{"rowid": 2294, "facility_name": "SAVANNAH SQUARE HEALTH CENTER", "facility_id": 115546, "address": "1 SAVANNAH SQUARE DRIVE", "city": "SAVANNAH", "state": "GA", "zip": 31406, "inspection_date": "2016-08-11", "deficiency_tag": 371, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "X51711", "inspection_text": "Based on observation, staff interview, and documentation review the facility failed to ensure opened food items in the walk-in refrigerator were labeled and dated; failed to ensure serving pans were stored dry not wet nested to prevent bacterial growth for two of four days of the survey; failed to ensure mixer was cleaned properly after usage; failed to have male staff working in the kitchen wear hair restraint over facial hair; and failed to ensure fans used in the food preparation area were clean and free from dust/lent. This deficient practice had the potential to effect thirty three (33) residents receiving an oral diet. Findings include: Review of the policy for Food Safety in Receiving and Storage revealed food that is repacked will be placed in a leak-proof, pest proof, non-absorbent, 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. Opened packages will be resealed tightly and dated with date open to prevent contamination. Review of the policy for Manual Cleaning and Sanitizing with Three (3) Compartment Sink revealed to allow all equipment, utensils, etc. to drain and air-dry. Review of the Equipment Cleaning Procedures revealed after each use wipe machine with warm water-detergent solution including legs and underside of shaft. Continued review of the Equipment Cleaning Procedures revealed no procedure for cleaning portable fans. Review of the policy for Uniforms for Food and Dining Service Employees revealed hair must be restrained and off shoulder. The facility also had a policy titled Security and Traffic in the Kitchen which revealed all individuals entering the department are required to wear hair restraints. Observation on 08/08/16 at 11:45 a.m. of the walk-in refrigerator revealed an opened three (3) pound bag of cheddar cheese cubes that had no label or date Observation on 08/08/16 at 11:50 a.m. revealed two (2) male dietary staff working in the kitchen with facial hair that was not covered. Observation on 08/08/16 at 12:05 p.m. of the wire storage rack near the dry storage area revealed it held a variety of different size aluminum serving pans. Continued observation revealed a stack of four (4) aluminum serving pans which were ten (10) inches in length, twelve (12) inches in width, and four (4) inches in depth when lifted the top 2 pans had water coming from underneath that pooled and puddled on top of the serving pans below, as well as on the floor. Observation on 08/08/16 at 12:10 p.m. of the stand-up mixer revealed shaft that connects the beater paddle or whip paddle had food debris that was off white in color and cover half of the shaft which was about one half inch in diameter. The off white substance was sticky to the touch. Interview on 08/08/16 at 12: 25 p.m. with the Dietary Manager (DM) revealed he confirmed the bag of cheddar cheese cubes were opened and did not have a label or a date. He expects staff to label and date all food items after opening. Continued interview with the DM revealed he confirmed that the stack of 4 serving pans were stored on the rack wet. He confirmed that they were wet nesting. The DM revealed that he expects staff to stack pans only after they are dry. Further interview with the DM revealed he confirmed the stand-up mixer had an off white substance on the shaft that connects the beater or whip. The DM expects dietary staff to properly clean the mixer after usage. Interview on 08/08/16 at 12:30 p.m. with the Dining Services Supervisor DD revealed that he was told that his facial hair only needed to be trimmed tight to the face and groomed. Interview on 08/08/16 at 4:35 p.m. with the DM revealed he confirmed that male staff with facial hair were in the kitchen and were not wearing a restraint over their facial hair. He revealed that Dining Services Supervisor DD miss spoke earlier regarding facial hair. The DM revealed the facility does require facial hair to be groomed however when in the kitchen the DM revealed he expects facial hair to be covered. Observation on 08/10/16 at 10:35 a.m. of the stainless steel food preparation table located in the middle of the kitchen revealed a twelve (12) inch black fan on a shelf above the table top towards the end near the walk in freezer. Continued observation of the black fan revealed it was pointed in the direction of the cooking area. The plastic housing around the fan blades was coated with grease and dust/lent. Further observation revealed a box fan two (2) feet in height on top of a small stainless steel food preparation table near the stand-up mixer. The housing surrounding the fan blade was covered with a black dust/lent. Observation on 08/10/16 at 10: 45 a.m. of the wire storage rack near the dry storage area that held the serving pans, three (3) aluminum pans that were ten (10) inches in length, twelve (12) inches in width and four (4) inches in depth, stacked together on top of each other. When the top pan was lifted the underside had a layer of water that pooled and puddled on the floor. Interview on 08/10/16 at 3:50 p.m. with the DM revealed the fans were placed in the kitchen due to the hot temperature. He confirmed the twelve (12) inch black fan and the box fan were both in the kitchen and both fans had a layer of dust/lent. The DM revealed that it had been difficult to clean the fans due to grease accumulation and the dust/lent sticks. He revealed that cleaning of the fans is not on the cleaning schedule for dietary staff to complete. Continued interview the DM revealed he confirmed the three (3) aluminum serving pans were stacked and had water on the underside. The DM revealed that he had spoken with dietary staff regarding pans need to be dry before stacking. He expects staff to stack pans after they had been properly air-dried. Review of In-services conducted in the dietary department from (MONTH) (YEAR) to (MONTH) (YEAR) revealed staff had no in-services regarding label/dating, cleaning equipment, wet nesting of pans, or covering facial hair.", "filedate": "2020-09-01"}
{"rowid": 2295, "facility_name": "SAVANNAH SQUARE HEALTH CENTER", "facility_id": 115546, "address": "1 SAVANNAH SQUARE DRIVE", "city": "SAVANNAH", "state": "GA", "zip": 31406, "inspection_date": "2016-08-11", "deficiency_tag": 520, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "X51711", "inspection_text": "Based on record review and staff interview, the facility failed to maintain a Quality Assessment and Assurance (QAA) Committee meeting quarterly for the first and second quarters of (YEAR), to identify, develop and implement corrective action plans ensuring deficient practices were corrected. The Census was thirty five (35). Findings include: During an interview with 5-Star Corporate Nurse, EE Registered Nurse (RN) on 8/11/16 at 2:25 p.m., she stated the facility was unable to provide documentation of the Quality Assessment and Assurance (QAA) Committee meetings during the first and second quarter of the year (YEAR). She stated that multiple staff turn-over caused missing documentation of these Quality Assessment and Assurance (QAA) Committee meetings being held.", "filedate": "2020-09-01"}
{"rowid": 2296, "facility_name": "SAVANNAH SQUARE HEALTH CENTER", "facility_id": 115546, "address": "1 SAVANNAH SQUARE DRIVE", "city": "SAVANNAH", "state": "GA", "zip": 31406, "inspection_date": "2018-10-03", "deficiency_tag": 695, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "API511", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain a clean air filter for an oxygen concentrator for one of one residents (R#6) reviewed. With a census sample of 16 residents. Findings include: Review of [DIAGNOSES REDACTED]. Review of the Physician order [REDACTED]. Observation on 9/30/18 at 12:36 p.m., 10/2/18 at 2:13 p.m. and 10/3/18 at 8:50 a.m. revealed that the oxygen concentrator filter for R#6 was very dirty with a heavy build-up of dust in the filter. Observation also revealed the tubing from the concentrator was connected to the resident's continuous positive airway pressure (C-PAP) machine. Review of the care plan revealed that the resident had recurring episodes of shortness of breath (SOB) due to musculoskeletal impairment with a goal to maintain normal breathing pattern as evidenced by eupnea, normal skin color, and regular respiratory rate/pattern through the review date. The resident was to use the [MEDICAL CONDITION] machine at night. The resident had the potential and/or an actual altered respiratory pattern due to inability to maintain an effective airway clearance with interventions to provide treatments as ordered, if ineffective notify his Healthcare Practitioner, and he was to use his [MEDICAL CONDITION] at night and would need assistance with placement and cleaning of his [MEDICAL CONDITION] device, which helped him have restful sleep and maintain his oxygenation. Observation and interview on 10/3/18 at 9:08 AM of R#6 with the Assistant Director Of Nursing/ Interim Director Of Nursing (DON) confirmed that the air filter to the oxygen concentrator was very dusty and that the oxygen concentrator was connnected to the resident's [MEDICAL CONDITION] machine at night. She stated that she did not know how many residents use oxygen and that they had no system in place to keep the air filters clean. The Interim DON also revealed that she was not sure when the last time was that the filter was cleaned. She stated that the filter should be cleaned at a minimum of monthly.", "filedate": "2020-09-01"}
{"rowid": 2297, "facility_name": "SAVANNAH SQUARE HEALTH CENTER", "facility_id": 115546, "address": "1 SAVANNAH SQUARE DRIVE", "city": "SAVANNAH", "state": "GA", "zip": 31406, "inspection_date": "2017-10-12", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IGQY11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to follow the plan of care for staff to provide water flushes per (physician) order for one resident (R) (R#39) who received enteral feedings through a [MEDEQUIP] tube ([DEVICE]) from a sample of twenty-two (22) residents. The census was twenty-eight (28) residents. Findings include: Review of the electronic record (e-record) for R#39 revealed that he had a [DIAGNOSES REDACTED]. Review of his care plan dated 9/26/17 revealed that he was at risk for an inability to maintain his nutrition/hydration related to his NPO (nothing by mouth) status with an intervention for licensed nursing staff to provide water flushes per (physician) order. Review of the Order Summary Report revealed a physician's orders [REDACTED].(ccs) of water before and after (enteral) feeding three times a day for hydration. During observation of medication and enteral feeding administration for R#39 on 10/11/17 at 11:19 a.m., Licensed Practical Nurse (LPN) AA drew up 30 ccs of water in a container and pushed the water with the syringe through the resident's [DEVICE]. LPN AA then administered 4[AGE] ccs of [MEDICATION NAME] 1.2 enteral feeding to R#39. LPN AA drew up another 30 ccs of water and pushed the water through the [DEVICE]. LPN AA then administered the crushed medication (Xenazyne, a medication that treats involuntary movement disorders) through the resident's [DEVICE] followed by another 30 ccs of water. LPN AA failed to flush the resident's [DEVICE] with 100 ccs water before and after the administration of the resident's feeding ([MEDICATION NAME] 1.2 cal) as ordered and as care planned. On 10/12/17 at 11:25 a.m., the Director of Nursing (DON) stated that he expected licensed nursing staff to administer water flushes as ordered by the physician and as care planned. Cross refer to F322.", "filedate": "2020-09-01"}
{"rowid": 2298, "facility_name": "SAVANNAH SQUARE HEALTH CENTER", "facility_id": 115546, "address": "1 SAVANNAH SQUARE DRIVE", "city": "SAVANNAH", "state": "GA", "zip": 31406, "inspection_date": "2017-10-12", "deficiency_tag": 322, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IGQY11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility Enteral Nutrition Guidelines Policy and Medication Pass Observation Policy and staff interview, the facility failed to use correct technique when checking the placement of the [MEDEQUIP] tube ([DEVICE])( a tube inserted through the abdomen that delivers nutrition/hydration directly into the stomach); failed to check the residual before a bolus enteral feeding was administered as ordered by the physician; failed to allow water flushes to flow by gravity through the [DEVICE] as recommended by professional standards of practice; and failed to administer the correct amount of water flush before and after administration of the enteral feeding as ordered by the physician and as care planed for one (1) resident (R#39) with a [MEDEQUIP] tube from a sample of twenty-two (22) residents. The census was twenty-eight (28) residents. Findings include: Review of the facility Enteral Nutrition Guidelines dated 3/15/12 revealed that the nurse checks placement of all feeding tubes prior to intermittent feedings .and the nurse irrigates the feeding tube with the prescribed amount of water every 4-8 hours to maintain or restore patency of the feeding tube and to provide free water to maintain adequate hydration for the resident. Review of the facility Medication Pass Observation Policy revealed that when medications were administered with enteral nutritional feedings, staff should check the placement of the [MEDEQUIP] tube and flush the tube with at least 30cc of warm water before and after medications are administered. However, review of the policies revealed that there were no specific procedural guidelines for how staff were supposed to check the tube for placement and administer a water flush. Review of the electronic record (e-record) for R#39 revealed that he had a [DIAGNOSES REDACTED]. Review of his care plan dated 9/26/17 revealed that he was at risk for an inability to maintain his nutrition/hydration related to his NPO (nothing by mouth) status with an intervention for licensed nursing staff to provide water flushes per (physician) order. Review of the Order Summary Report revealed a physician's orders [REDACTED]. Continued review revealed physician's orders [REDACTED]. shift before and after medication administration. During observation of medication and enteral feeding administration for R#39 on 10/11/17 at 11:19 a.m., Licensed Practical Nurse (LPN) AA stated that she would check placement of the resident's [DEVICE] by instilling 10 cc of air into the tube. LPN AA then drew up 10 ccs of air into the syringe and using the plunger pushed the air into the resident's [DEVICE]. However, LPN AA failed to listen to the resident's stomach with a stethoscope to verify the placement of the [DEVICE]. LPN AA drew up 30 ccs of water from a container and using the plunger pushed the water through the resident's [DEVICE] instead of allowing the water to flow through the tubing via gravity. LPN AA then administered two (2) 240 cc cartons of [MEDICATION NAME] 1.2 enteral feeding to R#39 via gravity. However, LPN AA failed to check the residual prior to the administration of the feeding to ensure that the residual was not greater than [AGE] ccs and the feeding held at that time. LPN AA drew up another 30 ccs of water into the syringe and using the plunger pushed the water through the [DEVICE] instead of allowing the water to flow through the tubing via gravity. LPN AA administered the crushed medication (Xenazyne, a medication that treats involuntary movement disorders) mixed with 5 ccs of water through the resident's [DEVICE] via gravity. LPN AA then drew up another 30 ccs of water into the syringe and using the plunger pushed the water through the [DEVICE] instead of allowing the water to flow via gravity. LPN AA failed to flush the resident's [DEVICE] with 100 ccs water before and after the administration of the resident's feeding ([MEDICATION NAME] 1.2 cal) as ordered and as care planned. Interview with LPN AA at that time revealed that R#39 was the first resident with a [DEVICE] to whom she had provided care. Continued interview revealed that she did not receive any training at facility related to administration of medications or feeding through a [DEVICE]. Review of the electronic record for R#39 revealed that he did not have any complications related to his [DEVICE]. Review of the Health and Wellness Department Orientation form dated 4/13/17 revealed that LPN AA had been in-serviced and provided correct return demonstration on medication administration for a resident with a [MEDEQUIP] tube. On 10/12/17 at 11:25 a.m., the Director of Nursing (DON) stated that he expected licensed nursing staff to use a stethoscope to auscultate the stomach when checking placement of a [DEVICE]. Continued interview revealed that he expected licensed nursing staff to check residual prior to administration of a feeding and to administer water flushes as ordered by the physician. Further interview revealed that he believed it was acceptable to push water flushes through a [DEVICE] if the tubing was clogged and the water would not flow via gravity.", "filedate": "2020-09-01"}
{"rowid": 2299, "facility_name": "SAVANNAH SQUARE HEALTH CENTER", "facility_id": 115546, "address": "1 SAVANNAH SQUARE DRIVE", "city": "SAVANNAH", "state": "GA", "zip": 31406, "inspection_date": "2017-10-12", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IGQY11", "inspection_text": "Based on observation, record review, review of facility policy and staff interview, the facility failed to have an effective monitoring system to ensure that safe hot water temperatures were maintained in three (3) resident rooms (rooms 326, 334 and 335) on one (1) of three (3) halls. The census was twenty-eight (28) residents. Findings include: During the Initial Tour of the facility on 10/10/17, the following unsafe hot water temperatures were obtained using the surveyor's digital thermometer: At 8:04 a.m., the hot water temperature in room 335 was 124.9 degrees Farenheit (F). One resident resided in the room. At 8:05 a.m., the hot water temperature in room 334 was 125.1 degrees (F). One resident resided in the room. At 8:08 a.m., the hot water temperature in room 326 was 125.1 degrees (F). One resident resided in the room. Interview with LPN AA on 10/10/17 at 8:15 a.m. revealed that the residents in rooms 326, 335 and 334 were cognitively impaired and did not use the sinks in their rooms unassisted by staff. On 10/10/17 at 8:26 a.m. the following unsafe hot water temperatures were confirmed with the Maintenance Supervisor using the facility digital thermometer: At 8:26 a.m., the hot water temperature in room 327 was 125.4 degrees (F). There were no residents occupying this room. At 8:29 a.m., the hot water temperature in room 335 was 123.1 degrees (F) At 8:31 a.m., the hot water temperature in room 334 was 122.3 degrees (F) At 8:34 a.m., the hot water temperature in room 326 was 120.5 degrees (F) Interview with the Maintenance Supervisor on 10/10/17 at 8:36 a.m. revealed that he had checked the hot water temperatures last week and that the highest temperature was 117 degrees (F). Continued interview revealed that he checked the hot water temperatures at least monthly in five (5) rooms. On 10/10/17 at 8:40 a.m., the temperature gauge for the boiler was 110 degrees (F). The Maintenance Supervisor adjusted the temperature down to 105 degrees (F) at that time. On 10/10/17 at 8: 45 a.m., the Director of Nursing (DON) was notified of the unsafe hot water temperatures and initiated 24 hour monitoring of the temperatures. Review of the electronic Logbook Documentation since 3/31/17 revealed that weekly hot water temperatures were obtained for the laundry, kitchen, staff breakroom, janitor's closet and resident room 323. However, there was no indication that hot water temperatures were checked for the residents' common shower room or for any other resident rooms. Continued review revealed that the last documented temperatures were obtained on 9/29/17, eleven (11) days prior to the identification of unsafe hot water temperatures on 10/10/17. Further review revealed that on 6/30/17 and 7/7/17, the hot water temperature in room 323 was 118 degrees (F). However, there was no indication that the facility adjusted the hot water temperature or provided frequent monitoring on those days to ensure that the hot water temperature did not increase to 120 degrees (F) and above. Interview with the Maintenance Supervisor on 10/10/17 at 9:00 a.m. revealed that he did not adjust the hot water temperature if it was 118 degrees (F.) because it was below the required 120 degrees (F). Interview with the Maintenance Supervisor on 10/10/17 at 9:55 a.m. revealed that none of the residents or staff have complained that the hot water was too hot. Interview with the DON on 10/10/17 at 10:00 a.m. revealed that none of the residents have been burned/scalded by hot water. Continued interview revealed that none of the residents or staff have complained that the hot water was too hot. Review of the facility's Five [ENTITY] Senior Living Water Temperature Policy revealed that monitoring should be completed daily in the a.m. at the beginning of the 7 a.m. to 3 p.m. shift and preferably before any bathing routines begin for the day.", "filedate": "2020-09-01"}
{"rowid": 2300, "facility_name": "SAVANNAH SQUARE HEALTH CENTER", "facility_id": 115546, "address": "1 SAVANNAH SQUARE DRIVE", "city": "SAVANNAH", "state": "GA", "zip": 31406, "inspection_date": "2017-10-12", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IGQY11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of facility policy and staff interview, the facility failed to ensure that licensed nursing staff washed her hands prior to donning clean gloves during wound care for one resident (R) (R#6) of three (3) residents observed for wound care from a sample of twenty-two (22) residents. Findings include: Review of the Five [ENTITY] Senior Living: Clean Dressing Change Technique dated 3/10/15 revealed that clean technique should be used to promote wound healing and prevent cross-contamination among and between residents and caregivers. A clean covering should be used for a work surface on which to place assembled supplies. Once a clean field was established, contamination should be prevented by only reaching into the clean field with clean hands and never after gloves have touched anything off the field. After the soiled dressing was removed, staff should remove the soiled gloves, dispose of them properly and wash her hands. Staff should don clean gloves and cleanse the wound. After cleansing the wound, staff should remove her soiled gloves, dispose of them properly and wash her hands. Staff should don clean gloves and apply treatment. After the wound was treated, staff should remove her gloves, dispose of them and wash her hands. Review of the medical record for R#6 revealed that he had [DIAGNOSES REDACTED]. Continued review revealed that he was admitted with shearing on the left dorsal second toe and had a current physician's orders [REDACTED]. During observation of wound treatment on 10/12/17 at 9:15 a.m., Licensed Practical Nurse (LPN) AA sanitized her hands and obtained supplies from the treatment cart that included Secora Protective ointment in a small medicine cup, a bottle of Saf Clens wound cleanser, one pad of skin prep and a packet of non-woven gauze sponges. However, instead of placing a clean cover on a work surface on which to place the supplies, LPN AA placed the supplies directly on top of the resident's dresser. LPN AA donned clean gloves and removed the soiled dressing from the resident's left second toe. Without removing her gloves and washing her hands, LPN AA then obtained the Saf Clens from the dresser and cleaned the wound. LPN AA removed the soiled gloves but, did not wash her hands prior to donning clean gloves and applying the skin prep and dry gauze dressing on the wound. LPN AA removed her gloves and without washing her hands, donned clean gloves to provide bladder incontinence care and remove barrier cream from the resident's sacrum. LPN AA then removed her gloves and without washing her hands, donned clean gloves and applied the Secora Protective Ointment on the red area on the resident's sacrum. LPN AA removed her gloves and without washing her hands applied a clean brief for the resident. LPN AA then removed her gloves but used sanitizer instead of washing her hands prior to leaving the resident's room. Interview with the Director of Nursing (DON) on 10/12/17 at 11:25 a.m., revealed that he expected the nurses to place treatment supplies on a tray and set up a clean field prior to treatment. Continued interview revealed that nurses should wash their hands after removing soiled gloves and prior to donning clean gloves to prevent cross-contamination during wound treatment.", "filedate": "2020-09-01"}
{"rowid": 3878, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2016-06-09", "deficiency_tag": 161, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "CYJG11", "inspection_text": "Based on interview and record review, the facility failed to ensure that the surety bond covered the daily balances for the Resident Trust Account for five (5) of six (6) months reviewed. Findings include: The facility had a surety bond in the amount of $25,000 effective from 6/15/15 to 6/15/16 and managed forty-eight (48) resident accounts. A review of the Resident Trust Account bank statements revealed that from (MONTH) (YEAR) to (MONTH) (YEAR), the daily balances exceeded the Bond amount every month, for the following number of days each month: January (YEAR): 12 of 31 days February (YEAR): 6 of 29 days March (YEAR): 6 of 31 days April (YEAR): 12 of 30 days May (YEAR): 15 of 31 days During an interview on 6/9/16 at 12:40 p.m., the Business Office Manager stated that the balances exceeded the surety bond limit due to dates social security deposits were received and vision and dental insurance money that had not been paid out yet, pending the vision and dental companies completing a credentialing process.", "filedate": "2020-09-01"}
{"rowid": 3879, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2016-06-09", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CYJG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to follow the plan of care to thoroughly and routinely complete assessments of pressure ulcers for two (2) residents #41 and #70 from a total sample of twenty-three (23) residents. Findings include: 1. Resident #41 had a plan of care in place since 3/23/16 for having an unstageable pressure ulcer to the coccyx due to poor nutrition, cognitive status and immobility. The plan of care was updated on 4/14/16 to include an intervention for nursing staff to assess the pressure ulcer weekly for location, stage, size (length, width and depth) presence or absence of granulation tissue and epithelization. However, there was no documented weekly assessment of the pressure ulcer after 4/12/16 until 4/25/16, when it was documented as closed. The resident was hospitalized from [DATE] through 4/28/16 and returned to the facility with a stage two pressure ulcer to the coccyx. After being thoroughly assessed on 4/28/16, there was no documented weekly assessment of the pressure ulcer again until 5/13/16, when it was documented as healed. A new stage two pressure ulcer was identified to the coccyx on 5/26/16. However, there was no documented weekly assessment of the pressure ulcer again until 6/8/16, when it was documented as healed. 2. Resident #70 was readmitted to the facility on [DATE] with a stage two pressure ulcer to the coccyx. There was a plan of care since 5/18/16 for being readmitted with a pressure ulcer to the coccyx. The plan of care included an intervention for nursing staff to assess the pressure ulcer weekly for location, stage, size (length, width and depth) presence or absence of granulation tissue and epithelization. However, after being thoroughly assessed on 5/5/16, there was no documented weekly assessment of the pressure ulcer again until 5/25/16, when it was documented as healed. During an interview on 6/9/16 at 12:20 p.m., the Assistant Director of Nursing (ADON) stated that she assessed the pressure ulcers weekly, however she had not been consistently getting the documentation in the clinical record. Cross reference to F314", "filedate": "2020-09-01"}
{"rowid": 3880, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2016-06-09", "deficiency_tag": 314, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CYJG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to complete thorough, weekly documented assessments of pressure ulcers for two (2) residents (#41) and (#70) from a total sample of twenty-three (23) residents. Findings include: The facility's Wound Protocol policy and procedure documented to assess pressure ulcers weekly, including measurement. 1. Resident #41 had [DIAGNOSES REDACTED]. There a plan of care in place since 3/23/16 for having an unstageable pressure ulcer to the coccyx due to poor nutrition, cognitive status and immobility. The plan of care was updated on 4/14/16 to include an intervention for nursing staff to assess the pressure ulcer weekly for location, stage, size (length, width and depth) presence or absence of granulation tissue and epithelization. A review of the clinical record revealed that nursing staff documented assessments of the pressure ulcer on 3/23/16, 3/24/16, 3/29/16, 4/6/16 and 4/12/16. However, the assessments on 3/29/16, 4/6/16 and 4/12/16 were not thorough to include staging and measurements. In addition, there was no documented weekly assessment of the pressure ulcer after 4/12/16 until 4/25/16, when it was documented as closed. The resident was hospitalized from [DATE] through 4/28/16 and returned to the facility with a stage two pressure ulcer to the coccyx. After being thoroughly assessed on 4/28/16, there was no documented weekly assessment of the pressure ulcer again until 5/13/16, when it was documented as healed. A new stage two pressure ulcer was identified to the coccyx on 5/26/16. However, there was no documented weekly assessment of the pressure ulcer again until 6/8/16, when it was documented as healed. During an observation on 6/8/16 at 11:04 a.m., with the ADON, the pressure ulcer to the coccyx was observed to be healed. 2. Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged to the hospital on [DATE] and returned on 5/5/16. Upon readmission to the facility on [DATE] nursing staff identified a stage two pressure ulcer to the coccyx. A plan of care was developed on 5/18/16 for the pressure ulcer to the coccyx. The plan of care included an intervention for nursing staff to assess the pressure ulcer weekly for location, stage, size (length, width and depth) presence or absence of granulation tissue and epithelization. However, after being thoroughly assessed on 5/5/16, there was no documented weekly assessment of the pressure ulcer again until 5/25/16, when it was documented as healed. During an interview on 6/9/16 at 12:20 p.m., the Assistant Director of Nursing (ADON) stated that she assessed the pressure ulcers weekly, however she had not been consistently getting the documentation in the clinical record.", "filedate": "2020-09-01"}
{"rowid": 3881, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2016-06-09", "deficiency_tag": 325, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CYJG11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to accurately assess the nutritional needs for one resident (#70), upon readmission from a hospital stay, from a total sample of twenty-three (23) residents. Findings include: Resident #70 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was discharged from the facility on 4/22/16, to receive aggressive therapy services, and returned on 5/5/16. The resident's weight on return from the hospital, on 5/5/16, was documented as 132.2 pounds. His/her previous weight on 4/18/16 (before going to the hospital on [DATE]) was 157 pounds. This was a loss of 24.8 pounds. Facility nursing staff identified the weight loss and implemented interventions. However, a readmission/hospital return nutritional assessment completed by the dietician on 5/12/16, failed to identify and address the resident's significant weight loss. The dietician documented on the 5/12/16 Medical Nutritional Therapy Assessment form that the resident weighed 157 pounds. The resident's BMI was calculated at 27.8 and classified as overweight. In addition, a dietary note completed by the dietary manager on 5/16/16 only documented the resident's weight of 157 pounds prior to the hospitalization , instead of the most recent weights available of 132.2 pounds on 5/5/16 and 136.3 pounds on 5/13/16. During an interview on 6/9/16 12:20 p.m. the Assistant Director of Nursing (ADON) stated she had not put in the hospital return weight in the computer when the dietary notes and assessment were completed. However, they did have a verbal meeting on the resident and dietary staff was aware the resident had a weight loss and that nursing staff was monitoring to make sure the hospital return weight was an accurate weight (since it was a big drop in weight from before the hospital admission) and interventions were in place.", "filedate": "2020-09-01"}
{"rowid": 3882, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2016-06-09", "deficiency_tag": 431, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "CYJG11", "inspection_text": "Based on observation and staff interview, the facility failed to ensure expired medications were properly disposed of in a timely manner in one (1) of one (1) medication room refrigerator. Findings Include: Observation on 6/9/16 at 8:15 a.m. in the medication room refrigerator revealed one (1) bag of nine (9) unopened vials and one (1) opened vial of Ativan 2 milligram (mg) per milliliter (ml) one (1) ml vials for R #24 with an expiration date of 5/2016 on all ten (10) vials. Observation further revealed a (MONTH) Daily Refrigerator Check Off Sheet secured to the refrigerator door with a signature present for 6/4 only. Instructions on the check off sheet stated refrigerator in medication room will be checked daily by an Licensed Practical Nurse(LPN) to make sure all medications are properly labeled with date opened written on bottle and not box and that all expired medications are pulled from the refrigerator as needed. After procedure is done LPN will initial in proper area that this has been done and that everything is correct in the refrigerator. During an interview on 6/9/16 at 8:15 a.m. with the Patient Care Coordinator, she revealed the ten (10) vials of Ativan 2 mg/ml one (1) ml vials expired on 5/31/16 and should have been removed from the refrigerator. The Patient Care Coordinator confirmed the (MONTH) Daily Refrigerator Check Off sheet was signed off in (MONTH) only on 6/4/16. The Patient Care Coordinator revealed that the LPN assigned to check the medication refrigerator according to the check off sheet should check for expired medications and initial that it has been checked according to the instructions on the sheet. She further revealed the medication refrigerator should be checked daily for expired medications according to the instructions. During an interview on 6/9/16 at 9:15 a.m. the Director of Nurses (DON) revealed the Daily Refrigerator Check Off sheet was an old internal form the Patient Care Coordinator developed and the new nurses would not know to use the check sheet. Futher interview on 6/9/16 at 11:40 a.m. and 12:15 p.m. with the DON revealed that she checks the medication refrigerator monthly for expired medications and missed the Ativan. The DON further stated that there is not a assigned nurse to check the refrigerator for expired medications. Continued interveiw revealed the medication cart nurses, are responsible for checking medication for their residents prior to administering medications. The DON further revealed the Ativan should have been removed and discarded from the refrigerator when not administered in the last three (3) months when the reconciliation of medications was done. The DON revealed it is her responsibility to remove the medications not used in three ( 3) months She further revealed that expired medications are not to be in the refrigerator. During an interview on 6/9/16 at 12:45 p.m. the Patient Care Coordinator revealed the Daily Refrigerator Check Off Sheet on the refrigerator was to be completed according to the instructions on the sheet and the nurses were aware and failed to complete the sheet as instructed.", "filedate": "2020-09-01"}
{"rowid": 3883, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2018-08-26", "deficiency_tag": 644, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "LV3R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy Admission Criteria, and staff interview, the facility failed to refer two residents (R) (#21 and #36) for a pre-admission screening and resident review (PASRR) Level II when the residents experienced a change in behavioral status. The sample size was 29. Findings include: Review of the facility policy titled Admission Criteria revised (YEAR) revealed: 8. Nursing and medical needs of individuals with mental disorders or intellectual disabilities will be determined by coordination with the Medicaid Pre-Admission Screening and Resident Review (PASRR) program to the extent practicable. 1. Record review for R#21 revealed a Pre-Admission Screening/Resident Review (PASRR) Level I assessment dated [DATE] that did not indicate that the resident had a serious mental illness, developmental disability or related condition. Review of the Nurse's Notes for R#21 dated 8/31/17 revealed the physician requested a psychiatric evaluation due to resident's recent behaviors. Further review of the Nurse's Notes dated 9/1/17 documented R#21 was sent to the behavior unit at the hospital. On 9/14/17 resident returned to the facility following a lengthy stay at the inpatient behavioral health unit. No behaviors noted at this time. Review of the clinical record for R#21 revealed [DIAGNOSES REDACTED]. The resident had admission [DIAGNOSES REDACTED]. Further review of the clinical record for R#21 revealed a physician order dated 1/15/18 for [MEDICATION NAME] 300 milligrams (mg) by mouth three times per day for manic episode, a physician's order dated 9/14/17 for [MEDICATION NAME] 1 mg at bedtime for delusional disorder and Trazadone 100 mg at bedtime for [MEDICAL CONDITION]. Review of the Care Plan last revised 5/4/18 revealed R#21 has socially inappropriate/disruptive behavioral symptoms as evidenced by hollering out and cussing. Further review revealed the resident requires [MEDICAL CONDITION] medication for depression. During an interview on 8/26/18 at 9:36 a.m., the Social Worker (SW) revealed that she normally does rescreen a resident for PASRR if they have changes in behavioral status. SW stated that she did not rescreen R#21 because she thought the resident came in with those diagnoses. 2.) Review of the clinical record for R#36 revealed [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the care plans for R#36 revealed that the resident has a care plan for [MEDICAL CONDITION] medication for depression with psychotic symptoms and a care plan for behavioral symptoms not directed to others (e.g. verbal/vocal symptoms like screaming, disruptive sounds). Interview on 8/26/18 at 11:24 a.m. with the Social Services Director revealed that R#36 was sent to the Behavioral until in (MONTH) of (YEAR) for hollering out and/or screaming. The Social Services Director revealed that the resident's primary [DIAGNOSES REDACTED]. Further interview revealed that R#36 should have been evaluated for the need for a level II Pre-Admission Screening/Resident Review (PASARR) but was not.", "filedate": "2020-09-01"}
{"rowid": 3884, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2018-08-26", "deficiency_tag": 656, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "LV3R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on Record review and staff interviews the facility failed to develop a comprehensive care plan for a [MEDICAL CONDITIONS] and for the use of a blood thinner (Eloquis) for one Resident (R) (R#31) and failed to develop a comprehensive care plan related to the use of an antianxiety medication for one residents (R) (R#19) for a total of two residents from a sample of 29 residents. Findings include: Record review revealed that R# 31 was admitted to the facility with [DIAGNOSES REDACTED]. Review of Nurses Notes dated 7/16/2018 03:05 revealed the following documentation: Called and spoke with the resident's Physician's office and reported that pulse was faint and the leg was warm to touch from knee down to foot and resident has 3+ [MEDICAL CONDITION] noted in foot as reported this AM. New orders to send to the ER for eval and treat. Notified responsible party of new orders to send resident to ER (emergency room ) via telephone. Report given to the ER. Resident in route to ER via gerichair accompanied by SMNH staff via facility ambulance. Record review revealed that R# 31 was transferred to the emergency roiagnom on [DATE], for [MEDICAL CONDITION] and pain to the right foot and leg. Radiology report dated 7/16/18, documented [MEDICAL CONDITION] of the SFV to peroneal artery. Physician admission orders [REDACTED].H. (Nursing Home) Dx (diagnosis) [MEDICAL CONDITION] to RLE (to right lower extremity). Physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the care plans for R# 31 revealed that there was no evidence that a care plan was developed to address the resident's [MEDICAL CONDITION] and there was no evidence of a care plan to address the Eloquis (blood thinner). Interview and review of medications for R# 31 on 8/26/18 at 8:57 a.m. with the RN Weekend Supervisor revealed that the resident is currently taking Eloquis but that she was not sure what this medication was for. The RN Weekend Supervisor looked up the medication and then stated that this medication is an anticoagulant and that the resident is taking the Eloquis for a [MEDICAL CONDITIONS] that the resident had in one of her legs. The RN Weekend Supervisor revealed that for someone taking an anticoagulant then you would monitor for signs and symptoms of bruising, bleeding and that the resident should be care planned for both the [MEDICAL CONDITION] and for being on an anticoagulant. The RN Weekend Supervisor reviewed the care plans for R#31 and stated that the resident should have been care planned for the [MEDICAL CONDITION] and for the Eloquis but that she did not find any care plans for the resident for either the [MEDICAL CONDITION] or for the blood thinner. Interview on 8/26/18 at 9:14 a.m. with the Director of Nursing (DON) revealed that the Minimum Data Set (MDS) Coordinator has been out since 8/7/18 but that she is currently working with the MDS. Review of the medications with the DON revealed that the resident has Physician orders [REDACTED]. Further interview revealed that the resident should have a care plan for both the [MEDICAL CONDITION] and for the blood thinner. The DON reviewed the resident's medical record in the residents electronic chart and revealed that although the resident should have been care planned for a [MEDICAL CONDITION] and for receiving a blood thinner, she didn't see any care plans for that, but that she would check with the RN Supervisor who has been creating the care plans since the MDS Coordinator has been out. Interview on 8/26/18 at 9:26 a.m. with the RN Supervisor with the DON present revealed that the RN Supervisor has been working on the care plans recently. The RN Supervisor reviewed the residents care plans in the residents electronic record and revealed that the resident should have been care planned for having a [MEDICAL CONDITION] and should have been care planned for receiving an anticoagulant, but that there were not any care plans for the [MEDICAL CONDITION] or for Eloquis (blood thinner). 2. Review of R#19's clinical record revealed [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set assessment ((MDS) dated [DATE] revealed that he received an antianxiety medication for three of the seven day assessment period. Review of R#19's physician orders [REDACTED]. Review of R#19's care plan initiated 11/22/16 and reviewed and updated 3/20/18 and 6/18/18 revealed there was no evidence that a care plan had been developed to address the use of the antianxiety medication. Interview on 8/26/18 at 10:53 a.m., with Register Nurse (RN) BB, she confirmed a care plan to address the resident's usage of [MEDICATION NAME] was not care planned.", "filedate": "2020-09-01"}
{"rowid": 3885, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2018-08-26", "deficiency_tag": 690, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "LV3R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and facility policy review Perineal Care and Catheter Care, the facility failed to ensure that incontinent care and/or Foley catheter care were performed in a timely manner to prevent a potential Urinary Tract Infection [MEDICAL CONDITION] due to fecal contamination for one resident (R) R#20 from a total sample of 29. Findings include: During observation of incontinent/Foley catheter care, on 8/24/18 at 11:28 a.m., revealed that the Certified Nursing Assistant (CNA) AA, put her gloves on her hands, then put six white wash clothes in the sink without a basin, and removed the soiled brief from the resident, which was soaked all the way down to the pink drawl sheet with brown liquid. Continued observation revealed that the CNA did not remove the pink drawl sheet at this time; however, she had the resident lay back on the drawl sheet. With the same gloves that were used to remove the soiled brief, she retrieved one of the wash clothes from the sink, and wiped front to back on the left side of the perineal area, then with another wash cloth she washed the labia using downward [MEDICAL CONDITION], changing the direction of her wash cloth. However, at no time did the CNA clean the right side of the perineal area. At this point, the CNA changed her gloves, and had the resident roll over to her left side, rolled the drawl sheet under the resident's bottom. The CNA changed her gloves, obtained another wash cloth from the sink, and began to wipe the Catheter tube while holding near the meatus, moving in a downwards direction. There was no Catheter strap observed at this time. The CNA again changed her gloves, and grabbed two wash cloths out of the sink, then she began cleaning the resident's bottom, wiping from bottom to top, removing all the brown liquid fecal matter from her bottom. After changing her gloves, she put two paper drawl sheets under the resident, rolled the resident onto her back, and obtained a hand towel, which she begins to clean her labia area again. During further observation, the CNA changed her gloves, had the resident roll to her right side, while she pulled the soiled drawl sheet from underneath the resident, changed her gloves again and then rubbed some cream on the resident's bottom, and placing a incontinent pad on the resident. During observation and staff interview with Registered Nurse (RN), BB on 8/25/18 at 1:20 p.m., she confirmed that there was no catheter strap; however, stated that there should be a catheter strap in place. During further interview at 1:38 p.m., she stated that the strap was attempted to be placed on the resident, who refused. Interview with the Director of Nursing (DON) on 8/25/18 at 4:00 p.m., revealed that the CNA that performed catheter/incontinent care was the housekeeping supervisor; however, she is cross-trained, but does not take care of residents on the floor all the time. Continued interview revealed that the last training for perineal care and catheter care was (MONTH) 29, (YEAR). She said that the staff are expected to place the wash clothes in a basin, not the sink, and to change gloves when going from soiled to clean. Also, she expected the staff to clean the residents as they were trained and/or checked off back in (MONTH) (YEAR). Review of an untitled document on Peri-care and Catheter care dated (MONTH) 29th revealed that CNA, AA was completed at 3:10 p.m. and signed her name. Review of the untitled document dated 6/29/18 signed check off sheet for dignity, hand washing, perineal care, and catheter care revealed that staff was able to perform without any issues. Continued review under the perineal care revealed that if fecal material is in place, turn resident to the side and clean thoroughly wiping front to back, dispose of fecal soiled linens appropriately, change gloves, wet cloth and apply soap to cloth not basin of water, wash out perineum to include thighs using downward [MEDICAL CONDITION], use a new cloth for the labia and meatus-using downward [MEDICAL CONDITION], and a new cloth to rinse and dry. Further review under the catheter care revealed to separate the labia to expose the meatus, while holding the catheter tubing near meatus-clean at least four inch moving in one direction, downward, the tubing, and then rinse using the same steps. Review of the Physician order [REDACTED]. Review of Catheter Care policy with revision date of 11/1/16 revealed to gently separate the labia to expose the urinary meatus, wipe from front to back with a clean cloth, moistened with water and perineal cleaner (soap), use a new part of the cloth or different cloth for each side, with a new moistened cloth starting at the urinary meatus moving out wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter, and dry area with towel. Review of the Perineal Care policy with revision date of 11/1/16 revealed that if the perineum is grossly soiled, turn the resident on their side, remove any fecal material with some toilet paper, then remove; cleanse buttocks and anus, front and back, vagina to anus in females, and scrotum to anus in males, using a separate piece of the cloth or wipes and dry thoroughly. Continued review revealed to then re-position resident in supine position, and change gloves if soiled.", "filedate": "2020-09-01"}
{"rowid": 3886, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2018-08-26", "deficiency_tag": 726, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "LV3R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility policy of Catheter Care and Perineal Care, it was determined that the facility failed to ensure that one Certified Nursing Assistant (CNA) demonstrated competency in providing adequate incontinent care and/or catheter care for one resident (R) (R#20) from a total sample of 29. Findings include: During observation of incontinent/Foley catheter care, on 8/24/18 at 11:28 a.m., revealed that the CNA, AA, put her gloves on her hands, then put six white wash clothes in the sink without a basin, and removed the resident's soiled brief, but did not remove the soiled drawl sheet. Continued observation revealed that the CNA had the resident lay back on the soiled drawl sheet. With the same gloves that were used to remove the soiled brief, she retrieved one of the wash clothes from the sink, and wiped front to back on the left side of the perineal area, then with another wash cloth she washed the labia using downward [MEDICAL CONDITION], changing the direction of her wash cloth. However, at no time did the CNA clean the right side of the perineal area. At this point, the CNA changed her gloves, and had the resident roll over to her left side, rolled the drawl sheet under the resident's bottom. The CNA changed her gloves, obtained another wash cloth from the sink, and began to wipe the Catheter tubing while holding near the meatus, in a downwards direction. The CNA again changed her gloves, and grabbed two wash cloths out of the sink, then she began cleaning the resident's bottom, wiping from bottom to top, removing all the brown liquid fecal matter from her bottom. After changing her gloves, she put two paper drawl sheets under the resident, rolled the resident onto her back, and obtained a hand towel, which she begins to clean her labia area again. During further observation, the CNA changed her gloves, had the resident roll to her right side, while the CNA pulled the soiled drawl sheet from underneath her, changed her gloves again and then rubbed some cream on resident's bottom, placing a incontinent pad on the resident. Interview with the Director of Nursing (DON) on 8/25/18 at 4:00 p.m., revealed that the CNA that performed catheter/incontinent care was the housekeeping supervisor; however, she is cross-trained, but does not take care of residents on the floor all the time. Continued interview revealed that the last training for perineal care and catheter care was (MONTH) 29, (YEAR). She said that the staff are expected to place the wash clothes in a basin, not the sink, and to change gloves when going from soiled to clean. Also, she expected the staff to clean the residents as they were trained and/or checked off back in (MONTH) (YEAR). Review of an untitled document on Peri-care and Catheter care dated (MONTH) 29th revealed that CNA, AA was completed at 3:10 p.m. and signed her name. Review of the untitled document dated 6/29/18, but signed check off sheet for dignity, hand washing, perineal care, and catheter care revealed that the CNA, AA, was able to perform all of these areas without any concerns. Continued review under the perineal care revealed that if fecal material is in place turn resident to the side and clean thoroughly wiping front to back, dispose of fecal soiled linens appropriately, change gloves, wet cloth and apply soap to cloth not basin of water, wash out perineum to include thighs using downward [MEDICAL CONDITION], and use a new cloth for the labia and meatus (downward [MEDICAL CONDITION]). Further review under the catheter care revealed to separate the labia to expose the meatus, while holding the catheter tubing near the meatus (cleaning at least four inch moving in one direction, downwards), and then rinse. Review of the Catheter Care policy with a revision date of 11/1/16 revealed to gently separate the labia to expose the urinary meatus, wipe from front to back with a clean cloth, moistened with water and perineal cleaner (soap), use a new part of the cloth or different cloth for each side, with a new moistened cloth starting at the urinary meatus moving out wipe the catheter making sure to hold the catheter in place so as to not pull on the catheter, and dry area with towel. Review of the Perineal Care policy with revision date of 11/1/16 revealed that if the perineum is grossly soiled, turn the resident on their side, remove any fecal material with some toilet paper, then remove; cleanse buttocks and anus, front and back, vagina to anus in females, and scrotum to anus in males, using a separate piece of the cloth or wipes and dry thoroughly. Continued review revealed to then re-position resident in supine position, and change gloves if soiled.", "filedate": "2020-09-01"}
