CMS-Nursing-Home-Full-Deficiencies
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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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 3841 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 578 | D | 0 | 1 | ZZXY11 | Based on record review and staff interview the facility failed to obtain a Physician's signature and a concurring Physician's signature for a Do Not Resuscitate Consent for one of three Residents (R) (R#29) without decision making capacity. The facility census was 62 residents. Findings include: Review of medical record for R#29 revealed a Do Not Resuscitate (DNR) Consent for an adult without decision making capacity that was signed by one Physician on 1/11/18 and the resident's son, who was not the resident's Health Care Agent, but there was no concurring Physician's signature. Further review of the Medical Record for R#29 revealed that there was a General Power of Attorney (POA) but not a Health Care Agent for R#29. On 9/7/18 at 4:45 p.m. DON provided copy of POA for R# 29 but the POA did not specify a health care agent. Admissions/Social Services reported that this is the only documentation that she has related to POA for R# 29. Interview on 9/8/18 at 11:05 a.m. with Admissions/Social Services who acknowledged that she educates residents and families related to choices related to formulating advance directives. She reported that residents without decision making capacity with no family available requires two physician signatures on DNR consent/order. If a resident has decision making capabilities and signs the consent/order only one physician's signature is needed. It was further reported that if a resident without decision making capacity has family the family member can sign, only one physician's signature would be needed. Lastly, it was reported that a resident without decision making capacity but with a health care agent only needs one physician's signature. Admissions/Social reported that she was not aware that a concurring physician's signature would be needed for a resident if the POA signed the consent/dnr form. | 2020-09-01 |
| 3842 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 636 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review and review of the Resident Assessment Instrument (RAI) Manual as well as staff interviews, the facility failed to correctly code one (1) Minimum Data Set Assessment (MDS) for one resident, Resident #37 (R#37). The facility census was 62 residents. Findings include: Record review revealed that R#37 has a [DIAGNOSES REDACTED]. Observations made on 9/7/2018 at 11:51 a.m., 9/8/2018 at 8:57, and 9/9/2018 at 9:13 am. revealed resident in bed with upper and lower bed rails elevated with padding on all rails and headboard. Review of the care plans for R#37 revealed side rails elevated times two for safety during care provisions, to assist with bed mobility, observe for injury, or entrapment related to side rail use. Interview on 9/7/2018 at 11:51 a.m. with Certified Nursing Assistant (CNA) AA revealed that the resident has a safety sitter with her at all times. She stated the padding on the side rails are used to keep her from hurting herself. The resident can get spastic at times. Continued interview on 9/8/2018 at 8:57 a.m. with CNA AA revealed R#37 will attempt to stand up in the bed and has no safety awareness. She is very unsteady on her feet. Interview with the Director of Nursing (DON) on 9/9/2018 at 9:30 a.m. revealed the facility uses the padded elevated side rails and padded head board for the resident's safety and protection from injury. The facility supplies a full-time safety sitter to be with the resident at all times. The DON stated he keeps a list at the nurse's desk of the residents who have side rails. Review of the list revealed R#37 required side rails but did not mention pads to side rails. His expectation is the MDS should reflect the use of side rails for R#37 Interview with the Minimum Data Set (MDS) Coordinator LPN CC on 9/09/2018 at 11:12 a.m. verified the most recent Quarterly MDS dated [DATE] did not indicate the use of side rails. Interview with the DON on 9/9/2018 at 12:11 p.m. revealed the facility does not complete side rail assessments or restraint assessments. The facility does not complete side rail consents or restraint consents for use from the resident or family. The facility does not have a policy for the use of side rails. | 2020-09-01 |
| 3843 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 644 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to refer one resident (#33) for a pre-admission screening and resident review (PASARR) Level II assessment when the resident experienced a change in his emotional and behavioral status which impacted his day-to-day functioning. The sample size was 32 residents. Findings include: Review of the policy titled Preadmission Screening for Individuals with Mental Disorders or Intellectual Disability dated 3/10/17, the facility must notify the applicable state authority for resident review promptly after a significant change in the mental or physical condition of a resident. Review of the clinical records for Resident (R) #33 revealed the resident was admitted on [DATE] and readmitted on [DATE] with no psychiatric diagnoses. A Level I PASSARR authorization of 3/22/17 documented that the resident did not have a suspected mental illness or developmental disability. The admission Minimum Data Set (MDS) assessment of 7/24/16 also documented that the resident had no psychiatric diagnoses. A review of social work notes documented between 9/5/18 and 9/21/18 revealed the resident was counseled by the social worker for symptoms of depression. Review of a progress note from the consulting psychiatrist on 9/29/17 revealed the resident was seen for symptoms of depression and anxiety. The note further documented that the psychiatrist planned to add 7.5 mg of [MEDICATION NAME] to the resident's existing dose of [MEDICATION NAME] 20 mg daily and to also add [MEDICATION NAME] 5 mg three times a day for anxiety. A review of the current physician's orders [REDACTED]. A review of the most recent MDS assessment - the annual - of 7/26/18 revealed that the resident was not referred for a Level II PASRR evaluation but had active [DIAGNOSES REDACTED]. During an interview on 9/9/18 at 10:10 a.m. with Certified Nursing Assistant (CNA) CC, it was revealed that she has cared for R#33 for more than two years. At first, he was very nice; very pleasant. However, as his health deteriorated, so too did his demeanor. He is sometimes verbally aggressive to the CNAs when they try to assist with activities of daily living such as taking a shower. In the beginning, he rarely refused to shower during his assigned shower times. Now, he rarely agrees to. During an interview on 9/9/18 at 10:50 a.m. with the Social Worker, it was revealed that she has counseled R#33 in the past about anxiety and he was referred for a psychiatric evaluation related to this. The social worker also said that the facility is currently looking at contracting with an outside behavioral help agency to have that agency provide therapy for residents such as R#3 who are referred for such. During a follow-up interview on 9/9/18 at 11:36 a.m. with the Social, Worker, it was revealed that the facility is currently doing an audit of the residents with Level II PASRR approvals and she can add R#33 to the list to be evaluated. During an interview on 9/9/18 12:14 p.m. with R#33 it was revealed that he has had several sessions with the psychiatrist in the past few months during which she addressed psychiatric issues. This included her prescribing medication aimed at addressing his symptoms. | 2020-09-01 |
| 3844 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 656 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interviews the facility failed to follow the care plan for four residents (R). R#37, R#45, R#54 and R#33. The facility census was 62 residents. Findings include: 1. R#37 has a [DIAGNOSES REDACTED]. Observations made on 9/7/2018 at 11:51 a.m., 9/8/2018 at 8:57, and 9/9/2018 at 9:13 am. revealed resident in bed with upper and lower bed rails elevated with padding on all rails and headboard. Review of R#37's care plan revealed side rails elevated times two for safety during care provisions, to assist with bed mobility, observe for injury, or entrapment related to side rail use. The care plan did not include the use of upper and lower rails and the use of padding to the rails and head board. Interview on 9/7/2018 at 11:51 a.m. with CNA AA revealed that the resident has a safety sitter with her at all times. She stated the padding on the side rails are used to keep her from hurting herself. The resident can get spastic at times. Continued interview on 9/8/2018 at 8:57 a.m. with CNA AA revealed R#37 will attempt to stand up in the bed and has no safety awareness. She is very unsteady on her feet. Interview with the DON on 9/9/2018 at 9:30 a.m. revealed the facility uses the padded elevated side rails and padded head board for the resident's safety and protection from injury. The DON stated he keeps a list at the nurse's desk of the residents who have side rails. Review of the list revealed R#37 required side rails, not the number of side rails, but did not mention pads to side rails. His expectation is the care plan should reflect the use of upper and lower side rails and the padding on the rails and head board for R#37. Interview with the MDS Coordinator LPN CC on 9/09/2018 at 11:12 a.m. verified the care plan only included side rails times two and did not include the padding to the rails or head board. Interview with the DON on 9/9/2018 at 12:11 p.m. revealed the facility does not complete side rail assessments or restraint assessments. The facility does not complete side rail consents or restraint consents for use from the resident or family. The facility does not have a policy for the use of side rails. 2. Minimum Data Set (MDS) Significant Change assessment dated [DATE] documented R#45 requires one person total dependence with bed mobility and dressing; and has one stage 2 pressure ulcer not present on admission. The Care Area Assessment (CAA) Summary triggered pressure ulcers with the option to be included in the care plan. Review of the Care Plan last reviewed on 8/16/18 revealed R#45 has potential/ actual impairment to skin integrity related to fragile skin and incontinence. Resident has stage 2 pressure ulcer to left lateral foot identified on 11/16/17. Interventions included: resident needs pressure relieving mattress, pillows, padding to protect skin while in bed. Review of the (MONTH) (YEAR) Physician order [REDACTED]. During wound care observation on 9/8/18 at 9:00 a.m., R#45 was in bed and no heel protectors were observed. Stage 2 pressure ulcer noted to left lateral foot. Treatment provided as ordered. Upon completion of the wound care treatment by Licensed Practical Nurse (LPN) HH, no heel protectors were placed the resident. Observation on 9/08/18 at 10:45 a.m. and 3:13 p.m. revealed R#45 in bed sleeping. Resident was not wearing heel protectors of any kind. Observation on 9/09/18 at 8:38 a.m. revealed R#45 up in Geri chair in the day room. Resident was not wearing heel protectors. Interview with LPN HH on 9/09/18 at 8:59 a.m. revealed that R#45 is supposed to have on the big bulky boots while in bed. 3. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed R#54 was unable to complete the Brief Interview of Mental Status (BIMS). The resident has [DIAGNOSES REDACTED]. Observation on 9/7/18 at 11:00 a.m. and 9/08/18 at 10:48 a.m. and 3:02 p.m. revealed R#54 with thick tan build up on the top teeth. Review of the Care Plan reviewed 8/23/18 revealed R#54 requires total care for all her Activities of Daily Living (ADL)'s due to severe mental [MEDICAL CONDITIONS], impaired vision/ hearing, contractures to fingers and feet, and limited passive range of motion (PROM). No interventions were listed related to providing oral care. Care plan related to resident requiring a feeding tube indicated resident to receive nothing by mouth. Interview with the Director of Nursing (DON) on 9/09/18 at 12:42 p.m. revealed that nursing staff are expected to review the care plans which are located at the nurse's station. He stated that oral care should be part of R#53's comprehensive care plan. DON stated that the facility does not have a Care Plan policy. Cross Refer F677 and F686 4. Review of the clinical records for Resident (R) #33 revealed he was originally admitted to the facility on [DATE]. A further review of the records revealed the resident has current [DIAGNOSES REDACTED]. Review of the Minimum Data Set Assessment (MDS) assessment records for R#33 revealed an annual assessment dated [DATE] which documented that the resident had verbal behavioral symptoms directed at others and rejection of care behaviors with occurred for 1-3 days of the assessment period. Under the Care Area Assessment Summary (CAAS), behavioral symptoms triggered and the decision was made to create a plan of care to address that area. Review of the care plan records for R#33 revealed there was not a plan of care included for behavioral symptoms. During an interview on 9/9/18 at 9:22 a.m. with MDS Coordinator BB, it was revealed a plan of care for behavioral symptoms had not been completed for R#33 and this was an oversight. The behaviors documented for this resident - rejection of care and verbal behaviors directed at others were new behaviors for the resident and, to her knowledge, a plan of care for this area had never been completed in the past to address them. During an interview with the Director of Nursing on 9/9/18 at 11:40 a.m., it was revealed that the facility has no policies related to care plans. Review of the plan of care records on 9/9/18 at 1:30 p.m. revealed a plan of care related to behavioral symptoms was created for R#33 on 9/9/18. | 2020-09-01 |
| 3845 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 677 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide oral care for one resident (R) (#54) out of 32 sampled residents. Findings include: Observations on 9/7/18 at 11:00 a.m. and 9/08/18 at 10:48 a.m. and 3:02 p.m. revealed R#54 with thick tan build up on the top teeth. Review of the Minimum Data Set (MDS) Annual assessment dated [DATE] revealed R#54 was unable to complete the Brief Interview of Mental Status (BIMS). The resident has [DIAGNOSES REDACTED]. Observation on 9/09/18 at 08:30 a.m. revealed R#54 in bed with teeth noted to be clean. During an interview on 9/09/18 at 10:25 a.m., Certified Nursing Assistant (CNA) II revealed that she cleaned R#54's mouth at the beginning of her shift this morning. She stated that oral care is supposed to be done every day. Interview with the Director of Nursing (DON) on 9/09/18 at 12:42 p.m. revealed that he expects oral care to be provided every shift or more often. He stated that oral care should be part of R#53's comprehensive care plan. DON stated that in-services are provided to nursing staff regularly which covers oral care. The education record is done electronically and is not available for review on a Sunday. Review of the in-service education materials titled Oral Health in Nursing Homes dated 2/8/18 revealed that oral hygiene should be provided twice a day but at a minimum once daily. Review of the Job Aid titled Oral Care reviewed (MONTH) (YEAR) revealed no indication of frequency of oral care and only outlined procedure. | 2020-09-01 |
| 3846 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 686 | D | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, review of the facility policy titled Villa Wound Care, and staff interview, the facility failed to provide heel protectors as physician ordered for one resident (R) (#45) out of 32 sampled residents. Findings include: During wound care observation on 9/8/18 at 9:00 a.m., R#45 was in bed and no heel protectors were observed. Stage 2 pressure ulcer noted to left lateral foot. Treatment provided as ordered. Upon completion of the wound care treatment by Licensed Practical Nurse (LPN) HH, no heel protectors were placed on the resident. Minimum Data Set (MDS) Significant Change assessment dated [DATE] documented R#45 requires one person total dependence with bed mobility and dressing; and has one stage 2 pressure ulcer not present on admission. Review of the (MONTH) (YEAR) Physician Orders revealed an order dated 4/24/18 for Prevalon boots (soft boot designed to lift the heel off the mattress) on while in bed (please keep straight) and an order dated 1/30/18 for heel protectors to be worn at all times. Review of the Care Plan last reviewed on 8/16/18 revealed R#45 has potential/ actual impairment to skin integrity related to fragile skin and incontinence. Resident has stage 2 pressure ulcer to left lateral foot identified on 11/16/17. Interventions included: resident needs pressure relieving mattress, pillows, padding to protect skin while in bed. Observation on 9/08/18 at 10:45 a.m. and 3:13 p.m. revealed R#45 in bed sleeping. Resident was not wearing Prevalon boots or heel protectors of any kind. Observation on 9/09/18 at 8:38 a.m. revealed R#45 up in Geri chair in the day room. Resident was not wearing heel protectors. Interview with LPN HH on 9/09/18 at 8:59 a.m. revealed that R#45 is supposed to have on the big bulky boots while in bed. Interview with the Director of Nursing (DON) on 9/09/18 at 12:42 p.m. revealed that R#45 should have on heel protectors as ordered and that information should be communicated from shift to shift and from nurses to nursing assistants. Review of the policy titled Villa Wound Care revised (MONTH) (YEAR)documented: Purpose: The purpose of this policy to establish guidelines to monitor and treat residents with wound care issues and to resolve skin integrity issues with an interdisciplinary approach. Procedure: 5) Pressure reduction devices. b) The nursing staff is responsible for monitoring the use of the pressure reduction devices once said devices have been recommended by physician orders. | 2020-09-01 |
| 3847 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2018-09-09 | 759 | E | 0 | 1 | ZZXY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the medication error rate was less than five per cent (5%). A total number of 27 medication opportunities were observed, and there were two errors for one of two residents (R) (R #14) by one of two nurses observed giving medications, for an error rate of 7.41%. The facility census was 62 residents, and the sample size was 32 residents. Findings include: On 9/8/18 at 11:30 a.m., Licensed Practical Nurse (LPN) KK was observed giving R#14 her noon medications which included [MEDICATION NAME] 20 grams (g or GM)/ 30 milliliters (ml's) and [MEDICATION NAME] Acid 750 mg/ 15 ml's given via gastrostomy tube ([DEVICE]). LPN KK combined both liquid medications together in a cup. Further observation revealed LPN KK poured 50 ml's of water through the tube, then the mixture of medications, and finally an additional 50 ml's of water. Review of R#14's (MONTH) (YEAR) Physician order [REDACTED]. [MEDICATION NAME] 10 GM/15 ml solution 20g - 20 g oral 3 times daily, first dose on Monday 7/16/18 at 8:00 p.m. oral or via peg; and valproate sodium 250 mg/5 ml syrup 750 mg - 750 mg oral three times daily, first does on Saturday 7/14/18 at 8:00 a.m. During an interview on 9/09/18 at 9:00 a.m., LPN KK revealed that her normal process is to mix all the medication together and give them together at one time for the [DEVICE]. Interview with the Director of Nursing (DON) on 9/09/18 at 12:42 p.m. revealed that it has always been the practice of the nurses at this facility to give medication all together and at one time through the g tube. Review of the document titled Patient Care Job Aide: Enteral Feedings - Instillation of Medications and PEG Care revised 2/12 revealed: 8. Pour liquid medication into measuring cup to obtain ordered amount. 10. Deliver the medication slowly and steadily. If the medication does not flow properly, do not force. If mixture too thick, dilute it. The facility had no other policies related to [DEVICE]s. | 2020-09-01 |
| 9357 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 279 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to develop a comprehensive care plan which included indwelling Foley catheter use for one (1) resident (#2) from a survey sample of eight (8) residents. Findings include: Please cross refer to F315, example 1, for more information regarding Resident #2. Record review for Resident #2 revealed that the Resident Care Plan documented the resident's admitted as 05/02/2011. A May 2011 physician's orders [REDACTED].#2 to have an indwelling Foley catheter to bedside drainage, with catheter care to be provided twice daily. Observation of Resident #2 on March 28, 2012 at 3:15 p.m. revealed that the resident had an indwelling Foley catheter in place. However, further review of the Resident Care Plan for Resident #2 revealed that the facility had failed to develop a plan of care for the indwelling Foley catheter. | 2015-07-01 |
| 9358 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 282 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility failed to follow the plan of care for one (1) resident (#2) regarding fluid restriction, and for one (1) resident (#3) regarding an enteral tube feeding, from a survey sample of eight (8) residents. Findings include: 1. Please refer to F309 for more information regarding Resident #2. Record review for Resident #2 revealed that the resident's March 2012 physician's orders [REDACTED]. A Resident Care Plan entry of 05/15/2011 identified a problem of the resident having the potential for alteration in cardiac output related to [DIAGNOSES REDACTED]. Interventions to address this noted problem included to encourage adequate fluid intake, while observing any ordered fluid restrictions. However, review of Resident #2's Intake and Output sheet revealed that during March 2012, the facility had given Resident #2 fluid in amounts which exceeded the physician's 1000 cc per 24 hour fluid restriction order on twelve (12) days in amounts ranging from 1277 ccs to 2134 ccs per 24 hours. 2. Please cross refer to F328 for more information regarding Resident #3. Record review for Resident #3 revealed a 03/02/2012 Care Plan entry identifying that the resident was dependent on tube feeding for nutrition, with an Approach to administer tube feedings as ordered. A physician's orders [REDACTED]. The resident's March 2012 medication record documented that on 03/02/2012, [MEDICATION NAME] was initiated at 30 mls per hour per gastrostomy tube, and on 03/03/2012, the resident received [MEDICATION NAME] at 35 mils per hour per gastrostomy. Then, on 03/04/2012, the resident began receiving [MEDICATION NAME] at 40 mls per hour. However, this medication record further documented that the formula continued at the rate of 40 mls per hour until 03/28/2012, with no documented additional attempts after 03/04/2012 to increase the resident's formula rate as ordered by the physician on 03/02/2012, even though there was no evidence to indicate that the resident failed to tolerate the last rate increase on 03/04/2012. | 2015-07-01 |
| 9359 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 309 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that one (1) resident (#2), who was on fluid restriction, received the ordered amount of fluids, from a survey sample of eight (8) residents. Findings include: Record review for Resident #2 revealed an Admission/Readmission Care Plan sheet which documented an admission date of [DATE], and also documented that the resident had [DIAGNOSES REDACTED]. The resident's March 2012 physician's orders [REDACTED]. However, review of Resident #2's Intake and Output sheet revealed that the resident was given over the ordered 1000 ccs. of fluid per twenty-four (24) hour period on the following dates in the following amounts: on 03/01/2012, 2084 ccs; on 03/02/2012, 1912 ccs; on 03/04/2012, 1374 ccs; on 03/05/2012, 2091 ccs; on 03/06/2012, 1297 ccs; on 03/08/2012, 1277 ccs; on 03/09/2012, 1315 ccs; on 03/10/2012, 1677 ccs; on 03/21/2012, 1915 ccs; on 03/22/2012, 2134 ccs; on 03/24/2012, 1320 ccs; and on 03/25/2012, 1320 ccs. Based on the above, during March 2012, the facility had given Resident #2 fluid in amounts which exceeded the physician's 1000 cc per 24 hour fluid restriction order on twelve (12) days in amounts ranging from 1277 ccs to 2134 ccs per 24 hours. During an interview with Nurse "EE" conducted on 03/28/2012 at 2:15 p.m., this nurse stated that the certified nursing assistants were responsible for keeping up with resident fluid intake. | 2015-07-01 |
| 9360 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 315 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the facility's policy for indwelling urinary catheter care, and staff interview, the facility failed to provide the appropriate urinary catheter care for two (2) residents (#2 and #3), from four (4) residents with indwelling urinary catheters, on a total survey sample of eight (8) residents. Findings include: 1. During observation of Certified Nursing Assistants (CNAs) "AA" and "BB" performing Foley catheter care for Resident #2 on March 28, 2012 at 3:15 p.m., these CNAs utilized wipes to wipe downward on either side of the Foley catheter tubing during pericare, and used [MEDICATION NAME] swabs to wipe the peri area on either side of the catheter tubing as well. However, the CNAs failed to clean the Foley catheter tubing at the insertion site at all. 2. During observation of CNAs "CC" and "DD" performing Foley catheter care for Resident #3 on March 28, 2012 at 3:35 p.m., these CNAs used wipes to wipe downward on either side of the Foley catheter during peri care, and used [MEDICATION NAME] swabs to wipe downward on either side of the peri area, but they failed to clean the Foley catheter tubing from the proximal to the distal end. Rather, the CNAs used a [MEDICATION NAME] swab to wipe one time on the top of the catheter tubing. Also, during the observation referenced above, the resident's Foley catheter tubing was not secured to the leg either prior to or after the completion of catheter care. The facility's policy for the care of indwelling Foley catheters was reviewed, and it was determined that the policy did not include cleansing of the Foley catheter tubing. This was acknowledged by the Director of Nursing during interview on 03/29/2012 at 12:15 p.m.. | 2015-07-01 |
| 9361 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 328 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow the physicians' orders for a gastrostomy tube feeding, and failed to clarify the length of administration for an intravenous solution, for one (1) resident (#3) from a total survey sample of eight (8) residents. Findings include: Record review for Resident #3 revealed a Physician's Orders and Progress Notes sheet with a 03/01/2012 entry which documented that the resident had a gastrostomy tube. A 03/02/2012 physician's order on this Physician's Orders and Progress Notes sheet ordered [MEDICATION NAME] at 30 milliliters (mls) per hour per gastrostomy tube, and to advance by 5 ml increments every 24 hours as tolerated. Review of the resident's March 2012 medication record revealed a 03/02/2012 entry indicating that [MEDICATION NAME] was initiated at 30 mls per hour per gastrostomy tube on that date. A Progress Notes entry of 03/02/2012 at 10:24 p.m. which documented that [MEDICATION NAME] was infusing at 30 mls per hour, with no distress noted at that time. A 03/03/2012 notation on the medication record documented that the infusion rate had increased and that the resident received [MEDICATION NAME] at 35 mils per hour per gastrostomy tube on that date. A Progress Notes entry of 03/03/2012 at 10:08 a.m. documented that [MEDICATION NAME] was infusing at 35 mls per hour, and a Progress Notes entry of 03/03/2012 at 6:15 p.m. documented that the gastrostomy tube site was intact and patent, with no distress noted. A 03/04/2012 entry on the medication record documented that Resident #3 began receiving [MEDICATION NAME] at 40 mls per hour per gastrostomy tube, but also documented that the formula continued at that rate until 03/28/2012. Record review revealed no documented attempts after 03/04/2012 to increase the resident's formula rate by 5 mls per hour every 24 hours as tolerated, as originally ordered by the physician on 03/02/2012, even though further record review revealed no evidence to indicate that the resident failed to tolerate the last rate increase to 40 mls per hour on 03/04/2012. Observation of Resident #3 on 03/28/2012 at 3:35 p.m. revealed that the resident was receiving [MEDICATION NAME] at 40 mls per hour. During an interview with Nurse "FF" conducted on 03/29/2012 at 4:15 p.m., this nurse acknowledged that nursing staff failed to follow the physician's orders for the tube feeding formula for Resident #3. Additional record review for Resident #3 also revealed a 03/20/2012 physician's order for Normal Saline intravenously at 75 mls per hour. However, the physician's order did not indicate the length of time the resident was to receive this intravenous fluid, nor was there evidence to indicate that facility staff made attempts to clarify the duration of this therapy. The resident's March 2012 medication record documented that the resident had begun receiving Normal Saline at 75 mls per hour on 03/20/2012, and that this intravenous therapy had continued through 03/28/2012. It was not until 03/28/2012, the second day of this complaint survey, that facility staff contacted the physician and received an order to discontinue this intravenous fluid. During an interview with Nurse "EE" conducted on 03/29/2012 at 4:15 p.m., this nurse acknowledged that the licensed nursing staff failed to clarify with the physician how long to run the intravenous Normal Saline for Resident #3. | 2015-07-01 |
| 9362 | JOE-ANNE BURGIN NURSING HOME | 115272 | 321 RANDOLPH STREET | CUTHBERT | GA | 39840 | 2012-03-29 | 502 | D | 1 | 0 | ZZLX11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain a urine culture and sensitivity laboratory test as ordered by the physician for one (1) resident (#2) from a survey sample of eight (8) residents. Findings include: Record review for Resident #2 revealed a 03/15/2012 physician's orders [REDACTED]. The Laboratory Report for this 03/15/2012 urinalysis revealed two-plus protein, one-plus occult blood, a three (3) to ten (10) white blood cell result, and "many bacteria". A 03/16/2012 physician's orders [REDACTED]. However, further record review revealed no evidence of a urine culture and sensitivity done as ordered on [DATE] or thereafter. During interview with the Director of Nursing on 03/28/2012 at 5:25 p.m., the DON acknowledged that the ordered 03/16/2012 urine culture and sensitivity had not been done. | 2015-07-01 |
| 3838 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2015-08-27 | 161 | C | 0 | 1 | ZZKN11 | **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 purchase a surety bond to assure the security of the resident trust fund account. The facility managed forty-eight (48) resident's accounts. The census was fifty-five (55). Findings include: Review of the surety bond provided by the Administrator on [DATE] at 11:50 am, revealed the surety bond had expired on (MONTH) 1, (YEAR). During an interview with the Administrator at that time, he confirmed the surety bond had expired. Review of the [DATE] current account balance revealed the facility currently managed forty-eight (48) resident accounts with a current balance of $21,426.40. Six months of bank statements for the resident trust fund were reviewed and revealed the following balances: ,[DATE]- $45,341.06, ,[DATE]- $41,743.02, ,[DATE]-$50,328.91, ,[DATE]- $53,636.20, ,[DATE]- $45,824.47, ,[DATE]- $55,550.59. | 2020-09-01 |
| 3839 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2015-08-27 | 371 | F | 0 | 1 | ZZKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews, it was determined that the facility had failed to ensure that the kitchen was clean, kitchen utensils cleaned appropriately and essential kitchen equipment was in good repair. Findings include: The following compliance issues were identified in the kitchen area on 8-25-15 at 3:10 pm: The rubber seal gasket on one door of the cooler had pulled away from the base of the door. Inside the cooler, there was a steam table pan underneath the condenser coil with dripping water into the pan. The Director of Food Service (DFS) stated that this was a [AGE] year old cooler. He had a requested of replacement about three weeks ago. Further interview revealed that the maintenance director had told him that this cooler could not be fixed anymore. Two large soup pots with soap and hot water, and one large roaster pan were on the floor, under the dish washing area. The head chef confirmed the above and stated that they were soaking or waiting to be cleaned. The following compliance issues were identified in the kitchen area on 8-25-15 at 4:10 pm: Observation revealed a fan with dust and dirt was on top of a food warmer and was blowing over the steam table area. A buildup up grease on the storage shelves behind the steam table. On top of these shelves, there were stored large pots and large serving spoons. This was confirmed by the head chef. He stated that these shelves had not been on a cleaning schedule. Two metal utility carts with rusted bases with a large baking pans on one and the tea and coffee dispensers on the other. A gouged area in the wall over the handwashing sink. There were chipped floor tiles in front of the convection oven. There was heavy grease and food debris build up on the inside of the blender base. There were three sheet pans and three large frying pans with heavy carbon build-up on the outside of them. This was confirmed by the DFS. | 2020-09-01 |
| 3840 | SGMC LAKELAND VILLA | 115707 | 138 WEST THIGPEN AVE | LAKELAND | GA | 31635 | 2015-08-27 | 406 | D | 0 | 1 | ZZKN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to provide the recommendation of Occupational and Physical rehabilitation services as outlined in the Preadmission Screening and Resident Review (PASRR) for one (1) resident #63. The sample census was eighteen (18). Findings Include: Review of the Admission Record on 8/26/15 at 2:40 p.m. revealed resident# 63 had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) admitted d 6-17-15 Section was noted that resident #63 had active [DIAGNOSES REDACTED]. The MDS Section C note Brief Interview for Mental Status (BIMS) score 5, and Section G Functional Increase for Activities of Daily Living (ADL) was noted yes, Review of the APS Healthcare Level II dated 5-27-15 on 8/25/15 at 2:54 p.m. revealed treatment recommendation for Skilled Nursing Facility (SNF) placement with rehabilitation. And 24/7 nursing supervision needed at temporary SNF placement for OT/PT rehabilitation to promote healing for eventual return to group home. Review of the admission orders [REDACTED]. The SGMC Lanier Campus Discharge Summary dated 6/4/15 revealed resident #63 was to continue with touchdown weight bearing only with PT. However, the Consulting Orthopedic Doctor order written on 6/5/15 was noted to continue TDWB with Physical Therapy (PT). On 6/5/15 the PT did an evaluation only citing patient not allowed to ambulate at this time and referred resident #63 to restorative nursing. There was no Occupational Therapy (OT) evaluation conducted. A Rehab Communication Tool form dated 6/8/15 noted discontinue PT effective 6/9/15 secondary severity of mental [MEDICAL CONDITION] and status [REDACTED]. Further investigation revealed that resident #63 was seen by the Consulting Orthopedic Doctor on 6/19/15 and to return in four weeks with x-rays of right hip and right femur; on 7/17/15 to continue treatment, weight bearing as tolerated with instructions do not force him/her to weight bear, but allow what weight bear he/she wants to do and return in one month with x-rays of right femur; on 8/17/15 with recommendations that patient cannot be seen without hard copies of x-rays of fracture. An observation on 8/26/15 at 10:36 a.m. revealed resident 63# stand with weight bearing on right leg and transfer to a Broda chair with two restorative Certified Nursing Assistant (CNA) assisting using a gait belt for safety. During an interview on 8/26/15 at 9:15 a.m. with OT revealed that resident #63 was not evaluated or seen in the skill nursing home. Continued to state that resident #63 was only seen and treated when he/she was in the hospital. During an interview on 8/26/15 at 1:39 p.m. with the Director of Nursing (DON) stated that resident was admitted in (MONTH) (YEAR) and the Touch Down Weight Bearing (TDWB) with PT was the current treatment order. And was not sure why PT stated resident #63 who was able to follow simple instruction was noted as severely MR. DON acknowledged that resident #63 did not receives skilled PT as needed. And acknowledged that the PASRR recommendation was not followed. During an interview on 8/26/15 2:20 p.m. the Physical Therapy (PT) stated that she treated resident #63 during his/her hospital stay and felt that resident #63 was not safe for TDWB and had orders to change to transfers only. After resident #63 was admitted to the nursing home, she did an evaluation but did not treat based on resident #63 mental [MEDICAL CONDITION] even though he/she could follow simple instructions. The PT stated he/she was unaware of the Orthopedic Doctor consultation order dated 7-17-15 for resident to weight bear as tolerated, and would have reassessed resident #63 for physical therapy. During an interview on 8/27/15 at 10:00 a.m. with the Orthopedics Consultant Doctor revealed that he/she unaware resident #63 was not receiving physical therapy. Continued to state that resident cognition does makes it difficulty and he order WBAT to promote tolerance until the femur had healed. However, the facility have fail to send x-rays hard copies or disk of resident #63 right femur fracture to his/her last two appointments. Therefore could not make any professional recommendations without knowing the extent of the healing of resident #63 femur fracture. | 2020-09-01 |
| 5431 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 242 | D | 0 | 1 | ZZBE11 | Based on observations, resident and staff interviews, the facility failed to honor meal perference/choice for one () residents (K) from a sample of thirty-two (32) residents. Findings Include: 1. Interview conducted 3/3/15 at 9:20am with resident K revealed that he used to get vegetable soup and a grilled cheese for his alternate meal but now he only gets cereal. K further indicated that for the past month the kitchen has served him the main menu and do not honor his request for vegetable soup and grilled cheese sandwich. The resident revealed he was told by the dietary staff that it is too much of a hassle to make him a grilled cheese sandwich and that he may eat cereal and milk instead. Interview on 03/03/15 at 12:10pm with the Dietary Manager revealed the meal alternative is decided each morning and is her choice. She further revealed that the alternate is posted with the main menu in the hall near the dining room each morning When the Dietary Manager was asked about a policy regarding if a resident did not like the meal or the alternate, she responded with you are talking about the vegetable soup and grilled cheese sandwich. She indicated that the facility stopped providing any other alternatives for meal choice other than the daily chef choice for a meal alternative because it got out of control, it was like a domino effect, everyone was asking for a grilled cheese sandwich. Interview conducted 03/05/15 at 10:45am with the Director of Nursing (DON) revealed that residents have the right to choose their meal and an alternate is provided. DON further revealed the if residents do not like the meal or alternate, they may ask for something else, provided they ask in advance. Choices can be voiced at any time; however, residents cannot choose an alternative during meal time. They must wait until after the meal time is completed, then they may ask for a different meal. Observation conducted 03/02/15 at 1:00pm revealed the menu was posted in hallway to dining room but no alternate choice was posted. Observation conducted 03/03/15 at 10:30am revealed the posted menu in the hallway to the dining room had a hand written alternate meal choice stapled to the menu. Observation conducted 03/03/15 at 12:45pm revealed resident K was in the dining room for lunch and he was served mashed potatoes, meat loaf and pinto beans. The resident ate approximately 30% of his pinto beans. He did not eat any potatoes or meatloaf. The resident served himself a bowl of cereal and a Certified Nursing Assistant (CNA) brought the resident milk for his cereal. He consumed 100% of the cereal. Observation conducted 03/04/15 at 1:00pm revealed the resident was in the dining room during lunch. A review of the resident's meal preference ticket was blank. He was served baked chicken and baked sweet potato. He ate 100% of his sweet potato. He then got up, served himself a bowl of cereal with milk. He ate 100% of the cereal. In addition, the CNA served the resident the alternate meal of fried chicken patty and mashed potato, neither of which he ate. | 2018-09-01 |
| 5432 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 282 | D | 0 | 1 | ZZBE11 | Based record review, and staff interview, the facility failed to follow plan of care for one (1) resident (A) from thirty-two (32) sampled residents. Findings include: Review of the care plan for resident A revealed a care plan related to poor dentition for teeth described as broken and discolored. An intervention for this was to provide medications as ordered and that the resident was receiving Magic mouth wash. This plan of care was developed on 5/29/2014 and was reviewed on 8/25/2014, 10/16/2014, and 1/14/2015 which continue to include the Magic Mouthwash as an intervention. Interview with Case Mix Coordinator CC conducted on 3/3/2015 at 2:00 p.m. revealed that the Magic Wash was ordered upon admission and was placed as one of the intervention, however, the Magic Wash was never ordered from the pharmacy and resident had never received it. Refer to F412, Example #1. | 2018-09-01 |
| 5433 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 412 | D | 0 | 1 | ZZBE11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, resident and staff interviews the facility failed to provide dental services for two (2) residents ( A and B) from thirty-two (32) sampled residents. Findings includes: 1. Observation conducted on 3/2/15 at 12:39 PM for resident A revealed multiple stain, missing, decayed /and or broken teeth. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] assessed the resident as having natural broken teeth. Review of the Care Area (CAA) Assessment Summary for this assessment revealed that dental care triggered and would be care planned. Review of an oral assessment conducted admission on 5/20/2014 revealed the resident had six (6) missing teeth and poor oral health. Review of admission physician's orders [REDACTED]. Interview with resident A conducted 3/3/2015 at 1:20 p.m. revealed she have never use any mouth wash since her admission nor seen a dentist. Interviews conducted 3/3/2015 at 1:30 p.m. with two (2) Certified Nursing Assistant (CNA) AA and BB, who cared for resident A revealed that they have never given the resident any mouth wash during oral care. Interview with Case Mix Coordinator CC conducted 3/3/2015 at 2:00 p.m. revealed that the Magic Wash was ordered upon admission, however, it was never ordered from the pharmacy and resident has never received it. 2. Observation conducted 3/2/2015 at 2:19 PM of resident B revealed missing lower teeth, with dark stain on her natural teeth. Interview with resident B on 3/3/2015 at 1:36 p.m. revealed when she was admitted to the facility she had a lower partial denture plate. Following her admission to the facility her dentures became missing and staff were unable to locate them. She revealed that she has asked on several occasions for facility staff to assist her in scheduling an appointment to have her partial replaced, without success. She further revealed that she has to eat soft food because her missing teeth make it hard for her to chew. She would like to be seen by a dentist. Review of admission nursing assessment conducted on 2/3/2012 revealed that resident had some of her own teeth and a lower partial plate. Review of facility grievance log revealed resident and family had filed several reports regarding resident's missing dentures. Interview with Senior Care Partner Coordinator conducted 3/3/2015 at 9:30 a.m. revealed that resident and family did filed reports regarding resident missing dentures however no appointments had been made for the resident to be evaluated by dentist for replacement. Interview with Director of Nursing (DON) conducted on 3/3/2015 at 11:50 a.m. revealed that the facility does not provide Dental services. However, if a resident complained of mouth pain and/or other concerns a local dentist would see, and accepted Medicaid residents. The facility would make arrangement for the resident to be seen. . | 2018-09-01 |
