p.m., she stated that incident reports were not kept after entering the information in the falls tracking system, and that Corporate organization no longer had a falls management program. She stated during further interview that herself or the ADON (Assistant DON) reviewed the notes after a fall, and they talked about it in their weekly PAR meeting and the day after a fall during morning meetings, and ensured that appropriate interventions were in place. During interview with the DON on 6/21/18 at 5:02 p.m., she stated that either she or MDS staff updated the care plan after every fall, after the fall was discussed in morning meetings. During interview with the Administrator at this time, she stated that there was no formal documentation of what was discussed in the morning meetings. During interview with the DON on 6/22/18 at 9:08 a.m., she stated that they did not have a formal Falls Committee or Falls Management Program. She further stated that in morning meetings, which was attended by the DON, ADON, Administrator, Treatment Nurse, Therapy, Care Plans, Social Services, Admissions, and Medical Records staff, they reviewed the 24-hour report from the previous day for any falls, and decided if a therapy screen should be done. She stated during further interview that they read the accident report completed by the nurse on duty so that everyone in the morning meeting was aware of the fall, but that there was no discussion of review of the current interventions to see if they were appropriate, and no documentation of what was discussed in the meeting. The DON stated that the morning meeting only lasted 10 to 15 minutes, and concerns other than falls were discussed, so there was not an in-depth discussion of the fall. She stated that after the morning meeting, the ADON and herself discussed any falls, and if any new interventions should be put in place, but that there was no documentation of this. The DON stated during continued interview that the dates of care plan interventions in the electronic care plan may be the date the facility went to the electronic system, and not necessarily the date the intervention was initially put in place. During further interview with the DON at this time, she stated that she didn't know if R#85 broke his arm after the fall on 11/30/17 when his roommate allegedly pushed him down, or if it happened when he fell behind the door in his room on 12/1/17. The DON stated that interventions of a night light and for the bed to be in low position were added after these two falls, and did not know why these interventions were chosen other than the resident liked for his room to be dark. The DON further stated she did not know if the bed bolsters were in place at the time of the fall on 12/1/17, and confirmed there was no investigation of where the resident was prior to the fall, if the bed was in low position, if he had non-skid socks on, or any other interventions that were in place at the time of the fall, so she didn't really know how the fall occurred. During continued interview with the DON at this time, she stated that it appeared R#85 was getting up from the chair in his room on 12/29/17, as the nurse's notes say that no chair alarm was in use, and he was found on the floor by the chair. She further stated that there was an intervention for a chair alarm on the care plan, but it was not dated so she didn't know if it was implemented before or after the fall on 12/29/17. During further interview with the DON at this time, she stated that Therapy must have been consulted for the bed bolster use, because they had to order them. She verified there was no date on the care plan as to when the bolsters were added, but thought it may have been after the fall on 12/29/17. She verified that there was no mention of bed bolsters in the PAR meetings except after the fall past the bolsters on 4/10/18. She further stated that they thought the bed bolsters would be a good intervention to keep him from falling out of bed, and that the bolsters were not a restraint because he could get around them. She stated during continued interview that she didn't recall discussing continued bolster use after the fall on 4/10/18, and verified that there was no documentation of an assessment done for continued use after this fall. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a Skilled Services Admission/Readmission Review dated 12/5/17 revealed that R#96 was admitted to the hospital after [MEDICAL CONDITION] in bathroom at home, resulting in left [MEDICAL CONDITION]. Further review revealed the Patient/Family Goals and Expectations was to return to prior level of function prior to fall, and anticipated length of stay in skilled care was short term, with a plan to discharge home with caregiver. Review of R#96's Admission assessment dated [DATE] revealed that he had a history of [REDACTED]. Review of R#96's Admission MDS dated [DATE] revealed that he had a BIMS score of 99 (indicates that interview could not be conducted due to cognitive impairmemt), needed limited assistance for ambulation, had a fall with fracture in the six months prior to admission, and one fall with no injury and one fall with a non-major injury since admission. Review of his Quarterly MDS dated [DATE] revealed that he had a BIMS score of 5 (a score of 0 to 7 indicates severe cognitive impairment), he did not walk in his room or corridor over the seven days of the assessment period, and had one fall with a major injury since the last assessment. Review of R#96's clinical record revealed a baseline care plan was not found. Review of a comprehensive care plan for risk for falls related to a history of falls with injuries and unsteadiness was developed on 12/14/17. Further review of this falls care plan revealed that it was revised on 12/4/17 for a room change closer to the nurse's station; on 12/22/17 to toilet after breakfast; on 12/29/17 to re-educate to use call light for assistance; on 1/7/18 to keep wheelchair nearby during toileting; on 1/9/18 for a therapy screen; on 3/6/18 for non-skid shoes when out of bed and gripper socks; and an undated intervention for a leg bag for catheter when out of bed when able. Review of a falls care plan with a developed date of 5/3/18 revealed the following interventions and dates: 3/1/18: Assess medications for contributing factors 3/1/18: Assess contributing factors related to fall history 3/1/18: Wheelchair 3/2/18: Bed in low position 3/2/18: Call light in reach: consider resident's cognition and re-educate as needed 3/4/18: Activity referral 3/4/18: Assist patient with ADLs (activities of daily living) as needed 3/4/18: Keep call light and most frequently used personal items within reach 3/25/18: Transfer to acute care setting for evaluation 3/30/18: Administer first aid as needed 3/30/18: Notify physician and family/responsible person of fall 3/30/18: Observe X 72 hours for possible injury related to a fall 4/2/18: Bed alarm sensor 4/2/18: Needed and desired items in reach/easy access 4/2/18: Place patient in open area for maximum observation opportunities 5/3/18: Notify hospice nurse as needed Review of R#96's Comprehensive Falls assessment dated [DATE] revealed that he was a new admission with history of fall at home (multiple falls). Review of a Comprehensive Falls assessment dated [DATE] revealed that he was a readmit from the hospital, and that he had not had a fall since the last assessment. Review of a Falls Report revealed that R#96 had falls on 12/4/17; 12/5/17; 12/22/17; 12/29/17; and 1/7/18. Review of a Fall Risk assessment dated [DATE] revealed that he had a score of 7 (score of 7 to 18 indicates high risk). Review of a Falls Report from 6/1/17 to 2/28/18, and a Records List (of falls) from 2/21/18 to 6/19/18 revealed that R#96 had 10 falls between admission on 12/4/17 and 4/2/18. In addition, there was one fall on 2/19/18 that was not captured on the falls reports. Review of clinical record documentation related to falls for R#96 revealed the following: -Fall on 12/4/17: An IPN dated 12/4/17 revealed that R #96 was admitted from the hospital on this date from home at 7:20 p.m. after fall at home with left [MEDICAL CONDITION] and hemiarthroplasty (surgical repair of the [MEDICAL CONDITION]). An IPN dated 12/4/17 at 10:00 p.m. revealed that upon med rounds found this resident lying on the floor between his bed and his roommate's bed. Resident was taking off his abduction pillow. No visible signs of injuries. -Fall on 12/5/17: Review of an IPN dated 12/5/17 at 7:55 p.m. revealed the resident was on the floor in bathroom with feet pointing out of bathroom, on buttock/back, naked, catheter on floor. S/T (skin tear) noted X 2 to left elbow. Stated he needed to have a bowel movement and fell . Resident educated on call light use importance of assistance. Non skid socks placed on feet, bed moved against wall and a bedside commode at bedside. Call light clipped to gown. Staff keeps reminding resident to use call light. An IPN dated 12/6/17 at 2:50 p.m. noted that at approximately 1:00 p.m. R#96 was gotten OOB (out of bed) by therapy and sat in W/C (wheelchair) to eat lunch. At 1:20 p.m. therapy went back to check and resident was in bathroom and catheter was attached to W/C with bag. Catheter was separate (sic) below tube and Y-port. FNP examined and ordered to sent to ER (emergency room ) to evaluate catheter and to check left hip placement related to previous falls. An IPN dated 12/6/17 at 6:30 p.m. revealed that R#96 being moved from D-12-D to A-1-W. It is closer to bathroom and nurses station. Resident to return (from hospital) with new catheter. Review of a Skilled Services Review Notes completed 12/19/17 revealed that patient found on floor in restroom on his buttock/back 12/5/17, no injuries. On 12/4/17 patient noted on floor between bed and roommate's bed attempting to move pillow",2020-09-01
1033,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2018-06-22,725,J,0,1,RKM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines, and staff interview, it was determined that the facility failed to have sufficient staff to provide supervision to prevent accidents for four residents (R) (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, 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 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. 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 (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revised date of 5/1/17 revealed the following: Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. Review of R#85's clinical record revealed an original admission date of [DATE] and that he resided on the MCU, and had falls in his room on 11/30/17 (he alleged that his roommate pushed him down), 12/1/17, 12/11/17, 12/29/17, and 4/10/18. Further record review revealed that he was diagnosed with [REDACTED]. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18.Review of the clinical records for R#85, R#96, R#70, R#71 revealed that there was no documentation that any of the falls noted above were witnessed by staff, except for the fall on 2/19/18 for R#96, and the fall on 12/11/17 for R#85. During interview with the Administrator on 6/22/18 at 8:30 p.m., she stated that there was nothing formally in QA (Quality Assurance) related to deploying staff to meet the residents' needs, and that staffing was deployed based on acuity of the residents. During an interview on 6/22/18 at 11:10 a.m. with the Director of Nursing (DON), she stated that she and a Certified Nursing Assistant (CNA) were responsible for creating the schedule for the nursing staff. During further interview with the DON, she stated that on the 7:00 a.m. to 7:00 p.m. shift, there was one nurse and three CNAs scheduled to provide care for the residents on the MCU, and on the 7:00 p.m. to 7:00 a.m. shift there was one nurse and three CNAs that were scheduled to provide care for the residents on both MCU and A-Hall. Continued interview revealed that when the MCU and A-Hall were at full capacity, it housed 50 residents. During an interview on 6/22/18 at 7:25 p.m., Licensed Practical Nurse (LPN) EE stated that she was the charge nurse from 7:00 p.m. to 7:00 a.m., and her assignment included the A-Hall, B-Hall (MCU), and private rooms P-1, P-2, P-3, and P-4. She stated that from 7:00 p.m. until 11:00 p.m. there was a total of four to five CNAs that worked the assignment with her, and that at 11:00 p.m., there were three CNAs total for the assignment. LPN EE stated during continued interview that it could be difficult for her to monitor the residents for behaviors and falls, because she was split between the three halls. During an interview on 6/22/18 at 7:40 p.m. with CNA FF, she stated that there were usually two CNAs scheduled on the 3:00 p.m. to 11:00 p.m. shift on the MCU. She stated during further interview that she didn't feel that there was enough staff to take care of the residents, and that she and the other CNA took turns making rounds so one CNA could change residents, and the other CNA could watch the residents who were up in the common area. Cross refer F689",2020-09-01
1034,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2018-06-22,835,J,0,1,RKM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines, and Job Title: Administrator, and staff interview, it was determined that the facility failed to be administered in a manner to ensure there was an effective falls program that consistently determined the root cause of falls, and provided adequate supervision to prevent falls for four residents (R) (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, 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 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. 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 (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines revised 5/1/17 revealed the following: Each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Director of Nursing (DON)/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Review of the facility's Job Title: Administrator job description with a revised date of 10/2014 revealed: Job Description: 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. Essential Regulatory Functions: 8. Enforces the Nursing Center guidelines. 14. Assumes responsibility with department supervisor to provide adequate staffing. During interview with the Administrator on 6/22/18 at 8:50 p.m., she stated that falls were discussed in morning meetings, interventions discussed and the care plan updated. She further stated that falls for individual residents may not be taken to QA for discussion as they handled falls as they occurred. She stated during further interview that she did not feel there was a trend in falls, as the residents had different co-morbidities and the falls occurred on different units. Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 6/18/18 through 6/22/18. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F 657. The facility failed to provide evidence that they consistently revised the care plan with interdisciplinary input after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for four residents (R) (R#85, R#96, R#70, R#71). Cross reference to F 689. The facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) or skilled services meetings per facility policy so that the root cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for four residents (R#85, R#96, R#70, R#71). Cross reference to F 725. The facility failed to have sufficient staff to provide supervision to prevent falls for four residents with multiple falls (R#85, R#96, R#70, R#71). Cross reference to F 867. The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, implemented, and analyzed the effectiveness of corrective action plans for residents that sustained multiple falls (R#85, R#96, R#70, R#71).",2020-09-01
1035,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2018-06-22,837,J,0,1,RKM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Quality Assurance-Performance Improvement policy, Board of Directors procedural guidelines, and staff interview, it was determined that the facility's Governing Body failed to ensure that there was an effective falls program including consistently determining the root cause of falls, and ensure the Quality Assurance (QA) program was effective in developing, implementing, and analyzing falls data to address falls for four residents (R) (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, 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 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. 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 (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Quality Assurance-Performance Improvement (QAPI) policy (undated) revealed: Governance and Leadership: Elements of the QAPI Process will be reported to the Board of Directors periodically. QAPI Communications: The QAPI Committee will communicate findings to the appropriate personnel for reporting to the governing body. Review of the facility's Board of Directors procedural guidelines with a reviewed date of (MONTH) (YEAR) revealed: Board of Directors: Utilizes market analysis and market research for community needs and develops strategies for our Centers. Plans for long range and prioritizes demands through our strategic planning and goal setting process. Our leaders implement the goals through integrated services in the markets we serve. Services are provided for management and clinical support. Alignment of services for staff and function with allocation of resources, professional staff, based on service provided while systematically assessing performance and implementing priority driven improvement management. Maintain improvement. During interview with the Regional Nurse Consultant GG on 6/22/18 at 8:20 p.m., she stated that the way the corporation was structured, that each building operated as an LLC (Limited Liability Company). She further stated that the Administrator was considered the governing body for their building, and all department heads reported to her. During interview with the Regional Nurse Consultant GG on 6/22/18 at 9:19 p.m., she stated that Regional Vice President HH was part of the Governing Body, and he appointed the Administrator at each facility. She stated during further interview that the facilities had weekly calls with him on Mondays and Fridays, so the Administrator stayed in touch with him a lot. Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 6/18/18 through 6/22/18. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F 657. The facility failed to provide evidence that they consistently revised the care plan with interdisciplinary input after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for four residents (R) (R#85, R#96, R#70, R#71). Cross reference to F 689. The facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) or skilled services meetings per facility policy so that the root cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for four residents (R#85, R#96, R#70, R#71). Cross reference to F 725. The facility failed to have sufficient staff to provide supervision to prevent falls for four residents with multiple falls (R#85, R#96, R#70, R#71). Cross reference to F 835. The facility failed to be administered in a manner to ensure there was an effective falls program that consistently determined the root cause of falls, and provided adequate supervision to prevent falls for four residents (R#85, R#96, R#70, R#71). Cross reference to F 867. The facility failed to maintain a Quality Assessment and Assurance (QAA) committee that identified, developed, implemented, and analyzed corrective action plans for residents that sustained multiple falls (R#85, R#96, R#70, R#71).",2020-09-01
1036,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2018-06-22,867,J,0,1,RKM711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of Quality Assurance (QA) information related to falls, review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines and Quality Assurance-Performance Improvement (QAPI) policy, and staff and physician interview, the facility failed to have a Quality Assessment and Assurance (QAA) committee that effectively identified, developed, implemented, and monitored corrective action plans for four residents (R) that sustained multiple falls (R#85, R#96, R#70, R#71). A total of four residents were reviewed for falls with fractures, and the sample size was 46 residents. Review of the facility Resident Census and Condition of Residents Form CMS-672 dated 6/18/18 revealed that the current facility census was 95 residents. 78 residents were identified by the facility as being high risk for falls. On 6/22/18, 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 6/22/18 at 4:08 p.m. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ). The noncompliance related to the immediate jeopardy was identified to have existed on 12/1/17. 1. IJ was determined to exist as of 12/1/17, when R#85 was found on the floor behind the door to his room, with a laceration to the left forehead and bridge of nose, and bruise around left eye. Review of an x-ray dated 12/1/17 revealed that R#85 also had a comminuted [MEDICAL CONDITION] right humerus. The facility failed to determine the root cause of the fall, and failed to determine if current interventions were in place at the time of the fall so that their effectiveness could be evaluated to prevent further falls. 2. Review of R#96's clinical record revealed that he was admitted to the facility on [DATE], after a fall with [MEDICAL CONDITION] at home. Further clinical record review revealed that he had 11 falls between admission and 4/2/18, which included falls on 12/4/17, 12/5/17, 12/22/17, 12/29/17, 1/7/18, 1/9/18, 2/1/18, 2/19/18, 3/2/18, 3/25/18, and 4/2/18. In addition, the fall on 3/25/18 resulted in a fractured humerus and nasal bone. 3. Review of R#70's clinical record revealed that she was admitted to the Memory Care Unit (MCU) on 3/2/18. Further review of the clinical record revealed that she had falls on 3/3/18, 3/17/18, 3/20/18, and 6/19/18. Further record review revealed the fall on 3/17/18 resulted in a right [MEDICAL CONDITION] and [MEDICATION NAME] and lumbar fractures, and the fall on 6/19/18 resulted in a fractured rib and [MEDICATION NAME] vertebra. 4. Review of R#71's clinical record revealed that she had falls on 2/8/18, 4/5/18, and 6/1/18, and she sustained a nasal fracture after the fall from her wheelchair on 2/8/18. 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 (F 657 Scope and Severity (S/S): J); CFR 483.25(d) Quality of Care (F 689 S/S: J); CFR 483.35(a) Nursing Services (F 725 S/S: J); CFR 483.70 Administration (F 835 S/S: J); CFR 483.70(d) Administration (F 837 S/S: J); and CFR 483.75(d) Quality Assurance and Performance Improvement (F 867 S/S: J). Additionally, Substandard Quality of Care was identified with the requirements at CFR 483.25(d) Quality of Care (F 689 S/S): J) At the time of exit on 6/22/18, an Allegation of Compliance (AoC) had not been received, therefore the IJ remains on going. Findings include: Review of the facility's Patient Safety: Falls Management Clinical Practice Guidelines with a revised date of 5/1/17 revealed that each patient is assisted in attaining/maintaining his or her highest practicable level of function by providing the patient adequate supervision, assistive devices and/or functional programs as appropriate to minimize the risk for falls. The Director of Nursing/Designee is responsible for coordination of an interdisciplinary approach to managing the processes for prediction, risk assessment, treatment, evaluation, monitoring, and calculation of resident falls. Review of the facility's Quality Assurance-Performance Improvement (QAPI) policy (undated) revealed the following: Guiding Principles: The QAPI Process will be used within daily operations to guide decision making and improving care and services to meet the current and future needs of patients, customers, and the community. Governance and Leadership: The implementation of the QAPI Process is the responsibility of the Administrator. The Administrator may delegate aspects of this process to the QAPI Committee and/or key associates but retains the responsibility for oversight of the process, including ensuring that: 1. An ongoing QAPI program is defined, implemented, and maintained and addresses identified priorities. 4. The QAPI program identifies and prioritizes problems and opportunities that reflect organization process, functions, and services provided to residents based on performance indicator data, and resident and staff input, and other information. 5. Corrective actions address gaps in systems, and are evaluated for effectiveness. Performance Improvement Projects (PIPs): PIPs will be chartered and implemented through the QAPI Committee based on priority as aligned with key customer expectations, center strategic objectives and resource availability. At least annually a PIP that focuses on high risk or problem-prone areas should be chartered. Concurrent PIPs should be limited to the number that the center is able to support within available resources for success. PIP team members should include representatives from various departments/units/shifts as affected and associates who work with the system/process on daily basis. During the course of PIP team charter, each PIP facilitator will be charged with leading the team in root cause analysis to determine underlying causes of issues, rather than applying quick fixes that address symptoms only. Reporting to the QAPI Committee should include root cause analysis findings. Systematic Analysis and Systemic Action: At the direction of the QAPI, changes in systems and processes should be monitored for a defined period after the change to identify these consequences which may be either positive or negative. QA Event (Just Do It) reports will be reviewed by QAPI Committee to ensure this tool is used for QA events in absence of system/process problems. The QA Event tool (Just Do It form) should not be used in place of the PIPs. During interview with the Director of Nursing (DON) on 6/22/18 at 3:01 p.m., she stated that they did not analyze falls immediately after the fall, except for what was discussed in morning meetings. She further stated that she took falls data to the QA monthly meetings and falls were discussed there. She stated during continued interview that they did not document drill downs (to determine the root cause of falls) during the monthly QA meeting. During interview with the Administrator on 6/22/18 at 3:18 p.m., she stated that falls were currently in QA but was not sure for how long, and that they had not made leaps and bounds progress, just small progress with it. During review of the facility's QA data related to falls and interview with the Administrator and DON on 6/22/18 at 4:10 p.m., the following was noted: 2/10/17 (2017): audits revealed that interventions not updated for falls. 3/17/17 (2017): audits revealed that some fall incident reports were not entered in the computer. During interview with the DON at this time, she verified that this affected the ability to accurately track the number of falls. The DON stated during further interview at this time that a PIP was developed to decrease the number of falls, falls with injury, and decrease recurrent falls for the same resident. She stated during continued interview that she did not know when this PIP was developed as there was no date on the form, but that it had a target date of 5/18/17. The DON stated at this time during interview and review of the facility's QA data that an audit was done on 5/15/17 (2017) of not filling out incident reports completely. During continued interview with the DON at this time, she stated that on 5/20/18, they did a Just Do It audit, which was part of of their QA, that included that some weeks of PAR were missed, and that some falls and pertinent information related to a fall was not listed on the PAR and/or skilled notes. The DON further stated that she had not done anything yet to address the concerns found with this audit, and did not respond when asked if she had to wait for a QA meeting to address identified concerns. During interview with the Administrator at this time, she stated that the Records List report (for falls) noted that there were falls on all of the halls, and occurred at different times of the day, so she did not see a pattern of falls. During interview with the DON at this time, she verified that other than printing this report off, that there was no documentation that the falls data was analyzed, such as identifying residents with frequent falls and/or falls with injuries, and time of day of the falls. The DON stated during continued interview that the Regional Nurse Consultant came out and identified where some of their weaknesses were, and it included adding interventions to care plans after a fall. She stated that there were glitches in their recently-implemented electronic health records (EHR) system that they were still working out, and that sometimes things entered didn't come over. She further stated that her investigation of a fall was only as good as the nurse's documentation after the fall, and that the incident report information was not always complete. During interview with the facility's Medical Director on 6/22/18 at 6:19 p.m., he stated that he attended QA meetings at least every two or three months, and that the Administrator went over any issues she needed for him to know about when he made rounds at the facility every two or three weeks. He further stated that they had discussed falls, but nothing specific as far as increased numbers of falls or not addressing falls. He further stated that he was called about every fall that happened in the facility so that he was aware of individual falls, but not necessarily anything specific related to problems with falls management. During interview with the Administrator on 6/22/18 at 8:30 p.m., she stated that there was nothing formally in QA related to deploying staff to meet the residents' needs, but that staffing was deployed based on acuity of the residents. Review of QA documents revealed the following: A Performance Improvement Project (PIP) with a chartered date by QAPI Committee and Date of Study on 2/5/18 revealed: The Key Performance Indicators and Desired Outcome was to decrease falls and falls with major injury over the next 30 days. The Summary of Root Cause Analysis (RCA) Findings revealed: Appropriate interventions placed upon admission. Communicate with staff daily aware of changes in condition change in inventions (sic). Daily rounding and communicating to staff. Weekly review-IDT (interdisciplinary team) rounds for changes, thoroughly investigating immediate at time of falls. Completion of incident report. Review of the Action Plan for this PIP revealed to retrain staff on fall prevention; review resident admission hx (history); rounding with IDT on each fall; complete thorough invest. (investigation); CP (care plan) imitated on admit; CNA (Certified Nursing Assistant) communication of fall risk; medication review/therapy consult; rethink use of alarms. Review of a Regional Nurse Center Visit Report dated 1/12/18: Opportunities for Improvement: 1. Fall documentation with detail description of fall, immediate intervention. 7. Care plan review, revise, update with appropriate interventions timely. Review of an untitled and undated QA document related to falls revealed: Target Date 5/18/17 ongoing: Review each fall in morning meeting. Bring charts, review the whole patient. Review why fall occurred. Documentation of detail description of the fall, assessment documented, and immediate interventions documented . Target Date 6/30/17: Review each resident's current fall care plan. Review, revise plan of care. Care plan should be thoroughly reviewed for appropriate interventions and goals. Add current fall and interventions place. An undated Performance Improvement Project (PIP) (Follow-up Date of 7/4/17) noted an opportunity to decrease number of falls, decrease falls with injury, decrease in number of residents with multiple falls. The Desired Outcome was to decrease number of falls by 20%, and decrease number of repeat falls by 20% over the next 60 days. Summary of Root Cause Analysis (RCA) Findings: Investigation of falls thoroughly to determine cause. Communicate cause, F/U (follow-up) to evaluate effectiveness of interventions. Observations, clinical records review, and staff interviews revealed the facility was not in substantial compliance during the standard/extended survey of 6/18/18 through 6/22/18. Refer to the following deficiencies for specific details of the noncompliance: Cross reference to F 657. The facility failed to provide evidence that they consistently revised the care plan with interdisciplinary input after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for four residents (R) (R#85, R#96, R#70, R#71). Cross reference to F 689. The facility failed to provide supervision to prevent accidents; failed to provide evidence that falls were consistently discussed in Patients At Risk (PAR) or skilled services meetings per facility policy so that the root cause of each fall could be determined; and failed to provide evidence of what interventions were in place at the time of each fall so that the effectiveness of current interventions to prevent falls could be reassessed for four residents (R#85, R#96, R#70, R#71). Cross reference to F 725. The facility failed to have sufficient staff to provide supervision to prevent falls for four residents with multiple falls (R#85, R#96, R#70, R#71). Cross reference to F 835. The facility failed to be administered in a manner to ensure there was an effective falls program that consistently determined the root cause of falls, and provided adequate supervision to prevent falls for four residents (R#85, R#96, R#70, R#71). Cross reference to F 837. The facility's Governing Body failed to ensure that there was an effective falls program including consistently determining the root cause of falls, and ensure the Quality Assurance (QA) program was effective in developing, implementing, and analyzing falls data to address falls for four residents (R) (R#85, R#96, R#70, R#71). During an interview with the Administrator, DON and Regional Nurse Consultant, conducted on 6/22/18 at 8:30 p.m., the Administrator was unable to provide any feedback regarding what type of model or system the facility's QAPI Committee utilizes to analyze data collected, develop their PIPs for problem areas identified and study the results of their actions to determine what, if any further action was required. She stated that the members of the QA Committee, if they identify something that isn't working in their department, have an option of doing a Performance Improvement Plan or PIP, introduce it into QA and then start working their plan; or they may complete a Just Do It plan which is used if they think they can resolve the problem quickly. Information (from the PIP and/or Just Do It) is brought back to the QA Committee for review. The Committee also use audits the management team (corporate) completes. She also stated the Consulting Pharmacist's monthly audits of each resident's drug regimen and audits of trends within the facility which are used to compare the facility's performance to their internal organizational data as well as state and national standards. The Administrator stated that sufficient staffing is always in Q[NAME] She discussed interventions utilized to reach their goal of being agency free which was met in April.",2020-09-01
4061,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2017-04-01,279,D,1,0,WLKC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, resident and staff interviews, the facility failed to develop a comprehensive, individualized care plan with appropriate interventions for the care of a [MEDICAL CONDITION] and [MEDICAL CONDITION] bag for one of one resident (R) (R#3) that had a [MEDICAL CONDITION]. The sample was three residents. Refer F328 Findings include: Record review for R#3 revealed an original admitted to the facility of 10/23/15 with a [MEDICAL CONDITION]. The resident was re-admitted to the facility on [DATE], [DIAGNOSES REDACTED]. Review of the care plan for R#3 with a start date of 11/6/15 identified that the resident requires a suprapubic catheter and a [MEDICAL CONDITION]. The Goal documents that the resident will be free of infection and associated complications. The interventions indicated only [MEDICAL CONDITION] care and Observe for signs and symptoms of infection, which did not specify if this was related to catheter care or [MEDICAL CONDITION] care. The care plan did not address how often [MEDICAL CONDITION] care was to be provided, what is included in [MEDICAL CONDITION] care, how often the [MEDICAL CONDITION] bag should be monitored and no individualized interventions Interview with R#3 on 4/1/17 at 11:20 a.m. revealed that the resident had [MEDICAL CONDITION] bag under his shirt on the left side of his stomach. The [MEDICAL CONDITION] bag could be seen bulging from under the shirt. When the shirt was lifted, it was observed that the [MEDICAL CONDITION] bag was filled with gas/air and stool was present. R#3 stated the [MEDICAL CONDITION] bag began blowing up around 5:30 a.m. and that no one had checked it yet today. R#3 stated in a further interview at 1:40 p.m., that he does not like the [MEDICAL CONDITION] bag to have stool in it and stated I don't want that stuff on me. Subsequent observations were conducted at 12:30 p.m., 1:40 p.m. and 2:15 p.m. on 4/1/17 of the [MEDICAL CONDITION] bag filled with gas/air and stool The resident stated during both subsequent observations that the Certified Nursing Assistant (CNA) had still not checked the bag. An interview with the Director of Nursing (DON) on 4/1/17 at 3:42 p.m. revealed the staff should be checking the [MEDICAL CONDITION] bag in the same manner as check and change every two hours and the CNA should report any abnormalities to the nurse. The DON further stated that R#3 is very funny about his bag being full of stool and that he did not like any stool on himself. He likes his [MEDICAL CONDITION] bag clean and empty. A telephone Interview on 4/1/17 at 4:23 p.m. with the Licensed Practical Nurse (LPN) RAI Coordinator revealed that the software program used for developing care plans is called Keane. In this program, a care area, such as [MEDICAL CONDITION], is selected. Once selected, the library has pre-selected interventions. Whoever is developing the care plan will de-select the interventions that do not apply and has the capability of entering individualized interventions. The RAI Coordinator stated that typically the interventions for a [MEDICAL CONDITION] would include things such as the frequency of [MEDICAL CONDITION] care, changing the bag, [MEDICAL CONDITION] cleaning instructions of the stoma site, re-applying a new wafer, check and changes every two hours and any individual interventions needed. The RAI Coordinator stated that since she was not in the facility, she could not say who developed the care plan or why the care plan for R#3's [MEDICAL CONDITION] was so vague. The RAI Coordinator further stated that several other people had been helping with assessments and care plans.",2020-08-01
4062,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2017-04-01,328,D,1,0,WLKC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, review of the undated General Care Guidelines- Ostomy Care, resident and staff interviews, the facility failed to monitor and empty the [MEDICAL CONDITION] bag that was full of gas and stool in a timely manner for one resident (R) (R#3) with a [MEDICAL CONDITION]. The sample was three residents. Findings include: Review of the facility's undated General Care Guidelines- Ostomy Care documented: Intent- Provide guidelines for proper application and maintenance of bag system maintaining intact [MEDICATION NAME] skin and patient comfort. [MEDICAL CONDITION] bags are designed to be emptied prn (as needed) and changed every 2-5 days when odor or discoloration is noted. During an interview with R#3 on 4/1/17 at 11:20 a.m., it was observed that the resident had a [MEDICAL CONDITION] bag under his shirt on the left side of his stomach. The [MEDICAL CONDITION] bag could be seen bulging from under the resident's shirt. When the shirt was lifted, it was apparent that the [MEDICAL CONDITION] bag was filled with gas/air and bowel movement was present. R#3 stated the [MEDICAL CONDITION] bag began blowing up around 5:30 a.m. and that no one had checked the bag yet today. He stated that the night CAN was in his room and emptied his catheter and thought she was going to check his [MEDICAL CONDITION] bag too but she turned and walked out of the room. R#3 stated that when he has his regular male Certified Nursing Assistant (CNA), he checks his bag every two hours and changes his bag, but when other CNA's take care of him, this does not happen. They come in and take care of his roommate and walk right out of the room. Record review for R#3 revealed an initial admission to the facility on [DATE] with a [MEDICAL CONDITION]. The resident was re-admitted to the facility on [DATE]. R#3 has 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 the resident had no cognitive impairment. The resident does not exhibit moods or behaviors and the resident requires extensive assistance with toileting. Section H- Bowel and Bladder indicated the resident had a [MEDICAL CONDITION] and indwelling catheter. Review of the Quarterly MDS assessment dated [DATE] indicated admission to the facility on [DATE]. Although in Section C- Cognitive Patterns checked that a BIMS should be conducted , there is no BIMS summary score. Review of the Quarterly MDS assessment dated [DATE] revealed in Section C- Cognitive Patterns that a BIMS should be conducted but no BIMS summary score indicated. Review of the care plan for R#3, with a start date of 11/6/15, identified a [MEDICAL CONDITION] with diagnosis (Dx) of [MEDICAL CONDITION]. The Goal documents the resident will be free of infection and associated complications. The interventions indicated only [MEDICAL CONDITION] care and Observe for signs and symptoms of infection. No other interventions in place. Review of the Physician order [REDACTED]. [MEDICAL CONDITION] care daily and as needed. An observation conducted on 4/1/17 at 12:30 p.m. of R#3 revealed the [MEDICAL CONDITION] bag could still be seen bulging from under the resident's shirt. Interview with R#3 stated that no one has checked his bag. The resident stated that CAN would probably come to check and change his bag after lunch. An observation conducted on 4/1/17 at 1:40 p.m. of R#3 revealed the [MEDICAL CONDITION] bag could still be seen bulging from under the resident's shirt. R#3 stated that the CNA had still not checked his bag. R#3 stated that he does not like his bag to be full and stated I don't want that stuff on me. R#3 further stated that he does not want his visitors to see the bag or smell anything. R#3 stated that he could call the staff to check his [MEDICAL CONDITION] bag but that he should not have to do that. R#3 stated that he cannot open his fingers or lift his shirt to check his own bag and they are supposed to check on him every two hours, or at least that's what they say. R#3 stated that he has voiced his concerns to the Director of Nursing (DON) and he was told that he needs to follow the chain of command and report this concern to his nurses. A subsequent observation at 2:15 p.m. revealed the [MEDICAL CONDITION] bag remained filled with gas/air and stool. An interview was conducted on 4/1/17 at 2:20 p.m. with CNA caring for R#3 (CNA AA) to ask when she would be conducting [MEDICAL CONDITION] care and that this care needed to be observed by the surveyor. CNA AA stated that she would finish with the resident she was working with and let the surveyor know when she was ready to provide [MEDICAL CONDITION] care for R#3. Observation on 4/1/2017 at 2:45 p.m. of [MEDICAL CONDITION] care for R#3 with CNA AA and CNA BB revealed the staff knocked on the resident's door, explained they were going to provide [MEDICAL CONDITION] care and requested permission from the resident for the surveyor to observe the care. R#3 stated that it would be acceptable. Observation of the [MEDICAL CONDITION] bag revealed it was filled tight with gas/air and with a small amount of stool. During the treatment ostomy care was provided utilizing clean technique and the ostomy appliance was changed. Observation of the ostomy sight revealed a pink opening with no evidence of broken skin or infection. The resident tolerated the procedure well and the care was appropriately performed by the staff. During an interview on 4/1/17 at 3:25 p.m. with CNA AA, she revealed that R#3 does not like to be bothered much but that he will call to have his [MEDICAL CONDITION] bag burped at times. CNA AA stated that the [MEDICAL CONDITION] bag is supposed to be checked every two hours just like a check and Change' and that she had been busy today trying to complete the Saturday baths. Interview conducted on 4/1/17 at 3:42 p.m. with the Director of Nursing (DON) revealed ultimately the CNAs are responsible for [MEDICAL CONDITION] care and will report any abnormalities to the nurse. The CNAs are expected to check on the [MEDICAL CONDITION] bag every two hours the same as a check and change for bowel movement (BM) or release of gas. The DON further stated that R#3 is real funny about his [MEDICAL CONDITION] bag. He does not like see BM and does not want BM on him. R#3 has been known to refuse treatment of [REDACTED]. The Don stated that the only documentation of [MEDICAL CONDITION] care is on the Medication Administration Record [REDACTED]. The only other documentation is a BM Report which document when the resident had a BM. There is no documentation of [MEDICAL CONDITION] checks every two hours or findings during these checks. Review of the MAR for (MONTH) 1 through (MONTH) 31, (YEAR) revealed [MEDICAL CONDITION] Care Daily and As Needed. Each day had a signature at 7:00 a.m. and 7:00 p.m. The (MONTH) (YEAR) MAR indicated [REDACTED].",2020-08-01
4063,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2017-04-01,356,C,1,0,WLKC11,"> Based on observation and interview, the facility failed to ensure that the nurse staffing data sheet was posted daily for public review. The facility census was Findings include: During initial tour of the facility with the Administrator on 4/1/17 at 10:55 a.m., it was noted, in the glass case outside of the dining room, that the last day the nurse staffing data was posted was on Monday, 3/27/17. An interview with the Administrator at the time of the observation revealed the Director of Nursing is responsible for posting the nursing hours each day by noon. The Administrator stated that there is no facility policy but that this was her expectation. The Administrator did not know why the nurse staffing data had not been posted since Monday and stated when the DON arrives to the facility we could ask her. Interview conducted on 4/1/17 at 1:06 p.m. with the DON revealed she had completed the daily nurse staffing forms for 3/28/17 (Tuesday), 3/29/17 (Wednesday), 3/30/17 (Thursday) and 3/31/17 (Friday) but they were in a folder and she had not posted them in the glass case for public view. The DON stated that she knows the nurse staffing hours should be posted everyday but she had a busy week and was doing the best she can. The DON said she usually has the form posted in the glass case by noon. The DON further stated that weekend supervisor is responsible for posting the nursing hours on the weekends. Interview conducted on 4/1/17 at 1:20 p.m. with the weekend Registered Nurse (RN) Supervisor revealed in the morning, she checks the schedule, verifies that everyone on the schedule is in the building, assigns the nurse's and CNAs on the Map Out (assignment sheet), fills out the nursing hours form and places it in the glass case, usually by 9:00 a.m. The RN Supervisor stated that she was late getting the nurse staffing hours posted because they facility had two late admits the day before and she was verifying the new admissions medications.",2020-08-01
4237,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2015-07-09,371,E,0,1,YESR11,"Based on observation, interview, and record review the facility failed to store refrigerated and frozen foods under sanitary conditions. Findings include: 1. Initial observation of the walk-in cooler on 7/6/2015 at 11:05 a.m. with the Dietary Manager (DM)revealed delivery boxes of potatoes, cantaloupes, packaged bacon and bagged salad sitting directly on the floor of the cooler. Staff and the DM immediately moved the boxes off the floor and into a sanitary storage space. The DM revealed that when the delivery arrived on Friday, 7/3/2015, there was not enough space on the shelves in the cooler for the boxes. The cooler temperature at 11:05 a.m. was 52 degrees Fahrenheit (F). Observation of the cooler temperature log revealed that the cooler was 40 F when checked that morning at the start of shift. The DM revealed that staff had used the cooler extensively for food prep and the temperature will return to normal. Observation of the dual vents in the walk-in cooler on 7/6/2015 at 11:05 a.m. and again on 7/8/2015 at 1:00 p.m. revealed thick, black, moist debris covering approximately half of the screens of both vents of the cooling unit which blows cooled air directly over the stored foods. The cooler temperature on 7/8/2015 at 1:00 p.m. was 49 F although it was recorded at 40 F that morning. The Administrator revealed that maintenance was checking the walk-in cooler. Observation of the walk-in cooler on 7/8/2015 at 3:05 p.m. with the Food Service Aide AA confirmed and acknowledged that there was thick, moist debris on the vents. 2. Observation of the upright freezer on 7/6/2015 at 11:15 a.m. with the DM revealed one prepared turkey meat roast wrapped in plastic that was partially defrosted. Three quarters (3/4) of the roast was soft and pliable to touch while the other portion was still firm. A plastic bag of individually wrapped pureed chicken servings were also soft and pliable to touch but not completely defrosted. The DM explained that these products were used for alternate choices on the menu. Once the alternate meals were prepared, the remainder of the products were placed back in the freezer for use at a later time. The DM removed and discarded both the turkey roast and the pureed chicken servings. Observation of the upright freezers on 7/8/2015 at 1:00 p.m. with the DM revealed a plastic bag of partially defrosted chicken wings. The DM explained that these were to be used for a specific resident's lunch, but the resident changed her mind and the wings were placed back in the freezer. The DM removed and discarded the chicken wings. 3. Observation of the dishwasher during operation on 7/8/2015 at 1:10 p.m. revealed that the hood over the dishwasher had large, thick brown balls of dust clinging to the inside and the outside of the hood. Clean, wet dishes were observed to exit the dishwasher under the hood. Observation of area with Food Services Aide AA on 7/8/2015 at 3:05 p.m. confirmed the heavy layers of dust both inside and outside of the hood. Interview with the Dietary Manager and the Administrator on 7/9/2015 at 2:45 p.m. Manager corroborated surveyors ' observations in the walk-in cooler, freezer, and the vent hood. She further revealed that there was no room in the cooler for all of the delivered food and agreed that partially defrosted food should not be re-frozen. The Administrator revealed that the vent hood over the dishwasher was not working.",2020-01-01
5519,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2014-06-12,157,D,0,1,VRTF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interview, the facility failed to ensure that the physician was aware of a radiologist's recommendation for a computerized axial tomography (CT) scan to rule out a [MEDICAL CONDITION] for one (1) resident (A). The sample size was forty-four (44) residents. Findings include: During interview with a family member of resident A on 06/10/14 at 9:20 a.m., he stated that the resident complained of constant pain after the second of two falls that occurred in one week sometime in May. During interview with another family member of resident A on 06/12/14 at 12:35 p.m., she stated the resident's hip pain got increasingly worse from somewhere around 05/21/14 until 06/03/14, at which time she insisted that the resident go to the emergency room (ER). Review of resident A's closed clinical record revealed that they were admitted to the facility on [DATE], and discharged to the hospital on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the facility's Event Log revealed falls on the following days: -04/22/14 at 4:00 a.m. during a toileting transfer. -05/20/14 at 12:00 p.m. in the bathroom at the [MEDICAL TREATMENT] center. -05/22/14 at 2:30 p.m. in the [MEDICAL TREATMENT] transport van. -05/23/14 at 6:30 a.m. resident found on floor next to bed. In addition, there was an undocumented fall at the end of (MONTH) sometime after 05/28/14, during a toileting transfer. Review of Interdisciplinary Progress Notes (IPN) noted the following: -05/23/14 at 6:30 a.m.: Resident call staff to room, stated she needed help getting off of floor. Observed resident sitting on floor in room beside bed, stated she was doing her bath and slid out of wheelchair. No injuries noted. Told to always call for assist with a.m. care and transfer, call light in reach. -05/23/14 at 7:10 a.m.: Dr. Jackson and responsible party (RP) notified of fall without injuries. -05/23/14 at 10:00 a.m.: Resident complained of pain to left upper thigh/hip area. X-ray ordered, RP notified. -05/24/14 at 2:00 p.m.: Resident in bed, some complaint of pain voiced to left upper thigh. Complained of tenderness. X-ray done 05/23/14 no fracture noted. -06/03/14 at 1:00 p.m.: Resident complained of left hip area and upper thigh area pain. Resident in tears. Pain med given. Called MD. Order to schedule CT scan at hospital. Appointment set for 8:00 in the morning. -06/03/14 at 3:45 p.m.: Resident's family arrived at facility to visit. Resident complained of pain to left hip. Family request resident go to ER now. Called MD. Order to send to ER to evaluate and treat. Transported via stretcher. -06/03/14 at 8:00 p.m.: Resident sent to Doctors Hospital for fractured left hip. Review of a left hip radiograph done after the fall on 05/23/14 revealed the following: Osteopenia with minimal [MEDICAL CONDITION] changes of the acetabulum. Shortening of the femoral neck. Nondisplaced fracture not entirely excluded. Limited by portable technique. Recommendation: Followup CT recommended. A pelvis and hip x-ray done in theER on [DATE] revealed a displaced [MEDICAL CONDITION] femoral neck. During interview with the interim Director of Nurses (DON) and Registered Nurse (RN) Corporate Consultant AA on 06/11/14 at 10:39 a.m., they verified that there was no documentation in the clinical record that the nurse that faxed the hip x-ray report to the doctor's office ensured that he received it and was aware of the recommendation for a follow-up CT scan. The interim DON stated that she obtained a statement from the nurse that said she talked to a nurse at the physician's office about the hip x-ray, but that she did not document this discussion in the chart. Review of a fax communication form dated 05/23/14 at 4:39 p.m. noted that the left hip radiograph was sent to a destination of Medical Specialists with a result of OK. During interview with resident A's primary physician BB on 06/11/14 at 1:50 p.m., he stated that the first time he would have been aware of the radiologist's recommendation for a CT to rule out a [MEDICAL CONDITION] would have been on the day he ordered it on 06/03/14. He added that he did not remember staff calling him to report the x-ray results and recommendation for the CT scan. He further stated that since the left hip x-ray was faxed to his office so late on a Friday, and because the office was closed through Monday due to the holiday, he would not have started going through the stack of faxes until 05/27/14 and it would have taken several days to go through them all. The physician verified that the nursing home staff had the ability to call his answering service if the office was closed to reach either him or one of the other practitioners. Review of the facility's Changes In A Patient's Condition policy and procedure noted: Nursing services should be responsible for notifying the patient's attending physician when: -There is a significant change in the patient's physical, mental, or emotional status. -Deemed necessary or appropriate in the best interest of the patient.",2018-08-01
5520,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2014-06-12,282,D,0,1,VRTF11,"**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 a two-person transfer for one (1) resident (A) resulting in a fall. The sample size was forty-four (44) residents. Findings include: Review of resident A's closed clinical record revealed that the resident was admitted to the facility on [DATE], and discharged to the hospital on [DATE]. Further record review revealed [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] noted that the resident had a Brief Interview for Mental Status Score (BIMS) of 11 (moderately impaired cognition per a scale of 0-15); noted that she was extensive assist by two staff for transfers; limited assist by one staff for toilet use; independent for locomotion; independent for personal hygiene with set-up help only; and needed physical help in part of bathing. Review of the care plan related to falls revealed that the resident was at risk for injury related to falls due to muscle weakness, difficulty walking, and right AKA with an intervention that included see Falls Intervention Plan. Review of the Falls Intervention Plan included the following intervention dated 4/22/14 to encourage staff not to transfer resident alone, requires 2-person or lift During interview with the Nursing Home Administrator (NHA) on 06/12/14 at 1:20 p.m., she stated that she learned of an undocumented fall early on the day shift somewhere around 05/30/14, and that the charge nurse told her that she did not document it as she did not consider it a fall because the resident was lowered to the floor by staff. During interview on 6/12/14 at 1:55 p.m., Certified Nursing Assistant (CNA) DD stated that when transferring resident A from the shower chair to the wheelchair, the resident said she was too weak to stand, and she held onto one of the resident's arms and lowered her to the floor. The CNA added that the resident did not go down hard and did not complain of pain, and that she reported the fall to LPN CC. There was no evidence that the resident was being assisted by two persons as per the plan of care dated 4/22/14.",2018-08-01
5521,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2014-06-12,309,D,0,1,VRTF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview with resident and staff, it was determined that the facility failed to follow the physician's order for a fluid restriction for one (1) resident (Z) from a sample of forty four (44) residents. Findings include: Review of the clinical record for resident Z revealed that the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Resident receives [MEDICAL TREATMENT] on Monday, Wednesday and Friday. Telephone interview, during the Quality Assurance process, with the facility Administrator on 6/25/14 at 2:30 p.m. revealed that on (MONTH) 16, 2013 a recommendation for fluid restriction at 1200 milliliters (mls) in 24 hours came from the [MEDICAL TREATMENT] Clinic. The physician was notified and accepted the recommendation giving an order for [REDACTED].>Review of the 1200ml fluid restriction overview form revealed that the resident should receive 120 ml of Nepro two times a day between meals , scheduled at 9:00 a.m. and 5:00 p.m., 120ml of fluid at breakfast and 240ml of fluid with lunch and dinner for a total of 840 mls allowing the resident 360 mls of fluid intake at other times during the day. Observation of the resident on 6/11/14 at 12:30 p.m. revealed the resident in the dining room for lunch. The resident was served 16 ounces (480 mls) of lemonade and 6 ounces (180 mls) of water. Review of the [MEDICAL TREATMENT] Communication Form dated 5/21/14 revealed a note under the problems/alerts area that resident has to much fluid please monitor fluid intake. There was no evidence that fluid intake had been monitored consistently in April, (MONTH) or June, 2014. Interview on 6/11/14 at 10:05 a.m,. with the Corporate Nurse revealed that the resident had not been consistently monitored for fluid intake.",2018-08-01
5522,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2014-06-12,323,D,0,1,VRTF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to use a two-person transfer for one (1) resident (A) resulting in a fall, and failed to document and report this fall. The sample size was forty-four (44) residents. Findings include: Review of resident A's closed clinical record revealed that the resident was admitted to the facility on [DATE], and discharged to the hospital on [DATE]. Further record review revealed [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] noted that the resident had a Brief Interview for Mental Status Score (BIMS) of 11 (moderately impaired cognition per a scale of 0-15); noted that she was extensive assist by two staff for transfers; limited assist by one staff for toilet use; independent for locomotion; independent for personal hygiene with set-up help only; and needed physical help in part of bathing. Review of the care plan related to falls revealed that the resident was at risk for injury related to falls due to muscle weakness, difficulty walking, and right AKA with an intervention that included see Falls Intervention Plan. Review of the Falls Intervention Plan included the following intervention dated 4/22/14 to encourage staff not to transfer resident alone, requires 2-person or lift During interview with the Nursing Home Administrator (NHA) on 06/12/14 at 1:20 p.m., she stated that she learned of an undocumented fall early on the day shift somewhere around 05/30/14, and that the charge nurse told her that she did not document it as she did not consider it a fall because the resident was lowered to the floor by staff. During interview with the Registered Nurse (RN) Corporate Consultant AA at this time, she stated that any change from one level to another would be considered a fall, and verified that it should have been discussed in PAR and the FIP updated. During interview with Licensed Practical Nurse (LPN) CC on 06/12/14 at 1:50 p.m., she stated that sometime in late (MONTH) she was told that resident A got weak and was lowered to the shower chair, but didn't have a fall. LPN CC added that she assessed the resident and her range of motion was fine, and the resident said she just got weak but didn't get hurt. During interview on 6/12/14 at 1:55 p.m., Certified Nursing Assistant (CNA) DD stated that when transferring resident A from the shower chair to the wheelchair, the resident said she was too weak to stand, and she held onto one of the resident's arms and lowered her to the floor. The CNA added that the resident did not go down hard and did not complain of pain, and that she reported the fall to LPN CC. There was no evidence that the resident was being assisted by two persons. Review of the facility's Falls Management At A Glance policy and procedure noted that should a fall occur, complete an Event Management form. Document circumstances of fall; implement an immediate intervention on the FIP; subsequent documentation for the next 72 hours or longer if indicated; record fall on 24-hour report; DON or designee will ensure updates occur for FIP, 24-hr report and Accunurse. All falls should be reviewed daily in morning meetings. Patients with recurring falls may require further review in PAR meetings.",2018-08-01
5523,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2014-06-12,371,D,0,1,VRTF11,"Based on observation and staff interviews the facility failed to ensure thickening liquids had not expired. There were five (5) residents receiving altered consistency fluids. The facility census was ninety (90) Findings include: Observations on 6/10/14 beginning at 4:20 p.m of the dry food storage area revealed there were twenty three (23) 8 ounce (oz) cartons of Resource Lemon Flavored Thickening Water with an expiration date of 12/15/2013; one (1) 8 oz carton of Resource Lemon Flavored Thickening Water that expired on 5/18/2014; and sixty six (66) 4 oz cartons of Resource Lemon Flavored Thickening Water that expired on 1/16/14. Continued observation revealed was one (1) 6.8 oz carton of Ensure Clear Therapeutic Nutrition Mixed Berry thickening that expired on 2/1/14; one (1) case of forty eight (48) 4 oz cups of Sysco Apple Juice Nectar Consistency that expired on 5/13/14, and thirty two (32) individual 4 oz cups of Sysco Apple Juice Nectar Consistency that expired on 3/17/14. Interview on 6/11/14 at 12:15 p.m. with the Administrator, Dietitian and Dietary Manager revealed there are five (5) residents who receive altered consistency fluids; four (4) who receives the lemon water and one (1) who receives apple juice.",2018-08-01
5524,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2014-06-12,441,D,0,1,VRTF11,"Based on observations and revew of the facility policy for Hand Hygiene, the facility failed to ensure staff sanitized their hands between resident's when serving and setting up their meals and beverages. The census was ninety (90) residents. Findings Include: 1. Observation on 6/9/14 from 12:07 p.m. until 1:23 p.m. of the first (1st) seating for resident dining revealed two (2) Certified Nursing Assistants (CNAs) and the Assistant Director of Nursing(ADON) passing meal trays to twenty five (25) residents who were seated at the tables. Both CNA's were observed passing and setting up meal trays and beverages, touching and handling the door and door knob that lead into the kitchen food prep area without sanitizing their hands between residents. Continued observation revealed CNA FF adjusting the smaller of the two (2) headsets that she wore around both ears and putting her hand into right side uniform pocket. After adjusting the headset, she wheeled a resident to the table, picked up the residents fork and knife and assisted with cutting the residents meat. The CNA continued to assist two additional residents with cutting their meat and did not sanitize her hands between the residents. 2. Observation on 6/10/14 between 5:20 and 5:40 p.m. in the main dining room revealed a CNA to cut up one residents tomato using utensils that the resident had already touched and guided the residents hand to the location of chicken on plate. Without sanitizing her hands the CNA obtained a tray for another resident, touched the tops of the water and tea glasses, removed straw from the wrapper and placed straw in tea touching the rim of the straw. Continued observation revealed the CNA without sanitizing her hands, obtained a tray for another resident, touched the top of a glass of lemonade, removed the straw from the wrapper and touching the rim of the straw, placed it in the lemonade. Review of the Hand Hygiene Policy revealed that to decrease the risk of transmission of infection by appropriate hand hygiene staff are to use alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those requiring soap and water such as when visibly dirty or contaminated with proteinaceous material, spore-forming organism, blood or body fluids.",2018-08-01
7037,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2012-08-30,281,D,0,1,YWXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Georgia Practical Nurse Practice Act and staff interviews the facility failed to ensure there was a physician order for [REDACTED]. Findings include: Review of the June and July, 2012 Medication Administration Records (MAR) for resident #103 revealed that fingerstick blood sugar checks were being done twice daily and sliding scale Insulin was being administered as indicated, Continued review revealed that there was no evidence of a physician's order for the fingerstick blood sugar checks or the sliding scale Insulin. Interview on 8/28/12 at 3:16 p.m. with Licensed Practical Nurse (LPN) DD revealed that the resident receives blood sugar checks at 6:30 a.m. and has sliding scale insulin coverage. The LPN revealed that the resident rarely needs Insulin coverage and that she had contacted the physician in early August to see if the physician wanted to continue the blood sugar checks with Insulin coverage twice daily. The physician ordered daily blood sugars checks with sliding scale Insulin coverage. Review of the medical record with LPN DD revealed that an order could not be found for either the blood sugar checks or the sliding scale insulin after the resident was readmitted to the facility from a hospital stay on 6/8/12. Interview with LPN EE the Admission Director on 8/28/12 at 3:16 p.m. at this time revealed that the resident went out to the hospital, and returned on 6/8/12 and the hospital orders did not include restarting the resident's Insulin or blood sugar checks. She explained the resident was on blood sugar checks with sliding scale Insulin prior to discharge from the facility. Confirmed there was no physician order from 6/8/12 through 7/12 and cannot explain how this was overlooked. Record review of the Medication Administration Record [REDACTED]. Review of the Georgia Practical Nurses Practice Act revealed that the practice of licensed practical nursing means the provision of care for compensation. Section 2.3.2--Subsection J- Implements appropriate aspects of client care in a timely manner, Administers medication accurately",2017-08-01
7038,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2012-08-30,309,D,0,1,YWXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure there was a physician order for [REDACTED]. Findings include: Review of the medical record for resident #103 revealed that the resident had [DIAGNOSES REDACTED]. Review of the medications administered to the resident revealed that fingerstick blood sugar checks were being done daily and sliding scale Insulin was being administered as indicated, Continued review revealed that there was no evidence of a physician's order for the fingerstick blood sugar checks or the sliding scale Insulin. Interview on 8/28/12 at 3:16 p.m. with Licensed Practical Nurse (LPN) DD revealed that the resident receives blood sugar checks at 6:30 a.m. and has sliding scale insulin coverage. The LPN revealed that the resident rarely needs Insulin coverage and that she had contacted the physician in early August to see if the physician wanted to continue the blood sugar checks with Insulin coverage twice daily. The physician ordered daily blood sugars checks with sliding scale Insulin coverage. Review of the medical record with LPN DD revealed that an order could not be found for either the blood sugar checks or the sliding scale insulin after the resident was readmitted to the facility from a hospital stay on 6/8/12. Interview with LPN EE the Admission Director on 8/28/12 at 3:16 p.m. at this time revealed that the resident went out to the hospital, and returned on 6/8/12 and the hospital orders did not include restarting the resident's Insulin or blood sugar checks. She explained the resident was on blood sugar checks with sliding scale Insulin prior to discharge from the facility. Confirmed there was no physician order from 6/8/12 through 7/12 and cannot explain how this was overlooked. Record review of the Medication Adminstration Record (MAR) for June and July 2012 revealed the resident had a blood sugar check twice daily and required insulin coverage 7/1, 7/15, 7/16 and on 8/11/12. Interview with Nurse Consultant FF on 8/28/12 at 3:20 p.m. revealed that the pharmacy consultant had reviewed the charts three (3) times since the resident returned from the hospital and that a nurse reviews the Physician Order Summary every month against the previous months MAR indicated [REDACTED]. She revealed this should have been noted and corrected prior to this date.",2017-08-01
7039,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2012-08-30,428,D,0,1,YWXI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the consultant pharmacist failed to identify and report the absence of a physician's order for administration of Insulin for one (1) resident (#103) of twenty one (21) sampled residents. Findings include: Review of the consultant pharmacists Drug Regimen Review for resident #103 revealed that reviews done monthly, from 6/08/12 through 8/28/12, failed to identify that there was no physician's order for fingerstick blood sugars with sliding scale Insulin administration as indicated. Interview with Licensed Practical Nurse (LPN) EE Admission Director on 8/28/12 at 3:16 p.m. revealed that the resident went out to the hospital, and returned on 6/8/12 and the hospital orders did not include restarting the resident's insulin or blood sugar checks. Interview with Nurse Consultant FF on 8/28/12 at 3:20 p.m. confirmed that the pharmacy consultant had reviewed the charts three (3) times since the resident returned from the hospital on [DATE].",2017-08-01
7611,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2014-02-27,309,D,1,0,9TRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on health record review and staff interview the facility failed to follow the physician's orders for pain relief medication for two residents (#1, #2) in a sample of six (6) residents. Findings include: Review of the Physician's Orders for Resident #1 dated 11/22/2013 through 11/30/2013 included a Protocol Order for APAP three hundred and twenty five milligrams (325mg) two (2) tablets by mouth as needed (PRN) for pain or fever, up to four (4) doses. A review of the Medication Administration Record [REDACTED]. An interview with the DON on 02/27/14 at 3:50 PM confirmed the Physician's protocol order was for up to four doses of APAP per month and he/she was not sure why Resident #1 received nine doses of Tylenol before another order for pain medication was received. Record review and staff interview for Resident #2 revealed the resident had Stage III pressure ulcer wounds to his/her right foot that required daily dressing changes. Review of the Physician's Orders indicated an order dated 12/31/13 for [MEDICATION NAME]/APAP 7.5/325 milligrams (mg) 1 tablespoon via tube before dressing change for pain. A review of the Medication Administration Record [REDACTED]. Resident #2 was not administered the the pain medication prior to the dressing changes as ordered on nine occasions; 1st,2nd,8th,13th,15th,16th,20th,21st and 22nd of February 2014.",2017-02-01
7612,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2014-02-27,314,D,1,0,9TRD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on pressure ulcer care observation, staff interview and health record review that included facility policies, Physician Order Sheets, Treatment Records, Medication Administration Records, the facility failed to ensure that one resident #1 of the three (3) residents with pressure ulcers of the six (6) sampled resident received the necessary treatment and services to promote healing of pressure ulcers. Findings include: Resident #1 was admitted into the facility in November of 2013 from an acute care hospital with a Stage II pressure ulcer on the buttocks. The facility care planned Resident #1 for a problem dated 12/05/2013 for Pressure Ulcer on buttocks. The facility had a policy for wound care that indicated on page five (5) that weekly documentation of wound status was required weekly. The policy also stipulated that a narrative note was required in addition to the grid documentation if the ulcer was not responding to treatment or to note additional information not specified in the grid. A review of the wound documentation since Resident #1's admission revealed: November Treatment Record - Wound documentation (TAR) with a single assessment dated [DATE] of a Stage II pressure ulcer to the buttocks that measured 2.3 x 4.0 x 0.1 on the grid. The next measurements were documented in a narrative note eighteen days later on the December TAR dated 12/13/13 with measurements of 2.0 x 1.5 x 0.1. On 12/26/13 another thirteen days later Resident #1's pressure ulcer was described as a Stage III ulcer that measured 2.0 x 1.5 x 0.5. An interview with the treatment nurse on 02/26/14 at 5:00PM and with the Administrator on 02/27/14 at 2:10 PM revealed that in October 2013 a possible problem was identified concerning wound care and a full house audit of skin, orders and treatments was performed. Both described nurse staff issues in the interim between full time treatment nurses October through December. However, the Administrator was not aware of any problems with the completion of wound assessments and measurements during the months of November and December. Additionally, for Resident #1, the facility failed to transcribe the pressure ulcer treatment orders after changes were made by the wound care clinic on 02/03/2014. This failure resulted in the wrong treatment from 02/03/2014 until the next wound clinc visit on 02/18/2014.An interview with the treatment nurse on 02/26/14 at 5:00pm revealed that the weekend treatment nurse had taken off the new order and marked the TAR incorrectly and she was not sure why the error was not captured sooner. Resident #1 was seen by the registered dietician (RD) on 01/22/2014 who recommended to offer the House Supplement 120 milliliters (ml) after meals when intake was less than twenty five percent (25%). The RD also recommended to discontinue the Prostat 30 ml once daily and add Prostat AWC 30 ml twice a day between meals for six (6) weeks or until wound healed. A review of the medial record revealed this recommendation was not written as an order until 1/30/2014. A review of the facimile (FAX) document revealed that the order had been signed by the physician (MD) on 1/24/14. An interview with the director of nursing (DON) on 02/27/14 at 11:30 am revealed the assistant director of nursing (ADON) was the staff person who followed through with the RD recommendations. When the FAX was returned by the MD it was put into the ADON ' s box. The DON further stated that ideally there should be a quicker turn around to RD recommendations of at least within 2 days. An interview with the Administrator on 02/27/14 at 4:15 pm revealed that she felt the dates on FAXES was not reliable as to when they were actually received by the facility and if the FAX had come in on a Friday ([DATE]th was on a Friday), it would have been put in the ADON box who would not have seen it until Monday the twenty seventh (27). A review of the facility Policy for the Prevention of Pressure Ulcers included a risk assessment tool the Braden Scale. The core is documented on the toll and placed in the patient' medical record using the appropriate for (Braden Scale-For Predicting Pressure Sore Risk).The tool should be completed weekly for four assessments with each admission, re-admission, and with other OBRA required assessments, and with Change of Condition. Risk of pressure ulcer development may also be determined by completion of a comprehensive minimum data set (MDS) with Care Area Assessments (CAAs), presence of recent history of pressure ulcer obr by clinical assessment and judgement. A review of the Braden Scale documentation for Resident #1 revealed the assessment had been completed on 11/22/13, when the resident was admitted , and again on 1/29/14. There were no Braden Scale assessments documented during the three weeks after Resident ##1's admission into the facility. An interview with the DON on 02/27/14 at 11:30 am revealed she was not sure who was supposed to be making sure the weekly Braden assessments were done on admission. An interview with the treatment nurse on 02/26/14 at 5:00pm revealed that the weekly Braden assessment was to be put on the calendar and whoever had that resident for that day completed it. A review of the Physician ' s order forms (POFs) for Resident #1 revealed an order dated 01/20/2014 for Regenacare Spray apply prior to wound care to sacral wound and as needed (PRN) daily (QD) for pain. A review of the January treatment record (TAR) and Medication Administration Record [REDACTED]. Review of the February TAR and MAR indicated [REDACTED]. An interview with the treatment nurse on 02/26/14 at 5:00 pm revealed that that although it was not being documented, Resident #1 received the Regneacare daily prior to treatment because there was no way he/she could tolerate the treatment without it.",2017-02-01