{"rowid": 3887, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2018-08-26", "deficiency_tag": 756, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "LV3R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility's consultant pharmacist failed to identify and report irregularities related to the continued use after 14 days of as needed (prn) [MEDICAL CONDITION] medications for two Ridents(R) (R# 19, R#11) of five residents reviewed. The sample size was 29 residents. Findings include: Review of the clinical record for R#19 revealed [DIAGNOSES REDACTED]. Review of the Phsysician orders for R#19's revealed an order since 8/17/17 for .5 milligrams(mg) of [MEDICATION NAME] every 12 hours prn. Review of R#19's monthly Medication Administration Records from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the prn [MEDICATION NAME] was administered to the resident one time in (MONTH) (YEAR), four times in (MONTH) (YEAR), seven times in (MONTH) (YEAR), seven times in (MONTH) (YEAR), five times in (MONTH) (YEAR), three times in (MONTH) (YEAR), one time in (MONTH) (YEAR), eight times in (MONTH) (YEAR) and two times in (MONTH) (YEAR). Review of the consultant pharmacist Monthly Drug Regimen Reviews dated 11/30/17, 12/29/18, 1/31/18, 2/27/18, 3/20/18, 4/30/18, 5/31/18, 6/29/18 and 7/31/18 revealed no recommendations to address the continued use of the prn [MEDICATION NAME]. Interview on 08/26/18 at 10:53 a.m. with Register Nurse(RN) BB revealed she was not aware of the regulation for a stop order date after 14 days of a [MEDICAL CONDITION] medication. 2. Review of the clinical recordfor R#11 revealed [DIAGNOSES REDACTED]. Review of the monthly Mediation Administration Records for R#11 for (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] 0.25 mg as needed was administered to the resident two time's in (MONTH) (YEAR) and (MONTH) (YEAR) three times, and (MONTH) (YEAR). Review of the consultant Pharmacist Monthly Drug Regimen Reviews dated 11/30/17, 12/29/18, 1/31/18, 2/27/18, 3/20/18, 4/30/18, 5/31/18, 6/29/18 and 7/31/18 revealed no recommendations to address the continued use of the prn [MEDICATION NAME] 0.25 mg. 3. Review of the clinical record for R#13 revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed that R#13 had a order for [MEDICATION NAME] 0.25 mg as needed. Review of R#13's monthly Medication Administration Records (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] was administered to the resident eighteen time's in (MONTH) (YEAR) and two time in (MONTH) (YEAR). Further review of the monthly Medication Administration Records for R#13 (MONTH) (YEAR) through. [MEDICATION NAME] was administered in (MONTH) (YEAR) two times, (MONTH) three times, and (MONTH) (YEAR) one time. Review of the consultant Pharmacist Monthly Drug Regimen Reviews dated 11/30/17, 12/29/18, 1/31/18, 2/27/18, 3/20/18, 4/30/18, 5/31/18, 6/29/18 and 7/31/18 revealed no recommendations to address the continued use of the prn [MEDICATION NAME] 0.25 mg. Review of R#13's monthly Medication Administration Records (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] was administered to the resident eighteen time's (MONTH) (YEAR) and two time in (MONTH) (YEAR). Further review of R# 13's monthly Medication Administration Records (MONTH) (YEAR) through. [MEDICATION NAME] was administered in (MONTH) (YEAR) two times, (MONTH) three times, and (MONTH) (YEAR) one time. Review of the physician's orders [REDACTED]. Further review revealed that resident had a order for [MEDICATION NAME] 0.25 mg as needed. Review of R#13's monthly Medication Administration Records (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] was administered to the resident eighteen time's (MONTH) (YEAR) and two time in (MONTH) (YEAR). Further review of R# 13's monthly Medication Administration Records (MONTH) (YEAR) through. [MEDICATION NAME] was administered in (MONTH) (YEAR) two times, (MONTH) three times, and (MONTH) (YEAR) one time. Review of R# 31's clinical record revealed [DIAGNOSES REDACTED]. Further review of physician's orders [REDACTED]. Review of physician's orders [REDACTED]. Review of the consultant pharmacist Monthly Drug Regimen Reviews dated 11/30/17, 12/29/18, 1/31/18, 2/27/18, 3/20/18, 4/30/18, 5/31/18, 6/29/18 and 7/31/18 revealed no recommendations to address the continued use of the of Ativian 0.5mg.", "filedate": "2020-09-01"}
{"rowid": 3888, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2018-08-26", "deficiency_tag": 758, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "LV3R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document the clinical indication for continued use and intended duration of therapy for four residents(R) #19, R#31, R#11, R#13) and that had orders for as needed (prn) [MEDICAL CONDITION] medications beyond the 14 days. The sample size was 29 residents. Findings include: 1. Review of R#19's clinical record revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Review of R#19's monthly Medication Administration Records from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the prn [MEDICATION NAME] was administered to the resident one time in December, four times in January, seven times in February, seven times in March, five times in April, three times in May, one time in June, eight times in (MONTH) and two times in August. Interview on 8/26/18 at 10:53 a.m. with Registered Nurse (RN) BB, revealed she was not aware of the 14 day stop order date required for prn [MEDICAL CONDITION] medications. 2. Record review revealed that R# 31 was admitted to the facility with [DIAGNOSES REDACTED]. Record Review of the Electronic Medication Administration Record [REDACTED]. Further review revealed that the resident is currently receiving [MEDICATION NAME] 0.5 mg two times daily without a stop order date. Record Review of the Medication Administration Records (MAR) from (MONTH) (YEAR) through (MONTH) (YEAR) for R#36 revealed that the resident has an order for [REDACTED]. Interview on 8/26/18 at 9: 50 a.m. with the Consultant Pharmacist revealed that he comes to the facility on e time a month to review medications. Further interview with the Consultant Pharmacist revealed that he stated that he was not familiar with the new Federal Regulation and that he was not aware that PRN (as needed) medications could not be ordered for more than 14 days without a stop date. 3. Review of R# 11's clinical record revealed [DIAGNOSES REDACTED]. Review of R# 11's monthly Mediation Administration Records (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] 0.25 mg as needed prn without stop order date. Review of R#11's monthly Medication Administration Records (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] was administered to the resident two time's (MONTH) (YEAR), (MONTH) (YEAR) three times, and (MONTH) (YEAR). Review of R#13's clinical record revealed [DIAGNOSES REDACTED]. Review of the physician's orders [REDACTED]. Further review revealed that resident had a order for [MEDICATION NAME] 0.25 mg as needed. 4. Review of R#13's monthly Medication Administration Records (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] was administered to the resident eighteen time's (MONTH) (YEAR) and two time in (MONTH) (YEAR). Further review of R# 13's monthly Medication Administration Records (MONTH) (YEAR) through. [MEDICATION NAME] was administered in (MONTH) (YEAR) two times, (MONTH) three times, and (MONTH) (YEAR) one time. Review of R# 31's clinical record revealed [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. Review of R# 31's monthly Mediation Administration Records (MONTH) (YEAR) through (MONTH) (YEAR) revealed [MEDICATION NAME] 0.5 mg as needed prn without stop order date.", "filedate": "2020-09-01"}
{"rowid": 3889, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2018-08-26", "deficiency_tag": 759, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "LV3R11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and facility policy review Administering Medications, the facility failed to ensure that the medication error rate was less than 5%. There were two errors with 32 opportunities for two of four residents (R) (R#38 and R#55) by one of two nurses observed, for a medication error rate of 6.25%. Findings include: 1.) On 8/25/18 at 8:21 a.m., Licensed Practical Nurse (LPN) CC was observed preparing R#38's medications, including one capsule of [MEDICATION NAME] (nerve pain medication and anticonvulsant) 100 milligram (mg). However, during further observation, the medication bag revealed to give 200 mg. At the end of preparing all 10 medications, the LPN agreed that was all that she was giving the resident at this time, and only one [MEDICATION NAME] capsule was prepared. Review of the Physician Order Report dated 7/25/18-8/25/18 revealed to give [MEDICATION NAME] 100 mg capsule, totaling 200 mg, twice a day (BID). Review of the Order Administration revealed that the last date the medication was administered was on 8/25/18 at 8:33 a.m. Interview with LPN, CC on 8/25/18 at 11:45 a.m., she confirmed that the resident takes 200 mg of [MEDICATION NAME]. Continued interview revealed that she was sure that she gave the resident 200 mg this morning and said that if there was an even number in his [MEDICATION NAME] bag then she did not give, but one. During interview, the LPN counted the medication with the surveyor and there was 18 pills in the [MEDICATION NAME] bag; however, unsure of the number in the bag at the start of the shift. After counting, the nurse said that if the package had an odd number in there then she only gave one and since there was an even number, she gave two capsules this morning. 2.) On 8/25/18 at 8:39 a.m., LPN CC, was observed preparing R#55's four medications, including Aspirin, Singular, [MEDICATION NAME], and [MEDICATION NAME]. At the end of preparing all four medications, the LPN agreed that was all she was giving the resident at this time. The surveyor saw the LPN only prepare and give R#55 four medication. However, at 8:55 a.m., the LPN, met the surveyor in the hallway, and said that when she was putting the resident's medication on a spoon and into his mouth, she counted five pills not four. She stated it was the resident's [MEDICATION NAME], but said she did not hand the medication bag to the surveyor to look at during the medication pass nor did she say anything about agreeing with it being in the medication cup at the time of the medication pass. Review of the Physician Order of Report dated 7/25/18-8/25/18 revealed Memantine 10 mg once a day and further review of the Order Administration revealed that Memantine 10 mg was last administered at 8:46 a.m. on 8/25/18. Interview with the Director of Nursing (DON) on 8/25/18 at 10:35 a.m., revealed that she did not expect that from this nurse and that she had just been observed by the pharmacist. Review of the facility policy Administering Medications with revised date of (MONTH) 2012 revealed that medications must be administered in accordance with the orders, including any required time frame; and the individual administering the medication must check the label three (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.", "filedate": "2020-09-01"}
{"rowid": 3890, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2018-08-26", "deficiency_tag": 812, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "LV3R11", "inspection_text": "Based on observation, record review, interviews, and review of the facility's policy titled, Monitoring Food Temperatures for Meal Service, the facility failed to ensure that two food items (chicken patties and pureed bread) were maintained on the steam table at a temperature of 135 degrees Fahreheit (F) or greater for two consecutive days. This affected 3 of 5 residents that received a pureed diet. Findings include: Interview on 8/24/18 at 12:34 p.m. with the Dietary Assistant revealed that the food comes from the hospital and that when the food is received then they take beginning temperatures and document those temperatures in the book. The Dietary Assistant revealed that after they have been serving food about 30 - 35 minutes then they retake the food temperatures to ensure that they are maintaining the food at the correct temperature. Further interview revealed that the temperature was not as hot as it should have been for the pureed bread and for the chicken patties. The Dietary Assistant revealed that the temperature for the chicken patties was 130.9 degrees and the temperature for the pureed bread was 112.9 degrees. Review of the steam table temperature log book revealed that temperatures for food served had been recorded prior to the food being served except for the chicken patties. Further review revealed that there was not a recorded temperature for the chicken patties. The Dietary Assistant said that the temperature of the chicken patties should have been taken and should have recorded in the book but that they were not. Interview on 8/25/18 at 11:00 a.m. with the Dietary Manager revealed that when the food is taken from the Hospital Kitchen to the Nursing Home that the temperature is to be taken on all food items and all temperatures are documented in the log book prior to the food being served. Further interview revealed that temperatures are taken before the food is served and again midway through or toward the end of serving and that these temperatures should be documented in the log book as well. Observation on 8/25/18 at 12:38 p.m. of the Steam Table food items with the Dietary Assistant revealed temperatures in the normal range for all food items except for the pureed bread. The temperature for the pureed bread measured 121.2 degrees. The Dietary Assistant stated that the temperature should be at least 135 degrees and that it would have to be reheated before it could be served. Further interview with the Dietary Assistant revealed that the facility has five residents that receive a pureed diet and that three of the residents have been served. The Dietary Assistant pulled two plates from on top of the steam table and checked the temperatures of the pureed bread on the plates. This revealed that the temperature was 118.9 degrees. The Dietary Assistant revealed that when a food item is not at least 135 degrees that it should not be served to the resident it should be reheated to at least 165 degrees. Further interview and observation of the temperature log book, with the Dietary Assistant, revealed that when the food items were received from the Hospital Kitchen that the temperatures of all food items were measured and documented in the log book except for the pureed bread. The Dietary Assistant revealed at this time that the temperature for the pureed bread was not documented but that it should have been measured and documented with all of the other food items. Review of the facility's policy titled, Monitoring Food Temperatures for Meal Service, revealed that food temperatures will be monitored daily to prevent food borne illness and ensure foods are served at palatable temperatures. Procedure #1 documents: Prior to serving a meal, food temperatures will be taken and documented for all hot and cold foods to ensure proper serving temperatures. Any food item not found at the correct holding/serving temperature will not be served but will undergo the appropriate corrective action listed. Review of the policy titled, Resident Nutrition Services, Procedure #4 documents, To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 to 135 degrees Fahrenheit) will be kept at a minimum. Review of the recipe for the pureed bread documented: Hold or serve hot food at or above 135 degrees Fahrenheit.", "filedate": "2020-09-01"}
{"rowid": 3891, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2017-09-09", "deficiency_tag": 241, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IEJF11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and facility policy titile Quality of Life-Dignity, the facility failed to maintain dignity for one resident, R56 of a sample of 25 twenty-five .The facility census was 55 fifty-five residents. Finding include: Review of clincial record revealed R56 was admitted to the facility on [DATE]. The following [DIAGNOSES REDACTED]. R56 had a urinary tract infection UTI on 7//17 and recieved treatment. Review of R56's care plan dated 1/31/17 i for occassional bladder incontinence and peri care with interventions. Review of facility policy title Quality of Life-Dignity revealed that staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal cae and during treatment procedure. Observation on 9/8/17 at 2;15 p.m. revealed R56 was exposed wearing a brief when Certified Nursing Assistant, CNA FF pulled down her pants in the front lobby to check for peri care R56 was sitting in a recliner in the front lobby with other residents. CNA FF approached resident pulled down her pants from waist to upper thigh and proceeded to pat R56's brief in different area without wearing gloves and washing her hands. When she patted R56 brief in between her legs, R56 holler out. This was done in the presence of another CNA, CNA HH and the surveyor who was standing next to R56 during the observation. Interview with CNA FF at the time of the observation revealed that R56 is unable to communicate her toilet needs. She further stated she was checking R56 to see if she need changing. During an attempt to interview R56 and review of a Basic Mental Status BIMS it was revealed that R56 was not cognitive and not able to be interviewed. Interview on 9/8/17 at 2:42 p.m. with CNAFF revealed she was assigned to monitor R56 and other residents in the front lobby. She stated residents in the front lobby are taken to hall bathroom in front of the nurses station to check for peri care needs. Interview on 9/9/17 at 11:02 a.m. at with Licensed Practical Nurse, LPN GG revealed that R56 requires total care for incontinent care. Continued interview revealed that he monitors CNA and resident interaction through observation of CNA's tone how they treat resident, by assessing privacy during resident continent care, and rough handling. LPN GG stated that he has not had any problems with staff treating residents with dignity and respect. Reported that he will educate any care staff if he identifiy problem with dignity and infection control during resident peri-care. Interview on 9/8/17 at 11:33 a.m. with Director of Nursing, DON related to respect and dignity of residents. DON reported in-services on respect and dignity is provided to staff and residents. It was explained that if an issues with respect and dignity including resident right. Resident has the opportunity to file a grievance. The DON provided documentation to reveal in-services was given to staff. Review of the facility policy title Perineal Care revealed knock and gain permission to enter resident's room, provide privacy, inform resident on procedure to be performed, set up supplies .", "filedate": "2020-09-01"}
{"rowid": 3892, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2017-09-09", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IEJF11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop individualized care plan related to multiple urinary tract infections and [MEDICATION NAME] antibiotics for one (1) resident #37 (R#37) from a census sample of twenty-five (25) residents. Findings include: Resident #37 was admitted with the diagnoses, that included but not limited to, hypertension, anxiety disorder, gastro-[MEDICAL CONDITION] reflux disease, diabetes mellitus type 2, [MEDICAL CONDITION], candidiasis, [DIAGNOSES REDACTED], vitamin B12 deficiency, anxiety disorder, [MEDICAL CONDITION], dementia. The Minimum Data Set (MDS) Section I - Active Diagnoses: [REDACTED].#37 had an urinary infection within the last thirty (30) days for a quarterly assessment dated [DATE]; PPS (Prospective Payment System) 5 day assessment dated [DATE]; PPS 14 day assessment dated [DATE]; PPS 30 day assessment dated [DATE]; and PPS 5 day assessment dated [DATE]. Review of resident #37 care plan dated 4/28/15 on 9/8/17 at 5:55 p.m. revealed that there was no individualized care for urinary tract infections or the [MEDICATION NAME] antibiotic which resident #37 was receiving on this care plan. During an interview with the MDS Coordinator on 9/9/17 at 12:05 p.m. revealed that R#37 did not have a care plan for the multiple urinary tract infection or the [MEDICATION NAME] antibiotics. She revealed that this should have been care planned, and that this was an oversight. Cross reference to F 315", "filedate": "2020-09-01"}
{"rowid": 3893, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2017-09-09", "deficiency_tag": 315, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IEJF11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and facility perineal care policy, the facility failed to provide proper technique and effective perineal care to prevent infection for one (1) resident #37 (R#37) from a sample of twenty-five (25) residents. Findings include: Review of Perineal Care policy dated 11/1/16 reads all staff members involved in performing perineal care to residents will promote cleanliness, prevent infections to the extent possible, prevent and assess for skin breakdown and promote comfort. 13. Females a. Cleanse perineum from front to back. b. Cleanse the labia folds, urethral meatus and vaginal orifice using clean portion of cloth or new cloth with each stroke. An observation on 9/8/17 at 3:11 p.m. of Certified Nurse Aide (CNA) CC performing perineal care on R#37 revealed that R#37 was assisted to a standing position and CNA CC begin washing her in a back and forth motion. Upon cleaning the rectum area of resident, brown fecal material was observed. During this observation, CNA CC stated that R#37 had not had a recent bowel that the feces from a prior perineal care. An observation on 9/9/17 at 10:12 a.m. with CNA AA and with the assistance of CNA BB who transfer R#37 from the wheelchair to the bed using a gait belt. Upon positioning the resident in the bed, the resident stated she needed to pee, and the two CNA's transfered the resident back to the wheel chair and took her to the bathroom. Resident was observed wearing a brief that was mildly wet. R#37 urinated in the toilet. During this observation, CNA AA stated that she would provide perineal care to R#37 who was sitting on the toilet. CNA AA assist R#37 to a standing position, and R#37 used the grab bar next to the commode for support. CNA BB got the wash cloth from the sink and towels located in R#37 room. CNA AA begin performing perineal care to R#37 who was standing. Resident thighs were observed to be tightly closed and CNA AA was using the wash cloth and was not able to properly perform the perineal care. Review of a local hospital urine culture report dated 7/19/17 revealed Escherichia coli (E.coli) and the antimicrobial susceptibility indicated the bacteria is resistance to [MEDICATION NAME], [MEDICATION NAME]/sulfa, [MEDICATION NAME]. The urinalysis report dated 7/19/17 revealed that [MEDICATION NAME] 100 mg daily as a [MEDICATION NAME] antibiotic was ordered. Review of a local hospital urine culture dated 5/15/17 revealed E. coli that is resistant to [MEDICATION NAME], aztreonam, cefotaxime, [MEDICATION NAME], cephalothin, [MEDICATION NAME], [MEDICATION NAME]. Review of a local hospital urinalysis report dated 4/11/17 revealed rare bacteria, and the urine culture is mixed contaminated. Review of a local hospital urine culture report dated 4/7/17 revealed the urine culture is contaminated. Review of a local hospital urine culture report dated 3/21/17 revealed Proteus mirabilis Review of a local hospital urine culture report dated 3/3/17 revealed >100,000 proteus mirabilis that is resistant to [MEDICATION NAME]/sulfa, [MEDICATION NAME]. an order for [REDACTED]. Review of a local hospital urine culture report dated 1/31/17 [MEDICAL CONDITION] Review of a local hospital urinalysis report dated 1/17/17 revealed rare bacteria and that R#37 is presently on [MEDICATION NAME] DS twice a day for 10 days then on 1/19/17 she will be back [MEDICATION NAME] mg twice a day as a [MEDICATION NAME] antibiotic. Review of a local hospital urine culture report dated 1/5/17 revealed Proteus mirabilis that is resistance to [MEDICATION NAME], and [MEDICATION NAME]. There is a note that revealed that R#37 is presently [MEDICATION NAME] mg twice a day, since 11/7/16 as a [MEDICATION NAME] antibiotic. The urinalysis report revealed that R#37 is presently [MEDICATION NAME] mg by mouth twice a day as a [MEDICATION NAME] antibiotic. Review of a local hospital urine culture report dated 10/3/16 revealed normal skin flora, the Escherichia coli had the drug [MEDICATION NAME] as intermediate, and proteus mirabilis is resistance to [MEDICATION NAME], and [MEDICATION NAME] An interview on 9/9/17 at 10:12 a.m. Certified Nurse Aide (CNA) AA revealed that her last training for perineal care was in (MONTH) (YEAR). She continue to reveal that she received a checklist and was told to follow the key points on perineal care. And that she had not received a demonstration on proper technique of perineal care. An interview on 9/9/17 at 10:20 a.m. CNA BB revealed the last time she had a check off on perineal care was when she was given a checklist in (MONTH) (YEAR). And that she knew to wipe front to back using a different part of a washcloth or change wash cloth. However she did not do a return demonstration training in (MONTH) (YEAR). An interview on 9/9/17 at 10:25 a.m. Infection Control Nurse revealed that she provided in-services to the CNAs' in (MONTH) (YEAR) and that she gave them a handout/checklist for them to follow. However, she did not do a demonstration and return of perineal care with the CNA's. In (MONTH) (YEAR), a consultant came to the facility to discuss perineal care. The CNAs' were provided two computerized inservices. And in regards to R#37, that she was aware of the numerous urinary tract infections. However, she could not confirm that R#37 had true infections or had been seen by an urologist. Further interview revealed that the Infection control Nurse feels there is a need to do more demonstration with the CNAs' on perineal care. Cross Reference F279", "filedate": "2020-09-01"}
{"rowid": 3894, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2017-09-09", "deficiency_tag": 441, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "IEJF11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review,and staff interviews, the facility failed to ensure the infection control program contained effective surveillance and tracking of nosocomial infections for the faciity, and the facility failed to use proper handwashing techniques and or don gloves while providing care for one resident (R#56) in a sample of 25 residents. The facility census was 55. Findings: 1. Review of facility infection control logs dated (MONTH) (YEAR) through (MONTH) (YEAR) revealed the facility did track some infections; however, the infection control log did not contain all of the nosocomial infections that occured in the facility, nor did it track the rate of infection. Additionally, there was no documented evidence of mapping, quality improvement activities, review of infection control policies and procedures or reccomended actions and follow-up related to nosocomial infections that occured in the facility. Review of the facility Policies and Procedures: Infection Control revealed the system shall monitor and evaluate all infections and communicable diseases of residents. Further review of the policy revealed the Infection Control Committee (ICC) is responsible for the investigation, control and prevention of infections associated with care provided by the facility. The functions of the ICC include; establishing surveillance and reporting programs, establishing policies and procedures, implementing outbreak investigation and control, reviewing policies and procedures for infection control and recommending actions and follow-up relating to nosocomial infections. Review of the facility Infection Control Surveillance Policy revealed the Infection Control Nurse (ICN) is responsible for surveillance of infections among residents. Further review of the policy revealed nosocomial rates will be calculated and when a resident is identified as having developed an infection an abstract of pertinent data including the identification and location of the cultures and results and antibiotics used. Interview conducted on 9/9/17 at 11:25 a.m. with the Infection Control Coordinator (ICC) revealed she is not tracking or addressing any drug resistant organisms and did not identify infection statistics in terms of percentage of individual infections. Additional interview conducted on 9/9/17 at 1:25 p.m. with the ICC revealed after a significant increase in UTI infections in (MONTH) (YEAR), the facility did not establish any documented surveillance or infection control policies or procedures and did not conduct any review of aseptic technique. She also, revealed the infection control log did not include discharged residents diagnosed with [REDACTED]. 2. Observation on 9/8/17 at 2:15p.m revealed that R56 was sitting in the front lobby with other residents and while in the open view of residents and visitors entering the facility. Certified Nursing Assistant , CNA FF was observed entering the lobby and approaching R56 in the presence of this surveyor and CNA HH who was standing next to R56 recliner. CNA FF walked up to R56 who was sitting in a recliner and began checking R56 for perineal care. She begin to pat resident brief in different area without wearing any gloves. Although CNA FF had gloves in her hands, she did not wear the gloves. Interview on 9/9/17 at 10:55 p.m., CNA FF stated that facility policy requires that all residents who requires peri care check should be checked in the bathroom and resident rooms and that hand washing techniques should be applied. Further interview revealed that she verifed that she had not washed her hands. She stated that she thought she was using her gloves and did not recall not putting the gloves on. Review of the facility policy title Hand Washing/Hand Hygiene revealed the facility considers hand hygiene the primary means to prevent the spread of infections. All personnel shall follow the handwashing /hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Use an alcohol based hand rub containing at least 62% alcohol, or alternatively , soap (antimicrobial or non-antimicrobial) and water for the following situations before and after direct contact with residents, after removing gloves, etc/", "filedate": "2020-09-01"}
{"rowid": 3895, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2017-09-09", "deficiency_tag": 520, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IEJF12", "inspection_text": "Based on record review, review of the facility's Plan of Correction, and interview, the facility failed to develop and implement corrective action plans to resolve an identified concern placed in Quality Assurance (QA) related to perineal/catheter care for one resident (R#16) from a sample of two residents. R#16 did not receive perineal/catheter care to prevent possible infection. Findings include: Interview on 11/3/17 at 2:45 p.m. with the Registered Nurse Infection Control and Quality Assurance office, (RN, IC, QA) revealed the facility had two urinary tract infections for the month of October, and no urinary tract infections for any of the resident's with catheters. She stated that perineal care and Foley catheter care was still in QA and that all citations from the standard survey were in Q[NAME] Review of the facility Plan of Correction revealed a Mandatory in-service was conducted on 11/2/17 on Superbugs an Infection Control, Perineal Care Validation Check-Offs/Surveillance was conducted monthly.", "filedate": "2020-09-01"}
{"rowid": 5268, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2015-04-23", "deficiency_tag": 315, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "20S111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, the facility failed to ensure that three (3) of three (3) residents with indwelling catheters ( #5, #21 ,#63) received the appropriate care and treatment for [REDACTED]. Findings include: Observations of resident #5 on 04/20/15 at 3:32 p.m., 4/21/15 at 8:49 a.m. and 3:11 p.m. and on 04/22/15 at 8:45 a.m. and 3:27 p.m. revealed that the resident did not have a dignity bag covering the catheter drainage bag. Observations of resident #21 on 04/20/15 at 1:41 p.m. and at 3:20 p.m. revealed that the resident did not have a dignity bag covering the catheter drainage bag. Observation of resident #63 on 4/21/15 at 3:05 p.m. and on 4/22/15 at 4:04 p.m. revealed that the resident was in the bed, with the Foley catheter hanging on the bedside with no dignity bad covering it. An interview conducted on 04/23/15 at 12.15 p.m. with Certified Nursing Assistant (CNA) BB revealed that all residents with indwelling catheters should have dignity bags covering the catheter drainage bag. An interview conducted on 04/22/15 at 4:00 p.m. with the Director of Nursing (DON) revealed the staff are to use dignity bags for all residents with indwelling catheters. Observation of resident #5 and #63 with the DON confirmed there was no dignity bags covering the catheter drainage bags.", "filedate": "2018-11-01"}
{"rowid": 5269, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2015-04-23", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "20S111", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy, observations and staff interviews, the facility failed to ensure that certified nursing staff washed or sanitized hands after direct resident contact during meal service on one (1) of three (3) halls (North Hall). The census was fifty nine (59) with three (3) residents receiving tube feedings. Findings include: Observation of North Hall noon meal service on 04/20/15 at 12:15 p.m. revealed Certified Nursing Assistant (CNA) AA removed a meal tray from the food cart and entered room [ROOM NUMBER]. He/she moved the bedside table next to the bed and assisted the resident to a sitting position by placing his/her hands on each shoulder of the resident. He/she moved the bedside table over the resident and set up the meal tray touching the drinking portion of the residents straw with his/her hand. Further observation revealed CNA AA entered room [ROOM NUMBER] with a meal tray and adjusted the bed by touching the remote control. He/she adjusted the residents' pillow and proceeded to set up the meal tray touching the residents bread and drinking portion of the straw with his/her hands. CNA AA returned to the food cart, retrieved another tray and entered room [ROOM NUMBER]. He/she adjusted the bed, touching the remote control and proceeded to set up the meal tray touching the drinking portion of the straw with her hand. CNA AA returned to the food cart, retrieved another tray and entered room [ROOM NUMBER]. He/she adjusted the bedside table and proceeded to set up the residents' meal tray touching the drinking portion of the straw with her hand. CNA AA failed to wash or sanitize his/her hands throughout the entire procedure. An interview conducted on 04/20/15 at 1:30 p.m. with CNA AA revealed he/she should wash/sanitize hands between residents when passing out trays. The CNA confirmed he/she did not sanitize/wash his/her hands. Review of the facility policy entitled Handwashing - Infection Control - #2 reads: Wash your hands before and after all procedures. An interview conducted on 04/22/15 at 4:00 p.m. with the Director of Nursing (DON) revealed he/she expects the staff to wash/sanitize their hands between resident care and procedures.", "filedate": "2018-11-01"}
{"rowid": 6840, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2014-07-24", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "P7B611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to revise the Care Plan of one (1) resident (#67) to reflect the resident's significant weight loss and interventions to address the resident's assessed nutritional needs, from a survey sample of twenty-seven (27) residents. Findings include: Resident #67's 06/18/2014 Quarterly Minimum Data (MDS) assessment documented diagnoses, in Section I-Active Diagnoses, including but not limited to [MEDICAL CONDITION] and Hypertension. Resident #67's July 2014 Physician order [REDACTED]. Resident #67's Vitals Report documented the 06/11/14 facility readmission weight to be 162.2 pounds, but also documented the resident's 06/02/2014 (pre-hospitalization ) weight had been 174.4 pounds, thus indicating that Resident #67 lost from 174.4 to 162.2 pounds, or seven (7) percent, while hospitalized . Further review of Resident #67's 06/18/2014 Quarterly MDS referenced above revealed that Section K - Swallowing/Nutritional Status identified the resident's weight loss of 5 percent or more in the previous month (as referenced in the June 2014 Vitals Report above). In addition, the Registered Dietician (RD) identified Resident #67's weight loss in a 06/18/2014 Nutritional Re-Evaluation form, and also recommended dietary supplementation with Ensure. However, review of the Comprehensive Care Plan for Resident #67 revealed that, despite the resident's recent colon resection surgery, despite the 06/18/2014 MDS identifying a significant weight loss in the previous month (during hospitalization ), and despite the RD identifying on 06/18/2014 that the resident needed nutritional supplementation with Ensure dietary supplement, the facility failed to revise the resident's Care Plan to identify the significant weight loss or interventions to address the assessed nutritional needs after the resident's facility readmission following colon surgery. During an interview conducted on 07/23/2014 at 2:00 p.m. with the Assistant Director of Nursing (ADON), the ADON stated that when Resident #67's 6/18/2014 MDS revealed a significant weight loss, this should have been added to resident's Care Plan, but further acknowledged that the Care Plan of Resident #67 had not been revised. Cross refer to F325 for more information regarding Resident #67.", "filedate": "2017-10-01"}
{"rowid": 6841, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2014-07-24", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "P7B611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure the provision of care in accordance with the Care Plan of one (1) resident (#68), regarding indwelling urinary catheter care, of six (6) sampled residents having indwelling urinary catheters, on the total survey sample of twenty-seven (27) residents. Findings Included: Resident #68's 04/30/2014 Quarterly Minimum Data Set assessment documented [DIAGNOSES REDACTED]. Resident #68's monthly July 2014 Physician order [REDACTED]. Review of Resident #68's current Care Plan dated 05/06/2014 revealed an entry originally dating from 11/12/0213 which identified the resident's use of an indwelling urinary catheter. This Care Plan listed Approaches, related to Resident #68's indwelling urinary catheter use, which included for staff to maintain the resident's urinary catheter system as a closed system as much as possible. However, during observations of Resident #68 on 07/21/14 at 11:31 a.m., and on 07/22/14 at 8:52 a.m., 10:20 a.m., and 5:00 p.m., the indwelling urinary catheter drainage bag was observed to leak urine onto the floor. An observation of Resident #68 on 07/23/14 at 8:42 a.m. then revealed the catheter drainage bag had been replaced and was no longer leaking. During an interview with the Treatment Nurse conducted on 07/23/2014 at 9:50 a.m., the Treatment Nurse acknowledged that prior to this standard survey, the most recent change of Resident #68's indwelling urinary catheter and catheter bag had occurred on 06/02/2014. Cross refer to F315 for more information regarding Resident #68.", "filedate": "2017-10-01"}
{"rowid": 6842, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2014-07-24", "deficiency_tag": 315, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "P7B611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to maintain the indwelling urinary catheter system in a manner to prevent leakage and the potential for urinary tract infections for one (1) resident (#68), whose indwelling urinary catheter drainage bag was observed to leak, of six (6) sampled residents having indwelling urinary catheters, on the total survey sample of twenty-seven (27) residents. Findings Included: Record review for Resident #68 revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of 04/30/2014 which documented a facility Entry Date of 12/06/2013, and documented in Section I - Active [DIAGNOSES REDACTED]. Section G - Functional Status of this MDS documented that Resident #68 was totally dependent on staff for toilet use. Section H - Bladder and Bowel of this MDS documented that Resident #68 utilized an indwelling urinary catheter, and Section M - Skin Conditions documented that Resident #68 had a Stage 3 pressure ulcer which had been present upon facility admission. Review of Resident #68's monthly July 2014 Physician order [REDACTED]. Observation of Resident #68 conducted on 07/21/2014 at 11:31 a.m., during the initial survey entry tour, revealed the resident's indwelling urinary catheter was intact; however, this observation also revealed that the indwelling urinary catheter drainage bag was leaking urine onto the floor. Observation of Resident #68 conducted on 07/22/2014 at 8:52 a.m. revealed the resident's indwelling urinary catheter drainage bag was again observed leaking urine onto the floor. Additional observations of Resident #68 conducted on 07/22/2014 at 10:20 a.m. and at 5:00 p.m. revealed the resident's indwelling urinary catheter drainage bag to continue to leak urine onto the floor. A subsequent observation of Resident #68 conducted on 07/23/2014 at 8:42 a.m. revealed the resident's indwelling urinary catheter drainage bag to have been replaced, and revealed that the urine was maintained within the drainage bag, with no leakage at that time. During an interview with the Director of Nursing (DON) conducted on 07/24/2014 at 11:00 a.m., the DON was informed of Resident #68's indwelling urinary catheter drainage having been observed while leaking during the observations conducted during the initial tour of 07/21/2014 and during subsequent 07/22/2014 observations as referenced above. During this interview, the DON acknowledged that Resident #68's catheter urinary drainage bag had required replacement.", "filedate": "2017-10-01"}
{"rowid": 6843, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2014-07-24", "deficiency_tag": 325, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "P7B611", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide follow-up related to a dietary supplement recommended by the Registered Dietician for one (1) resident (#67) upon the resident's facility readmission from the hospital after colon surgery, from a survey sample of twenty-seven (27) residents. Findings include: Record review for Resident #67 revealed a Quarterly Minimum Data assessment with an Assessment Reference Date of 06/18/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Review of Resident #67's Physician order [REDACTED]. A Vitals Report for Resident #67 documented that on 06/02/2014, prior to the resident's hospital admission for colon resection surgery, the resident's weight was 174.4 pounds. This Vitals Report then documented that upon Resident #67's readmission from the hospital to the nursing facility on 06/11/2014, his weight had declined to 162.2 pounds, thus representing a 12.2 pound, or 7 percent, weight loss while in the hospital. A Nutritional Re-Evaluation form for Resident #67, which was signed by the Registered Dietician (RD) and dated 06/18/2014, documented the resident's recent weight loss, and the RD recommended that the resident receive the dietary supplement Ensure twice a day between meals. However, further review of Resident #67's clinical record, to include review of the June 2014 and July 2014 Physician order [REDACTED].#67 receive Ensure as a dietary supplement. During an interview with the Director of Nurses (DON) conducted on 07/23/2014 at 11:45 a.m., the DON acknowledged that Resident #67 did not have a current physician's orders [REDACTED]. The DON also stated that the 06/18/2014 RD recommendation for Resident #67 should have been forwarded to the facility's Patient Care Coordinator for notification of the physician, but further acknowledged that this RD recommendation had not been forwarded. Further review of Resident #67's physician's orders [REDACTED].#67 receive one (1) can of Ensure twice a day at 10:00 a.m. and 2:00 p.m.", "filedate": "2017-10-01"}
{"rowid": 7392, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2014-05-28", "deficiency_tag": 225, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "JP8L11", "inspection_text": "Based on staff interviews, resident interviews, and review of the facility's abuse policy,the facility failed to report an allegation of abuse and failed to follow their policy during investigations of alleged abuse, for one resident (A) from a sample of four (4) residents. Findings include: During an interview with the Director of Nursing (DON) on 5-28-14 at 2:30 pm, she stated that on 5-12-14, it was reported to her, that on the previous night on the 3 to 11 shift a certified nursing assistant(CNA) BB had an altercation with resident A. Per the DON, resident A asked the 3 to 11 shift charge nurse (CC) around 8:00 PM for someone to come in and to change her. Nobody had checked on her or changed her since the day shift CNA about 1:30 PM. The charge nurse CC asked CNA BB who was assigned to resident A to go and change her. CNA BB and a second CNA went into resident A's room to change her. As the CNA, BB went into the room, resident A started yelling at the CNA BB, why hadn't she checked and/or changed her since she came on duty at 3:00 pm. CNA BB began to argue with resident A. During the resident's interview on 5-28-14 at 4:30 PM resident A stated, the CNA came in my room mad. Per the resident the CNA BB slammed down both side-rails hard and 'snatched my brief off''. She said, she didn't want to work with me. Record review of a Resident-Family Complaint form dated 5/11/14 revealed that the 3 to 11 charge nurse CC was in the hallway outside of the room and heard the commotion and went into the room and asked, CNA BB to step out of the room. As CNA BB was leaving the room, resident A' called CNA BB a whore. CNA BB turned back into the room, and pointed her finger in resident A's face and told her to go look into a mirror and she would see a whore. Resident A was interviewed on 5-28-14, at 4:30 pm, she said, CNA BB and I really do not like each other. However per the resident, CNA BB had never gotten rough with her before. Resident A stated that if she had moved her head while the CNA BB pointed that finger in her face, the CNA BB would have poked her in the eye. During an interview with the 3 to 11 shift charge nurse CC on 5-28-14 at 5:30 pm, it was noted that she confirmed the incident as described was accurate. The charge nurse reported this as an allegation of verbal and mental abuse to the registered nurse(RN) on call on 5-11-14 and sent CNA BB home after the CNA left the resident's room. The during an interview with the alleged perpetrator on 5-28-14 at 5:30 PM, with the DON asked the CNA about the incident she did not deny it. The DON did not request the CNA to provide a written statement during the interview of this incident. Review of the facility's abuse policy revealed that a written statement of the alleged perpetrator should be done. CNA BB was terminated from employment from the facility on 5-12-14, for arguing with resident A. During further interview with the DON at 2:30 pm on 5-28-14, she confirmed the incident had been reported to her as an allegation of abuse. Per the DON she investigated this alleged incident to rule out verbal, mental and physical abuse. However, the DON acknowledged that she believed it was a dignity issue, and was not reported to the state agency as abuse and neglect.", "filedate": "2017-05-01"}
{"rowid": 8117, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2012-10-04", "deficiency_tag": 159, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "JB8C11", "inspection_text": "Based on record review and staff interview, it was determined that the facility had failed to ensure that residents' personal funds in excess of $50.00 was deposited in an interest bearing account for 35 residents who had authorized the facility to manage their personal funds. Findings include: A review of the resident trust fund accounts revealed that the facility had a fiduciary responsibility for 35 residents' personal funds. A review of residents' trust fund accounts ledger sheets for the period from March 2012 to August 2012 revealed that no interest had been credited to any of those accounts for the 35 residents. In an interview on 10/02/12 at 2:30 p.m., a facility business office representative AA said that the facility had stopped crediting the earned interest to the residents' trust fund accounts about a year ago when the bank, in which the facility had deposited the residents' money, had stopped paying interest on that account. The facility had failed to system to effectively manage the personal funds of Medicaid residents with more than $50 and that of Medicare residents with more than $100 for which it had a fiduciary responsibility by not ensuring that it was deposited in an interest bearing account.", "filedate": "2016-07-01"}
{"rowid": 8118, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2012-10-04", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "JB8C11", "inspection_text": "Based on record review, observations and staff interviews, it was determined that the facility failed to implement care plan interventions for fall prevention for one resident (#61) in a sample of 34 residents. Findings include: Licensed nursing staff documented in the 9/11/12 nursing notes that resident #61 was in his/her room yelling. The resident was discovered on the floor at his/her bedside. Nursing staff documented that there were no visible injuries to the resident and he/she denied having any injuries. A review of the resident's care plan revealed that he/she was identified as being at risk for falls. There was an care plan intervention to prevent falls for nursing staff to apply a bed and chair alarm at all times. However, observations at 8 a.m. on 10/3/12 and 10/4/12 revealed that nursing staff had not effectively implement that intervention for the use of an alarm on 10/3/12 or applied it on 10/4/12 at 8 a.m. See F323 for additional information regarding resident #61.", "filedate": "2016-07-01"}
{"rowid": 8119, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2012-10-04", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "JB8C11", "inspection_text": "**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 implement a planned intervention to promote the safety of one resident (#61) in a total sample of 34 residents. Findings include: 1. Resident #61 had [DIAGNOSES REDACTED]. On 10/01/12 at 4:12 p.m., licensed nursing staff stated that on 9/11/12, resident #61 was in his/her room and yelling. The resident was discovered on the floor at his/her bedside. Nursing staff noted that there were not any visible injuries to the resident and he/she denied having any injuries. A review of the resident's care plan revealed that he/she was identified as being at risk for falls. There was an care plan intervention to prevent falls for nursing staff to apply a bed and chair alarm at all times but, it was not done. During an observation with registered nurse BB on 10/03/12 at 8:00 a.m., the resident was in bed. Although, there was a tab alarm and a pressure-sensor alarm present, nursing staff had not turned them on so, they were not functioning. Following that observation, nurse BB activated the alarms and confirmed that both of them should have been on while the resident was in bed. During an observation on 10/04/12 at 8:00 a.m., the resident was in his/her room sitting in a wheelchair. However, staff had not applied a chair alarm to the wheelchair. This observation was confirmed by the facility's social worker at that time.", "filedate": "2016-07-01"}