| 5434 | PRUITTHEALTH - FORT OGLETHORPE | 115409 | 1067 BATTLEFIELD PARKWAY | FORT OGLETHORPE | GA | 30742 | 2015-03-05 | 465 | D | 0 | 1 | ZZBE11 | Based on observations, resident and staff interviews the facility failed to provide a comfortable water temperature for bathing for two (2) residents (C and D) from a sample of thirty-two (32) residents. Findings Include: Interview with resident C on 03/03/15 at 9:43am revealed that water temperature in shower room was too cold. He indicated he had reported this Certified Nursing Assistant (CNA) and the nursing staff. Interview conducted with resident D on 03/04/15 at 3:10pm revealed he felt the water temperature in the men's shower room was cold. He indicated that it had been this way for quite some time and is worse in the winter months. Staff are aware and no one seems to know how to fix it. Interview conducted on 03/05/15 at 9:05am with CNA GG revealed that female residents complain about once or twice a week about the water in the shower rooms being too cold. When this happens we shut the water off in both the men's and women's shower rooms temporarily to give the water time to heat up again. We usually wait fifteen (15) to thirty (30) minutes. If this does not work we call maintenance. GG indicated that maintenance is usually called once or twice each week about the water in the shower rooms being too cold. Interview conducted with Maintenance Director on 03/05/15 at 09:20am revealed. he receives calls or verbal requests about the water being too cold in the shower rooms about once a week. He will adjust water valve and recheck the water temperatures to make sure the water temperatures are maintain at the proper temperature level for residents comfort. Water temperature for the Men's and Women's showers taken on 3/5/15 at 1:42pm by the Maintenance Director revealed the following: Men's Shower 96 and 98 degrees Fahrenheit (F.) Women's Shower 96 degrees F. | 2018-09-01 |
| 5831 | CHAPLINWOOD NURSING HOME | 115477 | 325 ALLEN MEMORIAL DRIVE SW | MILLEDGEVILLE | GA | 31061 | 2014-06-26 | 309 | D | 0 | 1 | ZYGZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews the facility failed to obtain a physician's order for [MEDICAL TREATMENT] treatments, and failed to monitor the [MEDICAL TREATMENT] for one (1) resident (# 68) receiving [MEDICAL TREATMENT] from a sample of twenty-seven (27) residents Findings include: Record review revealed that resident # 68 was admitted to the facility on [DATE] with the following diagnoses; Hypertension, End Stage [MEDICAL CONDITIONS], Chronic [MEDICAL CONDITION] Fibrillation, [MEDICATION NAME] Degeneration, and [MEDICAL CONDITION]. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident required extensive assistance with activities of daily living and was assessed as receiving [MEDICAL TREATMENT] while a resident in the facility. Review of the resident was care plan, initiated on 03/20/14, for alteration in health maintenance related to [MEDICAL CONDITION], revealed that the resident was receiving [MEDICAL TREATMENT] treatments at a local [MEDICAL TREATMENT] center and had a permacath in the right [MEDICATION NAME] for [MEDICAL TREATMENT] treatments. The interventions included; the resident will continue [MEDICAL TREATMENT] treatments without complications; ensure the resident attends [MEDICAL TREATMENT] treatments as scheduled; and observe access site for complications. Review of the medical records revealed no evidence of a physician order for [REDACTED]. Interview with Licensed Practical Nurse (LPN) GG on 06/25/14 at 8:40 a.m. revealed that resident # 68 was a [MEDICAL TREATMENT] patient and had an access site on her right upper chest that was covered by a dressing. Continued interview revealed that the site is checked each shift for signs of infection or drainage and that it is intact, but could provide no evidence that this monitoring was being done. Interview with the Director Of Nursing (DON) on 06/25/14 at 2:50 p.m. revealed that resident # 68 had [MEDICAL TREATMENT] orders written on the physician's order form (POF), but was unable to locate them in the medical record. She further revealed that the orders are probably documented on the resident's admission POF, and she would review the resident's thinned records for the order. Interview with the DON on 06/25/14 at 3:10 p.m. revealed that she was unable to find a physician's order for [MEDICAL TREATMENT] and after review of the interdisciplinary progress notes, was unable find any evidence that licensed staff were monitoring the resident's [MEDICAL TREATMENT]. Continued interview revealed that the facility policy was that [MEDICAL TREATMENT] residents have a physician's order for [MEDICAL TREATMENT] treatments and that the access site should be monitored by licensed staff. Interview with Resident Care Coordinator (RCC) HH on 06/26/14 at 1:15 p.m. revealed that resident # 68 should have had orders for [MEDICAL TREATMENT] three times weekly, and to monitor the site every shift on the admission orders [REDACTED]. | 2018-05-01 |
| 5832 | CHAPLINWOOD NURSING HOME | 115477 | 325 ALLEN MEMORIAL DRIVE SW | MILLEDGEVILLE | GA | 31061 | 2014-06-26 | 371 | F | 0 | 1 | ZYGZ11 | Based on observation and staff interview the facility failed to properly cover and label food items in the walk-in freezer, properly demonstrate the use of the three (3) compartment sink, and properly maintain temperature of puree food on the steam table to prevent the potential for foodborne illness. Thirteen (13) residents were receiving a puree diet. Findings include: Observation on 06/23/14 at 10:25 a.m. of the walk-in freezer revealed that there was a clear plastic bag that contained boneless rib patties that were not labeled or dated. Continued observation of the walk-in freezer revealed an open, unwrapped bag of French fries on the right side middle shelf. Observation on 06/25/14 at 12:45 p.m. of tray line temperatures taken by the Dietary Supervisor using the facilities calibrated thermometer revealed that the puree beef had a temperature of one hundred six degrees Fahrenheit (106F?). Observation on 06/25/14 at 2:25 p.m. revealed the evening cook AA pureed cooked carrots for the dinner meal. Continued observation revealed that AA washed the puree equipment in soapy water, rinsed, then dipped the items in the sanitizer solution and placed on drying rack. AA did not submerge the equipment for sixty (60) seconds as recommended for the chemical use of Quaternary Ammonium Compound (Quat) sanitizer. Interview on 06/23/14 at 10:40 a.m. with the Dietary Supervisor revealed that she confirmed that the boneless rib patties did not have a date and the French fries were not wrapped. Continued interview revealed that she expects staff to label and date all food items before placing them in the freezer or the refrigerator. She also expects staff to wrap items before placing them in the freezer or refrigerator. Interview on 06/25/14 at 12:55 p.m. with the Dietary Manager revealed that she confirmed that the puree beef was at one hundred six degrees Fahrenheit (106F?) and not at the proper holding temperature of one hundred thirty five degrees Fahrenheit (135F?). Interview on 06/25/14 at 2:30 p.m. with AA revealed that she always cleans any item in the 3 compartment sink as she demonstrated. Continued interview revealed that she was not aware that kitchen equipment that is washed and sanitized in the 3 compartment sink needs to be submerged for 60 seconds per manufactures recommendations. | 2018-05-01 |
| 5833 | CHAPLINWOOD NURSING HOME | 115477 | 325 ALLEN MEMORIAL DRIVE SW | MILLEDGEVILLE | GA | 31061 | 2014-06-26 | 441 | F | 0 | 1 | ZYGZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, and staff interview the facility failed to store resident personal care equipment in a sanitary manner on three (3) of three(3) halls. Findings include: 1. Observations on 06/23/14 beginning at 12:20 p.m. of the 100 Hall revealed the following: -room [ROOM NUMBER]-The bathroom shared by two (2) residents had an uncovered toothbrush, and toothpaste lying on the small metal shelf located under the mirror. There were two (2) uncovered bath basins observed on the shelf underneath the sink. -room [ROOM NUMBER]-The bathroom in room [ROOM NUMBER], a private room, revealed a urinal sitting on top of the toilet tank uncovered. -room [ROOM NUMBER]-The bathroom, shared by two (2) residents, had two (2) bath basins sitting on the shelf under the sink uncovered and stacked together and one (1) bedpan that was uncovered. -room [ROOM NUMBER]-The bathroom, shared by two (2) residents, had one (1) uncovered bed pan and two (2) uncovered bath basins under the sink on the shelf and one uncovered bath basin on the floor under the sink. -room [ROOM NUMBER]-The bathroom in room [ROOM NUMBER], a private room, had an uncovered bath basin in the bathtub, and an uncovered urinal hanging on the grab bar beside the toilet. Beside the residents bed on the floor was another uncovered bath basin. Observations on 06/24/14 beginning at 9:35 a.m. of the same bathrooms on the 100 hall revealed that the personal care equipment in each of the bathrooms remained uncovered Interview with the Director of Nursing (DON) on 06/26/14 at 3:00 p.m. revealed that the facility did not have a specific policy for personal care equipment but, it was her expectation that staff place all bedpans, urinals, and bath basins in a plastic bag when not in use. She further revealed that resident's care equipment should never be left uncovered when not in use, or on the floor. 2. Observation on 06/23/14 at 2:10 p.m. of room [ROOM NUMBER] revealed that the bathroom had two (2) pink wash basins that were stacked on top of each other, were not covered and were sitting on top of the toilet tank. There was a pink bed pan found on the floor next to the toilet that was uncovered. Observation on 06/24/14 at 10:00 a.m. of room [ROOM NUMBER] revealed that the wash basins and bed pan remained uncovered and in the same location. 3. Observation on 06/24/14 at 9:55 a.m. of room [ROOM NUMBER] revealed that the bathroom had two (2) pink uncovered wash basins that were located side by side on a wall rack and one (1) pink uncovered wash basin on a white wire rack under the sink. 4. Observation on 06/23/14 beginning at 2:20 p.m. of the 200 Hall revealed the following: -room [ROOM NUMBER]-The bathroom had two (2) uncovered pink wash basins were stacked within each other on a white wire rack on the floor and an uncovered urine collection hat inverted on a wire rack. -room [ROOM NUMBER]-The bathroom had two (2) uncovered pink wash basins that were stacked within each other on a white wire rack located near the toilet. -room [ROOM NUMBER]-The bathroom had two (2) uncovered pink wash basins that were sitting side by side on top of the toilet tank. -room [ROOM NUMBER]-The bathroom had two (2) pink wash basins stacked within each other, one (1) pink bed pan, and one (1) gray urine catcher located on a white wire rack on the floor under the sink, all items were uncovered. -room [ROOM NUMBER]-The bathroom had one (1) pink wash basin sitting on the floor and one (1) pink wash basin on a white wire rack stacked on top of a pink bed pan located under the sink. All items were uncovered. -room [ROOM NUMBER]-The bathroom had two (2) uncovered pink wash basins stacked within each other on a white wire rack located under the sink. Observations on 6/24/14 beginning at 9:30 a.m. of the same bathrooms on the 200 hall revealed the personal care equipment in each of the bathrooms remained uncovered 5. Observation on 06/24/14 at 9:20 a.m. of room [ROOM NUMBER] revealed that the bathroom had two (2) pink wash basins that were sitting side by side on white wire rack under sink and two (2) pink bed pans side by side on the floor under the wire rack All items were uncovered. 6. Observation on 6-23-14 at 10:15 a.m. revealed that in the bathroom of room [ROOM NUMBER], there was a bed pan sitting on the floor uncovered. 7. Observation of room [ROOM NUMBER] on 6/23/14 at 10:30 a.m. revealed that in the bathroom there were two (2) bed pans on the floor in bathroom uncovered. 8. Observation on 06/23/2014 at 10:20 a.m. of room [ROOM NUMBER] revealed that in the bathroom there were two (2) bath basins unlabeled and uncovered on the floor under the sink. Observation on 6/24/14 at 8:10 a.m. of room [ROOM NUMBER] revealed that the personal care equipment remained uncovered. 9. Observation on 6/23/14 at 10:40 a.m. of room [ROOM NUMBER] revealed that in the bathroom there was one (1) bath basin uncovered on the storage rack under the sink. Observation on 6/24/14 at 8:20 a.m. revealed that the personal care equipment remained uncovered. | 2018-05-01 |
| 2376 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2018-10-04 | 656 | D | 0 | 1 | ZYEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to implement the care plan related to oral care every shift, showers per facility policy, and clean nails as necessary for one resident (R) (R#61). In addition, the facility failed to implement the care plan related to monitoring for behaviors and side effects for one resident (R#48), who was routinely receiving an antipsychotic medication. The sample size was 34 residents. Findings include: Review of R#61's Admission Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 11 (a BIMS score of 8 to 12 indicates that a resident has moderately impaired cognition). Review of R#61's care plan for oral/dental health problems including several carious teeth dated 9/11/18, revealed an intervention for dental/oral care every shift and PRN (as needed). Review of R#61's self-care deficit related to activities of daily living care plan revised on 9/17/18 revealed interventions for bath/shower per facility policy and PRN. Shampoo hair regularly. Check nail length and trim/file and clean on bath day and as necessary. Provide sponge bath as needed. Assist/provide oral care [NAME]M. and P.M., clean gums with toothette, rinse mouth with wash. Assist resident with personal hygiene as needed. Review of the facility's shower schedules revealed that R#61 was scheduled to receive a shower on Tuesdays and Thursdays. During interview with R#61 on 10/2/18 at 8:55 a.m., he stated that he had not had a shower or bed bath, nor had mouth care, since he was admitted to the facility (on 9/11/18). Observation at this time revealed that his fingernails appeared dirty with dark debris both over and under his fingernails. Observation on 10/2/18 at 1:26 p.m. revealed that R#61's fingers appeared dirty, and had dark debris underneath the fingernails. R#61 denied receiving a bath, shower, or mouth care during interview at this time. During interview with CNA FF on 10/4/18 at 11:48 a.m., she stated that R#61 was scheduled for a shower on Mondays and Thursdays, was due for a shower that day, and that there was no documentation that he had received a shower in October. During continued interview, CNA FF stated that mouth care could be done by anyone in the morning, after lunch and at bedtime, and that she did nail care for residents on their shower day. During interview with the Assistant DON (ADON) on 10/4/18 at 2:10 p.m., she stated that the only documentation she found that R#61 received a shower since admission was on 9/11/18 and 9/25/18. Review of a Bathing: Self Performance report dated 10/4/18 revealed that R#61 received a shower on 9/11/18 at 4:08 p.m. (the day of admission), and 9/25/18 at 2:15 p.m. Cross-refer to F 677 2. Record review for R#48 revealed he was admitted with [DIAGNOSES REDACTED]. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] assessed that R#48 exhibited behaviors not directed towards others and received antidepressant and antianxiety medications. The Care Area Assessment (CAA) triggered Behavioral Symptoms and [MEDICAL CONDITION] Drug Use with the decision to be care planned. Review of the Care Plans for R#48 identified: * The resident has depression. Goal- the resident will remain free of signs and symptoms (s/s) of distress, symptoms of depression, anxiety or sad mood by/through review date of 9/10/18. Interventions included, but not limited to; Administer medications as ordered. Monitor for side effects and effectiveness. Monitor/report PRN (as needed) any s/s of depression, including hopelessness, anxiety, sadness, [MEDICAL CONDITION], anorexia, verbalizing, negative statements, repetitive anxious or health- related complaints, tearfulness, harm to self and harm to others. * The resident has a mood problem related to (r/t) depression anxiety. Goal- The resident will have improved mood state, happier, calmer appearance, no s/s of depression, anxiety or sadness through review date of 9/10/18. Interventions included, but not limited to; Administer medications as ordered. Monitor for side effects and effectiveness. Monitor any risk of harm to self or harm to others. Monitor/report to MD PRN acute episode feelings of sadness, loss of pleasure and interest in activities, feelings of worthlessness or guilt, change in appetite/ eating habits, change in sleep patterns, diminished ability to concentrate, change in psycho motor skills, impaired judgment or safety awareness. * The resident uses [MEDICAL CONDITION] medications r/t anxiety, dementia, depression. Interventions included, but not limited to; Administer [MEDICAL CONDITION] medications as ordered by physician. Discuss with MD, family ongoing need for use of medication. Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. Monitor/Record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others and document per facility policy. * The resident is receiving antipsychotic medication for management of dementia/depression. Goal: Resident will be managed/treated with the lowest possible antipsychotic dose and will not develop a movement disorder through the next review date of 9/10/18. Interventions included, but not limited to; Administer medication as ordered per physician. Document behaviors in MAR tracking form. Monitor for adverse medication reactions and report any to physician. Review of the Physician orders [REDACTED]. Review of the EMAR (Electronic Medication Administration Record) from (MONTH) (YEAR) through (MONTH) (YEAR) revealed no documentation of evidence of behavior or medication side effect monitoring. R#48 was observed with anxious pacing, wandering, sleepiness r/t [MEDICAL CONDITION], verbal growling and outburst, and overall flat affect all four days of the survey from 10/1/18 through 10/4/18. During interview on 10/4/18 at 10:40 a.m. with Certified Nursing Assistant (CNA) BB, she reported behaviors of constant pacing, excessive drinking coffee and disrobing in the halls. During interview on 10/4/18 at 10:50 a.m. with the Licensed Practical Nurse (LPN) AA, she reported behaviors of [MEDICAL CONDITION], daytime sleepiness, food seeking, excessive drinking of coffee and fluids, exit seeking, wandering, pacing, and verbal growling/grunting. Further LPN AA confirmed that behavior monitoring and medication side effect monitoring had not been conducted since the resident was admitted in March, (YEAR). LPN AA further stated that she never questioned why behavior monitoring and medication side effect monitoring was not on the residents EMAR but stated it should be. Interview on 10/4/18 at 11:10 a.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) confirmed R#48 had been receiving antipsychotic, antianxiety, antidepressants and mood stabilizers and that no monitoring for behaviors or medication side effects had been conducted since the resident's admission to the facility in (MONTH) (YEAR). had been conducted. The DON and the ADON stated that they do not follow up to ensure behavior and side effect monitoring was entered into the EMAR and being conducted. (Cross Refer F758) | 2020-09-01 |
| 2377 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2018-10-04 | 657 | D | 0 | 1 | ZYEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident and staff interview, the facility failed to notify two residents (R) (R#69 and R#171) of the dates of their scheduled care planning conferences, to enable these residents to participate in the development and/or revision of their care plans and allow them to make decisions about their care and treatment options. The sample size was 34 residents. Findings include: Review of the facility policy Care Planning-Interdisciplinary Team revised (MONTH) 2013 revealed: Policy Statement: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the resident's care plan. 1. During interview with R#69 on 10/1/18 at 4:03 p.m., she stated that she had never been invited to a care plan meeting, and that this was something she would be interested in. Review of R#69's Quarterly Minimum Data Set ((MDS) dated [DATE] revealed that she had a Brief Interview for Mental Status (BIMS) score of 14 (a BIMS score of 13 to 15 indicates that a resident is cognitively intact). Further review of her MDS revealed that she had MDS assessments completed on 12/28/17, 3/29/18, 5/30/18, 6/25/18, and 9/24/18. Review of R#69's Invitation to attend Resident Care Plan Meeting forms revealed that on 12/27/18 (sic), 3/22/18, 5/9/18, and 8/14/18, the invitations with dates of the scheduled care plan meetings were sent to the resident's responsible party (RP) listed on her admissions packet face sheet, but no evidence that R#69 was notified or invited to her meetings. Review of Plan of Care/MDS Notes dated 1/9/18, 4/3/18, 6/26/18, and 9/25/18 revealed: Note Text: Care plan reviewed with IDT (interdisciplinary team). Family did not attend. Continue with plan of care. Review of Care Plan Session forms revealed that the IDT met to discuss R#69's care planning on 1/9/18, 4/3/18, 6/26/18, and 9/25/18. Further review of these forms revealed that the section Resident Invited to Care Plan Conference was not checked for any of these meetings, and there were notations that the family was invited but did not attend. During interview with Registered Nurse (RN) MDS Coordinator CC on 10/4/18 at 9:50 a.m., she stated that she invited residents who were cognitively intact, and able to understand what was being discussed, to their care plan meetings, and that she also sent invitations to the RP. She verified during further interview that R#69 was cognitively able to attend her care plan meetings, but that she did not invite her. 2. Record review for R#171 revealed an Admission MDS assessment dated [DATE] which documented a BIMS summary score of 11, indicating the resident had moderate cognitive impairment. During an interview on 10/02/18 at 8:38 a.m., R#171 stated he had never attended a care plan meeting with staff and had never been invited to attend a meeting to discuss his treatment, goals or plan of care. R#171 expressed that he would like to participate in the care plan meetings and it is important to him to be involved in the decisions of his care. He stated it is his goal to be discharged back to the community. R#171 stated he is unsure if his cousin, who is helping him, attends the meetings. Review Patient Care Conference form dated 8/14/18 documented in handwriting Family requested phone review of care plan. A check mark indicated Letter sent to family member/responsible party to attend conference. There was no check mark to indicate Resident invited to care plan conference. Interview on 10/2/18 at 2:04 p.m. with the MDS/LPN CC revealed she did not invite R#171 to his Care Plan Conference meeting. She stated the resident is forgetful but he is cognitive and she should have invited him. MDS/LPN CC stated she is relatively new to MDS and she would make sure the residents are invited to their care plan meetings moving forward. | 2020-09-01 |
| 2378 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2018-10-04 | 677 | D | 0 | 1 | ZYEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, the facility failed to consistently provide showers, nail, and mouth care for one resident (R) (R#61). The sample size was 34 residents. Findings include: Review of R#61's Admission Minimum Data Set ((MDS) dated [DATE] revealed that he had a Brief Interview for Mental Status (BIMS) score of 11 (a BIMS score of 8 to 12 indicates that a resident has moderately impaired cognition); had no behaviors including rejection of care; needed supervision for personal hygiene; and extensive assistance for bathing. Review of R#61's care plan for oral/dental health problems including several carious teeth, revealed an intervention for dental/oral care every shift and PRN (as needed). Review of R#61's self-care deficit related to activities of daily living care plan revealed an intervention for bath/shower per facility policy and PRN. Shampoo hair regularly. Check nail length and trim/file and clean on bath day and as necessary. Provide sponge bath as needed. Assist/provide oral care [NAME]M. and P.M., clean gums with toothette, rinse mouth with wash. Assist resident with personal hygiene as needed. Review of the facility's shower schedules revealed that R#61 was scheduled to receive a shower on Tuesdays and Thursdays. During interview with R#61 on 10/2/18 at 8:55 a.m., he stated that he had not had a shower or bed bath since he had been admitted to the facility (21 days ago on 9/11/18), and that staff will tell him that they were going to come and get him, but never do. He stated during further interview that he would like a shower every day, and had never refused one. Observation at this time revealed that his fingernails appeared dirty with dark debris both over and under his fingernails, and stated during interview that he did not remember the last time they were cleaned. R#61 stated during continued interview that he had not had his teeth brushed since he had been there, and would like to have them brushed daily. Observation on 10/2/18 at 1:26 p.m. revealed that R#61's fingers appeared dirty, and had dark debris underneath the fingernails. R#61 denied receiving a bath, shower, or mouth care during interview at this time. Review of an admission Skin/Wound Note dated 9/11/18 revealed that R#61 was alert and oriented, was clean but unshaven, and had his own teeth in poor shape. Review of all of the Nurse's Notes since admission revealed that nothing was seen related to R#61 refusing care. During interview with Certified Nursing Assistant (CNA) DD on 10/3/18 at 2:58 p.m., she stated that the facility had a shower team, who worked every day but Sunday. She further stated that if other CNA staff called out, the shower team CNAs were pulled to take their place, and that this happened a lot but they still seemed to get the showers done. During interview with Licensed Practical Nurse (LPN) EE on 10/4/18 at 10:42 a.m., she stated that the shower team CNAs had been pulled to work the floor quite a bit in the past three weeks, because of a lot of call-outs and resignations recently. During interview with the Director of Nursing (DON) on 10/4/18 at 11:08 a.m., she stated that if a CNA called out for their shift, that they had to pull the shower team staff to take their place, and tried to make up the missed showers on the weekends. During interview with R#61 on 10/4/18 at 11:31 a.m., he stated that he did not believe that he had gotten a shower. During interview with CNA FF on 10/4/18 at 11:48 a.m., she stated that there were three CNAs scheduled to work the shower team, and they did an average of nine to ten showers each per day. She further stated that just about every other day at least one of the shower team staff was pulled to work the floor. She stated during further interview that if a shower team CNA got pulled, the residents assigned to them did not get a shower that day unless they had extra time at the end of the day. She stated during continued interview that showers were given sometimes on the weekend for the residents that missed their shower during the week. CNA FF further stated that R#61 was scheduled for a shower on Mondays and Thursdays, was due for a shower that day, and that there was no documentation that he had received a shower in October. During continued interview, CNA FF stated that mouth care could be done by anyone in the morning, after lunch and at bedtime, and that she did nail care for residents on their shower day. She further stated that she had never known R#61 to refuse care, and thought she may have bathed him one time but could not remember when. During interview with the Assistant DON (ADON) on 10/4/18 at 2:10 p.m., she stated that R#61's shower schedule had not been entered into the CNA's computerized system to be done routinely, but he had been scheduled for showers PRN only. She further stated that the only documentation she found that R#61 received a shower since admission was on 9/11/18 and 9/25/18. Review of a Bathing: Self Performance report dated 10/4/18 revealed that R#61 received a shower on 9/11/18 at 4:08 p.m. (the day of admission), and 9/25/18 at 2:15 p.m. During interview with the Administrator on 10/4/18 at 4:37 p.m., she stated that she had some residents recently tell her that they had not gotten their showers, and that she met with the nursing management team last Thursday to address the concern. Review of a document entitled Shower Meeting 9/27/2018 revealed that the Administrator and five nurses discussed a plan to ensure that residents received their scheduled shower if a shower team CNA got pulled. | 2020-09-01 |
| 2379 | FRIENDSHIP HEALTH AND REHAB | 115559 | 161 FRIENDSHIP ROAD | CLEVELAND | GA | 30528 | 2018-10-04 | 758 | D | 0 | 1 | ZYEV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, review of the policy titled Documentation- Behavior Monitoring and staff interviews, the facility failed to ensure that behavior and medication side effect monitoring was conducted for one resident (R) (#48) that exhibited behaviors of verbal outburst, pacing/wandering, exit seeking and obsessive drinking and received [MEDICATION NAME], an antipsychotic medication. The sample was 34 residents. Findings include: Review of the facility policy titled Documentation- Behavior Monitoring dated 3/10/16 documented When a resident receives and antipsychotic medication that is medically indicated and may help promote or maintain the resident's highest practicable mental, physical, and psychosocial wellbeing, the resident will be placed on behavior or monitoring. 1- All residents receiving antipsychotic medications will have Behavior Monitoring to include side effects monitoring in place. 2- Nursing Management will review all medication orders daily. 3- If there is a new order for antipsychotic medication, the nurse manager reviewing will verify that the resident has also been placed on Behavior Monitoring with side effects monitoring. 6- Behavior Monitoring will be initiated on all residents with Behavior incident, and the resident will remain on Behavior Monitoring until the Behavior has resolved or stabilized and Behavior Par is discontinued. 7- Behavior Monitoring will be documented each shift on the EMAR by the Charge Nurse. R#48 was admitted to the facility with [DIAGNOSES REDACTED]. Record review for R#48 revealed an Admission Minimum Data Set (MDS) assessment dated [DATE] which demented a Brief Interview for Mental Status summary score of 99 indicating the resident was unable to complete the interview. Staff assessed that the resident was fidgety or restless and moved around more than usual. R#48 exhibited behavioral symptoms not directed towards others and received antianxiety and antidepressant medications all seven days of the look back period. The Care Area Assessment (CAA) triggered Behavioral Symptoms with the decision to be care planned. Review of the Quarterly MDS assessment dated [DATE] documented a BIMS of 99. Staff assessed that the resident was fidgety or restless and moved around more than usual. R#48 exhibited behavioral symptoms not directed towards others and the presence of wandering 1-3 days of the look back period. The resident received antipsychotic, antianxiety and antidepressant medications all seven days of the look back period. Further record review for R#48 revealed a Wandering PAR tracking which documented two elopements in which the resident was found in the parking lot on 5/9/18 and 7/24/18. No further attempts to exit facility had been made by the resident. Review of the Medication Review Report revealed the following [MEDICAL CONDITION] medications: [REDACTED] 3/2/18- [MEDICATION NAME] 15 MG (milligrams) three times a day (TID) for Anxiety Disorder 3/15/18- [MEDICATION NAME] 10 MG one time a day for Major [MEDICAL CONDITION] with Severe Psychotic Symptoms 3/5/18- [MEDICATION NAME] Sprinkles 125 MG delayed release twice daily (BID) for Dementia with Mood Behaviors 3/14/18- [MEDICATION NAME] 0.25 MG once daily for Major [MEDICAL CONDITION] with Severe Psychotic Symptoms 3/16/18- [MEDICATION NAME] 1 MG once daily for Major [MEDICAL CONDITION] with Severe Psychotic Symptoms 9/28/18- Trazadone 150 MG once at bedtime for [MEDICAL CONDITION] Review of the Medication Administration Records (MAR) for R#48 from (MONTH) (YEAR) through (MONTH) (YEAR) revealed the medications were administered as ordered. Further review of the MARs revealed no evidence or documentation of target behavioral symptoms and no evidence or documentation of medication side effect monitoring of the [MEDICAL CONDITION] medications. Observation on 10/1/18 at 12:36 p.m. revealed the resident at the dining room table, waiting for lunch. The resident was noted to make verbal growling noise throughout the dining observation. Resident also noted to walk up and down the halls and in the dining room throughout the day. Observation on 10/3/18 at 8:13 a.m. revealed R#48 at the dining room table leaning over his breakfast tray sleeping. Staff observed waking the resident up to eat. The resident did wake up to eat would then fall back asleep. Interview attempted with R#48 but the resident just makes verbal growling noises and was not a candidate for interview. Interview on 10/3/18 at 8:20 a.m. with Licensed Practical Nurse (LPN) AA revealed R#48 often stays up late and paces the halls and will not lay down. She stated the resident always fights sleep. LPN AA stated R#48 did not receive any sedation last night but received his regular scheduled 150 MG (milligrams) of Trazadone for [MEDICAL CONDITION]. She stated some mornings he is like this and if they try to lay him down, he just gets back up, will go sit in a chair on the dining/day room and fall asleep in the chair. She stated the resident gets ups and lays down as he wants to. LPN stated he probably was up a lot last night. Observation on 10/3/18 at 12:30 p.m. revealed R#48 sleeping in his bed. At 1:28 p.m. the resident was observed in his bed and had not been to the dining room. Interview on 10/3/18 at 1:30 p.m. with the Certified Nursing Assistant (CNA) BB revealed R#48 was up and awake all night and was now sleeping. She stated the kitchen staff put his lunch away and they will heat his lunch up when he wakes up. Observation on 10/4/18 at 8:24 a.m. revealed R#48 in the dining room eating his breakfast. The resident was awake and alert and occasionally grunting and making growling noises. Interview on 10/4/18 at 8:30 a.m. with LPN AA revealed it was reported to her by the nightshift LPN that R#48 was up much of the night again last night. Nightshift reported that they put him to bed and he would get back up, come into the dayroom and fall asleep in the chair. Interview on 10/4/18 at 10:40 a.m. with CNA BB revealed she is very familiar with R#48. She stated that the resident does not have any physical aggression and rarely resist care but he paces the halls a lot. She further stated the resident drinks a lot of coffee and will just keep drinking it all day. Stated he also loves food and loves to eat a lot. Interview on 10/4/18 at 10:50 a.m. with the LPN AA revealed the R#48 does not have any physically aggressive behaviors, or verbal aggression. She stated he does make a growling nose that has seemed to improve some. She stated the resident was drinking so much coffee that his sodium was low and the Physician put him on fluid restrictions. She stated R#48 does not like that and he is not compliant with this. She stated he has a gastric bypass in the past and he is food seeking. LPN AA stated she can't leave anything out like a cup of pudding or applesauce for meds or he will take it. She stated he loves to eat. LPN AA stated R#48 was exit seeking but does not exhibit this behavior anymore. She stated he paces the halls, fights sleep and walks constantly. She stated the resident goes around touching things and messing with things. Further, LPN AA confirmed that since the resident' admission in March, (YEAR), there had been no behavior monitoring or monitoring of side effects of antipsychotic medications for R#48. LPN AA stated that as a nurse, any resident receiving an antipsychotic medication is supposed to monitor and document behaviors and medication side effects each shift daily. LPN AA was asked had she ever questioned why behavior monitoring or medication side effects was not on the MARS, she stated No. Interview on 10/4/18/at 11:43 a.m. with the Attending Physician for R#48 revealed the R#48 gets extremely agitated at times. He stated the resident has a behavior where he bellows out super loud and it can go on for hours at a time. He stated he has witnessed this behavior himself. He stated the resident was exit seeking although this has improved some but he still paces or walk around constantly and at night time. He stated the resident has exhibited obsessive behaviors and would drink 20-30 cups of coffee a day. He stated his sodium was low and he ordered fluid restriction for the resident although the resident is rarely compliant. He stated the resident touches everything and is food seeking and it's disconcerting to the resident and he is generally unsettled and miserable. The Attending Physician stated R#48 is not aggressive and very pleasant but dementia medications or that family of medications will not help with these types of behaviors. He stated he is trying the [MEDICATION NAME] for now and he has seen a little improvement. He stated he may try other medications down the road but this is currently what they are doing to try and address his behaviors. Interview on 10/4/18 at 11:10 a.m. with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) revealed the ADON typically enters the new admission orders [REDACTED]. The ADON stated new medication orders after admission are entered by the nurse receiving the orders and that nurse would be responsible for entering the behavior and medication side effect monitoring. The DON stated they discuss all new medications every morning in meeting. The DON and the ADON stated that they do not follow up to ensure the medication was entered in the Electronic Medical Record (EMER) or that behavior and side effect monitoring was entered on the MAR. The DON and ADON confirmed R#48 had been receiving antipsychotic, antianxiety, antidepressants and mood stabilizers and that no monitoring had been conducted. | 2020-09-01 |
| 4670 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 164 | E | 0 | 1 | ZXZ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of clinical records, facility policy and Quality Assurance Event documentation, resident and staff interviews, the facility failed to provide visual privacy in the shower room for six (6) residents ( A, B, C, D, E, and F) from a sample of thirty-four (34) residents. Findings include: An interview conducted on 08/11/15 at 9:39 a.m. with resident E revealed there are three (3) to four (4) naked women in the shower room at one time. Continued interview revealed that the resident was very uncomfortable with being unclothed in the presence of other residents. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) Summary score of 11 and was able to make her needs known. During an interview conducted on 08/11/15 at 2:06 p.m. with resident B revealed there are three (3) to four (4) women in the shower room at one time and they can see each other naked. Resident B indicated this makes her feel embarrassed because she is very modest. Review of the MDS assessment dated [DATE] revealed the resident Bhad a BIMS summary score of 15 which indicated that the resident was cognitively intact. An interview conducted on 08/12/15 at 11:30 a.m. with resident C revealed there was often times when several men would be in the shower room at one time with no privacy and they could see each other naked. The resident revealed he had told the administrator he was never going to the shower room again because he felt embarrassed. Review of MDS assessment completed on 05/25/15 indicated a BIMS summary score of 12. An interview conducted on 08/13/15 at 8:23 a.m. with resident D revealed there were times when there were two (2) to 3 residents in the shower room at one time undressed, and not provided with privacy. The resident explained she is modest and embarrassed being showered with other residents. Review of the MDS assessment dated [DATE] that indicated a BIMS summary score of 15 which indicated that the resident was cognitively intact. During an interview on 08/13/15 at 8:27 a.m. resident A indicated in the women's shower room there are typically 2 to 3 residents naked in front of each other. The MDS assessment dated [DATE] revealed resident A had a BIMS summary score of 15 and was cognitively intact. An interview conducted on 08/14/15 at 11:40 a.m. with resident F revealed there have been times when he was in the shower room with two other men that were naked and there was no privacy. The MDS assessment dated [DATE] indicated a BIMS summary score of 15 that the resident was cognitively intact. An observation conducted on 08/13/15 at 2:50 p.m. of the Men's Shower room revealed one privacy curtain at the shower stall and two privacy curtains in the dressing area. On 08/13/15 at 2:55 p.m. an observation of the Women's Shower room revealed one privacy curtain at the shower stall and two privacy curtains in the dressing area. A review of the facility Quality Assurance Event document entitled Just Do It, dated 12/05/14, indicated resident C had voiced concern of being naked in the presence of others while in the shower. A review conducted of the Dressing and Undressing the Patient- Procedural Guidelines documents revealed to: Allow the patient as much privacy as possible. Avoid unnecessary exposure. An Interview conducted 08/14/15 at 11:03 a.m. with the Administrator revealed that he does remember a male resident coming to him about multiple residents in the shower room with no privacy. The Administrator stated that he believes he referred this to nursing and that he would look into it. Cross refer to F 241 | 2019-08-01 |