9127,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2011-03-24,167,B,0,1,ZS4T11,"Based on observation and staff interview, the facility failed to make the survey results readily accessible, and did not post a notice of their availability on four of four days of the survey. Findings include: During environmental observations, the previous survey results were found inside a glassed-in bulletin board just outside the dining room on a short corridor off the 'P' hall. The survey reports were pinned to the bulletin board along with multiple other postings, and not likely to be seen by residents or visitors unless they went to this dining room. No signs were seen anywhere in the facility that announced the availability and location of the survey results. On 3/23/11 at 5:00 p.m., the Administrator verified there was currently no sign posting availability of the survey results.",2015-08-01
9128,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2011-03-24,282,D,0,1,ZS4T11,"**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 the tube feeding administration rate for one (1) resident (#87). The sample size was thirty (30) residents. Findings include: Review of resident #87's clinical record revealed they were receiving all of their nutrition via a gastrostomy tube (GT). A physician's orders [REDACTED]. The feeding tube care plan dated 9/10/10 included an intervention to provide feeding per physician order. Six observations from 3/21/11 at 1:13 p.m. to 3/23/11 at 8:40 a.m., revealed that resident #87's feeding pump was programmed to deliver the enteral formula at a rate of 55 mL per hour. On 3/23/11 at 10:00 a.m., Licensed Practical Nurse (LPN) ""BB"" stated the enteral formula order on the Medication Administration Record [REDACTED]. Cross-refer to F322.",2015-08-01
9129,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2011-03-24,312,D,0,1,ZS4T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview the facility failed to ensure that one (1) resident (""A"") on a sample of thirty (30) residents received the necessary services to maintain personal hygiene related to nail and oral care. Findings include: Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented that Resident ""A"" required extensive assistance for activities of daily living (ADLs) such as personal hygiene that included brushing their teeth. This MDS assessment also documented that this resident had limited range of motion (ROM) on one side of the body that included the upper and lower extremities. Interview with resident ""A"" on 3/21/11 at 1:53 p.m. revealed that the staff does not help the resident clean his/her teeth The resident revealed that he/she has never had his/her teeth cleaned since he/she had been at the facility. The resident also stated that he/she did not have a toothbrush or toothpaste. Observations of resident ""A"" on 3/21/11 at 1:56 p.m., on 3/22/11 at 9:20 a.m. and 4:05 p.m. revealed that the resident had long fingernails with a brown substance underneath the nails of both hands. Interview with a Licensed Practical Nurse (LPN) ""AA"" on 3/22/11 at 4:05 p.m. confirmed that the resident's nails were long and dirty and needed to be cleaned and trimmed.",2015-08-01
9130,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2011-03-24,322,D,0,1,ZS4T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to administer the ordered amount of enteral tube feeding for one (1) resident (#87). The sample size was thirty (30) residents. Findings include: Review of resident #87's clinical record noted they had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident was totally dependent on staff for all activities of daily living. The feeding tube care plan developed 9/10/10 noted the resident received all nutrition, hydration and medications via a gastrostomy tube (GT). Observations of wound care on 3/23/11 at 9:06 a.m., and 3/24/11 at 8:50 a.m., noted that the resident had a Stage IV pressure ulcer to the left hip, and unstageable/deep tissue injury (DTI) to the tip of the right great toe, left lateral foot, and top of the left fifth toe. Review of the facility's Registered Dietician's (RD) note dated 2/18/11 revealed the resident's estimated protein needs were 87-99 grams, and that they were receiving 82.8 grams at the current enteral formula rate of 55 milliliters (mL) per hour. She recommended the enteral feeding be increased to 60 mL per hour to provide 90 grams of protein. On 2/24/11, a physician's orders [REDACTED]. On 3/21/11 at 1:13 p.m.; 3/22/11 at 2:25 p.m., 3:30 p.m., and 5:20 p.m.; and 3/23/11 at 7:15 a.m. and 8:40 a.m., resident #87's feeding pump was noted to be programmed to deliver 55 mL per hour of the enteral formula. On 3/23/11 at 10:00 a.m., Licensed Practical Nurse (LPN) 'BB' verified the pump was set to 55 mL per hour, and that the ordered rate was 60 mL per hour. She noted that on the label of the enteral formula bottle, a notation for a rate of 55 mL per hour had been handwritten. On 3/23/11 at 10:45 a.m., the RD stated that she made the recommendation to increase the tube feeding rate to 60 mL per hour because the previous rate of 55 mL per hour was not meeting the resident's protein needs.",2015-08-01
9131,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2011-03-24,323,E,0,1,ZS4T11,"Based on observation, record review and staff interview, the facility failed to ensure the environment remained as free of accident hazards as possible by not securing chemicals in one Soiled Linen room; not locking doors leading to rooms containing hot water heaters in two (2) Soiled Linen rooms on one hall; not ensuring that grab/assist bars or devices were securely attached in two resident rooms; not ensuring that an exit door locking mechanism was functional on one hall; and by not removing a damaged chair from the gazebo. Potential environmental hazards were noted on four (4) of five (5) halls and an outside common area. Findings include: 1. On 3/21/11 at 12:31 p.m., the grab bars on either side of the commode for rooms B-5/B-7 were not affixed securely and able to be pulled away from the wall approximately one inch. This was verified by the Maintenance Director at 1:00 p.m. On 3/23/11 at 2:40 p.m., Certified Nursing Assistant (CNA) ""DD"" stated that three of the four residents in these rooms were independently ambulatory. During a walk-through of the facility environment on 3/23/11 starting at 2:00 p.m., the following concerns were identified, and verified by the Maintenance Director: 2. The assist bars secured to bolts on the back of the commode seat in room D-14 had come loose on one side, and was freely movable approximately eight inches to the side, and the legs were wobbly. At 3:24 p.m., Licensed Practical Nurse (LPN) ""EE"" stated that one of the three residents in this room was able to toilet themselves without assistance. 3. In an outside courtyard area off Station II was a gazebo used by staff and residents. One of the wrought-iron chairs was totally missing the back of the chair, except for the arched support, leaving a large open back rest. 4. A full one-gallon plastic bottle with screw-on lid of Premium Plus Carpet and Upholstery Extraction Cleaner was found on the floor by the utility sink in the unlocked Soiled Linen room close to the Station I nurse's station. The Maintenance Director stated this should not have been in there, and asked a Housekeeping employee to lock it up. The label on the bottle included a precautionary statement of ""Harmful if Swallowed."" The Material Safety Data Sheet (MSDS) listed health hazards that included eye irritation and tissue injury, and to not induce vomiting if ingested. 5. The exit doors at the end of 'A' hall were able to be pushed open without using the code to deactivate the lock. This door led to the parking lot where ambulances transported residents, and was not fenced in. There was a magnetic locking mechanism noted at the top of the door. The Maintenance Director stated he did not realize it was not working. Review of the Mag Lock Log provided by the Maintenance Director revealed the exit door on 'A' was last checked on 3/18/11 and was 'OK.' 6 and 7. Inside an unlocked Soiled Linen room across from the Station II nurse's station was another door leading to a room containing a hot water heater. This door had a key inserted in the lock, but the key did not need to be used to open the door. The pipes on the wall across the water heater were hot to the touch. The Maintenance Director stated this door should be locked at all times, and the key should have been locked inside a red box on the wall outside the door. In another unlocked Soiled Linen room across the hall from the Station I nurse's station, there was another unlocked door that led into a room containing a hot water heater. Again, the pipes across from the water heater were hot to the touch. At 3:28 p.m., Corporate Maintenance Consultant ""FF"" stated that these doors should be locked at all times. On 3/23/11 at 3:55 p.m., the Resident Assessment Instrument (RAI) Director stated there were 42 independently mobile residents (not including the nine residents on the locked unit), and all had some degree of cognitive impairment.",2015-08-01
9132,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2011-03-24,468,E,0,1,ZS4T11,"Based on observation and staff interview, the facility failed to ensure that there were handrails affixed to all sections of corridor walls on four of five halls. Findings include: During a walk-through of the facility environment with the Maintenance Director on 3/23/11 starting at 2:00 p.m., it was noted that there were no handrails affixed to the corridor walls in the following areas: (The approximate measurements included) STATION II: 1. Two 18-foot sections of wall on either side of the Activity Room doors across from the nurse's station; one 14-foot section outside the 'C' hall fire door; two 5-foot sections on the medication room side of the wall, and one 12-foot section on the opposite wall outside the fire doors on the 'P' hall. STATION I: 2. A 12-foot section of hallway on one side and 6-foot section on opposite wall near the small and large dining/activity rooms on the 'B' hall. The Maintenance Director stated these rails had been removed recently when renovation was done to the area. 3. A 6-foot section on one wall and 18-foot section on the opposite hallway wall between the main lobby and the nurse's station.",2015-08-01
9376,BRENTWOOD HEALTH AND REHABILITATION,115361,115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830,2012-03-06,328,E,1,0,PHYF11,"Based on observation, staff interview, and review of the facility's Respiratory Care Oxygen Therapy - Mask and Nasal Cannula Policy, the facility failed to properly store nebulizer masks/mouthpieces and nasal cannulas in accordance with facility policy, and/or failed to properly position oxygen tubing, for eight (8) residents (#s 3, 5, 6, 7, 8, 9, 10, and 11) who received respiratory care and resided on three (3) of four (4) halls, on a survey sample of eleven (11) residents. Findings include: The facility's Respiratory Care Oxygen Therapy - Mask and Nasal Cannula Policy specified that when masks and cannulas were not in use, they were to be stored in a plastic bag. However, observations made on 03/05/2012 between 3:20 p.m. and 4:15 p.m. on Hall C, Hall D, and Hall P revealed the following problems. 1. During observation of Resident #3 at 3:45 p.m., the resident's oxygen tubing was draped across the floor. 2. During observation of Resident #5 at 3:55 p.m., the resident's oxygen mask/mouthpiece was uncovered on the bedside table. 3. During observation of Resident #6 at 3:20 p.m., the resident's nebulizer mouthpiece was uncovered and the tubing was on the floor. 4. During observation of Resident #7 at 4:00 p.m., the resident's oxygen tubing was on floor, and the nebulizer mouthpiece was uncovered. 5. During observation of Resident #8 at 3:30 p.m., the resident's oxygen tubing with the nasal cannula was draped across a garbage can, with the tubing lying on the floor. 6. During observation of Resident #9 at 4:00 p.m., the resident's oxygen tubing was on the floor, and the mouthpiece to the nebulizer was uncovered. 7. During observation of Resident #10 at 3:35 p.m., the resident's oxygen tubing was on the floor, and the mouthpiece was uncovered. 8. During observation of Resident #11 at 3:40 p.m., the resident's oxygen tubing was draped across the floor. During an interview with the Director of Nursing at 4:15 p.m. on 03/05/2012, she acknowledged the above findings.",2015-07-01
1932,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,580,D,0,1,LWOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family and staff interview, record review, and policy titled Changes in Resident Condition, the facility failed to promptly notify the family/representative (RP) of one resident (#8) of a change in condition that led to his transfer to the emergency room for evaluation. The sample size was 40 Findings include: Review of the Admission Minimum Data Set (MDS) assessment of 6/16/17 revealed Resident (R)#8 was admitted on [DATE] with a Brief Interview for Mental Status (BIMS) score of 3 (indicative of severe cognitive impairment), and active [DIAGNOSES REDACTED]. Interview on 2/11/18 at 3:24 p.m. with family member A revealed R#8 was transferred to the acute care hospital for a few hours shortly after he was admitted . The family/RP was not notified and only learned of the transfer the next day when they visited the facility. Family member A said the family was very upset at the facility's failure to call them at the time of the transfer and advised facility staff that they should have called even though the transfer occurred in the early hours of the morning. Review of the policy titled Changes in Resident Condition dated (MONTH) 2005 and revised (MONTH) (YEAR) documented that nursing staff, resident, attending physician and the resident's legal representative are to be notified when changes in a resident's condition occur and the notification is to be documented on a Situation, Background, Assessment, and Recommendation (SBAR) Communication Form and in a progress note. Review of nurses' progress note of 6/19/17 at 12.45 a.m. revealed that R#8 was transported to the emergency room via ambulance after he was assessed and found to have symptoms that warranted further evaluation in an acute care setting. Review of the nurses' progress note of 6/19/17 at 3:40 a.m. revealed the resident had returned from the acute care hospital with no new orders. Review of grievance logs revealed the resident's family/RP visited later in the day on 6/19/17 and filed a grievance alleging that staff had not called the family to let them know that the resident was sent out to the hospital. The facility's investigation summary on the grievance form noted that the family's complaint was confirmed by the record of the nurse's note and by the nurse herself who stated that she forgot to call the family, but would remember to do so in the future. Interview on 2/15/18 at 2:50 p.m. the Director of Nursing (DON) revealed that nursing staff are expected to fill out an SBAR communication form when there is a change in a resident's condition that calls for the resident to be sent out for evaluation. The nurse in charge of the resident at the time of the transfer is to attempt to reach the resident's representatives - the first representative, then the second representative if the first representative cannot be reached - and to document this on the S-BAR. The staff are to attempt to conduct this notification at the time the resident is sent out.",2020-09-01
1933,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,644,D,0,1,LWOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of policy titled Preadmission Screening and Resident Review (PASRR), the facility failed to refer three residents (#6, #56, and #81) who, on admission, had a negative Level I Preadmission Screening and Resident Review (PASRR) to the state authority for a Level II PASRR evaluation when mental disability was later identified. The sample size was 40 residents. Findings include: Review of the policy titled, Pre-admission Screening and Resident Review (PASRR) dated (MONTH) (YEAR) revealed that the facility must not admit any new resident with a mental disorder or intellectual disability unless the state mental health authority has determined that the individual requires the level of services provided by the nursing facility. Preadmission screening is mandatory for all individuals except for those admitted for a period of less than 30 days or who are readmitted for the same condition for which they were originally hospitalized . The admission coordinator and Director of Nursing (DON) identify residents needing a PASRR during pre-admission. The admissions coordinator coordinates completion of the PASRR, and assists in making the admission decision. Staff will refer residents currently diagnosed or with newly evident mental disorder/intellectual disability or a related condition for a PASRR Level II review. Review of the clinical records revealed Resident (R)# 6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical records revealed [DIAGNOSES REDACTED]. Review of the current physician order [REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment of 8/21/17 revealed on Section A1500 that staff answered no to the question, is the resident currently considered by the state level II PASRR process to have serious a mental illness and/or intellectual disability? The same assessment also documented that the resident had active [DIAGNOSES REDACTED]. Review of the PASRR records for R#6 revealed a PASRR Level I Assessment and approval dated 12/15/11 in which the resident was assessed as having no mental illness, developmental disability, or dementia. Interview with the Director of Nursing (DON) on 2/14/18 at 5:46 p.m. revealed that members of the clinical team, including the DON, therapy, social work, activity, and dietary staff meet within 24 hours of a resident's admission to discuss new residents. One of the items discussed during this meeting is whether the resident has a Level I PASRR approval. During the next morning meeting of the Interdisciplinary Team, the team explores whether the resident has only a Level I approval or if he/she triggered for a Level II evaluation. If the resident was triggered for a Level II assessment due to the presence of a mental or intellectual disability or dementia, the social worker or business office manager is expected to arrange for one to be completed. If the need for a Level II evaluation was not triggered, the resident's Level I document is filed in his/her folder in the business office. If after admission, the resident is noted to have symptoms that would suggest a Level II assessment is needed, the social worker or business office manager is responsible for referring that resident for the necessary assessment. Interview on 2/15/18 at 11:55 a.m. with the Business Office Assistant, JJ, verified the resident has a Level I PASRR approval. She was not sure of the process in place for referring residents for a Level II assessment if a mental or intellectual disorder/disability is assessed after admission, but believed that the charge nurse on the resident's unit would be responsible for referring that resident if it becomes apparent that the Level I assessment is not correct and the resident needs to be referred for a Level II assessment. Interview on 2/15/18 at 1:35 p.m. with Licensed Practical Nurse (LPN) KK, revealed she does not refer residents for Level II assessments. If a resident shows signs of troubling behaviors, she first tries to rule out a physical concern and will contact the physician. If the behaviors are not a result of a physical problem, she will consult the psychologist during his/her next visit.",2020-09-01
1934,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,656,D,0,1,LWOJ11,"**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 caring for a urinary catheter as appropriated of one resident (R) R#71; intravenous (IV) dressing changes as ordered for one resident (R#87); and to observe for side effects and effectiveness of [MEDICAL CONDITION] drug use for one resident (R#56. Finding include: 1. Review of R #17's Admission MDS dated [DATE] 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 Quarterly MDS dated [DATE] revealed that she still had an indwelling catheter. Review of her indwelling catheter use due to [MEDICAL CONDITION] care plan , revised on 2/6/18, revealed a goal that she preferred not to experience infections and trauma from the catheter use, and interventions included to care for the catheter as appropriate. Observation on 2/12/18 at 9:03 a.m. and on 2/13/18 at 4:50 p.m. revealed that R #71 did not have any type of device to secure the catheter tubing to her leg to prevent tension on the urinary meatus. During observation of catheter care by RCS DD on 2/14/18 at 9:35 a.m. no catheter strap was observed. Further observation at this time revealed that the RCS failed to use a clean disposable wipe after it was soiled with feces, and /or filed to consistently use different sections of the wipe with each stroke of the catheter care. Cross -refer to F 690 2. Review of R #87's clinical record revealed that she was admitted to the facility on [DATE]. Review of her Admission MDS dated [DATE] revealed that she was receiving IV medications. Further review of this MDS revealed that she had a Brief Interview for Mental Status (BIMS) score of 14 ( a BIMS score of 13-15 indicates a resident is cognitively intact). Review of her undated care plans revealed that one was developed for IV antibiotics use, and interventions included to change the dressing at the IV site as ordered, and assess for redness or swelling. Review of hospital Outpatient IV Antibiotic Orders dated 1/31/18 revealed an order for [REDACTED]. Review of R #87's Medication Administration Records (MAR) and Treatment Administrations Records (TAR) revealed that there was no evidence that dressing changes were being done to the PICC line. During interview with Registered Nurse (RN) Unit Manager CC on 2/15/18 at 8:49 a.m. he stated the facility protocol was to change ICC line dressing every seven days, and verified that here was no evidence that this was being done. During observation on R #87's PICC line on 2/15/18 at 10:01 a.m. with RN CC, he verified that there was no date on the dressing and that it needed to be changed. During interview with R #87 at this time, she stated that the dressing had not been changed since they put the PICC line in at the hospital. Cross-refer to F 694 3. Review of R#56's clinical record revealed that she was admitted to the facility on [DATE]. Review of the admission MDS dated [DATE] revealed she was receiving [MEDICAL CONDITION] medications. Further review of the MDS revealed she had a BIMS sore of 7 out of 15 ( a BIMS score of 0-7 indicates a resident is severely cognitively impaired). Review of R#56's care plan with an initiated date of 1/15/18 revealed no [MEDICAL CONDITION] drug use care plan was developed. During an interview with MDS Coordinator, ll on 2/14/18 at 3:15 p.m. she stated that a care plan for this resident related to [MEDICAL CONDITION] medications use was not developed. She also stated not developing the care plan was an oversight. Review of the facility policy titled Comprehensive Care Plan with a revision date of (MONTH) (YEAR) indicated 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 completing of the Comprehensive assessment. Review of the facility policy titled [MEDICAL CONDITION] Management with a revision date of (MONTH) indicated 8) The Interdisciplinary Team (IDT) will individualize the resident's Care Plan and address: (a) The reason for the medications; (b) Opportunities for non-pharmacological interventions; (c) The goal for reducing or eliminating the medications, if not contraindicated: ( d)The resident's goals and preferences; and (e) the expected outcomes and Addressing the documented behaviors.",2020-09-01
1935,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,677,D,0,1,LWOJ11,"**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 scheduled showers for one Resident (R#6) dependent on staff for activities of daily living (ADLs) The sample size was 40. Finding include: During an interview on 2/12/18 at 12:43 p.m. Resident (R#6) revealed that he had not had a shower in over 10 months. He said the staff said they cannot take him to the showered. He was not sure why staff were unable to take him to the shower, but he said he needed a shower because he felt unclean and was convinced that he smelled due to this omission. Observation of the resident at the time of this interview revealed he was lying in bed in a hospital gown. His hair was uncombed and his facial hair untrimmed Review of the clinical record revealed R#6 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of a Transfer Assessment completed for R#6 on 1/16/18 documented the resident was non-ambulatory, non-weight -bearing, and unable to sit on the bedside without full back and neck support. Review of an Occupational Therapy (OT) assessment dated [DATE] documented that the resident was dependent for all self-care tasks except eating. The resident was referred to OT for assessment of seating and positioning to determine a possible transition from a Geri chair to a wheelchair. The OT assessed the resident as leaning hard to the right side and sliding out of the chair. The resident's sitting and standing balance was assessed as 0/5, the functional level of posture in the wheelchair was considered dependent with a posterior tilt and a [MEDICATION NAME] spine curve. The short-term goal was to increase the sitting balance during ADLs to 3/5. Review of the Quarterly Minimum Data Set (MDS) assessment of 11/21/17 revealed R#6 was assessed as needing extensive assistance with bed mobility, dressing, and personal hygiene, and needing total assistance with bathing (2+ person assistance needed with bathing), bed mobility, dressing and toileting. The quarterly MDS also documented active [DIAGNOSES REDACTED]. Review of the shower schedule book for the hallway on which the resident resides revealed that Resident Care Specialist (RCAs) are to complete shower sheets in the shower book. The CSS are to check whether a shower and/or other ADL car such as nail care is completed, the nurse should then review the sheets, and address any skin concerns and sign the sheet. Finally, the unit managers are to review the sheets daily. Further review of the shower schedule book revealed R#6 was scheduled to receive showers on Tuesdays and Fridays on the 3;00 p.m. to 11:00 p.m. shift. Review of the available shower records from 1/16/18 to 2/13/18 revealed the RCSs had checked that the resident was given a shower 7/9 times (the shower sheets for 1/16/18 and 1/23/18 were left blank). Of the seven occasions in which it was checked that a shower was give, the RCS had indicted on the sheet that a bed bath was actually given on five of those occasions. Interview on 2/14/18 at 4:50 p.m. with RCS MM revealed that R#6 had not had a shower in a long time. He could not be precise. The RCA further said that the resident had a back curvature that made it difficult for the resident to sit in the regular shower chair used by most residents. The resident is only able to sit in a shower chair and receive a shower with assistance of three members of staff and three staff members are usually not available to provide this care. Thus, staff gave the resident bed baths because they felt this was the safest thing to do. Interview on 2/14/18 at 5:02 p.m . with LPN DLL revealed that the resident does not receive showers, only bed baths; she attributed this to the resident being anxious and verbally abuse to staff about sitting in the available shower chair. /she also said that the resident couldn't sit up straight in the available shower chair and this contributes to his anxiety As a result , staff chose to give him bed baths, in place of the scheduled showers. Interview on 2/15/18 at 10:04 a.m. with MDS coordinator NN revealed that she had updated the plan of care for R#6 on 2/14/18 to reflect that he had requested and will receive a shower (not a bed bath) at least once per week. The resident received a showered on the evening of 2/14/18. Interview on 2/15/18 at 11:49 a.m. with resident #6 revealed he had indeed received a shower on the evening of 2/14/18. He said he had received this shower while sitting in a shower chair. He reported feeling clean and well-scrubbed for the first time in many months. He was not sure of the number staff members involved in providing his shower the evening before, but believed it may have been three or four. Interview on 2/15/18 at 12:35 p.m. RCS OO revealed she had assisted in giving the resident a shower on the evening of 2/14/18. She reported that three members of staff were involved in giving the resident a shower at that time. The staff did not use the regular shower chair found in he shower on the resident's hall (A Hall), but had borrowed a shower chair form C-Hall. The shower chair on\ the C-hall had an added foot rest.",2020-09-01
1936,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,690,D,0,1,LWOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to perform catheter care in a manner to prevent a potential urinary tract infection [MEDICAL CONDITION], and failed to secure the catheter tubing to prevent tension on the urethra for one resident (R) (R #71). The sample size was 40 residents. Findings include: Review of R #71's clinical record revealed [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 5 (a BIMS score of 0 to 7 indicates severe cognitive impairment), and an indwelling catheter. On 2/12/18 at 8:10 a.m. Resident Care Specialist (RCS) DD was observed turning R #71, and no strap or other device was seen securing R #71's catheter to her leg. On 2/13/18 at 4:50 p.m. R #71 showed the surveyor that her catheter tubing was not secured to her leg, and stated that it tugged on her sometimes but didn't really hurt. On 2/14/18 at 9:35 a.m. RCS DD was observed performing catheter care for R #71, and no catheter strap was seen securing the catheter when the covers were pulled back and incontinent brief removed. The RCS was observed to use a disposable wipe to wipe the catheter tubing twice from the urethra outward using the same section of the wipe. The RCS asked the resident if she felt like the catheter was pulling on her, and the resident stated, no, I don't know. The resident was turned to her left side, and the RCS wiped the perineal area from the front to the back, and feces was noted on the disposable wipe after the first stroke. Folding the wipe over but using the same soiled wipe, the RCS was observed to wipe from the front to the back five or six more times with the same section of the wipe. After the care was completed, RCS DD stated that some residents with a catheter had a strap while others didn't, and she did not know why unless they came from the hospital with one. She stated during further interview that she was taught to fold the wipe over each time she made a stroke during catheter care, and did not realize she had not done this. During interview with the interim Director of Nursing (DON) on 2/14/18 at 10:20 a.m., she stated that any resident that had a urinary catheter should have the catheter tubing secured with a device to prevent trauma. She further stated that these devices were kept on the treatment cart, and that the nurses were responsible for applying them. During further interview, the interim DON stated that when a RCS performed catheter care, she should preferably use a different wipe for each stroke, but could also fold the wipe over for each additional stroke to help prevent infection. The interim DON stated that if BM (bowel movement) was noted on the wipe, that a new wipe should be used and new gloves applied. Review of the facility's Indwelling Catheter Care (Daily Cleansing) policy with a revised date of (MONTH) 2009 revealed: Care and maintenance of indwelling catheters is essential to prevent infection and/or complications. Review of the facility's Indwelling Urinary Catheter (Foley) Care and Management policy with a revised date of (MONTH) 17, (YEAR) revealed: Make sure 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.",2020-09-01
1937,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,694,D,0,1,LWOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to change a peripherally inserted central catheter (PICC) line dressing since admission to the facility (a total of 14 days) for one resident (R) (R #87). The sample size was 40 residents. Findings include: Review of R #87's clinical record revealed that she was admitted to the facility from the hospital on [DATE], after irrigation, debridement, and re-closure of a lumbar wound. Review of her Outpatient IV (intravenous) Antibiotic Orders dated 1/31/18 revealed a [DIAGNOSES REDACTED]. Review of R #87's Medication Administration Record [REDACTED]. Review of her Admission Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 14 (a BIMS score of 13 to 15 indicates a resident is cognitively intact), and was receiving IV medications. On 2/11/18 at 1:45 p.m., R #87 was observed to have a single lumen PICC line in her left upper arm, and the transparent dressing covering it was undated. During interview with R #87 at this time, she stated that this dressing had not been changed since admission to the facility. Further observation of the PICC line dressing on 2/12/18 at 9:32 a.m. revealed that the site was clean without redness or drainage, but was undated. On 2/14/18 at 8:23 a.m., the PICC line dressing was observed to be undated, and R #87 stated she did not recall anyone changing the dressing since admission to the facility, and that the site was just left covered. During interview with Licensed Practical Nurse (LPN) BB on 2/15/18 at 8:47 a.m. she stated that they would change a PICC line dressing if there was an order for [REDACTED]. During interview with Registered Nurse (RN) Unit Manager CC on 2/15/18 at 8:49 a.m., he stated that PICC line dressing changes should be on the TAR, and that it was facility protocol to change the dressing every seven days. He further stated that whoever admitted the resident should have obtained an order for [REDACTED]. Observation with RN CC on 2/15/18 at 10:01 a.m. revealed that there was no date on R #87's transparent PICC line dressing, and he stated during interview that it needed to be changed. During interview with R #87 at this time, she stated that the PICC line site was not bothering her, and that the dressing had not been changed since they put the PICC line in at the hospital. Review of the facility policy Peripherally Inserted Central Catheter (PICC) Dressing Change revised (MONTH) 12, (YEAR) revealed: You should change a transparent semipermeable dressing over a peripherally inserted central catheter (PICC) every 5 to 7 days and a gauze dressing or a transparent semipermeable dressing with gauze underneath at least every 2 days. Label the dressing with the date the dressing was changed. Because infection is always a risk with a PICC, watch for such signs as swelling, redness, fever, and drainage at the site. Documentation should include the condition and length of the external catheter, the appearance of the site, and any reports of pain or tenderness. Record the date and the time of the dressing change, site care, dressing type, stabilization device type, and unexpected outcomes, and your interventions.",2020-09-01
1938,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,757,D,0,1,LWOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews and review of facility policy the facility failed to monitor and document behaviors and side effects for one (1) resident (R) #56 of five (5) residents reviewed that receive [MEDICAL CONDITION] medications. Findings include: Review of R#56's clinical record revealed she was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed the resident receives antipsychotic and antidepressant medications. Further review of this MDS revealed R#56 had a Brief Minimum Interview for Mental Status (BIMS) score of 7 out of 15 (0-7 indicates the resident is severely cognitively impaired). Review of R#56's physician's orders revealed an order dated 12/21/17 for quetiapine [MEDICATION NAME] 50mg (an antipsychotic) at bedtime that was discontinued on 1/14/18, an order dated 1/15/18 for quetiapine [MEDICATION NAME] 25mg at bedtime and an order dated 12/21/17 for [MEDICATION NAME] HCL ER 150mg (an antidepressant) twice a day. Review of R#56's Medication Administration Record [REDACTED]. During an interview with the Director of Nursing (DON) on 2/15/18 at 11:24 a.m. she stated when a resident is admitted to the facility an initial assessment of medications is completed and an Abnormal Involuntary Movement Scale (AIMS) is completed to determine residents' baseline if the resident is receiving [MEDICAL CONDITION] medication(s). There after a quarterly, annual and/or significant change assessment is completed. The pharmacist reviews the residents' medication on a weekly basis to determine if there is a possibility of a dose reduction. The nurses review the pharmacist's recommendations and have a 48 hour turn around to notify the physician of the recommendation. The physician then notifies the nurses via telephone with any new orders and the nurse notifies the pharmacy of the changes. She also stated monitoring for behaviors and side effects should be part of the medication order when the medication is entered on the Medication Administration Record [REDACTED]. She also confirmed there was no AIMS completed nor Psychoactive Medication Evaluation for this resident. Review of the facility policy titled [MEDICAL CONDITION] Management with a revision date of (MONTH) (YEAR) revealed Practice Guidelines 3) The Interdisciplinary Team (IDT) will complete the Psychoactive Medication Evaluation (UDA) upon admission with [MEDICAL CONDITION] medication, initial order, change in dosage, quarterly, and with the significant change in status. 4) The licensed nurse will complete the Abnormal Involuntary Movement Scale (AIMS) upon initiation and/or change of medication and every six (6) months thereafter for residents receiving antipsychotic medications. 5) The licensed nurse will institute the appropriate behavior monitoring form associated with the medication category via the Behavior Care Record and the Side Effect Care Record to: (a) Identify and document objective and quantifiable specific behaviors; (b) Document the number of episodes of behaviors; (c) Document interventions and outcomes; (d) Document the presence or absence of side effects and interventions implemented to address the identified side effects. Review of pharmacy consultation report dated (MONTH) 1, (YEAR) through (MONTH) 20, (YEAR) revealed a recommendation to please consider monitoring for involuntary movements by using one of the available scales (DISCUS, AIMS, etc.) now and then at least every six months thereafter (or per facility protocol). Please initiate and document behavior monitoring in this individual.",2020-09-01
1939,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,759,E,0,1,LWOJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the medication error rate was less than 5%. There were three errors with 29 opportunities for two of five residents (R) by two of four nurses observed, for a medication error rate of 10.34%. Findings include: 1. On 2/13/18 at 8:16 a.m., Licensed Practical Nurse (LPN) GG was observed giving R #3's scheduled 9:00 a.m. medications through his gastrostomy tube ([DEVICE]). The LPN prepared seven medications, including one [MEDICATION NAME] 25 mg (milligram) tablet. After all of the medications were prepared for R #3, LPN GG verified that she prepared only one pill or capsule of each of the seven medications. After the crushed medications were given to the resident, LPN GG administered one vial of [MEDICATION NAME] 2.5 mg per 3 mL (milliliters), 0.083% via R #3's nebulizer machine at 8:53 a.m. Observation of R #3 at this time revealed that he did not appear to have shortness of breath. Review of R #3's Order Listing Report (a list of the current physician's orders [REDACTED]. Further review of this report revealed an order for [REDACTED].m Further review of the MAR indicated [REDACTED]. Further review of the Order Listing Report revealed that the [MEDICATION NAME] observed given during the medication pass was ordered to be given every two hours as needed for shortness of breath. During interview with LPN GG on 2/13/18 at 2:55 p.m., she stated that the [MEDICATION NAME] order on the MAR for R #3 was for 25 mg, one pill three times a day, which would make a total of the ordered 75 mg. She further stated that she was not supposed to give three of the 25 mg tablets three times a day. During further interview, she verified that the [MEDICATION NAME] she gave to R #3 was ordered PRN (as needed), and was not able to find a box of [MEDICATION NAME] in her medication cart. During interview with the Director of Nursing on 2/13/18 at 3:08 p.m., she verified that LPN GG should have given three tablets of the 25 mg [MEDICATION NAME] to R #3. 2. On 2/13/18 at 9:06 a.m., LPN HH was observed preparing medications for R #1, and included one Vitamin B-12 500 mcg (micrograms) tablet along with the four other medications given. Review of R #1's Order Listing Report and MAR indicated [REDACTED]. During interview with LPN HH on 2/13/18 at 3:35 p.m., she verified that she gave only one Vitamin B-12 pill to R #1, and that she should have given two of the 500 mcg pills.",2020-09-01
1940,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2018-02-15,880,D,0,1,LWOJ11,"Based on observation, record review and staff interview, the facility failed to maintain infection control standard precautions by not removing gloves and performing hand hygiene after catheter care was performed for one resident (R) (R #71). The sample size was 40 residents. Findings include: On 2/14/18 at 9:35 a.m. Resident Care Specialist (RCS) DD was observed performing catheter care for R #71, and when the resident was turned to the side to clean her buttocks area, feces could be seen on the disposable wipe. Continued observation revealed that after the catheter/incontinence care was completed, the RCS did not remove the gloves used to perform the care, and she applied a new incontinence brief; obtained a clean gown from the closet and put it on the resident after removing the old gown; and put her gloved hand under the resident's right arm pit to assist her to sit up so she could pull the gown down. Further observation revealed that after this, RCS DD removed her gloves but did not wash her hands or use hand sanitizer, and put a clean top sheet on the resident's bed and pulled it over the resident; rubbed the resident's right hand with her ungloved hands; pulled the privacy curtain partially back before exiting the room and using the hand sanitizer located on the wall outside the room. During interview with RCS DD after the ADL (activity of daily living) care was completed, she verified that she did not remove her gloves after performing the catheter care, and that she probably forgot to take them off before performing other care for R #71. During interview with the interim Director of Nursing (DON) on 2/14/18 at 10:20 a.m., she stated that when a RCS performed pericare, that they should wash their hands before and after the procedure. Review of the facility's Hand Hygiene policy with a revision date of 12-2017 revealed: The purpose (of hand hygiene) is to decrease the risk of transmission of infection by appropriate hand hygiene. Washing with soap and water is appropriate when the hands are visibly soiled or contaminated with blood or other body fluids, when exposure to potential spore-forming pathogens is strongly suspected or proven, and after using the restroom. Using an alcohol-based hand rub is appropriate for decontaminating the hands before direct patient contact; before putting on gloves; before inserting an invasive device; after contact with a patient; when moving from a contaminated body site to a clean body site during patient care; after contact with body fluids, excretions, mucous membranes, nonintact skin, or wound dressings; after removing gloves; before eating, and after contact with inanimate objects in the patient's environment. Review of the facility's Hand Hygiene policy with a revision date of (MONTH) 12, (YEAR) revealed: Hand hygiene is the single most important procedure in preventing infection. To protect a patient from health care-associated infection, hand hygiene must be performed routinely and thoroughly. Keep in mind that glove use doesn't eliminate the need for hand hygiene.",2020-09-01
1941,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2019-02-28,580,G,0,1,TGBJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Changes in Resident Condition, resident, family and staff interviews, the facility failed to promptly notify the Physician and the responsible party for one of three residents (R) reviewed that sustained an injury in the facility (R#62). Actual harm was identified when R#62 sustained an injury to her left foot/ankle during a transfer from her wheel chair to her bed on 2/2/19. Findings include: Review of the facility policy titled Changes in Resident Condition with a revision date of (MONTH) (YEAR) documented: The nursing staff, the resident, the attending physician and the resident's legal representative are notified when changes in the resident's condition occur. GUIDELINES: 2. Prompt notification is required when there is an accident involving the resident which results in injury or has the potential for requiring physician intervention. 4. The SBAR Communication Form and in the Progress Note are used to assess and document changes in condition in an efficient and effective manner. Provide assessment information to the physician and provide clear comprehensive documentation. Record review for R#62 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, indicating no cognitive impairment. During an interview on 2/25/19 at 12:05 p.m. with R#62, she stated that her left foot got twisted when two Certified Nursing Assistants (CNA) were transferring her from her wheel chair back to her bed. R#62 stated she hollered out in pain and when the CNAs picked her legs up to place them in the bed, it really hurt. R#62 stated the CNA reported it to the nurse and she came and looked at her foot. R#62 stated that she had complained to the evening shift CNA's but the male nurse never came to see her. R#62 stated she reported the incident and that she was having pain to Registered Nurse (RN) CC the next morning and she gave her Tylenol. Review of the Progress Notes for R#62 revealed no documentation on 2/2/19 or 2/3/19 that R#62 twisted or hurt her left foot during a transfer from her wheel chair to her bed. There was no documentation on 2/2/19 or 2/3/19 that the attending Physician or the Responsible party had been notified of the incident. A Progress Note dated 2/4/19 written by Licensed Practical Nurse (LPN) JJ documented the Nurse Practitioner (NP) made rounds this shift. Received new order to obtain x-ray of left ankle. Mobile x notified and aware. Daughter (name) notified and aware of new order. Review of the document titled 24 Hour Report/Change of Condition Report revealed the following: Night shift (11:00 p.m. - 7:00 a.m.) of 2/2/19- c/o (Complaint of) Left ankle hurting, Tyl @ 7, wanting x-ray. Night shift of 2/3/19- Left ankle hurting- twisted, ok wants x-ray. Day shift (7:00 a.m. - 3:00 p.m.) of 2/4/19- Refused to get out of bed. New order for x-ray left ankle, completed at 2:00 p.m., results pending. The Situation Background Assessment Recommendation (SBAR) form was not initiated until 2/4/19 by RN CC. Review of the SBAR revealed documentation that R#62 complained of left ankle pain after twisting her foot during a transfer with the assistance of two CNAs. The form documented that the Physician was notified on 2/4/19 at 9:00 a.m. and the resident's responsible party was notified on 2/2/19 with no specified time. During an interview on 2/27/19 at 2:33 p.m., CNA EE stated he and CNA BB were transferring R#62 from the wheel chair to her bed. He stated during the pivot to turn the resident around, R#62 told him it was hurting her foot. CNA EE stated when he looked down, the resident's feet were crossed. CNA EE stated it was near the end of his day shift and he reported it to the day shift nurse, but did not remember who the nurse was. An interview on 2/27/19 at 2:41 p.m. LPN DD who was assigned to R#62 on the day shift of 2/2/19 revealed the incident had never been reported her and she knew nothing about the incident. Interview on 2/27/19 at 2:46 p.m. with RN CC revealed she was the C-Hall Unit Manager; however, the weekend of 2/2/19 and 2/4/19, she worked on the medication cart on the night shift. RN CC stated that the evening shift nurse did not report the incident to her at the beginning of her shift on 2/2/19. She stated that R#62 reported the incident to her early Sunday morning of 2/3/19, before her shift ended, and she complained of left ankle pain. RN CC stated she gave the resident Tylenol and went home. RN CC confirmed that she documented on the 24 Hour Report/Change of Condition Report on 2/2/18 that R#62 complained of her left ankle hurting and wanted an x-ray and on 2/3/19 documenting that R#62's left ankle was hurting, had twisted and the resident wanted an x-ray. RN CC stated she did not report the incident to the attending Physician or the resident's Responsible Party over the weekend. She stated the resident was just having a little pain in her foot when the CNA provided care or moved her leg. She stated there was no swelling or deformity of the resident's left foot. RN CC further stated that she initiated the SBAR on 2/4/19 and confirmed that the Physician was not notified until 2/4/19. RN CC stated the SBAR indicated that the resident's responsible party (RP) was notified on 2/2/19 but she did not notify the RP and did not ask weekend staff if they had notified the RP. She stated she thought the RP had not been notified of the incident until 2/4/19. Interview on 2/27/19 at 3:07 p.m. with the Director of Nursing (DON) revealed she first was aware of the incident with R#62 on Monday 2/4/19. The DON confirmed that the attending Physician and the resident's responsible party were not notified and should have been notified at the time of the incident on 2/2/19 when the resident had complaints of pain after the transfer. Interview on 2/27/19 at 4:48 p.m. with the Family of R#62 revealed that R#62 called her on Sunday 2/3/19 and reported the incident to her. The Family stated R#62 told her that she kept asking the staff all weekend for an x-ray because her foot was hurting after it had been twisted during a transfer. The Family confirmed that she was the responsible party for R#62 and the facility staff did not report the incident to her until after she had the x-ray on Monday that showed her ankle was fractured and they were going to have to send her to the hospital for a CT Scan. During an interview on 2/27/19 at 5:00 p.m., NP AA stated on 2/4/19, the facility called her on the phone and reported that the resident twisted her ankle and was experiencing pain and she ordered an x-ray. She stated she did not see or assess the resident on 2/4/19. Interview on 2/28/19 at 11:00 a.m. with the Medical Director and attending Physician of R#62 revealed that he was first notified that R#62 twisted her ankle and was having pain on Monday 2/4/19, when staff called to report the results of the x-ray. He stated his NP was notified first and she ordered the x-ray. Cross Refer F689",2020-09-01
1942,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2019-02-28,657,G,0,1,TGBJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policies titled Comprehensive Care Plan and Changes in Resident Condition, resident and staff interviews, the facility failed to revise the care plan for one of three residents (R) reviewed that required a mechanical lift for transfers (R#62). Specifically, R#62 had increased weakness, a decline in transfers and required the use of a Sit-to-Stand mechanical lift for transfers. Actual harm was identified when R#62 sustained an ankle fracture during a transfer with staff without using the Sit-to-Stand mechanical lift on 2/2/19. Findings include: Review of the facility policy titled Comprehensive Care Plan with a revision date of (MONTH) (YEAR) documented: 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. At a minimum, the care plan is updated with each comprehensive and quarterly assessment in accordance with the RAI (Resident Assessment Instrument) requirements. 11. Care Plan changes are communicated on an ongoing basis to all members of the IDT. Review of the facility policy titled Changes in Resident Condition with a revision date of (MONTH) (YEAR) documented: 4. Changes in the resident's status that affect the problem(s), goal(s) or approach(es) on his or her care plan are documented as revisions and communicated to the interdisciplinary caregivers. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) summary score of 15, indicating no cognitive impairment. The resident required extensive assistance with transfers and two-person physical assistance. Section G0300- Balance During Transfers and Walking assessed that R#62 was not steady and only able to stabilize with human assistance with moving from a seated to a standing position and surface to surface transfers. Section G0400- Functional Limitation in Range of Motion assessed R#62 with impairment on both sides of the lower extremities. An interview on 2/25/19 at 12:05 p.m. with R#62 revealed that on Saturday 2/2/19, the Certified Nursing Assistants (CNAs) transferred the resident from her wheel chair to her bed. R#62 stated they did not use the standing lift that day and they always used the lift before. R#62 stated that when the two CNAs turned her around to put her on her bed, it hurt her left foot and she yelled out in pain. R#62 stated that her left foot got twisted. R#62 stated that on Monday 2/4/19, she had an x-ray and was told that her ankle was broken. Further record review for R#62 revealed multiple [DIAGNOSES REDACTED]. A Care Plan for R#62 updated on 11/9/18 documented the resident had a self-care performance deficit related to decreased mobility and continued to require mostly extensive assistance with ADLS. Interventions did not include the use of a Sit-to-Stand lift. Review of the ADL Documentation Survey Reports for R#62 from (MONTH) (YEAR) through (MONTH) 2019 revealed the resident required extensive to total assistance of one - two staff and that a mechanical lift was used during transfers everyday with the exception of 10/19/18, 11/1/18, 11/27/18, 11/29/18, 12/8/18, 12/10/18, 12/11/18, 12/21/18, 1/17/19, and 1/24/19. The other days in (MONTH) (YEAR), (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) 2019 ADL's was coded that a mechanical lift was used or the activity did not occur. Interview on 2/28/19 at 9:30 a.m. with the Rehab Director/Speech Therapist revealed R#62 had been in the facility for many years and has been on their case load off and on. She stated the last time the resident was evaluated by Physical Therapy was 10/11/18 for increased weakness and a decline in her ability to transfer. The Rehab Director stated the therapy department receives an evaluation request form from nursing for all new admissions or changes in the status of current residents in the facility. She stated the evaluation does include the safest means of transfers. The Rehab Director stated it was documented at the time of the evaluation that the staff were already using the Sit-to-Stand mechanical lift and that the resident had been requiring the lift. She stated that she is a member of the Interdisciplinary team and attends the morning meetings. She stated that once an evaluation is completed, they verbally discuss the evaluation in morning meetings with the Director of Nursing (DON) and Unit Mangers which would include the safest means of transfer. The Rehab Director stated that once the information was provided in the morning meetings, she was not sure of the nursing process for updating that information or informing staff. Review of the Physical Therapy (PT) Evaluation and Plan of Treatment form dated 10/11/18 revealed R#62 was referred for PT evaluation only by the nursing staff due to increased weakness and a slight decline in transfers. The form documented that R#62 had required the use of the Stand Lift and that staff were already using the Stand Lift. R#62 declined PT Services and was educated by the Physical Therapist that she could potentially return to her prior level of function (PLOF) for transfers and how she could contact them if she decided she wanted the services. Interview on 2/28/19 at 4:27 p.m. with the MDS Coordinator/Licensed Practical Nurse (LPN) NN revealed she does not attend morning meetings. She stated she was not aware that staff were using the Sit-to-Stand Lift to transfer R#62. LPN NN stated after R#62 fractured her ankle, she went back and reviewed old therapy notes and she discovered the therapy evaluation on 10/11/18 that indicated the resident required and was using a Sit-to-Stand Lift for transfers. LPN NN stated if the PT Evaluation for R#62 on 10/11/18 was discussed in morning meeting by the therapy department, the MDS Manager would have reported it to her and she would have updated the care plan and the CNA Kardex at that time. LPN NN stated transfers that require a mechanical lift are always care planned. LPN NN stated when she is conducting a MDS assessment, she obtains information for the assessments by conducting resident interviews, a physical assessment of the resident, family interviews if available, review of the clinical records, Medication Administration Records, Progress Notes, ADL requirements, the Plan of Care (P[NAME]) look back report, nurse's notes, User Defined Assessment (UDA) and therapy notes if on therapy case load; and sometimes an interview with the CNAs. LPN NN stated she never interviewed the CNAs about the transfer requirements for R#62 because she wasn't aware of a change or that she needed a Sit-to-Stand Lift for transfers. LPN NN stated that had she interviewed the CNA staff, it is possible she may have learned that the CNAs were using the Sit-to-Stand Lift for transfers Interview on 2/28/19 at 4:43 p.m. with the MDS Coordinator/LPN SS revealed she does attend the morning meetings. She stated she reviews the dashboard before the morning meeting to see if there were any changes in condition or SBAR (Situation Background Assessment Recommendation) reports. LPN SS stated if a PT Evaluation or change in transfer needs were not discussed by the Rehab Director in morning meeting, the MDS department would not know. She stated the communication is verbal and they have no written type of communication that she was aware of. LPN SS stated she could not remember discussions in the morning meetings related to R#62's need for use of the Sit-to-Stand lift. Cross Refer F689",2020-09-01
1943,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2019-02-28,689,G,0,1,TGBJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy titled Lift, Transfer, and Repositioning Policy, resident, family and staff interviews, the facility failed to ensure the appropriate devices were used for one of three residents (R) reviewed that required a mechanical lift during transfers (R#62). Actual harm was identified when R#62 suffered an ankle fracture while being transferred from her wheel chair to her bed without the use of a mechanical lift on 2/2/19. Findings include: Review of the facility policy titled Lift, Transfer, and Repositioning dated 2010 documented: 1. PURPOSE: This policy is intended to provide guidance to the facility Committee, facility management, and direct care staff, regarding the process that must be undertaken to evaluate residents and implement a lift/transfer/repositioning protocol for those residents who are determined, through evaluation, to need assistance during transfers and repositioning. 2. POLICY: Each resident will be evaluated by the facility's Interdisciplinary Care Team (IDT) to determine the level of assistance needed for lifting, transfers and repositioning. Requirements for Resident Lifts and Transfers: lift, transfer and mobility evaluation will be provided. 3-B. Requirements for Resident Lifts and Transfers: The type and extent of assistance will be determined by the IDT based on functional ability and clinical diagnoses. 3-F. Program Components: The Resident Transfer Evaluation (RTE) will be the primary tool used to evaluate each resident to determine the level of assistance needed for lifting, transfers, mobility and repositioning. The IDT will determine and identify the appropriate means of transfer and mobility assistance using the RTE and the Lift and Transfer Guide. The IDT will be responsible to complete accurate documentation of the results of the evaluation. Record review for R#62 revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) summary score of 15, indicating no cognitive impairment. The resident did not exhibit behaviors or rejection of care. The resident required extensive assistance with transfers and two-person physical assistance. Section G0300- Balance During Transfers and Walking assessed that R#62 was not steady and only able to stabilize with human assistance with moving from a seated to a standing position and surface to surface transfers. Section G0400- Functional Limitation in Range of Motion assessed R#62 with impairment on both sides of the lower extremities. During an interview on 2/25/19 at 12:05 p.m., R#62 stated that two Certified Nursing Assistants (CNAs) were taking her out of her wheelchair to put her in bed and did not use the Standing Lift that they usually use to put her to bed. R#62 stated when they turned her around to set her on the bed, her left ankle got twisted. She stated it hurt some when it happened but when they sat her on the bed and picked her legs up, that was when it really hurt. The resident stated she hollered out in pain. R#62 stated when the CNA touched her left lower leg it liked to have sent me through the ceiling. The resident stated the CNA reported it to the nurse and she came and looked at it. R#62 stated this happened on a Saturday and they did not send her anywhere to have it checked. R#62 stated they did an x-ray on Monday and told her that her ankle was broken and sent her to the hospital the next day. Review of the Progress Notes for R#62 revealed no documentation of the incident on Saturday, 2/2/19 or Sunday, 2/3/19. A Nurses Note by Licensed Practical Nurse (LPN) JJ dated 2/4/19 at 11:10 a.m. documented Nurse Practioner (NP) made rounds this shift. Received new order to obtain x-ray of left ankle. Mobile-X notified and aware. Daughter notified and aware of new order. Review of the Situation Background Assessment Recommendation (SBAR) initiated on 2/4/19 indicated the incident in which R#62 twisted her left foot during a transfer occurred on 2/2/19 at 2:00 p.m. A note by Registered Nurse (RN)/ Unit Manager CC documented Resident was being transferred to bed with assistance of two RCS (CNA). During transfer, the residents left ankle twisted. Resident complained of left ankle pain after getting into bed. Resident was repositioned for comfort. No changes in the resident's baseline Activities of Daily Living (ADL) Function or mental status. I Suggest- Monitor vitals, x-ray, provider visit. The SBAR indicated that the family of R#62 was notified on 2/2/19. The time of the notification was not specified. The Physician was notified on 2/4/19 at 9:00 a.m. Review of the SBAR for R#62 initiated on 2/5/19 at 1:17 p.m. revealed a note by LPN TT which documented: This started on 2/2/19. Things that make the condition worse- moving left leg in bed. Things that make the condition better- remaining in bed. Send to Emergency Department (ED). Radiology report received for R#62 Ankle AP & Lat 2V left foot. Results indicate acute posterior malleolar fracture with limited view. Sent to ED to have 3 view exam or Computed tomography (CT) done. Daughter notified on 2/5/19 at 11:15 a.m. Medical Doctor (MD) notified on 2/5/19 at 11:00 a.m. Interview on 2/27/19 at 2:33 p.m. with CNA EE revealed he was one of the CNAs that helped transfer R#62 on Saturday of 2/2/19 at the end of his dayshift. He stated the resident wanted to go to bed and he got help from CNA BB. He stated that when we went to pivot her, R#62 said her foot hurt. CNA EE stated he looked down and her feet were crossed. CNA EE stated that he reported the incident to the dayshift nurse but did not recall which nurse was working that day. CNA EE stated he was not assigned to R#62 on Sunday 2/3/19. CNA EE stated when he returned to work on Monday 2/4/19, he was not assigned to R#62 but did hear that they were going to get an x-ray of the resident's left foot. Interview on 2/27/19 at 4:04 p.m. with CNA BB revealed CNA EE asked for her assistance on Saturday 2/2/19, near the end of the day shift, to transfer R#62 from her wheel chair to bed. She stated the Sit-to-Stand batteries were dead so CNA EE needed assistance to transfer R#62. CNA BB stated when they put R#62's leg on the bed, the resident said Ow. CNA BB stated she did not know what happened after that because she was not caring for R#62 and once she helped transfer the resident, she left the room. CNA BB stated they now must use the Hoyer Lift with two-person assist to transfer R#62 since she broke her foot. Interview on 2/27/19 at 2:41 p.m. with LPN DD revealed that she worked Saturday 2/2/19 on the dayshift and stated it was never reported to her by either CNA EE or CNA BB that R#62 twisted her foot during a transfer or that her foot hurt. LPN DD stated her shift ended at 3:00 p.m. and she knew nothing about the incident. Interview on 2/27/19 at 2:46 p.m. with the C-Hall RN/Unit Manager CC revealed she worked on the floor as a nurse on the night shift beginning on Saturday 2/2/19. RN CC stated that early Sunday morning (2/3/19), R#62 reported to her that when the CNAs were putting her back to bed during the day on Saturday 2/2/19, they twisted her ankle and she thought she needed an x-ray of her left foot. RN CC stated nobody mentioned anything to her in report. RN CC stated R#62 reported she was having pain, but when she assessed her left foot, there was no swelling or deformity. She stated she gave the resident Tylenol and passed it on in report and went home. On Monday 2/4/19, the Director of Nursing (DON) wanted her to investigate the incident and complete an SBAR. RN CC stated they put a request for a visit on Monday 2/4/19 in the Physician's communication book and that Nurse Practioner (NP) AA assessed R#62 that day and ordered an x-ray. She stated the x-ray was completed on 2/4/19 which reported the resident had a fracture and recommended a CT Scan. She stated R#62 to was sent to the hospital the next day for the CT Scan which confirmed a left ankle fracture. Interview on 2/28/19 1:30 p.m. with LPN JJ revealed she worked the dayshift on Monday 2/4/19 and stated it was reported to her by the night shift RN CC that R#62 twisted her ankle and was requesting an x-ray and that she had given her Tylenol over the weekend for pain. LPN JJ stated that she assessed the resident on 2/4/19 and there was no redness or swelling at the time of her assessment and the resident did not have any pain. LPN JJ stated her assessment was not documented but she was in the process of calling the NP when the NP walked into the facility; therefore, was verbally notified. Interview on 2/27/19 at 3:07 p.m. with the Director of Nursing (DON) revealed she first was aware of the incident on Monday 2/4/19 during morning meeting and that R#62 was having pain over the weekend. The DON stated they put a request for a visit in the Physician Communication Book. She stated the NP AA assessed R#62 and ordered an x-ray on 2/4/19. The DON stated the x-ray results reported that R#62 had an ankle fracture. She stated that R#62 was sent the next day to the emergency room (ER) for CT Scan on 2/5/19. The DON stated that R#62 returned from the hospital with a splint on her left foot and a follow up appointment with an Orthopedic doctor that was made by the hospital. The DON stated R#62 returned from Orthopedic doctor with a cast on her left foot. The DON further stated on 2/27/19 at 3:55 p.m. that CNA EE told her that they did not use the Sit-to-Stand Lift because the batteries were dead. The DON confirmed the staff had been using the Sit-to-Stand Lift for transfers prior to the incident on 2/2/19 and since the fracture, they have been using the Hoyer Lift. Review of the 24 Hour Report/Change of Condition Report revealed the following: Night shift (11:00 p.m. - 7:00 a.m.) of 2/2/19- c/o left ankle hurting, Tyl @ 7, wanting x-ray. Night shift of 2/3/19- left ankle hurting- twisted, ok wants x-ray. Day shift (7:00 a.m. - 3:00 p.m.) of 2/4/19- Refused to get out of bed. New order for x-ray left ankle, completed at 2:00 p.m., results pending. Day shift of 2/5/19- x-ray result positive for ankle fracture. Sent to hospital at 1300 (military time). Review of the Radiology Report for R#62 dated 2/4/19 documented: Examination: ANKLE AP and LAT 2V, LEFT. Results: Posterior malleolar fracture. Limited view. Conclusion: Acute posterior malleolar fracture with limited views. Recommend 3 view exam or CT. Review of the Hospital Emergency Documentation dated 2/5/19 for R#62 documented: the resident presented to the ED with complaint of (c/o) left ankle injury. The patient's paperwork states twisted ankle during transfer. X-ray positive for fracture, recommend CT. There are no other complaints at this time. Historian reports left ankle injury. There are chronic deformities to the bilateral feet. Tenderness to the left ankle with mild swelling. Splint was placed to ensure immobilization and adequate pain control. Adequate gauze padding was placed and the splint was secured with ACE bandage. CT (w/o) Contrast Left- Impression: Minimally displaced fracture involving the posterior medial aspect of the distal tibia with articular extension. Probable nondisplaced fracture distal fibula. Marked diffuse osteopenia. Adult- Pain Location: Ankle. Medical Decision Making- presenting with left ankle pain. She sustained an injury while being transferred from her wheel chair to the bed at her facility a few days ago. Further interview on 2/28/19 at 9:20 a.m. with CNA EE revealed that they had been using the Sit-to-Stand Lift to transfer R#62 for several months now because the resident had gained weight, was weaker, could no longer stand well and was not able to transfer by hand anymore. CNA EE stated on Saturday of 2/2/19 when they needed to put R#62 back to bed, the batteries on the Sit-to-Stand were dead. He stated there is one Sit-to-Stand Lift on each hall (the facility has three resident halls). He stated they checked both Sit-to-Stand on the second floor and the batteries for both were dead. CNA EE stated they document in the computer how much assistance is needed for ADLs and if they used a mechanical lift for transfers. Review of the ADL Documentation Survey Reports from (MONTH) (YEAR) through (MONTH) 2019 revealed the following: February 2019 indicated that R#62 required either extensive or total assistance with either one-two person physical assist for transfers and a mechanical lift was used every day except for 2/8/19, 2/9/19 and 2/10/19 which coded 8 for activity did not occur. On 2/2/19 (date of incident), it was documented that R#62 required total dependence of two-person physical assist for transfers and that a mechanical lift was used at 11:10 a.m. There was no documentation for a transfer at 2:00 p.m. when the ankle injury occurred. October (YEAR) through (MONTH) 2019 indicated that R#62 required either extensive to total assistance of either one-two person physical assist for transfers and a mechanical lift was used every day with the exception of 12/8/18 which had no documentation for day shift or night shift. For (MONTH) (YEAR), the evening shift coded 8 for the activity did not occur. Interview on 2/28/19 at 9:30 a.m. with the Rehab Director/Speech Therapist revealed she was a member of the Interdisciplinary Team (IDT) and when she receives a request form from nursing in morning meetings for a PT evaluation, it includes assessment for the safest means of transfers. She stated that once the evaluation is completed by the Physical Therapist, it is documented in the Physical Therapy (PT) Evaluation & Plan of Treatment electronic form. The Rehab Director stated all new admissions are assessed and current residents with a change in condition or decline are assessed. She stated it is then verbally discussed in morning meeting with the DON and Unit Managers what type of mechanical lift is needed. She stated the use of mechanical lifts requires a PT Evaluation for the safest means of transfer and the CNAs should never use mechanical lift without a PT recommendation. The Rehab Director stated that R#62 had been in the facility for a long time and has been on their case load many times. She stated the most recent evaluation was conducted on (MONTH) 11, (YEAR) and the safest means of transfer for R#62 was to use the Sit-to-Stand Lift. She stated once this is reported to nursing, she did not know what their process is after that to ensure it is used. Review of the PT Evaluation and Plan of Treatment form dated 10/11/18 documented: Physical Therapy Evaluation only. Reason for referral: Patient referred from nursing due to increased weakness. Tests and Measures- five times Sit to Stand= neural therapy (NT). Transfers: patient requires assistance, however, will not be address in treatment plan (Staff has been using Stand Lift with patient). Assessment Summary- Clinical Impressions: Patient is long term care resident who has had a slight decline in transfers. Patient was previously performing transfers with mod/max assist (5/2018) and prior to that was supervision. However, she has been requiring use of the Stand Lift for transfers recently. Patient is not agreeable to PT Services at this time despite PT explaining how not participating with PT could result in returning to PLOF (Prior Level of Functioning). PT educated patient on how to notify staff if/when she would like rehab services in the future. Interview on 2/28/19 2:20 p.m. with the Physical Therapist (PT) GG revealed she did not conduct the PT evaluation on 10/11/18 for R#62 and the therapist that did no longer works in the facility. She stated that once an evaluation is completed, she would go to the charge nurse right then and verbally tell them what type of Lift is safe for a resident's transfers. She stated they do not provide that information in a written format. PT GG stated she did not know how that information is communicated to anyone else once she reports it to the charge nurse. Interview on 2/28/19 at 11:10 a.m. with the Administrator revealed he and the Unit Manager investigated the incident for R#62 that occurred on 2/2/19 but he also conducted his own investigation. He stated he spoke with staff about the incident and reviewed the CNA Kardex which only indicated R#62 required two-person physical assist for transfers. The Administrator stated he did not have concerns related to staff improperly transferring R#62. The Administrator stated that the CNAs told him that sometimes they use the Sit-to Stand Lift and sometimes they don't, depending on what the resident wanted. The Administrator stated he was not aware that a Physical Therapy evaluation was requested in (MONTH) (YEAR) for increased weakness and decline in transfers or that the Physical Therapist documented that R#62 had been requiring the use of the Sit-to-Stand Lift and staff were already using the Sit-to-Stand Lift for transfers. Interview on 2/28/19 at 12:55 p.m. with the DON revealed the Weekend Supervisor RN II worked on the medication cart on the evening shift, Saturday 2/2/19. The DON stated that RN II was assigned to R#62 and during her investigation when she interviewed him, he stated that he did assess the resident's left foot on 2/2/19 and did not see any swelling of her ankle and the resident had no complaints of pain. The DON stated that his assessment should have been documented in the progress notes and confirmed it was not.",2020-09-01