{"rowid": 8120, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2012-10-04", "deficiency_tag": 328, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "JB8C11", "inspection_text": "**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 respiratory care equipment and suction catheters were stored in a sanitary manner for seven (#61, #32, #6, #49, #54, #12, and #30) of 23 residents receiving oxygen therapy or suctioning. Findings include: According to The Johns Hopkins Hospital Clinical Practice Manual for Respiratory Equipment, respiratory equipment has a role as an important source of transmitting microorganisms causing respiratory diseases. All equipment should be covered when not in use. However, nursing staff had failed to cover respiratory equipment being used by residents #61, #32, #6, #49, #54, #12 and #30 to reduce the risk for contamination. 1. During observations in resident #61's room (104B) on 10/01/12 at 3:25 p.m., 10/02/12 at 9:29 a.m., and 10/03/12 at 8:05 a.m., there was an uncovered nasal cannula and nebulizer mask. The nasal cannula was attached to an oxygen cylinder on the back of a wheelchair. It was dangling approximately eight (8) inches above the floor between the back and seat of the wheelchair. 2. Resident #32 was observed in his/her room (102B) on 10/01/12 at 12:50 p.m., His/Her portable suction machine was on his/her overbed table. There was approximately 100 milliliters (ml.) of cloudy liquid in the suction cannister and an uncovered [MEDICATION NAME] suction tip on the overbed table. On 10/02/12 at 10:15 a.m., there was approximately 200 ml of cloudy liquid in the suction cannister and the uncovered suction tip was on the resident's overbed table. On 10/03/12 at 8:05 a.m., the suction cannister had been emptied but, the suction tip remained uncovered on the resident's overbed table. 3. Resident #6's was observed in his/her room (98B) on 10/01/12 at 3:00 p.m., 10/02/12 at 9:12 a.m., and 10/03/12 at 8:05 a.m. His/her uncovered nasal cannula was attached to a portable oxygen tank on the left side of his/her bed. 5. During an observation in resident #54's room (101 A) on 10/2/12 at 9:27 a.m., an uncovered nasal cannula was attached to an oxygen cylinder. The cannula tubing was handing down the back of a wheelchair between the back and seat of the wheelchair. On 10/3/12 at 8:05 a.m., an uncovered nebulizer mask was on the resident's bedside table. 6. There were uncovered nebulizer masks observed lying on resident #12's and resident #30's overbed table. Observations on 10/03/12 at 11:15 a.m. with the Assistant Director of Nursing (ADON) revealed that resident #61's nasal cannula and nebulizer mask, resident #32's suction tip, residents #6, and #49 nasal cannulas, and resident #54's nebulizer mask were uncovered. During an interview at that time, the ADON stated that those nasal cannulas, nebulizer masks, and suction tips should have been covered for infection control purposes.", "filedate": "2016-07-01"}
{"rowid": 8121, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2012-10-04", "deficiency_tag": 441, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "JB8C11", "inspection_text": "Based on record review and staff interview, it was determined that the facility failed to ensure that the infection control program contained effective surveillance. Findings include: Review of the facility's infection control log from June 2012 to August 2012 revealed that there was not any evidence that the facility had identified the causative organism and implemented strategies to prevent the spread of infection. The facility documented that eight residents had urinary tract infections in 6/12 and four residents had urinary tract infections in 7/12. There was not any evidence that staff did an infection summary for 8/12. Although the facility documented if cultures had been done, there was no documentation if the culture was positive for organisms. There was no documentation to indicate if the infections were nosocomial or community acquired. During an interview on 10/3/12 at 3:00 p.m., the infection control nurse confirmed that the facility's infection control surveillance documentation was incomplete.", "filedate": "2016-07-01"}
{"rowid": 9667, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2011-03-03", "deficiency_tag": 281, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "YS9Q11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's policy and procedure on insulin administration and staff interview, it was determined that licensed nursing staff failed to consistently rotate the injection sites for insulin administration for five residents (#11, #4, #5, #12 and #2) who received subcutaneous insulin from a total sample of 15 residents. Findings include: The \"Rules and Regulations for Nursing Homes, Chapter 290-5-8-.10 notes that all medications must be administered by medical or nursing personnel in accordance with the Medical and Nurse Practice Acts of the State of Georgia. According to the University of Wisconsin Hospitals and Clinics Authority, \"Insulin Injection Sites\" Health Information ( April 4, 2004), insulin could be irritating to the skin and underlying fatty tissue. Damaged tissue did not absorb insulin easily or at the correct rate. Therefore, rotating the injection sites for insulin administration helped prevent damage to the skin and tissue and, allowed for the correct absorption of insulin. The \"Patient information: Diabetes mellitus type 2: insulin treatment\" information, authored by David K. McCullough MD, noted that the site of injection could affect how injected insulin worked. He wrote: clinicians usually recommended rotating injection sites to minimize tissue irritation. According to the facility's Policy and Procedure for subcutaneous injections, licensed nursing staff were supposed to rotate the sites of injections to prevent unnecessary trauma and to aid in the absorption of the medication. Licensed nursing staff were supposed to document the date, time, type and site of the injection. However, licensed nursing staff failed to rotate insulin injection sites for residents #2, #4, #5, #11 and #12. 1. Resident #11 had a [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, review of the Medication Administration Records (MARs) and Diabetic Flow Sheets revealed no evidence that licensed nursing staff had rotated the resident's insulin injection sites for 49 of 63 times in December, 2010, for 46 of 62 times in January, 2011, for 52 of 56 times in February, 2011 and for 5 of 5 times in March, 2011. 2. Resident #4 had [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, review of the MARs and Diabetic Flow Sheets revealed no evidence that licensed nursing staff had rotated the resident's insulin injection sites for 29 of 31 times in December 2010, for 31 of 31 times in January 2011, for 28 of 28 times in February 2011 and for 2 of 2 times in March 2011. 3. Resident #5 had [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, review of the MARs and Diabetic Flow Sheets revealed no evidence that licensed nursing staff had rotated the resident's insulin injection sites for 32 of 62 times in December 2010, for 39 of 62 times in January 2011, for 35 of 56 times in February 2011 and for 3 of 3 times in March 2011. 4. Resident #12 had [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, review of the MARs and Diabetic Flow Sheets revealed no evidence that licensed nursing staff had rotated the resident's insulin injection sites for 35 of 62 times in December 2010, for 32 of 62 times in January 2011 and for 28 of 56 times in February 2011. 5. Resident #2 had [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. There was an order since at least 12/9/09 for sliding scale administration of Regular insulin four times daily following a fingerstick check of the resident's blood sugar level. However, a review of the resident's MARs for the routine administration of the [MEDICATION NAME] 70/30 insulin revealed no evidence that the injection sites were rotated. Review of the \"Diabetic Flow Sheet\" documentation, used by the nurse to track the sliding scale insulin coverage, revealed either no evidence that injection sites were rotated or, documentation that the same sites were used repeatedly (#8 left deltoid, and #9 right upper arm). In November, 2010, licensed nurses gave the resident 120 insulin injections but, only recorded the site of those injections 28 times. In December, 2010, 101 injections were given but, only 35 times were the sites of those injections recorded. In January, 2011, 124 insulin injections were given but, only 49 times were the sites of the injections recorded. In February, 2011 112 insulin injections were given but, only 38 times were the sites of the injections recorded.", "filedate": "2015-06-01"}
{"rowid": 9668, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2011-03-03", "deficiency_tag": 282, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "YS9Q11", "inspection_text": "**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 the plans of care were followed to provide supplements as ordered for one resident (#6), to rotate the insulin injection sites for one resident (#4), to provide appropriate incontinence care for three residents (#4, #5 and #13) and to ensure that the oxygen humidifier bottles were filled with water for two residents (#3 and #2) from a total sample of 15 residents. Findings include: 1. Resident #6 had [DIAGNOSES REDACTED]. He/she had unavoidable significant weight loss because of his/her [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. The resident had a care plan intervention since 7/20/10 for staff to provide supplements as ordered. However, during observations of meals on 3/1/2011 at 12:25 p.m., on 3/2/2011 at 8:25 a.m., and on 3/3/2011 at 8:20 a.m., staff failed to serve the fortified milkshakes to the resident. See F325 for additional information regarding resident #6. 2. Resident #4 had [DIAGNOSES REDACTED]. The resident had a care plan since 12/14/10 with interventions that included licensed nursing staff to rotate injection sites for insulin doses. However, review of the resident's Medication Administration Records (MARs) and the Diabetic Flow Sheets revealed that there was no evidence that licensed nursing staff rotated the resident's insulin injection sites for 29 of 31 times in December 2010, for 31 of 31 times in January 2011, for 28 of 28 times in February 2011 and for 3 of 3 times in March 2011. See F281 for additional information regarding resident #4. Also, resident #4 had a care plan since 12/14/10 with interventions for nursing staff to provide incontinence care after each incontinent episode and to apply moisture barrier. However, during observation of urinary incontinence care provided on 3/2/11 at 11:05 a.m., nursing staff inappropriately wiped from the back to the front and failed to apply moisture barrier. See F315 for additional information regarding resident #4. 3. Resident #5 had [DIAGNOSES REDACTED]. He/She had a care plan since 5/1/08 with interventions that included licensed nursing staff to rotate injection sites for insulin doses. However, review of the resident's MARs and the Diabetic Flow Sheets revealed that there was no evidence that licensed nursing staff consistently rotated the resident's insulin injection sites. See F281 for additional information regarding resident #5. Also, resident #5 had a care plan since 5/1/08 with interventions that included nursing staff to provide incontinence care after each incontinent episode and to apply moisture barrier. However, during observation of urinary and bowel incontinence care provided by nursing staff on 3/2/11 at 10:45 a.m., the staff inappropriately wiped back to front and failed to apply moisture barrier. See F315 for additional information regarding resident #5. 4. Resident #12 had [DIAGNOSES REDACTED]. The resident had a care plan since 10/9/07 with interventions that included licensed nursing staff to rotate injection sites for insulin doses. However, review of the resident's MARs and Diabetic Flow Sheets revealed that there was no evidence that licensed nursing staff consistently rotated the resident's insulin injection sites. See F281 for additional information regarding resident #12. 5. Resident #13 had [DIAGNOSES REDACTED]. The resident had a care plan since 10/24/06 with interventions that included nursing staff to provide incontinence care after each incontinent episode and to apply moisture barrier. However, during observation of urinary incontinence care provided on 3/3/11 at 7:40 a.m., nursing staff inappropriately wiped from back to front and failed to apply any moisture barrier. See F315 for additional information regarding resident #13. 6. Resident #3 had [DIAGNOSES REDACTED]. The resident had a care plan since 11/2/10 that included an intervention to humidify oxygen with sterile or distilled water. The resident had continuous oxygen at a rate of 2 liters per minute via nasal cannula. However, during observations on 3/1/11 between 12:15 p.m. and 5:00 p.m., the humidifier bottle was empty while the resident was being administered oxygen. See F328 for additional information regarding resident #3. 7. Resident #2 was admitted with [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. The plan of care since 12/9/09 had an interventions to humidify oxygen with sterile or distilled water and, to change the oxygen humidifier bottle and tubing twice monthly. However, during the initial tour on 3/1/11 at approximately 9:00 a.m., and at 3:00 p.m., resident #2's oxygen humidifier bottle was empty. There was no documentation to verify when the tubing had last been changed. There was not a date on the humidifier bottle or oxygen tubing. See F328 for additional information regarding resident #2. Resident #2 had a care plan since 12/9/09 with an intervention for licensed nursing staff to rotate insulin injection sites. However, there was no documentation and incomplete documentation and, documentation of repeated use of injection sites on the Diabetic Flow Record. See F281 for additional information regarding resident #2.", "filedate": "2015-06-01"}
{"rowid": 9669, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2011-03-03", "deficiency_tag": 328, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "YS9Q11", "inspection_text": "**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 properly store nebulizer equipment for two unsampled residents, failed to ensure that the humidifier bottles were adequately filled with water for two sampled residents (#2 and #3) and failed to date the oxygen tubing and humidifiers for 11 unsampled residents and for five (#1, #2, #3, #4 and #13) sampled residents, who utilized oxygen in a census of 19 residents in the facility with respiratory therapy orders. 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 for cleaning nebulizer equipment documented that the mouthpiece/mask should be rinsed with warm water and dried after each use and that all equipment should be covered when not in use. The guideline related to the use of oxygen noted that replacing the delivery system was to be done every 7 days. However, staff failed to change respiratory equipment for residents #2, #3, #4 and #13 and 11 unsampled residents, and failed to cover respiratory equipment when not in use for two unsampled residents. In an interview on 3/1/11 at approximately 9:00 a.m., licensed nurse stated that the facility did not have a system to monitor the care of respiratory equipment and that changes in the equipment were usually done on an 'as needed' basis. 1. During the Initial Tour on 3/1/2011 at 9:30 a.m. and on 3/3/2011 at 10:40 a.m., the tubing on the oxygen concentrator for the resident in room [ROOM NUMBER]A was not dated. 2. During the Initial Tour on 3/1/2011 at 9:30 a.m. and on 3/3/2011 at 10:41 a.m., the tubing on the oxygen concentrator for the resident in room [ROOM NUMBER]B was not dated. 3. During the Initial Tour on 3/1/2011 at 9:35 a.m. and on 3/3/2011 at 10:30 a.m., the tubing on the oxygen concentrator for the resident in room [ROOM NUMBER] was not dated. 4. On 3/3/2011 at 10:33 a.m., the tubing on the oxygen concentrator and the tubing on the portable oxygen tank on the wheelchair for the resident in room [ROOM NUMBER] B was not dated. The resident's nebulizer mask was uncovered and on his/her bedside table at that time. There was a moderate amount of a dried white substance on the inside of the nebulizer mask. 5. Resident #2 was observed at approximately 9:00 a.m. on 3/1/11 with oxygen infusing at a rate of 3 liters per minute. However, the humidifier bottle was empty. At approximately 3:00 p.m. the same day, the water bottle was still empty. The oxygen tubing was not dated. 6. During the initial tour on 3/1/11 between 9:00 a.m. and 10:30 a.m., there was not a date on the oxygen tubing or humidifier bottle in rooms 119 A, 119 B, 120, 122 A, 122 B, 124 and 126. 7. The nebulizer mouth piece was uncovered and on top of nebulizer machine in room [ROOM NUMBER]. There was not a date on the nebulizer tubing/mouth piece. 8. Resident #3 was receiving oxygen at a rate of 2 liters per minute through a nasal cannula. He/She had a care plan since 11/2/10 for staff to humidify the oxygen with sterile or distilled water. However, during observations on 3/1/11 between 12:15 p.m. and 5:00 p.m., the humidifier bottle was empty. During observations on 3/1/11 at 12:15 p.m., 2:10 p.m., 3:25 p.m. and 4:58 p.m., on 3/2/11 at 7:10 a.m., 12:55 p.m. and 2:45 p.m. and on 3/3/11 at 7:30 a.m. and 12:15 p.m. there was not a date on the tubing or humidifier bottle. 8. Resident #4 was receiving oxygen at a rate of 2 liters per minute through a nasal cannula. However, during observations on 3/1/11 at 2:00 p.m. and 5:00 p.m. and on 3/2/11 at 7:05 a.m., 11:20 a.m. and 5:00 p.m. and on 3/3/11 at 7:10 a.m., the tubing and the humidifier bottle were not dated. 9. Resident #13 was receiving oxygen at a rate of 2 liters per minute through a nasal cannula. However, during observations on 3/2/11 at 5:05 p.m. and on 3/3/11 at 7:15 a.m. and 9:45 a.m., the tubing and the humidifier bottle were not dated. During an interview on 3/3/11 at 11:00 a.m., the Director of Nursing stated that residents' oxygen tubing and humidifier bottles were only changed on an 'as needed' basis. He/she stated that there was not any documentation done as to when those items were changed.", "filedate": "2015-06-01"}
{"rowid": 9670, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2011-03-03", "deficiency_tag": 325, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YS9Q11", "inspection_text": "**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 nutritional supplements were provided as ordered by the physician for one resident (#6) in a sample of seven residents with weight loss from a total sample of 15 residents. Findings include: Resident #6 had [DIAGNOSES REDACTED]. He/She received Hospice services and had an unavoidable significant weight loss of 10 percent in six months from 130 pounds (9/2010) to 117 pounds (2/14/2010) due to his/her [DIAGNOSES REDACTED]. The resident had a physician's orders [REDACTED]. There was a care plan intervention since 7/2010 for staff to provide supplements as ordered. However, during observations of lunch on 3/1/2011 at 12:25 p.m., and breakfast on 3/2/2011 at 8:25 a.m. and on 3/3/2011 at 8:20 a.m., staff failed to serve the fortified milkshake to the resident. The resident's diet card documented that he/she was to be served milkshakes at each meal. Although staff had failed to serve the resident the fortified milkshake at those times, staff had inaccurately documented on the Percentage Sheets that the resident had consumed 60 percent of his/her supplement at lunch on 3/1/2011 and 100 percent of his/her supplement at breakfast on 3/2/2011. On 3/2/2011 at 1:05 p.m., the dietary manager stated that dietary staff were responsible for placing the resident's milkshake on his/her meal tray prior to the tray leaving the kitchen. On 3/3/2011 at 11:45 a.m., the Assistant Director of Nursing (ADON) stated that certified nursing assistants were responsible for checking the resident's diet card and ensuring that all the supplements were on the resident's tray prior to serving the resident. Although staff had failed to serve the resident the fortified milkshakes, staff were observed to implement other care plan interventions to prevent further weight loss for the resident such as serving Ensure pudding to him/her at each meal.", "filedate": "2015-06-01"}
{"rowid": 9671, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2011-03-03", "deficiency_tag": 309, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YS9Q11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, it was determined that the facility failed to administer medication as ordered for one resident (#12) from a total sample of 15 residents. Findings include: Resident #12 had [DIAGNOSES REDACTED]. He/She had a physician's orders [REDACTED]. However, review of the resident's Medication Administration Records (MARs) and Diabetic Flow Sheets revealed that licensed nursing staff failed to administer the insulin as ordered on the 1/14 and 1/17/11 at 5:00 p.m. and on 2/9, 2/11, 2/21, and 2/25/11 at 5:00 p.m.. Licensed nursing staff documented that the insulin was held because the resident's fingerstick blood sugar (FSBS) levels were 118 on 1/14/11, 112 on 1/17/11, 113 on 2/9/11, 123 on 2/11/11, 72 on 2/21/11 and 153 on 2/25/11. There was not a physician's orders [REDACTED].", "filedate": "2015-06-01"}
{"rowid": 9672, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2011-03-03", "deficiency_tag": 315, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YS9Q11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations it was determined that the facility failed to provide effective incontinence care for three residents (#4, #5 and #13) from a sample of five incontinent residents from a total sample of 15 residents. Findings include: 1. Resident #4 had [DIAGNOSES REDACTED]. Licensed nursing staff coded the resident as requiring extensive assistance with personal hygiene and bathing on the 12/10/10 initial Minimum Data Set (MDS) assessment. He/She had a care plan since 12/14/10 with interventions that included nursing staff to provide incontinence care after each incontinent episode and to apply a moisture barrier. However, during an observation of urinary incontinence care being provided on 3/2/11 at 11:05 a.m., certified nursing assistant (CNA) \"GG\" inappropriately cleansed, rinsed and dried the resident's buttocks and rectal area from the back to the front. In addition, nursing staff \"GG\" failed to apply moisture barrier. 2. Resident #5 had [DIAGNOSES REDACTED]. Licensed nursing staff coded the resident as requiring total assistance with all activities of daily living on the 12/16/10 quarterly MDS assessment. He/She had a care plan since 5/1/08 with interventions for nursing staff to provide incontinence care and apply moisture barrier. However, during an observation of bowel and urinary incontinence care being provided on 3/2/11 at 10:45 a.m., CNA \"HH\" inappropriately wiped the resident from the rectal area to the vaginal area with a soiled washcloth. There was a small amount of bowel movement observed on the washcloth. In addition, nursing staff failed to apply moisture barrier. 3. Resident #13 had [DIAGNOSES REDACTED]. Licensed nursing staff coded the resident as requiring total assistance with all activity of daily living on the 1/27/11 quarterly MDS assessment. He/She had a care plan since 10/24/06 with interventions for nursing staff to provide incontinence care after each incontinent episode and to apply moisture barrier. However, during an observation of urinary incontinence care being provided on 3/3/11 at 7:40 a.m., CNAs \"GG\" and \"HH\" inappropriately cleansed, rinsed and dried the resident's buttocks and rectal area from the back to the front. In addition, nursing staff failed to apply moisture barrier.", "filedate": "2015-06-01"}
{"rowid": 9673, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2011-03-03", "deficiency_tag": 322, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YS9Q11", "inspection_text": "**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 (#5) with a gastrostomy tube received the appropriate treatment to prevent complications from a sample of three residents with gastrostomy tubes from a total sample of 15 residents. Findings include: According to the \"Best Practice Guidelines for Tube Feedings\" by Ross Products Division/Abbott Laboratories, to minimize the risk of aspiration, the head of the bed should be between 30 - 45 degrees during and for 30 to 60 minutes after tube feeding. However, staff failed to maintain the head of the bed elevated for an appropriate time period following a bolus feeding for resident #5. Resident #5 had [DIAGNOSES REDACTED]. cal. Glucerna five times daily. During observation of incontinence care being provided on 3/2/11 at 10:45 a.m., which immediately followed an observation of a bolus feeding at 10:35 a.m., the certified nursing assistant lowered the resident's head of the bed to flat position (10 minutes after the feeding).", "filedate": "2015-06-01"}
{"rowid": 9674, "facility_name": "SEMINOLE MANOR NURSING HOME", "facility_id": 115712, "address": "100 FLORENCE STREET", "city": "DONALSONVILLE", "state": "GA", "zip": 39845, "inspection_date": "2011-03-03", "deficiency_tag": 505, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "YS9Q11", "inspection_text": "**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 notify the resident's attending physician about a high critical BUN and Creatinine and a low potassium level for one resident (#3) from a total sample of 15 residents. Findings include: Resident #3 had [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. On 12/2/10, the attending physician ordered one dose of 40 milliequivalents (meq.) of Potassium and repeat the potassium level in one week. On 12/9/10, a potassium level of 3.2 (low) was reported to the physician and he/she ordered potassium 20 meq. twice daily for two days and repeat a metabolic panel on 12/16/10. The laboratory staff contacted the facility on 12/16/10 at 6:38 a.m. with the laboratory test results of a low potassium level of 3.0, a high critical BUN level of 62 and a high critical creatinine level of 3.1. Review of the nurses notes and the laboratory's test results form revealed that nursing staff failed to notify the physician about those abnormal test results until 12/17/10 at 8:30 a.m. (more than 24 hours later). At that time, the physician ordered 20 meq. of potassium twice daily for three days and repeat a potassium blood level on 12/21/10. During an interview on 3/3/11 at 1:25 p.m., the Director of Nursing was unable to provide any reason for the delay in notification of the physician.", "filedate": "2015-06-01"}
{"rowid": 8401, "facility_name": "HUTCHESON MED CTR SUBACUTE UNI", "facility_id": 115040, "address": "100 GROSS CRESCENT CIRCLE", "city": "FORT OGLETHORPE", "state": "GA", "zip": 30742, "inspection_date": "2011-09-22", "deficiency_tag": 170, "scope_severity": "B", "complaint": 0, "standard": 1, "eventid": "VTI211", "inspection_text": "Based on staff interviews and facility policy the facility failed to ensure that mail is delivered promptly following delivery to the facility for one (1) resident (P) from a sample of twenty-one (21) residents. Interview with resident P conducted on 9/22/2011 at 9:30 a.m. revealed that Saturday mail is delivered on occasions when activities staff is in the building otherwise they get their mail on Monday. Interview with Administrator conducted on 9/22/2011 at 10:00 a.m. revealed that postal service delivers mail on Saturdays to the facility and restorative staff is responsible for delivering it to the residents. Occasionally, when activity staff work on Saturday, they sometime deliver the mail. The Administrator further indicated that she cannot swear that the mail is delivered to residents on every Saturday. Interview conducted with Activity Director on 9/22/2011 at 10:36 a.m. revealed that Activity staff delivers mail to residents on Saturdays, when they are scheduled to work, and other staff member should be delivering the mail when Activity staff are not at work. During the week days all mail is delivered by Activities Staff. There has been several occurrences in which mail that was delivered on Saturday from postal services was still in the facility's mail box on Monday morning. Review of facility policy revealed that mail is to be delivered to the residents, sealed and unopened, through the facility's normal mail delivery system. The Administrator indicated normal mail delivery is Monday thru Saturday.", "filedate": "2016-01-01"}
{"rowid": 8402, "facility_name": "HUTCHESON MED CTR SUBACUTE UNI", "facility_id": 115040, "address": "100 GROSS CRESCENT CIRCLE", "city": "FORT OGLETHORPE", "state": "GA", "zip": 30742, "inspection_date": "2011-09-22", "deficiency_tag": 371, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "VTI211", "inspection_text": "Based on observation, and staff interviews, the facility failed to date and label open food items in the freezer in the building A kitchen. Findings include: On initial tour of the building A kitchen on 09/19/2011 at 1:35 p.m. with the Director of Dietary, the freezer contained french toast sticks, french fries, mandarin blend vegetables, and corn that had been opened and were labeled and dated. The Dietary Director acknowledged that the open containers should have been labeled and dated. Interview with BB on 09/21/2011 at 1:30 p.m., revealed that staff has been trained to store opened food in a labeled container with contents and date opened. Interview on 09/21/2011 at 1:40 p.m. with AA, revealed that any food being stored should be labeled with contents and the date opened.", "filedate": "2016-01-01"}
{"rowid": 8771, "facility_name": "HUTCHESON MED CTR SUBACUTE UNI", "facility_id": 115040, "address": "100 GROSS CRESCENT CIRCLE", "city": "FORT OGLETHORPE", "state": "GA", "zip": 30742, "inspection_date": "2012-10-25", "deficiency_tag": 241, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "HIQS11", "inspection_text": "Based on resident interview and family interview, the facility failed to provide assistance with toileting as requested to maintain the dignity of three (3) residents (A, B, and C) from a survey sample of nine (9) residents. Findings include: During an interview with Resident A conducted on 10/12/2012 at 12:00 p.m., the resident stated that he/she had needed to have a bowel movement and when he/she had requested to be toileted by staff, he/she was told by the certified nursing assistant to go in the brief. The resident stated that this made him/her feel bad. The resident's spouse, who was in attendance at the time of this interview, stated that the resident was told to go in the brief routinely. During an interview with Resident B conducted on 10/12/2012 at 11:30 a.m., the resident stated that she had been eating dinner in her room when her roommate, Resident C, requested to be taken to the bathroom. Resident B stated that the certified nursing assistant told Resident C to go in the brief because staff could not take the resident to the bathroom during meals. Resident B stated that Resident C then had a bowel movement in her brief, further stating that she had a hard time eating her dinner because the smell was unpleasant.", "filedate": "2015-10-01"}
{"rowid": 9697, "facility_name": "HUTCHESON MED CTR SUBACUTE UNI", "facility_id": 115040, "address": "100 GROSS CRESCENT CIRCLE", "city": "FORT OGLETHORPE", "state": "GA", "zip": 30742, "inspection_date": "2012-01-23", "deficiency_tag": 441, "scope_severity": "D", "complaint": 1, "standard": 0, "eventid": "4O0411", "inspection_text": "Based on observation, staff interview, and facility policy review, the facility failed to follow the infection control policy and ensure a sanitary environment related to the use of glucometers for four (4) residents (#7, #8, #9, and #10) in a survey sample of ten (10) residents. Findings include: Review of the operators manual for the glucometer used by the facility revealed that the machine was to be cleaned with a 10% bleach solution and that alcohol was not to be used. However, observation on 01/23/2012 of Nurse \"AA\" using the glucometer on Residents #7 and #8 at 11:34 a.m. and 11:38 a.m., respectively, revealed that the machine was not cleaned prior to the test on Resident #7, and was cleaned with alcohol after the blood was obtained and the tests were done on Residents #7 and #8. Observation of Patient Care Tech \"BB\" conducted on 01/23/2012 at 11:45 a.m. revealed that the glucometer was not cleaned prior to taking it into the room of Resident #9. Stains were observed on the over-bed table upon which the box containing the glucometer was placed. The Patient Care Tech was wearing gloves and placed the glucose strip on the over-bed prior to obtaining the blood sample. The glucose strip was then picked up and the resident's blood was placed on the strip. The hands were washed after the procedure, however, the glucometer was not cleaned after the test. Observation of Patient Care Tech \"BB\" conducted on 01/23/2012 at 11:50 a.m. revealed that the box with the glucometer was taken into the room of Resident #10 without being cleaned. The box with the glucometer was placed on the resident's over-bed table next to personal toiletry items. Wearing gloves, the Patient Care Tech placed the blood on the glucose strip and the test was completed. The hands were washed after the test, however, the glucometer was not cleaned. During an interview with the Infection Control Nurse conducted on 01/23/2012 at 3:00 p.m., this Nurse stated that the infection control policy was that reusable equipment was not used for the care of another resident until cleaned and reprocessed appropriately. It was further stated that the appropriate cleaning solution for glucometers was 10% bleach. During an interview with the Administrator conducted on 01/23/2012 at 4:35 p.m., the Administrator acknowledged that the over-bed tables should have been cleaned or a barrier placed prior to the placement of the box with the glucometer on the tables.", "filedate": "2015-05-01"}
{"rowid": 10528, "facility_name": "HUTCHESON MED CTR SUBACUTE UNI", "facility_id": 115040, "address": "100 GROSS CRESCENT CIRCLE", "city": "FORT OGLETHORPE", "state": "GA", "zip": 30742, "inspection_date": "2010-12-14", "deficiency_tag": 309, "scope_severity": "D", "complaint": null, "standard": null, "eventid": "7FWP11", "inspection_text": "**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 treatments as ordered by the physician for two (2) residents (#s 1 and 2) in a survey sample of six (6) residents. Findings include: 1. Record review for Resident #1 revealed a 10/20/2010 physician's orders [REDACTED]. However, further record review, to include review of the November 2010 Treatment record, revealed no evidence to indicate that this treatment was done on 11/18/2010 at 9:00 a.m., and on 11/01/2010, 11/02/2010, 11/03/2010, 11/23/2010 and 11/27/2010 at 9:00 p.m., as ordered and scheduled. 2. Record review for Resident #2 revealed an 11/04/2010 physician's orders [REDACTED]. However, further record review, to include review of the November 2010 Treatment record, revealed no evidence to indicate that this treatment was done on the 7:00 a.m.-7:00 p.m. shift on 11/07/2010, 11/08/2010, 11/09/2010, 11/12/2010, 11/14/2010, 11/23/2010, 11/26/2010, 11/27/2010, and 11/28/2010, as ordered and scheduled. During an interview with Nurse \"AA\" conducted on 12/14/2010 at 1:45 p.m., this nurse acknowledged that the treatments referenced above were not done as ordered for Resident #1 and Resident #2.", "filedate": "2014-04-01"}
{"rowid": 3904, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2019-01-10", "deficiency_tag": 600, "scope_severity": "J", "complaint": 0, "standard": 1, "eventid": "XS0411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review, staff and resident interviews, it was determined the facility failed to ensure two residents (R) (R#121 and R#55) from a sampled 57 residents were free from physical and psychological abuse. R#121 was subjected to a painful failed urinary catheter insertion along with verbal threats from a staff member. Five days later on 12/23/18, R#55 was subjected to painful dis-impaction removal of stool by the same employee. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training 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 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. Findings Include: 1. Interview conducted on 1/7/19 at 10:00 a.m. with the family of R#121 revealed approximately the week before last she was walking down the hall to R#121's room when the family heard R#121 screaming bloody murder. The family member walked into the room of R#121 and there were two Certified Nursing Assistant (CNAs) at the head of the resident's bed and Licensed Practical Nurse (LPN) II was attempting to insert a catheter. The family member also stated LPN II tried at least six times while the resident was still screaming. LPN II told family to get out of her way. The family member left the room to get LPN EE to put the catheter in. The family further stated they felt LPN II had abused R#121 because LPN II wouldn't stop even when R#121 was screaming in pain. The family was asked if they had told anyone and they stated yes, they had spoken to the Director of Nursing (DON), and LPN II is still working here. The family was questioned if LPN II had been assigned to the resident since the incident had occurred? They stated, No, we requested that nurse not be allowed to take of R#121. An interview was conducted with the Administrator and DON in the Administrative office outer room on 1/7/19 at 3:30 p.m. The Administrator and DON were informed of R#121's family's allegation of abuse concerning the insertion of R#121's urinary catheter by LPN II. The DON and Administrator stated they both were aware of the catheter incident with LPN II and they had investigated the incident and did not consider it to be abuse, but rather a personality conflict. The DON and Administrator stated the family never told them it was abuse. The Administrator further stated they would begin another investigation related to abuse and report to the State as such. Review of the resident's face sheet revealed R#121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's Quarterly Minimum Data Set (MDS), dated [DATE], revealed the Brief Interview for Mental Status (BIMS) indicated R#121 was severely cognitively impaired. A review of Section E, Behaviors, indicated the resident did not exhibit physical behavioral symptoms directed towards others (such as hitting, kicking, pushing, scratching and grabbing), verbal behavioral symptoms directed towards others(such as threatening, screaming or cursing at others) and Other behavioral symptoms not directed at others ( physical symptoms such as hitting or scratching self, .verbal/vocal sounds such as screaming and making disruptive sounds). A review of R#121's functional status indicated the resident was totally dependent for all activities of daily living (ADLs), with assistance from two or more people. This includes but is not limited to bed mobility, transfers, dressing, eating, toilet use and personal hygiene. A review of Section H, Bowel and Bladder indicated the resident had an indwelling catheter. Review of R#121's care plan, dated 10/17/18, problem: urinary catheter related to obstructive and reflux [MEDICAL CONDITION] as evidenced by indwelling catheter. Goal: patient will be free of complications of indwelling catheter through the review period. Interventions: assess for bladder distention, small frequent voids, dribbling, resident complaint of bladder feeling full, care/changing of urinary catheter as ordered, confer with physician regarding the continued need of urinary catheter, consider the risks and benefits of continuing the long-term use of an indwelling urinary catheter and remove it as soon as possible if indicated, keep catheter tubing placed below of bladder, maintain closed, sterile system, tubing free of kinks, medications as ordered, observe and report any signs and symptoms of urinary tract [MEDICAL CONDITION], observe output, observe urine appearance, amount, odor, clarity, secure catheter tubing, and Urology consult as ordered. The care plan did not indicate R#121 was difficult to insert a urinary catheter. Review of physician's orders [REDACTED]. Review of the grievance log for 8/1/18 through 1/7/19 and facility's reported incidents since last annual survey on 1/7/18 did not reveal any reports were made to the DON concerning R#121 and R#55. Review of the staff statements provided by the facility revealed the following: Review of CNA FF's signed statement dated 12/18/18 indicated that R#121 was agitated and screaming spank them, spank them, spank them! LPN II leaned down and told R#121 I'll spank you back. LPN II looked at R#121, and CNA FF and CNA HH we need to drug R#121 up because I can't deal with the screaming. R#121 is way too agitated, you won't be to hold R#121's legs open. CNA HH left the room, LPN II told me, you need to go and get someone to help hold R#121's hands while you hold R#121's legs. I don't have time for this, I have other things that I have to do. LPN II proceeded to try and insert the catheter into the clitoris and the vagina around eight times. family walked into room and asked what was going on. I explained the situation and the family came over to help. LPN II put a gloved hand up to the R#121's family members chest and told them to step away, you're in my light. The family immediately was agitated with LPN II and came to my side to help calm R#121. LPN II attempted to insert the catheter at least seven more times. The family and I told CNA GG to go and get LPN EE. LPN EE came in and asked what was going on? LPN II replied it won't go into R#121's meatus. LPN EE immediately took over and easily inserted the catheter on the first try. Review of CNA GG's signed statement dated 12/18/18 indicated that CNA GG was asked by CNA FF to help both CNA FF and LPN II insert a new catheter for R#121 because the resident's old catheter was clogged. LPN II attempted to insert the catheter into the clitoris around eight times. The resident's family entered the room and was wondering what was going on, CNA FF began to explain the catheter was clogged and it was being replaced. The family member stepped over near the bed by LPN II, when LPN II put her hand up and told the family Stay away, you are in my light. LPN II continued to put the catheter into R#121's vagina at least six more times and I was told by both the family and CNA FF to go get LPN EE. LPN EE inserted the catheter. Review of CNA HH's hand written statement, dated and signed on 12/18/18 indicated that CNA FF and CNA HH were changing R#121, when they noticed the resident's catheter was clogged and all the urine was going into the brief. CNA FF went and told LPN II about the catheter and LPN II agreed it needed to be changed. R#121 had become very agitated and was yelling slap them, slap them. LPN responded I'll slap you back. LPN II also got a little tense and told CNA FF and me that we need to drug R#121 up before I do this. CNA HH told LPN II No and CNA FF told LPN II that she could hold resident's legs open for LPN II to insert the catheter. At this time, I was so mad at the situation I walked out of the room to calm down. The facility provided no other witnesses statements/interviews from LPN EE, LPN II, Social Worker (SW) or, resident's family member or any other documentation related to this incident. The facility presented LPN II's written statement (undated) to the survey team on 1/8/19 after LPN II came to the facility and spoke to the Administrator. An interview was conducted with LPN EE on 1/7/19 at 4:20 p.m. in the Unit 1A nursing station. LPN EE was asked if she recalled the incident with R#121 and LPN II? LPN EE stated, Yes, CNA HH and R#121's family came out of room to get LPN EE. They stated LPN II was hurting R#121. When I went into the room, R#121 was sweating and appeared to be in pain. I was able to insert the urinary catheter, everything was visible. LPN II should have asked for help. LPN EE was asked how many times did it take her to insert the urinary catheter and did you have any difficulty inserting the urinary catheter? LPN EE stated, I was able to insert the catheter on the first attempt, I didn't have any difficulties and could visualize R#121's anatomy without any problems. Who did you report this to? The LPN stated, the Social Worker and DON. An interview was conducted with LPN JJ, the Unit Manager for Units 1A and 1B, on 1/7/19 at 4:39 p.m. at the Unit 1B nursing station. LPN JJ stated, The family came out of R#121's room upset about LPN II trying to insert the urinary catheter while the resident was yelling. The family told me not to let LPN II go back into resident's room. LPN JJ was asked what she did next? LPN JJ stated, I immediately informed the DON. Interview with the SW was conducted on 1/7/19 at 5:00 p.m. in the basement hallway. SW stated LPN EE called and told her what happened and told LPN EE to bring family down to talk to SW. The family told her that they had walked in when LPN II was attempting to insert the catheter. The family said they told LPN II to stop, do not touch her anymore. I took her to the DON's office to speak to the DON and Administrator. The SW was asked if there was any documentation of R#121's family and the SW's conversation? The SW stated, 'No. The SW was questioned who handles the complaints and grievances and who is the Abuse Coordinator? The SW replied, Complaints and grievances are handled by the SW, DON and Administrator. The Administrator is the Abuse Coordinator. An interview was conducted with Director of Nursing (DON) on 1/8/19 at 1:30 p.m. in the basement classroom. The DON was questioned when did the incident related to R#121 occur and what prompted her to obtain statements from CNA FF and CNA GG? The DON stated, the incident occurred on 12/18/18, R#121's family came to the DON's office and told the DON that LPN II had tried to insert the urinary catheter five or six times. The family member told the DON that they had offered to help but LPN II told her I have been a nurse for [AGE] years, I know what I am doing. The DON was asked what actions did she take? The DON stated, I took statements, spoke with and counseled LPN II and removed LPN II from R#121's care. The DON was asked why after reading the CNA's written statement and spoke with the family did the facility not report the incident or initiate an investigation? The DON stated, After speaking with LPN II, I did not feel the incident was abuse but a customer service issue. The DON was questioned if there was anything else included in the facility's investigation of the incident? The DON stated, No, I only have the CNA's statements. There were no statements from other nursing staff, family, other resident or LPN II's counseling included in the documentation provided to the survey team on 1/8/19. A review of the staffing reports from the date of incident on 12/18/18 until 1/8/19 revealed that LPN II continued to work at the facility either on the same or adjacent unit where R#121's room was located. A telephone interview was conducted on 1/8/19 at 5:29 p.m. with LPN II. LPN II was asked to describe the incident on 12/18/18 concerning R#121's catheter insertion. LPN II stated that she was passing medications when a CNA told her that R#121's catheter was occluded (blocked). LPN II went to resident's room and assessed the catheter, there was a white milky substance in catheter tubing. LPN II decided that it needed to be changed and went out to gather supplies. R#121 was agitated and yelling, LPN II asked the CNA FF to go get a second CNA to help while she stood at beside patting resident's hand and telling her what she was going to do. LPN II asked the CNAs to position R#121 so she could insert the catheter. The resident had a different anatomy, the meatus (urethral opening) is inside her vagina. LPN EE came into room to ask if she could help. LPN EE inserted catheter without difficulty. LPN II was asked how was R#121's demeanor at the time of the catheter insertion? LPN II stated that the resident was laughing, saying spank you, spank you and she replied to resident I'll spank you back. LPN II was asked how was the family during this procedure? The LPN stated the family did not appear to be upset. LPN II was asked how many times did you attempt to insert the catheter? The LPN stated two to three times, I stopped after the third attempt. LPN II was asked if she would do anything different the next time? The LPN stated In hindsight, it would have been better to get help. An interview was conducted on 1/9/19 at 8:40 a.m. with CNA HH in Unit 1B nursing station. CNA HH was questioned if she recalled the incident with R#121 and LPN II? CNA HH stated, Yes, CNA FF and I laid R#121 down after lunch to change her. The resident was agitated. While changing the resident's brief they noticed the urinary catheter appeared nasty and needed to be changed. CNA FF told R#121's nurse, LPN II. R#121 was very agitated and was yelling, smack you, smack you. LPN II told R#121 I'll smack you back. CNA HH was so upset she left the room and reported it to LPN EE. CNA HH was asked if LPN II was joking with R#121 when she said, I'll smack you back? CNA HH stated, No, LPN II was agitated and serious when LPN II said it. CNA HH was asked if she had ever witnessed any inappropriate treatment or responses by LPN II? The CNA stated, LPN II is always rude with other residents and has a bad attitude. CNA HH did she think LPN II was being abusive towards the resident? CNA HH stated Yes, LPN II had no patience and was verbally abusive to the resident. CNA HH was questioned what happened after she reported it to LPN EE? CNA HH stated, LPN II went to the DON's office, when she came back LPN II went right back to work. CNA HH was questioned if LPN II went back to taking care of R#121? CNA HH stated, No, LPN EE took over the care of the resident, but LPN II still work on the unit. Interview was conducted on 1/9/19 at 9:07 a.m. with CNA FF in Unit 1B nursing station. CNA FF stated remembering the incident with R#121 and LPN II. The resident was very agitated, yelling and clapping her hands. CNA HH and I were changing R#121's brief because the resident had a bowel movement and noticed the urinary catheter was clogged and there was no urine output. I went to tell her nurse, LPN II. LPN II came to room and assessed the catheter and agreed it needed to be changed. R#121 was yelling spank you, spank you when LPN II told R#121 I am going to spank you. CNA FF was asked if LPN II said this in a joking manner? CNA FF stated No, LPN II was very irritated with the resident, it did not come off as a joke but as a threat. This is when CNA HH left the resident's room. LPN II told me I needed to get some help and I asked CNA GG to come in to help. LPN II was struggling to get the urinary catheter inserted when R#121's family walked into the room. When the family stated, let me help, LPN II put her dirty hand up and told the family they needed to back up. At one-time LPN II stated, We need to drug R#121 up because she is too agitated. I felt I needed to stay in R#121's room or LPN II would hurt her. An interview was conducted with CNA GG on 1/9/19 at 9:25 a.m. in Unit 1B nursing station. The CNA was questioned if the CNA recalled the incident with R#121 concerning the urinary catheter insertion on R#121? The CNA stated, Yes, I do. The CNA stated, CNA FF asked if I could help with R#121. LPN II had tried to insert the urinary catheter about 10 times. CNA FF told LPN II that the nurse needed to go up higher. LPN II told CNA FF I know what I am doing. The family came in and LPN II put her hand up in front of family and told them, they were in the way. R#121 was getting more agitated and sweatier, CNA FF told me to go get LPN EE. LPN EE came in inserted the urinary catheter in one attempt. A telephone interview was conducted on 1/10/18 at 11:25 a.m. with the facility's Medical Director (MD). The MD was asked what level of competency for nursing with placing a Foley (urinary) catheter do you expect? The MD stated, Only difficulty I am aware of have been anatomical, i.e., men with [MEDICAL CONDITIONS]. If the catheter is difficult to place then we would send resident next door to the hospital, but I can't remember any instances. What are your expectations if the nurse is having difficulty inserting catheter? The MD stated, Even if proficient, if you realize you can't place the catheter, don't continue, ask for help, use good decision making. Related to R#121's incident what are your thoughts? R#121 anatomy is a little difficult (legs are contracted), the resident has had a catheter for four to five years. She not only gets agitated she can get really wound up. Need to limit people giving care, the nurse should have stopped, she lost control. 