| 4671 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 223 | D | 0 | 1 | ZXZ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview and staff interviews and review of the Abuse Prohibition Policy and Procedures, the facility failed to implement measures to protect two (2) residents (A and B) from a sample thirty four (34) residents from sexual abuse by a resident with a history of sexual advances and inappropriate touching of females. Findings include: Record review for Resident A revealed a Quarterly Minimum Data Set (MDS) assessment dated [DATE], Section C - Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) Summary Score of 15, indicating that the resident was cognitively intact. An interview conducted on 08/11/15 at 8:43 a.m. with resident A revealed about two (2) weeks ago, a visually impaired resident in the facility put his hand on her shoulder while walking then he slid his hand down her side and pinched her butt. She said she mentioned it to her Certified Nurse Assistant (CNA) BB that day and BB indicated that something should be done about this resident, that he touches the staff also. Record review for Resident B revealed a Quarterly MDS assessment dated [DATE], Section C BIMS Summary Score 15, indicating that the resident was cognitively intact. Continued record review of the Situation Background Assessment Recommendation (SBAR) Form and Progress Note dated 06/27/15 documents that resident B stated a male patient came into her room the previous evening and rubbed her face and touched her breast. She was offered but did not want to move to a different room. The Director of Nurses (DON) confirmed she was aware of the incident but it was not reported to the state because the resident did not want it reported. An interview conducted on 08/13/15 at 12:15 p.m. with resident B confirmed the above incident. She said she told the resident that he was in the wrong room and he needed to go back to his room in which he did comply. She said she did not tell anyone that night. She said she did report it to a CNA in the morning and the CNA said she had to report it to her supervisor. She said the bathroom connects her room to the room of the male resident and it is not always locked. She stated that she does not use the bathroom and acknowledged that the male resident has come into her room on occasion through the bathroom door. Observations at that time revealed the doors between the bathroom shared by the female residents and the adjoining male residents' room were unlocked on both sides. An observation conducted on 08/11/15 at 2:00 p.m. during initial tour revealed the bathroom for the adjoining rooms was unlocked at both room entrances. An interview conducted on 08/12/15 at 10:20 a.m. with CNA BB confirmed that the male resident has touched her and other staff inappropriately. She said they do not always report it because it has been going on for so long they are all aware that he does this out habit and they usually re-direct him and tell him it is not OK to touch them that way. She said she this usually happens when he places his hand on their shoulder to be led to a destination and his hand will start to wander. A review of the Abuse Prohibition Policy and Procedures documents each patient has the right to be free from verbal, mental and sexual abuse, including sexual harassment, sexual coercion or sexual assault. An interview conducted on 08/11/15 at 2:53 p.m. with the Administrator revealed the incident involving resident A was never reported to him. A further interview conducted on 08/13/15 at 11:00 a.m. with the Administrator revealed he was not aware that the visually impaired male resident was touching staff inappropriately. | 2019-08-01 |
| 4672 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 225 | D | 0 | 1 | ZXZ911 | Based on observation, resident interview, staff interviews, record review and review of the Abuse Prohibition Policy and Procedures, the facility failed to report and thoroughly investigate the alleged sexual abuse of one (1) resident (B) by another resident from a sample of thirty four (34) residents. Findings include: Record review of the Situation Background Assessment Recommendation (SBAR) Form and Progress Note dated 06/27/15 documented that resident B stated a male patient came into her room the previous evening and was rubbing her face and touched her breast. She did not want to move to a different room and she did not want a call to her husband because she did not want him to know. During a joint interview conducted on 08/13/15 at 1:26 p.m. with the Administrator and the Director of Nursing (DON) confirmed there was an incident on 06/26/15 that involved a male resident going into the room of female resident with inappropriate touching. The DON confirmed she was aware of the incident but it was not reported to the State as required by the facility Abuse Prevention Policy because the resident did not want it reported. | 2019-08-01 |
| 4673 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 241 | E | 0 | 1 | ZXZ911 | Based on observation, review of Quality Assurance Event documentation, review of facility policy, and resident and staff interviews, the facility failed to promote care in the shower room in a manner that maintained the dignity of six (6) residents (A, B, C, D, E and F) from a sample of thirty-four (34) residents. Findings include: An interview conducted on 08/11/15 at 9:39 a.m. with resident E revealed there are three (3) to four (4) naked women in the shower room at one time and she does not like that. She is very uncomfortable with this and she feels fat. She feels uncomfortable around the skinny residents and does not understand why they cannot be covered with a towel until it is time for their turn in the shower stall. On 08/11/15 at 2:06 p.m. an interview with resident A revealed there are 3 to 4 women in the shower room at one time and they can see each other naked. She said she had to lose her modesty a long time ago. She said it does not personally bother her but she realizes it might bother others. During an interview conducted on 8/13/15 at 8:23 AM with resident D, she revealed there were times when there were two (2) to three (3) residents in the shower room at one time in which they were all naked and not provided with privacy. She said she is a modest person and she does not like it. She said it was so embarrassing. An interview conducted on 8/13/15 at 8:27 AM with resident Brevealed in the women's shower room there is typically two (2) to three (3) residents at one time. She said they are naked in front of each other. She said this really bothers her because she is a very modest woman. She said she has never been comfortable with being naked and she never even got naked in front of her husband. She said she never told anyone because she was afraid to make a fuss. An interview conducted on 08/12/15 at 11:30 a.m. with resident C revealed there were often times when several men would be in the shower room together with no privacy and they could see each other naked. He said he told the Administrator that he was never going in the shower room again if there was going to be a bunch of naked men in there. During an interview conducted on 8/14/15 at 11:40 a.m. resident F revealed there have been times when he was in the shower room with two other men that were naked and there was no privacy. He said it does not bother him because he just doesn't look at them and he keeps his own clothes on until it's his turn for the shower stall A review conducted of the Dressing and Undressing the Patient- Procedural Guidelines documents: Allow the patient as much privacy as possible. Avoid unnecessary exposure. Facility Quality Assurance documentation entitled Just Do It dated 12/5/14 revealed resident C voiced concern of being naked in the shower in the presence of others. An Interview conducted 08/14/15 at 11:03 a.m. with the Administrator revealed he did remember a male resident coming to him about multiple residents in the shower room with no privacy. He said he believed he referred this to nursing and would look into it. He has not received any other complaints from any residents related to privacy in the shower rooms. | 2019-08-01 |
| 4674 | HARTWELL HEALTH AND REHABILITATION | 115435 | 94 CADE STREET | HARTWELL | GA | 30643 | 2015-08-13 | 272 | D | 0 | 1 | ZXZ911 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to accurately assess one (1) resident (#97) for the [MEDICAL CONDITION] drug usage from a sample of thirty-four (34) residents. Findings include: Review of the Minimum Data Set (MDS) for Significant Change dated 05/18/15 revealed that the resident was assessed as not receiving antipsychotic medications during the 7 day look back period for that assessment. Review of the record revealed a physician order [REDACTED]. Review of the Medication Administration Record [REDACTED]. Interview on 08/15/15 at 11:30 a.m. with Licensed Practical Nurse CC revealed that upon reviewing the Medication Administration Record [REDACTED]. | 2019-08-01 |
| 2919 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2016-08-26 | 251 | E | 0 | 1 | ZXOF11 | Based on record review and staff interview, the facility failed to ensure that the facility's Social Worker had the proper qualifications for a facility with over one hundred and twenty (120) beds. The facility census was one hundred and fifteen (115) residents. Findings include: Review of the facility's licensure revealed that the facility is licensed for one-hundred and twenty-six beds (126). Review of the facility's personnel files on 08/25/16 at 1:30 p.m. revealed that the education documented for the current Social Worker was an Associate's degree in Psychology. Interview on 08/25/16 at 2:30 p.m. with the Administrator revealed that the Social Worker has over one (1) year of experience working as a social worker at the facility. Post survey interview on 09/02/16 at 11:00 a.m. with the Director of Nursing (DON) revealed that the Social Services Director currently has an Associate's Degree in Psychology, thirty (30) hours Social Services Training course from Georgia Health Care Association (GHCA). Post survey interview on 09/06/16 at 10:03 a.m. with the Administrator revealed that the Social Services Director was hired prior to his coming to the facility and he was not aware that she does not have a Bachelor's degree. The Administrator further stated that his expectation of the Social Service Director would be to perform all job duties to meet all of the residents social service needs and he stated that the Social Services Director does that. The Administrator went on to say, she not only meets the needs but she exceeds expectations. Review of Section C of the Resident Census and Condition of Residents dated 08/23/16 documents that the facility has fifty-four (54) residents with documented signs and symptoms of depression, twenty-seven (27) residents with documented psychiatric diagnosis' (not including residents with dementia or residents with depression), ten residents with behavioral healthcare needs. Review of Section F of the Resident Census and Condition of Residents dated 08/23/16 documents that the facility has seventy-nine (79) residents on psychoactive medications, twenty-eight (28) residents on antipsychotic medications, thirty (30) residents on antianxiety medications, sixty-eight (68) residents on antidepressant medication, and five (5) residents on hypnotic medication. | 2020-09-01 |
| 2920 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2016-08-26 | 279 | D | 0 | 1 | ZXOF11 | **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 for urinary incontinence for one (1) Resident (R)137) of thirty-five (35) sampled residents. Findings include: Review of the clinical record note dated 06/01/16 for R137 revealed the resident was assessed by a urologist for gross hematuria (blood in the urine) and possible bladder mass. Findings from this same note revealed resident reported nocturia (the need to urinate at night) and occasional urine urgency. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE] Section H Bladder and Bowel revealed that R137 was assessed to be frequently incontinent (7 or more episodes of urinary incontinence, but at least one episode of continent voiding). No indwelling catheter. Continued review of the MDS Section V - Care Area Assessment (CAA) Summary revealed that Urinary Incontinence triggered as a concern, with the decision made to care plan. Review of the Southern Health Care Management (SHCM) Incontinence Evaluation Form dated 4/19/16 revealed that R137 had been incontinent for one week to one month, had a history of [REDACTED]. Review of the SHCM Incontinence Evaluation Form dated 5/17/16 revealed that R137 had been incontinent for one (1) week to one (1) month, required assistance of from one to two people to walk to the bathroom, to transfers to the toilet or bedside commode. Review of the care plans for R137 revealed no evidence that a care plan for urinary incontinence had been developed. Interview with the Registered Nurse (RN) Care Specialist Manager AA and LPN Care Specialist Manager BB, on 08/24/16 at 2:20 P.M., revealed the RN Care Specialist Manager AA is responsible for all MDS assessments and evaluations for the Care Area Assessment (CAA) and LPN Care Specialist Manager BB uses that data to complete individualized care plans and revisions. Continued interview revealed that R137 did not have a care plan addressing urinary incontinence and that the residents care plan for urinary incontinence must have been overlooked when the care plans were developed. Interview with the Director of Nursing (DON), on 08/26/16 at 2:34 P.M. revealed that a daily clinical meeting is held with care plan team being present. During this meeting resident problems and treatment interventions are discussed. Continued interview revealed the care plan team is also present during weekly focus meetings, which also addresses resident problems and it is the expectation, of the DON, that areas addressed are reflected on the residents care plans. The DON also revealed that urinary incontinence assessments are done at admissions and should be addressed at that time. | 2020-09-01 |
| 2921 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2016-08-26 | 371 | E | 0 | 1 | ZXOF11 | Based on observations, staff interviews, and facility policy review the facility failed to assure that food was labeled, dated, and not expired in the kitchen in one (1) of one (1) walk in coolers. The facility failed to ensure food was labeled, dated, and not expired in two (2) of two (2) resident pantry refrigerators (East and West wing). The facility failed to monitor temperatures for the refrigerator and the freezer in one (1) of two (2) resident refrigerators; and the facility failed to ensure there was no buildup on the on dispensing lid of the ice machine in one (1) of two (2) ice machines in the resident food pantry's. The resident sample size was thirty-five (35) and the census was one hundred and fifteen (115). Findings include: Observation on 08/24/16 at 12:15 p.m. of the walk in cooler in the kitchen revealed a twelve (12) pound box of diced ham that did not have a used by date. Further observation revealed five packages of ranch dressing packages that were not in their original package that were not labeled with a use by or expiration date. Review of the facility's policy titled Food Storage Principles revealed the following: each package, box, can, etc. should be labeled with the expiration date, date of receipt, or when the item was stored after preparation. Observation on 08/25/16 at 11:30 a.m. of the East Wing Resident food pantry revealed six (6) 3.5 ounce Jello cups with an expiration date observed to be 7/21/16 (over one month expired). Observation on 08/25/16 at 11:40 a.m. of the West Wing resident food pantry refrigerator revealed that there was not a thermometer in the freezer, further observation revealed one styrofoam cup with no name or date in the freezer, one (1) 24 ounce Everfresh Watermelon juice bottle that was not labeled or dated, one (1) Captain D ' s cup that was not labeled or dated, one (1) gallon container of 1% milk with an expiration date of (MONTH) 15 (ten days past the expiration date), and two (2) one (1) quart containers 2% milk that were not labeled. A sticky build up was observed on the pantry refrigerator door, and a single strand of hair was observed on the top shelf of the refrigerator. Interview on 08/25/16 at 11:59 a.m. with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the refrigerator is cleaned by either housekeeping or the Certified Nursing Assistants (CNAs). The DON reported that housekeeping staff are responsible for cleaning the resident food pantries and the refrigerators. The DON further explained that nursing and dietary staff are to ensure that there are not any expired foods. The DON also revealed that the nursing staff is responsible for checking the temperatures of the refrigerators and freezers in the resident's food pantries. Review of the temperature logs for the refrigerator and freezer for the West wing revealed that temperatures had only been documented once for the month of August. Review of the facility ' s policy titled Cold Food Storage Areas revealed that the facility must record and monitor the temperatures of the refrigerators and the freezers at least twice daily and record the findings on the Temperature Log sheet. Observation on 08/25/16 at12:14 p.m. in the East Wing food pantry revealed a pink buildup on the dispensing lid of the ice machine. The pink build up was also observed on the paper towel after the dispensing lid was wiped. Observation and interview on 08/25/2016 at 12:14 p.m. with the DON confirmed the 7/21/16 expiration date on the six Jello cups in the East Wing resident food pantry refrigerator. The DON reported that nursing and dietary staff should routinely come in to check the labeling and dating of items in the refrigerators. The DON also confirmed the presence of a pink build up on the dispensing lid of the ice machine. Interview on 8/26/16 at 11:30 a.m. with the facilit 's Administrator and the Maintenance Director revealed that the ice machines are deep cleaned monthly which consists of emptying the machine and cleaning the inside and outside. The ice machines should be cleaned weekly by cleaning the outside of the machine and looking inside the ice machine to determine if there is any buildup. The Administrator and the Maintenance Director confirmed that even after cleaning the ice machine on the East wing yesterday there was still a pink buildup on the dispensing lid of the ice machine. Review of the facility's policy titled Water Appliances Inspection and Maintenance for ice machines revealed that the ice machines should be checked at least weekly, to assure that the ice machines are producing the correct amount of ice, and that the machines are clean inside and outside. Interview on 8/26/16 at 12:59 p.m. with the Dietary Manager Dietary revealed the pantries are checked daily by either the Dietary Manager or the nursing staff for expired items or items that are not labeled. The Dietary Manager stated she was not aware that there were any expired Jello cups in the resident's East wing food pantry. | 2020-09-01 |
| 2922 | WARNER ROBINS REHABILITATION CENTER | 115612 | 1601 ELBERTA ROAD | WARNER ROBINS | GA | 31088 | 2016-08-26 | 441 | D | 0 | 1 | ZXOF11 | Based on observations and staff interviews, the facility failed to store wash basins, urinals, combs, and toothbrushes in a manner to prevent possible contamination in seven (7) of the thirty (30) shared bathrooms. The sample size was thirty-five (35) and the facility census was one hundred and fifteen (115). Findings include: 1. During an observation on 8/22/16 at 11:50 a.m. in the shared bathroom of room A-2 there were two (2) urinals sitting on the bathroom counter that were not labeled or in a plastic bag. This bathroom is noted to be shared by three residents. 2. During an observation on 8/22/16 at 11:54 a.m. in the shared bathroom of room A-11 there was one (1) urinal that was not labeled or in a plastic bag. This bathroom is noted to be shared by three residents. 3. During an observation on 8/22/16 at 11:56 a.m. in the shared bathroom of room C-1 there was one (1) urinal and one (1) wash basin observed on the shelf not bagged or labeled, one (1) wash basin on the floor, one (1) toothbrush and one (1) comb on bathroom counter not labeled or bagged. This bathroom is noted to be shared by three residents. 4. During an observation on 8/22/16 at 2:42 p.m. in the shared bathroom of room C-9 there was one (1) unlabeled wash basin that was not in a plastic bag. This bathroom is noted to be shared by three residents. 5. During an observation on 8/23/16 at 3:44 p.m. in the shared bathroom of room C-9 there was one (1) unlabeled wash basin that was not in a plastic bag. 6. During an observation on 8/23/16 at 1:12 p.m. in the shared bathroom for room D-1 there were two (2) toothbrushes that were not labeled or in a plastic bag, one (1) toothbrush bagged but not labeled, and two (2) yellow wash basins on the shelf in the bathroom that were not labeled or in a plastic bag. This bathroom is noted to be shared by two residents. 7. During an observation on 8/23/16 at 12:38 p.m. in the shared bathroom of room D8 there was one (1) wash basin on the shelf in the bathroom that was not labeled and was not in a plastic bag, and two (2) toothbrushes were sitting in cups on the counter that were not labeled or in a bag. This bathroom is noted to be shared with two residents. 8. During an observation on 8/26/16 at 8:33 a.m. In room D11 there is an unmarked or bagged comb on the counter in bathroom; one (1) pink wash basin sitting in one (1) yellow wash basin on the shelf in the bathroom and neither basins were in a plastic bag. This bathroom is noted to be shared with two residents. Interview with the Director of Nursing (DON) and the Regional Clinical Director (RCS) on 8/26/16 at 8:39 a.m. the DON revealed that his/her expectation is that personal care items such as wash basins and tooth brushes should be bagged and labeled. The RCS reported that there is no company policy regarding personal care items. However, the expectation is that the items will be stored in a bag that is labeled. 9. Observations on 8/26/16 at 8:35 a.m. and at 9:40 a.m. in the shared bathroom for room D1 there were two (2) toothbrushes not labeled or in a plastic bag, one (1) toothbrush bagged but not labeled, and two (2) yellow wash basins on the shelf in the bathroom that were not labeled or in a plastic bag. This bathroom is noted to be shared with two residents. Environmental tour conducted with the Administrator on 8/26/15 at 8:43 a.m. revealed that the unlabeled and unbagged items, mentioned above, were confirmed with the Administrator. The Administrator acknowledged that wash basins, urinals, combs, and tooth brushes should be labeled and in a plastic bag. During an observation on 8/26/16 at 9:01 a.m. in room C1 there was one (1) urinal and one (1) wash basin on the shelf not labeled or in a plastic bag, one (1) wash basin sitting on the floor, one (1) toothbrush and one (1) comb on the bathroom counter not labeled or bagged. This bathroom is noted to be shared with three residents. Post survey interview on 09/02/16 at 1:10 p.m. with the facility's DON revealed that the facility has thirty-six bathrooms of which thirty are shared and six are private. Further interview revealed that all of the bathrooms for the following rooms, that are mentioned above: A-2, A-11, C-1, C-9, D1, D8, D11, are shared bathrooms and that each of the bathrooms are shared with either two or three residents and that these residents are able to access and utilize these bathrooms. Post survey interview on 09/06/16 at 11:00 a.m. with the facility's DON revealed that it is the facility's process and the general expectation that each residents personal toiletry items be labeled and bagged and that this has to be constantly monitored by the staff to ensure that the items are labeled and bagged. Further interview revealed that urinals and wash basins should not be placed on the bathroom counters that they should be labeled and bagged and placed either on the shelf under the sink, or in the bottom drawer of the resident's dresser. The facility provides containers for resident's toothbrushes and the expectation is that each toothbrush container for each resident should be labeled with either the residents name or the resident's room number and the resident's bed identifier. | 2020-09-01 |
| 2202 | ARROWHEAD HEALTH AND REHAB | 115539 | 239 ARROWHEAD BOULEVARD | JONESBORO | GA | 30236 | 2018-05-10 | 656 | D | 0 | 1 | ZXJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review, the facility failed to implement observations of target behaviors, side effects and adverse reactions of psychoactive medications according to the care plan interventions for one resident (R) #56, from a sample of 22 residents. Findings include: Record review revealed that R #56 was admitted to the facility on [DATE] with psychiatric [DIAGNOSES REDACTED]. The resident was prescribed [MEDICATION NAME] for dementia, [MEDICATION NAME] for [MEDICAL CONDITION] and [MEDICATION NAME] for anxiety on admission. Review of the resident care plan dated 2/20/18 revealed the resident was care planned for [DIAGNOSES REDACTED]. She takes psyche (sic) meds. Further review of the care plan revealed the following interventions were to be implemented: Administer medications as ordered. Observe/document for side effects and effectiveness. Observe/record occurrence for target behavior symptoms and document per facility protocol. Observe/record/report to MD as needed (prn) side effects and adverse reactions of psychoactive medications. Review of R #56's electronic medical record, Medication Administration Record [REDACTED]. An interview was conducted with Licensed Practical Nurse (LPN) BB on 5/9/18 at 8:45 a.m. at the medication cart. LPN BB was asked what type of behavioral monitoring was conducted for the medications given to R #56. She stated she would have to look it up in the Physician's Desk Reference (PDR). LPN BB was asked where this is documented, and she replied that it is documented in the nursing notes or on a behavior monitoring record in the electronic chart. An interview was conducted with the Director of Nursing(DON) on 5/9/18 at 10:59 a.m. in the DON's office. The DON was requested to locate any documentation related to behavioral monitoring and side effects/effectiveness of psychoactive medications for R #56. The DON was unable to produce the behavioral monitoring documentation for February, March, and (MONTH) (YEAR). An interview was conducted on 5/9/18 at 4:14 p.m. with LPN EE in the conference room. LPN EE was asked where the nursing staff documents behaviors and effectiveness of medications. LPN EE stated it is documented on the behavioral monitoring record and on the Medication Administration Record [REDACTED] A review of the facility's policy titled, Behavior Assessment and Monitoring, dated (MONTH) 2014, page 1 of 2, paragraph titled Monitoring, section 1. If the resident is being treated for [REDACTED]. Section 2, The staff will document (either in progress notes, behavior assessment forms, or other comparable approaches) the following information about specific problem behaviors: number and frequency of episodes; preceding or precipitating factors; interventions attempted (if psychoactive drug is used as an intervention, institute appropriate psychoactive drug monitoring); and outcomes associated with interventions. | 2020-09-01 |
| 2203 | ARROWHEAD HEALTH AND REHAB | 115539 | 239 ARROWHEAD BOULEVARD | JONESBORO | GA | 30236 | 2018-05-10 | 842 | D | 0 | 1 | ZXJG11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record and facility document review it was determined the facility failed to document accurately the administration of medications for one resident (R) (#56)from a census of 106 residents. Findings include: Record review revealed #56 was admitted to the facility on [DATE] with psychiatric [DIAGNOSES REDACTED]. The Admission Minimum Data Set ((MDS) dated [DATE], Section C Cognitive Patterns, C indicated the resident did not receive a Brief Interview for Mental Status (BIMS) due to resident is rarely/never understood. The staff assessment for mental status section C1000 indicated R #56 cognitive skills were severely impaired. Review of R #56's physician's orders [REDACTED]. Review of the resident's electronic Medication Administration Records (MAR) for February, March, (MONTH) and (MONTH) (YEAR) indicated that both the donepezil five mg twice daily and [MEDICATION NAME] 10 mg once daily was documented as given from 4/19/18 through 5/8/18 by nursing for a total dose of 20 mg daily for 20 days. An observation was conducted on 5/9/18 at 8:45 a.m. during the morning medication pass with Licensed Practical Nurse (LPN) BB. LPN BB pointed out the duplicate order on the electronic MAR and stated, This is wrong, I need to get it clarified by pharmacy and the physician, before I can give it. The nurse proceeded to call pharmacy and spoke to Pharmacist AA at 9:10 a.m., who verified that both orders were on the MAR. A review of the Pharmacy Consultation Report dated 4/30/18 revealed the Consultant Pharmacist' comment has order for donepezil 5mg twice daily. The recommendation was Please consider changing donepezil to 10 mg in the evening (d/c previous order). Physician's Response was marked as I decline the recommendation above and do not wish to implement any changes due to the reasons below: Resident currently on donepezil 10mg daily in am. (dated 5/3/18) Order was faxed to physician's office. Spoke with (Medical Doctor) MD regarding recommendations, stated keep resident on current order. An interview was conducted on 5/9/18 at 10:15 a.m. with the LPN DD at her desk. LPN DD was asked what the process was for transcribing orders into the computer. LPN DD stated, First she receives the Pharmacist Consultant's Report (which is either faxed or handed to her), then she will fax the forms over or call the physician's office. The physician's office will then fax back a signed physician's orders [REDACTED]. LPN DD was shown a copy of the consultant's recommendations and asked to look at the resident's MAR. After looking at both, LPN DD verified the consultation order and that the donepezil five mg twice daily should have been discontinued. A telephone interview was conducted with the attending physician on 5/9/18 at 10:30 a.m., the Physician was asked if he was aware of the duplicate order of [MEDICATION NAME] and donepezil for R#56, he stated, No. He further stated that had he Ordered the medication it would have been in either the brand name or the generic name but not both. The Physician also stated that If the resident had taken the medication as indicated on the MAR there would be no harm for it is not unusual for resident to receive up to 20 mg twice a day of this medication. An interview was conducted with the Director of Nursing (DON) on 5/9/18 at 10:59 a.m. in the DON's office. The DON was asked what the expectation of nursing was related to the duplicate order of [MEDICATION NAME] and donepezil. The DON stated, The expectations would be that the order be transcribed correctly and for nursing to recognize the duplicate medications and question the order, call the pharmacist. A telephone interview was conducted on 5/9/18 at 2:00 p.m. with the Pharmacist CC, who initially reviewed the resident's record. Pharmacist CC was asked what the process was when reviewing the resident's medications? Pharmacist CC stated Look at the physician's orders [REDACTED]. Pharmacist CC was asked if she was aware of the duplicate order for R #56 and the Pharmacist stated Yes, that is one of the reasons it had been recommended to discontinue twice daily and to use the [MEDICATION NAME] 10mg daily. The other reason for the change in the order was due to the insurance not covering that particular medication. Observation made on 5/9/18 at 3:00 p.m. of the R #56's medications, donepezil ([MEDICATION NAME]) 10mg daily (filled 4/19/18) revealed there was nine pills left on card out of 30 pills. There was no medication card present for the donepezil five mg twice daily. Individual interviews were conducted with LPN BB, LPN DD, LPN EE, Registered Nurse (RN) FF, and LPN GG on 5/9/18 starting at 4:14 p.m. through 5:50 p.m. in the conference room. These nurses were responsible for medication administration on both day and evening shifts. The nurses were shown the MARs indicating where they had documented giving the donepezil 5 mg twice daily and were asked if they remembered giving the medication or not? All five nurses indicated they had not given the medication but had documented in error and that they should have gone back and corrected the error but had not done so. The nurses also denied cutting the 10mg tablet in half to deliver the doses. A review of the Pharmacy Manifest revealed the facility received the following medications from the pharmacy for R#56's: - 2/8/18 donepezil five mg tablet - quantity 30 - 2/21/18 donepezil five mg tablet - quantity 30 - 2/21/18 donepezil five mg tablet - quantity 30 - 4/5/18 donepezil five mg tablet- quantity 10 - 4/17/18 donepezil 10mg tablet - quantity 30 A total of 100 (five mg) tablets and 30 (10mg) had been received, indicating there was not a discrepancy and the resident could not have received a duplicate dose. | 2020-09-01 |
| 7939 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2013-09-29 | 282 | G | 1 | 0 | ZXFN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide services, related to incontinence care to address pressure sore prevention, as specified by the care plan for one (1) resident (#1), of three (3) residents having pressure sores, on the survey sample of eleven (11) sampled residents. Resident #1 subsequently developed two (2) dime-sized Stage 2 pressure sores. Findings include: Cross refer to F314 for more information regarding Resident #1. Record review for Resident #1 revealed an Annual Minimum Data Set assessment with an Assessment Reference Date of 09/03/2013 which documented, in Section I - Active Diagnoses, that the resident had [DIAGNOSES REDACTED]. The Care Plan for Resident #1 dated 9/11/2013 identified that the resident was at risk for pressure-sore development, and identified as Approaches to keep the resident as clean and dry as possible, to keep the linens clean and dry, and to provide incontinence care after each incontinent episode. During observation in the day room on 09/21/2013 at 12:00 noon, Resident #1 was noted to have a strong urine odor. A later interview, conducted on 09/21/2013 at 2:35 p.m., with Certified Nursing Assistant (CNA) EE revealed that this CNA had changed Resident #1's brief around 1:00 p.m., at the request of a nurse. Interview with Charge Nurse FF on 09/21/2013 at 2:40 p.m. revealed that Resident #1 been in the day room the entire morning, and that the nurse had to ask CNA EE to change Resident #1 at 1:00 p.m., when she smelled a urine odor. During a 09/21/13, 2:42 p.m. observation with Nurse FF and Nurse GG in attendance, even though Resident #1's diaper was dry after having been changed around 1:00 p.m., the draw sheets under the resident were still saturated with urine, and two Stage 2 pressure sores were observed on the resident's buttocks. During a 09/21/2013, 3:10 p.m. observation with the Wound Manager/Assistant Director of Nursing in attendance, this nurse acknowledged that the two dime-sized pressure ulcers on the resident's buttocks were new. Based on the above, Resident #1, the facility failed to provide pressure sore prevention in conformance with the Care Plan, which specified the provision of incontinence care as necessary for the prevention of pressure sores. The resident was subsequently noted to have two newly-developed dime-sized Stage 2 pressure sores on the buttocks. | 2016-09-01 |
| 7940 | ROSEMONT AT STONE MOUNTAIN | 115565 | 5160 SPRING VIEW AVENUE | STONE MOUNTAIN | GA | 30083 | 2013-09-29 | 314 | G | 1 | 0 | ZXFN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure that one (1) resident (#1), of three (3) sampled residents having pressure sores, on the survey sample of eleven (11) residents, received the necessary care to prevent pressure sore reoccurrence. This failure resulted in harm for Resident #1, who developed two dime-sized Stage 2 pressure sores after the failure to provide timely incontinence care. The findings include: Record review for Resident #1 revealed an Annual Minimum Data Set (MDS) assessment with an Assessment Reference Date of 09/03/2013 which documented, in Section C - Cognitive Patterns, that the resident had a Brief Interview for Mental Status score of 4, indicating severe cognitive impairment. Section I - Active [DIAGNOSES REDACTED]. Section H - Bladder and Bowel documented that the resident was always incontinent of both bowel and bladder, and Section G - Functional Status documented that the resident was totally dependent on staff for toilet use. Section M - Skin Conditions of this MDS documented that at the time of the assessment, the resident had no unhealed pressure sores, but that the resident did have a history of Stage 2 pressure sores. Further record review for Resident #1 revealed no documented evidence of any current pressure sores. During an observation conducted in the day room on 09/21/2013 at 12:00 noon, Resident #1 was observed to be seated in a geri-chair, and a strong urine odor was noted at that time. During a later observation of Resident #1 conducted in the resident's room on 09/21/2013 at 2:24 p.m., the resident was observed in bed. A strong urine odor was noted upon entering the room, which was even stronger at the resident's bedside. During an interview with Certified Nursing Assistant (CNA) EE conducted on 09/21/2013 at 2:35 p.m., this CNA stated that he had changed Resident #1's brief just before the resident's lunch tray arrived around 1:00 p.m., at the request of a nurse who had indicated that the resident smelled. The CNA stated that when the nurse asked him to change Resident #1, that was when he had changed the resident. During an interview with Charge Nurse FF conducted on 09/21/2013 at 2:40 p.m., Charge Nurse FF stated that Resident #1 had eaten breakfast in the dining room that morning at around 7:30 a.m., and that the resident had then been taken back directly to the day room after breakfast, then had remained there for the entire morning. Charge Nurse FF acknowledged that she had asked CNA EE to change Resident #1 at 1:00 p.m., when she had smelled an overpowering urine odor in the day room. During an observation of Resident #1 with Nurse FF and Nurse GG conducted on 09/21/13 at 2:42 p.m. in the resident's room, Resident #1's diaper was dry, however, the draw sheets under the resident were observed to be saturated with urine. These nurses said it appeared that CNA EE had changed the resident's brief during the earlier incontinence care, but did not change the wet draw sheets. Additionally, it was noted, and acknowledged by both nurses during the observation, that two open pressure sores were located on Resident #1's buttocks. During a 09/21/2013, 3:10 p.m. observation of Resident #1 with the Wound Manager/Assistant Director of Nursing in attendance, two dime-sized Stage 2 pressure ulcers were observed on the resident's buttocks. During an interview with this nurse conducted at the time of this observation, she stated that these two pressure ulcers were new. She further stated that CNAs were supposed to report new open skin areas to the charge nurse. Based on the above, Resident #1, who was incontinent of both bowel and bladder, had been placed in the day room for the entirety of the morning of 09/21/2013 without receiving incontinence care until approximately 1:00 p.m., by which time the resident was noted by nursing staff to have an overpowering urine smell. Upon observation at 2:42 p.m. on that date, the resident was noted to have two newly-developed dime-sized Stage 2 pressure sores on the buttocks. | 2016-09-01 |
| 6080 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2015-04-02 | 282 | G | 1 | 0 | ZW7F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, hospital history and physical examination [REDACTED]. The total survey sample consisted of seven (7) residents. The failure of the facility to ensure mechanical lift transfer for Resident X, as specified by the Care Plan, resulted in actual harm for Resident X, who was lowered to the floor during a chair-to-bed transfer and sustained a fractured arm and leg. Findings include: Record review revealed the Quarterly Minimum Data Set assessment of November 2014 to document, in Section I-Active Diagnoses, that Resident X had [DIAGNOSES REDACTED]. Section G - Functional Status documented Resident X's limitation/impairment in Range of Motion in the upper/lower extremities on both sides, and that he/she was totally dependent on staff for transfer. Review of the Care Plan for Resident X revealed a Problem/Need, originally dated October of 2014, which identified the resident to be at risk for falls related to reasons which included the [DIAGNOSES REDACTED]. An Approach included on the Care Plan to address the resident's risk for falls specified that the resident was to be transferred via total lift with the assistance of two (2) staff. However, despite the Care Plan of Resident X specifying the use of a lift during transfers as referenced above, a 01/02/2015, 5:25 p.m. Nurse's Notes entry for Resident X documented that certified nursing assistants (CNAs) transferred the resident from chair-to-bed by pivot transfer (instead of a lift, as required). This Nurse's Notes entry documented that Resident X could not bear weight and began going down, and due to the complaint of pain, an order for [REDACTED]. The 01/02/2015 Radiology Report for Resident X documented a moderately displaced fracture involving the proximal shaft of the right humerus, and a minimally displaced left femur fracture. A hospital History and Physical (H&P) Examination form for Resident X then documented hospital transfer and admission on 01/03/2015, and documented the resident's [DIAGNOSES REDACTED]. Review of the facility's investigation into the incident referenced above during which Resident X sustained fractures of the humerus and femur revealed Action Record forms for CNAs SS and ZZ which documented that these CNAs failed to follow the resident's plan of care. These Action Forms documented that CNAs SS and ZZ transferred Resident X using a stand-and-pivot transfer on 01/02/2015 and the resident was found with right humeral and left femur fractures. During an interview conducted on 01/28/2015 at 5:05 p.m., the Director of Nursing acknowledged that on 01/02/2015, Resident X was lifted by CNAs SS and ZZ without a lift, and the resident slid to the floor. Based on the above, Resident X had [DIAGNOSES REDACTED]. On 01/02/2015, however, CNAs SS and ZZ transferred Resident X via pivot transfer, rather than mechanical lift as specified by the Care Plan. Resident X slid to the floor and was later diagnosed with [REDACTED]. Cross refer to F323 for more information regarding Resident X. | 2018-04-01 |