1944,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2019-02-28,697,G,0,1,TGBJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy titled Pain Management, resident, family and staff interviews, the facility failed to promptly assess and treat pain for one of three residents (R) reviewed (R#62). Actual harm was identified when staff failed to use mechanical lift during transfer which caused a fracture resulting in pain. Findings include: Review of the facility policy titled Pain Management with the revision date of (MONTH) (YEAR) documented: The facility will evaluate and identify residents experiencing pain, evaluate the existing pain and the cause(s) and determine the type and severity of the pain. The staff monitors and documents the resident's response to pain management. The goal of the Pain Management System is to effectively and consistently identify and treat pain. ACUTE PAIN: Pain results from any condition that stimulates the body's sensors, such as infections, injuries, tumors, and metabolic and endocrine problems. Acute pain usually abates as the underlying problem is treated. Early management of acute pain may hasten the recovery of the causative problem and reduce the length of treatment. Basic Overview of Pain Management: Step 1. The licensed nurse screens for pain during various interaction and scheduled evaluations. With each interaction, the nurse is monitoring for signs that the resident may be experiencing pain on an ongoing basis. Step 2. For those residents who screen positive for pain, an in-depth evaluation of their pain is conducted, including such things as the intensity and characteristics of pain, and the effectiveness of prior treatments. An evaluation of pain should be completed when the resident has a new complaint of pain or when pain is suspected to be present. PRACTICE GUIDELINES: 3. The Pain Evaluation will be completed in the following circumstances: (a) Resident reports inadequate pain control (b) Resident is identified with a new onset of pain or displays new signs or symptoms of pain. 4. Following the pain evaluation, the nurse will notify the Physician/Licensed Practitioner of the findings and document on the SBAR Communication Form and Progress Notes (UDA) and implement new orders, if received. 12. The licensed nurse, when administering PRN pain medications, will record the drug administration and the following on the MAR: Pain level using 0-10 numerical rating scale, Non-pharmacological interventions attempted, if indicated and documented in the Progress Notes, Follow-up observations post-intervention to determine the effectiveness of PRN pain interventions (If a resident is sleeping or resting, document as an observation in the Progress Notes portion of the Follow-Up MAR documentation). Record review for R#62 revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE] which documented a Brief Interview for Mental Status (BIMS) summary score of 15, indicating no cognitive impairment. Interview on 2/25/19 at 12:05 p.m. with R#62 revealed on Saturday (2/2/19) two Certified Nursing Assistants (CNA) did not use the standing lift that they usually used to transfer her from the wheel chair back to her bed. R#62 stated that when they turned her around so she could sit on the side of her bed, her left foot got twisted and she yelled out in pain. R#62 stated when they lifted her legs to put her in the bed is when her left foot really hurt and stated it liked to have sent me through the ceiling. R#62 stated that the CNA reported it to a nurse and she came and looked at her foot. The resident stated on the evening shift (3:00 p.m. - 11:00 p.m.), I hate to say this, but I kept telling the CNA I needed something for pain but the male nurse never came to give me pain medicine. R#62 stated the CNA told her it was reported to the nurse but he never came to bring her pain medication. R#62 stated she could not sleep all night long because she was in so much pain. She stated that Registered Nurse (RN) CC gave her Tylenol the next morning on Sunday 2/3/19. R#62 stated that the Tylenol only helped a little bit. R#62 stated she was familiar with the pain scale of 1-10 and stated RN CC never asked her what her pain level was. R#62 stated that her pain prior to taking the Tylenol was a 10 and after was an 8. (Pain scale with 0 meaning no pain and 10 meaning worst pain possible). R#62 stated that she never received pain medication again and none of the nurses asked her to describe her pain level. R#62 stated they did an x-ray on Monday (2/4/19) and told her ankle was broken. She stated the next day she went to the hospital and they put a splint on her left foot and it helped with the pain but she still had some pain. She stated her pain level was mostly a 10 but anywhere from 5-10. She stated it hurt if anyone touched it and she stayed in bed because it hurt if they moved her leg. R#62 stated her leg hurt every day until she got the cast. Review of the Progress Notes revealed no documentation on 2/2/19 when the incident occurred or on 2/3/19 related to the incident or the resident's pain. On 2/4/19, a Situation Background Assessment Recommendation (SBAR) Communication form was initiated which documented that R#62 had twisted her ankle during a transfer and had complaints of pain. Interview on 2/28/19 at 11:00 a.m. with the attending Physician for R#62 revealed he was not notified until 2/4/19 when the facility called him with the results of the x-ray and reported that the resident had twisted her ankle over the weekend and was having pain. Interview on 2/27/19 at 2:33 p.m. with CNA EE revealed when he and CNA BB pivoted R#62 during a transfer, she told him her foot was hurting. CNA EE stated he looked down and her feet were crossed. CNA EE stated it happened at the end of his day shift (7:00 a.m. - 3:00 p.m.) and he reported to the day shift nurse. Interview on 2/27/19 at 2:41 p.m. with Licensed Practical Nurse (LPN) DD revealed she was assigned to R#62 on Saturday (2/2/19) on the day shift but the incident was never reported to her and she knew nothing about the resident twisting her ankle during a transfer. Interview on 2/27/19 at 2:46 p.m. with RN CC revealed she was the C-Hall Unit Manager and that it was not reported to her by LPN II, who worked the evening shift, that R#62 twisted her ankle during a transfer or that she had complaints of pain. RN CC stated R#62 reported to her that her ankle was twisted during a transfer and was hurting, early Sunday morning (2/3/19). RN CC stated that she gave R#62 Tylenol, reported it to the oncoming nurse and went home. RN CC confirmed that she did not ask the resident to describe her level of pain prior to administering the Tylenol or after administration. RN CC further confirmed that she documented on the 24 Hour Report on 2/2/19 and 2/3/19 that R#62's ankle was hurting and she wanted an x-ray. RN CC confirmed that she did not report the incident. RN CC stated she did not administer any further pain medication or call the Physician for pain medication because the resident was only having a little pain and there was no swelling or deformity of the residents left foot or ankle. RN CC confirmed that she did not document in the Progress Notes that R#62 reported to her that her ankle was injured and she was having pain and did not document her assessment. Interview on 2/27/19 at 4:04 p.m. with CNA BB revealed she assisted CNA EE with transferring R#62 from her wheel chair to her bed. CNA BB stated when they turned the resident, she said Ow. CNA BB stated she did not know what happened after that because once the transfer was complete, she left the room. During an interview on 2/27/19 at 4:48 p.m. with the family of R#62, she stated that R#62 called her on Sunday (2/3/19) and told her she twisted and hurt her ankle on the day shift Saturday (2/2/19) during a transfer. She stated that R#62 told her she did not sleep all night because she was in so much pain and never received any pain medicine. The family stated R#62 told her she kept asking for pain medication and kept asking them to do an x-ray of her foot. Interview on 2/28/19 at 12:55 p.m. with the Director of Nursing (DON) revealed she interviewed LPN II who was the weekend supervisor, assigned to care for R#62 on 2/2/19 and 2/3/19. The DON stated that LPN II told her that he did assess R#62 and did not see any swelling of her ankle and the resident had no complaints of pain over the weekend. The DON confirmed that there was no documentation of an assessment for R#62 and he should have documented his assessment in the Progress Notes and completed an SBAR Communication form when he became aware of the incident. The DON stated that the Weekend Supervisors are responsible for reviewing the 24 Hour Reports and based on the documentation on 2/2/19 and 2/3/19 that R#62's ankle was hurting and was requesting an x-ray, LPN II should have ensured that the Physician was notified and that the SBAR Communication form was completed. Interview on 2/28/19 at 1:30 p.m. with LPN JJ revealed she worked the day shift on Monday 2/4/19 and stated it was reported to her by the night shift nurse, RN CC, that R#62 twisted her ankle and was requesting an x-ray and that she had given R#62 Tylenol over the weekend for pain. LPN JJ stated that she assessed the resident on 2/4/19 and there was no redness or swelling noted and at the time of her assessment the resident did not have any pain. LPN JJ stated R#62 did refuse to get out of bed all week but she was comfortable and on the days she cared for her, she denied pain. She stated she documented a couple of times in her nurse's notes that R#62 was not having pain on her shift. LPN JJ stated R#62 reported to her that on Saturday (2/2/19) during a transfer, her ankle rolled. She stated she called the Nurse Practioner (NP) on the phone on 2/4/19 as she was entering the facility and was therefore notified verbally of the incident. She stated the NP ordered an x-ray on 2/4/19. LPN JJ confirmed that she did not document in the progress notes when R#62 reported the incident to her and wanted an x-ray or document her assessment of the resident's foot/ankle. Review of the 24 Hour Report/Change of Condition Report revealed the following: Night shift of 2/2/19- c/o (Complaint of) left ankle hurting, Tyl @ 7, wanting x-ray. Night shift of 2/3/19- left ankle hurting- twisted, ok wants x-ray. Day shift of 2/4/19- Refused to get out of bed. New order for x-ray left ankle, completed at 2:00 p.m., results pending. Day shift of 2/5/19- x-ray result positive for ankle fracture. Sent to hospital at 1300. Evening shift of 2/5/19- returned from hospital with new order for [MEDICATION NAME] 5/325 MG and appointment with ortho. Review of the SBAR Communication form for R#62 initiated on 2/5/19 at 1:17 p.m. documented: Things that make the condition worse- moving left leg in bed. Things that make the condition better- remaining in bed. Sent to Emergency Department (ED) to have 3 view exam or CT done. Daughter notified on 2/5/19 at 11:15 a.m. Medical Doctor (MD) notified on 2/5/19 at 11:00 a.m. Review of the Hospital Emergency Documentation dated 2/5/19 documented: Resident presented to the ED with c/o left ankle injury. The patient's paperwork states twisted ankle during transfer, X-ray positive for fracture, recommended CT. Historian reports left ankle injury. There are chronic deformities to the bilateral feet. Tenderness to the left ankle with mild swelling. Splint was placed to ensure immobilization and adequate pain control. CT w/o Contrast Left- Impression: Minimally displaced fracture involving the posterior medial aspect of the distal tibia with articular extension. Probable nondisplaced fracture distal fibula. Marked diffuse osteopenia. Adult- Pain Location: Ankle. Medical Decision Making- presenting with left ankle pain. She sustained an injury while being transferred from her wheel chair to the bed at her facility a few days ago. On exam, she does have tenderness and mild swelling to the left ankle and neurovascular intact. R#62 was discharged from the hospital with an order for [REDACTED]. Further record review for R#62 revealed no evidence that a Pain Evaluation was completed after the resident injured her ankle on 2/2/19 during a transfer and had complaints of pain. Interview on 2/28/19 at 3:49 p.m. with the DON revealed the staff are expected to ask resident's each shift if they are having pain. If a resident is positive for pain and request pain medication, the nurse is expected to ask the resident their pain level on a scale of 1-10 prior to administration of pain medication and again within an hour after administration to assess effectiveness. The pain level is to be recorded on the Medication Administration Record (MAR). The DON confirmed after review of the pain management policy that a Pain Evaluation should have been completed for R#62 due to a new onset of pain after the ankle injury on 2/2/19 and confirmed it had not been completed. Cross Refer F689",2020-09-01
1945,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2019-02-28,880,D,0,1,TGBJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, and review of the facility policy titled Infection Prevention Manual for Long Term Care; Section 4 Standard and Transmission - Based Precautions, the facility failed to implement contact precautions for one resident (R) (#26) with a [MEDICAL CONDITIONS] infection out of 38 sampled residents. Findings include: Prior to entering the room of R#26 on 2/25/19 at 11:50 a.m., Certified Nursing Assistant (CNA) OO stated that she thinks the resident has [MEDICAL CONDITION] and that she has been really careful when going in the room. During an interview on 2/25/19 at 12:12 p.m., R#26 stated that he went to an appointment a little over a week ago, and they did a test which came back positive for [MEDICAL CONDITION]. Observation at this time revealed no personal protective equipment (PPE) outside or inside the room. R#26 stated that he has never been on isolation in this facility. The resident has an ostomy bag which was empty at this time. Review of the billing statement for the appointment with the infectious disease doctor dated 2/13/19 revealed [MEDICAL CONDITION] resolved after 10 days of oral [MEDICATION NAME] but R#26 started having profuse watery diarrhea yesterday but none today reportedly. Will check for [MEDICAL CONDITION] today. Review of the Lab Order: [MEDICAL CONDITION] ToxinB, QL Real Time PC with a report date of 2/16/19 revealed the stool sample is positive for toxigenic[DIAGNOSES REDACTED]icile. The result was suggestive of [DIAGNOSES REDACTED]icile infection if accompanied by appropriate clinical symptoms. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] revealed R#26 has a Brief Interview of Mental Status (BIMS) score of 13, indicating cognition intact. Further review revealed resident has a [MEDICAL CONDITION] from history of a small bowel obstruction. Review of the Physician Orders dated 2/20/19 revealed the following: [MEDICATION NAME] (HCl) Solution 50 milligrams (MG)/milliliter (ML)(an antibiotic medication) give 125 ml by mouth four times a day for [MEDICAL CONDITION] for 14 Days. Further observations on 2/26/19 at 8:37 a.m., 2/27/19 at 8:30 a.m., and 2/28/19 at 8:35 a.m. revealed no PPE outside or inside the room of R#26. R#26 opened the bathroom door to revealed two bins lined with red biohazard bags. R#26 stated that he puts trash in one and linen in the other. Interview with Registered Nurse (RN) PP on 2/28/19 at 8:50 a.m. revealed that R#26 is on [MEDICATION NAME] isolation and that the results are always going to show up as positive for[DIAGNOSES REDACTED] and it does not mean that it is active. The RN stated that she always places PPE/contact isolation supplies for incontinent residents but because he has an ostomy and the stool is contained, PPE was not placed outside the door. She stated that housekeeping disinfects the residents room daily and ensures that the biohazard bins are removed appropriately. Interview with Nurse Practitioner (NP) QQ on 2/28/19 at 10:25 a.m. revealed that she usually refers to the facility policy for isolation precautions. She stated R#26 does have active [MEDICAL CONDITION]. The NP stated that she called the infectious disease doctor where he had the appointment and it was recommended that he be put on oral [MEDICATION NAME]. Interview with Housekeeper RR on 2/28/19 at 12:35 p.m. revealed that housekeeping cleans all bathrooms using a disinfectant and bleach wipes which are kept on the cart. The biohazard bags which are in R#26's bathroom are brought out of the room by the CNA's, not housekeeping. Interview with the Director of Nursing (DON) on 2/28/19 at 2:37 p.m. revealed that the PPE should have been outside the door for the CNA's to put on gown and gloves to go in the resident's bathroom to get the biohazard bins or when providing any care for the resident. Review of the infection control surveillance tracking and trending from (MONTH) (YEAR) through current revealed no other infections related to [MEDICAL CONDITION]. No other residents showed signs or symptoms of infectious diarrhea. Review of the policy Infection Prevention Manual for Long Term Care; Section 4 Standard and Transmission - Based Precautions: 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. A gown should be donned prior to entering the room or resident's cubicle. Contact precautions will be considered for [MEDICAL CONDITION] and other infectious causes of diarrhea. Infection/ Condition: [MEDICAL CONDITION] - C, DI - contact precautions for duration of illness.",2020-09-01
4851,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2015-04-16,309,D,0,1,G76V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and review of the (MONTH) and (MONTH) (YEAR) Medication Administration Record [REDACTED]. Findings include: Record review for resident #32 revealed a physician's orders [REDACTED]. In addition, the physician ordered [MEDICATION NAME] Sliding Scale as follows: 151 - 159 = 1 units 160 - 199 = 2 units 200 - 239 = 3 units 240 - 279 = 4 units 280 - 319 = 5 units 320 - 359 = 6 units 360 - 399 = 7 units 400 - 439 = 8 units 440 - 479 = 9 units 480 - 519 = 10 units 520 - 559 = 11 units 560 - 599 = 12 units Physician orders [REDACTED]. If the BS is less than sixty (60), give orange juice with sugar or [MEDICATION NAME] one (1) milligram intramuscular (IM). Repeat in thirty (30) minutes, if still less than 60 call medical doctor (MD). If BS is greater than four hundred (400) give coverage and repeat in 1 hour. If still greater than three hundred (300) give coverage and repeat in 2 hours. If still greater than 300 call MD. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] had been done but there was no evidence that insulin had been administered per physician's sliding scale order. The finger stick blood sugar results were as follows: 11:30 a.m. 4/8/15 BS was 156, and 1 unit of [MEDICATION NAME]should have been administered 4/14/15 BS was 152, and 1 unit of [MEDICATION NAME]should have been administered 4:30 p.m. 4/1/15 BS was 190, and 2 units of [MEDICATION NAME]should have been administered 4/2/15 BS was 288, and 5 units of [MEDICATION NAME]should have been administered 4/3/15 BS was 158, and 1 unit of [MEDICATION NAME]should have been administered 4/6/15 BS was 188, and 2 units of [MEDICATION NAME]should have been administered 4/8/15 BS was 221, and 3 units of [MEDICATION NAME]should have been administered 4/9/15 BS was 187, and 2 units of [MEDICATION NAME]should have been administered 4/10/15 BS was 158, and 1 unit of [MEDICATION NAME]should have been administered 4/13/15 BS was 209, and 3 units of [MEDICATION NAME]should have been administered 4/14/15 BS was 199, and 2 units of [MEDICATION NAME]should have been administered 9:00 p.m. 4/1/15 BS was 160, and 2 units of [MEDICATION NAME]should have been administered 4/3/15 BS was 320, and 6 units of [MEDICATION NAME]should have been administered 4/6/15 BS was 266, and 4 units of [MEDICATION NAME]should have been administered 4/7/15 BS was 246, and 4 units of [MEDICATION NAME]should have been administered 4/9/15 BS was 188, and 2 units of [MEDICATION NAME]should have been administered 4/13/15 BS was 222, and 3 units of [MEDICATION NAME]should have been administered Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The finger stick blood sugar results were as follows: 6:30 a.m. 3/3/15 - there was no evidence that the BS was checked or insulin administered. 3/12/15 -BS was 162, and 2 units of [MEDICATION NAME]should have been administered 3/16/15 -BS was 173, and 2 units of [MEDICATION NAME]should have been administered 11:30 a.m. 3/30/15 - BS was 161, and 2 units of [MEDICATION NAME]should have been administered 4:30 p.m. 3/2/15 - BS was 272, and 4 units of [MEDICATION NAME]should have been administered 3/4/15 - BS was 187, and 2 units of [MEDICATION NAME]should have been administered 3/18/15 - BS was 235, and 3 units of [MEDICATION NAME]should have been administered 3/19/15 - BS was 184, and 2 units of [MEDICATION NAME]should have been administered 3/20/15 - BS was 174, and 2 units of [MEDICATION NAME]should have been administered 3/24/15 - BS was 157, and 1 unit of [MEDICATION NAME]should have been administered 3/25/15 - BS was 189, and 2 units of [MEDICATION NAME]should have been administered 3/26/15 - BS was 173, and 2 units of [MEDICATION NAME]should have been administered 3/31/15 - BS was 164, and 2 units of [MEDICATION NAME]should have been administered 9:00 p.m. 3/9/15 - BS was 155, and 1 unit of [MEDICATION NAME]should have been administered 3/11/15 -BS was 204, and 3 units of [MEDICATION NAME]should have been administered 3/15/15 -BS was 181, and 2 units of [MEDICATION NAME]should have been administered 3/17/15 -BS was 185, and 2 units of [MEDICATION NAME]should have been administered 3/18/15 -BS was 211, and 3 units of [MEDICATION NAME]should have been administered 3/23/15 -BS was 199, and 2 units of [MEDICATION NAME]should have been administered 3/24/15 -BS was 165, and 2 units of [MEDICATION NAME]should have been administered 3/25/15 -BS was 198, and 2 units of [MEDICATION NAME]should have been administered 3/26/15 -BS was 167, and 2 units of [MEDICATION NAME]should have been administered 3/27/15 -BS was 295, and 5 units of [MEDICATION NAME]should have been administered 3/30/15 -BS was 175, and 2 units of [MEDICATION NAME]should have been administered 3/31/15 -BS was 177, and 2 units of [MEDICATION NAME]should have been administered Interview conducted 4/16/2015 at 9:21 a.m. with Unit Manager, Licensed Practical Nurse (LPN) AA revealed if the nurse could not access the sliding scale log in Point Click Care, computerized chart system, to chart the amount of insulin administered, then the nurse would document the information in the Progress Notes. She Indicated that the number eight (8) was used to indicated documentation was in the Progress Notes. AA also acknowledged that there was no evidence that the sliding scale [MEDICATION NAME] coverage was administered per MD orders.",2019-05-01
6147,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2014-02-06,241,D,0,1,Z4CR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record and care plan review, the facility failed to timely assist one (1) resident (A) with toileting from twenty-six (26) sampled residents. This failure embarrassed and angered the resident. Findings include: During interview with resident A conducted on 2/4/14 at 11:52 AM, the resident indicated he needs assistance with toileting but it takes up to an hour sometimes to get assistance. He further revealed that he often soils himself and has to remain lying in his wet bed until staff come. This embarrasses and angers him. Resident revealed that he has started to refuse his [MEDICATION NAME] so that he will not have to urinate as often. Follow-up interview with this resident on 2/5/14 at 12:30 PM revealed that staff have left him wet until the next morning. The resident indicated that this had happen twice about 2 weeks ago. The resident again indicated that he has requested to not take his [MEDICATION NAME] to keep him from urinating to much. The resident indicated he cannot toilet himself. Interview with Certified Nursing Assistant (CNA), AA on 2/5/14 at 3:08 PM revealed the resident is on the Catch Program and staff are suppose to toilet him every two (2) hours. He is usually in bed by 6:30 PM and refuses to go to restroom. Interview with LPN, CC on 2/5/14 at 3:30 PM revealed the resident is on Catch Program and should be toileted every two hours and monitored for wetness. CC further revealed that she was unaware of the resident refusing to be toileted. Review of resident's care plan dated 1/2/2014 revealed the resident is to be assisted with incontinence care at least every two (2) hours.",2018-03-01
6148,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2014-02-06,441,E,0,1,Z4CR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility policies and staff interview, the facility failed to follow acceptable standards related to infection control practice related to wound care for one (1) resident (#124) from twenty-six (26) sampled residents, serving meal trays on B hall and for equipment storage in one (1) of three (3) dirty utility rooms. Findings include: Observations of wound care for resident #124 conducted 2/4/14 at 1:37 PM revealed Treatment Nurse DD prepared supplies on a tray at wound care cart outside of resident ' s room. She entered the room, picked up the trash can on other side of room and placed it at the bedside and did not wash hands after handling the trash can. She then gloved, removed the soiled dressing and gloves. With new gloves, she cleaned the wound care, sanitizes her hands, and applied new gloves. She packed the wound with [MEDICATION NAME] and applied composite dressing. When finished she removed gloves, collected trash and left the room without washing or sanitizing hands. Observation of breakfast on B hall conducted 2/4/14 at 7:35 AM revealed uncovered cups of coffee were on breakfast trays, which were on an open food cart in the hallway. Interview with Staff Developer on 2/4/14 at 8:45 AM revealed everything should be covered on the open food cart when passing trays on the halls. She further indicated that if the treatment nurse touched the trash can she should have washed her hands before doing the wound care. Review of the facility ' s in-service on hand hygiene provided to staff on 12/30/13 revealed hand hygiene should be used before touching a patient, contaminated items or surfaces, and upon removing gloves. Observation conducted 2/6/14 at 10:45 AM revealed laboratory supplies, used to draw blood and collect cultures for the entire facility, were stored in the C Hall dirty utility room. Unit manager FF opened the locked door to this storage area which had a sign on the door that indicated this is also the dirty utility room. This room contained the following: Five (5) plastic red bag bins, four (4) were closed but one (1) was open with closed red bags in it. A large yellow plastic trash can with trash fully exposed. It was three fourths (3/4) full of trash. Hopper for cleaning of bedpans The counter had a refrigerator, a Centrifuge and a brown plastic tray containing equipment to draw blood. The brown plastic tray contained Vacutainer needles, and blood drawing supplies. There was an odor of urine and feces in the room. Interview with FF on 2/6/14 at 10:50 AM revealed this equipment is used by the phlebotomist, who comes to the facility five days a week. The lab storage area was moved to the dirty utility room in the last year and was previously on the first floor. Interview with the Director of Nursing (DON) on 2/6/14 at 10:55 AM revealed the equipment in this room is over stock. The phlebotomist brings her own supplies and uses this equipment to supplement her supplies as needed. Review of the facility ' s Infection Prevention Manual, page 10, revealed clean supplies should not be stored in the dirty utility room.",2018-03-01
9736,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2010-10-08,441,D,0,1,BCRX11,"Based on one (1) random observation, review of facility records and staff interview it was determined that facility failed to ensure that proper cleaning and disinfecting for blood glucose meter used for multiple residents. Finding includes: One (1) random observation of a resident receiving glucose testing using a glucose meter on 10/8/10 at 8:31 a.m. revealed that License Practical Nurse (LPN) ""FF"" removed the glucose meter from the medication cart, wiped it off with an alcohol wipe, cleaned the finger with alcohol wipe, use a new lancet and pricked the resident's finger, applied blood to the test strip, read the glucose level, cleaned the glucometer with a new alcohol wipe and put it away. The meter was not cleaned and sanitized appropriately. Interview with License Practical Nurse (LPN) ""DD"" on 10/8/10 at 8:25 a.m. revealed that she used Alcohol only to clean the glucose meter. Interview with Infection Control Nurse ""AA"" on 10/8/10 @ 8:35 a.m. revealed that the she is the primary source of training for staff in proper techniques related to infection control and the proper cleaning of the glucose meter. She revealed that until receiving information from Center for Medicare and Medicaid Services (CMS) regarding new procedures for cleaning and disinfecting glucose meters, the facility had used alcohol as the cleaning agent. She further indicated that since receiving the CMS information the facility was now using Sani-Wipes to clean and disinfect the machine before and after each resident use. She was unaware that some of the nurses were still using alcohol to clean the glucose meters. Review of facility inservices revealed that ""FF"" and ""DD"" had been trained on 3/31/10 to use Sani-Cloth wipes to clean and sanitize glucometers. As per the inservice training, Sani wipes were to be used before, after and in-between resident use.",2015-05-01
9737,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2010-10-08,514,D,0,1,BCRX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to ensure that a resident weight was accurately documented in the medical record for one (1) resident (#175) for nineteen (19) sampled residents. Findings include: Record review revealed that resident #175 had an admission was admitted to the facility on [DATE] with a weight of 136.6 pounds. Review of the weight flow sheet indicated that the next weight recorded was on 8/23/10 and this resident weighed 148.6 pounds. On 9/1/10 the weight was 137.6 pounds. Further record review revealed that the resident had weekly weights conducted for four weeks following admission. These weights were documented as 132.6, 137.6, 132.2 and 136.6 pounds. Review of the dietary progress notes dated 8/26/10 and 8/28/10 revealed the resident's weights were 132.2 pounds. A note dated 9/13/10 revealed the resident weighed 132.6 pounds. Interview conducted 10/7/2010 at 9:50 a.m. with Unit Manager""BB"" revealed that the facility Staff Development staff is responsible for documenting weights in each resident's medical record. Interview conducted 10/7/2010 at 10:00 a.m. with Staff Development staff ""AA"" revealed that she had made a mistake in documentation and had confused resident #175 with her roommate and no significant weight changes had occurred.",2015-05-01
10452,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2011-03-28,323,D,1,0,BJW311,"Based on observation, clinical record review, and staff interview, the facility failed to provide a Tab alarm, as directed by the care plan, for the safety of one (1) resident (#1) on the survey sample of six (6) residents. Findings include: Review of the clinical record for Resident #1 revealed an 11/04/2010 care plan entry which identified that the resident was at risk for falls and injury related to a history of falls, an unsteady gait, and the use of psychotropic medications. A 02/07/2011 notation on the care plan documented that the resident had fallen on 02/06/2011 while in the wheelchair, and specified as an Approach, dated 02/07/2011, to place a Tab alarm. However, observations of the resident up in the wheelchair on 03/28/2011 at 10:12 a.m., 11:40 a.m., and 3:05 p.m. revealed no Tab alarm on the wheelchair. During an interview with the Director of Nursing conducted on 03/28/2011 at 3:07 p.m., the Director of Nursing acknowledged that the resident did not have a Tab alarm in place that day for safety.",2014-07-01
10453,BRIAN CENTER HEALTH & REHABILITATION/CANTON,115508,150 HOSPITAL CIRCLE N.W.,CANTON,GA,30114,2011-03-28,157,D,1,0,BJW311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility Incident/Accident Report review, and staff interview, the facility failed to immediately notify the responsible party of one (1) resident (#1), in a survey sample of six (6) residents, of a change in an elbow wound which required physician notification and the initiation of antibiotic treatment. Findings include: Review of a facility Incident/Accident Report dated 01/13/2011 revealed that Resident #1 hit the right elbow on the wall beside the bed causing an abrasion. This Report documented that both the physician and the family member/resident representative were notified. A Nursing Daily Skilled Summary entry dated 01/15/2011 at 10:00 p.m. documented that redness had been noted around an opened on the right elbow, and documented that the physician, when notified, gave a new order for Keflex. A Physician's Telephone Orders sheet of 01/15/2011 documented an order for [REDACTED]. party was notified of the resident's change of condition and the initiation of antibiotic therapy. During an interview with the Director of Nursing at 3:30 p.m. on 03/28/2011, the Director of Nursing acknowledged that the resident's responsible party was not notified of the [MEDICAL CONDITION] in the resident's right elbow or of the new medication order.",2014-07-01
9583,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2013-05-31,282,D,0,1,9HRY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that Hospice services provided were integrated into the resident's plan of care for one (1) resident (#90) from a sample of forty (40) residents. Findings: Review of the medical record revealed Resident #90 had the [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED].#90. Review of the medical record nurse's note dated 5/23/13 revealed the resident was currently receiving hospice services. Review of the resident's care plan revealed that on 4/17/13 the care plan was revised to include the following: Resident received hospice care related to a decline in oral intake and [DIAGNOSES REDACTED]. Decline was anticipated. There was no evidence that a Hospice care plan had been developed and integrated into the facility care plan. Interview on 5/30/13 at 12:45 PM with Certified Nursing Assistant (CNA) ""EE"" and CNA ""FF"" revealed the hospice aide came to see the resident but were not aware of the aide's schedule. . Review of the Hospice Notebook for Resident #90 revealed no evidence that a care plan had been developed for this resident that was integrated with the facility care plan. Interview on 5/30/13 at 4:15 PM with the DON revealed it was her expectation that the Hospice personnel would be involved in the care plan meeting to integrate the facility and Hospice care plans. Continued interview confirmed there was no care plan or documentation of the extent of hospice services for the resident #90. Interview on 5/31/13 at 7:35 am with Registered Nurse (RN) ""BB"", Unit Manager, revealed the Hospice nurse came into the facility to see the resident but might or might not speak with the facility nursing staff at the time of the visit. Continued interview revealed that the Unit Manager was unaware of the schedule for the Hospice nurse, CNA or other Hospice staff. Review of the care plan summary meeting held May, 2013 revealed there was no Hospice involvement in the care plan meeting and there was no care plan in the Hospice notebook to indicate the amount or level of Hospice services provided to the resident.",2015-06-01
9584,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2013-05-31,323,D,0,1,9HRY11,"**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 appropriately assess and monitor one (1) resident (#207) after three (3) falls from a sample of forty (40) residents.. Findings include: Resident #207 was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the facility's Falls Log revealed the resident had three (3) unwitnessed falls: 5/13/13 at 4:36 p.m. with no injury apparent; 5/14/13 at 12:00 noon with a bruise on her forehead; and 5/14/13 at 6:44 p.m. with no injury apparent. Interview with Registered Nurse (RN) ""DD"" on 5/30/13 at 1:23 p.m. revealed that after any fall a resident is assessed every shift for 72 hours, including vital signs. Neurological checks are performed for 72 hours after any unwitnessed fall, on the following schedule: every fifteen (15) minutes for four (4) times; every one (1) hour for four (4) times, every four (4) hours for two (2) times; then every twenty-four (24) hours until seventy-two (72) hours after the fall. Review of the Falls Management Policy dated 5/1/11 revealed neuro checks are to be done for all unwitnessed falls. Review of the Neurological Assessment Flowsheet revealed no evidence that neuro checks were done after the unwitnessed falls of 5/13/13 at 4:36 p.m. and 5/14/13 at 6:44 p.m. Neuro checks were done irregularly for less than 24 hours after the 5/13/13 fall. Review of nurses notes after the three (3) falls revealed there was no evidence that the resident had been assessed every shift for seventy-two (72) hours after any of the falls. Interview with the Director of Nursing (DON) on 5/30/13 at 3:12 p.m. revealed that her expectation after a fall was that nurses monitor the resident and document in the nurses notes every shift for 72 hours. Continued interview revealed that she further expected that for any unwitnessed fall, neuro checks should be done for seventy-two (72) hours after the fall. Record review with the DON confirmed that neither vital signs nor neuro checks were done for seventy-two (72) hours following three (3) unwitnessed falls as expected.",2015-06-01
9585,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2013-05-31,329,D,0,1,9HRY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to ensure that adequate, consistent, monitoring and assessment for side effects and/or behvaiors were provided for three (3) residents (#62, # 84, and # 110) from a sample of forty (40) residents. Findings include: 1. Review of the medical record for resident # 62 revealed a care plan for risk for drug side effects and falls related to use of [MEDICAL CONDITION] medications. Further reveiw revealed the resident had a [DIAGNOSES REDACTED]. One of the interventions listed in the care plan for resident #62 was Monitor and document behaviors every shift. Review of the Behavior / Intervention Monthly Flow Record revealed the following: January 2013 under Behavior 1. Fear/Panic- the 11-7 shift staff failed to document seven (7) days out of thirty-one (31) days, the 7-3 shift staff failed to document nine (9)days out of thirty-one (31) days, and the 3-11 shift staff failed to document seventeen (17) days out of thirty-one (31) days. Behavior 2. Hallucinations/Paranoia/Delusions- the 11-7 shift staff failed to document eight (8) days out of thirty-one (31) days, 7-3 shift staff failed to document ten (10) days out of thirty-one (31) days, and the 3-11 shift failed to document seventeen (17) days out of thirty one (31) days. February 2013 under Behavior 1. Fear/Panic- the 11-7 staff failed to document five (5) days out of twenty eight (28)) days, 7-3 shift the staff failed to document twelve (12) days out of twenty eight (28) days, and 3-11 shift staff failed to document twenty three (23) days out of twenty-eight (28) days. Behavior 2. Hallucinations/Paranoia/Delusions- the 11-7 shift staff failed to document five (5) days out of twenty-eight (28) days, 7-3 shift staff failed to document sixteen (16) days out of twenty-eight (28) days, and the 3-11 shift failed to document twenty three (23) days out of twenty-eight (28) days. March 2013 under Behavior 1. Fear/Panic- the 11-7 shift failed to document three (3) days out of thirty-one (31) days, 7-3 shift the staff failed to document eleven (11) days out of thirty-one (31) days, and 3-11 shift staff failed to document twenty-four (24) days out of thirty-one (31) days. for Behavior 2. Hallucinations/Paranoia/Delusions- the 11-7 shift failed to document six (6) days days out of thirty-one (31) days, 7-3 shift failed to document ten (10) days days out of thirty-one (31) days, and the 3-11 shift failed to document twenty-four (24) days out of thirty-one (31) days. April 2013 under Behavior 1. Fear/Panic- 11-7 shift staff failed to document twenty-six (26) days out of thirty (30) days, 7-3 shift the staff failed to document twenty-four (24) days out of thirty (30) days, the 3-11 shift the staff failed to document twenty (20) days out of thirty (30) days. Behavior 2. Hallucinations/Delusions/Paranoia- the 11-7 shift staff failed to document twenty six (26) days out of thirty (30) days, 7-3 shift staff failed to document twenty three (23) days out of thirty (30) days, and the 3-11 shift staff failed to document twenty (21) days out of thirty (30) days. May 2013 under Behavior 1. Hallucinations/Paranoia/Delusions- the 11-7 shift staff failed to document eight (8) days out of thirty one (31) days, 7-3 shift staff failed to document three (3) days out of thirty-one (31) days, 3-11 shift staff failed to document two (2) days out of thirty (30) days. Behavior 2. Afraid/Panic- the 11-7 shift staff failed to document nine (9) days out of thirty(30) days, 7-3 shift staff failed to document twenty-one (21) days out of thirty (30) days, and the 3-11 shift staff failed to document thirty (30) days out of (30) thirty days. 2. Review of the care plan for resident # 84 revealed a problem of potential for adverse reaction to [MEDICAL CONDITION] medication due to receiving [MEDICATION NAME] and [MEDICATION NAME]. The interventions included monitor and record resident's target behaviors. Report onset or increase to physician. Review of the Behavior / Intervention Monthly Flow Record for resident # 84 revealed the following: January 2013, Behavior 1. Paranoia/Delusions/Hallucinations- the 11-7 staff failed to document three (3) days out of thirty-one (31) days, the 7-3 shift the staff failed to document five (5) days out of thirty-one (31)) days, 3-11 shift the staff failed to document fourteen (14) days out of thirty-one (31) days. February 2013, Behavior 1. Paranoia/Delusions/Hallucinations- the 11-7 staff failed to document six (6) days out of twenty-eight (28)) days, the 7-3 shift the staff failed to document eleven (11) days out of twenty-eight (28) days, the 3-11 shift the staff failed to document twenty-two (22) days out of twenty-eight (28) days. March 2013, Behavior 1. Paranoia/Delusions/Hallucinations- the 11-7 shift failed to document six (6) days out of thirty-one (31) days, the 7-3 shift the staff failed to document eleven (11) days out of thirty-one (31) days, the 3-11 shift the staff failed to document twenty-four (24) days out of thirty-one (31) days. April 2013, Behavioral 1. Paranoia/Delusions/Hallucinations- the 11-7 shift, the staff failed to document twenty-six (26) days out of thirty (30) days, the 7-3 shift staff failed to document twenty-four (24) days out of thirty (30) days, the 3-11 shift the staff failed to document twenty (20) days out of thirty (30) days. 3. Review of the care plan for resident # 110 revealed the resident is at risk for side effects from antipsychotic medications and receives [MEDICATION NAME]. An intervention included in the care plan was to monitor and record resident's target behavior. Report onset or increase to physician. Review of the Behavior / Intervention Monthly Flow Record revealed the following: March 2013, no behavior type was listed however, the medication [MEDICATION NAME] was listed and on the 11-7 shift documentation was made seven (7) days prior to the resident's admission on 3/15/13. Review further revealed that the 11-7 staff failed to document two (2) days out of sixteen(16) days, the 7-3 shift and the 3-11 shift staff failed to document from March 15th through March 30th. April 2013, Behavior 1. Hallucinations/Paranoia/Delusions- the 11-7 shift staff failed to document twenty one (21) days out of thirty (30) days, the 7-3 shift the staff failed to document eleven (11) days out of thirty (30 )days, and the 3-11 shift staff failed to document on thirty (30) days out of thirty (30) days. May 2013, Behavior 1. Hallucinations/Paranoia/Delusions- on the 11-7 shift, the staff failed to document nine (9) days out of twenty-nine (29) days, On the 7-3 shift the staff failed to document two (2) days out of twenty nine (29) days. On the 3-11 shift the staff failed to document twenty six (26) days out of twenty eight (28) days. Documentation on 5/29 not counted since the 3-11 shift is in progress. Interview with Registered Nurse (RN) ""AA"",on 5/29/13 at 6:20 p.m., confirmed the blank spaces on the Behavior/Intervention Monthly Flow Record/ which revealed no documentation for certain days regarding the behaviors. Continued interview revealed that the staff just failed to document behavior on the Behavior Monitoring sheets for Resident # 110 Interview with the Director of Nursing (DON) on 5/29/13 at 6:30 p.m. regarding blank spaces on Behavior/Intervention Monthly Flow Record for residents on [MEDICAL CONDITION] medications. Continued interview revealed that her expectations were that the staff would document on the records as ordered.",2015-06-01
9586,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2013-05-31,441,E,0,1,9HRY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of facility policy, the facility failed to ensure that glucometers, on one (1) of five (5) medication carts, were disinfected appropriately for two (2) residents (#78 and #148) from a sample of forty (40 residents. Findings include: 1. Observation on 5/30/13 at 11:37 a.m. of Registered Nurse (RN) ""CC"" perform a finger stick blood sugar (FSBS) for resident #78 revealed that she cleaned the EvenCare G2 Glucometer with an [MEDICATION NAME] alcohol 70% wipe and placed it on a tissue on the medication cart to air dry for approximately two minutes. She then used the machine to perform a FSBS on resident #78. After completing the FSBS, staff ""CC"" wiped the machine with an alcohol wipe and allowed it to air dry. 2. Continued observation revealed staff RN ""CC"" went into resident #148's room and performed a FSBS. She cleaned the meter after use on resident #148, wiping it thoroughly with an alcohol wipe and placing it on a tissue barrier on a medicine tray to air dry. She was never observed disinfecting the glucometer. Review of the facility's policy for Blood Glucose Monitor/[MEDICATION NAME] Time Meter Device Cleaning and Disinfecting dated 5/1/11 revealed the machine should be cleansed with an alcohol containing wipe followed by wiping the meter with a disposable disinfectant cloth. Interview with staff RN ""CC"" on 5/31/13 at 8:10 a.m. revealed that when she cleans the glucometer she always uses only an alcohol wipe. Interview with the Director of Nursing on 5/31/13 at 8:50 a.m. confirmed that the glucometer should be cleaned with an alcohol wipe and then disinfected with a disinfectant cloth.",2015-06-01
9587,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2013-05-31,502,D,0,1,9HRY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that laboratory results were received in a timely manner for one (1) resident (#217) from a sample of forty (40) residents. Findings include: Resident #217 was admitted [DATE] with [DIAGNOSES REDACTED]. Record review revealed a physician's orders [REDACTED]. There were no laboratory results in the chart. Interview with Registered Nurse (RN) ""DD"" on 5/30/13 at 4:48 p.m. confirmed the results were not in the chart or waiting to be filed. Review of the Laboratory Tracking Log revealed the BMP for resident #217 had been drawn 5/22/13. Interview with staff RN ""DD"" on 5/31/13 at 10:36 a.m. revealed Clinical Laboratory Services (CLS) was unable to determine whether the specimen had been received or the lab test had been performed. Interview with the DON on 5/31/13 at 10:41 a.m. revealed she had spoken to the facility's contact person at CLS who had looked for the specimen but could not find it; the CLS representative was unable to explain what had happened.",2015-06-01
9588,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2013-05-31,356,B,0,1,9HRY11,"Based on observation during the four days of the survey from May 28, 2013 through May 31, 2013, the facility failed to post complete nurse staffing information. Findings: Observation during the four (4) days of the standard survey conducted May 28, 2013 through May 31, 2013, revealed the facility failed to post complete staffing hour information. The facility failed to post the total number of hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift.",2015-06-01
10186,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2011-12-15,157,D,0,1,L06211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to notify the physician related to holding medication for one (1) resident (#68) from a sample of thirty-one (31) residents. Findings Include: Observation on 12/14/11 at 10:25 a.m. during medication pass for resident #68 revealed that Licensed Practical Nurse (LPN) ""BB"" checked the residents pulse prior to administering [MEDICATION NAME]. The pulse rate was 58 and the nurse held the [MEDICATION NAME] 50 milligrams (mg). The nurse did not notify the physician of the pulse rate or that she had held the medication. Review of the December, 2011 Physician order [REDACTED]. Interview with the LPN on 12/14/11 at 1:59 p.m., revealed that she held the medication because the pulse rate was low. Continued interview revealed that she did not notify the physician and/or physician assistant (PA) of the pulse rate or that she held the medication.",2014-12-01
10187,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2011-12-15,280,D,0,1,L06211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the comprehensive care plan to address interventions for a decline in urinary incontinence for one (1) resident (#125) from a sample of thirty-one (31) residents. Findings include: Review of the initial Minimum Data Set (MDS) assessment dated [DATE] for resident #125 revealed that the resident was assessed as always continent. Review of the quarterly MDS assessment dated [DATE] revealed that the resident was assessed as frequently incontinent, indicating a decline in resident status. Review of nurse's notes, physician orders [REDACTED]. Review of resident care plan revealed no evidence that a care plan had been initiated for the decline in urinary incontinence after the quarterly assessment. Interview with the Clinical Reimbursement Manager conducted on 12/15/2011 at 10:16 a.m. revealed that the care plan was not updated to include a decline in urinary incontinence following the quarterly assessment. Continued interview revealed that this was an oversight on her part.",2014-12-01
10188,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2011-12-15,309,D,0,1,L06211,"Based on record review and staff interview, the facility failed to follow a physician's order for one (1) resident (#125) from a sample of thirty-one (31)residents. Findings include: Review of the clinical record for resident #125 revealed a physician's order dated 10/20/2011 for a referral for the resident to be seen by a Urologist. Review of the facility Transportation Request form revealed that the appointment was not made until 11/15/2011. Further review of the clinical record revealed no evidence that an attempt was made to schedule an appointment before 11/15/2011, a month after the order was written. Interview with Assistance Director of Nursing (ADON) ""CC"" on 12/14/2011 at 11:10 a.m. revealed that the Urology appointment for the resident was not made until 11/15/2011 because she could not reach the facility physician for five (5) weeks to clarify the order. Continued interview revealed that she left a message for the resident's sister on the answering machine on 11/15/2011 regarding the appointment but was not sure if she got a response back from the sister confirming if she could or could not escort the resident to her appointment. Interview with Registered Nurse (RN) ""EE"" on 12/14/2011 at 11:00 a.m. revealed that the appointment with the Urologist for resident #125 was scheduled for for 12/12/2011 but had to be canceled because there was no one to escort the resident to the appointment. Continued interview revealed that she contacted the resident's sister on 12/12/2011 at 7:30 a.m. regarding escorting the resident to the appointment. The resident's sister stated that she could not accompanied resident because of her schedule and requested that the facility provide an escort. The sister stated that she had received the message last month regarding the appointment but did not confirm that she would escort her sister to the appointment. Interview with Director of Nursing (DON) on 12/15/2011 at 9:00 a.m. revealed that although family members are encouraged to escort residents to their scheduled , appointments, it is the responsibility of the facility to provide escorts as needed. Continued interview revealed that the procedures for appointments made outside of the facility is as follows: -The Unit Assistant Director of Nursing (ADON) makes the appointment, and contacts the family to arrange possible escort to the appointment; -a copy of the transfer paper is forward to the Scheduler to assign a staff to accompany the resident if family cannot make the appointment; and a second copy is forward to Social Services to arrange transportation to the appointment. This process should be completed within 24-48 hours Monday thru Thursday during regular business hours . Interview with facility staff Scheduler on 12/15/2011 at 9:30 a.m. revealed that she did not schedule staff to escort resident #125 to her appointment because she was under the impression that the sister was going to escort her. Continued interview revealed that she did not follow-up to ensure that the sister was going to accompany the resident and was notified that the resident's sister was not able to escort the resident day of the appointment an hour after the scheduled appointment. Interview with Social Services on 12/15/11 at 9:40 a.m. revealed that South East Transportation was scheduled to pick the resident up for the appointment on 12/12/2011 at 7:30 a.m. when they arrived she was informed that the there was no one scheduled to escort the resident and the appointment was canceled.",2014-12-01
10189,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2011-12-15,441,D,0,1,L06211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and facility policy review, the facility failed to store two (2) nebulizer's properly for two (2) residents (#138 and #142) and failed to ensure that one (1) out of eleven (11) employee files reviewed had evidence that a [DIAGNOSES REDACTED] test was read in 2010. Findings include: 1. Observation on 12/12/2011 at 11:00 a.m. revealed a nebulizer lying on the bedside table of resident #142. The nebulizer was uncovered and still contained medication. The resident's last nebulizer treatment was given at 9:00 a.m. 2. Observation on 12/12/2011 at 11:00 a.m. revealed a nebulizer in the drawer of the bedside table for resident #138. The nebulizer was uncovered and still contained medication. The resident's last nebulizer treatment was given at 9:00 a.m. Interview with Registered Respiratory Therapist (RRT) ""GG"" on 12/13/2011 at 2:30 p.m. revealed that the nebulizer should be rinsed out after each use and stored in a plastic bag that is labeled with the date and residents name.. During an interview with the Weekend Supervisor ""AA"", on 12/13/2011 at 2:45 p.m., she concurred that the nebulizer should be rinsed out and stored in a plastic bag after each use. Review of the Small Volume Nebulizer Policy, last revised date of 5/1/11, revealed to rinse the small volume nebulizer with tap water and let dry, then place in treatment bag labeled with patient name and date. 3. Review of eleven (11) employee files revealed that one (1) Licensed Practical Nurse (LPN) had an [DIAGNOSES REDACTED] (TB) test performed on 12/8/10 to the left arm; however, during further review, there was no evidence that the test was read. Interview with Registered Nurse (RN), ""DD"" on 12/15/11 at 11:20 a.m., she concurred that the [DIAGNOSES REDACTED] test was not read and indicated that it should have been. Review of the Infection Control Policy dated 5/1/2010 revealed to re-administer the [DIAGNOSES REDACTED] test to a purified protein derivative (PPD) negative employee at regular intervals as determined by the facilities [DIAGNOSES REDACTED] risk assessment.",2014-12-01
10190,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2011-12-15,502,D,0,1,L06211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview, the facility failed to ensure that laboratory tests were completed for two (2) residents (#24 and #62) for weekly [MEDICATION NAME] Time and International Normalized Ratio (PT/INR) according to physician orders. Findings include: 1. Review of the clinical record for resident #24 revealed a physician's orders [REDACTED]. Review of the PT/INR laboratory results from 7/20/11-12/07/11 revealed no evidence that a PT/INR had been done on 7/27/11. Interview with weekend supervisor ""AA"" on 12/13/11 at 3:31 p.m. revealed that she concurred that resident #24 did not have the weekly PT/INR drawn according to physician orders. Interview with the 400 hall Unit Manager ""CC"" on 12/13/11 at 4:05 p.m. revealed that the nurse who takes off the order puts it into the computer and then the night nurse does a twenty-four (24) hour chart check on the 11-7 shift, going over physician orders, labs and medications in the previous twenty-four (24) hours. Continued interview revealed that the order dated 7/20/11 failed to be sent to the lab as a standing order until 7/29/11 and that was why it was missed on 7/27/11. 2. Review of the clinical record for resident #62 revealed a physician's orders [REDACTED]. Review of the INR laboratory results from 10/26/11-12/07/11 revealed no evidence that an INR had been done on 10/26/11. Interview with 400 hall Unit Manager ""CC"" on 12/14/11 at 11:05 a.m. revealed that she concurred that the INR should have been completed on 10/26/11 and that it was not completed as ordered.",2014-12-01
10545,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,314,D,,,I73X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to assess and provide treatments to pressure ulcers for one (1) resident (#235) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record for resident #235, revealed that the resident was admitted to the facility on [DATE] at 12:14 p.m. with [DIAGNOSES REDACTED]. Review of the clinical record revealed no evidence that the pressure ulcers had been assessed by the facility staff, including staging and measuring, until 04/27/10, three days after admission. Review of the pressure ulcer assessment dated [DATE] revealed the following pressure ulcers: on the right buttock a Stage IV, five by three by two centimeter (5x3x2 cm) with tunneling; on the sacrum a Stage IV, 1x1x1 cm with tunneling; on the left heel an unstageable 2x2 cm, black color eschar pressure ulcer and on the right heel an unstageable 3x1 cm black color eschar covered pressure ulcer. Observation 04/29/10 at 2:39 p.m. of the identified pressure ulcer areas revealed the following: two (2) Stage IV pressure ulcers as assessed on 4/27/10 and one (1) Stage II. pressure ulcer to the left buttock that was previously not assessed. Observation and interview on 04/30/10 at 10:03 a.m. with Treatment Nurse ""HH"" revealed that the small area on the left buttock had not been staged or measured. The Treatment Nurse assessed the smaller area, revealing a 4x2 cm, Stage II pressure sore Review of the clinical record revealed a physician's order dated 4/23/10, for Dakins wet-to-dry dressings daily to the sacral pressure ulcers and [MEDICATION NAME] ointment to be applied topically every day. Review of the ""Treatment Administration Record"" (TAR) revealed that the sacral pressure ulcer was being treated with Dakins wet-dry dressing twice a day, [MEDICATION NAME] ointment was being applied topically every day but there was no evidence of where the [MEDICATION NAME] ointment was being applied. Observation on 04/29/10 at 2:39 p.m. of wound care for resident #235, performed by Treatment Nurse ""HH"" revealed that the nurse applied the [MEDICATION NAME] inside the sacral pressure ulcer and the right buttock pressure ulcer. Continued observation revealed that Treatment Nurse cleaned the wound with Saline and applied the Dakins wet-to dry gauze to the sacral wounds. The Treatment Nurse, then applied [MEDICATION NAME] to the left buttock pressure ulcer, although there was no physician order. Further observation revealed the resident had multipodus boots on both feet but the Treatment Nurse did not remove the multipodus boots for assessment and/or a treatment. Interview on 04/30/10 at 8:40 a.m. with Treatment Nurse ""HH"", revealed that the multipodus boots had not been removed and/or a treatment administered on 4/29/10. The Treatment Nurse indicated she had no knowledge of the wounds to the heels. Observation on 4/30/10 at 8:40 a.m. with Treatment Nurse ""HH"", revealed that when the left multipodus boot was removed the left heel had a black area. When the right heel multipodus boot was removed it revealed an unsecured dressing , without a date of application, and a pressure ulcer that was partially covered with eschar. Interview on 4/30/10 at 9:32 a.m. with Treatment Nurse ""GG"", revealed that both heels have eschar and are being treated with SafGel and a gauze dressing. Continued interview revealed that the treatments orders for the pressure ulcers were written on the hospital transfer orders. Interview on 04/30/10 at 10:03 a.m., with Treatment Nurse ""HH"", revealed that [MEDICATION NAME] ointment should not have been applied to the inside of the pressure ulcers but should have been only applied around the outside of the pressure ulcer areas.",2014-04-01
10546,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,281,D,,,I73X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to clarify a physician's order related to wound care and failed to follow the facility program related to weekly weights for two (2) residents (#15 and #235) of the sampled thirty-five (35) residents. Findings include: 1. Review of the clinical record for resident (#235) revealed physician's order dated 4/23/10, for [MEDICATION NAME] ointment to be applied topically every day. Review of the ""Treatment Administration Record"" (TAR) revealed that [MEDICATION NAME] ointment was being applied topically every day but there was no evidence of where the [MEDICATION NAME] ointment was being applied. Observation on 04/29/10 at 2:39 p.m. of wound care for resident #235, performed by Treatment Nurse ""HH"" revealed that the nurse applied the [MEDICATION NAME] inside the sacral pressure ulcer, the right buttock pressure ulcer and the left buttock pressure ulcer. Interview on 04/30/10 at 10:03 a.m., with Treatment Nurse ""HH"", revealed that the [MEDICATION NAME] ointment should not have been applied to the inside of the pressure ulcers but should have been applied on the outside of the pressure ulcer areas. The facility failed to clarify the use of the [MEDICATION NAME] ointment. 2. Review of the clinical record for resident #15 revealed the resident was admitted to the facility on [DATE] with a weight of one-hundred-ninety-six (196) pounds (lbs). Review of the weight history revealed that on 12/23/09 the resident weighed 186 lbs., which was a 10 lb. weight loss and/or a five percent (5%) weight loss in two (2) weeks. Further review revealed that the resident continued to lose weight, with the last recorded weight dated 4/6/10 at 170 lbs., thus a total weight loss of 26 lbs in four (4) months. Continued review of the clinical record revealed that on 4/06/2010 the resident was placed on a Weight Loss Risk Alert Program and Medals, a nutritional supplement, four (4) ounces three (3) times a day, then weekly weights for four (4) weeks to track the success or failure of the supplement. Interview on 4/30/2010 at 1:15 p.m. with the Registered Nurse Unit Manager, revealed that the resident had only been weighed once in the month of April, and not the weekly per the Weight Loss Risk Alert program. Review of the ""Georgia Registered Profession Nurse Practice Act"" revealed that ""Practice of nursing as a registered nurse"" means to perform for compensation any of the following: -Conducts a comprehensive nursing assessment that is an extensive data collection -Detects faulty or missing patient/client information -Provides appropriate monitoring Review of ""The practice of licensed practical nursing"" means the provision of care for compensation...which shall include, but not be limited to, the following: (A) Participating in the assessment, planning, implementation, and evaluation of the delivery of health care services",2014-04-01
10547,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,156,B,,,I73X11,"Based on record review and staff interview, it was determined that the facility failed to include all of the required elements of the Medicare Denial notices issued for two (2) of three (3) residents reviewed. Findings include: Review of three (3) Medicare Denial notices that were issued to residents/family members revealed that notices failed to inform the residents of their right for an immediate appeal of the facility's determination and potential liability for payment of non-covered services in order to allow them to make an informed decision. Interview on 04/30/10 at 3:25 p.m. with Social Service Director (SSD), revealed that she is responsible for Medicare Denial Notices, using the Liability Beneficiary (LBN) Notices, Continued interview revealed that she does not issue the ""Skilled Nursing Facility Advanced Beneficiary Notice"" (CMS ), which informs the resident and/or responsible parties of an estimate of their cost if they decide to remain in the facility once skilled services are no longer needed.",2014-04-01
10548,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,371,F,,,I73X11,"Based on observation and staff interview the facility failed to store food under sanitary conditions for all ninety-four (94) residents who consumed food orally. Findings include: Observation on 4/29/2010 at 11:00 a.m. of the dry storage area revealed the following: the lid for the sugar container was cracked and taped together with frayed duct tape; the lid for the thickener container was not on properly leaving a gap open on the top; the cornmeal was stored in a plastic bag in a bin with no lid and a portable compact disc player was on the top of the bin. Continued observation revealed the HVAC system, running the length of the kitchen, was coated in dust and there was dust observed in the grill cover on the front of the system. Interview on 4/29/10 at 11:00 a.m. with the Dietary Manager, revealed that the HVAC system was only used in the kitchen and they tried to keep it clean but were unable to remove the sticky substance and dust off the grill cover. During continued interview, the Dietary Manager acknowledged the food storage concerns.",2014-04-01
10549,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,280,D,,,I73X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the plan of care to address weight loss for one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record for resident #15, revealed the resident was re-admitted to the facility on [DATE]. Continue review of the clinical record revealed, a plan of care dated 12/2/09, that addressed the nutritional/hydration status and the potential for weight loss related to risk factors including age and need of assistance. Continued review of the clinical record revealed that the Dietary Manager (DM) had identified a weight loss of five (5) percent (%) or ten (10) pounds in two (2) weeks on 1/11/2010. The DM had recommended a dietary supplement be given twice a day and that the resident be weighed once a week for two (2) weeks. Further review revealed that a Quarterly Minimum Data Set (MDS) was completed on 3/10/10 but there was no evidence that the nutritional status of the resident had been updated to reflect the weight loss. The DM had clearly identified the significant weight loss in January and the weight records revealed a seventeen (17) pound weight loss since admission.",2014-04-01
10550,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,325,D,,,I73X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure that interventions were implemented for a significant weight loss for one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Observation on 4/29/2010 at 8:10 a.m. and 12:30 p.m. of the meals for resident #15, revealed the resident was served a regular diet with thin liquids and after set-up by staff was able to feed him/herself with supervision. Review of the clinical record revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Continued review revealed an admission weight of one-hundred-ninety-six (196) pounds (lbs) and the resident was seventy-four (74) inches tall. Review of the weight history revealed that on 12/23/09 the resident weighed 186 lbs., which indicated a ten (10) lb. weight loss and/or a five percent (5%) weight loss in two (2) weeks. Continued clinical record review revealed that the Dietary Manager (DM), assessed the significant weight loss on 1/11/2010 and recommended that a nutritional supplement be provided to the resident twice a day. Further review revealed no evidence that a nutritional supplement was ever physician ordered and/or administered to the resident. The resident continued to lose weight, with the last recorded weight dated 4/6/10 at 170 lbs., thus a total weight loss of 26 lbs in four (4) months. Interview on 4/30/2010 at 10:30 a.m. with the DM, revealed that there was no systematic method to assure that nursing or the physician had received recommendations for supplements. Interview on 4/29/2010 at 1:30 p.m. with Licensed Practical Nurse (LPN) ""AA"", acknowledged that prior to 4/06/10, the resident had not received nutritional supplements. Review of the clinical record revealed that on 4/06/2010 the resident was placed on a Weight Loss Risk Alert Program and Medals, a nutritional supplement, four (4) ounces was to be administered, three (3) times a day and weekly weights for four (4) weeks to track the success or failure of the supplement. The last recorded weight was dated 4/06/10 of 170 lbs. Interview on 4/30/2010 at 1:15 p.m. with the Registered Nurse Unit Manager, revealed that the resident had only been weighed once in the month of April, and not the weekly per the Weight Loss Risk Alert program",2014-04-01
10551,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,157,D,,,I73X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that the physician was notified of a change in condition related to weight loss for one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record weight history for resident #15, revealed a twenty-seven (27) pound weight loss since admission on 12/01/2009. Review of the January 2010, physician progress notes [REDACTED]. Interview on 4/30/2010 at 12:30 p.m. with the Nurse Consultant revealed that the physician was not aware of the weight loss until notified on 4/29/10.",2014-04-01
10552,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,520,D,,,I73X11,"Based on facility record review and staff interview, the facility failed to conduct the Quality Assurance Program with the required staff for three (3) of four (4) quarters. Findings include: Review of the Quality Assurance (QA) minutes, attendance sign in sheets for the last calendar year revealed that the Medical Director had attended only two (2) of the quarterly meetings and that one (1) of the quarterly meetings had been attended by only four (4) of the five (5) required staff members.. Interview on 04/30/10 at 1:30 p.m., with the Administrator, revealed that at a minimum, the Director of Nursing, Assistant Director of Nursing, Medical Director and the Administrator were in attendance at most of the Quarterly Meetings meetings throughout the year.",2014-04-01
10553,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,278,D,,,I73X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record for resident #15, revealed a Comprehensive Minimum Data Set (MDS) was completed on 12/11/2009, which included a weight of one-hundred-ninety-six (196) pounds. Interview on 4/29/2010 at 1:20 p.m. with the MDS/Care Plan Nurse revealed that she was not familiar with this resident . She stated that they were short of help in the MDS office and had a temporary nurse helping her. Continued interview revealed that the resident had weight loss that was not identified. Review during the Quality Assurance Process revealed a Quarterly MDS had been completed on 3/10/10.. Review of the Quarterly MDS, dated [DATE] revealed, that resident #15, weighed 179 pounds. Continued review of the Quarterly MDS assessment, (Section ""K"", question number 3) revealed, that the weight status was coded incorrectly indicating that there had been no change in the weight of the resident.",2014-04-01
10554,BRIARCLIFF HAVEN HEALTHCARE AND REHAB CENTER,115531,1000 BRIARCLIFF ROAD,ATLANTA,GA,30306,2010-04-30,514,D,,,I73X11,"Based on record review and staff interview the facility failed to ensure that the clinical record contained sufficient information including a Quarterly Minimum Data Set (MDS) assessment for one (1) resident (#15) of the sampled thirty-five (35) residents. Findings include: Review of the clinical record for resident #15, revealed that a Comprehensive MDS was completed on 12/11/2009. There was no evidence in the clinical record that a required Quarterly MDS due in March 2010 had been completed. Interview on 4/29/2010 at 1:20 p.m. with the MDS/Care Plan Nurse revealed that they were short of help in the MDS office and had a temporary nurse helping her. She acknowledged that the resident should have been assessed in March but it had not been done. Review during the Quality Assurance Process revealed a Quarterly MDS had been completed on 3/10/10 but there was no evidence in the clinical record of the assessment and the MDS/Care Plan Nurse was not aware that an assessment had been completed.",2014-04-01
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
4076,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2016-03-31,282,D,0,1,EOMQ11,"Based on observation, interview, and record review, the facility failed to follow care plan interventions for one (1) Resident (R1) related to denture care and for 1 Resident (R106) related fall precautions out of thirty three (33) sampled residents. Findings include: 1. Interview with the R1 during Stage 1 on 3/29/16 at 11:11 a.m. revealed that staff do not assist with oral care or cleaning dentures. R1 informed that she takes her dentures out. She stated that she does not clean her dentures when she takes them out. Observation on 3/29/16 at 11:15 a.m. revealed resident with dentures in her mouth. The dentures were dirty with debris and thick film like substance. Review of the care plan revised on 2/10/16 revealed resident dependent for ADL's. Interventions included but not limited to oral care assistance- oral hygiene and denture care daily and as needed. Dental exams as necessary. Observation on 3/30/16 at 11:48 a.m. revealed no denture cup in the R1's room or bathroom. Interview with R1 revealed she used to have a denture cup. Resident informed that she cannot remember the last time that someone cleaned her dentures or where the denture cup might be. Observation on 3/31/16 at 7:30 a.m. revealed resident with dentures in her mouth. The dentures were dirty with debris and thick film like substance. An interview with the Certified Nursing Assistance II on 3/31/16 at 8:00 a.m. revealed that the night shift are responsible for cleaning the dentures. CNA II informed that night shift staff take the dentures out at night and let them soak. CNA II continued that resident places dentures back in mouth in the morning. CNA II informed that she has not yet provided oral care today for R1. CNA II could not explain why R1's dentures had not been cleaned on 3/28/16, 3/29/16, or 3/30/16. An interview with the Licensed Practical Nurse JJ on 3/31/16 at 8:20 a.m. revealed that the CNA's clean R1's dentures daily and more frequently due to the resident being on tube feedings. LPN JJ confirmed that the CNA's have the Kardex which provides the information about care related to each resident. Review of the MDS Kardex Report binder on 3/31/16 at 8:35 a.m. revealed R1's Kardex indicating total dependence with personal hygiene. An interview with the Director of Nursing on 3/31/16 at 8:50 a.m. revealed that it is her expectation that assistance with oral care if offered for each resident in the facility daily and as needed. DON confirmed that she could not provide documentation that the dentures were cleaned daily. DON informed that the CNA's chart by exception in Care Tracker under personal hygiene. Review of the Clinical Health Status, Additional Assessments and Immediate Plans of Care (IP[NAME]) Guideline last reviewed on 3/23/16 revealed instructions for completing needed additional assessments and should be completed quarterly. Review of the Policy/ Guideline for Oral Hygiene revised on 1/20/16 revealed: - Procedure for cleaning dentures - Documentation Guidelines: condition of dentures - Care plan Guidelines: List responsible discipline, instructions unique to this resident, and necessary monitoring/ observation of the underlying condition that relates to oral hygiene 2. Review of Care Plan for R103, initiated on 1/18/16 and revised on 3/3/16 reveals: At risk for falls related to new environment; Goal - No Fall related injuries.; Interventions - apply anti-tippers to wheelchair, date initiated 2/20; bed in low position, date initiated on 1/18/16; floor mats, date initiated 3/22/16; w/c alarm, date initiated 1/19/16. However, observations on 3/29/2016 revealed these interventions were not in place as required in the care plan. Interviews reveals resident did not have interventions in place upon initial observation confirmed by the following: on 3/30/16 at 4:52 p.m with the Assistant DON, on 03/29/2016 at 7:42 a.m. with Unit Nurse DD, 03/29/2016 at 10:33 a.m. with CNA EE and 3/29/16 at 7:50 a.m. interview with nurse FF . Cross reference to F323.",2020-04-01
4077,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2016-03-31,309,D,0,1,EOMQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and medical record review, the facility failed to ensure that physician orders [REDACTED].#201) of the sampled thirty-three (33) residents. Findings include: Resident # 201 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The resident has a laceration to the upper back that was sustained in the fall. The resident has not fallen since admission to the facility. A review of physician orders [REDACTED].>An observation conducted on 03/30/2016 at 9:38 a.m. revealed the resident was in bed without evidence of a bed alarm on the bed or attached to the resident. An observation conducted o 3/30/16 at 12:58 p.m. revealed the resident sitting in a wheelchair in the day room with a tab alarm in place. A subsequent observation conducted on 3/30/16 at 3:07 p.m. revealed the resident was sleeping in bed without a bed alarm in place. An observation on 03/31/2016 at 9:11 a.m. revealed the resident was awake in bed. A tab alarm lying on bedside table and not attached to the resident. During an Interview conducted with Certified Nursing Assistant (CNA) AA on 3/31/16 at 9:10 a.m., he revealed the bed alarm is not used when the resident is in bed because the resident does not try to get out of bed. CNA AA advised that the alarm is used when the resident is in the wheelchair because the resident has tried to stand. CNA AA revealed that he reviews the residents ' Minimum Data Set (MDS) Kardex to obtain information regarding a resident's need for alarms and other care areas. A review of Resident 201 ' s MDS Kardex revealed that the resident had a history of [REDACTED]. An interview was conducted with Licensed Practical Nurse (LPN) BB on 3/31/16 at 9:20 a.m. BB revealed she did not know if the resident was supposed to have a bed alarm or not, and stated she would have to check with her supervisor. During an interview conducted with the unit manager CC on 3/31/16 at 9:30 a.m., CC confirmed that a bed and wheelchair alarm should be used when the resident is in bed or in a chair when ordered by the physician. CC revealed she did not know why the bed alarm was not in use. CC confirmed there was a physician's orders [REDACTED]. CC advised that the CNAs did not have the discretion to determine if the alarm should be used or not. An interview conducted with the Assistant Director of Nursing (ADON) on 03/31/2016 at 11:09 a.m. revealed that information is communicated to CNAs by the CNA Kardex and during Huddles. She also revealed that it is communicated to nursing in the nurse to nurse report. A subsequent interview conducted on 3/31/16 at 4:33 p.m. revealed the facility does not have a policy regarding the use of bed or chair alarms.",2020-04-01
