cms_GA: 3908
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3908 | NORTHRIDGE HEALTH AND REHABILITATION | 115714 | 100 MEDICAL CENTER DRIVE | COMMERCE | GA | 30529 | 2019-01-10 | 835 | J | 0 | 1 | XS0411 | **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. | 2020-09-01 |