2. During an interview conducted with CNA GG on 1/9/19 at 9:25 a.m. in Unit 1B nursing station. CNA GG was asked if LPN II was involved in any other incident regarding resident care? CNA GG stated, Yes, about a month ago, CNA GG was in R#55's room holding him on his side so LPN II could remove stool from R#55's rectum. During the procedure, R#55 told LPN II I need a break. LPN II told R#55, We don't take breaks, I have other residents to take care of. CNA GG stated after LPN II had finished removing stool from the resident's rectum, I went to LPN EE and let her know what had happened. LPN EE and I both wrote statements of what happened. An interview was conducted with LPN EE in Unit 1B hallway on 1/9/19 at 9:45 a.m. LPN EE stated CNA GG came to me and told me that LPN II had refused to stop the dis-impaction when the resident had yelled and told LPN II he needed a break. I immediately went into the resident's room and did an assessment. There were no injuries. CNA GG and I both wrote statements and I placed them on the DON's desk. LPN EE was asked if she had done any dis-impactions at the facility? LPN EE stated, No, I will try other interventions such as medications, suppositories and rectal massage but not dis-impaction. If none of that worked, then I would contact the physician. The facility could not produce any written statements for 12/23/18 incident written by the staff. An interview was conducted with R#55 at the resident's bedside on 1/9/19 at 10:15 a.m. R#55 was asked if he recalled LPN II and initially he stated, No. R#55 was then questioned if he has a problem with constipation and ever needed any help to have a bowel movement? The resident was hesitating to reply but stated Yes, I do have constipation and sometimes I ask for help. The resident was asked what does staff usually do to help with the constipation? R#55 stated the nurse usually gives me some pills to help. R#55 was questioned if he recalled an incident before Christmas where he yelled at a nurse helping him to stop, he needed a break? The resident stated, Yes, he did recall that incident, the nurse was very rough with me. R#55 was asked why he had yelled and asked the nurse for a break? R#55 stated, Because she was hurting me. When questioned if he could recall who the nurse was, R#55 stated No I don't recall her name. R#55 was asked if he reported the incident to anyone? The resident stated, No, but the other nurse came in and checked me. An interview was conducted with the DON on 1/9/18 at 4:15 p.m. in the basement classroom. The DON was asked what the expectation of the nursing staff and treating a resident with constipation? What should have LPN II done when R#55 asked the nurse to stop because it hurt? The nursing staff is expected to administer medications first, if no results than notify the Physician. LPN II should have not have been dis-impacting the resident because we don't do dis-impaction of stool. The nurse should have notified the Physician for further orders. The DON made the survey team aware that LPN II was let go. When the DON was questioned what was the reason for letting the LPN go? The DON stated it was based on not following professional standards related to the dis-impaction of R#55. There were no concerns expressed prior to (MONTH) concerning LPN II. On 1/10/19 at 10:00 a.m. and at 11:30 a.m. two failed attempts were made to contact LPN II for an interview related to R#55. There was no answer and the voice mailbox was full. Record review revealed R#55 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission MDS dated [DATE], indicated R#55's BIMS of 14 indicating the resident was cognitively intact. Review of the resident's functional status indicated R#55 required extensive assistance with bed mobility, toilet use and personal hygiene with an assistance of two or more persons. Review of section HH, Bowel and Bladder, indicated the resident was frequently incontinent of bowel and bladder but did not indicate the resident currently has a [MEDICAL CONDITION]. A review of the physician's history and Physical dated 11/9/18 indicated R#55 had a [MEDICAL CONDITION] repair, hemicolectomy with [MEDICAL CONDITION] and [DIAGNOSES REDACTED]. Review of physician's orders [REDACTED]. [MEDICATION NAME] EC 5 mg tablet, delayed release, one tablet by mouth one time per day as needed for constipation. Order dated 11/12/18 for [MEDICATION NAME] sodium 100mg capsule, 1 capsule one time per day for constipation A review of the nursing notes dated 12/23/18 indicates R#55 was administered [MEDICATION NAME] EC 5mg tablet at 9:02 a.m. and reassessed the resident at 12:11 p.m. as having no results. Further review of the nursing note did not indicate that LPN II notified the Physician of the resident's condition or to receive Physician orders [REDACTED].#55's stool impaction at 1:25 p.m. During a telephone interview on 1/10/19 at 11:25 a.m. with the facility's Medical Director (MD), the MD was asked if there is a standing order for nursing to dis-impact a resident? Is nursing supposed to dis-impact a resident? The MD stated, not unless they communicate with the Physician. Dis-impaction should not be a first choice, there should be orders for stool softener/laxative. Questioned what are the risks of dis-impaction? Stated rectal exam is a low risk, in general with dis-impaction could develop a tear. The MD was questioned concerning R#55's incident related to dis-impaction. Did you recall if LPN II called you about R#55 and dis-impacting the resident? The MD stated, I don't recall anyone asking me about dis-impaction. I recently added a new medication for R#55, he has had a problem in the past. Dis-impaction is not something I would encourage and is not commonly done. The facility implemented the following actions to remove the Immediate Jeopardy: 1. Associate LPN was immediately suspended from services until investigation is completed. 2. Interview was conducted with resident #121 daughter in law by Administrator on 1/7/2018. No concerns around patient care was expressed at this time. Patient #55 was interviewed and did not recall any concerns with the nurse: patient states he trusted the nurse however patient did state that during the middle of the procedure he did ask her to stop and because she was in the middle, she did not immediately stop but did shortly after. 3.1/8/2019 resident #121 and #55 received a complete body assessment by unit manager. No signs of adverse. were noted. Resident #121 unable to be interviewed. No signs of emotional distress were noted during assessment or have been reported by staff. On 12/23/2018 resident #55 received an assessment post procedure to look for signs of injury and none were noted by change nurse statement. Reason for post assessment by different change nurse was due to a CNA voice concerns around the treatment resident #55 had just received. 4. On 1/8/2019 All 78 current residents with a BIM score of one or higher were interviewed by Social Services Coordinator and Admissions Coordinator regarding abuse. Two of 78 residents were interviewed, indicated concerns that are currently under investigation. The two concerns that were voiced where: 1) CNA handled a resident rough during a shower and 2) resident claimed that she was handled rough CNA delivering care. Both incidents have been self-reported as allegations of abuse. All 73 current residents with a BIM score of nine or lower were given full body assessments by ADON, MDS, Unit Managers and wound care nurse, and education coordinator. No evidence of abuse was identified (0/73). 5. As of 1/8/2019 review of Resident #121's care plan was conducted by DON and Regional Nurse. Changes were made to resident #121's care plan to reflect current behavior of crying, yelling, and pinching. Interventions were added to reflect anxiety/agitation is demised by watching TV, and if resident displays anxiety/agitation to stop care and re-approach. The sections of the care plan on obstructive and reflux [MEDICAL CONDITION] had interventions added to ensure visualization of urethra before attempting to place Foley catheter. 6. Beginning 1/8/2019 staff education was provided by the education coordinator to associates currently on duty regarding recognition and reporting abuse/neglect. This education included Activities (4/4), Administration (9/10), Dietary (23/23), Social Services (2/2), RN's (11/11), LPN's (24/25), CNA's (54/60), Environmental Services (5/6) and Maintenance (2/2) associates. In total 95% (134/141) of associates have been educated on abuse and neglect. Associates that have not received the education will be in-serviced before returning to work. 7. As of 1/8/2019 physician and Medical Director was notified of incidents related to patients #55 and #121 with no new orders indicated. 8. Ad-hoc QAPI meeting was held 1/9/2019 at 8:00 am to discuss finding from patient interviews, finding from body assessments, professional standards of care. The QAPI policy was discussed for process improvement. No changes were made to the current policy on abuse, professional standards of care, or QAPI. Systemic Changes 1. Beginning 1/8/19 staff education was provided by the education coordinator to associates currently on duty regarding recognition and reporting of abuse/neglect. This education included Activities (4/4), Administration (9/10), Dietary (23/23), Social Services (2/2), RN's (11/11), LPN's (24/25), CNA's (54/60), Environmental Services (5/6) and Maintenance (2/2) associates. In total 95% (143/141) of associated have been educated on abuse and neglect. Associates that have not received the education will be in-serviced before returning to work. 2. On 1/8/2019 The Social Service Director and admissions director conducted patient interviews for all 78/78 interviews for all 78/78 interview able residents to determine if there are concerns involving abuse. On 1/8/2019 all 73/73 non-interviewable residents received a full body assessment from ADON, MDS, Wound Nurse, education coordinator, and unit managers. These results were submitted to the QAPI committee. 3. 78/78 interviewable residents received verbal education on how to report abuse, neglect, and /or exploitations by Unit Mangers on 1/9/2019, 151/151 residents received a printout on how to contact the abuse preventive officer for suspected abuse. On, 1/9/2019 a letter was mailed to 73/73 on interview able residents responsible parties o (TRUNCATED)", "filedate": "2020-09-01"}
{"rowid": 3905, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2019-01-10", "deficiency_tag": 607, "scope_severity": "J", "complaint": 0, "standard": 1, "eventid": "XS0411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of the facility's abuse investigation, and review of facility policy titled Abuse Prohibition, it was determined the facility failed to implement abuse interventions for two alleged abuse incidents involving residents (R) R#121 and R#55 by the same employee. The facility failed to implement a thorough investigative process for R#121. The facility failed to implement a monitoring system of the alleged perpetrator thereby leading a second abuse incident involving R#55. The survey sample was 57 residents. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training 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 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: The facility's Abuse Prohibition policy dated (MONTH) (YEAR) indicated it is the intent of this center to actively preserve each patient's right to be free from mistreatment, neglect, abuse and misappropriation of patient property. Whenever a patient, family member, or anyone else makes a complaint on behalf of the patient that alleges abuse, corporal punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property, or exploitation has occurred, the procedures listed in this policy will be adhered to. Under the section titled Identification of possible abuse, neglect, or exploitation indicates 'Once an injury or event is identified as suspicious and may constitute abuse, the center will follow the investigation procedures. 5. It will be the responsibility of any department head receiving the complaint of alleged abuse, corporate (sic) punishment, involuntary seclusion, neglect, mistreatment, misappropriation of patient property or exploitation to inform the Administrator or designee immediately The section titled Prevention B. indicated the Center will identify, correct and intervene in situations in which abuse, neglect and /or misappropriation of patient property is more likely to occur. This will include an analysis of: 3. The supervision of staff to identify in appropriate behaviors, such as using derogatory language, rough handling, ignoring patients while giving care, directing patients who need tilting assistance to urinate or defecate in their beds. 1. During an interview on 1/7/19 at 10:00 a.m. the family of R#121 revealed the family reported they had walked into the resident's room where they witnessed LPN II attempted at least six times to unsuccessfully insert a urinary catheter into R#121. The family added that LPN II did not stop even though the resident was screaming. The family reported the incident to the Director of Nursing (DON). Review of the facility's investigation dated 12/18/18 revealed documents that consisted of three CNA witness statements. Review of the witness documentation dated 12/18/18 from CNA FF indicated R#121 was agitated and screaming spank them, spank them, spank them! LPN II leaned down and told R#121 I'll spank you back. LPN II looked at R#121, and CNA FF and CNA HH we need to drug R#121 up because I can't deal with the screaming. R#121 is way too agitated, you won't be to hold R#121's legs open. CNA HH left the room, LPN II told me, you need to go and get someone to help hold R#121's hands while you hold R#121's legs. I don't have time for this, I have other things that I have to do. LPN II proceeded to try and insert the catheter into the clitoris (area above the urethral opening) and the vagina around eight times. Family walked into room and asked what was going on. I explained the situation and the family came over to help. LPN II put a hand up to R#121's family member and told them to step away, you're in my light. The family immediately was agitated with LPN II and came to my side to help calm R#121. LPN II attempted to insert the catheter at least seven more times. The family and I told CNA GG to go and get LPN EE. LPN EE came in and asked what was going on? LPN II replied it won't go into R#121's meatus. LPN EE immediately took over and easily inserted the catheter on the first try. Review of the witness documentation dated 12/18/18 from CNA GG indicated that CNA GG was asked by CNA FF to help both CNA FF and LPN II insert a new catheter for R#121 because the resident's old catheter was clogged. LPN II attempted to insert the catheter into the clitoris around eight times. The family entered the room and was wondering what was going on, CNA FF began to explain the catheter was clogged and it was being replaced. The family stepped over near the bed by LPN II, when LPN II put her hand up and told the family Stay away, you are in my light. LPN II continued to put the catheter into R#121's vagina at least six more times and I was told by both the family and CNA FF to go get LPN EE. LPN EE inserted the catheter. Review of the witness documentation dated 12/18/18 from CNA HH indicated that CNA FF and CNA HH were changing R#121, when they noticed the resident's catheter was clogged and all the urine was going into the brief. CNA FF went and told LPN II about the catheter and LPN II agreed it needed to be changed. R#121 had become very agitated and was yelling slap them, slap them. LPN responded I'll slap you back. LPN II also got a little tense and told CNA FF and me that we need to drug R#121 up before I do this. CNA HH told LPN II No and at this time, I was so mad at the situation I walked out of the room to calm down. The facility's investigation report failed to include statements from LPN EE, the family member, and additional residents taken care of by LPN II. In addition, the investigation did not include the determination or outcome of the investigation and what corrective actions were put in place to prevent a reoccurrence of this type of incident. Review of Nursing Notes dated from 12/1/18 to 1/7/19 failed to reveal any documentation of the incident involving R#121. Review of the Physician's Notes dated from 12/1/18 to 1/7/19 failed to reveal any medical documentation of assessing the resident after incident. An interview was conducted with the Administrator and DON in the Administrative office outer room on 1/7/19 at 3:30 p.m. informed the Administrator and DON of R#121's family allegation of abuse concerning #121's urinary catheter and LPN II. The DON and Administrator stated they both were aware of the catheter incident with LPN II They investigated it but did not find it to be abuse, it was a personality conflict. Both the DON and Administrator stated the family never told them it was abuse. The Administrator stated they will begin another investigation related to abuse and report to state as such. Interview was conducted with LPN JJ, Unit Manager for Units 1A and 1B, on 1/7/19 at 4:39 p.m. at the Unit 1B nursing station. LPN JJ was questioned what she recalled about the incident with R#121 and LPN II? LPN JJ stated, The family came out of R#121's room upset about LPN II trying to insert the urinary catheter while the resident was yelling. The family told me not to let LPN II go back into resident's room. LPN JJ was asked what she did next? LPN JJ stated, I told the DON. LPN JJ was questioned what else did LPN JJ do after informing the DON? LPN JJ stated the DON instructed me to remove LPN II from R#121's care and assign LPN II to another resident. LPN JJ was asked if LPN II was working on the same unit after their assignment was changed? LPN JJ stated, Yes, the only change was R#121's nurse assignment. 2. During an interview conducted with CNA GG on 1/9/19 at 9:25 a.m. in Unit 1B nursing station, CNA GG stated, About a month ago, she was in R#55's room holding him on his side so LPN II could dis-impact the resident. During the procedure, R#55 told LPN II I need a break. LPN II told R#55, we don't take breaks, I have other residents to take care of. CNA GG stated after LPN II was done, I went to LPN EE and let her know what had happened. LPN EE and I both wrote statements of what happened. During an interview with the Administrator on 1/9/19 at 10:30 a.m. the Administrator was asked if he was aware of the incident with R#55 related to the painful removal of stool from the resident's rectum? The Administrator stated, No I was not aware of that incident, but I will speak with the DON. The Administrator was asked if there was any documentation of an investigation being conducted? The Administrator stated, I will have to get with the DON on that. The facility was unable to provide investigative documentation of 12/23/18 incident. Review of the Nurses Notes dated 12/23/18 at 1:25 p.m. indicated Resident complained of constipation this a.m. (morning) States hasn't had a bowel movement in a week. Large fecal impaction cleared manually. Review of physician progress notes [REDACTED]. Interview was conducted with R#55 at the resident's bedside on 1/9/19 at 10:15 a.m. R#55 was asked if he recalled the incident on 12/23/18, R#55 stated, yes, he did recall that incident, the nurse was very rough with me. R#55 was asked why he had yelled and asked the nurse for a break? R#55 stated, because she was hurting me. When questioned if he could recall who the nurse was, R#55 stated no I don't recall her name. Interview on 1/9/19 at 4:15 p.m. with the DON revealed when asked who collects and investigates the complaints and grievances? The DON stated, I do, the Social Service Director and the Administrator. The DON was questioned concerning the incidents involving R#121 and R#55? The DON stated, I wasn't aware of R#55's incident until today and R#121 I perceived it to be a customer service issue. The DON was asked why she wasn't aware of R#55's situation until today, when LPN EE and CNA GG left written statements on her desk? The DON stated, I was told it was on my desk, but I never received the statements.", "filedate": "2020-09-01"}
{"rowid": 3906, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2019-01-10", "deficiency_tag": 610, "scope_severity": "J", "complaint": 0, "standard": 1, "eventid": "XS0411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and review of facility investigations, it was determined the facility failed to thoroughly investigate the 12/18/18 incident where R#121 was subjected to a painful urinary catheter insertion and verbal threats. The facility failed to develop preventive measures in place to ensure no other vulnerable residents experience abuse from the same nurse. This failure resulted in the 12/23/18 incident in which R#55 was subject painful removal of stool by the same nurse. The sample size was 57. This deficient practice created the potential that abuse would go unrecognized, not addressed, and perpetuate a culture in which abuse could occur. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training 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 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: 1. An interview was conducted with R#121's family on 1/7/19 at 10:00 a.m. during the initial resident pool selection. The family expressed concerns related to LPN II that is currently employed by the facility. The family stated they had reported an incident that occurred on 12/18/18 to the Director of Nursing (DON) involving LPN II attempting at least six times to insert a urinary catheter into the resident while the resident was screaming. They requested the nurse no longer take care of R#121. Although this occurred, LPN II continues to work at the facility on the same unit. Interview with the DON and Administrator on 1/7/19 at 3:30 p.m. revealed when asked if they were aware of the allegation from R#121's family? They both stated, Yes, they were aware of it. They were asked if it had been investigated and if there was any documentation of the investigation? The DON stated she had investigated it and the Administrator and the DON agreed they thought it was a personality conflict between the family and the nurse. But that they were unable provide complete documentation of the investigation. The facility was only able to provide three CNAs' witnesses statements, no other documentation of the investigation. The DON was questioned if there was any further documentation? The DON stated, No, this was all they had. Interview on 1/8/19 at 1:30 p.m. with the DON revealed when asked what type of investigation did the facility conduct following the incident with R#121 and LPN II? The DON stated, I took statements from the CNAs present, and spoke with LPN II and provided counseling for the nurse. The DON was questioned if the facility had interviewed any other staff or residents concerning care they received from LPN II and why after reading the CNA's written statement and speaking with the family did the facility not report the incident or initiate an investigation? The DON stated, No I didn't interview anyone else because after speaking with LPN II, I did not feel the incident was abuse but a customer service issue. The DON was asked for the counseling provided to LPN II but was only able to provide the nurse's orientation training from (MONTH) (YEAR). A review of the facility's staffing schedule for 12/1/18 through 1/7/19 indicated LPN II had continued to work on both nursing units that R#121 and R#55 were located. Although LPN II was no longer assigned to R#121 after the incident was reported, LPN II continued to care for R#55 after the 12/23/18 incident had occurred until the nurse was suspended on 1/7/19. Review of the facility reported incidents since the last annual survey in 2/2018 and the incident/grievance log from 8/2018 through 1/7/18 was conducted and there were no reports that included R#121 or R#121's family. 2. During an interview with CNA GG on 1/9/19 at 9:25 a.m. at the Unit 1B nursing station it was revealed that LPN II was involved in an incident with R#55. While LPN II was manually removing stool from R#55's rectum it became too painful and the resident asked to take a break. LPN II responded We don't take breaks . and proceeded with the procedure. CNA GG immediately reported the incident to the LPN EE CNA GG and LPN EE stated during interviews on 1/9/19 at 9:25 a.m. and 9:45 a.m., respectively, that they had written a statement regarding the incident as it occurred and placed it on the DON's office desk. LPN EE did not report the incident to the Unit Manager (UM), the UM was not available due to the holidays and the nurse did not recall if she had called the DON. An interview with the DON on 1/9/18 at 4:15 p.m. revealed when asked if there was any written statements from the staff concerning R#55's incident with LPN II, the DON stated, No, I wasn't aware of the situation until today. The DON was asked what should the staff do if they need to report an incident such as R#55s? The DON stated, The staff are to notify their Charge Nurse or Unit Manager. If unavailable, they are to notify either the DON or Administrator. The DON was asked what happens next? The DON stated, the facility would start an investigation to see if it was abuse or not. The staff member involved would be suspended during the investigation. A review of the facility's reportable incidents since last survey in 2/2018 and the incident/grievance log failed to indicate R#55's incident had been investigated.", "filedate": "2020-09-01"}
{"rowid": 3907, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2019-01-10", "deficiency_tag": 658, "scope_severity": "J", "complaint": 0, "standard": 1, "eventid": "XS0411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and review of the Georgia Practical Nurses Practice Act, it was determined the facility failed to ensure professional standards of care were maintained for two residents (R) (R#121 and R#55) from a sampled 57 residents. Specifically, nursing staff were not following the standard of care related to urinary catheter insertion for R#121 and the treatment for [REDACTED]. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training 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 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: Review of the Georgia Practical Nurses Practice Act with a copyright date of 2013 documents the following: The practice of licensed practical nursing means the provision of care for compensation, under the supervision of a physician [MEDICATION NAME] medicine, a dentist [MEDICATION NAME] dentistry, a podiatrist [MEDICATION NAME] podiatry, or a registered nurse [MEDICATION NAME] nursing in accordance with applicable provisions of law. Such care shall relate to the maintenance of health and prevention of illness through acts authorized by the board, which shall include, but not be limited to, the following: [NAME] Participating 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 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, home health care, or other such areas of practice . C. Performing comfort and safety measures . D. Administering treatments and medication . 1. An interview on 1/7/19 at 10:00 a.m., with R#121's family revealed approximately the week before last while walking down the hall R#121 could be heard screaming bloody murder. When the family member entered R#121's room she witnessed LPN II attempting at least six times to insert a urinary catheter into R#121, while the resident was still screaming. The family also stated they requested the nurse to stop since the resident was so agitated. However, LPN II told the family member to leave the room and continued to insert the urinary catheter. The family member further stated the incident was reported to the Social Worker (SW) and the Director of Nursing (DON). A review of the resident's electronic record revealed R#121 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident was assessed to be severely cognitively impaired with limited range of motion of the lower extremities and required the use of an indwelling urinary catheter. Review of the facility's investigation dated 12/18/18 revealed three witness statements from the Certified Nursing Assistants (CNAs) present during the incident with R#121. Review of CNA FF's signed statement dated 12/18/18 indicated that R#121 was agitated and screaming spank them, spank them, spank them! LPN II leaned down and told R#121 I'll spank you back. LPN II looked at R#121, and CNA FF and CNA HH We need to drug R#121 up because I can't deal with the screaming. R#121 is way too agitated, you won't be able to hold R#121's legs open. CNA HH left the room, LPN II told me, you need to go and get someone to help hold R#121's hands while you hold R#121's legs. I don't have time for this, I have other things that I have to do. LPN II proceeded to try and insert the catheter into the clitoris (located above the urethral opening) and the vagina around eight times. LPN II attempted to insert the catheter at least seven more times. (sic) Review of CNA GG's signed statement dated 12/18/18 indicated that CNA GG was asked by CNA FF to help both CNA FF and LPN II insert a new catheter for R#121 because the resident's old catheter was clogged. LPN II attempted to insert the catheter into the clitoris around eight times. LPN II continued to put the catheter into R#121's vagina at least six more times and I was told by both the family and CNA FF to go get LPN EE. LPN EE inserted the catheter.(sic) Review of CNA HH's hand written statement, dated and signed on 12/18/18 indicated that R#121 had become very agitated and was yelling slap them, slap them. LPN responded I'll slap you back. LPN II also got a little tense and told CNA FF and me that We need to drug R#121 up before I do this. CNA HH told LPN II No and CNA FF told LPN II that she could hold resident's legs open for LPN II to insert the catheter. Interview was conducted with LPN EE on 1/7/19 at 4:20 p.m. in the Unit 1A nursing station. LPN EE was questioned on what type of orientation or training does the nursing staff receive upon hire? LPN EE stated that the nursing staff receives two weeks of nursing orientation and must complete a skills competency list with their preceptor. All other training is conducted with the education coordinator. LPN EE was asked if they she knew who had conducted the orientation for LPN II? LPN EE stated that she had done the orientation/competency training. LPN EE was asked if there had ever been any concerns prior to the incident with R#121? LPN EE stated, No, there were no issues prior to that incident. LPN EE asked if she had checked LPN II off on the urinary catheter insertion? LPN EE stated, Yes and LPN II did it without any problems. LPN EE did not indicate that she spoke to LPN II regarding the incident, although LPN EE had conducted LPN II's orientation and competency check off. LPN II was interviewed by telephone on 1/8/19 at 5:29 p.m. LPN II was asked what had happened on 12/18/18 during the re-insertion of R#121's urinary catheter? LPN II said the catheter needed to be changed because it was occluded and there was a white milky substance in it. LPN II stated she had attempted two to three times to insert the catheter but stopped after the third attempt. LPN II was asked if R#121 was agitated or upset? LPN II stated the resident was laughing and saying, spank you, spank you, so I replied, I'll spank you back. The nurse was asked if the family was present during the procedure and if so were they concerned? LPN II stated, Yes, the family was there, but didn't seem to be upset or concerned. LPN II was asked what should have happened when the nurse could not get the urinary catheter inserted? LPN II stated, I should have asked for assistance. An Interview on 1/9/19 at 9:07 a.m. with CNA FF revealed when questioned if she recalled the incident with R#121 and LPN II? CNA FF stated LPN II was struggling to get the urinary catheter inserted when R#121's family walked into the room. When the family stated, let me help, LPN II put her hand up and told the family they needed to back up. At one-time LPN II stated, we need to drug R#121 up because she is too agitated. I felt I needed to stay in R#121's room or LPN II would hurt her. A telephone interview on 1/10/18 at 11:25 a.m. with the facility's Medical Director (MD) revealed if the catheter is difficult to place then we would send the resident next door to the hospital. The MD also stated, Even if proficient, if you realize you can't place the catheter, don't continue, ask for help; the nurse should use good decision making. 2. Record review for R#55 revealed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's admission MDS dated [DATE] revealed the resident had intact cognition and required extensive assistance of two persons for activities of daily living, toileting, and mobility. Review of the Physicians Orders' dated 11/8/18 revealed the resident was to receive Senna (laxative) 8.6 milligrams (mg) one tablet twice a day as needed for constipation; [MEDICATION NAME] (laxative) [MEDICATION NAME] coated 5 mg delayed release one tablet daily by mouth for constipation. Additional review of the physician orders [REDACTED].>A review of R#55's clinical record revealed, LPN II's Nurse Note dated 12/23/18 at 1:25 p.m. resident complained of constipation this a.m. (morning) States hasn't had a bowel movement in a week. Large fecal impaction cleared manually. Large bowel movement later. Resident states feel better. An interview with CNA GG on 1/9/19 at 9:25 a.m. revealed about a month ago, I was in R#55's room holding him on his side so LPN II could dis-impact the resident. LPN II just walked up to the side of the R#55's bed, put a glove on and some lubrication and started to remove the stool from the resident's rectum. During the procedure, R#55 told LPN II I need a break. LPN II told R#55, We don't take breaks, I have other residents to take care of. Interview with LPN EE on 1/9/19 at 9:45 a.m. revealed that CNA GG came to me and told me that LPN II had refused to stop the dis-impaction when the resident had yelled in pain that he needed a break, but that LPN II didn't stop, saying to the resident we don't take breaks. I immediately went into resident's room and did an assessment. There were no injuries. LPN EE stated, We do not perform dis-impactions at this facility. I would try other interventions such as medications, suppositories and rectal massage but not dis-impaction. If none of that worked, I would contact the Physician. An attempt was made to contact LPN II by telephone for an interview on 1/10/19 at 10:00 a.m. and at 11:30 a.m. related to R#55's incident. There was no answer and the voice mail was full. An interview was conducted with R#55 at the resident's bedside on 1/9/19 at 10:15 a.m. R#55 was asked if he recalled LPN II and initially he stated, No. R#55 was than questioned if he has a problem with constipation and ever needed any help to have a bowel movement? R#55 stated Yes, I do have constipation and sometimes I ask for help. R#55 was questioned if he recalled an incident before Christmas where he yelled at a nurse helping him to stop, he needed a break? The resident stated, Yes, he recalled that incident, the nurse was very rough with me. R#55 was asked why he had yelled and asked the nurse for a break? R#55 stated, because she was hurting me. An interview with the DON on 1/9/18 at 4:15 p.m. revealed dis-impaction would require a doctor's order. The DON stated, The facility does not provide training for dis-impaction, this is not a typical procedure that we do. I am not aware of staff doing dis-impaction. The DON further revealed, There is no policy, because we don't do dis-impactions. The DON was questioned who is responsible for training the staff and are they qualified to conduct training? The training is conducted by the most proficient nurse based on documentation and observations. LPN II was oriented by LPN EE in November. There were no concerns expressed prior to the (MONTH) incident. Staff Development Coordinator (SDC) gets involved with on-going education. During a telephone interview on 1/10/19 at 11:25 a.m. with the facility's MD revealed, The nurses should not attempt a dis-impaction unless they communicate with the Physician. Dis-impaction should not be a first choice, they should have orders for stool softener/laxative. The MD also stated the rectal exam is a low risk, in general with dis-impaction could develop a tear. The MD further stated, I don't recall anyone asking me about dis-impaction. I recently added a new medication for R#55, he had a problem with constipation in the past. Dis-impaction is not something I would encourage and is not commonly done. A Review of LPN II 's employment records revealed the LPN was hired 11/13/18 and her training included the following: - Patients (sic) Rights: Abuse Reporting on 11/13/18 - Catheter Insertion for Males and Females on 11/19/18 The facility was unable to provide documentation of further performance training for LPN II. Cross reference to F600 The facility implemented the following actions to remove the Immediate Jeopardy: 1. Patient assessment performed by DON on 1/8/19 to determine if any abnormalities in anatomy exist that would make it difficult to insert catheter per procedural guidelines. 5 of 151 residents have catheters and the ADON conducted patient assessments on the 5 of with catheters. 2. On 1/8/19 Patient #121's plan of care was reviewed by DON and updated to reflect that if patient becomes agitated during a procedure that the procedure is to be discontinued and re-approached at a later time to decrease the risk for increasing the patient's anxiety. On 1/9/19, 24/25 (96%) LPN's and 10/11 (90%) RN's received this education from the education coordinator. In total 34/36 (94%) Licensed nurses were educated. 3. Education was provided to six of six licensed nurses on 7-7 am shift regarding the following subjects on 1/8/19 by Education Coordinator: a. Importance of following professional standards when providing care to patients. b. Procedure for insertion of Foley catheter including assessment of anatomy to determine abnormalities prior to initiation of procedure. c. Identifying signs and symptoms of patient anxiety during care. d. Recognizing need to stop procedures or care if a patient refuses or shows signs and symptoms of pain or anxiety. 4. Nurse in questions related to R#121 and R#55 regarding professional services was suspended on 1/7/19 pending outcomes of the investigation. 5. Termination of charge nurse in question related to patient R#121 and R#55 was initiated on 1/9/19. Systemic Changes 1. Education began on 1/7/19 and competed on 1/9/19 provided on professional services and standards related to catheter insertion and digital evacuation of hard stool. 24/25 (96%) LPN's and 10/11 (90%) RN's received this education. In total 34/36 licensed nurses received this education. 2. Professional competencies began on 1/7/19 by the DON, ADON and education coordinator, on professional services and standards related to catheter insertion. 24/25 (96%) LPN's and 10/11 (90%) RN's received this education. In total 34/36 licensed nurses received this education. 3, Remedial education to be provided to licensed nurses as opportunities for improvement are identified by education coordinator starting on 1/9/19. 4. All finding will be addressed through the center's QAPI process on a monthly bases under the directions of the Administrator. The State Survey Agency (SSA) validated the Allegation of Compliance (A[NAME]) Jeopardy Removal as follows: 1. Review of the facility A[NAME] documentation verified on 1/8/19 the DON and ADON performed assessments on five of five residents that had catheters including R#121 to assess any abnormalities that persist that would impede catheter insertion. The survey team had already assessed these residents during the initial pool process. Training on the professional standards related to catheter insertion and evacuation of hard stool was reviewed by in-service roster and interviews with Registered Nurse (RN) DD, LPN EE, LPN JJ, LPN LL, LPN MM and LPN NN on 1/10/19 between 2:00 p.m. and 4:00 p.m. 2. Review of the facility A[NAME] documentation for When a patient becomes agitated during a procedure, the procedure is to be discontinued and re-approached later to decrease the risk of increasing the patient's anxiety. This training was provided to LPNs and RNs by the Education Coordinator on 1/8/19. This was verified by R#121's care plan and interviews with staff nurses, LPN EE, LPN JJ, RN DD, LPN LL, LPN MM, and LPN NN currently providing resident care on 1/10/19 between 2:00 p.m. and 4:00 p.m., and by the training roster signed by all licensed staff. 3. Review of the facility A[NAME] documentation related to the systemic changes indicated the facility, specifically the DON, ADON, and Education Coordinator began educating licensed staff (Registered Nurses and Licensed Practical Nurse) beginning 1/7/19 through 1/9/19 on the following subjects: a. Importance of following professional standards when providing care to patients b. Procedure for insertion of Foley catheter including assessment of anatomy to determine abnormalities prior to initiation of procedure c. Identifying signs and symptoms of patient anxiety during care d. Recognizing need to stop procedures or care if a patient refuses or shows signs and symptoms of pain. This education was validated through staff education rosters dated 1/7/19 through 1/9/19 indicating the attendance by staff for training. Interviews were conducted on 1/10/19 from 2:00 p.m. to 4:00 p.m. by surveyors with RN DD, LPN EE, LPN JJ, LPN LL, and LPN NN verifying the training provided by the facility through verbal demonstration of the Foley catheter procedures, abnormalities in residents anatomy, identifying patient anxiety during care and what to do to ease resident's anxiety, and to stop if resident refuses treatments or is exhibiting signs of pain. 4. LPN II in relation to R#121 and R#55 regarding professional services was suspended pending investigation on 1/7/19. This was verified through review of staff schedule for 1/7/19 through 1/11/19 and observations of staffing during the survey process from 1/7/19 through 1/10/19. 5. LPN II was terminated by the Administrator on 1/9/19 as verified through observations and staffing schedules for 1/9/19 through 1/10/19 and interview with the DON on 1/9/19 at 4:15 p.m. in the conference room. Systemic Changes: 1. Review of the facility's A[NAME] indicated beginning 1/7/19 through 1/9/19 staff nurses were educated on professional services and standards related to catheter insertion and digital evacuation of hard stool. On 1/10/19 from 2:00 p.m. to 4:00 p.m. surveyors interviewed nursing staff (LPN EE, LPN JJ, RN DD, LPN LL, LPN MM and LPN NN) concerning their training related to catheter insertion and digital evacuation of hard stool. The nursing staff confirmed that the staff does not conduct digital evacuation of hard stool, they would contact the physician first and request assistance when having difficulty with inserting an indwelling catheter. 2. Review of the facility's A[NAME] indicated professional competencies were conducted starting on 1/7/19 by the DON, ADON and Education Coordinator. Interviews were conducted during the A[NAME] verification process on 1/10/19 from 2:00 p.m. to 4:00 p.m. with the following nurses: LPN EE, LPN JJ, RN DD, LPN LL, LPN MM, and LPN NN. The nursing staff was asked to verbally explain the process for urinary catheter procedures related to insertion, identifying correct anatomy and when to request assistance. 3. Review of the facility's A[NAME] indicated remedial education was to be provided to licensed staff as opportunities for improvement starting on 1/9/19. Interviews were conducted on 1/10/19 between 2:00 p.m. and 4:00 p.m. with LPN EE, LPN JJ and LPN NN concerning identifying and reporting abuse 4. Review of the facility's A[NAME] indicated all findings will be addressed through the center's QAPI process monthly under the direction of the Administer. This was validated through review of the ad hoc QAPI meeting documentation on 1/8/19 revealed a Performance Improvement Project was developed and presented during the QAPI meeting for identifying, addressing and investigation of abuse. An interview was conducted on 1/10/19 at 1:23 p.m. with the Administrator in the Administrator's office. The Administrator stated, The systematic analysis and actions were discussed during the ad hoc QAPI meeting. The QAPI Committee recognizes that any change that is made has the potential to have broader impact than intended. 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 Performance Improvement Plans (PIPs).", "filedate": "2020-09-01"}
{"rowid": 3908, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2019-01-10", "deficiency_tag": 835, "scope_severity": "J", "complaint": 0, "standard": 1, "eventid": "XS0411", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews it was determined that Administration failed to ensure that the facility was administered in a manner that enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained the highest possible level of physical, mental and psychological well-being. The Administration failed to conduct a thorough investigation of an employee's verbal threats and physical abusive actions for Resident (R) #121 on 12/12/18 while attempting to insert an indwelling urinary catheter and for disregarding R #55's complaints of pain during a rectal dis-impaction to remove stool on 12/23/18. The facility census was 151 residents. On 1/8/19, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator, Director of Nursing, and the Regional Nurse Consultant and Regional Nurse Consultant were informed of the immediate jeopardy on 1/8/19 at 5:14 p.m. The noncompliance related to the immediate jeopardy was identified to have existed on 12/18/18. The immediate jeopardy continued through 1/9/19 and was removed on 1/10/19. The immediate jeopardy was related to the facility's noncompliance with the program requirements at 42 C.F.R. 483.12 (a)(a)(1), Freedom from Abuse, Neglect, and Exploitation (F600, Scope/Severity: J); 42 CFR 483.12(b)(1)?(4), Develop/Implement Abuse/Neglect, etc. Policies (F607, Scope/Severity: J); 42 CFR 483.12(c)(2)?(4) Alleged Violations-Investigate/Prevent/Correct (F610, Scope/Severity: J); 42 C.F.R. 483.21(b)(3)(i), Professional Standards (F658, Scope/Severity: J); 42 C.F.R. 483.70, Administration (F835, Scope/Severity: J). Additionally, Substandard Quality of Care was identified at: F600, Freedom from Abuse, Neglect and Exploitation F607, Develop/Implement Abuse/Neglect, etc. Policies F610, Alleged Violations-Investigate/Prevent/Correct A Credible Allegation of Compliance was received on 1/10/19. Based on observations, record reviews, interviews and review of the facility's policies and staff training 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 1/10/19. The facility remained out of compliance at a lower scope and severity of D while the facility continued management level staff oversight of staff treatment of [REDACTED]. Observation and interviews were conducted with staff and residents to ensure they demonstrated knowledge of facility Policies and Procedures governing identifying and reporting Abuse, Neglect and Exploitation of residents. The Immediate Jeopardy is outlined as follows: 1. The facility's failure to protect R#121 from abuse were related to lack of a complete investigative procedures of the multiple attempts to insert an indwelling urinary catheter for R#121. During the initial tour of the facility on 1/7/19 the surveyor conducted a family interview and was informed that on 12/18/18 a urinary catheter insertion was attempted at least nine times on R#121. Interviews with staff revealed that during the failed attempts R#121 was screaming spank them . The nurse replied to the resident, I will spank you. The facility did not conduct a full investigation when this incident of alleged abuse was reported to the Director of Nursing (DON) and Administrator by Resident (R) #121's family member and three Certified Nurse Aides (CNA) who were present in the room with R#121 when the incident occurred. The alleged perpetrator, Licensed Practical Nurse (LPN) II, continued to work at the facility until dismissed on 1/9/19. 2. On 1/9/19 the surveyor was made aware during staff interviews of R#55 receiving a forceful dis-impaction by the same nurse on 12/23/18. The nurse continued to digitally dis-impact the resident when he yelled out in pain Can we take a break, the nurse replied to R#55, We don't take breaks here. The alleged perpetrator refused to stop attempts to dis-impact stool from R#55's rectum when the resident yelled and told the nurse he needed a break because she was hurting him. The resident has a [DIAGNOSES REDACTED].#55 received digital stimulation by LPN II without a physician's orders [REDACTED]. The findings include: On 1/7/19 at 3:30 p.m. an interview was conducted with the Administrator and the DON in the Administrative office outer room. The Administrator and DON were made aware of an interview with family of R#121 and an incident that occurred on 12/18/18. They stated they had been made aware by the surveyor of a concern for abuse on 12/18/18. Both the Administrator and DON stated that they were aware of the incident and they had investigated but determined that abuse did not occur, rather it was a personality conflict. The Administrator stated that they would begin another investigation related to abuse and report to the appropriate authorities. Review of the investigation that was conducted on 12/18/18 revealed three statements written by the nursing aides who witnessed the abuse to R#121, however there were no statements from the family member or the nurses involved in the incident. The facility was unable to provide documentation that LPN II received any type of counseling or re-training following this incident. The Administrator stated that he did not personally investigate, the DON had taken the lead on the discussion, and it was believed that abuse had not occurred. During the investigation of the incident on 12/18/18 with R#121 an additional incident was identified for possible abuse involving R#55 and LPN II. This incident occurred on 12/23/18. Interview on 1/8/19 at 5:15 p.m. with the Administrator revealed that he was made aware of the allegation of abuse for R#121 but that he felt that the DON had conducted an investigation and determined that abuse had not occurred. The Administrator further stated that R#121 was known to scream and yell out as part of her behaviors. The Administrator was not able to state whether or not R#121's comprehensive care plan had been reviewed to determine if her behavior had been addressed as it pertained to changing out her Foley catheter when needed. A review of the Administrator's job description revealed, in part, the following documentation; Essential Regulatory Functions 7. Operates the Nursing Center in accordance with the established guidelines of the Organization and in compliance with federal, state and local regulations. 18. Assumes responsibility for and honors patients' rights to fair and equitable treatment, self-determination, individuality, privacy, property and civil rights, including the right to wage complaints. 19. Assumes responsibility for procedural guidelines relative to the prevention and reporting patient abuse. 20. Reviews, investigates and arbitrates patient complaints and grievances and makes available to supervisor written reports of action taken. 22. Maintains appropriate documentation in regard to accidents/incidents. 31. Ensures that all associates, patients, visitors and the general public follow established policies and procedures. Cross Refer F600 The facility implemented the following actions to remove the Immediate Jeopardy: The Regional Vice President was to provide education to the Administrator and DON on job description, roles, and responsibilities and duty to ensure the safety of all the residents. Also, the Regional Vice President was to provide education on the abuse, neglect, and exploitation policy and procedure to the Administrator and DON. The Administrator and DON were to be re-educate on their roles in the Quality Assurance Performance Improvement process. The State Survey Agency (SSA) validated the Allegation of Compliance (A[NAME]) Jeopardy Removal as follow: The AoC presented for validation documented that the Regional Vice President (RVP) would provide education to the Administrator and the DON on their job descriptions, roles and responsibilities and duties to ensure the safety of residents. Education was also provided on 1/8/19 at 10:00 p.m. on abuse, neglect and exploitation policy and procedures to the Administrator and DON. A performance evaluation review document was acknowledged and reviewed on 1/8/19 by the Administrator and the RVP as received. The Administrator job description was reviewed, signed and dated on 1/9/19 by the Administrator and the RVP. The facility document Job Description: Nursing Services. Director of Nursing was reviewed, signed and dated by the DON and RVP on 1/8/19. During the interview with the Administrator and the RVP conducted on 1/10/19 at 2:53 p.m. in the Administrators office the RVP confirmed that he had reviewed with the Administrator and the DON their job descriptions and job expectations. Review of the facility's AoC revealed the RVP provided education to the Administrator and the DON on 1/8/19 regarding their roles and responsibilities of the QAPI process. This education was verified by interview with the Administrator and the RVP on 1/10/19 at 2:53 p.m. during a meeting in the Administrator's office.", "filedate": "2020-09-01"}