4078,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2016-03-31,312,D,0,1,EOMQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide denture care for one (1) Resident (R1) out of thirty-three (33) sampled residents. Cross Reference F282 Findings include: Interview with R1 during Stage 1 on 3/29/16 at 11:11 a.m. revealed that staff do not assist with her oral care or cleaning her dentures. R1 informed that she takes her dentures out. She stated that she does not have the supplies to clean her dentures when she takes them out. Observation on 3/29/16 at 11:15 a.m. revealed resident with dentures in her mouth. The dentures were dirty with debris and thick film like substance. Record review for R1 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 had a Brief Interview for Mental Status (BIMS) summary score of 14 (fourteen), indicating cognition intact. Section G- Functional Status documented the resident required extensive assistance with one (1) person physical assist with personal hygiene. Section K- Swallowing/Nutritional Status documented resident requires [MEDICATION NAME] feeding, tube feeding, and mechanically altered diet while a resident in the facility. Section L- Dental Status and Services documented resident has no natural teeth or tooth fragments (edentulous). Section V- Care Area Assessment (CAA) Summary triggered Activities of Daily Living (ADL) Functional/ Rehabilitation Potential and Dental Care with the option to be included in the care plan. Review of the Clinical Health Status Admission assessment dated [DATE] revealed condition of teeth/oral cavity: Full upper and lower dentures. Review of the care plan revised on 2/10/16 revealed resident dependent for ADL's. Interventions included but not limited to oral care assistance- oral hygiene and denture care daily and as needed. Dental exams as necessary. Observation on 3/30/16 at 10:30 a.m. revealed resident with dentures in her mouth. The dentures were dirty with debris and thick film like substance. Interview with the resident on 3/30/16 at 10:35 a.m. revealed staff had not cleaned her dentures. Observation on 3/30/16 at 11:48 a.m. revealed no denture cup in R1's room or bathroom. Interview with R1 revealed she used to have a denture cup. Resident informed that she cannot remember the last time that someone cleaned her dentures or where the denture cup might be. Observation on 3/30/16 at 4:00 p.m. revealed R1 with dentures in her mouth. The dentures were dirty with debris and thick film like substance. Observation on 3/31/16 at 7:30 a.m. revealed resident with dentures in her mouth. The dentures were dirty with debris and thick film like substance. An interview with the Certified Nursing Assistance II on 3/31/16 at 8:00 a.m. revealed that the night shift are responsible for cleaning the dentures. CNA II informed that night shift staff take the dentures out at night and let them soak. CNA II continued that resident places dentures back in mouth in the morning. CNA II informed that she has not yet provided oral care today for R1. CNA II could not explain why R1 ' s dentures had not been cleaned on 3/28/16, 3/29/16, or 3/30/16. An interview with the Licensed Practical Nurse JJ on 3/31/16 at 8:20 a.m. revealed that the CNA ' s clean R1's dentures daily and more frequently due to the resident being on tube feedings. LPN JJ confirmed that the CNA ' s have the Kardex which provides the information about care related to each resident. Review of the MDS Kardex Report binder on 3/31/16 at 8:35 a.m. revealed R1's Kardex indicating total dependence with personal hygiene. Information related to dentures was not documented on the Kardex. An interview with the Director of Nursing on 3/31/16 at 8:50 a.m. revealed her expectation is that assistance with oral care be offered for each resident in the facility daily and as needed. DON confirmed that she could not provide documentation that the dentures were cleaned daily. DON informed that the CNA's chart by exception in Care Tracker under personal hygiene. Review of the ADL Flow Sheet printed 3/31/16 at 9:11 a.m. revealed personal hygiene did not occur on night shift for the following dates: 3/24/16, 3/25/16, 3/26/16, 3/30/16, and 3/31/16. Observation on 3/31/16 at 10:00 a.m. revealed resident's dentures white, clean and with no film like substance. Interview on 3/31/16 at 10:05 a.m., R1 revealed that her mouth and dentures feel brand new. Review of the Policy/ Guideline for Oral Hygiene revised on 1/20/16 revealed: - Procedure for cleaning dentures - Documentation Guidelines: condition of dentures - Care plan Guidelines: List responsible discipline, instructions unique to this resident, and necessary monitoring/ observation of the underlying condition that relates to oral hygiene",2020-04-01
4079,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2016-03-31,323,D,0,1,EOMQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, staff interviews and review of policy and procedure, the facility failed to ensure adequate supervision for one (1) resident (103) with a history of multiple falls out of a sample of thirty-three (33) residents. Findings include: Resident 103 was admitted on [DATE] with a fracture of part of neck of right femur, seizures, dementia with behavioral disorders, cerebral ischemic attack, chronic kidney disease stage III, type II DM and retention of urine. Review of resident ' s MDS Assessment completed 01/23/16 reveals a BIMS score of three (3) and the following areas triggered: Falls, Cognitive loss/dementia; Visual function; communication; urinary incontinence; falls; nutritional status; pressure ulcer and psychotropic drug use. He was admitted to Dekalb Medical Center 3/11/16 with [DIAGNOSES REDACTED]. Functional status on discharge from DMC - impaired mobility, impaired speech, impaired vision and requires assistance with ADLs. A Risk Assessment done on readmission to facility from acute hospital stay show the following scores under Section M - Risk for falls: 2= Disoriented x3 at all times, 2= 1-2 falls in past 3 mos., 2= Requires restraints and assist with elimination, 1= balance problems while standing, 1= balance problems while walking, 1= Lower extremities weakness, 1= Requires use of assistive devices, e.g. cane, walker, 2= takes 1-2 medications that could contribute to falls currently or in last 7 days and 2= changes in dosage of 1-2 medications in past 5 days. Review of Social Service admission note dated 1/20/16 regarding events leading to placement - fall and broken hip . Review of Care Plan initiated on 1/18/16 and revised on 3/3/16 reveals: At risk for falls related to new environment; Goal - No Fall related injuries.; Interventions - apply anti-tippers to wheelchair, date initiated 2/20; bed in low position, date initiated on 1/18/16; floor mats, date initiated 3/22/16; w/c alarm, date initiated 1/19/16. Post Fall Analysis/Plan for fall on 1/18/16- Resident was in dining room when he attempted to transfer himself unassisted and fell on the floor. Review of recommendations and Interventions post fall: Pain assessment, Clear environmental obstacles, Mats beside bed, Offer food/fluid between meals, Bed in low position, Toileting schedule, Call light within reach, Bed/chair alarm, Items within reach. Care plan not revised, IDT reviewed on 1/18 and recommended w/c/ alarm. Post Fall Analysis/Plan for fall 2/20/16-Treatment nurse heard resident fall with wheelchair landing on his back. Review of Recommendations and Interventions post fall: 1/2 bedrails, Bed/chair alarm, Care plan not revised, IDT reviewed on 2/22/16 and recommended apply anti-tippers upon readmission. Review of Kardex report provided by Unit Nurse Interview with DON on 3/30/16 at 11:40 AM reveals the Post Fall Analysis for fall on 3/20/16 was completed on 3/30/16 after surveyor requested the document for review. DON reveals she was not aware an assessment was not completed and it is her expectation that an assessment is completed after a fall. Observation on 03/29/2016 at 7:42 a.m. revealed the resident asleep in his room reveals no floor mats on the floor and bed not lowered per resident ' s care planned interventions. Unit Nurse DD states she did not know resident was supposed to have floor mats. She located the floor mats on resident's night stand and stated the morning CNA may have moved them on the last round forgot to put them back after changing resident. CNA has now left for the day. Observation on 03/29/2016 at 8:22 a.m. revealed one floor mat on right side of resident's bed. A second floor mat is observed folded next to resident's night stand. The bed is not observed to be lowered, no tag alarm is observed attached to resident. Observation on 03/29/2016 at 9:34 a.m the resident in bed with floor mats on each side of the bed. Bed is not lowered, no tag alarm observed attached to resident. Side rails are raised. Observation on 03/30/2016 at 9:38 a.m the resident asleep in lowered bed with tag alarm in place and flashing light is on to indicate power is working. Bed mats are observed on the floor on either side of the bed. No evidence of discomfort or distress noted. Side rails are raised, bed is not lowered. On 3/31/2016 at 8:12 AM-Observation reveals resident asleep in lowered bed with working alarm attached and bed mats on either side of his bed. Side rails are raised and bed is lowered. On 3/29/16 at 7:50AM Interview with nurse FF revealed she located resident ' s Care Sense Personal Monitor/Bed Alarm on the floor at the head of resident's bed. The tag was disengaged but the device was not alarming. Unit Nurse inspected the tag alarm and revealed it was not working and stated the battery must be dead because the alarm string had disengaged and the alarm was not sounding off. Nurse states she is aware resident is required to have the tab alarm on at all times. She also reveals she was unaware resident was care planned for floor mats. FF revealed the nurses do not look at the care plan or Kardex for updates, nurses look at orders and CNA ' s use the Kardex. Interview on 03/29/2016 8:50:14 AM with Assistant DON reveals the facility has no written process or policy regarding tab alarms or alarm maintenance. She states there are no work orders, maintenance logs, or other documentation related to alarm maintenance or checking alarm batteries. All communications regarding alarms and alarm maintenance are verbal. Interview with CNA EE 03/29/2016: 10:33 AM reveals she did not know resident was supposed to have floor mats placed beside his bed. She states the DON gave her a floor mat yesterday and told her to place it in the resident ' s room. Aide states resident had not had the floor mats on the floor prior to yesterday. Aide revealed and surveyor observed one folded floor mat in resident's room beside a night stand. Aide reveals she had not observed resident with bed mats in the room or on the floor prior to the DON directive this morning instructing the aide to place the mat in resident ' s room. Aide reveals depends on the Kardex and nurse updates for updates on resident interventions. She contends resident ' s Kardex did not indicate a need for floor mats. On 3/29/16 at11:37 AM-Interview Unit Nurse HH reveals she is responsible for documenting interventions in Care Plans and updating Kardex forms per IDT recommendations. She reveals updates are communicated verbally to nurses during the daily morning huddle meeting and on the twenty-four (24) hour report. Interventions are not placed on orders. She denies knowing nurses do not review the Kardex updates. On 3/29/2016 a 11:45 AM-Interview with DON reveals her expectation regarding alarm maintenance is the CNA ' s and nurses will make sure alarms are in place and working properly when they do their rounds. DON reveals she does not know why the batteries were not changed in the bed alarm, the bed was not lowered and the mats were not on the floor as required per resident ' s care plan. The DON states she expects things that are on the care plan to be implemented. She reveals there is no written policy or process related to alarms, lowered beds or floor mats. She reveals alarm lights do not come on if batteries are dead and need to be replaced and there is no facility process or standard for checking batteries, they are changed when staff notice the batteries are not working. Staff are expected to check each shift. DON states the facility will conduct an inservice on care plans and the way interventions are documented on Kardex sheets so the Kardex can accurately reflect interventions. DON reveals all of the chair and bed alarms were checked by unit managers and CNA ' s on 3/30/16 and staff are now working on a process to make sure alarms do not die before batteries are changed. On 3/31/16 at 4:57 PM-Interview with the Assistant DON reveals resident is care planned for a lowered bed, tab alarm intervention and floor mats. Tab alarm is attached to resident when he is in bed or in the wheelchair. Resident had a fall on 1/18/16 after which his care plan was updated to initiate the tab alarm for resident when he is in bed or in the wheelchair. Assistant DON explains the tab alarm is attached to the resident, not the item so it goes where he goes. Review of Post Fall Analysis/Plans for falls on 1/18/16 and 3/20/16 reveal resident had no interventions in place at the time of the falls. On 3/30/16 at 4:52 PM Interview with the Assistant DON reveals she cannot confirm whether interventions were in place or if alarm sounded because the SBAR is notes do not provide that information. She adds there is no information documented elsewhere that may confirm whether interventions were in place. She can only safely say they were in place based on the care plan. When asked why interventions were not in place when resident was observed on 3/29/16, she stated I think interventions were not in place due to an error on the part of the nurse. Review of resident ' s Kardex report provided by Unit Nurse (HH) reveals resident listed as a fall risk. Interventions listed include lowered bed, tabs monitored in and out of bed. Floor mats are not listed on the Kardex as an intervention.",2020-04-01
4080,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2016-03-31,371,D,0,1,EOMQ11,"Based on observation, interviews and policy review, the facility failed to maintain the temperature of one (1) of two (2) resident snack refrigerators at or below forty one (41) degrees Fahrenheit. The facility failed to have staff wear a head covering at all times while preparing food items. The facility also failed to have a male staff wear a beard guard at all times while preparing food items; There were ninety-two (92) residents in the facility that received an oral diet. Findings include: 03/30/16 8:35:08 AM East Wing snack refrigerator observation with Assistant DON and Unit Manager (HH) reveals refrigerator thermometer temperature to be 50 (fifty) degrees. 03/30/16 8:35:08 AM Interview with Assistant DON reveals the refrigerator temperature should be at or below forty (40) degrees at all times and any refrigerature temperatures higher than forty (forty) degress should be reported to maintenance. She states the current temperature is too warm to safely store food and all the food currently stored in the refrigerator will be discarded. Discarded items belonging to residents include: Two (2) Containers of broccoli salad, One (1)Red Lobster Dish, One (1)Smoothie and (1) Soul Food Dish, One (1) Buttermilk, Danish Pastry, Pasta Salad, Pears, One (1)Lemon Juice, One (1) Ranch Salad Dressing One (1) Italian Salad Dressing, Two (2) cartons of Orange Juice (Some Pulp Natures Choice), Thirty-two (32) ounce Coffee Creamer, Carmel Macchiato, One (1) Jello Dark Chocolate Pudding, Great Value Cranberry Juice Discarded resident food items list provided by employee (HH). 03/30/2016 9:21:04 AM Interview with Assistant DON reveals a work order has now been placed with maintenance to repair the refrigerator. 03/30/2016 9:22:54 AM Observation of the East wing snack refrigerator reveals all food has been removed. 03/30/2016 10:26:40 AM -Observation with Assistant DON of East Wing snack fridge thermometer reveals temperature is now 40 degrees. All perishable items have been discarded. Review of Facility Cold Food Storage Policy (no date) reveals foods must be maintained at or below forty one (41) degrees farenheit unless otherwise specified by law. Review of Facility Refrigerator/Freezer Temp Log reveals daily temperatures ranging thirty-eight (38) to forty (40) degrees Farenheit 3/1/16-3/30/16. 03/30/2016 11:26:34 PM Interview with Maintenance Director reveals maintenance discovered a piece of paper blocking the evaporator coil in the East Wing Snack refrigerator. The refrigerator has been repaired with the removal of the paper. Maintenance director denies receiving any work orders for the refrigerator prior to this incident as the refrigerator was recently purchased. Review of Quarterly Maintenance Document dated 3/17/16 reveals preventative maintenance was conducted on the refrigerator by the Maintenance Director and no problems were noted. 03/28/16-10:20 AM, 11:55 AM and 12:40 PM-Observed the Dietary Manager in kitchen food preparation area without head covering and one (1) kitchen staff member (ZZ) in kitchen food preparation area without beard covering. Review of Golden Living Infection Control-Dining Services Employee Hair Guidelines reveals-All staff (whether a Dining Services employee or not) in the preparation area or steam table meal line area must wear appropriate hair restraint covering all hair. Keep beards well trimmed and covered with an effective hair restraint. 03/30/2016 7:33:05 AM-Interview with Dietary Manager reveals the facility has beard guards that she expects to be worn by staff with facial hair anytime while they are in the kitchen. The Dietary Manager reveals she did not realize until surveyor made her aware that staff member (ZZ) was not wearing a beard guard. She also reveals her own head covering must have fallen off or been caught on something without her knowledge as she did not initially realize she was not wearing a hair net. Dietary Manager contends the lack of head and beard coverings were just an oversight and not usual practice.",2020-04-01
4081,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2016-03-31,466,E,0,1,EOMQ11,"Based on observation and staff interview the facility failed to maintain the required amount of emergency water on site. The current facility census was ninety-eight (98) residents. Findings include: An observation and interview on 03/28/16 at 10:20 a.m. with the Dietary Manager, revealed forty-three (43) gallons of water stored for emergency use. The Dietary Manager agreed forty-three (43) gallons of water did not meet the facility emergency water requirement and explained that much of the emergency water supply recently expired and was removed stock. A review of the Golden Living-Briarwood Water Outage Emergency Action Plan (no date) revealed one (1) gallon per resident per day, plus five (5) gallons per day for staff to pass meds plus five (5) to ten (10) gallons for dietary to prepare and serve emergency menus as the daily requirement for the emergency potable water supply.",2020-04-01
4318,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2016-12-04,282,D,1,0,RXE811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interviews, the facility failed to follow care plan interventions for one (1) resident Z related to incontinent care out of three (3) residents on the sample of thirteen (14) residents. Refer F312 Findings include: Resident Z was interviewed at 12:20 p.m. on 12/04/16, and the resident informed the Surveyor that staff had not changed the resident since 12/03/16 at 10:00 p.m. During an observation on 12/04/16, at 12:25 p.m., the CNA LL changed the resident's adult brief and resident Z, during the change, was noted to be saturated with urine and brown stains. The CNA LL informed the Surveyor that the resident's adult brief was changed last at 9:00 a.m., 12/04/16. Review of resident Z's care plans identified the resident was dependent for ADLs , bilateral leg [MEDICAL CONDITION] and incontinent of bladder and bowel, revealed that the resident was dependent on staff for all of their ADLs and that interventions included on the revised care plan dated 7/15/16, was to check the resident frequently and give the resident incontinent care as needed. During an interview with the Director of Nursing (DON) on 12/04/16, at 2:00 p.m., she informed the Surveyor that the CNA LL told her that she was confused and that she had not changed the resident's diaper since she came on to her shift at 7:00 a.m. The DON informed this surveyor during the interview that staff CNA should check the residents every two hours and change the residents if needed.",2019-11-01
4319,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2016-12-04,312,D,1,0,RXE811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interviews, observation, record review and staff interviews, the facility failed to provide incontinence care as per the resident's comprehensive care plan for one (1) resident (Z) from a sample of three (3) residents. Findings include: Record review for resident Z revealed a Minimum Data Set 3.0 ((MDS) dated [DATE], documenting a BIMS score of 12 with the resident assessed for their activities of daily living as needing extensive assistance for toileting/personal hygiene with an admitted to the facility of 2/17/15. Review of the comprehensive care plan for activity of daily living (ADL) dated 7/15/16, revealed that the resident was assessed as dependent for bed mobility, transfers, incontinent of bladder and bowel related to [MEDICAL CONDITION] and bilateral above the knee [MEDICAL CONDITION]. Interventions included to anticipate ADL needs and assist the resident with all bathing, dressing, personal hygiene, transfers, positioning and incontinent care. During resident interviews with alert and oriented residents, resident W on 12/4/16 at 11:05 a.m. revealed that a resident (resident Z) was not receiving incontinent care from Certified Nursing Staff in a timely manner. At 12:20 p.m. on 12/4/16, this Surveyor interviewed resident Zwho was able to answer all screening questions and was found to be alert and oriented. Resident Z informed the Surveyor during the interview that he/she had not been cleaned and changed since 12/3/16, at 10:00 p.m. At 12:25 p.m. on 12/4/16, resident Z put her call light on and the CNA assigned to the resident answered the call light and resident Z asked the CNA LL to change her adult brief. The resident was sitting in her wheel chair and two CNAs put resident back into her bed. The CNA LL then began to change her diaper and resident Z was observed to have a diaper saturated with urine and some brown stains. The CNA LL cleaned the resident and put on a dry diaper. This surveyor then asked CNA LL when did she last change the resident and she informed this surveyor that the resident was changed her at around 9:00 a.m. after the resident had breakfast. At 12:50 p.m., the Director of Nursing (DON) came into the resident room and resident Z told the DON that no one had changed her diaper since 10:00 p.m. the night before on 12/3/16. Resident Z also told the DON that another CNA YY told her that can only change the resident two times during an 8 hour shift. During an interview with the DON on 12/4/16 at 2:45 p.m., the DON informed the surveyor that CNA LL told her that she was confused when she told the surveyor that she had changed the resident at 9:00 a.m. on 12/04/16, as she did not change her then. Further the CNA LL told the DON that she thought the resident's family changed her when the family got her out of bed at 9:15 a.m. The DON also informed the surveyor that residents should be checked every two hours for incontinent care.",2019-11-01
5406,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2015-02-26,371,E,0,1,CMHB11,"Based on observations and staff interview the facility failed to maintain the rinse cycle of the dish machine above one hundred and eighty degrees Fahrenheit (180 F) to properly sanitize dishware; failed to properly demonstrate the usage of the three (3) compartment sink to prevent the potential for food borne illness. The facility census was ninety-three (93) residents with three (3) residents receiving enteral feedings. Findings include: 1. Observation on 02/23/15 at 9:50 a.m. revealed the high temperature dish machine in the kitchen was not able to reach the required 180 F during the rinse cycle. Continued observation revealed 3 attempts were made and the temperature readings were as follows: 178 F, 178 F, and 175 F. Interview on 02/23/15 at 9:50 a.m. with the Registered Dietitian (RD) revealed that the rinse cycle on the dish machine needs to be 180 F for sanitation purposes. She acknowledged that after the three observed attempts the dish machine did not reach the appropriate temperature to properly sanitize the dishware. Continued interview with the RD revealed that she was not informed that the dish machine had any problems and that the temperature this morning was above 180 F. Interview on 02/25/15 at 12:45 p.m. with the Dietary Manager (DM) revealed that he expects staff to record the wash and rinse temperatures of the dish machine on the log sheet located near the dish room. Continued interview revealed that he expects staff to notify him immediately if the temperatures are not as indicated on the log sheet, wash cycle of 150 F and rinse cycle of 180 F. Review of the dish machine temperature log for (MONTH) (YEAR) revealed two (2) days where staff logged the rinse temperature below the minimums recorded of 150 F Wash and 180 F Rinse. On 2/12/15 the rinse was 178 F and on 2/22/15 the rinse was 179 F. 2. Observation on 02/25/15 at 9:05 a.m. of the 3 compartment sink revealed AA cook was unable to properly demonstrate the proper technique for sanitizing dish ware. The cook was observed washing pots and pans in soapy water, rinsing them with clean water and then she swished the pan in the sanitizing solution. Continued observation revealed that a poster was hung above the 3 compartment sink with the proper steps for sanitizing items. The poster indicated that items need to be immersed in the sanitizing solution for no less than one (1) minute. Interview on 02/25/15 at 9:05 a.m. with AA, cook revealed that all staff were in-serviced on the proper usage of the 3 compartment sink last month. Continued interview with the cook revealed that she was able to verbalize that items needed to be submerged for at least 1 minute. She was not able to explain why she did not demonstrate what she was in-serviced to do. She did reveal that the way she demonstrated how to wash the pan is how she typically washes items in the 3 compartment sink. Interview on 02/25/15 at 9:05 a.m. with the DM revealed that he conducted an in-service on kitchen sanitation and the proper usage of the 3 compartment sink was discussed last month. He acknowledged that the cook did not demonstrate the proper use of the 3 compartment sink to properly sanitize the pan.",2018-09-01
6709,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2013-10-31,157,D,0,1,WDND11,"**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 a compromised area of skin for one (1) resident (#54) from a sample of forty (40) residents Findings include: Review of the admission skin condition assessment for resident #54, dated 9/6/13 revealed the following concerns: 1. Stage II open area to the mid and right sacrum with granulation and surrounding flesh tone tissue; 2. Open [MEDICAL CONDITION] to the right inner thigh area; and 3. Mushy heel on the left foot with profuse scaliness of left foot. Review of the admission progress note dated 9/6/13 revealed that the resident was assessed for cognitive status, skin condition, activities of daily living needs and continence status. There is no evidence that the physician or the responsible party were notified of the mushy heel on the left foot or the stage 2 area to the sacrum. Review of a nurses note dated 10/24/13 revealed that the resident was seen by the treatment nurse for skin assessment. Continued review revealed that the resident had a 2 centimeter (cm) by 2 cm 100% hard black eschar to the left lateral heel. Interview with Licensed Practical Nurse (LPN) AA, on 10/30/13 at 10:43 a.m. revealed that she was made aware of the Deep tissue injury (DTI) to left heel on 10/24/13 and that she had not spoken with the physician or patient representative concerning this new finding.",2017-10-01
6710,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2013-10-31,253,E,0,1,WDND11,"Based on observation and staff interview, the facility failed to maintain a sanitary and comfortable environment related to bathroom floors and functional mirrors, which involved a total of fourteen (14) rooms on two (2) of two (2) wings. Findings include: During initial environmental tour of the facility at 10:55 a.m., the following concerns were identified: West Wing: 1. In the bathroom of 21 and 22 the flooring/molding was loose from the wall at multiple sites. 2. The mirrors in bathrooms 21 and 22, and 23 and 24, were on the wall above the sinks at heights above the height that a resident in a wheelchair could visualize themselves. 3. In the bathroom of 23 the doorframe was rusted and missing six (6) inches on the lower left edge. East Wing: 4. The mirrors in bathrooms 41 and 42, 43 and 44, and 45 and 46, were on the wall above the sinks at heights above the height that a resident in a wheelchair could visualize themselves 5. In the bathroom of 47 and 48 the flooring was loose from the walls on two (2) sides 6. In the bathroom of 49 and 50 the flooring was loose from the wall behind and beside the toilet. Interview with the Maintenance Supervisor on 10/31/13 at 11:25 a.m., revealed that the above items should be repaired and/or corrected. Continued interview revealed that the bathroom flooring in a lot of rooms was warped.",2017-10-01
6711,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2013-10-31,314,D,0,1,WDND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility Skin Integrity Guideline and staff interview, the facility failed to monitor and/or notify the treatment nurse of a Deep Tissue Injury so that treatment could be initiated timely for one (1) resident (#54) and failed to follow a physician's orders [REDACTED].#164) from a sample of forty (40) residents Findings include: Review of the clinical record for resident #54 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident was a right above the knee [MEDICAL CONDITION]. Review of the admission skin condition assessment for resident #54, dated 9/6/13 revealed the following concerns: 1. Stage II open area to the mid and right sacrum with granulation and surrounding flesh tone tissue; 2. Open [MEDICAL CONDITION] to the right inner thigh area; and 3. Mushy heel on the left foot with profuse scaliness of left foot. Review of the Braden Scale for Predicting Pressure Sore Risk revealed that the resident was assessed with [REDACTED]. Review of the progress notes revealed a note dated 9/24 stating resident noted with multiple excoriations at the gluteal area, groin and inner thigh being treated with Colosgyne as needed. New treatment initiated with [MEDICATION NAME] ointment twice a day and on 9/29/13-no new openings of the skin noted, wound dressing to the sacral region is being changed regularly as ordered. Continued review revealed a progress note dated 10/13/13 that stated-skin review assessment performed, skin is intact, no new breakdown noted; barrier cream applied to buttock and groin areas for protection. There is no evidence that the mushy, boggy left heel identified on admission was assessed after the admission assessment. Review of a progress note date 10/24/13 revealed that the resident was seen by the wound nurse for assessment and noted with a 2 centimeter (cm) by 2cm wound to left lateral heel that is 100% hard black eschar. Interview with Licensed Practical Nurse (LPN) AA, on 10/30/13 at 10:43 a.m. revealed that she was made aware of the Deep tissue injury (DTI) to left heel on 10/24/13. Review of the Immediate Plan of Care for Pressure Ulcer Risk developed 10/24/13 revealed that the resident had a pressure ulcer (DTI) to the left heel with interventions that included soft heel boot, daily skin inspection during care and repositioning every two hours use proper techniques to avoid friction and shearing. Observation of wound on 10/30/13 at 10:43 a.m. with LPN AArevealed the left foot with a booty in place. Continued observation revealed the Left lateral heel with black eschar to the entire wound bed. Interview with Director of nursing on 10/31/13 at 2:08 p.m. revealed the resident was admitted with a red and soft left heel. Continued interview revealed that weekly assessments are done by each nurse as assigned to them. The Electronic treatment admission record (ETAR) is initialed each week with expectancy that they were done and we ask that the nurse write a brief description that it was done in the progress note. Telephone interview with the Director of Nurses on 11/15/13 at 11:14 a.m. during the Quality of Assurance process, revealed that the staff nurses are responsible for skin assessments weekly. Continued interview revealed that although she was sure that the assessments were being done, there was no evidence in the clinical record that 2. Review of Wound Evaluation Flow Sheets dated 10/25/13 for resident #108 revealed that the resident had two Stage IV pressure ulcers to the right and left ischiums. This was confirmed during observation of wound care on 10/31/13 at 10:38 a.m. Review of a Wound Care Specialist Initial Evaluation dated 10/17/13 revealed an assessment of Stage 4 pressure wounds of the right and left ischium. Physician recommendations included Zinc Sulfate 220 milligrams (mg) daily for fourteen days. During interview with Licensed Practical Nurse (LPN) Supervisor HH on 10/31/13 at 3:00 p.m., she stated that when the wound doctor made a recommendation, the wound care nurse printed the physician's notes, and was responsible for writing an order for [REDACTED].",2017-10-01
6712,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2013-10-31,431,D,0,1,WDND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and facility policy review, the facility failed to ensure that multi-dose vials and/or inhalers were dated when opened on three (3) of four (4) medication carts and two (2) of two (2) wings. Finding include: 1. Observation of medication cart #2 on the West wing on 10/31/13 at 8:10 a.m., revealed that one (1) vial of Novolog Insulin 100 units was opened for resident #188. Continued observation revealed that there was no evidence of a date that the vial was opened on either the vial and/or the medication box. Interview with Licensed Practical Nurse (LPN) ZZ on 10/31/13 at 8:25 a.m., revealed that when a vial is opened it should be dated. 2. Observation of medication cart #1 on the West wing on 10/31/13 at 8:30 a.m., revealed one (1) opened and undated box of Advair 500/50, which was sent to the facility on [DATE] and had fifty-eight (58) doses left. Interview with LPN YY on 10/31/13 at 8:30 a.m., revealed that the medication was most likely opened recently; however, each medication should have a date when opened. 3. Observation of the medication cart #2 on the East wing at 8:40 a.m., revealed an opened and undated Ventolin HFA/Albuterol Aerosol inhaler. Review of the Medication Storage In the Facility policy with revision date of November, 2011 revealed that when the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. Continued review revealed that 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 thirty (30) days unless the manufacturer recommends another date or regulations/guidelines require different dating.",2017-10-01
6713,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2013-10-31,441,E,0,1,WDND11,"Based on observations, staff interview, and facility policy review, the facility failed to wash hands and/or sanitize hands during dining and failed to change gloves during wound care to prevent the transmission of a possible infection. The total census was (40) forty. Findings include: 1. Observation of the breakfast meal on the Upper East Hall on 10/30/13 at 7:45 a.m., revealed that the trays were distributed to the residents by the Certified Nursing Assistants (CNA) and the Licensed Practical Nurses (LPN) and during the observation the staff were touching the residents on the shoulders, adjusting their chairs, opening milk cartons, uncovering drinking glasses, cutting pancakes with the residents utensils, then returning to the cart, and retrieving another resident's tray and assisting them in the same way. Continued observation revealed that after the trays were distributed, three (3) of the staff sat and fed residents. All of this was done without sanitizing and/or washing hands between residents. Interview with LPN EE on 10/30/13 at 2:10 p.m., revealed that there is hand sanitizer located across from the nurse's station; however, not in the near vicinity of the dining area. Continued interview revealed that after a resident and/or chair is touched hands need to be washed before delivering another meal tray. 2. Review of the Wound Evaluation Flow Sheets dated 10/25/13 for resident #108 revealed that resident #108 had two (2) Stage four (4) Pressure ulcers to the right and left ischiums. Observation during wound care on 10/31/13 at 10:38 a.m., with Licensed Practical Nurse (LPN)/Wound Care Nurse AA revealed she removed the dressing with a moderate amount of light brown drainage to the right ischial ulcer and changed her gloves. However after changing her gloves, the nurse grasped the overbed table, where the dressing supplies were located, pulled it closer to the bed and adjusted the privacy curtain. Continued observation revealed that the Wound Care Nurse proceeded to clean the wound on the right ischium without changing her gloves and/or washing her hands. Before providing care to the second wound, the LPN washed her hands and changed her gloves. After completing the wound care, to the left ischium, the nurse changed the resident's incontinent brief, repositioned the resident's legs on pillows, pulled the resident up in the bed and adjusted the linen all without removing her gloves and washing her hands. Review of the facility's Handwashing/Hand Hygiene Policy and Procedure with revision date of August 2012 revealed that employees must wash their hands for at least fifteen (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: Before and after assisting a resident with meals; after blowing or wiping nose; and before and after direct resident contact for which hand hygiene is indicated by acceptable professional practice. 3. Observation of the lunch meal served on the Lower East Wing dining area on 10/28/13 at 12:28 p.m., revealed six (6) residents seated in the dining room at a large table and four (4) staff members assisting to distribute trays to the rooms, as well as the dining area. Continued observation revealed that the staff were distributing the trays, and assisting the residents with tray set up without washing and/or sanitizing their hands between residents. Further observation revealed one (1) CNA assisting a resident at the table by opening the cartons, adjusting the resident's wheelchair, and positioning the resident closer to the table. The same CNA then turned and assisted another resident at the table by cutting up their chicken. All of this was done without washing and/or sanitizing her hands. During this observation there were two (2) residents at the table that were being fed by staff, after distributing trays, and positioning their chairs; however, no evidence of washing hands and/or the use of hand sanitizer were observed. There was no hand sanitizer station observed in the dining room. Observation of the second breakfast meal served on the Lower East Wing dining area on 10/30/13 at 8:00 a.m., revealed that there were eight (8) residents seated in wheelchairs around a large table where staff were distributing trays and/or assisting in set up, without washing and/or sanitizing their hands between residents. 4. Observation of lunch on the West Wing on 10/28/13 at 12:45 p.m., revealed staff not washing hands in between passing meal trays while assisting residents with meal set-up and/or feeding. 5. Observation in the Upper West Wing on 10/30/13 at 8:15 a.m., revealed that the staff serving resident trays in the dining room from the food cart, delivering trays to the dining tables and to the resident rooms were not washing their hands and/or sanitizing between serving. Continued observation revealed that hand sanitizer was not available in the dining area. The staff would deliver a tray to a resident, and prepare the resident's tray by opening and distributing the condiment packets, napkins containing flatware and placing clothing protectors on the resident. This process was repeated for each resident who received a tray without evidence of any hand washing. Continued observation revealed that while setting up a tray for a resident, one (1) staff member picked up a napkin off the floor with her left hand and used the same hand to open a condiment packet; however, no evidence of washing her hands. During observation of CNA FF who had nasal congestion and coughing, and who was feeding a dependent resident, revealed she blew her nose and coughed into a tissue without washing and/or sanitizing her hands before she continued to feed the dependent resident.",2017-10-01
6714,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2013-10-31,502,D,0,1,WDND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews the facility failed to obtain laboratory services ordered by the physician for two (2) residents (# 49 and #108) from a sample of forty (40) residents. Findings include: Resident # 49 is a sixty-six (66) year old long term care resident admitted to the facility on [DATE] after a hospitalization for exacerbation of [MEDICAL CONDITIONS] . His [DIAGNOSES REDACTED]. Review of the resident's medical records revealed a physician's orders [REDACTED]. Review of the medical record, and electronic chart revealed no evidence that the CBC, CMP, and PT/INR were drawn on 10/14/13. Interview with the Assistant Director of Nursing (ADON) on 10/29/13 at 4:00 p.m., revealed that she was not able to find the CBC, CMP and PT/INR results that were ordered on admission for resident # 49. Continued interview revealed that the Unit Manager is responsible for reviewing the chart for any outstanding physician's orders [REDACTED]. Interview with the Director of Nursing (DON) on 10/31/13 at 2:00 p.m., revealed that daily chart checks are completed by the night shift nurses, they review the charts for any overlooked orders from the previous shifts, and act on them immediately, or flag them for the morning shift to take care of the order. 2. Resident #108 was admitted to the facility in August 2013 with a Decubitus ulcer, Depression, [MEDICAL CONDITION] Bladder, and [MEDICAL CONDITION] (MS). Review of resident's medical record revealed that on 10/17/13 resident was seen by a Wound Care Specialist and was noted to have Stage four (4) pressure sores of the right and left ischium. Continued review revealed that the physician recommended a [MEDICATION NAME] level; however, no evidence that this lab was completed. Interview with Licensed Practical Nurse (LPN) II on 10/31/13 at 3:45 p.m., revealed that the wound care physician's orders [REDACTED].",2017-10-01
6715,BRIARWOOD HEALTH AND REHABILITATION CENTER,115322,3888 LAVISTA ROAD,TUCKER,GA,30084,2013-10-31,514,D,0,1,WDND11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interviews the facility failed to ensure that the clinical record maintained accurate and complete information for one (1) resident (#126) from a sample of forty (40) residents. Findings include: Review of the clinical record for resident #126 revealed that the resident was admitted to the facility on [DATE] after a pelvic fracture from a fall at home. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's weight was eighty-eight pounds (88lbs), and she received a mechanically altered therapeutic diet. Review of the Electronic Nurses Progress Note dated 06/28/13 revealed a Change of Condition Note related to a 5 pound Weight Loss. The physician was notified of the weight loss and orders were received for a Speech Therapy Evaluation, assistance with all meals, Frozen treat at lunch, and to add fortified cereal at breakfast. The Responsible Party (RP) was notified of the weight loss, and interventions, and requested to be present when the speech evaluation was done. Continued review of the clinical record revealed no evidence that the Speech Therapy Evaluation was completed as ordered. Interview with the Licensed Practical Nurse (LPN) Supervisor GG on 10/31/13 at 10:30 a.m., revealed that she was unable to find the speech consultation results. Interview with the Rehab Director on 10/31/13 at 10:35 a.m., revealed that after looking through their computer system he was unable to find where a speech evaluation was completed for resident # 126 and had called the former speech therapist to ask her if she remembered doing this evaluation. Continued interview revealed that the former Speech Therapist informed him that the screen was not completed because she had conferred with the resident's daughter who felt it was not necessary because her mother was just a picky eater. Further interview revealed that the Speech Therapist should have written that speech services were not needed.",2017-10-01
2369,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWNAN ROAD,GRIFFIN,GA,30223,2018-10-19,812,F,0,1,CQVQ11,"Based on observations, interview, record review, and policy review, the facility failed to ensure the reach-in freezer temperature was cold enough to ensure food remained frozen affecting 119 residents who received meals prepared in the kitchen (three residents received tube feeding) out of a total of 122 residents. The failure to ensure frozen foods were maintained at proper temperatures created the potential for the spread of food borne illness. Findings include: 1. Facility Policy The Refrigerators and Freezers policy dated (MONTH) 2008 indicated, This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. The policy indicated the following: 1. Acceptable temperatures should be 35 (degrees) F to 41 (degrees) F for refrigerators and less than 0 (degrees) F for freezers. 2. Monthly tracking sheets for all refrigerators and freezers will be posted to record temperatures . 4. Food Service Supervisors or designated employees will check and record refrigerator and freezer temperatures daily with the first opening and at closing in the evening. 5. The supervisor will take immediate action if temperatures are out of range. 2. The initial kitchen inspection was conducted on 10/16/18 from 9:16 a.m. through 9:44 a.m. with the Dietary Director. The reach-in freezer by the three-sink pot washing area had an internal temperature of 22 degrees Fahrenheit (F) according to a thermometer inside. The thermometer gauge on the exterior of the freezer read 10 degrees F; there were cases of pies with individually boxed boxes of pies in the reach-in freezer. 3. A follow-up observation was made in the kitchen with the Dietary Director on 10/19/18 at 11:15 a.m. The temperature of the reach in freezer by the three-sink pot washing area had an internal temperature of 31 degrees F according to a thermometer inside. The thermometer gauge on the exterior of the freezer read 20 degrees F. The freezer contained individually portioned cups of ice cream, and individual cups of fortified ice cream/pudding, boxes of apple pie, and boxes of sweet potato pie. The surveyor checked five ice cream cups located within different areas in the freezer for firmness. All the ice cream cups were soft with the sides of the Styrofoam cups being easily pushed in. 4. The Reach In by Pot and Pan Sink Freezer Temperature Record for the month of (MONTH) (YEAR) was reviewed in the kitchen with the Dietary Director on 10/19/18 at 11:23 a.m. The temperatures were measured twice daily, once in the morning and once in the evening. The Dietary Director stated the morning temperatures were taken between 7:00 a.m. and 8:00 a.m. Although it was after 11:00 a.m., the morning temperature had not been recorded yet for 10/19/18. Out of the 36 temperatures recorded in the log for the month of (MONTH) (YEAR), there were 12 temperatures above the maximum allowable temperature of 0 degrees F per the Refrigerators and Freezers policy dated (MONTH) 2008. The elevated temperatures were all recorded on the morning temperature check and were as follows: 1) 20 degrees F on 10/1/18 2) 20 degrees F on 10/2/18 3) 30 degrees F on 10/4 18 4) 30 degrees F on 10/5/18 5) 30 degrees F on 10/6/18 6) 30 degrees F on 10/7/18 7) 30 degrees F on 10/8/18 8) 20 degrees F on 10/9/18 9) 18 degrees F on 10/10/18 10) 30 degrees F on 10/13/18 11) 30 degrees F on 10/14/18 12) 19 degrees F on 10/16/18 Upon review of the temperature log in the kitchen with the Dietary Director at 11:28 a.m., the Dietary Director stated staff had not notified her of the elevated temperatures of the reach-in freezer and she stated she had not been aware of the elevated temperatures. 5. A third kitchen observation was made on 10/19/18 at 11:45 a.m. with the Dietary Director. The individual portioned cups of ice cream, fortified ice cream/pudding, boxes of apple pie, and sweet potato pie had just been moved to the walk-in freezer per the Dietary Director. Five more individual cups of ice cream, fortified ice cream/pudding were checked, and they continued to be soft and not firm/frozen. The case with three apple pies inside was removed from the freezer, the individually boxed pies were removed from the larger cardboard box. Each of the three individually boxed apple pies had a sticky coating of the apple filling covering the exterior of the boxes, indicating the pies had not been frozen solid. 6. On 10/19/18 at 12:13 p.m. the Dietary Director was interviewed in the Chapel and stated the dietary staff were to notify her if the temperature of the freezer was 32 degrees and above. The Dietary Director stated she checked the freezer logs a couple times a month; however, had not identified the issue with the reach in freezer. When notified the policy indicated the temperature should be less than 0 degrees for the freezer and not 32 degrees, she agreed it should be less than 0 degrees F. The Dietary Director stated she would educate her staff about the required temperatures for the freezer. When asked if she had notified maintenance about the elevated freezer temperature, she stated she had not, but would put in a work order now.",2020-09-01
5255,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2015-04-09,279,D,0,1,98VD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care for the use of antidepressant medication for one (1) resident (#18) from a sample of thirty (30) residents. Findings include: Record review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident received an antidepressant for the seven (7) days of the assessment period. Continued review of the Care Area Assessment Summary revealed that the [MEDICAL CONDITION] Drug Use triggered and would be care planned. Review of the current physician's orders [REDACTED]. Review of the resident's care plan revealed no evidence that a care plan for [MEDICAL CONDITION] Drug use had been developed. Interview with the Minimum Data Set (MDS) Director on 04/08/2015 at 11:35 a.m., revealed that a care plan should have been developed but was not.",2018-11-01
6397,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2013-11-21,272,D,0,1,Y90X11,"Based on observation, record review, and staff interview, the facility failed to assess the use of a positioning device as a potential restraint and for potential negative outcomes for one (1) resident (#5), of three (3) sampled residents reviewed for restraints, from a total survey sample of twenty-eight (28) residents. Findings include: Resident #5 was observed on 11/19/2013 at 11:11 a.m. seated in a wheelchair with a shoulder harness device in place. The device was attached to the back of the resident's wheelchair and had Velcro straps that wrapped around the resident's shoulders. A review of the clinical record for Resident #5 revealed a 06/06/2013 entry on a Physical Restraint Flowsheet form that documented the use of a table top (in the wheelchair) was discontinued and that the use of a shoulder harness while up in the wheelchair was added for upright positioning. This form also documented that the harness was the less restrictive device. However, there was no evidence in the clinical record of an initial assessment of the shoulder harness device for safety and as a potential restraint. Further review of Resident #5's clinical record revealed that nursing staff completed a significant change Minimum Data Set (MDS) assessment for the resident on 07/10/2013. Even though there was no evidence to indicate that the shoulder harness device had been assessed for safety and as a potential restraint at that time, review of this 07/10/2013 MDS revealed that Section P - Restraints indicated that no physical restraints were in use for Resident #5 at that time. This MDS thus indicated that the use of the shoulder harness for Resident #5 was not coded as a restraint, with no evidence of an actual assessment of the device at that time to determine if the device did, or did not, serve as a restraint. The 07/18/2013 fall CAT module form accompanying the 07/10/2013 MDS for Resident #5 documented the self-release shoulder harness used while in the wheelchair was for upright positioning and as a reminder to the resident to call for assistance with transfers. Further record review for Resident #5 revealed no evidence to indicate that the resident could remove the shoulder harness until 08/28/2013, when a subsequent entry on the Restraint Flowsheet form indicated that the device was not a restraint and that the resident was able to remove it when he/she wanted. During interviews conducted on 11/20/2013 at 12:35 p.m. with Certified Nursing Assistant AA, and on 11/21/2013 at 10:45 a.m. with the Director of Nursing and at 1:55 p.m. with the Therapy Director, these staff members stated that Resident #5 could remove the shoulder harness straps.",2018-01-01
6398,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2013-11-21,280,G,0,1,Y90X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to revise the Care Plan related to fall-prevention for two (2) residents (#5 and #139), who had a history of [REDACTED]. This failure resulted in actual harm for Resident #5, who experienced a fall and sustained a 3 centimeter (cm) by 1 cm skin tear to the left ankle, and a 7 cm by 7 cm area of swelling and blue discoloration to the right ankle. Findings include: 1. Record review for Resident #5 revealed an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 04/03/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS indicated that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 09 at that time, thus indicating that the resident had only moderate cognitive impairment. Additionally, this MDS further documented, in Section G - Functional Status, that Resident #5 required the extensive physical assistance of two-plus persons with bed mobility, but required the extensive physical assistance of only one (1) person for dressing. Review of the current Care Plan for Resident #5 revealed a Focus area, dated as having been initiated on 04/22/2013, which identified that the resident was at risk for falls related to a history of multiple falls secondary to poor safety awareness and attempting to transfer unassisted. Interventions to address Resident #5's fall-risk included to answer the call light promptly, to place the bed in the lowest position, to place a Dycem to the wheelchair, to provide frequent check rounds, and to keep the call light and most frequently used personal items within reach. The 04/22/2013 Care Plan also included a Focus area which indicated that Resident #5 required assistance with his/her daily care needs related to cognitive deficits and physical limitation. Interventions included to allow sufficient time for daily Activities of Daily Living (ADL) care, to assist with ADLs daily, to give baths as scheduled, to check for incontinence upon rounds and as needed, and to give the resident choices of attire. A Significant Change MDS having an Assessment Reference Date of 07/10/2013 for Resident #5 documented in Section - Cognitive Patterns that as of that date, the resident's BIMS score had declined to 03 (a decline from a BIMS score of 09 as documented on the 04/03/2013 MDS referenced above), thus indicating that the resident's cognitive status had declined and was now severely impaired. Section G - Functional Status of this 07/10/2013 MDS also indicated that Resident #5 continued to require the extensive physical assistance of two-plus persons for bed mobility, but also noted that the resident's status had declined to now require the extensive assistance of two-plus persons for dressing (a decline from requiring only one-person physical assistance with dressing as reflected on the 04/03/2013 MDS referenced above). Review of the Care Plan for Resident #5 revealed that the Focus area for fall-prevention was dated as having been reviewed/revised on 07/19/2013, with Interventions added to include the use of a body alarm while in the wheelchair, and the use of a shoulder harness to the wheelchair when out of bed for upright positioning. Additional Care Plan Interventions which were added for fall-prevention included the 08/30/2013 addition of the use of a bed alarm, fall mat, and bed bolsters; a 10/08/2013 addition for the provision of pain management as needed; and, a 10/13/2013 addition specifying the use of a thrust cushion in the wheelchair. The Care Plan Focus area for ADL care for Resident #5 was also dated as having been reviewed on 07/19/2013, but with no Care Plan revisions added at that time. The only subsequent Care Plan revision related to ADL Care Plan for Resident #5 was dated 10/11/2013, and specified referral to the Restorative Nursing Program/Functional Maintenance Program. However, even though the 07/10/2013 Significant Change MDS referenced above for Resident #5 had identified that the resident's cognitive status had declined to reflect severe cognitive impairment, and even though the resident's ADL status had declined to require the extensive assistance of two-plus staff persons during dressing (verses requiring the assistance of only one (1) staff person per the earlier 04/03/2013 MDS), further review of the fall-prevention and ADL/dressing Care Plan Interventions for Resident #5 revealed no evidence to indicate that the existing Interventions on the Care Plan of 04/22/2013 had been assessed for effectiveness to ensure the resident's safety during dressing. There was also no evidence to indicated that any revisions had been made to the original Care Plan of 04/22/2013 for Resident #5 to reflect the need for two (2) staff persons to assist the resident during dressing, or to reflect new interventions, to ensure the resident's safety while being assisted with dressing by staff. Clinical record review for Resident #5 revealed a Nurse's Notes entry of 10/23/2013 at 11:00 a.m. which documented that a certified nursing assistant had been attempting to place a shirt on the resident while the resident was sitting on the side of the bed and the resident had fallen to the floor. A later 10/23/2013, 2:30 p.m. Nurse's Notes entry documented that Resident #5 had sustained a 3 centimeter (cm) by 1 cm skin tear to the left ankle, and a 7 cm by 7 cm area of swelling and light blue discoloration on the inside of the right ankle. However, further review of Resident #5's current Care Plan revealed that, even after Resident #5's fall from the bed on 10/23/2013 while being assisted with dressing by the CNA, there was no evidence to indicate that the Care Plan Interventions for the identified Focus areas of fall-prevention and ADL/dressing had been reviewed for their effectiveness or to reflect additional interventions to ensure the resident's safety during dressing after this fall. Subsequent record review revealed that Interventions had been added to Resident #5's Care Plan on 11/20/2013 (during this standard survey), for both fall-prevention and ADL Focus areas, to specify that staff were not to dress the resident while sitting on the side of the bed, but there remained no reference to the number of staff persons needed to assist the resident while dressing. During an interview with the Director of Nursing (DON) conducted on 11/21/2013 at 9:40 a.m., the DON stated that it was the Unit Manager's responsibility to update resident Care Plans, and further acknowledged that the Care Plan for Resident #5 had not been updated to ensure the resident's safety until after surveyor inquiry on 11/20/2013. Cross refer to F323 for more information regarding Resident #5. 2. Record review for Resident #139 revealed an Annual MDS having an Assessment Reference Date of 09/18/2013 which documented in Section C - Cognitive Patterns that the resident had a BIMS score of 09, indicating moderate cognitive impairment. Section I - Active [DIAGNOSES REDACTED].#139 had [DIAGNOSES REDACTED]. Section G - Functional Status documented that Resident #139 required the extensive assistance of staff for toilet use, and also that the resident was not steady moving on and off the toilet. Review of Resident #139's Care Plan revealed a Focus area, dated as having been initiated on 10/03/2012 and reviewed as recently as 10/23/2013, which identified that the resident was at risk for injury from falls related to impaired mobility, cognitive deficits, diuretic medication use, [MEDICAL CONDITION] medication use and senile dementia. This Care Plan identified multiple Interventions to address this resident's risk for falls, such as a 10/03/2012 Intervention specifying that staff monitor for proper footwear, 10/07/2013 Interventions which specified the use of a bed alarm, the use of a chair alarm in the recliner, and the use of a floor mat at the bedside, and a 10/23/2013 Intervention which specified the application of Blue Bolsters to the bed. During an observation of Resident #139 conducted on 11/20/2013 at 9:30 a.m., the resident was noted to be seated in a wheelchair in the room, with a chair alarm attached to the back of the wheelchair and non-skin socks applied to the feet, in accordance with the Care Plan. Additionally, a floor mat was noted to be placed on the floor by the resident's bed, per the current Care Plan. During a later observation on 11/20/2013 at 10:40 a.m., Resident #139 was observed to be seated in the facility's common area in a wheelchair, and at that time, a chair alarm was applied to the back of the wheelchair and non-skid socks were applied to the feet, per the current Care Plan. Clinical record review for Resident #139 revealed a Nurse's Notes (NN) entry of 10/19/2013 at 7:30 p.m. which documented that the resident was noted in the restroom on the knees between the toilet and the wheelchair. This NN entry documented that the resident had slid down onto the knees, with the CNA being unable to stop the fall. The NN also documented that there were no apparent injuries, and that the physician was notified of the fall. A Patients At Risk (PAR) notes entry of 10/20/2013 for Resident #139 documented that the resident had been lowered to the floor in the bathroom on 10/19/2013. This PAR notes entry documented that Resident #139 was being assisted by staff when the resident voiced he/she was coming off the toilet, and staff then lowered the resident to the floor. This PAR notes entry further documented that staff had been educated to make sure that the resident was all the way back on the toilet during toileting, and to stay close by the resident during toileting. However, review of Resident #139's current Care Plan revealed no evidence to indicate that the Care Plan had been reviewed since the time of the 10/19/2013 fall from the toilet referenced above to assess the effectiveness of the current Interventions related to fall-prevention during toileting. There was also no evidence to indicate that the resident's Care Plan had been review and revised to reflect the need for the staff to ensure that the resident was seated all the way back on the toilet during toileting, and the need for staff to stay close to the resident during toileting, as reflected in the 10/20/2013 PAR note referenced above. Further record review for Resident #139 revealed that it was only on 11/20/2013, during this standard survey, that an Intervention was added to Resident #139's Care Plan Focus area for fall-prevention which specified, as referenced in the 10/20/2013 PAR note, that staff were to encourage the resident to sit back on the commode seat during toileting. However, the resident's Care Plan for fall-prevention still did not reference the need for staff to stay close to the resident during toileting, as had been indicated in the 10/20/2013 PAR notes entry. During an interview conducted on 11/21/2013 at 9:40 a.m., the DON acknowledged that the Care Plan for Resident #139 had not been revised after the resident's fall from the toilet on 10/19/2013 to reflect the new 10/20/2013 fall-prevention intervention involving resident placement on the commode seat, as indicated in the PAR notes entry, until after surveyor inquiry on 11/20/2013.",2018-01-01
6399,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2013-11-21,282,D,0,1,Y90X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and resident interview, the facility failed to provide care in accordance with the Care Plan, related to the assessment of pain per the specified pain scale, for one (1) resident (A) from a survey sample of twenty-eight (28) residents. Findings include: Record review for Resident A revealed a Minimum Data Set assessment of 11/06/2013 which indicated in Section I - Active [DIAGNOSES REDACTED]. Review of Resident A's Care Plan revealed a Problem, originally dating from 08/23/2013, indicating that the resident had the potential for alteration in comfort related to pain due to the [DIAGNOSES REDACTED]. Care Plan Interventions to address Resident As pain included to administer medications as ordered, and also to assess the characteristics of the resident's pain to include the location, frequency, and severity utilizing a pain scale of 0-10. A verbal physician's orders [REDACTED]. Resident A voiced, during an interview conducted on 11/20/2013 at 1:50 p.m., that he/she was experiencing right shoulder pain, and the nurse was called. Licensed Practical Nurse (LPN) KK responded and came to administer pain medication to Resident A at 2:00 p.m. However, LPN KK was observed to administer the resident the pain medication without inquiring of the resident, or assessing in any manner, the severity level of the pain. Based on the above, despite the Care Plan of Resident A specifying the assessment of the resident's pain, to include determining the severity of the pain utilizing a pain scale of 0-10, Nurse KK was observed to administer the resident pain medication as a result of the resident vocalizing pain, but failed to assess the severity of the resident's pain, as specified by the Care Plan. Cross refer to F309 for more information regarding Resident A.",2018-01-01
6400,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2013-11-21,309,D,0,1,Y90X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure pain management related to the assessment of pain severity, per the specified pain scale, for one (1) resident (A) from a total survey sample of twenty-eight (28) residents. Findings include: Record review for Resident A revealed a Minimum Data Set (MDS) assessment having an Assessment Reference Date of 11/06/2013 which indicated in Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status score of 13, indicating that the resident was cognitively intact. Section I - Active [DIAGNOSES REDACTED]. A Nurse's Notes (NN) entry of 11/09/2013 at 4:30 a.m. for Resident A documented that the resident was observed lying on the floor in the room. This NN entry documented that Resident A complained of shoulder pain and stated that he/she had hit his/her right shoulder during the fall. The physician was notified of this fall. A subsequent November 2013 physician's orders [REDACTED]. A Care Plan entry for Resident A noted that the resident experienced pain, and specified for licensed nursing staff to assess the characteristics of the pain, to include the severity of the pain, utilizing a scale of 0-10. During an post-survey Quality Assurance telephone interview conducted on 12/04/2013 at 11:52 a.m., Nurse BB stated that the facility's pain scale of 0-10 was progressive, with a score of 10 representing the most severe pain. During an interview with Resident A conducted on 11/20/2013 at 1:50 p.m., the resident complained of pain in the right shoulder. Resident A was observed to be tearful at that time, and stated that the pain was awful. Nursing staff was called at 1:56 p.m. regarding the resident's expressed pain, and Licensed Practical Nurse (LPN) KK came into the room and administered a dose of pain medicine to Resident A at 2:00 p.m. on 11/20/2013. However, during this observation, LPN KK failed to assess the characteristics of Resident A's pain, related to determining the severity of the pain (as specified by the Care Plan) in any manner, to include asking the resident the severity of the pain, before administering the pain medication. Further clinical record review for Resident A revealed an entry on the resident's November 2013 Medication Administration Record [REDACTED]. However, further review of the record, including this MAR, revealed no evidence of any documentation or assessment of the severity of the resident's pain for which this dose of medication had been administered. A separate area of this MAR indicated [REDACTED]. But, further review of this MAR indicated [REDACTED]. During an interview with LPN KK conducted on 11/20/2013 at 3:30 p.m., LPN KK stated that she had administered the dose of pain medication to Resident A earlier that day for right shoulder pain, but acknowledged that she had not assessed the severity of the resident's pain when the medication was given. During an interview with the Director of Nursing (DON) conducted on 11/21/2013 at 9:40 a.m., the DON stated that she would expect nursing staff to assess resident pain prior to administering pain medication. The DON stated that the facility's system by which nursing staff were to assess the level of resident pain utilized either a Smiley Face diagram for the resident to indicate the pain level, or directed nursing staff to ask the resident to assign a number to the pain level. The DON further acknowledged that LPN KK should have assessed Resident As pain level before administering the resident the dose of pain medication on 11/20/2013.",2018-01-01
6401,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2013-11-21,323,G,0,1,Y90X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, Physical Restraint Flowsheet review, Resident ADL Record review, and staff interview, the facility failed to ensure that one (1) resident (#5) who was at risk for falls, of four (4) sampled residents reviewed for falls, from a total sample of twenty-eight (28) residents, received the necessary supervision to prevent a fall. This failure resulted in actual harm for Resident #5, who fell from the bed and sustained a 3-by-1 centimeter (cm) skin tear to the left ankle and a 7-by-7 cm area of swelling and blue discoloration to the right ankle. Findings include: Clinical record review for Resident #5 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 10/02/2013 which indicated in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #5 had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Section G - Functional Status indicated that Resident #5 had required the extensive physical assistance of two-plus persons for bed mobility, and had also required the extensive physical assistance of two-plus persons for dressing (including putting on and removing all items of clothing). A Physical Restraint Flowsheet for Resident #5 documented a 04/03/2013 entry which indicated that the resident was unaware of his/her safety needs, and would lean forward at times. Resident #5's Care Plan referenced a Focus Area, dated as having been originally initiated on 04/22/2013, which identified that the resident was at risk for falls. A CAT Module dated 07/18/2013 also documented that the resident was at risk for injuries related to falls, and documented that the resident had a history of [REDACTED]. A Bed Safety Assessment form having an Assessment Date of 10/11/2013 for Resident #5 documented that the resident was unaware of his/her safety needs (had made unsafe attempts to get out of bed), had physical weakness, was unable to support his/her trunk in the upright position, and had a balance deficit. A subsequent Fall Risk Evaluation dated 10/19/2013 documented a Total Score of 26 for Resident #5, thus indicating that the resident continued to be at high risk for falls. A Nurse's Notes (NN) entry of 10/23/2013 at 11:00 a.m. for Resident #5 documented that a certified nursing assistant (CNA) reported that she had lowered the resident to the floor. This NN entry further documented that the CNA was attempting to put a shirt on the resident while the resident was sitting on the side of the bed. The CNA further reported that Resident #5 then started leaning over forward and was too heavy for the CNA to support, and thus the CNA lowered the resident to the floor. A later NN entry of 10/23/2013 at 2:30 p.m. documented that Resident #5 was noted to have sustained a 3 centimeter (cm) by 1 cm skin tear to the left ankle, and a 7 cm by 7 cm area of swelling with light blue discoloration to the inside of the right ankle. This NN entry documented that an ice pack was applied and that the physician was notified. A physician's orders [REDACTED]. A Patients At Risk (PAR) Note of 10/25/2013 documented Resident #5's 10/23/2013 fall during which the resident had slid off the bed and was lowered to the floor while being assisted with dressing by the CNA. This PAR note further documented that the CNA had been educated after Resident #5's fall that, when dressing the resident, he/she was not to sit the resident on the bedside, but rather to sit the resident upright in the bed until ready for transfer utilizing two people. During an interview with the Director of Nursing (DON) conducted on 11/21/2013 at 9:40 a.m., the DON stated that the CNA who had sat Resident #5 up on the side of the bed while assisting the resident with dressing on 10/23/2013, thus allowing the resident to fall, was not the resident's normally-assigned CNA. The DON stated that the Resident ADL Record for Resident #5 had been in the resident's room on 10/23/2013 when the resident fell while being assisted with dressing by the CNA, but stated that the Resident ADL Record did not instruct staff on how to assist the resident with dressing. The DON further acknowledged that this CNA had not had specific instructions on how to assist Resident #5 with dressing at the time of the 10/23/2013 fall which resulted in the skin tear to the left ankle and swelling and bruising to the right ankle. Review of the Resident ADL Record form for Resident #5 revealed a section entitled Bathing & Dressing which only indicated to Assist the resident. A hand-written notation on this Resident ADL Record did instruct staff to not dress the resident on the side of the bed, but this notation was dated 11/20/2013 (during this standard survey). Based on the above, for Resident #5, despite the resident having been assessed to require the assistance of two-plus persons for dressing, despite the resident having a history of falls and being assessed as being at high risk for falls, despite the resident having dementia and poor safety awareness, and despite the resident being unable to support his/her trunk in the upright position and having a history of leaning forward, the facility failed to ensure that the CNA providing care to the resident was knowledgeable about, or had specific instructions regarding, the safe procedure by which to assist the resident with dressing. This failure resulted in this staff member, who was providing care to the resident without assistance, allowing Resident #5 to sit on the side of the bed while placing a shirt on the resident, resulting in the resident sustaining a fall to the floor which caused a 3 cm by 1 cm skin tear to the left ankle and a 7 cm by 7 cm area of swelling and bruising to the right ankle.",2018-01-01
6402,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2013-11-21,325,D,0,1,Y90X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, Medical Nutritional Therapy Assessment review, Medicare Assessment form review, and staff interview, the facility failed to ensure timely intervention to address a significant weight loss for one (1) resident (#82) of a sample of twenty-eight (28) residents. Findings include: Medical record review for Resident #82 revealed an Admission Minimum Data Set (MDS) Assessment having an Assessment Reference Date of 06/13/2013 which documented an admission date of [DATE]. This MDS assessment identified in Section I - Active [DIAGNOSES REDACTED]. Section K - Swallowing/Nutritional Status of this MDS documented that the resident had a height of 64 inches, and that the resident had experienced a weight loss of five percent or more in the past month or ten percent or more in the last six months, prior to facility admission. Further record review for Resident #82 revealed a Nurse's Notes entry of 06/06/2013 at 5:00 p.m. which also documented the resident's admission to the facility, and that the resident's admission was following a hospital stay for a [MEDICAL CONDITION] with repair. The admission physician's orders [REDACTED].#82 receive a No Added Salt diet and routine weights. A Medicare Assessment form for Resident #82 documented an admission weight of 123 pounds. The Individual Weight History Log for Resident #82 also documented a 06/06/2013 admission weight of 123 pounds, but then documented a weight of 119 pounds on 06/11/2013 and a weight of 115 pounds on 06/18/2013. This represented a significant weight loss of eight (8) pounds, or 6.5 percent, in the twelve (12) days between Resident #82's 06/06/2013 facility admission and 06/18/2013. However, even though Resident #82 had experienced a significant weight loss of 6.5 percent between the 06/06/2013 admission and 06/18/2013, further record review revealed no evidence to indicate that any interventions were put into place to address this weight loss, or that the physician was notified of the significant weight loss, when it was identified on 06/18/2013. A RD (Registered Dietitian) Progress Notes entry of 06/19/2013 for Resident #82 documented an assessment by the RD on that date. This Progress Notes entry noted that Resident #82 was a new admission and that future weight loss was expected. The RD noted that a house supplement was to be added, if deemed necessary for stable weight, but further noted that there were no dietary concerns at that time. There was no evidence to indicate that the RD noted the significant weight loss of 6.5 percent (as of 06/18/2013) for Resident #82 since admission. Review of Resident #82's Individual Weight History Log referenced above revealed that after the 06/18/2013 weight of 115 pounds, the resident's weight declined further to 112.6 pounds on 06/25/2013. This represented a total weight loss of 10.4 pounds, or 8.5 percent, between Resident #82's 06/06/2013 facility admission and 06/25/2013. A Nurse's Notes summary for June 2013 documented Resident #82's weight loss for that month, and documented that the resident's meal consumption record reflected consumption of fifty (50) percent or less of meals. However, further record review for Resident #82 revealed that, despite the resident's limited meal consumption during June of 2013, significant weight loss of 6.5 percent as of 06/18/2013, and further significant weight loss of 8.5 percent as of 06/25/2013, there was no evidence to indicate that any interventions had been put into place related to this significant weight loss as of 06/25/2013. A subsequent Medical Nutrition Therapy Assessment of 07/10/2013 for Resident #82 indicated that the resident's Ideal Body Weight was 120 pounds. A 06/27/2013 physician's orders [REDACTED].#82 to receive a House Supplement by mouth three times daily. During an interview with Director of Nursing (DON) conducted 11/21/2013 at 1:04 p.m. regarding the facility's policy for nutritional assessment for newly admitted residents, the DON stated that all residents with weight loss were to be reviewed weekly with interventions identified.",2018-01-01