| 6081 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2015-04-02 | 323 | G | 1 | 0 | ZW7F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, hospital history and physical examination [REDACTED]. The total survey sample was seven (7) residents. This failure to transfer Resident X via mechanical lift as required resulted in actual harm for Resident X, who was lowered to the floor during transfer from the chair to the bed and sustained a fractured arm and leg. Findings include: Record review for Resident X revealed a Quarterly Minimum Data Set (MDS) assessment having an Assessment Reference Date of November 2014 which documented in Section I - Active [DIAGNOSES REDACTED]. Section C - Cognitive Patterns of this MDS documented Resident X to have a Brief Interview for Mental Status Summary Score of 13, indicating the resident was cognitively intact. Further review of the MDS assessment of Resident X referenced above revealed that Section G - Functional Status documented the resident had limitation in Range of Motion and impairment in both the upper and lower extremities on both sides, and that the resident was totally dependent on two-plus staff persons for transfer between surfaces. The Care Plan of October 2014 for Resident X identified that the resident was at risk for falls and specified that the resident was of a total-lift status. A Nurse's Notes entry of 01/02/2015, timed at 5:25 p.m., for Resident X documented that certified nursing assistants (CNAs) were transferring the resident from a Broda chair to the bed by way of a pivot transfer. This Nurse's Notes entry documented that Resident X could not stand or bear weight due to his/her [DIAGNOSES REDACTED]. The Nurse's Notes entry documented that Resident X was then placed in bed and began complaining of pain in the right upper arm and left thigh, and an order for [REDACTED]. A Physician's Telephone Orders form of 01/02/2015 for Resident X specified a STAT X-ray of the right arm humerus, elbow, and forearm related to pain, and a STAT X-ray of the left leg femur and tibula/fibula related to pain. A Nurse's Notes entry of 01/02/2015, timed at 8:00 p.m., for Resident X documented that the X-ray technician had arrived and conducted an X-ray of the resident's right arm and left leg (in accordance with the Physician's Telephone Orders form referenced above). Review of the Radiology Report listing a Date of Service date of 01/02/2015 for Resident X revealed X-ray results which included a recent moderately displaced fracture involving the proximal shaft of the right humerus, and a recent left femur fracture with minimal displacement. A subsequent Nurse's Notes entry of 01/03/2015, timed at 7:30 a.m., for Resident X documented the X-ray results which revealed fractures of the right humerus and left femur and that the resident would be transferred to the hospital emergency room (ER) for evaluation. This Nurse's Notes entry documented physician notification and that Emergency Medical Services (EMS) 911 was called, and that at 7:40 a.m., EMS staff arrived to transport the resident to the ER. The hospital History and Physical (H&P) Examination form for Resident X documented the resident's hospital transfer, documented a hospital admission date of [DATE], and documented the resident's [DIAGNOSES REDACTED]. This hospital H&P Examination form documented, in the Reason for Admission section, that Resident X was admitted to the hospital due to the left distal femur fracture and the right proximal humerus fracture, and that surgery was planned. A Nurse's Notes entry of 01/07/2015, timed at 11:50 a.m., for Resident X documented that the resident was readmitted to the nursing facility from the hospital. This Nurse's Notes entry documented that at the time of facility readmission, Resident X had two (2) staples in the mid-upper arm, nine (9) staples in the upper right arm at the shoulder, and nineteen (19) staples to the left thigh. Review of the facility's investigation into the 01/02/2015 incident involving Resident X referenced above revealed a facility Action Record form dated 01/07/2015 for CNA SS, and an Action Record form dated 01/09/2015 for CNA ZZ, which documented that these CNAs failed to follow the resident's plan of care and incorrectly transferred the resident. These Action Forms for CNA SS and CNA ZZ indicated that Resident X required lift transfer with the assistance of two (2) staff, and that this transfer requirement was listed on the resident's Resident Care Sheet. These Action Forms further documented, however, that CNA SS and CNA ZZ utilized a stand-and-pivot transfer (rather than a mechanical lift transfer as required) to transfer Resident X on 01/02/2015, and the resident was subsequently found to have fractures of the right humerus and left femur. During an interview with Resident X conducted on 01/28/2015 at 5:45 p.m., the resident stated that two (2) CNAs had transferred him/her from the chair to the bed with their hands rather than a lift, and that he/she slipped to the floor. During an interview with the Director of Nursing (DON) conducted on 01/28/2015 at 5:05 p.m., the DON acknowledged that on 01/02/2015, Resident X was lifted by CNA SS and CNA ZZ during transfer without the use of a mechanical lift and that the resident slid to the floor. The DON further stated that for any resident, CNA staff were to review the Resident Care Sheets posed inside resident closets to obtain information and instructions on how to transfer each resident. During an interview with CNA SS conducted on 01/29/2015 at 2:10 p.m., CNA SS acknowledged that he/she had assisted with transferring Resident X on 01/02/2015 when Resident X was lowered to the floor during the transfer. CNA SS acknowledged that he/she should have used a mechanical lift during this transfer, but that a lift was not used. Based on the above, Resident X had [DIAGNOSES REDACTED]. However, on 01/02/2015, two CNA staff transferred the resident using a pivot transfer rather than a mechanical lift. During this transfer, Resident X slid to the floor, complained of pain, was diagnosed with [REDACTED]. The facility therefore failed to ensure the safe transfer of Resident X, and the resident was lowered to the floor and sustained injury. | 2018-04-01 |
| 6082 | PROVIDENCE HEALTHCARE | 115484 | 1011 SOUTH GREEN STREET | THOMASTON | GA | 30286 | 2015-04-02 | 498 | G | 1 | 0 | ZW7F11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, hospital history and physical examination [REDACTED]. A total of seven (7) residents were sampled. The failure to ensure mechanical lift transfer for Resident X resulted in actual harm, when Resident X was lowered to the floor during transfer and sustained a fractured arm and leg. Findings include: Resident X's November 2014 Quarterly Minimum Data Set assessment documented diagnoses, in Section I-Active Diagnoses, including, but not limited to, Hypertension and [DIAGNOSES REDACTED], and Section C - Cognitive Patterns documented a Brief Interview for Mental Status Score of 13, indicating he/she was cognitively intact. Resident X's Care Plan identified a risk for falls and specified that he/she was total-lift status. However, a 01/02/2015, 5:25 p.m. Nurse's Notes entry documented that as certified nursing assistants (CNAs) were transferring Resident X from chair-to-bed by pivot transfer (rather than mechanical lift transfer as required), Resident X began going down. This Nurse's Notes entry documented that Resident X complained of right arm and left thigh pain, and a 01/02/2015 Radiology Report documented X-ray results revealing a moderately displaced [MEDICAL CONDITION] shaft of the right humerus and a minimally displaced left femur fracture. A 01/03/2015, 7:30 a.m. Nurse's Notes entry documented that Emergency Medical Services staff arrived to transport Resident X to the hospital, and the hospital history and physical examination [REDACTED]. The facility's investigation into the 01/02/2015 incident involving Resident X revealed facility Action Record forms for CNA SS and CNA ZZ documenting that, although Resident X required lift transfer, these CNAs used a stand-and-pivot transfer (rather mechanical lift transfer) to transfer Resident X, and he/she sustained right humerus and left femur fractures. During an interview with Resident X conducted on 01/28/2015 at 5:45 p.m., the resident acknowledged that two (2) CNAs had transferred him/her from the chair to the bed with their hands rather than a lift. Resident X stated that he/she was transferred using a mechanical lift, and that he/she had told the CNAs that he/she was dead weight and they were conducting the transfer incorrectly, but the CNAs lifted her anyway. He/she stated that during this transfer, he/she slipped to the floor. During a 01/28/2015, 5:05 p.m. interview, the Director of Nursing (DON) acknowledged that on 01/02/2015, Resident X was lifted by CNA SS and CNA ZZ during transfer without the use of a lift and that the resident slid to the floor. The DON further stated that for any resident, CNA staff were to review the Resident Care Sheets posed inside resident closets for information and instructions on how to transfer each resident. During an interview conducted on 01/29/2015 at 2:10 p.m., CNA SS acknowledged that he/she had assisted with Resident X's 01/02/2015 transfer when the resident was lowered to the floor. CNA SS stated he/she was aware he/she should have referred to Resident X's Resident Care Sheet, but acknowledged that he/she did not check the Resident Care Sheet for Resident X before transferring the resident without a mechanical lift. CNA SS further acknowledged that he/she should have used a mechanical lift during the transfer of Resident X. During a subsequent telephone interview with CNA SS conducted on 04/02/2015 at 12:35 p.m., CNA SS stated that he/she was knowledgeable about the procedures related to the use of mechanical lifts. CNA SS also stated that he/she knew how to access resident Care Plans and where resident Care Plans were located. CNA SS acknowledged, however, that during the transfer of Resident X on 01/02/2015, he/she and another CNA involved in the transfer did not use the mechanical lift as the resident's Care Plan required, and the resident was injured. During interviews conducted on 04/02/2015 at 11:50 a.m., CNAs DD, EE, FF, GG, and HH all stated that the facility had provided orientation training on how to use equipment, including mechanical lifts, and on location of resident Care Plans for reference. Based on the above, Resident X required transfer via mechanical lift. However, despite having received training regarding the use of mechanical lifts and resident transfer procedures, CNAs SS and ZZ failed to demonstrate competency when they transferred Resident X on 01/02/2015 by pivot transfer rather than mechanical lift. Resident X slid to the floor, was diagnosed with [REDACTED]. The facility therefore failed to ensure the safe transfer of Resident X, and the resident was lowered to the floor and sustained injury. Cross refer to F323 for more information regarding Resident X. | 2018-04-01 |
| 10466 | FOX GLOVE CENTER | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2011-03-15 | 157 | D | 1 | 0 | ZVWY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy, and staff interview, the facility failed to notify the family in a timely manner of a change in condition for one (1) resident (#1) out of a sample of four (4) residents. Findings include: Review of the Interdisciplinary Progress Notes dated 1/2/11 revealed that resident #1 was observed during care to have a skin tear to the right buttock, the physician was contact and a [MEDICATION NAME] dressing was ordered. The responsible party was notified. On 1/10/11 the physician's order was changed to cleanse the right buttocks with wound cleanser and apply santyl ointment, and a wet to dry dry dressing with Dakin's solution daily. Continue review from 1/2/11 until resident went to the hospital on [DATE], revealed there was no evidence that the responsible party/family was notified that the skin tear progressed to a bed sore and/or that the treatment had changed. Review of the Pressure Ulcer Documentation Form for January 2011 for resident #1 revealed that there was a stage three (3) pressure sore on the sacrum, which progressed from 4x6 on 1/6/11 to 4x6.3 on 1/12/11 with no tunneling and/or undermining present. However, there was no evidence the family was notified of this change. Review of the facility policy, "Change in Condition of a Resident", effective date 1/2008, revealed the facility is to take appropriate action and provide timely communication to the resident's physician and responsible party relating to a change in condition of a resident. Interview with the Director of Nursing (DON) on 3/15/11 at 2:20 p.m., revealed that the family should have been notified and was unable to give a particular reason why they were not notified in change of condition. | 2014-07-01 |
| 10467 | FOX GLOVE CENTER | 115569 | 2850 SPRINGDALE ROAD SW | ATLANTA | GA | 30315 | 2011-03-15 | 441 | D | 1 | 0 | ZVWY11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that staff maintained a clean field during dressing change of a pressure ulcer for one (1) resident (#2) from four (4) sampled residents. Findings include: Observation of a pressure ulcer treatment for [REDACTED]. all supplies and placed them on the built in dresser in the resident's room. The supplies were a box of gloves, a small pink tray with two (2) stacks of gauzes, a box of Santyl, a bottle of wound cleanser, tape and on top of one (1) stack of gauze was a non-stick dressing. Also, a clear plastic bag was placed on the bed. The nurse washed her hands and donned gloves prior to starting. The old dressing was already removed, so the nurse cleansed the wound, removed her gloves, and placed her balled up gloves to the left side of the pink tray with the gauzes and non-stick dressing. The nurse then washed her hands, gloved and cleaned the wound. After cleaning she removed her gloves and placed them in the bag on the bed, then washed hands and gloved again. At that time, she moved the non-stick dressing from the stack of gauze and placed it on the balled up soiled gloves and proceed to open the Santyl and place Santyl on the dressing. Then the nurse cleanse the wound again, removed gloves, and her washed hands. At this point, when the nurse went to get gloves out of the box, which was next to the dressing with the Saintly on it, the gloves were hard to come out and the nurse had to pull on the box which caused the bos to be lifted up and when lowered back down was lowered onto the Santyl dressing. She then applied the dressing to the resident's wound and secured the dressing with tape. Interview with the Director of Nursing (DON) on 3/15/11 at 3:15 p.m. revealed the soiled gloves should never have been placed next to the tray nor should have the Santyl dressing have been placed on the resident after contact with the glove box. Interview with the Staff Development Coordinator on 3/15/11 at 3:35 p.m. revealed that all her inservices have been handwashing, last being 2/18/11, and that soiled items should not be place on clean items. | 2014-07-01 |
| 10473 | AZALEA HEALTH AND REHABILITATION | 115642 | 300 CEDAR ROAD | METTER | GA | 30439 | 2009-03-31 | 364 | E | 1 | 0 | ZVRN11 | Based on resident interview and a test tray, the facility failed to serve foods at the proper temperature for four (4) residents of ten (10) sampled residents. Findings include: During an interview conducted on 03/31/2009 at 10:30 a.m., Resident "D" stated that the food that was served was cold, and that staff did not ask to reheat the food. During an interview conducted on 03/31/2009 at 10:05 a.m., Resident "A"stated the food that was served earlier that morning was cold and that the three (3) meals served the previous day were all cold. Also, the resident stated that the food had always been cold since he/she had lived in the facility. Resident "B" stated during an interview conducted on 03/31/2009 at 10:20 a.m. that the food was sometimes cold and that staff never asked if they could reheat the food. Resident "C" stated during an interview conducted on 03/31/2009 at 10:55 a.m. that the food was always cold at breakfast. The surveyor was served a test tray at 12:15 p.m. on 03/31/2009, and the pork chop and gravy were only lukewarm. | 2014-07-01 |
| 5541 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2015-08-11 | 314 | D | 1 | 0 | ZVO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that an indwelling urinary drainage catheter did not cause a pressure ulcer on the meatus of one resident's penis (Z) in a sample of three residents with in-dwelling urinary catheters in a total sample of eight (8). Findings include: Health record review indicated that resident Z was admitted into the facility in (MONTH) of (YEAR). His [DIAGNOSES REDACTED]. Resident Z Brief Interview for Mental Status Score (BIMS) was nine (9) on the (MONTH) 9, (YEAR) quarterly assessment. Interview with the medication nurse CC on 08/12/15 at 1:15 p.m. revealed that resident Z returned from the hospital with a catheter in July. Interview with CNA II on 08/12/15 at 1:24 p.m. revealed that she did catheter care for resident Z on 08/4/15 and reported an open area on his penis to the nurse on that day. Observed the Skin Care Alert form dated 08/4/15 that the CNA provided to the nurse. Review of the Pointclickcare electronic nurses progress notes dated 08/04/15 at 7:35 p.m. for resident Z indicated that the resident was noted during activity of daily living (adl) care to have open areas around the tip of his penis with swelling and a foul odor. Resident Z was seen by the urologist on 08/04/15 and it was noted that he had raw non-infected skin on the meatus visible and nml. There were no physician's orders for care to resident Z's penile ulcer. Review of the facility policy for Urinary Catheter Care indicated in the Complication section D that the staff were to report any complaints the resident may have of burning, tenderness or pain in the urethral area. There was not further record in the nursing progress notes of the ulcer to resident Z's penis. On 08/10/15 at 12:46 p.m. the wound nurse documented on the Nursing: Weekly Skin condition Report (Pressure and Non Pressure Combined, Option 2) that resident Z had trauma via catheter on the meatus of his penis that measured 0.7 centimeter (cm) x 0.3 cm x 0.5 cm. The wound bed was first observed on 08/10/15. Six days after the initial notification by the CNA. It had a dark pink wound bed with the surrounding skin reddened. The wound nurse treated the wound with xeroform guaze dressing. Interview with the wound care nurse on 08/12/15 at 1:40 p.m. revealed that she was not informed of the ulcer to resident Z until 08/10/15 and that was when she started treatment. Interview with resident Z on 08/12/15 at 12:15 p.m. revealed that the treatment had lessened the discomfort that he experienced from the ulcer to his penis. | 2018-08-01 |
| 5542 | MEADOWBROOK HEALTH AND REHAB | 115561 | 4608 LAWRENCEVILLE HIGHWAY | TUCKER | GA | 30084 | 2015-08-11 | 328 | D | 1 | 0 | ZVO111 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that oxygen therapy was administered at the rate ordered by the Physician for one resident (X) of three residents with oxygen sampled in a total sample of eight (8) residents. Findings include: Health record review for resident X indicated a physician's orders [REDACTED]. Resident X was observed with Oxygen at 3.5 l/m on 08/11/15 at 4:00 p.m A second observation of resident X with Oxygen at 3.5 l/m on 08/12/15 at 7:45 a.m. The oxygen was observed on 8/12/15 on resident XX at 10:40 AM. Interview with the Director of Nursing (DON) on 08/12/15 at 10:45 a.m. revealed that resident X's oxygen order should have carried over onto the (MONTH) (YEAR) Physician order [REDACTED]. She added that the Oxygen orders were reviewed yesterday on 08/11/15. Resident X was observed with the DON on 08/12/15 at 10:45 a.m. with oxygen per nasal cannula at 3.5l/m. The oxygen rate of 3.5 l/m was confirmed with the DON. The DON immediately lowered the rate of the oxygen to 2 l/m and said that it was supposed to be on 2l/m not 3.5 l/m. | 2018-08-01 |
| 501 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 568 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interviews, staff interviews, and the review of the facility policy Resident Trust Fund the facility failed to provide resident trust fund account quarterly statements for three of three resident (R) A, R B, and R C reviewed. One hundred and eleven (111) resident trust fund accounts are managed by the facility. Findings included: Review of the policy updated 4/2014 titled, Resident Trust Fund revealed send statements to the resident or responsible parties, at a minimum on a quarterly basis. 1. Record review for R A was admitted to the facility on [DATE]. Review of a Minimum Data Set (MDS) annual assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) summary score of 7 out of 15 which indicates the resident is severe impairment. During an interview on 12/16/18 at 12:41 p.m. with R A regarding his trust fund account that the facility manages. Resident A revealed he has a trust fund account with the facility. Resident A revealed he does not receive a quarterly statement for his trust fund account that the facility manages. 2. Record review for R B was admitted to the facility on [DATE]. Review of an MDS quarterly assessment dated [DATE] revealed a BIMS of 13 out of 15 which indicates the resident is cognitively intact. During an interview on 12/16/18 at 1:01 p.m. with R B regarding his trust fund account that the facility manages. Resident B revealed he does not receive a quarterly statement for his trust fund account that the facility manages. Resident B revealed if he asks for his balance the staff will verbally tell him how much he has in his account. An Interview was conducted on 12/7/18 at 2:50 p.m. with QQ Business office Assistant regarding resident trust funds account. QQ Business office Assistant verified that R A and R B has a trust fund accounts that the facility manages. An Interview was conducted on 12/7/18 at 3:00 p.m. with RR the Business Office Manager (BOM) regarding resident's trust funds accounts that the facility manages. The BOM could not confirm that R A or R B received their quarterly statement. An interview was conducted on 12/20/18 at 12:43 p.m. with SS Business Office Assistant who is responsible for resident trust funds, sends statements to the responsible Person/resident. Business Office Assistant SS revealed she does not have proof that the resident/family are receiving quarterly statements. An interview was conducted 12/20/18 at 2:30 p.m. on the BOM. The BOM revealed the office has no written proof that the resident received their statement. The facility failed to provide quarterly statement as required. 3. Record review revealed that Resident (R) C admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Annual Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated he was cognitively intact. In an interview with R C on 12/17/18 at 11:08 a.m., he stated he did have a Resident Trust Fund (RTF) Account with the facility. He stated he did not receive quarterly statements on this account. He further stated he held a credit union account which was missing money. He stated the Social Services Director (SSD) had all the information. In an interview with the Business Office Manager (BOM) on 12/20/18 at 1:28 p.m. regarding the RTF account for R C, she stated she issued monthly statements to her RTF account holder-residents. She stated she did not require residents to sign for their statements and could provide no documentation to corroborate her actions. She stated R C was his own Responsible Party (RP) and no statements were sent to his family members. In an interview with Social Worker (SW) XX on 12/20/18 at 2:31 p.m. regarding the RTF account for R C, she stated she was aware of the resident's concern about his credit union account but this facility had nothing to do with that account. She confirmed R C was his own RP and there was little family involvement. | 2020-09-01 |
| 502 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 656 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff, resident, and family interview the facility failed to follow the care plan for one resident (R) (R#224) related to providing diabetic ulcer treatment as order. The sample size was 87 residents. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating R#224 to be cognitively intact. Section G Functional Status revealed R#224 requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed R#224 is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem onset date of 11/21/18 related to pressure ulcer/potential for skin breakdown related to impaired mobility, incontinent of bowel and bladder, frequent diarrhea, multiple diabetic ulcers of the right foot and first and second fingers. Left below the knee [MEDICAL CONDITION]. Has abdominal abscess. History of reversal ostomy. Fragile skin. Resident noted to pick at skin; [DIAGNOSES REDACTED]. Approaches: Labs/Meds/Treatments as ordered. Notify the MD/NP of abnormal findings. An interview on 12/16/18 at 1:37 p.m. with the resident revealed that he has a wound on his right foot and it is supposed to be changed every other day but the last time it was changed was last week. Observation during this time of dressing on the right foot revealed a date of 12/12 (2018) written on tape attached to the dressing. A second interview on 12/17/18 at 1:15 p.m. with the resident revealed that the dressing to his right foot has not been changed. Observation of the dressing, at this time, revealed a date of 12/12 (2018) written on tape attached to the dressing. During an interview on 12/17/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) KK in the resident's room, revealed that the dressing to the resident's right foot is dated 12/12 (2018). During an interview on 12/17/18 at 1:22 p.m. with Unit Manager FF revealed that the dressing to the resident's right foot is dated 12/12 (2018). Continued interview revealed that the Physician order [REDACTED]. Unit Manager FF stated that she expects the nurses to be checking dates on dressing changes as part of the assessment. During an interview on 12/18/18 at 4:00 p.m. with LPN MM revealed that she did the wound care on the resident on 12/12/18. She stated that the dressing is to be done every other day and as needed (prn) and on (MONTH) 14, (YEAR) and that she was going to do the dressing change when he came back from [MEDICAL TREATMENT] but when she got to the rehab floor there was an ambulance there to get him to take him to a doctor appointment and she wasn't able to do the dressing change. She stated that she forgot to tell the oncoming nurse that she wasn't able to do his dressing change and stated she is not here on the weekend and that is why the dressing change was missed. On 12/18/18 the resident was discharged to the hospital due to swelling in his left arm which prevented wound care observation on that date. Review of Physician order [REDACTED]. Review of the policy Wound Care Treatment Protocol revealed the wound is to be evaluated for signs and symptoms of infection and for signs of healing while performing treatment. Document/report findings. Provide treatment as per physician's orders [REDACTED].> | 2020-09-01 |
| 503 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 657 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to update the care plan to include a change from Foley catheter to Suprapubic catheter for one resident (R#137) of 87 sampled residents. Findings include: Review of the medical record for R#137 revealed the resident was admitted on [DATE]. Further review revealed the resident had a [DIAGNOSES REDACTED]. Review of the Quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) of 99 indicating severe cognitive impairment. Review of the resident's care plan, updated on 10/30/18, revealed that the resident had an indwelling catheter with supporting diagnosis. Goals and approaches include but not limited to change Foley as directed in catheter policy and monitor for signs and symptoms of Urinary Tract Infection [MEDICAL CONDITION]. Review of the nephrology Consult dated 8/13/18 revealed recommendations for the resident to return for further tests. Review of the nephrology assessment and plan include but is not limited to; problem: [MEDICAL CONDITION] with chronic Foley; plan: Urology planning for Suprapubic catheter. In an interview on 12/19/18 at 10:45 a.m. with the dayshift unit manager of 300 hall, LPN AA, confirmed that the care plan has not been up-dated to show the suprapubic catheter that was inserted on 11/5/18 before this time. LPN AA further revealed that it is ultimately her responsibility to ensure that the care plan is updated with new and changing information and that the staff were made aware of the change in report that is held every shift. | 2020-09-01 |
| 504 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 684 | D | 1 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, staff, resident, and family interview the facility failed to follow the care plan for one resident (R) (R#224) related to providing diabetic ulcer treatment as order. The sample size was 87 residents. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating R#224 to be cognitively intact. Section G Functional Status revealed R#224 requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed R#224 is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. Review of the resident's care plan revealed a problem onset date of 11/21/18 related to pressure ulcer/potential for skin breakdown related to impaired mobility, incontinent of bowel and bladder, frequent diarrhea, multiple diabetic ulcers of the right foot and first and second fingers. Left below the knee [MEDICAL CONDITION]. [DIAGNOSES REDACTED]. Approaches: Labs/Meds/Treatments as ordered. Notify the MD/NP of abnormal findings. An interview on 12/16/18 at 1:37 p.m. with the resident revealed that he has a wound on his right foot and it is supposed to be changed every other day but the last time it was changed was last week. Observation during this time of dressing on the right foot revealed a date of 12/12 (2018) written on tape attached to the dressing. A second interview on 12/17/18 at 1:15 p.m. with the resident revealed that the dressing to his right foot has not been changed. Observation of the dressing, at this time, revealed a date of 12/12 (2018) written on tape attached to the dressing. During an interview on 12/17/18 at 1:20 p.m. with Licensed Practical Nurse (LPN) KK in the resident's room, revealed that the dressing to the resident's right foot is dated 12/12 (2018). During an interview on 12/17/18 at 1:22 p.m. with Unit Manager FF revealed that the dressing to the resident's right foot is dated 12/12 (2018). Continued interview revealed that the Physician order [REDACTED]. Unit Manager FF stated that she expects the nurses to be checking dates on dressing changes as part of the assessment. During an interview on 12/18/18 at 4:00 p.m. with LPN MM revealed that she did the wound care on the resident on 12/12/18. She stated that the dressing is to be done every other day and as needed (prn) and on (MONTH) 14, (YEAR) and that she was going to do the dressing change when he came back from [MEDICAL TREATMENT] but when she got to the rehab floor there was an ambulance there to get him to take him to a doctor appointment and she wasn't able to do the dressing change. She stated that she forgot to tell the oncoming nurse that she wasn't able to do his dressing change and stated she is not here on the weekend and that is why the dressing change was missed. On 12/18/18 the resident was discharged to the hospital due to swelling in his left arm which prevented wound care observation on that date. Review of Physician order [REDACTED]. Review of the policy Wound Care Treatment Protocol revealed the wound is to be evaluated for signs and symptoms of infection and for signs of healing while performing treatment. Document/report findings. Provide treatment as per physician's orders [REDACTED].> | 2020-09-01 |
| 505 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 689 | E | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to maintain safe water temperatures in resident rooms (sinks) on three of five units. The census was 220. Findings include: Observation on 12/16/18 at 2:47 p.m. revealed the hot water at the sink of room [ROOM NUMBER] on the MT unit was uncomfortably hot to the hand and could not be run over the bare skin for even a few seconds. Observation on 12/16/18 between 3:15 p.m. and 3:51 p.m. of the water temperatures taken by the maintenance assistant XX at the sink in resident rooms on the MT unit revealed the following: 208=124.3 degrees Fahrenheit (F) 205= 121.8 degrees F 204= 136.5 degrees F 209= 121.9 degrees F 206= 131.5 degrees F 203= 132.4 degrees F 211= 121.2 degrees F 202=128.1 degrees F 210= 128.4 degrees F 224=122.1 degrees F 222= 122.3 degrees F 220=124.7 degrees F 218=123 degrees F 236=139.2 degrees F 234=146 degrees F 233=138.9 degrees F 232=142.1 degrees F 231=145 degrees F 239=138.5 degrees F 240=144.5 degrees F 241 Near shower) = 80.5 degrees F 242= (near shower) 81.5 degrees F 243= 83 degrees F (near shower) 244= 84.5 degrees F (near shower) Shower room = 81.1 degrees F During an interview on 12/16/18 at 4:29 p.m. with the Administrator, it was revealed that the maintenance department checks both showers and rooms but she was not sure how often these checks were one. Residents on the West unit had complained of the water on that unit being cold a few weeks before. As a result, the administrator had called the plumbers in and they had adjusted and/or replaced the existing hot water valves during their visit. She had not been made aware of any concerns with the water being too hot on any of the units. She planned immediately inform the staff to keep the residents from using the hot water on all the units until the water temperatures could be adjusted to comfortable and safe ranges. During a follow up interview on 12/16/18 at 4:42 p.m. with the Administrator revealed that she had notified the staff that residents should not be allowed to use the hot water in the residents' rooms until further notice. She had placed signs to that effect on the units and the maintenance director was on his way in to oversee any further adjustments. During an interview on 12/16/18 at 5:02 p.m. with the Maintenance Director revealed he checks the hot water in the rooms at least once each week and the water in the showers daily. During his weekly checks, he takes the temperature of the water in one room on each side (north and south) of each hallway. He checks rooms closest to the shower rooms. His aim is for the water temperatures on the hallways to range between 95 degrees F and 110 degrees F. If the water temperatures are found to be below 95 degrees F, he goes to the mixing valve associated with that unit and adjusts the value up, and if it is more than 110, he adjusts it downward. His aim is to achieve temperatures at the mixing valve of approximately 130 degrees F because that temperature works well to attain an appropriate temperature in the rooms on that hallway. He checks the temperature at the mixing valve each day and that value was 132 degrees F on the morning of 12/16/18. He is not alarmed if only one or two rooms are above the desired temperature. However, should the hot water in rooms that he checks be higher than 118 degrees or so, then he checks more rooms and adjusts the mixing valve as necessary. His plan was to immediately adjust the temperature downwards at the valves on the affected units downward. A review of the maintenance records titled Water Temperatures revealed that water temperatures recorded in the rooms on the MT, 300, and Vent units in the week prior to 12/16/18 showed several temperatures over 120 degrees F on some days. However, no hallway showed a pattern of high temperatures on consecutive days. A review of the accident log for the previous six months revealed no accidents associated with elevated water temperatures. The Maintenance Director had adjusted the values upon arrival at the facility, therefore a recheck of the following rooms on 12/16/18 at 7:45 p.m. with Maintenance Assistant XX revealed that the water temperatures were not at a safe level at this time on the Memory Unit (MT). The highest water temperature was 145 degrees F and the lowest was 129 degrees F. During an interview on 12/20/18 at 1:29 p.m. with the Maintenance Director revealed that the water was shut off on the evening of 12/16/18 and that waster temperatures were monitored for 24 hours after the plumber visited on 12/17/18. Review of the 24-hour water temperature monitoring log of 12/17/18 to 12/18/18 revealed all rooms on the halls were monitored during that period; the highest temperature logged over 24 hours was 114 degrees F, on the Vent Unit, and the log documented the final temperature for that room was 105.5. Observation on 12/16/18 of the 300 hall water temperatures with Maintenance Assistant XX revealed: room [ROOM NUMBER] at 4:10 p.m. was 133 degrees F, room [ROOM NUMBER] at 4:11 p.m. was 138.8 degrees F, room [ROOM NUMBER] at 4:12 p.m. was 140 degrees F, room [ROOM NUMBER] at 4:13 p.m. was 136 degrees F, room [ROOM NUMBER] at 4:14 p.m. was 118 degrees F, room [ROOM NUMBER] at 4:15 p.m. was 113 degrees F, room [ROOM NUMBER] at 4:17 p.m. was 134 degrees F, room [ROOM NUMBER] at 4:18 p.m. was 115 degrees F, room [ROOM NUMBER] at 4:19 p.m. was 126 degrees F, room [ROOM NUMBER] at 4:22 p.m. was 134 degrees F, room [ROOM NUMBER] at 4:25 p.m. was 123 degrees F, room [ROOM NUMBER] at 4:27 p.m. was 132 degrees F, room [ROOM NUMBER] at 4:30 p.m. was 130 degrees F, room [ROOM NUMBER] at 4:31 p.m. was 128 degrees F, room [ROOM NUMBER] at 4:33 p.m. was 132 degrees F, room [ROOM NUMBER] at 4:33 p.m. was 140 degrees F, room [ROOM NUMBER] at 4:35 p.m. was 137 degrees F, room [ROOM NUMBER] at 4:36 p.m. was 132 degrees F, room [ROOM NUMBER] at 4:40 p.m. was 102.2 degrees F, room, 313 at 4:41 p.m. was 136 degrees F, room [ROOM NUMBER] at 4:42 p.m. was 103 degrees F, room [ROOM NUMBER] at 4:43 p.m. was 139 degrees F, room [ROOM NUMBER] at 4:45 p.m. was 104 degrees F, room [ROOM NUMBER] at 4:46 p.m. was 140 degrees F, room [ROOM NUMBER] at 4:50 p.m. was 138 degrees F, room [ROOM NUMBER] at 4:51 p.m. was 116 degrees F, room [ROOM NUMBER] at 4:52 p.m. was 140 degrees F, room [ROOM NUMBER] at 4:43 p.m. was 116 degrees F, room [ROOM NUMBER] at 4:55,p.m. was 140 degrees F. A recheck of rooms on the 300 hall, with Maintenance Assistant XX, after the Maintenance Director made changes to water heater values revealed: room [ROOM NUMBER] at 7:16 p.m. was 123 degrees F, room [ROOM NUMBER] at 7:17 p.m. was 109 degrees F, room [ROOM NUMBER] at 7:18 p.m. was 116 degrees F, room [ROOM NUMBER] at 7:19 p.m. was 121 degrees F, room [ROOM NUMBER] at 7:27 p.m. was 140 degrees F, room [ROOM NUMBER] at 7:29 p.m. was 142 degrees F. An interview with the Administrator at 7:31 p.m. revealed that all hot water to building will be shut off until master plumber can come fix it. and is planned for 5:30 a.m. 12/17/18. Disposable products will be used for breakfast. The water temperatures on 12/17/18 between the hours of 5:04 p.m. through 5:59 p.m. with Maintenance Assistance XX confirmed that the water temperatures on the 200 and 300 hall were all below 110 A recheck of rooms on the 300 hall, with Maintenance Assistant XX, after the Maintenance Director made changes to water heater values revealed: room [ROOM NUMBER] at 7:16 p.m. was 123 degrees F, room [ROOM NUMBER] at 7:17 p.m. was 109 degrees F, room [ROOM NUMBER] at 7:18 p.m. was 116 degrees F, room [ROOM NUMBER] at 7:19 p.m. was 121 degrees F, room [ROOM NUMBER] at 7:27 p.m. was 140 degrees F, room [ROOM NUMBER] at 7:29 p.m. was 142 degrees F. A recheck of rooms on the 300 hall, with Maintenance Assistant XX, after the Maintenance Director made changes to water heater values revealed: room [ROOM NUMBER] at 7:16 p.m. was 123 degrees F, room [ROOM NUMBER] at 7:17 p.m. was 109 degrees F, room [ROOM NUMBER] at 7:18 p.m. was 116 degrees F, room [ROOM NUMBER] at 7:19 p.m. was 121 degrees F, room [ROOM NUMBER] at 7:27 p.m. was 140 degrees F, room [ROOM NUMBER] at 7:29 p.m. was 142 degrees F. Observation on 12/17/18 between 5:04 p.m. and 5:59 p.m. of the 100, 200, 300 halls and the vent unit with Maintenance Assistant XX revealed that all water temperatures were below 110 degrees F. Observation of the water temperatures with the Maintenance Director (MD) began on 12/16/18 at 5:55 p.m. in the ventilator unit revealed the following by room number with temperatures expressed in Fahrenheit degrees using a digital thermometer: Rooms: 101=120.5 degrees Fahrenheit (F) 102=116.5 degrees F 103=124 degrees F 104=121 degrees F 105=118.5 degrees F 106=112.4 degrees F 107=117 degrees F 108=112 degrees F 109=107 degrees F 110=108 degrees F 111=107.9 degrees F 112=109 degrees F 113=108 degrees F 114=109 degrees F 115=108 degrees F Shower room: Stall 1=98.4 9 degrees F (right); Stall 2=97.5 degrees F (left) Shower room sink=106 degrees F The boiler's mixing valve temperature was 120 degrees F on 12/16/18 at 6:00 p.m. The MD decreased the temperature of the mixing valve to 115 degrees F at 6:10 p.m. The temperatures which exceeded 110 degrees F were re-checked beginning at 6:45 p.m. and revealed the following: Rooms: 101=111 degrees F 102=113 degrees F 103=110 degrees F 104=110 degrees F 105=113 degrees F 107=114 degrees F In an interview with the Administrator on 12/17/18 at 9:05 a.m., she stated the plumber arrived at 5:30 a.m. this morning to service or replace the existing mixing valves in the facility's main building. She stated the plumber began his evaluation in the ventilator unit (separate building). She stated the dietary staff were instructed to use paper products were used for serving meals until safe hot water temperatures could be re-established. | 2020-09-01 |
| 506 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 690 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff and family interview, and record review, the facility failed to remove a Foley catheter when clinically warranted for one resident (R) (R#205). The sample size was 87 residents. Findings Include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#205 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that R#205 was cognitively intact. Section G Functional Status revealed that R#205 required extensive one person assist with toilet use and managing catheter care. Section H Bowel and Bladder revealed R#205 has an indwelling Foley catheter, is always incontinent of bowel, and no toileting program has been used. Section I revealed Active [DIAGNOSES REDACTED]. An interview on 12/16/18 at 3:56 p.m. with a family member of R#205 revealed that she took the resident to the Urologist on Thursday, 12/6/18. She stated that the Urologist told her the catheter needed to come out and he would write the order for the nursing home to take it out on Monday. The family member asked that the date be changed to 12/11/18 due to other upcoming physician appointment, which the Urologist agreed. The Urologist office sent her a large envelope and a paper with the order to remove the catheter on Tuesday, 12/11/18, to give to the nursing home. The family member stated that the envelope was given to the nurse, at the medication cart, on return to the nursing home. The family member revealed that the catheter was still in and had not been removed yet. She stated that nurse FF told her that she had called the Urologist office but has not gotten a response back from them but stated that was several days ago. Observation on 12/17/18 at 6:00 p.m. and 12/18/18 at 12:00 p.m. revealed the resident in his bed with Foley Catheter in place. Review of the Urologist, History and Physical dated 12/6/18. Instructions: We will have his nursing home remove his urethral catheter on Tuesday (MONTH) 11, (YEAR) at seven in the morning. They can insert if he is unable to void or he can follow up at the local office of the urologist. We will give him a prescription to start Tamulosin 0.4 milligrams (mg) daily. A written order from the Urologist was not found in the medical record. Review of the Medication Administration Record [REDACTED]. The same day as the order to remove the catheter. An interview on 12/18/18 at 1:20 p.m. with Unit Manager FF revealed that she had to call and ask the Urologist office to fax over the order to remove the resident's catheter. She stated that the resident's family member told her that the family brought in the order and paperwork from the visit with the Urologist on 12/6/18 and gave it to the nurse, but she could not find it. Unit Manager FF stated that she started this job last Thursday and the paperwork was not on the chart until yesterday and she was not aware the catheter was supposed to be removed and can't explain where the documentation was before yesterday. Record review revealed a telephone Physician order [REDACTED]. Patient to increase fluids. Insert Foley catheter if patient isn't able to void that afternoon. | 2020-09-01 |
