cms_GA: 5980

In collaboration with The Seattle Times, Big Local News is providing full-text nursing home deficiencies from Centers for Medicare & Medicaid Services (CMS). These files contain the full narrative details of each nursing home deficiency cited regulators. The files include deficiencies from Standard Surveys (routine inspections) and from Complaint Surveys. Complete data begins January 2011 (although some earlier inspections do show up). Individual states are provides as CSV files. A very large (4.5GB) national file is also provided as a zipped archive. New data will be updated on a monthly basis. For additional documentation, please see the README.

This data as json, copyable

rowid facility_name facility_id address city state zip inspection_date deficiency_tag scope_severity complaint standard eventid inspection_text filedate
5980 ABBEVILLE HEALTHCARE & REHAB 115623 206 MAIN STREET EAST ABBEVILLE GA 31001 2016-02-06 223 D 1 0 R5VO11 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility self-reported incidents, interview and policy review, the facility failed to protect residents from abuse. This deficient practice affected one (R74) of two residents sampled as evidenced by the review of two incident reports for abuse. Findings included: Review of the facility self-reported incident completed on 1/25/16 revealed a staff member was observed pushing a resident (R74) down the hallway with excessive force on 1/22/16. Further review of the report revealed the time of the incident had not been documented. The allegation also identified a Licensed Practical Nurse (LPN)2, who had pushed R74 with excessive force. Review of the facility investigation revealed the process initiated to prevent further incidents was Social Service Designee (SSD) 1 had spoken to LPN 2 about the harsh treatment per documentation on the incident investigation report completed on 1/25/16. There was no documented evidence of an attempt to interview R74 or other residents on the 100 Hall. LPN2 continued to work in the facility on 1/22/16 to the end of the shift. Review of the record for R74 revealed [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Assessment ((MDS) dated [DATE] revealed the resident had documented behaviors of wandering. Review of the care plan dated 7/31/15, revealed staff was to redirect the resident away from the area to his room and provide medications as ordered. Interview on 2/6/16 at 10:45 a.m., the Director of Nursing (DON) acknowledged she was not aware of the incident until 1/25/16 when it was reported by Social Service. The DON stated that LPN2 had quit on 1/25/16 related to her pay check bounced. The DON verified LPN2 continued to work after the incident through the end of the shift on 1/22/16 and for an additional two days. Interview with SSD1 on 2/6/16 at 11:00 a.m. identified LPN2 as the staff person she witnessed using excessive force to push R74 on 1/22/16 about 5:30 p.m. SSD1 stated R74 was threatening to hit another resident and she called for help because she couldn't redirect him. SSD1 stated LPN2 responded and stepped in between the residents to protect the resident who was threatened by R74. LPN2 pushed R74 in the back twice through the door way using excessive force. SSD1 felt this met the definition of abuse; however SSD1 failed to report this to the DON until Monday 1/25/16. SSD1 confirmed she should have reported the incident on 1/22/16 but the DON had left for the day and stated I should have called her at home. Interview with Nurse Aide (NA)2 at 11:15 a.m. on 2/6/16, identified LPN2 as the staff member who shoved R74 on 1/22/16 at about 5:30 p.m. NA2 reported LPN2 was trying to protect another resident from R74 because he was going to hit another resident. NA2 reported R74 swung at LPN2 and that is when LPN2 shoved R74 hard in the back. NA2 demonstrated, with the surveyor, how hard LPN2 shoved R74 in the back causing the surveyor to stumble forward. NA2 stated I think that was abuse. NA2 did not report to any other staff because SSD1 was present and the NA thought the SSD would report the abuse. Review of the facility time record revealed LPN2 continued to work until the end of the shift on Friday 1/22/16 and worked 12 hours on Saturday, 1/23/16 and Sunday 1/24/16. Interview of seven residents included R11, R36, R57, R54 and R42 identified by the facility as able to give reliable interviews and two additional residents R30 and R27 on 2/6/16 between 11:15 a.m. and 12:00 p.m. revealed they had no concerns of abuse or mistreatment by staff. Interview of staff on 2/5/16 and 2/6/16 included one LPN, four NAs and two housekeepers, revealed they had received training in the facility abuse policy and all confirmed they knew to report immediately. Review of the facility policy Abuse Prevention Policy and Procedure dated revised 3/13/14 instructed staff to report all allegations of abuse immediately to the DON and Administrator. Any allegation of abuse is reported immediately to the state agency and to all other agencies as required per state and federal guidelines. Immediately means as soon as possible, but should not exceed 24 hours after the discovery of the incident, in absence of a shorter state timeframe requirement. The policy defined abuse as the harmful treatment of [REDACTED]. The Investigation File Checklist included: suspend any employee suspected of abuse, neglect or misappropriation immediately after taking their written statement; Maintain the employee on suspension until the investigation is concluded and is either substantiated or unsubstantiated. However; this was not a part of the facility policy. Review of the facility policy on abuse investigation with the DON on 2/6/16 at 10:45 a.m. verified there was no direction to staff to remove the staff member who committed the alleged abuse during the investigation until the investigation was complete. 2018-05-01