6403,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2013-11-21,361,D,0,1,Y90X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and Registered Dietician interview, the facility failed to ensure that the Registered Dietitian (RD) provided an accurate assessment, related to weight loss, for one (1) resident (#82), who had experienced a significant weight loss at the time of assessment by the RD, from a survey sample of twenty-eight (28) residents. Findings include: Medical record review for Resident #82 revealed an Individual Weight History Log which documented a 06/06/2013 admission weight of 123 pounds, and documented that the resident's weight had declined to 115 pounds as of 06/18/2013. However, even though Resident #82 had experienced a significant weight loss of eight (8) pounds, or 6.5 percent, during the twelve (12) days between admission on 06/06/2013 and 06/18/2013, an RD (Registered Dietitian) Progress Notes entry of 06/19/2013 documented the resident's admission weight of 123 pounds (rather than the 06/18/2013 weight of 115 pounds, which reflecting a weight loss of 6.5 percent). This 06/19/2013 RD (Registered Dietician) Progress Notes assessment failed to document the resident's significant weight loss, but rather documented that there were no dietary concerns for this resident at that time. During an interview with Director of Nursing (DON) conducted 11/21/2013 at 1:04 p.m. regarding the facility's policy for nutritional assessment for all newly admitted residents, the DON stated that a communication notification was to be placed in the RD's box to be reviewed every Wednesday during the RD's visit. The DON further stated that all residents with weight loss were to be reviewed weekly by the RD, with recommendations to be made to the physician. During an interview with RD conducted on 11/20/2013 at 11:00 a.m., the RD acknowledged having assessed Resident #82 on 06/19/2013. She further revealed that she noted the weight loss and believed that the weight loss was due to the resident's poor appetite and [DIAGNOSES REDACTED]. She acknowledged that she did not recommend any laboratory tests. Cross refer to F325 for more information regarding Resident #82.",2018-01-01
7419,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2014-04-23,201,D,1,0,U2LV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint allegation, record review and staff interview the facility failed to allow the resident to remain in the facility. Problems were found on one (1) resident from a sample of four (4) residents. Findings include: Resident # 1 was admitted to the facility after being hospitalized for [REDACTED]. A daily skilled nursing note dated 3/22/2014 revealed that the resident was transferred to the hospital at the request of the family member. PAR (Patients At Risk) notes dated 3/25/2014 revealed that the resident was transferred back to the facility 3/24/2014. Social Service Progress notes dated 3/24/2014 indicated that the resident had been discharged for m the facility 3/22/2014 when he was admitted to the hospital. Social Service Progress notes notes dated 3/12/2014 indicated that the resident was participating in therapy and the intention was to return to the assisted living facility where he previously resided. Social Service Progress notes dated 3/24/2014 indicated that the resident had been discharged for m the facility 3/22/2014 when he was admitted to the hospital. The note further indicated that upon return the family member inquired about long term admission and was reminded that the resident's admission was for short term rehabilitation. A Social Services Progress note dated 3/28/2014 indicated that a meeting was held with the resident's family and at that time the family inquired about long term admission. The note further indicated that the resident's admission was for short term therapy only and the family was reminded again. A Discharge Planning Note dated 4/8/2014 indicated that the family came by to discuss discharge issues. The family member had been to the assisted living facility and the spoken with the person there about the resident's mobility issues. Social Services and therapy discussed the resident's progress. The note further indicated that the family member was reminded that the admission was for a short term therapy stay only. physician's orders [REDACTED]. Review of the facility Admit/discharge to/from Report revealed that the resident discharged for m the facility 4/22/2014. Interview with the Social Services Person on 4/23/2014 at 12:00 p.m. revealed that the resident was never offered a bed to stay long term. On admission the family was told he was here for short term therapy and the family signed an agreement that he was short term stay. This social worker statedshe was not part of the admission process. Interview with the administrator at 2:00 p.m. on 4/23/2014 indicated that the family had signed the short term agreement and were made aware that he was short term stay.",2017-04-01
7750,"BRIGHTMOOR HEALTH CARE, INC",115556,3235 NEWMAN ROAD,GRIFFIN,GA,30224,2012-03-22,309,D,0,1,UYIE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility policy review and staff interview, the facility failed to follow physician orders related to administering sliding scale insulin for three (3) residents (#64, #84 and #137) out of twenty-nine (29) sampled residents. Findings include: 1. Record review for #64 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Orders for January, 2012 revealed orders for accuchecks three (3) times a day at 6:00 a.m., 4:00 p.m., and 8:00 p.m., [MEDICATION NAME] thirty-six (36) units at bedtime, [MEDICATION NAME] 70/30 Insulin forty (40) units at 6:00 a.m., and [MEDICATION NAME] Regular Insulin per sliding scale for blood sugar over 250 using the formula, Blood Sugar minus 100 divided by 40. Review of the Medication Administration Record [REDACTED]. Review of the Physician Orders for February, 2012 revealed orders for accuchecks three (3) times a day at 6:00 a.m., 4:00 p.m., and 8:00 p.m., [MEDICATION NAME] thirty-six (36) units at bedtime, [MEDICATION NAME] 70/30 Insulin forty-two (42) units at 6:00 a.m., and [MEDICATION NAME] Regular Insulin per sliding scale for blood sugar over 250 using the formula, Blood Sugar minus 100 divided by 40. Review of the MAR for February, 2012 revealed the following: on 2/2/12: The BS at 4:00 p.m. was two hundred eighty (280) with no evidence that sliding scale Insulin had been given; on 2/6/12 the blood sugar at 4:00 p.m. was two hundred eighty-six (286) with no evidence that sliding scale Insulin had been given; on 2/8/12 the blood sugar at 4:00 p.m. was three hundred and five (305) with no evidence that sliding scale Insulin had been given; on 2/11/12 the blood sugar at 4:00 p.m. was three hundred thirty-eight (338) with no evidence that sliding scale Insulin had been given; on 2/13/12 the blood sugar at 4:00 p.m. was three hundred eleven (311) with no evidence that sliding scale Insulin had been given; on 2/14/12 the blood sugar at 4:00 p.m. was three hundred fifty-four (354)with no evidence that sliding scale Insulin had been given; on 2/20/12 the blood sugar at 4:00 p.m. was three hundred thirty-four (334) with no evidence that sliding scale Insulin had been given. Review of the Physician Orders for March 01-17, 2012 revealed orders for accuchecks three (3) times a day at 6:00 a.m., 4:00 p.m., and 8:00 p.m., [MEDICATION NAME] thirty-six (36) units at bedtime, [MEDICATION NAME] 70/30 Insulin forty-two (42) units at 6:00 a.m., and [MEDICATION NAME] Regular Insulin per sliding scale for blood sugar over 250 using the formula, Blood Sugar minus 100 divided by 40. Review of the MAR for March 01-17, 2012 revealed the following: on 3/1/12 the blood sugar at 4:00 p.m. was two hundred fifty-five (255) with no evidence that sliding scale Insulin had been given and on 3/5/12 the blood sugar at 4:00 p.m. was two hundred fifty-four (254) with no evidence that sliding scale Insulin had been given. Interview with the Director of Nursing (DON) on 3/21/12 at 2:10 p.m. revealed that the resident should have received coverage at these four (4) o'clock blood sugar's because the resident did not have anything routinely ordered at this time. Review of Policy and Procedures for Blood Sugar Testing dated 8/1/11 revealed that if a resident has a high blood sugar reading follow the resident's sliding scale protocol for coverage. If they do not have an individual sliding scale order, then use the facilities sliding scale. If a resident that receives a scheduled Insulin has a high blood sugar, do not administer sliding scale coverage in addition to the scheduled Insulin. 2. Record review for resident #137 revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Physician's orders for January, February, and March, 2012 revealed orders for accuchecks three (3) times a day at 6:30 a.m., 11:30 a.m. and 4:30 p.m., [MEDICATION NAME] 24 units daily at 4:00 p.m. and [MEDICATION NAME] Regular Insulin per sliding scale for blood sugar greater than 250 as needed per facility protocol. Review of the facility policy for Medication Administration Use of Regular Insulin Sliding Scale Protocol revealed that if a resident has a blood sugar greater than two hundred fifty (250) via finger stick then the administration of Regular Insulin for sliding scale would be as follows unless otherwise specified by physician order: 251-300 give 6 units of Regular Insulin, 301-350 give 7 units of Regular Insulin, 351-400 give 9 units of Regular Insulin, 401-450 give 11 units of Regular Insulin, 451-500 give 12 units of Regular Insulin, and 501-550 give 15 units of Regular Insulin. Anything greater than 550 notify the physician unless there is a specific order on the chart for the resident Review of January 2012 MAR indicated [REDACTED].There was no evidence that sliding scale Insulin had been given. Review of February 2012 MAR indicated [REDACTED]. There was no evidence that sliding scale Insulin had been given; on 2/19/12 the blood sugar at 11:00 a.m., was two hundred fifty-nine (259). There was no evidence that sliding scale Insulin had been given; on 2/27/12 the blood sugar at 11:00 a.m., was two hundred seventy-seven (277). There was no evidence that sliding scale insulin had been given. Review of the March 2012 MAR indicated [REDACTED]. Interview with the Director of Nursing (DON) on 3/21/12 at 1:40 p.m. revealed that the an inservice was held in November, 2011 to clarify the facility policy on sliding scale Insulin administration. 2. Record review for resident # 84 revealed the resident was admitted [DATE] with [DIAGNOSES REDACTED]. Review of the Physician Orders for January, 2012 revealed orders for accuchecks three (3) times a day at 6:30 a.m., 4:30 p.m., and 8:00 p.m., [MEDICATION NAME] 7.5 units at 8:00 a.m. and 8:00 p.m., [MEDICATION NAME] 70/30 Insulin twenty-six (26) units at 6:00 a.m., and [MEDICATION NAME] Regular Insulin per sliding scale for blood sugar over 250 using the formula, Blood Sugar minus 100 divided by 30. Review of the MAR for January, 2012 revealed the following: on 01/20/12 the 8:00 p.m. blood sugar was four hundred and eight five (485) there was no evidence that the sliding scale [MEDICATION NAME] R insulin was given or the scheduled [MEDICATION NAME] was given as prescribed. Interview with Registered Nurse (RN) Supervisor CC on 03/21/12 at 10:30 a.m. confirmed that the nurse did not follow the physician's order.",2016-12-01
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
4058,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2017-04-25,328,D,1,0,0HOE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interviews, the facility failed to maintain the proper positive airway pressure mode and settings as prescribed by the physician for one of two residents (R) that required a [MEDICAL CONDITION] (Continuous Positive Airway Pressure) device while lying in bed and/or sleeping (R#1). The sample was 11 residents that required respiratory treatment. Findings include: Interview on 4/24/17 at 11:42 a.m. with R#1 revealed that a Certified Nursing Assistant (CNA) accidentally knocked his [MEDICAL CONDITION] machine to the floor and it broke. R#1 stated that the facility got him another machine but he could tell that the pressure was too low and he didn't feel he was getting enough air. Additionally, R#1 stated he knew the pressure was not enough because after using the machine for a few days, he started getting headaches and was not getting a good night's rest. R#1 stated that he had made an appointment with his pulmonologist and when he took his machine in, they told him it was not on the right settings and the air pressure was too low. The pulmonologist told the resident that the device was set on [MEDICAL CONDITION] (a biphasic device which delivers individually set positive airway pressure on inhalation and exhalation) and not [MEDICAL CONDITION]. R#1 stated that they set his machine on the right settings and now everything is ok. Interview with the Administrator on 4/24/17 at 12:19 p.m. revealed the facility borrowed a [MEDICAL CONDITION] from a Respiratory DME (Durable Medical Equipment) company the day the [MEDICAL CONDITION] of R#1 was broken. They were not sure of the settings but they were able to provide the Respiratory DME company was able to retrieve the [MEDICAL CONDITION] settings from the computer chip in the machine. The facility borrowed the [MEDICAL CONDITION] device over the weekend until their own supplier could ship a [MEDICAL CONDITION] to them. Record review for R#1 revealed [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview for Mental Status (BIMS) summary score of 15, indicating the resident has no cognitive impairment. Section O- Special Treatment and Programs did not indicate the use of a [MEDICAL CONDITION] or [MEDICAL CONDITION] device. A care plan identifying R#1 uses a [MEDICAL CONDITION] machine related to Obstructive Sleep Apnea (OSA) and [MEDICAL CONDITION] was not developed until 4/24/17. The Problem/Strength area documents the resident has a history of manipulative type behaviors with [MEDICAL CONDITION] such as: telling pulmonologist that we gave him the wrong machine, we changed the settings on his machine, stating his mask does not fit properly, etc. Resident has been observed manipulating his machine and face masks. Review of the physician's orders [REDACTED]. On 3/23/17 a clarification order from the pulmonologist read: Use [MEDICAL CONDITION] machine while lying in bed with setting of 20/16 cmH20 due to [MEDICAL CONDITION]. Review of the Physician's Progress Notes dated 3/23/17 written by the Physician's Assistant (PA) EE, of the pulmonology group that treats R#1's respiratory conditions documented that R#1 has profoundly severe OS[NAME] He needs [MEDICAL CONDITION] but the current machine is not set properly at IPAP (inspiratory) of 19 cm and EPAP (expiratory) of 8 cm (19/8). If [MEDICAL CONDITION] to equal [MEDICAL CONDITION] this has to be IPAP at 19 cm and EPAP at 19 cm. We have set his machine to 20/16 which were his pressure requirements in the (YEAR) trial of home [MEDICAL CONDITION]. Do not make changes in his settings unless there is a qualified Respiratory Therapist available please. Follow up in six weeks. An interview on 4/24/17 at 1:47 p.m. with the Respiratory Therapist (RT) DD, of the Respiratory DME company in Lavonia, Georgia revealed that they had provided a loaner [MEDICAL CONDITION] to the facility and they did not a physician order [REDACTED]. Interview conducted on 4/24/17 at 1:59 p.m. with the Central Supply (CS) staff AA revealed she had taken the computer chip from R#1's [MEDICAL CONDITION] device to a Respiratory DME company in Lavonia, Georgia so that they could determine the prescribed pressure for a loaner [MEDICAL CONDITION]. The pressure setting on the loaner [MEDICAL CONDITION] was set to 19 by the DME company in Lavonia. They needed to borrow the device for the weekend until they received a [MEDICAL CONDITION] from their own supplier. CS AA provided a copy of the email that she sent to the facility's supplier which was reviewed at 2:05 p.m. The email confirmed a request to send a [MEDICAL CONDITION] rental for R#1 as soon as one could be sent. There was no mention of a prescribed pressure setting for the [MEDICAL CONDITION] device in the email. The email was dated 3/10/17. CS AA stated that they had received the [MEDICAL CONDITION] device from their supplier on 3/13/17 and when she turned it on, she noticed it was set at 16 and she knew it should be on 19 based on the chip from his previous [MEDICAL CONDITION] device. CS AA stated she took the device to unit manager (Licensed Practical Nurse CC) and told her the [MEDICAL CONDITION] setting should be set at 19. Interview on 4/24/17 at 2:18 p.m. with a Customer Service Representative (CSR) from the facility's supplier revealed their company supplies medical equipment to nursing homes. The CSR stated they only supply the equipment they do not set it up. They sent the instructions (manual) with the [MEDICAL CONDITION]/[MEDICAL CONDITION] device and the facility is responsible for setting the machine. Further, the CSR stated that a phone number for a Respiratory Therapist is provided as well. In an interview on 4/24/17 at 2:29 p.m. with the Unit Manager/LPN CC, she stated that she called the supplier and they told her the [MEDICAL CONDITION] could be used as a [MEDICAL CONDITION]. They did not give her instructions on how to use the machine as a [MEDICAL CONDITION] and told her to follow the instructions. LPN BB stated she had never set up a [MEDICAL CONDITION] machine before, therefore, she and CS AA read the instructions together and is confident that they followed the device manual for [MEDICAL CONDITION]. She stated she set it to 19 and does not remember setting a second setting at an eight. She remembered she had to hit the confirm button. Interview on 4/25/17 at 11:59 a.m. with the facility's regional Respiratory Therapist (RT) FF revealed she is one of four therapist and covers 17 facilities in her region and she visits quarterly to check all respiratory equipment and check all physician orders [REDACTED]. RT FF stated that anytime someone is uncomfortable with any respiratory equipment or a concern with a resident's respiratory status, they can call her. The facility has her phone number but she is not sure how the facility has made it available to the staff. They could get the number form the Director of Nursing (DON) if unable to locate or after hours. RT FF stated that the facility does not have a policy related to setting up [MEDICAL CONDITION] or [MEDICAL CONDITION] or who is qualified to do so but that policies and procedures are currently being developed. RT FF stated that if a staff member had never set up a [MEDICAL CONDITION] or [MEDICAL CONDITION] machine, she would not consider them qualified and they should have called for assistance. Interview on 4/25/17 at 1:00 p.m. with the Physician Assistant (PA) EE, of the pulmonology group that treats R#1's respiratory conditions revealed that not only is she a PA, but she is also a Respiratory Therapist and that the pulmonology group specializes in sleep medicine. PA EE stated that when R#1 came to the office with his PAP (positive airway pressure) device to be checked, he told her that he felt like he was smothering under the mask and that he been reporting this to the facility and they were not doing anything about it. The PA EE stated that when she turned on the device, it was set in the [MEDICAL CONDITION] mode with an IPAP (inspiratory) setting of 19 cmH20 and an EPAP (expiratory) setting of 8 cmH20 (19/8) which is set much too low for R#1. The PA EE also stated that they had trialed an Auto Adjust [MEDICAL CONDITION] in (YEAR) to obtain optimal treatment but his insurance would not cover a [MEDICAL CONDITION] titration study, therefore, [MEDICAL CONDITION] was continued at 19 cmH20. She stated that R#1 tolerated the [MEDICAL CONDITION] at 19 cmH20 well and his last download in (YEAR) on this setting revealed an AHI (Apnea Hyponea Index- an index used to indicate the severity of sleep apnea) of 2.1 (AHI 30, severe), indicating that he did not tolerate this setting and his apnea was severe. The PA EE stated she would email the device down load for review. After this visit, the resident is now prescribed [MEDICAL CONDITION] at 20/16 with a follow up appointment in six weeks. In a subsequent interview with RT FF on 4/25/17 at 1:08 p.m., she stated that she did not receive a call from the facility on 3/10/17 when R#1's [MEDICAL CONDITION] was broken by a staff member. She did not receive a call from the facility when LPN CC received a [MEDICAL CONDITION]/[MEDICAL CONDITION] machine on 3/13/17 from the facility supplier, for assistance with the set up or to request that the device be checked to ensure that she had set the device on the proper settings. She did not receive a call when R#1 complained of his pressure settings on 3/20/17. RT FF stated that it was her professional opinion that a nurse who has never seen and not familiar with the equipment, should have called her. She would have either personally come to the facility or if she could not get to the facility right then, she would walk them through it over the phone and then follow up within a few days to check the machine. Review of the Interdisciplinary Progress Notes dated 3/20/17 and written by LPN CC documented Resident appeared nurses' station with an appointment date and time to go to pulmonologist. Appointment set up for 3/23/17 at 9:00 a.m., transportation set up. An observation of the PAP device for R#1, with RT FF on 4/25/17 at 1:25 p.m. revealed the PAP device had the capability of being used in a [MEDICAL CONDITION] mode and a [MEDICAL CONDITION] mode. When the power button was pushed by RT FF, the machine turns on to the preset settings. The device required a secret method of pushing a combination of buttons to enter the provider mode in which the settings could be adjusted. The device was in [MEDICAL CONDITION] mode on 20/16 as prescribed. Interview on 4/25/17 at 2:20 p.m. with the Unit Manager/LPN CC revealed she had not heard R#1 complain about his [MEDICAL CONDITION] until 3/20/17. She stated that he stopped her in the hallway and told her he needed the pressure on his machine turned up. LPN CC stated that she told R#1 that she could not do that without an order and she would need to make an appointment with his pulmonologist for that. LPN CC stated that R#1 had already called the pulmonologist made the appointment before she had a chance to, and she had to reschedule it for three days later due to Medicaid requiring a three day notice for transportation. LPN CC further stated she had never set up a [MEDICAL CONDITION] device before and had only met the regional Respiratory Therapist once before. LPN CC stated that she did not call the Respiratory Therapist to assist her with the set up or to let her know that she had set up the [MEDICAL CONDITION] device for R#1 on 3/13/17. She did not call the Respiratory Therapist on 3/20/17 to check the [MEDICAL CONDITION] device when R#1 complained about his pressure being too low and had to wait three days before seeing the pulmonologist. LPN CC stated that the [MEDICAL CONDITION] machines usually come with a resident already set and she has never worked in a facility with a Respiratory Therapist. She is not in the habit of calling one. She stated she had met the Respiratory Therapist once, did not know how to reach her or find her phone number and was not sure how often they visit the facility. She thought that she had followed the correct manual for [MEDICAL CONDITION] and set the device properly and it would be checked the next time the Respiratory Therapist visited the facility. Review of the computer download, provided by the pulmonology group that treats R#1's respiratory conditions (via email dated 4/25/17 at 2:28 p.m.), indicated a date range of usage for 10 days from 3/13/17 through 3/22/17. The average AHI was 35.9. The device mode was Bi-Level (same meaning as [MEDICAL CONDITION]) set at IPAP- 19 cmH20 and EPAP at 8 cmH20.",2020-08-01
4168,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2015-10-16,155,D,0,1,JNZX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the clinical record, review of federal regulations, and staff and corporate consultant interview, the facility failed to have a clear record of Do Not Resuscitate (DNR)status for one (1) resident (# 51) from a sample of twenty-eight. The facility failed to maintain a written policy to implement Do Not Resuscitate (DNR) advanced directives. The facility census was one hundred twenty-two (122). Findings include: Review of the clinical record for resident #51 revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Review of the face sheet indicated the age of the resident was eighty-eight. Review of the document entitled Advanced Directive and Other ACP Documents Face Sheet in the front of the chart in a clear plastic sleeve, revealed the line specifying DO NOT RESUSCITATE ORDER was highlighted in yellow and checked. The first line of the document reads as follows: If checked, the following advance directives or DNR orders have been executed and are complete. The form lists residents name, physician and room number. The second document in the sleeve, not visible without removing it, was a document entitled ADVANCED DIRECTIVES CHECKLIST. The resident's personal representative had checked the line indicating an advanced directive had not been executed but would like to obtain additional information. The area indicating information was provided was blank. The document was signed by the personal representative on 11/25/14. Continued review of the clinical record revealed the care plan of resident #51 dated 11/15/14, included Advance Directive- request DNR Status, with an intervention to adhere to no Cardiopulmonary Resuscitation request. Interview conducted on 10/15/15 at 3:37 PM with AA confirmed there was a DNR on the chart and resident #51 was care planned to be a DNR but the DNR document is not clear because there is no signature on the only visible form, but DNR is checked indicating the order is complete. AA revealed the only indicator of DNR status is the ADVANCED DIRECTIVES FACE SHEET, and the wishes of the residents family were not clearly expressed. Interview conducted on 10/15/15 at 4:45 PM with Corporate Consultant revealed the facility had no policy or procedure for a DNR advanced directive. Continued interview revealed the Personal Representative of resident #51 had been contacted and the family had not decided to formulate a DNR advanced directive.",2020-02-01
4169,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2015-10-16,221,D,0,1,JNZX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the clinical record and facility policy, and interview, the facility failed to follow their restraint policy for one (1) resident (#51),from a sample of twenty-eight (28) residents. Findings include: Review of the clinical record for resident #51 revealed [DIAGNOSES REDACTED]. Resident #51 had an unwitnessed fall on 9/29/15 that resulted in no injury. Review of the care plan revealed interventions for falls included a self release velcro seat belt. Review of the facility policy entitled Restraints indicated prior to the use of a restraint a restraint assessment form, consent, and physician order must be completed. Observation of resident #51 on 10/13/15 at 11:00 AM revealed resident was wearing a push button seat belt. When the resident was asked to unfasten it she did not react or make eye contact. Observations 10/14/15 at 12:15 PM included resident #51 wearing the same seat belt and when asked to unfasten, made eye contact and touched the belt but did not touch the indented button to release the belt. Observation 10/15/15 at 3:37 PM revealed resident #51 up in a chair with the same push button closure seat belt and when asked, could not unfasten the belt. Interview 10/13/15 at 11:05 AM with BB revealed the resident was wearing a seat belt to keep her from falling and acknowledged the resident could not unfasten the belt. In an interview conducted on 10/15/2015 at 3:37 PM AAacknowledged the resident was restrained by the seatbelt currently in use because she was unable to unfasten it and there was no order, assessment, consent or care plan for a restraint. Interview conducted on 10/15/15 at 3:41 PM the Director of Nurses (DON) indicated the resident should not have had the seat belt on for the last three days and acknowledged it was restraining her.",2020-02-01
4170,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2015-10-16,371,E,0,1,JNZX11,"Based on observations, review of the Center of Disease Control and Prevention (CDC) guidelines for Environmental Infection Control in Health Care Facilities Ice Machines and Ice, and staff interviews the facility failed to store ice scoops in a sanitary manner on one (1) unit (100) of three (3) units (100, 200, and 300) and in the kitchen. This had the potential to affect one hundred sixteen (116) of one hundred twenty-two (122) residents. Observation conducted during initial tour of the facility on 10/13/15 at 10:35 am revealed an ice chest on 100 hall outside of room 33 unattended with the cover open and the ice scoop in the ice inside the ice chest. Continued observation revealed there were no staff in sight or found in any nearby rooms. Observation conducted on 10/13/15 at 11:15 am during initial tour of the kitchen revealed an ice scoop stored inside the ice machine laying on top of the ice with a few pieces of ice in the scoop. Observation conducted on 10/15/15 at 11:45 am in the kitchen revealed the ice scoop laying face down inside the ice machine on top of the ice. Interview conducted at this time with the Dietary Manager revealed the facility was informed by the health department that this was satisfactory for storage of the ice scoop. Review of the CDC guidelines for Environmental Infection Control in Health Care Facilities Ice Machines and Ice revealed the following guidelines: [NAME] Do not handle ice directly by hand, and wash hands before obtaining ice. B. Use a smooth-surface ice scoop to dispense ice. 1. Keep the ice scoop on a chain short enough that the scoop cannot touch the floor or keep the scoop on a clean, hard surface when not in use. 2. Do not store the ice scoop in the ice bin. E. Limit access to ice-storage chests, and keep container doors closed except when removing ice.",2020-02-01
4171,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2015-10-16,502,D,0,1,JNZX11,**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and staff interview the facility failed to ensure laboratory services were provided in a timely manner for one (1) resident (# 3) from a sample of twenty-five (25) residents. Findings include: Review of the medical record for resident #3 revealed a physician's orders [REDACTED]. Further review revealed no evidence the TSH level had been obtained. Interview conducted on 10/16/15 at 4:30pm with the unit manager of the three hundred (300) unit revealed she could not find any evidence the TSH was drawn and she conceded that it must have been overlooked.,2020-02-01
4299,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-11-07,157,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Medication Discrepancy/Errors Guideline and staff interview, it was determined that the facility failed to notify the physician and responsible party that a Licensed Practical Nurse (LPN) had administered an incorrect dose of [MEDICATION NAME] to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/16, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that the medication error should be reported to the Director of Nursing (DON) or acting supervisor immediately and the physician promptly. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her fasting blood sugar level (FSBS) was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. She was discharged back to the facility on [DATE]. Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, had inaccurately administered 100 units of [MEDICATION NAME] to R10 instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m.and that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 and that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m. There was no indication that the family was notified of the medication error at that time. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/23/16 at 11:20 a.m. with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-11-01
4300,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-11-07,281,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Orientation Policy, review of the facility's Medication Discrepancies/Errors Procedural Guidelines, review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10) and interview, it was determined that the facility failed to ensure that services provided met professional standards. The facility failed to ensure that licensed nursing staff administered Insulin correctly and safely to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Orientation Period policy revealed that the first three (3) calendar months of employment was considered an orientation period for newly hired employees. Continued review revealed that During this time the associate's job performance should be observed by the supervisor. Review of the facility's Medication Discrepancy/Errors Procedural Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the National Council of State Boards of Nursing, Chapter 410-10-.02 Standards of Practice for Licensed Practical Nurses, Authority: O.C.G.[NAME] 43-1-25, 43-26-2, 43-26-3, 43-26-5, 43-26-32, and 43-26-42 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 failed to ensure that a new licensed nurse orientee administered the correct dose of [MEDICATION NAME] to R10 on 8/31/16 at 9:00 p.m. which resulted in the resident's hospitalization for [DIAGNOSES REDACTED] (low blood sugar level) on 9/1/16. (Cross refer to F333) There was no indication that licensed nursing staff identified that the [MEDICATION NAME] was a long-acting Insulin that may have required monitoring of blood sugar levels after 4:00 p.m. and the probable need to hold all subsequent Insulin administration. (Cross refer to F333) Although licensed nursing staff had obtained the resident's blood sugar levels on 8/31/16 at 11:00 p.m. (122) and on 9/1/16 at 1:30 a.m. (217), 2:45 a.m. (277), 11:00 a.m. (49) and 4:00 p.m. (70), there was no indication that staff were monitoring the resident closely for twenty-four (24) hours after the incident per facility policy. (Cross refer to F333) The facility failed to ensure that licensed nursing staff notified the Physician and Director of Nursing (DON) immediately of the significant medication error per facility policy until twenty-four (24) hours later. (Cross refer to F157) There was no indication that staff notified the Physician/NP of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. or the interventions staff implemented to increase the blood sugar level at that time. There was no indication that the family was notified timely of the significant medication error until after the resident was sent to the hospital on [DATE] at 11:00 p.m. (Cross refer to F157) Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. (cross refer to F333) review of the resident's medical record revealed [REDACTED]. (Cross refer to F333) Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-11-01
4301,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-11-07,282,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to follow the care plan to administer insulin as ordered by the physician for one (1) Resident (R) (R10) of six (6) residents reviewed for insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Cross refer to F333) Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that LPN CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician and as care planned on 8/31/16 at 9:00 p.m. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-11-01
4302,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-11-07,333,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to ensure that one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin was free of a significant medication error from a sample of sixteen (16) residents. This failure resulted in harm for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer Insulin as ordered. review of the resident's medical record revealed [REDACTED]. [REDACTED]. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Continued review revealed that the resident received 1/2 amp of [MEDICATION NAME] (D) 50 and that her blood sugar level was currently 208. Further review revealed that her vital signs were stable and she was alert. Review of the hospital physician progress notes [REDACTED]. Continued review revealed that the resident's blood sugar levels stabilized and she was moved to the Medical/Surgical floor by 9/4/16. She was discharged back to the facility on [DATE]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident's caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., twenty-four (24) hours after she had incorrectly administered 100 units of [MEDICATION NAME] to the resident and two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. Further interview revealed that she instructed the Certified Nursing Assistants (CNAs) to transfer the resident to the wheelchair, place her at EE's medication cart so that LPN EE could monitor her closely and LPN EE gave her Med Pass to drink. Continued interview revealed that the resident was alert and without symptoms of [DIAGNOSES REDACTED] when LPN EE left the facility at 11:00 p.m. Continued interview with LPN EE revealed that she notified the on-coming nurse LPN FF who worked 11:00 p.m. to 7:00 a.m. about the incident and instructed LPN FF to continue to monitor the resident. Interview on 9/22/16 at 1:55 p.m. with LPN GG via telephone revealed that she had observed LPN CC draw up the correct amount of [MEDICATION NAME] (12 units) and administer it to R#10 on 9/1/16 at 9:00 p.m. two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 4:00 p.m. with the Consultant Pharmacist via telephone revealed that he was unaware that nursing staff had administered 100 units of [MEDICATION NAME] instead of 12 units as ordered to R#10 on 8/31/16. Continued interview with the Consultant Pharmacist revealed that [MEDICATION NAME] was a long-acting Insulin and that the resident could possibly have abnormally low blood sugar levels up to twenty-six (26) hours after administration of such a high dose, especially if she was not eating well and nursing staff continued to administer Insulin. Further interview revealed that he expected nursing staff to hold the 6 units [MEDICATION NAME] R Insulin at 7:00 a.m. and the 12 units of [MEDICATION NAME] at 9:00 p.m. on 9/1/16. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/22/16 at 5:40 p.m. with the Nurse Practitioner (NP) via telephone revealed that she was in the facility on 9/1/16 but, that she was unaware that the resident had received the incorrect dose of [MEDICATION NAME] the night before on 8/31/16 at 9:00 p.m. until after the resident was hospitalized . Continued interview revealed that she had not been notified by staff of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. Further interview revealed that if nursing staff had notified her of the medication error from the previous night she would have notified the physician. Continued interview revealed that she would expect nursing staff to hold the 6 units of [MEDICATION NAME] R insulin at 7:00 a.m. Further interview revealed that the resident's blood sugar levels fluctuated but, she could not remember if the levels had ever been as low as 27 without reviewing the resident's medical record. Interview with LPN EE on 9/23/16 at 11:20 a.m. revealed that she and LPN CC, the new orientee, were the only nurses working on Unit II on 8/31/16 between 7:00 p.m. and 11:00 p.m. Continued interview revealed that she also needed to administer medications at that time and that CC told her she felt confident that she could administer the insulin. Continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven (7) rooms without problems; however, she did not observe LPN CC administer Insulin to those residents at that time. Further interview with LPN EE revealed that she had never observed LPN CC administer Insulin to any resident. LPN EE stated that LPN CC was a licensed nurse and should have been able to administer Insulin correctly. Continued interview with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Further interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interview on 9/23/16 at 1:23 p.m. with LPN FF, an agency nurse, via phone revealed that she worked 8/31/16 from 11:00 p.m. to 7:00 a.m. and took over the medication cart from LPN EE at 11:00 p.m. Continued interview revealed that she was not notified that LPN CC had administered an incorrect dose of insulin to R#10 at 9:00 p.m. and therefore, did not notify the physician of the error. Further interview revealed that she did not observe LPN CC administer any medications on her shift because she was an agency nurse and did not orient other nurses. Observation of R10 on 9/23/16 at 12:35 p.m. revealed that she was alert with confusion and without symptoms of [DIAGNOSES REDACTED]. She stated at that time that she was happy to be home. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. (100% as of 11/7/16) 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. (100% nurses were inserviced by 11/7/16) 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. (LPN no longer employeed at facility-she resigned) 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-11-01
4303,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-11-07,514,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that the clinical record for one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration was complete and accurately documented from a sample of sixteen (16)residents. The facility failed to ensure that a factual description of the medication error and the on-going monitoring of the condition for 24 to 72 hours was accurately and completely documented in the medical record as per facility policy for R10. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R#10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident ' s caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., two hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked 7:00 p.m. to 11:00 p.m. on 8/31/16 when LPN CC administered 100 units of [MEDICATION NAME] to R10. Continued interview revealed that CC notified her of the medication error and that the resident was placed in a wheelchair by her medication cart, given Med Pass to drink and monitored closely. Further interview revealed that she notified the on-coming nurse FF at 11:00 p.m. to continue monitoring the resident. However, there was no indication that staff on subsequent shifts had been notified about the significant medication error. Interview with LPN EE again on 9/23/16 at 11:20 a.m. revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document any change in a resident's status or condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-11-01
4719,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,157,J,1,0,LC8U12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Medication Discrepancy/Errors Guideline and staff interview, it was determined that the facility failed to notify the physician and responsible party that a Licensed Practical Nurse (LPN) had administered an incorrect dose of [MEDICATION NAME] to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/16, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that the medication error should be reported to the Director of Nursing (DON) or acting supervisor immediately and the physician promptly. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her fasting blood sugar level (FSBS) was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. She was discharged back to the facility on [DATE]. Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, had inaccurately administered 100 units of [MEDICATION NAME] to R10 instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m.and that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 and that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m. There was no indication that the family was notified of the medication error at that time. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/23/16 at 11:20 a.m. with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-07-01
4720,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,226,D,1,0,LC8U11,"> Based on review of facility investigation documentation and their Abuse Prohibition Policy and Procedure, and staff interview, the facility failed to thoroughly investigate an allegation of missing money, and failed to submit the final report of their investigation to the State Complaint and Investigations unit in a timely manner. The current facility census was one hundred twenty nine (129)residents. Findings include: Review of a Facility Incident Report Form dated 07/06/16 revealed that a family member of resident #9 alleged that the resident was missing approximately $28.00 that had been kept in the resident's dresser drawer. Review of a facility fax confirmation revealed that this initial investigation was sent to the State Complaint Coordinator on 07/05/16. Review of a form letter from the State Complaint and Investigations unit dated 07/15/16 revealed that they had never received the facility's five-day follow-up investigation report from this self-reported incident (complaint GA 393). Review of a facility fax confirmation form revealed that the final investigation report dated 07/15/16 was sent to the State Complaint Coordinator on this day. Review of this final investigation report dated 07/15/16 revealed that staff that worked on the unit were interviewed regarding their knowledge of the missing money, but there were no written statements, no list of which staff were interviewed, and no date of the interview. During interview with the Assistant Administrator on 07/18/16 at 4:52 p.m., she stated that she must have put the wrong date on the initial investigation report as 07/06/16, as the incident was faxed to the State complaint agency on 07/05/16. During further interview, she stated she attempted to fax the final investigation to the State agency on 07/08/16, but that the fax never went through, and she did not follow-up and attempt to re-fax it until she got the notification from the State Complaint and Investigations unit on 07/15/16. During further interview, she stated that she interviewed a group of 7:00 a.m. to 3:00 p.m. and 3:00 p.m. to 11:00 p.m. staff who were often assigned to work with resident #9 all together in one group, but that she did not get written statements nor a list of those interviewed. Upon further interview, she stated that she did not interview any of the 11:00 p.m. to 7:00 a.m. staff. During interview with the Administrator at this time, she stated that the staff should not have been interviewed together as a group. During interview with the Administrator on 07/18/16 at 5:55 p.m., she stated that the facility's investigation did not include documentation if the family was asked if they wanted the police to be involved in the investigation. Review of the facility's Abuse Policy and Procedure revealed to contact the local police department if there was a reasonable cause to believe or suspicion of a crime has occurred. A written report of the investigation will be submitted to the Long Term Care Section Complaint Coordinator within five working days of the incident.",2019-07-01
4721,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,246,E,1,0,LC8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation , record review, policy and procedure review and interviews, the facility failed to ensure that daily wound care was provided at the preferred time for one (1) resident (#2) that wanted to be out of bed everyday for lunch and other activities. The sample was seven (7) residents. Refer F353, F490, F520 Findings include: Review of the policy titled Patient's Rights documented: A patient at Brown Health & Rehabilitation has the right to get up and go to bed as desired. Observation and interview on 7/7/16 at 2:00 p.m. revealed Resident #2 in his room in bed. Interview at the time of observation revealed the resident was still in bed because he was waiting for wound care and could not get out of bed until the treatment was done. Resident # 2 stated he required assistance from the staff to get out of bed and likes to be out of bed by lunch. He likes to go to the dining room for lunch, socialize and attend activities but often cannot because he is waiting for wound treatment. Resident #2 further stated that everyone knows that he would like his treatment to be completed no later than 11:00 a.m. so that the Certified Nursing Assistants (CNAs) can get him up for lunch. He said his mother works here and she has made it known to all staff and management that he is to have his treatment around 9:30-10:00 a.m. so he can get up and out of bed however, he still waits in his bed sometimes all day. Record review for Resident #2 revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] documented a Brief Interview of Mental Status (BIMS) summary score of 15 indicating the resident is cognitively intact. An observation on 7/7/16 at 3:30 p.m. revealed Resident #2 remains in his room in bed. An observation on 7/7/16 at 5:05 p.m. revealed Resident #2 in his wheelchair propelling through the hallway. Interview with the resident at this time revealed he had just gotten up out of bed and finally got his wound treatment about an hour earlier. Review of the Resident Council Minutes dated 4/16/16 documented: Resident #2 (resident's name) wants to be up every Monday for Man Cave activity. An interview on 7/8/16 at 10:20 a.m. with CNA EE revealed Resident #2 eats breakfast in his room but likes to be out of bed by 11:00 a pm for bingo and to go to the dining room for lunch. CNA EE confirmed that she has to wait until the resident has received his wound treatment and this often falls behind and she is unable to get the resident up. CNA EE further stated that the resident's mom works here and will often ask if Resident #2 is up out of bed, She gets very upset when the resident is still in bed. The resident's mom tells them that he needs to have his wound treatment around 9:30 a.m. so that he can get up. CNA EE further stated that she has reported to the charge nurse when the resident is upset because he is still in bed and they in turn will call the treatment nurse. An interview on 7/8/16 at 10:50 a.m. with the mother of Resident #2 revealed she works in the facility on dayshift as a Licensed Practical Nurse (LPN) HH. She said that before Resident #2 got sick, he lived at home with her. She said he likes to sleep until about 9:30 -10:00 a.m. then he gets up and cooks, goes outside, watches TV etc. He loves to be up. LPN HH said she has been voicing for a long time that Resident #2 is not getting up or getting his wound care in a timely manner. She said she had been told by the Resident Care Coordinator (RCC) that his treatment would be done in the mornings. LPN HH feels that there is a staffing concern and the staff is not able to accommodate his needs. An interview on 7/8/16 at 11:15 a.m. with the Treatment Nurse FF revealed Resident #2 does not have a scheduled treatment time but his wishes are to have his treatment in the morning so that he can be up by lunch. Most days this does happen but not always. The resident likes to sleep in but be up by lunch. The CNA's are supposed to call her after his bath, however, sometimes they do not inform her that he has had his bed bath or she is in treatment with another resident at that time. Treatment Nurse FF further stated there are a total of thirty one (31) residents receiving some form of wound care treatment and she can not handle this workload by herself. When she knows she cannot get to the Resident #2 for early treatment she will ask the nurse in care of Resident #2 to assist with his dressings but they will not do it. An interview on 7/8/16 at 1:11 a.m. with the Director of Nursing (DON) revealed Resident #2 wants to get up for lunch but that he sometimes refuses if he stayed up late the night before. Typically, he wants to get up everyday by lunch.",2019-07-01
4722,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,280,E,1,0,LC8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy and procedure review and interviews, the facility failed to make revisions to the pressure ulcer care plan to reflect multiple wounds with individualized treatment and interventions for two (2) of three (3) sampled residents out of thirty one (31) residents that received wound care treatment (Resident #1 and 2). Refer F314 Findings include: Review of the policy titled Patient's Plan of Care documented: It is the intent of this center to develop and maintain an individualized plan of care for each. An interdisciplinary team, in co-ordination with other patient care services, develops and maintains a care plan for each resident. The care plan is developed from the patient assessment (MDS) and in coordination with the with the attending physician's regimen of care. The care plan is available for use by all personnel care/services to/for the patient. It includes, but not limited to: incorporate identified problem areas, incorporate risk factor (s) associated with the identified problem (s), reflect treatment goals and objectives in measurable goals. 1. Record Review for Resident #1 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was at risk for pressure ulcers but did not have any pressure ulcers do Stage I or higher at that time. The Care Area Assessment (CAA) triggered Pressure Ulcer with the decision to be care planned. Review of the Significant Change MDS assessment dated [DATE] indicated the resident had one (1) unstageable pressure ulcer. Review of the physician's orders [REDACTED]. On 5/17/16 the order for treatment was changed to daily (QD) and as needed (PRN). On 6/14/16 the physician wrote an order to contact the wound care clinic for consult related to the unstageable pressure ulcer on the left heel. Review of the care plan initiated on 1/23/16 identified that Resident #1 was at risk for additional impaired skin with a goal that the resident will not develop additional pressure ulcers unless medically unavoidable through review period. The care plan had general interventions, however, there was no documented intervention to reflect the physician's regimen of care nor were there any revisions to the care plan to reflect an unstageable pressure ulcer to the left heel that developed on 4/27/16. The care plan was not revised to reflect that resident received treatment at the wound care center. Review of an Acute Care Plan for Resident #1 dated 6/16/16 identified an unstageable pressure ulcer to the left heel, nearly two months after it was identified, with an intervention that included but not limited to; Provide treatment per algorithm as ordered. 2. Record review for Resident #2 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] indicated the resident had two (2) Stage II pressure Ulcers with one (1) on admission and one (1) Stage IV pressure ulcer on admission. The CAA triggered Pressure Ulcers with the decision to be care planned. Review of the Care Plan initiated on 7/16/15 for Resident #2 identified the resident has pressure ulcers and is at risk for additional pressure ulcers. There are two (2) hand written dates below the original date (5/10/16 and 6/2/16) however, there is no documentation that reflects any of the multiple wounds that Resident #2 has or an intervention to reflect the physician's regimen of care. The interventions are generalized and do not reflect an individualized treatment regimen or interventions. The interventions for this Care Plan are as follows: 7/16/15- Turn and reposition routinely 7/16/15- Pressure reduction/redistribution mattress (the resident is currently has a Low Air Loss (LAL) mattress on his bed) 7/16/15- Heel protection 7/16/15- Reposition or lift using turn/lift sheet 7/16/15- Observe for and report signs of pressure ulcer development 7/16/15- Encourage food and fluid intake. The pressure ulcer care plan revealed that it was not individualized to reflect the resident's wounds, use of a LAL mattress, and treatment at the wound care center. Post survey interview on 7/25/16 at 10:46 a.m. with the RAI Director and the DON revealed the two added dates on the care plan reflect the dates of the care plan meetings. An Acute care plan is developed on admission or any time a new concern is identified. The Acute care plan has more specific interventions and is incorporated into the comprehensive care plan when a comprehensive assessment is done. Revisions to the comprehensive care plan should be added to the care plan at the time a concern is identified with goals and interventions. The care plan should reflect the location of the pressure ulcers. The RAI Director stated that she spoke with the Corporate RAI Director and learned that the comprehensive care plan should reflect a goal and intervention directly related to the pressure ulcer and that this was not added to the care plan for Resident #2 until 7/22/16. Additionally, the comprehensive care plan did not make mention of the physician regimen until it was added on 7/22/16. She said she has been going through all the care plans for residents that received wound care treatment and has begun updated and revising the care plans. The DON stated that Resident #2 did have an acute care plan on admission that addressed the pressure ulcers with interventions, however, it had never been updated or revised to the current comprehensive care plan. The DON confirmed that a facility acquired pressure ulcer was never added to the care plan. Review of the Care Plan during the post survey Quality Assurance process, provided by the Administrator revealed on 7/22/16 a goal was added that Resident #1 will be free of signs/symptoms of infection in pressure areas through review period. Two (2) interventions were added that include: Observe and report to nursing signs and symptoms of infection in the pressure areas and pressure ulcer treatment as ordered by the physician. On 7/25/16 the location of the pressure ulcers were added to the Problem/Strengths section of the care plan.",2019-07-01
4723,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,281,J,1,0,LC8U12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of the facility's Orientation Policy, review of the facility's Medication Discrepancies/Errors Procedural Guidelines, review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10) and interview, it was determined that the facility failed to ensure that services provided met professional standards. The facility failed to ensure that licensed nursing staff administered Insulin correctly and safely to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Orientation Period policy revealed that the first three (3) calendar months of employment was considered an orientation period for newly hired employees. Continued review revealed that During this time the associate's job performance should be observed by the supervisor. Review of the facility's Medication Discrepancy/Errors Procedural Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the National Council of State Boards of Nursing, Chapter 410-10-.02 Standards of Practice for Licensed Practical Nurses, Authority: O.C.G.A. 43-1-25, 43-26-2, 43-26-3, 43-26-5, 43-26-32, and 43-26-42 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 failed to ensure that a new licensed nurse orientee administered the correct dose of [MEDICATION NAME] to R10 on 8/31/16 at 9:00 p.m. which resulted in the resident's hospitalization for [DIAGNOSES REDACTED] (low blood sugar level) on 9/1/16. (Cross refer to F333) There was no indication that licensed nursing staff identified that the [MEDICATION NAME] was a long-acting Insulin that may have required monitoring of blood sugar levels after 4:00 p.m. and the probable need to hold all subsequent Insulin administration. (Cross refer to F333) Although licensed nursing staff had obtained the resident's blood sugar levels on 8/31/16 at 11:00 p.m. (122) and on 9/1/16 at 1:30 a.m. (217), 2:45 a.m. (277), 11:00 a.m. (49) and 4:00 p.m. (70), there was no indication that staff were monitoring the resident closely for twenty-four (24) hours after the incident per facility policy. (Cross refer to F333) The facility failed to ensure that licensed nursing staff notified the Physician and Director of Nursing (DON) immediately of the significant medication error per facility policy until twenty-four (24) hours later. (Cross refer to F157) There was no indication that staff notified the Physician/NP of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. or the interventions staff implemented to increase the blood sugar level at that time. There was no indication that the family was notified timely of the significant medication error until after the resident was sent to the hospital on [DATE] at 11:00 p.m. (Cross refer to F157) Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. (cross refer to F333) review of the resident's medical record revealed [REDACTED]. (Cross refer to F333) Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-07-01
4724,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,282,J,1,0,LC8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, policy and procedure review and interviews, the facility failed to follow the care plan interventions related to the physician's regimen of care for three (3) of three (3) sampled residents with pressure ulcers out of thirty one (31) residents that received wound care treatment. (Resident #1, 2 and 3). Refer F314 Findings include: Review of the policy titled Patient's Plan of Care documented: It is the intent of this center to develop and maintain an individualized plan of care for each. An interdisciplinary team, in co-ordination with other patient care services, develops and maintains a care plan for each resident. The care plan is developed from the patient assessment (MDS) and in coordination with the with the attending physician's regimen of care. The care plan is available for use by all personnel care/services to/for the patient. It includes, but not limited to: incorporate identified problem areas, incorporate risk facto (s) associated with the identified problem (s), reflect treatment goals and objectives in measurable goals. 1. Record Review for Resident #1 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was at risk for pressure ulcers but did not have any pressure ulcers of Stage I or higher at that time. The Care Area Assessment (CAA) triggered Pressure Ulcer with the decision to be care planned. Review of the Significant Change MDS assessment dated [DATE] indicated the resident had one (1) unstageable pressure ulcer. Review of an Acute Care Plan for Resident #1 dated 6/16/16 identified an unstageable pressure ulcer to the left heel with an intervention that included but not limited to; Provide treatment per algorithm as ordered. Review of the physician's orders [REDACTED]. On 5/17/16 the order for treatment was changed to daily (QD) and as needed (PRN). Review of the Treatment Administration Record (TAR) From (MONTH) through (MONTH) (YEAR) for Resident #1 revealed no evidence that the wound care treatment was administered to the left heel, as prescribed by the physician, for a total of thirty one (31) times. 2. Record review for Resident #2 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] indicated the resident had two (2) Stage II pressure Ulcers with one (1) on admission and one (1) Stage IV pressure ulcer on admission. The CAA triggered Pressure Ulcers with the decision to be care planned. Review of the Care Plan initiated on 7/16/15 for Resident #2 identified the resident has pressure ulcers and is at risk for additional pressure ulcers. There is no documentation that reflects any of the multiple wounds that Resident #2 has or an intervention to reflect the physician's regimen of care, however, an Acute Care Plan dated 7/7/15 identified a Stage IV pressure ulcer to the sacrum, Stage II to the left buttock and a Stage II to the left lateral foot. The interventions included, but not limited to: Provide treatment per algorithm. Review of the Physician order [REDACTED]. An order dated 12/7/16 for treatment to a Stage II pressure ulcer of the Sacral Coccygeal daily (QD) and PRN. An order dated 1/15/16 for treatment to a wound of the right groin/scrotal area daily (QD) and PRN. An order on 4/23/16 for treatment to a Stage II wound of the right posterior leg (thigh) daily (QD) and PRN. Review of the TAR from (MONTH) through (MONTH) (YEAR) for Resident #2 revealed no evidence that the wound care treatment, as prescribed by the the physician, was administered a total of twenty two (23) times to a wound on the sacral/coccygeal area. A total of twenty five (26) times to a wound of the groin/scrotal area and a total of twenty four (25) times to as wound to the right leg/thigh area. 3. Record review for Resident #3 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] indicated the resident had one (1) Stage III pressure ulcer that was not present on admission to the facility. The CAA triggered pressure ulcers with the decision to be care planned. Revive of the Quarterly MDS assessment dated [DATE] indicated the resident had one (1) unstageable pressure ulcer. Review of the Care Plan initiated on 12/12/14 identified the resident is at risk for developing pressure ulcers and updated on 5/24/16 indicating a Stage II pressure ulcer to the the left medial ankle and on 6/24/16 indicating an unstageable pressure ulcer to the left foot. Review of the Physician order [REDACTED]. An order dated 3/15/16 for treatment to the left foot every Monday, Wednesday and Friday. Review of the TAR revealed no evidence or documentation that the treatment was administered on (MONTH) 9 (W), 11 (W) and 18 (W). An order dated 5/23/16 revealed an order for [REDACTED]. Review of the TAR from (MONTH) through (MONTH) for Resident #3 revealed no evidence that the wound care treatment to the left medial ankle and foot, as prescribed by the physician, was administered for a total nineteen (19) times. Interview on 7/8/16 beginning at 10:40 a.m. with the Treatment Licensed Practical Nurse (LPN) FF revealed that a blank space with no signature on the TAR indicates, as far as she knows, that the treatment was not administered. The dressing changes have not been getting done consistently on the evening shift or weekends. She stated that she cannot handle everyone in the facility that requires wound care treatment and that there are thirty one (31) residents that require some form of wound care treatment. When she is off on the weekends, the nurses in care are responsible for the treatment but when she reviews the TAR on Monday, it has rarely been done. An interview on 7/8/16 at 1:11 p.m. with the DON revealed that she and the Assistant Director of Nursing (ADON) have helped with wound care treatments at times but not consistently. If the Treatment LPN is unable to administer treatment to a resident, it is the responsibility of the direct care nurse to provide the wound care. The DON confirmed that she did have a discussion with the nurses that if the Treatment Nurse could not complete any wound treatment that they are responsible for getting it done.",2019-07-01
4725,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,314,E,1,0,LC8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, policy and procedure review and interviews, the facility failed to consistently provide wound care treatment in accordance to the physician orders [REDACTED].#1, 2 and 3) out of thirty one (31) residents receiving wound care treatment. Findings include: Review of the policy titled treatment of [REDACTED]. condition. Wound Care Strategies: Care of pressure ulcers involve debridement, cleansing and application of dressings and possible adjuvant therapies as appropriate. Interview with the Complainant for Complaint intake # GA 418 conducted on 7/7/16 at 1:41 p.m. revealed that Resident #2 had not consistently been receiving dressing changes for his wounds, in accordance to the physician order, by the staff at the nursing home facility. She said this is evident when the resident comes to the wound clinic and the date on the dressing is over 2 days old. 1. Record Review for Resident #1 revealed admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] indicated the resident was at risk for pressure ulcers but did not have any pressure ulcers of Stage I or higher at that time. The Care Area Assessment (CAA) triggered Pressure Ulcer with the decision to be care planned. Review of the Significant Change MDS assessment dated [DATE] indicated the resident had one (1) unstageable pressure ulcer. Review of the resident's pressure ulcer care plan included an intervention for wound treatments per routine. Review of the Physician order [REDACTED]. An order dated 4/27/16 revealed an order for [REDACTED]. An order dated 5/17/16 revealed an order for [REDACTED]. On (MONTH) 2, 4, 7, 9, 11, 12, 15, 18, 21, 22 and 23. An order dated 6/24/16 revealed an order for [REDACTED]. Review of the TAR revealed no evidence or documentation that the treatment was administered on the dayshift (7a-7p) on (MONTH) 5 and 7 or on the evening shift (7p-7a) on (MONTH) 4, 5 and 7. Review of the Wound Clinic Patient Instructions forms revealed the following instructions: On 7/6/16- Frequency of dressing change is twice daily, Please change dressing twice daily (last date on dressing was 7/4/16). On 6/22/16 - Frequency of dressing is twice daily. Obtain sheep skin heel protectors or equivalent, keep heel elevated as much as possible to reduce pressure. Observation on 7/8/16 at 9:45 a.m. revealed Resident #1 in a geriatric chair with feet elevated at the the nurses station. There is a gauze dressing on his left foot dated 7/8/16. The resident was not wearing any sheep skin heel protectors. Interview on 7/8/16 at 10:40 a.m. with the Treatment Licensed Practical Nurse (LPN) FF revealed Resident #1 goes to the wound care clinic due to her recommendation for treatment of [REDACTED]. The treatment is Dakins wet to dry dressing twice (BID) daily. She performs the a.m. dressing changes and the evening shift nurse is responsible for the second daily dressing change. The dressing changes have not been getting done consistently on the evening shift. The Treatment LPN FF said that a blank space with no signature indicates as far as she knows, that the treatment was not administered. There has been no increase in stage or worsening of the resident's wound as a result of the inconsistent wound dressing changes. During observation of wound care on 07/18/16 at 9:42 a.m., by Registered Nurse Surveyor #2 revealed the pressure ulcer to the left heel for Resident #1 was measured, and the length and width of the wound had decreased slightly and depth increased slightly from the previous measurement on 06/06/16. The wound bed was red with a few areas of what appeared to be greenish slough. The treatment was done as per the physician's orders [REDACTED]. The resident's feet were observed to be floated on a triangular-shaped foam cushion, and heel protectors were on bilaterally prior to the wound care. Review of the wound documentation on the facility's Treatment Administration Record (TAR) revealed that the wound developed on 02/21/16 as an unstageable, suspected deep tissue injury. Review of the TAR dated 07/18/16 revealed that it was still assessed as unstageable. Review of wound clinic notes dated 06/22/16 revealed the left heel wound was classified as a primary etiology of pressure, secondary etiology of diabetes. Review of the resident's pressure ulcer care plan included an intervention for wound treatments per routine. During a telephone interview with the wound center Registered Nurse Case Manager on 07/19/16 at 1:00 p.m., she stated that the resident's heel wound was initially assessed as a Stage III, and was still a Stage III at the last clinic visit. 2. Record review for Resident #2 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] indicated the resident had two (2) Stage II pressure Ulcers with one (1) on admission and one (1) Stage IV pressure ulcer on admission. The CAA triggered Pressure Ulcers with the decision to be care planned. Review of the Care Plan for Resident #2 initiated on 7/16/15 and last updated on 6/2/16 identified the resident has pressure ulcers and is at high risk for additional pressure ulcers. Review of the Physician order [REDACTED]. An order dated 12/7/16 for treatment to a Stage II pressure ulcer of the Sacral Coccygeal daily (QD) and PRN. Review of the TAR revealed no evidence or documentation that the treatment was administered on (MONTH) 2, 3, 6, 7, 8, 11, 12, 13, 16, 18, 22, 24, 25, 26 and 27. On (MONTH) 2, 5, 7, 9, 20, 21 and 23. An order dated 1/15/16 for treatment to a wound of the right groin/scrotal area daily (QD) and PRN. Review of the TAR revealed no evidence or documentation that the treatment was administered on (MONTH) 2, 3, 6, 7, 8, 11, 12, 13, 16, 18, 21, 22, 24, 26, 27, 28, 29 and 31. On (MONTH) 2, 5, 7, 9, 20, 21, 23 and (MONTH) 5. An order on 4/23/16 for treatment to a Stage II wound of the right posterior leg (thigh) daily (QD) and PRN. Review of the TAR revealed no evidence or documentation that the treatment was administered on (MONTH) 2, 3, 6, 7, 8, 11, 12, 13, 18, 21, 22, 24, 26, 27, 28, 29 and 31. On (MONTH) 2, 5, 7, 9, 20, 21 and 23. Review of the Wound Care Clinic Nursing Wound/Ulcer Assessment form dated 6/21/16 indicated that Resident #2 continued to receive treatment for [REDACTED]. The progress notes section documented the same wounds/some better. Interview on 7/8/16 at 11:18 a.m. with the Treatment LPN FF revealed Resident #2 was admitted to the facility with multiple wounds and goes to the wound care clinic for treatment. He has a Stage II wound to the coccyx area that has not increased in stage with pink granulated tissue. The Stage II wound to the right thigh is getting smaller with pink granulated tissue. Initially the order was for Chlorapactin but the facility is not able to obtain Chlorapactin. The orders were changed to Dakins daily. There are times when she is unable to get to Resident #2 for his wound care due to her workload and the resident likes to sleep until 9:30 - 10:00 a.m. If she is working with another resident and cannot get to Resident #2 by the time he is ready to get up, she will ask the nurse to administer the treatment but they will not do it. When she is off on the weekends, the nurses in care are responsible for the treatment but when she reviews the TAR on Monday, it has rarely been done. During observation of wound care on 07/18/16 beginning at 10:23 a.m., wounds were noted to the posterior right thigh, medial buttocks, and left lower buttocks. Continued observation revealed the wounds on the buttocks were very irregular in shape making measurements difficult. Further observation revealed that the treatments were done as ordered, with no infection control concerns. Observation of the resident's bed at this time revealed that he was on a low air loss (LAL) mattress. During an interview with a family member of resident #2 on 07/18/16 at 10:47 a.m., they stated that at one time they had a concern of the resident having to wait sometimes until 5:00 p.m. to have his wound care done, and that the resident liked to get out of bed around lunch time. During further interview, the family member stated that they knew of five or six times in the past two months where the resident did not receive his dressing changes. The family member further stated that the resident's wounds had gotten smaller. During an interview with the wound clinic Registered Nurse Case Manager on 07/19/16 at 1:00 p.m., she stated that resident #2 had been coming to the wound clinic for years, and that the staging of the wounds had remained the same with some improvement. 3. Record review for Resident #3 revealed an admission to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual MDS assessment dated [DATE] indicated the resident had one (1) Stage III pressure ulcer that was not present on admission to the facility. The CAA triggered pressure ulcers with the decision to be care planned. Revive of the Quarterly MDS assessment dated [DATE] indicated the resident had one (1) unstageable pressure ulcer. Review of the Care Plan initiated on 12/12/14 identified the resident is at risk for developing pressure ulcers and updated on 5/24/16 indicating a Stage II pressure ulcer to the the left medial ankle and on 6/24/16 indicating an unstageable pressure ulcer to the left foot. Review of the Physician order [REDACTED]. An order dated 3/15/16 for treatment to the left foot every Monday, Wednesday and Friday. Review of the TAR revealed no evidence or documentation that the treatment was administered on (MONTH) 9 (W), 11 (W) and 18 (W). An order dated 5/23/16 revealed an order for [REDACTED]. On (MONTH) 2, 7, 11, 12, 18, 21 and 23. An order dated 6/24/16 revealed a change in the treatment regimen to the left foot daily (QD) and PRN. Review of the TAR revealed no evidence or documentation that the treatment was administered on (MONTH) 25 and 29. There were no concerns in the month of July. Review of the PAR Review form dated 4/28/16 documented that Resident #3 had an unstageable pressure ulcer to the left medial ankle and foot. A PAR Review form dated 5/24/16 indicated the resident had a Stage II pressure ulcer to the left medial ankle. Interview on 7/8/16 at 11:32 a.m. the Treatment LPN FF revealed Resident #3 had a partial amputation of the left foot and she has [MEDICAL CONDITION]. The resident's shoe rubbed the left side of the remaining left foot that caused an unstageable pressure ulcer. The Treatment LPN FF further stated that if she cannot get to wound care, she flags the TAR so that it sticks out and reports to the evening nurse that she was unable to do wound care. When she comes back the next day, the treatment still has not been done. An interview on 7/8/16 at 1:11 p.m. with the Administrator and the Director of Nursing (DON) revealed that she and the Assistant Director of Nursing (ADON) have helped with wound care treatments at times but not consistently. If the Treatment LPN is unable to administer treatment to a resident, it is the responsibility of the direct care nurse to provide the wound care. The Administrator stated the charge nurses are supposed to be administering wound care treatment on the evening shift and weekends. During observation by RN Surveyor #2 of wound care on 07/18/16 at 9:09 a.m., the pressure ulcer to the left medial foot was measured as 1.7 centimeters (cm) by 1.8 cm by 0.1 cm. The wound bed appeared tannish in color. The dressing change was done as ordered without infection control concerns. The resident's feet were observed to be floated off the mattress after the treatment was completed. Review of an SBAR (Situation-Background-Assessment-Recommendation) dated 01/07/16 for resident #3 revealed that a pressure ulcer to her inner left foot was identified on that date measuring 3.0 cm by 3.0 cm by 0.1 cm, and was classified as an unstageable wound. Review of (MONTH) physician's orders [REDACTED]. Continued review of the (MONTH) physician's orders [REDACTED]. Review of the Treatment Administration Record (TAR) revealed that there was no documentation of the appearance and measurements of this wound after the initial identification on the SBAR, until the wound healed on 01/29/16. This was verified during interview with the Assistant Director of Nursing (ADON), who stated that any wound should be measured weekly. Review of resident #3's pressure ulcer care plan revealed that it was updated on 06/24/16 to reflect an unstageable pressure ulcer to the left foot, and interventions included to do wound care as indicated.",2019-07-01