| 507 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 695 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and review of Physician's Orders and facility policies titled Oxygen Therapy and Guidelines for Frequency Changes of Respiratory Supplies, the facility failed to change disposable oxygen equipment in a timely manner for one resident (R), R#178. The sample size was 87. Findings include: Review of the clinical record revealed R#178 was [AGE] year-old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed a comatose resident (Section B-Hearing, Speech and Vision) who required total/two-person assistance (Section G-Functional Status) for all activities of daily living (ADLs); and required oxygen (O2), suctioning, [MEDICAL CONDITION] (Section O-Special Treatments and Programs). Review of the care plan, reviewed 11/23/18, documented the problem/need related [MEDICAL CONDITION] was: risk for respiratory complications to include respiratory distress, infection, dehydration, and accidental decannulation. The goals included patent and adequate air exchange and freedom from recurrent infections, dehydration and decannulation. The interventions included: monitor for symptoms of respiratory infection-cough, increased secretions, change in color/odor, fever, abnormal laboratory values;[MEDICAL CONDITION] per Respiratory Therapy (RT). Review of the Physician's Orders, updated 7/31/18, revealed an order (originally dated 9/27/17) to [MEDICAL CONDITION] or t-piece every week. Review of the facility policy titled, Oxygen Therapy, revealed under Procedure, #8: change tubing weekly. Review of the policy titled, Guidelines for Frequency Changed of Respiratory Supplies, revealed [MEDICAL CONDITION]/collar, refillable humidifiers, aerosol corrugated tubing, and drainage bag should all be changed weekly. Observation of R#178 on 12/16/18 at 7:00 p.m. revealed a trach-dependent female, spontaneously breathing via a 35% (O2) aerosol t-piece (ATP), lying in her bed in no apparent respiratory distress. The date written on the drainage bag was 11/26/18. Observation of R#178 on 12/18/18 at 12:01 p.m. revealed she continued with the 35% ATP in no apparent respiratory distress. The date marked on the drainage bag was 11/26/18. Observation of R#178 on 12/19/18 at 11:15 a.m. revealed she continued the 35% ATP without apparent respiratory distress. The drainage bag was dated 11/26/18. In an interview with Respiratory Therapist (RT) YY on 12/19/18 at 11:21 a.m. regarding the frequency of disposable O2 supplies, she [MEDICAL CONDITION], aerosol corrugated, drainage bags, and nebulizer (sterile water) bottles are due for change out every Saturday and as needed (PRN) by RT staff per facility protocol. During an interview with the RT Manager on 12/19/18 at 11:36 a.m. regarding changing out disposable O2 supplies in R#178's room, he confirmed the date on the drainage bag was 11/26/18. He clarified the date as the day the O2 supplies were last changed. He acknowledged the facility policy and physician orders called for the disposable O2 supplies to be changed weekly. He stated his staff were directed to change disposable O2 supplies on Saturdays. The RT Manager further stated he would change the disposable O2 supplies as soon as possible (ASAP) and could offer no explanation for the delay in change-out for R#178. The RT Manager stated he would re-educate his staff on the schedule for changing disposable O2 supplies, cleaning of reusable equipment and supplies and the importance of performing and maintaining effective infection control practices. In an interview with the Infection Control Nurse (ICN) on 12/19/18 at 1:40 p.m. regarding respiratory supplies and equipment, she stated there was no infection control policy specifically related to RT equipment cleaning, air filters or disposable supplies. She stated she asked the RT Manager, about a month ago, to provide her with a log indicating the RT cleaning equipment/supplies schedule with documentation of compliance. She stated she had not received those items but would work closely with the RT Manager to obtain the data, monitor staff for compliance with facility policy and protocol, and update infection control policies related to respiratory residents as indicated. | 2020-09-01 |
| 508 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 758 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the behavior management policy, and staff interview, the facility failed to monitor behaviors for two residents (#169 and #16) receiving [MEDICAL CONDITION] medications. The sample size was 87 residents. Findings include: (1) Review of the policy Behavior Management and Psycho-pharmacological Medication Monitoring Protocol last updated 3/18 revealed that for each residents admitted on or receiving psycho-pharmacological medication, planned interventions for that resident's behaviors will be communicated to the appropriate staff members and those interventions and the responses to them are to be documented. The policy also revealed that those residents receiving psycho-pharmacological medications will be referred to the Behavior Management Committee. The committee will establish a behavior management program and review behavior monitoring documentation as part of that program as long as the resident continued to receive psycho-pharmacological medication. 1. A Review of the clinical records for Resident (R) #169 revealed he was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED].#169 to receive: [MEDICATION NAME] (an antipsychotic) 50 mg twice a day (this was increased from 25 mg bid on 12/5/18); [MEDICATION NAME] (an anxiolytic) 1mg every six hours for agitation (this was increased from 0.5 mg on 11/14/18) ; [MEDICATION NAME] (an antidepressant) 40 mg daily; and [MEDICATION NAME] (an antidepressant) 75 mg daily (increased from 50 mg on 12/14/18). A review of the Minimum Data Set (MDS) assessment records for the resident revealed an Admission MDS assessment of 6/14/18 which revealed the resident had behavioral symptoms directed at himself which occurred daily. However, these behaviors were judged to not have a significant impact on the resident, his care, or his interaction with others. He was also assessed as exhibiting rejection of care behaviors 1-3 days during the assessment period. His active [DIAGNOSES REDACTED]. The assessment also documented that the resident was receiving daily doses of antipsychotic and antidepressant medications. A further review of the MDS records for R#169 revealed a Quarterly MDS of 9/8/18 which documented that his behavioral symptoms (verbal and physical) were now directed at others 1-3 days during the assessment period, and that the resident was still receiving daily doses of antidepressant and antianxiety medications; A review of the pharmacy records for R#169 revealed a review on 8/21/18 which documented that, since the previous review, the resident had been sent on a 1013 document to the emergency room with combative/aggressive/threatening behaviors, but had returned with no new orders. The following review on 9/14/18 documented that [MEDICATION NAME] and [MEDICATION NAME] were increased during the physician's visit of 8/22/18, and the most recent pharmacy review of 12/13/18 documented that the resident's [MEDICATION NAME] was increased related to increasing behaviors. A review of a nurses' note for 7/29/18 revealed the resident was sent to the emergency room under a 1013 order following behaviors such as lashing out at staff, pulling of staff's hair, getting out of his wheelchair and placing himself on floor, and making threats towards a female resident. He could not be calmed or redirected by staff. He returned from the emergency room with no new findings. A review of a physician's progress note of 11/14/18 revealed that the resident was seen following a report by the nurse that the resident was exhibiting increased aggression and anxiety. A further review of the nurses' notes revealed two episodes of the resident throwing himself to the floor, being resistive to care and combative on the evening of 12/16/18. After an order for [REDACTED]. A review of the Behavior/Intervention Monthly Flow Records revealed that R#169 was being monitored for depression, and changes in mood. The log required nursing staff to document any of these behaviors observed on each of two shifts. Besides documenting the number of episodes (including zero), staff were also to record what intervention(s) were used to address the behavior, and the resident's response to the intervention(s). A review of the (MONTH) (YEAR) Behavior/Intervention Monthly Flow Record for R#169 revealed that staff had documented the absence/presence of behaviors only 5/30 times on the day shift and only 21/30 times on the evening shifts. During an interview on 12/19/18 10:49 with Registered Nurse (RN) OO it was revealed that R#169 exhibits a number of challenging behaviors. For example, staff sometimes hear him yelling down the hallway, but and when they rush to his room he might say he usually denies needing assistance with anything. At other times he removes himself from his wheelchair and lies on the floor in the dining room. Family members have reported that these are behaviors the resident exhibited in childhood and to which he seemed to be reverting. He is, therefore, monitored for various behaviors which can change from day-to-day. 2. Review of the clinical records for R#16 revealed she was readmitted on [DATE] with [DIAGNOSES REDACTED]. A review of the current physician's orders [REDACTED]. A review of the MDS records for the resident revealed an Admission MDS of 9/7/18 which documented a depression score of 4 (minor symptoms), but no behavioral symptoms. The assessment also documented active [DIAGNOSES REDACTED]. A review of the nurses' notes revealed a note on 12/11/18 which documented that R#16 continued to have mood and behavior issues related to her [DIAGNOSES REDACTED]. Review of the Behavior/Intervention Monthly Flow Records revealed the resident should be monitored for anxiety and mood changes and receives [MEDICATION NAME] 10 mg daily and [MEDICATION NAME] 0.5 mg on an as needed basis. Review of the (MONTH) (YEAR) Behavior/Intervention Monthly Flow Records for R#16 revealed staff did not consistently document the resident's targeted behaviors. During that month, staff had documented the absence/presence of anxious behaviors only 4/30 times on the day shift and 3/30 times on the evening shifts. For mood changes the staff had documented only 5/30 times on both the day and evening shifts. During an interview with Certified Nursing Assistant (CNA) PP it was revealed that the CNA has worked with R#16 since she was admitted and currently knows of no behaviors that should be a concern. The resident did sometimes cry in evenings saying she wanted to go home, the CNA said. However, she was easily soothed with a brief hug during those episodes. During an interview on 12/19/18 at 10:56 a.m. with RN OO, it was revealed that the Behavior/Intervention Monthly Flow Sheets are kept to track interventions that can be used with a resident experiencing troubling behaviors prior to ordering/administering medications. The behavior logs are to be filled out by the nurses on every shift. However, the nurses have not always been consistent with this documentation and management has had to provide education on remembering to complete the logs and reminding nurses of the importance of documenting the behaviors and interventions apart from any documentation they might make in the nurses' notes. The flow sheet is one part of the decision piece for the physician (others include talking with staff/residents) in making decisions whether residents need to receive medications for behaviors. During an interview on 12/19/18 01:50 p.m. with the Director of Nursing (DON) it was revealed that she was aware that there were issues with the nurses not documenting consistently on the behavior monitoring flow sheets and, as a result, she had provided education earlier that day to the nurses to remind them of the reason for the logs, review the appropriate policy with them, and remind them to consistently document the residents' targeted behaviors. The behavior logs are used by staff to document what targeted behaviors are occurring for each resident being monitored, what interventions are tried, and how effective those interventions are. The flow sheets are also helpful when making decisions related to what interventions would be used to manage the targeted behaviors - whether pharmacological or non-pharmacological. The behavior flow sheet is one of the considerations the MD uses in making medication determinations. | 2020-09-01 |
| 509 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 812 | E | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of policy Food Storage (Dry, Refrigerated, and Frozen), the facility failed to discard expired food items, and failed to sanitize the thermometer probe between the taking of the temperatures of various food items on the steam table. These deficient practices had the potential to affect 210 residents receiving an oral diet, of whom six received thickened liquids. Findings include: Review of the policy titled Food Storage (Dry, Refrigerated, and Frozen) dated (YEAR), staff are to discard food that has passed the expiration date. Observation of the walk-in refrigerator while accompanied by the dietary manager during initial kitchen tour on [DATE] at 11:30 a.m. revealed three 46-ounce cartons of (brand) Nectar-like Thickened Orange juice with a use-by date of [DATE] and one 46-ounce (brand) Thickened Cranberry Cocktail with a use-by date of [DATE]. Interview on [DATE] at 11:40 a.m. with the dietary manager (DM) revealed that all food items in the kitchen have either a best by/use by manufacturer's date or a received on date added by staff when those foods are delivered. Most foods received in the kitchen are used or discarded within a year, or discarded by the manufacturer's expiration date. However, if opened at any time during that period, the staff add a discard by date and this is usually 3 or 7 days, depending on the food item. The thickened juices that were past the use-by date should have been used or discarded by the date indicated by the manufacturer. The employee responsible for stocking/restocking the shelves should have noticed the date and discarded these products. Observation on [DATE] at 11:49 a.m. of the DM taking the temperatures of various food items on the steam table revealed the DM sanitize the shaft of the thermometer using an alcohol wipe before wiping the shaft with a disposable napkin. Next, she proceeded to insert the shaft of the thermometer into a succession of food items on the steam table - meat sauce, then spaghetti, then mixed vegetable, pureed spaghetti, and pureed vegetables. Between taking the temperature of each of these items, the DM did not sanitize the thermometer shaft but wiped it clean with the same soiled paper napkin. At that point, the dietary manager discarded the soiled napkin before inserting the thermometer into chicken noodle soup, then sweet and sour pork on the steam table. Observation on [DATE] at 8:30 a.m. of the Cook NN taking the temperature of various food items on the steam table revealed she sanitized the shaft of the thermometer with an alcohol wipe, took the temperature of grits and wiped the shaft with a paper napkin before inserting the shaft into scrambled eggs. Next, she sanitized the shaft of the thermometer again with an alcohol wipe before inserting into pureed meat. After taking the temperature of the pureed meat, NN wiped the thermometer shaft with a paper napkin, before inserting it into oatmeal. During an interview on [DATE] 08:55 a.m. with Cook NN it was revealed that one of her responsibilities as cook is to monitor the temperature of the food items on the steam table. During this process, she should sterilize the shaft of the thermometer with an alcohol pad before drying it off with a napkin. This process should take place between and before taking the temperature of every item on the steam table if those items are different foods. During an interview on [DATE] at 9:00 a.m. with the DM it was revealed that she does not require staff to sanitize the thermometer between taking the temperature of different food items on the steam table. Once the shaft is sanitized at the start of taking the temperatures, staff can simply wipe the thermometer shaft with a paper towel between taking the temperature of different food items on the steam table. The DM further said that it was probably a good practice to sanitize the thermometer between different food items, but her staff had not been trained to do so. There was no policy or procedure related to this practice. | 2020-09-01 |
| 510 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 842 | D | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview the facility failed to ensure that medications were recorded in the electronic Medication Administration Record [REDACTED]. Findings include: Review of the Minimum Data Set (MDS) Admission assessment dated [DATE] for R#224 revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating the resident to be cognitively intact. Section G Functional Status revealed the resident requires 2-person assistance for toileting. Section H Bowel and Bladder (B&B) revealed the resident is always incontinent of bowel and bladder. Section I Active [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Review of the Medication Administration Record [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the Departmental Notes for (MONTH) (YEAR) revealed that [MEDICATION NAME] 2.5 mg given on 11/26/18 at 7:59 a.m., 11/25/18 at 1:18 a.m., 11/28/18 at 2:30 p.m.,, 11/29/18 at 4:33 a m., 11:29 at 2:22 p.m., 11/29/18 at 7:08 p.m. and 11/30/18 at 4:46 a.m. Review of the (MONTH) (YEAR) Department Notes revealed that [MEDICATION NAME] 2.5 mg was given at 12/2/18 at 4:23 p.m., 12/3/18 at 6:46 a.m., 12/14/18 at 4:24 a.m., 12/15/18 at 7:35 a.m., 12/21/18 at 8:14 a.m. and 12/24/18 at 4:02 a.m. An interview with the Director of Nursing (DON) on 1/11/19 at 5:10 p.m. revealed that the facility has a new electronic record for medications and that they are aware of recording errors on the Electronic MAR. She did confirm that the nurses had made notes in their nursing notes (Departmental Notes) but not on the MAR indicated [REDACTED]. | 2020-09-01 |
| 511 | DOUGLASVILLE NURSING AND REHABILITATION CENTER | 115273 | 4028 HWY 5 | DOUGLASVILLE | GA | 30135 | 2019-01-11 | 880 | F | 0 | 1 | ZVL511 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, and policy reviews the facility failed to provide evidence that infection control surveillance data was collected in (MONTH) of (YEAR). Failed to provide documentation that infection control data collected in (MONTH) of (YEAR) was analyzed for trends and appropriate actions taken in response. In addition, the facility failed to do the following; conduct annual review and update their policies and infection prevention control program (IPCP); failed to don appropriate personal protective equipment (PPE) when entering a resident's room on transmission-based precautions; failed to use hand hygiene prior to donning PPE and during medication administration. The facility census was 220. Findings included: Review of an undated policy titled, Surveillance For Healthcare Associated Infections revealed; Policy Surveillance for Healthcare Associated Infections will be completed to calculate baseline rates, detect outbreaks, track progress, and to determine trends to help prevent the development or spread of infection (HAI). Procedure 3. Complete the Monthly Control Surveillance Log utilizing a new form each month. 1. Review of the Monthly Healthcare-Associated Infection (HAI) Report dated (MONTH) (YEAR)-November (YEAR) revealed facility did not have collected surveillance data for the month of (MONTH) (YEAR). Review of the Monthly Healthcare-Associated Infection (HAI) Report dated (MONTH) (YEAR) 18 revealed total infection cases; 1 UTI's with a Foley, 8 UTI's without a Foley, 3 URI, 2 LRI, 2 pressure ulcers, 2 skin, 1 [MEDICAL CONDITION], 1 other. Further review of the (MONTH) infection control data revealed that no infection control surveillance log was done nor summary of the infections. An interview was conducted on 12/19/18 at 11:45 a.m. with the Director of Nursing (DON) confirmed that the Monthly Infection Control Surveillance log should be used/completed per the policy. 2. Review of the IPCP no evidence that the facility was conducting an annual review of their program. An Interview was conducted on 12/17/18 at 5:15 p.m. with Infection Control Preventionist (ICP). The ICP revealed the infection control policies and manual is updated annually and as needed. The following Policy were provided to the surveyor by the DON and reviewed by the surveyor: 1. Surveillance For Healthcare Associated Infections undated policy 2. Communicable Disease Reporting dated 10/09 3. Management Of Communicable Diseases dated 10/09 4. [MEDICAL CONDITION] Surveillance dated 10/09 5. Standard Precautions dated 10/09 6. Contact Precautions dated 10/09 7. Droplet Precautions dated 10/09 8. Regulated Infectious Waste dated 10/09 9. Stool Specimen dated 10/09 10. Laundry Handling dated 10/09 11. Multi Drug Resistant Organisms (MDROs) dated 10/09 12. Hand Washing dated 8/17 13. Ear Culture dated 8/11 14. Eye Culture dated 8/11 15. Throat Culture dated 8/11 16. Wound Culture dated 8/11 17. Sputum Culture dated 8/11 18. Immunization/Vaccination Protocol-Resident dated 10/09 19. Influenza and Pneumococcal Vaccination-Resident dated 10/09 20. [MEDICAL CONDITION] Skin Testing-Employee & Resident dated 1/16 21. Exposure Control Plan dated 1/16 22. Engineering and Work Practice Controls for Bloodborne Pathogens dated 8/13 23. Training on Exposure Control Plan and Bloodborne Pathogen Education dated 8/13 The facility is not annual reviewing and updating policy to ensure effectiveness and that they are in accordance with current standards of practice for preventing and controlling infections. Observation on 12/17/18 at 9:00 a.m. revealed Certified Nursing Assistant (CNA) TT carry a breakfast tray into the room of R#151, who is on Transmission Based Precautions for Extended Spectrum Beta-Lactamase (ESBL) in her urine, without putting on Personal Protective Equipment (PPE). CNA TT sat the tray down on the bedside table and moved the table toward the resident then walked out of the room, put on gloves, reentered the room, and assist with meal set up without washing or sanitizing her hands. During an observation on 12/18/18 at 9:25 a.m. during medication pass on R#232 on Magnolia wing, with Transmission Based Precautions for ESBL in the urine, with LPN UU she sanitized her hands, put on a gown and put a pair of gloves in her hand, gathered meds for R#232, entered the residents room and placed the meds and water on the bedside table and moved the table next to the residents bed. She then turned off the feeding pump, used the control to lower the head of the bed of the resident, then walked around to the bedside table and put her gloves on. She did not wash or sanitize her hands before putting on her gloves. When she finished administering the medications, via the feeding tube, she replaced the feeding, removed her gloves and gown and threw them away in the trash can, raised the head of the bed, restarted the feeding, washed her hands and used the paper towels she dried her hands with to wipe off the bedside table and move it back to the window and exited the room. During an observation on 12/18/18 at 12:55 p.m., during lunch in the rehab unit, revealed CNA GG sanitize her hands and take a tray from the cart and go into a residents room, R#158, who is on contact isolation for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in a surgical wound without putting on PPE. During this time a staff member informed the CNA that the resident was gone to [MEDICAL TREATMENT]. During an interview on 12/18/18 at 1:00 p.m. with CNA GG revealed that she should have put on a gown and gloves prior to entering the room of R#158 but stated she just forgot. During an interview on 12/19/18 at 9:00 a.m. with the DON revealed that she spoke with CNA GG and that she expects all staff to use PPE prior to entering a room of a resident on transmission-based precautions. During a medication pass on 12/19/18 at 9:10 a.m. with LPN VV on C-Hall she did not wash or sanitized her hands before administering medication to the resident. After administration and before leaving the room she washed her hands in the resident sink. During an interview on 12/19/18 at 11:15 a.m. with the DON, in her office, she stated she expects the nursing staff to follow the policy on Transmission Based Precautions. She stated when staff see the sign that says Stop and See Nurse the staff know that they lift the sign and the other side will instruct them exactly what PPE is needed for that resident and she expects them to wash or sanitize their hands, put on the appropriate PPE, enter the resident room and take care of their needs, remove the PPE and dispose of it in the room, wash their hands, and exit the room. She stated that she expects nurses who are doing med pass to wash or sanitize their hands, prepare the medication, sanitize their hands, administer the medication to the resident and wash their hands prior to leaving the room. DON stated that she expects the nurse giving medications to follow the transmission-based precaution policy as she previously stated to this surveyor. | 2020-09-01 |
| 869 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2017-10-19 | 282 | D | 0 | 1 | ZVHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow the care plan related to administration of insulin and Finger Stick Blood Sugar (FSBS) monitoring for one residents (#65) and failed to follow the plan of care related to behavior monitoring for one resident (#103) with behavioral symptoms that received an anti-psychotic medication. The sample size was 30 residents. Findings include: 1. Review of clinical record revealed R#65 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15. Review of the care plan last updated 8/24/17 revealed that R#65 has a [DIAGNOSES REDACTED]. Interventions include FSBS as ordered and medications as ordered. Review of the physician's orders [REDACTED].#65 revealed the following: FSBS three (3) times a day and Humalog Insulin 100 Units per milliliters (U/ML) 10 units (0.10 ML) subcutaneous (Sub-Q) AC with breakfast, lunch and supper. Review of the Medication Administration Record [REDACTED]. During an interview with the RN, FF on 10/19/17 at 12:10 a. m., she revealed that the nurse responsible for recording FSBS and Humalog administration no longer works at the facility. She also stated nurses are expected to document FSBS and administration of Humalog; however, she doesn't know what happened that caused the lack of documentation. 2. Review of the clinical record for Resident (R) #103 revealed [DIAGNOSES REDACTED]. Further review of the clinical record revealed a current physician's orders [REDACTED]. Review of the resident's records revealed a plan of care, last updated 9/6/17, for [MEDICAL CONDITION] medication use related to [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. However, the behavior monitoring sheets revealed that the licensed nursing staff did not consistently monitor the resident for the targeted behaviors. There were at least 23 shifts in (MONTH) (YEAR) during which behaviors were not documented as being monitored and seven days during the first 18 days for (MONTH) (YEAR) in which there was no documentation that behaviors were monitored; | 2020-09-01 |
| 870 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2017-10-19 | 309 | D | 0 | 1 | ZVHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to follow the Physician's order to document observation of [MEDICAL TREATMENT] port every shift for one (1) resident (R#65) of one resident who receives [MEDICAL TREATMENT] treatment of [REDACTED]. Findings include: Review of clinical record revealed R#65 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 14 out of 15. Review of the Physician's orders dated (MONTH) (YEAR) and (MONTH) (YEAR) for R#65 revealed to observe [MEDICAL TREATMENT] port to right (rt) upper chest every shift for signs or symptoms (s/s) of bleeding. Review of the Medication Administration Record (MAR) dated (MONTH) (YEAR) and (MONTH) (YEAR) revealed no documentation of observation of [MEDICAL TREATMENT] port on 10/4/17 (11-7) shift, 9/16/17, 9/22/17, 9/26/17 (11-7) shift and 9/30/17 (7-3) shift. During an interview with Registered Nurse (RN) RCC, FF on 10/19/17 at 11:00 a.m., revealed the [MEDICAL TREATMENT] port should be checked every shift and documentation of the check should be recorded on the MAR and it was not. | 2020-09-01 |
| 871 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2017-10-19 | 329 | D | 0 | 1 | ZVHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor targeted behaviors for one residents (#103) with behavioral symptoms and failed to monitor for side effects for two residents (#103, and #30) that received anti-psychotic medications from a sample of thirty (30) residents. Findings include: 1. Review of the clinical record for Resident (R) #103 revealed [DIAGNOSES REDACTED]. Further review of the medical record revealed a current physician's orders [REDACTED]. Review of policy titled: Monitoring of Antipsychotics last updated (MONTH) (YEAR) documented: when antipsychotic therapy is initiated, the resident is to be monitored for behaviors on each shift every day. Side effects are also to be monitored on each shift, every day, and staff are to indicate whether side effects are noted or not noted. If side effects are observed and noted, then an explanation must be documented in the nurses' notes. Review of clinical records for R#103 revealed a Behavior Monitoring Record: [MEDICAL CONDITION] Medications sheet which indicated that the resident was to be monitored for two targeted behaviors: striking out at staff/other residents and crying. The sheet contained areas for the number of episodes per targeted area to be monitored each shift, the type of intervention to be initiated if the behaviors were observed, and the outcome of that intervention. The back of this sheet contained an area for side effects of the resident's [MEDICAL CONDITION] medications to be documented each shift; if no side effects were documented for the month, a box was available to check that no side effects noted this month. Review of the Medication Administration Record [REDACTED]. However, the behavior monitoring sheets revealed that the licensed nursing staff did not consistently monitor the resident for the targeted behaviors. There were at least 23 shifts in (MONTH) (YEAR) during which behaviors were not documented as being monitored and seven during the first 18 days of (MONTH) (YEAR) during which there was no documentation that behaviors were monitored; There was no documentation on the Behavior Monitoring Record: [MEDICAL CONDITION] Medications that side effects were monitored or documented for (MONTH) (YEAR) or (MONTH) (YEAR)and the box indicating that there were no side effects during the month of (MONTH) was unchecked. 2. Review of the clinical record for Resident (R) #30 revealed a [DIAGNOSES REDACTED]. Further review of the medical record revealed a current physician's orders [REDACTED]. Review of the MAR for (MONTH) (YEAR) and (MONTH) (YEAR) staff administered antipsychotic medication, quetiapine, as ordered. However, side effects (or no side effects) were not documented on the sheets titled: Behavior Monitoring Record: [MEDICAL CONDITION] Medications. During an interview on 10/19/17 at 3:18 p.m., with the Director of Nursing (DON) it was revealed that staff are expected to document behaviors and side effects on every shift for residents placed on [MEDICAL CONDITION] medications. If there are no side effects, this too is documented on the back of the behavior monitoring sheet indicating that there were no side effects; if there are side effects then action is taken, including notifying the physician and other necessary actions. The facility initiated a new behavior monitoring sheet in (MONTH) on which behaviors are monitored on the front, and side effects on the back. | 2020-09-01 |
| 872 | RIDGEWOOD MANOR HEALTH AND REHABILITATION | 115341 | 1110 BURLEYSON DRIVE | DALTON | GA | 30720 | 2017-10-19 | 514 | D | 0 | 1 | ZVHZ11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document administration of [MEDICATION NAME] and failed to document Physician notification of fingerstick blood sugars (FSBS) outside of parameters for one resident (R#83) from a sample of 30 residents. Findings include: 1. Review of the clinical record for R#77 revealed Physician orders [REDACTED]. The original order date was 3/10/17. Review of the Medication Administration Record (MAR) for R#77 for September, (YEAR) and October, (YEAR) revealed no documentation that nursing staff administered [MEDICATION NAME] as ordered at bedtime on 9/1/17, 9/2/17, 9/3/17 and 9/4/17. Continued review revealed no documentation for the administration of [MEDICATION NAME] Sprinkles from 9/8/17 through 9/13/17, 9/15/27 through 9/20/17, and 9/23/17 through 10/17/17. Continued review of the medical record revealed that the resident was in the facility on the dates that the above medications were to be administered. During an interview conducted on 10/17/17 at 4:40 p.m. the 100 hall Unit Manager revealed there was no regular evening charge nurse for the long hall for the first three weeks of September. Charge nurses from other areas and other shifts covered until the current full-time evening charge nurse was hired and trained. The Unit Manager confirmed the [MEDICATION NAME] ordered for R#77 to be administered at bedtime had only been documented as administered six times since 9/1/17. During and interview conducted on 10/17/17 at 4:50 p.m., Licensed Practical Nurse (LPN) AA revealed she had administered bedtime medications to R#77 since the last week of (MONTH) and remembers that she gave the [MEDICATION NAME] every evening but indicated she missed signing for administering the routine medication because it was listed with the as needed (PRN) medications. LPN AA confirmed she usually compares the medications listed on the packaging with the medications listed on the MAR but must have missed doing this. An interview conducted on 10/18/17 at 9:20 a.m. with the Director of Nurses (DON) revealed she expects the Unit Managers to review every residents' previous months MAR at the beginning of the next month. The DON confirmed the missing documentation of administration for R#77 had been missed by the Unit Manager when she reviewed the MAR for (MONTH) because the pharmacy had changed the area where [MEDICATION NAME] was listed from the routine medication listings to the PRN medication area of the MAR. The DON revealed she had identified this as a possible source for documentation omissions on another residents MAR and had contacted the pharmacy in (MONTH) and (MONTH) to correct the location of [MEDICATION NAME] on the MARS. The DON indicated she had checked other residents MARs that received [MEDICATION NAME] but had not checked the MAR for R#77. There were no documentation omissions on any other residents MARS. 2. Review of Physician orders [REDACTED]. Review of the MARS for R#83, including (MONTH) through October, (YEAR) revealed FSBS results less than 60 and over 400 as follows: 10/3/17 at 11:30 a.m. - 403 10/5/17 at 8:00 a.m. - 438 10/9/17 at 8:00 a.m. - 422 10/10/17 at 11:30 a.m. - 458 10/11/17 at 11:30 a.m. - 428 9/4/17 at 8:00 a.m. - 58 9/25/17 at 8:00 a.m. - 426 8/9/17 at 11:30 a.m. - 429 8/10/17 at 8:00 a.m. - 54 8/11/17 at 11:30 a.m. - 478 7/21/17- 11:30 a.m. - 408 Review of Nurse's Progress Notes for R#83 for (MONTH) through (MONTH) (YEAR) revealed no documentation of Physician or Nurse Practitioner notification of the above FSBS results. Patient at Risk (PAR) review notes dated 9/26/17 revealed R#83 is a brittle diabetic with blood sugars that range from very low to very high. During an interview, Licensed Practical Nurse (LPN) BB on 10/18/17 at 12:50 p.m. confirmed she initialed FSBS results on the MAR for R#83 on 10/3/17 at 11:30 a.m., 10/5/17 at 8:00 a.m., 10/9/17 at 8:00 a.m., 10/10/17 at 11:30 a.m., 10/11/17 at 11:30 a.m., 9/4/17 at 8:00 a.m., 9/25/17 at 8:00 a.m., 8:10/17 at 8:00 a.m. and 7/21/17 at 11:30 a.m. LPN BB revealed R#83 is a brittle diabetic and has FSBS results over 400 or less than 60 several times each month. LPN BB acknowledged there were no nurses progress note entries documenting Physician or Nurse Practitioner notification of the above FSBS results but she is certain she called. LPN BB indicated she was aware she is expected to document Physician and Nurse Practitioner notifications but had missed these documentations. An interview conducted on 10/18/17 at 2:40 p.m. with the Nurse Practitioner confirmed she is sure she is notified of FSBS results less than 60 and greater than 400 for R#83 because she checks this residents' blood sugar results when she visits the facility and is aware of being called each time. An interview on 10/18/17 at 4:10 p.m. with the Regional Nurse confirmed the charge nurses should document when a Physician or Nurse Practitioner is notified of FSBS results less than 60 or greater than 400. The Regional Nurse revealed she had reviewed the Nurses Progress Notes and was unable to find documentation of notification for the above blood sugar results. | 2020-09-01 |
| 1636 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-10-01 | 278 | F | 0 | 1 | ZV7N11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to accurately assess the Minimum Data Set (MDS) assessments for the use of corrective lenses for one (1) resident (#41), and dental status for one (1) resident (#31). The sample size was twenty-five (25) residents. Findings include: 1. Review of the Quarterly MDS assessment for resident #41 dated 07/09/15 noted that she had visual impairment, with no corrective lenses. Review of the Care Plan Notes dated 07/13/15 noted that she wore glasses for visual acuity with a history of retinal repair. Review of the comprehensive care plans revealed that a care plan had been developed for impaired visual function with the use of glasses for visual acuity. On 09/30/15 at 2:39 p.m., resident #41 was observed wearing eyeglasses while reading a magazine, and during interview stated that she wore glasses for reading only. During interview with Licensed Practical Nurse (LPN) MDS Coordinator on 10/01/15 at 10:02 a.m., she stated that she assumed that glasses had to be prescription glasses to be coded as having corrective lenses. Upon further interview, she stated that when she did the MDS vision assessment for resident #41, the resident had told her that she wore glasses for reading only, so she coded the resident as not having corrective lenses as she did not wear glasses at any other time. Upon further interview, she verified that resident #41 wore her glasses when the vision assessment was done. During further interview and record review with the MDS Coordinator at this same time, she verified that according to the MDS 3.0 section B1000 for Vision, the guidance was to code 'Yes' if corrective lenses or other visual aids were used when the visual ability was assessed. 2. During observation on 09/29/15 at 11:31 a.m., resident #31 was noted to be missing all of her upper teeth. During interview with the resident at this same time, she stated that she had no mouth or tooth pain, and could chew her food without problems. Review of an Oral Health Worksheet dated 06/22/15 noted no upper teeth, and missing lower teeth. Review of a Dynamic Mobile Dentistry Progress Note dated 08/06/15 noted no upper teeth, several fractured and carious teeth, and recommended the extraction of five lower teeth. Review of the Annual MDS assessment dated [DATE] revealed that there was no oral or dental concerns, and Dental Care did not trigger on the Care Area Assessment Summary (CAAS). Review of the care plans revealed that a care plan for dental issues was not developed. During interview with the MDS Coordinator on 10/01/15 at 9:57 a.m., she stated that she coded resident #31 as having no dental issues on the MDS assessment because the resident had a few teeth remaining. Upon further interview and record review, she verified that the MDS 3.0 Section L0200 B, noted to select no natural teeth or tooth fragment(s) (edentulous): if the resident is edentulous or lacks all natural teeth or parts of teeth. Upon further interview, she stated that if she had coded the dental section this way, that Dental Care would have triggered on the CAAS, and she would have developed a care plan for it. | 2020-09-01 |
| 1637 | MADISON HEALTH AND REHAB | 115457 | 2036 SOUTH MAIN STREET | MADISON | GA | 30650 | 2015-10-01 | 371 | E | 0 | 1 | ZV7N11 | The facility failed to maintain one (1) item (chopped ham) on the steam table at 135 degrees (Fahrenheit) or above to prevent potential foodborne illness during observations at one (1) meal. There were sixty-eight (68) residents who consumed an oral diet, and two (2) residents on a diet with chopped meats. Findings include: Observed on 09/30/15 at 12:05 p.m., multiple food carts to have already been set up with trays for individual residents containing utensils, tea, water, and cartons of milk. Continued observations, revealed all foods on the steam table were at an acceptable temperature (above 135 degrees) to prevent foodborne illness, except for the chopped ham, which was 131.2 degrees using facility thermometer. This was verified during interview with the Dietary Supervisor, who stated that one tray with chopped ham had already been served to a resident. Interview with dietary aide AA on 9/30/15 at 12:05 p.m. she stated that she had taken the temperature of the chopped ham before serving and it was 160 degrees, but the reason the temp dropped so low was because she did not have a lid to cover the chopped ham once it was put on the steam table, and that she usually covered everything. Review of the facility's Dietary Services Policy and Procedure noted the following: -Steam Table: Must be able to maintain hot foods at temperatures of 135 degrees Fahrenheit or above. | 2020-09-01 |
| 9898 | GRACEMORE NURSING AND REHAB | 115554 | 2708 LEE STREET | BRUNSWICK | GA | 31520 | 2010-09-23 | 322 | D | 0 | 1 | ZUT111 | **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 one (#6) of four sampled residents with feeding tubes received the correct amount of feeding as ordered by the physician from a total sample of 14 residents. Findings include: Resident #6 had a current physician's orders [REDACTED]. feeding was still infusing. During an interview on 9/22/10 at 8:30 a.m., licensed nurse "TT" stated that he/she did not know why the resident's tube feeding was still infusing. Review of the clinical record, Medication Administration Record [REDACTED] | 2015-04-01 |
