cms_GA: 73
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| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 73 | GLENWOOD HEALTH AND REHABILITATION CENTER | 115025 | 4115 GLENWOOD RD | DECATUR | GA | 30032 | 2016-07-28 | 226 | D | 0 | 1 | 44GN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and review of facility policy, the facility failed to ensure the abuse policy and procedure was followed to ensure 1 of 1 allegations of abuse was thoroughly investigated for 1 of 1 residents reviewed for abuse. (Resident #45) Findings include: On 7/25/16 at 3:30 PM, the Executive Director provided a policy titled Verification of Investigation of Alleged Mistreatment, Abuse, Neglect, Injuries of Unknown Source and Misappropriation of Resident Property Guideline, dated 3/2002 and revised 2013, and indicated the policy was the one currently used by the facility. The policy indicated .In the event of an alleged violation .involving mistreatment, neglect, abuse, injuries of unknown source or misappropriation of property, the center investigates the alleged violation thoroughly and reports the results of all investigation to the Executive Director as well as to state agencies as required by state and federal law. Investigation is conducted per the nursing policy Reporting Alleged Violations and documented on the Verification of Investigation form. Documentation reflects resident assessment; record reviews and sufficient employees/individuals were interviewed to derive at conclusion findings .Event Investigation: .The Executive Director, Director of Nursing or designee will initiate an event investigation immediately after the occurrence .2. Interview all people involved in the event. Discuss the event with associates involved, but DO NOT take written statements .8. Determine what recommendation or interventions have been or will be taken to prevent recurrence On 7/27/16 at 8:58 [NAME]M., record review indicated Resident # 45 was originally admitted to the facility on [DATE] with the most recent readmission on 7/15/16 with [DIAGNOSES REDACTED].diabetes mellitus type II, obesity, [MEDICAL CONDITION] and [MEDICAL CONDITION] A quarterly MDS (Minimum Data Set) assessment, completed on 5/11/16, indicated the resident had a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had normal cognition, the resident had no hallucinations or delusions, required extensive 2 person transfer assist and was independent for locomotion off of the unit. A sign out/in log for all appointment and leave of absence (LOA) form for Resident #45 indicated I, the responsible person named below, hereby accept complete responsibility for the above named resident, while away from (facility name). I will complete this form on departure from (facility name) and return to (facility name) . The sign in/out log indicated the resident signed himself out LOA on 7/7/16 at 11:51 [NAME]M. and returned to the facility on [DATE] at 2:30 P.M. A nurse note, dated 7/8/16 at 10:31 P.M., indicated received resident in bed sleeping, which was not the normal behavior. Writer could not wake the resident to take evening medications, vs (vital signs) blood pressure: 102/65, spo2 (oxygen saturation) 93%, blood sugar 165. Family members (mother and sister) visited because he did not answer their calls. Writer notified his NP (nurse practitioner), advised to hold BP (blood pressure) medications only for this evening. Will continue to monitor. A nurse note, dated 7/9/16 at 11:23 [NAME]M., indicated change of condition altered mental status. Resident received this morning in his bed, very difficult to wake up. Resident was unable to say any word but 'yes Mam', very slow to arouse, unable to swallow, very poor left hand grip tongue protruding from mouth which is not normal. Resident is on ABT (antibiotic)[MEDICATION NAME] mg (milligrams) for urinary tract infection [MEDICAL CONDITION] but was not given this morning because resident was unable to swallow, VS (vital signs) 97.6, 74, 18, 135/64, O2 (oxygen) saturation (sat) 93 at room air, O2 applied at 3 l (liters)/m (minute) and O2 sat went up to 97%. NP notified and she came and assessed resident, order received to send resident to emergency room (ER) on a 911. Resident sent to ER. Residents mother called and notified, resident left facility at 10:30 [NAME]M. A laboratory report, dated 7/9/16, indicated Resident #45 had a urine drug screen completed the test indicated the resident tested positive for cocaine and opiates. A consultation from the hospital dated 7/10/16, indicated history of present illness: a [AGE] year old male with a history of [MEDICAL CONDITION] secondary to a fall, hypertension, diabetes, recurrent UTI (urinary tract infection) and [MEDICAL CONDITION]. He presented to the emergency room via EMS due to altered mental status. It was reported that normally he is able to carry on conversation and feed himself and yesterday he was found to be very confused and unable to do any of the activities of daily living that he normally does. (Resident ' s name) was actually recently admitted to (hospital name) from (MONTH) 30th to (MONTH) 2nd due to a UTI. At that time, he also presented with altered mental status and [MEDICAL CONDITION]. Urine drug screen was done, interestingly was positive for cocaine and opiates. An Incident report, dated 7/11/16, was faxed to the Department of Health Regulation Division. The report indicated date and time of incident: 7/10/16. Details of incident: Resident was sent to (hospital name) due to altered mental status. Hospital called facility and stated that it was abuse on our part because (resident name) tested positive for cocaine. Physician notified: YES. Steps taken by facility to prevent further incidents: blank A 5 day follow up investigation, dated 7/15/16, was faxed to the Department of Health Regulation Division. The report indicated the resident was sent to (hospital name) due to altered mental status. Hospital called facility and stated that it was abuse on the facility's part because (resident name) tested positive for cocaine. Case Manager from the hospital contacted the facility and informed the facility that the hospital doctor believed this was abuse because the resident tested