4726,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,333,J,1,0,LC8U12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review and interview, it was determined that the facility failed to ensure that one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin was free of a significant medication error from a sample of sixteen (16) residents. This failure resulted in harm for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer Insulin as ordered. review of the resident's medical record revealed [REDACTED]. [REDACTED]. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Continued review revealed that the resident received 1/2 amp of [MEDICATION NAME] (D) 50 and that her blood sugar level was currently 208. Further review revealed that her vital signs were stable and she was alert. Review of the hospital physician progress notes [REDACTED]. Continued review revealed that the resident's blood sugar levels stabilized and she was moved to the Medical/Surgical floor by 9/4/16. She was discharged back to the facility on [DATE]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident's caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., twenty-four (24) hours after she had incorrectly administered 100 units of [MEDICATION NAME] to the resident and two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. Further interview revealed that she instructed the Certified Nursing Assistants (CNAs) to transfer the resident to the wheelchair, place her at EE's medication cart so that LPN EE could monitor her closely and LPN EE gave her Med Pass to drink. Continued interview revealed that the resident was alert and without symptoms of [DIAGNOSES REDACTED] when LPN EE left the facility at 11:00 p.m. Continued interview with LPN EE revealed that she notified the on-coming nurse LPN FF who worked 11:00 p.m. to 7:00 a.m. about the incident and instructed LPN FF to continue to monitor the resident. Interview on 9/22/16 at 1:55 p.m. with LPN GG via telephone revealed that she had observed LPN CC draw up the correct amount of [MEDICATION NAME] (12 units) and administer it to R#10 on 9/1/16 at 9:00 p.m. two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 4:00 p.m. with the Consultant Pharmacist via telephone revealed that he was unaware that nursing staff had administered 100 units of [MEDICATION NAME] instead of 12 units as ordered to R#10 on 8/31/16. Continued interview with the Consultant Pharmacist revealed that [MEDICATION NAME] was a long-acting Insulin and that the resident could possibly have abnormally low blood sugar levels up to twenty-six (26) hours after administration of such a high dose, especially if she was not eating well and nursing staff continued to administer Insulin. Further interview revealed that he expected nursing staff to hold the 6 units [MEDICATION NAME] R Insulin at 7:00 a.m. and the 12 units of [MEDICATION NAME] at 9:00 p.m. on 9/1/16. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/22/16 at 5:40 p.m. with the Nurse Practitioner (NP) via telephone revealed that she was in the facility on 9/1/16 but, that she was unaware that the resident had received the incorrect dose of [MEDICATION NAME] the night before on 8/31/16 at 9:00 p.m. until after the resident was hospitalized . Continued interview revealed that she had not been notified by staff of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. Further interview revealed that if nursing staff had notified her of the medication error from the previous night she would have notified the physician. Continued interview revealed that she would expect nursing staff to hold the 6 units of [MEDICATION NAME] R insulin at 7:00 a.m. Further interview revealed that the resident's blood sugar levels fluctuated but, she could not remember if the levels had ever been as low as 27 without reviewing the resident's medical record. Interview with LPN EE on 9/23/16 at 11:20 a.m. revealed that she and LPN CC, the new orientee, were the only nurses working on Unit II on 8/31/16 between 7:00 p.m. and 11:00 p.m. Continued interview revealed that she also needed to administer medications at that time and that CC told her she felt confident that she could administer the insulin. Continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven (7) rooms without problems; however, she did not observe LPN CC administer Insulin to those residents at that time. Further interview with LPN EE revealed that she had never observed LPN CC administer Insulin to any resident. LPN EE stated that LPN CC was a licensed nurse and should have been able to administer Insulin correctly. Continued interview with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Further interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interview on 9/23/16 at 1:23 p.m. with LPN FF, an agency nurse, via phone revealed that she worked 8/31/16 from 11:00 p.m. to 7:00 a.m. and took over the medication cart from LPN EE at 11:00 p.m. Continued interview revealed that she was not notified that LPN CC had administered an incorrect dose of insulin to R#10 at 9:00 p.m. and therefore, did not notify the physician of the error. Further interview revealed that she did not observe LPN CC administer any medications on her shift because she was an agency nurse and did not orient other nurses. Observation of R10 on 9/23/16 at 12:35 p.m. revealed that she was alert with confusion and without symptoms of [DIAGNOSES REDACTED]. She stated at that time that she was happy to be home. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. (100% as of 11/7/16) 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. (100% nurses were inserviced by 11/7/16) 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. (LPN no longer employeed at facility-she resigned) 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-07-01
4727,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,353,E,1,0,LC8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, resident, family and staff interviews, the facility failed to ensure that there was sufficient staff to provide consistent wound care treatment in accordance with the Physician order [REDACTED].#1, 2 and 3) from thirty one (31) residents receiving wound care treatment. Refer F246, F315, F490, F520 Findings include: Review of complaint intakes GA 458 documented concerns related to being short staffed. Complaint intake GA 418 documented concerns related to wound care treatments not being administered in accordance to Physician Orders. Review of the policy titled Administration documented: It is the intent of this center to provide nursing care twenty four (24) hours a day, seven (7) days a week. The nursing department of this center is budgeted, organized and staffed to meet the nursing needs of all our patients, Requirements of staffing rest with the Director of Nursing (DON). The DON should evaluate and review the staffing patterns to match the nursing needs of patients as needed. Licensed Practical Nurse/Registered Nurse (LPN/RN) around the clock twenty four (24) hour per day. This number may vary according to needs. Certified Nursing Assistant (CNA) 24 hours per day. This number may vary according to needs. Staff assignments are assignments are supervised by the DON and are based on the acuity needs of the patients and the education and/or experience of the staff. Review of the Grievance Log revealed nine (9) complaints directly related to lack of staff, not answering call lights and resident care on (MONTH) 5 and 12 (x2), on (MONTH) 25, on (MONTH) 28, on (MONTH) 6 and 13, on (MONTH) 16 and 20 of (YEAR). Review of the Resident Council Meeting Minutes dated 3/3/16 documented concerns by the residents with a request for a shower team. An interview on 7/7/16 at 1:03 p.m. with the Director of Nursing and the Administrator revealed in the past six (6) to eight (8) months there had many many positions available for both Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN). Many of the positions have been filled. Staffing shortage was placed in Quality Assurance (QA) as a major focus company wide. The Corporate office told the facility to do whatever it takes to get the positions filled. They are using agency staff if they cannot cover shifts with the facility staff first. They offer the staff overtime and bonuses. They have advertised, posted flyers throughout the community and held a job fair approximately a month and a half earlier. Review of the Treatment Administration Record (TAR) From (MONTH) through (MONTH) (YEAR) for Resident #1 revealed no evidence that the wound care treatment was administered to the left heel, as prescribed by the physician, for a total of thirty one (31) times. Review of the TAR from (MONTH) through (MONTH) (YEAR) for Resident #2 revealed no evidence that the wound care treatment, as prescribed by the the physician, was administered a total of twenty two (22) times to a wound on the sacral/coccygeal area. A total of twenty five (25) times to a wound of the groin/scrotal area and a total of twenty four (24) times to as wound to the right leg/thigh area. Review of the TAR from (MONTH) through (MONTH) for Resident #3 revealed no evidence that the wound care treatment to the left medial ankle and foot, as prescribed by the physician, was administered for a total nineteen (19) times. Interview on 7/8/16 beginning at 10:40 a.m. with the Treatment Licensed Practical Nurse (LPN) FF revealed that a blank space with no signature on the TAR indicates, as far as she knows, that the treatment was not administered. The dressing changes have not been getting done consistently on the evening shift. There are times when she is unable to get to Resident #2 for his wound care due to her workload and the resident likes to sleep until 9:30 - 10:00 a.m. If she is working with another resident and cannot get to Resident #2 by the time he is ready to get up, she will ask the nurse to administer the treatment but they will not do it. She stated that she cannot handle everyone in the facility that requires wound care treatment. The Treatment LPN FF further stated that if she cannot get to wound care, she flags the TAR so that it sticks out and reports to the evening nurse that she was unable to do wound care. When she comes back the next day, the treatment still has not been done. LPN 'FF stated that she had personally overheard a nurse at the nurse's station say Why do we have to do wound care when we have a wound care nurse now?' LPN FF stated that she has asked for help from the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) and they just keep telling her they are trying to get some help for her. The Resident Care Coordinator (RCC) is the only person that has physically helped her with wound treatment. When she is off on the weekends, the nurses in care are responsible for the treatment but when she reviews the TAR on Monday, it has rarely been done. LPN FF further said that the DON held a meeting with the staff discussing Braden Scale, Skin Assessments and Wound Reports. The DON also told the staff that she cannot handle all of the wound treatments herself and that it was the responsibility of the nurse's to administer wound treatment to anyone she was unable to get to. An interview on 7/8/16 at 1:11 p.m. with the Administrator and the DON revealed that she and the ADON have helped with wound care treatments at times but not consistently. If the Treatment LPN is unable to administer treatment to a resident, it is the responsibility of the direct care nurse to provide the wound care. The DON confirmed that she did have a discussion with the nurses that if the Treatment Nurse could not complete any wound treatment that they are responsible for getting it done. The Administrator stated they had just today hired a full time, experienced LPN for wound care and there would now be two (2) Treatment Nurses. An interview on 7/8/16 at 2:30 p.m. with the Resident Council President revealed she has been the President for nearly two (2) years. There had been many discussions in council meetings related to short staffing. The facility is mostly short of Certified Nursing Assistants (CNAs) and mostly on the evening shift. The Council President stated that the residents needs are not being met as evident by the call lights sounding and not being answered. In the evening the residents remain up late and she can hear them calling out for someone to put them to bed. The CNAs cannot be everywhere at the same time. The nurses are short on evenings as well and it takes a long time to get medication. This has been going on for nearly a year and there has been a ridiculous turnover of CNAs and Administration! The Administrator, department heads and kitchen staff is invited to attend the council meetings. The residents are told at the meetings that the facility is working on staffing concerns. She does not overhear the staff complaining about being short staffed but she does over hear the residents complaining about the short staff. The Resident Council President further stated that she applauds the staff that is working, they work so hard and she feels if it were her I would have just physically dropped or quit!'",2019-07-01
4728,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,490,E,1,0,LC8U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of policy and procedure, resident, staff and family interviews, the facility failed to have a functioning administration that used it's resources effectively and efficiently to ensure that wound care treatments were administered in accordance with the Physician order [REDACTED].#1, 2 and 3) out of thirty one (31) residents that received wound care treatment and to ensure the Activities of Daily Living (ADL) care was consistently provided while the facility has had a shortage of staffing from (MONTH) (YEAR) through (MONTH) (YEAR). This failure had the potential to affect all one hundred twenty nine (129) residents in the facility. Findings include: Review of the policy titled Administration documented: It is the intent of this center to provide nursing care twenty four (24) hours a day, seven (7) days a week. The nursing department of this center is budgeted, organized and staffed to meet the nursing needs of all our patients, Requirements of staffing rest with the Director of Nursing (DON). The DON should evaluate and review the staffing patterns to match the nursing needs of patients as needed. 1. Review of the Treatment Administration Record (TAR) From (MONTH) through (MONTH) (YEAR) for Resident #1 revealed no evidence that the wound care treatment was administered to the left heel, as prescribed by the physician, for a total of thirty one (31) times. Review of the TAR from (MONTH) through (MONTH) (YEAR) for Resident #2 revealed no evidence that the wound care treatment, as prescribed by the the physician, was administered a total of twenty two (23) times to a wound on the sacral/coccygeal area. A total of twenty five (26) times to a wound of the groin/scrotal area and a total of twenty four (25) times to as wound to the right leg/thigh area. Review of the TAR from (MONTH) through (MONTH) for Resident #3 revealed no evidence that the wound care treatment to the left medial ankle and foot, as prescribed by the physician, was administered for a total nineteen (19) times. Interview on 7/8/16 beginning at 10:40 a.m. with the Treatment Licensed Practical Nurse (LPN) FF revealed that a blank space with no signature on the TAR indicates, as far as she knows, that the treatment was not administered. The dressing changes have not been getting done consistently on the evening shift or weekends. She stated that she cannot handle everyone in the facility that requires wound care treatment and that there are thirty one (31) residents that require some form of wound care treatment. When she is off on the weekends, the nurses in care are responsible for the treatment but when she reviews the TAR on Monday, it has rarely been done. An interview on 7/8/16 at 1:11 p.m. with the DON revealed that she and the Assistant Director of Nursing (ADON) have helped with wound care treatments at times but not consistently. If the Treatment LPN is unable to administer treatment to a resident, it is the responsibility of the direct care nurse to provide the wound care. The DON confirmed that she did have a discussion with the nurses that if the Treatment Nurse could not complete any wound treatment that they are responsible for getting it done. The DON further stated that staffing concerns were placed in Quality Assurance (QA) on (MONTH) 15, (YEAR). The DON said there are numerous other nurses in the facility that could assist when they are short staff such as the DON, ADON, Resident Care Coordinator (RCC) and MDS/Care Plan nurses. 2. A facility tour conducted on at 11:45 a.m. revealed a very large group of residents in the main dining room attending a Bingo activity. Numerous residents were up in their wheelchairs in the hallways and in front of the nurses station. Numerous residents in the 2nd Hall dining room preparing for lunch. There was very few residents in bed in their rooms. At 11:58 a.m. there was numerous staff of all disciplines assisting residents with dining. An interview on 7/7/16 at 1:25 p.m. with the Ombudsman revealed she does not think the staff attends to the resident needs. The Ombudsman further stated that she visits the facility, unannounced every month and that she has personally witnessed call lights sounding and not being answered by the staff. Observation and interview on 7/7/16 at 2:00 p.m. revealed Resident #1 in his room in bed. Interview at the time of observation revealed the resident was still in bed because he was waiting for wound care and could not get out of bed until the treatment was done. Everyone knows that he would like his treatment to be completed no later than 11:00 a.m. so that the CNAs can get him up for lunch. Resident #1 further stated his mother works here and she has made it known to all staff and management that he is to have his treatment around 9:30-10:00 a.m. so he can get up and out of bed however, he still waits in his bed sometimes all day. A family interview for Resident #7 conducted on 7/7/16 at 12:40 p.m. revealed although the staff are good to her mother, she does not feel there is enough staff. It is not from the lack of that they don't want to help, two (2) CNAs on the evening shift for one (1) hall is not enough. An interview on 7/7/16 at 2:25 p.m. two (2) dayshift CNAs (AA and BB) revealed CNA AA has worked in this facility for one (1) year and CNA BB has worked in this facility for four (4) years. They both said that often on weekends it is really bad and they only have two (2) CNAs on the hall with over twenty (20) residents a piece to care for. Sometimes the evening shift will only have (1) CNA on a hall. This has bee going on for about six (6) months. The facility hires new staff but they don't stay. They both said they are short staff and nobody from the front comes to help them, They said that today, all the people out helping is only because the surveyor is here and is not the normal routine. CAN AA and BB said they do not feel like they can give the care needed. Residents are not getting their baths or brief changes when they are supposed to. Everything looks good today because the are fully staffed. They are best staffed on Wednesdays and Thursdays. The nurses do answer call lights, they sit at the desk and just keep paging the CNAs until the CNA answers the light, even when they know we are short staffed. A family interview for Resident #8 conducted on 7/7/16 at 2:40 p.m. revealed their mother had been in the facility for two (2) years and she is completely dependent on the staff for care. The two (2) daughters (M and P) further stated a family member is in the facility everyday to check on their mother. At the beginning of the year they knew their mother was not being bathed because she had greasy hair and cradle cap in which they treated themselves by using a dandruff shampoo and washing their mother's hair. At times they would find their mother wet, completely soaked through her clothes. They have found her with a soiled brief and they just change her themselves. At times the bowel movement is dried to their mother's skin. M and P said they have made complaints to the Administrator and the nurses. An interview on 7/7/16 at 2:58 p.m. with two (2) dayshift CNAs (CC and DD) revealed CNA CC has worked in the facility for one month and CNA DD has worked in the facility for two (2) years. Both CNAs said they are short staffed and the facility is trying to hire staff. resident care is being affected and they are not always able to give baths, conduct every two (2) hour checks of the residents or change resident's brief timely. An observation on 7/7/16 at 3:30 p.m. revealed Resident #1 remains in his room in bed. An interview on 7/7/16 at 5:00 p.m. with two (2) evening shift CNAs (NN and SS) revealed CNA NN has worked in the facility for two (2) months and CNA SS has worked in the facility for five (5) months. Both CNAs said they team up and help each other out when they are short staffed. Sometimes they do not get a break because by the time they get everyone to bed it's already 9:30 - 10:00 p.m. and their shift is about to end. Sometimes the nurse's are rude to the CNAs and they quit. The nurse's just sit at the nurse's station instead of helping when the need help. When they are bust feeding a resident, the nurse's should get up and help. An observation on 7/7/16 at 5:05 p.m. revealed Resident #1 in his wheelchair propelling through the hallway. Interview with the resident at this time revealed he had just gotten up out of bed and finally got his wound treatment about an hour earlier. An interview on 7/8/16 at 10:20 a.m. with CNA EE confirmed that she has to wait until the Resident #2 has received his wound treatment and this often falls behind and she is unable to get the resident up. CNA EE further stated that she has reported to the charge nurse when the resident is upset because he is still in bed and they in turn will call the treatment nurse. On 7/8/16 at 1:11 p.m. the DON provided the only bath/shower logs she had available. the Log was for (MONTH) and (MONTH) (YEAR) for the third (3rd) Unit only. Review of the logs revealed inconsistent documentation with numerous empty dates that baths or showers had been received. Interview with the DON at this time revealed that the CNAs don't always sign the sheets like they should be and she cannot be sure that the residents received a bath or shower for all of the empty spaces on the sheet. She further stated that Unit one (1) has never had a bath/shower log. They have been transitioning CNA documentation in the Accu Nurse computer program and the CNAs should be documenting ADL care through the headsets. She was unable to provide reports from this system to indicate bathing/showers for the residents in the facility. The DON further stated that 'Accu Nurse has been utilized in the facility since she has worked in the facility for one (1) year. An interview on 7/8/16 at 2:30 p.m. with the Resident Council President revealed she has been the President for nearly two (2) years. There had been many discussions in council meetings related to short staffing. The facility is mostly short of Certified Nursing Assistants (CNAs) and mostly on the evening shift. The Council President stated that the residents needs are not being met as evident by the call lights sounding and not being answered. In the evening the residents remain up late and she can hear them calling out for someone to put them to bed. The CNAs cannot be everywhere at the same time. The nurses are short on evenings as well and it takes a long time to get medication. This has been going on for nearly a year and there has been a ridiculous turnover of CNAs and Administration! The Administrator, department heads and kitchen staff is invited to attend the council meetings. The residents are told at the meetings that the facility is working on staffing concerns. She does not overhear the staff complaining about being short staffed but she does over hear the residents complaining about the short staff. The Resident Council President further stated that she applauds the staff that is working, they work so hard and she feels if it were her I would have just physically dropped or quit!'",2019-07-01
4729,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,514,J,1,0,LC8U12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and interview, it was determined that the facility failed to ensure that the clinical record for one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration was complete and accurately documented from a sample of sixteen (16)residents. The facility failed to ensure that a factual description of the medication error and the on-going monitoring of the condition for 24 to 72 hours was accurately and completely documented in the medical record as per facility policy for R10. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R#10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident ' s caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., two hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked 7:00 p.m. to 11:00 p.m. on 8/31/16 when LPN CC administered 100 units of [MEDICATION NAME] to R10. Continued interview revealed that CC notified her of the medication error and that the resident was placed in a wheelchair by her medication cart, given Med Pass to drink and monitored closely. Further interview revealed that she notified the on-coming nurse FF at 11:00 p.m. to continue monitoring the resident. However, there was no indication that staff on subsequent shifts had been notified about the significant medication error. Interview with LPN EE again on 9/23/16 at 11:20 a.m. revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document any change in a resident's status or condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since (MONTH) (YEAR). She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2019-07-01
4730,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-07-18,520,E,1,0,LC8U11,"> Based on staff interviews and review of policy and procedure, the facility failed to have an effective Quality Assessment and Assurance (QAA) committee that was involved in developing and implementing a plan of action for a concern related to staffing, that was identified on (MONTH) 15, (YEAR), to ensure resident care was not affected during an ongoing staffing shortage. This failure had the potential to affect all one hundred twenty nine (129) residents in the facility. Findings include: Review of the policy titled Quality Assurance review Process documented: To promote center compliance with DHR regulations and provide our patients quality care. A performance improvement plan should be developed to respond to opportunities identified in the review. An interview on 7/7/16 at 1:03 p.m. with the Director of Nursing(DON) and the Administrator revealed in the past six (6) to eight (8) months there had many many positions available for both Certified Nursing Assistants (CNA) and Licensed Practical Nurses (LPN). Many of the positions have been filled. Staffing shortage was placed in QAA as a major focus company wide. The shortage of staffing was placed in QA on (MONTH) 15, (YEAR). The Corporate office told the facility to do whatever it takes to get the positions filled. They are using agency staff if they cannot cover shifts with the facility staff first. They offer the staff overtime and bonuses. They have advertised, posted flyers throughout the community and held a job fair approximately a month and a half earlier. A subsequent interview was conducted on 7/8/16 at 1:11 p.m. the Administrator and the DON. The Administrator revealed that she has only been the Administrator for one (1) week. The previous Administrator was terminated for not addressing concerns, not following up on concerns, not providing leadership, not supportive of the staff or developing teamwork. She is not able to provide documentation or say what kind of plan of action was in place to ensure resident care was not affected while the facility is short staffed. The Administrator said that the facility needs to do a better job listening to the residents and the staff and that is her goal. The DON revealed that the only plan of action that she is aware of is related to the hiring bonuses, staff bonuses, overtime, advertising etc. The DON said there was no plan in place for ensuring that the resident care was not affected during the staffing shortage over the past eight (8) months. There was no auditing, monitoring or collection of data related to ensure that all aspects of resident care was provided. Because there was no collection of data related to resident care, there were no discussions in the QA meetings, that she can recall, addressing a decline in resident care.",2019-07-01
5382,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2014-12-18,431,D,0,1,F0VN11,"Based on observations, review of facility policy and staff interview the facility failed to discard medications timely in one (1) medication storage room (Unit 3) and on one (1) medication cart (Unit 2 ). Observations on 12/17/14 at 10:00am revealed the following : Unit 3 medication storage room had one (1) vial of Tuberculin PPD with an opened date of 9/17/14 and one (1) box of Aginate with an expiration date of 8/11/2014. Unit 2 Medication Cart had one (1) box of Aginate with expiration date of 8/11/2014. A review of the facility's Medication Storage policy revealed outdated medications are to be immediately removed from stock, disposed of according to procedures for medication destruction and reordered from the pharmacy, if a current order exists. A review of the facility's Medication Storage Conditions & Expiration Dates policy revealed the shelf life of Tuberculin PPD is one (1) month after first use. Interview conducted with the DON on 12/17/14 at 10:20am revealed that Tuberculin PPD is only good for 1 month from the date opened. The staff nurses and Resident Care Coordinators are to check medication storage areas at least weekly. We currently do not have sign off sheets for this process.",2018-09-01
6565,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2013-03-28,431,E,0,1,O6JK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and review of the facility policy, it was determined the facility failed to label medications with the date that they had initially been opened for five (5) of twenty-seven (27) residents receiving Insulin. Findings include: The facility policy recommended the following medication storage parameters: Multi-dose vials are dated with date opened and discarded after twenty-eight (28) days. Insulin vials replaced every twenty-eight (28) days if out of fridge. During observation of the Unit Three (3) Insulin cart on [DATE] at 4:00 p.m., it was noted that there were five (5) vials of Insulin without an opened date. The five (5) opened insulin vials were individually labeled with a resident's name on the plastic bags. The date opened labels located on the bottles were all blank. The following vials were found: two (2) vials Humulin R Insulin, opened date label located on the bottle was blank; one (1) vial Humulin R Insulin, do not use after label on the bottle with no date, no opened date label on the bottle; one (1) vial Levemir Insulin, opened date label located on the bottle was blank; one (1) vial Novolin R Insulin, opened date label located on the bottle was blank, the resident's room number was written on the bottle. Interview on [DATE] at 4:15 p.m. with AA Assistant Director of Nursing (ADON), revealed that the medication nurses were responsible for inspecting medication carts for expired and unlabelled medications, and the consultant pharmacist checked dates and/or labeling monthly. AA revealed it was expected that the medication nurses would put the date the vial was opened on the bottle, or on the labeled plastic bag. Further observation of Unit One (1) on [DATE] at 5:20 p.m. the following multi-dose medication was observed in the medication refrigerator, one (1) vial of opened Tuberculin Purified Protein Derivative (PPD) without an opened date. Interview with BBLicensed Practical Nurse (LPN) on [DATE] at 5:25 p.m., she revealed that when they open a new medication they write the date it was opened on the bottle or the label. She further revealed that she did not know when the vial of PPD was opened.",2017-11-01
7661,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-09-23,157,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's Medication Discrepancy/Errors Guideline and staff interview, it was determined that the facility failed to notify the physician and responsible party that a Licensed Practical Nurse (LPN) had administered an incorrect dose of [MEDICATION NAME] to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/16, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that the medication error should be reported to the Director of Nursing (DON) or acting supervisor immediately and the physician promptly. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her fasting blood sugar level (FSBS) was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. She was discharged back to the facility on [DATE]. Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, had inaccurately administered 100 units of [MEDICATION NAME] to R10 instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m.and that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 and that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m. There was no indication that the family was notified of the medication error at that time. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/23/16 at 11:20 a.m. with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2017-01-01
7662,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-09-23,281,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's Orientation Policy, review of the facility's Medication Discrepancies/Errors Procedural Guidelines, review of the National Council of State Boards of Nursing, Georgia Practical Nurses Practice Act (Chapter 410-10) and interview, it was determined that the facility failed to ensure that services provided met professional standards. The facility failed to ensure that licensed nursing staff administered Insulin correctly and safely to one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin. R10 was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Orientation Period policy revealed that the first three (3) calendar months of employment was considered an orientation period for newly hired employees. Continued review revealed that During this time the associate's job performance should be observed by the supervisor. Review of the facility's Medication Discrepancy/Errors Procedural Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the National Council of State Boards of Nursing, Chapter 410-10-.02 Standards of Practice for Licensed Practical Nurses, Authority: O.C.G.A. 43-1-25, 43-26-2, 43-26-3, 43-26-5, 43-26-32, and 43-26-42 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 failed to ensure that a new licensed nurse orientee administered the correct dose of [MEDICATION NAME] to R10 on 8/31/16 at 9:00 p.m. which resulted in the resident's hospitalization for [DIAGNOSES REDACTED] (low blood sugar level) on 9/1/16. (Cross refer to F333) There was no indication that licensed nursing staff identified that the [MEDICATION NAME] was a long-acting Insulin that may have required monitoring of blood sugar levels after 4:00 p.m. and the probable need to hold all subsequent Insulin administration. (Cross refer to F333) Although licensed nursing staff had obtained the resident's blood sugar levels on 8/31/16 at 11:00 p.m. (122) and on 9/1/16 at 1:30 a.m. (217), 2:45 a.m. (277), 11:00 a.m. (49) and 4:00 p.m. (70), there was no indication that staff were monitoring the resident closely for twenty-four (24) hours after the incident per facility policy. (Cross refer to F333) The facility failed to ensure that licensed nursing staff notified the Physician and Director of Nursing (DON) immediately of the significant medication error per facility policy until twenty-four (24) hours later. (Cross refer to F157) There was no indication that staff notified the Physician/NP of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. or the interventions staff implemented to increase the blood sugar level at that time. There was no indication that the family was notified timely of the significant medication error until after the resident was sent to the hospital on [DATE] at 11:00 p.m. (Cross refer to F157) Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. (cross refer to F333) review of the resident's medical record revealed [REDACTED]. (Cross refer to F333) Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2017-01-01
7663,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-09-23,282,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to follow the care plan to administer insulin as ordered by the physician for one (1) Resident (R) (R10) of six (6) residents reviewed for insulin administration from a sample of sixteen (16) residents. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer insulin as ordered. review of the resident's medical record revealed [REDACTED]. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Cross refer to F333) Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that LPN CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician and as care planned on 8/31/16 at 9:00 p.m. (Cross refer to F333) Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2017-01-01
7664,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-09-23,333,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, it was determined that the facility failed to ensure that one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin was free of a significant medication error from a sample of sixteen (16) residents. This failure resulted in harm for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Interview with anonymous person AA on 9/22/16 at 8:15 a.m. revealed that a nurse on the third shift had administered an incorrect dose of Insulin to the resident and that the resident had been admitted to the hospital Intensive Care Unit (ICU). Continued interview with AA revealed that staff failed to notify the resident's family. R10 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's care plan dated 10/17/14 revealed that she was at risk for [DIAGNOSES REDACTED] (low blood sugar) or [MEDICAL CONDITION] (high blood sugar) with an intervention for licensed nursing staff to administer Insulin as ordered. review of the resident's medical record revealed [REDACTED]. [REDACTED]. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that the resident was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Review of the Emergency Department Nursing Record dated 9/2/16 at 12:25 a.m. revealed that the resident was assessed due to an accidental overdose of Insulin. Continued review revealed that the resident's blood sugar level was 38 upon EMS arrival to the nursing home. Continued review revealed that the resident received 1/2 amp of [MEDICATION NAME] (D) 50 and that her blood sugar level was currently 208. Further review revealed that her vital signs were stable and she was alert. Review of the hospital physician progress notes [REDACTED]. Continued review revealed that the resident's blood sugar levels stabilized and she was moved to the Medical/Surgical floor by 9/4/16. She was discharged back to the facility on [DATE]. Review of the August 2016 Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the August 2016 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident's caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., twenty-four (24) hours after she had incorrectly administered 100 units of [MEDICATION NAME] to the resident and two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked on 8/31/16 from 7:00 p.m. to 11:00 p.m. continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven rooms without problems. Continued interview revealed that LPN CC stated that she felt confident she could administer Insulin and that LPN CC had been orienting with another nurse for at least one (1) week. Further interview with LPN EE revealed that she reviewed R#10's insulin orders with LPN CC and that LPN CC was left to draw up the Insulin and administer it to the resident by herself. Continued interview with LPN EE revealed that LPN CC notified her shortly thereafter that she had administered too much Insulin to R#10. Further interview revealed that she instructed the Certified Nursing Assistants (CNAs) to transfer the resident to the wheelchair, place her at EE's medication cart so that LPN EE could monitor her closely and LPN EE gave her Med Pass to drink. Continued interview revealed that the resident was alert and without symptoms of [DIAGNOSES REDACTED] when LPN EE left the facility at 11:00 p.m. Continued interview with LPN EE revealed that she notified the on-coming nurse LPN FF who worked 11:00 p.m. to 7:00 a.m. about the incident and instructed LPN FF to continue to monitor the resident. Interview on 9/22/16 at 1:55 p.m. with LPN GG via telephone revealed that she had observed LPN CC draw up the correct amount of [MEDICATION NAME] (12 units) and administer it to R#10 on 9/1/16 at 9:00 p.m. two (2) hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 4:00 p.m. with the Consultant Pharmacist via telephone revealed that he was unaware that nursing staff had administered 100 units of [MEDICATION NAME] instead of 12 units as ordered to R#10 on 8/31/16. Continued interview with the Consultant Pharmacist revealed that [MEDICATION NAME] was a long-acting Insulin and that the resident could possibly have abnormally low blood sugar levels up to twenty-six (26) hours after administration of such a high dose, especially if she was not eating well and nursing staff continued to administer Insulin. Further interview revealed that he expected nursing staff to hold the 6 units [MEDICATION NAME] R Insulin at 7:00 a.m. and the 12 units of [MEDICATION NAME] at 9:00 p.m. on 9/1/16. Interview on 9/22/16 at 4:22 p.m. with the resident's physician via telephone revealed that he was not notified that the resident had received the inaccurate dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. until the next night. Continued interview revealed that if he was notified on 8/31/16, he would have instructed nursing staff to hold subsequent Insulin, monitor her and ensure that she ate. Further interview revealed that the resident's blood sugar levels fluctuated. Interview on 9/22/16 at 5:40 p.m. with the Nurse Practitioner (NP) via telephone revealed that she was in the facility on 9/1/16 but, that she was unaware that the resident had received the incorrect dose of [MEDICATION NAME] the night before on 8/31/16 at 9:00 p.m. until after the resident was hospitalized . Continued interview revealed that she had not been notified by staff of the resident's low blood sugar level of 49 on 9/1/16 at 11:00 a.m. Further interview revealed that if nursing staff had notified her of the medication error from the previous night she would have notified the physician. Continued interview revealed that she would expect nursing staff to hold the 6 units of [MEDICATION NAME] R insulin at 7:00 a.m. Further interview revealed that the resident's blood sugar levels fluctuated but, she could not remember if the levels had ever been as low as 27 without reviewing the resident's medical record. Interview with LPN EE on 9/23/16 at 11:20 a.m. revealed that she and LPN CC, the new orientee, were the only nurses working on Unit II on 8/31/16 between 7:00 p.m. and 11:00 p.m. Continued interview revealed that she also needed to administer medications at that time and that CC told her she felt confident that she could administer the insulin. Continued interview revealed that LPN EE observed LPN CC administer medications for residents in seven (7) rooms without problems; however, she did not observe LPN CC administer Insulin to those residents at that time. Further interview with LPN EE revealed that she had never observed LPN CC administer Insulin to any resident. LPN EE stated that LPN CC was a licensed nurse and should have been able to administer Insulin correctly. Continued interview with LPN EE revealed that she was responsible for immediately notifying the physician about the significant medication error but, was unable to state the reason for not notifying him immediately after the incident. Further interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interview on 9/23/16 at 1:23 p.m. with LPN FF, an agency nurse, via phone revealed that she worked 8/31/16 from 11:00 p.m. to 7:00 a.m. and took over the medication cart from LPN EE at 11:00 p.m. Continued interview revealed that she was not notified that LPN CC had administered an incorrect dose of insulin to R#10 at 9:00 p.m. and therefore, did not notify the physician of the error. Further interview revealed that she did not observe LPN CC administer any medications on her shift because she was an agency nurse and did not orient other nurses. Observation of R10 on 9/23/16 at 12:35 p.m. revealed that she was alert with confusion and without symptoms of [DIAGNOSES REDACTED]. She stated at that time that she was happy to be home. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. (100% as of 11/7/16) 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. (100% nurses were inserviced by 11/7/16) 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. (LPN no longer employeed at facility-she resigned) 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2017-01-01
7665,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2016-09-23,514,J,1,0,HU6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, it was determined that the facility failed to ensure that the clinical record for one (1) Resident (R) (R10) of six (6) residents reviewed for Insulin administration was complete and accurately documented from a sample of sixteen (16)residents. The facility failed to ensure that a factual description of the medication error and the on-going monitoring of the condition for 24 to 72 hours was accurately and completely documented in the medical record as per facility policy for R10. The Administrator was informed on 10/31/2016, that 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, which began on 8/31/16 when one resident was administered an incorrect dose of insulin for R10 who was administered 100 units of [MEDICATION NAME] instead of the physician ordered 12 units which resulted in her hospitalization for [DIAGNOSES REDACTED]. Findings include: Review of the facility's Medication Discrepancy/Errors Guideline revealed that a medication error was defined as any medication that was administered to the wrong patient, in the wrong dose, by the wrong route, at the wrong time or without a physician's orders [REDACTED]. The physician's orders [REDACTED]. Continued review revealed that a factual description of the error, the name of physician and time notified, the physician's subsequent orders and the resident's condition for 24 to 72 hours or as directed should be documented in the resident's medical record. Review of the nurse's note dated 9/1/16 at 11:00 p.m. revealed that R#10 was lethargic, not talking or moving. Her blood pressure was 90/60, her respirations were 13 and her FSBS was abnormally low at 27 (normal blood sugar levels are between 60 and 100). Staff administered [MEDICATION NAME] to the resident and notified 911. Continued review revealed that the resident's physician and family were notified at that time that the resident was being transferred to the hospital. Further review revealed that when the Emergency Medical Technicians (EMTS) arrived to the facility, they administered additional [MEDICATION NAME] to the resident which increased her blood sugar level to 38. Interview on 9/22/16 at 11:20 a.m. with the Director of Nursing (DON) revealed that Licensed Practical Nurse (LPN) CC, who was a new nurse orientee, had inaccurately administered 100 units of [MEDICATION NAME] to the resident instead of 12 units as ordered by the physician on 8/31/16 at 9:00 p.m. This inaccurate administration was twenty-six (26) hours prior to the resident having a blood sugar level of 27 on 9/1/16 at 11:00 p.m. Continued interview revealed that staff had not notified her of the medication error until 9/1/16 at 11:15 p.m., twenty-six (26) hours and 15 minutes after it had occurred. Continued interview revealed that she would expect nursing staff to notify her and the physician immediately of a medication error. Further interview revealed that interventions to prevent another significant medication error from occurring were implemented on 9/2/16 when LPN CC was inserviced on Insulin administration and instructed to have another nurse observe her when administering Insulin until further notice. Review of the Situation/Background/Appearance/Review and Notify (SBAR) form dated 8/31/16 provided by the DON revealed that a medication error occurred on 8/31/16 (no time documented). Although staff obtained a FSBS on 8/31/16 at 11:00 p.m. (122), on 9/1/16 at 1:30 a.m. (217), on 9/1/16 at 2:45 a.m. (277) and on 9/1/16 at 11:00 a.m. (49), there was no indication what the medication was or the dose administered to the resident. Continued review of the SBAR revealed that the physician was not notified of the medication error until 9/1/16 at 9:00 p.m., twenty-four (24) hours after the resident received the incorrect dose of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. Further review revealed that the physician instructed staff to monitor the resident and encourage intake (of food/drink) at that time. There was no indication that the family was notified of the medication error at that time. Review of the August 2016 Medication Administration Record [REDACTED]. Although the DON stated that LPN CC had administered 100 units of [MEDICATION NAME] to R#10 on 8/31/16 at 9:00 p.m., review of the August 2016 MAR indicated [REDACTED]. Continued review of the MAR indicated [REDACTED]. DD circled her initials indicating that the 6 units of [MEDICATION NAME] R scheduled before lunch was not administered. Further review of the MAR indicated [REDACTED]. LPN BB who was the resident ' s caregiver on the 7:00 a.m. to 7:00 p.m. shift circled her initials indicating that the 6 units of [MEDICATION NAME] R insulin scheduled before supper was not administered. Continued review revealed that LPN CC, who worked the 7:00 p.m. to 7:00 a.m. shift, administered 12 units of [MEDICATION NAME] as scheduled on 9/1/16 at 9:00 p.m., two hours prior to staff assessing the resident as lethargic with a blood sugar level of 27. Interview on 9/22/16 at 10:40 a.m. with LPN BB via telephone revealed that the resident had a poor appetite and that her blood sugar levels were frequently low or high. Continued review revealed that she knew the 6 units of [MEDICATION NAME] R Insulin before meals was a new physician order [REDACTED]. Continued interview revealed that the resident did not show any symptoms of [DIAGNOSES REDACTED] at that time. Further interview revealed that the FSBS at 11:00 a.m. was low at 49 so LPN BB did not administer the 6 units [MEDICATION NAME] R Insulin. Further interview revealed that the Nurse Practitioner (NP) was in the facility and that she told the NP about the resident's low blood sugar level at that time. Continued interview revealed that the NP instructed BB to give the resident orange juice and to monitor her. LPN BB stated at that time that she did not obtain a follow-up FSBS and that she thought LPN DD had obtained it; however, LPN BB did not know the result of the follow-up FSBS level. Further interview revealed that LPN BB obtained the 4:00 p.m. FSBS which was 70 and did not administer the 6 units of [MEDICATION NAME] R before supper because the level was still in the lower range. review of the resident's medical record revealed [REDACTED]. sugar level at that time. There was no indication that licensed nursing staff had obtained a follow-up FSBS until 4:00 p.m., five (5) hours after the low blood sugar level of 49. There was no indication that licensed nursing staff monitored the resident's condition for twenty-four (24) hours after she was incorrectly administered the 100 units of [MEDICATION NAME] on 8/31/16 at 9:00 p.m. as per facility policy. Interview with LPN EE on 9/22/16 at 12:20 p.m. revealed that she had worked 7:00 p.m. to 11:00 p.m. on 8/31/16 when LPN CC administered 100 units of [MEDICATION NAME] to R10. Continued interview revealed that CC notified her of the medication error and that the resident was placed in a wheelchair by her medication cart, given Med Pass to drink and monitored closely. Further interview revealed that she notified the on-coming nurse FF at 11:00 p.m. to continue monitoring the resident. However, there was no indication that staff on subsequent shifts had been notified about the significant medication error. Interview with LPN EE again on 9/23/16 at 11:20 a.m. revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document any change in a resident's status or condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Based on the corrective actions that the facility implemented related to the medication error which occurred on 8/31/16, reported to facility administration on 9/1/16, it was determined that the immediacy of the jeopardy began on 8/31/16 and was removed on 9/23/16. The facility implemented the following corrective actions: 1. The physician and Director of Nursing (DON) were notified of the medication error on 9/1/16. 2. LPN CC the new orientee who administered the incorrect dose of Insulin to R#10 was suspended on 9/1/16. 3. LPN CC, returned to the facility on [DATE] for disciplinary action (verbal reprimand), and received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. 4. The Charge Nurse spoke with the family on 9/4/16. 5. The DON spoke with the responsible party for R#10 on 9/6/16 to discuss measures to address the medication error. 6. Administrative staff met with the family on 9/13/16. 7. The majority of Licensed Nurses received in-services beginning 9/15/16 about reading and understanding the facility Insulin Administration Policy, reading an Insulin order correctly and drawing up the correct dose of Insulin with return demonstration. 8. The majority of Licensed Nurses received inservices beginning 9/15/16 about notification of the physician/DON about medication errors, notification of family and complete documentation of a resident's change in condition. 9. The facility Quality Assurance and Performance Improvement (QAPI) committee which included the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error. Review of the 5 Whys Tool form provided by the facility revealed that the facility had determined that the mentor nurse failed to check the dose of Insulin drawn up by the new LPN orientee because she may have been in a hurry or had too many interruptions. Continued review revealed that the physician/DON/family were not notified timely and that the event was poorly documented because the nurses were in a hurry to ensure that the resident was stable. 10. No licensed nurse, including part-time, PRN (as needed) or agency, was allowed to work until they had received the in-services and completed the competency demonstration. The State Survey agency, validated the actions taken by the facility as follows: 1. Interview with the DON on 9/22/16 at 11:40 a.m. and with the physician on 9/22/16 at 4:22 p.m. both confirmed that they were notified of the medication error on 9/1/16. 2. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC was verbally reprimanded. 3. Review of a form titled, Associates Improvement Plan dated and signed by LPN CC on 9/2/16 confirmed the LPN CC with the following actions for opportunity to improve: received one-to one (1:1) education on the facility policy related to medication administration including insulin; orientation with a nurse will continue; that she could only administer Insulin in the presence of another nurse until further notice; that she would notify nurse orienting her if she did not understand something, and; how to document and report a medication error. In addition, LPN CC received inservice again on 9/20/16. 4-6. Review of the a document titled, Timeline confirmed that the Charge Nurse spoke with the family on 9/4/16, the DON spoke with the responsible party on 9/6/16 and Administrative staff met with the family on 9/13/16. 7-8. Review of the inservice education beginning 9/15/16, including: understanding the facility Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of Insulin with return demonstration, medication errors, notification of family and complete documentation of a resident's change in condition was completed for 22 Licensed Nurses (LN) of the 31 LNs listed as employed by the facility by 9/23/16. Interview with LPN EE on 9/23/16 at 11:20 a.m. interview revealed that she was in-serviced by the DON approximately one to two (1-2) weeks ago about staying with an orientee at every step of medication administration, to report a medication error immediately to the physician and family and to thoroughly document a change in a resident's condition. Continued interview revealed that licensed nurses had to demonstrate to the DON the ability to read an Insulin order and draw up the correct amount of Insulin as ordered. Interviews on 9/23/16 at 2:30 p.m. with LN II and LN JJ confirmed education was received Insulin Administration Policy, reading an Insulin order correctly, drawing up the correct dose of insulin, medication errors, notification of family and complete documentation of a resident's change in condition. Observation of Insulin administration was conducted on 9/23/16 at 11:02 a.m. with LN II for R14, at 11:37 a.m. with LN EE for R13, at 11:55 a.m. with LN HH for R12, at 3:55 p.m. with LN DD for R X , at 4:10 p.m. for R7 and 4:20 p.m. for R Z with LN JJ revealed no concerns. Interview on 11/7/16 at 9:59 a.m. with LPN DD revealed that she had been in-serviced by the previous DON on the Right Medication and Right Dose. Review of the in-service sign in sheets revealed that LPN DD had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/2016 at 10:05 a.m. with Registered Nurse (RN) GG Resident Care Coordinator (RCC) for Unit 1, revealed that she had attended an inservice on 9/15/16 and 9/16/16 related to Medication Errors, poor documentation, MD not notified timely, Director of Nursing (DON) not being notified timely. All nurses were required to be observed for insulin administration for following the physician's orders [REDACTED]. An interview on 11/7/16 at 10:08 a.m. with Licensed Practical Nurse (LPN) HH revealed that she had worked for the facility since May 2016. She was required to work with a mentor to follow and then observe all care she gave to resident's for two weeks. She was required to read the facility Policies and Procedures, including on administering Insulin. LPN HH further revealed attending an in-service on 9/15/16 related to demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had done a one on one inservice with her and observed her administering Insulin. She also had to read and sign reading the Insulin Policy. An interview with RN EE on 11/7/16 at 10:10 a.m. revealed that she had attended an in-service regarding insulin administration. Review of the in-service sign in sheets revealed that RN EE had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had done a one on one in-service and return demonstration for Insulin Administration. LPN AA is also found to have attended an in-service on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. An interview with RN FF on 11/7/16 at 10:20 a.m. revealed that she was the previous DON and had conducted many of the inservices related to Insulin Administration and had been in-serviced on 9/16/16. An interview with LPN CC on 11/7/16 at 11:30 a.m. revealed that she had been in-serviced related to insulin administration, Physician notification and the facility policy and procedure. Review of the in-service sign in sheets revealed that LPN CC had also attended on 9/15/16 related to Demonstrating ability to read an Insulin order correctly, administering the correct dose of Insulin and to read and understand the facility insulin administration policy. Observation of Insulin administration was conducted on 11/7/2016 at 11:34 a.m. with LNAA R1, at 11:41 a.m. of LN AA for R2, and at 11:00 a.m. with LPN BB for R3 FBS results were 265 requiring [MEDICATION NAME] R 6U per sliding scale protocol. LPN BB revealed no concerns. 9. Review of the Quality Assurance Event dated 9/14/16, referred to the Quality Assurance and Performance Improvement (QAPI) committee and review of the QA/QI Interim meeting dated 9/16/16 confirmed that the Medical Director, Interim Administrator, DON, MDS Coordinator, Patient Care Coordinator RN, Patient Care Coordinator LPN and LPN/Treatment Nurse met on 9/16/16 to discuss the medication error, including the root cause, corrective actions and continuing monitoring. Record review of the Corrective Action Improvement Plan dated 9/2/16, supplied by the facility during the Quality Assurance (QA) review, revealed that LPN EE received a verbal warning for not notifying the resident's Physician when made aware of the medication error by LPN CC. Further review revealed that LPN EE received additional training for supervision of trainees and how to report medication errors timely. 10. Interview with the DON on 9/23/16 at 6:05 p.m. revealed that supervisory nursing staff will perform random observations of Insulin administration with different nurses on different shifts including weekends to ensure that Insulin is administered correctly and as ordered by the Physician. Interview on 9/23/16 at 6:15 p.m. with the new Administrator, who began work on 9/19/16, revealed that those random observations will be monitored to cover 10% of Licensed Nurses weekly for four (4) weeks then monthly for two (2) months to verify on-going compliance. Further interview revealed that documentation will be reviewed daily for one (1) week then three (3) times a week for three (3) weeks then two (2) times a week for two (2) months to verify on-going compliance. Continued interview revealed that the Consultant Pharmacist will conduct monthly medication administration observations of Licensed Nursing staff and that all observations and reviews will be reviewed in the monthly QAPI meetings. An interview on 11/7/16 at 10:10 a.m. with LPN BB revealed that the previous DON had completed an one on one inservice with her and observed her administering Insulin. An interview on 11/7/16 at 10:18 a.m. with LPN AA revealed that RCC GG had completed an one on one in-service and return demonstration for Insulin Administration. Therefore the IJ was removed effective 9/23/16, however the scope and severity was decreased to a D while the facility's provision of staff in-service training and newly implemented process for orientation of newly hired nurses, notification of the Physician for medication errors and for ensuring correct dosage of medications were administered continued. In-service records and materials were reviewed. Interviews with Licensed Nurses were conducted to ensure they were knowledgeable about the facility's policies and procedures related to correct medication dosage, administration of insulin, and notification of the resident's physician, family and administration for a change in condition or for a medication error.",2017-01-01
8274,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2013-04-24,206,D,1,0,JE3M11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to allow one (1) resident (#2), from a survey sample of seven (7) residents, to return to the facility after a hospital transfer related to behavioral issues. Findings include: Record review for Resident #2 revealed a 04/01/2013 Nurses' Bedside Record which documented that the resident was exhibiting combative behavior, including threatening staff. This Nurses' Bedside Record documented that the physician was notified, and that an order was received to transfer the resident via 1013 transfer. A physician's orders [REDACTED].#2 to the hospital for evaluation and treatment of [REDACTED]. Further review of Resident #2's medical record revealed no evidence to indicate that the resident had been readmitted to the facility as of the 04/24/2013 date of this complaint survey, or of any additional assessment or evaluation of the resident after the 04/01/2013 hospital transfer. During an interview with the Assistant Director of Nursing (ADON) conducted on 04/24/2013 at 2:00 p.m., the ADON stated that on 04/01/2013, Resident #2 was initially transferred to an acute care hospital for evaluation, and that the acute care hospital then transfered the resident to a psychiatric hospital for evaluation on 04/02/2013. On 04/08/2013, staff at the psychiatric hospital contacted the skilled nursing facility, stating that the resident was no longer a danger to himselfself or others and had completed treatment. Psychiatric hospital staff also informed skilled nursing facility staff that Resident #2 was planned for transfer back to the skilled nursing facility on 04/09/2013. However, skilled nursing facility staff informed the psychiatric treatment center staff that Resident #2 had been discharged and was not allowed to return to the skilled nursing facility. During this interview, the ADON acknowledged that neither nursing facility staff nor the physican had re-evaluated the resident at the time of the request for the resident's tranfer back to the skilled nursing facility, to determine if he was appropriate for readmission at that time. Rather, Resident #2 was refused readmission, after the hospital stay, based only on a history of aggressive behavior.",2016-04-01
8403,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,279,D,0,1,Z6CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to develop a comprehensive care plan with appropriate interventions to address fluid restrictions and non-compliance for one (1) resident (# 30) on a sample of thirty-three (33) residents. Findings include: Record review revealed resident # 30 has a [DIAGNOSES REDACTED]. The resident was receiving [MEDICAL TREATMENT] three days a week. Review of the Physician order [REDACTED]. During an interview on 10/05/11 at 3:00 p.m.,the Director of Nurses stated the resident was non-compliant with her fluid restrictions and drinks fluids when she wants. Review of the comprehensive care plan revealed a care plan had been developed to address the nutritional needs for the resident on [MEDICAL TREATMENT], however there were no interventions to address the resident's fluid restrictions or her non-compliance. During an interview on 10/5/11 at 3:05 p.m. the Minimum Data Set (MDS) Coordinator confirmed the care plan for [MEDICAL TREATMENT] did not include interventions to address the resident's fluid restrictions or the resident's non-compliance. She further stated it had been addressed on a previous care plan, but had failed to include those interventions on the current care plan.",2016-01-01
8404,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,309,G,0,1,Z6CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to assess and treat pain experienced during pressure sore treatments for two residents, #112 and #23 of thirty-three (33) sampled residents. This resulted in actual harm to residents #112 and #23. Findings include: 1. Review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed resident # 112 was assessed at risk for pressure sores and was assessed as having a Stage II pressure sore which was present on admission. Review of the current Comprehensive Care Plan revealed the resident had a current Stage II pressure sore on the left lateral foot. The Treatment Nurse and Certified Nursing Assistants (CNAs) JJ and KK were observed on 10/05/11 at 10:15 a.m. while doing a pressure sore treatment to the resident's left lateral foot. The resident called out in pain each time the wound was touched. The resident also verbally expressed pain when the old dressing was removed. The Treatment Nurse acknowledged the resident's expressions of pain and stated she would check with the Medication Nurse after the treatment to find out when he was last medicated. CNAs JJ and KK proceeded with the treatment. The resident asked the Treatment Nurse to check with the Medication Nurse. The Treatment Nurse left the room and returned stating he had his last pain medication at 2:o'clock. The treatment was completed. Review of the resident's current Physician order [REDACTED]. Review of the MAR for October 2011 revealed the resident received this medication for the first time in October 2011 on 10/05/2011 following completion of the pressure sore treatment. Review of the current Comprehensive Care Plan revealed the resident was care planned to receive support related to pain. Interventions included medicate for pain as needed and monitor effectiveness. 2. Review of the quarterly Minimum Data Set (MDS) Assessments dated 4/27/11 and 7/27/11 revealed resident # 23 had a healing Stage IV on the right heel. Review of the current Comprehensive Care Plan also revealed the resident had a Stage IV, now presenting as a Stage II on the right heel. Interventions included monitoring for pain and medicating as needed. The Treatment Nurse and Certified Nursing Assistants (CNAs), JJ and KK were observed doing the treatment to the pressure sore on 10/05/11 at 10:40 a.m. The resident winced when her foot was raised to begin the treatment. The resident winced and verbalized pain when the area was cleansed. CNA JJ asked her if it hurt and the resident said it hurt when touched. CNA JJ proceeded with the treatment. When the treatment was complete the Treatment Nurse asked the resident if she wanted a pain pill. The resident said it stopped hurting once the treatment was completed. Review of the current Medication Administration Record [REDACTED] Review of the facility's policy on Pain Management revealed residents should be assessed and kept free of pain as much as possible. The facility's Pressure Sore Treatment Policy did not address pain The Treatment Nurse was interviewed on 10/06/11 at 11:20 a.m. and stated she did not feel resident #23 had pain during treatments, but acknowledged the resident did indicate pain when the area was touched. She further stated resident #112 did express pain during his treatment and that the treatment should have been stopped until the resident had pain medication with relief. During an interview on 10/06/11 at 12:25 p.m. the Director of Nursing (DON) stated she would have expected the nurse to stop the treatment, cover the wound with a dry sterile dressing (DSD), medicate the resident for the pain and wait an hour before resuming the treatment.",2016-01-01
8405,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,332,E,0,1,Z6CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to achieve a medication error rate of less than five percent (5%). Four (4) errors were observed on three (3) residents (#30, #41 and #98). The errors were made by three (3) of six (6) nurses on three of six medication carts resulting in a medication error rate of 5.26 percent. Findings include: Observation of medication administration to resident #41 by Licensed Practical Nurse (LPN) CC on 10/05/11 at 10:00 a.m. revealed the nurse administered one puff of a [MEDICATION NAME] HFA 220 mcg inhaler to the resident. The observation revealed the nurse failed to shake the canister thoroughly before administration. Review of the manufacturers specifications indicated to shake the canister well before administration. The LPN confirmed she should have shook the canister before giving the medications. Review of the current physician's orders [REDACTED]. During an interview on 10/5/11 at 10:41 a.m. LPN CC confirmed the resident was supposed to receive the eye drops and she forgot to give them. Observation of medication pass on 10/5/11 at 11:40 a.m. on resident #30 by LPN BB revealed the resident was given Luminer (insulin) 100 units subcutaneous at 11:44 a.m. Review of the October 2011 physician orders [REDACTED]. Licensed Practical Nurse AA gave resident #98 synthoid,100 micrograms ( mcg) on 10/05/11 at 9:39 a.m. Review of the current physician's orders [REDACTED].",2016-01-01
8406,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,356,C,0,1,Z6CD11,"Based on observation, record review and staff interview the facility failed to accurately post nurse staffing in a location easily accessible to residents and visitors. Findings include: During initial tour of the facility on 10/03/11 at 11:30 a.m. posting of nursing staff hours was not observed on any unit by the survey team. During the remainder of the survey on 10/03/11 through 10/06/11 at 12 noon nursing staff hours were not observed on any unit. On 10/06/11 at 12:20 p.m. the Director of Nursing (DON) was interviewed and stated nursing hours were posted inside the nurses' stations, which are glassed in enclosures. This was observed with the DON on Unit 1. It was covered with paper. The DON also stated it was posted in the time clock room which had a sign on the door which read, employees only. She further stated it was an assignment posting for staff as well as residents, but agreed it was not accessible to residents and visitors in the present locations Review of the assignment sheet also revealed it did not include the number of hours each staff member worked per shift.",2016-01-01
8407,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,441,D,0,1,Z6CD11,"Based on observation, record review and staff interview the facility failed to appropriately dispose of a used lancet for one (1) resident (#30) on a sample of thirty-three (33) residents Findings include: During observation of glucometer testing for resident #30 on 10/05/11 at 11:30 a.m. with Licensed Practical Nurse (LPN) BB, the LPN was observed cleaning the resident's finger with an alcohol swab. She then stuck the resident's finger with a lancet. LPN BB removed her gloves and placed the used lancet inside of the glove then placed the glove in the regular trash can. During an interview at this time LPN BB confirmed she should have placed the lancet in the sharps container. During an interview on 10/05/11 at 3:00 p.m. the Director of Nursing stated the nurse should have disposed of the lancet in the sharps container. Review of the facility's policy for Sharps Containers revealed that needles and other sharp items should be placed directly into impervious, rigid leak-proof and puncture-resistant containers to reduce the hazard of physical injury.",2016-01-01
8408,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2011-10-06,465,B,0,1,Z6CD11,"Based on observation, record review and staff interview the facility failed to maintain the freezer compartments of two (2) refrigerators located in the snack pantries on two (2) of three (3) units free of a heavy buildup of ice. Findings include: During environmental tour on 10/05/11 at 3:30 p.m., on Unit 2, the refrigerator in the snack kitchen did not have a door on the freezer compartment and a heavy build-up of ice was observed. A thermometer in the freezer was covered with ice and could not be read. There was nothing stored in the freezer. At 3:40 p.m. the freezer compartment in the pantry refrigerator on Unit 3 was observed to have the same heavy build-up of ice and no door. A container of ice cream was soft to touch and a gel freezer pack was also not frozen solid. There were no other items in the freezer. The thermometer in the freezer read 15 degrees. Review of the temperature log on the front of the refrigerator revealed that from 10/01/11 through 10/0/2011 the freezer temperature range was 15-20 degrees. These two (2) freezer compartments were observed in the same condition again on 10/06/11 at 8:45 a.m. during an environmental tour of the facility with the Director of Nursing (DON). The temperature of the freezer on Unit 3 was 20 degrees.",2016-01-01
8409,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2013-01-29,282,D,1,0,17VA11,"br>Based on observation, record review, and staff interview, the facility failed to provide chair alarms per the plan of care for two (2) residents (#1 and #4), and failed to provide a Pommel Cushion, also per the plan of care, for one (1) resident (#4) in a survey sample of four (4) residents. Findings include: 1. Please cross refer to F323, example 1, for more information regarding Resident #1. Record review for Resident #1 revealed a plan of care entry originally dated 10/13/2011 which specified, as a Current Approach, the application of a chair alarm to address the resident's fall-risk. However, observations of Resident #1 conducted on 01/29/2013 at 11:20 a.m., 1:00 p.m., 3:00 p.m., 3:30 p.m., and 4:45 p.m. conducted while the resident was seated in a wheelchair revealed no chair alarm in place. During an interview with Licensed Practical Nurse (LPN) BB conducted on 01/29/2013 at 4:45 p.m., this LPN acknowledged that there was no chair alarm applied to the resident's wheelchair. 2. Please cross refer to F323, example 2, for more information regarding Resident #4. Record review for Resident #4 revealed a plan of care entry, originally dated 06/13/2012, which specified, as Current Approaches, the use of a Pommel Cushion as an enhancer and the use of a chair alarm to address the resident's fall-risk. However, during observations of Resident #4 while sitting in the wheelchair conducted on 01/29/2013 at 1:00 p.m. and 4:30 p.m., no chair alarm was observed to be in place. During a 5:00 p.m. observation on 01/29/2013, with the Director of Nursing (DON) in attendance, neither a chair alarm nor Pommel Cushion were observed to be in place. During an interview conducted at the time of this 5:00 p.m. observation, the DON acknowledged that the resident was to have a chair alarm and Pommel Cushion placed on the wheelchair.",2016-01-01
8410,BROWN HEALTH AND REHABILITATION,115090,545 COOK STREET,ROYSTON,GA,30662,2013-01-29,323,D,1,0,17VA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide chair alarms, per the plan of care, for two (2) residents (#1 and #4) who had been identified as being at risk for falls, and failed to provide a Pommel Cushion, as ordered by the physician and as care planned, for one (1) resident (#4) in a survey sample of four (4) residents. Findings include: 1. Record review for Resident #1 revealed a plan of care entry originally dated 10/13/2011 which indicated that the resident was at risk for falls, with a Current Approach specifying the application of a chair alarm. However, observations of Resident #1 conducted on 01/29/2013 at 11:20 a.m., 1:00 p.m., 3:00 p.m., and 3:30 p.m. revealed the resident to be seated in a wheelchair in her room, but with no chair alarm attached to the wheelchair. During an additional observation conducted on 01/29/2013 at 4:45 p.m., conducted while the resident was seated in a wheelchair and located in a common area adjacent to the nurse's station, again revealed no chair alarm attached to the wheelchair. During an interview with Licensed Practical Nurse (LPN) BB conducted on 01/29/2013 at 4:45 p.m., this LPN acknowledged that there was no chair alarm applied to the resident's wheelchair. During an interview with Certified Nursing Assistant (CNA) CC', also conducted on 01/29/2013 at 4:45 p.m., this CNA also stated that the resident's alarm was actually in the resident's room, and she was observed at that time to obtain the alarm and attach the alarm for the resident's safety. 2. Record review for Resident #4 revealed that the January 2013 physician's orders [REDACTED]. Additionally, review of the resident's plan of care revealed an entry, originally dated 06/13/2012, which identified the resident to be at risk for falls, and which specified as Current Approaches the use of a Pommel Cushion as an enhancer, and the use of a chair alarm. However, observations of Resident #4 while sitting in the wheelchair conducted on 01/29/2013 at 1:00 p.m. and 4:30 p.m. revealed no chair alarm to be in place. An additional observation conducted on 01/29/2013 at 5:00 p.m., with the Director of Nursing (DON) in attendance, revealed neither a chair alarm nor Pommel Cushion to be in place. During an interview conducted at the time of this observation, the DON acknowledged that the resident was to have a chair alarm and Pommel Cushion placed on the wheelchair.",2016-01-01