| 9899 | GRACEMORE NURSING AND REHAB | 115554 | 2708 LEE STREET | BRUNSWICK | GA | 31520 | 2010-09-23 | 371 | F | 0 | 1 | ZUT111 | Based on observation and staff interview, it was determined that the facility failed to ensure that the high temperature dishwasher was properly functioning to effectively destroy potential food borne illness. Findings include: During an observation of dietary staff washing dishes in the high temperature dishwasher on 9/23/10 at 8:20 a.m., the rinse cycle only reached 150 degrees Farenheit (F.). During an interview with the dietary manager at that time, she stated that the rinse cycle should reach 180 degrees F. (to effectively rinse dishware). | 2015-04-01 |
| 5503 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 323 | D | 0 | 1 | ZUHN11 | Based on observations, record review, facility policy and staff interview it was determined that the facility failed to ensure that the resident's environment was free of accident hazards for one (1) resident (#57) from a sample of forty-eight (48) residents. Findings include: Observation during intial tour of the facility on 02/02/15 at 11:00 a.m. room E-69, revealed a private bathroom for resident #57 with a soft raised toilet seat that was torn on both sides and the back with jagged edges exposing the foam. Continued observation on 2/03/15, at 3:00 p.m., 02/04/15 at 7:45 a.m. and 2:30 p.m., and again on 02/05/15 at 7:30 a.m. and 8:10 a.m., revealed that the raised soft toilet seat was still torn with jagged edges exposing the foam remained in the resident's private bathroom. Interview with CC the Private Sitter on 02/04/2015 at 9:24 a.m., revealed that resident #57 uses the raised soft toilet seat several times daily with assistance from staff. CC further revealed that the resident was not able to ambulate to the bathroom unassisted and required help from staff. Interview with the Infection Control (IC) Nurse on 02/04/15 at 10:45 am revealed that resident #57 uses the private bathroom with the soft raised toilet seat daily, and required assistance from the staff but continued to wear adult diapers. Observation on 02/05/15 at 9:15 a.m. of the private bathroom for resident #57 with the IC Nurse she confirmed that the soft toilet seat was torn on both sides and in the back with jagged edges exposing the foam. She further revealed that the toilet seat would be replaced. Interview with Certified Nursing Assistant (CNA) BB on 02/05/15 at 8:15 a.m. revealed that resident #57 was on a toileting program with staff toileting the resident every two (2)hours especially after meals and as needed. CNA BB further revealed that the resident continues to use the private bathroom with the torn toilet seat several times daily and at times asks to remove the torn seat to allow the resident to sit on the regular seat. Interview on 02/05/2015 at 8:45 a.m. with the IC Nurse revealed that part of her job was to make sure that resident personal care equipment was replaced if anything was wrong with it. She further revealed that all staff are responsible for checking each residents, personal care equipment daily for any defects or potential hazards. Continued interview revealed that if any equipment is found to be a danger or hazard to any resident it should be removed and disposed of and replaced immediately. The IC Nurse revealed that after seeing the soft torn raised toilet seat with jagged edges, and the foam exposed, she was embarrassed and upset that none of the staff or housekeeping had informed her. She revealed that the soft raised torn toilet seat with jagged edges, was a potential accident and or hazard to the resident and that resident #57 could have potentially scratched her bottom causing an injury. Observation of resident #57's skin on 02/05/2015 at 3:30 p.m. revealed no skin abrasions noted on her bottom or her legs related to the torn toilet seat. | 2018-08-01 |
| 5504 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 371 | E | 0 | 1 | ZUHN11 | Based on observation and staff interviews the facility failed to properly demonstrate the usage of the three (3) compartment sink to prevent the potential for food borne illness. This had the potential to effect one hundred and fifty-two (152) residents who received oral alimentation. Findings include: Observation on 02/04/15 at 3:40 p.m. revealed that AA , the cook did not properly sanitize the blender bowl and lid after usage in the three (3) compartment sink. Continued observation revealed that the cook washed the blender bowl and lid in soapy water; next she rinsed the items in the rinse compartment. The cook then placed the blender bowl and lid in the sanitizing solution and then removed both items after being immersed for only (fifteen) seconds. Further observation of the three (3) compartment sink revealed that a poster was hanging above the sink from Patco, the company that provides the facility with chemicals, which indicated the appropriate steps and technique for usage of the three (3) compartment sink including how long to submerge items in the sanitizing solution which stated one (1) minute or longer. Interview with AA the cook on 02/04/15 at 3:40 p.m. revealed that the way she demonstrated to the surveyor how to clean and sanitize the blender bowl and lid was how she was told to clean items in the three (3) compartment sink. Continued interview revealed that she does not recall the last time there was an in-service regarding the proper usage of the three (3) compartment sink. Interview with the Dietary Manager (DM) on 02/04/15 at 3:42 p.m. revealed that she was not able to verbalize to the surveyor how to properly use the 3 compartment sink. Continued interview with the DM revealed that she had been educating her staff that they just need to swish items in the sanitizing solution and then place them on the rack to dry. The DM revealed that she was not aware that items needed to be immersed in the sanitizing solution for at least one minute per recommendations of the manufacturer as indicated on the poster. | 2018-08-01 |
| 5505 | PARK PLACE NURSING FACILITY | 115005 | 1865 BOLD SPRINGS ROAD | MONROE | GA | 30655 | 2015-02-05 | 372 | C | 0 | 1 | ZUHN11 | Based on observations and staff interviews the facility failed to maintain the condition of one (1) large compacting dumpster to ensure it was free from leakage and failed to properly cover the garbage in the dumpster to prevent the harborage of pests. Findings include: Observation on 02/02/15 at 11:00 a.m. of the dumpster area revealed that the facility had one (1) compacting dumpster sitting on a concrete pad. Continued observation of the dumpster revealed that the area to deposit garbage was open and ten (10) garbage bags were visible. Further observation revealed a large leak coming from under the front of the dumpster. A stream of pale white fluid ran forward to the front of the concrete pad and formed a pool. The pool of white fluid was eight (8) feet in length, 1 foot in width, and two (2) inches deep. Interview with the Dietary Manager (DM) on 02/02/15 at 11:00 a.m. revealed that she had never seen the area to deposit garbage closed and that garbage was constantly exposed. Continued interview revealed that she knew about the leak in the dumpster for two (2) weeks and admitted that the white fluid coming from the dumpster was milk and juices from the dietary department. The DM further revealed that dietary and housekeeping share responsibility for keeping the dumpster area clean. Interview with the Director of Maintenance on 02/02/15 at 11:05 a.m. revealed that the only time the area to deposit garbage in the dumpster is closed is when garbage is being compacted or at the end of the day. He revealed that at the end of the day the last individual discarding garbage compacts the garbage and leaves the compacting ram inside the main garbage storage area. Once the plunger is pushed in it covers the area that garbage is deposited. The Director of Maintenance confirmed that they have known about the leak coming from the dumpster for the past few weeks. He confirmed that the white liquid coming from the dumpster was milk and juices from the kitchen garbage. Observation on 02/03/15 at 3:45 p.m. of the compacting dumpster revealed that garbage bags were visible and no lid or door was covering the dumpster. Continued observation revealed that the dumpster was still leaking and had developed a new stream of fluid approximately three (3) feet in length and 1 inch in width that traveled across the side walk in front of the concrete pad from where the dumpster was located. Observation on 02/04/15 at 5:50 p.m. revealed that the area to deposit garbage in the dumpster was still open and the garbage bags were still visible. | 2018-08-01 |
| 3270 | PARKSIDE POST ACUTE AND REHABILITATION | 115643 | 3000 LENORA CHURCH DRIVE | SNELLVILLE | GA | 30078 | 2018-12-13 | 804 | E | 0 | 1 | ZU6H11 | Based on observation, interview, record review and policy review, the facility failed to ensure six out of 37 sampled residents (R) (R#6, R#14, R#16, R#57, R#133, R#134), residents attending resident council meetings, and residents attending the group interview were served palatable food. Specifically, food was not satisfactory in taste or temperature and condiments were not consistently served creating the potential for dissatisfaction and weight loss. Findings include: 1.Background information Review of the Parkside Post-Acute & Rehabilitation Census dated 12/10/18 revealed there were 94 residents prescribed regular texture diets, 62 prescribed mechanical soft texture diets, and 23 prescribed pureed texture diets. Interview with the Dietary Manager on 12/10/18 at 9:30 a.m. was conducted in the kitchen during the initial kitchen inspection. The Dietary Manager indicated meal times were between 7:00 a.m. and 8:30 a.m. for breakfast, 12:00 p.m. and 1:20 p.m. for lunch, and 5:00 p.m. and 6:30 p.m. for dinner. The Dietary Manager stated meals were also served to residents residing in the personal care part of the building; they were served prior to the nursing home residents. The food was dished up in the kitchen from the steamtable and the individual meal trays were sent to residents eating off the hall carts and dining rooms on the units. Food was dished up from a steamtable in the main dining room for residents eating in the main dining room. The main dining room was served first for the nursing home residents. The Dietary Manager stated there was a main dining room and small dining rooms in the A and B units. The Dietary Manager stated residents could eat in their rooms if they wanted to or could eat in the dining rooms. The Dietary Manager stated there were six meal carts that were sent to A, B, C and [NAME] halls; A and B halls had two carts whereas C and [NAME] halls had one cart each. The facility Food Delivery Log undated, revealed for the lunch meal the main dining room meal service began at 12:00 noon, [NAME] hall meal service was from 12:10 p.m. - 12:30 p.m., B hall meal service was from 12:30 p.m. - 12:50 p.m., A hall meal service was from 12:50 p.m. - 1:10 p.m. and C hall meal service was from 1:10 p.m. - 1:20 p.m. 2. Resident council minutes a. (MONTH) (YEAR) Resident Council Minutes dated 9/13/18 under New Business, indicated food was not being prepared to residents' satisfaction. Residents wanted more variety of food. Desserts did not look like desserts and were missing a lot of ingredients. b. (MONTH) (YEAR) Resident Council Minutes dated 10/11/18 under New Business, indicated food was not prepared properly and was missing a lot of condiments. The food was not tasty. c. (MONTH) (YEAR) Resident Council Minutes dated 11/8/18 under New Business, indicated the food was often overcooked or undercooked. Residents stated they were tired receiving fruit for dessert. 3. The Resident group interview was held on 12/11/18 at 11:00 a.m. in the A hall restorative dining room. Nine residents were in attendance, three residents each from A and B halls, two residents from C hall and one resident from [NAME] hall. A resident from A hall said the meals were served cold at times. When asked to clarify if the cold meals were served at a specific time, the resident said it could be anytime. The remaining residents in group concurred they were served cold meals at times. 4. Resident interviews revealed concerns with the food: a. In an interview on 12/12/18 at 10:10 a.m. in the resident's room, R#57 stated she did not like the food, especially mushy food. b. In an interview on 12/11/18 at 2:06 p.m. in the resident's room, R#16 stated, The food is not so great. The food does not taste good. c. In an interview on 12/10/18 at 12:26 p.m. in the resident's room, R#133 stated, I don't like the food. d. In an interview on 12/10/18 at 2:53 p.m. in the resident's room, R#14 stated she did not like the food. e. In an interview on 12/10/18 at 10:12 a.m. in the resident's room, R#134 stated the food was terrible in appearance and taste. 5. In an interview on 12/12/18 at 10:24 a.m. in the surveyor conference room the Ombudsman stated there had been a lot of food issues. The Ombudsman stated she attended the (MONTH) (YEAR) resident council meeting and there were numerous complaints voiced by the residents about the food, including complaints of overcooked food, a lack of condiments, and cold food. 6. Meal Observations a. Lunch 12/10/18 The menu Week at-a-Glance, Week 4 revealed lunch on 12/10/18 consisted of an open-faced turkey sandwich, mashed potatoes, whole kernel corn, roll/bread, and fruit salad for dessert. The alternate was lemon pepper fish fillet, parsley rice, and seasoned zucchini. Meal observations were made in the main dining room and on all the units (A, B, C, and E) from 12:00 p.m. to 1:05 p.m. Residents eating in the main dining room were served starting at 12:13 p.m. There were approximately 30 residents eating in the dining room. Residents were first served beverages, then foods from the salad bar (fruit, salad, cottage cheese) per request, then homemade pea soup was poured into bowls and the bowls were placed on a cart which was wheeled around the dining room and offered to residents. A staff member offered soup to most of the residents. Crackers were not served at the time soup was served, which started at 12:18 p.m. Approximately 10 minutes after the soup was served a staff member offered crackers to most of the residents who were served soup. However, R#6 asked for crackers when she was served her soup at 12:21 p.m. The resident asked two staff members for crackers; neither brought the resident crackers. R#6 did not eat any of her soup until she received crackers after asking in a loud exasperated manner, We don't get any crackers? at 12:34 p.m. at which time an activity staff member passing through the dining room notified staff R#6 requested crackers and they were then served to her. The resident waited 13 minutes to be served crackers. The alternate vegetable was zucchini which was served to residents in a small bowl. The zucchini was a faded green color, was mushy and overcooked in a watery solution. The residents did not have salt and pepper served with the meal (either on the table or salt and pepper packets). One resident asked for salt and staff went and obtained a salt packet. Residents were not served margarine with their rolls. Staff were not observed to ask residents if they wanted margarine; it was not observed to be served. At 12:34 p.m. the first plate was served (entree, vegetable and starch). There was one dietary staff member dishing up the plates from the steamtable. There were four staff members delivering the plates, one at a time, to residents seated in the dining room. The dietary staff member was not able to keep up with the nursing staff serving the plates. There were usually three to four nursing staff members standing at the steamtable waiting for plates to be dished up. The plates were not covered after they were dished up. They were served directly from the shelf above the steamtable to residents in the dining room. The last resident was served their plate at 12:55 p.m. b. Lunch 12/12/18 The menu Week at-a-Glance, Week 4 revealed lunch on 12/12/18 consisted of garlic herb pork loin, ranch style potato wedge, succotash, dinner roll/bread, and peach crisp for dessert. The alternate was breaded chicken on a bun, buttered noodles, and roasted brussel sprouts. French fries were served instead of ranch style potato wedges. The homemade soup was cabbage/tomato. The hot foods on three (main dining room, A unit, and B unit) of four test trays (main dining room, A unit, B unit and [NAME] unit) were cool or lukewarm; these menu items were not palatable. Test Tray A Unit On 12/12/18, the sheet pan rack with residents' trays arrived on the unit at 12:35 p.m. The test tray was evaluated at 12:50 p.m. after the last resident was served their meal; the test tray was a regular diet main meal selection. Temperatures of the foods were measured; the entree and starch were not hot. Temperatures were 110 degrees F for the pork and 110 degrees F for the french fries. Test Tray B Unit On 12/12/18, the sheet pan rack with residents' trays arrived on the unit at 12:35 p.m. There were ten resident trays located on the rack. The staff began distributing the trays to residents seated in the B Unit dining room. When there were three trays remaining on the cart, the B Unit Manager came walking down the hall and placed an additional tray on the cart and stated it was the test tray. When the remaining three trays were served, the test tray was obtained from the cart. The test tray was a regular diet with pork loin, french fries, and corn with lima beans. Temperature was 110.8 for the pork loin, 110 for the french fries. The food tasted as though it was room temperature and not hot. Test Tray Main Dining Room On 12/12/18 at 12:40 p.m., there were approximately 30 residents in the main dining room for lunch. Residents had already been served beverages, salad bar items per preference and soup. Tray line meal service began at 12:40 p.m. All the lids were removed from the steamtable pans. The steamtable pans of food remained completely uncovered for the duration of the tray line meal service. There was one dietary staff member dishing up the plates from the steamtable. There were four to five staff members delivering the plates, one at a time, to residents seated in the dining room. The dietary staff member was not able to keep up with the nursing staff serving the plates. Four to five staff were waiting at the steamtable for the dietary staff to dish up the plates. The plates were not covered after they were dished up. They were served directly from the shelf above the steamtable to residents in the dining room. The last resident was served his/her plate at 1:00 p.m. No ketchup was served with the french fries and no margarine was served with the dinner rolls. Residents were served salt and pepper if they requested it. Residents who were served the alternate meal of a dry chicken breast on a bun with a tomato slice and piece of lettuce were served the sandwich without mayonnaise or any other sauce/dressing. If residents asked, staff obtained mayonnaise packets for them. A test tray of the alternate meal consisting of the chicken sandwich on a bun with lettuce and tomato, egg noodles, brussel sprouts and cabbage tomato soup was evaluated right after the last resident was served his/her tray at 1:00 p.m. The chicken was 102 degrees F and was cool to the palate. The egg noodles were cool at 89 degrees F. The brussel sprouts were lukewarm at 115 degrees F. The cabbage tomato soup was 123 degrees F. The cabbage chunks in the soup were hard and undercooked. 7. Staff interviews In an interview on 12/13/18 at 2:31 p.m. in the personal care day room, the Dietary Manager stated she attended resident council meetings and had been working to address residents' concerns related to food palatability/food temperatures. The Dietary Manager stated she occasionally tested the temperatures of meals; however, she did not provide documentation of checking the temperatures. The Dietary Manager stated meal temperatures had been a problem and the facility recently purchased three insulated food carts. The Dietary Manager stated there were a total of six carts used for transporting residents' meals to the A, B, C and [NAME] halls. The Dietary Manager stated the other three carts used to transport residents' meals were sheet pan racks that were not enclosed or insulated in any way. The trays with residents' meals were placed on the shelving of the sheet pan racks. There were no sides, no bottom, and no top to the sheet pan racks. The Dietary Manager stated the temperature of the hot food should be 135 degrees Fahrenheit (F) when residents received their meals. The Dietary Manager stated the plates were placed into a plate warmer to heat prior to meal service. Plates of dished food were placed onto plastic bases and lids were placed on top of the plates for delivery to the halls. In an interview on 12/13/18 at 9:13 a.m. in the surveyor conference room, the Registered Dietitian stated she causally checked things out in the kitchen; however, did not complete any kitchen audits per se. The Registered Dietitian stated she did not check tray line food temperatures or check the temperatures of meals that had been plated. The Registered Dietitian stated she had been working with the Dietary Manager to address the residents' food concerns raised in resident council meetings. 8. Policies a. The Food Quality and Palatability Policy dated (MONTH) 2014 revealed the policy was for food to be, prepared by methods that conserve nutritive value, flavor and appearance. The policy indicated food was to be palatable, attractive and served at the proper temperature. Under Action Steps, the Food Service Director and Cooks were noted as being responsible for food preparation. Menu items were to be prepared according to the menu, production guidelines and standardized recipes. The cook was to season food appropriately in accordance with recipes, regional and/or ethnic preferences, and use cooking techniques to ensure color and flavor retention. b. The Food Preparation Policy dated (MONTH) 2014 revealed the Food Service Director and Cook were responsible for food preparation techniques, which minimized the amount of time, that food items were exposed to temperatures greater than 41 degrees Fahrenheit and/or less than 135 degrees Fahrenheit, or per state regulation. | 2020-09-01 |
| 4791 | WINDER HEALTH CARE & REHAB CTR | 115536 | 263 E MAY STREET | WINDER | GA | 30680 | 2015-06-18 | 309 | D | 0 | 1 | ZT7P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy, and staff interview, the facility failed to ensure that proper assessment and documentation was provided for the arteriovenous (AV) access site of one (1) resident (#147) that received [MEDICAL TREATMENT] treatment from a sample size of thirty-two (32) residents. Findings include: Review of the physician's orders [REDACTED]. Further review of the Physician's Progress Notes dated 05/19/15 revealed the resident had a left AV graft placement that was approved to use for [MEDICAL TREATMENT]. Observation of Licensed Practical Nurse (LPN) AA on 06/18/2015 at 10:35 a.m. revealed the nurse assessing resident #147's [MEDICAL TREATMENT] access for bruit and thrill. The dressing was noted to be clean and dry. Review of the Nurse's Notes and Medication Administration Record [REDACTED]. Review of the Nursing Department [MEDICAL TREATMENT] Facilitation Policy revealed that nursing staff are trained to check AV shunt daily for bruit and document the results of the assessment in the resident's clinical record. Interview with LPN AA on 06/18/2015 at 10:45 a.m. revealed that she checked for resident #147's bruit and thrill when he returned from [MEDICAL TREATMENT] but acknowledged that she forgets to document the assessment in the resident's clinical record. Interview with Unit Two Coordinator LPN BB on 06/18/2015 10:45 a.m., she confirmed that bruit and thrill had not been documented for resident #147 for the months of (MONTH) and (MONTH) (YEAR). Continued interview revealed that licensed staff should document the bruit and thrill in the nurse's notes section of the resident's clinical record after each assessment. LPN BB further revealed that she would be doing an inservice with the licensed staff about the importance of documentation for [MEDICAL TREATMENT] residents. Interview with the Director of Nursing (DON) on 06/18/2015 at 10:50 a.m. revealed that her expectation of the nursing staff was to document bruit and thrill in the cinical record of all residents receiving [MEDICAL TREATMENT]. The DON acknowledged this should be done each time a resident returns from [MEDICAL TREATMENT] treatment. | 2019-06-01 |
| 4792 | WINDER HEALTH CARE & REHAB CTR | 115536 | 263 E MAY STREET | WINDER | GA | 30680 | 2015-06-18 | 371 | E | 0 | 1 | ZT7P11 | Based on observation and staff interview the facility failed to label and date six (6) food items in the refrigerators and dry storage area for two (2) of four (4) days of the survey; and failed to properly clean the stand-up mixer after usage to prevent cross contamination. There were one hundred and thirty-seven (137) residents that received meals from the kitchen. Findings include: Observation on 06/15/15 at 10:35 a.m. of the stand-up mixer revealed that it was covered with a clear plastic bag. Continued observation revealed that after uncovering the stand-up mixer there was a powdery white food substance under the mixing arm and on the shaft to connect the beater. Interview on 06/15/15 at 10:35 a.m. with the Dietary Manager (DM), he confirmed that there was a white powdery food substance on the stand up mixer. The DM revealed that when the clear plastic bag is placed over the top of the stand-up mixer, this indicates that the equipment is clean and ready for use. The DM acknowledged that the plastic bag should not have been placed over the mixer since it was dirty. Continued interview revealed that he expected that all kitchen equipment should be cleaned after usage. Observation on 06/15/15 at 10:40 a.m. revealed that the single door stand up refrigerator had items on the top shelf that were opened and not labeled or dated. These items included a fifteen (15) ounce Starbucks ice coffee which was open with no label or date, 2 hardboiled eggs in a white eight (8) ounce Styrofoam cup covered with saran wrap with no label or date and a twenty four (24) ounce Heinz ketchup bottle was opened with no date. Interview on 06/15/15 at 10:40 a.m. with the DM revealed that he expects all food items stored in the kitchen should have a label and date. The DM confirmed that the Starbucks ice coffee, hard boiled eggs, and the ketchup all did not have a label or date and that they should. Observation on 06/15/15 at 10:45 a.m. of the metal preparation counter in the kitchen revealed a 4 gallon clear plastic container that contained Raisin Bran cereal with no label or date. Interview on 06/15/15 at 10:45 a.m. with the DM revealed that he expects that when staff transfer opened food product to a different container there should be a label and date. The DM acknowledged that the Raisin Bran was not in its original container and was not labeled or dated. Observation on 06/15/15 at 10:55 a.m. of the dry storage area revealed an opened bag of tortilla chips that was wrapped in saran wrap but did not have a date of when opened. Interview on 06/15/15 at 10:55 a.m. with the DM revealed that he expects staff to date all food items after opened and before placing them in the dry storage area. He confirmed that the tortilla chips did not have a date. Observation on 06/17/15 at 9:30 a.m. of the walk in refrigerator revealed that there was an opened forty eight (48) ounce jar of Grey Poupon Dijon Mustard with no date. Continue observation revealed that there was also a sixty four (64) ounce container of Daisy cottage cheese that was opened and not dated. Interview on 06/17/15 at 9:30 a.m. with the DM, he acknowledged that both food products were opened and placed in the walk-in refrigerator with no dates. Review of the facilities policy for Protection of Food from Contamination revealed that all food items must be properly labeled and items in the refrigerators or freezer must be dated. Review of the facilities policy for Safe Storage of Leftover Foods revealed that labels should have the food item, date, and time be place on items before placed in refrigerator or freezer. Review of the dietary department Daily Responsibilities List revealed that each shift cook should clean the equipment used and that each cook helper should ensure all items are wrapped and dated each shift. Review of a dietary staff meeting note provided by the DM revealed that a staff meeting was conducted on 08/04/14. One of the meeting topics discussed was the daily cleaning responsibilities as well as to check leftover shelf and use or discard in six (6) days. | 2019-06-01 |
| 4793 | WINDER HEALTH CARE & REHAB CTR | 115536 | 263 E MAY STREET | WINDER | GA | 30680 | 2015-06-18 | 441 | E | 0 | 1 | ZT7P11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, facility policy, and staff interview, the facility failed to ensure infection control procedures were followed for the care of linens of residents on isolation to prevent possible cross contamination. The resident census was one hundred thirty-nine (139). Findings include: Interview with Laundry Services (LS) CC, on 06/16/15 at 9:10 a.m. revealed that when they handle and sort the isolation linens, they wear a yellow, cloth, patient gown and disposable gloves. CC stated that when when she is done with the gown, she hangs the gown on the shelf where the regular dirty laundry is sorted. When asked what they wear to sort the regular dirty laundry, CC pointed to the same yellow, patient gown she wears to handle and sort the isolation linen. When asked how she prevents cross contamination by wearing the the same gown for the isolation linens and regular dirty linens, she shrugged her shoulder and stated I just wear that, pointing to the yellow gown. When asked if there was any disposable Personal Protective Equipment (PPE) provided for the laundry staff, CC acknowledged there was no disposable PPE in the laundry department. Interview with the Maintenance Supervisor (MS), on 06/18/15 at 10:55 a.m. revealed that he has not conducted any inservices with the laundry staff regarding infection control and the handling of isolation linens. The MS revealed that he thought there was currently disposable PPE in the laundry area and was surprised to find there was none. He confirmed that there should be a disposable PPE station in the laundry area for the handling of isolation linens and added that the laundry staff should not be wearing the same gown for the sorting of isolation linens and regular dirty linens. Continued interview revealed that the Housekeeping Supervisor (HS) normally handles the laundry inservices but stated that he knew that she hasn't done one related to infection control. Interview with the Infection Control Nurse (ICN), on 06/18/15 at 11:05 a.m. revealed that she thought the laundry area had disposable PPE. The ICN acknowledged that there should be disposable PPE in the laundry area. Continued interview revealed that the Housekeeping Supervisor was responsible for conducting any inservices on infection control or PPE for the laundry staff. Review of the facility Infection Control Policy revealed that laundry staff is to wear PPE when necessary while handling isolation or contaminated linen. Review of the resident sample records revealed that there was one (1) resident in the facility on isolation precautions that was currently being treated for [REDACTED]. | 2019-06-01 |
| 9347 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2011-06-03 | 279 | D | 0 | 1 | ZSUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan, after an annual assessment, related to pressure ulcer for one (1) resident (#20) from a sample of thirty-one (31) residents. Findings include: Review of the medical record for resident # 20 revealed that the resident was admitted to the facility on [DATE]. The resident's [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident was assessed as being at high risk for pressure sores. The Care Area Assessment (CAA) triggered for pressure ulcer with a decision to care plan. The current Quarterly MDS 3.0 revealed resident #20 with a Stage ll (2) pressure ulcer to the sacrum. Review of the medical record revealed that the resident had a history of [REDACTED]. Review of the Wound Evaluation Flow Sheet dated 03/30/11 identified a Stage ll (2) pressure ulcer to the sacrum measuring 1.0 centimeter (cm) long by 0.5 cm wide with granulation tissue. The current treatment included cleaning the wound daily with wound cleanser and applying Santyl ointment (a debrider). Review of the resident care plan revealed no evidence that a care plan had been developed related to pressure ulcer. Interview on 06/02/11 1:20 p.m. the MDS coordinator revealed no evidence of a care plan in the electronic record or the chart for the pressure ulcer. | 2015-07-01 |
| 9348 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2011-06-03 | 309 | D | 0 | 1 | ZSUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow physician's orders for two residents (#6 and "A") from a sample of thirty-one (31) residents. Findings include: 1. Review of the medical record for resident #6 revealed that the resident had a discharge date of [DATE]. Review of the physician's order for discharge revealed the following: resident may discharge (d/c) home with home health services to include, nursing evaluation for medication and diabetic management, nursing assistant, medical social worker, physical therapy, occupational therapy, medications to include narcotics and durable medical equipment per therapy recommendation. The order was signed by the Physician on 3/31/11.. Review of the Physician Discharge Summary, written by the Social Worker, revealed that the resident received all medications but that no narcotics were given to the resident because none were ordered. The Interdisciplinary Discharge Summary dated 03/31/11 indicated the same. Review of the Physician Order sheet for March, 2011, which includes all active orders for March, 2011 revealed an order for [REDACTED]. Interview on 06/03/11 at 9:19 a.m. with the Assistant Director of Nursing revealed that after reviewing the medical record she was unable to find an order to discontinue the narcotic prior to discharge, therefore, the narcotic should have been given to the resident at discharge. Further interview revealed that the narcotics were not discharged with the resident as ordered by the physician. 2. Observation at 7:30 a.m.on 06/03/11 revealed a non-emergency transportation vehicle parked and waiting to transport a resident to an appointment. Interview at 8:50 a.m. on 06/03/11 the Social Worker revealed that resident "A" had an appointment outside the facility but that the appointment had to be rescheduled and that this was the second time for rescheduling. Continued interview revealed that the resident always had to have someone with her because of anxiety and that the family member had cancelled the first appointment due to personal reasons. Interview on 6/03/11 at 9:00 a.m. with a family member of resident "A" revealed that she had cancelled the first appointment due to personal reason, but that the appointment had to be cancelled today because the resident had eaten breakfast and was supposed to have nothing by mouth after midnight (NPO). Continued interview revealed that the family member had spoken with Licensed Practical Nurse (LPN) "DD last evening (06/02/11) between 4:00 - 5:00 p.m. to ensure that the resident's appointment was still on, that transportation arrangements had been made and that the resident would be NPO after midnight as ordered. She was told everything had been taken care of and there would be no problems. Interview at 9:10 a.m. on 6/03/11 with LPN "EE" revealed that if a resident is NPO, a dietary sheet is sent to dietary and a notation is placed on a calendar at the desk. The resident was listed on the calendar as NPO after midnight on 06/02/11. Continued interview revealed that a sign is placed over the resident's bed and the appointment is placed in an appointment book. Observation of the resident on 06/03/11 at 9:18 a.m. revealed no sign above the resident's bed that indicated the NPO status. However, there was a diet sheeet in the room which revealed that the resident received breakfast and consumed 80% of the meal. Interview at 10:02 a.m. on 6/03/11 with the Director of Nursing (DON) revealed that a diet sheet would go to the dietary manager who would document NPO on the residents meal ticket so that no tray would be made for the resident. Interview with the Dietary Manager at 10:10 a.m. on 6/03/11 revealed that she never received a diet slip on resident "A"to indicate that the resident was NPO. Review of the medical record revealed no evidence of a written physician order for [REDACTED]. Interview with the DON at 11:23 a.m. on 6/03/11revealed that the facility usually follows the consultation reports received from the vascular physicians office. Further interview revealed that the facility does have a system but somewhere the ball just got dropped. | 2015-07-01 |
| 9349 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2011-06-03 | 441 | D | 0 | 1 | ZSUO11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure that appropriate infection control practices were followed related to handwashing after a dressing change for one (1) resident (#40) from a sample of thirty-one (31) residents. Findings include: Observation on 06/02/11 at 3:00 p.m.revealed Licensed Practical Nurse (LPN) "DD" perform a pressure ulcer treatment for [REDACTED]. After completing the treatment, the nurse gathered all soiled and unused [MEDICATION NAME] swabs, alcohol swabs and cotton applicators and put them into a red bio-hazard bag, along with her soiled gloves. While attempting to close the zip lock red bag, the nurse touched the inside and outside of the bag several times. The nurse put a glove onto her left hand, opened the door, went to the medication cart and discarded the red bag and her gloves into a large red bag on the side of the medication cart. Continued observation revealed that the nurse returned to the room, picked up two (2) packs of 4 by 4 gauze, took them to the medication cart, placed the packs on top of the cart and then placed inside the cart. The LPN did not wash her hands after removing her gloves, before picking up the packs of 4 x 4's or before entering the medication cart. Interview at 3:25 p.m. on 6/02/11 with LPN "DD" revealed that her hands were dirty when she picked up the 2 packs of gauze. Continued interview revealed that she should not have placed the packs of gauze into the medication cart but thrown them away. | 2015-07-01 |
| 9350 | GOLDEN LIVINGCENTER - DECATUR | 115012 | 2787 NORTH DECATUR ROAD | DECATUR | GA | 30033 | 2011-06-03 | 280 | D | 0 | 1 | ZSUO11 | **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 related to pressure ulcer after a quartertly assessment for one (1) resident (#40) from a sample of thirty-one (31) residents. Findings include: Review of the quarterly Minimum Data Assessment (MDS) for resident #40 dated 4/15/11 revealed that the resident was assessed at high risk for pressure ulcer. Review of the medical record revealed that the facility had identified a Stage III (3) pressure ulcer on the right lateral ankle on 4/17/11. Review of the resident care plans revealed no evidence that a care plan was developed to address care and treatment of [REDACTED]. Interview with the Care Plan Coordinator on 6/1/11 at 2:45 p.m. confirmed that a care plan had not been developed related to pressure ulcer. | 2015-07-01 |
| 781 | HARBORVIEW HEALTH SYSTEMS THOMASTON | 115329 | 310 AVENUE F | THOMASTON | GA | 30286 | 2019-04-26 | 812 | F | 0 | 1 | ZS6U11 | Based on observation, interviews, and review of policies titled Thawing. Storing Prepared Foods, and Foods Brought by Family/Visitors the facility failed to assure that items were labeled and dated, used by expiration date, failed to use step to open trash can, failed to keep can opener free of buildup, failed to assure dishwasher was functioning at appropriate temperatures, failed to assure the cleanliness of the ice machine in the kitchen, and failed to follow the recipe when preparing puree meals. The facility also failed to assure the cleanliness of 1 of 2 resident food pantries and to assure that items in the resident refrigerator were stored appropriately. This practice affected 100 residents that received an oral diet. The facility census was 102. Findings include: During the initial kitchen tour with the Dietary Manager (DM) on 4/23/19 at 11:55 a.m. the following was observed: 1. In the reach in cooler there were five 32 fluid ounce (fl. oz.) containers of concentrated orange juices that were thawed and did not have an open date or expiration date. The package said to keep frozen. 2. In the dry storage area there was a bag of hamburger buns with a use by date of 2/12/19 and there was also a bag of hot dog buns that did not have an open date or an expiration date. 3. There was no step to open trashcan noted by either of the hand washing sinks. 4. The containers containing flour, sugar, rice, corn meal, and thickener were not labeled or dated. The thickener container noted to not have a tight-fitting lid and the thickener was in a white trash bag in the container. 5. The lip of ice machine had black buildup when the DM wiped it with a paper napkin. During interview with the DM on 4/23/19 at 12 p.m. she confirmed that she was not able to tell when the juice items in the refrigerator would expire due to not having a thaw date. DM reported that the bread was kept in the freezer and had been thawed for use although, the bread did not contain an open or use by date as a result of the freezing. DM further reported that everything should be labeled and dated. DM reported that the ice machine is cleaned monthly and Maintenance is scheduled to clean on this Thursday. During the follow up kitchen tour on 4/25/19 at 12:14 p.m. with the DM the following was observed: 1. In the dry storage area there was a 12-pack container of hotdog buns that were not labeled or dated with expiration date. The DM reported that the hot dog buns were taken out of the freezer today and they have seven days to use them. DM acknowledge that no one would be able to tell when the hotdog buns were thawed or when they should be used by without labeling. 2. In the dry storage area there were four 12 pack hamburger buns and 1 case of eight 12 pack hamburger buns that did not indicate a thaw date. Dm reported that hamburger buns had been in walk in cooler since last Thursday. 3. In the dry storage area there was one package of fettuccine open 1/27/19 and use by 2/27/19. DM reported all staff responsible for labeling and dating. has had in-services in the past but none recently. 4. There were no step to open trash cans by either of the two hand washing sinks. 5. The containers with flour, sugar, rice, corn meal, and thickener were not labeled or dated. 6. The canned items in the dry food storage area were not dated and DM unable to read codes on cans to determine expiration dates. During observation of dishwasher usage on 4/25/19 at 12:47 p.m. it was reported that the dishwasher was a high temp dishwasher. The wash temperature was 164 degrees Fahrenheit (F) and the rinse temperature was 153 degrees F. The Dietary Manager reported that whenever the rinse temperature is not 180 degrees F maintenance is notified and adjustments are made. On 4/25/19 at 12:58 p.m. the Director of Maintenance reported that he made adjustments to the dishwasher and it is now rinsing at 190 degrees F. He reported that whenever the temperature on the dishwasher needed adjusting dietary staff typically call him and he is able to make the necessary adjustments. The DM reported that a sanitizing solution is used in the dishwasher, but they are not checking it daily. DM reported that the dishwasher was a high temperature dishwasher and the range for water temperatures was noted on the dishwasher. The sign on the dishwasher revealed a wash temperature of 150 degrees F and a rinse temperature of 180 degrees F. Review of the dishwasher temperature log for (MONTH) 2019 revealed that the dishwasher did not wash at 150 degrees F on 4/1/19 through 4/6/19 and the rinse was not 180 degrees F on 4/1/19 through 4/11/19, 4/15/19 through 4/17/19, and 4/18/19 through 4/24/19. During the evening meal the dishwasher rinse temperature was recorded but it was never documented as being 180 degrees F for the month of (MONTH) 2019. Observation of the front resident pantry tour conducted on 4/26/19 at 9:00 a.m. revealed the following: 1. One container of Med Pass was open and sitting on the table. However, there was no open date noted. Instructions revealed once opened four days to use if refrigerated or four hours usage if not refrigerated. 2. There was build up on the floor near the refrigerator and on baseboards and two glasses were on the floor between the cabinet and the table holding the microwave. 3. In the refrigerator there was a bag with a resident's name dated 4/6/19 that contained two boxes, one containing a chicken sandwich and one box containing a cheeseburger. All had keep frozen on the package. Interview on 3/26/19 at 9:15 a.m. with Unit Manager BB who reported that housekeeping is responsible for cleaning of the pantry. She also reported that the Med Pass should be thrown away at the end of every shift. She confirmed that the MedPass did not have an open date on it. Unit Manager BB reported that she does not typically look into residents' bags to see what they have or check for expiration dates when the items are placed in the resident refrigerator and said she could not speak for anyone else. Unit Manager BB further reported that the items in the refrigerator are not kept longer than a week and the sandwiches should have been thrown away. An interview with the DM on 4/26/19 at 9:33 a.m. who reported that there has not been a system in place related to labeling and dating canned items to identify first in first out per the policy. When viewing the containers with flour, sugar, rice, and cornmeal she confirmed that there were no labels or dates on the containers. She also reported that a new shipment comes in each week. She reported that the old product is removed so that the new product can be placed in the container. Once the new product is in the container the old product is then poured on top of it. Observation of food puree process began on 4/26/19 at 9:43 a.m. with Cook CC who was preparing the puree and the DM who observed the process. Cook CC reported 12 residents would receive the puree meal and she would be using 9 fish patties for the 12 residents. The DM then directed Cook JJ to get 3 more patties so that there would be a serving for each resident. When preparing the puree fish Cook JJ used four cups of water and 3/4 cup of thicker to the fish and did not follow the recipe. When questioned if the recipe recommended using water Cook JJ reviewed the recipe and said yes. Interview with the DM on 4/26/19 at 10:15 a.m. revealed that the Registered Dietitian was contacted about the preparation of the fish puree who informed her that water should not be used to thin foods when preparing the puree. DM then reported that Cook CC has been given instructions to redo the puree. DM reported that she assumed that staff were using broth instead of water because she used broth when she had to prepare the puree. Recipe for Pureed fish week 4, day 6 lunch read as follows: 2. Measure desired # of servings into food processor. Blend until smooth. Add broth or gravy if product needs thinning. Add commercial thickener if product needs thickening. Thawing Policy, dated 2011 Acceptable thawing method: Identify food with date placed in refrigerator for thawing and a use by date. Foods Brought by Family/Visitors, revised (MONTH) 2014 6. Perishable foods must be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item and the use by date. Storing Prepared Foods, dated 2001 Labeling: For dry goods such as flour or sugar, identify the item by its name and date and place in appropriate container for dry good items. | 2020-09-01 |