{"rowid": 3909, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2016-11-03", "deficiency_tag": 157, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "BL1O11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the responsible party (RP) of a change in treatment for 1 resident (R) (R#188) with severe cognitive impairment. The sample was twenty five (25) resiednts. Findings include: Record review for R#188 revealed the resident had a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for R#188 dated 7/7/16 revealed a Brief Interview for Mental Status (BIMS) summary score of 6 indicating severe cognitive impairment. A telephone interview conducted on 10/31/2016 at 11:45 a.m. with the complainant/RP for R#188 revealed he had concerns with the facility withdrawing money from R#188's personal funds account to purchase a sexual device without notifying him first. The complainant/RP stated the Social Worker and the Unit Nurse called him after the device had already been purchased and attempted to let R#188 to try it. He further stated they asked him to pick up this sexual device because R#188 was not able to use it. The complainant said R#188 has Alzheimer ' s and does not remember anything. He is the representative of R#188's funds and the facility should have contacted him before they purchased this item. The complainant stated that he facility should have informed him and of their decision to purchase and try a sexual device because he would have told them no and does not agree with it. Review of the care plan for R #188 identified the resident had inappropriate behaviors with an intervention to purchase of a personal item for possible relief of sexual desires at the resident's request. The care plan revealed that the family discontinued the intervention. The note did not provide a date for the discontinuation of the intervention. Review of a Social Service note dated 10/3/16 documented the faimily/RP of R#188 was notified of the purchase of a personal item to assist in possible relief of sexual desires on 9/30/16 and the family expressed an understanding. Review of a nurse's note dated 10/14/16 documented the RP came to the facility and asked for the personal sexual device that was purchased for R#188, which was stored in the Unit [NAME] medication room. The RP wanted to ensure that the device was not reintroduced to the resident. The device was given to the RP as requested. Interview on 11/2/16 at 4:24 p.m. with the Social Service Director (SSD) and Social Service Coordinator (SSC) revealed that during an interdisciplinary team (IDT) meeting on 09/30/16 the team made the decision to purchase a personal sexual device for R#188. The SSD confirmed that the Director of Nursing (DON) and all unit managers attended the meeting. Both the SSD and SSC confirmed that the team discussed R#188's inappropriate sexual behaviors and potential interventions. The SSD and SSC confirmed that corporate Social Service Consultant was consulted, and in conjunction with the IDT team, they made the decision to purchase a sexual device as a treatment for [REDACTED]. The device was intended for the personal use of R#188. Both the SSD and SSC confirmed that on 09/30/16 they purchased a sexual device. The SSD confirmed that she gave the device to R#188's unit manager, who went with another nurse to introduce the device to R#188. The SSD confirmed that on 09/30/16, following the purchase of the device she made a phone call to R#188's family to notify them of the purchase of a personal sexual device for R#188. The SSD confirmed that the family expressed an understanding. Interview on 11/2/16 at 4:33 p.m. with the Director of Nursing (DON) and Regional Nurse revealed that the DON was not a part of the decision making process for the purchase of a sexual device for R#188 as an attempt to reduce sexual behaviors. The DON revealed that she did not attend the IDT meeting held on 9/30/16 as she was at a conference out of town. The Regional Nurse confirmed that she also attended the conference with the DON during this time. The DON revealed that she did not become aware of the purchase of a sexual device for R#188 until 10/28/16 when she was notified by the SSD and the Administrator. She revealed that she was in support of the decision. The DON revealed that she was told that the R#188 spoke with the SSD and requested the sexual device. The DON confirmed that she was told that SSD purchased the device, then notified the family. The DON confirmed that the device was kept in the Unit [NAME] medication storage and the resident was to request device when needed. The DON confirmed that the resident never requested to use the personal device. Interview on 11/2/16 at 4:41 p.m. with the Administrator revealed that the during a morning IDT meeting approximately three weeks ago (unable to recall the exact date) the decision was made to purchase a personal sexual device for R#188. The Administrator confirmed that social services, dietary, and all unit managers were in attendance. The Administrator confirmed that the decision was a team decision made in conjunction with the corporate Social Service consultant. The Administrator revealed that he instructed the SSD contact R# 188's family to inform them of the decision, to ensure that the family was aware and in agreement with the decision prior to the purchase of the device. The Administrator revealed that after contacting the family the SSD presented the device to the resident. Interview on 11/3/16 at 2:56 p.m. with the Administrator, SSD, SSC, Regional Nurse, DON, and Unit Manager confirmed that the personal sexual device was considered a treatment for [REDACTED]. The SSD confirmed that R#188 had never requested the personal sexual device. The SSD confirmed that she did not notify the responsible party of R#188 prior to the purchase or introduction of the sexual device in an effort to protect the resident's privacy. She confirmed that after the item was introduced to R#188 she changed her mind and thought that the responsible party should know. The SSD further stated that when she did contact the family/RP, they expressed an understanding but explained that the device would not have been their first choice.", "filedate": "2020-09-01"}
{"rowid": 3910, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2016-11-03", "deficiency_tag": 159, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "BL1O11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party (RP) for 1 resident (R) (R#188) with severe cognitive impairment, prior to withdrawing personal funds for the purchase of a personal sexual device. The sample was twenty five (25) residents. Refer F157 Findings include: A telephone interview conducted on 10/31/2016 at 11:45 a.m. with the complainant/RP for R#188 revealed he had concerns with the facility withdrawing money from R#188's personal funds account to purchase a sexual device without notifying him first. The complainant/RP stated the Social Worker and the Unit Nurse called him after the device had already been purchased and attempted to let R#188 to try it. He further stated they asked him to pick up this sexual device because R#188 was not able to use it. The complainant said R#188 has Alzheimer ' s and does not remember anything. He is the representative of R#188's funds and the facility should have contacted him before they purchased this item. The complainant stated that he facility should have informed him and of their decision to purchase and try a sexual device because he would have told them no and does not agree with it. Record review for R#188 revealed the resident had a [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS) assessment for R#188 dated 7/7/16 revealed a Brief Interview for Mental Status (BIMS) summary score of 6 indicating severe cognitive impairment. Review of the Patient Trust Fund Authorization Agreement dated 1/13/16 for R#188 revealed the RP signed the agreement authorizing the facility to make personal petty cash withdrawals and pay for barber/beauty charges from the resident's personal trust fund account. Review of R#188's personal trust fund account summary revealed a withdrawal in the amount of forty-three dollars and eighty-five cents ($43.85). The withdrawal posted to the account on 10/3/16. Record review for R#188 revealed a receipt dated 9/30/16 in the amount of forty-three dollars and eighty-five cents (43.85). The receipt documented the purchase of one personal sexual device and cleaning spray. Interview on 11/2/16 at 4:24 p.m. with the Social Service Director (SSD) and Social Service Consultant (SSC) confirmed that on 9/30/16, together they purchased a personal sexual device for R#188. The SSD confirmed that on 09/30/16, after the purchase of the device, she made a phone call to R#188's family/RP to notify them of the purchase. The SSD confirmed that the family expressed an understanding at that time. Interview on 11/3/16 at 2:56 pm with the Administrator, SSD, SSC, Regional Nurse, Director of Nursing (DON), and Unit Manager the Administrator confirmed that the personal sexual device was considered a treatment for [REDACTED]. The SSD confirmed that R#188 never requested the personal sexual device. The SSD revealed that on 9/30/16 she withdrew $45.00 dollars from R#188's personal funds account for the purchase of a personal sexual device. The SSD confirmed that she and the SSC purchased the personal sexual device for R#188. The SSD revealed that she provided the receipt from the purchase to the business office. The SSD confirmed that she did not notify the responsible party of R#188 prior to the purchase or introduction of the sexual device in an effort to protect the resident's privacy. The SSD confirmed that after the item was purchased and introduced to R#188 she changed her mind and thought that the responsible party should know. The SSD revealed that when she did contact the family they expressed an understanding but explained that the device would not have been their first choice.", "filedate": "2020-09-01"}
{"rowid": 3911, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2016-11-03", "deficiency_tag": 253, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "BL1O11", "inspection_text": "Based on observation, interview, and record review, the facility failed to maintain a clean, comfortable and sanitary environment on two (2) of five (5) halls. Findings include: Observation on 11/01/2016 at 10:49 a.m. and 11/03/2016 at 08:17 a.m. of Room 264 revealed a strong urine odor in the resident bathroom, which was a shared bathroom. Observation on 10/31/2016 at 12:00 p.m. and 11/03/2016 at 08:10 a.m. of Room 283 revealed a strong urine odor in the resident bathroom, which was a shared bathroom. Observation on 10/31/2016 at 12:10 p.m. and 11/03/2016 at 08:14 a.m. of Room 275 revealed a strong urine odor in the resident bathroom, which was a shared bathroom. Observation of dried brown material on the arm of the raised toilet seat and a brown build-up around the base of the toilet. Debris was also observed in the heating and air conditioning unit. Observation on 11/01/2016 at 09:04 a.m. and 11/03/2016 at 08:15 a.m. of Room 271 revealed that the privacy curtain between the A and B bed had black circular stains towards the bottom of the curtain. Observation on 10/31/2016 at 12:05 p.m. and 11/03/2016 at 11:50 a.m., in the hallway on C-Unit revealed that the handrail near the dining area had a corner bumper with an area that was uncovered and a gap in the handrail of approximately 1 inch. The handrail near the dinning room on C Unit, was also observed to have one of the supporting brackets that had broken through the sheetrock. The handrail had multiple supporting brackets and so was secure on the wall at this time. Interview and observation on 11/03/2016 at 12:08 p.m. with Head of Housekeeping revealed that environmental services was responsible for preventing chronic odors in the bathrooms. During the interview, he stated that they had a chemical that would break down the build up in the bathrooms that created the odor. He confirmed that there was a strong urine odor in the above listed bathrooms, dried brown material on the arm of the raised potty seat in Room 275 which was a shared bathroom and that there was a brown build-up around the base of the toilet in Room 275. He stated that deep cleaning was provided for one room per unit per day. He stated that laundry was responsible for cleaning the privacy curtains and confirmed that the privacy curtain in Room 271 had been missed. He stated that housekeeping checked the privacy curtains routinely, when deep cleaning was provided for the room. Observation and interview on 11/03/2016 12:10 p.m. with the Head of Maintenance confirmed that maintenance was responsible for the up-keep of handrails, removal of debris from the air conditioning and heating unit and replacement of missing or broken tile. He confirmed that the above listed areas had these problems. Interview on 11/03/2016 at 1:25 p.m. with the Head of Housekeeping to clarify the difference between a total or deep cleaning of rooms and daily cleaning of rooms, revealed that the total room clean was more detailed and more time was spent in the resident room and bathroom cleaning all surfaces, than for the routine daily cleaning of rooms and bathrooms. Interview also revealed that when the room was deep cleaned that the bathroom was also deep cleaned. Interview on 11/03/2016 at 1:30 p.m. with the Head of Housekeeping revealed that Room 264 and Room 283 were last deep cleaned on 10/13/2016. Room 271 and [RM #]2 were last deep cleaned on 10/25/2016. Rm. 275 was last deep cleaned 10/31/16.", "filedate": "2020-09-01"}
{"rowid": 3912, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2016-11-03", "deficiency_tag": 371, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "BL1O11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, and document review the facility failed to ensure opened and bulk food items were covered, labeled and dated in one (1) of two (2) walk in refrigerators, baking dry storage area and shelving unit under stainless steel food preparation table. The facility failed to discard food by the use by date and failed to ensure the stand-up mixer was clean and sanitary. This deficient practice had the potential to effect one hundred fifty two (152) residents receiving an oral diet. Findings include: Observation on 10/31/16 at 2:10 p.m. of walk-in refrigerator #1 revealed an opened 1 gallon container of Fat Free Raspberry Vinaigrette and 1 gallon container of French Dressing with no date. Observation on 10/31/16 at 2:35 p.m. of 2 white storage bins with wheels containing sugar and flour revealed the clear plastic lid to the sugar bin was left opened. Observation on 10/31/16 at 2:40 p.m. of the wire storage rack towards the back of the kitchen containing baking supplies revealed three (3), fourteen (14) ounce cans of Nestle La Lechera sweetened condensed milk with a use by date of [DATE]. Observation on 10/31/16 at 3:00 p.m. of the stand-up mixer revealed it was covered with a frosted white plastic bag which had black marking stating cleaned and sanitized on 10/23. The plastic bag was removed from the mixer which revealed inside the mixing bowl was a dark brown substance on the bottom that was 2 inches in length and one eighth (1/8) inch in width. Continued observation revealed the dark brown substance was on the mixing beater in 2 spots the size of a pencil eraser. Further observation revealed the Food Service Director touching the underside of the mixing arm and their hand was covered with the dark brown substance, surveyor touched the area under the mixing arm and the brown substance was sticky to touch and had the smell of grease. Observation on 10/31/16 at 3:10 p.m. of a large white rectangle storage bin under a stainless steel food preparation table revealed it contained a white powdery substance. Continued observation revealed no label or date was found on the storage bin. Interview on 10/31/16 at 3:30 p.m. with the Food Service Director (FSD) revealed they confirmed the gallon containers of Fat Free Raspberry Vinaigrette and French Dressing in the walk-in refrigerator were opened and did not have a date when opened. The FSD revealed they expect dietary staff to label and date all opened food items before storage. Continued interview with the FSD revealed they confirmed the lid was left open on the storage bin containing sugar. The FSD revealed they expect dietary staff to close the lids to the flour and sugar bins after usage. The FSD confirmed the 3 can of sweetened condensed milk had a use by date of [DATE] indicating (MONTH) (YEAR). They expect dietary staff to review dates of food items when performing cleaning tasks and to discard if past the use by date. Continued interview with the FSD revealed when a plastic bag is covering the mixer it indicates the mixer is clean and ready for usage. They confirmed the dark brown substance was dripping from under the mixing arm and contaminated the mixing bowl and beater. Further interview with the FSD revealed they confirmed the white powdery substance in the large white rectangle storage bin was a bulk food item that was taken from the original packaging, placed in the storage bin with no label or date. They expect staff to label and date all bulk food items when place in storage bin. Interview on 11/03/16 at 8:30 a.m. with the Food Service Director (FSD) revealed when he conducted in-services with the dietary staff he would discuss sanitation practices in the kitchen. When asked if he recalled what sanitation topics and which dates they were discussed the FSD could not recall. Interview on 11/03/16 at 9:00 a.m. with the Administrator and FSD revealed the dietary department is expected to follow Ethica policies which is to follow Georgia Guidelines for food sanitation. The FSD revealed the dietary staff are also expected to follow Serve Safe Guidelines. Review of the ServSafe Guidelines revealed all items that are not in their original containers must be labeled. Continue review of ServSafe Guidelines revealed to use containers that are durable, leak proof and able to be sealed or covered. Review of documentation provided by the FSD revealed the date and time of the earliest food prepared shall either be marked on the container or documented by an alternate method acceptable to the Health Authority. Continued review of the Food Service documentation revealed expired foods, used as an ingredient in other foods shall be immediately discarded and shall not be sold, served, or used after the manufacturer's expiration date or the sell-by date. Review of the in-services conducted by the FSD in the past twelve months revealed no documentation of sanitization education.", "filedate": "2020-09-01"}
{"rowid": 3913, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2016-11-03", "deficiency_tag": 514, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "BL1O11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to consistently document wound assessments to reflect measurements and staging of a pressure ulcer for one (1) of three (3) sampled residents (R) (R#187) with pressure ulcers. The sample size was twenty-five (25). Findings include: Staff interview on 11/01/2016 at 08:00 a.m. with Registered Nurse (RN)/Treatment Nurse AA revealed that R#187 had a terminal ulcer on right heel that was covered with eschar. The resident was receiving hospice services and was care planned for decline. The interview also revealed that the resident had an unstageable ulcer to the right lateral calf also along with multiple [MEDICAL CONDITION]. Review of the Treatment Administration Record (TAR) for R#187 revealed a wound to the right calf and right lateral foot. Neither wound was staged or identified as to type of wound. Review of Significant Change Minimum Data Set (MDS) assessment dated [DATE] revealed that R#187 was receiving Hospice Services, had a Brief Interview of Mental Status (BIMS) summary score of 10, indicating moderate cognitive impairment, was always incontinent of bladder and bowel and had active [DIAGNOSES REDACTED]. Observation and interview on 11/02/2016 at 10:10 a.m. of wound care for R#187 with RN AA revealed no concerns. The wound on the right heel was covered with eschar, it measured 2.5 x 2.5 centimeter. Wound on right MTPJ was covered with eschar, it measured 2.5 x 2 centimeters. The wound on the right lateral foot was covered with eschar, it measured 2 x 1.7 centimeters, the wound on the right ankle had been covered by an eschar cap but it has sloughed off according to the wound care nurse, the total area for this wound measures1 x 1 centimeters and the open area measures 0.5 x 0.5 centimeters. This area had a small to moderate amount of bright red bleeding, indicating that there was some blood flow. The wound to the right lateral calf was treated every other day and treatment was last done on 11/01/2016. Observation also revealed that resident had a pressure reduction mattress on the bed and heel boots were on the resident's feet prior to dressing change. Interview with RN AA revealed that R#187's appetite was very poor. Observation also revealed that resident was lying on his right side before and during treatment and that he kept his right leg drawn towards his body. RN, AA further revealed that the resident was able to straighten his leg but preferred not to straighten it and that he had been premedicated for pain. Review of Physician order [REDACTED]., right lateral foot, right heel, right ankle, right anterior foot-side of foot. Clean right lateral calf with Normal Saline, pat dry, apply Dakins soaked gauze to wound bed cover with dry dressing and secure with gauze wrap and tape every other day. Review of the Care plan for R#187 documented that resident was at risk for foot ulceration r/t [DIAGNOSES REDACTED]. Resident bends right leg up at times and pushes off heel lifts. Review reveals that there is an acute care plan for pressure ulcer. Interview on 11/02/2016 at 1:18 p.m. with RN AA and Treatment Nurse, Licensed Practical Nurse (LPN) BB revealed that there was a Corporate Wound Care Nurse Consultant who was available to answer their questions. Interview also revealed that the treatment nurses were responsible for identifying the type of wound that the resident had and staging pressure ulcers. RN AA stated that when they idenify the wound type and stage pressure ulcers that they call the physician and he verifies or clarifies their findings. Observation on 11/02/2016 at 2:20 p.m. revealed that R#187 was lying on his right side. Observation on 11/03/2016 at 10:00 a.m. revealed that the R#187 was lying on his (R) side. Review of Policy for Assessment of Wounds revealed that it was the responsibility of a licensed nurse to complete the wound assessment, identify the type of wound, and that pressure ulcers were to be staged. Assessment of the wound and surrounding areas were to be documented in the record. Interview on 11/03/2016 at 2:28 p.m. with Certified Nursing Assistant (CNA), CC revealed that R#187 required total assistance with all activities of daily living, he was turned every 2 hours but frequently refused to be turned or he would turn himself back to his right side. She stated that he wears lift boots to reduce pressure to his lower extremities and so she had to make sure he had them on and they were properly applied. Interview on 11/03/2016 at 2:52 p.m. with the Director of Nursing (DON) revealed that all the nurses were responsible for assessing wounds, but that treatment nurses were responsible for staging wounds. She went on to state that Treatment Nurse, LPN BB had received the ETHICA wound certification classes. She stated that Treatment Nurse, RN AA was new to the position as treatment nurse, having started the position in August, (YEAR). She also stated that Treatment Nurse, RN AA was scheduled to attend the wound care certification class. The DON stated that she would expect the wound care nurses to document the type of wound and if appropriate, the stage also. The DON stated that if the treatment nurses have questions regarding wounds that they can call the local wound care clinic, the physician, and the Corporate Wound Care Consultant, who was certified as a Wound, Ostomy, Continence Nurse. Review of Treatment Administration Record from July, (YEAR) through November, (YEAR) revealed that the wounds were not consistently identified as to type of wound or staging for wounds that the wound nurse verbally identified as pressure related wounds and that were observed to be wounds covered by eschar over bony prominences.", "filedate": "2020-09-01"}
{"rowid": 5064, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2015-04-09", "deficiency_tag": 309, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "79CJ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to document the Arteriovenous Fistula (AV) site for bruit and thrill in the Medication Administration Record [REDACTED]. The resident sample size was thirty-four (34). Findings include: Resident #117 was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the clinical records for resident #117 revealed that the physician's orders [REDACTED]. Further review of the resident's MAR from 03/01/15 through 04/08/15 revealed that there was no evidence of documentation showing that licensed staff had checked the resident's AV fistula for bruit and thrill as ordered. Interview on 04/09/15 at 9:25 a.m. with Licensed Practical Nurse (LPN) GG revealed that she checks resident #117's AV fistula every shift for bruit and thrill, but does not record it on the MAR indicated [REDACTED]. Continued interview revealed that she could not explain why licensed staff did not document checking the AV Fistula for bruitt and thrill for over one month, despite the resident receiving [MEDICAL TREATMENT] since admission on 08/03/11. LPN GG confirmed that the MAR indicated [REDACTED]. Interview on 04/09/15 at 10:15 a.m. with Registered Nurse (RN) FF consultant for Ethica and the Director of Nursing (DON) revealed that they expect licensed staff to document when the bruit and thrill are checked on the resident's MAR. They both confirmed that the MAR for checking AV fistula to left upper arm bruit and thrill had not been documented from 03/01/15 through 04/09/15. The DON acknowledged that it was basic nursing practice to document that the bruit and thrill were completed as ordered by the physician. Continued interview with the DON revealed that she expected licensed staff to document that the fistula site had been checked as soon as it was completed. Observation on 04/09/15 at 9:30 a.m. revealed LPN GG adding in the times for nursing staff to complete checking the AV fistula on resident #117's MAR.", "filedate": "2019-02-01"}
{"rowid": 5065, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2015-04-09", "deficiency_tag": 328, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "79CJ11", "inspection_text": "Based on observations, staff interview and review of facility records/policies, the facility failed to ensure that oxygen concentrator filters were clean for two (2) of thirty-one (31) residents (#192,#156) that received continuous oxygen therapy. Findings include: Observation of resident #192 on 04/06/15 at 9:20 a.m. during intial tour of the facility revealed the resident resting in bed receiving oxygen therapy via nasal cannula at two liters per min (2L/Min). The oxygen concentrator located at the residents bedside had one filter which was heavily covered in white lint. Observation of resident #192 on 04/06/15 at 2:35 p.m. revealed the resident sitting up in bed watching television with continuous oxygen therapy via nasal cannula at 2L/min in progress. The oxygen concentrator was still heavily covered in white lint. Observations of resident #192 on 4/07/15 at 9:25 a.m. and again on 04/08/15 at 8:00 a.m. revealed the resident in her room with continuous oxygen via nasal cannula at 2L/min in progress. The residents oxygen filter continued to be heavily covered in white lint and the sterile water bottle was not labeled or dated. Observations of Unit D on 4/06/15 at 9:25 a.m., 04/07/15 at 2:23 p.m. and again on 04/08/15 at 9:27 a.m. revealed that resident #156 was receiving oxygen therapy via nasal cannula at 2L/min. The oxygen concentrator had a filter which was heavily covered with white lint. Random observations on Units A, B, C and E conducted on 04/08/15 at 10:30 a.m. revealed that there were a total of (31) thirty-one residents in the facility receiving oxygen therapy. Twenty-nine (29) of those residents had clean oxygen concentrators filters. During observation rounds of resident #192 and resident #156 with the Director of Nursing (DON) on 4/08/15 at 10:49 a.m. she confirmed that the oxygen concentrator filters for both residents were heavily covered in lint. The DON further revealed that the filters had not been changed per facility policy. Continued interview revealed that maintenance was responsible for changing the oxygen concentrator filters monthly and as needed when dirty. Interview on 04/08/15 at 10:10 a.m. with the Unit D Charge Nurse revealed that staff were responsible for changing the resident's tubing and filters weekly on Sunday night. The Charge Nurse further revealed that the night shift staff were responsible for making sure that the resident's oxygen equipment was clean and changed weekly. Interview on 04/08/15 at 11:51 a.m. with the Maintenance Supervisor revealed that they were only responsible for replacing the oxygen concentrator filters monthly with new filters. He further revealed that it was the responsibility of the nurses to maintain the cleanliness of the filters and to rinse them out as needed when they were dirty. Interview on 04/09/15 at 11:25 a.m. with the Administrator revealed that maintenance was responsible for the overall up keep and functioning of the oxygen machines, as well as changing out the filters monthly. The administrator further revealed that it was his expectation that the staff nurses remain responsible for keeping the oxygen concentrator filters clean in between. Review of the facility Policy Use of Oxygen last updated (MONTH) 2014 revealed the following: The filter on the concentrator should be checked at least every month and cleaned as needed. The filter check can be documented on tape on the concentrator. If a reusable humidifier is used , it should be emptied, rinsed, dried, and refilled with sterile water daily. The person changing the water should label it with the date, time and initials.", "filedate": "2019-02-01"}
{"rowid": 5066, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2015-04-09", "deficiency_tag": 371, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "79CJ11", "inspection_text": "Based on observations and staff interview the facility failed to ensure food items in one (1) of two (2) walk-in refrigerators had valid expiration dates; failed to properly clean stand-up mixer and meat slicer after usage; failed to properly maintain the cleanliness of 1 of five (5) resident nourishment freezers. The census during the survey was one hundred forty (140). Findings include: 1. Observation on 04/06/15 at 9:30 a.m. revealed the kitchen had two (2) walk-in refrigerators and the first walk-in refrigerator contained dairy products. Continued observation of the dairy walk-in refrigerator revealed there were 5, thirty two (32) ounce containers of vanilla flavored Dannon yogurt and 1, (32) ounce container of strawberry flavored Dannon yogurt with an expiration date of (MONTH) 03, (YEAR). Interview on 04/06/15 at 9:30 a.m. with the Dietary Manager (DM) revealed that he expects staff to review the expiration dates on food products when being stored in the walk-in refrigerator. He confirmed that the six (6) containers of Dannon flavored yogurts were expired. The DM acknowledged that the expired yogurt was in the walk-in refrigerator and that food items should have a current/valid expirations date. He further revealed that he expects staff to throw way expired food items. Observation on 04/06/15 at 9:45 a.m. of the stand-up mixer revealed that it was covered with a clear plastic bag. When the clear plastic bag was removed there was a powdery white substance covering the area under the mixing arm where the beater would be attached. Continued observation of the stand-up mixer revealed that there was also an orange food substance under the mixing arm. The orange food substance was two (2) inches in length and one half (1/2) inch in width near where that beater would be attached. Interview on 04/06/15 at 9:45 a.m. with the DM revealed that when the clear plastic bag is covering any kitchen equipment it is expected that the equipment is clean and ready for use. He confirmed that the stand-up mixer had the powdery white food debris and the orange substance under the mixing arm. The DM acknowledge that the mixer should have been cleaned properly before the clear plastic bag was placed over the top. Continued observation on 04/06/15 at 9:55 a.m. of the slicer revealed that is was covered with a clear plastic bag. When the clear plastic bag was removed it revealed that were was a brown food substance underneath by the blade. Interview on 04/06/15 at 9:55 a.m. with the DM revealed that when a clear plastic bag is covering any kitchen equipment it is expected that the equipment is clean and ready for use. He confirmed that the slicer had brown food debris underneath by the blade. The DM acknowledged that the staff did not properly clean the slicer before placing the clear plastic bag over it. Continued interview revealed that there are cleaning schedules that staff are expected to follow and to initial when items had been cleaned. 2. Observation on 04/07/15 at 4:30 p.m. of Unit A resident nourishment room revealed that there was a standard refrigerator with freezer unit on top. Continued observation revealed that the resident nourishment freezer had a red liquid substance that was frozen to the bottom towards the front middle. This area was four (4) inches in length and three (3) inches in width, oval in shape. There were 3, pre-portioned vanilla ice cream cups touching the red substance. Continued observation revealed that toward the front right of the freezer was a brown liquid frozen food substance that was 2 inches in length and width, circular in shape. There was one pre-portioned ice cream cup touching the brown substance. Further observation of Unit A resident nourishment revealed that there was a dead flying insect on the bottom of the freezer. Observations on 04/08/15 at 3:45 p.m. and again on 04/09/15 at 9:30 a.m. of the Unit A resident nourishment room freezer revealed that the red frozen substance, brown frozen substance, and the dead insect all remained in the bottom of the freezer. Interview on 04/09/15 at 9:30 a.m. with the Director of Nursing (DON) and the DM revealed that dietary staff was only responsible for stocking the resident refrigerator and freezer. The DM further revealed that the resident nourishment freezer had no requests this week for more supplies. He revealed that if dietary staff would encounter any dead insect or spill in the freezer he would expect staff to clean it before re-stocking. The DON revealed that housekeeping was responsible for cleaning the resident nourishment refrigerator and freezer. She further revealed that she would expect nursing staff to clean any spill or dead insect as they take items from the refrigerator or the freezer. The DON and DM confirmed that there was a dead insect in the freezer and that there was a frozen red and brown fluid on the bottom of the freezer. They both acknowledged that the resident nourishment room refrigerator and freezer should be cleaned. Interview on 04/09/15 at 9:40 a.m. with Housekeeper EE on Unit A revealed that she had not been told that she needed to clean the inside of the resident refrigerator or freezer. She revealed that she had only been told to clean the microwave, counter tops, and the floors. EE further revealed that if she would have known to clean the refrigerator and freezer she would have. Interview on 04/09/15 at 10:05 a.m. with the Housekeeping Supervisor revealed that she did not know and was not told that housekeeping staff were responsible for cleaning the resident nourishment refrigerators and freezers. She revealed that the signage posted on the front of the resident nourishment refrigerator and freezer indicate that Certified Nursing Assistants (CNA) and nursing were responsible for the cleaning of the resident refrigerator and freezer. Observation on 04/07/15, 04/08/15, and 04/09/15 revealed a sign posted on the front of each resident nourishment refrigerator that revealed that Nursing/CNA's are responsible for: 1) Discarding out of date products. 2) The cleanliness and organization of the refrigerators.", "filedate": "2019-02-01"}
{"rowid": 5067, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2015-04-09", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "79CJ11", "inspection_text": "Based on observations and staff interviews the facility failed to ensure appropriate infection control measures were followed during the provision of direct care for one (1) resident (#129) who had a positive urine culture for Extended Spectrum Beta Lactamase (ESBL). The facility also failed to wash or sanitize hands during the delivery, set-up, and assistance between residents during one (1) of two (2) dining observations. The census was one hundred and forty (140) residents, with one hundred and thirty-four (134) of whom received oral alimentation. Findings include: 1. Observation of resident #129 on 04/06/15 at 4:00 p.m. revealed that the resident was on isolation precautions. Further observation revealed a sign on the resident's door indicating the need to see the nurse before entering the resident's room. An Isolation cart with Personal Protective Equipment (PPE) was noted outside of the resident's door. Interview with Registered Nurse (RN) BB on 04/07/2015 at 9:00 a.m., BB confirmed that resident #129 was on contact isolation for ESBL in her urine and indicated the ESBL was detected in the resident's labs on 04/02/15. RN BB revealed that staff was to don PPE before entering the room and to remove the PPE before exiting the room. BB added that the staff had also been instructed to wash their hands or to use the hand sanitizer before leaving the room. Continued interview revealed that there was a sign outside the resident's door requesting that all visitors see the nurse before entering the resident's room for instructions on how and why to wear the PPE. Observation of Certified Nursing Assistant (CNA) DD on 04/08/15 at 8:40 a.m. revealed DD entering the room of resident #129 after donning gloves only before entering the room. DD was observed in resident #129's room readjusting the resident's linens and reaching over and leaning against the resident's bed while assisting the resident. DD was observed leaving the room without washing her hands after removing her gloves. Interview with the Director of Nursing (DON), on 04/08/15 at 8:45 a.m. revealed that she expects her staff to be aware of the type of isolation that any resident is on before entering a room and to wear the appropriate PPE for that type of isolation. When asked specifically about the isolation precautions for resident #129 the DON stated that the resident was on contact isolation for ESBL. The DON added that she expected her staff to wear a gown and gloves when assisting Resident #129 and to remove their PPE and wash their hands before exiting the room. Interview with CNA DD on 04/08/2015 at 8:55 a.m. revealed that she did not wear a gown before entering resident #129's room because she was told by a Licensed Practical Nurse (LPN) that it makes resident #129 nervous when staff wears a gown in her room. DD verbalized that she was aware that resident #129 was on contact isolation for ESBL and acknowledged that she should have put on the proper PPE before assisting the resident. DD added further that she was counseled by the DON to wear the proper PPE when entering resident 129's room. 2. Observation of lunch service on the B hall on 04/06/15 at 1:15 p.m. revealed CNA CC assisting residents with their lunch in the main dining room. CC pulled her cell phone from her pocket, touched multiple wheelchairs and cabinet doors without washing or sanitizing her hands before handling a resident's dinner roll to place butter on it. CC also touched multiple resident's cutlery and the unprotected rims of drinking glasses without washing or sanitizing her hands after touching wheelchairs, resident's clothing, dirty meal trays, and cabinet doors. Continued observation of CNA CC on 04/06/15 at 1:25 p.m. revealed CC feeding a resident her lunch during lunch service in the main dining room/B Hall without washing or sanitizing her hands prior to assisting the resident. The resident was observed to be fully dependent on staff for all aspects of feeding. CC was observed touching the resident's bread, unprotected rim of the resident's drinking glass, and cutlery without washing her hands after being observed touching dirty meal trays, wheelchairs, cabinets, and resident clothing. Interview with CNA CC on 04/08/15 at 3:10 p.m. revealed that when she assists with meal trays and feeding residents she always uses the hand sanitizer before meal service begins and after meal service ends. CC further revealed that she has never washed or sanitized her hands during meal service. She acknowledged that she has seen other staff using the hand sanitizer during the meal services but she only uses it before meals and after she is done assisting with meal services. Interview with the DON on 04/08/2015 at 3:45 p.m. revealed that staff was expected to sanitize or wash their hands before the distribution of each meal tray for all meal services as well as in between each contact with residents. The DON further revealed that the facility has inservices on handwashing to make sure that staff are aware of the proper times and techniques for handwashing.", "filedate": "2019-02-01"}
{"rowid": 6300, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2013-11-14", "deficiency_tag": 371, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "3YTE11", "inspection_text": "Based on observation, and staff interviews the facility failed to properly sanitize pots and pans in the three (3) compartment sink. This failure effected all residents receiving oral alimentation or one hundred and thirty five (135) residents. Findings include the following : 1. Observation on 11/11/2013 at 11:45 a.m., of the three (3) compartment sink located in the dish washing area revealed that there were pots soaking in the wash compartment of the sink. The Quaternary sanitizing sink was full with no pots or pans in it. The Sanitizer solution was tested with the solution registering 0 ppm. Normal range per manufacturer recommendation was 150 parts per million (ppm)-200 ppm. Review of the daily Sanitizer Reporting Log for 11/11/13 read 200 ppm. Interview with the Food Service Director on 11/13/13 at 12:19 p.m., revealed that the EcoLab representative needed to come in to re-educate the employees on the use of the Sanitizer solution, and how to read the strips.", "filedate": "2018-02-01"}
{"rowid": 7657, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2014-02-20", "deficiency_tag": 224, "scope_severity": "J", "complaint": 1, "standard": 0, "eventid": "LWSQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, staff interview, hospital ER Triage Record review, and facility Follow-Up Report review, the facility failed to prevent neglect by failing to ensure that the WanderGuard system, utilized by facility staff for the supervision of residents at risk for elopement/wandering behavior on the first floor Units B and C, provided alarm coverage which included a set of unlocked doors located in a first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into the adjoining hospital. This failure resulted in neglect by allowing the elopement of one (1) Unit B resident (#1), who was at risk for wandering/elopement and who utilized a WanderGuard bracelet, on the total survey sample of fourteen (14) residents. Resident #1, while wearing a WanderGuard bracelet, was able to access this unsecured first-floor corridor on 02/09/2014, pass through the unalarmed corridor doors, exit the nursing facility through this corridor, enter the adjoining hospital and elope. Resident #1 then fell and hit his/her head on pavement, was taken to the hospital emergency room and found to have facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via a set of unlocked, unalarmed, and unsecured doors located within a corridor which lead from the nursing facility to the adjoining hospital), continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During an interview with the Administrator conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged Resident #1's nursing facility elopement on 02/09/2014. The Administrator acknowledged that the unlocked corridor doors located in the corridor leading from the nursing facility to the hospital did not have a WanderGuard alarm, and it was thought that Resident #1 had gone through the unalarmed corridor doors, entered the hospital and exited through the front main entrance/exit doors of the hospital. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of D while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of elopement/wandering. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: Resident #1's Minimum Data Set assessment of 02/06/2014 documented [DIAGNOSES REDACTED]. Section C - Cognitive Patterns recorded a Brief Interview for Mental Status score of six (06), indicating severe cognitive impairment. Section E - Behavior documented that Resident #1 had exhibited wandering behavior, and a 01/31/2014 Physician's Interim Orders form specified a WanderGuard bracelet at all times. A Nurse's Notes (NN) entry of 02/09/2014 for the 7:00 a.m.-7:00 p.m. shift documented that Resident #1 was walking up and down the hallways requiring staff redirection, and that the resident had stated Which way is the way out? I need to get home. The NN documented that at around 3:45 p.m. on 02/09/2014, Resident #1 had been at an activity in the Day Room being assisted by a certified nursing assistant. However, a 02/09/2014, 5:00 p.m. NN documented that a facility nurse received a telephone call from a family member to inform her that Resident #1 had been found with injuries at the roadside, and that Emergency Medical Service (EMS) 911 had been called for hospital transport. The 02/09/2014 hospital ER Triage Record documented that Resident #1 had fallen onto pavement and hit his/her face and forehead. The 02/09/2014 hospital ED Nursing Record (EDNR) documented lacerations/abrasions to Resident #1's face, nose, and forehead, and that the resident had been found by a former neighbor in the highway close to the resident's former home. Resident #1's 02/09/2014 ED Discharge Instructions form documented a laceration repair and injuries which included nasal and right knee patella fractures. A 02/14/2014 facility Follow-Up Report (FR) for Resident #1 documented that Resident #1 was originally admitted to Unit E, a second floor unit, but was moved to first floor Unit B on 02/05/2014 at family request. This FR documented that at 3:45 p.m. on 02/09/2014, Resident #1 was in the Day Room in an activity being assisted by Certified Nursing Assistant (CNA) BB, who left Resident #1 in the Day Room around 4:05 p.m. This FR documented that Resident #1 then left the Day Room and eloped, sustaining a fall before reaching his/her former home located 0.83 mile from the facility. This FR documented Resident #1's hospital transfer after the elopement and fall, and documented treatment for [REDACTED]. During an observation of Unit B conducted on 02/14/2014 at 12:30 p.m. at the end of the B Hall of Unit B, a corridor turned to the right off of B Hall. Within this corridor which was directly accessible from Unit B, observation revealed a set of double doors which were not locked and did not have a WanderGuard alarm. The corridor within which these unalarmed double doors were located, and which originated at the end of the B Hall of nursing facility Unit B, continued into the hospital which adjoined the nursing facility, and terminated at the main entrance/exit doors located at the front of the hospital. A two lane street was observed to run in front of the hospital/nursing facility buildings. Interview with the Administrator conducted on 02/14/2014 at 11:50 a.m. revealed that Resident #1's former home, close to which the resident was found to have fallen after eloping on 02/09/2014, was located on this street which ran directly in front of the hospital/nursing home facilities. During an interview conducted on 02/14/2014 at 12:48 p.m., the DON stated that Resident #1's Unit B room had been located close to the set of unalarmed corridor doors. The DON stated that, based on investigation, the facility determined that on 02/09/2014, Resident #1 had walked down the corridor off of Unit B, passed through the unalarmed corridor doors, continued walking out of the nursing facility and exited out the front door of the hospital. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard alarm bracelets, and despite Resident #1 having severe cognitive impairment and a known history of wandering requiring a WanderGuard bracelet for supervision, the facility neglected Resident #1 by failing to provide supervision, per the resident's WanderGuard device, to address the resident's risk of elopement. Instead, the facility failed to ensure the placement of a WanderGuard alarm on the set of unlocked double doors located in the corridor leading from Unit B, where Resident #1 resided, and continuing into the hospital located adjacent to the nursing facility. This allowed Resident #1, who utilized a WanderGuard bracelet, to exit through these unalarmed, unlocked corridor double doors without the knowledge of nursing facility staff, to exit through the hospital's front entrance/exit doors and elope from the facility, then to gain access to a street where he/she subsequently fell and sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. The immediate jeopardy was determined to have been removed on February 19, 2014, at which time the facility had presented and implemented a credible allegation of jeopardy removal with the following interventions: A. On February 9, 2014, after learning of Resident #1's elopement, the facility conducted a full resident audit to assure the presence of all residents. B. On February 9, 2014, all doors exiting the nursing facility were checked to ensure the proper working order of the WanderGuard alarm system. All existing WanderGuard alarms were functioning properly. C. On February 9, 2014, a procedure was put into place by which a facility employee was placed at the doorway, located in the corridor leading from the nursing facility to the hospital, which was not equipped with a WanderGuard alarm. A scheduled was developed reflecting specific employees who were assigned to be in place at the unalarmed doorway, at specific times and continuously around the clock, until a WanderGuard alarm was installed on the doorway. D. On February 9, 2014, chart audits for all current facility residents were conducted to ensure that all residents who demonstrated a potential for elopement had been accurately identified by the facility. During these chart audits, no new residents were identified to have the potential for elopement. E. On February 9, 2014, Care Plan reviews were conducted for residents assessed to be at risk for elopement to ensure that a comprehensive approach to address this risk was in place. During these Care Plan reviews, no problems were identified. F. On February 9, 2014, in addition to daily WanderGuard bracelet checks completed by the Activities Director which were in place prior to Resident #1's elopement, the facility implemented audits of the door alarms through the preventative maintenance program. The door alarms would be checked weekly, on each Tuesday, by the Maintenance Director, and these door alarm checks would be documented via computer data entry. The door alarm test would include a check of the power indicator light to ensure proper function, and also a check for battery condition. A sensor button was to be used to test each door alarm, with the alarm to sound when within six feet of an alarmed doorway. If a door alarm did not initially sound, the test was to be repeated with a different sensor button. Any deviation from full working order found during these weekly door alarm checks would be reported to the Administrator for immediate correction. The Administrator or DON would monitor the results of these weekly door alarm audits, conducted by the Maintenance Director, by reviewing the computer data entered as a result of the door alarm checks weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. The results of these supervisory audits will be submitted to the Quality Assessment/Performance Improvement (QA/PI) Committee for their review. G. On February 9, 2014, the facility contacted the Medical Director to inform him of the elopement of Resident #1. Additionally, a meeting which consisted of some members of the QA/PI Committee, including the Administrator, DON, and Director of Maintenance, was held to review the elopement event and the actions which had been taken by the facility, and to identify any additional actions that were needed. H. On February 15, 2014, the corridor doorway, which lead from the nursing facility to the hospital and which had previously lacked a WanderGuard alarm, was equipped with a WanderGuard alarm. I. On February 18, 2014, the facility continued to provide staff in-service training to facility staff, including licensed nurses, CNAs, and maintenance/housekeeping staff. This in-service training served to both reinforce current facility protocols involving the routine monitoring of residents having WanderGuard bracelet devices and also to provide staff training on newly-implemented protocols related to the facility's WanderGuard alarm system. As of February 18, 2014, 116 of the facility's total 118 employees had received this in-service training. The two (2) remaining staff members, who were on Family and Medical Leave Act leave at the time this in-service training was provided, will received the training upon their return to work. J. On February 18, 2014, the QA/PI Committee met to review the elopement event involving Resident #1, to review the actions taken by the facility as of that date, and to review the monitoring systems put into place as a result of the elopement. The QA/PI Committee will review the results of WanderGuard bracelet monitoring and door alarm audits weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter to ensure ongoing compliance with the systemic measures implemented to correct the identified issue and prevent recurrence. The information will be analyzed by the QA/PI Committee, and subsequent plans of correction will be developed and implemented as needed. This will be an ongoing process. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 19, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On February 9, 2014, the facility implemented a weekly audit of WanderGuard door alarms to be accomplished through the preventative maintenance program by the Maintenance Director. These weekly WanderGuard door alarm audits would check for the proper function of all facility WanderGuard door alarms, and were to be documented via computer data entry. However, these weekly WanderGuard door alarm audits had been initiated only on February 9, 2014, and had occurred only twice prior to the February 20, 2014 exit date of this complaint survey. Therefore, ongoing staff compliance with this newly implemented procedure involving routine, scheduled WanderGuard door alarm monitoring could not be entirely assessed at the time of survey completion, and will thus need future evaluation. Additionally, by February 18, 2014, the facility had completed in-service training for 116 of its 118 facility employees, to include licensed nurses, CNAs, and maintenance/housekeeping staff, regarding both existing and newly-implemented protocols involving the monitoring of residents with WanderGuard bracelets and the WanderGuard alarm system. However, two (2) remaining staff members, who were on leave and had been unavailable for training, will need to receive this training upon returning to work, and this training will thus need future evaluation. Additionally, the QA/PI Committee was to include the review the results of WanderGuard bracelet monitoring and door alarm audits in future meetings, but the Committee had met on On February 18, 2014, only two (2) days prior to the February 20, 2014 exit date of this complaint survey, to begin this process. Thus, the QA/PI Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the D level.", "filedate": "2017-02-01"}
