cms_TN: 2390
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2390 | ADAMSVILLE HEALTHCARE AND REHABILITATION CENTER | 445397 | 409 PARK AVENUE | ADAMSVILLE | TN | 38310 | 2019-07-16 | 865 | J | 1 | 0 | 98W311 | > Based on review of the Administrator job description, review of the Director of Nursing (DON) job description, Quality Assurance (QA) Coordinator job description, medical record review, and interview, the Quality Assurance Performance Improvement (QAPI) committee failed to ensure an effective QAPI program that recognized concerns related to exit seeking behavior assessments, completion of incident investigations, completion of elopement assessments, developing plans of action and interventions for exit seeking behaviors, failed to ensure systems and processes were in place and consistently followed by staff to address quality concerns, and failed to ensure the facility was administrated in a manner that enabled it to use its resources effectively and efficiently. Failure of the QAPI Committee to ensure the facility implemented and/or provided new interventions related to active exit seeking, and that staff ensured a safe environment for residents placed 1 of 4 (Resident #1) sampled residents in Immediate Jeopardy when Resident #1, a cognitively impaired resident with known wandering and exit seeking behaviors, was missing for approximately 1 hour and 20 minutes before the staff realized he had eloped from the facility. Resident #1 was found by a customer when Resident #1 was wandering outside of a local grocery store located 0.7 miles from the facility. This resulted in an IJ for Resident #1. Immediate Jeopardy (IJ) is a situation in which the provider's noncompliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident. The Administrator and the Director of Nursing (DON) were notified of the Immediate Jeopardy (IJ) on 7/13/19 at 5:30 PM in the Conference Room. F-600, F-657, F-689, F-835, and F-865 were cited at a scope and severity of [NAME] F-600 J and F-689 J are Substandard Quality of Care. A partial extended survey was conducted on 7/14/19. An acceptable Allegation of Compliance (A[NAME]), which removed the immediacy of the Jeopardy, was received on 7/15/19 at 4:20 PM, and the A[NAME] was validated onsite by the surveyor on 7/16/19 through review of assessments, policies related to active exit seeking behavior, in-service training records and staff interviews. The IJ was effective from 5/20/19 to 7/16/19. The findings include: The Nursing Home Administrator job description with a revision date of 6/2006 documented.lead and direct the overall operations of the facility in accordance with .government regulations and Company policy, with focus on maintaining excellent care for the residents .This facility expects their employees to promote an atmosphere .hospitality and comfort for its residents .ensure residents needs are being addressed .Maintain a working knowledge of and confirm compliance with all governmental regulations .improvement of services . The facility's Director of Nursing Job description with a revision date of 6/2006 documented, .manage the overall operations of the Nursing Department in accordance with .policies, standards of nursing practice and governmental regulations so as to maintain excellent care of all residents' needs .plan, develop, organize, implement, evaluate and direct the nursing services department .resident care of the nursing service department .participate in coordination of resident services .provide appropriate departmental in-service education .in compliance with .State and Federal Guidelines .complete investigative analysis .study .resident Incident Reports for corrective action .Keep Administrator informed on a daily basis of nursing department functions, recommending changes in techniques or procedures .efficient operation .Assure residents are comfortable, clean .safe environment .Verify that medical and nursing care is administered .assist with development of and approve final version of the Interdisciplinary Plan of Care for each resident .review nurses notes to confirm that they are informative and descriptive of the nursing care being provided, that they reflect the resident's response to care, and that such care is provided . Review of the QA Coordinator job description revised 6/2008 documented, .reports to Director of Nursing .supports successful implementation and maintenance of clinical and quality initiatives and protocols for use at the facility .to assure the facility is following .regulations .Identify deficit(s) related to policy/procedures and develop draft policy for review .identify weakness .of clinical initiatives to provide/promote resident well-being .new clinical initiatives to correct weaknesses .develop a detailed report on findings to report to QA Committee. Report any high risk areas immediately .staff .to provide accurate information and correct negative trends .Identifies Safety and Risk Management issues and communicates areas of weakness to Administrator .conduct meaningful weekly Quality Assurance meetings .weekly Quality Services department meetings .Protect residents from neglect . Interview with Clinical Manager #1 on 7/15/19 at 10:27 AM, Clinical Manager #1 was asked if she attended Interdisciplinary Team (IDT) Meetings. Clinical Manager #1 stated, .yes I attend the meetings . Clinical Manager #1 was asked if exit seeking behaviors were discussed in the meetings. Clinical Manager #1 stated, .I don't recall discussing exit seeking behavior or (discussing) him (Resident #1) leaving the Secure Unit in (MONTH) (2019) . Clinical Manager #1 was the staff member who saw Resident #1 leave the Secure Unit on (MONTH) 20, 2019. Interview with the QA Coordinator on 7/15/19 at 3:04 PM, in the Conference Room, the QA Coordinator was asked if any concerns related to behaviors and exit seeking behaviors had been identified. The QA Coordinator stated, .no . Interview with the QA Coordinator on 7/16/19 at 5:15 PM, in the Conference Room, the QA Coordinator was asked if the QA committee was effective. The QA Coordinator stated, .no .the things we put in place (indicating the A[NAME]) will help it to be better . 1. The facility's QA committee failed to identify areas of improvement related to active exit seeking behaviors. Refer to F600, F657, F689, F835 2. The facility's QA committee failed to identify an incident of elopement, failed to investigate the incident to determine the root cause of the incident, failed to identify appropriate plans of action, and failed to ensure new interventions related to the incident of elopement were added to the resident's care plan. Refer to F 600, F657, F689, F835 3. The facility's QA committee failed to identify that elopement risk assessments were not current and updated for residents of the facility's Secure Unit. Refer to F 600, F657, F689, F835 The surveyor verified the A[NAME] by: 1. Housekeeping Director or Designee will audit doors daily beginning 7/15/19 to ensure signage is still in place for two weeks, then weekly for two months and/or substantial compliance is achieved. The surveyor reviewed the audit forms. 2. Maintenance Director or Designee began elopement drills on each shift beginning 6/28/19 then weekly for four weeks then one shift weekly for two months and/or when substantial compliance is achieved. The surveyor reviewed the audit forms. 3. Beginning 6/28/19 the DON, Staff Development Coordinator or Designee began to conduct audits of resident head counts at shift change for two weeks, then three times weekly for four weeks, then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 4. Social Services Director or Designee will audit elopement books beginning 7/15/19 to ensure they are updated based on new and updated elopement risk assessments weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 5. Employee Relations Director or Designee will audit new hires beginning 7/15/19 to ensure they received elopement procedure training weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. The surveyor reviewed the audit forms. 6. Beginning 7/15/19 the DON and/or Designee will audit five elopement risk assessments weekly for four weeks then monthly for two months to ensure any exit seeking behaviors are care planned appropriately. The surveyor reviewed the audit forms. 7. On 7/15/19 results of the audits will be discussed at the Quality Assurance Performance Improvement Committee weekly for four weeks then monthly for two months and/or until substantial compliance is achieved. Noncompliance of F-865 continued at a scope and severity of D for the monitoring and the effectiveness of corrective actions. The facility is required to submit a plan of correction. | 2020-09-01 |