| 9127 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 167 | B | 0 | 1 | ZS4T11 | Based on observation and staff interview, the facility failed to make the survey results readily accessible, and did not post a notice of their availability on four of four days of the survey. Findings include: During environmental observations, the previous survey results were found inside a glassed-in bulletin board just outside the dining room on a short corridor off the 'P' hall. The survey reports were pinned to the bulletin board along with multiple other postings, and not likely to be seen by residents or visitors unless they went to this dining room. No signs were seen anywhere in the facility that announced the availability and location of the survey results. On 3/23/11 at 5:00 p.m., the Administrator verified there was currently no sign posting availability of the survey results. | 2015-08-01 |
| 9128 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 282 | D | 0 | 1 | ZS4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to follow the care plan related to the tube feeding administration rate for one (1) resident (#87). The sample size was thirty (30) residents. Findings include: Review of resident #87's clinical record revealed they were receiving all of their nutrition via a gastrostomy tube (GT). A physician's orders [REDACTED]. The feeding tube care plan dated 9/10/10 included an intervention to provide feeding per physician order. Six observations from 3/21/11 at 1:13 p.m. to 3/23/11 at 8:40 a.m., revealed that resident #87's feeding pump was programmed to deliver the enteral formula at a rate of 55 mL per hour. On 3/23/11 at 10:00 a.m., Licensed Practical Nurse (LPN) "BB" stated the enteral formula order on the Medication Administration Record [REDACTED]. Cross-refer to F322. | 2015-08-01 |
| 9129 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 312 | D | 0 | 1 | ZS4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview the facility failed to ensure that one (1) resident ("A") on a sample of thirty (30) residents received the necessary services to maintain personal hygiene related to nail and oral care. Findings include: Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] documented that Resident "A" required extensive assistance for activities of daily living (ADLs) such as personal hygiene that included brushing their teeth. This MDS assessment also documented that this resident had limited range of motion (ROM) on one side of the body that included the upper and lower extremities. Interview with resident "A" on 3/21/11 at 1:53 p.m. revealed that the staff does not help the resident clean his/her teeth The resident revealed that he/she has never had his/her teeth cleaned since he/she had been at the facility. The resident also stated that he/she did not have a toothbrush or toothpaste. Observations of resident "A" on 3/21/11 at 1:56 p.m., on 3/22/11 at 9:20 a.m. and 4:05 p.m. revealed that the resident had long fingernails with a brown substance underneath the nails of both hands. Interview with a Licensed Practical Nurse (LPN) "AA" on 3/22/11 at 4:05 p.m. confirmed that the resident's nails were long and dirty and needed to be cleaned and trimmed. | 2015-08-01 |
| 9130 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 322 | D | 0 | 1 | ZS4T11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to administer the ordered amount of enteral tube feeding for one (1) resident (#87). The sample size was thirty (30) residents. Findings include: Review of resident #87's clinical record noted they had [DIAGNOSES REDACTED]. A quarterly Minimum Data Set ((MDS) dated [DATE] noted the resident was totally dependent on staff for all activities of daily living. The feeding tube care plan developed 9/10/10 noted the resident received all nutrition, hydration and medications via a gastrostomy tube (GT). Observations of wound care on 3/23/11 at 9:06 a.m., and 3/24/11 at 8:50 a.m., noted that the resident had a Stage IV pressure ulcer to the left hip, and unstageable/deep tissue injury (DTI) to the tip of the right great toe, left lateral foot, and top of the left fifth toe. Review of the facility's Registered Dietician's (RD) note dated 2/18/11 revealed the resident's estimated protein needs were 87-99 grams, and that they were receiving 82.8 grams at the current enteral formula rate of 55 milliliters (mL) per hour. She recommended the enteral feeding be increased to 60 mL per hour to provide 90 grams of protein. On 2/24/11, a physician's orders [REDACTED]. On 3/21/11 at 1:13 p.m.; 3/22/11 at 2:25 p.m., 3:30 p.m., and 5:20 p.m.; and 3/23/11 at 7:15 a.m. and 8:40 a.m., resident #87's feeding pump was noted to be programmed to deliver 55 mL per hour of the enteral formula. On 3/23/11 at 10:00 a.m., Licensed Practical Nurse (LPN) 'BB' verified the pump was set to 55 mL per hour, and that the ordered rate was 60 mL per hour. She noted that on the label of the enteral formula bottle, a notation for a rate of 55 mL per hour had been handwritten. On 3/23/11 at 10:45 a.m., the RD stated that she made the recommendation to increase the tube feeding rate to 60 mL per hour because the previous rate of 55 mL per hour was not meeting the resident's protein needs. | 2015-08-01 |
| 9131 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 323 | E | 0 | 1 | ZS4T11 | Based on observation, record review and staff interview, the facility failed to ensure the environment remained as free of accident hazards as possible by not securing chemicals in one Soiled Linen room; not locking doors leading to rooms containing hot water heaters in two (2) Soiled Linen rooms on one hall; not ensuring that grab/assist bars or devices were securely attached in two resident rooms; not ensuring that an exit door locking mechanism was functional on one hall; and by not removing a damaged chair from the gazebo. Potential environmental hazards were noted on four (4) of five (5) halls and an outside common area. Findings include: 1. On 3/21/11 at 12:31 p.m., the grab bars on either side of the commode for rooms B-5/B-7 were not affixed securely and able to be pulled away from the wall approximately one inch. This was verified by the Maintenance Director at 1:00 p.m. On 3/23/11 at 2:40 p.m., Certified Nursing Assistant (CNA) "DD" stated that three of the four residents in these rooms were independently ambulatory. During a walk-through of the facility environment on 3/23/11 starting at 2:00 p.m., the following concerns were identified, and verified by the Maintenance Director: 2. The assist bars secured to bolts on the back of the commode seat in room D-14 had come loose on one side, and was freely movable approximately eight inches to the side, and the legs were wobbly. At 3:24 p.m., Licensed Practical Nurse (LPN) "EE" stated that one of the three residents in this room was able to toilet themselves without assistance. 3. In an outside courtyard area off Station II was a gazebo used by staff and residents. One of the wrought-iron chairs was totally missing the back of the chair, except for the arched support, leaving a large open back rest. 4. A full one-gallon plastic bottle with screw-on lid of Premium Plus Carpet and Upholstery Extraction Cleaner was found on the floor by the utility sink in the unlocked Soiled Linen room close to the Station I nurse's station. The Maintenance Director stated this should not have been in there, and asked a Housekeeping employee to lock it up. The label on the bottle included a precautionary statement of "Harmful if Swallowed." The Material Safety Data Sheet (MSDS) listed health hazards that included eye irritation and tissue injury, and to not induce vomiting if ingested. 5. The exit doors at the end of 'A' hall were able to be pushed open without using the code to deactivate the lock. This door led to the parking lot where ambulances transported residents, and was not fenced in. There was a magnetic locking mechanism noted at the top of the door. The Maintenance Director stated he did not realize it was not working. Review of the Mag Lock Log provided by the Maintenance Director revealed the exit door on 'A' was last checked on 3/18/11 and was 'OK.' 6 and 7. Inside an unlocked Soiled Linen room across from the Station II nurse's station was another door leading to a room containing a hot water heater. This door had a key inserted in the lock, but the key did not need to be used to open the door. The pipes on the wall across the water heater were hot to the touch. The Maintenance Director stated this door should be locked at all times, and the key should have been locked inside a red box on the wall outside the door. In another unlocked Soiled Linen room across the hall from the Station I nurse's station, there was another unlocked door that led into a room containing a hot water heater. Again, the pipes across from the water heater were hot to the touch. At 3:28 p.m., Corporate Maintenance Consultant "FF" stated that these doors should be locked at all times. On 3/23/11 at 3:55 p.m., the Resident Assessment Instrument (RAI) Director stated there were 42 independently mobile residents (not including the nine residents on the locked unit), and all had some degree of cognitive impairment. | 2015-08-01 |
| 9132 | BRENTWOOD HEALTH AND REHABILITATION | 115361 | 115 BRENTWOOD DRIVE | WAYNESBORO | GA | 30830 | 2011-03-24 | 468 | E | 0 | 1 | ZS4T11 | Based on observation and staff interview, the facility failed to ensure that there were handrails affixed to all sections of corridor walls on four of five halls. Findings include: During a walk-through of the facility environment with the Maintenance Director on 3/23/11 starting at 2:00 p.m., it was noted that there were no handrails affixed to the corridor walls in the following areas: (The approximate measurements included) STATION II: 1. Two 18-foot sections of wall on either side of the Activity Room doors across from the nurse's station; one 14-foot section outside the 'C' hall fire door; two 5-foot sections on the medication room side of the wall, and one 12-foot section on the opposite wall outside the fire doors on the 'P' hall. STATION I: 2. A 12-foot section of hallway on one side and 6-foot section on opposite wall near the small and large dining/activity rooms on the 'B' hall. The Maintenance Director stated these rails had been removed recently when renovation was done to the area. 3. A 6-foot section on one wall and 18-foot section on the opposite hallway wall between the main lobby and the nurse's station. | 2015-08-01 |
| 4962 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2016-03-29 | 280 | G | 1 | 0 | ZRKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on policy and procedure review, record review and staff interviews, the facility failed to revise the Care Plan interventions in an effort to reduce the likelihood of subsequent falls and /or injuries related to falls for one (1) resident (D) with severe cognitive impairment, [MEDICAL CONDITION] disorder and physical behaviors. The sample was (6) residents. Resident D fell eleven (11) times from (MONTH) (YEAR) through (MONTH) (YEAR). Review of the Care Plan titled Falls dated 1/30/14 identified Resident D was at risk for falls. The Goal documented the resident will not suffer injury from a fall for the next three (3) months. The Long Term Target Date was 10/29/15, then updated through 1/21/16. Resident D had three (3) falls without injuries on 8/13/15, 9/8/15, 9/28/15 and one (1) fall with injury on 9/23/15 before a new intervention was added the Care Plan titled Falls. On 9/28/15 a new intervention was added to monitor the resident and re-direct as needed. After the new intervention had been implemented, Resident D had four (4) falls without injury on 10/2/15, 10/6/15, 10/7/15 and 10/8/15 and one (1) fall with an injury on 10/13/15. New interventions were not added until 10/13/15 and 10/22/15. A new intervention was added to the Care Plan titled Falls on 10/13/15 to start Occupational Therapy to assist with Activities of Daily Living (ADL) care, therapeutic exercises and neuromuscular re-education. On 10/22/15 a new intervention was added to the Care Plan titled Falls, to remind the resident to not transfer without assistant. However, review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] and the Annual MDS assessment dated [DATE] for Resident D both revealed a Brief Interview for Mental Status (BIMS) summary score of 01, indicating severe cognitive impairment. After the interventions were added on 10/13/15 and 10/22/15, Resident D had one (1) fall with injury on 11/9/15 and one (1) fall with no new injury, however, continued evidence of an injury from the fall on 11/9/15. No new interventions were added to the Care Plans after either fall. (Refer F323) The facility's failure to revise the Care Plan interventions in an effort to reduce the likelihood of subsequent falls and/or injuries related to falls, resulted in actual harm for Resident D when an unwitnessed fall on 9/23/15 resulted in a head injury that required staples. On 10/13/15 when an unwitnessed fall resulted in bruising and swelling of the left eye. On 11/9/15 when an unwitnessed fall resulted in re-injury to the left eye with bruising and swelling. On 11/18/15, Resident D was sent to the hospital and diagnosed with [REDACTED]. Findings include: Review of the policy titled Care Plans documented: It is the policy of this facility to establish and maintain a care plan for each resident on admission and thereafter. The resident care plan is reviewed no less than quarterly during the resident's stay. It is also reviewed whenever there is a significant change in resident condition. The resident care plan interventions are reflective of changes in resident condition as well as Physician orders [REDACTED]. Review of the policy titled Falls Management Program documented: Any resident who experiences a fall will have the circumstances surrounding the incident evaluated to reduce the likelihood of subsequent falls. Monitoring identifies changes in the resident's pattern of risk of falls and allows proactive alteration in the resident's plan of care to eliminate or reduce the risk of falls. Monitor and document the resident's response to interventions intended to reduce falling or its risks. For continuing falls, evaluate possible causes and reconsider current preventative measure. Evaluate and adjust the falls prevention program using interdisciplinary team efforts. Re-evaluate the fall prevention plan in the resident's care plan. Review of the policy titled Post Fall Review documented: It is the policy of this facility to review the circumstances surrounding resident falls and initiate interventions to prevent future falls. Care interventions will be indicated on the resident Care Plan. Review of the Care Plan titled Falls with a Problem Start Date of 1/30/14 identified the resident is at risk for fall related to unsteady gait and unable to see secondary to diabetic retinopathy and history of [MEDICAL CONDITION] disorder. The resident had eye surgery in (MONTH) 2014 which triggered multiple falls. The resident had fall on 8/13/15 and 9/8/15 without injury. On 9/23/15 the resident was found lying face down. She had a head injury, was sent to the ER and returned the same day with staples. On 9/28/15 the resident had a fall with no injury noted. On 10/2/15 the resident was found on the floor in the day room. On 10/6/15 the resident was in the hallway and fell , no injury noted. On 10/7/15 the resident was found on the floor. On 10/8/15 the resident was found on the floor in the day room and was screaming stating she did not fall. On 10/13/15 the resident had a fall with swelling noted over her left eye. On 11/9/15 the resident had a fall with minor injury, the left eye had bruising and was swollen. On 11/12/15 the resident was observed on the floor in the day room. No injury noted. The interventions included: Approach Start Date 4/22/14- Her vision has decline related to diabetic [MEDICAL CONDITION] and diabetic retinopathy. Eye MD visit on 4/7/15 Approach Start Date 9/8/14- Make sure room is clutter free to prevent injury from fall. Staff to assist with guided assistance in hallway while ambulating Approach Start Date 1/30/14- Use call light when she needs assistance from staff Approach Start Date 1/30/14- Supervision by staff while ambulating in hallway related to poor vision Approach Start Date 1/30/14- Encourage her to calm down when she is agitated Approach Start Date 1/30/14- Administer [MEDICATION NAME] as ordered and prn [MEDICATION NAME] as ordered Approach Start Date 1/30/14- Make sure she takes her medication Approach Start Date 1/30/14- Monitor for signs and symptoms of [MEDICAL CONDITION] disorder like lethargy, increase agitation or increase restlessness, call MD immediately Approach Start Date 1/30/14- [MEDICATION NAME] as ordered, [MEDICATION NAME] level on 9/1/15. Approach Start Date 10/13/15- Occupational Therapy to assist with ADL care and therapeutic exercises and neuro-muscular re-education Approach Start Date 10/22/15- Remind resident to not transfer without assistance. Record review for Resident D revealed three (3) falls without injury (8/13/15, 9/8/15 and 9/28/15) and one (1) fall (9/23/15) with an injury before new interventions were added to the Care Plan titled Falls. On 9/28/15 an intervention was added to monitor the resident and re-direct as needed. On 8/13/15 8:00 p.m. the resident had a witnessed fall in the 200 dining room. No injuries were noted and the MD was notified. Review of the Care Plan titled Falls updated 8/13/15 documented the fall with no injuries, PT/OT Screen and continue with interventions. On 9/8/15 at 11:55 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries were noted and the Nurse Practitioner (NP) was notified. Review of the Care Plan titled Falls updated 9/8/15 documented the resident was observed on the floor with no injuries and PT/OT Screen. There is no evidence of new/revised interventions to the care plans. Interview on 3/29/16 at 9:58 a.m. with the Registered Nurse (RN) Resident Care Coordinator (RCC) revealed she is sure this fall was discussed as a team but she was unable to provide documentation. The team consisted of the Director of Nursing (DON), the Administrator, Therapy staff, Nursing, RCC and herself. The RN RCC further revealed she was the Assistant RCC up until (MONTH) (YEAR) and she has been the RCC for about three (3) weeks now. She confirmed there were no new interventions in place after the falls occurred on 8/13/15 or 9/8/15. On 09/23/15 at 11:35 a.m. the resident had an unwitnessed fall on the 200 hall. The resident had an injury to the head that required being sent to the emergency room (ER). The resident returned the same day with staples to the wound on the back of the head. Review of the Care Plan titled Falls updated 9/23/15 documented the resident fell and was face down on the floor, sent to the emergency room (ER) for evaluation and treatment. Open area on the head. PT/OT Screen. Interview on 3/29/15 at 10:03 a.m. with the RN/RCC revealed she did attend the team meeting related to this fall, however, there is no documentation of the meeting. The meetings are held every morning after any falls but there is no sign-in sheets or documentation of the morning meetings. She confirmed there were no interventions placed after this fall and that she was not the RCC at this time. She said she cannot speak for the previous RCC and does not know why new interventions were not put into place after a fall with injuries. She said the resident was non-compliant, had behavioral issues and had vision problems. On 09/28/15 at 11:55 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. Review of the Care Plan titled Falls updated 9/28/15 documented the resident was observed sitting on the floor with no injuries noted. PT/OT Screen. Monitor resident and re-direct as needed. Interview on 3/29/15 at 8:30 a.m. with the LPN YY revealed she was the direct care nurse at the time of this fall. LPN YY revealed she was aware of the resident's care plan interventions and that the effectiveness of the interventions are to be documented by the nurse taking care of the resident. However, she did not have any documentation related to the effectiveness of the existing interventions. The MDS/Care Plan Coordinator is responsible for documenting new interventions. LPN YY further revealed she knows a bed alarm was never added as an assistive device because the resident mainly fell in the day room. Interview on 3/29/15 at 10:10 a.m. with the RN/RCC revealed an new intervention was placed to monitor the resident and re-direct the resident as needed. The RN/RCC could not explain what type of monitoring that was to be conducted, just monitoring in general. Further, the RN/RCC said that the resident does not respond to re-direction. Continued record review for Resident D revealed after the intervention was added to the Care Plan titled Falls on 9/28/15, the resident had four (4) falls (10/2/15, 10/6/15, 10/7/15 and 10/8/15) without injury and one (1) fall (10/13/15) with an injury before a new intervention was added to care plan on 10/13/15 and 10/22/15. On 10/02/15 at 10:45 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries were noted and the NP was notified. Review of the Care Plan titled Falls updated 10/2/15 documented the resident was found on the floor in the day room. Neurocheck list done. Continue with current care. On 10/06/15 at 1:50 p.m. the resident had an unwitnessed fall in the 200 Hall hallway. No injuries noted and the NP was notified. Review of the Care Plan titled Falls updated 10/6/15 documented the resident was standing in the hall and fell . No injuries. PT/OT Screen. Continue with the current care plan. On 10/07/15 at 11:55 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries were noted and the NP was notified. Review of the Care Plan titled Falls updated 10/7/15 documented the resident was found on the floor. No injury. There was no evidence of new/revised interventions after this fall. On 10/08/15 at 11:15 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. Review of the Care Plan titled Falls updated 10/8/15 documented the resident was found on the floor. The resident said she did not fall. PT/OT screening. There was no evidence of new/revised interventions after this fall Interview on 3/29/16 at 10:18 a.m. with the RN/RCC revealed the existing interventions were continued after the falls on 10/2/15, 10/6/15, 10/7/15 and 10/8/15. She said she could not speak for the previous RCC or why new interventions were not developed after the resident had four (4) falls in six (6) days. She said that every fall was discussed with the team in morning meeting. The RN/RCC further said that it is the role as the RCC to develop or revise interventions to try and prevent further falls. On 10/13/15 at 1:25 a.m. the resident had an unwitnessed fall in the resident's room. The resident sustained [REDACTED]. The NP was notified. Review of the Care Plan titled Falls updated 10/13/15 documented the resident was found on the floor in room. Swelling over the left eye. A new intervention documented Occupational Therapy (OT) started on 10/13/15. On 10/22/15 a new intervention was included to remind the resident to not transfer without assistance. Continued record review for Resident D revealed after the intervention was added to the Care Plan titled Falls on 10/13/15 and 10/22/15, the resident had one (1) unwitnessed fall (11/9/15) with an injury and one (1) fall (11/12/15) without injury. There is no evidence that the care plans were updated with new/revised interventions after either fall. Interview on 3/29/15 at 8:00 a.m. with the nightshift (11:00 p.m. - 7:00 a.m.) LPN XX revealed on 10/13/15, Resident D was found on the floor by the CNA. Upon her assessment, there was swelling to the left temporal area but no bruising at that time. On 10/14/15, the left eye was swollen and bruising appeared. LPN XX revealed she does not document in the residents clinical chart or care plan if the current interventions are not working. The interventions are discussed in the morning meeting after a resident has a fall and she thinks new interventions are documented in the care plan by the MDS nurse. Interview on 3/29/16 at 10:21 a.m. with the RN/RCC revealed due to the resident's cognitive status, interventions related to reminders for the resident would not be an appropriate intervention and not the intervention she would have chosen however, she was not the RCC at the time of the fall on 10/13/15. Further, the intervention added on 10/22/15 was placed after the patient care conference. The RN/RCC said the main intervention for this resident is supervision and that the staff is supposed to be supervising the resident. On 11/09/15 at 2:15 p.m. the resident had an unwitnessed fall in the 200 Hall day room. The resident sustained [REDACTED]. The NP was notified. Review of the Care Plan titled Falls updated 11/9/15 documented a fall with minor injury. Left eyebrow swollen. PT/OT Screen. There is no evidence of a new/revised intervention after this fall. Interview on 3/29/15 at 10:23 a.m. with the RN/RCC revealed that during the discussion with the team, the current interventions would have been looked at after this fall. Further, the RN/RCC said that no new interventions were developed and the interventions at the time of the fall on 11/9/15 were continued. On 11/12/15 at 7:50 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No new injuries were noted but bruising and swelling of the left eye from the fall on 11/9/15 continued to be evident. The NP was notified. Review of the Care Plan titled Falls updated 11/12/15 documented the resident was observed on the floor in the day room. No evidence of a new/revised intervention after this fall. An update on 11/13/15 documented bruising to the left eye. An update on 11/18/15 documented the resident was sent to DeKalb Medical Center. Interview on 3/29/15 at 10:26 a.m. with the RN/RCC revealed the nurses hand writes new interventions on the main Care Plans that remain in the resident's chart. The Care Plans in the resident's chart is the most updated care plan. After each quarterly patient care conference, all the new interventions that were hand written on the main care plan is added to the care plans in the computer. Review of the Care Conference Report documented a quarterly care conference was conducted on 7/30/15 with four (4) names in attendance and 10/22/15 with six (6) names in attendance. An interview was conducted on 3/29/15 at 11:26 a.m. with the Administrator and the DON. The Administrator revealed she was aware that Resident D has had multiple falls that included several injuries. All resident falls are discussed during the morning meetings with all departments heads and therapies. The discussion includes the determining factors and route cause of a resident's falls and actions to be taken. The Administrator said the staff try to monitor and supervise the resident closely but there has never been one on one supervision for Resident D. When the CNA's have any down time, they will sit in the day room with the residents but they cannot be in there all the time. As soon as the staff would leave Resident D, within minutes she would get out of the chair and start walking around. The DON revealed Resident D wanted to be independent and whatever they would tell her to do, she would do the opposite. They did not provide one on one supervision and the minute they would turn their back, the resident was walking around again. The DON said the resident was seen in (MONTH) (YEAR) by the eye doctor. PT/OT did screened the resident after the falls. OT was started. They checked the resident for UTI's and order labs after the falls in (MONTH) but could not explain why additional, appropriate interventions were not developed after multiple falls or after the falls with injuries. | 2019-03-01 |
| 4963 | EAST LAKE ARBOR | 115482 | 304 FIFTH AVENUE | DECATUR | GA | 30030 | 2016-03-29 | 323 | G | 1 | 0 | ZRKM11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of policy and procedure, record review and staff interviews, the facility failed to ensure adequate supervision for one (1) resident (D) with a history of multiple falls. The sample was six (6) residents. Resident D had a total of eleven (11) falls from (MONTH) (YEAR) through (MONTH) (YEAR). Ten (10) of the eleven (11) falls were unwitnessed (9/8/15, 9/23/15, 9/2815, 10/2/15, 10/6/15, 10/7/15, 10/8/15, 10/13/15, 11/9/15 and 11/12/15). Three (3) of the eleven (11) falls resulted in jury for Resident D (9/23/15, 10/13/15 and 11/9/15). Resident D had three (3) care plans that documented the resident's need for supervision. A Care Plan titled Visual Function documented in Approach with a start date of 1/30/14, that the resident needs supervision while ambulating in the hallway. A Care Plan titled Activities of Daily Living (ADL) Function/Rehabilitation Potential documented in Approach with a start date of 1/30/14 that the resident needs supervision and at times guided assistance while in hallway related to poor vision. A Care Plan titled Falls documented in Approach with a start date of 1/30/14 that the resident needs supervision by staff while ambulating in the hallway related to poor vision. Interview on 3/29/16 at 10:21 a.m. with the Registered Nurse (RN) Resident Care Coordinator (RCC) revealed the main intervention for this resident is supervision and that the staff is supposed to be supervising the resident. The facility's failure to ensure adequate supervision for a resident with a history of multiple falls caused actual harm for Resident D. On 9/23/15 the resident had an unwitnessed fall in the 200 Hall day room and sustained a head injury that required staples. On 10/13/15 the resident had an unwitnessed fall in her room and sustained an injury to the left eye with bruising and swelling. On 11/9/15 the resident had an unwitnessed fall in the 200 Hall day room and sustained a bleeding open wound to the left side of her head and swelling to the left eye. On 11/12/15 the resident had an unwitnessed fall in the 200 Hall day room and did not sustain any new injuries however, bruising and swelling of the left eye remained evident. Resident D began to show decline on 11/16/15 when she was not eating or drinking. The MD was not notified at this time and the Licensed Practical Nurse (LPN) XX continued to monitor the resident. On 11/17/15 the resident did not have any output of urine. The Nurse Practitioner was notified and an order was received for a straight catheterize, Urinalysis and labs (CBC and CMP). On 11/18/15 the resident was having difficulty swallowing and continued to have swelling of the left eye and left jaw. Resident D was sent to a hospital emergency room (ER) for evaluation on 11/18/15. On 11/19/15, the hospital reported to the nursing home facility that Resident D had an Acute Mandibular Fracture. The resident was transferred to a different hospital for continued management and treatment of [REDACTED]. Findings include: Review of the policy titled Falls Management Program documented: It is the policy of this facility to accurately assess each resident's s condition for prompt recognition of the risk of falls and to minimize injury to the resident. Each resident will be assessed for the risk of falls upon admission and quarterly. Any resident who experiences a fall will have the circumstances surrounding the incident evaluated to reduce the likelihood of subsequent falls. Careful management of the identified risk and underlying conditions for a resident can eliminate or reduce the risk of falls and may include: limits to treatment or managing the resident, managing the cause of fall(s) and managing factors that may increase the risk of serious consequences of falling. Monitoring identifies changes in the resident's pattern of risk of falls and allows proactive alteration in the resident's plan of care to eliminate or reduce the risk of falls. Record review for Resident D revealed an Annual Minimum Data Set (MDS) assessment dated [DATE] which documented in Section C- Cognitive Patterns that the resident had a Brief Interview for Mental Status (BIMS) summary score of 01, indicating severe cognitive impairment. Section G-functional Status documented the resident required supervision/oversight for walking in room, walking in corridor and locomotion on unit assisted by set-up only. The resident required limited assistance for locomotion off unit with one person physical assistance. Section J- Health Conditions documented the resident had two (2) or more falls without injury, one (1) fall with a minor injury and one (1) fall with a major injury. The Care Area Assessment (CAA) triggered Cognitive Loss/Dementia, Visual Function and Falls with the decision to be care planned. Review of the Quarterly MDS assessment dated [DATE] documented in Section C- Cognitive Patterns that the resident had a BIMS summary score of 01, indicating severe cognitive impairment. Section G-functional Status documented the resident required supervision/oversight for walking in room,walking in corridor and locomotion on unit assisted by set-up only. The resident required limited assistance for locomotion off unit with one person physical assistance. Resident D had three (3) care plans that documented the resident's need for supervision. A Care Plan titled Visual Function documented in Approach with a start date of 1/30/14, that the resident needs supervision while ambulating in the hallway. A Care Plan titled Activities of Daily Living (ADL) Function/Rehabilitation Potential documented in Approach with a start date of 1/30/14 that the resident needs supervision and at times guided assistance while in hallway related to poor vision. A Care Plan titled Falls documented in Approach with a start date of 1/30/14 that the resident needs supervision by staff while ambulating in the hallway related to poor vision. Interview on 2/24/15 at 2:35 p.m. with the dayshift (7:00 a.m. - 3:00 p.m.) Licensed Practical Nurse (LPN) CC revealed Resident D resided on the locked behavioral unit. Resident D was a good resident but had behavior symptoms such as hollering out, and required re-direction. Resident D had a vision problem and would often fall and/or bump into things. At times the resident would walk up on other residents, which caused altercations. The facility was unaware that Resident D had a fractured jaw. An investigation was completed to figure out what happened to Resident D and when it happened. Interview on 2/24/16 at 3:20 p.m. with the evening shift (3:00 p.m. - 11:00 p.m.) Certified Nurse Assistant (CNA) GG revealed that Resident D was going blind, was a wanderer and she was a fighter. Resident D wanted attention and attention seeking was one of the resident's behaviors. Sometimes Resident D would fight when she was being re-directed. CNA GG further stated that she did not know that Resident D had a fracture. Interview on 2/24/16 at 3:25 p.m. with the evening shift (3:00 p.m. - 11:00 p.m.) LPN HH revealed that Resident D needed assistance for walking and was a wanderer. She revealed that the resident's vision was not good after she had eye surgery. LPN HH further stated she did not know what was going on with all of falls for Resident D . After each fall, the nurses would assess the resident, check vital signs, and notify the Nurse Practitioner (NP), Responsible Party (RP), and Medical Doctor (MD). Interview on 2/24/16 at 3:30 p.m. with LPN II of the 3-11 shift revealed that Resident D was none compliant, and would get up and try to walk; she would some times fall. She revealed that Resident D did not have a steady balance. She revealed that the resident fell during the morning shift. She revealed that she received a report that the Resident D fell and hit her head. She revealed that Resident D had a bruise to left eye and that her jaw was swollen because the resident had a tooth ache. She revealed that she did not know when the resident's jaw was injured. She revealed that NP and family was notified. Interview on 2/24/16 at 4:40 p.m. with Clinical Nurse LL she revealed that the Resident D was sent to the hospital emergency room and that her head was wrapped. The resident was examined that day (11/17/15) by a Nurse Practitioner (NP). Clinical Nurse LL further state that there was no swelling or discoloration noted to resident's jaw. Review of the Event Reports for Resident D revealed one (1) witnessed fall (8/13/15) without injury, seven (7) unwitnessed falls (9/8/15, 9/28/15, 10/2/15, 10/6/15, 10/7/15, 10/8/15 and 11/12/15) without injury and three (3) unwitnessed falls with injury (9/23/15, 10/13/15 and 11/9/15). On 8/13/15 at 8:00 p.m. the resident had a witnessed fall in the 200 Hall dining room. No injuries were noted and the MD was notified. On 9/8/15 at 1:02 p.