2838,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2018-05-02,812,F,0,1,VC7211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and facility policies titled Refrigerator /Freezer Temperature Log and Food Labeling Reference Guide, the facility failed to store, labeled, and discard of expired food items for one of two reach in refrigerator and one of two freezers, and monitor the daily temperature for one milk floor chest cooler. This had the potential to affect a total of 59 orally fed residents. Findings include: Reviewed document dated ,[DATE] titled Refrigerator /Freezer Temperature Log stated purpose to record temperatures of all refrigerator/freezer units located in the kitchen area.1. Record month and year walk in refrigerator, walk in freezer, cooks reach in refrigerator, serving table refrigerator, serving table refrigerator, and milk cooler. 2. Mark in column heading which unit is to be recorded 3. record temperature in the [NAME]M column when unit first opened for the day. 4. Record temperature in the P.M. column prior to closing for the day. Reviewed document dated ,[DATE] titled Food Labeling Reference Guide stated frozen foods stored in the freezer : used by date of 6 months, open date and 7 day use by date Meats, eggs, and other frozen food items that are placed in the refrigerator to thaw-manufacture's expiration date for use by date, open date and 7 days used by date. Observation on [DATE] at 10:40 a.m. of Refrigerator #2 revealed the following: 1. leftover macaroni & beef pasta storage in a tupperware labeled with a cook date [DATE] and no used by date 2. leftover pasta noodles stored in a plastic bag labeled with a cook date [DATE] and no used by date 3. leftover lemon icing wrapped in a plastic wrap labeled with preparation date [DATE] and no used by date 4. slice cheese wrapped in plastic wrap which was not labeled 5. tortilla wraps wrapped in plastic wrap which was not labeled 6. cheese sauce with an open date of [DATE] stored in a plastic tupperware container and no expiration date Observation on [DATE] at 10:43 a.m. of freezer #1 revealed the following: 1. leftover cooked Texas Toast stored in a large freezer zipper bag labeled with a preparation date [DATE] and no used by date 2. leftover cooked corn bread squares stored in a large freezer zipper bag labeled with a preparation date [DATE] and no expiration date 3. cooked garlic bread which was not labeled and stored in large freezer zipper bag 4. ,[DATE] bag of tater tots which was not labeled 5. turkey meat dated [DATE], with no expiration date 6. bag of cooked dinner rolls dated [DATE] with no expiration date 7. open bag of chicken tenders which was not label Observation on [DATE] at 10:01 a.m. revealed a large floor milk chest cooler with several crates of milk stored inside with a temperature log titled Temperature /Cleaning Log for Milk Cooler/Refrigerator Unit dated ,[DATE] taped to the outside of the chest. Further observation of the temperature log revealed missing temperature loggings for several days during the month of April. Out of a total of 30 days for the month of (MONTH) the dietary staff only documented temperature logs for only 10 days. (The following entries were made for only the days listed on the (MONTH) (YEAR) log : ,[DATE], ,[DATE], ,[DATE] ,,[DATE], ,[DATE], ,[DATE], ,[DATE], and ,[DATE], ,[DATE]/ and ,[DATE]). During an interview on [DATE] at 1:44 p.m., the Register Dietician (RD) stated her expectations are for all food items to be stored and labeled properly. During an interview on [DATE] at 2:00 p.m., the Food Service Manager (FSM), revealed that her expectations are for the staff to label and store all food items based on the received date, expiration date, used by date and remove all expired food items from the refrigerator and freezer. Interview with Administrator on [DATE] at 2:55pm revealed that his expectations are anything food items that is received or open should have an expiration date and used by date.",2020-09-01
2839,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2019-05-08,761,E,0,1,8W4711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the facility's policy titled Medication Administration Guidelines: (MONTH) (YEAR) Safe Medication Administration, and interviews, the facility failed to discard expired biologicals prior to the expiration dates in two out of two medication storage rooms. The facility census was 59 residents. Finding include: An observation made of the Unit Two's medication room with Licensed Pracital Nurse (LPN) FF on 5/07/19 at 9:10 a.m. revealed an opened vial of [MEDICATION NAME] solution with an opened date of 2/28/19 written on the vial. According to the package insert the solution expires 30 days after opening (3/30/19). Two [MEDICATION NAME] flush syringes had an expiration date of 4/30/19 for resident R#54. The resident was on intravenous antibiotics with a scheduled [MEDICATION NAME] flush. An observation made of the Unit One's medication room with LPN BB on 5/07/19 at 3:00 p.m. revealed a bottle of Thera Vital multivitamins that had an expiration date of 4/2019 and a bottle of calcium+vitamin D 600 milligram (mg) that had an expiration date of 4/2019. Review of the facility policy titled Medication Administration Guidelines: (MONTH) (YEAR) Safe Medication Administration revealed medications are to be stored appropriately as per manufacturer instructions. All expired non-controlled medications or medications to be destroyed are to be taken off the medication cart and properly destroyed per the Environmental Protection Agency guidelines. Controlled medications stay secured on double locked medication cart. An interview with LPN FF on 5/07/19 at 9:10 a.m. verified the expired medications in the Unit Two medication room. She revealed when a medication is expired it should be removed and put in the destruction box located in the medication room. An interview made with LPN BB on 5/07/19 at 3:00 p.m. verified the expired medications in the Unit One medication room. She revealed when a medication is expired it is removed from stock and put in the box for destruction. An interview held on 5/08/19 at 11:48 a.m. with the Director of Nursing (DON) revealed her expectations are to have the medications rooms checked daily on the night shift. She expects the nurses to remove medications on or before the expiration date.",2020-09-01
2840,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2017-05-12,282,D,1,1,U34V11,"> Based on observation, interview, and record review, the facility failed to follow the care plan related to oral care for one resident (R) #42 out of 33 sampled residents. Findings include: Review of the care plan revised 3/1/17 documented R#42 to have a self-care deficit related to needing assistance with bathing, grooming, and personal hygiene. Residents needs total assistance by staff as indicated. Interventions included oral care daily and as needed. Observation on 05/10/17 at 11:00 a.m. revealed resident in bed resting. Mouth noted with dried skin and/or debris on lips and in the corner of right side of mouth. Teeth noted with thick white film. Observation on 05/10/17 at 4:15 p.m. revealed R#42's mouth noted with dry skin; thick white film on teeth and foul odor from mouth when resident speaks. Observation on 05/11/17 at 10:45 a.m. revealed R#42 with thick white film on teeth. Interview on 5/12/17 at 11:00 a.m., Certified Nursing Assistant (CNA) AA stated that oral care for R#42 is usually provided after each feeding. Interview with the Director of Nursing (DON) on 05/12/17 at 12:17 p.m. revealed that her expectation is for staff to follow the care plan and to assist R#42 with oral care every day and more than once a day. Cross Reference F312",2020-09-01
2841,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2017-05-12,312,D,1,1,U34V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, interview, and record review, the facility failed to provide oral care for one resident (R) #42 out of 33 sampled residents. Findings include: During an interview on 5/9/17 at 2:52 p.m. R#42's family member revealed that when he visits, the resident's teeth are dirty. Review of the Minimum Data Set (MDS) Quarterly assessment dated [DATE] documented the resident to be rarely/ never understood and requires one person total assistance with personal hygiene. Resident data collection form dated 2/14/14 documented that resident has own teeth. Review of the care plan revised 3/1/17 documented R#42 to have a self-care deficit related to needing assistance with bathing, grooming, and personal hygiene. Residents needs total assistance by staff as indicated. Interventions included oral care daily and as needed. Observation on 05/10/17 at 11:00 a.m. revealed resident in bed resting. Mouth noted with dried skin and/or debris on lips and in the corner of right side of mouth. Teeth noted with thick white film. Observation on 05/10/17 at 4:15 p.m. revealed R#42's mouth noted with dry skin; thick white film on teeth and foul odor from mouth when resident speaks. Observation on 05/11/17 at 10:45 a.m. revealed R#42 with thick white film on teeth. Interview on 5/12/17 at 11:00 a.m., Certified Nursing Assistant (CNA) AA stated that oral care for R#42 is usually provided after each feeding. Observation on 05/12/17 at 11:31 a.m. revealed CNA AA performed oral care for R#42 with mouth swabs and mouth rinse. The resident had stringy white particles in mouth. Resident did clench teeth down some during cleaning. Lips were washed with a wash cloth and Chap Stick applied. Interview with the Director of Nursing (DON) on 05/12/17 at 12:17 p.m. revealed that her expectation is for staff to assist R#42 with oral care every day and more than once a day. Review of the Nursing Procedure Manual: Oral Care dated (MONTH) 2013 documented: Purpose- to remove soft plaque deposits and calculus from teeth, to clean and massage the gums, and reduce mouth odor. Procedure- provide/ assist with oral care in the morning and before bed and more often as indicated.",2020-09-01
2842,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2017-05-12,441,E,1,1,U34V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, review of the Facility's Infection Control Manual, Infection Prevention: Handwashing, review of the Centers for Disease Control (CDC) Hand Hygiene Guidelines: Standard Precautions and staff interview, it was determined that the facility failed to ensure that nursing staff washed/sanitized hands between resident contact during one (1) of two (2) meal services on one (1) of three (3) halls (A Hall). The census was 59 residents. Findings include: Review of the facility's Infection Contol Manual, Infection Prevention: Handwashing revealed that handwashing is the single most important procedure for preventing nosocomial infections. Handwashing is mandated between resident contact and hands must be washed after contact with contaminated items or surfaces. Review of the CDC Hand Hygiene Guidelines: Standard Precautions provided by the facility revealed that use of alcohol hand sanitizer is the preferred method of hand hygiene in health care settings. On 5/8/17 at 12:36 p.m., during observation of the lunch meal on A Hall, Certified Nursing Assistant (CNA) AA obtained a meal tray from the meal cart and placed it on the overbed table for the resident in room [ROOM NUMBER]. The CNA moved the overbed table closer to the resident in the bed and used the remote to raise the head of the bed. Without washing/sanitizing her hands CNA AA obtained another meal tray from the meal cart and placed it on the overbed table for the resident in room [ROOM NUMBER]. CNA AA then repositioned the resident's legs in the bed, placed a clothing protector around the resident's neck, moved the overbed table closer to the resident in the bed, adjusted the resident's bed linens and raised the head of the bed. CNA AA unwrapped the utensils from the napkin and placed the fork in the resident's food on the plate. Without washing/sanitizing her hands CNA AA then left the room to obtain another meal tray from the cart for the resident in room [ROOM NUMBER]. While walking to the room, CNA AA touched her hair. CNA AA placed the meal tray on the overbed table, used the remote to lower the foot rest of the recliner that the resident was sitting in, placed shoes on the resident's feet, moved the overbed table closer to the resident, removed the top from the resident's tea glass, held the top of the tea glass while stirring sweetener into the tea, unwrapped the utensils from the napkin and placed the fork in the food on the plate. CNA AA then reached under the resident's arm to assist her to sit up straighter in the recliner. Without washing/sanitizing her hands, CNA AA obtained a meal tray from the cart for the resident in room [ROOM NUMBER], turned on the ceiling light, placed the tray on the overbed table, unwrapped the utensils from the napkin and placed the fork in the food on the plate. Without washing/sanitizing her hands, CNA AA then obtained a meal tray from the cart for the resident in room [ROOM NUMBER], placed the tray on the overbed table, unwrapped the utensils from the napkin and placed them next to the plate for the resident to use. Review of the facility In-service dated 1/9/17 revealed that eleven (11) staff including CNA AA attended the in-service on the CDC Hand Hygiene Guidelines: Standard Precautions. Interview with the Director of Nursing (DON) on 5/12/17 at 12:05 p.m. revealed that she expected staff to use sanitizer between resident contact during meal service. Continued interview revealed that during the survey, she had observed staff failing to sanitize their hands during the meal service and in-serviced them this week on appropriate hand hygiene. She provided a copy of the inservice dated 5/10/17 which was two days after observation of the lunch meal on 5/8/17 when staff failed to wash/sanitize between residents.",2020-09-01
4810,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2015-07-30,223,D,0,1,HTB111,"Based on observation, residents and staff interviews, and record review the facility failed to implement measures to protect one (1) resident (C) from potential from staff for one (1) resident from a sample of sixty-two (62) residents. Finding includes: During a resident Interview on 07/28/15 at 12:57 p.m. Resident A revealed that on (MONTH) 25, (YEAR),a Certified Nursing Assistant (CNA) GG came into the activity room. and not saying anything, snatched another resident sitting in a geri-chair around harshly and proceeded to take her out of the activity room with an angry disposition. Resident A further stated that the GG exhibit a bad attitude all of the time. Continuing her statement A stated that the Director of Nurses (DON) called her in Monday, (MONTH) 27, (YEAR) and asked if she had seen this happen. On 07/29/15 at 8:00 a.m. interview with the Administrator revealed that she was aware of the incident that occurred on (MONTH) 25, (YEAR). The Administrator further stated that she, and the DON, had discussed it on (MONTH) 27, (YEAR). Interview with the Administrator conducted on 07/29/15 at 1:00 p.m. revealed that there had not been any allegations of abuse since (MONTH) 2014. On 07/30/15 at 08:55 a.m. an interview with the Human Resources person regarding the incident that occurred on (MONTH) 25, (YEAR) she stated that on Saturday, (MONTH) 25, (YEAR), she came in to work and was in the Activity Room doing BINGO c GG came into the activity room visibly upset and demonstrated abrupt and harsh manner toward one resident in a gerichair and took her out of the activity room. She also revealed that GG was angry when she came into that day. The Human Resources representative stated and demonstrated the abrupt and harsh manner that the CNA GG used. She further stated that when the GG returned to the area that she spoke with her and in told her that she needed to be more appropriate with approaching the residents. Further statement revealed that the incident was reported to the Registered Nurse (RN) supervisor. The Human Resources representative stated that they wrote a statement and gave it to the DON. Interview with the RN Supervisor on 07/30/15 at 09:15 a.m. regarding the incident with the CNA on (MONTH) 25, (YEAR) revealed that the GG started taking residents out of Bingo and stated in a loud voice that these people are wet and I have to go change them. She was very, very upset and really angry. This is not the first time this has happened. I did not write GG up, but filled out a grievance and put it in the DON's door on (MONTH) 27, (YEAR). Resident Grievance Report Form written by RN Supervisor dated (MONTH) 27, (YEAR) regarding incident that occurred 07/25/15, states the following: Human Resources was playing BINGO in TV room when the CNA came in and started taking residents out of BINGO. Human Resources asked what the CNA was doing. The CNA said these patients are wet and need to be changed. The CNA was very disruptive and other patients saw what was going on. The RN Supervisor decided to let the DON talk with the CNA since this has happened before. A review of the Performance Counseling & Improvement Plan for Corrective Action dated 10/19/12 revealed a Verbal and Written Warning to the CNA for complaining about not having enough help, also complaining about other CNA's not helping out and for using foul language in the hallway among residents, staff and family members.' Performance Counseling & Improvement Plan for Corrective Action dated 11/16/13 revealed the CNA spoke to residents aggressively and inappropriately. Also using profanity by flipping resident off. Review of Employee Handbook regarding Progressive Discipline offenses revealed that per facility: Critical Offense: is a serious violation of Facility rules or employee misconduct which justifies immediate discharge without regard to the employees length of service or prior conduct. 07/30/15 at 12:05 PM Review of Performance Counseling and Improvement Plan for Corrective Action Written by DON for HG regarding Incident dated 07/25/15 revealed the following: Type of Corrective Action: Final Warning Reason for Counseling: Date and Time: 07/25/15 Supporting Documentation (who, what, when, where, why): Employee had a severe activities around her residents and family members in dining room while residents were playing bingo. See attached note. On 07/30/15 at 12:32 p.m. and interview with the Administrator revealed that a critical offense is any type of abuse including verbal or physical. The Administrator stated that foul language in the building would be a critical offense and that if a staff member flipped off a resident that would be a critical offense. Administrator stated that the incident with the CNA on (MONTH) 25, (YEAR) was not abuse, it was attitude. Interview on 07/30/15 at 12:50 p.m. with the Administrator revealed that the incident on (MONTH) 25, (YEAR), was abuse and that the CNA GGshould have been terminated. The Administrator stated that the GG had worked the complete shift on 07/25/15 and then on 07/26, 27, and 28/15. The RN Supervisor should have sent the CNA home on Saturday, (MONTH) 25, (YEAR), and suspended her pending the investigation.",2019-06-01
4811,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2015-07-30,225,D,0,1,HTB111,"Based on observations,resident and staff interviews, and record review the facility failed to follow facility policy in the protection of residents and the prevention, identification, investigation, and reporting of abuse of one(1)resident ( C.) ON 07/29/15 at 10:24 a.m. during a resident interview, resident A stated that this past Saturday, July, 25, (YEAR) that a Certified Nursing Assistant (CNA), abused resident C and that it happened in the activity room and that the activities person stopped the CNA on Saturday and talked to her. Then, on Monday, the Director of Nurses (DON) had asked A about the incident. 07/30/15 at 08:00 a.m. an interview with the Administrator revealed that she was aware of the incident that happened last Saturday and they (Administrator and DON) had discussed the incident on Monday and that the CNA had continued to work for the next 3 days. Record review revealed that a report had not been submitted to the State Agency until 07/30/15, four days after the incident. Interview on 07/31/15 at 10:06 a.m. with the Administrator revealed that resident's family's had not been contacted about the incident from 07/25/15. An interview on 07/31/15 with the Administrator confirmed that there was a failure to follow the Abuse Policy for reporting to the State Agency in a timely manner and failure to follow up the the administrator with an investigation when found to be abuse.",2019-06-01
4812,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2015-07-30,253,E,0,1,HTB111,"Based on observation and staff interview the facility failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior as evidenced by heavy build up of dust/debris on air conditioning units, missing paint on walls and door frames, missing finish on drawers and closets, a bathroom light that did not function and a hole in a closet door. This failure affected three (3) of four (4) hallways and ten (10) of forty-one (41) resident rooms and two (2) of four (4) halls and four (4) of thirty-four (34) resident bathrooms. Findings include: Dining Hall and Room 1 and 2: During observations in room 2 A on 07/28/15 at 1:19 p.m. the board along the wall behind the bed was scuffed and the dresser had missing paint. C Hall: During observations in room 13 on 07/28/15 at 12:58 p.m. paint was missing from the walls and baseboards. During observations in room 14 on 07/28/15 at 8:22 a.m. paint was missing from the walls and baseboards and the finish was missing in areas on the drawers and the closet. During observations in room 15 on 07/28/15 at 9:14 a.m. paint was missing from the wall and the finish was missing in areas on the closet door. During observations in room 16 on 07/28/15 at 8:37 a.m. paint was missing from the wall , the finish was missing in areas on the closet door. The closet door near est the A bed had a hole in the door. The drawers had a white discoloration. During observations in room 17 on 07/28/15 at 9:43 a.m. the finish was missing in areas on bed A drawers, the base boards and the closet doors. The C bed resident's drawers had a white discoloration. A Hall During the initial tour on 07/27/15 at 1:17 p.m. observation revealed in room 41, sheet rock mud was noted behind the head of the bed approximately eight inches long. In room 36, a crack was noted to the right of the air conditioner unit and the air conditioner unit was noted to have a heavy build up of dirt and debris. In room 32, the wallpaper above the air conditioner unit was noted to be peeling and stained and the air conditioner unit was noted to have a heavy build up of dirt and debris. In room 28, the air conditioner unit was noted to have a heavy build up of dirt and debris. The bathroom for room 28 was noted to have two areas of sheet rock mud with no paint approximately 4 inches x 4 inches on each side of the bathroom mirror. Resident Bathrooms: During observations in room 11/13 bathroom on 07/28/15 at 10:42 a.m. The door frame was missing paint and the light did not work. During observations in room 14/16 bathroom on 07/26/15 at 8:22 a.m. paint was missing from the bathroom trim. During observations in room 15/17 bathroom on 07/28/15 at 9:14 a.m. paint was missing from the walls and two (2) screws were sticking out from the wall and had been painted over. During tour on 07/31/15 at 6:00 p.m. with the Maintenance Director the above areas of concern were confirmed.",2019-06-01
4813,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2015-07-30,323,E,0,1,HTB111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and record review, the facility failed to maintain safe water temperatures for four (4) of four (4) halls, follow smoking waiver for one (1) resident (#19,) and maintain correct posture to prevent injury for one (1) resident (B) from a sample of twenty-seven (27) residents. Findings include: Observation on 07/27/15 at 3:20 p.m., with the Administrator, revealed the following hot water temperatures to be equal to or greater than one-hundred and twenty (120)degrees Fahrenheit (F.) for the following bathroom sinks using the facilities mechanical thermometer: Room 1/2 bathroom sink revealed hot water temperature of 124 degrees F. Room 3/4 bathroom sink revealed hot water temperature of 122 degrees F. Further observation on 07/27/15 at 3:45 p.m. with the Director of Nursing (DON) revealed the following hot water temperatures to be equal to or greater than 120 degrees F. for the following bathroom sinks using the facilities mechanical thermometer: Room 18 bathroom sink revealed hot water temperature of 130 degrees F. Room 19 bathroom sink revealed hot water temperature of 126 degrees F. Room 20 bathroom sink revealed hot water temperature of 132 degrees F. Room 21 bathroom sink revealed hot water temperature of 130 degrees F. Room 22 bathroom sink revealed hot water temperature of 124 degrees F. Room 23 bathroom sink revealed hot water temperature of 130 degrees F. Room 24 bathroom sink revealed hot water temperature of 124 degrees F. Room 36 bathroom sink revealed hot water temperature of 124 degrees F. An interview on 07/31/15 at 6:30 p.m. with the Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) nurse provided documentation revealing that three (3) of sixteen (16) residents were able to use their bathroom sinks independently. During an interview on 07/31/15 at 6:20 p.m. the Administrator revealed her expectation is that hot water temperatures were to be between 98-110 degrees F. and confirmed that the above temperatures were not in this range. Review of admission records for resident D revealed that the resident was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Observation and interview on 07/31/15 at 10:20 a.m. revealed the resident in her room in bed with eyes closed and oxygen on by nasal cannula. The resident stated that she kept her cigarettes and lighter in the compartment/basket of her walker. Observation revealed two pack of cigarettes and two lighters that were easily accessible. During an interview with Licensed Practical Nurse (LPN) BB on 07/31/15 at 10:15 a.m. it was revealed that the resident kept her cigarettes and lighter in her room. During an interview with the Administrator on 07/31/15 11:33 a.m. it was revealed that per the Resident's Smoking Waiver that no resident is allowed to retain a cigarette lighter in their room. Lighters were to be kept at the nurse's station or in a secure area. The Administrator further stated that a resident on oxygen should not be allowed to keep a lighter in their room. The Administrator confirmed that resident D had cigarettes and lighters in her room that were not in a secure area as required by the waiver. Observation and interview on 07/28/15 at 11:00 a.m. revealed that resident B's left hand was trapped between the side rails and mattress on the left upper side of the bed. Licensed Practical Nurse (LPN) BB was summoned and extricated the resident's hand. When the resident's hand was released from being trapped the resident gasped and grimaced. The resident's left hand was noted to be swollen with indention's approximately one inch to one and half inches long on the right and and left lateral sides of resident's wrist. Per LPN BB the resident's hand and fingers were swollen approximately two times it's usual size. The resident was observed to rub her left hand for approximately one to two minutes. After one to two minutes, resident said that her left hand no longer hurt. The resident stated her hand had been trapped in the rails since breakfast. Per the resident, her left hand had been trapped three hours. Resident noted to be able to use the call button, however, the call button was observed to be on the residents upper left side rail and resident is noted to have left sided paralysis and her left hand was trapped between the rail and the bed making the resident unable to reach or use the call button. Observation on 07/29/15 at 08:00 a.m. revealed that the resident's left hand continued to be edematous. The resident denies any pain at that time.",2019-06-01
4814,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2015-07-30,371,F,0,1,HTB111,"Based on Observation, interviews, and record review the facility failed to maintain foods at safe temperatures, at or below forty-one degrees in one (1) of one (1) Refrigerators. On 07/27/15 at 1:19 p.m. during the initial tour it was noted that the temperature in Refrigerator/Cooler #1 was sixty-four degrees Fahrenheit per the external thermometer and sixty degrees Fahrenheit per the internal thermometer. On 07/27/15 at 6:20 p.m. a re-check of Refrigerator/Cooler #1's temperature revealed the internal temperature remained elevated at fifty-two degrees Fahrenheit. A review of the Temperature log sheets for (MONTH) and (MONTH) revealed the following temperatures for the month of (MONTH) (YEAR): June 4 -- 48.9 degrees June 6 -- 45.9 degrees June 7 -- 44.2 degrees June 11 - 48.9 degrees June 13 - 47.0 degrees June 15 - 48.7 degrees June 16 - 43.4 degrees June 18 - 64.9 degrees June 19 - 43.4 degrees June 21 - 49.6 degrees June 24 - 48.7 degrees June 25 - 48.7 degrees June 27 - 42.4 degrees June 30 - 42.4 degrees 07/27/15 at 6:39 PM - Recheck of temperatures revealed two internal thermometers one thermometer registered fifty degrees Fahrenheit, the second thermometer registered forty-eight degrees Fahrenheit. External thermometer registered 48.6 degrees Fahrenheit. Observation at this time revealed the contents of Refrigerator/Cooler #1 to include: One Bowl of cooked hotdog's One bowl of Pea Salad Several cooked Rolls Bowl of Cooked Shrimp Bowl of Stewed Tomatoes Fresh Tomatoes Bowl of Cooked Broccoli Cooked ham Cooked Chicken Noodle Soup Cooked Baked Sweet Potatoes Several pieces of cooked Cornbread Fresh Vegetables including: box of Cauliflower, box of carrots, box of bell pepper, box of tomatoes. 15 dozen eggs Institutional size Mayonnaise 3/4 full Institutional size Mustard, ketchup, salsa, ketchup The following Dairy Products: Yogurt 1 case + 10 individual cartons Approximately 20 slices of cheese Sour Cream - 24 ounce container Butter Packs - 12 packs House Shakes - 7 individual containers Thousand Island Salad Dressing 15 individual packs and Chicken - 4 bags of thawing chicken approximately 90% thawed (confirmed by the dietary manager) Temperatures were confirmed with the dietary manager. The Dietary Manager stated that foods were used from this refrigerator for breakfast, lunch and dinner. During this same interview the dietary manager stated refrigerator temperatures are checked each day by staff. If the temperature is out of normal range, then the staff are to report the temperature to her. The Dietary Manager states she reviews the temperature logs daily. The Dietary Manager states she contacts the maintenance man and the Administrator if there are temperature problems. On 07/27/15 at 6:22 p.m. during an interview with the Dietary Manager it was revealed that her expectations were for the temperatures in the refrigerator to be forty-one degrees Fahrenheit or lower. On 07/27/15 at 7:25 p.m. an interview with the Administrator revealed that her expectations of staff were that staff members would notify the dietary manager when temperatures are elevated above forty-one degrees Fahrenheit.",2019-06-01
5950,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2014-10-09,371,F,0,1,UUZV11,"Based on observations, and staff interview, the facility failed to ensure that one of one (1 of 1) ice machine was maintained in a sanitary manner. Findings include: Observations of the ice machine on 10/07/2014 at 10:50 a.m. and 10/07/2014 at 1:00 p.m. revealed that the facility had one (1) ice machine located inside the kitchen. It had a black discoloration on the white plastic inside the ice machine, a black and white substance on the inside of the ice machine lid and heavy dust on the filter vent on the outside of the machine. Observation and interview with the Dietary Supervisor, on 10/07/2014 at 1:30 p.m. confirmed the presence of a black discoloration on the white plastic inside the ice machine, a black and white substance on the inside lid of the ice machine, and the presence of heavy dust on the filter vent on the outside of the ice machine. The Dietary Supervisor further stated that the cleaning of the ice machine was on the weekly cleaning schedule and should have been cleaned the previous week by dietary staff. She further stated that Maintenance cleans the machine monthly. Review of the kitchen cleaning schedule revealed the the last cleaning date for the ice machine by dietary staff was the week of 6/2-8/2014.",2018-05-01
6793,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2014-10-24,157,D,1,0,MTHV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to notify the responsible party of a need to significantly alter the treatment of [REDACTED]. Findings include: Interview with resident X on 10/24/14 at 11:00 a.m. revealed that he thought his doctor was making him sick. Resident X said that his daughter had changed his doctor but he had not met the new doctor yet. He said that he feels tired now and had a nagging pain in his back. Health record review indicated that resident X was admitted into the facility in May of 2012, [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) Quarterly dated 09/11/14 indicated a Brief Interview Mental Status (BIMS) Score of 10 for resident X. The MDS indicated that resident X had behavior of rejection of care for 1-3 days of the look back period. Pain was not indicated during the look back period. Resident X received diuretics for seven (7) days of the look back period. Review of the Medication Administration Records for 10/01/2014 through 10/09/2014 indicated that resident X refused all of his morning medications on 10/02, 10/03, 10/04. 10/06, 10/07 and on 10/08/14. Review of the Nurse's Notes dated 10/09/14 revealed documentation that the physician discontinued all of resident X's medication related to his refusal of medications. Review of the Physician order [REDACTED]. [MEDICATION NAME], Vitamin B-1, Vitamin B-12, Calcium 600 + Vitamin D, [MEDICATION NAME], Liquid Protein. Further review of the Nurse's Notes revealed no documentation on 10/09/14 of family notification that resident X had refused his medication or that all of the medications were discontinued. Subsequent review of the Nurse's Notes revealed the first documented entry of family notification that the medications were discontinued was on 10/14/14. This was five days after the physician had discontinued all of the resident's medications. Interview with the medication nurse AA on 10/24/14 at 2:00 p.m. revealed that she called resident X son and notified him on 10/14/14 that the resident's medications were discontinued. She said that she was not on duty when the medications were first stopped. Nurse AA reported that resident X had no symptoms of adverse reaction to the lack of his medications. Interview with the physician for resident X on 10/24/14 at 3:10 p.m. revealed that the nursing home staff were impatient with the resident. The physician said that resident X said the medication made him nauseated in the mornings, he told the nurses to hold the medications. The physician added that it was not uncommon for residents with dementia to refuse medications. He reiterated that he told the facility to hold the medications. The physician stated that communication was horrible at the facility because they didn't talk to the residents. The physician commented that no one bothered to find out why the resident refused his medication. The physician added that the medications were re-started on 10/21/14. Interview with resident X son who was his guardian on 10/24/14 at 4:00 p.m. revealed that he was responsible for anything that went on with the resident. He stated that the medications made resident X sick because the nurse's crushed the medications. He added that resident X did not like the time that the nurse's brought the medications to him. The son added that the nurses would only offer the morning medications twice, after that the nurse would say that he refused the medication and not offer it a third time. The son said that he was not told until five days after the medication were discontinued that they had been stopped.",2017-10-01
6948,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2014-09-04,323,D,1,0,G94311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to provide the appropriate amount of assistance during a transfer to prevent falls for one resident (#1) from a total sample of four (4) residents. Findings include: Resident #1 had [DIAGNOSES REDACTED]. The resident was assessed as being dependent and needing two (2) or more people for transfers on the recent Minimum Data Set (MDS) assessment dated [DATE]. A review of the resident's About Your Resident's form, which is kept in the Activities of Daily Living (ADL) book as information for the Certified Nursing Assistants (CNA's) documented that the resident required a two (2) person, maximum assistance, with a mechanical lift transfer. On 8/28/14 Resident #1 experienced a fall without injury. A review of the resident's clinical record and facility investigation revealed that Resident #1 was inapproriately transferred from the bed to the wheelchair with a mechanical lift with only one CNA assisting. Once Resident #1 was seated in the wheelchair, on a pillow that was in the seat of the wheelchair, the resident to begin to slide out of the wheelchair. The CNA eased Resident #1 onto the floor. The Director of Nursing (DON) stated during an interview on 9/4/14 at 9 a.m. that the pillow that was in the seat of the resident's wheelchair was not suppose to be there. There was no evidence the CNA had checked the wheelchair prior to putting Resident #1in it. She also confirmed that the resident required a mechanical lift and two staff assistance for transfers and that the CNA was aware of that prior to the transfer that resulted in Resident #1's fall on 8/28/14.",2017-09-01
7317,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2012-12-19,314,D,0,1,XID811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and a closed record review, it was determined that the facility failed to perform thorough weekly skin assessments of a pressure sore for one resident (# 74) in a sample of three residents with pressure sores in a total sample of 31 residents. Findings include: The U.S. Department of Health and Human Services Clinical Practice Guideline, Number 15: treatment of [REDACTED]. 23). Pressure sores should be reassessed at least weekly in order to monitor the progress or deterioration of the pressure sores. The weekly assessment should include an accurate measurement of the length, width, depth of the ulcer, a description of sinus tracts, tunneling, undermining, necrotic tissue, or exudate and the presence or absence of granulation and [MEDICATION NAME]. However, nursing staff failed to perform thorough weekly skin assessments that included descriptions and locations for resident # 74. Review of the closed record for resident #74 revealed that he/she had been admitted to hospice services on [DATE]. He/She had [DIAGNOSES REDACTED]. There was a [DATE] care plan to address the resident's impaired skin integrity with an intervention for nursing staff to assess his/her skin weekly, document and report to the family and physician. Licensed nursing staff documented in the [DATE] nursing notes that resident #74 had a 3 centimeter (cm) by 2 cm, stage 2 pressure sore on his/her left buttock. However a review of the Weekly Skin Assessments revealed that on [DATE] and [DATE], there was no documentation about the resident's left buttock. On [DATE], [DATE], [DATE], and [DATE], there were documented measurements but, there were not any descriptions of the pressure sore on the resident's left buttock. On [DATE] nursing staff documentation noted a 5.5 x 2.6 x 0.3 cm pressure sore on the resident's coccyx but, there was no description of the area. On [DATE], nursing staff's documentation noted a 6.2 x 3.1 x unknown depth area on a diagram of the coccyx but, there was no description of it. On [DATE], the nurse's documentation did not specify a location of the pressure sore but, documented the presence of black necrosis. On [DATE], the nurse noted that there was the presence of black necrosis with a strong, foul odor but, there were no measurements, description or specified location of the pressure sore. During a review of the Dermal Wound Tracking forms provided by the Director of Nurses (DON), there was no documentation of the pressure sore on the resident's buttock area. The DON stated on [DATE] at 9:35 a.m. that she had done a treatment on the resident's coccyx before he/she died and the area had a horrible odor, was approximately one inch deep and covered with necrotic tissue.",2017-06-01
7318,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2012-12-19,329,D,0,1,XID811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to ensure that there was a clinical rationale for the continued use of [MEDICATION NAME] for one (#56) of 31 sampled residents. Findings include: Resident #56 had a physician's orders [REDACTED]. However, a review of the Monthly Weight Record documentation back to November, 2011 revealed that the resident's weight had been stable. According to the AGS 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, the use of [MEDICATION NAME] ([MEDICATION NAME]) should be avoided in the elderly due to it being highly [MEDICATION NAME]. Although the consultant pharmacist had made monthly visits, there was no documentation that the pharmacist had identified and reported the continued use of the [MEDICATION NAME] to the facility and the attending physician. During an interview and review of the clinical record with the Director of Nursing on 12/18/12 at 10:15 a.m., she was unable to provide documentation of the clinical rationale for the continued use of the [MEDICATION NAME] since 9/12/11.",2017-06-01
7319,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2012-12-19,428,D,0,1,XID811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the consultant pharmacist failed to identify and report the lack of a clinical rationale for the continued use of Periactin for one (#56) of 31 sampled residents. Findings include: Resident #56 had a physician's orders [REDACTED]. However, a review of the Monthly Weight Record documentation since November, 2011 revealed that the resident's weight had been stable. According to the AGS 2012 Updated Beers Criteria for Potentially Inappropriate Medication Use in Older Adults, the use of Cyproheptadine (Periactin) should be avoided in the elderly due to it being highly anticholinergic. Although the consultant pharmacist had made monthly visits, there was no documentation that the pharmacist had identified and reported the continued use of the Periactin to the Director of Nursing and the attending physician. During an interview and review of the clinical record with the Director of Nursing on 12/18/12 at 10:15 a.m., she was unable to provide documentation of the clinical rationale for the continued use of the Periactin.",2017-06-01
7320,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2012-12-19,463,D,0,1,XID811,"Based on observation, and staff and resident interview, it was determined that the facility failed to ensure that the bedside call lights were working for two residents (A and B) of 40 residents' rooms sampled in Stage I. Findings include: On 12/17/12 at 9:10 a.m., the call light for resident A did not work. On 12/17/12 at 9:29 a.m., the call light for resident B did not work. On 12/17/12 at 11:40 a.m., resident A stated that the call light beside his/her bed would frequently stop working and that he/she would notify staff to fix it. Resident A stated that he/she was aware that the call light did not work but, he/she could not remember if he/she had notified staff this time. A stated that he/she did not know how long the call light had not worked. On 12/17/12 at 11:44 a.m., resident B stated that he/she was not aware that the call light beside his/her bed did not work. On 12/17/12 at 11:50 a.m., the Maintenance Supervisor stated that he checked the call lights in all the residents rooms and bathrooms and the common baths once a month. He stated, however, that he did not document that monitoring. The Maintenance Supervisor stated that the last time he had checked all of the call lights was three weeks ago.",2017-06-01
8971,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,157,D,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, it was determined that the facility failed to consult the physician about a significant change in the physical condition of one resident (J) or the need for a therapeutic diet for one resident (#76) in a sample of 28 residents. Findings include: 1. Resident J had medical [DIAGNOSES REDACTED]. A review of the nurse's notes revealed that on 2/19/11 at 1:30 p.m., the resident had thick green nasal drainage. At that time, the resident's physician was paged and, he said that he would visit the resident at the nursing home. The nurse's notes on 2/20/11 indicated that the resident continued to have copious amounts of yellow and green nasal drainage. The nurse's notes on 2/20/11 at 4:00 p.m. continued to describe the resident as having had congestion with thick greenish nasal drainage. On 2/21/11 (two days after the initial symptoms were reported) at 2:25 p.m., the physician visited the resident and ordered 2 sprays of [MEDICATION NAME] 0.03% nasal spray in each nostril two times day for 30 days. The nurse documented in the nurses' notes on 2/22/11 at 2:00 a.m. that the resident still had a thick green nasal drainage. The nurses notes on 2/24/11 at 3:00 a.m. documented that the resident still had nasal congestion and was refusing to use the nasal spray. However, there was no evidence that the physician was consulted. The licensed nursing staff documented on 2/27/11 at 10:00 a.m. that the resident had more thick yellow nasal drainage and had coughing episodes. Documentation revealed that, although the nasal spray was provided, the resident had difficulty using it. Licensed nursing staff documented at that time that the resident's family member stated that he/she was going to call the physician. Documentation in the 2/28/11 nurse's notes at 12:00 a.m. revealed that the resident continued to have yellow nasal drainage and that the nurse was going to contact the physician. That note also indicated that the resident's family member stated that he/she was going to call the physician. However, there was no evidence that the physician had been consulted. Nursing staff's documentation on 3/02/11 at 2:00 p.m. revealed that the resident continued to have nasal drainage and stuffiness. The resident refused his/her medications on 3/18/11 and 3/19/11. However, there was no evidence until 3/28/2011 that the physician was consulted about the resident's continuing nasal drainage, the coughing episodes on 2/27/11, his/her refusal to use the nasal spray on 2/24/2011 and refusal to take medications on 3/18/11 and as needed medications on 3/19/11. When the physician made rounds on 3/28/2011, he/she did not order any other interventions. 2. Resident # 76 was admitted with [DIAGNOSES REDACTED]. According to the resident's 4/27/11 care plan, he/she was at nutritional risk and should be evaluated by the dietician as indicated. The resident had abnormal laboratory test results reported for [MEDICATION NAME] and total protein on 11/02/10 and 5/20/11. After assessing the resident's nutritional status on 5/26/11, the registered dietician recommended that the resident be given 30 milliliters (ml) of liquid protein twice a day. However, there was no evidence that staff had consulted the physician about that recommendation for a nutritional supplement until after surveyor inquiry on 6/22/11. In an interview on 6/22/11 at approximately 11:00 a.m., the Director of Nursing (DON) stated that the the dietician usually assessed the residents then gave a copy of the recommendations to the DON and the dietary supervisor. Nursing staff was then supposed to consult the resident's attending physician about the recommendations for any action that the physician deemed appropriate. The DON said that if the physician ordered the dietary recommendations, then they would be implemented. During a subsequent interview at 11:45 a.m. on 6/21/2011, the DON explained that the dietician had not given nursing staff/DON a copy of her 5/26/2011 recommendations. The DON said that the dietary manager, who had been given a copy of those recommendations, was not aware that the DON did not have one. However, the DON said that the physician had been sent a copy that day (6/22/2011), after surveyor inquiry, and he had ordered the protein supplement as recommended. See F325 for additional information regarding resident #76.",2015-09-01
8972,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,201,D,0,1,QVJ611,"Based on review of the clinical record, a written notice of discharge, and interviews with staff and a family member, it was determined that the facility inappropriately issued a discharge notice to one resident (D) in a sample of 28 residents. Findings include: On 6/21/11 at 3:35 p.m., a family member of resident D reported that on 6/16/11 at 4:30 p.m., the facility had issued a written notice (letter) of its intent to discharge the resident on 7/14/11. The resident's family member stated that the notice of discharge was in retaliation for the family's complaints about facility staff's treatment and care of the resident. According to the letter, the reason for the resident's discharge was that the facility was unable to meet the needs of the resident and the family's demands were disrupting the care of other residents and the operations of the facility. However on 6/23/11 at 12:40 p.m., the Director of Nursing stated the resident's needs were being met by the facility but, the facility could not meet the needs of the resident's family members. The Administrator stated on 6/23/11 at 2:15 p.m.,that the facility was able to meet the needs of the resident but not his/her family's needs. There was not any evidence in the clinical record that the facility could not meet the resident's needs.",2015-09-01
8973,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,225,D,0,1,QVJ611,"Based on record review, and interviews with staff and family members, it was determined that the facility failed to report an allegation of verbal abuse to the State Survey Agency for one resident (D) from a sample of 28 residents. Findings include: The facility's Abuse Prohibition policy defined verbal abuse as any use of oral, written, or gestured language that willfully included disparaging or derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of a resident's age, ability to comprehend or mental and/or physical disability. The policy also documented that the facility, under the administrator's direction, would thoroughly investigate any alleged violation involving mistreatment, abuse or neglect and would follow individual state reporting requirements. However, the facility failed to report an allegation of verbal abuse to the State agency as required. During an interview on 6/21/11 at 3:35 p.m., a family member of resident D stated that on 5/20/11, the resident had told his/her family that during incontinence care, a staff member was alleged to have been very mean and fussed at the resident, said that he/she did not want to be there and, wasn't going to put up with this sh_t. The family member said that the resident had been so upset that he/she had refused to go to physical therapy that day. The family member stated that they had reported that allegation of verbal abuse to licensed nurse ZZ and to the administrator on 5/20/11 but, they did not receive any type of follow up about the allegation until 6/7/2011. On 6/23/11 at 2:15 p.m., the Administrator provided documentation about a Follow up from Meeting on Bath Incident which was dated 6/7/11. The follow up included a summary of the resident's allegation about a staff member cursing during his/her care. However, there was no evidence that the allegation of verbal abuse of the resident by a staff member was reported to the state survey agency.",2015-09-01
8974,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,241,D,0,1,QVJ611,"Based on observations and interviews with residents and staff, it was determined that the facility failed to promote the dignity of one resident (K) and one randomly observed resident waiting for assistance to shower and; to ensure that a nursing staff person talked to two residents in a respectful manner in a sample of 28 residents. Findings include: 1. During a random observation on 6/22/11 at 10:30 a.m., a resident, who was dressed in a hospital gown and seated in a wheelchair, had been left by staff in the hall outside of the shower room. The resident's clean clothes had been put on his/her lap. His/Her clean incontinence brief had been laid on top of his/her clothes while he/she was waiting for the staff to take him/her into the shower. On 6/23/11 at 9:05 a.m., resident K stated that after 6:00 a.m. that morning, the certified nursing assistant (CNA) had assisted him/her to the waiting area for the shower and he/she had to sit in the hallway outside of the shower room to wait for his/her shower . Resident K stated that he/she had to sit in the hallway on his/her rolling walker for an hour before it was his/her turn to get a shower. He/She said that sitting on the walker for that length of time was uncomfortable. During a subsequent interview on 6/23/11 at 3:00 p.m., resident K stated that there had been eight (8) other residents seated in the hallway and television room that morning. They had their clothes while waiting for their turn to be assisted to shower. During the subsequent interview, Resident K stated that the nursing staff piled residents in the hall outside of the shower room and in the common area where the television (television room ) was located to wait for their turn to get a shower. He/She said that there were only two CNAs on the bath team that provided showers for residents. On 6/23/11 at 2:55 p.m., licensed nurse VV stated that CNAs brought the residents with their clothes to the hall outside the shower. He/She said that they could leave residents there to wait for their showers but, they were not supposed to leave more than two residents at a time. However, on 6/23/11 at 10:00 a.m., there were three residents seated in the hall outside of the shower room waiting for their turn to be given a shower. 2. During individual interviews, two residents said that one licensed nurse did not interact with all residents in a respectful manner but talked to some residents in a harsh tone of voice. One (resident A) of the two residents said that she had heard that nurse talking to other residents in an unkind manner. The other resident (resident B) said that a staff person had spoken harshly to him/her. In an interview on 6/22/11 at 1:10 p.m., resident A said that he/she was concerned about how a licensed nurse, who worked on weekends, spoke to other residents while giving care. The resident said that he/she had not told any staff person about his/her concern for fear of retaliation. The resident said that he/she did not want his/her name used for that reason. However, he/she denied being afraid of that licensed nurse and said that he/she did not feel that nurse would physically hurt him/her or another resident. He/She stated that if a resident asked that nurse for their medicine then, the nurse told them in a very unkind tone of voice to go to their room and she would give it to them. The resident reported recently having overheard that nurse arguing with a confused resident, who was giving it back to the nurse. Resident A stated that 5 minutes after something happened the resident did not remember it so, that resident would not be unable to tell anyone how she felt about the argument. He/she said that the nurse was using a harsh and mean tone of voice during the argument. Resident A felt that nurse had a bad attitude towards some residents but was nice to her favorites. Resident A said that several residents had complained about that nurse among themselves but, he/she did not know if they had ever complained about it to facility staff. During an Interview on 6/23/11 at 8:45 a.m., resident B said that a licensed nurse, who worked on the weekends, had talked mean and hateful to him/her. He/she stated that when he/she had gone to the nurses' desk to ask for him/her medications, that nurse had told him/her to go to his/her room and she would bring them to him/ her. Resident B stated that the nurse spoke in a very rude and hurtful tone of voice which made him/her feel bad. The resident stated that he/she did not like being talked to in such a manner and it upset her. The resident stated that nurse had spoken harshly to him/her on other occasions. He/She said that he/she had overheard that nurse talk to other residents the same way. The resident stated that he/she had not ever complained about that nurse because of a fear of being mistreated later.",2015-09-01
8975,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,242,D,0,1,QVJ611,"Based on resident and staff interviews, and record review, it was determined that the facility failed to ensure one resident's (K) right to his/her choice about when to be given a shower in a sample of 28 residents. Findings include: During an interview on 6/20/11 at 2:15 p.m., resident K stated that he/she was supposed to be given a shower three times each week (Tuesday, Thursday and Saturday). However, he/she said that he/she did not usually get a shower on Saturday but would like one. Resident K stated that he/she did not get one on Saturday, June 18, 2011. The Resident Care Flow Record was used by the certified nursing assistants to determine the care/assistance to be given to residents and to document care that had been provided. According to that record, nursing staff was supposed to give resident K a shower on Tuesdays, Thursdays and Saturdays. However, a review of that record for June 2011 revealed no evidence that nursing staff had given the resident a shower as scheduled on Saturdays. According to staff's documentation, he/she was not given a shower on 5/21/11, 5/28/11, 6/4/11, 6/11/11 or 6/18/11. In an interview on 6/23/11 at 9:10 a.m., CNA SS stated that she and the other CNA, who was on the shower team, only worked from Monday through Friday. CNA SS stated that showers were occasionally provided on the weekend but only on an as needed basis. On 6/23/11 at 9:45 a.m., CNA TT said that weekend showers were provided by the shower team. When CNA UU reviewed the bath/shower and staffing schedules for June on 6/23/11 at 1:30 p.m., he/she said that there was not a facility staff person scheduled to give residents a shower on any Saturday in June.",2015-09-01
8976,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,246,D,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and observations, it was determined that the facility failed to accommodate the wheelchair positioning needs of one resident (#30) from a total sample of 28 residents. Findings include: Resident #30's had [DIAGNOSES REDACTED]. Licensed nursing staff completed an initial, comprehensive Minimum Data Set (MDS) assessment on 10/14/10. Nursing staff coded the resident as being totally dependent for locomotion on and off the unit and as requiring extensive staff assistance with bed mobility, and transfers. Licensed staff coded that the resident did not walk in his/her room or in the corridor. On the MDS for his/her quarterly assessment completed 4/15/11, licensed staff coded the resident as requiring extensive staff assistance with locomotion on and off the unit, transfers and bed mobility. There had been a care plan since 10/15/10 for staff to maintain the resident's body alignment and assess for the use of adaptive/supportive equipment as needed. However, staff failed to accommodate the resident's positioning needs when seated in a wheelchair. The resident was observed sitting in his/her wheelchair on 6/21/11 at 4:30 p.m., on 6/22/11 at 7:30 a.m., 10:20 a.m., 12:30 p.m., 2:25 p.m. and 4:00 p.m. but, staff had not attached a footrest to it so, his/her feet were dangling approximately 6 inches off of the floor. Although it was observed on 6/23/11 at 7:00 a.m. and 8:25 a.m. that staff had put foot rests on his/her wheelchair while resident #30 was seated in it, they were too long. The footrests did not provide any support for the resident's feet and legs. The resident's feet were dangling above the footrests. The resident did not attempt to propel himself/herself in the wheelchair during any of those observations. .",2015-09-01
8977,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,253,D,0,1,QVJ611,"Based on observations, it was determined that the facility failed to maintain an environment that was free of dirt, debris, mold, holes and cobwebs in isolated areas on one (Wing I) of two halls. Findings include: Observations were made during the General Observations Tour of the Facility on 6/23/11 from 10:30 a.m. to 12:00 p.m. Wing I 1. There were two brown stained ceiling tiles in the hall near room 5. 2. There was a brown stained ceiling tile in the hall near the air vent and room 8. 3. There was a one inch hole on the corner of a ceiling tile in the hall near room 9. 4. There was dust and cobwebs on two of the double windows on the sun porch. Common Shower Room 5. There were dried brown stains on the elevated commode seat in the common bathroom. 6. The tank cover did not properly fit the commode. 7. There was a 1 and 1/2 inch hole in the wall around the pipe under the sink. 8. There was a brown and black substance on the plumbing fixtures under the sink. 9. There was a rusty overbed table in the room. 10. There was a build-up of dust and hair in the whirlpool tub.",2015-09-01
8978,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,279,D,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to develop a comprehensive plan of care to address mental health issues and recommendations for one resident (#8) in a sample of 28 residents. Findings include: Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a completed Georgia PASRR Psychiatric and MR/RC Evaluation and Medical History form from APS Healthcare with an assessment date of 1/26/10 in the resident's clinical record. Based on that PASRR assessment, the resident needed specialized mental illness (MI) services which included psychiatric assessment, individual or group activity/counseling, and case management. The facility was provided that evaluation with those recommendations at the time of the resident's admission to the facility. When the facility developed the initial comprehensive care plan on 3/30/11, the resident's problems were determined to include his/her risk for verbally, physically, and socially inappropriate behavior related to a history of a prior psychotic event, polypharmacy for dementia, and depression and anxiety. However, the facility failed to develop and implement a plan to address any of the services recommended by PASRR for the resident's individualized psychosocial and psychiatric needs. It did not include any of the specific specialized mental health services based on the PASRR psychiatric evaluation of the resident's needs. See F406 for additional information regarding resident #8.",2015-09-01
8979,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,280,D,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and staff interviews, it was determined that the facility failed to revise a plan of care to reflect a resident's pain during the current restorative nursing care for one resident (C) from a total sample of 28 residents. Findings include: On the 3/13/11 quarterly Minimum Data Set (MDS) assessment, licensed nursing staff coded resident C as having had impaired range of motion of one upper extremity and one lower extremity. There was a 6/03/11 physician's orders [REDACTED]. On 6/22/11 at 10:10 a.m., the restorative certified nursing assistant (RCNA) began providing range of motion exercises with the resident's left hand, extending the fingers. The resident complained of pain. The RCNA stopped the range of motion exercises and stated that she would notify the nurse about the resident's complaints of pain. The RCNA stated the resident always experienced pain with range of motion exercises and that she notified the nurse about the resident's pain. The RCNA stated that she would come back and attempt to perform range of motion exercises again after the resident received pain medication but, the resident usually continued to have pain. The resident's plan of care was most recently reviewed on 6/16/11 and included Restorative Nursing Program (RNP) interventions to maintain the highest level of functioning, including range of motion exercises to both upper extremities and a splint to the resident's left hand. However, despite the RCNA's awareness that the resident could not tolerate the range of motion exercises, even on repeated attempts during the day, the staff failed to revise the plan of care to include interventions to enable the resident to have a greater tolerance of the range of motion exercises to maintain function. See F318 for additional information regarding resident C.",2015-09-01
8980,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,282,E,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with resident and staff, it was determined that the facility had failed to implement care plan interventions to assess and provide pain medications as needed for two residents (C and #8) , from a total sample of 28 residents. Findings include: 1. Resident C had a care plan intervention since at least 9/03/10 for nursing staff to monitor the resident for discomfort or pain before or during range of motion exercises and splinting activities to the left hand and to notify the nurse for (pain)medication to be administered if needed. There was a 6/03/11 physician's orders [REDACTED]. During an interview and observation of the Restorative Certified Nursing Assistant (RCNA) performing range of motion exercises to the resident's left hand on 6/22/11 at 10:10 a.m., the resident complained about being in pain. The RCNA stated that the resident had pain daily during range of motion exercises. However, there was no evidence that staff notified the nurse to assess the resident's need for pain medication. See F309 for additional information regarding resident C. 2. Resident #8 had a 3/30/11 care plan problem for being at risk for alteration in comfort with an intervention for nursing staff to administer pain medications per physician's orders [REDACTED]. The resident returned to the facility on [DATE] with a physician's orders [REDACTED]. However, there was no evidence in the clinical record that the resident received pain medication as ordered on [DATE] when nursing staff documented his/her pain level as 3 on the Medication Administration Record. See F309 for additional information regarding resident #8.",2015-09-01
8981,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,309,E,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, it was determined that the facility failed to assess the residents for pain and provide pharmacological and/or nonpharmacological interventions for pain relief as needed for two residents (C and #8) from a total sample of 28 residents. Findings include: 1. Resident C had [DIAGNOSES REDACTED]. On his/her 3/13/11 quarterly Minimum Data Set (MDS) assessment, licensed nursing staff coded resident C as having had impaired range of motion of one upper extremity and one lower extremity. Resident C had a care plan intervention since at least 9/03/10 for nursing staff to monitor the resident for discomfort or pain before or during range of motion and splinting activities to the left hand and to notify the nurse for medication to be administered if needed. There was a 6/03/11 physician's orders [REDACTED]. During an interview and observation of the Restorative Certified Nursing Assistant (RCNA) performing range of motion exercises to the resident's left hand on 6/22/11 at 10:10 a.m., the resident complained of pain. The RCNA stated that the resident had pain daily with range of motion exercises. The RCNA stated that she had notified the charge nurse when the resident complained of pain. The RCNA stated that occasionally she would go back and attempt to do range of motion exercises later in the day but, the resident did not always tolerate them because of having continued pain. In an interview on 6/23/11 at 10:00 a.m., licensed nurse AA stated that until yesterday (6/22/11) restorative nursing staff had not reported that the resident had pain in his/her left hand with range of motion exercises over the past month. Licensed nurse AA stated that she had not been made aware of the resident experiencing pain with range of motion but would have administered pain (relief) medication if she had been made aware of it. A review of the resident's Medication Administration Record (MAR) revealed that licensed nurses had only administered pain medication once in 22 days in June, 2011. 2. Resident #8 had a 3/30/11 care plan problem for being at risk for alteration in comfort with an intervention for nursing staff to administer pain medications according to the physician's orders [REDACTED]. The resident was hospitalized from 4/4 through 4/11/11 surgery. The resident returned to the facility on [DATE] with a physician's orders [REDACTED]. According to the nurses notes, the facility did not receive the ordered [MEDICATION NAME] tablets until 4/13/11. However, despite [MEDICATION NAME] being unavailable, there was no evidence in the clinical record that the resident had been given any pain relief medication on 4/12/11 when nursing staff documented on the Medication Administration Record that the resident had a pain level of 3. There was no evidence in the clinical record that nursing staff had thoroughly assessed the resident's pain as care planned and/or provided pharmacological or nonpharmacological interventions for optimum control of the pain, or notified the physician that [MEDICATION NAME] was unavailable on 4/12/11. ,/",2015-09-01
8982,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,318,D,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, and record review, it was determined that the facility failed to implement care plan interventions to attempt to increase tolerance with range of motion exercises for one resident (C), from a total sample of 28 residents. Findings include: Resident C had [DIAGNOSES REDACTED]. On the 3/13/11 quarterly Minimum Data Set (MDS) assessment, licensed nursing staff coded resident C as having had impaired range of motion of one upper extremity and one lower extremity. Resident C had care plan interventions since at least 9/03/10 for staff to monitor him/her for discomfort or pain before or during range of motion exercises and splinting activities to his /her left hand and to notify the nurse if medication was needed to be administered (for pain relief). There was a 6/03/11 physician's orders [REDACTED]. During an interview and observation 6/22/11 at 10:10 a.m., the Restorative Certified Nursing Assistant (RCNA) was performing range of motion exercises on the resident's left hand. While the RCNA was doing those range of motion exercises, the resident complained of having pain. The RCNA stated that the resident had pain daily during range of motion exercises. The RCNA said that she had told the charge nurse when the resident complained of pain. However, a review of the June 2011 Medication Administration Record [REDACTED]. The RCNA said that occasionally she went back later in the day and attempted to do the range of motion exercises again but, the resident did not always tolerate them because she/he continued to have pain. During an interview on 6/23/11 at 10:00 a.m., licensed nurse AA stated that until yesterday (6/22/11) the restorative nursing staff had not reported that, over the past month, the resident had pain in his/her left hand during range of motion exercises. Licensed nurse AA stated that no one had made her aware of the resident's pain during range of motion but, she would have administered pain medication if someone had informed her. According to the June 2011 Restorative Nursing Program's (RNP) documentation, the RCNA had provided 15 minutes of range of motion exercises and 15 minutes of applying the left hand splint daily from 6/3/11 through 6/22/11. However, it had been observed that the resident complained of pain so, the RCNA did not complete the ROM exercises on 6/22/11.",2015-09-01
8983,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,323,D,0,1,QVJ611,"Based on observation, it was determined that the facility failed to maintain an environment that was free of potentially hazardous chemicals and objects on one (Wing I) of 2 wings in the facility. Findings include: The Wing I clean linen room was unlocked on 6/23/11 at 11:30 a.m. The room contained six boxes of 'Med Line' disposable razors. There was also a spray bottle of 'Spitfire Power Cleaner' which had a manufacturer's label with warnings to keep it out of reach of children and that it was for commercial and industrial use only and to avoid contact with skin and eyes.",2015-09-01
8984,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,325,D,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to promptly address dietary recommendations to attempt to maintain weight or normal laboratory values for two residents (#76 and #30) at risk for inadequate nutrition in a sample of 28 residents. Findings include: 1. Resident # 76 was admitted with [DIAGNOSES REDACTED]. According to the resident's 4/27/11 care plan, he/she was at nutritional risk and should be evaluated by the dietician as indicated. The laboratory results for a routine basic metabolic panel (BMP) done in May, 2010 reported that the resident's [MEDICATION NAME] level was 3.8 (normal range of 3.5 to 4.80) and total protein was 6.4 (normal range of 6.1 - 7.9). The 11/02/10 BMP test results reported that the resident's [MEDICATION NAME] level had decreased to 3.4 and his/her total protein was 6.0. According to the resident's 5/20/11 BMP test results, his/her [MEDICATION NAME] level was reported to have dropped to 3.1 and his/her total protein level was 5.7. At that time, the Registered Dietician (RD) was notified about the need for an evaluation of the resident's nutritional status. The dietician assessed the resident on 5/26/11 and recommended that the resident be given 30 milliliters (ml) of liquid protein twice a day. However, there was no evidence that staff notified the physician about that recommendation for a nutritional supplement until 6/22/11, after surveyor inquiry. In an interview on 6/22/11 at approximately 11:00 a.m., the Director of Nursing (DON) stated that the usual process was for the RD to list her recommendations and give a copy of them to DON and the dietary supervisor. Nursing staff was then supposed to consult the resident's attending physician about the recommendations for any action that the physician deemed appropriate. The DON said that the physician would write an order to carry out the RD's recommendations. At 11:45 a.m. on 6/21/2011, the DON stated that the RD had given the recommendations for resident #76 to the dietary manager but had not given her a copy. The DON said that the dietary manager was not aware that nursing staff did not have a copy of the recommendations. However, the DON said that one would be sent to the physician. The physician was consulted and ordered the protein supplement on 6/22/11. 2. Resident #30 had [DIAGNOSES REDACTED]. The licensed nursing staff assessed and developed a care plan dated 10/15/10 to address his/her poor appetite with potential for weight loss. There were interventions for staff to discuss his/her food preferences, offer alternates, weigh per protocol, encourage family to bring in food items from home and provide nutritional supplements as ordered. However, the facility failed to provide a therapeutic diet to the resident as ordered from 10/13 to 10/18/10 and after 11/29/10. The 10/07/10 Initial Nutritional assessment documented the resident's admission weight as 96 lbs. with an IBW of 98 lbs. At that time, the resident was started on house shake three times a day with meals and was placed on weekly weights. On 10/08/10, the resident was started on [MEDICATION NAME] to increase his/her appetite. On 10/12/10, the RD recommended 90 cubic centimeters (cc) of Resource four times a day for 6 weeks and a multivitamin every day. The physician accepted those recommendations on 10/13/10. However, nursing staff failed to transcribe those orders so, the recommendations were not started until 10/18/10. A physician's orders [REDACTED]. However, a review of the resident's November MAR indicated [REDACTED]. There was not any evidence of a physician's orders [REDACTED]. During an interview on 6/23/11 at 11:20 a.m., the DON was unable to provide a reason for nursing staff's delay in writing the order for the 10/13/10 dietician's recommendations until 10/18/11 or why nursing staff inaccurately noted that Resource was discontinued on 11/29/10. She stated that she had investigated the two situations but, was unable to provide any reason or clarification for the delay in starting Resource or for stopping it.",2015-09-01
8985,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,371,E,0,1,QVJ611,"Based on observations, it was determined that the facility failed to ensure the ice machine on Wing I and areas of the pantry on Wing II were maintained in a clean and sanitary condition to prevent contamination. Findings include: Observations were made during the General Environmental Tour of the Facility on 6/23/11 from 10:30 a.m. to 12:00 p.m. Wing I The facility used an ice machine that was in the pantry on Wing I. The internal components of the ice machine were not clean. There was a piece of white plastic inside the ice machine along the width of the machine. There was a build-up of a black substance along the length of that white plastic. There was a white substance on the inside lip of the door on the ice machine and along the outside of it. Wing II Pantry There were crumbs and dirt inside the cabinets in the pantry near room 24. There was green mold on the wood shelving under the sink.",2015-09-01