{"rowid": 7658, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2014-02-20", "deficiency_tag": 282, "scope_severity": "K", "complaint": 1, "standard": 0, "eventid": "LWSQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility staff interview, hospital ED Nursing Record review, hospital ED Discharge Instructions review, and facility Follow-Up Report review, the facility failed to ensure resident supervision for elopement/wandering behavior, in accordance with the Care Plan which specified WanderGuard bracelet use to address elopement/wandering behavior, by failing to ensure that the WanderGuard system provided protection which included a set of double doors located in one (1) first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into an adjoining hospital facility. The failure of the facility to ensure WanderGuard alarm protection on the double doors contained within this unsecured corridor allowed this corridor to serve as an unsecured route of exit for one (1) resident (#1) who eloped through this corridor, and as a potential unsecured route of exit for four (4) additional residents (#5, #11, #12, and #14), whose Care Plans specified the use of WanderGuard bracelets to address known elopement/wandering behavior, on the total survey sample of fourteen (14) residents. Resident #1 subsequently accessed this unsecured corridor on 02/09/2014 without the knowledge of facility staff, exited the facility through the corridor, and eloped through the adjoining hospital. Resident #1 traveled along a street for approximately one-half mile, fell on to the pavement, was taken to the hospital Emergency Department (ED), and was found to have facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via the unlocked, unalarmed, and unsecured doors located within a corridor which lead from the nursing facility to an adjoining hospital), continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During this survey, it was determined that Resident #1, who had a history of [REDACTED]. In addition to Resident #1, Resident #s 5, 11, 12, and 14, who all had cognitive impairment and whose Care Plans all specified the use of WanderGuard bracelets for known elopement/wandering behavior, also resided on Unit B or Unit C, and all had direct access to these unlocked, unalarmed corridor doors which lead directly to the hospital. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged that the set of unlocked corridor doors located in the corridor leading from the nursing facility into the hospital did not have a WanderGuard alarm. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of E while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of wandering/elopement. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: During a tour of the facility's first floor conducted on 02/14/2014 at 12:30 p.m., observations were made in first floor Unit B and Unit C. Observation during this tour revealed that the facility utilized a WanderGuard alert system to allow for the supervision of residents at risk for elopement/wandering. A WanderGuard alarm was observed on the nursing facility's main entrance/exit doors located at the front of the facility, and a WanderGuard alarm was observed on doors located at the terminal end of the Unit C front corridor which opened into a corridor of the adjoining hospital facility. However, observation of Unit B revealed a corridor which turned off the end of the B Hall of Unit B and lead into the adjoining hospital facility. This corridor which connected the nursing facility and the hospital was noted to contain a set of double doors which did not have a WanderGuard alarm. These doors were not locked, and opened upon pressing a wall-mounted button. This corridor containing these unalarmed, unlocked doors lead from the nursing facility to the adjoining hospital, continued through the hospital and exited through the hospital's main front entrance/exit doors. During this observation, it was noted that the nursing facility's Unit B and Unit C adjoined, and that residents of both units could travel between units, thus allowing residents of both units to have access to this corridor which exited from Unit B and which contained these unalarmed, unlocked double doors leading into the adjoining hospital. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged that the double doors located in the corridor leading off of Unit B had no WanderGuard alarm and were not locked. 1. Resident #1's Minimum Data Set (MDS) Assessment of 02/06/2014, for an admission of 01/30/2014, documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITION] Fibrillation, [MEDICAL CONDITION] Disorder, and Non-Alzheimer's Dementia, and Section C - Cognitive Patterns indicated severe cognitive impairment, with a Brief Interview for Mental Status (BIMS) Summary Score of six (06). Section E - Behavior documented that Resident #1 had exhibited wandering behavior 1 to 3 days during the look-back period. Resident #1's Nursing Admission Care Plan, dated 01/30/2014, identified that the resident was at risk for elopement, and was also at risk for falls. This Nursing Admission Care Plan identified an Approach which specified the use of a WanderGuard alarm to address Resident #1's risk for elopement, with the indicated Goal being that the resident would remain free of injuries and falls. A Nurse's Notes (NN) entry of 02/09/2014 for the 7:00 a.m.-7:00 p.m. shift documented that at around 3:45 p.m., Resident #1 had been seated in the Day Room for an activity. However, a subsequent 02/09/2014, 5:00 p.m. NN documented that Resident #1 had been found at the side of a road by a previous neighbor and was being taken to the hospital. Resident #1's hospital ED (Emergency Department) Nursing Record of 02/09/2014 documented lacerations/abrasions to the face, nose, and forehead, and that the resident had been found by a previous neighbor in the highway outside of the resident's former home. Resident #1's ED Discharge Instructions form of 02/09/2014 documented [DIAGNOSES REDACTED]. A 02/14/2014 facility Follow-Up Report (FR) documented that at 3:45 p.m. on 02/09/2014, Resident #1, who resided on first floor Unit B, had left the facility's Day Room sometime after 4:00 p.m. and eloped, almost reaching his/her former home located 0.83 mile from the nursing facility. This FR documented that the facility believed Resident #1 could have eloped through a set of double doors located in a corridor which lead to the adjoining hospital. As indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the corridor which lead off the B Hall of facility Unit B, to which Resident #1 had direct access, contained unlocked double doors which had no WanderGuard alarm, were not locked, and continued into the adjoining hospital facility, passed through the hospital, and exited through the hospital's main entrance/exit doors. During an interview conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged these corridor doors off of the Unit B corridor were not locked and did not have a WanderGuard alarm. The Administrator stated that it was thought that on 02/09/2014, Resident #1 walked down the B Hall corridor, passed through the unalarmed double doors, entered into the hospital and eloped through the hospital's front main entrance/exit doors. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, and despite Resident #1 having severe cognitive impairment and a known history of wandering behavior, thereby requiring the use of a WanderGuard bracelet as specified by the Nursing Admission Care Plan, the facility failed to ensure that the unlocked double doors located in the corridor leading from the Unit B hall where Resident #1 resided were equipped with a WanderGuard alarm, to thus ensure WanderGuard bracelet supervision as specified by the Care Plan. Resident #1 then exited the nursing facility through the unalarmed, unlocked corridor double doors and then exited the hospital through the front entrance/exit doors and eloped. Resident #1 then traveled approximately one-half (1/2) mile, fell and sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. Cross refer to F323, example 1, for more information regarding Resident #1. 2. Resident #12's MDS of 11/11/2013 documented diagnoses, in Section I - Active Diagnoses, which included Hypertension and Dementia, and Section C - Cognitive Patterns documented a BIMS Summary Score of seven (7), indicating severe cognitive impairment. Review of Resident #12's Care Plan revealed that the resident resided on Unit B of the facility. An entry on this Care Plan, indicated as a Problem/Need and originally dated 12/31/2013, identified Resident #12 to have wandering behavior. Approaches listed on Resident #12's Care Plan to address this wandering behavior included the use of a WanderGuard bracelet to be applied at all times, and to redirect the resident as indicated. The Goal for these Approaches identified on Resident #12's Care Plan included that the resident would not leave the facility unescorted. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the corridor leading to the adjacent hospital facility, and located at the end of the B Hall of Unit B where Resident #12 resided and to which Resident #12 had direct access, contained double doors which were unlocked and not equipped with a WanderGuard alarm. This corridor continued into the hospital facility and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #12, who resided on Unit B, having Dementia and severe cognitive impairment and having been assessed to have a history of wandering behavior, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet and that staff redirect the resident as indicated, the facility failed to ensure that double doors located in the corridor which exited Unit B and lead directly into the adjoining hospital were WanderGuard alarm equipped. By failing to ensure WanderGuard alarm placement on the unlocked double doors contained within this corridor leading from the nursing facility to the hospital, and which served as a direct route of egress from the nursing facility, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #12, as specified by the Care Plan, would allow redirection of the resident as indicated, also as specified by the Care Plan, by alerting staff to wandering/elopement attempts through this unsecured corridor. This presented a wandering risk for Resident #12. Cross refer to F323, example 2, for more information regarding Resident #12. 3. Resident #14's MDS of 01/06/2014 documented diagnoses, in Section I - Active Diagnoses, which included [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION], Dementia, [MEDICAL CONDITION] Disorder, and a [MEDICAL CONDITION], and Section C - Cognitive Patterns documented severe cognitive impairment, with a BIMS Summary Score of ninety-nine (99). Resident #14's Care Plan identified that the resident resided on Unit C. The Care Plan also identified, as a Problem/Need originally dated 04/18/2013, that Resident #14 was at risk for elopement from the facility. The Care Plan referenced Approaches to address Resident #14's elopement risk which include the use of a WanderGuard bracelet at all times, and for staff to provide redirection as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, Resident #14, who wore a WanderGuard bracelet for elopement-risk and resided on Unit C, had direct access to Unit B, where observation revealed the corridor which lead off of Unit B and contained the double doors which were not locked or equipped with a WanderGuard alarm, and lead to the hospital facility that adjoined the nursing facility, exiting through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #14 (who resided on Unit C and had direct access to Unit B) having Dementia and severe cognitive impairment, despite the resident having been assessed to be at risk for elopement, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet for this elopement-risk and that staff redirect the resident as indicated, the facility failed to ensure WanderGuard alarm placement on the unlocked double doors located in the corridor which exited Unit B, lead directly into the adjoining hospital, and allowed nursing facility egress. By failing to ensure WanderGuard alarm placement on these unlocked double doors, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #14, as specified by the Care Plan, would allow redirection as indicated, also as specified by the Care Plan, by alerting staff to elopement attempts through this unsecured corridor. This presented an elopement risk for Resident #14. Cross refer to F323, example 3, for more information regarding Resident #14. 4. Resident #5's MDS of 11/19/2014 documented diagnoses, in Section I - Active Diagnoses, of [MEDICAL CONDITION], Heart Failure, Hypertension, [MEDICAL CONDITION], Diabetes Mellitus, Arthritis, a history of [MEDICAL CONDITION], and Dementia. Section C - Cognitive Patterns documented that Resident #5 had moderate cognitive impairment, with a BIMS Summary Score of twelve (12). The Care Plan of Resident #5 identified that he/she resided on facility Unit B. Resident #5's Care Plan also identified, as a Problem/Need originally dated 11/20/2013, that the resident had the potential for elopement related to both episodes of confusion with wandering and a history of wandering. This Care Plan identified Approaches to address Resident #5's elopement-risk which included the use of a WanderGuard at all times, and also staff redirection as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, the double doors located within the corridor which lead off of Unit B, where Resident #5 resided, were unlocked and were not equipped with a WanderGuard alarm. This corridor within which these unlocked, unalarmed double doors were located was accessible by Resident #5, lead into the adjoining hospital facility, and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #5, who resided on Unit B, having Dementia and cognitive impairment and having been assessed to have the potential for elopement due to confusion and a history of wandering behavior, and despite the resident's Care Plan specifying the use of a WanderGuard bracelet and that staff redirect the resident as indicated, the facility failed to ensure that double doors located in the corridor which exited Unit B and lead directly into the adjoining hospital were WanderGuard alarm-equipped. By failing to ensure WanderGuard alarm placement on the unlocked double doors within this corridor which served as a direct route of egress from the nursing facility, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #5, as specified by the Care Plan, would allow redirection of the resident as indicated, also as specified by the Care Plan, by alerting staff to wandering/elopement attempts through this unsecured corridor. This presented an elopement risk for Resident #5. Cross refer to F323, example 4, for more information regarding Resident #5. 5. Resident #11's MDS assessment of 01/06/2014 documented in Section I - Active [DIAGNOSES REDACTED]. The Care Plan of Resident #11 identified that the resident resided on facility Unit C. The Care Plan also identified, as a Problem/Need originally dated 07/16/2013, that Resident #11 had the potential for wandering behavior, with a history of wandering in the hallways. Care Plan Approaches to address Resident #11's risk for wandering included the use of a WanderGuard bracelet at all times and for staff to redirect the resident as indicated. However, as indicated in the 02/14/2014, 12:30 p.m. tour observation referenced above, Resident #11, who utilized a WanderGuard bracelet and resided on Unit C, had access to the corridor which exited off of Unit B, contained the double doors which were unlocked and were not equipped with a WanderGuard alarm, and which lead from the nursing facility to the adjoining hospital and exited through the hospital's main front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #11 (who resided on Unit C and had direct access to Unit B) having Dementia/severe cognitive impairment and having been assessed with [REDACTED]. Unit B, lead directly into the adjoining hospital, and allowed nursing facility egress. By failing to ensure WanderGuard alarm placement on these unlocked doors, the facility failed to ensure that the WanderGuard bracelet utilized by Resident #11, as specified by the Care Plan, would allow redirection as indicated, also as specified by the Care Plan, by alerting staff to resident wandering in this unsecured corridor. This represented a wandering risk for Resident #11. Cross refer to F323, example #5, for more information regarding Resident #11. The immediate jeopardy was determined to have been removed on February 19, 2014, at which time the facility had presented and implemented a credible allegation of jeopardy removal with the following interventions: A. On February 9, 2014, after learning of Resident #1's elopement, the facility conducted a full resident audit to assure the presence of all residents. B. On February 9, 2014, all doors exiting the nursing facility were checked to ensure the proper working order of the WanderGuard alarm system. All existing WanderGuard alarms were functioning properly. C. On February 9, 2014, a procedure was put into place by which a facility employee was placed at the doorway, located in the corridor leading from the nursing facility to the hospital, which was not equipped with a WanderGuard alarm. A scheduled was developed reflecting specific employees who were assigned to be in place at the unalarmed doorway, at specific times and continuously around the clock, until a WanderGuard alarm was installed on the doorway. D. On February 9, 2014, chart audits for all current facility residents were conducted to ensure that all residents who demonstrated a potential for elopement had been accurately identified by the facility. During these chart audits, no new residents were identified to have the potential for elopement. E. On February 9, 2014, Care Plan reviews were conducted for residents assessed to be at risk for elopement to ensure that a comprehensive approach to address this risk was in place. During these Care Plan reviews, no problems were identified. F. On February 9, 2014, in addition to daily WanderGuard bracelet checks completed by the Activities Director which were in place prior to Resident #1's elopement, the facility implemented audits of the door alarms through the preventative maintenance program. The door alarms would be checked weekly, on each Tuesday, by the Maintenance Director, and these door alarm checks would be documented via computer data entry. The door alarm test would include a check of the power indicator light to ensure proper function, and also a check for battery condition. A sensor button was to be used to test each door alarm, with the alarm to sound when within six feet of an alarmed doorway. If a door alarm did not initially sound, the test was to be repeated with a different sensor button. Any deviation from full working order found during these weekly door alarm checks would be reported to the Administrator for immediate correction. The Administrator or DON would monitor the results of these weekly door alarm audits, conducted by the Maintenance Director, by reviewing the computer data entered as a result of the door alarm checks weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. The results of these supervisory audits will be submitted to the Quality Assessment/Performance Improvement (QA/PI) Committee for their review. G. On February 9, 2014, the facility contacted the Medical Director to inform him of the elopement of Resident #1. Additionally, a meeting which consisted of some members of the QA/PI Committee, including the Administrator, DON, and Director of Maintenance, was held to review the elopement event and the actions which had been taken by the facility, and to identify any additional actions that were needed. H. On February 15, 2014, the corridor doorway, which lead from the nursing facility to the hospital and which had previously lacked a WanderGuard alarm, was equipped with a WanderGuard alarm. I. On February 18, 2014, the facility continued to provide staff in-service training to facility staff, including licensed nurses, CNAs, and maintenance/housekeeping staff. This in-service training served to both reinforce current facility protocols involving the routine monitoring of residents having WanderGuard bracelet devices and also to provide staff training on newly-implemented protocols related to the facility's WanderGuard alarm system. As of February 18, 2014, 116 of the facility's total 118 employees had received this in-service training. The two (2) remaining staff members, who were on Family and Medical Leave Act leave at the time this in-service training was provided, will received the training upon their return to work. J. On February 18, 2014, the QA/PI Committee met to review the elopement event involving Resident #1, to review the actions taken by the facility as of that date, and to review the monitoring systems put into place as a result of the elopement. The QA/PI Committee will review the results of WanderGuard bracelet monitoring and door alarm audits weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter to ensure ongoing compliance with the systemic measures implemented to correct the identified issue and prevent recurrence. The information will be analyzed by the QA/PI Committee, and subsequent plans of correction will be developed and implemented as needed. This will be an ongoing process. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 19, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On February 9, 2014, the facility implemented a weekly audit of WanderGuard door alarms to be accomplished through the preventative maintenance program by the Maintenance Director. These weekly WanderGuard door alarm audits would check for the proper function of all facility WanderGuard door alarms, and were to be documented via computer data entry. However, these weekly WanderGuard door alarm audits had been initiated only on February 9, 2014, and had occurred only twice prior to the February 20, 2014 exit date of this complaint survey. Therefore, ongoing staff compliance with this newly implemented procedure involving routine, scheduled WanderGuard door alarm monitoring could not be entirely assessed at the time of survey completion, and will thus need future evaluation. Additionally, by February 18, 2014, the facility had completed in-service training for 116 of its 118 facility employees, to include licensed nurses, CNAs, and maintenance/housekeeping staff, regarding both existing and newly-implemented protocols involving the monitoring of residents with WanderGuard bracelets and the WanderGuard alarm system. However, two (2) remaining staff members, who were on leave and had been unavailable for training, will need to receive this training upon returning to work, and this training will thus need future evaluation. Additionally, the QA/PI Committee was to include the review the results of WanderGuard bracelet monitoring and door alarm audits in future meetings, but the Committee had met on On February 18, 2014, only two (2) days prior to the February 20, 2014 exit date of this complaint survey, to begin this process. Thus, the QA/PI Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the E level.", "filedate": "2017-02-01"}
{"rowid": 7659, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2014-02-20", "deficiency_tag": 323, "scope_severity": "K", "complaint": 1, "standard": 0, "eventid": "LWSQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, EMS Prehospital Care Report Summary review, hospital Record of Admission report review, hospital ER Triage Record review, hospital ED Nursing Record review, nursing facility Follow-Up Report review, Weather.com report review, MapQuest.com report review, hospital staff interview, and nursing facility staff interview, the facility failed to ensure that the WanderGuard alarm system, utilized by the facility to alert staff of attempts by residents having wandering/elopement behavior to exit the facility, included alarm coverage for a set of unlocked double doors contained in one (1) first floor corridor which was accessible to Unit B and Unit C residents, and which exited the nursing facility into the adjoining hospital facility. The facility's failure to ensure WanderGuard alarm protection on these unlocked doors located in this corridor leading from the nursing facility into the hospital thus allowed this corridor to serve as a route of elopement for one (1) resident (#1) who utilized a WanderGuard bracelet for wandering/exit-seeking behavior and eloped through these unlocked/unalarmed doors, and as a potential route of elopement for four (4) additional residents (#5, #11, #12, and #14) on the survey sample with known elopement/wandering behavior, all of whom utilized WanderGuard bracelets and had access to this unsecured nursing home/hospital corridor, on the total survey sample of fourteen (14) residents. Resident #1 accessed this unsecured corridor on 02/09/2014, exited the nursing facility through this corridor via these unalarmed and unlocked doors, and eloped through the adjoining hospital. Resident #1 then traveled along a street for a distance of approximately one-half mile, fell hitting his/her head on the pavement, was taken to the hospital Emergency Department (ED), and was found to have sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via the set of unlocked, unalarmed, and unsecured doors located within the corridor which lead from the nursing facility to the adjoining hospital) continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During this survey, it was determined that the facility failed to ensure supervision of Resident #1, who had a history of [REDACTED]. On 02/09/2014, Resident #1 eloped from the facility, traveled a distance of approximately one-half mile, and sustained a fall resulting in facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. On 02/05/2014, prior to this elopement incident of 02/09/2014, Resident #1 had been transferred to Unit B located on the nursing facility's first floor after having been admitted to Unit E located on the second floor upon original facility admission. However, a Unit B corridor directly connected with, and lead into, a corridor of the hospital which adjoined the nursing facility, and double doors within this corridor were not equipped with a WanderGuard alarm and were not locked. During an interview with the Administrator conducted on 02/14/2014 at 11:50 a.m., when questioned about Resident #1's 02/09/2014 nursing facility elopement, the Administrator acknowledged that Resident #1's Unit B room had been located in close proximity to the unlocked corridor doors which were located in the corridor leading into the hospital and which did not have a WanderGuard alarm. The Administrator stated it was thought that Resident #1 had passed through the unalarmed corridor double doors into the hospital and exited through the front main entrance/exit doors of the hospital. In addition to Resident #1, four (4) more sampled residents (#5, #11, #12, and #14) who had cognitive impairment and utilized WanderGuard bracelets for known elopement/wandering/exit-seeking behavior, also resided either on Unit B or Unit C, both of which allowed direct access to this set of unlocked, unalarmed corridor doors which lead into the hospital. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of E while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of wandering/elopement. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: 1. Record review for Resident #1 revealed a 5-day PPS Minimum Data Set (MDS) Assessment having an Assessment Reference Date of 02/06/2014 which documented a facility Entry Date of 01/30/2014. Section I - Active [DIAGNOSES REDACTED].#1 had [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident #1 had a Brief Interview for Mental Status (BIMS) Summary Score of 06, indicating that the resident had severe impairment in cognition. Section G - Functional Status indicated that Resident #1 was independent with walking, and Section E - Behavior documented that the resident had exhibited wandering behavior 1 to 3 days during the look-back period, and that this wandering placed the resident at significant risk of getting to a potentially dangerous place (e.g., outside of the facility). Review of Resident #1's admission physician's orders [REDACTED]. A Physician's Interim Orders form dated 01/31/2014 specified that Resident #1 was to wear a WanderGuard bracelet at all times. The 01/30/2014 admission physician's orders [REDACTED].#1 referenced above also documented that upon facility admission, Resident #1 was admitted to a room on Unit E (one of the facility's second floor units utilized for the placement of residents at risk for elopement). However, a Nurse's Notes (NN) entry of 02/05/2014 at 4:40 p.m. documented that Resident #1 had been transferred to Unit B (a first floor, ground-level unit) per the family's request. A NN entry of 02/06/2014 of the 7:00 a.m.-7:00 p.m. shift for Resident #1 documented that the resident was alert but with confusion, and that the resident had been pacing in the hall and going into other residents' rooms. This NN also documented that Resident #1 had approached the C Hall doors twice that shift, and that staff had to redirect the resident. A NN entry of 02/07/2014 of the 7:00 p.m.-7:00 a.m. shift for Resident #1 documented that the resident had been walking up and down the hall, and a twenty-four hour summary assessment sheet of 02/07/2014 for Resident #1 documented that the resident had exhibited wandering behavior on both the day and night shifts. A NN entry of 02/08/2014 of the 7:00 a.m.-7:00 p.m. shift for Resident #1 documented that the resident remained confused, was looking to go home, and stating that someone was coming to get her. This NN also documented that Resident #1's family would visit, but that the resident would wander after the family left. A twenty-four hour shift summary assessment of 02/08/2014 for Resident #1 documented that the resident had exhibited wandering behavior on the day shift of that date. A NN entry of 02/09/2014 of the 7:00 a.m.-7:00 p.m. shift for Resident #1 documented that the resident continued to show confusion and was following staff around from room-to-room. This NN documented that Resident #1 was walking up and down the hallways, and that staff would redirect him/her as he/she got to the end of the hallways. This NN also documented that Resident #1 had stated Which way is the way out? I need to get home. The NN documented that at around 3:45 p.m. on 02/09/2014, Resident #1 had been given drawing material and Crayons by Licensed Practical Nurse (LPN) AA and seated in the Day Room for an activity, and that moments later, a certified nursing assistant was noted assisting Resident #1 with the activity while seated at the table in the Day Room. However, a NN entry of 02/09/2014, timed at 5:00 p.m., for Resident #1 documented that the nurse received a telephone call from a family member of Resident #1 to inform the nurse that the resident had been found at the roadside, and in close proximity to a local lake, by a previous neighbor, who had noted injuries and called Emergency Medical Service (EMS) 911. The family member informed the nurse that Resident #1 was being taken to the hospital emergency room . In this NN, the nurse referenced the resident's use of a WanderGuard bracelet and indicated that it was unknown how the resident had eloped from the building. A NN entry of 02/09/2014, timed at 5:10 p.m., for Resident #1 documented that the nurse copied the necessary paperwork from the resident's nursing facility medical record and walked the paperwork over to the hospital (which was located adjacent to the nursing home and connected to the nursing home via a shared corridor). The nurse documented in this NN that once she arrived in the hospital ER, she was informed by an Emergency Medical Technician that he had cut a WanderGuard bracelet off of Resident #1. The EMS Prehospital Care Report Summary for Resident #1 documented that on 02/09/2014 at 4:40 p.m., EMS had received a telephone call regarding Resident #1. This EMS Report Summary documented that EMS staff responded and found Resident #1 to have walked from the nursing home to her prior private home and to have fallen face-first to the roadway. This EMS Summary documented a hematoma to Resident #1's forehead and a contusion with laceration to the nose, and further documented the resident's hospital transport. Review of the hospital Record of Admission for Resident #1 revealed a hospital admission date of [DATE], with an Admitting [DIAGNOSES REDACTED]. The ER Triage Record for Resident #1 documented, in the Assessment section, a Chief Complaint of the resident having fallen onto pavement and having hit his/her face and forehead approximately thirty (30) minutes prior to hospital arrival. The hospital ED Nursing Record (EDNR) for Resident #1 contained an entry, dated 02/09/2014 and timed at 5:10 p.m., which documented the resident's hospital ED nursing assessment. This EDNR entry documented that Resident #1 stated he/she had fallen and hit his/her face. The EDNR entry also documented that lacerations and abrasions were noted to Resident #1's face, bridge of the nose, and forehead. The EDNR entry further documented that Resident #1 had been found by a previous next-door neighbor, who had found the resident in the highway and on the ground outside of the resident's former home (the place of dwelling prior to nursing home admission). A subsequent EDNR entry for Resident #1, dated 02/09/2014 and timed at 8:20 p.m., documented that Resident #1 had been discharged to home from the hospital with family members. The ED Discharge Instructions form for Resident #1 documented an ED discharge date of [DATE], and documented ED [DIAGNOSES REDACTED]. During an interview with hospital ED Registered Nurse (RN) CC conducted on 02/18/2014 at 1:15 p.m., RN CC stated that he was working in the hospital's ED on the evening of 02/09/2014 when Resident #1 was brought to the ED for treatment of [REDACTED].#1 was wearing a long-sleeve shirt, jogging pants, and shoes when he/she presented at the hospital ED for treatment. Review of Weather.com revealed that the exterior environmental temperature for the Commerce, Georgia area, in which the nursing facility was located, registered at 59 degrees Fahrenheit on 02/09/2014 at 4:55 p.m., the date and approximate time of Resident #1's elopement from the facility. A facility Follow-Up Report (FR) dated 02/14/2014 referenced Resident #1 and documented the facility's investigation into Resident #1's 02/09/2014 elopement. This facility FR documented, in the Background section, that after Resident #1's original facility admission to Unit E (on the facility's second floor) where residents considered to be at risk for elopement were housed, the resident was moved from Unit E to Unit B (on the facility's first floor) on 02/05/2014 at the request of the resident's family. The Review of Initial Report section of this FR documented that on 02/09/2014 at 5:00 p.m., the facility received a telephone call from a family member informing facility staff that Resident #1 had left the facility. Further review of the FR revealed, in the Details of Investigation/Chronology of Events section, that at 3:45 p.m. on 02/09/2014, Resident #1 had been placed in the Day Room for an activity by LPN AA, and that Certified Nursing Assistant (CNA) BB had assisted Resident #1 in the Day Room from 4:00 p.m. until 4:05 p.m. CNA BB then left Resident #1 to assist other residents in preparing for dinner. This FR documented that sometime after 4:00 p.m. on 02/09/2014, Resident #1 left the Day Room and headed toward his/her former home. The FR documented that Resident#1 almost reached his/her former home, located 0.83 mile from the nursing facility, but sustained a fall prior to arriving. This FR documented that at 5:00 p.m., the facility received a telephone call from the family of Resident #1 informing facility staff of the resident's elopement and hospital transfer, and that upon Resident #1's arrival at the hospital after the elopement and fall, the resident was treated for [REDACTED]. This FR documented that later in the evening of 02/09/2014 at 8:20 p.m., Resident #1 left the hospital in the company of a family member and went home, not returning to the nursing facility. The Summary/Conclusion section of the FR, which chronicled the facility's investigation into Resident #1's elopement and fall with injuries on 02/09/2014 as referenced above, documented the facility had concluded that it was unknown how Resident #1 was able to elope from the facility undetected. This section of the FR further documented that it was believed that Resident #1 could have eloped through the set of double doors located in a corridor which went past the facility's kitchen and eventually lead to the adjoining hospital's main entrance/exit. During an observation conducted on 02/14/2014 at 12:30 p.m., accompanied by the facility's Administrator, a tour of the entire facility was conducted, to include the former Unit B room where Resident #1 had resided prior to the 02/09/2014 elopement. Resident #1's former room was observed to be at the end of the B Hall of Unit B. Approximately ten (10) feet from Resident #1's former room, and at the end of the B Hall of Unit B, a corridor turned to the right. After the right turn, this corridor extended a distance of approximately twenty (20) feet, at which point a set of double doors was encountered. These double doors were observed to be unalarmed, and were observed to open after activation via a wall-mounted button located on an adjacent wall and in close proximity to the double doors. These doors were not locked, and opened when the wall-mounted button was pressed. Upon passing through this set of unlocked double doors, the corridor continued for a distance of approximately twenty (20) feet, then turned right and continued for a distance of approximately another eighty (80) feet, passing through the adjoining hospital facility and exiting through the hospital's main entrance/exit doors, which were unlocked, unalarmed, and located at the front of the hospital. Upon exit through the hospital's front main entrance/exit doors, the hospital's front parking lot was located directly in front of the entrance/exit doors. The hospital parking lot then adjoined a two lane street which ran in front of the hospital and nursing facility buildings. During an interview with the Administrator conducted on 02/14/2014 at 11:50 a.m., the Administrator stated that Resident #1's former home, where the resident had resided prior to nursing facility admission, was located on the street which was adjacent to the hospital parking lot, at a distance of 0.83 mile (Source: MapQuest.com) from the nursing facility/hospital. The Administrator further stated that it was on this street, and in close proximity to Resident #1's former home, that Resident #1 was found to have fallen and sustained injuries after having eloped from the nursing facility on 02/09/2014. During the 02/14/2014, 12:30 p.m. nursing facility tour referenced above, observations made of the facility's first floor units (both of Unit B where Resident #1 had resided and Unit C) revealed a WanderGuard alarm on the entrance/exit doors located at the nursing facility's main entrance at the front of the facility. Additionally, observation in Unit C's front corridor revealed WanderGuard-alarmed doors located at the terminal end of Unit C's front corridor which opened into a corridor of the adjoining hospital facility. However, as referenced above, the double doors which were located in the corridor leading off of Unit B and continuing into the adjoining hospital facility, and through which Resident #1 exited Unit B and eloped on 02/09/2014, did not have a WanderGuard alarm and were not locked. During this observation, it was noted that Unit B was contiguous to Unit C, allowing residents of both Unit B and Unit C to move freely between units, and thus allowing residents of both units access to the Unit B corridor, ultimately leading to the hospital, in which the unlocked double doors were not equipped with a WanderGuard alarm. During the 02/14/2014, 11:50 a.m. interview with the Administrator referenced above, the Administrator was questioned regarding Resident #1's 02/09/2014 nursing facility elopement. During this interview, the Administrator stated that Resident #1's room, located on the B Hall of Unit B, was located in close proximity to the set of corridor doors which were not locked, which did not have a WanderGuard alarm, and which were located in the corridor leading past the kitchen area and then into the hospital. The Administrator stated that on 02/09/2014 at approximately 4:00 p.m., Resident #1 had been observed by staff while participating in an activity in the Day Room. The Administrator stated that it was thought that Resident #1 left the Day Room shortly after 4:00 p.m. to return to his/her room, but then continued to walk down the B Hall corridor, passed through the unalarmed corridor double doors, entered into the hospital corridor, and exited the hospital through the hospital's front main entrance/exit doors. The Administrator stated it was thought that Resident #1, upon exiting the hospital, walked across the front parking lot, went to the street in front of the hospital, made a left onto the street, walked approximately one-half (1/2) mile, and was found by a former neighbor to be lying face down in a ditch by the street. The Administrator acknowledged that Resident #1's prior home was located approximately 0.83 mile from the nursing facility/hospital on the street where he/she was found to have fallen after the 02/09/2014 elopement from the nursing facility. The Administrator further stated that after Resident #1's elopement, all facility doors having WanderGuard alarms were checked and were found to be functioning properly, but acknowledged that the corridor doors through which it was though Resident #1 had passed (and then eloped through the hospital's main entrance/exit) did not have a WanderGuard alarm. During an interview with the DON conducted on 02/14/2014 at 12:48 p.m., the DON stated that on 02/09/2014, after Resident #1 eloped from the facility, the Maintenance Supervisor had tested all existing WanderGuard-alarmed exit doors and had found them to be working properly. However, the DON stated that Resident #1's former room was located close to the end of the B Unit corridor and close to the set of unalarmed corridor doors at the end of the corridor. The DON stated that, based on the Maintenance Supervisor's finding that all existing WanderGuard-alarmed doors were functioning correctly on 02/09/2014, the facility determined that Resident #1 had walked down the Unit B corridor upon which his/her room was located, but then the unalarmed corridor doors allowed the resident to continue walking down the corridor out of the nursing facility and to exit out the front doors of the hospital. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #1 having severe cognitive impairment and a known history wandering behavior requiring the use of a WanderGuard bracelet, despite Resident #1 being observed on multiple occasions to continue exhibiting both wandering behavior and exit-seeking behavior, the facility transferred Resident #1 on 02/05/2014 from Unit E (a second floor unit for which the exit was WanderGuard alarm protected) to Unit B (a first floor unit which allowed access to a set of unsecured, unlocked corridor doors which did not have a WanderGuard alarm and which lead to the hospital.) Resident #1 then exited through the unalarmed, unlocked corridor double doors while wearing a WanderGuard bracelet but without the knowledge of nursing facility staff, gained access to the hospital corridor, exited the hospital through the hospital's front entrance/exit doors, and eloped from the facility. The facility thus failed to ensure supervision of Resident #1 related to his/her risk for elopement/wandering, via the use of the WanderGuard bracelet as ordered by the physician, by failing to ensure the placement of a WanderGuard alarm on the unlocked corridor doors contained within the corridor which exited off of Unit B where Resident #1 resided, allowing the resident to exit through these doors undetected by staff and to elope. After Resident #1 eloped, he/she then traveled approximately one-half (1/2) mile toward his/her former home, fell , and sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. In addition to Resident #1 referenced above, four (4) additional sampled residents (#5, #11, #12, and #14) utilized WanderGuard bracelets for elopement and/or wandering behaviors and resided on either Unit B or Unit C of the facility's first floor. As documented in the 02/14/2014, 12:30 p.m. observation of Unit B and Unit C referenced above, these units were contiguous, therefore allowing Residents #5, #11, #12, and #14 to move freely between these units. However, as also documented in the 02/14/2014, 12:30 p.m. Unit B and Unit C observation referenced above, the unlocked double doors located in the facility corridor which lead off of Unit B, into the adjoining hospital facility, and ultimately allowing exit through the hospital's main front entrance/exit doors, were neither locked nor WanderGuard alarm-equipped. This placed Residents #5, #11, #12, and #14 (who all had wandering and/or elopement behaviors requiring WanderGuard bracelet use and who all had access to these unlocked/unalarmed corridor doors) at risk for elopement, as evidenced by the following: 2. Record review for Resident #12 revealed a Quarterly MDS having an Assessment Referenced Date of 11/11/2013 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #12 had a BIMS Summary Score of 7, indicating that the resident had severe cognitive impairment. Section G - Functional Status documented that Resident #12 utilized a walker and wheelchair as mobility devices, and Section J - Health Conditions documented that the resident had a history of [REDACTED].#12's Care Plan identified that he/she resided on Unit B, and that he/she had a history of [REDACTED]. An Interdisciplinary Progress Notes (IPN) entry of 02/14/14 at 2:00 p.m. for Resident #12 documented that the resident was rolling himself/herself in the wheelchair, going to the C Hall and trying to go home. However, the 02/14/2014, 12:30 p.m. observation referenced above revealed that, even though Resident #12 resided on Unit B and required a WanderGuard bracelet, the resident had access to the double doors, which were neither locked nor WanderGuard alarm protected, located within the corridor exiting Unit B and then exiting through the adjoining hospital's main front entrance/exit doors. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #12 (who resided on Unit B) having severe cognitive impairment, despite the resident having been assessed to have a history of wandering behavior and continuing to exhibit exit-seeking behavior thereby requiring the use of a WanderGuard bracelet, and despite the resident being ambulatory via wheelchair and walker, the facility failed to ensure that the WanderGuard system, intended to prevent resident elopement, included a WanderGuard alarm on the unlocked double doors in the nursing facility corridor which exited Unit B (upon which Resident #12 resided) and lead into an unsecured corridor in the hospital. The facility thus failed to ensure adequate supervision, via the WanderGuard bracelet, for Resident #12, who was at risk for wandering/elopement and who required the use of the WanderGuard bracelet for this risk. 3. Record review for Resident #14 revealed a Quarterly MDS assessment having an Assessment Reference Date of 01/06/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns documented that Resident #14 had a BIMS Summary Score of 99, indicating that the resident had severe cognitive impairment, and documented that the resident had both short-term and long-term memory problems. Section G - Functional Status documented that Resident #14 required only supervision/limited assistance with locomotion, and that the resident utilized a wheelchair as a mobility device. Resident #14's Care Plan identified the resident to be at risk for elopement, and specified the use of a WanderGuard bracelet. An Interdisciplinary Progress Notes (IPN) entry of 02/08/2014 at 11:00 a.m. for Resident #14 documented that the resident resided on Unit C (located on the facility's first floor and adjacent to Unit B), and that the resident was noted to be following other residents into their rooms, requiring redirection. A later IPN of 02/08/2014 at 3:00 p.m. documented that Resident #14 continued going into other residents' rooms, and that Resident #14 was following a resident down the hallway. An IPN of 02/13/2014 at 2:30 p.m. for Resident #14 documented that Resident #14 had again gone into another resident's room. However, the 02/14/2014, 12:30 p.m. observation referenced above revealed that, even though Resident #14 required the use of a WanderGuard bracelet for a risk of elopement and resided on Unit C, the resident also had access to Unit B and thus had access to the double doors, which were neither locked nor WanderGuard alarm protected, located within the corridor which exited Unit B and then exited the adjoining hospital's main front entrance/exit doors. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #14 (who resided on Unit C) having severe cognitive impairment and having been assessed to be at risk for elopement requiring the use of a WanderGuard bracelet, and despite the resident being ambulatory via a wheelchair and continuing to exhibit wandering behavior, the facility failed to ensure that the WanderGuard alert system, intended to prevent resident elopement, included the placement of a WanderGuard alarm on the set of unlocked double doors in the nursing facility corridor which exited Unit B (to which Resident #14 had access) and lead into a corridor in the hospital adjacent to the nursing facility. The facility thus failed to ensure adequate supervision, via the WanderGuard bracelet, for Resident #14 who was at risk for elopement and who required the use of the WanderGuard bracelet for this risk. 4. Record review for Resident #5 revealed an Annual MDS assessment having an Assessment Reference Date of 11/19/2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented that Resident #5 had a BIMS Summary Score of 12, indicating that the resident had moderate cognitive impairment. Section G - Functional Status documented that Resident #5 utilized a walker and a wheelchair as mobility devices, and required the limited assistance with walking in the room and in the corridor of his/her unit, but was totally dependent on staff for locomotion off of the unit. Resident #5's Care Plan identified that the resident had the potential for elopement, and that the resident required the use of a WanderGuard bracelet. Further record review for Resident #5 revealed a NN entry of 11/17/2013 for the 7:00 a.m.-7:00 p.m. shift which documented that the resident resided on Unit B, and documented that the resident propelled himself/herself utilizing a wheelchair. However, the 02/14/2014, 12:30 p.m. observation referenced above revealed that, even though Resident #5 resided on Unit B and required a WanderGuard bracelet for the risk of elopement, the resident had access to the double doors which were not locked or WanderGuard alarm equipped, and were located in the corridor which exited Unit B and then exited through the hospital's front entrance/exit. Based on the above, despite the facility's system for supervision of residents at risk of wandering/elopement involving the use of WanderGuard bracelets, despite Resident #5 (who resided on Unit B) having cognitive impairment and having been assessed to be at risk for elopement and requiring the use of a WanderGuard bracelet, the facility failed to ensure that the WanderGuard alert system, intended to prevent resident elopement, included a WanderGuard alarm on the unlocked double doors in the corridor which exited Unit B and lead into a corridor in the hospital adjacent to the nursing facility.", "filedate": "2017-02-01"}