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries were noted and the Nurse Practitioner (NP) was notified. On 9/23/15 at 11;20 a.m. the resident had an unwitnessed fall in the 200 Hall day room. The resident sustained [REDACTED]. Review of the Resident Progress Notes dated 9/23/15 by the LPN documented the resident was laying face down with her head turned towards the side in the dining room. Moderate amount of blood on the floor next to the resident's head. Notified the NP and received orders to transfer the resident to the hospital for evaluation and treatment. Review of the Resident Progress Notes dated 9/23/15 by the LPN documented the resident returned from the hospital at 9:10 p.m. Neurochecks continued. Three (3) staples noted at the back of the resident's head. Will continue to monitor. Review of the hospital emergency room (ER) Report for Resident D dated 09/23/15 documented, in part: the resident presents from the nursing home after a fall. The resident was found on the ground. The residents states that she thinks that she was turning too quickly, at which point she lost her balance and fell . Per reports from the staff there, she was actually calling for help after she fell . The resident does report pain in the back part of her head, mild in severity. Again, it was an unwitnessed fall. Plan: resident instructed as well, in discharge note that within 12-14 days she is to have staples taken out. Diagnosis: [REDACTED]. Mechanical Fall. Procedure Note: For her laceration repair, occipital region, approximately one centimeter (1 cm) in length, linear. The staples were applied with good approximation. On 9/28/15 at 11:55 a.m. the resident had an unwitnessed fall in the in the 200 Hall day room. No injuries noted and the NP was notified. On 10/2/15 at 10:45 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. On 10/6/15 at 1:50 p.m. the resident had an unwitnessed fall in the 200 Hall hallway. No injuries noted and the NP was notified. On 10/7/15 at 11:55 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. On 10/8/15 at 11:15 a.m. the resident had an unwitnessed fall in the 200 Hall day room. No injuries noted and the NP was notified. On 10/13/15 at 1:25 a.m. the resident had an unwitnessed fall in her room. The resident received an injury to the left temporal area with complaints of pain. As needed (PRN) pain medication given. The NP was notified. There is no documentation in the report of orders received. Review of the Resident Progress Notes dated 10/13/15 at 2:25 a.m. by the LPN documented the resident was found on the floor in room. Resident stated I got up because I was hungry. Injury to the left temporal area with complaints of pain. PRN medication given and effective. Call light within reach. Will continue to monitor and NP notified. On 10/13/15 at 6:27 a.m. a LPN documented: due to fall, resident has some swelling over left eye. On 10/14/15 at 6:25 a.m. a LPN documented: swelling of left eye with bruising. Neurochecks in progress. On 10/15/15 at 6:40 a.m. a LPN documented: swelling of the left eye with bruising. Neurochecks in progress. On 10/15/15 at 9:58 p.m. a LPN documented: eye still swollen at site of fall. Discoloration of eye still present. Resident encouraged to call for help, call light within reach. On 10/16/15 at 6:40 a.m. a LPN documented: slight swelling on the left eye and bruising. Neurochecks in progress. There is no evidence of nursing progress notes from 10/17/15 through 10/23/15 and no further documentation related the injury of the left eye as a result of the fall on 10/13/15. Review of the Progress Notes dated 10/13/15 written by the Nurse Practitioner (NP) and signed by the Physician on 10/16/15 at 3:32 p.m. documented the patient has a history of repeated falls. No further evidence of visible injuries. Physical Therapy to evaluate for strengthening. Review of the Physician order [REDACTED]. On 11/9/15 at 2:15 p.m. the resident had an unwitnessed fall in the 200 Hall day room. The resident was observed on the floor. There was small bleeding area to the left side of the head and the left eye swollen. The NP was notified and neurochecks started. There is no documentation in the report of orders received. Review of the Resident Progress Notes dated 11/9/15 at 2:31 p.m. written by a LPN documented: resident was observed on the floor in the dayroom 200 Hall. Resident is agitated and could not tell why she was on the floor. Resident fighting while trying to stop bleeding to small area to left side of head. Left eye swollen. MD notified. Start neurochecks. Will continue to observe. On 11/9/15 at 10:50 p.m. a LPN documented: eye still swollen at top left eye, left jaw also still swollen at site of fall. Discoloration of eye present, noted. Signs of pain and discomfort noted at this time, Resident was given pain medication. Resident took all medications without difficulty. Resident encouraged to call for help, call light within reach. On 11/10/15 at 6:34 a.m. a LPN documented: complaints of pain, PRN medication given and effective. Left eye swollen and purple in color. Call light within reach. Will continue to monitor. On 11/11/15 at 6:09 a.m. a LPN documented: complaints of pain, PRN medication given and effective. Left eye swollen and purple in color. Call light within reach. Will continue to monitor. On 11/12/15 at 6:04 a.m. a LPN documented: Left eye swollen and purple in color. Call light within reach and will continue to monitor. There is no evidence of Progress Notes by the NP or MD after this fall. Review of the Physician order [REDACTED]. On 11/12/15 at 7;50 a.m. the resident had a fall in the 200 Hall day room. No new injuries noted but bruising and swelling to the left eye from a previous fall on 11/9/15 remained evident. The NP was notified. Review of the Resident Progress Notes dated 11/12/15 at 9:50 a.m. the LPN documented: resident observed on the floor in the 200 Hall day room by the Certified Nursing Assistant (CNA). No new injuries noted. Continue with swelling and discoloration of the right eye. NP notified. Start neurochecks. Will continue to observe. On 11/13/15 at 6:43 a.m. a LPN documented: left eye slight swelling. Call light within reach. Will continue to monitor. On 11/15/15 at 4:43 a.m. a LPN documented: resident has bruise and edema around the left eye. Encouraged to use the call light. Will continue to observe. On 11/16/15 at 1:55 a.m. a LPN documented: no complaints or pain or discomfort. Resident consumed 0% for breakfast and 0% for lunch and no liquids. Resident encouraged to eat and drink. Will continue to observe. On 11/17/15 at 12:00 p.m a LPN documented: resident noted to not have any output. Fluids pushed. NP and MD in the building, assessed the resident and stated to continue to push fluids. New order for CBC and CMP. Will continue to observe. On 11/17/15 at 2:02 p.m. a LPN documented: resident continues with no output. NP called. New order for straight catheterize. Output was 400 cc. NP notified. New order for Urinalysis (UA) with Culture and Sensitivity (C&S). Continue to observe resident for output and for next shift to call if no output. Continue to push fluids. On 11/18/15 at 6:39 a.m. a LPN documented: no output for this shift, but straight catheterize for UA output 250 cc. Left eye slight swelling. Call light within reach. Will continue to monitor. On 11/18/15 at 10:02 a.m. a LPN documented: resident had difficulty swallowing. Left eye and left jaw still swollen due to previous fall. Resident unable to eat or drink any food or fluids. No urine output. Still pushing fluids per physician orders. Weakness in upper and lower extremities, barely responsive to tactile stimuli. Unable to squeeze hands in response or follow simple commands. Stiffness in head and neck. NP notified and order obtained to transfer to the hospital for evaluation and treatment. On 11/19/15 at 6:35 a.m. a LPN documented: received call from MD of hospital stating the resident has been transferred to another hospital with a mandible fracture and will be admitted . Review of the hospital emergency room (ER) Report for resident D dated 11/18/15 at 15:07 hours documented the resident is a [AGE] year old female with a prior history of dementia, retinopathy, hypertension and epilepsy, who presents after being brought by ambulance by EMS here for difficulty swallowing. Initially EMS states the patient's last normal mental status was on Monday per the nursing staff there. The patient has noted bruising around her left eye. the patient had a fall on (MONTH) 11, (YEAR). The patient did not go to any medical facility after this fall. The patient upon further discussion with the nursing staff, the nurse told that the patient was sent over to the ER and stated that the patient had difficulty swallowing, was not taking her med's and states that previously she had been taking her med's and this was new and thus they sent her here to be evaluated. The nurse states she talked to the Physician's Assistant (PA) at this facility and they sent her here for evaluation. The patient is legally blind, currently is oriented to person and to place, and here in the emergency department, does not verbalize any complaints. The patent has mild swelling noted in the left mandibular region as well. Cat Scan (CT) of the face showed an acute comminuted fracture of the left mandibular ramus, age indeterminate, fracture of the left orbit 11 is appreciated; however, given likely hematoma and inflammatory changes, it is likely and old injury. Diagnosis: [REDACTED]. Review of the CT Facial Bones w/o contrast report for Resident D dated 11/18/15 at 16:30 documented: The mandible is fractured at the left ramus with small comminuted fracture fragment. The remainder of the mandible is grossly intact. Impression: 1. Comminuted Fracture of the Left Mandibular Ramus. 2. Age indeterminate Fracture of the left orbit lamina papyracea. However, given the lack of Hematoma or Inflammatory stranding, this likely is old injury. 3. Left periorbital soft tissue swelling. Interview on 2/25/16 at 1:40 p.m. with Occupational Therapist NN he revealed that the resident had vision difficulty, balance problems, and that her gait fluctuates. He revealed that Resident D had a set back, a decline with her ADL about a week before going to hospital. He revealed that he did not recall any swelling in Resident D's face. He revealed that because of the decrease in Resident D ADL's, she was lethargic and had difficulty eating and drinking. Interview on 2/25/16 at 1:52 p.m. with the Director of Nursing (DON) revealed that Resident D had a fall (11/9/15) and was sent to the hospital on [DATE]. The DON said she was told that the resident had a fall with swelling to the jaw. The DON observed Resident D with swelling from left eye to the jaw. Neurological checks were conducted. X-rays are taken if ordered by the MD, however no x-rays were ordered at that time. The DON further stated according tow the Quality Assurance (QA) report, the NP reported that Resident D had a fractured jaw that occurred on 11/9/16. She revealed that the resident did not return to the facility. She revealed that there is no documentation in the Resident Ds record that indicates a fractured jaw and the facility did not know when the fracture occurred. Interview on 2/25/16 at 5:25 p.m. by telephone with the Medical Director (MD) OO revealed that he received a report from the facility on 11/17/15 that Resident D had recent falls. He revealed that a screening exam was done on the chest, and the bump on Resident Ds head. The resident was not eating or drinking and was sent to the hospital on [DATE] because of a change in her condition. The MD OO said that the resident did not have a fracture, however, he did not palpate the resident's mandible during his assessment. He revealed that there were no signs of pain in the jaw area. He revealed that the resident was checked for eye movement and that he obtained lab work. He revealed that there were no complaints of pain from the resident. The MD OO further stated there is a possibility that the fracture was there, but he did not identify one during his assessment on 11/17/15. Anytime a resident has swelling a x-ray is ordered but he was not aware that Resident D had a swollen jaw. He revealed that he did not feel that the resident's fall had anything to do with her decline in health. Interview on 3/29/15 at 8:00 a.m. with the nightshift (11:00 p.m. - 7:00 a.m.) LPN XX revealed she took care of Resident D on a regular basis. Resident D had always had poor vision. She was ambulatory but required guidance. LPN XX further stated she had seen Resident D ambulating through the hallway without staff supervision on numerous occasions and had to call for assistance to guide her back to bed. She would also find the resident in her bathroom or standing behind her bed. LPN XX stated that she provided supervision of the resident by performing every two (2) hour visual checks. At times, Resident D would already be up and out of her bed and hollering out. The resident was confused all the time. She would provide the resident with the call light button but Resident D could not see it. Once it was placed in the resident's hand she would just drop it. LPN XX revealed on 10/13/15, Resident D was found on the floor by the CNA. Upon her assessment, there was swelling to the left temporal area but no bruising at that time. She called the NP and received orders to start neurological checks and monitor for changes in condition. LPN XX said the next day, 10/14/15, the left eye was swollen and bruising appeared. She noticed swelling and bruising of the left eye through 10/16/15. LPN XX said she did not work with the resident again until 10/19/15 and she did not notice any further swelling or bruising to the resident's left eye. Interview on 3/29/15 at 8:30 a.m. with LPN YY revealed she worked with Resident D on a regular basis on the dayshift (7:00 a.m. - 3:00 p.m.). Resident D was consistently confused. Resident D was able to walk on her own but she was legally blind and required assistance. LPN YY often saw the resident wandering the halls by herself and she would immediately intervene and assist the resident with whatever her need was at that time. The staff would assist her to the 200 Hall day room so that they could better supervise her but the staff does not stay in the day room at all times. The CNA's will sit in the day room with the residents when they could and they would conduct frequent visual checks. She would try and supervise Resident D by keeping her cart close to the dayroom. LPN YY stated there was no one (1) on one (1) supervision for Resident D. The LPN is split between two (2) halls and there is only one (1) CNA assigned to that end of the hall. It was impossible to watch Resident D constantly. On 9/28/15, another resident alerted her that Resident D was on the floor in the 200 Hall dayroom. There was no staff supervision in the day room when she arrived to assess the resident. The resident did not appear to have any injuries and she reported it to the NP. LPN YY further stated she does remember the resident having bruising and swelling to the left eye in (MONTH) after a fall. LPN YY revealed she was the nurse on duty when Resident had a fall on 11/9/15. The resident was found on the floor in the 200 Hall day room. There was no staff supervision in the day room when the resident fell but was sure that the CNA had just stepped out of the room. Upon her assessment, Resident D had a small open and bleeding area to the left eye and it was swollen. She said this was new bruising and swelling. The bruising and swelling from the fall in (MONTH) had since subsided. LPN YY revealed that she documented the right eye in her notes on 11/12/15 and that this was an error. It was the left eye that was injured. Interview on 3/29/15 at 9:19 a.m. with the CNA ZZ revealed she worked with Resident D on a regular basis on the dayshift (7:00 a.m. - 3:00 p.m.). The CNA ZZ stated Resident D was confused and would not listen to instructions. The resident was constantly walking around her room, into other resident's rooms, in the hallways and in the 200 Hall day room. Resident D would tell the staff she could do what she wanted. She would assist Resident D in the hallway until the resident would tell her she no longer needed her help. The CNA ZZ stated they would instruct the resident to hold onto the side rails and she was able to guide herself. Some days the resident could ambulate safely by herself and other times she would bump into the walls. CNA 'ZZ further revealed the staff would try to place her in the 200 Hall day room so that they could better supervise her but the resident was all over the place. She would try and stay in the day room as much as possible but she could not provide one (1) on one (1) supervision because she had other residents to take care of. CNA ZZ said she would check on the resident frequently and she always reported to the nurse if she was in the shower room with another resident. Interview on 3/29/16 at 11:05 a.m. with the Nurse Practitioner (NP) revealed the nursing staff did report to her when the resident had a fall. If the fall was unwitnessed with no injuries she would tell the nurse to start neurological checks and monitor the resident for any changes in condition. The NP stated she reports all falls to the MD. The NP revealed that she does remember the resident had an injury in the past that required staples to her head and she was sent to the hospital. The NP further stated that she is in the facility every Tuesday either by herself or with the MD. If the nature of an injury after a fall was minor, she would assess the resident on the next Tuesday visit. She does not remember seeing any bruising or swelling to the resident's left eye on any of her assessments after the resident had a fall in (MONTH) or November. An interview was conducted on 3/29/15 at 11:26 a.m. with the Administrator and the DON. The Administrator said the staff try to monitor and supervise the resident closely but there has never been one on one supervision for Resident D. When the CNA's have any down time, they will sit in the day room with the residents but they cannot be in there all the time. As soon as the staff would leave Resident D, within minutes she would get out of the chair and start walking around. The DON revealed Resident D wanted to be independent and whatever they would tell her to do, she would do the opposite. They did not provide one on one supervision and the minute they would turn their back, the resident was walking around again. | 2019-03-01 |
| 5595 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2014-12-04 | 157 | D | 0 | 1 | ZQN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family and staff interviews, the facility failed to notify the family member/responsible party of a new diagnosis, isolation precautions and change in treatment for one (1) resident (X) from a sample of thirty-four (34) residents. Findings include: Interview with the family member of resident X conducted on 12/1/2014 at 2:41 p.m. revealed the resident was diagnosed with [REDACTED]. Record review for resident X revealed the family member was the responsible party and emergency contact for resident X. Review further revealed the resident tested positive for [MEDICAL CONDITION] on 11/22/2014. The Nurse Practitioner was notified and a new order was given to place X on isolation and to start two (2) antibiotics. There was no evidence in the clinical record that the responsible party/family member for resident X was notified of the new diagnosis, isolation or the new medication orders. Interview with License Practical Nurse AA conducted on 12/4/2014 at 8:15 a.m. revealed that laboratory test results were faxed to the facility on [DATE]. AA contacted the Nurse Practitioner who ordered contact precaution and isolation along with antibiotic therapy. AA acknowledged that the responsible party was not notified until 11/27/14 when she came to visit. Review of the facility Policy and Procedure: Change in Resident's Condition or Status revealed that except in medical emergencies, notifications will occur within twenty-four (24) hours of a change occurring in the resident's medical/mental condition or status. | 2018-07-01 |
| 5596 | SIGNATURE HEALTHCARE OF BUCKHEAD | 115110 | 54 PEACHTREE PARK DRIVE N.E. | ATLANTA | GA | 30309 | 2014-12-04 | 309 | D | 0 | 1 | ZQN211 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, the facility's policy for Controlled Medications, resident and staff interviews, the facility failed to ensure a physician's order for a pain medication was obtained and filled in a timely manner for one (1) resident (Z) from a sample of thirty-four (34) residents. Findings include: Review of the medical record for resident Z revealed an admission date of [DATE] with [DIAGNOSES REDACTED]. Further review revealed a physician's order dated 10/17/14 for [MEDICATION NAME] 5/325 milligrams (mg) give one (1) tablet for pain level one (1) thru five (5) and give two ( 2) tablets for pain level six (6) thru ten (10) by mouth (PO) every six (6) hours as needed (PRN) for [DIAGNOSES REDACTED]. Review of the Electronic Medication Administration Record [REDACTED]. Review of the EMAR for (MONTH) 2014 revealed no [MEDICATION NAME] was administered after 11/7/14 at 9:00 p.m. until 11/14/14 at 8:26 p.m. Interview conducted on 12/2/14 at 11:00 a.m. with resident Z revealed that during the month of (MONTH) for about a week, the facility did not have [MEDICATION NAME] available, that she had been taking for pain. Interview conducted 12/3/14 at 2:10 p.m. with resident Z revealed that during the time the [MEDICATION NAME] was unavailable she was unable to get a restful night's sleep. Review of the twenty-four (24) hour shift reports revealed that on 11/8/14 on the 11pm-7am shift and on 11/12/14 on the 10pm to 8am shift a hard script for [MEDICATION NAME] was needed for resident Z. Review of the medical record for resident Z revealed no evidence that the facility followed up with the physician to get a hard copy prescription for [MEDICATION NAME] for resident Z. Further review revealed no evidence that licensed staff attempted to contact the physician regarding the prescription until 11/11/14. Interview with the Director of Pharmacy on 12/4/14 at 11:45 a.m. revealed that the only [MEDICATION NAME] orders filled for the resident Z was on 10/17/14 an order from the primary physician for thirty (30) tablets which was filled and delivered to the facility and an order on 11/13/14 from a Rehabilitation physician for sixty (60) tablets that was filled and delivered to the facility. Interview conducted with the Director of Nursing (DON) on 12/4/14 at 2:34 p.m. revealed his expectations were that the nurse should follow up with the medical director if a physician does not respond after three (3) attempts to contact him. Interview on 12/4/14 at 10:38 a.m. with Rehabilitation physician CC revealed that on 11/13/14 she renewed the [MEDICATION NAME] script for resident Z when the resident told her that she did not have a good night rest due to the pain she experienced the previous night related to her regular pain medication not being available. Review of the facility's policy: Ordering and Receiving Controlled Medications revealed that the Drug Enforcement Agency (DEA) requires a valid prescriber signed prescription in order to dispense controlled substances. | 2018-07-01 |
| 10159 | TRANSITIONAL CARE CENTER | 115661 | 901 EAST 18TH ST | TIFTON | GA | 31793 | 2013-04-25 | 431 | D | 0 | 1 | ZQJG11 | Based on observation, staff interview and review of facility's policy, it was determined that the facility failed to discard seven vials of expired, unopened Pneumococcal Vaccine from the refrigerator in the medication room adjacent to the only nurses' station. Findings include: Review of the facility's policy for "Storage of Medications" dated 2010 revealed that the policy was for drugs and biologicals to be stored in a safe, secure and orderly manner and according to State and Federal Laws. the procedures included that no discontinued, outdated, or deteriorated drugs or biologicals were to be available for use in the facility. All such drugs were to be destroyed. Medications requiring refrigeration were to be stored in the refrigerator located in the drug room at the nurses' station. Medications would be stored separately from food and labeled. The refrigerator was supposed to be checked weekly, remain in clean condition and expired medications were to have been sent back to the pharmacy if unopened- if opened, they were to have been discarded per the designated disposal container. However, the facility failed to send seven unopened vials of expired Pneumococcal Vaccine back to the pharmacy. During the tour of the medication room on 4/24/13 at 11:17 a.m., there was a box containing seven unopened vials of Pneumococcal Vaccine Polyvalent (lot # 8) with expiration dates of 03/07/2013. During an interview on 4/24/13 at 11:20 a.m., nurse "AA" said that the in-house hospital pharmacy was responsible for checking dates and removing expired medications, other than insulin, from the facility's medication room refrigerator. After consulting with the Director of Nursing (DON), nurse "AA" said that the nurses on the unit were responsible for checking medications' expiration dates. Nurse "AA" removed the vials of expired medication and stated that he/she would return it to the in-house pharmacy for disposal. After surveyor inquiry, the facility changed their protocol for procurement of pneumovax to be prescribed as needed for individual residents and not kept as floor stock. | 2015-01-01 |
| 5525 | PRUITTHEALTH - MONROE | 115379 | 4796 HIGHWAY 42 NORTH | FORSYTH | GA | 31029 | 2014-09-25 | 371 | D | 0 | 1 | ZOJ711 | Based on observation, and staff interview the facility failed to thaw frozen raw chicken in a sanitary manner to prevent the potential for food borne illness. Findings include: Observation on 09/24/14 at 11:50 a.m. revealed frozen raw chicken in a stainless steel colander under running water in a sink. The frozen raw chicken was not submerged in water. Interview with the Dietary Manager on 09/24/14 at 11:50 a.m. revealed that the frozen chicken should have been submerged in water with the water running. Interview with the Registered Dietitian on 09/24/14 at 12:30 p.m., she confirmed that the frozen chicken should have been submerged under running water for thawing. | 2018-08-01 |
| 8933 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 156 | C | 0 | 1 | ZNQD11 | Based on record review and staff interview, it was determined the facility failed to issue the mandatory written Notice of Provider Noncoverage (form CMS- ) and a completed Skilled Nursing Facility Advance Beneficiary Notice (form CMS- ) to three of three residents (#107, #81, and #70) reviewed who had been discharged from Medicare Part A services. Findings include: The facility issued a Skilled Nursing Facility Advance Beneficiary Notice (form CMS- ) to resident #107 on 7/14/11, to resident #81 on 8/26/11, and to resident #70 on 6/6/11 notifying them of their discharge from Medicare Part A services on 7/17/11, 8/25/11, and 6/8/11 respectively. However, the facility failed to complete the estimated cost section of the form. Additionally, the facility had failed to issue the required Notice of Provider Noncoverage (CMS- ) to residents who had been discharged from Medicare Part A services. During an interview on 9/28/11 at 3:10 p.m., the business office manager, who was responsible for issuing the mandatory liability forms, said that she was not aware of the form CMS . She said that the facility had issued notices to the 12 residents who had been discharged from Medicare Part A services since June 2011. | 2015-09-01 |
| 8934 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 166 | D | 0 | 1 | ZNQD11 | Based on review of the social service notes and interviews with residents and facility staff, it was determined that the facility failed to respond or attempt to resolve verbal complaints by two residents (A and B) about the rudeness of nursing staff from a total sample of 25 residents. 1. During interview on 09/26/11 at 10:45 a.m., resident A said that a certified nursing assistant had been rude to Resident C and he/she had reported it to the supervising nurse on the day it occurred. Resident A did not recall which supervisory nurse to whom he/she had reported the incident. In an interview 09/28/11 at 12:50 p.m., Resident C recalled the incident and said that the employee's (bad) attitude had been reported to a supervisor. In a subsequent interview on 09/28/11 at 1:00 p.m. about resident A's complaint involving rude behavior by an employee, Director of Nursing (DON) said that she did not remember it. Later that day at 2:48 p.m., the DON said that licensed practical nurse (LPN) AA had mentioned to her (DON) in passing that resident A had reported a certified nursing assistant (CNA) had been rude and had kicked the door. She said that the day of that report she had gone to Resident A's room with several other nurses to assist in the resident's care. The DON said at that time neither residents A or C , who had also been in the room, mentioned any concerns. The DON stated that there had not been a formal investigation of the incident and no other interview was conducted because, the resident did not indicate to her that there were any problems. In an interview on 09/29/11 at 8:00 a.m., the Administrator said that that the two nurses had been remiss in not investigating the resident's complaint but, it was now being addressed. She said that the employee named in the allegation had been suspended during the investigation. 2. During an interview on 9/27/11 at 11:35 a.m., resident B stated that staff had been rude to him/her. According to the 8/4/11 social service notes, resident B had complained during a care plan meeting about the staff having been rude. In a 9/28/11 at 1:30 p.m. interview, the Social Service director stated that when she had asked the resident who the employees had been, the resident could not give her any names. She said that she had not written up that grievance or done an any further investigation. See F241 for additional information about residents A. B and C. | 2015-09-01 |
| 8935 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 241 | D | 0 | 1 | ZNQD11 | Based on interviews with residents and staff, it was determined that the facility failed to ensure that nursing staff members were not rude in their interactions with three ( A B and C ) residents from a sample of twenty-five residents. Findings include: 1. During an interview on 09/26/11 at 10:45 a.m., resident A said that when an (nursing) employee had been rude to another resident, he/she had reported it to the supervising nurse on the day it happened. Resident A did not recall which supervisory nurse to whom he/she had reported the incident. The resident said that the nursing staff person was being rude to resident C (his/her roommate). Resident A said that he/she had intervened and told the nursing staff person not to speak to an elderly person that way. Resident A said the employee continued to have an attitude while assisting resident C to use a bedpan. In an interview 09/28/11 at 12:50 p.m., Resident C recalled the incident and the employee's (bad) attitude which had been reported to a supervisor. Resident A said that he/she told the nursing staff person that he/she also needed to use a bedpan but, the nursing staff person left the room without providing one. A said that after the nursing staff person was told to return to the resident's room, he/she had to ask the nursing staff person to clean the bedpan which still contained feces from earlier in the day. The resident added that the employee had cleaned it but with a very negative attitude. Resident A said the employee went into the bathroom, kicked something and later kicked the wall and and used profane language while in the bathroom. During the interview at 2:48 p.m. on 09/28/11 after interviewing resident A and some investigation, the DON and licensed practical nurse (LPN) AA, said AA had mentioned to her (DON) in passing that resident A had reported that a certified nursing assistant (CNA) had been rude and had kicked the door. The DON said that she did not recall AA's report but later that day she had gone into Resident A's room with several other nurses to assist the resident's treatments. The DON said that she had asked resident A how everything was or if there were any problems. She said that the resident did not mention any issues. DON said that C, who had also been in the room, did not mention any concerns. The DON stated that there had not been a formal investigation of the incident. Despite the concerns reported by resident A about the rude behavior of a specific nursing staff person to a supervisory nurse, there was not any evidence that supervisory nursing staff responded to ensure that certified nursing assistants provided toileting assistance and interacted with residents A and C in a dignified, professional manner. 2. During an interview on 9/27/11 at 11:35 a.m., resident B stated that staff had been rude to him/her. Resident B's 8/4/11 social service notes included information that during a care plan meeting the resident had complained about the staff having been rude. In an interview 9/28/11 at 1:30 p.m., the Social Service Director said at that time she had gone to talk to the resident about facility staff having been rude to him. She said that the resident became anxious and upset when she questioned him and could not give her any employees' names. She said that she had not written any notes about that interview or done an any further investigation. Although the interdisciplinary care plan team heard resident B's concerns about staff having rude to him/her during their 8/4/2011 care plan meeting, as of 9/28/2011 there was not any evidence that facility staff had responded to the resident's concern or intervened to ensure that staff interacted with the resident in a respectful manner. | 2015-09-01 |
| 8936 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 279 | D | 0 | 1 | ZNQD11 | Based on review of the clinical record, care plans and interviews with facility staff, it was determined that the facility failed to develop a care plan for one of 25 residents (# 77) to ensure appropriate precautions in meeting the safety needs of other residents. During an interview on 9/28/11 at 8:15 a.m. the Social Service Director said that resident # 77 had not demonstrated any sexually inappropriate behavior since being admitted to the facility in July 2011. She said that he/she did not demonstrate that type of behavior in her/his previous communal living facility or the previous health care facility and had been assessed as safe by his/her caseworker. However, the resident had been included on the sex offender registry for an incident which in 9/28/11 at 9 a.m. interview, the Social Service Director described as a misdemeanor. Although the resident's history has the potential of putting her/him at risk for inappropriate behavior, the facility did not develop a care plan to address how to monitor the resident for the targeted behavior in order to decrease the potential risk to other residents. | 2015-09-01 |
| 8937 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 309 | D | 0 | 1 | ZNQD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the facility failed to administer a medication as ordered for one resident (# 110) from a sample of 25 residents. Findings include: Resident #110 had a physician's orders [REDACTED]. However, a review of the June 2011 Medication Administration Record [REDACTED]. The Director of Nursing stated on 9/29/11 at 10:49 a.m. that she could not confirm whether or not the medication was administered. | 2015-09-01 |
| 8938 | WOODLANDS HEALTH CARE | 115553 | 652 COASTAL HIGHWAY 17 NORTH | MIDWAY | GA | 31320 | 2011-09-29 | 428 | D | 0 | 1 | ZNQD11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, it was determined the pharmacist failed to identify a medication omission for one resident (# 110) from a sample of 25 residents. Findings include: Resident #110 had a physician's orders [REDACTED]. However, a review of the June and July 2011 Medication Administration Record [REDACTED]. It was observed that nursing staff initialed the MAR indicated [REDACTED]. However, nursing staff had not initialed the MAR indicated [REDACTED]. The Director of Nursing stated on 9/29/11 at 10:49 a.m. that she could not confirm whether or not the medication was administered. A review of the pharmacist signature sheet in the clinical record revealed that although the pharmacist had reviewed the resident's medication regime monthly on 6/24/11, 7/18/11, 8/15/11, and 9/14/11, he/she had not identified this irregularity. | 2015-09-01 |
| 2481 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2017-12-22 | 568 | C | 0 | 1 | ZNPV11 | Based on record review and staff interview, the facility failed to provide a quarterly financial statement of a resident trust fund account for one resident (R) (#51). The deficient practice had the potential to affect 112 residents with trust fund accounts managed by the facility. Findings include: Review of a Resident Funds Accounts document with no revision date revealed that the Center shall furnish residents/patients with quarterly statements at the end of each calendar quarter. Record review for R#51 revealed a Quarterly Minimum Data Set (MDS) assessment which documented a Brief Interview for Mental Status (BIMS) summary score of 03, indicating severe cognitive impairment. During an interview on 12/18/17 at 2:32 p.m., with a Family member of R#51 revealed that she does not get quarterly statements and that her mother has been in the facility for 5 years. Family stated that they will tell her how much is in there if she asks. Review of the Resident Statement Landscape from 6/1/17 through 12/4/17 revealed R#51 to have an open Resident Trust Fund Account. No documentation was available to indicate that quarterly statements had been issued. Interview with Business Office Staff CC on 12/21/17 at 3:16 p.m. revealed that she has no idea how or when quarterly statements were sent out prior to the new company taking over on 10/1/17. She stated that the Business Office Manager recently quit and that she was responsible for the resident trust fund. Interview with the Administrator on 12/22/17 at 9:50 a.m. revealed that she was not aware of any issues with the resident trust fund until she reviewed the trial balance report requested by the surveyor. She stated that she expects a file to be maintained for each resident to include an appropriate authorization to handle the account and documentation of the method of sending the quarterly statement whether it was mailed or delivered in hand to the resident or family. | 2020-09-01 |
| 2482 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2017-12-22 | 569 | C | 0 | 1 | ZNPV11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure four of four sampled residents' (R) (#20, #9, #76, #15) trust fund accounts remained under the $2,000 limit to maintain eligibility for Medicaid services; and failed to convey resident funds and final accounting to the individual administering the resident's estate within 30 days upon the death of one residents (R) (#50). The facility managed 112 resident trust funds accounts. Findings include: Record review of a Resident Funds Accounts document with no revision date revealed that the facility will provide for the temporary safekeeping of personal funds only upon approval of the resident/patient or legal representative. Residents/Patients or estate representatives will receive a statement of account and refund, if applicable, within the time frame designated by the state after discharge or upon death of the resident. Review of the Trial Balance report as of [DATE] revealed the following current balances: R#20: The account balance was $3043.28. R#9: The account balance was $2245.52. R#76: The account balance was $2114.14. R#15: The account balance was $2324.93. R#50: The account balance was $832.15 and the status indicated that the resident expired on [DATE]. During an interview on [DATE] at 9:49 a.m., with Business Office Staff CC revealed that the Business Office Manager had recently quit on [DATE]. She stated that she would highlight the accounts that were over the Social Security Income (SSI) limit for the business office manager but was unsure why resident accounts were still over the limit. The Business Office Associate could not explain why funds were not disbursed after death for R#50. Interview with the Administrator on [DATE] at 9:34 a.m. revealed that she was not aware of the balances exceeding the SSI limit. She stated that the business office manager quit last week and was responsible for the resident trust fund. Administrator stated that she expects resident trust fund accounts to be assessed and addressed when reaching $1500. She feels that a sweep to cover resident liability was not done. She stated that the funds for R#50 should have been disbursed within 30 days. | 2020-09-01 |
| 2483 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2017-12-22 | 570 | C | 0 | 1 | ZNPV11 | Based on record review and staff interview, the facility failed to maintain a surety bond sufficient to cover the current total funds in the resident trust account. The deficient practice had the potential to affect 112 residents with trust fund accounts managed by the facility. Findings include: Resident Funds Accounts document with no revision date revealed that Centers will provide for the temporary safekeeping of personal funds only upon approval of the resident/patient or legal representative. The Center shall maintain a surety bond in accordance with CMS Regulations. Review of the Trial Balance Report as of 12/21/17 revealed the Resident Trust Fund Account totaling to $131, 855.81. Review of the State of Georgia, Department of Community Health, Long Term Care Facility Residents' Fund Bond dated 9/30/17 revealed a surety in the amount of $100,000. Interview with the Administrator on 12/22/17 at 09:50 a.m. revealed that she was not aware of the issues with the resident trust fund until she reviewed the trial balance report requested by the surveyor. She expects the trial balance report to be reviewed monthly to ensure that the resident liability care cost is swept and the surety bond to be adjusted as needed. | 2020-09-01 |
| 2484 | RIVER TOWNE CENTER | 115566 | 5131 WARM SPRINGS RD | COLUMBUS | GA | 31909 | 2017-12-22 | 756 | D | 0 | 1 | ZNPV11 | Based on medical record review, staff interviews, review of the facility policy titled, Pneumococcal Vaccine, and review of the Pharmacy Consultant Agreement it was determined that the facility Pharmacist failed to review the medication regimen for five of the five residents (R) #4, R #86, R #92, R #115, R #235 reviewed for pneumonia vaccine. The sample size was 39 residents. The findings include: Medical records review revealed that five of the five residents (R) #4, R #86, R #92, R #115, R #235) reviewed did not have a screening, education form or consents in the medical record for the pneumonia vaccine. Interview on 12/21/17 at 3:30 p.m. in the office of the Infection Control Practitioner (ICP) RN revealed that there was not any evidence of any documentation available for the pneumococcal vaccine tracking and monitoring, and that the facility does not offer the pneumonia vaccination on admission or give education on the vaccination to the residents or resident's representatives. Interview on 12/22/17 at 9:55 a.m. in the Administrator's office with the Administrator and the Pharmacist (via telephone) revealed that the Pharmacist did training when the Prevnar 13 vaccine came out about two years ago, she has not done any education since then. The Pharmacist has seen orders for the pneumonia vaccine but does not remember how long ago it was, could have been two years she is not sure exactly. The Pharmacist does monthly medication reviews but does not look at vaccines specifically so she does not know when the last vaccine was ordered or given. The Pharmacist stated that she has seen vaccine orders in the electronic medical record system but does not remember how long ago it was, she did not have access to the new electronic medical record system for a month or more during the transition process. The Pharmacist stated the facility gets updates and educational material through corporate emails, she does not know if they pull it off, print or what they do with it. The Pharmacist stated that she has seen the vaccine in the refrigerators but does not know how long ago that was and that the facility has corporate nurses that check the facility. The Pharmacist stated she would report it if she had identified that the residents are not being offered or receiving the vaccine, but she has not been looking specifically at vaccines. Interview on 12/22/17 at 9:55 a.m. in the Administrator's office with the Administrator revealed that she had been in the interim position since (MONTH) (YEAR) and became full-time Administrator on 10/23/17. The Administrator revealed that she does not know anything about the pneumonia vaccine process in this facility. Review of the facility's policy titled Pneumococcal Vaccine version 2.0 requires that all residents will be offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Requirements under subparts include: 1. Prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine, and when indicated, will be offered the series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. 2. Assessments of pneumococcal vaccine status will be conducted within five working days of the resident's admission if not conducted prior to admission. 3. Before receiving a vaccination, the resident of legal representative shall receive information and education regarding the benefits and potential side effects of the vaccine 4. Vaccines will be administered to residents per facility's physician approved vaccination protocol. 5. Resident have the right to refuse the vaccination. If refused, appropriate entries will be documented in each resident's medical record indicating the date of the refusal of the vaccine. 6. For residents that receive the vaccine, the date if the vaccine, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's medical record. 7. Administration of the vaccine or revaccinations will be made in accordance with the current Center for Disease Control and prevention (CDC) recommendations at the time of the vaccination. Review of the Pharmacy Consultant Agreement, effective (MONTH) 1, (YEAR), revealed under Schedule 1-A, required consultant services: 2 (b) strive to assure that medications and/or biologicals are requested, received and administered in a timely manner as ordered by the authorized prescriber (in accordance with the applicable law) 5. Consultant shall identify any irregularities as defined in the State Operations Manual. | 2020-09-01 |