8986,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,406,E,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the PASRR evaluation, clinical record ,and staff interviews, it was determined that the facility failed to provide mental health interventions needed to maintain and/or promote two residents (#8 and #72) highest level of psych-social functioning in a sample of 28 residents. Findings include: 1. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. There was a completed Georgia PASRR Psychiatric and MR/RC Evaluation and Medical History from APS Healthcare with an assessment date of 1/26/10 in the resident's clinical record. According to that evaluation, the resident needed specialized mental illness (MI) services that included a psychiatric assessment, individual or group activity/counseling, and case management. However, there was not any evidence that the facility had provided or arranged for the provision of those interventions by qualified mental health professionals or programs. The resident's admitting physician to the nursing home completed an initial history and physical (H&P) on 3/31/11. He documented on the history and physical that the resident had previously lived in another nursing home and had a long history of dementia and had been admitted to the hospital for agitation and confusion. The doctor documented that the resident had a history of [REDACTED]. Facility staff developed a comprehensive care plan for the resident on 3/30/11 which included a problem of the resident being at risk for exhibiting verbally, physically, and socially inappropriate behavior related to his/her history of a psychotic event, polypharmacy for dementia, depression and anxiety. The care plan problem was updated on 6/21/11 to include additional documentation about the resident's behavioral problems which included having demonstrated manipulative behavior and fabricating the truth. Staff noted that the resident had played staff against staff and family. Staff wrote as an example that the resident had told the family that no one assisted him/her at meals but, staff observed and assisted the resident at each meal. During an interview on 6/22/11 at 3:15 p.m., licensed nurses MM and AA described resident #8 as being alert and oriented. They said that she was anxious and displayed manipulative behaviors. They described his/her anxiety as increasing when family members visited and after talking with them on the phone. A review of the nurses' notes and physicians' progress notes revealed that the family had arranged for the resident to be seen by a psychiatrist on 4/21/11 and took the resident to that appointment. According to the psychiatrist's 4/21/11 progress note, the family took the resident to the appointment and he/she had reviewed the resident's history since his/her previous visit (5/10). The psychiatrist wrote that he/she had reviewed the resident's current medication regime as well as what had been recently discontinued. The psychiatrist's notes only indicated that information was obtained from the resident's family member and the resident about the resident's anxiety and depression about being in nursing home. The psychiatrist wrote that they had discussed recent adjustments and/or stressors that the resident had experienced. However, there was no evidence that the facility had provided any information to that psychiatrist about the resident's psycho-social functional status in the facility or attempted to elicit any recommendations to assist in developing systemic plans to address any of the behavioral problems being demonstrated by the resident. There was not any evidence the facility had provided or arranged for the resident to receive the additional PASRR specialized mental illness (MI) services of individual or group activity/counseling, and case management to promote the resident's highest psycho-social functioning level. Despite the recommendations about the need for for mental services, the resident's history of psychiatric problems and hospitalization s and behavioral problems being presented by the resident, there was no documentation in the social service notes or in the nursing notes about the facility providing or arranging for the provision of any specialized mental health services. There was not any documentation in those notes about any interactions with the resident's family about obtaining any psychiatric services. The Social Services Director stated on 6/23/11 at 8:20 a.m., that the facility had not provided or arranged for any type of specialized psychiatric services for the resident. The Director of Nursing said on 6/23/11 at 12:40 p.m. that she was not aware of the PASRR recommendations for specialized mental illness services for the resident. 2. Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident required the completion of a PASRR level 2 assessment prior to admission. There was a level 2 PASRR evaluation in his medical record that had been completed prior to his/her admission to the facility however, the evaluation was incomplete. The assessment was missing the page that included the care and services recommendations. During an interview on 6/23/11 at 11:15 a.m., the business office manager was unable to locate a complete copy of that evaluation of the resident. He/she said that he/she was unaware that there should have been more pages to the evaluation. He/She stated that he /she would investigate to see what he/she could find out about the incomplete Level 2 evaluation information. The business office manager obtained the missing evaluation pages from Georgia PASRR by 12:15 p.m. that day, after surveyor inquiry. Licensed staff assessed and developed a care plan dated 4/8/11 to address the resident's risk for mood alteration because of his/her [MEDICAL CONDITION] disorder. Interventions included providing emotional support, observing (for) and documenting targeted behaviors, administering medications as ordered, and notifying the physician as indicated. Nursing staff documented that the resident had started refusing his/her medications on 4/01/11. According to licensed nursing staff's documentation on the resident's Medication Administration Record [REDACTED]. They documented in May, 2011 that he/she refused to take [MEDICATION NAME] for 30 of 31 times, Trazadone for 5 of 6 times and [MEDICATION NAME] (antipsychotic) all 50 times that it had been scheduled (as ordered) to be given. Nursing staff documented on 5/05/11 that the resident was agitated and combative at times during his/her therapy and also refused to take his/her medications or have his/her vital signs taken by staff. Even though the resident was refusing to take oral medications, the attending physician discontinued the Trazadone on 5/06/11 and ordered 25 mg of [MEDICATION NAME] to be given to the resident twice a day. Documentation in the nurse's notes and on the MAR indicated [REDACTED]. The resident was transferred on 6/01/11 to a psychiatric treatment facility because of not eating at times, not sleeping, refusing medications and poor self care. The resident returned to the facility on [DATE] with orders for [MEDICATION NAME] at bedtime, 40 mg of Protonex every day, 10 mg of [MEDICATION NAME] every morning, 100 mg of [MEDICATION NAME] every day, 250 mg of [MEDICATION NAME] ER every bedtime, and 25 mg of [MEDICATION NAME] every bedtime. Licensed nursing staff documented in the nurses notes and on the MAR indicated [REDACTED]. On 6/23/11 at 2:15 p.m., licensed nurse ZZ said that the resident was not any better now than he /she was before going to the psychiatric treatment facility. ZZ stated that the nurse from the behavioral unit, who had called the report about the resident prior to his/her 6/15/11 transfer back to the nursing facility, stated that the resident's condition was not any better. ZZ said that the other nurse had reported that the resident resisted care, frequently refused to eat, and continued to refuse to take medications and to go to bed at times. On 6/23/11 at 4:15 p.m., the DON said the resident should have been sent out to the psychiatric/behavioral facility sooner but, he/she was not any better than before having been transferred out for psychiatric treatment. Based on the complete evaluation of the resident obtained by the facility on 6/23/11, it was recommended that the facility provide the resident with a psychiatric assessment and care. In an interview on 6/23/11 at 4:15 p.m., the DON stated that he /she did not know that any resident's Level 2 evaluation had any recommendations that the facility might have to provide for a resident or that resident #72's was missing any pages. During an interview on 6/23/11 at 4:50 p.m., the Social Service Director said that he /she was not aware that (implementing) PASRR recommendations was the responsibility of the facility. She was not aware of what the PASRR Level 2 recommendations were for resident #72. The facility staff failed to obtain a complete copy of resident #72's PASRR Level 2 evaluation prior to 6/ 23/11 and was not aware that any of the pages of that evaluation were missing. Although the resident was transferred to another facility for psychiatric services from 6/01/11 to 6/15/11, the resident had not demonstrated any improvement in his/her psycho-social functioning level since his/her return to the facility. The resident had continued to refuse his/her medications prescribed for his/her psychiatric treatment. He/she had refused to eat at times and had a 13% weight loss in last 3 months. He/she had refused ordered nutritional supplements. However, as of 6/23/11, there was no evidence that the resident's attending physician had been notified about the resident's current functional status.",2015-09-01
8987,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,441,E,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined that the facility failed to maintain surveillance records for in-house infection control for two months (April and June, 2011) and failed to ensure that one of five newly hired employees was free of communicable diseases prior to beginning work with residents. Findings include: 1. Review of the facility's infection control surveillance log on 6/22/11 revealed that there was not any staff documentation that surveillance had been done to identify and control infections in April and June 2011. Staff did not record if any resident had an infection, the type of infection, any treatment of [REDACTED]. During an interview on 6/23/11 at 8:45 a.m., the Director of Nursing confirmed that there were not any infection control surveillance records maintained by the facility staff during those months. 2. A review of newly hired employees' personnel files revealed that licensed practical nurse (LPN) MM was hired 5/23/11. However, her most recent [MEDICATION NAME] skin test had been done on 10/31/10.",2015-09-01
8988,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-06-23,469,D,0,1,QVJ611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, family and staff interviews and record reviews, it was determined that the facility failed to maintain an environment free of ants in one resident's room (C) from a total sample of 28 residents. Findings include: During an interview on 6/21/11 at 1:10 p.m., the family member of resident C stated that she had seen ants in the resident's room last week and reported them to facility staff. The resident's family member stated that the family had put ant bait in the resident's room last week. Small ants were observed crawling along the chair-rail on the wall at the head of resident C 's bed on 6/21/11 at 1:30 p.m. and on 6/22/11 at 10:10 a.m., 11:50 a.m., 2:45 p.m. and 4:00 p.m. During those observations, two square black ant baits were under the resident's bed near the window and head of the bed. Despite the family members claim of having reported the ants to staff the previous week and multiple observations of ants on 6/21 and 6/22/11, there was no evidence that facility staff had identified and reported the problem until the afternoon of 6/22/2011. In an interview on 6/22/11 at 4:00 p.m., the Maintenance Director said that he had been unaware of ants in the resident's room until earlier that day (6/22/11) when the Restorative Certified Nursing Assistant had noticed them and reported them to him. On 6/23/11 at 9:55 a.m., housekeeping staff NN stated that she had seen the ant baits in the resident's room while cleaning it but thought that the maintenance department had placed them there. She said that she was aware of other rooms that were being treated for [REDACTED]. In an interview on 6/23/11, the Administrator said and provided evidence that the facility's pest control company provided monthly service and came each time a complaint was made to provide treatment. There was evidence that the pest control company provided treatment when there had been complaints about ants or cockroaches on 5/9/11, 5/16/11 and 5/23/11. After the facility reported the ant problem in resident C 's room, the pest control company did treatment on 6/23/11. However, although staff were aware of the ant bait containers under the resident's bed and ants were visible in the resident's room, staff did not notice the ants or report them to maintenance director or other staff member to arrange for treatment of [REDACTED].",2015-09-01
9770,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2012-01-04,157,D,1,0,HN5G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to immediately notify the responsible party of one (1) resident (#1), in a survey sample of six (6) residents, of significant changes in the resident's status related to the initiation of new drug therapy and a significant decline prior to the resident's death. Findings include: Record review for Resident #1 revealed a Nurse's Note of 10/26/2011 at 10:30 a.m. which documented that the resident was noted to be vomiting and that the physician extender, when notified, had given a new order for Haldoperidol 0.5 milligram by mouth every six (6) hours as needed for nausea and vomiting. However, further record review revealed no evidence to indicate that the resident's family was notified of the initiation of this [MEDICATION NAME] drug therapy. A Nurse's Note of 10/27/2011 at 10:30 a.m. documented that a new physician's orders [REDACTED]. However, further record review revealed no evidence to indicate that the resident's family was notified of the initiation of this [MEDICATION NAME] drug therapy. A Nurse's Note of 11/18/2011 at 8:45 p.m. documented that the resident had a change in vital signs, including a body temperature of 93.9 degrees Fahrenheit, and that Hospice staff was notified. A Nurse's Note of 11/18/2011 at 10:00 p.m. documented that the resident remained cold to touch and had shallow breath sounds. A Nurse's Note of 11/19/2011 at 2:00 a.m. documented that the resident's oxygen saturation was unobtainable, with oxygen continuing, and a Nurse's Note of 11/19/2011 at 7:00 a.m. documented that the resident was found unresponsive and without obtainable vital signs. This 11/19/2011, 7:00 a.m. Note documented that Hospice staff and a family member of the resident were contacted at that time regarding the resident's change in status. However, there was no evidence to indicate that the family had been notified prior to that time of the resident's significant change in status as noted in the Nurse's Notes of 11/18/2011 at 8:45 p.m. and 10:00 p.m. and the Nurse's Note of 11/19/2011 at 2:00 a.m. referenced above. During an interview with the Director of Nursing and the Administrator conducted on 01/04/2012 at 3:00 p.m., the Director of Nursing and Administrator acknowledged that the resident's responsible party was not notified of the above concerns, however should have been called promptly.",2015-05-01
10514,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-02-01,280,D,1,0,S73111,"Based on record review and staff interview, the facility failed to revise the care plan to put interventions in place to provide safe methods of transportation for one (1) resident (#1), who had been assessed to be at risk for falls, on the survey sample of five (5) residents. Findings include: Cross refer to F323 for more information regarding Resident #1. Record review for Resident #1 revealed a Quarterly Minimum Data Set of 10/21/2010 which indicated the resident had both long-term and short-term memory problems, required extensive assistance with all activities of daily living, required assistance with transfers, and ambulated via a wheelchair. Further review revealed the Resident Assessment Protocols (RAPs) triggered for the risk of falls, and a 07/22/2010 Care Plan entry identified this risk for falls. A Nurse's Note of 01/12/2011 at 6:45 p.m. documented that while a certified nursing assistant (CNA) was pushing the resident in a wheelchair from the dining room to her room, the resident planted her feet firmly on the floor causing her to fall from the wheelchair. During interviews conducted with Licensed Practical Nurse (LPN) ""BB"", CNA ""CC"", LPN ""DD"", and Certified Occupational Therapy Assistant ""EE"" conducted on 02/01/2011 at 2:35 p.m., 2:40 p.m., 2:45 p.m., and 2:50 p.m., respectively, all staff members stated that they had observed Resident #1 to have the behavior of putting her feet down while being transported in the wheelchair. However, despite the resident's assessed fall-risk and staffs' knowledge of the resident's behavior of lowering her feet during transport via wheelchair, record review revealed no evidence to indicate that the facility had reviewed and revised the resident's Care Plan to develop interventions to address this behavior until a 01/14/2010 entry on the Care Plan indicated that leg rests were to be placed on the wheelchair while staff were assisting the resident with locomotion.",2014-06-01
10515,BROWN'S HEALTH & REHAB CENTER,115604,226 SOUTH COLLEGE STREET,STATESBORO,GA,30458,2011-02-01,323,D,1,0,S73111,"Based on record review and staff interview, the facility failed to ensure that one (1) resident (#1), on the survey sample of five (5) residents, received adequate supervision related to fall-prevention from the wheelchair during transport by staff. Findings include: Record review for Resident #1 revealed a Nurse's Note of 01/12/2011 at 6:45 p.m. which documented that the nurse was called to the resident's room to observe a hematoma to the forehead above the right eye. This Note documented the certified nursing assistant (CNA) stated that while the resident was being pushed in the wheelchair from the dining room to her room, the resident planted her feet firmly on the floor causing her to fall from the wheelchair and to hit her head on the floor. This Note documented that the CNA was able to catch the resident by the arm preventing the full impact of the fall. This Note further documented that an assessment of the resident revealed no open area, and some confusion and weakness, which were normal for the resident. The physician and family were notified. During interviews conducted with Licensed Practical Nurse (LPN) ""BB"", CNA ""CC"", LPN ""DD"", and Certified Occupational Therapy Assistant ""EE"" conducted on 02/01/2011 at 2:35 p.m., 2:40 p.m., 2:45 p.m., and 2:50 p.m., respectively, all staff members stated that they had observed Resident #1 to have the behavior of putting her feet down while being transported in the wheelchair. LPN ""BB"" specifically stated that staff had to cue the resident frequently to keep her feet up during transport via the wheelchair. Review of the resident's Care Plan revealed a 07/22/2010 entry identifying the resident to be at risk for falls. However, despite staffs' knowledge of the resident's behavior of lowering her feet during transport via wheelchair, record review revealed no evidence to indicate that the facility had evaluated the resident to develop interventions to address this behavior. A Nurse's Note of 01/13/2011 documented the consideration of the use of leg rests on the wheelchair to help prevent another incident and that occupational therapy was to screen the resident, and a 01/14/2010 entry on the Care Plan indicated that leg rests were to be placed on the wheelchair while staff were assisting the resident with locomotion.",2014-06-01
3004,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2019-04-26,655,D,0,1,522011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, staff interviews, review of the facility policy titled, Care Plans - Baseline the facility failed to ensure that five of 31 residents (R#238), R#79, R#73, R#52 and R#11) , or their responisble partyreceived a baseline care plan or a copy/summary of the baseline care plan. Therefore, they were not made aware of the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality of care. Findings include: During review of the facility policy entitled, Care Plans - Baseline, under the section Policy Interpretation and Implementation number 4, 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. 1. Record review revealed taht R #238 was admitted to the facility on [DATE] with multiple health concerns including but not exclusive to: left kidney cysts, [MEDICAL CONDITIONS], depression, stenosis of carotid artery, diabetes and a history of a [MEDICAL CONDITION]. He admitted from the acute care hospital after treatment and resolution for a fungal urinary tract infection. Although a baseline care plan was completed for this resident there was no evidence that a copy or a summary of that information was provided to the resident or his responsible party. Record review revealed that R#79 was admitted to the facility on [DATE] with multiple health concerns including but not exclusive to: existing pressure ulcer, [MEDICAL CONDITION], hypertension, arthritis, malnutrition and an anxiety disorder. Although a baseline care plan was completed for this resident there is no evidence that a copy or a summary of that information was provided to the resident or her family representative. R#11 was admitted to the facility on [DATE] with multiple health concerns including but not exclusive to: diabetes, [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION], chronic pai[DIAGNOSES REDACTED], depression and dementia with delusions. Although a baseline care plan was completed for this resident there is no evidence that a copy or a summary of that information was provided to the resident or her family representative. During an interview on 04/25/19 at 11:07 a.m., with the Minimum Data Set (MDS) Coordinator AA revealed that MDS AA was not aware of the regulation that the family and resident must receive a copy/summary of the baseline care plan and that she hasn't been giving them the baseline care plans During an interview with the Director of Nursing (DON) on 04/25/19 at 11:38 a.m., revealed that she knew this would be a citation because she had spoken with the MDS Coordinator on 4/24/19 and that she understands that bother MDS AA and the DON were was unaware of this regulation. 2. Record review revealed that R#52 was admitted with multiple medical problems including but not limited to [MEDICAL CONDITION], dementia, hypertension, depression, restless leg syndrome, [MEDICAL CONDITION] and gastric reflux. She was admitted under the services of a local hospice organization. Review of a baseline care plan reflects it was completed on the day of admission; however, there is no evidence that a summary of the baseline care plan was provided to the resident or responsible party. Record review revealed that R#73 was admitted with multiple serious medical conditions including but not limited to adult failure to thrive, stenosis or narrowing of cervical spine, stage two decubitus ulcer, low potassium levels and [MEDICAL CONDITION]. There is no evidence that a baseline care plan was developed within 48 hours of admission. An interview was conducted on 4/25/19 at 3:15 PM with MDS AA, the MDS Coordinator, who confirmed that a copy or summary of the baseline care plan was not provided to the residents or the residents responsible party.",2020-09-01
3005,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2019-04-26,761,E,0,1,522011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and review of the policy titled, Medication Storage in the Facility: Storage of Medications and Expiration Dating of Medications, the facility failed to ensure medications were dated appropriately when opened to determine the discard date in two of three medication carts; and failed to discard expired biological's prior to expiration date in three of three medication carts inspected. Findings include: Review of the facility policy titled Medication Storage in the Facility: Storage of Medications effective date 4/1/16 revealed the following: When the original seal of the manufacturer's container or vial is initially broken, the container or vial will be dated. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration. The nurse will check the expiration date of each medication before administering it. All expired medications will be removed from the active supply and destroyed in the facility, regardless of the amount remaining. The medication will be destroyed in the usual manner. Review of the facility policy titled Medication Storage in the Facility: Expiration Dating of Medications effective 3/1/16 revealed the following: Oral solid medications (capsules and tablets) packaged by the manufacturer will be labeled with an expiration date. Ophthalmic medications will be discarded sixty (60) days after initial dose or according to the manufacturer recommendation discard date. The medication will be noted with the date the medication was initially opened. Injectable medications dispensed by the pharmacy will be discarded thirty (30) days after initial dose or according to manufacturer recommended discard date. The medication will be noted with the date the medication was initially opened. Review of the package insert for [MEDICATION NAME] revealed unused [MEDICATION NAME] should be stored in a refrigerator between 36 degrees and 45 degrees. 1. An observation and inspection made on 4/25/19 at 8:30 a.m. of the B Hall Medication Cart revealed a bottle of multivitamin with iron with an expiration date of (MONTH) (YEAR), a bottle of zinc 220mg with an expiration date of (MONTH) 2019, and a bottle of folic acid 400mg with an expiration date of (MONTH) (YEAR). An opened bottle of dorzolamide 2% ophthalmic drops for resident (R)#9 that was not labeled with an open date that had a delivery date of 4/8/19. 2. An observation and inspection on 4/25/19 at 9:10 a.m. of the A Hall Medication Cart revealed an unopened vial of [MEDICATION NAME]for R#65 delivered on 4/2/19. The label reads to store in the refrigerator until opened. An unopened vial of [MEDICATION NAME] 40,000 units for R#84, delivered 4/24/19. The label reads to store in the refrigerator until opened. An opened bottle of lantanoprost 0.005% eye drops for R#65, delivered on 3/25/19 that was not labeled with an open date indicated on the bottle. A bottle of Aspirin 81mg [MEDICATION NAME] coated (EC) with an expiration date of (MONTH) 2019. 3. An observation and inspection made on 4/25/19 at 1:29 p.m. of the D Hall Medication Cart revealed an opened bottle of KAO-Tin [MEDICATION NAME] 262 milligram (MG) bottle that expired on (MONTH) (YEAR). An interview held on 4/25/19 at 2:46 p.m. with the Director of Nursing (DON) revealed medications should be removed when they are expired. Medications should be labeled with an open date. The DON stated the 11-7 nurses are supposed to be checking the medication carts and medications rooms weekly on Tuesday nights for expired medications and proper labeling of medications. She stated they do not keep a log of checking the carts or med rooms. Her expectations are to not have any expired meds on the cart or in the med room. An interview held on 4/26/19 at 9:54 a.m. with Registered Nurse (RN) Assistant Director of Nursing (ADON) revealed when the nurses are hired they are educated during orientation on medication storage and destruction. She stated the nurses instruct the orienteers during the floor orientation on the process of removing expired medications. She further stated the 11-7 nurses are instructed to check the carts and med rooms weekly for expired medications and to remove them from the cart for destruction. Review of an inservice held on 3/21/19 for all nurses revealed the 11-7 nurses are responsible for several tasks on their shift that include cleaning drug carts every Sunday, remove loose pills, expired medications and re-stocking items that need replacing. All nursing staff reminder included to date all vials/drops when opened.",2020-09-01
3006,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2019-04-26,812,F,0,1,522011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and the facility policies titled, Food Storage and Policy on Flour, Corn Meal, and Sugar, the facility failed to properly store food items in a sanitary condition to prevent food contamination, failed to remove dented cans from stock to be use, failed to label and date food items, and disposed of expired food items, failed to clean a commercial fan with brown greyish substance on the blades and rim fan position on the blades and rim fan position in an area facing the steam table This had the potential to effect 87 of 87 residents receiving an oral diet. Findings include: Record review of facility policy titled, Food Storage documented the following: Sufficient storage facilities are provided to keep food safe, wholesome, and appetizing. Food is stored in an area that is clean, dry and free from contaminants. Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination or cross contamination. a. Foods will be stored and handled to maintain the integrity of the packaging until ready for use. (Food stored in bins may be removed from its original packaging). 8. All stock must be rotated with each new order received. Rotating stock is essential to assume the freshness and highest quality of all foods. a. Old stock is always used first (first in-first out method) d. Date marking to indicate the date or day by which a ready-to-eat , potentially hazardous food should be consumed, sold or discarded will be visible on all high risk food 14. Refrigerated Food Storage: f. All foods should be covered , labeled and dated . All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable ) or discarded. Leftover food is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded. 13. Frozen Foods; c. All foods should be covered , labeled and dated. All foods will be checked to assure that foods will be consumed by their safe used by dated or discarded. Record review of facility policy titled, Policy on Flour, Corn Meal, and Sugar documented the following: Canisters are used to store Flour, Sugar and Corn Meal. One bag at a time is put into the containers and when that bag is gone then container is washed, air dried and another bag is emptied in the container. Observation with the Dietary Manager (DM) on [DATE] at 11:55 a.m. revealed a sticky light brown substance on the inner side of the bin containing flour. When the DM swiped the light brown substance with a napkin, the substance stuck to the napkin. Interview on [DATE] at 11:55 a.m. at the time of observation of the bin labeled four with the DM revealed that her expectations are for staff to clean the flour bin prior to restocking. Observation of the pantry with the DM [DATE] at 11:57 a.m. revealed a open can of ceiling paint with no lid sitting on the second pantry shelf. Directly below on the second shelf was an open box of graham cracker crumbs. A dented can of jellied cranberry sauce (one gallon can) next to various food items on the same shelf. The DM stated that her expectations are for the staff to place all dented cans in the designated area for dented cans. She further stated that the ceiling was in the process of being painted by a painter who comes in the afternoon. The painter was at the facility on last night [DATE] painting. Observation with the DM on [DATE] at 11:57a.m. of the walk in freezer revealed concerns with the following food items: an open bag of hash browns with a large hole in the side of the bag, hot dogs in a plastic bag with no label and no open/expiration date. A open bag of green peas with no open date. A open bag of diced chicken with no open date. Observation with the DM on [DATE] at 11: 59 a.m. of Reach in Refrigerator #1 revealed a large gallon open container of pickles reddish and a large gallon open container of mayonnaise with no open date. Container meat balls with no open and expiration date Observation with the DM on [DATE] at 12:02 a.m. of the milk cooler revealed 3 (three) half pint of milk carton with expiration date of [DATE] mixed in the crate with other milk cartons. Observation with the DM and Administrator on [DATE] at 5:15 p.m. revealed the following: a large commercial fan with brown greyish substance on the blades and rim fan position in a area facing the steam table.(The DM identified the substance as dust and debris.). The Administrator at the time of the interview stated that his expectation is for the fan to be clean. He further stated that Maintenance is responsible for cleaning the fan.",2020-09-01
3007,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2019-04-26,880,E,0,1,522011,"Based on observations, review of the facility policy titled, Storage of Patient's Basins and Bedpans and Toothbrushes, and staff interview the facility failed to store patient care equipment in a sanitary manner to prevent the spread of infection in four of six bathrooms. Finding include: Review of the facility policy titled Storage of Patient's Basins and Bedpans and Toothbrushes dated 4/25/19 revealed each resident's personal basin and bedpan will be labeled with their name. After each use, each will be cleaned and dried. They will be stored in a plastic bag on a shelf in the patient's bathroom. Patient's toothbrushes will be rinsed after use and stored in a toothbrush holder labeled with their name. Observations made in room C42's bathroom on 4/23/19 at 2:50 p.m., 4/24/19 at 10:40 a.m. and on 4/25/19 at 2:03 p.m. revealed one wash basin on the shelf in the bathroom that was not labeled with a resident's name or bagged to prevent the spread of infection. Observations made in room C43's bathroom on 4/23/19 at 1:55 p.m., 4/24/19 at 10:41 a.m. and 4/25/19 at 2:03 p.m. revealed one wash basin on the shelf in the bathroom that was not labeled with a resident's name or bagged to prevent the spread of infection. And one basin that was labeled with a resident's name but was not bagged to prevent the spread of infection. Observation and interview on 4/25/19 at 2:03 p.m. with the Administrator and the DON they both verified the basins should have been labeled with the resident's name and bagged to prevent the spread of infection. Observations made in room C41's bathroom on 4/23/19 at 1:51 p.m., 4/24/19 at 10:43 a.m. and 4/25/19 at 2:03 p.m. revealed one wash basin on the shelf that was not labeled with a resident's name or bagged to prevent the spread of infection and one basin that was labeled with a resident's name but was not bagged to prevent the spread of infection. Also, two toothbrushes were noted on the back of the sink that were not labeled with a resident's name or stored in a container to prevent the spread of infection. Observation and interview on 4/25/19 at 2:03 p.m. during a tour with the Administrator and the DON revealed they both verified the basins and toothbrushes should have been labeled with the resident's name and bagged to prevent the spread of infection. Observations made in room C44's bathroom on 4/23/19 at 1:56 p.m., 4/24/19 at 10:45 a.m. and 4/25/19 at 2:03 p.m. revealed two wash basins on the shelf that were not labeled with a resident's name or bagged to prevent the spread of infection and one bed pan that was not labeled with a resident's name or bagged to prevent the spread of infection. Observation and interview on 4/25/19 at 2:03 p.m. with the Administrator and the Director of Nursing (DON) they both verified the basins and bedpans should have been labeled with the resident's name and bagged to prevent the spread of infection. An interview held on 4/25/19 at 1:16 p.m. with Licensed Practical Nursing (LPN) BB revealed she has received education on infection control related to the storage of bed pans, wash basins and toothbrushes. The expectations are when the Certified Nursing Assistant (CNA) is finished with the bed pan, wash basin or tooth brush, it should be cleaned out and stored in a bag and should be labeled with the resident's name. An interview held on 4/25/19 at 1:19 p.m. with CNA EE revealed the bedpans, wash basins and toothbrushes should be labeled with the resident's name, cleaned after use, dried out and stored in a bag on the shelf in the bathroom. An interview held on 4/25/19 at 2:05 p.m. with the DON revealed the wash basins, bed pans and tooth brushes should be labeled with the resident's name and stored in a separate container like a bag. An interview held on 4/25/19 at 2:06 p.m. with the Administrator revealed the staff should check the wash basins, bed pans and toothbrushes daily to ensure the personal equipment is properly labeled and stored to prevent the spread of infection. He revealed that the equipment should not be stored all together and not labeled. His expectations are to store them labeled with their name and bagged separately. An interview held on 4/26/19 at 9:50 a.m. with Registered Nurse (RN) Assistant Director of Nursing (ADON) revealed she has given in-services related to infection control. She stated the CNA's have been educated on the proper way to store the resident's personal equipment that include the wash basins, bed pans and toothbrushes. She has instructed them the store the supplies in a bag and labeled with the resident's name.",2020-09-01
3008,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2018-06-28,644,D,0,1,3FKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to screen one Resident (R) (R#67) for Pre-Admission Screening Annual Resident Review (PASARR) Level ll services. The facility census was 94 residents. Findings include: Review of the medical record for R#67 revealed a [DIAGNOSES REDACTED]. Further review of the record revealed that the resident had resided in the facility since 7/13/15. The record also revealed that R#67 was approved for a PASARR Level I on 12/3/10 and that a screening for a PASSARR level II was never conducted. Review of the nurse's notes revealed that R#67 has had some recent episodes of behaviors of refusing medications, resisting care, and exhibiting behaviors of anxiety such as yelling out and refusing to leave her room and wanting to stay in bed and not participating in activities. Review of R#67's Physician order [REDACTED]. Interview on 6/27/18 at 11:33 a.m., Certified Nursing Assistant (CNA) FF revealed that R#67 has a history of exhibiting behavior of refusing care with other CNA's. Interview on 6/27/18 at 11:43 a.m., Licensed Practical Nurse (LPN) EE stated that R#67 can be rude and disrespectful to the CNA's and basically not wanting to get out of bed or shower. LPN EE further revealed that R#67 exhibits these behaviors often. During an interview on 6/27/18 at 3:34 p.m., the Social Service Director (SSD) stated that R#67 was admitted from another facility with the [DIAGNOSES REDACTED]. The SSD verified that she is the designated staff to complete the screening process for PASARR Level II for all residents; however, she only reviews residents for a PASARR Level II only if they have changes in behaviors, such as behaviors of self inflicting harm and [MEDICAL CONDITION]. SSD revealed that she is not aware of any policy for PASARR Level II. Interview on 6/27/18 at 3:45p.m. the Director of Nursing (DON) reported that residents should be process prior to admission to the facility for PASSR Level l and Level II. The DON revealed that she is not familiar with the criteria for a PASARR Level II, the policy or location of the facility policy for screening residents for a PASARR Level II.",2020-09-01
3009,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2018-06-28,658,D,0,1,3FKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record and Medication Administration Records (MAR) review, policy review and interviews the facility failed to ensure that finger stick blood sugars (FSBS) were completed for one resident, Resident#48 (R#48) so that insulin could be administered per the physician orders [REDACTED]. The facility had a census of 94 residents. Findings include: Record review revealed that R#48 was admitted to the facility with [DIAGNOSES REDACTED]. Her cognition was moderately impaired. She was placed on medication management for her [DIAGNOSES REDACTED]. Record review revealed that R#48 had a physician order [REDACTED]. During review of R#48's finger stick blood sugars (FSBS) on the Medication Administration Records (MAR) for insulin sliding scale amounts the following information was revealed: Record review of the MAR for R#48 for (MONTH) 8, (YEAR) at 6:30 a.m. revealed that the Finger Stick Blood Sugar (FSBS) was not drawn and that there was no insulin administered at the time as ordered by the Physician. Record review of the MAR for R#48 for (MONTH) 15, (YEAR) at 4:30 p.m. revealed that the Finger Stick Blood Sugar (FSBS) was not drawn and that there was no insulin administered at the time as ordered by the Physician. Further review revealed that there was no documentation present in the nursing notes or on the back of the MAR indicated [REDACTED]. Record review of the MAR for R#48 for (MONTH) 16, (YEAR) at 4:30 p.m. revealed that the Finger Stick Blood Sugar (FSBS) was not drawn and that there was no insulin administered at the time as ordered by the Physician. Record review of the MAR for R#48 for (MONTH) 23, (YEAR) at 4:30 p.m. revealed that the Finger Stick Blood Sugar (FSBS) was not drawn and that there was no insulin administered at the time as ordered by the Physician. There was no documentation present in the nursing notes or on the back of the MAR indicated [REDACTED]. Record review of the MAR for R#48 for (MONTH) 9, (YEAR) at 4:30 p.m. revealed that the Finger Stick Blood Sugar (FSBS) was not drawn and that there was no insulin administered at the time as ordered by the Physician. Record review of the MAR for R#48 for (MONTH) 10, (YEAR) at 4:30 p.m. revealed that the Finger Stick Blood Sugar (FSBS) was not drawn and that there was no insulin administered at the time as ordered by the Physician. There was no documentation in the nursing notes or on the back of the MAR indicated [REDACTED]. Review of the facility policies and procedures entitled, Medication Administration - General Guidelines, effective (MONTH) 1, (YEAR), revealed that under subpart, B Administration Number 2, Medications are administered in accordance with written orders of the prescriber. Also, the policy stated under subpart D, Documentation, Number 6, If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled. An explanatory note is entered on the reverse side of the record. Interview on 6/27/18 at 11:43 a.m. with the Director of Nursing (DON) on (MONTH) 27, (YEAR) at 11:43 a.m., revealed that the FSBS should be completed according to the Physician orders [REDACTED].",2020-09-01
3010,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2018-06-28,758,D,0,1,3FKP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy titled, Pharmacy Partners of Ga (Georgia) and Final Rule Implementation of Phase 2 Pharmacy Services (483.45) (F758) the facility failed to stop an order for [REDACTED]. Findings include: Review of Physician Order dated 5/1/18 revealed an order for [REDACTED]. Further review of the MAR indicated [REDACTED]. Review of a Gradual Dosage Reduction document dated 5/24/18 revealed [MEDICATION NAME] (q hs prn) every night as needed for [MEDICAL CONDITION] was reviewed by the Pharmacist. The Pharmacist's recommendation included a statement that made a reference to the 14 days requirement for all prn medications. Interview on 6/28/18 at 2:31 p.m., with the Director of Nursing (DON) revealed that she felt [MEDICATION NAME] re-written as an ongoing order by the Physician and that her expectation as it relates to 14 days prn medications are that the 14 days prn medication requirements are followed per policy. Interview on 6/28/18 at 3:00p.m., with the Administrator revealed that his expectations are for nursing staff to follow all stop orders for medications including prn medications. Review of policy titled Pharmacy Partners of Ga and Final Rule Implementations Phase 2 Pharmacy Services (483.45) F758), the policy documents: (5) PRN orders for [MEDICAL CONDITION] drugs are limited to 14 days. If the attending Physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she would document their rationale in the resident 's medical record and indicate the duration for the PRN order. .",2020-09-01
3011,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2018-06-28,812,F,0,1,3FKP11,"Base on observation, staff interview, and the facility policy titled Ice Machine Disinfecting Policy & Procedure, the facility failed to maintain the cleanliness and sanitation of the following dietary equipment: one ice machine, one three compartment sink faucet and the faucet and inside panels of the two compartment vegetable sink. This had the potential to effect 91 residents receiving an oral diet. Findings include: An interview was conducted at the time of an observation on 6/25/18 at 10:15 a.m. of the three compartment sink faucets with the Dietary Manager (DM), the observation revealed a thick white filmy and flaky substance on the spout, hot and cold water control handles, and the circular areas and rim of aerator (where the water is dispensed). The DM described the filmy and flaky substances as a product of corrosion which resulted from water residue and calcium deposit built up, The DM further stated that she had attempted on several occasions to remove the substances with various cleanser. She stated that once the faucets are dried the substances returns. Observation, and interview, on 6/25/18 at 10:26 p.m. with the DM of the two compartment vegetable sink revealed a similar thick white filmy and flaky substances covering the spout, the hot and cold water control handles, and the circular areas and rim of the aerator (where the water is dispensed) of the sink. The inside panels of both sinks also revealed the same white filmy and flaky substances coating the left and right panels of both sinks. The DM confirmed that she uses the sink to wash vegetables and had also tried to clean the sinks with various products. She reported that her last attempt to clean the sinks was a few days ago. She could not provide information about the exact date that the cleaning was completed on the two compartment vegetable sink. Observation and interview on 6/25/18 at 10:30 a.m. with the DM revealed a black slimy substance in the ice machine. Interview at the time of the observation with the DM revealed that her expectations are for the ice machine to be cleaned thoroughly and free from grime and debris. Interview on 6/28/18 at 1:44 p.m., the Administrator stated he because of the calcium built up on the faucets, there were no products that could completely clean the faucets for both the two compartment vegetable sink and the three compartment sink. He also stated that the inside side of the vegetable sinks could not be thoroughly cleaned for use. Review of the facility policy titled Ice Machine Disinfecting Policy & Procedure revealed Policy: The following procedure will be followed to prevent the spread of infection. Staff Responsible- Dietary, Housekeeping or Administrator will designate Procedure (performed monthly) C. Sanitize entire ice machine (including filters with bleach. (1/2 ounce per gallon of water_). D. Rinse entire ice chest with clear water. . \",2020-09-01
3012,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2017-07-27,282,D,1,1,6DS411,"**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) #15 out of 35 sampled residents, by qualified staff, in accordance with their care plan related to the administration of medications. As a result, the resident received medications at the wrong time according to the physician order. There was no adverse outcome to the resident. Findings include: Review of the Admission Record showed Resident (R ) #15 12/14/16 with diagnses that included, but may not be limited to; [MEDICAL CONDITION] with behavioral disturbances, peripheral artery disease, [MEDICAL CONDITION], weakness, [MEDICAL CONDITIONS] left upper extremity, hypertension, chronick obstructive [MEDICAL CONDITION] disease, macrocytic [MEDICAL CONDITION]. Review of resident the Care Plan for R#15 revealed the resident was at risk for injury and decreased quality of life related to the fact she is resistive to care at times and can become physically abusive to staff. She receives [MEDICAL CONDITION] medications and is at risk for adverse side effects. Date initiated: 12/23/2016. The care plan indicated staff was to administer the mediations as ordered by the physician. Review of the physician's orders [REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Records (MAR) revealed staff failed to administer the resident's [MEDICATION NAME] as ordered by the physician. Staff failed to follow physician order [REDACTED]. Specifically, the [MEDICATION NAME] 0.5mg was administered by staff on 7/10/17 at 2 p.m. , 7/16/17 @ 630 p.m. , 7/17/17 at 10:45 a.m., 7/24/17 at 12 p.m. , 7/25/17 at 10:45a.m. , and 7/26/17 at 2 a.m 7/7/17. Record review revealed [MEDICATION NAME] was administered to the resident other than the QHS PRN direction. Review of the Nursing note dated 7/4/17, revealed the resident had unzipped canopy bed (start date per Care Plan 12/28/16, due to getting out of bed (OOB) without assistance and high risk of falls) and pulled Foley catheter out. There was vaginal bleeding noted and resident was sent to the emergency room (ER) for evaluation. Foley catheter was re-inserted in the ER. When resident returned per note, she was very agitated. [MEDICATION NAME] 1mg was administered. (This was documented when the [MEDICATION NAME] order was 1mg QHS prn.) The order changed to 0.5mg QHS prn on 7/7/17 per physician order. LPN # CC was interviewed on 07/27/2017 at 9:30 a.m. , and voiced that there has been no change noted in (R) #15's behavior. She stated she has not observed resident being drowsy or lethargic. She stated resident needs [MEDICATION NAME] prn for agitation mostly in the evening. She stated the canopy bed is to protect resident from falls. She said the resident is up in her wheelchair every day and is cooperative and pleasant with staff and residents. On 07/27/2017 at 12:20 p.m. , LPN # CC stated resident receives [MEDICATION NAME] for agitation. She stated the increase agitation is noted after lunch, after physical therapy and/or at bedtime. On 07/27/2017at 1:50 p.m. , RN # BB, reported her expectations for a nurse giving a medication ordered at bedtime as needed means to give the medication when needed at night. She reported she agrees the times administered and documented on the MAR and Narcotic sheet does not follow the physician order. She voiced these were medication administration errors.",2020-09-01
3013,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2017-07-27,323,E,1,1,6DS411,"> Based on observation and staff interview the facility failed to ensure that the resident environment remained as free of accident hazards as possible for two of four halls as evidenced by: Observation on 6/25/17 at 4:10 p.m. , of a medication pass, it was noted that LPN # FF, left her medication cart unlocked, unsupervised and out of her view while administering medication to a resident on A Hall. The cart was unlocked and unsupervised approximately 2-3 minutes while nurse and this surveyor were in the resident room. Observation on 6/25/17 at 4:35 p.m. revealed that LPN # AA, left her medication cart assigned to her on C Hall (Memory Care Unit) unlocked, unsupervised and out of her view while she was administering medications to a resident. The cart was unlocked and unsupervised for approximately 2-3 minutes and during that time a resident with cognitive impairment propelled herself by the medication cart. Observation on 6/25/17 at 4:55 p.m. revealeed that LPN # AA, left her medication cart assigned to her on C Hall (Memory Care Unit) unlocked, unsupervised and out of her view while she was administering medications to a resident. The cart was unlocked and unsupervised for approximately 5minutes while she was administering medications in the resident room. interview on 07/27/2017 at 4:05 p.m. with RN BB (nurse supervisor) revealed that the expectation of the nurses is to keep their carts locked when not in sight of them or when they go off the floor or unit. She reported any new nurse employed here receives training from the medication nurse of the hall she is assigned to. She reported this is something they are trained in nursing school and should know this before being hired. She also confirmed if a nurse goes off the floor she is to leave her keys with the other nurse assigned on the same hall or unit.",2020-09-01
3014,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2017-07-27,371,F,1,1,6DS411,"> Based on observation, record review, review of the facility's Food Storage Policy, review of Georgia Department of Public Health Rules and Regulations Food Service and staff interview, it was determined that the facility failed to ensure cleanliness of the kitchen floors; failed to discard food items in reach-in cooler #2 within two (2) days of their open dates as per facility policy; failed to maintain hot food temperatures at or above 135 degrees Fahrenheit (F) and cold food temperature at or below 41 degrees (F) to prevent food borne illness; and failed to ensure that one (1) non-dietary staff wore protective hair covering when in the kitchen. This deficient practice had the potential to affect 91 residents who received an oral diet. Findings include: 1. During the kitchen tour on 7/24/17 at 10:10 a.m. there was a buildup of a dark substance on the floor along the wall under the three compartment sink, on the floor under the table holding the Stearcraft Steamer and on the floor along the wall of the table on which the tea and coffee makers were stored. There was a heavy buildup of a dark substance on the floor along the wall under the dishwasher, on the floor under the oven and on the floor under the fryer. Also there was a heavy buildup of a dark substance and food debris on the floor under the steam table as well as paper and food debris on the floor under the metal shelf on which the strainers and metal bowls were stored. 2. During the kitchen tour on 7/24/17 at 10:20 a.m., there was an open package of sliced honey ham with an open date of 7/20/17, a plastic storage container of fruit cocktail with an open date of 7/12/17 and a container of sliced cheese with an open date of 7/19/17 inside reach-in cooler #2. Interview with the Dietary Supervisor at that time revealed that the dates on the food items were the dates the food items were opened. Continued interview revealed that opened food items were kept two days and then thrown out. Review of the Food Storage Policy revealed the cooks will check leftovers daily and discard those leftovers not used within two days. 3. Observation of the steam table temperatures taken by Dietary Cook MM with the facility's calibrated thermometer on 7/26/17 at 12:36 p.m. revealed that all of the hot foods prepared for service at lunch were being held at the acceptable level above 135 degrees Fahrenheit (F) except for the chili which was 120 degrees (F), the chopped hotdog which was 115 degrees (F) and the ground hotdog which was 120 degrees (F). Although those food items were not held at the appropriate temperature to prevent potential food borne illness, dietary staff did not remove and reheat the food items. Continued observation of the lunch service revealed that 27 residents received the chili, two (2) residents received the chopped hotdog and four (4) residents received the ground hotdog. On 7/26/17 at 1:00 p.m., observation of the cole slaw temperature taken by Dietary Aide OO using the facility's calibrated thermometer revealed that the temperature was 48 degrees (F). Continued observation revealed that Dietary Aide OO continued to serve the cole slaw to 23 residents. Review of the Steam Table Temperature Log for the lunch service on 7/26/17 revealed that the documented temperatures of the hot foods were above 160 degrees (F) and the temperature of the cold food was 40 degrees (F). Review of the facility Food Temperature form provided by the Dietary Supervisor revealed that cold foods such as cole slaw should be prepared and stored at temperatures between 35 and 40 degrees (F). Continued review revealed that meat and pureed meat should be held on the steam table at 140 degrees (F) or above. Interview with the Dietary Supervisor on 7/26/17 at 12:44 p.m. revealed that all dietary staff are in-serviced on the appropriate temperatures for hot and cold foods. Interview on 7/26/17 at 12:46 p.m. with Dietary Aide LL, who was serving residents from the steam table, revealed that she was newly hired and was not aware of the temperatures that the hot food items should be maintained. Interview with Dietary Aide OO on 7/26/17 at 1:18 p.m. revealed that cold food items should be maintained at 40 degrees (F) or below. When asked why she continued to serve the cole slaw to residents after obtaining a temperature of 48 degrees (F), she stated that the cole slaw was on ice. Interview with Dietary Cook MM on 7/26/17 at 2:32 p.m. revealed that temperatures of hot foods were checked when they were first removed from the oven and prior to placing the food items on the steam table. Continued interview revealed that she checked the food temperatures again while on the steam table during the meal service but, did not document the temperatures at that time. Further interview revealed that if a food item was 100 degrees (F), she would reheat the food. Continued interview revealed that if a food item was 120 degrees (F), the food was alright to serve. Review of the Georgia Department of Public Health Rules and Regulations Food Service, Time/Temperature Control for Safety Food, Hot and Cold Holding revealed that except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained at 41 degrees F or below, or 135 degrees F or above. 4. On 7/26/17 at 1:05 p.m. during observation of the lunch service, a Certified Nursing Assistant (CNA) walked into the kitchen and stood close to the steam table to request food for a resident in the dining room. The CNA did not apply a protective covering over her hair to prevent her hair from potentially falling into the food. Interview with the Dietary Supervisor on 7/26/17 at 2:55 p.m. revealed that the temperature of the hot food items should be checked when they first come out of the oven and should be between 170 and 180 degrees (F) at that time. Continued interview revealed that the food items should be greater than 136 degrees (F) when they are placed on the steam table. Continued interview revealed that the hot food items should arrive to the resident or point of service at temperatures between 115 and 120 degrees (F). Further interview revealed that the Dietary Supervisor did not know that hot food items should be maintained at 135 degrees (F) or above while on the steam table. Continued interview revealed that the temperature of food items was not checked at point of service. Interview with the Dietary Supervisor on 7/27/17 at 9:25 a.m. revealed that dietary staff were assigned to check the reach-in cooler daily to ensure that food items were within date. Continued interview revealed that the package of sliced honey ham observed 7/24/17 with an open date of 7/20/17 should have been removed in two days, on 7/22/17. She stated that the container of fruit cocktail dated 7/12/17 should have been removed within two days on 7/14/17. Further interview revealed that the container of sliced cheese dated 7/19/17 could be kept for three to four days but, should have been removed 7/23/17. Continued interview with the Dietary Supervisor at that time revealed that the dietary staff swept and mopped the kitchen floor daily and that deep cleaning of the kitchen floors was done by an employee who no longer worked at the facility. The Dietary Supervisor stated that housekeeping had taken over the task but, she did not know when housekeeping had last deep cleaned the kitchen floor. Further interview revealed that she expected non-dietary staff to refrain from entering the kitchen during meal times and to call dietary staff to bring food items out of the kitchen. Review of the 10/27/16 and 1/5/17 In-service Education attendance records revealed that dietary staff were educated on cleaning duties for the kitchen. Continued review revealed that Dietary Cook MM attended both in-services. However, continued review revealed that there was no education specific to monitoring the temperatures of hot and cold foods during meal service.",2020-09-01
3015,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2017-07-27,425,D,1,1,6DS411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, it was determined that the facility failed to ensure that prescribed medications were provided in a timely manner for one resident, R57. This failure resulted in no actual harm with the potential for more than minimal harm. Findings include: Review of the medication administration record (MAR) documentation for R57 revealed that the following medications were not available to be administered as ordered. Staff did not notify the physician nor the pharmacy, and subsequently, nursing staff did not administer the medications for one medicine, trazodone 50 milligram (mg) every hour of sleep (q hs) until 6 days later and one medicine, cymbalta 30 mg q hs was never administered. R57 had a physician order [REDACTED]. Staff documented that this medication was not available and not given on 7/19/17, 7/20/17, 7/21/17, 7/22/17, 7/23/17 and not given until 7/24/17. R57 had a physician order [REDACTED]. Staff documented that this medication was not available and not given from time period of 7/19/17 until 7/26/17. During an interview on 7/26/17 at 10:24am with licensed staff, Register Nurse (RN) Weekend Supervisor, she stated that nurses were to inform Director of Nurses when medications are not available on the nursing cart. She stated that nurses can use the backup pharmacy, to get medications if the facility pharmacy, cannot provide the medications. She stated that she was not aware that the medications listed above were not available for administration as ordered by the R57's physician. Interview with LPN CC on 7/26/17 at 11:11am verified her unawareness of the physician order [REDACTED]. Reported if a medication was discontinued this will be documented on the MAR and indicated on a physician order. Reported she was made of aware of the missing medication error today by the Weekend RN Supervisor Interview with LPN EE on 7/27/17 at 3:37pm verified that physician order [REDACTED]. She verified viewing the order on R57's MAR and perceived the order as being discontinued because it was highlighted. She later verified that there was nothing in the record to indicate that order was discontinued. Interview with the facility Administrator on 7/27/17 at 10:00 a.m. revealed that his expectations are that medications are to be given and order per physician order. Reported nurses should use the EK kit Emergency Kit for medications whenever there's a problem with the pharmacy. He stated that the facility also used their back up pharmacy. Interview with RN DD on 7/27/17 at 5:20 p.m. verified and identified herself as the nurse who took the order on 7/19/17. She stated that she faxed the order in on 7/19/17 and felt this order was discontinued. She reported that the last time she worked the 2nd shift (3pm to 11pm) was 7/21/17. Review of a fax transmittal to the facilitiy pharmacy indicated that physician order [REDACTED]. Review of facility policy title Medication Ordering and Receiving from Pharmacy revealed if the medication is not available, calls and faxes the pharmacy, using the after-hours emergency numbers(s) if necessary.",2020-09-01
3016,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2017-07-27,490,F,1,1,6DS412,"> Based on record review and interview, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain the highest practicable, physical, mental and psychosocial wellbeing of the residents. During this revisit survey, Federal Deficiency F371 was re-cited for failure to ensure that the Plan of Correction was fully implemented related to monitoring for protective hair covering being worn and the facility failed to monitor test tray food temperatures as indicated in the facility's Plan of Correction. Findings include: Record review and interview revealed that the facility was not in substantial compliance during the Standard survey of 7/24/17 through 7/27/17. Refer to the following deficiencies for specific details of noncompliance during the Revisit survey. Cross reference to F371: The facility failed to support the corrective actions of the Plan of Correction. Specifically, the facility failed to monitor the food temperatures on the random trays after the trays had been delivered, and the facility failed to monitor to ensure protective hair covering was worn in the timeframe stated in the Plan of Correction. This failure placed all 91 residents who, consumed food orally, at an increased likelihood of foodborne illnesses. Interview via telephone on 9/28/17 at 1:42 p.m. the Administrator confirmed that the monitoring was not conducted on the dates stated due to his Dietary Supervisor is only there Monday through Friday. He further stated it was an error on his part for writing daily monitoring in the Plan of Correct. Further interview revealed that there were no food temperatures documented on the Test Tray Evaluation Forms. He stated that the Dietary Supervisor kept temperatures in her office only if foods were not palatable, however she did not document them on the forms. He further stated he did not know why the Test Tray Evaluation Form was not completed as stated in the corrective action on the week of (MONTH) 27, (YEAR) and (MONTH) 2, (YEAR).",2020-09-01
3017,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2017-07-27,493,F,1,1,6DS411,"> Based on interviews and record review of employee files, the facility failed to ensure the Administrator's professional licensure was kept up-to-date. The Administrator's license had expired on (MONTH) 31, (YEAR). Findings include: Record review of the personnel files revealed that the Administrator license had expired on (MONTH) 31, (YEAR). During an interview with the Administrator on (MONTH) 26, (YEAR), at 4:00 p.m he revealed that due to multiple family and personal issues he had forgotten to re-new his Administrators license.",2020-09-01
4815,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2015-09-03,253,E,0,1,7RVL11,"Based on observation and staff interview the facility failed to provide effective housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior as evidenced by stained/discolored floors, build up dust debris on floors, thresholds and baseboard missing handles on drawers, stained window blinds, peeling non skid floor strips, build up dust/debris in air conditioner covers and rusty metal frame of raised toilet seat. This failure affected three (3) of four(4) hallways, four (4) of eighteen (18) rooms on A hall, six (6) of fourteen (14) rooms on C hall and four (4) of seven (7) rooms on D hall. Findings include: A hall During observation in room 8 on 8/31/15 at 12:18 p.m., the cover of the air conditioner unit had a build up of food particles. During observations in room 10 B on 8/31/15 at 4:37 p.m. and 9/1/15 at 8:34 a.m., there was build up of debris on the floor. During observation in room #14 on 8/31/15 at 11:55 a.m., the perimeter of the floor and under the beds had build up of debris and the closet door had visible signs of spillage/stained areas. In addition, in the bathroom the ceiling vent and areas in the ceiling stained. During observation in room #18 on 8/31/15 at 1:38 p.m.,the chest of drawers had a missing handle on the bottom drawer and the wood is broken and jagged. In addition, the floor had a build up of dust/debris. C hall During observation in room #36 on 9/1/15 at 11:48 a.m., the floor in the bathroom had a large stained/discolored area, the floor tile near the edges was loose and the threshold as well as around the bathroom door frame had a heavy build up of dust/debris. During observation in room #40 on 9/1/15 at 12:15 p.m., the edges of the floor and the baseboard had a heavy build up of dust/debris. During observation in room #42 on 9/1/15 at 12:06 p.m., the floor along the edges and the baseboard had a heavy build up of dust/debris. During observation in room #43 on 9/1/15 at 12:30 p.m., the floor along the edges, the baseboard and the bathroom threshold had a heavy build up of dust/debris. In addition the bathroom floor had a large stained/discolored area. During observation in room #44 on 9/1/15 at 1:01 p.m., the floor edges, the baseboard in the room as well as the threshold to the bathroom had a heavy build up dust/debris. During observation in room #46 on 9/1/15 at 11:39 a.m., the floor edges, the baseboard and the threshold to the bathroom doorway had a heavy build up dust/debris. D hall During observation in room #49 on 9/1/15 at 11:54 a.m., the edges of the floor, the baseboard and the threshold to the bathroom doorway had a heavy build up dust/debris. Also, in the bathroom the metal frame to the raised toilet seat had several rusted areas. During observation in room #50 on 9/1/15 at 11:02 a.m., the room floor along the edges, the baseboard and the threshold going into the bathroom had a heavy build up of dust/debris. In addition, the non skid strips in the bathroom were peeled up on one side and the arm rest on the wheelchair for A bed had torn covering in several areas. During observation in room #52 on 9/1/15 at 12:42 p.m., the over head light was missing the cover, the window sill had a build up of cob webs and dust, the window blind had several stained spots on the lower slats, the edges of the floor, the baseboard and the threshold of the bathroom doorway had a heavy build up dust/debris. During observation in room #53 on 9/1/15 at 1:06 p.m., the edges of the floor and the baseboard had a heavy build up of dust/debris. During an observation and interview on 9/3/15 at 2:00 p.m.,with housekeeping staff FF confirmed the above areas of concerns.",2019-06-01
4816,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2015-09-03,353,E,0,1,7RVL11,"Based on interviews and record reviews, the facility failed to meet the needs for three (3) of fourteen (14) residents (Resident #41, #40 and #118) and 1 of 3 families interviewed from a total sample of twenty-eight (28). Findings include: 1). In an interview with resident #41 on 9/1/15 at 10:34 a.m. stated that recently there has not been enough staff and occasionally she had to wait for assistance. In a second interview with Resident (#41) on 9/3/15 at 9:35 a.m. she said last night the aid was not aware she needed to be woken up and changed every 2 hours because she has had a bad rash in her peri area. Resident (#54) said she went to bed around 10 p.m. last night and wasn't changed again until around 6 a.m. She said her brief was soaked and the bed was wet. She said the aid was nice but she was not told to wake her up during the night to change her. Resident B said night before last she was asked to go to the dining room to eat. She said after dinner she went back to her room and turned on her call light because she wanted to go to bed. She said a staff came into the room and asked her what she needed then left and never returned. Resident (#54) said she waited for an hour then turned on the call light once again and waited another 1/2 hour to be put into bed. The resident said she is not going to go to the dining room for dinner any more. She said she told a staff member about the long wait. Resident #41 is cognitively intact. 2.) In an interview with resident #40 on 9/1/15 at 10:34 a.m. that she sometimes has to wait a long time for assistance. In a second interview with Resident (#40) on 9/3/15 around 9:15 a.m. she stated that she is able to let staff know when she need to go to the bathroom. She also revealed that she has had to go in her diaper and it makes her feel terrible. Resident (#40) is cognitively intact. 3). In an interview with resident 118 and her daughter on 9/1/15 at 10:34 a.m. revealed that there have been a couple of days she has had to go to the bathroom early in the day and staff did not come quick enough for her. In a second interview with the Resident #118 daughter on 9/2/15 at 1:18 p.m. she said during the admission process there was not any type of orientation to the facility. She said her mother did not get a shower or bath the first week she was here. She said it took a long time for the staff to assist the resident to the bathroom and she thinks her mother took herself. She said her mother did not know what the routine was and they did not know who to talk with about it. She said there was a staff member in the facility that knew her mother and advocated for her to get things done. She said things have gotten a little better. A follow-up interview with Resident #118 on 9/3/15 at 9:28 a.m. she said she was having a time getting up and dressed this morning and the things she needed was out of her reach. She said the staff took her She said none of the things she needed were nearby. She said the staff took her to the bathroom and then left in a hurry. She said they come and go quickly. She said the aid assisted her to the bathroom then left before she had a chance to ask for help getting dressed. She said she struggled to do it herself. In an interview with the Assistant Director of Nursing (ADON) on 9/3/14 state that she tries to work with the aides to ensure they are happy at what they are doing. She said there have been some grievances related to call lights not being answered timely, however she said she try to resolve the issue as soon as she is aware. There are no documented grievances related to Resident needs not being met for the last 6 months and staffing numbers meet and/or exceed minimum requirements.",2019-06-01
4817,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2015-09-03,371,F,0,1,7RVL11,"Based on observation and interview the facility failed to store foods in a safe and sanitary manner and failed to keep the food preparation area clean and well maintained. This places all residents who eat from the kitchen at risk for food borne illnesses. The total census was sixty-eight with three (3) residents receiving enteral feeding. Findings include: During an initial tour of the kitchen with the Certified Dietary Manager (CDM) on 8/31/15 at 9:30 a.m. the following was observed: The entire perimeter of the kitchen floor and dry storage room with debris. The two(2) vents on the inside of the cooler have visible debris. The dry storage room has packages of seasoning mixes that have been taken out of the package. Some of the packages are labeled honey glaze mix and others are potato mix. One of the honey glaze packets is opened. There are no expiration dates on these items as they have been removed from the original packaging. On the corner shelf of the dry storage room there are packages of food that have been taken out of the box. There are no labels to identify what the food and along with no expiration date. Items in this area appear to be cookies, cereal and cake mixes. The CDM said the staff take the food out of the boxes to free up shelf space. The walk in freezer has a large bag of bread sticks, cookies and other items that have been taken out of the original package and are not labeled or dated. There is what appear to be a package of some type of frozen meat item that is not labeled or dated. The floor in the dry storage has a broken surface and is not clean. The door frame into the dry storage is in poor condition, exposing paint on the metal and appears to be rusted. The metal shelving in the food preparation area has missing paint. The shelf where the clean plates and other dishes are stored is missing paint and the surface is dirty. The walls in the dry storage are stained with drips. The outside surface of the steamer, convection oven and refrigerators are dirty. There are two rodent boxes in the dry storage area without evidence of any droppings. A follow up visit to the dry storage area on 9/3/15 at 12:19 p.m. revealed that there was still visible debris especially in the corners where a cookie was on the floor. The two rodent traps are still on the floor and appear to have been there for awhile. The CDM said she is not aware of any mice or other rodents in the dry storage and she does not know when those traps were placed. The entire kitchen and dry storage floor,especially the perimeter is full of debris. The CDM said it has been awhile since shelves were removed and the floor deep cleaned. The motor on the outside of the convection is full of debris, the knobs are dirty and the leg has a piece of cardboard under it to keep it level. The kitchen floor underneath the deep fryer has built up greasy brown substance. The kitchen floor underneath the clean muffin tins and strainers has visible debris. The two (2) shelf counter where the clean dishes are stacked has missing paint and has visible debris. The fans inside of the refrigerator where juice and milk is stored has crusty debris. The wire wrack over the clean pots and pans and utensils has visible thick debris resembling dust and the vent above has visible condensation with black crusty debris. The sprinkler head is full of what appears to be dust. The rubber spatulas have broken surfaces. The steamer is sitting on a very dirty stand with visible food particles on the outside and there are clean dishes sitting on top of it. The vent above the ice machine is packed with debris appearing as dust. The dishwashing area where food is scraped from the dishes has dried food on both legs of the table and underneath. It has been observed this way for three (3) days. The end of the table where clean dishes come out of the dishwasher to be placed on a rack is being leveled with two brick underneath.",2019-06-01
5559,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2014-11-14,253,D,0,1,CPCC11,"Based on observation, staff and resident interview, the facility failed to maintain a clean and comfortable environment as evidenced by stained ceilings; stained or damaged flooring; dirty siderail; patched and unpainted wall; and dusty vents in seven (7) resident rooms and bathrooms on one (1) of four (4) halls. The facility census was ninety-eight (98) residents. Findings include: The following observations were made in resident rooms on the B-hall: Room B-19-A: On 11/11/2014 at 10:39 a.m., the inner aspect of the top quarter side rail on the right side of the bed was observed to have several brown smears on it. Room B-21: On 11/10/14 at 3:29 p.m., a large light brown crescent-shaped stain was observed on the ceiling above commode, and an approximately twelve-inch by twelve-inch plastered but unsanded and unpainted section of wall above the commode was noted. Room B-23: On 11/10/14 at 4:08 p.m., the vinyl flooring behind the commode and sink was was observed curling up and away from the wall, and a small amount of water was noted on the floor under the sink. During interview with resident R, she stated that a small amount of water sometimes leaked from under the wall behind the sink, and staff had fixed it, but it still occasionally leaked. Room B-25: On 11/11/14 at 9:20 a.m., the bathroom floor was observed to have large areas of a grayish discoloration, and the bathroom vent was dusty. Room B-26: On 11/11/14 at 9:41 a.m., the bathroom vent was noted to be dusty. Room B-27: On 11/11/14 at 10:05 a.m., a large circular brown stain was observed surrounding the ceiling vent in the bathroom, and this vent was dusty. The above areas of concern were verified during a walk-through of the B-hall environment with the Housekeeping and Maintenance Supervisors on 11/14/14 at 11:00 a.m. In addition, they verified that in Room B-20 there was a long brown stain on the bathroom ceiling along the right wall, and the vinyl flooring behind the sink and commode was curling away from the wall.",2018-08-01
5560,BRYAN COUNTY HLTH & REHAB CTR,115621,127 CARTER ST,RICHMOND HILL,GA,31324,2014-11-14,279,D,0,1,CPCC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, family and staff interview, the facility failed to develop a care plan for skin tears and bruising for one (1) resident (Q) who sustained multiple recurrent skin tears. The sample size was thirty-two (32) residents. Findings include: On 11/10/14 at 5:05 p.m., and 11/11/14 at 8:13 a.m. and 4:04 p.m., resident Q was observed in a wheelchair with gauze dressings to both lower legs and a scabbed area to the right inner lower leg below one of these dressings. During an interview with a family member of resident Q on 11/11/14 at 12:50 p.m. she revealed that the resident had been prone to skin tears for a long time, and had very fragile skin. On 11/12/14 at 7:35 a.m., the resident was observed in bed, and most of the upper right arm had purplish-red discolorations. Review of resident Q's Admission Quarterly Minimum Data Set ((MDS) dated [DATE] and the Quarterly MDS dated [DATE] noted that the resident had skin condition problems of skin tear(s). Review of the care plans revealed that there was a care plan for potential for skin breakdown, but the interventions addressed pressure ulcer prevention, but included nothing about skin tears or bruising. Review of the resident's Treatment records revealed that wound care for new skin tears was initiated fourteen times to the resident's arms and legs since admission on 06/24/14. During an interview with MDS Coordinator AA on 11/14/14 at 12:20 p.m., she stated she was aware when residents had skin tears by reviewing their skin assessments and treatment records, and verified that she had not developed a care plan for skin tears for resident Q. Cross-refer to F 309.",2018-08-01