{"rowid": 7660, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2014-02-20", "deficiency_tag": 520, "scope_severity": "K", "complaint": 1, "standard": 0, "eventid": "LWSQ11", "inspection_text": "Based on observation, record review, and staff interview, the facility failed to ensure oversight by, and the involvement of, the Quality Assessment/Performance Improvement (QA/PI) Committee in the formulation and implementation of a corrective action plan developed in response to resident elopement. This corrective action plan was developed regarding the elopement of one (1) resident (#1) who resided on Unit B, had wandering/elopement behavior, and utilized a WanderGuard bracelet, of five (5) sampled Unit B and Unit C residents (#1, #5, #11, #12, and #14) with known elopement/wandering behavior who utilized WanderGuard bracelets, on the total survey sample of fourteen (14) residents. Resident #1, who utilized a WanderGuard bracelet to address wandering behavior and resided on Unit B, eloped through unlocked double doors which had no WanderGuard alarm and which were located in a corridor leading from facility Unit B into the adjoining hospital. Facility administrative staff developed a corrective action plan in response to Resident #1's elopement to address this failure of the WanderGuard alert system to protect Resident #1, and the additional residents of Units B and C who were at risk for elopement/wandering, from eloping through these unlocked and unalarmed corridor doors. However, this corrective action plan was developed and implemented prior to QA/PI Committee review, analysis and evaluation. This resulted in a situation in which the facility's non-compliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the immediate jeopardy on February 18, 2014 at 9:30 a.m. The non-compliance related to the immediate jeopardy was identified to have existed on February 9, 2014 (the date Resident #1 eloped from the facility via the set of unlocked, unalarmed, and unsecured doors located within the corridor which lead from the nursing facility to the adjoining hospital) continued through February 18, 2014, and was removed on February 19, 2014. The facility implemented a credible allegation of jeopardy removal related to the immediate jeopardy on February 18, 2014. During an interview with the Administrator conducted on 02/14/2014 at 11:50 a.m., the Administrator acknowledged Resident #1's 02/09/2014 nursing facility elopement, and that a plan of action had been developed by facility management staff in response to the resident's elopement. However, the Administrator further acknowledged that at the time of this 02/14/2014 interview, the QA/PI Committee had not met to review and analyze this plan of action which had been developed by facility management staff. An allegation of jeopardy removal was received on February 19, 2014. Based on the corrective plans which had been developed and implemented by the facility, the immediacy of the deficient practice was determined to have been removed on February 19, 2014, and the facility remained out of compliance at a lower scope and severity of E while the facility completed a process which involved the retraining, via staff in-service, of available nursing staff related to procedural revisions made to ensure adequate supervision for residents at risk of wandering/elopement, but continued to provide in-service training to staff who were initially unavailable for training, as they reported to work. In-service materials and records were reviewed. Interviews were conducted with staff to ensure they were knowledgeable about the monitoring of residents requiring supervision related to the risk of wandering/elopement. Observations were made to assess staffs' performance of care and supervision of these residents. Findings include: Cross refer to F323. Based on observation, clinical record review, and staff interview, the facility failed to ensure that the WanderGuard alarm system included alarm coverage for unlocked double doors located in a first floor corridor which was accessible to residents having elopement/wandering behavior of Unit B and Unit C and which exited the nursing facility into the adjoining hospital. The failure allowed this unlocked and unsecured corridor to serve as a route of elopement, or potential route of elopement, for five (5) residents who utilized WanderGuard bracelets for elopement/wandering behavior (#1, #5, #11, #12, and #14), on the survey sample of fourteen (14) residents. Resident #1 exited the nursing facility through this corridor on 02/09/2014, eloped through the adjoining hospital, traveled along a street for a distance of approximately one-half mile, then fell , was transferred to the hospital, and had sustained facial abrasions, a nasal laceration requiring sutures, a nasal fracture, and a fractured right knee cap. An interview was conducted with the Administrator and DON on 02/20/2014 at 11:30 a.m. related to the facility's QA/PI Committee. During this interview, the Administrator was questioned regarding the QA/PI Committee's involvement in the oversight and evaluation of the facility's system for monitoring residents at risk for elopement/wandering, and of the Committee's involvement in the formulation of corrective actions which were developed and implemented as a result of Resident #1's 02/09/2014 elopement. The Administrator presented a written response to the questions posed during this 02/20/2014, 11:30 a.m. interview. In this written response, the Administrator documented that, prior to the elopement incident of 02/09/2014 involving Resident #1, the WanderGuard system had not been presented to the QA/PI Committee as it had not been identified as an issue that needed to be addressed. The Administrator documented that on the night of 02/09/2014, after Resident #1 eloped, the Administrator, DON, and Director of Maintenance met and developed a corrective action plan. However, the Administrator documented that there had been no meeting of the QA/PI Committee related to the 02/09/2014 elopement of Resident #1 until 02/18/2014, and acknowledged that it was not until that date (some nine (9) days after the incident involving Resident #1's elopement and injury) that the QA/PI Committee had conducted an analysis of the elopement of Resident #1, and had reviewed and evaluated the corrective actions, which included procedural changes and staff in-service training, which had been developed and put into place by the Administrator, DON, and Director of Maintenance. No evidence was presented by the facility to indicate that the QA/PI Committee had been involved in the formulation of the corrective action plan, developed and put into place by management staff as a result of the 02/09/2014 elopement of Resident #1, to evaluate the effectiveness of the corrective actions in assuring the supervision of residents at risk for elopement. Instead, this corrective action plan was developed and implemented in the absence of input by the QA/PI Committee, and without oversight by the Committee, prior to plan implementation. By the time the QA/PI Committee met on 02/18/2014 to review the plan of action, originally developed on 02/09/2014 by facility management staff and which involved procedural modifications related to the facility's WanderGuard alert system, 116 of the facility's 118 employees (as documented in the facility's credible allegation of jeopardy removal) had already received inservice training regarding these procedural changes. The immediate jeopardy was determined to have been removed on February 19, 2014, at which time the facility had presented and implemented a credible allegation of jeopardy removal with the following interventions: A. On February 9, 2014, after learning of Resident #1's elopement, the facility conducted a full resident audit to assure the presence of all residents. B. On February 9, 2014, all doors exiting the nursing facility were checked to ensure the proper working order of the WanderGuard alarm system. All existing WanderGuard alarms were functioning properly. C. On February 9, 2014, a procedure was put into place by which a facility employee was placed at the doorway, located in the corridor leading from the nursing facility to the hospital, which was not equipped with a WanderGuard alarm. A scheduled was developed reflecting specific employees who were assigned to be in place at the unalarmed doorway, at specific times and continuously around the clock, until a WanderGuard alarm was installed on the doorway. D. On February 9, 2014, chart audits for all current facility residents were conducted to ensure that all residents who demonstrated a potential for elopement had been accurately identified by the facility. During these chart audits, no new residents were identified to have the potential for elopement. E. On February 9, 2014, Care Plan reviews were conducted for residents assessed to be at risk for elopement to ensure that a comprehensive approach to address this risk was in place. During these Care Plan reviews, no problems were identified. F. On February 9, 2014, in addition to daily WanderGuard bracelet checks completed by the Activities Director which were in place prior to Resident #1's elopement, the facility implemented audits of the door alarms through the preventative maintenance program. The door alarms would be checked weekly, on each Tuesday, by the Maintenance Director, and these door alarm checks would be documented via computer data entry. The door alarm test would include a check of the power indicator light to ensure proper function, and also a check for battery condition. A sensor button was to be used to test each door alarm, with the alarm to sound when within six feet of an alarmed doorway. If a door alarm did not initially sound, the test was to be repeated with a different sensor button. Any deviation from full working order found during these weekly door alarm checks would be reported to the Administrator for immediate correction. The Administrator or DON would monitor the results of these weekly door alarm audits, conducted by the Maintenance Director, by reviewing the computer data entered as a result of the door alarm checks weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter. The results of these supervisory audits will be submitted to the Quality Assessment/Performance Improvement (QA/PI) Committee for their review. G. On February 9, 2014, the facility contacted the Medical Director to inform him of the elopement of Resident #1. Additionally, a meeting which consisted of some members of the QA/PI Committee, including the Administrator, DON, and Director of Maintenance, was held to review the elopement event and the actions which had been taken by the facility, and to identify any additional actions that were needed. H. On February 15, 2014, the corridor doorway, which lead from the nursing facility to the hospital and which had previously lacked a WanderGuard alarm, was equipped with a WanderGuard alarm. I. On February 18, 2014, the facility continued to provide staff in-service training to facility staff, including licensed nurses, CNAs, and maintenance/housekeeping staff. This in-service training served to both reinforce current facility protocols involving the routine monitoring of residents having WanderGuard bracelet devices and also to provide staff training on newly-implemented protocols related to the facility's WanderGuard alarm system. As of February 18, 2014, 116 of the facility's total 118 employees had received this in-service training. The two (2) remaining staff members, who were on Family and Medical Leave Act leave at the time this in-service training was provided, will received the training upon their return to work. J. On February 18, 2014, the QA/PI Committee met to review the elopement event involving Resident #1, to review the actions taken by the facility as of that date, and to review the monitoring systems put into place as a result of the elopement. The QA/PI Committee will review the results of WanderGuard bracelet monitoring and door alarm audits weekly for four (4) weeks, then monthly for three (3) months, then quarterly thereafter to ensure ongoing compliance with the systemic measures implemented to correct the identified issue and prevent recurrence. The information will be analyzed by the QA/PI Committee, and subsequent plans of correction will be developed and implemented as needed. This will be an ongoing process. Based on these corrective actions which had been developed and implemented by the facility as outlined above, the immediacy of the deficient practice was removed on February 19, 2014. However, the effectiveness of the corrective action plans could not be fully assessed to ensure ongoing application and completion. On February 9, 2014, the facility implemented a weekly audit of WanderGuard door alarms to be accomplished through the preventative maintenance program by the Maintenance Director. These weekly WanderGuard door alarm audits would check for the proper function of all facility WanderGuard door alarms, and were to be documented via computer data entry. However, these weekly WanderGuard door alarm audits had been initiated only on February 9, 2014, and had occurred only twice prior to the February 20, 2014 exit date of this complaint survey. Therefore, ongoing staff compliance with this newly implemented procedure involving routine, scheduled WanderGuard door alarm monitoring could not be entirely assessed at the time of survey completion, and will thus need future evaluation. Additionally, by February 18, 2014, the facility had completed in-service training for 116 of its 118 facility employees, to include licensed nurses, CNAs, and maintenance/housekeeping staff, regarding both existing and newly-implemented protocols involving the monitoring of residents with WanderGuard bracelets and the WanderGuard alarm system. However, two (2) remaining staff members, who were on leave and had been unavailable for training, will need to receive this training upon returning to work, and this training will thus need future evaluation. Additionally, the QA/PI Committee was to include the review the results of WanderGuard bracelet monitoring and door alarm audits in future meetings, but the Committee had met on On February 18, 2014, only two (2) days prior to the February 20, 2014 exit date of this complaint survey, to begin this process. Thus, the QA/PI Committee's ongoing process of facility procedural oversight could not be evaluated at the time of survey completion. Therefore, the non-compliance continues, but the scope and severity is reduced to the E level.", "filedate": "2017-02-01"}
{"rowid": 7781, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2012-03-22", "deficiency_tag": 166, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "7S9T11", "inspection_text": "Based on record review, family, resident and staff interviews, the facility failed to make a prompt effort to address grievances related to missing personal property for three (3) residents (D, Q and R). The sample size was forty-three (43) residents. Findings include: On 3/19/12 at 12:20 p.m., a family member of resident Q stated that missing personal property was an ongoing problem at the facility. They stated that the resident was currently missing pants and jackets. They added that they see resident's clothing on the wrong resident. On 3/20/12 at 2:20 p.m., resident R stated there had been an ongoing problem with missing clothing or that it took a long time to get clothing back, and that they were currently missing pants. They added that they knew that some of their labeled clothes had been found in other resident's closets. Review of the Resident Council minutes revealed the following: October 2011: Two (2) residents reported missing clothing, and one (1) resident reported missing eyeglasses. November 2011: Four (4) residents reporting missing clothing December 2011: Noted the facility was addressing issues with clothes being mixed in with the linen. January 2012: Three (3) residents reported having socks that weren't theirs, and one (1) resident reported missing socks. February 2012: One (1) resident expressed there was a delay in getting clothing returned once it goes to the laundry. Two (2) residents reported missing clothing items. An internal e-mail dated 02/20/12 to the Social Services Director noted the facility had 81 pieces of resident clothing that was returned from the laundry service (outside the facility) due to resident's clothing being mixed into the linens. March 2012: Notation that the social worker would be available on 3/11/12, as she had acquired many lost items such as glasses and dentures. Two (2) residents reported missing clothing at this meeting. On 3/22/12 at 8:52 a.m., Social Services employee MM stated there had been an ongoing problem with missing laundry for some time. She said that for the past several years, facility linens were sent out to a laundry service, but that resident clothing was washed locally at their facility. She added that it depended on how items were bagged by the facility staff, and that if resident clothing was mixed in with facility laundry, it got sent to the linen service and if that happened, it took three (3) to four (4) weeks to get the items returned. Resident D was interviewed on 3/20/12 at 10:04 a.m. and stated she was missing two blankets. She stated she reported these items missing to facility staff. She also reported that a flannel sheet set she brought from home was missing from a previous, but recent admission in 2011. Review of the facility's Grievance Log revealed numerous reports from residents and families of missing items and clothing. Further review of documentation revealed that on 7/14/11 the resident had not received her clothing back from the laundry after three (3) weeks, This included three (3) shirts and pants, and two (2) sweaters. The grievance reported on 3/04/2012 involved a cream colored nightgown that had been missing for two (2)weeks. Laundry staff member ZZ was interviewed on 3/22/12 at 12:00 p.m. and stated resident clothing and other personal items get mixed in with the linens and are sent to an outside laundry service. She further stated this has been an ongoing problem.", "filedate": "2016-12-01"}
{"rowid": 7782, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2012-03-22", "deficiency_tag": 167, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "7S9T11", "inspection_text": "Based on observation, resident and staff interviews, the facility failed to post the availability of the State survey results. The facility census was 147, and the sample size was forty-three (43) residents. Findings include: On 3/20/12 at 2:20 p.m., resident R, who resided on Unit C, stated that they knew they had the option to review the State survey results, but did not know where they were located. At 2:50 p.m., a notebook containing the State inspection results were found on a table on a short hallway near an elevator on the main level (Units B and C) of the facility. No posting of the availability of these survey results were found on any of the five (5) nursing units on the three (3) floors of the facility. On 3/22/12 at 9:45 a.m., Social Services employee MM verified that there was no posting of availability of the State survey results anywhere in the facility.", "filedate": "2016-12-01"}
{"rowid": 7783, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2012-03-22", "deficiency_tag": 246, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "7S9T11", "inspection_text": "Based on observation and staff interview the facility failed to provide seating with appropriate seat height related to dining surfaces that encourages independence and comfort during meals for three (3) residents (#164, #12 and #31) from a sample of forty-three (43) residents. Findings include: Observation of the E Unit dining area on 3/19/12 at 1:15 p.m. revealed resident #164 was sitting in a low dining room chair at lunch; the resident had to lift their arms up and over the table to reach their food. On 3/21/12 at 1:20 p.m., residents #12 and # 31 were observed sitting in low dining room chairs at lunch; their chins were at the level of the top of the table. Resident #31 was having to raise her arm up and over the table to reach the items on the lunch tray. At 1:40 p.m., Licensed Practical Nurse E-Unit Manager verified this observation, and stated the table was too high and the chair was too low.", "filedate": "2016-12-01"}
{"rowid": 7784, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2012-03-22", "deficiency_tag": 252, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "7S9T11", "inspection_text": "Based on observation, family and staff interviews, the facility failed to provide a homelike dining environment on two (2) of five (5) nursing units (B and E). Findings include: On 3/19/12 at 12:24 p.m., a family member of resident Q stated that the E-Unit needed a day room that was more elder-friendly, such as one that contained rockers and sofas. The family member added that the facility used the dining room for activities, and it was the only place the residents could socialize. During observations in the E-Unit dining and activity room on 3/19/12 at 1:15 p.m. and 3/21/12 at 3:28 p.m., the following was noted: There was a large screen TV on the wall and a radio/CD player machine on a window ledge, but both were off. The blinds were lowered so that there was very little natural light coming in, and there were no curtains on the windows. The only furnishings in the room were six square institutional-appearing tables, and two large plastic semi-circular tables. Eight of eight wood-framed chairs were badly marred on the armrests and legs. On top of a soft drink vending machine was a suction machine, clearly visible inside a clear plastic bag. There were a few arts and crafts-type decorations on the wall, and two pieces of framed artwork near the corner of one wall. There was a brown-stained ceiling tile just inside the entrance to the room. On one wall there was a fixture covered with a metal shield that contained a soft blue light; a resident was noted to sit directly under this light during lunch observations on 3/19/12 and 3/21/12. The paint around the pipe encasing the electric cord for this light was peeling. There were multiple scuff marks on all four walls. On 3/22/12 at 9:57 a.m., Maintenance Director CC stated that the blue bulb light fixture in the dining room was a fly trap. He added that dining room chairs were not replaced unless they were broken. On 3/22/12 at 11:00 a.m., the Director of Nurses (DON) verified that the dining room on the E-Unit was institutional-like. She added that the chairs were mismatched and the furniture wasn't coordinated well. She stated the facility had thought about developing a fine dining experience, but there was nothing scheduled at this time, and she did not know of any plans to obtain additional furniture such as rocking chairs or sofas. Observation of the lunch service in the B-Unit dining room 3/19/2012 at 12:20 p.m. revealed a very spacious room with large picture windows on three sides. The picture window on the right of the entrance door was covered with a whitish film and streaks down the middle, and the right side of it had heavy cobwebs and a build-up of leaves on the outside. This was visible to all residents in the room. The tables were bare without any decoration. There were seven (7) chairs lined up along the walls that were mismatched. There was a small radio and TV at the far end of the room. Neither were playing during the meal. There were two (2)vending machines along the wall to the right of the entrance door and a large gray trash can. A tall orange ladder reaching almost to the ceiling was stored in the corner next to the trash can and the vending machines. This dining area was also observed on 3/21/12 at 8:30 a.m. and again at 12:30 p.m. There was no change in the conditions noted on 3/19/2012 except that the radio was playing music, but it was not audible throughout the entire room. The Director of Nursing (DON) was interviewed on 3/22/12 at 12:15 p.m. related to a home-like environment and agreed there were concerns. She also was not aware of the orange ladder was being stored next to the vending machines.", "filedate": "2016-12-01"}
{"rowid": 7785, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2012-03-22", "deficiency_tag": 253, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "7S9T11", "inspection_text": "Based on observation and staff interview the facility failed to provide a clean and well maintained environment on four (4) of five (5) Units, A,B,E, and D; in three (3) of four (4) dining rooms, A, B and E; two (2) of four (4) pantries, A and B Units; four (4) resident rooms, 303, 306, 311, and 314 on A-Unit and 259 and 261 on D-Unit. This involved sticky floors, broken and marred furniture, dirty windows, and stained and scuffed walls. Findings include: B-Unit dining room observations on 3/19/12 at 12:20 p.m. just prior to the lunch service and again on 3/20/12 at 12:30 p.m. revealed: 1. The floor was sticky and had visible dirt and grime. A large window on the right side of the room had a heavy build-up of cobwebs, debris, dirt and dried brown leaves all around the outside of the window. Fifteen (15) residents were in the dining room waiting to be served lunch. 2. Observations on 3/21/12 at 8:30 a.m. the floor remained sticky and dirty. The lower walls, painted blue under a chair rail of molding, had numerous white streaks going down the walls. These streaks were present around the parameter of the room. A tall gray trash can cover had dried red stains. Three (3) serving carts were observed along the left wall and the bottom shelf of two (2) had large dried coffee colored stains and a build-up of dirt and grime in the corners. The water fountain in the immediate left corner nearest the entrance had a heavy build-up of dust on the side vent. The dining room was observed again at 12:30 p.m. and the same concerns remained. 3. The Pantry adjacent to the B-Unit dining room was observed on 3/21/12 at 8:30 a.m. and 12:30 p.m. Floor tiles were missing in front of the refrigerator and there was a heavy build up of dirt in the corner of the floor by the refrigerator and also along the bottom grill of the refrigerator. On 3/22/12 at 11:45 a.m. a tour was conducted with Environmental Services Staff, CC, DD, and EE . Concerns were reviewed with them for the B-Unit dining room and the snack kitchen next to it. They agreed the floor felt sticky and stated the areas of concern needed to be addressed. A-Unit Observations on 3/19/12 at 2:06 p.m., 03/20/2012 08:05:50 a.m. and 3/21/12 at 11:10 a.m. revealed the following: 4. Room A303 had walls with peeling paint and multiple nail holes. There were scuffed marks on all lower walls. The ceiling fan vent in the bathroom was soiled with dust and lint. 5. The windows in the dining room were streaked with dirt and had strips of tape on the glass. The lower walls in the dining room were scuffed with black marks. 6. Observation on 3/21/12 at 1:32 p.m. and at 3:01 p.m. revealed there was black debris and stains in the cabinet drawer in the A-Unit pantry. 7. Room A306 had mats that were beside the A and B beds with rips and tears and were soiled with dirt, spills and stained. The pole that held the feeding pump for both the A and B bed had a crusted yellow substance on the foot of the poles. The lower walls in this room were also scuffed with multiple black marks. 8. Room A311 had mats by the bed A that had rips, tears and were soiled with dirt. Also one closet door had no paint, another closet door had areas of paint missing. The lower walls were scuffed with black marks and peeling paint. The ceiling fan vent in the bathroom was soiled with dust and lint. 9. Room A314 had a strong urine odor in the room and bathroom. The lower walls were scuffed with black marks 10. The ceiling vent near room A309 was rusted. 11. The lower walls in the hallway on A-Unit were scuffed with black marks and peeling paint. E-Unit observations on 3/20/12 at 8:30 a.m. and 3/21/12 at 8:16 a.m. revealed: 12. Room E-283B had floor mats by the bed that had rips and tears and soiled with dirt. The ceiling fan vent in the bathroom was filled with dust and lint. 13. Room 269: There were multiple scrapes on the wall at the head of the bed. There was a five-inch long hole in the wall just inside the hallway door on the left side above the baseboard. 14. Room 271: The baseboard had pulled away from the wall just outside the bathroom door, and the surrounding wall was chipped and marred. The vent of the air conditioning unit contained debris. 15. Room 275: The wall and bathroom door had long scrapes measuring 2.5 to 4 feet up from floor just inside the hallway door around to the middle of the wall across from the residents' beds. There was a hole in the wall approximately four (4) inches long under the handrail in the hall outside this room. 16. Room 278: The vinyl flooring at the entrance of the bathroom was curled. The shower curtain in the bathroom only extended 3/4 of the way to the floor, and most of the curtain was off the track. The baseboard had pulled away from the wall just inside the hall door on the right side. The floor fall mats were soiled, and one mat had a three (3) by two(2) inch tear at one end. 17. The foot platform of the mechanical lift in the hall was soiled, with debris on the upper end. This was verified on 03/22/12 at 11:35 a.m. by Licensed Practical Nurse (LPN) Unit Manager LL 18. In the Dining/Activity room, eight of eight wooden chairs had marred areas on the armrests and legs. There was a stained ceiling tile just inside and to the right after entering the room. There was a light fixture on the wall on the left side of the room that was covered by a metal shield and had a soft blue light; the paint around the pipe encasing the electric cord was peeling. There were multiple scuff marks on the lower part of the walls on all four sides of the room. The left armrest of one of the wood-framed chairs was broken. On 03/21/12 at 9:57 a.m., a walk-through was done of these environmental concerns with Facilities Management Manager 'CC;' Environmental Services Manager 'DD,' and Environmental Services Director 'EE,' who verified the above observations. Facilities Management Manager 'CC' stated they rotated where they painted every three months, but that there was no written schedule nor documentation of what had already been done. 19. The following observations were made of resident ambulation equipment on all four days of the survey on E-Unit. The Geri-chair used by resident #157 had a large crack on the right side panel and torn vinyl on the armrests and upper back cushion. The right side of seat cushion of the merry walker, used by resident #57, was taped with duct tape. The Geri-chair used by resident #99 had multiple tears in the vinyl on both armrests and the footrest. The Posey positioning cushion for the right arm had tears along the lower edge. The wheelchair used by resident !175 had torn foam padding on the left armrest that had almost totally come off the armrest. The padding on the right armrest had been wrapped with tape. The Merry Walker used by resident #164 had duct tape on the right side of the seat cushion the entire length of the seat from the front to the back. Half of the tape was ripped at the top end of the chair. Observations of the D-Unit revealed: 20. During a resident interview and observation conducted during Stage 1, on 3/19/12 at 11:50 a.m., with resident C revealed one chair in the room. The chair had pillows stacked on the seat of the chair. The resident stated the multiple pillows were on the seat of the chair because if you sit in the chair without them, the seat sinks deeply, making it uncomfortable and difficult to get up from the chair. The walls of the room were scrapped and gouged with paint missing in those areas from floor to approximately three (3) feet high. A portion of the baseboard was coming off in the corner near the bathroom door. There were two (2) over bed tables in the room with chips and cracks on the top surface. 21. Random observation on 3/20/12 at 11:00 a.m. revealed a resident drinking from the water fountain on the D-Unit. The water fountain drain had a heavy build up of dark debris and rust. 22. Observation on 3/22/12 at 10:00 a.m. revealed the walls across from the beds, in room 259, were heavily scrapped and gouged from the floor to approximately three (3) inches above the floor. 23. Observation on 3/22/12 at 10:05 a.m. of the hallway walls on D-Unit, between rooms 258 and 256 reveal a hole just above covebase which was three (3) inches long.", "filedate": "2016-12-01"}
{"rowid": 7786, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2012-03-22", "deficiency_tag": 280, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "7S9T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and observation it was determined that the facility failed to update and/ or revise the care plan for two (2) residents (# 156 and #167)) following each assessment from a sample of forty-three (43) residents. The facility failed to update a care plan regarding actual/ current needs for assistance with dinning for #156 and to address behaviors for another resident, #167. Findings included: 1. The care plan for resident # 156 indicated that she was unable to eat independently and needed assistance with nutritional intake. The care plan directed staff to cut her food into bite-sized pieces, provide verbal cues to encourage intake and maintain a low noise level in the dining room. The resident was observed at lunch on 3/21/12 between 12:45 a.m. and 1:15 p.m. The staff served her a sloppy joe sandwich on a bun, baked beans, salad and grapes. The sandwich was left whole, no verbal cueing from staff was observed, and a radio placed behind the resident was playing loud music. The music was audible from 35 feet away and the resident was seated 7 feet from the radio. The resident was observed to eat more than half of her food without the need for assistance and/or cueing. 2. Interview with Licensed Practical Nurse (LPN) GG on 3/20/12 at 2:15 p.m. revealed resident # 167 had behaviors of hitting out at staff and refusing care, particularlly in the early morning. LPN GG described this not a big problem because Certified Nursing Aides (CNA) have been told to leave the resident and return at a later time or have a different staff person provide care. Resident #167 was assessed on the quarterly Minimum Data Set ((MDS) dated [DATE] as having physical and verbal behaviors one (1) to three (3) times during the assessment process. Review of the Social Service, dated 3/05/12 revealed that the resident tried to hit another resident that had wandering behaviors. Review of the care plan dated 01/12/12 revealed that the resident was not care planned with interventions related to her behaviors. Interview with LPN HH on 3/20/12 at 3:15 p.m. revealed that although the resident triggered for the behaviors in the Care Area Assessment, the determination to care plan was only initiated on annual and significant change assessments. 2. Interview with Licensed Practical Nurse (LPN) GG on 3/20/12 at 2:15 p.m. revealed resident # 167 had behaviors of hitting out at staff and refusing care, particularlly in the early morning. LPN GG described this not a big problem because Certified Nursing Aides (CNA) have been told to leave the resident and return at a later time or have a different staff person provide care. Resident #167 was assessed on the quarterly Minimum Data Set ((MDS) dated [DATE] as having physical and verbal behaviors one (1) to three (3) times during the assessment process. Review of the Social Service, dated 3/05/12 revealed that the resident tried to hit another resident that had wandering behaviors. Review of the care plan dated 01/12/12 revealed that the resident was not care planned with interventions related to her behaviors. Interview with LPN HH on 3/20/12 at 3:15 p.m. revealed that although the resident triggered for the behaviors in the Care Area Assessment, the determination to care plan was only initiated on annual and significant change assessments.", "filedate": "2016-12-01"}
{"rowid": 7787, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2012-03-22", "deficiency_tag": 323, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "7S9T11", "inspection_text": "Based on observation, record review and staff interview, the facility failed to secure a chemical so that it was inaccessible to cognitively-impaired residents on one (1) of five (5) units (E-Unit). Findings include: On 03/22/12 at 11:08 a.m., the Patient (common) Bath on E-Unit was noted to be unlocked. Just inside the door on the sink at wheelchair-height was a half-full spray bottle of Virex 256, One-Step Disinfectant and Deodorant. In the hallway close to this common bath were two (2) residents who were able to walk without assistance; three (3) residents that could maneuver their merrywalkers without assistance; and one (1) resident who could self-propel their wheelchair. This was verified by Licensed Practical Nurse Unit Manager LL, who stated all of these residents had cognitive impairment. She added that the staff did not keep this door locked all the time, but that the Certified Nursing Assistants were supposed to lock up the chemicals when they were done using them. The Material Safety Data Sheet (MSDS) on Virex noted that it may be mildly irritating to eyes and skin, and may cause irritation and corrosive effects to nose, throat and respiratory tract if inhaled.", "filedate": "2016-12-01"}
{"rowid": 7788, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2012-03-22", "deficiency_tag": 332, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "7S9T11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure a medication error rate of 5% or less for four (4) residents, residents #80, #92, #159 and # 147. Fifty-six (56)opportunities were observed with four (4) medication errors for three (3) of six (6) nurses on four (4) of five (5) halls resulting in a medication error rate of 7.14%. Findings include: Observation of Licensed Practical Nurse (LPN) II on 3/21/12 at 8:25 a.m. on the C-Unit revealed: 1. Resident # 92 received one 81 milligram [MEDICATION NAME] coated extended release Aspirin. Review of the physician orders [REDACTED]. Interview with the nurse on 3/21/12 at 9:43 a.m. confirmed that she gave the [MEDICATION NAME] coated extended release Aspirin instead of the chewable. Interview with LPN KK, the C-Unit Manager on 3/21/2012 at 9:45 a.m. revealed that resident # 92 should have received the 81 milligram chewable aspirin as ordered. Observation of LPN JJ on 3/21/12 at 8:58 a.m. on the D-Unit revealed: 2. Resident # 159 was administered one (1) drop of Liquitears in each eye. Review of the physician orders [REDACTED]. Interview with LPN JJ on 3/21/12 at 9:25 a.m. revealed that she had given the Liquitears instead of the ordered [MEDICATION NAME]. Observation of LPN JJ on 3/21/12 at 9:20 a.m. on the B-Unit revealed: 3. Resident # 80 was handed [MEDICATION NAME] nasal spray to self administer. The resident did not blow their nose before using the nasal inhalation spray and gave herself the two inhalations in each nostril about 5 seconds apart. The only directions on the medication label was for 2 sprays each nostril every day for 4 weeks, with a prescribed date of 3/14/12. Review of the policy for nasal inhalations revealed that the resident was supposed to blow their nose gently before the nasal inhalation spray was administered and if the resident required more than one inhalation spray, the nurse should wait one minute between the nasal inhalations. Interview with the Director of Nurses (DON) on 3/21/2012 at 10:50 a.m. revealed that LPN JJ did not give the nasal inhalations correctly. She also stated that resident # 80 had not been assessed for self medication. Observation of LPN FF on Tuesday, 3/20/12 at 8:47 a.m. on E-Hall revealed: 4. Resident #147 was administered [MEDICATION NAME] seventeen (17) grams mixed in water. Review of the physician orders [REDACTED]. The MAR indicated [REDACTED]. The [MEDICATION NAME] was given ten (10) times between 3/01/12 and 3/20/12 the date of the medication pass observation. According to the physician orders, the [MEDICATION NAME] should have been admininstered only eight (8) times during the same time period. Interview with LPN FF on 3/20/12 at 9:02 a.m. revealed she had not noticed that the highlighted days, indicating to give the medication, did not reflect the physician order [REDACTED].", "filedate": "2016-12-01"}
{"rowid": 9828, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2010-11-04", "deficiency_tag": 156, "scope_severity": "B", "complaint": 0, "standard": 1, "eventid": "IGRP11", "inspection_text": "Based on record review and staff interview the facility failed to provide appropriate notification of Medicare non-coverage for three (3) residents (#21, #43 and #51) on a sample of thirty-one (31) residents. Findings include During an interview on 11/04/10 at 2:15 p.m. the Business Office Manager stated she called the responsible parties of residents #43, #51 and #21 and notified them of the resident's date to be discharged from skilled Medicare services and informed them of their right to have a demand bill submitted. She stated she then mailed the Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) (CMS form- ) to the responsible party. Review of the SNFABN for the resident's revealed there was no signature and no indication on the form as to the decision to submit a demand bill. Further review revealed these residents remained in the facility after they were discharged from skilled Medicare services. She stated she usually received the forms returned to the facility with a signature. She further stated she does not have documentation of the decision as to whether a demand bill was to be submitted. She does not provide the resident or the responsible party with the Notice of Medicare Provider Non-coverage (CMS form ). She stated she was not aware she had to issue the notice.", "filedate": "2015-05-01"}
{"rowid": 9829, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2010-11-04", "deficiency_tag": 279, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IGRP11", "inspection_text": "**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 that reflected the resident's individual needs and plan of care for one (1) resident, #106, from a sample of thirty-one (31). Findings include. Record review revealed resident #106 has [DIAGNOSES REDACTED]. Further review of the medical record also indicated that the resident received [MEDICAL TREATMENT] three times per week at a center outside the facility. The care plan dated 4/18/10 identified the resident as receiving [MEDICAL TREATMENT], however, there was no specific intervention that included care of the access site, potential infection control concerns or monitoring measures. Interview on 11/04/10 at 10:15 am with Licensed Practical Nurse \"AA\" revealed that the [MEDICAL TREATMENT] should have been monitored and should have been included in the care plan. She stated that when a resident returns from [MEDICAL TREATMENT], they were to have a [MEDICAL TREATMENT] communication checklist. This list included pre and post [MEDICAL TREATMENT] weight, any complication related to [MEDICAL TREATMENT] or the access site, insulin sliding scale before and after [MEDICAL TREATMENT], weights and blood sugar results, if done in the [MEDICAL TREATMENT] center. She stated that this communication form was not consistently used and a staff member calls once a week to get the pre and post [MEDICAL TREATMENT] weights.", "filedate": "2015-05-01"}
{"rowid": 9830, "facility_name": "NORTHRIDGE HEALTH AND REHABILITATION", "facility_id": 115714, "address": "100 MEDICAL CENTER DRIVE", "city": "COMMERCE", "state": "GA", "zip": 30529, "inspection_date": "2010-11-04", "deficiency_tag": 456, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "IGRP11", "inspection_text": "Based on observation and staff interview the facility failed to ensure that two (2) of two (2) walk-in freezers in the dietary department had door seals that were secure and prevented the build-up of frost and ice on the thresholds and floors of the freezers. Findings include: During the initial tour of the kitchen on 11/02/10 at 10:00 a.m. a build-up of frost was observed around the right side of the large walk-in freezer that held meats. On 11/04/10 at 10:10 am the same large walk-in freezer was observed to have a broken gasket/seal around the right door frame with a build up of frost and ice in that area. Interview at that time with the Dietary Manager revealed the gasket had a heat source in it that prevented the frost build-up but it is not functioning properly at the present time. The freezer that held the frozen vegetables and bread had a metal strip around the door area that had fallen off when the Dietary Manager opened the door on 11/04/10 at 10:15 a.m. There was frost build-up on the right side of the door and on the inside of the freezer door and handle. She stated that they had tried to repair the meat freezer but it continues to pull away from the door edge and you can see where foam filler has been sprayed into the area. The temperature of the meat freezer was observed to be 2 degrees Farenheit and the temperature in the vegetable and bread freezer was 9 degrees Farenheit. The facility had just received a food delivery by their purveyor. The Administrator was notified of the problem with the walk-in freezers on 11/04/10 at 11:00 a.m. On 11/05/10 at 8:45 a.m. observation of the meat freezer and the vegetable freezer revealed that there was no frost around the door but both thresholds had ice on them and the floor of both freezers had a thin coating of ice on them. This was confirmed with a dietary line supervisor.", "filedate": "2015-05-01"}
{"rowid": 4053, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2018-08-19", "deficiency_tag": 584, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "EQDC11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of the policy titled Enteral Nutrition Pump- Cleaning and Disinfection and staff interviews, the facility failed to maintain tube feeding poles in a clean and sanitary condition for nine of 17 resident (R) (#25, #3, #7, #76, #10, #9, #14, #15, and #178) that received enteral tube feeding, and failed to maintain clean and dust free hallway walls in one of two units (Unit 1). Findings include: 1. Observations of the tube feeding pole for R#25 on 8/17/18 at 12:00 p.m., on 8/18/18 at 8:40 a.m. and 11:30 a.m., and on 8/19/18 at 8:50 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 2. Observations of the tube feeding pole for R#3 on 8/17/18 at 12:45 p.m., on 8/18/18 at 8:30 a.m., 11:35 a.m. and 2:40 p.m., and on 8/19/18 at 8:40 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 3. Observations of the tube feeding pole for R#7 on 8/17/18 at 1:00 p.m., on 8/18/18 at 8:25 a.m., 11:40 a.m. and 2:36 p.m., and on 8/19/18 at 8:45 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 4. Observation of the tube feeding pole for R#76 on 8/17/18 at 1:15 p.m., on 8/18/18 at 9:05 a.m., 11:45 a.m. and 2:43 p.m., and on 8/19/18 at 8:30 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 5. Observations of the tube feeding pole for R#10 on 8/17/18 at 1:10 p.m., on 8/18/18 at 9:10 a.m., 11:50 a.m. and 2:40 a.m., and on 8/19/18 at 8:35 a.m. revealed dried, heavily splattered tube feeding on the base and wheels of the pole. 6. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for Resident (R)#9 in bed A had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/18 beginning at 10:50 a.m. revealed the tube feeding pole for R#9 in bed A had a large amount of dried, beige-colored substance in the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#9 in bed A had a moderate amount of dried, beige-colored substance on the base of the pole. There was a housekeeping log sheet titled, Camelia Unit Pole Accountability, on the back of the door of room [ROOM NUMBER] which documented the tube feeding pole for bed A was cleaned on 8/18/18 and 8/19/18, however, a moderate amount of dried, beige-colored substance remained on the base of the pole. 7. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for R#14 in bed B had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/18 beginning at 10:50 a.m. revealed the tube feeding pole for R#14 in bed B had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#14 in bed B had a moderate amount of dried, beige-colored substance on the base of the pole. There was no housekeeping log sheet available for R#14 in bed B. 8. Observation of room [ROOM NUMBER] on 8/17/18 beginning at 2:58 p.m. revealed the tube feeding pole for R#15 in bed C had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/18/19 beginning at 10:50 a.m. revealed the tube feeding pole for R#15 in bed C had a large amount of dried, beige-colored substance on the base of the pole. Observation of room [ROOM NUMBER] on 8/19/18 beginning at 9:56 a.m. revealed the tube feeding pole for R#15 in bed C had a moderate amount of dried, beige-colored substance on the base of the pole. There was no housekeeping log sheet available for R#15 in bed C. 9. Observations of the tube feeding pole for R#178 on 8/17/2018 at 11:00 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. Observations of the tube feeding pole for R#178 on 8/18/2018 at 9:44 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. Observations of the tube feeding pole for R#178 on 8/19/2018 at 9:30 a.m. revealed dried, heavily splattered tube feeding on the pole, base and wheels. There was no housekeeping log sheet available for R#178. Observation on 8/17/18 at 1:33 p.m. there was brown dripping stains on walls and dust on lower portion of walls in hallway throughout living unit one. Observation on 8/18/18 at 8:47 a.m. there was brown splatter stains on right side of the wall near the window. Observation on 8/18/18 at 8:49 a.m. There were brown stains on wall near rooms [ROOM NUMBERS] that looks like spillage. There was also black staining noted towards the lower areas of the wall. There continues to be dust on walls throughout the hallway of unit one. Interview on 8/19/18 at 11:34 a.m. with the on-call Housekeeping Team Leader who reported that housekeeping staff should pull trash, make beds, clean restroom, clean activity rooms, and closets. It was further reported resident rooms should be wiped down to include the walls. Housekeeping tour began at 8/19/18 11:38 a.m. with on-call Housekeeping Team Leader and the following was confirmed: 1. Observation in room [ROOM NUMBER] revealed splatter on wall. 2. Observation of hallway across from room [ROOM NUMBER] and room [ROOM NUMBER] revealed dust buildup on lower wall and dripping stains on walls. 3. Loose baseboards near room [ROOM NUMBER] and near water fountain unit 1. 4. There was dust buildup under sink in hallway and dust buildup on walls throughout Unit 1. During an interview with the on-call Housekeeping Team Leader on 8/19/18 at 11:50 a.m. it was reported that inspections are supposed to be done weekly by the supervisor to assure that areas are being cleaned. She further reported that when she does her inspections if areas of concerns are identified the worker is notified to correct the issue. She further reported that as areas are identified the expectation is that the areas will be cleaned. Interview on 8/19/18 at 12:15 p.m. with Nurse Manager who reported that it is the expectation that staff will correct an issue if they see it, when addressing the splatter stains on the wall in room [ROOM NUMBER]. Explaining that they can wipe something and clean it instantly, but if they are not able to clean they are to notify housekeeping so that they can address the issue. She further reported that the stains in the hallway look as if someone sprayed something and did not wipe the wall thereafter. Observation on 8/19/18 with the Nurse Manager beginning at 10:00 a.m. and ending at 10:20 a.m. confirmed the tube feeding poles and bases were dirty and had dried tube feeding drippings on the base for R#25, R#3, R#7, R#76, R#10, R#9, R#14, R#15 and R#178. She confirmed that the tube feeding nozzles for R#76 and R#10 was not in use but was not capped off. The Nurse Manager stated she had spoken with the staff about ensuring the tube feeding nozzles were capped off when not in use and to keep the caps in the plastic bag at bedside when tube feeding was in use. She confirmed that not capping off the tube feeding nozzles could cause dripping unto the base of the pole and the floor. She stated that it is just a matter of laziness. She stated she just spoke with staff about this last Wednesday. The Nurse Manager stated the responsibility to ensure the poles are clean is between both the nurses and the housekeeping staff. She stated that housekeeping had tried to clean the poles bases before and that the tube feeding had dried to the point they had trouble removing it. The Nurse Manager confirmed that if the caps were properly used and the tube feeding was wiped off when it drips or on a regular basis, it would not be dried to the point of difficult removal and cleaning. The Nurse Manager stated they had discussed getting new tube feeding poles but had not yet ordered any. Interview on 8/19/18 at 12:25 p.m. with the Nurse Manager revealed they do not have a policy for cleaning the tube feeding poles and that the current policy only addresses cleaning the kangaroo pump itself. She further stated they do not have a policy and procedure related to capping the tube feeding nozzles when disconnected from the residents and not in use. Review of the policy titled Eternal Nutrition Pump- Cleaning and Disinfection approved 4/14/10 documented A pump in continuous client use will be surface cleaned of all spills on the living area as needed or at least weekly. The policy did not address cleaning of the pump pole.", "filedate": "2020-09-01"}