positive for cocaine. Because the potential allegation of abuse was present, the facility self-reported this incident. Details of the investigation: Executive Director, Admissions Director and hospital liaison met with the specific doctor that made the statement (allegation) at (hospital name). After speaking directly to the specific doctor making the statement, the doctor informed the Executive Director and all parties at the meeting that she was not aware that the resident in question was able to get around and/or sign themselves out to go into the community. The doctor initially believed that since the resident was paraplegic, that the resident was bed ridden. She also stated that she never suggested or agreed that the hospital case manager should document or contact the facility with an allegation of abuse as to it was merely her opinion. She was speaking from her opinion without fully understanding the resident's ability to leave the facility. It was explained to the doctor that this resident signs himself out, and leaves the facility for hours. The resident also catches transportation to move throughout the city and the resident is self-responsible. After receiving more information in regards to the resident's ability and resident rights, the doctor apologized for the allegation and stated that maybe I should ask questions first before using words like abuse or neglect. Conclusion: Facility concluded that this was a non-substantiated allegation. Facility will continue to monitor and respond to all allegations from residents, family members and all interested parties. Plan: Facility will continue to monitor for any allegations of abuse, neglect or any other incident involving its resident and staff. During an interview, on 7/27/16 at 2:30 P.M., Employee DD indicated she was the charge nurse on duty the morning of 7/9/16. She indicated she could not figure out what was causing the residents change in his mental status other than he was having increased pain from leg spasms and was on pain medication for this. She indicated the resident does not have many visitors other than his mother but she had a recent accident and has not been able to come to the facility. She indicated the resident is his own legal representative, he is alert and oriented and signs himself out for LOA's. She indicated she has never seen the resident come back from a leave of absence impaired. During an interview, on 7/27/16 at 2:50 P.M., Employee JJ indicated she was on duty the day of 7/9/16 and observed the change in mental status for the resident and reported it to the charge nurse and the charge nurse assessed the resident and sent him to the emergency room for an evaluation. She indicated the resident goes LOA and takes the Transport bus by himself and is not accompanied by anyone. She indicated he is usually gone just a couple of hours and has never seen him return from a LOA impaired. During an interview, on 7/27/16 at 3:30 P.M., the DON (Director of Nursing) indicated on the evening of 7/10/16 the evening supervisor contacted her and indicated a case worker from the hospital called the nursing facility and indicated the resident had a drug screen completed and tested positive for cocaine, and the doctor at the hospital feels the facility was negligent and it was abuse on the facilities part because the resident tested positive for cocaine. The DON indicated she did not interview any residents or staff as part of the investigation because of confidentiality, she indicated she notified the Executive Director and turned the investigation over to him. During an interview, on 7/27/16 at 3:35 PM, the Executive Director indicated the facility was made aware of the situation on 7/10/16 an incident report was completed and faxed to the state and an investigation was started. The ED (Executive Director) indicated the 5 day follow up investigation was completed and faxed to the state on 7/15/16. The ED indicated the investigation consisted of obtaining an appointment with the physician at the hospital where the resident was transferred to and discussed the allegation of abuse/neglect and that the resident was his own legal representative and did leave the facility on LOA's. The ED indicated he did interview staff verbally but there was no written documentation of this. On 7/27/16 at 5:15 P.M., the Executive Director presented 2 written statements from employees and indicated these were the 2 employees that were verbally interviewed regarding the situation but was never documented on paper until 7/27/16. Letter #1, dated 7/27/16, (resident name) was readmitted to the unit on 7/15/16. Prior to his arrival, a verbal report was called to the receiving nurse. This report stated that the resident was positive for cocaine abuse. I asked (resident name) if he was aware of the above and he stated emphatically that the hospital made a mistake and that if needed he was willing to have a repeat blood test. He stated that has never been my lifestyle. I informed (resident name) that I did not have an order to do a blood test but that it was ill advised for him to continue taking illegal drugs. Letter #2, dated 7/27/16, upon residents return from the hospital on [DATE] writer interviewed resident about dx (diagnosis) cocaine abuse per hospital report. Writer explained and educated the resident regarding cocaine especially since he's already on multiple pain medications. Resident denied any cocaine use and stated that I got wrong information. He stated that his mom already spoke to the hospital because they have misidentified somebody's blood as his. An Admission Agreement, undated, was received from the Director of Nursing on 7/28/16. The Admission Agreement indicated: .Drug and Medication: No medications (including non- prescription items such as aspirin or vitamins) are to be brought in for residents in this facility .Personal Choice: Entering and Leaving the Nursing Home: You have the right to enter and leave the nursing home as you choose, unless medically contraindicated as determined by your physician in accordance with state law. The facility may require you to inform it at the time you are leaving and re-entering the nursing home's grounds . | 2020-09-01 |