{"rowid": 4054, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2018-08-19", "deficiency_tag": 730, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "EQDC11", "inspection_text": "Based on record review and staff interview, the facility failed to ensure that the annual 12-hour minimum education for Certified Nursing Assistants (CNA) included Dementia Care training for three of three CNA education transcripts reviewed. Findings include: Review of the employee files for CNA AA, CNA BB and CNA CC revealed all three CNAs had completed an annual minimum education/training of 12 hours, however, the training did not include the required annual Dementia Care training. Interview on 8/18/18 at 9:00 a.m. with the Training Program Administrator (TPA) and the Registered Nurse Educator (RNE) revealed that Dementia Care training is typically conducted in (MONTH) of each year. The TPA and the RNE stated they did not have record of the rosters for Dementia Care training in (MONTH) (YEAR). They stated another person was in the position. They stated that they looked but could not find the roster sign-in sheets. The RNE stated the facility did not have a policy related to required education for CNAs.", "filedate": "2020-09-01"}
{"rowid": 4055, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2018-08-19", "deficiency_tag": 812, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "EQDC11", "inspection_text": "Based on observation and staff interviews, the facility failed to maintain a clean floor in the satellite kitchen in Building 15 of the hospital complex and to clear state who is responsible for cleaning the ktichen floor. The facility census was 29. Findings include: Observation of the satellite kitchen in Building 15 on 8/18/18 at 11:30 a.m. revealed three dead cockroaches in the corner of the room next to a broken dishwasher and two dead cockroaches underneath the dishwashing sink next to the broken dishwasher. During an observation of the satellite kitchen in Building 15 with the Assistant Food Service Manager (FSM) on 8/18/18 at 12:19 p.m., he confirmed the presence of the dead cockroaches. He stated the facility received routine visits from a local pest control service to address problems with bugs throughout the facility complex as evidenced by the cockroaches being dead. He stated the satellite kitchen was used to receive bulk cooked food from the main kitchen. The food is placed on the steam table, checked for appropriate serving temperatures, plated and transported to the skilled nursing facility (SNF) for the residents. He further stated the kitchen staff was responsible for cleaning the areas of the satellite kitchen where food is handled but the housekeeping staff was responsibility for cleaning the satellite kitchen floor when the kitchen staff was done for the day. On 08/18/18 at 2:28 p.m., the Assistant FSM supplied the pest control service records dating back one year from (MONTH) (YEAR) to date which detailed monthly service calls, services provided and areas of concentration including the satellite kitchen. The satellite kitchen received monthly treatments for roaches. The last pest control service visit was 8/14/18. During an observation of the satellite kitchen in Building 15 with the Housekeeping Team Leader on 8/19/18 at 1:21 p.m. she confirmed the presence of the dead bugs still in the same places for the second day of observation. She stated, to her knowledge, the housekeeping staff was not responsible for cleaning the satellite kitchen floor. She stated she could reach her manager by phone, if necessary. During a telephone interview with the Housekeeping Manager (HM) on 8/19/18 at 1:32 p.m., she stated before the facility used that location as a satellite kitchen, the housekeeping staff was responsible for cleaning that area because there is a dining room next to it which serves other non-SNF residents of the hospital complex. She stated once the dietary staff began using it as a satellite kitchen, it became the responsibility of the dietary staff to clean the kitchen daily, including the floor. She further stated she would have her staff clean the satellite kitchen floor that day but would speak to her Director as soon as possible to address the controversy of cleaning responsibilities in the satellite kitchen. During an interview with the Administrator on 8/19/18 at 1:50 p.m. he stated he was unaware the satellite kitchen floor was not being cleaned on a regular basis. He stated the kitchen areas of the complex were part of the hospital and not the SNF and the kitchen and dietary staff work for the hospital. He stated the SNF received its food directly from the satellite kitchen but is prepared in the main kitchen. He stated he was not sure which department was responsible for cleaning the satellite kitchen. He stated he would attempt to locate any policies which address the responsibilities of the housekeeping and dietary departments, but he doubted there were any policies specific to that situation. He finally stated he would assist each department in determining their areas of responsibility going forward.", "filedate": "2020-09-01"}
{"rowid": 4056, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2019-09-26", "deficiency_tag": 759, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "2COK11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and a review of the facility policy and procedure Medication Administration in DBHDD Hospitals, the facility failed to ensure the medication error rate was less than five percent (5%). There were two errors with 26 opportunities by two of three nurses observed which resulted in a medication error rate of 7.14%. Findings include: 1. On 9/25/19 at 7:45 a.m., Registered Nurse (RN) AA was observed giving R#16 his morning medications. The medications included Levetiracetam 100 milligrams (mg) / 2.5 milliliters (ml). After preparing all of the medications for R#16, RN AA verified she poured 2.5 ml in a liquid medication cup. A review of the Physician's Orders dated 9/12/19 revealed to administer Levetiracetam 100 mg/ml solution, 500 mg twice daily starting on 9/23/19. During an interview on 9/25/19 at 9:15 a.m., RN AA verified that she did not check the Medication Administration Record (MAR) and only went by the label instructions on the medication bottle which was for 2.5 ml twice daily. She confirmed that the label on the medication bottle did not match the current Physician Order An interview with the Nurse Manager on 9/25/19 at 9:56 p.m. revealed the medication nurses are responsible for checking the MAR prior to administering any prepared medications. 2. Observation on 9/25/19 at 11;58 a.m. of Licensed Practical Nurse (LPN) BB giving R#6 his medications. The medications included a multivitamin liquid suspension. After giving R#6 all of the medications via a [DEVICE], she confirmed she did not shake well the liquid multivitamin as per the manufacturer's instructions. An interview with the Nurse Manager on 9/25/19 at 12:45 p.m. confirmed that LPN BB did not follow the manufacturer's instructions or the facility's policy for the liquid multivitamin by not shaking it well prior to administration. A record review of the Medication Administration in DBHDD Hospitals reviewed and revised on 3/4/2019 revealed the following information: D. Medication Preparation 5. Liquid or suspension medications are shaken well (if not contraindicated) prior to measuring for administration. E. Medication Administration 2. The nurse reviews eMar or MAR and 24-Hour Support Plan (if apllicable), to identify medications to be administered along with consistency, texture, adaptive equipment, positioning, and other guidelines required for medication administration. 15. Medications are administered ensuring that the eight rights are maintained: a. Right Medication: Compare drug container label to the eMAR/MAR three (3) times (as described above). Note expiration date. Know action, dosage, and method of administration. Know side effects of the drug and any allergies [REDACTED]. An interview on 9/25/19 at 12:50 p.m. the Pharmacist revealed they were aware of the incorrect medication label for the Levetiracetam 100 mg/2.5 ml, administer 2.5 ml. The label should read 100mg/2.5 ml administer 5 ml. The pharmacist also stated that the liquid multivitamin is a suspension and requires to be shaken well prior to administering. An interview with the Administrator on 9/26/19 at 12:11 p.m. revealed his expectations of the nursing staff are to administer medications as ordered.", "filedate": "2020-09-01"}
{"rowid": 4057, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2019-09-26", "deficiency_tag": 812, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "2COK11", "inspection_text": "Based on observations, staff interview, and the facility policy titled Policy -Food Purchasing, Receiving, Production, and Preparation 03-6647 Storage, the facility failed to ensure one of one walk in freezer was maintained in a clean sanitize condition and that food items were properly labeled and stored in a sanitary manner in one of two walk in coolers , one of one walk in freezer, and one of three food storage floor bins . This had the potential to effect 10 residents receiving oral fed diets. Findings include: Record review of the facility policy titled Policy-Food Purchasing, Receiving, Production and Preparation, 03-6647 Storage revealed the following: (1). protect food from contamination and spoiling during storage and preparation. Discard food in open containers within three (3) days of opening. (4). b. store all food in original containers or in NSF internationl approved containers. and once removed from the original containers store unused portion of opened food in tightly closed approval food grade bulk containers. (b). as appropriate cover with cool wrap or aluminum foil and label with the contents and dated (c). label all perishable food with the date it was put in the container and a use-by date determined according to Georgia DPH (Department of Public Health) Food Service Rules and Regulation Observation of one walk in freezer 's floor on 9/23/19 at 11:53 a.m. revealed the following concerns: 1. small bits of food particles and one unwrapped chicken breast patty on the freezer floor 2. dark brown substances, and pieces of white and brown cardboard scattered on the freezer floor 3. unlabeled opened sausage links wrapped in Saran wrap with no open date and expiration date 4. unlabeled open hash brown in a plastic bag with no open date with no open date and expiration date 5. open bag of carrots (unlabeled) stored in a plastic bag not properly sealed and stored in a large cardboard box with flaps not properly sealed Observation of one walk in cooler on 9/23/19 at 11:56 a.m. revealed the following concerns: 1. a pan of cooked bacon in a 1/3 loaf pan dated 9/17/19 (open date) to 9/21/19 (discard date) 2. a pan of cooked green beans in a 1/3 loaf pan dated 9/19/19 (open date) to 9/28/19 (discard date) 3. a pan of cooked puree green beans in a 1/3 loaf pan dated 9/19/19 (open date) to 9/28/19 (discard date) 4. a pan of cooked beef in a 1/3 loaf pan dated 9/17/19 (open date) to 9/21/19 (discard date) Observation of flour bin on 9/23/19 at 11:58 a.m. revealed the following: 1. Scoop merge down into the flour bin with only the handle being exposed. Further observation of the scoop revealed the handle completely covered with sticky and flakily white substance (flour). Interview on 9/23/19 at 12:02 p.m. with the Register Dietician/Food Service Director (RD) revealed that her expectations are for food items to be labeled and dated, stored in a sanitary manner to prevent food borne illness. All leftover food items should be properly labeled for a 72 hour or three-day time usage. RD-DM further stated that she has new dietary staff who require more in-services on labeling and 72 hours policy on discarding of cooked food items. She was unaware that the freezer floor was not maintained in a clean sanitary manner. She described the white substances on the scoop in the flour bin as flour. She stated that the scoop should be washed after each use and stored in a separate container. RD further stated that staff are trained on the Dietary Policies during orientation, quarterly, and as needed.", "filedate": "2020-09-01"}
{"rowid": 4491, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2016-03-24", "deficiency_tag": 282, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TMDQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff and Nurse Practitioner interviews, the facility failed to follow the Care Plan/Client Profile for turning and re-positioning for (1) resident (#1) with existing pressure sores from a sample size of twenty-two (22) residents. Findings include: Record review revealed that resident #1 was admitted [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility and had one (1) existing Stage I pressure sore, one (1) Stage II pressure sore and one (1) Stage III pressure sore with slough. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the facility's Policy titled Care of the Individual with a Decubitus Ulcer documented that all pressure should be relieved from the ulcer. The individual must not sit or lie on the decubitus ulcer (pressure sore) even for a few minutes. Review of Care plan/Client Profile for resident #1 documents turn and reposition turn every two (2) hours. Interview on 3/24/2016 at 2:45 p.m. with the Nurse Practitioner (NP) revealed that the resident had current Physician orders [REDACTED]. On 3/24/16 at 3:00 p.m. the NP confirmed that the resident was not fully turned and repositioned as per the Physician/NP orders. Interview with the Director of Therapy on 3/24/16 at 1:46 p.m. revealed that the resident was supposed to be fully turned on his/her left side or right side and those positions were maintained with the use of supportive devices. Continued interview revealed that multiple wedges and positioning devices were available and that the certified nursing staff had been trained how to use the wedges and the positioning devices. Interview with the Director of Nursing on 3/24/16 at 1:48 p.m. revealed that she expected the staff to turn and reposition residents as they were trained. Continued interview revealed that the facility did not have a specific policy for turning and repositioning residents but the nursing staff were taught proper procedure during training and were expected to follow the physician's orders [REDACTED]. Cross refer to F314", "filedate": "2019-10-01"}
{"rowid": 4492, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2016-03-24", "deficiency_tag": 314, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TMDQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff and Nurse Practitioner interview, the facility failed to properly turn and re-position one (1) resident (#1) with existing pressure sores from a sample size of twenty-two (22) residents. Findings include: Record review revealed that resident #1 was admitted [DATE] with the following Diagnosis: [REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that the resident was totally dependent on two staff persons for bed mobility and had one (1) existing Stage I pressure sore, one (1) Stage II pressure sore and one (1) Stage III pressure sore with slough. review of the resident's medical record revealed [REDACTED]. review of the resident's medical record revealed [REDACTED]. Review of the facility's Policy titled Care of the Individual with a Decubitus Ulcer documented that all pressure should be relieved from the ulcer. The individual must not sit or lie on the decubitus ulcer (pressure sore) even for a few minutes. Observation on 3/22/2016 at 6:50 a.m. and at 8:10 a.m., revealed the resident was lying on his/her back in the bed placing pressure on the pressure sores on the resident' s right hip and the right ischium. Observation on 3/22/16 at 10:20 a.m., revealed the resident was lying on his/her back in the bed. Staff had placed a wedge under the resident's left middle back and the resident was observed lying on his/her right side with direct pressure being placed on the resident' s pressure sores on the resident's right hip and right ischium. Observation on 3/22/2016 at 11:55 a.m., revealed the resident was lying on his/her back in the bed. Although the staff had placed a wedge under his/her right hip, the resident's pressure sore on his/her right ischium was observed to remain in contact with the mattress. Observation on 3/22/2016 at 1:32 p.m., revealed the resident was lying on his/her back in the bed with unrelieved pressure on the pressure sore on the right ischium. Interview on 3/24/2016 at 2:45 p.m. with the Nurse Practitioner (NP) revealed that the resident had current Physician orders [REDACTED]. On 3/24/16 at 3:00 p.m. the NP confirmed that the resident was not fully turned and repositioned as per the Physician/NP orders. Interview with the Director of Therapy on 3/24/16 at 1:46 p.m. revealed that the resident was supposed to be fully turned on his/her left side or right side and those positions were maintained with the use of supportive devices. Continued interview revealed that multiple wedges and positioning devices were available and that the certified nursing staff had been trained how to use the wedges and the positioning devices. Interview with the Director of Nursing on 3/24/16 at 1:48 p.m. revealed that she expected the staff to turn and reposition residents as they were trained. Continued interview revealed that the facility did not have a specific policy for turning and repositioning residents but the nursing staff were taught proper procedure during training and were expected to follow the physician's orders [REDACTED].", "filedate": "2019-10-01"}
{"rowid": 4493, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2016-03-24", "deficiency_tag": 371, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "TMDQ11", "inspection_text": "Based on observation and staff interview, the facility failed to date opened food items prior to storage in one (1) of two (2) dry storage rooms, in three (3) of four (4) walk- in refrigerators, and in one (1) of two (2) walk- in freezers; failed to appropriately store scoops in the containers of sugar, rice and flour in one (1) of two (2) dry storage rooms; failed to ensure that the fan was free of dust in one (1) of four (4) walk-in refrigerators. The census was forty-two (42) residents. Finding include: Observations on 3/21/16 at 10:45 a.m. revealed the following: Observation of one (1) of the two (2) dry storage rooms revealed one (1) open five (5) pound bag of Quick Grits, one (1) open two (2) pound bag of Bran Flakes cereal and one (1) open two (2) pound bag of oatmeal. These items were noted to be opened but were not labeled with the date the items were opened. Further observation revealed a scoop, with the handle touching the food items, in each of the following containers: sugar, rice and the flour container. Observation in the walk-in refrigerator #1 revealed one (1) opened plastic bag of hamburger patties that was not labeled with the open date. Observation also revealed a build-up of dust on the fan in the walk-in refrigerator #1. Observations of the walk-in refrigerator #2 revealed one (1) opened bag of French fries and one (1) opened bag of flour that were observed to be open but did not have the dates of when they were opened. Observation also revealed one (1) plastic bag of an unidentified substance on the floor under the food that was not dated or labeled. Observation of the walk-in refrigerator #3 revealed one (1) opened package of sliced cheese that was opened but did not have the date when it was opened. Observation of the walk-in freezer #4 revealed one (1) opened package of chocolate chip cookie dough that did not have the date when it was opened. Interview on 3/21/16 at 2:00 p.m. with the Registered Dietician /Dietary Manager, revealed that all the food items in the dry storage area, in the refrigerators and in the freezers should be labeled with the name of the item and all opened items should be dated with the dates the items were opened. Further interview revealed that the scoops should not have been submerged in the containers of sugar, rice and flour. Interview on 3/24/2016 at 3:50 p.m. with the Dietary Food Service Manager revealed that she expected the staff to label all food items and to label the opened items with the date the item was opened. Further interview revealed that the Food Service Manager constantly informed dietary staff that all opened food items in the dry storage areas, in the refrigerators and in the freezers were supposed to be labeled and dated. Review of the facility's policy of food storage revealed that opened food items should be closed, contents listed, and the date the item was open, documented on the item, prior to the item being stored in the refrigerators, freezers, or the dry storage area.", "filedate": "2019-10-01"}
{"rowid": 4494, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2016-03-24", "deficiency_tag": 514, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "TMDQ11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility staff and physician interview, the facility failed to accurately and completely document the appearance of non-pressure wounds for one (1) resident (#5). The sample size was twenty-two (22) residents. Findings include: Review of resident #5's Admission Minimum Data Set ((MDS) dated [DATE] revealed that the resident was at risk of pressure ulcer development and had a Stage 2 pressure ulcer. Review of the care plan dated 06/11/15 revealed that the resident was at risk for impaired skin integrity as related to history of decubitus and high risk assessment score for decubitus. Further review of this care plan revealed that it was updated on 01/26/16 to note that the resident's buttocks had some small red areas, and to continue with current treatment and monitor. Review of a hospital wound care assessment dated [DATE] revealed that resident #5's buttocks had several unmeasurable areas of maceration and redness; evidence of peeling and open skin to some areas; bloody and dark brown drainage; and full thickness ulceration to the sacrum and bilateral buttocks extending to the posterior thighs. Review of resident #5's Nurse's Notes on re-admission to the facility dated 01/29/16 noted the resident's sacrum had full-thickness ulceration, but there was no measurements or other description of the appearance of the wound. Review of a Hospital Return Nursing assessment dated [DATE] noted that the section labeled Body Chart was left blank with no abnormalities listed. Review of a Health Note dated 01/29/16 noted that resident #5 had returned from the hospital, a body inspection was completed with an RN and the attending physician DD, and multiple open areas were noted to the buttocks, crease as well as an open area to the groin. Further review of this form revealed that the wounds were not classified as to the type of wound, measured, nor any documentation of the appearance of the wounds. Review of Registered Nurse (RN) Wound Care Nurse CC's first assessment of the wound after return to the facility dated 01/31/16 noted that wound care was done, but there was no documentation of the appearance or measurements of the wounds. Review of RN Wound Care Nurse CC's wound notes dated 02/10/16 noted wounds to the buttock area which were pink in color with no signs of infection, but no documentation of size, depth, or any drainage. Review of the wound care nurse's notes dated 02/15/16 noted an area to the right medial buttock which was open, and five distinct areas of redness with thick and rough skin, and noted she was unable to measure due to the resident's breathing issues. Wound care notes dated 02/22/16 noted inability to measure the wounds due to the resident ' s inability to maintain position, and that the wounds appeared to be decreasing. Review of wound care notes dated 03/21/16 noted the buttocks had an offensive odor, were macerated with approximately five areas with redness and one area at tip of coccyx that was bleeding, but no documentation of exact locations, type and measurements of the wounds. During interview with the RN Wound Care Nurse CC on 03/22/16 at 1:33 p.m., she stated the facility did not use a special form to document wounds, whether they were pressure-related or not. She further stated that the attending physician had classified resident #5's wounds to the buttocks as moisture-related breakdown rather than pressure. Observation of the resident's buttocks on 03/23/16 at 10:10 a.m. with Licensed Practical Nurse (LPN) EE revealed that there were four areas of skin on the buttocks that were covered with Xeroform gauze. Further observation revealed that three of the areas of skin under the gauze were dark pink with no ulceration noted. Further observation revealed that there was one large (unmeasured) triangular-shaped area on the left buttock with a shallow ulceration and drainage, and an odor was noted. Continued observation revealed that it took three staff to turn the resident and LPN EE to pull back the Xeroform gauze, but resident #5 was noted to have no respiratory distress during the observation. During interview with LPN EE at this time, she stated that the treatment nurse would be the one to document the appearance of the wounds. During interview with the Director of Nurses (DON) on 03/23/16 at 1:05 p.m. she verified that the Body Chart section on the Annual Nursing Assessment/Hospital Return dated 01/29/16 was not completed, and stated the receiving nurse should have done this. During interview with the resident's attending physician DD on 02/23/16 at 1:40 p.m., she stated that she felt the areas to resident #5's buttocks were from maceration, and not from pressure. During interview with the DON on 03/23/16 at 5:41 p.m., she stated that she had talked to wound care nurse CC earlier that day, and had been told that there was no other documentation of the measurements and/or description of the wounds to the resident's buttocks. Upon further interview, the DON stated that she was not aware of any policy and procedure related to non-pressure wounds measurement and tracking. Review of the facility's Prevention of Pressure Ulcer Development policy and procedure docuemented that direct care staff would observe skin integrity, and if the nurse determined that any impaired skin was not a pressure ulcer, the nature of the impaired skin integrity would be determined, documented and reported.", "filedate": "2019-10-01"}
{"rowid": 6844, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2013-07-17", "deficiency_tag": 371, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "UVWN11", "inspection_text": "Based on observations and staff interview, it was determined that the facility failed to ensure that two (2) portable fans with dust/debris did not blow over uncovered food. Census= two (22) residents. Finding include: 1. Observation on 7/15/13 at 12:30 p.m. revealed a large portable fan, with an accumulation dust/debris sitting on the floor behind the steam table. This fan was blowing directly towards the steam table where meal trays were being prepared. 2. Observation on 7/16/13 at 1:35 p.m. revealed one (1) of the two (2) portable fans with an accumulation of dust/debris blowing towards the food prep area where food items were being prepared. Observation on 7/16/13 at 1:40 p.m. revealed , the second fan, with an accumulation of dust and debris, on top of a rolling cart, next to the conveyor belt, where clean dishes were coming out of the dishwasher. This fan was blowing directly on three (3) large metal pans. 2. Observation on 7/17/13 at 9:00 a.m. revealed a fan with an accumulation of dust/debris clinging to it, in the steam table area. This fan was blowing across a multiple level cart of food, some uncovered. Interview with the Dietary Supervisor on 7/17/13 at 9:00 a.m., revealed that the fan should not be blowing across the steam table.", "filedate": "2017-10-01"}
{"rowid": 6845, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2013-07-17", "deficiency_tag": 469, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "UVWN11", "inspection_text": "Based on observations, and staff interviews, the facility failed to maintain an effective pest control program in the kitchen. The facility census was twenty-two (22). Findings include: Observation in the kitchen on 7/16/13 between 1:45 p.m. and 2:00 p.m., revealed the following concerns: a red roach crawling on top of the table next to the steamer machine, a small black bug crawling on the wall next to the pantry door, a red roach crawling on the floor behind the steam table and a red roach crawling on a stack of Styrofoam plates on top of the steam table. Observation of the kitchen on 07/17/2013 at 9:00 a.m., revealed two (2) brown roaches crawling on the post near the steam stable and one (1) dead roach on the bottom of the post. Continued observation revealed four (4) small black bugs crawling on the post, a brown roach and a small black bug crawling on the lower shelf on the middle of the steam table. Interview with the Dietary Supervisor on 7/16/13 at 2:05 p.m. revealed that from time to time there are issues with roaches in the kitchen . Continued interview revealed that there are four (4) wooden pallets in the kitchen, and had seen roaches crawling on these pallets. She indicated that she has been trying to replace these pallets. Interview on 7/17/13 at 9:00 a.m. with the Dietary Supervisor revealed that approximately two (2) weeks ago she had noticed a worsening problem with the bugs and had notified the pest control provider, Orkin, who came the evening of 7/1/13, providing treatment. Interview with the Administrator on 7/17/2013 at 2:35 p.m., revealed that she was not aware of any current problems with pest in the kitchen; however, the facility has had problems in the past and contracted with Orkin, who would come quarterly and as needed.", "filedate": "2017-10-01"}
{"rowid": 6846, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2013-07-17", "deficiency_tag": 520, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "UVWN11", "inspection_text": "Based on record review and staff interview, the facility failed to hold Quality Assessment and Assurance (QAA) meetings at least quarterly and failed to ensure that a physician attended those meetings. The facility census was twenty-two (22). Findings include: Review of the QAA minutes, provided by the facility during the standard survey, revealed that the meetings were held on 3/29/12, 7/30/12, 11/30/12, 4/10/13 and 6/28/13. Continued review revealed that the physician was present for two (2) of the five (5) meetings, on 4/10/13 and 6/28/13; however, there was no evidence there was any quarterly QAA meeting held between November 2012 and April 2013. Interview with the Unit Manager on 7/17/13 at 1:00 p.m., revealed that the physician was not present at every meeting and confirmed there was no evidence of a meeting being held between November 2012 and April 2013. Telephone interview with the Administrator on 7/24/13 at 2:30 p.m. during the QA process revealed that there was no evidence of any QAA meeting sign in sheets for the physician.", "filedate": "2017-10-01"}
{"rowid": 8122, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2012-01-12", "deficiency_tag": 253, "scope_severity": "B", "complaint": 0, "standard": 1, "eventid": "IUIJ11", "inspection_text": "Based on observations, staff interviews and review of the facility policy, the facility failed to ensure that six (6) wheelchairs on two (2) of two (2) halls and one (1) IV pole were free of an soiled matter. Findings include: Random observations of wheelchairs during the environmental rounds on 1/10/11 at 2:00 p.m. revealed that there was a build up an ivory colored, dried substance on sides and under the bottoms of the crossbars on six (6) different wheelchairs. Living Area 1 1. The purple wheelchair in room 116 had an dried, ivory substance on the left side and under its cross bars. 2. The blue wheelchairs in room 109 had an dried, ivory colored substance on the left side and under its crossbars. Living Area 2- The blue wheelchairs in rooms 267, 266, 259 and 256 had an ivory, colored substance on both sides and under their crossbars. During an interview on 1/10/12 at 2:50 p.m., Certified Nursing Assistant (CNA) FF said Occupational Therapy department (OT) had a staff member who was responsible for pressure washing all of the wheelchairs. FF said that the dried, Ivory colored substance on the wheelchairs was formula. In an interview on 1/11/12 at 10:49 am, the OT/Physical Therapy Tech EE said that all of the wheelchairs were scheduled to be cleaned every six weeks. EE said the wheelchairs had last been cleaned on 11/16/11. EE explained that he/she was behind on the cleaning schedule because of the holidays. EE said that there was not a facility policy for cleaning. She/He said that he/she was responsible for pressure washing all of the wheelchairs for the whole campus. EE added that the CNAs on each unit were responsible for cleaning the wheelchairs, if it was needed before the scheduled time for pressure cleaning. Review of the Pressure Washing schedule indicated that the last steam cleaning for the wheelchairs were done between 11/15/11-11/21/11. Living Area 2 The bottom bottom of the IV/ tube feeding pole In room 258 was soiled with a dried, ivory substance.", "filedate": "2016-07-01"}
{"rowid": 8123, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2012-01-12", "deficiency_tag": 332, "scope_severity": "E", "complaint": 0, "standard": 1, "eventid": "IUIJ11", "inspection_text": "**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%. Five (5) errors out of fifty (50) opportunities for four (4) of ten (10) residents were noted by two (2) of five (5) nurses on two (2) of two (2) units. The facility's medication error rate was 10%. Findings include: 1. During an observation on 01/10/12 at 8:15 a.m., Licensed Practical Nurse (LPN) HH crushed all of resident #7's pills, including a [MEDICATION NAME] Delayed Release Orally Disintegrating Tablet, then mixed them with applesauce and gave them to the resident by mouth. However, according to the physician's orders [REDACTED]. A review of the Geriatric Dosage Handbook, 12th Edition, revealed that orally-disintegrating [MEDICATION NAME] ([MEDICATION NAME]) tablets should not be swallowed whole or chewed, but could either be placed on the tongue and allowed to dissolve, or dispersed in 10 milliliters (mL) of water in an oral syringe and administered. 2. On 01/10/12 at 11:42 a.m., LPN HH was observed giving medications to resident #25. HH gave the resident two puffs from an Atrovent inhaler in quick succession and then immediately gave the resident Iwo quick puffs of an [MEDICATION NAME] inhaler. However, review of the manufacturers' package inserts for the inhalers revealed that they had not been administered correctly. The nurse was supposed to firmly press the Atrovent canister against the mouthpiece one (1) time and then wait at least 15 seconds before repeating. If a resident's doctor prescribed more than one spray of [MEDICATION NAME] ([MEDICATION NAME]) then, the facility should have waited one (1) minute and shaken the inhaler again (before administering another spray). On 01/10/12 at 2:35 p.m., LPN HH confirmed that he/she had crushed the [MEDICATION NAME] tablet for resident #7. She provided the pharmacy packaging for the [MEDICATION NAME], which was labeled to include instructions to dissolve the drug before giving it. He/ She confirmed having given the [MEDICATION NAME] and Atrovent inhaler puffs without waiting in between each one. He/She said he/she was not aware of a facility policy of how long to wait. On 01/10/12 at 3:06 p.m., the Unit Manager provided the facility's Nursing Procedure on the administration of inhalers, which confirmed that the staff should have waited 2 minutes before a second inhalation. 3. LPN AA administered medications to resident #20 at 8:35 a.m. After that observation, the physician's medication orders were reviewed. There was an order for [REDACTED]. 4. LPN AA administered medications to resident #16 at 9:15 a.m. There was an order for [REDACTED].", "filedate": "2016-07-01"}
{"rowid": 8124, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2012-01-12", "deficiency_tag": 356, "scope_severity": "C", "complaint": 0, "standard": 1, "eventid": "IUIJ11", "inspection_text": "Based on observations and interviews with staff, the facility failed to post the nurse staffing data on all three days of the survey. Findings include: During observations in Liviing Areas 1 and 2 on 1/9/12, 1/10/12, and 1/11/12, it was noted that the facility had failed to post the required notice about nurs staffing data. The facilty had not posted a notice whcih included the following information: the facility name; the day's date; the total number and actual number of hours worked by licensed and unlucensed nursing staff providieng direct resident care on each shift and; resicent census. During an interview on 1/11/11 at 11:05 am, the Director of Nursing said that the facility had not posted the (nurse) staffing data the survey. The Director of Nursing said that she had not been poating the required informaton but only the nurses'schedule. In an interview on 1/11/12 at 11:10 a.m., the Infection Control Nurse said that she was unaware of the regulation for posted staffing.", "filedate": "2016-07-01"}
{"rowid": 8125, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2012-01-12", "deficiency_tag": 441, "scope_severity": "D", "complaint": 0, "standard": 1, "eventid": "IUIJ11", "inspection_text": "Based on observation, record review, and staff interview, the facility failed to ensure that facility staff washed their hands and/or changed their gloves after handling a contaminated object for one resident (#30). The sample size was twelve (12) residents. Findings include: On 01/11/12 at 7:45 a.m., an observation of resident #30's skin was done with Registered Nurse (RN) CC. When the incontinent brief was pulled back, the resident had a small amount of non-formed stool in the brief, as well as a plastic thermometer probe cover. The nurse removed the probe cover from the brief with his/her gloved fingers and threw it in the trash. Without changing his/her gloves or washing his/her hands, he/she then removed and replaced the resident's heel protectors, pulled down the resident's shirt, pulled up the bed covers and patted the resident on the back before removing her gloves and washing her hands. On 01/11/12 at 8:55 a.m., the Unit Manager stated that if the gloves were contaminated then she expected the staff to change gloves and/or wash their hands before they provided any other care. Review of the facility's Infection Control Policy on Standard and Transmission Based Precautions outlined that hand hygiene was the single most effective method to prevent the spread of disease. Employees and clients should wash their hands frequently and thoroughly and use good hand washing technique after removal of gloves and anytime there was exposure to blood or body fluids. Clean, non-sterile gloves should be worn when touching or at risk of touching excretions, and changed between procedures on the same client. However, during an interview on 01/11/12 at 11:00 a.m., RN CC confirmed that he/she did not immediately change gloves after handling the thermometer probe cover that had been in resident #30's incontinent brief.", "filedate": "2016-07-01"}
{"rowid": 9966, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2010-09-23", "deficiency_tag": 371, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "C3EB11", "inspection_text": "Based on observation, record review, review of facility policy, and staff interview the facility failed to store, prepare and serve food under sanitary conditions. This was evidenced by: storing pots and utensils that were dirty and wet; improper storage of food scoops; not ensuring that walk-in refrigerators were clean; not repairing water leaks; maintaining potentially hazardous hot food food on the steam table below 135 degrees Fahrenheit; improper storage of baking pans; improper functioning of the dishwashing machine; and lack of sanitizer in the manual 3 compartment sink. This failure affected all residents who were fed orally. Findings include: Observation on 9/21/10 between 10:00 a.m.-11:30 a.m. with the Dietary Manager revealed the following concerns: 1. Three of six serving ladles were stored wet; 1 of 2 scoops was stored dirty and wet; 6 large baking pans were stored wet. 2. A large storage unit of sugar contained a scoop with the handle touching the product. 3. The walk-in meat refrigerator had a very strong foul odor. Interview at that time with the dietary staff who maintained this area revealed that the area is cleaned daily. However, review of the facility's Central Kitchen Cleaning Checklist for the Meat Room revealed that the last cleaning verification was signed on 7/26/10. 4. Observation of the tray line at the beginning of the lunch meal on 9/21/10 revealed that the Dietary Manager calibrated her thermometer and obtained the following temperatures from food being held on the steam table: Pureed beets 100 degrees Fahrenheit (F) Pureed green beans 100 degrees F Pureed carrots 100 degrees F Ground carrots 98 degrees F Ground noodles 118 degrees F Pureed noodles 112 degrees F Pureed beef 130 degrees F Review of the food temperature log for 9/21/10 for the lunch meal revealed that dietary staff had only checked the temperature of three (3) food items on the steam table. 5. Observation of the dishwashing machine with the Food Service Supervisor on 9/22/10 at 8:00 a.m. revealed the following: The manufacturer's directions for the facility's high temperature dishwashing machine required a wash cycle temperature of 150 degrees F, rinse cycle of 160 degrees F and the final rinse cycle at 180 degrees F. The dishwashing machine had already run several loads. The Food Service Supervisor ran two additional loads, the temperatures were as follows: a rinse temperature of 152 degrees F, and a final rinse temperature of 130 degrees F. The Food Service Supervisor was not aware of the required minimum dishwashing machine temperatures. The above was followed by an observation of the manual 3 compartment sink. The Food Service Supervisor indicated that the facility uses a 4 sink method. He added that the fourth sink should contain rinse water heated to 180 degrees F. Staff was observed washing pans at the first sink and passing them to other staff, who rinsed them in the second and third sink and them put the pans aside to dry. The fourth sink had very little water (approximately less than 1/8 of its' capacity). Another dietary employee said she used a chlorine sanitizer in the rinse sinks. When asked to check both rinse sinks, the chlorine strip indicated that no sanitizer was present. The same dietary employee later acknowledged that she put chlorine in the wash sink, and ran out of chlorine for the rinse sinks. Review of facility's policy for Cleaning Pots, Pans and Mixing Blades revealed that that the fist sink should contain detergent and hot water. The fourth sink should contain water that was heated to 180 degrees F and San-T-10, a chemical sanitizer. This was not done. Interview with the Dietary Manager on 9/22/10 at 8:30 a.m. confirmed that the staff had incorrectly filled the 4 compartment sink.", "filedate": "2015-04-01"}
{"rowid": 9967, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2010-09-23", "deficiency_tag": 372, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "C3EB11", "inspection_text": "Based on observation, review of facility policy and staff interview the facility failed to ensure that areas around refuse containers were clean and free of foul odors to prevent harborage of pests. Findings include: Observation on 9/21/10 between 10:00 a.m.-11:30 a.m. with the Dietary Manager revealed the following concerns: One (1) of two (2) trash compactors located in a parking area behind the loading dock had a stream (about 9 feet long) of a dark foul smelling liquid that also contained some unknown debris. The Dietary Manager indicated that the bottom of one of the trash compactors had been leaking and needed to be replaced. This replacement occurred several days ago, but the area around the compactor had not been cleaned. The top of the waste oil container (located in the same parking area) had a pool of oil that contained food debris. Review of the facility's Clean Parking Area policy revealed that it would be hosed down daily. This was not done.", "filedate": "2015-04-01"}
{"rowid": 9968, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2010-09-23", "deficiency_tag": 469, "scope_severity": "F", "complaint": 0, "standard": 1, "eventid": "C3EB11", "inspection_text": "Based on observation, record review and staff interview the facility failed to maintain an environment that is free from pests. This failure affected all residents who were served food prepared in the kitchen and who were fed in the dining area on Unit 1. Findings include: Observation with the Dietary Manager and Food Service Supervisor in the kitchen on 9/20/10, between 11:15 a.m.- 11:40 a.m., 9/21/10, between 10:00 a.m.-11:30 a.m. and 9/22/10 between 8:00 a.m.- 9:00 a.m. revealed live roaches on the steam table, other food preparation surfaces, walls and floor. Review of the facility's pest extermination contract revealed the contract was valid until until 6/30/13. According to this contract, the kitchen was scheduled for two (2) service treatments per month to address an infestation of German Roaches. Interview with the Dietary Manager (DM) on 9/21/10 at 10:00 a.m. revealed roaches in the kitchen area had been an on-going problem. She added that the most recent extermination service for the kitchen was provided on 9/08/10. However, the tray line area continues to be heavily populated with roaches. During dining observation on 9/20/10 at 12:45 p.m. in Unit 1 dinning area, three (3) large roaches were observed on the floor of the dinning area while four (4) resident's were being fed lunch by staff. An interview with Registered Nurse \"RR\" at this time revealed that the exterminator had sprayed about three (3) days ago. The meal trays were delivered on a rolling cart from the main kitchen. A large gap was noted at the bottom and top of the outside door located in the dinning room. Observation on 9/22/10 at 4:45 p.m. of the Unit 1 shower room revealed several small bugs crawling on the shower table. Observation on 9/22/10 at 4:15 p.m. of resident room 267 revealed a small bug crawling on the hand washing sink.", "filedate": "2015-04-01"}
{"rowid": 9969, "facility_name": "GRACEWOOD NSG FACILITY(UNIT 9)", "facility_id": "11A200", "address": "100 MYRTLE BLVD., EAST CENTRAL REG HOSP", "city": "GRACEWOOD", "state": "GA", "zip": 30812, "inspection_date": "2010-09-23", "deficiency_tag": 281, "scope_severity": "G", "complaint": 0, "standard": 1, "eventid": "C3EB11", "inspection_text": "**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to provide services that met professional standards of quality. This was evidenced by the failure to clarify with the physician the urgency of providing x-ray services to rule out a possible fractured extremity resulting in harm for one (1) resident #23 of twenty one (21) sampled residents. Findings include: Record review revealed that resident #23 had a Health Note dated 3/02/10 at 7:00 a.m., indicating that nursing staff noted swelling of the right upper thigh and knee, with a light brown discoloration below the knee. It also indicated that the right lower extremity was warm to touch. Based on facility assessments (MDS, dated [DATE]) the resident was unable to communicate or make her needs known and was totally dependent on staff for all activities of daily living. Review of a physician's orders [REDACTED]. Review of a Health Note dated 3/02/10 at 10:00 a.m. revealed the nurse indicated that the x-ray would be done on 3/03/10, 24 hours after the injury was identified. In an interview on 9/22/10 at 11:00 a.m. with Licensed Practical Nurse (LPN) \"AA\" she acknowledged the physician's orders [REDACTED]. She added that since the physician did not request \"stat\" (immediate) x-rays she accepted that date without question. The nurse did not clarify with the physician the urgency of obtaining the x-rays sooner than 3/03/10. The Registered Nurse (RN) Manager was also present at the time of the interview with this LPN and later indicated that because of the resident's condition she would have expected the LPN to report the 24 hour delay of x-ray services to the RN Manager for further guidance. This was not done. The RN Manager acknowledged that other arrangements could have been made to have the x-ray services provided in a timelier manner. Standards of Practice for Licensed Practical Nurses-- In accordance with 2.3.2 Standards Related to Licensed Practical Nurses: The licensed practical nurse [MEDICATION NAME] under the direction of a registered nurse ... ... ...licensed physician or other authorized licensed health care provider: A. Conducts a focus nursing assessment, which is an appraisal of the client's status and situation at hand that contributes to ongoing data collection. E. Seeks clarification of orders when needed.", "filedate": "2015-04-01"}